DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.

NONRESIDENT

TRAINING

COURSE

August 2000

Hospital Corpsman

NAVEDTRA 14295

NOTICE

Pages 1-29, 1-30, 7-15, and 7-20

must be printed on a

COLOR printer.
DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.

Although the words "he," "him," and

"his" are used sparingly in this course to

enhance communication, they are not

intended to be gender driven or to affront or

discriminate against anyone.
K

PREFACE

By enrolling in this self-study course, you have demonstrated a desire to improve yourself and the Navy.

Remember, however, this self-study course is only one part of the total Navy training program. Practical

experience, schools, selected reading, and your desire to succeed are also necessary to successfully round

out a fully meaningful training program.

THE COURSE: This self-study course is organized into subject matter areas, each containing learning

objectives to help you determine what you should learn along with text and illustrations to help you

understand the information. The subject matter reflects day-to-day requirements and experiences of

personnel in the rating or skill area. It also reflects guidance provided by Enlisted Community Managers

(ECMs) and other senior personnel, technical references, instructions, etc., and either the occupational or

naval standards, which are listed in the Manual of Navy Enlisted Manpower Personnel Classifications

and Occupational Standards, NAVPERS 18068.

THE QUESTIONS: The questions that appear in this course are designed to help you understand the

material in the text.

VALUE: In completing this course, you will improve your military and professional knowledge.

Importantly, it can also help you study for the Navy-wide advancement in rate examination. If you are

studying and discover a reference in the text to another publication for further information, look it up.

THANKS: A special note of thanks is given to the following activities and their staffs for providing

valuable information during the preparation of this course: Bureau of Medicine and Surgery,

Washington, DC; Navy Environmental Health Center, Norfolk, Virginia; and Naval Hospital, Pensacola,

Florida.

2000 Edition Prepared by

HMCM(SW) Steve Kilroy, USN

HMCM(SW) Lawrence A. Yates, USN

HMCS(AW) Charla Bethune, USN (Ret.)

Published by

NAVAL EDUCATION AND TRAINING

PROFESSIONAL DEVELOPMENT

AND TECHNOLOGY CENTER

NAVSUP Logistics Tracking Number

0504-LP-022-4740
KK

Sailor’s Creed

“I am a United States Sailor.

I will support and defend the

Constitution of the United States of

America and I will obey the orders

of those appointed over me.

I represent the fighting spirit of the

Navy and those who have gone

before me to defend freedom and

democracy around the world.

I proudly serve my country’s Navy

combat team with honor, courage

and commitment.

I am committed to excellence and

the fair treatment of all.”
KKK

TABLE OF CONTENTS

CHAPTER PAGE

1 Anatomy and Physiology........................................................................................ 1-1

2 Fundamentals of Patient Care................................................................................. 2-1

3 First Aid Equipment, Supplies, Rescue, and Transportation.................................. 3-1

4 Emergency Medical Care Procedures..................................................................... 4-1

5 Poisoning, Drug Abuse, and Hazardous Material Exposure .................................. 5-1

6 Pharmacy and Toxicology...................................................................................... 6-1

7 Clinical Laboratory................................................................................................. 7-1

8 Medical Aspects of Chemical, Biological, and Radiological Warfare................... 8-1

9 Diet and Nutrition................................................................................................... 9-1

10 Emergency Dental Care/Preventive Medicine ....................................................... 10-1

11 Physical Examinations............................................................................................ 11-1

12 Health Records ....................................................................................................... 12-1

13 Supply..................................................................................................................... 13-1

14 Administration........................................................................................................ 14-1

15 Healthcare Administration...................................................................................... 15-1

16 Decedent Affairs Program...................................................................................... 16-1

APPENDIX

I History of the Hospital Corps, United States Navy................................................ AI-1

II Commonly Used Abbreviations ............................................................................. AII-1

III Prefixes and Suffixes Used in Medical Terminology............................................. AIII-1

IV Common Pharmaceuticals...................................................................................... AIV-1

V Glossary.................................................................................................................. AV-1
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VI Trademarks............................................................................................................. AVI-1

VII References .............................................................................................................. AVII-1

INDEX ................................................................................................................................. INDEX-1
X

INSTRUCTIONS FOR TAKING THE COURSE

ASSIGNMENTS

The text pages that you are to study are listed at

the beginning of each assignment. Study these

pages carefully before attempting to answer the

questions. Pay close attention to tables and

illustrations and read the learning objectives.

The learning objectives state what you should be

able to do after studying the material. Answering

the questions correctly helps you accomplish the

objectives.

SELECTING YOUR ANSWERS

Read each question carefully, then select the

BEST answer. You may refer freely to the text.

The answers must be the result of your own

work and decisions. You are prohibited from

referring to or copying the answers of others and

from giving answers to anyone else taking the

course.

SUBMITTING YOUR ASSIGNMENTS

To have your assignments graded, you must be

enrolled in the course with the Nonresident

Training Course Administration Branch at the

Naval Education and Training Professional

Development and Technology Center

(NETPDTC). Following enrollment, there are

two ways of having your assignments graded:

(1) use the Internet to submit your assignments

as you complete them, or (2) send all the

assignments at one time by mail to NETPDTC.

Grading on the Internet: Advantages to

Internet grading are:

• you may submit your answers as soon as

you complete an assignment, and

• you get your results faster; usually by the

next working day (approximately 24 hours).

In addition to receiving grade results for each

assignment, you will receive course completion

confirmation once you have completed all the

assignments. To submit your assignment

answers via the Internet, go to:

http://courses.cnet.navy.mil

Grading by Mail: When you submit answer

sheets by mail, send all of your assignments at

one time. Do NOT submit individual answer

sheets for grading. Mail all of your assignments

in an envelope, which you either provide

yourself or obtain from your nearest Educational

Services Officer (ESO). Submit answer sheets

to:

COMMANDING OFFICER

NETPDTC N331

6490 SAUFLEY FIELD ROAD

PENSACOLA FL 32559-5000

Answer Sheets: All courses include one

“scannable” answer sheet for each assignment.

These answer sheets are preprinted with your

SSN, name, assignment number, and course

number. Explanations for completing the answer

sheets are on the answer sheet.

Do not use answer sheet reproductions: Use

only the original answer sheets that we

provide—reproductions will not work with our

scanning equipment and cannot be processed.

Follow the instructions for marking your

answers on the answer sheet. Be sure that blocks

1, 2, and 3 are filled in correctly. This

information is necessary for your course to be

properly processed and for you to receive credit

for your work.

COMPLETION TIME

Courses must be completed within 12 months

from the date of enrollment. This includes time

required to resubmit failed assignments.

PASS/FAIL ASSIGNMENT PROCEDURES

If your overall course score is 3.2 or higher, you

will pass the course and will not be required to

resubmit assignments. Once your assignments

have been graded you will receive course

completion confirmation.

If you receive less than a 3.2 on any assignment

and your overall course score is below 3.2, you

will be given the opportunity to resubmit failed

assignments. You may resubmit failed
XK

assignments only once. Internet students will

receive notification when they have failed an

assignment--they may then resubmit failed

assignments on the web site. Internet students

may view and print results for failed

assignments from the web site. Students who

submit by mail will receive a failing result letter

and a new answer sheet for resubmission of each

failed assignment.

COMPLETION CONFIRMATION

After successfully completing this course, you

will receive a letter of completion.

ERRATA

Errata are used to correct minor errors or delete

obsolete information in a course. Errata may

also be used to provide instructions to the

student. If a course has an errata, it will be

included as the first page(s) after the front cover.

Errata for all courses can be accessed and

viewed/downloaded at:

http://www.cnet.navy.mil/netpdtc/nac/neas.htm

STUDENT FEEDBACK QUESTIONS

We value your suggestions, questions, and

criticisms on our courses. If you would like to

communicate with us regarding this course, we

encourage you, if possible, to use e-mail. If you

write or fax, please use a copy of the Student

Comment form that follows this page.

For subject matter questions:

E-mail: n313.products@cnet.navy.mil

Phone: Comm: (850) 452-1001, Ext. 2167

DSN: 922-1001, Ext. 2167

FAX: (850) 452-1370

(Do not fax answer sheets.)

Address: COMMANDING OFFICER

NETPDTC (CODE N313)

6490 SAUFLEY FIELD ROAD

PENSACOLA FL 32509-5000

For enrollment, shipping, grading, or

completion letter questions

E-mail: fleetservices@cnet.navy.mil

Phone: Toll Free: 877-264-8583

Comm: (850) 452-1511/1181/1859

DSN: 922-1511/1181/1859

FAX: (850) 452-1370

(Do not fax answer sheets.)

Address: COMMANDING OFFICER

NETPDTC (CODE N331)

6490 SAUFLEY FIELD ROAD

PENSACOLA FL 32559-5000

NAVAL RESERVE RETIREMENT CREDIT

If you are a member of the Naval Reserve, you

will receive retirement points if you are

authorized to receive them under current

directives governing retirement of Naval

Reserve personnel. For Naval Reserve

retirement, this course is evaluated at 14 points:

12 points upon satisfactory completion of unit 1,

assignments 1-8; and 2 points upon satisfactory

completion of unit 2, assignment 9. (Refer to

Administrative Procedures for Naval Reservists

on Inactive Duty, BUPERSINST 1001.39, for

more information about retirement points.)

COURSE OBJECTIVES

In completing this nonresident training course,

you will demonstrate a knowledge of the subject

matter by correctly answering questions on the

following subjects: anatomy and physiology;

fundamentals of patient care; first aid equipment, supplies, rescue, and transportation; emergency medical care procedures; poisoning, drug

abuse, and hazardous material exposure;

pharmacy and toxicology; clinical laboratory;

medical aspects of chemical, biological, and

radiological warfare; diet and nutrition;

emergency dental care; preventive medicine;

physical examinations; health records; supply;

administration; healthcare administration; and

decedent affairs.
XKK

Student Comments

Course Title: Hospital Corpsman

NAVEDTRA: 14295 Date:

We need some information about you:

Rate/Rank and Name: SSN: Command/Unit

Street Address: City: State/FPO: Zip

Your comments, suggestions, etc.:

Privacy Act Statement: Under authority of Title 5, USC 301, information regarding your military status is

requested in processing your comments and in preparing a reply. This information will not be divulged without

written authorization to anyone other than those within DOD for official use in determining performance.

NETPDTC 1550/41 (Rev 4-00)

CHAPTER 1

ANATOMY AND PHYSIOLOGY

Knowledge of how the human body is constructed

and how it works is an important part of the training of

everyone concerned with healing the sick or managing

conditions following injury. This chapter will provide

you with a general knowledge of the structures and

functions of the body.

The human body is a combination of organ

systems, with a supporting framework of muscles and

bones and an external covering of skin. The study of

the body is divided into three sciences:

Anatomy—the study of body structures and the

relation of one part to another.

Physiology—the study of the processes and

functions of the body tissue and organs. Physiology is

the study of how the body works and how the various

parts function individually and in relation to each other.

Embryology—the study of the development of

the body from a fertilized egg, or ovum.

TERMS OF POSITION AND

DIRECTION

LEARNING OBJECTIVE: Identify

anatomical terms of position and direction.

The planes of the body are imaginary lines

dividing it into sections. These planes are used as

reference points in locating anatomical structures. As

shown in figure 1-1, the median, or midsagittal, plane

divides the body into right and left halves on its vertical

axis. This plane passes through the sagittal suture of

the cranium; therefore, any plane parallel to it is called

a sagittal plane. Frontal planes are drawn

perpendicular to the sagittal lines and divide the body

into anterior (front) and posterior (rear) sections. Since

this line passes through the coronal suture of the

cranium, frontal planes are also called coronal planes.

The horizontal, or transverse, plane, which is drawn

at right angles to both sagittal and frontal planes,

divides the body into superior (upper) and inferior

(lower) sections.

To aid in understanding the location of anatomical

structures, you should use a standard body position

called the anatomical position as a point of reference.

This anatomical position is assumed when the body

1-1

HM3F0101

MIDLINE

LATERAL

MEDIAL

ANTERIOR (VENTRAL) POSTERIOR (DORSAL) MIDSAGITTAL PLANE CORONAL (FRONTAL) PLANE

INFERIOR SUPERIOR

TRANSVERSE

PLANE

SAGITTAL PLANE

Figure 1-1.—Planes of the body.
stands erect with the arms hanging at the sides and the

palms of the hands turned forward (fig. 1-2).

Other commonly used anatomical terms include

the following:

Anterior or ventral—toward the front, or ventral

(pertaining to the belly; abdomen), side of the body.

Posterior or dorsal—toward the back, or rear,

side of the body.

Medial—near or toward the midline of the body.

Lateral—farther away from the midline of the

body.

Internal—inside.

External—outside.

Proximal—nearer the point of origin or closer to

the body.

Distal—away from the point of origin or away

from the body.

Superior—higher than or above.

Cranial—toward the head.

Caudal—toward the lower end of the body.

Inferior—lower than or below.

Erect—normal standing position of the body.

Supine—lying position of the body, face up.

Prone—lying position of the body, face down.

Lateral recumbent—lying position of the body

on either side.

Peripheral—the outward part or surface of a

structure.

CHARACTERISTICS OF LIVING

MATTER

LEARNING OBJECTIVE: Identify the

characteristics of living matter.

All living things, animals and plants, are

organisms that undergo chemical processes by which

they sustain life and regenerate cells. The difference

between animals and plants is that animals have

sensations and the power of voluntary movement, and

they require oxygen and organic food. On the other

hand, plants require only carbon dioxide and inorganic

matter for food and have neither voluntary movement

nor special sensory organs.

In man, some of the characteristic functions

necessary for survival include digestion, metabolism,

and homeostasis. Digestion involves the physical and

chemical breakdown of the food we eat into its

simplest forms. Metabolism is the process of

absorption, storage, and use of these foods for body

growth, maintenance, and repair. Homeostasis is the

body's self-regulated control of its internal

environment. It allows the organism to maintain a state

of constancy or equilibrium, in spite of vast changes in

the external environment.

THE CELL

LEARNING OBJECTIVE: Identify the

parts of the cell and their functions.

The cell, the smallest unit of life, is the basic

structural unit of all living things and a functional unit

all by itself. Cells are composed of a viscid, jellylike

substance, called protoplasm, upon which depend all

the vital functions of nutrition, secretion, growth,

1-2

HM3F0102

Figure 1-2.—Anatomical position.
circulation, reproduction, excitability, and movement.

Protoplasm, thus, has often been called “the secret of

life.”

A typical cell is made up of the plasma membrane,

the nucleus, and the cytoplasm.

The plasma membrane is a selectively permeable

membrane surrounding the cell. In addition to holding

the cell together, the membrane selectively controls the

exchange of materials between the cell and its

environment by physical and chemical means. Gases

(such as oxygen) and solids (such as proteins,

carbohydrates, and mineral salts) pass through the

plasma membrane by a process known as diffusion.

The nucleus is a small, dense, usually spherical

body that controls the chemical reactions occurring in

the cell. The substance contained in the nucleus is

called nucleoplasm. The nucleus is also important in

the cell's reproduction, since genetic information for

the cell is stored there. Every human cell contains 46

chromosomes, and each chromosome has thousands of

genes that determine the cell's function.

The cytoplasm is a gelatinous substance

surrounding the nucleus and is contained by the plasma

membrane. The cytoplasm is composed of all of the

cell protoplasm except the nucleus.

The simplest living organism consists of a single

cell. The amoeba is a unicellular animal. The single

cell of such a one-celled organism must be able to carry

on all processes necessary for life. This cell is called a

simple or undifferentiated cell, one that has not

acquired distinguishing characteristics.

In multicellular organisms, cells vary in size,

shape, and number of nuclei.When stained, the various

cell structures can be more readily recognized under a

microscope. Other differences such as the number and

type of cells can be seen with the aid of a microscope.

Many cells are highly specialized. Specialized cells

perform special functions (e.g., muscle cells, which

contract, and epithelial cells, which protect the skin).

TISSUES

LEARNING OBJECTIVES: Identify the

types of tissues in the human body and their

functions.

Tissues are groups of specialized cells similar in

structure and function. They are classified into four

main groups: epithelial, connective, muscular, and

nervous.

EPITHELIAL TISSUE

The lining tissue of the body is called epithelium.

It forms the outer covering of the body known as the

free surface of the skin. It also forms the lining of the

digestive, respiratory, and urinary tracts; blood and

lymph vessels; serous cavities (cavities which have no

communication with the outside of the body, and

whose lining membrane secretes a serous fluid), such

as the peritoneum or pericardium; and tubules (small

tubes which convey fluids) of certain secretory glands,

such as the liver and kidneys. Epithelial tissues are

classified according to their shape, arrangement, and

the function of their cells. For example, epithelial

tissues that are composed of single layers of cells are

called “simple,” while cells with many layers are said

to be “stratified.” In the following paragraphs we will

discuss the three categories of epithelial tissue:

columnar, squamous, and cuboidal.

Columnar Epithelial Tissue

Epithelial cells of this type are elongated, longer

than they are wide. Columnar tissue is composed of a

single layer of cells whose nuclei are located at about

the same level as the nuclei in their neighboring cells

(fig. 1-3). These cells can be located in the linings of

the uterus, in various organs of the digestive system,

and in the passages of the respiratory system. In the

digestive system, the chief function of columnar tissue

is the secretion of digestive fluids and the absorption of

nutrients from digested foods. In certain areas (such as

the nostrils, bronchial tubes, and trachea), this tissue

has a crown of microscopic hairlike processes known

as cilia. These cilia provide motion to move secretions

1-3

HM3F0103

Figure 1-3.—Columnar epithelial tissue.
and other matter along the surfaces from which they

extend. They also act as a barrier, preventing foreign

matter from entering these cavities.

Squamous Epithelial Tissue

Squamous epithelial tissue is composed of thin

platelike or scalelike cells forming a mosaic pattern

(fig. 1-4). This tissue is found in the tympanic

membrane (eardrum) as a single layer of cells, or in the

free skin surface in multiple layers. Squamous tissue is

the main protective tissue of the body.

Cuboidal Epithelial Tissue

The cells of cuboidal tissue are cubical in shape

(fig. 1-5) and are found in the more highly specialized

organs of the body, such as the ovary and the kidney. In

the kidneys, cuboidal tissue functions in the secretion

and absorption of fluids.

CONNECTIVE TISSUE

This is the supporting tissue of the various

structures of the body. It has many variations and is the

most widespread tissue of the body. Connective tissue

is highly vascular, surrounds other cells, encases

internal organs, sheathes muscles, wraps bones,

encloses joints, and provides the supporting

framework of the body. Structures of connective tissue

differ widely, ranging from delicate tissue-paper

membranes to rigid bones. Connective tissue is

composed of cells and extracellular materials

(materials found outside the cells). Extracellular

materials include fibers and the ground substance.

The ground substance contains proteins, water, salts,

and other diffusible substances. These extracellular

materials give connective tissue varying amounts of

elasticity and strength, depending on the type of tissue

and location. In the following paragraphs we will

discuss the three predominant types of connective

tissue: areolar, adipose, and osseous.

Areolar Connective Tissue

Areolar tissue consists of a meshwork of thin

fibers that interlace in all directions, giving the tissue

both elasticity and tensile strength (fig. 1-6). This type

of connective tissue is extensively distributed

throughout the body, and its chief function is to bind

parts of the body together. Areolar tissue allows a

considerable amount of movement to take place

because of its elasticity. It is found between muscles

and as an outside covering for blood vessels and

nerves. The areolar tissue layer connects the blood

vessels and nerves to the surrounding structures.

1-4

HM3F0105

Figure 1-5.—Cuboidal epithelial tissue.

HM3F0104

Figure 1-4.—Squamous epithelial tissue.

HM3F0106

Figure 1-6.—Areolar connective tissue.
Adipose Connective Tissue

Adipose tissue is “fatty tissue.” The adipose cell at

first appears star-shaped. When the cell begins to store

fat in its cytoplasm, it enlarges, losing its star shape as

the nucleus is pushed to one side (fig. 1-7). When this

process occurs to many cells, the other cell types are

crowded out and adipose tissue is formed. Adipose

tissue is found beneath skin, between muscles, and

around joints and various organs of the body. Adipose

tissue acts as a reservoir for energy-producing foods;

helps to reduce body heat loss (because of its poor heat

conductivity); and serves as support for various organs

and fragile structures, such as the kidneys, blood

vessels, and nerves.

Osseous Connective Tissue

This type of tissue, known as “bone tissue,” is a

dense fibrous connective tissue that forms tendons,

ligaments, cartilage, and bones (fig. 1-8). These tissues

form the supporting framework of the body.

MUSCULAR TISSUE

Muscular tissue provides for all body movement.

Contracting muscles cause body parts to move. The

three types of muscle tissue are skeletal, smooth, and

cardiac.

Skeletal Muscle Tissue

Skeletal (voluntary) muscle fiber is striated, or

striped, and is under the control of the individual's will

(fig. 1-9). For this reason, it is often called “voluntary”

muscle tissue. Skeletal muscle tissues are usually

attached to bones. When muscle fibers are stimulated

by an action of a nerve fiber, the fibers contract and

relax. This interaction between muscle and nervous

fibers produces movement.

Smooth Muscle Tissue

These muscle fibers are smooth, or nonstriated,

and are not under the control of the individual's will

(fig. 1-10). For this reason, this type of muscle tissue is

called “involuntary.” Smooth muscle tissue is found in

the walls of hollow organs, such as the stomach,

intestines, blood vessels, and urinary bladder. Smooth

muscle tissues are responsible for the movement of

food through the digestive system, constricting blood

vessels, and emptying the bladder.

1-5

CELL

MEMBRANE

FAT

DROPLET

NUCLEUS

HM3F0107

Figure 1-7.—Adipose connective tissue.

HM3F0108

Figure 1-8.—Osseous (bone) connective tissue.

HM3F0109

Figure 1-9.—Skeletal muscle tissue.

HM3F0110

Figure 1-10.—Smooth muscle tissue.
Cardiac Muscle Tissue

The cardiac muscle cells are striated and are joined

end to end, resulting in a complex network of

interlocking cells (fig. 1-11). Cardiac muscles are

involuntary muscles and are located only in the heart.

These tissues are responsible for pumping blood

through the heart chambers and into certain blood

vessels.

NERVE TISSUE

Nerve tissue is the most complex tissue in the

body. It is the substance of the brain, spinal cord, and

nerves. Nerve tissue requires more oxygen and

nutrients than any other body tissue. The basic cell of

the nerve tissue is the neuron (fig. 1-12). This highly

specialized cell receives stimuli from, and conducts

impulses to, all parts of the body.

ORGANS

LEARNING OBJECTIVE: Recall how

organs and body systems are composed of two

or more kinds of tissue that perform specialized

functions within the body.

As a group of similar cells forms tissues, two or

more kinds of tissues grouped together and performing

specialized functions constitute an organ. Organs are

grouped together to form systems (such as the urinary

system, composed of the kidneys, ureters, bladder, and

urethra).

THE SKELETAL SYSTEM

LEARNING OBJECTIVE: Identify the

parts of bone and their functions.

The skeleton, the bony framework of the body, is

composed of 206 bones (fig. 1-13). It supports and

gives shape to the body; protects vital organs; and

provides sites of attachment for tendons, muscles, and

ligaments. The skeletal bones are joined members that

make muscle movement possible.

ANATOMY OF BONES

Osteology is the study of the structure of bone.

Bone is made up of inorganic mineral salts (calcium

and phosphorus being the most prevalent) and an

organic substance called ossein. If human bones were

soaked in dilute acid until all inorganic mineral salts

were washed out, all that would remain would be a

flexible piece of tissue that could be easily bent and

twisted. Inorganic mineral salts give bone its strength

and hardness.

Bone consists of a hard outer shell, called compact

bone, and an inner spongy, porous portion, called

cancellous tissue (fig. 1-14). In the center of the bone

is the medullary canal, which contains marrow.

There are two types of marrow, red and yellow. Yellow

marrow is ordinary bone marrow in which fat cells

predominate. It is found in the medullary canals and

cancellous tissue of long bones. Red marrow is one of

the manufacturing centers of red blood cells and is

found in the articular ends of long bones and in

cancellous tissue.

At the ends of the long bones is a smooth, glossy

tissue that forms the joint surfaces. This tissue is called

articular cartilage because it articulates (or joins)

with, fits into, or moves in contact with similar

surfaces of other bones. The thin outer membrane

surrounding the bone is called the periosteum. An

important function of the periosteum is to supply

nourishment to the bone. Capillaries and blood vessels

run through the periosteum and dip into the bone

surface, supplying it with blood and nutrients. The

1-6

HM3F0112 AXON

DENDRITES

CELL BODY

Figure 1-12.—Neuron.

HM3F0111

Figure 1-11.—Cardiac muscle tissue.
periosteum is the pain center of the bone. When a bone

fractures, the pain that is felt comes from the

periosteum, not the bone proper. Periosteum also forms

new bone. The diaphysis is the elongated, cylindrical

portion (or “shaft”) of the bone that is between the

epiphyses (sing. epiphysis) or ends of the bone.

BONE CLASSIFICATIONS

Bones are classified according to their shape. The

four bone classifications and examples of each are as

follows:

• Long bones—femur and humerus

• Short bones—wrist and ankle bones

• Flat bones—skull, sternum, and scapula

• Irregular bones—vertebrae, mandible, and

pelvic bones

DIVISIONS OF SKELETON

The human skeleton is divided into two main

divisions, the axial skeleton and the appendicular

skeleton.

Axial Skeleton

The axial skeleton consists of the skull, the

vertebral column, and the thorax.

1-7

HM3F0113

CRANIUM

FACE

SKULL

CLAVICLE

SCAPULA

STERNUM

RIBS

HUMERUS

ULNA

COXAL BONE

RADIUS

CARPALS

FEMUR

PATELLA

TIBIA

FIBULA

TARSALS

METATARSALS

PHALANGES

HYOID

VERTEBRAL

COLUMN

METACARPAL

VERTEBRAL

COLUMN

SACRUM

COCCYX

PHALANGES

Figure 1-13.—Human skeleton.
SKULL.—The skull consists of 28 bones (figs.

1-15 and 1-16), 22 of which form the framework of the

head and provide protection for the brain, eyes, and

ears; six are ear bones. With the exception of the lower

jaw bone and the ear bones, all skull bones are joined

together and fixed in one position. The seams where

they join are known as sutures. The bones of the skull

are classified as either cranial or facial bones.

Cranial Bones.—The cranium is formed by eight

major bones, most of which are in pairs (fig. 1-15). The

frontal bone forms the forehead and the roof of each

orbit (or eye socket) and the nasal cavity. The parietal

bones form the roof of the skull. The temporal bones

help form the sides and base of the skull and also house

the auditory and hearing organs. The occipital bone

forms part of the base and back of the skull, and

contains a large hole called the foramen magnum. This

opening permits passage of the spinal cord from the

cranium into the spinal column. The sphenoid bones

are wedged between several other bones in the anterior

portion of the skull. These bones help form the base of

the cranium, the sides of the skull, and the floors and

sides of the orbits. The ethmoid bones are located in

front of the sphenoid bone. They form sections of the

nasal cavity roof, the cranial floor, and the orbital wall.

Facial Bones.—The facial bones of the skull

consists of 14 bones: 13 immovable bones and a

movable lower jawbone (fig. 1-16). The facial bones

give the face its basic shape and provide attachment

sites for various muscles that move the jaw and control

facial expressions.

1-8

HM3F0114

EPIPHYSEAL

DISKS PROXIMAL

EPIPHYSIS

ARTICULAR

CARTILAGE

SPACE OCCUPIED

BY RED MARROW

CANCELLOUS

TISSUE

COMPACT

BONE

MEDULLARY

CANAL

YELLOW

MARROW

PERIOSTEUM

DIAPHYSIS

DISTAL

EPIPHYSIS

SPONGY

BONE

Figure 1-14.—Anatomy of a long bone.

HM3f0115

MENTAL

FORAMEN MANDIBLE

CORONAL

SUTURE

FRONTAL

BONE

SPHENOID

BONE

ETHMOID

BONE

LACRIMAL

BONE

NASAL

BONE

ZYGOMATIC

BONE

INFRAORBITAL

FORAMEN

ZYGOMATIC PROCESS

OF TEMPORAL

TEMPORAL PROCESS

OF ZYGOMATIC

OCCIPITAL

BONE

TEMPORAL

BONE

LAMBDOIDAL

SUTURE

SQUAMOSAL

SUTURE

PARIETAL

BONE

MAXILLA

Figure 1-15.—Lateral view of the skull.
The maxillary bones form the upper jaw, the

anterior roof of the mouth, the floors of the orbits, and

the sides and floor of the nasal cavity. The small holes

on each side of the nasal opening are called the

infraorbital foramina (sing. foramen). The maxillary

bones contain large cavities called maxillary sinuses.

The palatine bones are L-shaped bones located

behind the maxillary bones. They form the posterior

section of the hard palate and the floor of the nasal

cavity.

The zygomatic bones are responsible for the

prominence of the cheeks. The zygomatic bones serve

as part of the posterior section of the hard palate and the

floor of the nasal cavity.

The lacrimal bones provide a pathway for a tube

that carries tears from the eye to the nasal cavity. The

lacrimal bone is a thin, scalelike structure located in

the medial wall of each orbit.

The nasal bones have cartilaginous tissues

attached to them. These tissues contribute

significantly to the shape of the nose. The nasal bones

are long, thin, and nearly rectangular in shape. They lie

side by side and are fused together to form the bridge of

the nose.

The vomer bone is connected to the ethmoid bone,

and together they form the nasal septum (the wall

separating the two nasal cavities).

The middle and inferior nasal conchae are

fragile, scroll-shaped bones that are attached to the

lateral wall of the nasal cavity. The inferior nasal

concha provides support for mucous membranes

within the nasal cavity.

The lower jawbone is called the mandible. The

mandible is horseshoe-shaped with flat, bony

projections on each end. The two small holes on the

jawbone are called the mental foramina. The

mandible's main function is mastication (chewing

food).

VERTEBRAL (SPINAL) COLUMN.—The

vertebral column consists of 24 movable or true

vertebrae; the sacrum; and the coccyx, or tail bone (fig.

1-17). The vertebrae protect the spinal cord and the

nerves that branch out from the spinal cord. Each

vertebra has an anterior portion, called the body, which

is the large solid segment of the bone (fig. 1-18). This

vertebral body supports not only the spinal cord but

other structures of the body as well. At the bottom of

the spinal column is the sacrum and the coccyx. Many

of the main muscles are attached to the vertebrae.

The vertebral foramen is a hole directly behind

the body of the vertebrae that forms the passage for the

spinal cord. The vertebral projections are for the

attachments of muscles and ligaments and for

facilitating movement of one vertebra over another.

The spinal column is divided into five regions in the

following order: cervical (neck), thoracic (chest),

1-9

HM3F0116

PARIENTAL

BONE

FRONTAL

BONE

LACRIMAL

BONE

ETHMOID

BONE

SQUAMOSAL

SUTURE

TEMPORAL

BONE

SPHENOID

BONE

PERPENDICULAR PLATE

OF THE ETHMOID BONE

INFRAORBITAL

FORAMEN

VOMER

BONE

MANDIBLE

MENTAL

FORAMEN

MAXILLA

INFERIOR NASAL

CONCHA

ZYGOMATIC

BONE

MIDDLE NASAL

CONCHA

SPHENOID

BONE

NASAL

BONE

Figure 1-16.—Facial bones.
lumbar (lower back), and sacral and coccygeal

(pelvis).

Cervical.—There are seven cervical vertebrae in

the neck. The first is called the atlas and resembles a

bony ring. It supports the head. The second is the

highly specialized axis. It has a bony prominence that

fits into the ring of the atlas, thus permitting the head to

rotate from side to side. The atlas and the axis are the

only named vertebrae; all others are numbered. See

figure 1-19. Each cervical vertebra has a transverse (or

intervertebral) foramen (fig. 1-19) to allow passage of

nerves, the vertebral artery, and a vein. The seventh

cervical vertebra has a prominent projection that can

easily be felt at the nape of the neck. This landmark

makes it possible for physicians to count and identify

the vertebrae above and below it.

Thoracic.—There are 12 vertebrae in the thoracic

region. The thoracic vertebrae articulate with the

posterior portion of the 12 ribs to form the posterior

wall of the thoracic, or chest, cage.

1-10

HM3F0117

VERTEBRA

PROMINENS

RIB

FACET

VERTEBRAE

INTERVERTEBRAL

DISKS

INTERVERTEBRAL

FORAMINA

SACRUM

COCCYX

CERVICAL

VERTEBRAE

CERVICAL

VERTEBRAE

THORACIC

VERTEBRAE

THORACIC

VERTEBRAE

LUMBAR

VERTEBRAE

PELVIC

CURVATURE

LUMBAR

VERTEBRAE

A. B.

Figure 1-17.—Vertebral column: A. Left lateral view of vertebral column; B. Posterior view of vertebral column.
Lumbar.—There are five lumbar vertebrae.

Located in the small of the back, these vertebrae are the

larger and stronger segments of the vertebral column.

Sacrum.—The sacrum is the triangular bone

immediately below the lumbar vertebrae. It is

composed of five separate vertebrae that gradually

fuse together between 18 and 30 years of age. The

sacrum is connected on each side with the hip bone and

with the coccyx to form the posterior wall of the pelvis.

THORAX.—This cone-shaped bony cage is

about as wide as it is deep (fig. 1-20). The thorax is

formed by 12 ribs on each side and articulates

posteriorly with the thoracic vertebrae. The first set of

ribs are attached to the manubrium, a flat irregular

bone atop the sternum. The first seven pairs of ribs are

called true ribs. The remaining five pairs are called

false ribs. They are called false ribs because their

cartilages do not reach the sternum directly. The

eighth, ninth, and tenth ribs are united by their

cartilages and joined to the rib above. The last two rib

pairs, also known as floating ribs, have no

cartilaginous attachments to the sternum. The

sternum is an elongated flat bone, forming the middle

portion of the upper half of the chest wall in front. The

xiphoid process, located at the inferior aspect of the

sternum, serves as a landmark in the administration of

cardiopulmonary resuscitation.

1-11

HM3F0118

SPINOUS

PROCESS LAMINA

TRANSVERSE

PROCESS

SUPERIOR

ARTICULAR

PROCESS

PEDICLE

BODY

PEDICLE

BODY

INTERVERTEBRAL

FORAMEN INFERIOR

ARTICULATING

PROCESS

SUPERIOR

ARTICULATING

PROCESS

TRANSVERSE

PROCESS

FACET FOR

TUBERCLE

OF RIB

SPINOUS

PROCESS

A

B

Figure 1-18.—Typical vertebra: A. Lateral view of a typical

vertebra; B. Superior view of a typical thoracic vertebra.

INTERVERTEBRAL

FORAMEN

3RD TO 7TH

CERVICAL

VERTEBRAE

HM3F0119

AXIS

ATLAS

Figure 1-19.—Cervical vertebrae.
Appendicular Skeleton

The appendicular skeleton consists of the bones of

the upper and lower extremities.

UPPER EXTREMITY.—The upper extremity

consists of the bones of the shoulder, the arm, the

forearm, the wrist, and the hand (figs. 1-21 and 1-22).

The bones that form the framework for the upper

extremities are listed in table 1-1.

Clavicle.—The clavicle (commonly called the

collar bone) lies nearly horizontally above the first rib

and is shaped like a flat letter S. The clavicle is a thin

brace bone that fractures easily. Its inner end is round

and attached to the sternum; its outer end is flattened

and fixed to the scapula. The clavicle forms the

anterior portion of the pectoral girdle (fig. 1-21). The

pectoral girdle is composed of the two clavicles and

two scapulae (shoulder blades). It functions as a

support for the arms and serves as an attachment for

several muscles.

Scapula.—The scapula is a triangular bone that lies

in the upper part of the back on both sides, between the

second and seventh ribs, forming the posterior portion

of the pectoral girdle. Its lateral corner forms part of the

shoulder joint, articulating with the humerus.

Humerus.—The humerus is the longest bone of

the upper extremity and is often called the arm bone

(fig. 1-22). It articulates with the pectoral girdle to

form the shoulder joint, and with the bones of the

1-12

HM3F0120

THORACIC

VERTEBRA

MANUBRIUM

BODY STERNUM

XIPHOID

PROCESS

RIBS

COSTAL

CARTILAGE

STERNAL

ANGLE

TRUE RIBS

(VERTEBROSTERNAL

RIBS)

FALSE

RIBS FLOATING RIBS

(VERTEBRAL RIBS)

(VERTEBROCHONDRAL

RIBS)

1

2

3

4

5

6

7

8

9

10

11

12

Figure 1-20.3⁄4Anterior view of thorax,

HM3F0121

STERNAL

END

CLAVICLE HEAD OF

HUMERUS

STERNUM

COSTAL

CARTILAGE

RIB

SCAPULA

HUMERUS

ULNA

RADIUS

Figure 1-21.—Pectoral girdle.

BONE

COMMON

NAME

TOTAL

NUMBER

IN BODY

clavicle collar bone 2

scapula shoulder blade 2

humerus arm bone 2

radius and ulna forearm bones 4

carpals wrist bones 16

metacarpals bones of the palm 10

phalanges finger bones 28

Table 1-1.—Bones of the Upper Extremities
forearm to form the elbow. Its anatomical portions

include a head (a rounded portion that fits into a recess

of the scapula) called the glenoid fossa; the shaft,

which is the main part of the humerus; and the distal

end, which includes the prominence (called an

epicondyle) and the surfaces that articulate with the

bones of the forearm.

Radius and Ulna.—When the arm is in the

anatomical position with the palm turned forward, the

radius is on the lateral (thumb) side and the ulna is on

the medial (little finger) side of the forearm (fig. 1-22).

When the hand is pronated (with the palm turned

downward), the bones rotate on each other and cross in

the middle. This pronation makes it possible to turn the

wrist and hand (as when opening doors). The ulna and

the radius articulate at their proximal ends with the

humerus, at their distal ends with some of the carpal

bones, and with each other at both ends.

Carpal.—There are eight carpal bones, arranged

in two rows, forming the wrist.

Metacarpal.—The metacarpal bones are

numbered one to five, corresponding with the five

fingers, or digits, with which they articulate. The

fingers are named as follows: 1st—thumb;

2nd—index; 3rd—middle; 4th—ring; and 5th—little.

Phalanges.—The small bones of the fingers are

called phalanges, and each one of these bones is called

a phalanx. Each finger has three phalanges, except the

thumb (which has two). The phalanges are named for

their anatomical position: The proximal phalanx is the

bone closest to the hand; the distal phalanx is the bone

at the end of the finger; and the middle phalanx is the

bone located between the proximal and distal

phalanges.

LOWER EXTREMITY.—The lower extremity

includes the bones of the hip, thigh, leg, ankle, and

foot. The bones that form the framework of the lower

extremities are listed in table 1-2.

1-13

HEAD OF HUMERUS

(GLENOID FOSSA)

HUMERUS

RADIUS

ULNA

SHAFT OF

HUMERUS

ULNA

DISTAL END

(EPICONDYLE)

CARPALS

METACARPALS

PHALANGES

HAND

SUPINATED

HAND

PRONATED HM3f0122 A B

Figure 1-22.—Left arm: A. Frontal view of left arm with hand supinated; B. Frontal view of left arm with hand pronated.
Innominate.—The innominate bone, commonly

known as the hip, is a large, irregularly shaped bone

composed of three parts: the ilium, ischium, and pubis

(fig. 1-23). In children these three parts are separate

bones, but in adults they are firmly united to form a

cuplike structure, called the acetabulum, into which

the head of the femur fits. The ilium forms the outer

prominence of the hip bone (the crest of the ilium,

referred to as the iliac crest, provides an anatomical

landmark above the ilium); the ischium forms the hard

lower part; and the pubis forms the front part of the

pelvis.

Symphysis Pubis.—The area where the two pubic

bones meet is called the symphysis pubis and is often

used in anatomical measurements. The largest

foramen, or opening, is located in the hip bone,

between the ischium and the pubis, and is called the

obturator foramen (fig. 1-23). The crest of the ilium

is used in making anatomical and surgical

measurements (e.g., location of the appendix, which is

approximately halfway between the crest of the ilium

and the umbilicus).

Femur.—The femur, or thigh bone, is the longest

bone in the body (fig. 1-24). The proximal end is

rounded and has a head supported by a constricted neck

1-14

HM3F0123

ILIAC

CREST

SACRUM

ACETABULUM

OBTURATOR

FORAMEN

SYMPHYSIS

PUBIS

ISCHIUM

COCCYX

ILIUM

Figure 1-23.—Pelvic girdle.

GREATER

TROCHANTER LESSER

TROCHANTER

FEMUR

PATELLA

FIBULA

TIBIA

METATARSALS

PHALANGES

TARSAL HM3f0124

Figure 1-24.—Anterior view of the right leg.

BONE COMMON

NAME

TOTAL

NUMBER

IN BODY

innominate hip bone 2

femur thigh bone 2

patella knee cap 2

tibia leg bone 2

fibula leg bone 2

tarsals ankle bones 14

metatarsals foot bones 10

phalanges toe bones 28

Table 1-2.—Bones of the Lower Extremities
that fits into the acetabulum. Two processes called the

greater and lesser trochanters are at the proximal end

for the attachment of muscles. The neck of the femur,

located between the head and the trochanters, is the site

on the femur most frequently fractured. At the distal

end are two bony prominences, called the lateral and

medial condyles, which articulate with the tibia and

the patella.

Patella.—The patella is a small oval-shaped bone

overlying the knee joint. It is enclosed within the

tendon of the quadriceps muscle of the thigh. Bones

like the patella that develop within a tendon are known

as sesamoid bones.

Tibia.—The tibia, or shin bone, is the larger of the

two leg bones and lies at the medial side. The proximal

end articulates with the femur and the fibula. Its distal

end articulates with the talus (one of the foot bones)

and the fibula (fig. 1-25). A prominence easily felt on

the inner aspect of the ankle is called the medial

malleolus.

Fibula.—The fibula, the smaller of the two leg

bones, is located on the lateral side of the leg, parallel

to the tibia. The prominence at the distal end forms the

outer ankle and is known as the lateral malleolus.

Tarsus.—The tarsus, or ankle, is formed by seven

tarsal bones: medial cuneiform, intermediate

cuneiform, lateral cuneiform, cuboid, navicular,

talus, and calcaneus. The strongest of these is the heel

bone, or calcaneus.

Metatarsus.—The sole and instep of the foot is

called the metatarsus and is made up of five

metatarsal bones (fig. 1-25). They are similar in

arrangement to the metacarpals of the hand.

Phalanges.—The phalanges are the bones of the

toes and are similar in number, structure, and

arrangement to the bones of the fingers.

JOINTS

LEARNING OBJECTIVE: Recognize joint

classifications and identify joint movements for

the key joints in the body.

Wherever two or more bones meet, a joint is

formed. A joint binds various parts of the skeletal

system together and enables body parts to move in

response to skeletal muscle contractions.

JOINT CLASSIFICATIONS

Joints are classified according to the amount of

movement they permit (fig. 1-26). Joint classifications

are as follows:

• Immovable. Bones of the skull are an example

of an immovable joint. Immovable joints are

characterized by the bones being in close contact with

each other and little or no movement occurring between

the bones.

• Slightly movable. In slightly movable joints,

the bones are held together by broad flattened disks of

cartilage and ligaments (e.g., vertebrae and symphysis

pubis).

1-15

HM3f0125 METATARSUS TARSUS

PHALANGES

METATARSALS

MEDIAL

CUNEIFORM

NAVICULAR

TALUS

TIBIA

FIBULA

CALCANEUS

TALUS

NAVICULAR

CUBOID

LATERAL

CUNEIFORM

INTERMEDIATE

CUNEIFORM

MEDIAL

CUNEIFORM

PROXIMAL

PHALANX

MIDDLE

PHALANX

DISTAL

PHALANX

TARSALS

METATARSALS

PHALANGES

Figure 1-25.—The foot: A. Lateral view of foot; B. Right foot viewed from above.
• Freely movable. Most joints in the body are

freely movable joints. The joint consists of the joint

capsule, articular cartilage, synovial membrane,

and synovial (joint) cavity (fig. 1-26). There are six

classifications of freely movable joints: ball-in-socket,

condyloid, gliding, hinge, pivot, and saddle joints

(fig. 1-27). These joints have much more complex

structures than the immovable and slightly movable

joints. The ends of the bones in this type of joint are

covered with a smooth layer of cartilage. The whole

joint is enclosed in a watertight sac or membrane

containing a small amount of lubricating fluid. This

lubrication enables the joint to work with little friction.

Ligaments (cords or sheets of connective tissue) reach

across the joints from one bone to another and keep the

bone stable. When ligaments are torn, we call the injury

a sprain; when bones are out of place, we refer to this as

a dislocation; and when bones are chipped or broken,

the injury is called a fracture.

TYPES OF JOINT MOVEMENTS

Joint movements are generally divided into four

types: gliding, angular, rotation, and circumduction.

Gliding

Gliding is the simplest type of motion. It is one

surface moving over another without any rotary or

angular motion. This motion exists between two

adjacent surfaces.

Angular

Angular motion decreases or increases the angle

between two adjoining bones. The more common

types of angular motion are as follows:

• Flexion—bending the arm or leg.

• Extension—straightening or unbending, as in

straightening the forearm, leg, or fingers.

• Abduction—moving an extremity away from

the body.

• Adduction—bringing an extremity toward the

body.

Rotation

Rotation is a movement in which the bone moves

around a central point without being displaced, such as

turning the head from side to side.

1-16

SYNOVIAL

MEMBRANE

SYNOVIAL

(JOINT)

CAVITY

JOINT

CAPSULE

ARTICULAR

CARTILAGE

FREELY MOVABLE

JOINT

SYMPHYSIS

PUBIS

CORONAL

SUTURE

INTERNASAL

SUTURE

FIBROUS

SUTURE

IMMOVABLE

JOINT

SLIGHTLY MOVABLE

JOINT

HM3F0126

Figure 1-26.—Example of immovable, slightly movable, and freely movable joints.
Circumduction

Circumduction is the movement of the hips and

shoulders.

Other Types of Movement

Other types of movement generally used to

indicate specific anatomical positions include the

following:

• Supination—turning upward, as in placing the

palm of the hand up.

• Pronation—turning downward, as in placing

the palm of the hand down.

• Eversion—turning outward, as in turning the

sole of the foot to the outside.

• Inversion—turning inward, as in turning the

sole of the foot inward.

MUSCLES

LEARNING OBJECTIVE: Identify primary

muscle functions, muscle characteristics, types

of muscle tissue, and important functional

muscles.

Muscles are responsible for many different types

of body movements. The action of the muscle is

1-17

PIVOT

JOINT

COXAL

BONE

HEAD OF FEMUR

IN ACETABULUM

FEMUR

BALL-AND-SOCKET

JOINT

CONDYLOID

JOINT

METACARPAL

PHALANX

GLIDING

JOINT

CARPALS

RADIUS

ULNA

HUMERUS

HINGE

JOINT

ODONTOID

PROCESS

TRANSVERSE

LIGAMENT

ATLAS

FIRST

METACARPAL

TRAPEZIUM

SADDLE

JOINT HM3F0127

A

B

C

D

E

F

Figure 1-27.—Types of joints: A. Ball-in-socket joint; B. Condyloid joint; C. Gliding joint; D. Hinge joint; E. Pivot joint; F. Saddle

joint.
determined mainly by the kind of joint it is associated

with and the way the muscle is attached to the joint. At

one end of some muscles are long white tendons that

attach the muscles to bone. The point of fixed

attachment of a muscle to bone is called the origin. The

more flexible attachments, especially attachments to a

movable bone, are termed insertions.

Muscles seldom act alone; they usually work in

groups held together by sheets of a white fibrous tissue

called fascia. Muscles make up about one-half of the

total body weight. Their main functions are threefold:

• Providing movement—including internal

functions such as peristalsis (rhythmic waves of

muscular contraction within the intestines).

• Maintaining body posture—through muscle

tone, as in the muscles of the head, neck and shoulders,

which keep the head up.

• Providing heat—through chemical changes that

take place during muscle activity, such as exercise that

warms the body.

In addition, muscles are involved in such essential

bodily functions as respiration, blood circulation,

digestion, and other functions such as speaking and

seeing.

MUSCLE CONTRACTION

Muscle tissue has a highly developed ability to

contract. Contractibility enables a muscle to become

shorter or thicker, and this ability, along with

interaction with other muscles, produces movement of

internal and external body parts. Muscle contraction in

a tissue or organ produces motion and provides power

and speed for body activity. A contracting muscle is

referred to as a prime mover. Amuscle that is relaxing

while a prime mover is contracting is called the

antagonist.

STIMULUS FOR CONTRACTION

All muscles respond to stimulus. This property is

called excitability or irritability. The mechanical

muscular action of shortening or thickening (also

called contraction) is activated by a stimulus sent

through a motor nerve. All muscles are linked to nerve

fibers that carry messages from the central nervous

system.

CONTRACTION AND RECOVERY

The chemical action of muscle fibers consists of

two stages, contraction and recovery. In the

contraction stage, two protein substances (actin and

myosin) react to provide energy through the

breakdown of glycogen into lactic acid. In the recovery

stage, oxygen reacts with lactic acid to release carbon

dioxide and water.

MUSCLE FATIGUE

When a muscle contracts, it produces chemical

waste products (carbon dioxide, lactic acid, and acid

phosphate) which make the muscle more irritable. If

contraction is continued, the muscle will cramp and

refuse to move. This condition is known asfatigue. If it

is carried too far, the muscle cells will not recover and

permanent damage will result. Muscles, therefore,

need rest to allow the blood to carry away the waste

materials and bring in fresh glucose, oxygen, and

protein to restore the muscle protoplasm and the

energy that was used.

TONICITY

Tonicity, or muscular tone, is a continual state of

partial contraction that gives muscles a certain

firmness. Isometric muscle contraction occurs when

the muscle is stimulated and shortens, but no

movement occurs, as when a person tenses his or her

muscles against an immovable object.Isotonic muscle

contraction occurs when the muscle is stimulated. The

muscle shortens and movement occurs. An example

would be lifting an object.

EXTENSIBILITY AND ELASTICITY

Muscles are also capable of stretching when force

is applied (extensibility) and regaining their original

form when that force is removed (elasticity).

MAINTENANCE OF MUSCLE TISSUE

During exercise, massage, or ordinary activities,

the blood supply of muscles is increased. This

additional blood brings in fresh nutritional material,

carries away waste products more rapidly, and enables

the muscles to build up and restore their efficiency and

tone.

The importance of exercise for normal muscle

activity is clear, but excessive muscle strain is

damaging. For example, if a gasoline motor stands

1-18
idle, it eventually becomes rusty and useless.

Similarly, a muscle cell that does not work atrophies,

becoming weak and decreasing in size. On the other

hand, a motor that is never allowed to stop and is forced

to run too fast or to do too much heavy work soon wears

out so that it cannot be repaired. In the same way, a

muscle cell that is forced to work too hard without

proper rest will be damaged beyond repair.

When a muscle dies, it becomes solid and rigid and

no longer reacts. This stiffening, which occurs from 10

minutes to several hours after death, is called rigor

mortis.

MUSCLE TISSUES

There are three types of muscle tissue: skeletal,

smooth, and cardiac. Each is designed to perform a

specific function.

Skeletal

Skeletal, or striated, muscle tissues are attached to

the bones and give shape to the body. They are

responsible for allowing body movement. This type of

muscle is sometimes referred to as striated because of

the striped appearance of the muscle fibers under a

microscope (fig. 1-9). They are also called voluntary

muscles because they are under the control of our

conscious will. These muscles can develop great

power.

Smooth

Smooth, or nonstriated, muscle tissues are found in

the walls of the stomach, intestines, urinary bladder,

and blood vessels, as well as in the duct glands and in

the skin. Under a microscope, the smooth muscle fiber

lacks the striped appearance of other muscle tissue

(fig. 1-10). This tissue is also called involuntary

muscle because it is not under conscious control.

Cardiac

The cardiac muscle tissue forms the bulk of the

walls and septa (or partitions) of the heart, as well as

the origins of the large blood vessels. The fibers of the

cardiac muscle differ from those of the skeletal and

smooth muscles in that they are shorter and branch into

a complicated network (fig. 1-11). The cardiac muscle

has the most abundant blood supply of any muscle in

the body, receiving twice the blood flow of the highly

vascular skeletal muscles and far more than the smooth

muscles. Cardiac muscles contract to pump blood out

of the heart and through the cardiovascular system.

Interference with the blood supply to the heart can

result in a heart attack.

MAJOR SKELETAL MUSCLES

In the following section, the location, actions,

origins, and insertions of some of the major skeletal

muscles are covered. In figures 1-28 and 1-29 the

superficial skeletal muscles are illustrated. Also note,

the names of some of the muscles give you clues to

their location, shape, and number of attachments.

Temporalis

The temporalis muscle is a fan-shaped muscle

located on the side of the skull, above and in front of the

ear. This muscle's fibers assist in raising the jaw and

pass downward beneath the zygomatic arch to the

mandible (fig. 1-29). The temporalis muscle's origin is

the temporal bone. It is inserted in the coronoid process

(a prominence of bone) of the mandible.

Masseter

The masseter muscle raises the mandible, or lower

jaw, to close the mouth (fig. 1-28). It is the chewing

muscle in the mastication of food. It originates in the

zygomatic process and adjacent parts of the maxilla

and is inserted in the mandible.

Sternocleidomastoid

The sternocleidomastoid muscles are located on

both sides of the neck. Acting individually, these

muscles rotate the head left or right (figs. 1-28 and

1-29). Acting together, they bend the head forward

toward the chest. The sternocleidomastoid muscle

originates in the sternum and clavicle and is inserted in

the mastoid process of the temporal bone. When this

muscle becomes damaged, the result is a common

condition known as a “stiff neck.”

Trapezius

The trapezius muscles are a broad,

trapezium-shaped pair of muscles on the upper back,

which raise or lower the shoulders (figs. 1-28 and

1-29). They cover approximately one-third of the back.

They originate in a large area which includes the 12

thoracic vertebrae, the seventh cervical vertebra, and

the occipital bone. They have their insertion in the

clavicle and scapula.

1-19
Pectoralis Major

The pectoralis major is the large triangular muscle

that forms the prominent chest muscle (fig. 1-28). It

rotates the arm inward, pulls a raised arm down toward

the chest, and draws the arm across the chest. It

originates in the clavicle, sternum, and cartilages of the

true ribs, and the external oblique muscle. Its insertion

is in the greater tubercle of the humerus.

Deltoid

The deltoid muscle raises the arm and has its origin

in the clavicle and the spine of the scapula (figs. 1-28

and 1-29). Its insertion is on the lateral side of the

humerus. It fits like a cap over the shoulder and is a

frequent site of intramuscular injections.

Biceps Brachii

The biceps brachii is the prominent muscle on the

anterior surface of the upper arm (fig. 1-28). Its origin

is in the outer edge of the glenoid cavity, and its

insertion is in the tuberosity of the radius. This muscle

rotates the forearm outward (supination) and, with the

aid of the brachial muscle, flexes the forearm at the

elbow.

1-20

HM3F0128

MASSETER

STERNOCLEIDOMASTOID

DELTOID

PECTORALIS

MAJOR

BICEPS

BRACHII

ADDUCTOR

LONGUS

GRACILIS

GASTROCNEMIUS

SOLEUS

TIBIALIS

ANTERIOR

VASTUS

MEDIALIS

VASTUS

LATERALIS

RECTUS

FEMORIS

QUADRICEPS

SARTORIUS

LATISSIMUS

DORSI

TRAPEZIUS

Figure 1-28.—Anterior view of superficial skeletal muscles.
Triceps Brachii

The triceps brachii is the primary extensor of the

forearm (the antagonist of the biceps brachii) (fig. 1-29).

It originates at two points on the humerus and one on the

scapula. These three heads join to form the large muscle

on the posterior surface of the upper arm. The point of

insertion is the olecranon process of the ulna.

Latissimus Dorsi

The latissimus dorsi is a broad, flat muscle that

covers approximately one-third of the back on each

side (figs. 1-28 and 1-29). It rotates the arm inward and

draws the arm down and back. It originates from the

upper thoracic vertebrae to the sacrum and the

posterior portion of the crest of the ilium. Its fibers

converge to form a flat tendon that has its insertion in

the humerus.

Gluteus

The gluteus (maximus, minimus(not shown), and

medius) are the large muscles of the buttocks, which

extend and laterally rotate the thigh, as well as abduct

and medially rotate it (fig. 1-29). They arise from the

ilium, the posterior surface of the lower sacrum, and

the side of the coccyx. Their points of insertion include

the greater trochanter and the gluteal tuberosity of the

femur. The gluteus maximus is the site of choice for

intramuscular injections.

1-21

HM3F0129

STERNOCLEIDOMASTOID

DELTOID

TRICEPS

BRACHII

GRACILIS

GASTROCNEMIUS

SOLEUS

VASTUS

LATERALIS

SARTORIUS

LATISSIMUS

DORSI

TRAPEZIUS

GLUTEUS

MEDIUS

GLUTEUS

MAXIMUS

BICEPS

FEMORIS

DELTOID

TEMPORALIS

Figure 1-29.—Posterior view of superficial skeletal muscles.
Quadriceps

The quadriceps is a group of four muscles that

make up the anterior portion of the thigh. The four

muscles of this group are the rectus femoris that

originates at the ilium; and the vastus lateralis, v.

medialis, v. intermedius (not shown), that originate

along the femur (fig. 1-28). All four are inserted into

the tuberosity of the tibia through a tendon passing

over the knee joint. The quadriceps serves as a strong

extensor of the leg at the knee and flexes the thigh.

Additionally located in the quadriceps area is the

adductor longus that adducts, rotates, and flexes the

thigh.

Biceps Femoris

The biceps femoris (often called the hamstring

muscle) originates at the tuberosity of the ischium (the

lowest portion of the coxal bone, part of the pelvic

girdle) and the middle third of the femur (fig. 1-29). It

is inserted on the head of the fibula and the lateral

condyle of the tibia. It acts, along with other related

muscles, to flex the leg at the knee and to extend the

thigh at the hip joint.

Gracilis

The gracilis is a long slender muscle located on the

inner aspect of the thigh (figs. 1-28 and 1-29). It

adducts the thigh, and flexes and medially rotates the

leg. Its origin is in the symphysis pubis, and its

insertion is in the medial surface of the tibia, below the

condyle.

Sartorius

The sartorius is the longest muscle in the body. It

extends diagonally across the front of the thigh from its

origin at the ilium, down to its insertion near the

tuberosity of the tibia (fig. 1-29). Its function is to flex

the thigh and rotate it laterally, and to flex the leg and

rotate it slightly medially.

Gastrocnemius and Soleus

The gastrocnemius and soleus (together

commonly called the calf muscles) extend the foot at

the ankle (figs. 1-28 and 1-29). The gastrocnemius

originates at two points on the femur; the soleus

originates at the head of the fibula and the medial

border of the tibia. Both are inserted in a common

tendon called the calcaneus, or Achilles tendon.

Tibialis Anterior

The tibialis anterior originates at the upper half of

the tibia and inserts at the first metatarsal and

cuneiform bones (fig. 1-28). It flexes the foot.

Diaphragm

The diaphragm (not shown) is an internal (as

opposed to superficial) muscle that forms the floor of

the thoracic cavity and the ceiling of the abdominal

cavity. It is the primary muscle of respiration,

modifying the size of the thorax and abdomen

vertically. It has three openings for the passage of

nerves and blood vessels.

THE INTEGUMENTARY SYSTEM

LEARNING OBJECTIVE: Identify skin, its

functions, structure, and appendages.

Organ systems are comprised of tissues grouped

together to form organs, and groups of organs with

specialized functions. Since the skin acts with hair

follicles, sebaceous glands, and sweat glands, these

organs together constitute the integumentary system.

SKIN FUNCTION

The skin covers almost every visible part of the

human body. Even the hair and nails are outgrowths

from it. It protects the underlying structures from

injury and invasion by foreign organisms; it contains

the peripheral endings of many sensory nerves; and it

has limited excretory and absorbing powers. The skin

also plays an important part in regulating body

temperature. In addition, the skin is a waterproof

covering that prevents excessive water loss, even in

very dry climates.

SKIN STRUCTURE

The skin, or integument, consists of two layers, the

epidermis and the dermis, and supporting structures

and appendages (fig. 1-30).

Epidermis

The epidermis is the outer skin layer (fig. 1-30). It

is made up of tough, flat, scalelike epithelial cells. Five

sublayers or strata of epidermal cells have been

identified, and, listed from superficial to deep, they are

1-22
the stratum corneum, stratum lucidum (not always

present), stratum granulosum, stratum spinosum,

and stratum basale.

Dermis

The dermis, or true skin, lies below the epidermis

and gradually blends into the deeper tissues (fig. 1-30).

It is a wide area of connective tissue that contains blood

vessels, nerve fibers, smooth muscles, and skin

appendages.

BLOOD VESSELS.—The blood vessels of the

dermis can dilate to contain a significant portion of the

body's blood supply (fig. 1-30). This ability, along with

the actions of the sweat glands, forms the body's

primary temperature-regulating mechanism. The

constriction or dilation of these blood vessels also

affects blood pressure and the volume of blood

available to the internal organs.

NERVE FIBERS.—The skin contains two types

of nerve fibers that carry impulses to and from the

central nervous system (fig. 1-30). The nerve fibers are

distributed to the smooth muscles in the walls of the

arteries in the dermis and to the smooth muscles around

the sweat glands and hair roots. The first type of nerve

fiber carries impulses to the dermal muscles and

glands, while the other type carries impulses from

sensory receptors (i.e., detecting touch). Both nerve

fibers send messages about the external environment

to the brain.

SMOOTH MUSCLES.—Smooth involuntary

muscles are found in the dermis. They are responsible

for controlling the skin surface area. When dilated,

these muscles allow for maximum skin surface

exposure to aid heat loss. When constricted, the skin

surface exposure is decreased, thus impeding heat

radiation. Repeated muscle contractions (shivering)

are also a rapid means of generating body heat.

Skin Appendages

The appendages of the skin are the nails, hairs,

sebaceous glands, sweat glands, and ceruminous

glands.

NAILS.—The nails are composed of horny

epidermal scales and are found on the dorsal surfaces

of the fingers and toes. They protect the many sensitive

nerve endings at the ends of these digits. New

formation of nail will occur in the epithelium of the

nail bed. As a new nail is formed, the whole nail moves

forward, becoming longer.

HAIR.—Hair is an epithelial structure found on

almost every part of the surface of the body (fig. 1-30).

Its color depends on the type of melanin present. The

hair has two components: the root below the surface

and the shaft projecting above the skin. The root is

embedded in a pit-like depression called the hair

follicle. Hair grows as a result of the division of the

cells of the root. A small muscle, known as the

arrector (fig. 1-30), fastens to the side of the follicle

and is responsible for the gooseflesh appearance of the

skin as a reaction to cold or fear. Each hair follicle is

associated with two or more sebaceous glands.

SEBACEOUS GLANDS.—Sebaceous glands

are found in most parts of the skin except in the soles of

the feet and the palms of the hand (fig. 1-30). Their

ducts open most frequently into the hair follicles and

secrete an oily substance that lubricates the skin and

hair, keeping them soft and pliable and preventing

bacterial invasion.

SWEAT GLANDS.—Sweat glands are found in

almost every part of the skin (fig. 1-30). They are

control mechanisms to reduce the body's heat by

evaporating water from its surface. The perspiration

secreted is a combination of water, salts, amino acids,

and urea. Normally, about one liter of this fluid is

excreted daily. However, the amount varies with

atmospheric temperature and humidity and the amount

of exercise taken. When the outside temperature is

high, or upon exercise, the glands secrete large

amounts to cool the body through evaporation. When

1-23

HM3F0130

SHAFT OF

HAIR

OPENING OF

SWEAT DUCT NERVE

FIBERS

SWEAT

DUCT

SWEAT

GLAND

SEBACEOUS

GLAND

HAIR

FOLLICLE

ARRECTOR

MUSCLE

BLOOD

VESSELS

DERMIS

EPIDERMIS

Figure 1-30.—Cross section of the skin.
evaporation does not remove all the sweat that has been

excreted, the sweat collects in beads on the surface of

the skin.

CERUMINOUS GLANDS.—Ceruminous

glands are modified sweat glands found only in the

auditory canal. They secrete a yellow, waxy substance

called cerumen that protects the eardrum.

THE CIRCULATORY SYSTEM

LEARNING OBJECTIVE: Identify the parts

of the circulatory system, and recognize their

major components and functions.

The circulatory system, also called the vascular

system, consists of blood, heart, and blood vessels.

The circulatory system is close circuited (i.e., there is

no opening to external environment of the body). The

function of this system is to move blood between the

cells and the organs of the integumentary, digestive,

respiratory, and urinary system that communicate with

the external environment of the body. This function is

facilitated by the heart pumping blood through blood

vessels. The blood travels throughout the body

transporting nutrients and wastes, and permitting the

exchange of gases (carbon dioxide and oxygen).

BLOOD

Blood is fluid tissue composed of formed elements

(i.e., cells) suspended in plasma. It is pumped by the

heart through arteries, capillaries, and veins to all parts

of the body. Total blood volume of the average adult is

5 to 6 liters.

Plasma

Plasma is the liquid part of blood (fig. 1-31).

Plasma constitutes 55 percent of whole blood (plasma

and cells). It is a clear, slightly alkaline, straw-colored

liquid consisting of about 92 percent water. The

remainder is made up mainly of proteins. One of these

proteins, fibrinogen, contributes to coagulation.

Blood Cells

The blood cells suspended in the plasma constitute

45 percent of whole blood. Its cells, which are formed

mostly in red bone marrow, include red blood cells

(RBCs) and white blood cells (WBCs). The blood also

contains cellular fragments called blood platelets.

When blood components are separated, the WBCs and

platelets form a thin layer, called the buffy coat,

between the layers of plasma and RBCs. These layers

are illustrated in figure 1-31.

RED BLOOD CELLS.—Red blood cells, or

erythrocytes, are small, biconcave, nonnucleated

disks, formed in the red bone marrow (fig. 1-32).

Blood of the average man contains 5 million red cells

per cubic millimeter. Women have fewer red cells, 4.5

million per cubic millimeter. Emotional stress,

strenuous exercise, high altitudes, and some diseases

may cause an increase in the number of RBCs.

During the development of the red blood cell, a

substance called hemoglobin is combined with it.

Hemoglobin is the key of the red cell's ability to carry

oxygen and carbon dioxide. Thus, the main function of

erythrocytes is the transportation of respiratory gases.

The red cells deliver oxygen to the body tissues,

holding some oxygen in reserve for an emergency.

Carbon dioxide is picked up by the same cells and

discharged via the lungs.

The color of the red blood cell is determined by the

hemoglobin content. Bright red (arterial) blood is due

to the combination of oxygen and hemoglobin. Dark

1-24

BLOOD

SAMPLE

LIQUID

(PLASMA)

"BUFFY

COAT"

RED BLOOD

CELLS

55%

45%

HM3F0131

Figure 1-31.—Blood sample illustrating blood components.

HM3F0132

PLATELETS

WHITE

BLOOD

CELLS

RED

BLOOD

CELLS

PERIPHERAL BLOOD SMEAR

Figure 1-32.—A blood smear showing red blood cells, white

blood cells, and platelets.
red (venous) blood is the result of hemoglobin

combining with carbon dioxide.

Red blood cells live only about 100 to 120 days in

the body. There are several reasons for their short life

span. These delicate cells have to withstand constant

knocking around as they are pumped into the arteries

by the heart. These cells travel through blood vessels at

high speed, bumping into other cells, bouncing off the

walls of arteries and veins, and squeezing through

narrow passages. They must adjust to continual

pressure changes. The spleen is the “graveyard” where

old, worn out cells are removed from the blood stream.

Fragments of red blood cells are found in the spleen

and other body tissues.

WHITE BLOOD CELLS.—White blood cells,

or leukocytes, are almost colorless, nucleated cells

originating in the bone marrow and in certain

lymphoid tissues of the body (fig. 1-32). There is only

one white cell to every 600 red cells. Normal WBC

count is 6,000 to 8,000 per cubic millimeter, although

the number of white cells may be 15,000 to 20,000 or

higher during infection.

Leukocytes are important for the protection of the

body against disease. Leukocytes can squeeze between

the cells that form blood cell walls. This movement,

called diapedesis, permits them to leave the blood

stream through the capillary wall and attack

pathogenic bacteria. They can travel anywhere in the

body and are often named “the wandering cells.” They

protect the body tissues by engulfing disease-bearing

bacteria and foreign matter, a process called

phagocytosis. When white cells are undermanned,

more are produced, causing an increase in their number

and a condition known as leukocytosis. Another way

WBC's protect the body from disease is by producing

bacteriolysins that dissolve the foreign bacteria. The

secondary function ofWBCs is to aid in blood clotting.

BLOOD PLATELETS.—Blood platelets, or

thrombocytes, are irregular- or oval-shaped discs in

the blood that contain no nucleus, only cytoplasm

(fig. 1-32). They are smaller than red blood cells and

average about 250,000 per cubic millimeter of blood.

Blood platelets play an important role in the process of

blood coagulation, clumping together in the presence

of jagged, torn tissue.

Blood Coagulation

To protect the body from excessive blood loss,

blood has its own power to coagulate, or clot. If blood

components and linings of vessels are normal,

circulating blood will not clot. Once blood escapes

from its vessels, however, a chemical reaction begins

that causes it to become solid. Initially a blood clot is a

fluid, but soon it becomes thick and then sets into a soft

jelly that quickly becomes firm enough to act as a plug.

This plug is the result of a swift, sure mechanism that

changes one of the soluble blood proteins, fibrinogen,

into an insoluble protein, fibrin, whenever injury

occurs.

Other necessary elements for blood clotting are

calcium salts; a substance called prothrombin, which

is formed in the liver; blood platelets; and various

factors necessary for the completion of the successive

steps in the coagulation process. Once the fibrin plug is

formed, it quickly enmeshes red and white blood cells

and draws them tightly together. Blood serum, a

yellowish clear liquid, is squeezed out of the clot as the

mass shrinks. Formation of the clot closes the wound,

preventing blood loss. A clot also serves as a network

for the growth of new tissues in the process of healing.

Normal clotting time is 3 to 5 minutes, but if any of the

substances necessary for clotting are absent, severe

bleeding will occur.

Hemophilia is an inherited disease characterized

by delayed clotting of the blood and consequent

difficulty in controlling hemorrhage. Hemophiliacs

can bleed to death as a result of minor wounds.

THE HEART

The heart is a hollow, muscular organ, somewhat

larger than the closed fist, located anteriorly in the

chest and to the left of the midline. It is shaped like a

cone, its base directed upward and to the right, the apex

down and to the left. Lying obliquely in the chest, much

of the base of the heart is immediately posterior to the

sternum.

Heart Composition

The heart is enclosed in a membranous sac, the

pericardium. The smooth surfaces of the heart and

pericardium are lubricated by a serous secretion called

pericardial fluid. The inner surface of the heart is

lined with a delicate serous membrane, the

endocardium, similar to and continuous with that of

the inner lining of blood vessels.

The interior of the heart (fig. 1-33) is divided into

two parts by a wall called the interventricular

septum. In each half is an upper chamber, the atrium,

which receives blood from the veins, and a lower

chamber, the ventricle, which receives blood from the

1-25
atrium and pumps it out into the arteries. The openings

between the chambers on each side of the heart are

separated by flaps of tissue that act as valves to prevent

backward flow of blood. The valve on the right has

three flaps, or cusps, and is called the tricuspid valve.

The valve on the left has two flaps and is called the

mitral, or bicuspid, valve. The outlets of the

ventricles are supplied with similar valves. In the right

ventricle, the pulmonary valve is at the origin of the

pulmonary artery. In the left ventricle, the aortic valve

is at the origin of the aorta. See figure 1-33 for valve

locations.

The heart muscle, the myocardium, is striated like

the skeletal muscles of the body, but involuntary in

action, like the smooth muscles. The walls of the atria

are thin with relatively little muscle fiber because the

blood flows from the atria to the ventricles under low

pressure. However, the walls of the ventricles, which

comprise the bulk of the heart, are thick and muscular.

The wall of the left ventricle is considerably thicker

than that of the right, because more force is required to

pump the blood into distant or outlying locations of the

circulatory system than into the lungs located only a

short distance from the heart.

Heart Functions

The heart acts as four interrelated pumps. The right

atrium receives deoxygenated blood from the body via

the superior and inferior vena cava. It pumps the

deoxygenated blood through the tricuspid valve to the

right ventricle. The right ventricle pumps the blood

past the pulmonary valve through the pulmonary

artery to the lungs, where it is oxygenated. The left

atrium receives the oxygenated blood from the lungs

through four pulmonary veins and pumps it to the left

ventricle past the mitral valve. The left ventricle

pumps the blood to all areas of the body via the aortic

valve and the aorta.

The heart's constant contracting and relaxing

forces blood into the arteries. Each contraction is

followed by limited relaxation or dilation. Cardiac

muscle never completely relaxes: It always maintains a

degree of tone. Contraction of the heart is called

systole or “the period of work.” Relaxation of the heart

is called diastole or “the period of rest.” A complete

cardiac cycle is the time from onset of one contraction,

or heart beat, to the onset of the next.

1-26

AORTIC ARCH

LEFT

PULMONARY

ARTERY

RIGHT

PULMONARY

ARTERY

PULMONARY

TRUNK

BRANCHES

OF LEFT

PULMONARY

VEIN

AORTIC

SEMILUNAR

VALVE

MITRAL

VALVE

LEFT

VENTRICLE

INTERVENTRICULAR

SEPTUM

MYOCARDIUM

(HEART MUSCLE)

PAPILARY

MUSCLE

DESCENDING

AORTA

INFERIOR VENA

CAVA

(FROM TRUNK

AND LEGS)

RIGHT

VENTRICLE

TRICUSPID

VALVE

RIGHT

ATRIUM

PULMONARY

SEMILUNAR

VALVE

SUPERIOR

VENA CAVA

(FROM HEAD

AND ARM)

FROM LUNG

FROM LUNG

TO LUNG TO LUNG

LEFT

ATRIUM

HM3F0133

Figure 1-33.—Frontal view of the heart—arrows indicate blood flow.
Cardiac Cycle

The cardiac cycle is coordinated by specialized

tissues that initiate and distribute electrical (cardiac)

impulses (fig. 1-34). The contractions of the heart are

stimulated and maintained by the sinoatrial (SA)

node, commonly called the pacemaker of the heart.

The SA node is an elongated mass of specialized

muscle tissue located in the upper part of the right

atrium. The SA node sets off cardiac impulses, causing

both atria to contract simultaneously. The normal heart

rate, or number of contractions, is about 70 to 80 beats

per minute.

This same cardiac impulse continues to travel to

another group of specialized tissue called the

atrioventricular (AV) node. The AV node is located

in the floor of the right atrium near the septum that

separates the atria. The cardiac impulse to the AV node

is slowed down by junctional fibers. The junctional

fibers conduct the cardiac impulse to the AV node;

however, these fibers are very small in diameter,

causing the impulse to be delayed. This slow arrival of

the impulse to the AV node allows time for the atria to

empty and the ventricles to fill with blood.

Once the cardiac impulse reaches the far side of the

AV node, it quickly passes through a group of large

fibers which make up the AV bundle (also called the

bundle of His). The AV bundle starts at the upper part

of the interventricular septum and divides into right

and left branches. About halfway down the

interventricular septum, the right and left branches

terminate into Purkinje fibers. The Purkinje fibers

spread from the interventricular septum into the

papillary muscles, which project inward from the

ventricular walls. As the cardiac impulse passes

through the Purkinje fibers, these fibers in turn

stimulate the cardiac muscle of the ventricles. This

stimulation of the cardiac muscles causes the walls of

the ventricles to contract with a twisting motion. This

action squeezes the blood out of the ventricular

chambers and forces it into the arteries. This is the

conclusion of one cardiac cycle.

Blood Pressure

Blood pressure is the pressure the blood exerts on

the walls of the arteries. The highest pressure is called

systolic pressure, because it is caused when the heart is

in systole, or contraction. A certain amount of blood

pressure is maintained in the arteries even when the

heart is relaxed. This pressure is the diastolic pressure,

because it is present during diastole, or relaxation of

the heart. The difference between systolic and diastolic

pressure is known as pulse pressure.

Normal blood pressure can vary considerably with

an individual's age, weight, and general condition. For

young adults, the systolic pressure is normally

between 120 and 150 mm of mercury, and the diastolic

pressure is normally between 70 and 90 mm of

mercury. On average, women have lower blood

pressure than men.

1-27

HM3F0134

INTERATRIAL

SEPTUM

S-A NODE

AV NODE

AV BUNDLE

LEFT

BUNDLE

BRANCH

PURKINJE

FIBERS INTERVENTRICULAR

SEPTUM

Figure 1-34.—Cardiac cycle.
BLOOD VESSELS

Blood vessels form a closed circuit of tubes that

transport blood between the heart and body cells. The

several types of blood vessels include arteries,

arterioles, capillaries, venules, and veins.

Blood Vessel Classifications

The blood vessels of the body fall into three

classifications:

• Arteries and arterioles—distributors

• Capillaries—exchangers

• Veins and venules—collectors

Arteries and Arterioles

Arteries are elastic tubes constructed to withstand

high pressure. They carry blood away from the heart to

all parts of the body. The smallest branches of the

arteries are called arterioles. The walls of arteries and

arterioles consist of layers of endothelium, smooth

muscle, and connective tissue. The smooth muscles of

arteries and arterioles constrict and dilate in response

to electrical impulses received from the autonomic

nervous system.

Capillaries

At the end of the arterioles is a system of minute

vessels that vary in structure, but which are spoken of

collectively as capillaries. It is from these capillaries

that the tissues of the body are fed. There are

approximately 60,000 miles of capillaries in the body.

As the blood passes through the capillaries, it releases

oxygen and nutritive substances to the tissues and

takes up various waste products to be carried away by

venules. Venules continue from capillaries and merge

to form veins.

Veins and Venules

Veins and venules form the venous system. The

venous system is comprised of vessels that collect

blood from the capillaries and carry it back to the heart.

Veins begin as tiny venules formed from the

capillaries. Joining together as tiny rivulets, veins

connect and form a small stream. The force of muscles

contracting adjacent to veins aids in the forward

propulsion of blood on its return to the heart. Valves,

spaced frequently along the larger veins, prevent the

backflow of blood. The walls of veins are similar to

arteries, but are thinner and contain less muscle and

elastic tissue.

Arterial System

Arterial circulation is responsible for taking

freshly oxygenated blood from the heart to the cells of

the body (fig. 1-35). To take this oxygenated blood

from the heart to the entire body, the arterial system

begins with the contraction of blood from the left

ventricle into the aorta and its branches.

AORTA.—The aorta, largest artery in the body, is

a large tube-like structure arising from the left

ventricle of the heart. It arches upward over the left

lung and then down along the spinal column through

the thorax and the abdomen, where it divides and sends

arteries down both legs (fig. 1-35).

KEY BRANCHES OF THE AORTA.—Key

arterial branches of the aorta are the coronary,

innominate (brachiocephalic), left common carotid,

and left subclavian. The coronary arteries are branches

of what is called the ascending aorta. The coronary

arteries supply the heart with blood. There are three

large arteries that arise from the aorta as it arches over

the left lung. First is the innominate artery, which

divides into the right subclavian artery to supply the

right arm, and the right common carotid to supply the

right side of the head. The second branch is the left

common carotid, which supplies the left side of the

head. The third branch is the left subclavian, which

supplies the left arm.

ARTERIES OF THE HEAD, NECK, AND

BRAIN.—The carotid arteries divide into internal

and external branches, the external supplying the

muscle and skin of the face and the internal supplying

the brain and the eyes.

ARTERIES OF THE UPPER EXTREMITIES.—The subclavian arteries are so named

because they run underneath the clavicle. They supply

the upper extremities, branching off to the back, chest,

neck, and brain through the spinal column (fig. 1-35).

The large artery going to the arm is called the

axillary. The axillary artery becomes the brachial

artery as it travels down the arm and divides into the

ulnar and radial arteries. The radial artery is the

artery at the wrist that you feel when you take the pulse

of your patient (fig. 1-35).

ARTERIES OF THE ABDOMEN.—In the

abdomen, the aorta gives off branches to the abdominal

viscera, including the stomach, liver, spleen, kidneys,

1-28
and intestines. The aorta later divides into the left and

right common iliacs, which supply the lower

extremities (fig. 1-35).

ARTERIES OF THE LOWER EXTREMITIES.—The left and right common iliacs, upon

entering the thigh, become the femoral artery. At the

knee, this same vessel is named the popliteal artery

(fig. 1-35).

Venous System

Venous circulation is responsible for returning the

blood to the heart after exchanges of gases, nutrients,

and wastes have occurred between the blood and body

cells (fig. 1-36). To return this blood to the heart for

reoxygenation, the venous system begins with the

merging of capillaries into venules, venules into small

veins, and small veins into larger veins. The blood

vessel paths of the venous system are difficult to

1-29

HM3F0135C

LEFT

COMMON

CAROTID

LEFT

SUBCLAVIAN

PULMONARY

AXILLARY

BRACHIAL

LEFT

CORONARY

RADIAL

ULNAR

INTERNAL

CAROTID

EXTERNAL

CAROTID

RIGHT

COMMON

CAROTID

RIGHT

SUBCLAVIAN

INNOMINATE

ARCH OF

AORTA

RIGHT

CORONARY

AORTA

COMMON

ILIAC

EXTERNAL

ILIAC

FEMORAL

POPLITEAL

Figure 1-35.—Principal vessels of the arterial system.
follow, unlike the arterial system. However, the larger

veins are commonly located parallel to the course

taken by their counterpart in the arterial system. For

instance, the renal vein parallels the renal artery, the

common iliac vein parallels the common iliac artery,

and so forth.

THREE PRINCIPAL VENOUS SYSTEMS.—

The three principal venous systems in the body are the

pulmonary, portal, and systemic.

• The pulmonary system is composed of four

vessels, two from each lung, which empty into the left

atrium. These are the only veins in the body that carry

freshly oxygenated blood.

• The portal system consists of the veins that

drain venous blood from the abdominal part of the

digestive tract—the spleen, pancreas, and gallbladder,

but not the lower rectum—and deliver it to the liver.

There, it is distributed by a set of venous capillaries. The

blood in the portal system conveys absorbed substances

from the intestinal tract to the liver for storage,

1-30

HM3F0136C

LEFT

INNOMINATE

LEFT

SUBCLAVIAN

CEPHALIC

BASILIC

INTERNAL

JUGULAR

EXTERNAL

JUGULAR

RIGHT

SUBCLAVIAN

COMMON

ILIAC

FEMORAL

CUBITAL

MEDIAN

INTERNAL ILIAC

(HYPOGASTRIC)

EXTERNAL

ILIAC

GREAT

SAPHENOUS

INFERIOR

VENA CAVA

SUPERIOR

VENA CAVA

RIGHT

INNOMINATE

Figure 1-36.—Principal vessels of the venous system.
alteration, or detoxification. From the liver the blood

flows through the hepatic vein to the inferior vena cava.

• The systemic system is divided into the deep and

superficial veins. The superficial veins lie immediately

under the skin, draining the skin and superficial structures.

The deep veins, usually located in the muscle or deeper

layers, drain the large muscle masses and various other

organs. Deep veins commonlylie closetothelarge arteries

that supply the various organs of the body and typically

have the same name as the artery they accompany.

VEINS OF THE HEAD, NECK, AND

BRAIN.—The superficial veins of the head unite to

form the external jugular veins. The external jugular

veins drain blood from the scalp, face, and neck, and

finally empty into the subclavian veins.

The veins draining the brain and internal facial

structures are the internal jugular veins. These

combine with the subclavian veins to form the

innominate veins, which empty into the superior

vena cava (fig. 1-36).

VEINS OF THE UPPER EXTREMITIES.—The veins of the upper extremities begin at

the hand and extend upward. A vein of great interest to

you is the median cubital, which crosses the anterior

surface of the elbow. It is the vein most commonly used

for venipuncture. Also found in this area are the basilic

and cephalic veins, which extend from the midarm to

the shoulder.

The deep veins of the upper arm unite to form the

axillary vein, which unites with the superficial veins

to form the subclavian vein. This vein later unites with

other veins to form the innominate and eventually,

after union with still more veins, the superior vena cava

(fig. 1-36).

VEINS OF THE ABDOMEN AND THORACIC REGION.—The veins from the abdominal

organs, with the exception of those of the portal

system, empty directly or indirectly into the inferior

vena cava, while those of the thoracic region

eventually empty into the superior vena cava (fig.

1-36).

VEINS OF THE LOWER EXTREMTIES.—In the lower extremities (fig. 1-36), a similar

system drains the superficial areas. The great

saphenous vein originates on the inner aspect of the

foot and extends up the inside of the leg and thigh to

join the femoral vein in the upper thigh. The great

saphenous vein is used for intravenous injections at the

ankle.

The veins from the lower extremities unite to form

the femoral vein in the thigh, which becomes the

external iliac vein in the groin. Higher in this region,

external iliac unites the internal iliac (hypogastric)

vein from the lower pelvic region to form the common

iliac veins. The right and left common iliac veins unite

to form the inferior vena cava.

THE LYMPHATIC SYSTEM

LEARNING OBJECTIVE: Identify the parts

of the lymphatic system and their function.

All tissue cells of the body are continuously bathed

in interstitial fluid. This fluid is formed by leakage of

blood plasma through minute pores of the capillaries.

There is a continual interchange of fluids of the blood

and tissue spaces with a free interchange of nutrients

and other dissolved substances. Most of the tissue fluid

returns to the circulatory system by means of

capillaries, which feed into larger veins. Large protein

molecules that have escaped from the arterial

capillaries cannot reenter the circulation through the

small pores of the capillaries. However, these large

molecules, as well as white blood cells, dead cells,

bacterial debris, infected substances, and larger

particulate matter, can pass through the larger pores of

the lymphatic capillaries and, thus, enter the lymphatic

circulatory system with the remainder of the tissue

fluid.

The lymphatic system also helps defend the tissues

against infections by supporting the activities of the

lymphocytes, which give immunity, or resistance, to

the effects of specific disease-causing agents.

PATHWAYS OF THE LYMPHATIC SYSTEM

The lymphatic pathway begins with lymphatic

capillaries. These small tubes merge to form lymphatic

vessels, and the lymphatic vessels in turn lead to larger

vessels that join with the veins in the thorax.

Lymphatic Capillaries

Lymphatic capillaries are closed-ended tubes of

microscopic size (fig. 1-37). They extend into

interstitial spaces, forming complex networks that

parallel blood capillary networks. The lymphatic

capillary wall consists of a single layer of squamous

epithelial cells. This thin wall makes it possible for

interstitial fluid to enter the lymphatic capillary. Once

1-31
the interstitial fluid enters the lymphatic capillaries,

the fluid is called lymph.

Lymphatic Vessels

Lymphatic vessels are formed from the merging

of lymphatic capillaries (fig. 1-37). Lymphatic

vessels, also known simply aslymphatics, are similar

to veins in structure. The vessel walls are composed of

three layers: an inner layer of endothelial tissue, a

middle layer of smooth muscle and elastic fibers, and

an outer layer of connective tissue. Like a vein, the

lymphatic vessel has valves to prevent backflow of

lymph. The larger lymphatic vessels lead to

specialized organs called lymph nodes. After leaving

these structures, the vessels merge to form still larger

lymphatic trunks.

Lymphatic Trunks and Ducts

Lymphatic trunks drain lymph from large regions

in the body. The lymphatic trunks are usually named

after the region they serve, such as the subclavian

trunk that drains the arm. There are many lymphatic

trunks through out the body. These lymphatic trunks

then join one of two collecting ducts, the thoracic

duct and the right lymphatic duct (fig. 1-38).

Lymphatic trunks from the upper half of the right

side of the body converge to form the right lymphatic

duct, which empties into the right subclavian vein.

Drainage from the remainder of the body is by way of

the thoracic duct, which empties into the left

subclavian vein.

LYMPH NODES

Lymph nodes, which are frequently called glands

but are not true glands, are small bean-shaped bodies of

lymphatic tissue found in groups of two to fifteen

along the course of the lymph vessels (fig. 1-38).

Major locations of lymph nodes are in the following

regions: cervical, axillary, inguinal, pelvic cavity,

abdominal cavity, and thoracic cavity. Lymph nodes

vary in size and act as filters to remove bacteria and

particles from the lymph stream. Lymph nodes

produce lymphocytes, which help defend the body

against harmful foreign particles, such as bacteria,

cells, and viruses. Lymph nodes also contain

macrophages, which engulf and destroy foreign

substances, damaged cells, and cellular debris.

THE RESPIRATORY SYSTEM

LEARNING OBJECTIVE: Identify the

location and function of each part of the

respiratory system, and recall the process of

respiration.

Respiration is the exchange of oxygen and carbon

dioxide between the atmosphere and the cells of the

body. There are two phases of respiration:

• Physical, or mechanical, respiration involves

the motion of the diaphragm and rib cage. The

1-32

LYMPH

CAPILLARY

TISSUE

CELLS

VENULE

LYMPHATIC

VESSEL

ARTERIOLE

HM3F0137

Figure 1-37.—Lymphatic capillary and vessel.
musculoskeletal action, which resembles that of a

bellows, causes air to be inhaled or exhaled.

• Physiological respiration involves an exchange

of gases, oxygen and carbon dioxide, at two points in the

body. The first is the transfer that occurs in the lungs

between the incoming oxygen and the carbon dioxide

present in the capillaries of the lungs (external

respiration). The second transfer occurs when oxygen

brought into the body replaces carbon dioxide build up

in the cellular tissue (internal respiration).

Normally, oxygen and carbon dioxide exchange in

equal volumes; however, certain physiological

conditions may throw this balance off. For example,

heavy smokers will find that the ability of their lungs to

exchange gases is impaired, leading to shortness of

breath and fatigue during even slight physical exertion.

This debilitating situation is the direct result of their

inability to draw a sufficient amount of oxygen into the

body to replace the carbon dioxide build-up and

sustain further muscular exertion. On the other hand,

hyperventilation brings too much oxygen into the

body, overloading the system with oxygen, and

depleting the carbon dioxide needed for balance.

ANATOMY OF THE RESPIRATORY

SYSTEM

Air enters the nasal chambers and the mouth, then

passes through the pharynx, larynx, trachea, and

bronchi into the bronchioles. Each bronchiole is

surrounded by a cluster of alveoli (fig. 1-39).

Nasal Cavity

Air enters the nasal cavity through the nostrils

(nares). Lining the nasal passages are hairs, which,

together with the mucous membrane, entrap and filter

out dust and other minute particles that could irritate

the lungs. Incoming air is warmed and moistened in the

1-33

HM3f0138

AREA DRAINED BY

RIGHT LYMPHATIC

DUCT

RIGHT LYMPHATIC

DUCT LEFT INTERNAL

JUGULAR VEIN

THORACIC

DUCT

LEFT

SUBCLAVIAN

VEIN

THORACIC

DUCT

LYMPHATIC

TRUCK

LYMPH

NODE

LYMPHATIC

VESSEL

LEGEND

Figure 1-38.—Pathway of right lymphatic duct and thoracic duct.
chambers of the nasal cavity to prevent damage to the

lungs. The nasal and oral cavities are separated by the

palate. The anterior, rigid portion is called the hard

palate, and the posterior fleshy part is called the soft

palate. The mouth and nose serve as secondary

respiratory structures.

Pharynx

The pharynx, or throat, serves both the respiratory

and digestive systems and aids in speech. It has a

mucous membrane lining that traps microscopic

particles in the air and aids in adjusting temperature

and humidifying inspired (inhaled) air. The pharynx

connects with the mouth and nasal chambers

posteriorly. According to its location, the pharynx is

referred to as the nasopharynx posterior to the nasal

chambers), the oropharynx (posterior to the mouth),

or the laryngopharynx (posterior to the pharynx).

Epiglottis

The epiglottis is a lidlike, cartilaginous structure

that covers the entrance to the larynx and separates it

from the pharynx. It acts as a trap door to deflect food

particles and liquids from the entrance to the larynx

and trachea.

Larynx

The larynx, or voice box, is a triangular

cartilaginous structure located between the tongue and

the trachea. It is protected anteriorly by the thyroid

cartilage (commonly called the Adam's apple), which

is usually larger and more prominent in men than in

women. During the act of swallowing, it is pulled

upward and forward toward the base of the tongue. The

larynx is responsible for the production of vocal sound

(voice). This sound production is accomplished by the

passing of air over the vocal cords. The ensuing

vibrations can be controlled to produce the sounds of

speech or singing. The nose, mouth, throat, bone

sinuses, and chest serve as resonating chambers to

further refine and individualize the voice.

Trachea

The trachea, or windpipe, begins at the lower end

of the larynx and terminates by dividing into the right

and left bronchi. It is a long tube composed of 16 to 20

C-shaped cartilaginous rings, embedded in a fibrous

membrane, that support its walls, preventing their

collapse (fig. 1-39).

The trachea has a ciliated mucous membrane

lining that entraps dust and foreign material. It also

propels secretions and exudates from the lungs to the

pharynx, where they can be expectorated.

Bronchi

The bronchi are the terminal branches of the

trachea, which carry air to each lung and further divide

into the bronchioles.

Bronchioles

The bronchioles are much smaller than the bronchi

and lack supporting rings of cartilage. They terminate

at the alveoli (fig. 1-40).

Alveoli

The alveoli are thin, microscopic air sacs within

the lungs (fig. 1-40). They are in direct contact with the

pulmonary capillaries. It is here that fresh oxygen

exchanges with carbon dioxide by means of a diffusion

process through the alveolar and capillary cell walls

1-34

HM3F0139

NOSTRIL

SINUS NASAL

CAVITY

HARD

PALATE

SOFT

PALATE

PHARYNX

LARYNX

BRONCHUS

RIGHT

LUNG

LEFT

LUNG

EPIGLOTTIS

TRACHEA

ORAL

CAVITY

Figure 1-39.—Organs of the respiratory system.
(fig. 1-41). The lungs are cone-shaped organs that lie

in the thoracic cavity. Each lung contains thousands of

alveoli with their capillaries. The right lung is larger

than the left lung and is divided into superior, middle,

and inferior lobes. The left lung has two lobes, the

superior and the inferior.

Pleurae

The pleurae are airtight membranes that cover the

outer surface of the lungs and line the chest wall. They

secrete a serous fluid that prevents friction during

movements of respiration.

Mediastinum

The mediastinum is the tissue and organs of the

thoracic cavity that form a septum between the lungs. It

extends from the sternum to the thoracic vertebrae and

from the fascia of the neck to the diaphragm. The

mediastinum contains the heart, the great blood

vessels, the esophagus, a portion of the trachea, and the

primary bronchi.

Diaphragm

The diaphragm is the primary muscle of

respiration. It is a dome-shaped muscle and separates

the thoracic and abdominal cavities. Contraction of

this muscle flattens the dome and expands the vertical

diameter of the chest cavity.

Intercostal Muscles

The intercostal muscles are situated between the

ribs. Their contraction pulls the ribs upward and

outward, resulting in an increase in the transverse

diameter of the chest (chest expansion).

Inhalation is the direct result of the expansion

caused by the action of the diaphragm and intercostal

muscles. The increase in chest volume creates a

negative (lower than atmospheric) pressure in the

pleural cavity and lungs. Air rushes into the lungs

through the mouth and nose to equalize the pressure.

Exhalation results when the muscles of respiration

relax. Pressure is exerted inwardly as muscles and

1-35

HM3F0140

ALVEOLI

ALVEOLAR

DUCT

PULMONARY

ARTERY

BLOOD

FLOW

BRONCHIOLE

PULMONARY

VEIN

PULMONARY ARTERIOLE

CAPILLARY NETWORK

ON SURFACE OF ALVEOLUS

BLOOD

FLOW

BLOOD

FLOW

PULMONARY VENULE

Figure 1-40.—Bronchiole and alveoli.

HM3F0141

ALVEOLAR

WALL

ALVEOLUS

PULMONARY

CAPILLARY

BLOOD

O2

CO2

Figure 1-41.—Pulmonary exchange at alveolus.
bones return to their normal position, forcing air from

the lungs.

THE PROCESS OF RESPIRATION

The rhythmical movements of breathing are

controlled by the respiratory center in the brain.

Nerves from the brain pass down through the neck to

the chest wall and diaphragm. The nerve that controls

the diaphragm is called the phrenic nerve; the nerve

that controls the larynx is the vagus nerve; and the

nerves that control the muscles between the ribs are the

intercostal nerves.

The respiratory center is stimulated by chemical

changes in the blood. When too much carbon dioxide

accumulates in the blood stream, causing the blood to

become acidic, the respiratory center signals the lungs

to breathe faster to get rid of the carbon dioxide.

The respiratory center can also be stimulated or

depressed by a signal from the brain. For example,

changes in one's emotional state can alter respiration

through laughter, crying, emotional shock, or panic.

The muscles of respiration normally act

automatically, with normal respiration being 14 to 18

cycles per minute. The lungs, when filled to capacity,

hold about 6,500 ml of air, but only 500 ml of air is

exchanged with each normal respiration. This

exchanged air is called tidal air. The amount of air left

in the lungs after forceful exhalation is about 1,200 ml

and is known as residual air.

THE NERVOUS SYSTEM

LEARNING OBJECTIVE: Identify the

components and function of a neuron, recall the

process of impulse transmission, and identify

the components and functions of the central

and peripheral nervous systems.

The activities of the widely diverse cells, tissues,

and organs of the body must be monitored, regulated,

and coordinated to effectively support human life. The

interaction of the nervous and endocrine systems

provides the needed control.

The nervous system is specifically adapted to the

rapid transmission of impulses from one area of the

body to another. On the other hand, the endocrine

system, working at a far slower pace, maintains body

metabolism at a fairly constant level.

In this section, you will study the neuron, the basic

functional unit of the nervous system. Also, you will

study the components and functions of the different

divisions of the nervous system. The nervous system is

divided into two major groups, the central nervous

system (CNS) and the peripheral nervous system

(PNS). Another division of the nervous system is the

autonomic nervous system (ANS), which is further

subdivided into the sympathetic and parasympathetic nervous systems.

THE NEURON

The structure and functional unit of the nervous

system is the nerve cell, or neuron, which can be

classified into three types. The first is the sensory

neuron, which conveys sensory impulses inward from

the receptors. The second is the motor neuron, which

carries command impulses from a central area to the

responding muscles or organs. The third type is the

interneuron, which links the sensory neurons to the

motor neurons.

The neuron is composed of dendrites, a cyton, and

an axon (fig. 1-42). The dendrites are thin receptive

branches, and vary greatly in size, shape, and number

with different types of neurons. They serve as

receptors, conveying impulses toward the cyton. The

cyton is the cell body containing the nucleus. The

single, thin extension of the cell outward from the

cyton is called the axon. It conducts impulses away

from the cyton to its terminal branches, which

transmit the impulses to the dendrites of the next

neuron.

Large axons of the peripheral nerves are

commonly enclosed in a sheath, called neurilemma,

composed of Schwann cells(fig. 1-42). Schwann cells

wrap around the axon and act as an electrical insulator.

1-36

HM3F0142

MYELIN

SHEATH

AXON

CYTON

DENDRITES

NODES OF

RANVIER

SCHWANN NEURILEMMA

CELL

TERMINAL

BRANCHES

Figure 1-42.—The neuron and its parts.
The membranes of the Schwann cell are composed

largely of a lipid-protein called myelin, which forms a

myelin sheath on the outside of an axon. The myelin

sheath has gaps between adjacent Schwann cells called

nodes of Ranvier. Nerve cells without Schwann cells

also lack myelin and neurilemma sheaths.

IMPULSE TRANSMISSION

When dendrites receive a sufficiently strong

stimulus, a short and rapid change in electrical charge,

or polarity, of the neuron is triggered. Sodium ions rush

through the plasma membrane into the cell, potassium

ions leave, and an electrical impulse is formed, which

is conducted toward the cyton. The cyton receives the

impulse and transmits it to the terminal filaments of the

axon. At this point a chemical transmitter such as

acetylcholine is released into the synapse, a space

between the axon of the activated nerve and the

dendrite receptors of another neuron. This chemical

transmitter activates the next nerve. In this manner, the

impulse is passed from neuron to neuron down the

nerve line to a central area at approximately the speed

of a bullet.

Almost immediately after being activated, the

chemical transmitter in the synapse is neutralized by

the enzyme acetylcholinesterase, and the first neuron

returns to its normal state by pumping out the sodium

ions and drawing potassium ions back in through the

plasma membrane. When these actions are completed,

the nerve is ready to be triggered again. A particularly

strong stimulus will cause the nerve to fire in rapid

succession, or will trigger many other neurons, thus

giving a feeling of intensity to the perceived sensation.

NERVES

A nerve is a cordlike bundle of nerve fibers held

together with connective tissue. Each nerve fiber is an

extension of a neuron. Nerves that conduct impulses

into the brain or the spinal cord are called sensory

nerves, and those that carry impulses to muscles and

glands are termed motor nerves. Most nerves,

however, include both sensory and motor fibers, and

they are called mixed nerves.

CENTRAL NERVOUS SYSTEM

The central nervous system (CNS) consists of the

brain and spinal cord. The brain is almost entirely

enclosed in the skull, but it is connected with the spinal

cord, which lies in the canal formed by the vertebral

column.

Brain

The brain has two main divisions, the cerebrum

and the cerebellum. The cerebrum is the largest and

most superiorly situated portion of the brain. It

occupies most of the cranial cavity. The outer surface is

called the cortex. This portion of the brain is also

called “gray matter” because the nerve fibers are

unmyelinated (not covered by a myelin sheath),

causing them to appear gray. Beneath this layer is the

medulla, often called the white matter of the brain

because the nerves are myelinated (covered with a

myelin sheath), giving them their white appearance.

CEREBRUM.—The cortex of the cerebrum is

irregular in shape. It bends on itself in folds called

convolutions, which are separated from each other by

grooves, also known as fissures. The deep sagittal

cleft, a longitudinal fissure, divides the cerebrum into

two hemispheres. Other fissures further subdivide the

cerebrum into lobes, each of which serves a localized,

specific brain function (fig. 1-43). For example, the

frontal lobe is associated with the higher mental

processes such as memory, the parietal lobe is

concerned primarily with general sensations, the

occipital lobe is related to the sense of sight, and the

temporal lobe is concerned with hearing.

CEREBELLUM.—The cerebellum is situated

posteriorly to the brain stem (which is made up of the

pons, mid-brain, and medulla oblongata) and inferior

to the occipital lobe. The cerebellum is concerned

chiefly with bringing balance, harmony, and

coordination to the motions initiated by the cerebrum.

PONS AND MEDULLAOBLONGATA.— Two

smaller divisions of the brain vital to life are the pons

and the medulla oblongata. Together, the pons and

medulla form the brain stem (fig. 1-43). The pons

consists chiefly of a mass of white fibers connecting

the other three parts of the brain (the cerebrum,

cerebellum, and medulla oblongata).

The medulla oblongata is the inferior portion of the

brain, the last division before the beginning of the

spinal cord. It connects to the spinal cord at the upper

level of the first cervical vertebra (C-1). In the medulla

oblongata are the centers for the control of heart action,

breathing, circulation, and other vital processes such

as blood pressure.

MENINGES.—The outer surface of the brain and

spinal cord is covered with three layers of membranes

called the meninges. The dura mater is the strong

outer layer; the arachnoid membrane is the delicate

1-37
middle layer; and the pia mater is the vascular

inner-most layer that adheres to the surface of the brain

and spinal cord. Inflammation of the meninges is

called meningitis. The type of meningitis contracted

depends upon whether the brain, spinal cord, or both

are affected, as well as whether it is caused by viruses,

bacteria, protozoa, yeasts, or fungi.

CEREBROSPINAL FLUID.—Cerebrospinal

fluid is formed by a plexus, or network, of blood

vessels in the central ventricles of the brain. It is a clear,

watery solution similar to blood plasma. The total

quantity of spinal fluid bathing the spinal cord is about

75 ml. This fluid is constantly being produced and

reabsorbed. It circulates over the surface of the brain

and spinal cord and serves as a protective cushion as

well as a means of exchange for nutrients and waste

materials.

Spinal Cord

The spinal cord is continuous with the medulla

oblongata and extends from the foramen magnum,

through the atlas, to the lower border of the first lumbar

vertebra, where it tapers to a point. The spinal cord is

surrounded by the bony walls of the vertebral canal

(fig. 1-44). Ensheathed in the three protective

meninges and surrounded by fatty tissue and blood

vessels, the cord does not completely fill the vertebral

canal, nor does it extend the full length of it. The nerve

roots serving the lumbar and sacral regions must pass

some distance down the canal before making their exit.

The sympathetic trunk contains the paravertebral

ganglia (sing. ganglion), knotlike masses of nerve cell

bodies (fig. 1-44).

A cross section of the spinal cord shows white and

gray matter (fig. 1-45). The outer white matter is

composed of bundles of myelinated nerve fibers

arranged in functionally specialized tracts. It

establishes motor communication between the brain

and the body parts. The inner gray unmyelinated

1-38

HM3f0143

MOTOR AREAS INVOLVED WITH THE

CONTROL OF VOLUNTARY MUSCLES

CONCENTRATION, PLANNING,

PROBLEM SOLVING

FRONTAL

LOBE

MOTOR SPEECH AREA

(BROCA'S AREA)

INTERPRETATION OF SENSORY EXPERIENCES,

MEMORY OF VISUAL AND AUDITORY PATTERNS

TEMPORAL

LOBE BRAIN

STEM

VISUAL

AREA

VISUAL IMAGES,

VISUAL RECOGNITION

OF OBJECTS

OCCIPITAL

LOBE

GENERAL

INTERPRETATIVE

AREA

PARIETAL

LOBE

UNDERSTANDING SPEECH,

USING WORDS

SENSORY AREA INVOLVED WITH

CUTANEOUS AND OTHER SENSES

CEREBELLUM

AUDITORY

AREA

Figure 1-43.—Functional areas of the brain.

HM3F0144

SYMPATHETIC

TRUNK

PARAVERTEBRAL

GANGLION

SPINE

NERVES

TRANSVERSE

PROCESS

INTERVERTEBRAL

FORAMEN

POSTERIOR

ROOT

DORSAL

ROOT

GANGLION

PIA

MATER

ARACHNOID

MATER

DURA

MATER

VERTEBRAL

CANAL

BODY OF

VERTEBRA

ANTERIOR

ROOT

SPINAL

CORD

Figure 1-44.—Spinal cord.
matter is shaped roughly like the letter H. It establishes

sensory communication between the brain and the

spinal nerves, conducting sensory impulses from the

body parts.

The spinal cord may be thought of as an electric

cable containing many wires (nerves) that connect

parts of the body with each other and with the brain.

Sensations received by a sensory nerve are brought to

the spinal cord, and the impulse is transferred either to

the brain or to a motor nerve. The majority of impulses

go to the brain for action. However, a system exists for

quickly handling emergency situations. It is called the

reflex arc.

If you touch a hot stove, you must remove your

hand from the heat source immediately or the skin will

burn very quickly. But the passage of a sense impulse

to the brain and back again to a motor nerve takes too

much time. The reflex arc responds instantaneously to

emergency situations like the one just described. The

sensation of heat travels to the spinal cord on a sensory

nerve. When the sensation reaches the spinal cord, it is

picked up by an interneuron in the gray matter. This

reception then triggers the appropriate nerve to

stimulate a muscle reflex drawing the hand away. An

illustrated example of the reflex arc is shown in figure

1-45.

The reflex arc works well in simple situations

requiring no action of the brain. Consider, however,

what action is involved if the individual touching the

stove pulls back and, in so doing, loses balance and has

to grab a chair to regain stability. Then the entire spinal

cord is involved. Additional impulses must travel to

the brain, then down to the muscles of the legs and arms

to enable the individual to maintain balance and to hold

on to a steadying object. While all this activity is going

on, the stimulus is relayed through the sympathetic

autonomic nerve fibers to the adrenal glands, causing

adrenalin to flow, which stimulates heart action. The

stimulus then moves to the brain, making the

individual conscious of pain. In this example, the

spinal cord has functioned not only as a center for

spinal relaxes, but also as a conduction pathway for

other areas of the spinal cord to the autonomic nervous

system and to the brain.

PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system (PNS) consists of

the nerves that branch out from the CNS and connect it

to the other parts of the body. The PNS includes 12

pairs of cranial nerves and 31 pairs of spinal nerves.

Cranial and spinal nerves carry both voluntary and

involuntary impulses.

Cranial Nerves

The 12 pairs of cranial nerves are sensory, motor,

or mixed (sensory and motor). Table 1-3 shows the 12

cranial nerves and parts of the body they service.

Spinal Nerves

There are 31 pairs of spinal nerves that originate

from the spinal cord. Although spinal nerves are not

named individually, they are grouped according to the

level from which they arise, and each nerve is

numbered in sequence. Thus, there are 8 pairs of

cervical nerves, 12 pairs of thoracic nerves, 5 pairs of

lumbar nerves, 5 pairs of sacral nerves, and 1 pair of

coccygeal nerves. See figure 1-46.

Spinal nerves (mixed) send fibers to sensory

surfaces and muscles of the trunk and extremities.

Nerve fibers are also sent to involuntary smooth

muscles and glands of the gastrointestinal tract,

urogenital system, and cardiovascular system.

1-39

HM3F0145

CYTON OF

SENSORY

NEURON

DORSAL

ROOT

SPINAL

NERVE

VENTRAL

ROOT

WHITE

MATTER

GRAY

MATTER

4

4

4

3

2

2

1

5

6

Figure 1-45.—Cross section of the spinal cord and reflex

arc—arrows and numbers show impulse pathway.
AUTONOMIC NERVOUS SYSTEM

The autonomic nervous system (ANS) is the

portion of the PNS that functions independently,

automatically, and continuously, without conscious

effort. It helps to regulate the smooth muscles, cardiac

muscle, digestive tube, blood vessels, sweat and

digestive glands, and certain endocrine glands. The

autonomic nervous system is not directly under the

control of the brain but usually works in harmony with

the nerves that are under the brain's control. The

autonomic nervous system includes two subdivisions

(the sympathetic and parasympathetic nervous

systems) that act together.

The sympathetic nervous system's primary

concern is to prepare the body for energy-expending,

stressful, or emergency situations. On the other hand,

the parasympathetic nervous system is most active

under routine, restful situations. The parasympathetic

system also counterbalances the effects of the

sympathetic system, and restores the body to a resting

1-40

HM3F0146

C1

C2

C3

C4

C5

C6

C7

C8

T1

T2

T3

T4

T5

T6

T7

T8

T9

L1

L2

L3

L4

L5

S1

S2

S3

S4

S5

Co

T10

T11

T12

POSTERIOR

VIEW

CERVICAL

NERVES

THORACIC

NERVES

LUMBAR

NERVES

SACRAL

NERVES

COCCYGEAL

NERVE

Figure 1-46.—Spinal nerves.
state. For example, during an emergency the body's

heart and respiration rate increases. After the

emergency, the parasympathetic system will decrease

heart and respiration rate to normal. The sympathetic

and parasympathetic systems counterbalance each

other to preserve a harmonious balance of body

functions and activities.

THE ENDOCRINE SYSTEM

LEARNING OBJECTIVE: Identify

endocrine glands and the hormone(s) they

produce, and determine the effect each

hormone has on the body.

Homeostasis, the self-balancing of the body’s

internal environment, is achieved and maintained by

the endocrine system and the nervous systems. These

systems work alone and together to perform similar

functions in the body: communication, integration,

and control. Their communication capabilities provide

the means for controlling and integrating the many

different functions performed by organs, tissues, and

cells. The endocrine system, however, performs these

functions by different mechanisms than the nervous

system.

The endocrine system sends messages by way of

chemical messengers called hormones. Minute

amounts of these hormones are secreted from

endocrine gland cells into the blood and distributed by

the circulatory system. Endocrine glands secrete

hormones directly into the blood, because they have no

duct system. The glands of this system are often called

ductless glands. Cells that are affected by the hormone

are referred to as target organ cells.

Today, many hormones can be extracted from the

glands of animals or produced synthetically. Medical

officers may prescribe these naturally derived or

synthetic hormones for patients who are deficient in

them or who might otherwise benefit from their use.

For example, oxytocin (the hormone which stimulates

uterine contractions during pregnancy) has been

synthesized and is used during the delivery process for

women who are deficient in this hormone.

The hormone-producing glands include the

hypothalamus, pituitary, thyroid, parathyroids,

adrenals, pancreas, and gonads (the testes and ovaries)

(fig. 1-47).

HYPOTHALAMUS

The hypothalamus, a structure in the brain,

synthesizes chemicals that are secreted to the pituitary

1-41

CRANIAL NERVE FUNCTION(S)

Olfactory Sense of smell.

Optic Vision.

Oculomotor Eye movement, size of pupil, and eye focus.

Trochlear Eye movements.

Trigeminal Sensations of head and face and chewing movements.

Abducens Abduction of eye (muscles that turn eye outward).

Facial Facial expressions, secretion of saliva, and sense of taste.

Acoustic Sense of hearing and balance or equilibrium sense.

Glossopharyngeal Taste and other sensations of the tongue, swallowing movements, secretion of

saliva.

Vagus Sensations of movement (e.g., decrease in heart rate, increase in peristalsis, and

contracting of muscles for voice production).

Accessory Shoulder movements, turning movements of the head, and voice production.

Hypoglossal Tongue movements.

Table 1-3.—Cranial Nerves
gland to stimulate the release of its hormones and to

help regulate body temperature (fig. 1-47).

PITUITARY GLAND

The pituitary is a small, pea-sized gland located at

the base of the brain in the sella turcica, the

saddle-shape depression of the sphenoid bone

(fig. 1-47). It is often called the master gland of the

body because it influences many other endocrine

glands. Although the pituitary looks like just one

gland, it actually consists of two separate glands, the

anterior pituitary gland and the posterior pituitary

gland.

Anterior Pituitary Gland

The anterior pituitary gland plays the more

important role in influencing body functions. The

hormones produced by the anterior pituitary gland

have a broad and significant range of effects.

SOMATOTROPIN.—Somatotropin, the growth

hormone, influences body growth and development.

During the growth years, an overproduction of

somatotropin causes giantism, while the lack of it

causes dwarfism. An overproduction after the growth

years causes acromegaly, which is characterized by

the development of abnormally large hands, feet, and

jaw.

THYROTROPIN.—Thyrotropin, or the

thyroid-stimulating hormone (TSH), influences the

growth, development, and secreting activities of the

thyroid gland.

GONADOTROPIN.—Gonadotropin influences

the gonads and is essential for the normal development

and functioning of both male and female reproductive

systems.

ADRENOCORTICOTROPIN .—The

adrenocorticotropin hormone (ACTH) acts primarily

on the adrenal cortex (the outer portion of the adrenal

glands), stimulating its growth and its secretion of

corticosteroids. Corticosteroid hormones affect every

cell in the body and are discussed in more detail later in

this section.

Posterior Pituitary Gland

The posterior pituitary gland produces two

hormones, antidiuretic hormone (ADH) and oxytocin.

ANTIDIURETIC.—The ADH hormone,

promotes the conservation of water by the kidney.

When ADH is not produced in adequate amounts, the

daily urine volume is between 10 and 15 liters instead

of the normal 1.5 liters. This condition is known as

diabetes insipidus.

OXYTOCIN.—Oxytocin stimulates contraction

of the muscles of the uterus, particularly during

pregnancy. It also plays an important role in the

production of milk in the mammary glands of nursing

mothers.

THYROID GLAND

The thyroid gland, shaped like a butterfly, lies in

the anterior part of the neck, below the larynx

(fig. 1-47). It consists of two lobes, one on each side of

the upper trachea, connected by a strip of tissue called

the isthmus. The thyroid secretes the iodine containing

hormone thyroxin, which controls the rate of cell

metabolism. Excessive secretion of thyroxin raises the

metabolic rate and causes hyperthyroidism. This

condition is characterized by a fast pulse rate,

dizziness, increased basal metabolism, profuse

sweating, tremors, nervousness, and a tremendous

appetite coupled with a loss of weight.

1-42

HM3F0147

HYPOTHALAMUS

PITUITARY

GLAND

PARATHYROID

GLAND

THYROID

GLAND

KIDNEY

PANCREAS

ADRENAL

GLAND

OVARY

(IN FEMALE)

TESTIS

(IN MALE)

Figure 1-47.—Major endocrine glands.
Iodine is essential for the formation of thyroxin.

Simple goiter, a diffuse and painless enlargement of

the thyroid gland, was once common in areas of the

United States where the iodine content of the soil and

water was inadequate. In simple goiter, the gland

enlarges to compensate for the lack of iodine. To

prevent formation of a simple goiter, iodinecontaining foods, such as vegetables, iodized salt, and

seafood, should be eaten.

A condition known as hypothyroidism is caused

by an insufficient secretion of thyroxin. The patient

exhibits a decrease in basal metabolism, and sweating

is almost absent. There may be a weight gain and

constant fatigue. The heart rate may be slow, and a

simple goiter may form. There may also be personality

changes characterized by slow, lethargic mental

functioning. Hypothyroidism during childhood can

lead to the development of cretinism. Cretinism is a

condition characterized by retarded mental and

physical development.

PARATHYROID GLANDS

Parathyroid glands are four small round bodies

located just posterior to the thyroid gland (fig. 1-47).

Their hormone, parathormone (PTH), regulates the

calcium and phosphorus content of the blood and

bones. The amount of calcium is important in certain

tissue activities, such as bone formation, coagulation

of blood, maintenance of normal muscular excitability,

and milk production in the nursing mother. Diminished

function or removal of the parathyroid glands results in

a low calcium level in the blood. In extreme cases

death may occur, preceded by strong contraction of the

muscles (tetany) and convulsions.

Hyperparathyroidism, an excess of parathyroid

hormone in the blood, causes calcium levels in the

blood to become elevated by the withdrawal of

calcium from the bones, leaving the skeleton

demineralized and subject to spontaneous fractures.

The excess calcium may be deposited as stones in the

kidneys.

ADRENAL GLANDS

The adrenal glands are located on the superior

surface of each kidney, fitting like a cap (fig. 1-47).

They consist of an outer portion, the cortex, and an

inner portion, the medulla.

Adrenal Cortex

Specialized cells in the outer layer of the adrenal

cortex produce three types of steroid hormones that are

of vital importance.

MINERALOCORTICOIDS.—Mineralocorticoids are regulators of fluid and electrolyte balance.

They are sometimes called salt and water hormones

because they regulate the excretion and absorption of

sodium, chlorine, potassium, and water.

GLUCOCORTICOIDS.—Glucocorticoids are

essential to metabolism. They increase certain liver

functions and have an anti-inflammatory effect.

Clinically, they are used to suppress inflammatory

reactions, to promote healing, and to treat rheumatoid

arthritis.

ANDROGENS AND ESTROGENS.—The

adrenal cortex also produces sex hormones, some with

male characteristics (androgens), others with female

characteristics (estrogens). These hormones appear in

different concentrations in both men and women.

Adrenal Medulla

The adrenal medulla secretes epinephrine

(adrenalin) in the presence of emotional crises,

hypoglycemia (low blood sugar), or low blood

pressure. Epinephrine causes powerful contractions of

many arterioles (especially in the skin, mucous

membranes, and kidneys), but it dilates other arterioles

(such as those of the coronary system, skeletal

muscles, and lungs). Heart rate, respiration rate and

depth, blood pressure, blood sugar levels, and

metabolism are all increased by epinephrine. It also

stimulates the production of other adrenal cortical

hormones.

Norepinephrine is also produced in the adrenal

medulla. It is a chemical precursor to epinephrine. Its

effects are similar to those of epinephrine, but its action

differs.

Despite these marked influences, the medullary

tissue of the adrenal gland is not essential to life,

because its various functions can be assumed by other

regulatory mechanisms.

PANCREAS

The pancreas contains two types of secretory

tissues. The first secretory tissue secretes digestive

juice through a duct to the small intestine, while the

other tissue releases hormones into body fluids. The

1-43
endocrine portion of the pancreas consists of cells

arranged in groups, called “islands (islets) of

Langerhans.” The islands (islets) of Langerhans

contain three types of endocrine cells: alpha, beta, and

delta. The alpha cells secrete the hormone glucagon.

Glucagon causes a temporary rise in blood sugar

levels. The beta cellssecrete insulin, which is essential

for carbohydrate metabolism. Insulin lowers blood

sugar levels by increasing tissue utilization of glucose

and stimulating the formation and storage of glycogen

in the liver. Together, glucagon and insulin act to

regulate sugar metabolism in the body. Delta cells

produce the hormone somatostatin. Somatostatin

helps regulate carbohydrates by inhibiting the

secretion of glucagon.

When the islet cells are destroyed or stop

functioning, the sugar absorbed from the intestine

remains in the blood and excess sugar is excreted by

the kidneys into the urine. This condition is called

diabetes mellitus, or sugar diabetes. Insulin, a

synthetic hormone, is given to patients having this

disease as part of their ongoing treatment.

GONADS (TESTES AND OVARIES)

The term gonads refers to the primary sex organs

of the reproductive system (male and female).

Testes

The male gonad is the testis (pl. testes), and the

existence of the testes is the primary male sex

characteristic (fig. 1-47). The testes produce and

secrete the male hormone testosterone, which

influences the development and maintenance of the

male accessory sex organs and the secondary sex

characteristics of the male. The male accessory sex

organs include two groups of organs: the internal sex

organs and the external sex organs. See section titled

“Male Reproductive System” for more information on

the male accessory sex organs.

Male Secondary Sex Characteristics

Male secondary sex characteristics influenced by

the hormone testosterone are as follows:

• Increased growth of hair, particularly in the areas

of the face, chest, axilla, and pubic region.

• Enlargement of the larynx (Adam's apple) and

thickening of the vocal cords, which produces a

lower-pitched voice.

• Thickening of the skin.

• Increased muscle growth, broadening of the

shoulder and narrowing of the waist.

• Thickening and strengthening of the bones.

Ovaries

The female gonads, the ovaries, produce the

hormones estrogen and progesterone (fig. 1-47).

Estrogen influences the development and

maintenance of the female accessory sex organs

and the secondary sex characteristics, and

promotes changes in the mucous lining of the uterus

(endometrium) during the menstrual cycle.

Progesterone prepares the uterus for the reception

and development of the fertilized ovum and

maintains the lining during pregnancy.

Today, progesterone and estrogen hormones

(naturally derived) are incorporated into oral

contraceptives or birth control pills. The combination

of hormones released through this monthly series of

pills fools the body into not preparing (building-up of

uterine lining) for implantation of an embryo. Because

the uterus has not prepared for implantation,

pregnancy cannot occur.

Female accessory sex organs are also divided into

internal and external accessory sex organs. See section

titled “Female Reproductive System” for more

information on the female accessory sex organs.

Female Secondary Sex Characteristics

Female secondary sex characteristics influenced

by the hormone estrogen are listed below.

• Development of the breasts and the ductile

system of the mammary glands within the

breasts.

• Increased quantities of fatty (or adipose) tissue

in the subcutaneous layer, especially in the

breasts, thighs, and buttocks.

• Increased vascularization of the skin.

1-44
THE SENSORY SYSTEM

LEARNING OBJECTIVE: Recognize the

senses of the body, and identify their physical

characteristics.

The sensory system informs areas of the cerebral

cortex of changes that are taking place within the body

or in the external environment. The special sensory

receptors respond to special individual stimuli such as

sound waves, light, taste, smell, pressure, heat, cold,

pain, or touch. Positional changes, balance, hunger,

and thirst sensations are also detected and passed on to

the brain.

SMELL

Odor is perceived upon stimulation of the receptor

cells in the olfactory membrane of the nose. The

olfactory receptors are very sensitive, but they are

easily fatigued. This tendency explains why odors that

are initially very noticeable are not sensed after a short

time. Smell is not as well developed in man as it is in

other mammals.

TASTE

The taste buds are located in the tongue. The

sensation of taste is limited to sour, sweet, bitter, and

salty. Many foods and drinks tasted are actually

smelled, and their taste depends upon their odor. (This

interdependence between taste and smell can be

demonstrated by pinching the nose shut when eating

onions.) Sight can also affect taste. Several drops of

green food coloring in a glass of milk will make it all

but unpalatable, even though the true taste has not been

affected.

SIGHT

The eye, the organ of sight, is a specialized

structure for the reception of light. It is assisted in its

function by accessory structures, such as the eye

brows, eyelashes, eyelids, and lacrimal apparatus.

The lacrimal apparatus consists of structures that

produce tears and drains them from the surface of the

eyeball.

Structure of the Eye

Approximately five-sixths of the eyeball lies

recessed in the orbit, protected by a bony socket. Only

the small anterior surface of the eyeball is exposed.

The eye is not a solid sphere but contains a large

interior cavity that is divided into two cavities, anterior

and posterior. The anterior cavity is further subdivided

into anterior and posterior chambers (fig. 1-48).

The anterior cavity of the eye lies in front of the

lens. The anterior chamber of the anterior cavity is

the space anterior to the iris, but posterior to the cornea.

The posterior chamber of the anterior cavity consists

of a small space directly posterior to the iris, but

anterior to the lens. Both chambers of the anterior

cavity are filled with a clear, watery fluid called

aqueous humor. Aqueous humor helps to give the

cornea its curved shape.

The posterior cavity of the eye is larger than the

anterior cavity, since it occupies all the space posterior

to the lens, suspensory ligaments, and ciliary body. The

posterior cavity contains a substance, with the

consistency similar to soft gelatin, called vitreous

humor. Vitreous humor helps maintain sufficient

pressure inside the eye to prevent the eyeball from

collapsing.

The eyeball is composed of three layers. From the

outside in, they are the sclera, choroid, and retina (fig.

1-48).

OUTER LAYER.—The outer layer of the eye is

called the sclera. The sclera is the tough, fibrous,

protective portion of the globe, commonly called the

white of the eye. Anteriorly, the outer layer is

transparent and is called the cornea, or the window of

the eye. It permits light to enter the globe. The exposed

sclera is covered with a mucous membrane, the

conjunctiva, which is a continuation of the inner lining

of the eyelids. The lacrimal gland produces tears that

constantly wash the front part of the eye and the

conjunctiva. The tear gland secretions that do not

1-45

HM3F0148

VITREOUS

HUMOR

SCLERA

OPTIC

DISK

OPTIC

NERVE

FOVEA

CENTRALIS

POSTERIOR

CAVITY

RETINA

CHOROID

COAT CILIARY

BODY

ANTERIOR

CHAMBER

POSTERIOR

CHAMBER

ANTERIOR

CAVITY

AQUEOUS

HUMOR

LENS

PUPIL

IRIS

CORNEA

SUSPENSORY

LIGAMENTS

Figure 1-48.—Transverse section of the eye.
evaporate flow toward the inner angle of the eye,

where they drain down ducts into the nose.

MIDDLE LAYER.—The middle layer of the eye

is called the choroid. This layer is a highly vascular,

pigmented tissue that provides nourishment to the

inner structures. Continuous with the choroid is the

ciliary body. The ciliary body is formed by a

thickening of the choroid and fits like a collar into the

area between the retina and iris. Attached to the ciliary

the body are the suspensory ligaments, which blend

with the elastic capsule of the lens and holds it in place.

Iris.—The iris is continuous with the ciliary body.

The iris is a circular, pigmented muscular structure that

gives color to the eye. The iris separates the anterior

cavity into anterior and posterior chambers. The

opening in the iris is called the pupil (fig. 1-49). The

amount of light entering the pupil is regulated through

the constriction of radial and circular muscles in the

iris. When strong light is flashed into the eye, the

circular muscle fibers of the iris contract, reducing the

size of the pupil. If the light is dim, the pupil dilates to

allow as much of the light in as possible. The size and

reaction of the pupils of the eyes are an important

diagnostic tool.

Lens.—The lens is a transparent, biconvex

(having two convex surfaces) structure suspended

directly behind the iris. The optic globe posterior to the

lens is filled with a jellylike substance called vitreous

humor, which helps to maintain the shape of the

eyeball by maintaining intraocular pressure. The lens

separates the eye into anterior and posterior cavities.

INNER LAYER.—The inner layer of the eye is

called the retina (fig. 1-48). It contains layers of the

nerve cells, rods, and conesthat are the receptors of the

sense of vision. The retina is continuous with the optic

nerve, which enters the back of the globe and carries

visual impulses received by the rods and cones to the

brain. The area where the optic nerve enters the eyeball

contains no rods and cones and is called the optic disc

(blind spot) (fig. 1-50).

Rods.—Rods respond to low intensities of light

and are responsible for night vision. They are located

in all areas of the retina, except in the small depression

called the fovea centralis, where light entering the eye

is focused, and which has the clearest vision.

Cones.—Cones require higher light intensities for

stimulation and are most densely concentrated in the

fovea centralis. The cones are responsible for daytime

vision.

Vision Process

The vision process begins with rays of light from

an object passing through the cornea. The image is then

received by the lens, by way of the iris. Leaving the

lens, the image falls on the rods and cones in the retina.

The image then is carried to the brain for interpretation

by the optic nerve (fig. 1-51). Note the image received

by the retina is upside down, but the brain turns it

right-side up.

REFRACTION.—Deflection or bending of light

rays results when light passes through substances of

varying densities in the eye (cornea, aqueous humor,

lens, and vitreous humor). The deflection of light in the

eye is referred to as refraction.

ACCOMMODATION.—Accommodation is the

process by which the lens increases or decreases its

curvature to refract light rays into focus on the fovea

centralis.

CONVERGENCE.—The movement of the

globes toward the midline, causes a viewed object to

come into focus on corresponding points of the two

1-46

SYMPATHETIC

MOTOR

NERVE

RADIALLY ARRANGED SMOOTH

MUSCLE FIBERS OF THE IRIS

CIRCULARLY ARRANGED SMOOTH

MUSCLE FIBERS OF THE IRIS

PUPIL

PARASYMPATHETIC

MOTOR NERVE FIBER

IN DIM

LIGHT

IN BRIGHT

LIGHT

HM3F0149

Figure 1-49.—Anterior view of the eye.
retinas. This process, called convergence, produces

clear, three-dimensional vision.

HEARING

The ear is the primary organ of hearing. Its major

parts are illustrated in figure 1-52. The ear is divided

into three parts: the external, middle, and inner ear.

External Ear

The external (outer) ear is composed of two parts,

the auricle and the external auditory canal

(fig. 1-52). The auricle, or pinna, is a cartilaginous

structure located on each side of the head. The auricle

collects sound waves from the environment, which are

then conducted by the external auditory canal to the

eardrum. The lining of the external auditory canal

contains glands that secrete a wax-like substance

called cerumen. Cerumen aids in protecting the

eardrum against foreign bodies and microorganisms.

The tympanic membrane, or eardrum, is an oval

sheet of fibrous epithelial tissue that stretches across

the inner end of the external auditory canal. The

eardrum separates the outer and middle ear. The sound

waves cause the eardrum to vibrate, and this vibration

transfers the sounds from the external environment to

the auditory ossicles.

Middle Ear

The middle ear is a cavity in the temporal bone,

lined with epithelium. It contains three auditory

ossicles—the malleus (hammer), the incus (anvil), and

the stapes (stirrup)—which transmit vibrations from

the tympanic membrane to the fluid in the inner ear

1-47

HM3f0151

OPTIC

NERVE

IMAGE ON

RETINA

OBJECT

IRIS

PUPIL LENS CORNEA

Figure 1-51.—The vision process.

SCLERA

CHOROID

RETINA

OPTIC DISK

(BLIND SPOT)

NASAL

SIDE

TEMPORAL

SIDE

FOVEA CENTRALIS

HM3f0150 (AREA OF SHARPEST VISION)

Figure 1-50.—Ophthalmoscope view of the eye.
(fig. 1-52). The malleusis attached to the inner surface

of the eardrum and connects with the incus, which in

turn connects with the stapes. The base of the stapes is

attached to the fenestra ovalis (oval window), the

membrane-covered opening of the inner ear. These

tiny bones, which span the middle ear, are suspended

from bony walls by ligaments. This arrangement

provides the mechanical means for transmitting sound

vibrations to the inner ear.

The eustachian tube, or auditory tube, connects

the middle ear with the pharynx. It is lined with a

mucous membrane and is about 36 mm long. Its

function is to equalize internal and external air

pressure. For example, while riding an elevator in a tall

building, you may experience a feeling of pressure in

the ear. This condition is usually relieved by

swallowing, which opens the eustachian tube and

allows the pressurized air to escape and equalize with

the area of lower pressure. Divers who ascend too fast

to allow pressure to adjust may experience rupture of

their eardrums. The eustachian tube can also provide a

pathway for infection of the middle ear.

Inner Ear

The inner ear is filled with a fluid called

endolymph. Sound vibrations that cause the stapes to

move against the oval window create internal ripples

that run through the endolymph. These pressurized

ripples move to the cochlea, a small snail-shaped

structure housing the organ of Corti, the hearing

organ (fig. 1-52). The cells protruding from the organ

of Corti are stimulated by the ripples to convert these

mechanical vibrations into nerve impulses, and these

impulses are relayed through the vestibulocochlear

(8th cranial) nerve to the auditory area of the cortex in

the temporal lobe of the brain. There they are

interpreted as the sounds we hear.

Another structure located in the inner ear is

composed of the three semicircular canals, situated

perpendicular to each other. Movement of the

endolymph within the canals, caused by general body

movements, stimulates nerve endings, which report

these changes in body position to the brain, which in

turn uses the information to maintain equilibrium.

The fenestra rotunda (round window) is another

membrane-covered opening of the inner ear. It

contracts the middle ear and flexes to accommodate

the inner ear ripples caused by the stapes.

TOUCH

Until the beginning of the last century, touch

(feeling) was treated as a single sense. Thus, warmth or

coldness, pressure, and pain, were thought to be part of

a single sense of touch or feeling. It was discovered

that different types of nerve ending receptors are

widely and unevenly distributed in the skin and

mucous membranes. For example, the skin of the back

possesses relatively few touch and pressure receptors

while the fingertips have many. The skin of the face has

relatively few cold receptors, and mucous membranes

have few heat receptors. The cornea of the eye is

sensitive to pain, and when pain sensation is abolished

by a local anesthetic, a sensation of touch can be

experienced.

1-48

HM3F0152

MALLEUS

INCUS

STAPES

SEMICIRCULAR

CANALS

INNER

EAR

VESTIBULOCOCHLEAR

NERVE

COCHLEA

OVAL

WINDOW

ROUND

WINDOW

TYMPANIC

CAVITY

MIDDLE

EAR

TYMPANIC

MEMBRANE EXTERNAL

AUDITORY

CANAL

OUTER

EAR

AURICLE

PHARYNX

Figure 1-52.—Major parts of the ear.
Receptors are considered to be sensory organs.

They provide the body with the general senses of

touch, temperature, and pain. In addition, these

receptors initiate reactions or reflexes in the body to

maintain homeostasis. For example, receptors in the

skin perceive cold, resulting in goosebumps. This

reaction is the body's attempt to maintain internal

warmth.

Receptors are classified according to location,

structure, and types of stimuli activating them.

Classified according to location, the three types of

receptors are as follows: superficial receptors

(exteroceptors), deep receptors (proprioceptors), and

internal receptors (visceroceptors). See table 1-4 for

receptor locations and the senses resulting from the

stimulation of these receptors.

THE DIGESTIVE SYSTEM

LEARNING OBJECTIVE: Identify the

location and function of each part of the

digestive system.

The digestive system includes the organs that

digest and absorb food substances, and eliminate the

unused residuals. The digestive system consists of the

alimentary canal and several accessory organs. The

accessory organs release secretions into the canal.

These secretions assist in preparing food for

absorption and use by the tissues of the body. Table

1-5 illustrates principal digestive juices (secretions)

produced by alimentary and accessory organs.

Digestion is both mechanical and chemical.

Mechanical digestion occurs when food is chewed,

swallowed, and propelled by a wave-like motion

called peristalsis. When peristalsis occurs, a ring of

contraction appears in the walls of the alimentary

canal. At the same time, the muscular wall just ahead of

the ring relaxes. This phenomenon is called receptive

relaxation. As the wave moves along, it pushes the

canal's contents ahead of it. Chemical digestion

consists of changing the various food substances, with

the aid of digestive enzymes, into solutions and simple

compounds. Carbohydrates (starches and sugars)

change into simple sugars (glucose); fats change into

fatty acids; and proteins change into amino acids. Once

the food substances have been broken down into

simple compounds, the cells of the body can absorb

and use them.

THE ALIMENTARY CANAL

The alimentary canal (tract) is 9 meters in length,

tubular, and includes the mouth, pharynx, esophagus,

stomach, small intestine, and large intestine

(fig. 1-53).

Mouth

The mouth, which is the first portion of the

alimentary canal, is adapted to receive food and

prepare it for digestion (fig. 1-53). The mouth

mechanically reduces the size of solid particles and

mixes them with saliva. This process is called

mastication. Saliva, produced by the salivary gland,

moistens food making it easier to chew. Saliva also

lubricates the food mass to aid swallowing. The tongue

assists with both mastication and swallowing.

Pharynx

The pharynx (covered earlier in “The Respiratory

System”) is the passageway between the mouth and the

esophagus and is shared with the respiratory tract

(fig. 1-53). The epiglottis is a cartilaginous flap that

1-49

TYPES LOCATIONS SENSES

Superficial receptors At or near surface of body Touch, pressure, heat, cold, and pain

Deep receptors In muscles, tendons, and joints Sense of position and movement

Internal receptors In the internal organs and blood

vessel walls

Usually none (except hunger, nausea, pain

from stimuli such as chemicals (e.g.,

aspirin) and distension (e.g., stomach

expansion from gas))

Table 1-4.—Types of Receptors, Their Location, and Affected Sense
1-50

HM3F0153

MOUTH

TONGUE

TOOTH

SUBLINGUAL

SALIVARY

ESOPHAGUS

PAROTID

SALIVARY

GLAND

PHARYNX

SUBMANDIBULAR

SALIVARY GLAND

STOMACH

PANCREAS

TRANSVERSE

COLON

JEJUNUM

DESCENDING

COLON

SIGMOID

COLON

APPENDIX

CECUM

SMALL

INTESTINE

ASCENDING

COLON

DUODENUM

(OF SMALL INTESTINE)

GALLBLADDER

LIVER

ILEUM

RECTUM

ANAL

CANAL

Figure 1-53.—The digestive system.

Digestive Juice Source Substance Acted Upon Product

Amylase Salivary glands and

pancreas

Starch Complex sugars

(maltose)

Hydrochloric acid Gastric glands Pepsinogen (Proteins) Pepsin (Split proteins)

Bile Liver Fats Emulsified fats

Proteinase Pancreas Proteins and split

proteins

Peptides and

polypeptides

Lipase Pancreas Fats (triglycerides) Fatty acids and glycerol

Carbohydrase Intestinal glands Complex sugars

(maltose, sucrose,

and lactose)

Simple sugars (glucose,

fructose, and galactose)

Peptidase Intestinal glands Peptides and

polypeptides

Amino acids

Table 1-5.—Principal Digestive Juices
closes the opening to the larynx when food is being

swallowed down the pharynx. Food is deflected away

from the trachea to prevent particle aspiration

(inhalation).

Esophagus

The esophagus is a muscular tube about 25 cm (10

inches) long (fig. 1-53). It is the passageway between

the pharynx and the stomach. By means of peristalsis,

food is pushed along this tube to the stomach. When

peristalsis is reversed, vomiting occurs.

Stomach

The stomach acts as an initial storehouse for

swallowed material and helps in the chemical

breakdown of food substances. The stomach is a

saccular enlargement of the gastrointestinal tube and

lies in the left upper quadrant of the abdomen (fig.

1-53). It connects the lower end of the esophagus with

the first portion of the small intestine (the duodenum).

The stomach is divided into the cardiac, fundic, body,

and pyloric regions (fig. 1-54). At each end of the

stomach, muscular rings (or sphincters) form valves to

close off the stomach. The sphincters prevent the

stomach's contents from escaping in either direction

while food substances are being mixed by peristaltic

muscular contractions of the stomach wall. The

sphincter at the esophageal end is the cardiac

sphincter; at the duodenal end it is the pyloric

sphincter.

The chemical breakdown of food in the stomach is

accomplished through the production of digestive

juices (enzymes) by small (gastric) glands in the wall

of the stomach. The principal digestive enzymes

produced by the gastric glands are hydrochloric acid

and pepsinogen. Hydrochloric acid activates pepsin

from pepsinogen, kills bacteria that enter the stomach,

inhibits the digestive action of amylase, and helps

regulate the opening and closing of the pyloric

sphincter. Pepsin is a protein-splitting enzyme capable

of beginning the digestion of nearly all types of dietary

protein.

Most food absorption takes place in the small

intestine. In general, food is not absorbed in the

stomach. An exception is alcohol, which is absorbed

directly through the stomach wall. It is for this reason

that intoxication occurs quickly when alcohol is taken

on an empty stomach.

Abdominal Cavity

The stomach and intestines are enclosed in the

abdominal cavity, the space between the diaphragm

and the pelvis. This cavity is lined with serous

membrane called the peritoneum. The peritoneum

covers the intestines and the organs and, by secreting a

serous fluid, prevents friction between adjacent

organs. The mesentery (double folds of peritoneum)

extends from the cavity walls to the organs of the

abdominal cavity, suspending them in position and

carrying blood vessels to the organs.

Small Intestine

The small intestine is a muscular, convoluted,

coiled tube, about 7 meters (23 feet) long and attached

to the posterior abdominal wall by its mesentery

(fig. 1-53).

The small intestine is divided into three contiguous

parts: the duodenum, jejunum, and ileum. It receives

digestive juices from three accessory organs of

digestion: the pancreas, liver, and gallbladder.

DUODENUM.—The duodenum is approximately 25 cm (10 inches) long and forms a C-shaped

curve around the head of the pancreas, posterior to the

liver. It is lined with a mucous membrane that contains

small glands. These glands secrete intestinal juices

containing the enzymes carbohydrase, peptidase, and

lipase.

JEJUNUM.—The jejunum is the middle part of

the small intestine and is approximately 2.5 meters (8.2

feet) long. Its enzymes continue the digestive process.

1-51

HM3F0154

FUNDIC REGION

OF STOMACH

BODY OF

STOMACH

ESOPHAGUS

CARDIAC

SPHINCTER

CARDIAC REGION

OF STOMACH

PYLORIC SPHINCTER

(PYLORUS)

DUODENUM

PYLORIC

CANAL

PYLORIC REGION

OF STOMACH

Figure 1-54.—Major regions of the stomach.
ILEUM.—The ileum is the last and longest part of

the small intestine. It is approximately 3.5 meters (11.5

feet) long. Most of the absorption of food occurs in the

ileum, where fingerlike projections (villi) provide a

large absorption surface. After ingestion, it takes 20

minutes to 2 hours for the first portion of the food to

pass through the small intestine to the beginning of the

large intestine.

Large Intestine

The large intestine is so called because it is larger

in diameter than the small intestine (fig. 1-53). It is

considerably shorter, however, being about 1.5 meters

(5 feet) long. It is divided into three distinct parts: the

cecum, colon, and rectum.

CECUM AND COLON.—The unabsorbed food

or waste material passes through the cecum into the

ascending colon, across the transverse colon, and

down the descending colon through the sigmoid

colon to the rectum. Twelve hours after the meal, the

waste material passes slowly through the colon,

building in mass and reaching the rectum 24 hours after

the food is ingested.

The appendix, a long narrow tube with a blind

end, is a pouchlike structure of the cecum located near

the junction of the ileum and the cecum (fig. 1-53).

There is no known function of this structure.

Occasionally, the appendix becomes infected, causing

inflammation to develop. This inflammation of the

appendix is known as appendicitis.

RECTUM.—The rectum is approximately 12.5

cm (5 inches) long and follows the contour of the

sacrum and coccyx until it curves back into the short

(2.5 to 4 cm) anal canal. The anus is the external

opening at the lower end of the digestive system.

Except during bowel movement (defecation), it is kept

closed by a strong muscular ring, the anal sphincter.

ACCESSORY ORGANS OF DIGESTION

The accessory organs of digestion include the

salivary glands, pancreas, liver, and gallbladder. As

stated earlier, during the digestive process, the

accessory organs produce secretions that assist the

organs of the alimentary canal.

Salivary Glands

The salivary glands are located in the mouth (fig.

1-53). Within the salivary glands are two types of

secretory cells, serous cells and mucous cells. The

serous cells produce a watery fluid that contains a

digestive juice called amylase. Amylase splits starch

and glycerol into complex sugars. The mucous cells

secrete a thick, sticky liquid called mucus. Mucus

binds food particles together and acts to lubricate

during swallowing. The fluids produced by the serous

and mucous cells combine to form saliva.

Approximately 1 liter of saliva is secreted daily.

Pancreas

The pancreas is a large, elongated gland lying

posteriorly to the stomach (fig. 1-53). As discussed

earlier in “The Endocrine System,” the pancreas has

two functions: It serves both the endocrine system and

the digestive system. The digestive portion of the

pancreas produces digestive juices (amylase,

proteinase, and lipase) that are secreted through the

pancreatic duct to the duodenum. These digestive

juices break down carbohydrates (amylase), proteins

(proteinase), and fats (lipase) into simpler compounds.

Liver

The liver is the largest gland in the body. It is

located in the upper abdomen on the right side, just

under the diaphragm and superior to the duodenum and

pylorus (fig. 1-53).

Of the liver's many functions, the following are

important to remember:

• It metabolizes carbohydrates, fats, and proteins

preparatory to their use or excretion.

• It forms and excretes bile salts and pigment from

bilirubin, a waste product of red blood cell

destruction.

• It stores blood; glycogen; vitamins A, D, and

B12; and iron.

• It detoxifies the end products of protein

digestion and drugs.

• It produces antibodies and essential elements of

the blood-clotting mechanism.

Gallbladder

The gallbladder is a pear-shaped sac, usually

stained dark green by the bile it contains. It is located in

the hollow underside of the liver (fig. 1-53). Its duct,

the cystic duct, joins the hepatic duct from the liver to

form the common bile duct, which enters the

duodenum. The gallbladder receives bile from the liver

and then concentrates and stores it. It secretes bile

1-52
when the small intestine is stimulated by the entrance

of fats.

THE URINARY SYSTEM

LEARNING OBJECTIVE: Recall the parts

of the urinary system and their function(s).

The urinary system is the primary filtering system

of the body (fig. 1-55). This system is composed of two

main organs, the kidneys and urinary bladder. The

kidneys produce urine, which is drained from the

kidneys by two tubes called ureters. Urine flows down

both ureters to the bladder. The urinary bladder is a

large reservoir where the urine is temporarily stored

before excretion from the body. A tube called the

urethra carries the urine from the bladder to the

outside of the body. All these parts, except the length of

the urethra, are the same in both sexes.

KIDNEYS

The importance of the kidney can be realized only

when its structure and functions are understood. The

bladder, ureters, and urethra store and pass the

products of the kidneys.

The kidneys are two large, bean-shaped organs

designed to filter waste materials from the blood (figs.

1-55 and 1-56). They also assist in controlling the rate

of red blood cell formation, and in the regulation of

blood pressure, the absorption of calcium ions, and the

volume, composition, and pH of body fluids. The

kidneys are located in the upper posterior part of the

abdominal cavity, one on each side of the spinal

column. The upper end of each kidney reaches above

the level of the 12th rib. The suprarenal (adrenal) gland

sits like a cap on top of each kidney. The kidneys are

protected by a considerable amount of fat and

supported by connective tissue and the peritoneum.

Attached to the hollow side of each kidney is the

dilated upper end of the ureter, forming the renal

pelvis.

Structure

The lateral surface of the kidneys is convex in

shape, and the medial side is deeply concave. The

medial side of each kidney possesses a depression that

leads to a hollow chamber called the renal sinus (fig.

1-55). The entrance of the renal sinus is referred to as

the hilum (fig. 1-55). Blood vessels, nerves, lymphatic

vessels, and the ureters pass through the hilum.

The superior end of the ureter forms a

funnel-shaped sac called the renal pelvis (fig. 1-56).

The renal pelvis is divided into two or three tubes,

called major calyces. The major calyces (sing. calyx)

are further subdivided into minor calyces.

There are groups of elevated projections in the

walls of the renal pelvis. These projections are called

renal papillae. The renal papillae connect to the minor

calyces, through tiny openings in the minor calyces.

The principal portion of the kidney is divided into

two distinct regions: an inner medulla and outer cortex

(fig. 1-56). The renal medulla is composed of

pyramid-shaped masses of tubes and tubules called

renal pyramids. Renal pyramids drain the urine to

the renal pelvis. The renal cortex forms a shell over

the renal medulla. Renal cortex tissue dips down, like

fingers, between the renal pyramids, and forms what

are called renal columns. The cortex possesses very

small tubes associated with nephrons. Nephrons are

the functional units of the kidneys.

RENAL BLOOD VESSELS.—The renal artery

supplies blood to the kidneys (fig. 1-56). The renal

artery enters the kidneys through the hilum, and sends

off branches to the renal pyramids. These arterial

branches are called interlobar arteries. At the border

between the medulla and cortex, the interlobar arteries

branch to form the arciform arteries. The arciform

arteries branch also and form the interlobular

arteries.

1-53

HM3F0155

RENAL

ARTERY KIDNEY

RENAL

SINUS

AORTA

URETER

URETHRA

URINARY

BLADDER

INFERIOR

VENA

CAVA

HILUM

RENAL

VEIN

Figure 1-55.—The urinary system.
The venous system of the kidneys generally follow

the same paths as the arteries. Venous blood passes

through the interlobular, arciform, interlobar, and renal

veins (fig. 1-56).

NEPHRONS.—The functional units of the

kidneys are called nephrons. There are about 1 million

nephrons in each kidney. Each nephron consists of a

renal corpuscle and a renal tubule (fig. 1-56, view C).

The renal corpuscle (Malpighian corpuscle) is

composed of a tangled cluster of blood capillaries

called a glomerulus. The glomerulus is surrounded by

a sac-like structure referred to as the glomerulus

capsule or Bowman's capsule (figs. 1-56, view C, and

1-57).

Leading away from the glomerulus is the renal

tubule. The initial portion of the renal tubule is coiled

and called the proximal convoluted (meaning coiled

or twisted) tubule. The proximal convoluted tubule

dips down to become the descending loop of Henle.

The tubule then curves upward toward the renal

corpuscle and forms the ascending loop of Henle.

Once the ascending limb reaches the region of the

renal corpuscle, it called the distal convoluted tubule.

Several distal convoluted tubules merge in the renal

1-54

HM3F0156

RENAL

PYRAMID

RENAL

CAPSULE

RENAL

CORTEX

RENAL

MEDULLA

MINOR

CALYX

MAJOR

CALYX

RENAL

PELVIS

RENAL

ARTERY RENAL

COLUMN RENAL

VEIN

RENAL

PAPILLA

RENAL

PYRAMID

URETER

RENAL

CORPUSCLE

COLLECTING

DUCT

RENAL

TUBULE

ASCENDING

LOOP OF

HENLE

DESCENDING

LOOP OF HENLE

GLOMERULUS

(BOWMAN'S

CAPSULE)

A

B

NEPHRONS

RENAL

CORTEX

RENAL

MEDULLA

PAPILLARY

DUCT

MINOR

CALYX

C

Figure 1-56.—Principal parts of the kidney: A. Longitudinal section of a kidney; B. A renal pyramid containing nephrons; C. A

single nephron.
cortex to form a collecting duct. The collecting duct

begins to merge within the renal medulla. The

collecting ducts become increasingly larger as they are

joined by other collecting ducts. The resulting tube is

called the papillary duct. The papillary duct empties

into the minor calyx through an opening in the renal

papilla.

Function

The kidneys are effective blood purifiers and fluid

balance regulators. In addition to maintaining a normal

pH of the blood (acid-base balance), the kidneys keep

the blood slightly alkaline by removing excess

substances from the blood. The end product of these

functions is the formation of urine, which is excreted

from the body.

Urine is formed through a series of processes in the

nephron. These processes are filtration, reabsorption,

and secretion.

FILTRATION.—Urine formation begins when

water and various dissolved substances are filtered out

of blood plasma from a glomerular capillary into the

glomerular capsule. The filtered substance (glomerular

filtrate) leaves the glomerular capsule and enters the

renal tubule.

REABSORPTION.—As glomerular filtrate

passes through the renal tubule, some of the filtrate is

reabsorbed into the blood of the peritubular capillary

(fig. 1-57). The filtrate entering the peritubular

capillary will repeat the filtration cycle. This process

of reabsorption changes the composition of urine. For

instance, the filtrate entering the renal tubule is high in

sugar content, but because of the reabsorption process,

urine secreted from the body does not contain sugar.

SECRETION.—Secretion is the process by

which the peritubular capillary transports certain

substances directly into the fluid of the renal tubule

(fig. 1-58). These substances are transported by similar

mechanisms as used in the reabsorption process, but

done in reverse. For example, certain organic

compounds, such as penicillin and histamine, are

secreted directly from the proximal convoluted tubule

to the renal tubule. Also, large quantities of hydrogen

ions are secreted in this same manner. The secretion of

hydrogen ions plays an important role in regulating pH

of body fluids.

The glomerulus filters gallons of blood each day. It

is estimated that 2,500 gallons of blood pass through

the kidneys in 24 hours, and about 80 gallons of

glomerular filtrate. All the water from this filtrate is

reabsorbed in the renal tubules except that containing

the concentrated waste products.

1-55

HM3F0158

EFFERENT

ARTERIOLE AFFERENT

ARTERIOLE

GLOMERULAR

CAPSULE

GLOMERULUS

GLOMERULAR

FILTRATE

RENAL

TUBULE

PERITUBULAR

CAPILLARY

SECRETION

Figure 1-58.—The secretion process.

HM3F0157

EFFERENT

ARTERIOLE

BLOOD

FLOW

AFFERENT

ARTERIOLE

GLOMERULAR

CAPSULE

GLOMERULUS

GLOMERULAR

FILTRATE

REABSORPTION

RENAL

TUBULE

PERITUBULAR

CAPILLARY

BLOOD

FLOW

Figure 1-57.—The reabsorption process.
The average amount of urine an adult excretes

varies from 1,000 to 1,500 ml per day. However, the

amount of urine excreted varies greatly with

temperature, water intake, and state of health. No

matter how much water one drinks, the blood will

always remain at a constant concentration, and the

excess water will be excreted by the kidneys. A large

water intake does not put a strain on the kidneys.

Instead it eases the load of concentration placed on the

kidneys.

URETERS

The ureters' only function is to carry urine from

each kidney to the urinary bladder. The ureters are two

membranous tubes 1 mm to 1 cm in diameter and about

25 cm in length. Urine is transported through the

ureters by peristaltic waves (produced by the ureter's

muscular walls).

URINARY BLADDER

The urinary bladder functions as a temporary

reservoir for urine. The bladder possesses features that

enable urine to enter, be stored, and later be released

for evacuation from the body.

Structure

The bladder is a hollow, expandable, muscular

organ located in the pelvic girdle (fig. 1-59). Although

the shape of the bladder is spherical, its shape is altered

by the pressures of surrounding organs. When it is

empty, the inner walls of the bladder form folds. But as

the bladder fills with urine, the walls become

smoother.

The internal floor of the bladder includes a

triangular area called the trigone (fig. 1-59). The

trigone has three openings at each of its angles. The

ureters are attached to the two posterior openings. The

anterior opening, at the apex of the trigone, contains a

funnel-like continuation called the neck of the bladder.

The neck leads to the urethra.

The wall of the bladder consists of four bundles of

smooth muscle fibers. These muscle fibers, interlaced,

form the detrusor muscle (which surrounds the

bladder neck) and comprise what is called the internal

urethral sphincter. The internal urethral sphincter

prevents urine from escaping the bladder until the

pressure inside the bladder reaches a certain level.

Parasympathetic nerve fibers in the detrusor muscle

function in the micturition (urination) process. The

1-56

HM3F0159 B

URETER

URETER

URINARY

BLADDER

URINARY

BLADDER

DETRUSOR MUSCLE

(INTERNAL URETHRAL

SPHINCTER)

PROSTATE

GLAND

BULBOURETHRAL

GLAND

PENIS

EXTERNAL

URETHRAL

ORIFICE

EXTERNAL

URETHRAL

ORIFICE

PENILE

URETHRA

PROSTATIC

URTHRA

TRIGONE

TRIGONE

A

MEMBRANOUS

URETHRA

URETHRA

Figure 1-59.—Urinary bladder and urethra:

A. Frontal section of the female urinary bladder and urethra;

B. Frontal section of the male urinary bladder and urethra.
outer layer (serous coat) of the bladder wall consists of

two types of tissue, parietal peritoneum and fibrous

connective tissue.

Micturition (Urination)

Micturition is the process by which urine is

expelled from the bladder. It involves the contraction

of the detrusor muscle, and pressure from surrounding

structures. Urination also involves the relaxation of the

external urethral sphincter. The external urethral

sphincter surrounds the urethra about 3 centimeters

from the bladder, and is composed of voluntary

muscular tissue.

Urination is usually stimulated by the distention of

the bladder as it fills with urine. When the walls of the

bladder contract, nerve receptors are stimulated, and

the urination reflex is triggered. The urination reflex

causes the internal urethral sphincter to open and the

external urethral sphincter to relax. This relaxation

allows the bladder to empty. The bladder can hold up to

600 ml of urine. The desire to urinate may not occur

until the bladder contains 250-300 ml.

URETHRA

The urethra is the tube that carries urine from the

bladder to the outside of the body (fig. 1-59, views A

and B). The urinary meatus is the external urethral

orifice. In the male, the urethra is common to the

urinary and reproductive systems; in the female, it

belongs only to the urinary system.

Female Urethra

The female urethra is about 4 cm long, extending

from the bladder to the external orifice, (fig. 1-59, view

A).

Male Urethra

The male urethra is about 20 cm long and is

divided into three parts: the prostatic, membranous,

and penile portions. See view B of figure 1-59 for an

illustration of the male urethra.

PROSTATIC URETHRA.—The prostatic

urethra is surrounded by the prostate gland; it contains

the orifices of the prostatic and ejaculatory ducts. This

portion of the male urethra is about 2.5 cm long.

MEMBRANOUS URETHRA.—The membranous urethra is about 2 cm in length and is

surrounded by the external urethral sphincter.

PENILE URETHRA.—The penile urethra, the

longest portion, is about 15 cm long. It lies in the

ventral portion of the penis. The urethra terminates

with the external orifice at the tip of the penis.

MALE REPRODUCTIVE SYSTEM

LEARNING OBJECTIVE: Recall the parts

of the male reproductive system and their

function(s).

The organs of the male and female reproductive

systems are concerned with the process of reproducing

offspring, and each organ is adapted to perform

specialized tasks. The primary male sex organs of the

reproductive system are the testes. The other structures

of the male reproductive system are termed accessory

reproductive organs. The accessory organs include

both internal and external reproductive organs. See

figure 1-60 for an illustration of the male reproductive

system.

1-57

HM3F0160

LARGE

INTESTINE

SEMINAL

VESICLE

EJACULATORY

DUCT

PROSTATE

GLAND

BULBOURETHRAL

GLAND

EPIDIDYMIS ANUS

TESTIS

SCROTUM

URINARY

BLADDER

SYMPHYSIS

PUBIS

VAS

DEFERENS

URETHRA

PENIS

GLANS

PENIS

PREPUCE

Figure 1-60.—The male reproductive system.
TESTES

The testes, as stated earlier, are the primary male

reproductive organs. They produce sperm cells

(spermatozoa) and male hormones, both necessary for

reproduction.

Structure

The testes are oval glands suspended inside a sac

(the scrotum) by a spermatic cord. The spermatic

cords are formed by the vas deferens, arteries, veins,

lymphatics, and nerves, all bound together by

connective tissue.

Each testis is encapsulated by a tough, white,

fibrous tissue called the tunica albuginea. The interior

of the testis is divided into 250 lobules (small lobes).

Each lobule contains 1 to 4 highly coiled, convoluted

tubules called seminiferous tubules. These tubules

unite to form a complex network of channels called the

rete testis. The rete testis give rise to several ducts that

join a tube called the epididymis (fig. 1-60).

Functions

The testes perform two functions: to produce

sperm cells and to secrete male sex hormones. The

process by which sperm cells are produced is called

spermatogenesis. Spermatogenesis occurs in the

seminiferous tubules of the testes. Once the sperm

cells are formed, they collect in the lumen of each

seminiferous tubule. When the sperm cells are ready,

they pass through the rete testis to the epididymis,

where they remain for a time to mature. The production

of sperm cells occurs continually throughout the

reproductive life of a male.

The male hormone testosterone is produced in the

testes. This hormone is initially responsible for the

formation of the male reproductive organs. During

puberty, testosterone stimulates the enlargement of the

testes and various other accessory reproductive

organs. It also causes the development of the male

secondary sexual characteristics. Refer to the section

titled “The Endocrine System” for more detailed

discussion on male secondary sexual characteristics.

Other actions of testosterone include increasing

the production of red blood cells. As a result, the

average number of red blood cells in blood is usually

greater in males than in females.

INTERNAL ACCESSORY ORGANS

The internal accessory organs of the male

reproductive system include the epididymis, vas

deferens, ejaculatory ducts, seminal vesicle, urethra,

prostate gland, bulbourethral glands, and semen (fig.

1-60).

Epididymis

Each epididymis is a tightly coiled, thread-like

tube that is approximately 6 meters long. This tube is

connected to the ducts within the testis. The

epididymis covers the top of the testis, runs down the

testis' posterior surface, and then courses upward to

form the vas deferens.

The epididymis secretes the hormone glycogen,

which helps sustain the lives of stored sperm cells and

promotes their maturation. When immature sperm

cells enter the epididymis, they are not mobile.

However, as the sperm cells travel through the

epididymis, they mature and become mobile. Once the

sperm cells are mature, they leave the epididymis and

enter the vas deferens.

Vas Deferens

The vas deferens is a small tube that connects the

epididymis and ejaculatory duct. It ascends as part of

the spermatic cord through the inguinal canal of the

lower abdominal wall into the pelvic cavity, and

transmits the sperm to the ejaculatory ducts.

Ejaculatory Ducts

The vas deferens and the seminal vesicles

converge, just before the entrance of the prostate

gland, to form the ejaculatory ducts (fig. 1-60). The

ejaculatory ducts open into the prostatic urethra. Its

function is to convey sperm cells to the urethra.

Seminal Vesicles

The seminal vesicles are two pouches that are

attached to the vas deferens near the base of the urinary

bladder. The lining of the inner walls of the seminal

vesicles secrete a slightly alkaline fluid. This fluid is

thought to help regulate the pH of the tubular contents

as sperm cells are conveyed to the outside. The

secretion produced by the seminal vesicles also

contains a variety of nutrients, such as fructose (simple

sugar), that provides the sperm cells an energy source.

1-58
At the time of ejaculation, the contents of the

seminal vesicles are emptied into the ejaculatory ducts.

This action greatly increases the volume of fluid that is

discharged by the vas deferens.

Urethra

The urethra is an important organ of both the

urinary and reproductive systems. The role of the

urethra, in the reproductive system, is to transport

sperm through the penis to outside the body. See “The

Urinary System” section for information on the

structure of the urethra.

Prostate Gland

The prostate gland, made of smooth muscle and

glandular tissue, surrounds the first part of the urethra.

It resembles a chestnut in shape and size, and secretes

an alkaline fluid to keep the sperm mobile, protecting it

from the acid secretions of the female vagina. This

substance is discharged into the urethra as part of the

ejaculate, or semen, during the sexual act.

Bulbourethral Glands

Bulbourethral glands, also known as Cowper's

glands, are two pea-sized bodies located below the

prostate gland and lateral to the membranous urethra.

These glands are enclosed by fibers of the external

urethral sphincter. They release a mucous-like fluid in

response to sexual stimulation and provide lubrication

to the end of the penis in preparation for sexual

intercourse.

Semen

Semen is composed of sperm and secretions from

the seminal vesicles, prostate, and bulbourethral

glands. It is discharged as the ejaculate during sexual

intercourse. There are millions of sperm cells in the

semen of each ejaculation, but only one is needed to

fertilize the ovum. It is generally considered that

fertilization of the ovum occurs while it is still in the

fallopian tubes. Therefore, it is apparent that sperm

cells can move actively in the seminal fluid deposited

in the vagina and through the layers of the secretion

lining the uterus and fallopian tubes.

EXTERNAL ACCESSORY ORGANS

The external accessory organs of the male

reproductive system include the scrotum and penis

(fig. 1-60).

Scrotum

The scrotum is a cutaneous pouch containing the

testes and part of the spermatic cord. Immediately

beneath the skin is a thin layer of muscular fibers (the

cremaster), which is controlled by temperature and

contracts or relaxes to lower or raise the testes in

relation to the body. This muscular activity of the

scrotum is necessary to regulate the temperature of the

testes, which is important in the maturation of sperm

cells.

Penis

The penis is a cylindrical organ that conveys urine

and semen through the urethra to the outside. The penis

is composed of three columns of spongy cavernous

tissue, bound together by connective tissue and loosely

covered by a layer of skin. Two of the columns, the

corpora cavernosa, lie superiorly side by side; the

third column, the corpus spongiosum, lies below the

other two columns. The urethra is located in the corpus

spongiosum. The dilated distal end of the corpus

spongiosum is known as the glans penis (fig. 1-60).

The urethra terminates at the glans penis.

The cavernous tissue becomes greatly distended

with blood during sexual excitement, causing an

erection of the penis. The loose skin of the penis folds

back on itself at the distal end (forming the prepuce, or

foreskin) and covers the glans. The prepuce is

sometimes removed by a surgical procedure called a

circumcision.

FEMALE REPRODUCTIVE

SYSTEM

LEARNING OBJECTIVE: Recall the parts

of the female reproductive system and their

function(s).

The organs of the female reproductive system are

specialized to produce and maintain the female sex

cells, or egg cells; to transport these cells to the site of

fertilization; to provide an environment for a

developing offspring; to move the offspring outside;

and to produce female sex hormones. The primary

female reproductive organs are the ovaries. The other

structures of the female reproductive system are

considered accessory reproductive organs. The

1-59
accessory organs include both internal and external

reproductive organs (fig. 1-61).

OVARIES

The ovaries, as stated earlier, are the primary

female reproductive organs, producing the female sex

cells and sex hormones (fig. 1-61).

Structure

The ovaries, or female gonads, are two

almond-shaped glands suspended by ligaments in the

upper pelvic cavity. There is one ovary on each side of

the uterus. The ligaments that suspend the ovaries

contain ovarian blood vessels and nerves.

The tissues of an ovary are divided into two

regions, an inner medulla and an outer cortex. The

ovarian medulla is largely composed of loose

connective tissue, numerous blood vessels, lymph

vessels, and nerves. The ovarian cortex is composed of

compact tissue containing tiny masses of cells called

ovarian (primordial) follicles. The follicles contain

the female sex cells or ova. The external surface of the

ovary is covered by a layer of cuboidal epithelium

cells. Beneath the epithelium is a layer of dense

connective tissue.

Primordial Follicle

In the outer region of the ovarian cortex,

microscopic groups of cells are referred to as

primordial follicles. The primordial follicles consist of

a single large cell, called an oocyte, which is

surrounded by a layer of flattened epithelial cells

called follicular cells. The oocyte is an immature egg

cell. Follicular cells surround a developing egg cell

and secrete female sex hormones. There are

approximately 400,000 primordial follicles at puberty.

Of these, probably fewer than 500 will be released

from the ovary during the reproductive life of a female.

At puberty, the anterior pituitary gland secretes

increased amounts of FSH (follicle-stimulating

hormone). In response, the ovaries enlarge and many

of the primordial follicles begin to mature. During this

maturation process, the oocyte enlarges and the follicle

cells multiply until there are 6 to 12 layers. Fluid-filled

spaces begin to appear among the follicle cells. These

spaces join to form a single cavity called the antrum.

Ten to fourteen days after this process begins, the

primordial follicle reaches maturity. The mature

primordial follicle (preovulatory or graafian follicle)

and its fluid-filled cavity bulges outward on the surface

of the ovary, like a blister.

Ovulation

Ovulation is the process by which the mature

oocyte is released from the primordial follicle (fig.

1-62). Ovulation is stimulated by hormones from the

anterior pituitary gland. These hormones cause the

mature follicle to swell rapidly and its walls to weaken.

Eventually the wall ruptures, permitting the oocyte and

1 or 2 layers of follicle cells to be released from the

ovary's surface.

After ovulation, the oocyte is usually propelled to

the opening of a nearby fallopian tube. If the oocyte is

not fertilized by a sperm cell within a relatively short

time, it will degenerate.

This process of ovulation occurs once a month.

Each ovary normally releases an ovum every 56 days.

The right and left ovary alternately discharge an ovum

approximately every 28 days. The menstrual cycle in

most women is therefore approximately 28 days.

Female Sex Hormones

Female sex hormones are produced by the ovaries

and various other tissues, such as the adrenal glands,

pituitary gland, and placenta (during pregnancy).

These female sex hormones are estrogen and

progesterone.

The primary source for estrogen is the ovaries. At

puberty, estrogen stimulates enlargement of various

accessory organs, which include the vagina, uterus,

fallopian tubes, and external structures. Estrogen is

also responsible for the development and maintenance

1-60

HM3F0161

ANUS

SYMPHYSIS

PUBIS

URETHRA

CERVIX

RECTUM

VAGINA

VAGINAL

ORIFICE LABIA

MINORA

LABIA

MAJORA

CLITORIS

URINARY

BLADDER

UTERUS

OVARY

UTERINE

TUBE

Figure 1-61.—The female reproductive system.
of female secondary sexual characteristics. See section

titled “Endocrine System” for listing of secondary

female sexual characteristics.

The ovaries are also the primary source of

progesterone (in a nonpregnant female). This hormone

promotes changes that occur in the uterus during the

female reproductive cycle. In addition, progesterone

stimulates the enlargement of mammary glands and

ducts, and increases fat deposits in female breasts

during puberty.

INTERNAL ACCESSORY ORGANS

The internal accessory organs of the female

reproductive system include a pair of fallopian tubes,

the uterus, and the vagina (fig. 1-61).

Fallopian Tubes

The fallopian tubes, also known as uterine tubes,

serve as ducts for the ovaries, providing a passageway

to the uterus. The fallopian tubes are composed of three

tissue layers. These tissue layers include an inner

mucosal layer, a middle muscular layer, and an outer

serous layer, and they are continuous with the layers of

the uterus. The fallopian tubes are in contact with the

ovaries but are not continuous with them. Their

funnel-shaped openings, called free openings, are

fringed with fingerlike processes that pick up an ovum

and draw it into the fallopian tubes. Once the ovum

enters the fallopian tubes, it is transported to the uterus

by peristalsis and gravity. Fertilization of an ovum

normally takes place in the fallopian tubes.

Uterus

The function of the uterus is to receive the embryo

that results from the fertilization of an egg cell, and to

sustain its life during development. The uterus, or

womb, is a hollow, pear-shaped organ with thick,

muscular walls. The uterus is divided into two main

regions, the body and cervix (fig. 1-61). The body of

the uterus consists of the upper two-thirds of the uterus.

The cervix is the lower one-third portion of the uterus

that projects into the upper part of the vagina. The

cervical opening into the vagina is called the external

os.

The uterine wall is composed of three layers: the

endometrium, the myometrium, and the perimetrium.

The inner lining consists of specialized epithelium,

called endometrium, which undergoes partial

destruction approximately every 28 days in the

nonpregnant female. The middle layer, the

myometrium, consists of bundles of interlaced

muscular fibers. The muscular layer produces

powerful rhythmic contractions that are important in

the expulsion of the fetus at birth. The perimetrium

consists of an outer serosal layer that covers the body

of the uterus and part of the cervix. The uterus also has

three openings: superiorly and laterally, two openings

connect the fallopian tubes to the uterus, and inferiorly,

an opening leading to the vagina.

1-61

FOLLICULAR

FLUID

OOCYTE

FOLLICULAR

CELLS

OVARY

PRIMORDIAL

FOLLICLE

TIME

TIME

TIME

TIME

TIME

OVULATION

FALLOPIAN

TUBE HM3F0162

Figure 1-62.—Ovulation process.
Vagina

The vagina is the organ that receives the male

sperm during intercourse. It also forms the lower

portion of the birth canal, stretching widely during

delivery. In addition, it serves as an excretory duct for

uterine secretions and menstrual flow.

The vagina is a fibromuscular tube capable of great

distention. The canal is approximately 9 cm long and

extends from the uterus to the outside. The vaginal

orifice is partially closed by a thin membrane of tissue

called the hymen. The wall of the vagina consists of

three layers. The inner mucosal layer does not have

mucous glands; the mucous found in the vagina comes

from the glands of the cervix. The middle muscular

layer consists mainly of smooth muscles fibers. At the

lower end of the vagina is a thin band of smooth muscle

that helps close the vaginal opening. The outer fibrous

layer consists of dense fibrous connective tissue

interlaced with elastic fibers. These fibers attach the

vagina to the surrounding organs.

EXTERNAL ACCESSORY ORGANS

Many of the external accessory organs of the

female reproductive system are referred to collectively

as the vulva. The vulva includes the labia majora, the

labia minora, the clitoris, and the vestibular glands

(fig. 1-63). The mammary glands are also considered

an accessory organ of the female reproductive system.

Labia Majora

The function of the labia majora is to enclose and

protect the other external reproductive organs. The

labia majora are composed of two round folds of fat

tissue and a thin layer of smooth muscle, covered by

skin. On the outer portion of the labia majora, the skin

has numerous hairs, sweat glands, and sebaceous

glands. The inner portion of skin is thin and hairless.

The labia majora extend from the mons pubis

anteriorly to the perineum (the region between the

vaginal orifice and the anus). The mons pubis is the

pad of fatty tissue beneath the skin, which overlies the

symphysis pubis.

Labia Minora

Within the labia majora folds are two smaller

folds, called the labia minora. The labia minora extend

from the clitoris to either side of the vaginal orifice.

Clitoris

The clitoris is a small projectile at the anterior end

of the vulva between the labia minora. It is richly

endowed with sensory nerves that are associated with

the feeling of pleasure during sexual stimulation.

Vestibule

The vestibule is the area enclosed by the labia

minora that includes that vaginal and urethral

openings. The vestibule contains a pair of vestibular

glands, more commonly known as the Bartholin's

glands. The Bartholin's glands lay on each side of the

vaginal opening. The ducts of these glands secrete

fluid that moistens and lubricates the vestibule.

Mammary Glands

The mammary glands, or breasts, are accessory

organs of the female reproductive system. They

develop during puberty under the influence of the

hormones estrogen and progesterone. The breasts are

responsible for the secretion of milk (lactation) for the

nourishment of newborn infants.

Structurally, the breasts resemble sweat glands. At

the center is a nipple containing 15 to 20 depressions

into which ducts from the lobes of the gland empty.

During pregnancy, placental estrogen and progesterone

stimulate further development of the mammary glands

1-62

MONS

PUBIS

LABIA

MAJORA

LABIA

MINORA

HYMEN

ANUS

CLITORIS

URETHRAL

ORIFICE

VAGINAL

ORIFICE

OPENING OF

VESTIBULAR

GLAND

HM3f0163

Figure 1-63.—External reproductive organs.
in preparation for lactation. After childbirth, hormones

secreted by the anterior lobe of the pituitary gland

stimulate production for 6 to 9 months.

FEMALE REPRODUCTIVE CYCLE

Females around age 11 begin to experience the

female reproductive cycle and continue into middle

age, after which it ceases. The female reproductive

cycle, or menstrual cycle, is characterized by regular,

recurring changes in the uterine lining, resulting in

menstrual bleeding (menses). The first phase of the

recurring reproductive cycle is menstrual bleeding.

Menstrual bleeding begins when the endometrial

lining starts to slough off from the walls of the uterus,

and it is characterized by bleeding from the vagina.

This is day 1 of the cycle, and this phase usually lasts

through day 5. The time between the last day of the

menses and ovulation is known as the postmenstrual

phase. It lasts from day 6 through day 13 or 14 and is

characterized by proliferation of endometrial cells in

the uterus, which develop under the influence of the

hormone estrogen. Ovulation, as discussed earlier in

this section, is the rupture of a primordial follicle with

the release of a mature ovum into the fallopian tubes. It

usually occurs on day 14 or 15 of the cycle. The

postovulatory (premenstrual) phase is the time

between ovulation and the onset of the menstrual

bleeding and normally lasts 14 days. During this phase

the ovum travels through the fallopian tubes to the

uterus. If the ovum becomes fertilized during this

passage, it will become implanted in and nurtured by

the newly developed endometrial lining. However, if

fertilization does not take place, the lining deteriorates

and eventually sloughs off, marking day 1 of the next

cycle.

SUMMARY

In this chapter, you have learned about the basic

structures of the cell to the many complex systems of

the human body. In addition, you have acquired the

understanding of how each body system functions and

how each system is interdependent upon each other.

You will use this knowledge of human anatomy and

physiology throughout your career in the medical

services. For example, the anatomical terminology

will be used in describing location of injuries or

conditions. Also, when you perform patient

assessments, a clear and thorough understanding of

anatomy and physiology is essential. Patient

assessment and documentation procedures will be

discussed in the next chapter, entitled “Fundamentals

of Patient Care.”

1-63

CHAPTER 2

FUNDAMENTALS OF PATIENT CARE

Twentieth century advances in the medical and

technological sciences have made a significant impact

on the methods of marketing healthcare services. The

numbers and kinds of healthcare providers have

expanded greatly. Patients have become more

informed about both their healthcare needs and

expectations. Additionally, patients have become

more vocal, seeking answers for the “what’s” and

“why’s” of the entire spectrum of healthcare services.

The goal of this chapter is to give the Hospital

Corpsman basic theory concerning the

multidisciplinary aspects of patient care. This chapter

is an introduction to some of the critical basic concepts

for providing care to individuals seeking healthcare

services.

HEALTH AND ILLNESS

LEARNING OBJECTIVE: Recognize the

concepts of health and illness.

To intelligently and skillfully discharge your

duties as a member of the Navy Medical Department

healthcare team, you must first understand the

concepts of health and illness.

The concept of health includes the physical,

mental, and emotional condition of human beings that

provide for the normal and proper performance of

one’s vital functions. Not only is health the absence of

disease or disability; health is also a state of soundness

of the body, mind, and spirit. Conversely, the concept

of illness includes conditions often accompanied by

pain or discomfort that inhibit a human being’s ability

to physically, mentally, or emotionally perform in a

normal and proper manner.

In most cultures, when people need assistance in

maintaining their health, dealing with illness, or

coping with problems related to health and illness, they

seek assistance from personnel specialized in the fields

of healthcare.

Physicians, nurses, and Hospital Corpsmen are

frequently referred to as the core team. All health

personnel comprise the total healthcare team.

Obviously, individual members of the team use their

skills differently, depending upon their personal,

professional, and technical preparation and

experience. Nevertheless—and despite the

differences in clinical expertise—they all share one

common objective: to respond to the patient’s health

needs. The overall goal of this response is to assist the

patient to maintain, sustain, and restore or rehabilitate

a physical or psychological function.

THE PATIENT

LEARNING OBJECTIVE: Recognize the

Patients’ Bill of Rights and Responsibilities.

No discussion about healthcare or the healthcare

team would be complete without including the patient,

often referred to as the consumer. A patient is a human

being under the care of one or more healthcare

providers. The patient may or may not be hospitalized.

However, regardless of healthcare needs or

environmental disposition, the patient is the most

important part of the healthcare team. Without a

patient, the healthcare team has little, if any, reason for

existence.

As a Hospital Corpsman, you are tasked to provide

every patient committed to your charge with the best

care possible. This care must reflect your belief in the

value and dignity of every person as an individual.

Additionally, you must understand the patient’s rights

and responsibilities as they apply to providing and

receiving healthcare services.

The Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) has developed

standards that address the rights and responsibilities of

patients. Because the goal of JCAHO is to promote

excellence in providing healthcare services, this goal is

compatible with that of the Navy Medical Department.

The next two sections review the rights and

responsibilities of patients when they enter a

relationship with a healthcare service facility.

Students seeking additional detailed information

2-1
should refer to the Patients’ Bill of Rights and

Responsibilities (an enclosure to BUMEDINST

6300.10) and the Accreditation Manual for Hospitals

published by the JCAHO.

PATIENT’S RIGHTS

The following are the patient’s rights:

• Medical Care and Dental Care—A patient has

the right to quality care and treatment consistent

with available resources and generally accepted

standards. The patient has the right to refuse

treatment to the extent permitted by law and

government regulations. However, the patient

should be informed of the consequences of

refusal.

• Respectful Treatment—A patient has the right

to considerate and respectful care, with

recognition of his personal dignity.

• Privacy and Confidentiality—A patient,

within law and military regulations, is entitled to

privacy and confidentiality concerning medical

care.

• Identity—A patient has the right to know, at all

times, the identity, professional status, and

professional credentials of healthcare personnel,

as well as the name of the healthcare provider

primarily responsible for his care.

• Explanation of Care—A patient has the right to

an explanation concerning his diagnosis,

treatment, procedures, and prognosis of illness

in terms the patient can understand.

• Informed Consent—A patient has the right to

be advised in nonclinical terms of information

needed to make knowledgeable decisions on

consent or refusal of treatments. Such

information should include significant

complications, risks, benefits, and alternative

treatments available.

• Research Projects—A patient has the right to

be advised if the facility proposes to engage in or

perform research associated with his care or

treatment. The patient has the right to refuse to

participate in any research projects.

• Safe Environment—A patient has the right to

care and treatment in a safe environment.

• Medical Treatment Facility (MTF) or Dental

Treatment Facility (DTF) Rules and

Regulations—A patient has the right to be

informed of the facility’s rules and regulations

that relate to patient or visitor conduct. The

patient is entitled to information for the

initiation, review, and resolution of patient

complaints.

PATIENT’S RESPONSIBILITIES

The following are the patient’s responsibilities:

• Providing Information—A patient has the

responsibility to provide, to the best of his

knowledge, accurate and complete information

about complaints, past illnesses, hospitalizations, medications, and other matters relating to

his personal health.

• Respect and Consideration—A patient has the

responsibility to be considerate of the rights of

other patients and MTF or DTF healthcare

personnel, and to assist in the control of noise,

smoking, and the number of visitors. The patient

is responsible for being respectful of the

property of other persons and of the facility.

• Compliance with Medical Care—A patient is

responsible for complying with the medical and

nursing treatment plan, including followup care

recommended by healthcare providers.

• Medical Records—A patient is responsible for

ensuring that medical records are promptly

returned to the medical facility for appropriate

filing and maintenance when those records are

transported by the patient for the purpose of

medical appointments or consultation, etc.

• MTF and DTF Rules and Regulations—A

patient is responsible for following the MTF or

DTF rules and regulations affecting patient

care.

• Reporting of Patient Complaints—A patient is

responsible for helping the MTF or DTF

commander provide the best possible care to all

beneficiaries. The patient’s recommendations,

questions, or complaints should be reported to

the patient contact representative.

2-2
PROFESSIONAL PRACTICE

LEARNING OBJECTIVE: Recognize the

key elements of professional practice.

Each member of the healthcare team has specific

responsibilities and limitations that define his area of

practice. To fulfill your role as a member of the

Hospital Corps within the context of the total mission

of the Navy Medical Department, it is imperative that

your practice be based on a sound body of knowledge

and the development of well-defined technical skills.

The rate training manual (TRAMAN) contributes to

the development of your body of knowledge. The HM

occupational standards (NAVPERS 18068F, chapter

40) define minimal technical skills required of a

Hospital Corpsman. As a member of the healthcare

team, the mechanism of on-the-job training, in-service

classes, and continuing education programs contribute

significantly to your continued growth in both

healthcare knowledge and skills.

PROFESSIONAL LIMITATIONS

In conjunction with their professional

responsibilities, all healthcare providers should realize

that they are subject to certain limitations in providing

healthcare services. These standards of practice are

based on the amount and kind of education, training,

experience, local regulations, and guidelines

possessed by the healthcare provider. The mature,

responsible individual will recognize, accept, and

demand that these limitations be respected. In clinical

settings, Hospital Corpsmen are tasked with

administering medication, performing treatments, and

providing individual patient care in compliance with

the orders of the senior healthcare provider. In the

hospital and some clinical environments, a Nurse

Corps officer divides and delegates portions of the

patient’s care to other members of the team based on

the skills and experiences of each member. In

situations where a Nurse Corps officer is not a member

of the team, such delegation of duties will generally be

made by an experienced chief petty officer or a senior

petty officer of the Hospital Corps.

ACCOUNTABILITY

Regardless of rank, rate, or corps membership, all

members of the healthcare team are held accountable

for their performance. Being accountable means being

held responsible for your actions. As a healthcare

provider, you should continue to acquire new

knowledge and skills and to strive for clinical

competency. Equally important is your ability to apply

new knowledge and acquired skills as a competent

professional in providing total healthcare.

Accountability becomes a critical issue when

determining issues of malpractice. Malpractice occurs

when an individual delivers improper care because of

negligence or practicing outside of his area of

expertise. Because the areas of expertise and

responsibility in medicine frequently overlap, legal

limits of practice are defined by each state. The

assignments and responsibilities of Hospital

Corpsmen frequently include areas of practice usually

provided by physicians and nurses in the civilian

sector. These responsibilities are only legal when

Hospital Corpsmen are performing such duties

while under the authority of the United States

Government. Because of this requirement, it is vital

that you thoroughly understand your legal rights and

limitations when providing patient care services both

in government and civilian sectors.

PATIENT ADVICE

Another area that has potential medical and legal

implications regarding your role as a healthcare

provider is that of giving advice or opinions. As a

result of your frequent and close contact with patients,

you will often be asked your opinion of the care or the

proposed care a patient is undergoing. Often, these

questions are extremely difficult to respond to,

regardless of who the healthcare provider is. No one is

ever totally prepared or has so much wisdom that he

can respond spontaneously in such situations. In such

cases, it is best to refer the question to the nurse or

physician responsible for the patient’s care.

You must always be conscious that you are seen as

a representative of Navy medicine by the recipients of

your care. As such, you will be accorded the respect

that goes with having a specialized body of knowledge

and an inventory of unique skills. A caduceus on the

sleeve of the Hospital Corpsman marks that person as a

member of a prestigious corps worthy of respect.

PATIENT BEHAVIOR

Remember, you have been charged to provide care

to a total, feeling, human person. The person seeking

healthcare service has the same needs for security,

safety, love, respect, and self-fulfillment as everyone

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else. When something threatens the soundness of the

body, mind, or spirit, an individual may behave

inappropriately. Occasionally, there are temper

outbursts, episodes of pouting, sarcastic remarks,

unreasonable demands, or other inappropriate

responses, often to the point of disruptive behavior.

The healthcare provider is challenged to look beyond

the behavior being displayed to identify the underlying

stress and to attempt to relieve the immediate and

obvious source of anxiety. This may be as simple as

communicating, through your care and understanding

of the patient as an individual, that Navy medicine is

pleased to provide a caring service.

PROFESSIONAL ETHICS

LEARNING OBJECTIVE: Recognize the

concept of professional ethics.

The word ethicsis derived from the Greek “ethos,”

meaning custom or practice, a characteristic manner of

acting, or a more-or-less constant style of behavior in

the deliberate actions of people. When we speak of

ethics, we refer to a set of rules or a body of principles.

Every social, religious, and professional group has a

body of principles or standards of conduct that

provides ethical guidance to its members.

During your indoctrination into the military, you

were introduced to the Code of the U.S. Fighting

Forces. This code of conduct is an ethical guide that

charges you with certain high standards of general

behavior as a member of the Armed Forces.

All professional interactions must be directly

related to codes of behavior that support the principles

of justice, equality of human beings as persons, and

respect for the dignity of human beings. Upholding

medical ethics is the responsibility of all Hospital

Corpsmen. Upon completion of basic Hospital Corps

School, you took the following pledge:

I solemnly pledge myself before God and

these witnesses to practice faithfully all of my

duties as a member of the Hospital Corps. I

hold the care of the sick and injured to be a

privilege and a sacred trust and will assist the

Medical Officer with loyalty and honesty. I

will hold all personal matters pertaining to the

private lives of patients in strict confidence. I

dedicate my heart, mind, and strength to the

work before me. I shall do all within my power

to show in myself an example of all that is

honorable and good throughout my naval

career.

This pledge morally binds you to certain

responsibilities and rules that are included in the

science of medical ethics. Ethics, whether they be

classified general or special (e.g., legal or medical),

teach us how to judge accurately the moral rightness

and wrongness of our actions. The one element that

makes healthcare ethics different from general ethics is

the inclusion of the moral rule, “Do your duty.” This

statement is a moral rule because it involves

expectations (e.g., of confidentiality). It involves what

others have every reason to believe will be

forthcoming. Failure to fulfill these expectations is to

do harm to your clients (i.e., your patients) and/or your

colleagues. Through the Hospital Corpsman Pledge,

you committed yourself to fulfilling certain duties, not

only to those entrusted to your care, but also to all

members of the healthcare team. It is this commitment

to service and to mankind that has traditionally

distinguished the United States Navy Hospital Corps

wherever its members have served.

PERSONAL TRAITS

LEARNING OBJECTIVE: Recognize

important personality traits of a healthcare

professional.

AHospital Corpsman must develop many personal

traits that apply to all petty officers. You can get a

general understanding of them by referring to Military

Requirements for Petty Officer Third Class

(NAVEDTRA 12024).

The following traits, however, apply especially to

your Hospital Corps duties and are essential for good

performance.

INTEGRITY

Nowhere in the Navy is the need for personal

integrity so great as in the Hospital Corps, where we

deal continually with people, their illnesses, and their

personal problems. The information that we have

access to falls into the category of “privileged

communication.” We, as Hospital Corpsmen, have no

right whatsoever to divulge any medical information,

however trivial, to any unauthorized individuals.

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Medical information is prime gossip material. The

prohibition on the release of medical information is

sometimes difficult to remember, but it is essential to

the maintenance of professional integrity.

One important commitment that all Corps

personnel have is the obligation never to abuse the

controlled substances that we have access to—or to

tolerate abuse by others. These substances are on the

ward or in the mount-out block for use, under a medical

officer’s supervision, for the care of patients. Any

other use must not be tolerated.

PERSONAL APPEARANCE

Excellent personal hygience habits, including

cleanliness, neat hair styles, and spotless, correct

uniforms are essential for the Hospital Corps. Our

appearance can positively or negatively influence the

opinion the public has of the medical community. Both

a professional appearance and attitude enhance the

overall reputation of the Navy Medical Department and

reinforce our role as competent healthcare providers.

LEADERSHIP

Naval leadership is based on personal example,

good management, and moral responsibility. All of the

personal traits previously discussed are also

considered leadership traits. You will learn that many

examples of effective leadership are those that are set

by officers, chief petty officers, and senior petty

officers. The success of the Medical Department rests

heavily on the petty officer. Good petty officers are the

backbone of the Medical Department, whether they are

supervising military personnel or conducting

specialist duties.

INTERPERSONAL RELATIONS

LEARNING OBJECTIVE: Recognize how

an understanding of a patient’s culture, race,

religion, sex, and age can affect interpersonal

relations.

As a healthcare provider, you must be able to

identify, understand, and use various kinds of

information. In addition, it is important that you

develop good “interpersonal relations” skills. In

providing total patient care, it is important that you see

the individual not only as a biological being, but also as

a thinking, feeling person. Your commitment to

understanding this concept is the key to your

developing good interpersonal relationships.

Simply stated, your interpersonal relationships are

the result of how you regard and respond to people.

Many elements influence the development of that

regard and those responses. In the following

discussion, some of these elements will be discussed as

they apply to your involvement in the military service

and to your relationships with other healthcare

providers and the patient.

CULTURE

Because of the multi- and cross-cultural nature and

military mission of the Navy Medical Department, you

will frequently encounter members of various cultures.

Culture is defined as a group of socially learned,

shared standards (norms) and behavior patterns.

Concepts such as perceptions, values, beliefs, and

goals are examples of shared norms. In addition,

apparel, eating habits, and personal hygiene reflect

common behavior patterns of specific groups of

people. An understanding of common norms and

behavior patterns enhances the quality—and often the

quantity—of service a provider is able to make

available. An individual’s cultural background has an

effect on every area of healthcare service, ranging from

a simple technical procedure to the content and

effectiveness of health education activities. Becoming

familiar with the beliefs and practices of different

cultural and subcultural groups (the military

community, for example) is not only enriching to the

healthcare provider, but also promotes an understanding and acceptance of the various peoples in the

world community.

RACE

The term race is a classification assigned to a

group of people who share inherited physical

characteristics. This term becomes a socially

significant reality since people tend to attach great

importance to assuming or designating a racial

identity. Information identifying racial affiliation can

be an asset to the healthcare provider in assessing the

patient’s needs, carrying out direct-care activities, and

planning and implementing patient education

programs. Racial identification has the potential to

create a negative environment in the healthcare setting

when factors such as skin color differences motivate

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prejudicial and segregational behaviors. When this is

permitted to occur, an environment that feeds a

multitude of social illnesses and destructive behaviors

develops. In the Navy Medical Department, no

expressions or actions based on prejudicial attitudes

will be tolerated.

It is both the moral and legal responsibility of the

healthcare provider to render services with respect for

the life and human dignity of the individual without

regard to race, creed, gender, political views, or social

status.

RELIGION

A large majority of people have some form of

belief system that guides many of their life decisions

and to which they turn to in times of distress. A

person’s religious beliefs frequently help give

meaning to suffering and illness; those beliefs may

also be helpful in the acceptance of future incapacities

or death.

As a healthcare professional, you must accept in a

nonjudgmental way the religious or nonreligious

beliefs of others as valid for them, even if you

personally disagree with such beliefs. Although you

may offer religious support when asked and should

always provide chaplain referrals when requested or

indicated, it is not ethical for you to abuse your

patients by forcing your beliefs (or nonbeliefs) upon

them. You must respect their freedom of choice,

offering your support for whatever their needs or

desires may be.

GENDER

In today’s Navy, you will encounter many

situations where you are responsible for the care and

treatment of service members of the opposite sex.

When you treat service members of the opposite sex,

you must always conduct yourself in a professional

manner.

To ensure the professional conduct of a healthcare

provider is not called into question, the Navy Medical

Department provides specific guidelines in

BUMEDINST 6320.83, Provisions of Standbys

During Medical Examinations. Some of these

guidelines are as follows:

• A standby should be present when you are

examining or treating a member of the opposite

sex. Whether this standby is a member of the

same sex as the patient may be dictated by the

availability of personnel.

• Common sense dictates that when you are caring

for a patient, sensitivity to both verbal and

nonverbal communication is paramount. A grin,

a frown, or an expression of surprise may all be

misinterpreted by the patient.

• Explanations and reassurances will go far in

preventing misunderstandings of actions or

intentions.

Knowledge, empathy, and mature judgment

should guide the care provided to any patient. This is

especially crucial when the care involves touching. As

a member of the healthcare team, you are responsible

for providing complete, quality care to those who need

and seek your service. This care must also be provided

in a manner compatible with your technical

capabilities.

AGE

The age of the patient must be considered in

performance of patient care. As a Hospital Corpsman,

you will be responsible for the care of infants, children,

adults, and the elderly. Communication techniques

and patient handling may need to be modified because

of the age of the patient.

Infants and Children

Infants can communicate their feelings in a variety of

positive and negative ways, and they exhibit their needs

by crying, kicking, or grabbing at the affected area of

pain. An infant, however, usually responds positively to

cuddling, rocking, touching, and soothing sounds.

Children need emotional support and display the

same feelings an adult would when ill: fear, anger,

worry, and so on. When ill, children may display

behavior typical for an earlier age. For example, when

hospitalized, a child who has been toilet trained may

soil himself. This is not unusual, and parents should be

informed that this behavior change is temporary.

While the child is under your care in the hospital, you

are a parent substitute and must gain the child’s

confidence and trust. Offer explanations of what you

are going to do in ways the child will understand.

Elderly

In taking care of the elderly patient, a healthcare

professional must be alert to the patient’s mental and

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physical capabilities (i.e., physical coordination,

mental orientation, reduced eyesight). Medical

management should be modified to accommodate the

individual patient. Show genuine respect and warmth

with the elderly. Avoid using terms like “gramps” or

“granny.” You should always show the elderly respect

by treating them as the adults they are.

Give older patients the opportunity to control as

many aspects of their self-care as possible. Allowing

patients to self-pace their own care may take more

time, but it will result in reducing their feelings of

frustration, anger, and resentment. Listen to patients

and allow them to reminisce if they wish to. The

conversation can be used as a vehicle to bring today’s

events into focus for the patient. Remember to involve

family members, as needed, into the patient education

process. Some of your elderly patients will require

assistance from family members for their medical

needs once they are back home.

COMMUNICATION SKILLS

LEARNING OBJECTIVE: Recognize

communication techniques used in a

healthcare setting.

Communication is a highly complicated interpersonal process of people relating to each other through

conversation, writing, gestures, appearance, behavior,

and, at times, even silence. Such communications not

only occur among healthcare providers and patients, but

also among healthcare providers and support personnel.

Support personnel may include housekeeping,

maintenance, security, supply, and food service staff.

Another critical communication interaction occurs

among healthcare providers and visitors. Because of the

critical nature of communication in healthcare delivery, it

is important that you understand the communication

process and the techniques used to promote open, honest,

and effective interactions. It is only through effective

communication that you are able to identify the goals of

the individual and the Navy healthcare system.

THE COMMUNICATION PROCESS

The human communication process consists of

four basic parts: the sender of the message, the

message, the receiver of the message, and feedback.

The sender of the message starts the process. The

message is the body of information the sender wishes

to transmit to the receiver. The receiver is the

individual intended to receive the message. Feedback

is the response given by the receiver to the message.

Feedback, at times, is used to validate whether

effective communication has taken place.

Verbal and Nonverbal

Communication

The two basic modes of communication are verbal

and nonverbal. Verbal communication is either spoken

or written. Verbal communication involves the use of

words. Nonverbal communication, on the other hand,

does not involve the use of words. Dress, gestures,

touching, body language, face and eye behavior, and

even silence are forms of nonverbal communication.

Remember that even though there are two forms of

communication, both the verbal and the nonverbal are

inseparable in the total communication process.

Conscious awareness of this fact is extremely

important because your professional effectiveness is

highly dependent upon successful communication.

Barriers to Effective

Communication

Ineffective communication occurs when obstacles

or barriers are present. These barriers are classified as

physiological, physical, or psychosocial.

Physiological barriers result from some kind of

sensory dysfunction on the part of either the sender or

the receiver. Such things as hearing impairments,

speech defects, and even vision problems influence the

effectiveness of communication. Physical barriers

consist of elements in the environment (such as noise)

that contribute to the development of physiological

barriers (such as the inability to hear). Psychosocial

barriers are usually the result of one’s inaccurate

perception of self or others; the presence of some

defense mechanism employed to cope with some form

of threatening anxiety; or the existence of factors such

as age, education, culture, language, nationality, or a

multitude of other socioeconomic factors.

Psychological barriers are the most difficult to identify

and the most common cause of communication failure

or breakdown. A person’s true feelings are often

communicated more accurately through nonverbal

communication than through verbal communication.

Listening

Listening, a critical element of the communication

process, becomes the primary activity for the

healthcare provider, who must use communication as a

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tool for collecting or giving information. When one is

engaged in listening, it is important to direct attention

to both the verbal and nonverbal cues provided by the

other person. Like many other skills necessary for

providing a healthcare service, listening requires

conscious effort and constant practice. Your listening

skills can be improved and enhanced by developing the

following attitudes and skills:

• Hear the speaker out.

• Focus on ideas.

• Remove or adjust distractions.

• Maintain objectivity.

• Concentrate on the immediate interaction.

As a healthcare provider, you will be using the

communication process to service a patient’s needs,

both short and long-term. To simplify this discussion,

short-term needs will be discussed under the heading

of “patient contact point.” Long-term needs will be

discussed under the heading of “therapeutic

communications.”

PATIENT CONTACT POINT

To give you a frame of reference for the following

discussion, the following definitions will clarify and

standardize some critical terms:

• Initial contact point—The physical location

where patients experience their first

communication encounter with a person

representing, in some role, the healthcare

facility.

• Contact point—The place or event where the

contact point person and the patient meet. The

contact point meeting can occur anywhere in a

facility and also includes telephone events.

• Contact point person—The healthcare

provider in any healthcare experience who is

tasked by role and responsibility to provide a

service to the patient.

The contact point person has certain criteria to

meet in establishing a good relationship with the

patient. Helping the patient through trying

experiences is partially the responsibility of all contact

point personnel. Such healthcare providers must not

only have skills related to their professional

assignment, but they must also have the ability to

interact in a positive, meaningful way to communicate

concern and the desire to provide a service.

Consumers of healthcare services expect to be

treated promptly, courteously, and correctly. They

expect their care to be personalized and communicated

to them in terms they understand. The Navy healthcare

system is a service system, and it is the responsibility

of every healthcare provider to give professional,

quality customer service.

The significance of the contact point and the

responsibility of the personnel staffing this area are

important to emphasize. The following message from

a former Surgeon General of the Navy reflects the

philosophy of the Navy Medical Department regarding

contact point interactions.

Some of the most frequent complaints

received by the Commander, Bureau of

Medicine and Surgery, are those pertaining to

the lack of courtesy, tact, and sympathetic

regard for patients and their families exhibited

by Medical Department personnel and initial

points of contact within Navy Medical

facilities. These points of initial patient

contact, which include central appointment

desks, telephones, patient affairs offices,

emergency rooms, pharmacies, laboratories,

record offices, information desks, walk-in and

specialty clinics, and gate guards, are critical

in conveying to the entering patient the sense

that Navy Medicine is there to help them. The

personnel, both military and civilian, who man

these critical areas are responsible for

ensuring that the assistance that they provide is

truly reflective of the spirit of “caring” for

which the Navy Medical Department must

stand.

No matter how excellent and expert the care in

the facility may be, an early impression of

nonchalance, disregard, rudeness, or neglect

of the needs of patients reflects poorly on its

efforts and achievements. Our personnel must

be constantly on their guard to refrain from

off-hand remarks or jokes in the presence of

patients or their families. We must insist that

our personnel in all patient areas are

professional in their attitudes. What may be

commonplace to us may be to a patient

frightening or subject to misinterpretation.

By example and precept, we must insist that, in

dealing with our beneficiaries, no complaint is

ever too trivial not to deserve the best response

of which we are capable....

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THERAPEUTIC COMMUNICATION

A distinguishing aspect of therapeutic

communication is its application to long-term communication interactions. Therapeutic communication is

defined as the face-to-face process of interacting that

focuses on advancing the physical and emotional

well-being of a patient. This kind of communication

has three general purposes: collecting information to

determine illness, assessing and modifying behavior,

and providing health education. By using therapeutic

communication, we attempt to learn as much as we can

about the patient in relation to his illness. To

accomplish this learning, both the sender and the

receiver must be consciously aware of the confidentiality of the information disclosed and received

during the communication process. You must always

have a therapeutic reason for invading a patient’s

privacy.

When used to collect information, therapeutic

communication requires a great deal of sensitivity as

well as expertise in using interviewing skills. To

ensure the identification and clarification of the

patient’s thoughts and feelings, you, as the interviewer,

must observe his behavior. Listen to the patient and

watch how he listens to you. Observe how he gives and

receives both verbal and nonverbal responses. Finally,

interpret and record the data you have observed.

As mentioned earlier, listening is one of the most

difficult skills to master. It requires you to maintain an

open mind, eliminate both internal and external noise

and distractions, and channel attention to all verbal and

nonverbal messages. Listening involves the ability to

recognize pitch and tone of voice, evaluate vocabulary

and choice of words, and recognize hesitancy or

intensity of speech as part of the total communication

attempt. The patient crying aloud for help after a fall is

communicating a need for assistance. This cry for help

sounds very different from the call for assistance you

might make when requesting help in transcribing a

physician’s order.

The ability to recognize and interpret nonverbal

responses depends upon consistent development of

observation skills. As you continue to mature in your

role and responsibilities as a member of the healthcare

team, both your clinical knowledge and understanding

of human behavior will also grow. Your growth in both

knowledge and understanding will contribute to your

ability to recognize and interpret many kinds of

nonverbal communication. Your sensitivity in

listening with your eyes will become as refined as—if

not better than—listening with your ears.

The effectiveness of an interview is influenced by

both the amount of information and the degree of

motivation possessed by the patient (interviewee).

Factors that enhance the quality of an interview consist

of the participant’s knowledge of the subject under

consideration; his patience, temperament, and

listening skills; and your attention to both verbal and

nonverbal cues. Courtesy, understanding, and

nonjudgmental attitudes must be mutual goals of both

the interviewee and the interviewer.

Finally, to function effectively in the therapeutic

communication process, you must be an informed and

skilled practitioner. Your development of the required

knowledge and skills is dependent upon your

commitment to seeking out and participating in

continuing education learning experiences across the

entire spectrum of healthcare services.

PATIENT EDUCATION

LEARNING OBJECTIVE: Recognize the

importance of patient education.

Patient (health) education is an essential part of the

healthcare delivery system. In the Navy Medical

Department, patient education is defined as “the

process that informs, motivates, and helps people

adapt and maintain healthful practices and life styles.”

Specifically, the goals of this process are to

• assist individuals acquire knowledge and skills

that will promote their ability to care for

themselves more adequately;

• influence individual attitudinal changes from an

orientation that emphasizes disease to an

orientation that emphasizes health; and

• support behavioral changes to the extent that

individuals are willing and able to maintain their

health.

All healthcare providers, whether they recognize it

or not, are teaching almost constantly. Teaching is a

unique skill that is developed through the application

of principles of learning. Patient teaching begins with

an assessment of the patient’s knowledge. Through

this assessment, learning needs are identified. For

example, a diabetic patient may have a need to learn

how to self-administer an injection. After the learner’s

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needs have been established, goals and objectives are

developed. Objectives inform the learner of what kind

of (learned) behavior is expected. Objectives also

assist the healthcare provider in determining how

effective the teaching has been. These basic principles

of teaching/learning are applicable to all patienteducation activities, from the simple procedure of

teaching a patient how to measure and record fluid

intake/output to the more complex programs of

behavior modification in situations of substance abuse

(i.e., drug or alcohol) or weight control.

As a member of the healthcare team, you share a

responsibility with all other members of the team to be

alert to patient education needs, to undertake patient

teaching within the limitation of your own knowledge

and skills, and to communicate to other team members

the need for patient education in areas you are not

personally qualified to undertake.

REPORTING AND ASSESSMENT

PROCEDURES

LEARNING OBJECTIVE: Recall proper

patient care reporting and assessment

procedures.

Although physicians determine the overall

medical management of a person requiring healthcare

services, they depend upon the assistance of other

members of the healthcare team when implementing

and evaluating that patient’s ongoing treatment.

Nurses and Hospital Corpsmen spend more time with

hospitalized patients than all other providers. This

situation places them in a key position as datacollecting and -reporting resource persons.

The systematic gathering of information is called

data collection and is an essential aspect in assessing

an individual’s health status, identifying existing

problems, and developing a combined plan of action to

assist the patient in his health needs. The initial

assessment is usually accomplished by establishing a

health history. Included in this history are elements

such as previous and current health problems; patterns

of daily living activities, medication, and dietary

requirements; and other relevant occupational, social,

and psychological data. Additionally, both subjective

and objective observations are included in the initial

assessment gathering interview and throughout the

course of hospitalization.

REPORTING

Accurate and intelligent assessments are the basis

of good patient care and are essential elements for

providing a total healthcare service. You must know

what to watch for and what to expect. It is important to

be able to recognize even the slightest change in a

patient’s condition, since such changes indicate a

definite improvement or deterioration. You must be

able to recognize the desired effects of medication and

treatments, as well as any undesirable reactions to

them. Both of these factors may influence the

physician’s decision to continue, modify, or

discontinue parts or all of the treatment plan.

Oral and Written Reporting

Equally as important as assessments is the

reporting of data and observations to the appropriate

team members. Reporting consists of both oral and

written communications and, to be effective, must be

done accurately, completely, and in a timely manner.

Written reporting, commonly called recording, is

documented in a patient’s clinical record. Maintaining

an accurate, descriptive clinical record serves a dual

purpose: It provides a written report of the information

gathered about the patient, and it serves as a means of

communication to everyone involved in the patient’s

care. The clinical record also serves as a valuable

source of information for developing a variety of

care-planning activities. Additionally, the clinical

record is a legal document and is admissible as

evidence in a court of law in claims of negligence and

malpractice. Finally, these records serve as an

important source of material that can be used for

educating and training healthcare personnel and for

conducting research and compiling statistical data.

Basic Guidelines for Written Entries

It is imperative that you follow some basic

guidelines when you make written entries in the

clinical record. All entries must be recorded

accurately and truthfully. Omitting an entry is as

harmful as making an incorrect recording. Each entry

should be concise and brief; therefore, avoid extra

words and vague notations. Recordings must be

legible. If an error is made, it must be deleted

following the standard Navy policy for correcting

erroneous written notations. Finally, your entries in

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the clinical record must include the time and date, your

signature, and your rate or rank.

SOAP Note Format

SOAP stands for SUBJECTIVE, OBJECTIVE,

ASSESSMENT, and PLAN. Medical documentation

of patient complaint(s) and treatment must be

consistent, concise, and comprehensive. The Navy

Medical Department uses the SOAP note format to

standardize medical evaluation entries made in clinical

records. The four parts of a SOAP note are discussed

below. For more detailed instructions, refer to chapter

16 of the MANMED.

SUBJECTIVE.—The initial portion of the SOAP

note format consists of subjective observations. These

are symptoms verbally given to you by the patient or by

a significant other (family or friend). These subjective

observations include the patient’s descriptions of pain

or discomfort, the presence of nausea or dizziness, and

a multitude of other descriptions of dysfunction,

discomfort, or illness.

OBJECTIVE.—The next part of the format is the

objective observation. These objective observations

include symptoms that you can actually see, hear,

touch, feel, or smell. Included in objective

observations are measurements such as temperature,

pulse, respiration, skin color, swelling, and the results

of tests.

ASSESSMENT.—Assessment follows the

objective observations. Assessment is the diagnosis of

the patient’s condition. In some cases the diagnosis

may be clear, such as a contusion. However, an

assessment may not be clear and could include several

diagnosis possibilities.

PLAN.—The last part of the SOAP note is the

plan. The plan may include laboratory and/or

radiologic tests ordered for the patient, medications

ordered, treatments performed (e.g., minor surgery

procedure), patient referrals (sending patient to a

specialist), patient disposition (e.g., binnacle list,

Sick-in-Quarters (SIQ), admission to hospital), patient

directions, and follow-up directions for the patient.

SELF-QUESTIONING TECHNIQUES

FOR PATIENT ASSESSMENT AND

REPORTING

Table 2-1 outlines the self-questioning techniques

for patient assessment and reporting is a good guide to

assist you in developing proficiency in assessing and

reporting patient conditions.

INPATIENT CARE

A patient will often require inpatient care, whether

due to injury or illness. Frequently, the inpatient will

need specialized treatments, perhaps even surgery. In

this part of the chapter, we will discuss the procedures

for assisting both the medical inpatient and the surgical

inpatient.

THE MEDICAL PATIENT

LEARNING OBJECTIVE: Evaluate the

needs of a medical patient.

For purposes of this discussion, the term medical

patient applies to any person who is receiving

diagnostic, therapeutic, and/or supportive care for a

condition that is not managed by surgical-,

orthopedic-, psychiatric-, or maternity-related therapy.

This is not to infer that patients in these other

categories are not treated for medical problems. Many

surgical, orthopedic, psychiatric, and maternity

patients do have secondary medical problems that are

treated while they are undergoing management for

their primary condition. Although many medical

problems can be treated on an outpatient basis, this

discussion will address the hospitalized medical

patient. It should be noted that the basic principles of

management are essentially the same for both the

inpatient and outpatient.

The medical management of the patient generally

consists of laboratory and diagnostic tests and

procedures, medication, food and fluid therapy, and

patient teaching. Additionally, for many medical

patients, particularly during the initial treatment phase,

rest is a part of the prescribed treatment.

Laboratory Tests And Diagnostic Procedures

A variety of laboratory and diagnostic tests and

procedures are commonly ordered for the medical

patient. Frequently, the Hospital Corpsman is assigned

to prepare the patient for the procedure, collect the

specimens, or assist with both the procedure and

specimen collection. Whether a specimen is to be

collected or a procedure is to be performed, the patient

needs a clear and simple explanation about what is to

2-11
2-12

Area of Concern Assessment Criteria

General Appearance Is the patient

• of average build, short, tall, thin, or obese?

• well-groomed?

• apparently in pain?

• walking with a limp, wearing a cast, walking on crutches, or wearing a prosthetic extremity?

Behavior Does the patient

• appear worried, nervous, excited, depressed, angry, disoriented, confused, or unconscious?

• refuse to talk?

• communicate thoughts in a logical order or erratically?

• lisp, stutter, or have slurred speech?

• appear sullen, bored, aggressive, friendly, or cooperative?

• sleep well or arouse early?

• sleep poorly, moan, talk, or cry out when sleeping?

• join ward activities?

• react well toward other patients, staff, and visitors?

Position Does the patient

• remain in one position in bed?

• have difficulty breathing while in any position?

• use just one pillow or require more pillows to sleep well?

• move about in bed without difficulty?

Skin Is the patient’s skin

• flushed, pale, cyanotic (bluish hue), hot, moist, clammy, cool, or dry?

• bruised, scarred, lacerated, scratched, or showing a rash, lumps, or ulcerations?

• showing signs of pressure, redness, mottling, edema, or pitting edema?

• appearing shiny or stretched?

• perspiring profusely?

• infested with lice?

Eyes Are the patient’s

• eyelids swollen, bruised, discolored, or dropping?

• sclera (whites of eyes) clear, dull, yellow, or bloodshot?

• pupils constricted or dilated, equal in size, react equally to light?

• eyes tearing or showing signs of inflammation or discharge?

• complaints about pain; burning; itching; sensitivity to light; or blurred, double, or lack of vision?

Ears Does the patient

• hear well bilaterally?

• hold or pull on his ears?

• complain of a buzzing or ringing sound?

• have a discharge or wax accumulation?

• complain of pain?

Nose Is the patient’s

• nose bruised, bleeding, or difficult to breathe through?

• nose excessively dry or dripping?

Are the patient’s nares (nasal openings) equal in size?

Is the patient sniffling excessively?

Mouth Does the patient’s

• mouth appear excessively dry?

• breath smell sweet, sour, or of alcohol?

• tongue appear dry, moist, clean, coated, cracked, red, or swollen?

• gums appear inflamed, ulcerated, swollen, or discolored?

• teeth appear white, discolored, broken, or absent?

Does the patient

• wear dentures, braces, or partial plates?

• complain of mouth pain or ulcerations?

• complain of an unpleasant taste?

Table 2–1.—Self-Questioning Techniques for Patient Assessment and Reporting
2-13

Area of Concern Assessment Criteria

Chest Does the patient

• have shortness of breath, wheezing, gasping, or noisy respirations? cough?

• have a dry, moist, hacking, productive, deep, or persistent cough?

• have white, yellow, rusty, or bloody sputum?

 ̄ Is it thin and watery or thick and purulent (containing pus)?

 ̄ How much is produced?

 ̄ Does it have an odor?

• complain of chest pain?

 ̄ Where is the pain?

 ̄ Is the pain a dull ache, sharp, crushing, or radiating?

 ̄ Is the pain relieved by resting?

 ̄ Is the patient using medication to control the pain (i.e., nitroglycerin)?

Abdomen Does the patient

• have an abdomen that looks or feels distended, boardlike, or soft?

• have a distended abdomen, and, if so, is the abdomen distended above or below the umbilicus or over the

entire abdomen?

• belch excessively?

• feel nauseated, or has he vomited?

 ̄ If so, how often, and when?

 ̄ What is the volume, consistency, and odor of the vomitus?

 ̄ Is it coffee ground, bilious (containing bile), or bloody in appearance?

 ̄ Is patient vomiting with projectile force?

Bladder & Bowel Does the patient have

• bladder and bowel control?

• normal urination volume and frequency?

 ̄ Does the urine have an odor?

 ̄ Is the urine dark amber or bloody?

 ̄ Is the urine cloudy; does it have sediment in it?

 ̄ Is there pain, burning, or difficulty when voiding?

• diarrhea, soft stools, or constipation?

 ̄ What is the color of the stool?

 ̄ Does the stool contain blood, pus, fat, or worms?

 ̄ Does the patient have hemorrhoids, fistulas, or rectal pain?

Vagina or Penis Does the patient have

• ulcerations or irritations?

• a discharge or foul odor?

 ̄ If there is a discharge present, is it bloody, purulent, mucoid (containing mucous), or watery?

 ̄ What is the amount?

• associated pain?

 ̄ If pain is present, where is it located?

 ̄ Is it constant or intermittent?

 ̄ Is it tingling, dull, aching, burning, gnawing, cramping, or crushing?

Food & Fluid Intake Does the patient

• have a good, fair, or poor appetite?

• get thirsty often?

• have any kind of food intolerance?

Medications Does the patient

• take any medications? (If so: what, why, and when last taken?)

• have medications with him?

• have any history of medication reactions or allergies?

Table 2–1.—Self-Questioning Techniques for Patient Assessment and Reporting3⁄4Continued
be done and what the patient can do to assist with the

activity. Often the success of the test or procedure is

dependent upon the patient’s informed cooperation.

When collecting specimens, the Hospital Corpsman

must complete the following procedures:

• Collect the correct kind and amount of specimen

at the right time.

• Place the specimen in the correct container.

• Label the container completely and accurately.

This often differs somewhat for each facility, and

local policies should be consulted.

• Complete the laboratory request form

accurately.

• Record on the patient’s record or other forms, as

appropriate; the date, time, kind of specimen

collected; the disposition of the specimen; and

anything unusual about the appearance of the

specimen or the patient during the collection.

When assisting with a diagnostic procedure, the

Hospital Corpsman must understand the sequence of

steps of the procedure and exactly how the assistance

can best be provided. Since many procedures

terminate in the collection of a specimen, the above

principles of specimen collecting must be followed.

Following the completion of a procedure or

specimen collection, it is the responsibility of the

assisting Hospital Corpsman to ensure that the

patient’s safety and comfort are attended to, the

physician’s orders accurately followed, and any

supplies or equipment used appropriately discarded.

Medications

Amajor form of therapy for the treatment of illness

is the use of drugs. It is not uncommon for the medical

patient to be treated with several drugs. As members of

the healthcare team, Hospital Corpsmen assigned to

preparing and administering medications are given a

serious responsibility demanding constant vigilance,

integrity, and special knowledge and skills. The

preparation and administration of medications were

addressed in great detail in the Hospital Corps School

curriculum. References and the continued in-service

training devoted to medication administration at all

medical facilities support the importance of accurate

preparation and administration of drugs.

An error—which also includes omissions—can

seriously affect a patient, even to the point of causing

death. Each Hospital Corpsman is responsible for his

own actions, and this responsibility cannot be

transferred to another. No one individual is expected to

know all there is to know about all patients and

medications. However, in every healthcare

environment, the Hospital Corpsman can access other

healthcare providers who can assist in clarifying

orders; explaining the purposes, actions, and effects of

drugs; and, in general, answering any questions that

may arise concerning a particular patient and that

patient’s medications. There should be basic drug

references available to all personnel handling

medications, including the Physicians’Desk Reference

and a hospital formulary. As a Hospital Corpsman, it is

your responsibility to consult these members of the

team and these references for assistance in any area in

which you are not knowledgeable or whenever you

have questions or doubts. You are also responsible for

knowing and following local policies and procedures

regarding the administration of medications.

Food and Fluid Therapy

The following brief discussion covers food and

fluid and how it relates specifically to the medical

patient. Loss of appetite, food intolerance, digestive

disturbances, lack of exercise, and even excessive

weight gain influence a medical patient’s intake

requirements. Regardless of their medical problems,

patients have basic nutritional needs that frequently

differ from those of the healthy person. As a part of the

patient’s therapeutic regimen, food is usually

prescribed in the form of a special diet. Regardless of

the kind of diet prescribed, the patient must understand

why certain foods are ordered or eliminated, and how

compliance with the regimen will assist in his total

care. It is the responsibility of the Corpsman to assist

the patient in understanding the importance of the

prescribed diet and to ensure that accurate recording of

the patient’s dietary intake is made on the clinical

record.

In many disease conditions, the patient is unable to

tolerate food or fluids or may lose these through

vomiting, diarrhea, or both. In these cases,

replacement fluids as well as nutrients are an important

part of the patient’s medical management. On the other

hand, there are several disease conditions in which

fluid restrictions are important aspects of the patient’s

therapy. In both of these instances, accurate

measurement and recording of fluid intake and output

must be carefully performed. Very frequently this

becomes a major task of the staff Hospital Corpsman.

2-14
Patient Teaching

Earlier in this chapter, under “Patient Education,”

the goals and principles of patient teaching were

addressed. When taken in the context of the medical

patient, there are some general areas of patient

teaching needs that must be considered, particularly as

the patient approaches discharge from an inpatient

status. Those areas include the following:

• Follow-up appointments

• Modification in daily living activities and habits

• Modification in diet, including fluid intake

• Medications and treatment to be continued after

discharge

• Measures to be taken to promote health and

prevent illness

Rest

The primary reason for prescribing rest as a

therapeutic measure for the medical patient is to

prevent further damage to the body or a part of the body

when the normal demand of use exceeds the ability to

respond. However, prolonged or indiscriminate use of

rest—particularly bed rest—is potentially hazardous.

Some of the common complications occurring as a

result of prolonged bed rest are

• circulatory problems (such as development of

thrombi and emboli) and subsequent skin

problems (such as decubiti);

• respiratory problems (such as atelectasis and

pneumonia);

• gastrointestinal problems (such as anorexia,

constipation, and fecal impactions);

• urinary tract problems (such as retention,

infection, or the formation of calculi);

• musculoskeletal problems (such as weakness,

atrophy, and the development of contractures);

and

• psychological problems (such as apathy,

depression, and temporary personality changes).

The prevention of complications is the key concept

in therapeutic management for the patient on

prolonged bed rest. Awareness of the potential hazards

is the first step in prevention. Alert observations are

essential: Skin condition, respirations, food and fluid

intake, urinary and bowel habits, evidence of

discomfort, range of motion, and mood are all critical

elements that provide indications of impending

problems. When this data is properly reported, the

healthcare team has time to employ measures that will

arrest the development of preventable complications.

THE SURGICAL PATIENT

LEARNING OBJECTIVE: Evaluate the

needs of a surgical patient during the

preoperative, operative, recovery, and

postoperative phases of his treatment.

Surgical procedures are classified into two major

categories: emergency and elective. Emergency

surgery is that required immediately to save a life or

maintain a necessary function. Elective surgery is that

which, in most cases, needs to be done but can be

scheduled at a time beneficial to both the patient and

the provider. Regardless of the type of surgery, every

surgical patient requires specialized care at each of

four phases. These phases are classified as

preoperative, operative, recovery, and

postoperative. The following discussion will address

the basic concepts of care in each phase.

Preoperative Phase

Before undergoing a surgical procedure, the

patient must be in the best possible psychological,

spiritual, and physical condition. Psychological

preparation begins the moment the patient learns of the

necessity of the operation. The physician is

responsible for explaining the surgical procedure to the

patient, including the events that can be expected after

the procedure. Since other staff personnel reinforce

the physician’s explanation, all members of the team

must know what the physician has told the patient. In

this manner, they are better able to answer the patient’s

questions. All patients approaching surgery are fearful

and anxious. The staff can assist in reducing this fear

by instilling confidence in the patient regarding the

competence of those providing care. The patient

should be given the opportunity and freedom to

express any feelings or fears concerning the proposed

procedure. Even in an emergency, it is possible to give

a patient and the family psychological support. Often

this is accomplished simply by the confident and

skillful manner in which the administrative and

physical preoperative preparation is performed.

2-15
The fears of presurgical patients derive from their

insecurities in the areas of anesthesia, body

disfigurement, pain, and even death. Frequently,

religious faith is a source of strength and courage for

these patients. If a patient expresses a desire to see a

clergyman, every attempt should be made to arrange a

visit.

ADMINISTRATIVE PREPARATION.—

Except in emergencies, the administrative preparation

usually begins before surgery. A step-by-step

procedure is outlined in Fundamental Skills and

Concepts in Patient Care, “Caring for the Patient

Undergoing Surgery.” Only the Request for

Administration of Anesthesia and for Performance of

Operations and Other Procedures (SF 522) will be

addressed here. The SF 522 identifies the operation or

procedure to be performed; has a statement written for

the patient indicating in lay terms a description of the

procedure; and includes the signatures of the

physician, patient, and a staff member who serves as a

witness. An SF 522 must be completed before any

preoperative medications are administered. If the

patient is not capable of signing the document, a

parent, legal guardian, or spouse may sign it. It is

customary to require the signature of a parent or legal

guardian if the patient is under 21 years of age, unless

the patient is married or a member of the Armed

Forces. In these latter two cases, the patient may sign

his own permit, regardless of age.

Normally, the physical preparation of the patient

begins in the late afternoon or early evening the day

before surgery. As with the administrative

preparation, each step is clearly outlined in

Fundamental Skills and Concepts in Patient Care,

“Caring for the Patient Undergoing Surgery.”

PREOPERATIVE INSTRUCTIONS.—

Preoperative instructions are an important part of the

total preparation. The exact time that preoperative

teaching should be initiated greatly depends upon the

individual patient and the type of surgical procedure.

Most experts recommend that preoperative

instructions be given as close as possible to the time of

surgery. Appropriate preoperative instructions given

in sufficient detail and at the proper time greatly reduce

operative and postoperative complications.

Operative Phase

The operative (or intra-operative) phase begins the

moment the patient is taken into the operating room.

Two of the major factors to consider at this phase are

positioning and anesthesia.

POS IT ION ING.—The specific surgical

procedure will dictate the general position of the

patient. For example, the lithotomy position is used

for a vaginal hysterectomy, while the dorsal

recumbent position is used for a herniorrhaphy.

Regardless of the specific position the patient is placed

in, there are some general patient safety guidelines that

must be observed. When positioning a patient on the

operating table, remember the following:

• Whether the patient is awake or asleep, place the

patient in as comfortable a position as possible.

• Strap the patient to the table in a manner that

allows for adequate exposure of the operative

site and is secure enough to prevent the patient

from falling, but that does not cut off circulation

or contribute to nerve damage.

• Secure all the patient’s extremities in a manner

that will prevent them from dangling over the

side of the table.

• Pad all bony prominences to prevent the

development of pressure areas or nerve damage.

• Make sure the patient is adequately grounded to

avoid burns or electrical shock to either the

patient or the surgical team.

ANESTHESIA.—One of the greatest

contributions to medical science was the introduction

of anesthesia. It relieves unnecessary pain and

increases the potential and scope of many kinds of

surgical procedures. Therefore, healthcare providers

must understand the nature of anesthetic agents and

their effect on the human body.

Anesthesia may be defined as a loss of sensation

that makes a person insensible to pain, with or without

loss of consciousness. Some specific anesthetic agents

are discussed in the “Pharmacy” chapter of this

manual. Healthcare providers must understand the

basics of anesthesiology as well as a specific drug’s

usage.

The two major classifications of anesthesia are

regional and general.

Regional Anesthesia.—Regional anesthetics

reduce all painful sensations in a particular area of the

body without causing unconsciousness. The following

is a listing of the various methods and a brief

description of each.

2-16
• Topical anesthesia is administered topically to

desensitize a small area of the body for a very

short period.

• Local blocks consist of the subcutaneous

infiltration of a small area of the body with a

desensitizing agent. Local anesthesia generally

lasts a little longer than topical.

• Nerve blocks consist of injecting the agent into

the region of a nerve trunk or other large nerve

branches. This form of anesthesia blocks all

impulses to and from the injected nerves.

• Spinal anesthesia consists of injecting the agent

into the subarachnoid space of the spinal canal

between the third and fourth lumbar space or

between the fifth lumbar and first sacral space of

the spinal column. This form of anesthesia

blocks all impulses to and from the entire area

below the point of insertion, provided the

patient’s position is not changed following

injection of the agent. If the patient’s position is

changed, for example, from dorsal recumbent to

Trendelenburg’s, the anesthetic agent will move

up the spinal column and the level of the

anesthesia will also move up. Because of this

reaction, care must be exercised in positioning

the patient’s head and chest above the level of

insertion to prevent paralysis (by anesthesia) of

the respiratory muscles. In general, spinal

anesthesia is considered the safest for most

routine major surgery.

• Epidural blocks consist of injecting the agent

into the epidural space of the spinal canal at any

level of the spinal column. The area of

anesthesia obtained is similar to that of the

subarachnoid spinal method. The epidural

method is frequently used when continuous

anesthesia is desired for a prolonged period. In

these cases, a catheter is inserted into the

epidural space through a spinal needle. The

needle is removed, but the catheter is left in

place. This provides for continuous access to the

epidural space.

• Saddle blocks consist of injecting the agent into

the dural sac at the third and fourth lumbar space.

This form of anesthesia blocks all impulses to

and from the perineal area of the body.

• Caudal blocks consist of injecting the agent into

the sacral canal. With this method, anesthesia is

obtained from the umbilicus to the toes.

General Anesthesia.—General anesthetics cause

total loss of sensation and complete loss of

consciousness in the patient. They are administered by

inhalation of certain gases or vaporized liquids,

intravenous infusion, or rectal induction. The

induction of inhalation anesthesia is divided into four

stages. These stages and the body’s main

physiological reaction in each phase are explained

below and depicted in figure 2–1.

• Stage 1 is called the stage of analgesia or

induction. During this period, the patient

experiences dizziness, a sense of unreality, and a

lessening sensitivity to touch and pain. At this

stage, the patient’s sense of hearing is increased,

and responses to noises are intensified (fig. 2-1).

• Stage 2 is the stage of excitement. During this

period, there is a variety of reactions involving

muscular activity and delirium. At this stage, the

vital signs show evidence of physiological

stimulation. It is important to remember that

during this stage the patient may respond

violently to very little stimulation (fig. 2–1).

• Stage 3 is called the surgical or operative stage.

There are four levels of consciousness (also

called planes) to this stage. It is the

responsibility of the anesthetist or

anesthesiologist to determine which plane is

optimal for the procedure. The determination is

made according to specific tissue sensitivity of

2-17

Figure 2–1.—Stages of anesthesia.
the individual and the surgical site. Each

successive plane is achieved by increasing the

concentration of the anesthetic agent in the tissue

(fig. 2–1).

• Stage 4 is called the toxic or danger stage.

Obviously, this is never a desired stage of

anesthesia. At this point, cardiopulmonary

failure and death can occur. Once surgical

anesthesia has been obtained, the healthcare

provider must exercise care to control the level

of anesthesia. The fourth level of consciousness

of stage 3 is demonstrated by cardiovascular

impairment that results from diaphragmatic

paralysis. If this plane is not corrected

immediately, stage 4 quickly ensues (fig. 2–1).

Recovery Stage

For purposes of this discussion, the recovery phase

consists of the period that begins at the completion of

the operation and extends until the patient has

recovered from anesthesia. The recovery phase

generally takes place in a specialized area called the

recovery room. This unit is usually located near the

operating room and has access to the following:

• Surgeons and anesthesiologists or anesthetists

• Nurses and Hospital Corps personnel who are

specially prepared to care for immediate

postoperative patients

• Special equipment, supplies, medication, and

replacement fluids

From the time of admission to patient discharge,

routine care in the recovery room consists of the

following:

• Measuring temperature and vital signs (taken

immediately upon admission and as ordered by

the physician thereafter)

• Maintaining airway patency

—Patients having an artificial airway in place

will automatically expel it as they regain

consciousness.

—Have a mechanical suction apparatus

available to remove excess excretions from

the patient’s airway.

• Ensuring the integrity of dressings, tubes,

catheters and casts

—Locate the presence of any of the above.

—Make notations regarding all drainage,

including color, type, and amount.

—Immediately report the presence of copious

amounts of drainage to a nurse or physician.

• Monitoring intravenous therapy (including

blood and blood components)

—Make notations including type of infusion,

rate of flow, and condition of the infusion site.

—Observe patients receiving blood or blood

components closely for untoward reactions.

• Monitoring skin color changes

—Check dressings and casts frequently to

ensure they are not interfering with normal

blood circulation to the area.

—Notify a physician or nurse of general skin

color changes that may indicate airway

obstruction, hemorrhage, or shock.

• Assessing level of responsiveness

—For general anesthetics, check for orientation

to the environment each time vital signs are

taken.

—For regular anesthetics, check for return of

sensory perception and voluntary movement

each time vital signs are taken.

• Observing for side effects of the anesthetic agent

—Each agent has the potential for causing

specific side effects. Some common major

side effects that may occur following the

administration of both spinal and general

anesthesia consist of the following:

• Hypotension/shock

• Respiratory paralysis

• Neurological complications

• Headache

• Cardiac arrest

• Respiratory depression

• Bronchospasm/laryngospasm

• Diminished circulation

• Vomiting/aspiration

2-18
Postoperative Phase

After the patient’s condition has been stabilized in

the recovery room, a physician will order the patient’s

transfer to another area of the facility. Generally, this

transfer is to the unit that the patient was assigned to

preoperatively. Since both surgery and anesthesia

have unavoidable temporary ill effects on normal

physiological functions, every effort must be made to

prevent postoperative complications.

POSTOPERATIVE GOALS.—From the time

the patient is admitted to the recovery room to the time

recovery from the operation is complete, there are

definite goals of care that guide the entire

postoperative course. These goals are as follows:

• Promoting respiratory function

• Promoting cardiovascular function

• Promoting renal function

• Promoting nutrition and elimination

• Promoting fluid and electrolyte balance

• Promoting wound healing

• Encouraging rest and comfort

• Encouraging movement and ambulation

• Preventing postoperative complications

The physician will write orders for postoperative

care that are directed at accomplishing the above goals.

Although the orders will be based on each individual

patient’s needs, there will be some common orders that

apply to all patients. These orders will center around

the promotion of certain physiological functions and

areas addressed in the following paragraphs.

Respiratory function is promoted by

encouraging frequent coughing and deep breathing.

Early movement and ambulation also help improve

respiratory function. For some patients, oxygen

therapy may also be ordered to assist respiratory

function. Cardiovascular function is assisted by

frequent position changes, early movement and

ambulation, and, in some cases, intravenous therapy.

Renal function is promoted by adequate fluid intake

and early movement and ambulation. Nutritional

status is promoted by ensuring adequate oral and

correct intravenous intake and by maintaining accurate

intake and output records. Elimination functions are

promoted by adequate diet and fluid intake.

Postoperative patients should be advanced to a normal

dietary regimen as soon as possible, since this, too,

promotes elimination functions. Early movement and

ambulation also help to restore normal elimination

activities.

In addition to various medications and dressing

change procedures ordered by the physician, wound

healing is promoted by good nutritional intake and by

early movement and ambulation. Rest and comfort

are supported by properly positioning the patient,

providing a restful environment, encouraging good

basic hygiene measures, ensuring optimal bladder and

bowel output, and promptly administering

pain-relieving medications. Early movement and

ambulation are assisted by ensuring maximum

comfort for the patient and providing the

encouragement and support for ambulating the patient,

particularly in the early postoperative period. As

indicated in the above discussion, the value of early

movement and ambulation, when permissible, cannot

be overemphasized.

POSTOPERATIVE COMPLICATIONS.—

During the early postoperative phase, the major

complications to be guarded against are respiratory

obstruction, shock, and hemorrhage. As the patient

progresses in the postoperative period, other

complications to avoid are the development of

pneumonia, phlebitis and subsequent

thrombophlebitis, gastrointestinal problems ranging

from abdominal distention to intestinal obstruction,

and, finally, wound infections. Accurate

implementation of the physician’s orders and careful

observation, reporting, and recording of the patient’s

condition will contribute markedly to an optimal and

timely postoperative recovery course for the patient.

THE ORTHOPEDIC PATIENT

LEARNING OBJECTIVE: Evaluate the

needs of the orthopedic patient.

Patients receiving orthopedic services are those

who require treatment for fractures, deformities, and

diseases or injuries of some part of the musculoskeletal

system. Some patients will require surgery,

immobilization, or both to correct their condition.

General Care

The basic principles and concepts of care for the

surgical patient will apply to orthopedic patients. The

majority of patients not requiring surgical intervention

2-19
will be managed by bed rest, immobilization, and

rehabilitation. Many of the basic concepts of care of

the medical patient are applicable for orthopedic

patient care. In the military, the usual orthopedic

patient is fairly young and in good general physical

condition. For these patients, bed rest is prescribed

only because other kinds of activity are limited by their

condition on admission.

Immobilization

Rehabilitation is the ultimate goal when planning

the orthopedic patient’s total management. Whether

the patient requires surgical or conservative treatment,

immobilization is often a part of the overall therapy.

Immobilization may consist of applying casts or

traction, or using equipment (such as orthopedic

frames). During the immobilization phase, simple

basic patient care is extremely important. Such things

as skin care, active-passive exercises, position changes

in bed (as permitted), good nutrition, adequate fluid

intake, regularity in elimination, and basic hygiene

contribute to both the patient’s physical and psychological well-being.

Lengthy periods of immobilization are

emotionally stressful for patients, particularly those

who are essentially healthy except for the limitations

imposed by their condition. Prolonged inactivity

contributes to boredom that is frequently manifested

by various kinds of acting-out behavior.

Often, the orthopedic patient experiences

exaggerated levels of pain. Orthopedic pain is

commonly described as sore and aching. Because this

condition requires long periods of treatment and

hospitalization, the wise management of pain is an

important aspect of care. Constant pain, regardless of

severity, is energy consuming. You should make every

effort to assist the patient in conserving this energy.

There are times when the patient’s pain can and should

be relieved by medications. There are, however,

numerous occasions when effective pain relief can be

provided by basic patient-care measures such as proper

body alignment, change of position, use of heat or cold

(if permitted by a physician’s orders), back rubs and

massages, and even simple conversation with the

patient. Meaningful activity also has been found to

help relieve pain. Whenever possible, a well-planned

physical/occupational therapy regimen should be an

integral part of the total rehabilitation plan.

CAST FABRICATION.—As mentioned

previously, immobilization is often a part of the overall

therapy of the orthopedic patient, and casting is the

most common and well-known form of long-term

immobilization. In some instances, a Corpsman may

be required to assist in applying a cast or be directed to

apply or change a cast. In this section, we will discuss

the method of applying a short and long arm cast, and a

short leg cast.

In applying any cast, the basic materials are the

same: webril or cotton bunting, plaster of Paris, a

bucket or basin of tepid water, a water source (tap

water), protective linen, gloves, a working surface, a

cast saw, and seating surfaces for the patient and the

Corpsman. Some specific types of casts may require

additional material.

SHORT ARM CAST.—A short arm cast extends

from the metacarpal-phalangeal joints of the hand to

just below the elbow joint. Depending on the location

and type of fracture, the physician may order a specific

position for the arm to be casted. Generally, the wrist is

in a neutral (straight) position, with the fingers slightly

flexed in the position of function.

Beginning at the wrist, apply three layers of webril

(fig. 2–2A). Then apply webril to the forearm and the

hand, making sure that each layer overlaps the other by

a third (as shown in figure 2–2B). Check for lumps or

wrinkles and correct any by tearing the webril and

smoothing it.

Dip the plaster of Paris into the water for

approximately 5 seconds. Gently squeeze to remove

excess water, but do not wring out. Beginning at the

wrist (fig. 2–2C) wrap the plaster in a spiral motion,

overlapping each layer by one-third to one-half.

Smooth out the layers with a gentle palmar motion.

When applying the plaster, make tucks by grasping the

excess material and folding it under as if making a

pleat. Successive layers cover and smooth over this

fold. When the plaster is anchored on the wrist, cover

the hand and the palmar surface before continuing up

the arm (figs. 2–2D and 2–2E). Repeat this procedure

until the cast is thick enough to provide adequate

support, generally 4 to 5 layers. The final step is to

remove any rough edges and smooth the cast surface

(fig. 2–2F). Turn the ends of the cast back and cover

with the final layer of plaster, and allow the plaster to

set for approximately 15 minutes. Trim with a cast

saw, as needed.

LONG ARM CAST.—The procedure for a long

arm cast is basically the same as for a short arm cast,

except the elbow is maintained in a 90E position, the

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cast begins at the wrist and ends on the upper arm

below the axilla, and the hand is not wrapped.

SHORT LEG CAST.—In applying a short leg

cast, seat the patient on a table with both legs over the

side, flexed at the knee. Instruct the patient to hold the

affected leg, with the ankle in a neutral position (90E).

Make sure that the foot is not rotated medially or

laterally. Beginning at the toes, apply webril (figs.

2–3A, 2–3B, and 2–3C) in the same manner as for the

short arm cast, ensuring that there are no lumps or

2-21

Figure 2–2.—Applying a short arm cast.
wrinkles. Apply the plaster beginning at the toes (fig.

2–3E), using the same technique of tucks and folds and

smoothing as for the short arm cast. Before applying

the last layer, expose the toes and fold back the webril.

As the final step, apply a footplate to the plantar

surface of the cast, using a generous thickness of

plaster splints secured with one or two rolls of plaster

(fig. 2–3F). This area provides support to the cast and a

weight-bearing surface when used with a walking

boot.

Whenever a cast is applied, you must give the

patient written and verbal instruction for cast care and

circulation checks (i.e., numbness, cyanosis, tingling

of extremities). Instruct the patient to return

immediately should any of these conditions occur.

When a leg cast is applied, the patient must also receive

instructions in the proper use of crutches. The cast will

take 24 to 48 hours to completely dry, and it must be

treated gently during this time. Since plaster is

water-soluble, the cast must be protected with a

waterproof covering when bathing or during wet

weather. Nothing must be inserted down the cast (e.g.,

coat hangers) since this action can cause bunching of

the padding and result in pressure sores. If swelling

occurs, the cast may be split and wrapped with an

elastic wrap to alleviate pressure.

Cast Removal

A cast can be removed in two ways: by soaking in

warm vinegar-water solution until it dissolves, or by

2-22

Figure 2–3.—Applying a short leg cast.
cutting. To remove by cutting, cast cutters, spreaders,

and bandage scissors are necessary. Cuts are made

laterally and medially along the long axis of the cast,

then widened with the use of spreaders. The padding is

then cut with the scissors.

THE TERMINALLY ILL PATIENT

LEARNING OBJECTIVE: Evaluate the

needs of the terminally ill patient.

The terminally ill patient has many needs that are

basically the same as those of other patients: spiritual,

psychological, cultural, economic, and physical. What

differs in these patients may be best expressed as the

urgency to resolve the majority of these needs within a

limited time frame. Death comes to everyone in

different ways and at different times. For some

patients, death is sudden following an acute illness.

For others, death follows a lengthy illness. Death not

only affects the individual patient; it also affects family

and friends, staff, and even other patients. Because of

this, it is essential that all healthcare providers

understand the process of dying and its possible effects

on people.

Individual’s Perspective on Death

People view death from their individual and

cultural value perspectives. Many people find the

courage and strength to face death through their

religious beliefs. These patients and their families

often seek support from representatives of their

religious faith. In many cases, patients who previously

could not identify with a religious belief or the concept

of a Supreme Being may indicate (verbally or

nonverbally) a desire to speak with a spiritual

representative. There will also be patients who,

through the whole dying experience, will neither

desire nor need spiritual support and assistance. In all

these cases, it is the responsibility of the healthcare

provider to be attentive and perceptive to the patient’s

needs and to provide whatever support personnel the

patient may require.

Cultural Influences

An individual’s cultural system influences

behavior patterns. When we speak of cultural systems,

we refer to certain norms, values, and action patterns of

specific groups of people to various aspects of life.

Dying is an aspect of life, and it is often referred to as

the final crisis of living. In all of our actions, culturally

approved roles frequently encourage specific behavior

responses. For example, in the Caucasian,

Anglo-European culture, a dying patient is expected to

show peaceful acceptance of the prognosis; the

bereaved is expected to communicate grief. When

people behave differently, the healthcare provider

frequently has difficulty responding appropriately.

Five Stages of Death

A theory of death and dying has developed that

provides highly meaningful knowledge and skills to all

persons involved with the experience. In this theory of

death and dying (as formulated by Dr. Elizabeth

Kubler-Ross in her book On Death and Dying), it is

suggested that most people (both patients and

significant others) go through five stages: denial,

anger, bargaining, depression, and acceptance.

The first stage, denial, is one of nonacceptance.

“No, it can’t be me! There must be a mistake!” It is not

only important for the healthcare provider to recognize

the denial stage with its behavior responses, but also to

realize that some people maintain denial up to the point

of impending death. The next stage is anger. This is a

period of hostility and questioning: “Why me?” The

third stage is bargaining. At this point, people revert

to a culturally reinforced concept that good behavior is

rewarded. Patients are often heard stating, “I’d do

anything if I could just turn this thing around.” Once

patients realize that bargaining is futile, they quickly

enter into the stage of depression. In addition to

grieving because of their personal loss, it is at this point

that patients become concerned about their family and

“putting affairs in order.” The final stage comes when

the patient finally accepts death and is prepared for it.

It is usually at this time that the patient’s family

requires more support than the patient. It is important

to remember that one or more stages may be skipped,

and that the last stage may never be reached.

Support for the Dying

Despite the fact that we all realize our mortality,

there is no easy way to discuss death. To the strong and

healthy, death is a frightening thought. The fact that

sooner or later everyone dies does not make death

easier. There are no procedure books that tell

healthcare providers “how to do” death. The “how to”

will only come from the individual healthcare provider

who understands that patients are people, and that,

more than any other time in life, the dying patient

needs to be treated as an individual person.

2-23
An element of uncertainty and helplessness is

almost always present when death occurs. Assessment

and respect for the patient’s individual and cultural

value system are of key importance in planning the

care of the dying. As healthcare personnel, we often

approach a dying patient with some feelings of

uncertainty, helplessness, and anxiety. We feel

helpless in being unable to perform tasks that will keep

the patient alive, uncertain that we are doing all that we

can do to either make the patient as comfortable as

possible or to postpone or prevent death altogether. We

feel anxious about how to communicate effectively

with patients, their family, or even among ourselves.

This is a normal response since any discussion about

death carries a high emotional risk for the patient as

well as the healthcare provider. Nevertheless,

communicating can provide both strength and comfort

to all if done with sensitivity and dignity, and it is

sensitivity and dignity that is the essence of all

healthcare services.

PATIENT SAFETY

LEARNING OBJECTIVE: Identify patient

safety concerns in a medical treatment

facility.

The primary goal of the healthcare provider is

maintaining, sustaining, restoring, and rehabilitating a

physical or psychological function of the patient. To

achieve this goal, healthcare facilities and providers

are charged with developing policies and

implementing mechanisms that ensure safe, efficient,

and therapeutically effective care. The theme of this

discussion is safety and will address the major aspects

of both environmental and personal safety.

ENVIRONMENTAL SAFETY

For purposes of this discussion, the environment is

defined as the physical surroundings of the patient and

includes such things as lighting, equipment, supplies,

chemicals, architectural structure, and the activities of

both patient and staff personnel. Maintaining safety

becomes even more difficult when working with

people who are ill or anxious and who cannot exercise

their usual control over their environment. Loss of

strength, decreased sensory input, and disability often

accompany illness. Because of this, you must be

constantly alert and responsive to maintaining a safe

environment.

Both JCAHO and the National Safety Council of

the American Hospital Association (AHA) have

identified four major types of accidents that

continually occur to patients. These hazards consist of

falls, electrical shocks, physical and chemical burns,

and fire and explosions.

Patient Fall Precautions

The most basic of hospital equipment, the patient’s

bed, is a common cause of falls. Falls occur among

oriented patients getting in and out of bed at night in

situations where there is inadequate lighting. Falls

occur among disoriented or confused bed patients

when bedrails are not used or are used improperly.

Slippery or cluttered floors contribute to patient, staff,

and even visitor falls. Patients with physical

limitations or patients being treated with

sensory-altering medications fall when attempting to

ambulate without proper assistance. Falls result from

running in passageways, carelessness when going

around blind corners, and collisions between

personnel and equipment. Unattended and improperly

secured patients fall from gurneys and wheelchairs.

Healthcare personnel can do much to prevent the

incidence of falls by following some simple

procedures. These preventive measures include

properly using side rails on beds, gurneys, and cribs;

locking the wheels of gurneys and wheelchairs when

transferring patients; and not leaving patients

unattended. Safety straps must also be used to secure

patients on gurneys or in wheelchairs. Maintaining dry

and uncluttered floors markedly reduces the number of

accidental falls. Patients with physical or sensory

deficiencies should always be assisted during

ambulation. Patients using crutches, canes, or walkers

must receive adequate instructions in the proper use of

these aids before being permitted to ambulate

independently. The total care environment must be

equipped with adequate night lights to assist

orientation and to prevent falls resulting from an

inability to see.

Electrical Safety Precautions

The expanded variety, quantity, and complexity of

electrical and electronic equipment used for diagnostic

and therapeutic care has markedly increased the

hazards of burns, shock, explosions, and fire. It is

imperative that healthcare providers at all levels be

alert to such hazards and maintain an electrically safe

environment. Knowledge and adherence to the

2-24
following guidelines will contribute significantly to

providing an electrically safe environment for all

personnel, whether they be patients, staff, or visitors.

• Do not use electrical equipment with damaged

plugs or cords.

• Do not attempt to repair defective equipment.

• Do not use electrical equipment unless it is

properly grounded with a three-wire cord and

three-prong plug.

• Do not use extension cords or plug adapters

unless approved by the Medical Repair

Department or the safety officer.

• Do not create a trip hazard by passing electrical

cords across doorways or walkways.

• Do not remove a plug from the receptacle by

gripping the cord.

• Do not allow the use of personal electrical

appliances without the approval of the safety

officer.

• Do not put water on an electrical fire.

• Do not work with electrical equipment with wet

hands or feet.

• Have newly purchased electronic medical

equipment tested for electrical safety by Medical

Repair before putting it into service.

• Operate all electrical and electronic equipment

according to manufacturer’s instructions.

• Remove from service electrical equipment that

sparks, smokes, or gives a slight shock. Tag

defective equipment and expedite repair.

• Be aware that patients with intravenous therapy

and electronic monitoring equipment are at high

risk from electrical shocks.

• Call Medical Repair when equipment is not

functioning properly or Public Works if there is

difficulty with the power distribution system.

Since accidents resulting in physical and chemical

burns have initiated numerous consumer claims of

healthcare provider and facility malpractice, all

healthcare personnel must be thoroughly indoctrinated

in the proper use of equipment, supplies, and

chemicals.

Physical and Chemical Burn Precautions

The following discussion will address common

causes and precautions to be taken to eliminate the

occurrence of burn injuries.

HOT WATER BOTTLES.—A common cause of

burns—particularly in the elderly, diabetics, and

patients with circulatory impairments—is the hot

water bottle. When you are filling the bottle, the water

temperature must never exceed 125EF (51EC). Test

the bottle for leaks and cover it so that there is a

protective layer of cloth between the patient and the

bottle itself.

HEATING PADS.—Heating pads present a dual

hazard of potential burns and electrical shock. The

precautions that should be taken when using heating

pads are the same ones that should be used for hot

water bottles: temperature control and protective cloth

padding. Precautions you should observe to avoid

shock include properly maintaining the equipment;

conducting preuse inspections; testing the equipment

for wiring and plug defects; and ensuring periodic

safety inspections are conducted by Medical Repair

personnel.

ICE BAGS OR COLD PACKS.—Like hot water

bottles, ice bags and cold packs (packaged chemical

coolant) can cause skin-contact burns. This kind of

burn is commonly referred to as local frostbite. The

precautions taken for applying ice bags and cold baths

are the same as those for hot water bottles with regard

to attention to elderly, diabetic, and patients with

circulatory impairments.

HYPOTHERMIA BLANKETS.—Like ice

bags, hypothermia blankets can also cause contact

burns. When using hypothermia blankets, check the

patient’s skin frequently for signs of marked

discoloration (indicating indirect localized tissue

damage). Ensure that the bare blanket does not come in

direct contact with the patient’s unprotected skin. This

precaution is easily accomplished by using sheets or

cotton blankets between the patient and the

hypothermia blanket itself. When using this form of

therapy, follow both the physician’s orders and the

manufacturer ’s instructions in managing the

temperature control of the equipment.

HEAT (BED) CRADLE.—When using the heat

(bed) cradle, protect the patient from burns resulting

from overexposure or placement of the equipment too

close to the area of the patient being treated. As with

heating pads, heat cradles present the dual hazard of

2-25
potential burns and electrical shock. Another hazard to

keep in mind is that of fire. Ensure that the bedding and

the heat source do not come in direct contact and cause

the bedding to ignite. Occasionally, heat lamps are

used to accomplish the same results as a heat cradle.

Do not use towels, pillow cases, or linen of any kind to

drape over heat lamps. In fact, no lamps of any kind

should be draped with any kind of material, regardless

of the purpose of the draping.

STEAM VAPORIZERS AND HOT FOODS

AND LIQUIDS.—Steam vaporizers and hot foods

and liquids are common causes of patient burns. When

using steam vaporizers, ensure that the vapor of steam

does not flow directly on the patient as a result of the

initial positioning of the equipment or by accidental

movement or bumping. Patients sensitive to hot foods

and liquids are more likely burned. Also, because of

lack of coordination, weakness, or medication,

patients may be less able to handle hot foods and

liquids safely without spilling them.

In the direct patient care units as well as in

diagnostic and treatment areas, there is unlimited

potential for inflicting burns on patients. When the

modern electrical and electronic equipment and the

potent chemicals used for diagnosis and treatment are

used properly, they contribute to the patient’s recovery

and rehabilitation. When they are used carelessly or

improperly, these same sources may cause patients

additional pain and discomfort, serious illness, and, in

some cases, death.

Fire and Explosion Precautions

Often when we speak of safety measures, one of

our first thoughts is of a fire or an explosion involving

the loss of life or injury to a number of people. Good

housekeeping, maintenance, and discipline help

prevent such mishaps. Remember that buildings

constructed of fire-resistant materials may not be

fireproof, and they are certainly not explosion proof.

Good maintenance includes checking, reporting, and

ensuring correct repair of electrical equipment, and

routine checking of fire fighting equipment by

qualified personnel. The education and training of

personnel are the most effective means of preventing

fires. Used in the context of fire safety measures, good

discipline means developing a fire plan to use as

outlined in a fire bill, having periodic fire drills, and

enforcing no-smoking regulations.

FIRE EVACUATION PROCEDURES.—Staff

members should be familiar with the fire regulations at

their duty station and know what to do in case of fire.

Staff should know how to report a fire, use a fire

extinguisher, and evacuate patients. When a fire

occurs, there are certain basic rules to follow: The

senior person should take charge and appoint someone

to notify the fire department and the officer of the day

of the exact location of the fire. Everyone should

remain calm. All oxygen equipment and electrical

appliances must be turned off unless such equipment is

necessary to sustain life. All windows and doors

should be closed and all possible exits cleared. When

necessary and directed by proper authority, patients

should be removed in a calm and orderly fashion and

mustered outside.

SMOKING REGULATIONS.—By regulation

(BUMEDINST 6200.12, Tobacco Use in Navy

Medical Department Activities), smoking is no longer

permitted in Navy hospitals. To ensure general safety

and awareness of this prohibition, inform patients,

visitors, and staff of the facility’s no-smoking status by

prominently displaying “No Smoking” signs

throughout the hospital—especially in rooms and

areas where oxygen and flammable agents are used and

stored.

Safety Precautions

in the Operating Room

Since safety practices are important to emphasize,

this section will cover some of the situations that are

potentially hazardous in the operating room and

discuss what might be done to eliminate the hazard.

All personnel should know the location of all

emergency medications and equipment in the

operating room. This includes drugs, cardiac arrest

equipment, and resuscitators. All electrical equipment

and plugs must be of the explosion-proof type and bear

a label stating such. There should be written schedules

of inspections and maintenance of all electrical

equipment. Navy regulations prohibit the use of

explosive anesthetics in the operating room. These

regulations, however, do not mean we can lessen our

concern for fire and explosion hazards. The surface of

all floors in the operating room must provide a path of

electrical conductivity between all persons and

equipment making contact with the floor to prevent the

accumulation of dangerous electrostatic charges. All

furniture and equipment should be constructed of

metal or of other electrically conductive material and

should be equipped with conductive leg tips, casters, or

equivalent devices. Periodic inspections should be

made of leg tips, tires, casters, or other conductive

2-26
devices of furniture and equipment. These inspections

will ensure that they are maintained free of wax, lint, or

other foreign material that may insulate them and

defeat the purpose for which they are used. Excess

lubrication of casters should be avoided to prevent

accumulation of oil on conductive wheels. Dry

graphite and graphite oil are the preferred lubricants.

Rubber accessories for anesthesia machines

should be of the conductive type, plainly labeled as

such, and routinely tested to ensure that conductivity is

maintained. It is essential that all replacement items be

of conductive material.

All personnel entering the operating room should

be in electrical contact with the conductive floor by

wearing conductive footwear or an alternative method

of providing a path of conductivity. Conductive

footwear and other personnel-to-floor conductive

equipment should be tested on a regularly scheduled

basis.

All apparel worn in the operating room should be

made of a nonstatic-producing material. Fabrics of

100 percent cotton are the most acceptable. Fabrics

made of synthetic blends may be used only if they have

been treated by the manufacturer for use in the

operating room. Wool blankets and apparel made of

untreated synthetic fabrics are not permitted in the

operating room.

Operating rooms must have adequate

air-conditioning equipment to maintain relative

humidity and temperature within a constant range. The

relative humidity should be kept at 55 to 60 percent.

This level will reduce the possibility of electrostatic

discharge and possible explosion of combustible

gases. The temperature should be chosen on the basis

of the well-being of the patient. The recommended

temperature is between 65E and 74EF. The control of

bacteria carried on dust particles is facilitated when the

recommended humidity and temperature are

maintained.

All oxygen cylinders in use or in storage will be

tagged with DD Form 1191, Warning Tag for Medical

Oxygen Equipment, and measures will be taken to

ensure compliance with instructions 1 through 7

printed on the form. An additional tag is required on all

cylinders to indicate “EMPTY,” “IN USE,” or

“FULL.” Safety precautions should be conspicuously

posted in all areas in which oxygen cylinders are stored

and in which oxygen therapy is being administered.

This posting should be made so it will immediately

make all personnel aware of the precautionary

measures required in the area.

All electrical service equipment, switchboards, or

panelboards should be installed in a nonhazardous

location. Devices or apparatus that tend to create an

arc, sparks, or high temperatures must not be installed

in hazardous locations unless these devices are in

compliance with the National Electrical Code. Lamps

in a fixed position will be enclosed and will be properly

protected by substantial metal guards or other means

where exposed to breakage. Cords for portable lamps

or portable electrical appliances must be continuous

and without switches from the appliance to the

attachment plug. Such cords must contain an insulated

conductor to form a grounding connection between the

electrical outlet and the appliance.

GENERAL SAFETY

In addition to the specifics presented earlier, some

other basic principles are relevant to patient safety.

They are:

• Ensure your patients are familiar with their

environment, thus making it less hazardous to

them. This familiarization can be accomplished

in many ways, such as by showing your patients

the floor plan of the ward they have been

admitted to and by indicating key areas (lounge,

bathrooms, nursing station, etc.) that may be of

interest to them.

• Be aware of patient sensory impairment and

incorporate precautionary procedures into their

patient-care plan. For example, this principle

can be applied to patients who have been given a

pain medication, such as morphine or

Demerol®. Medications such as these dull body

senses. If a patient in this condition wishes to

walk around, precautionary actions dictate that

you either be close at hand to prevent the patient

from accidental falls or that you do not permit

the patient to ambulate until the effects of the

medication have stopped.

• Understand that all diagnostic and therapeutic

measures have the potential to cause a patient

harm.

• Ensure that all accidents and incidents are

documented and analyzed to identify and correct

high-risk safety hazards.

2-27
ENVIRONMENTAL HYGIENE

LEARNING OBJECTIVE: Identify

environmental hygiene concerns in a medical

treatment facility.

Today’s public is very much aware of the

environment and its effect on the health and comfort of

human beings. The healthcare setting is a unique

environment and has a distinct character of its own.

You need to be aware of that character and ensure that

the environment will support the optimum in health

maintenance, care, and rehabilitation.

In the context of the environment, hygiene may

best be described as practices that provide a healthy

environment. Basically, environmental hygiene

practices include the following three areas of concern:

safety (which has already been addressed);

environmental comfort and stimuli; and, finally,

infection control (which will be discussed briefly here,

but in greater detail later in this chapter under “Medical

Asepsis”). You have certain responsibilities for

helping to control the facility’s general environment as

well as the patient’s immediate surroundings.

CONCURRENT AND TERMINAL

CLEANING

Maintaining cleanliness is a major responsibility

of all members of the healthcare team, regardless of

their position on the team. Cleanliness not only

provides for patient comfort and a positive stimulus, it

also impacts on infection control. The Hospital

Corpsman is often directly responsible for the

maintenance of patient care areas. The management of

cleanliness in patient care areas is conducted

concurrently and terminally. Concurrent cleaning is

the disinfection and sterilization of patient supplies

and equipment during hospitalization. Terminal

cleaning is the disinfection and sterilization of patient

supplies and equipment after the patient is discharged

from the unit or hospital. Both concurrent and terminal

cleaning are extremely important procedures that not

only aid the patient’s comfort and psychological

outlook, but also contribute to both efficient physical

care and control of the complications of illness and

injury.

AESTHETICS

Aesthetically, an uncluttered look is far more

appealing to the eye than an untidy one. Other

environmental factors,such as color and noise, can also

enhance or hinder the progress of a person’s physical

condition. In the past, almost all healthcare facilities

used white as a basic color for walls and bedside

equipment. However, research has shown that the use

of color is calming and restful to the patient, and, as has

been previously stated, rest is a very important healing

agent in any kind of illness. Noise control is another

environmental element that requires your attention.

The large number of people and the amount of

equipment traffic in a facility serve to create a high

noise level that must be monitored. Add to that the

noise of multiple radios and televisions, and it is

understandable why noise control is necessary if a

healing environment is to be created and maintained.

CLIMATE CONTROL

Another important aspect of environmental

hygiene is climate control. Many facilities use air

conditioning or similar control systems to maintain

proper ventilation, humidity, and temperature control.

In facilities without air conditioning, windows should

be opened from the top and bottom to provide for

cross-ventilation. Ensure that patients are not located

in a drafty area. Window sill deflectors or patient

screens are often used to redirect drafty airflows.

Maintain facility temperatures at recommended

energy-conservation levels that are also acceptable as

health-promoting temperatures. In addition to

maintaining a healthy climate, good ventilation is

necessary in controlling and eliminating disagreeable

odors. In cases where airflow does not control odors,

room fresheners should be discretely used. Offensive,

odor-producing articles (such as soiled dressings, used

bedpans, and urinals) should be removed to

appropriate disposal and disinfecting areas as rapidly

as possible. Objectionable odors (such as bad breath or

perspiration of patients) are best controlled by proper

personal hygiene and clean clothing.

LIGHTING

Natural light is important in the care of the sick.

Sunlight usually brightens the area and helps to

improve the mental well-being of the patient.

However, light can be a source of irritation if it shines

directly in the patient’s eyes or produces a glare from

the furniture, linen, or walls. Adjust shades or blinds

2-28
for the patient’s comfort. Artificial light should be

strong enough to prevent eyestrain and diffuse enough

to prevent glare. Whenever possible, provide a bed

lamp for the patient. As discussed earlier under

“Safety Aspect,” a dim light is valuable as a comfort

and safety measure at night. This light should be

situated so it will not shine in the patient’s eyes and yet

provide sufficient light along the floor so that all

obstructions can be seen. A night light may help orient

elderly patients if they are confused as to their

surroundings upon awakening.

In conclusion, it is important that you understand

the effects of the environment on patients. People are

more sensitive to excessive stimuli in the environment

when they are ill, and they often become irritable and

unable to cooperate in their care because of these

excesses. This is particularly apparent in critical care

areas (e.g., in CCUs and ICUs) and isolation, terminal,

and geriatric units. You must realize and respond to the

vital importance of the environment in the total

medical management plan of your patients.

PATHOGENIC ORGANISM CONTROL

LEARNING OBJECTIVE: Recall medical

asepsis principles and recognize medical

asepsis practices.

All health care, regardless of who provides it or

where it is provided, must be directed toward

maintaining, promoting, and restoring health. Because

of this goal, all persons seeking assistance in a

healthcare facility must be protected from additional

injury, disease, or infection. Adherence to good safety

principles and practices protects a patient from

personal injury. Additionally, attention to personal and

environmental hygiene not only protects against

further injury, but also constitutes the first step in

controlling the presence, growth, and spread of

pathogenic organisms. The discussion that follows

addresses infection control, particularly in the context

of medical and surgical aseptic practices.

MEDICAL ASEPSIS

Medical asepsis is the term used to describe those

practices used to prevent the transfer of pathogenic

organisms from person to person, place to place, or

person to place. Medical aseptic practices are

routinely used in direct patient care areas, as well as in

other service areas in the healthcare environment, to

interrupt a chain of events necessary for the

continuation of an infectious process. The

components of this chain of events consist of the

elements defined below.

Infectious Agent

An infectious agent is an organism that is capable

of producing an infection or infectious disease.

Reservoir of Infectious Agents

A reservoir of infectious agents is the carrier on

which the infectious agent primarily depends for

survival. The agent lives, multiplies, and reproduces

so that it can be transferred to a susceptible host.

Reservoirs of infectious agents could be man, animal,

plants, or soil. Man himself is the most frequent

reservoir of infectious agents pathogenic to man.

PORTAL OF EXIT.—The portal of exit is the

avenue by which the infectious agent leaves its

reservoir. When the reservoir is man, these avenues

include various body systems (such as respiratory,

intestinal, and genitourinary tracts) and open lesions.

MODE OF TRANSMISSION.—The mode of

transmission is the mechanism by which the infectious

agent is transmitted from its reservoir to a susceptible

being (host). Air, water, food, dust, dirt, insects,

inanimate objects, and other persons are examples of

modes of transmission.

PORTALOFENTRY.—The portal of entry is the

avenue by which the infectious agent enters the

susceptible host. In man, these portals correspond to

the exit route avenues, including the respiratory and

gastrointestinal tracts, through a break in the skin, or

by direct infection of the mucous membrane.

SUSCEPTIBLE HOST.—The susceptible host

is man or another living organism that affords an

infectious agent nourishment or protection to survive

and multiply.

Removal or control of any one component in the

above chain of events will control the infectious

process.

Two Basic Medical Asepsis Practices

The two basic medical asepsis practices that are

absolutely essential in preventing and controlling the

spread of infection and transmittable diseases are

2-29
frequent hand washing and proper linen-handling

procedures.

HAND WASHING.—The following are some

common instances when provider hand washing is

imperative:

• Before and after each patient contact

• Before handling food and medications

• After coughing, sneezing, or blowing your nose

• After using the toilet

LINEN HANDLING.—Improper handling of

linen results in the transfer of pathogenic organisms

through direct contact with the healthcare provider’s

clothing and subsequent contact with the patient,

patient-care items, or other materials in the care

environment. Proper linen handling is such an

elementary procedure that, in theory, it seems almost

unnecessary to mention. However, it is a procedure so

frequently ignored that emphasis is justified.

All linen, whether clean or used, must never be

held against one’s clothing or placed on the floor. The

floors of a healthcare facility are considered to be

grossly contaminated, and, thus, any article coming in

contact with the floor will also be contaminated. Place

all dirty linen in appropriate laundry bags. Linen from

patients having infectious or communicable diseases

must be handled in a special manner.

Isolation Technique

Isolation technique, a medical aseptic practice,

inhibits the spread and transfer of pathogenic

organisms by limiting the contacts of the patient and

creating some kind of physical barrier between the

patient and others. Isolation precautions in hospitals

must meet the following objectives. They must

• be epidemiologically sound;

• recognize the importance that body fluids,

secretions, and excretions may have in the

transmission of nosocomial (hospital

originating) pathogens;

• contain adequate precautions for infections

transmitted by airborne droplets and other routes

of transmission; and

• be as simple and as patient friendly as possible.

In isolation techniques, disinfection procedures

are employed to control contaminated items and areas.

For purposes of this discussion, disinfection is

described as the killing of certain infectious

(pathogenic) agents outside the body by a physical or

chemical means. Isolation techniques employ two

kinds of disinfection practices, concurrent and

terminal.

CONCURRENT DISINFECTION.— Concurrent disinfection consists of the daily measures

taken to control the spread of pathogenic organisms

while the patient is still considered infectious.

TERMINAL DISINFECTION.—Terminal

disinfection consists of those measures taken to

destroy pathogenic organisms remaining after the

patient is discharged from isolation. There are a

variety of chemical and physical means used to

disinfect supplies, equipment, and environmental

areas, and each facility will determine its own

protocols based on the recommendation of an Infection

Control Committee.

SURGICAL ASEPTIC TECHNIQUE

LEARNING OBJECTIVE: Recall the

principles and guidelines for surgical aseptic

technique, and determine the correct

sterilization process for different types of

materials.

As used in this discussion, surgical aseptic

technique is the term used to describe the sterilization,

storage, and handling of articles to keep them free of

pathogenic organisms. The following discussion will

address the preparation and sterilization of surgical

equipment and supplies, and the preparation of the

operating room for performing a surgical procedure. It

should be noted that specific methods of preparation

will vary from place to place, but the basic principles of

surgical aseptic technique will remain the same. This

discussion will present general guidelines, and

individual providers are advised to refer to local

instructions regarding the particular routines of a

specific facility.

Before an operation, it is necessary to sterilize

and keep sterile all instruments, materials, and

supplies that come in contact with the surgical site.

Every item handled by the surgeon and the surgeon’s

assistants must be sterile. The patient’s skin and the

hands of the members of the surgical team must be

thoroughly scrubbed, prepared, and kept as aseptic as

possible.

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During the operation, the surgeon, surgeon’s

assistants, and the scrub corpsman must wear sterile

gowns and gloves and must not touch anything that is

not sterile. Maintaining sterile technique is a

cooperative responsibility of the entire surgical team.

Each member must develop a surgical conscience, a

willingness to supervise and be supervised by others

regarding the adherence to standards. Without this

cooperative and vigilant effort, a break in sterile

technique may go unnoticed or not be corrected, and an

otherwise successful surgical procedure may result in

complete failure.

Basic Guidelines

To assist in maintaining the aseptic technique, all

members of the surgical team must adhere to the

following principles:

• All personnel assigned to the operating room

must practice good personal hygiene. This

includes daily bathing and clothing change.

• Those personnel having colds, sore throats, open

sores, and/or other infections should not be

permitted in the operating room.

• Operating room attire (which includes scrub

suits, gowns, head coverings, and face masks)

should not be worn outside the operating room

suite. If such occurs, change all attire before

re-entering the clean area. (The operating room

and adjacent supporting areas are classified as

“clean areas.”)

• All members of the surgical team having direct

contact with the surgical site must perform the

surgical hand scrub before the operation.

• All materials and instruments used in contact

with the site must be sterile.

• The gowns worn by surgeons and scrub

corpsmen are considered sterile from shoulder to

waist (in the front only), including the gown

sleeves.

• If sterile surgical gloves are torn, punctured, or

have touched an unsterile surface or item, they

are considered contaminated.

• The safest, most practical method of sterilization

for most articles is steam under pressure.

• Label all prepared, packaged, and sterilized

items with an expiration date.

• Use articles packaged and sterilized in cotton

muslin wrappers within 28 calendar days.

• Use articles sterilized in cotton muslin wrappers

and sealed in plastic within 180 calendar days.

• Unsterile articles must not come in contact with

sterile articles.

• Make sure the patient’s skin is as clean as

possible before a surgical procedure.

• Take every precaution to prevent contamination

of sterile areas or supplies by airborne

organisms.

Methods of Sterilization

Sterilization refers to the complete destruction of

all living organisms, including bacterial spores and

viruses. The word “sterile” means free from or the

absence of all living organisms. Any item to be

sterilized must be thoroughly cleaned mechanically or

by hand, using soap or detergent and water. When

cleaning by hand, apply friction to the item using a

brush. After cleaning, thoroughly rinse the item with

clean, running water before sterilization. The

appropriate sterilization method is determined

according to how the item will be used, the material

from which the item is made, and the sterilization

methods available. The physical methods of

sterilization are moist heat and dry heat. Chemical

methods include gas and liquid solutions.

PHYSICAL METHODS.—Steam under

pressure (autoclave) is the most dependable and

economical method of sterilization. It is the method of

choice for metalware, glassware, most rubber goods,

and dry goods. All articles must be correctly wrapped

or packaged so that the steam will come in contact with

all surfaces of the article. Similar items should be

sterilized together, especially those requiring the same

time and temperature exposure. Articles that will

collect water must be placed so that the water will drain

out of the article during the sterilization cycle. A

sterilizer should be loaded in a manner that will allow

the free flow of steam in and around all articles. Each

item sterilized must be dated with the expiration of

sterility. Sterilization indicators must be used in each

load that is put through the sterilization process. This

verifies proper steam and temperature penetration.

The operating procedures for a steam sterilizer will

vary according to the type and manufacturer. There are

a number of manufacturers, but there are only two

types of steam-under-pressure sterilizers. They are the

2-31
downward displacement and the prevacuum,

high-temperature autoclaves.

Downward Displacement Autoclave.—In the

downward (gravity) displacement autoclave, air in the

chamber is forced downward from the top of the

chamber. The temperature in the sterilizer gradually

increases as the steam heats the chamber and its

contents. The actual timing does not begin until the

temperature is above 245EF (118EC).

Prevacuum, High-temperature Autoclave.—

The prevacuum, high-temperature autoclave is the

most modern and economical to operate and requires

the least time to sterilize a single load. By use of a

vacuum pump, air is extracted from the chamber

before admitting steam. This prevacuum process

permits instant steam penetration to all articles and

through all cotton or linen dry goods. The sterilization

time is reduced to 4 minutes. The temperature of the

chamber is rapidly raised and held at 274EF (134EC).

The cycle is timed automatically.

Sterilizing Times.—If the temperature is

increased, the sterilization time may be decreased. The

following are some practical sterilization time periods.

• 3 minutes at 270EF (132EC)

• 8 minutes at 257EF (125EC)

• 18 minutes at 245EF (118EC)

All operating rooms are equipped with high-speed

(flash) sterilizers. Wrapped, covered, opened

instruments placed in perforated trays are “flash”

sterilized for 3 minutes at 270EF (132EC).

Sterilization timing begins when the above

temperature is reached, not before.

Dry-Heat Sterilization.—The use of dry heat as a

sterilizing agent has limitations. It should be restricted

to items that are unsuitable for exposure to moist heat.

High temperatures and extended time periods are

required when using dry heat. In most instances, this

method often proves impractical. The temperature

must be 320EF (160EC), and the time period must be at

least 2 hours.

CHEMICAL STERILIZATION.—Only one

liquid chemical, if properly used, is capable of

rendering an item sterile. That chemical is

glutaraldehyde. The item to be sterilized must be

totally submerged in the glutaraldehyde solution for 10

hours. Before immersion, the item must be thoroughly

cleansed and rinsed with sterile water or sterile normal

saline. It should be noted that this chemical is

extremely caustic to skin, mucous membranes, and

other tissues.

The most effective method of gas chemical

sterilization presently available is the use of ethylene

oxide (ETO) gas. ETO gas sterilization should be

used only for material and supplies that will not

withstand sterilization by steam under pressure. Never

gas-sterilize any item that can be steam-sterilized. The

concentration of the gas and the temperature and

humidity inside the sterilizer are vital factors that

affect the gas-sterilization process.

ETO gas-sterilization periods range from 3 to 7

hours. All items gas-sterilized must be allowed an

aeration (airing out) period. During this period, the

ETO gas is expelled from the surface of the item. It is

not practical here to present all exposure times, gas

concentrations, and aeration times for various items to

be gas-sterilized. When using an ETO gas-sterilizer,

you must be extremely cautious and follow the

manufacturer’s instructions carefully.

Preparation of Supplies for Autoclaving

Comply with the following guidelines in preparing

supplies that are to be autoclaved.

• Inspect all articles to be sterilized, making sure

they are clean, in good condition, and in working

order.

• Wrap instruments and materials in double

muslin wrappers or two layers of disposable

sterilization wrappers.

• When muslin wrappers are routinely used,

launder them after each use, and carefully

inspect them for holes and tears before use.

• When articles are placed in glass or metal

containers for autoclaving, place the lid of the

container so the steam will penetrate the entire

inside of the container.

• Arrange the contents of a linen pack in such a

way that the articles on top are used first.

• Label every item that is packaged for

sterilization to specify the contents and

expiration date.

• Do not place surgical knife blades or suture

materials inside linen packs or on instrument

trays before sterilization.

2-32
The following are specific guidelines for

sterilizing instruments, glassware, suture materials,

and rubber latex materials.

Instruments:

• Wash each instrument after use with an

antiseptic detergent solution. When washing by

hand, pay particular attention to hinged parts and

serrated surfaces. Rinse all instruments, and dry

them thoroughly.

• Use an instrument washer/sterilizer, if available,

to decontaminate instruments and utensils

following each surgical procedure.

• Following cleaning and decontamination, leave

hinged instruments unclasped and wrapped

singly or placed on trays for resterilization.

Glassware:

• Inspect all reusable glassware for cracks or

chips.

• Wash all reusable glassware with soap or

detergent and water after use, and rinse it

completely.

• When preparing reusable glass syringes

—match numbers or syringe parts;

—wrap each plunger and barrel separately in

gauze; and

—wrap each complete syringe in a double

muslin wrapper.

• When glassware, tubes, medicine glasses, and

beakers are part of a sterile tray, wrap each glass

item in gauze before placing it on the tray.

Suture Material: Suture materials are available

in two major categories: absorbable and

nonabsorbable. Absorbable suture materials can be

digested by the tissues during the healing process.

Absorbable sutures are made from collagen (an animal

protein derived from healthy animals) or from

synthetic polymers. Nonabsorbable suture materials

are those that effectively resist the enzymatic digestion

process in living tissue. These sutures are made of

metal or other inorganic materials. In both types, each

strand of specifically sized suture material is uniform

in diameter and is predictable in performance.

Modern manufacturing processes make all suture

materials available in individual packages, presterilized,

with or without a surgical needle attached. Once

opened, do not resterilize either the individual

package or an individual strand of suture

material.

NOTE: The only exception to this rule

involves the use of surgical stainless steel.

This material is often provided in unsterile

packages or tubes. Individual strands or entire

packages of surgical stainless steel must be

sterilized before use.

Rubber Latex Materials:

• Wash rubber tubing in an antiseptic detergent

solution.

—Pay attention to the inside of the tubing. Rinse

all tubing well and place it flat or loosely

coiled in a wrapper or container.

—When packing latex surgical drains for

sterilization, place a piece of gauze in the

lumen of the tray. Never resterilize surgical

drains.

—Never resterilize rubber catheters bearing

a disposable label.

—Never resterilize surgeon’s disposable

(rubber) gloves. These gloves are for

one-time use only.

Handling Sterile Articles

LEARNING OBJECTIVE: Recall sterile

article handling and surgical hand scrubbing

techniques, donning procedure for gowning

and gloving, and the steps to clean an

operating/treatment room.

When you are changing a dressing, removing

sutures, or preparing the patient for a surgical

procedure, it will be necessary to establish a sterile

field from which to work. The field should be

established on a stable, clean, flat, dry surface.

Wrappers from sterile articles may be used as a sterile

field as long as the inside of the wrapper remains

sterile. If the size of the wrapper does not provide a

sufficient working space for the sterile field, use a

sterile towel. Once established, only those persons

who have donned sterile gloves should touch the sterile

2-33
field. Additionally, the following basic rules must be

adhered to:

• An article is either sterile or unsterile; there is no

in-between. If there is doubt about the sterility of

an item, consider it unsterile.

• Any time the sterility of a field has been

compromised, replace the contaminated field

and setup.

• Do not open sterile articles until they are ready

for use.

• Do not leave sterile articles unattended once they

are opened and placed on a sterile field.

• Do not return sterile articles to a container once

they have been removed from the container.

• Never reach over a sterile field.

• When pouring sterile solutions into sterile

containers or basins, do not touch the sterile

container with the solution bottle. Once opened

and first poured, use bottles of liquid entirely. If

any liquid is left in the bottle, discard it.

• Never use an outdated article. Unwrap it, inspect

it, and, if reusable, rewrap it in a new wrapper for

sterilization.

Surgical Hand Scrub

The purpose of the surgical hand scrub is to reduce

resident and transient skin flora (bacteria) to a

minimum. Resident bacteria are often the result of

organisms present in the hospital environment.

Because these bacteria are firmly attached to the skin,

they are difficult to remove. However, their growth is

inhibited by the antiseptic action of the scrub detergent

used. Transient bacteria are usually acquired by direct

contact and are loosely attached to the skin. These are

easily removed by the friction created by the scrubbing

procedure.

Proper hand scrubbing and the wearing of sterile

gloves and a sterile gown provide the patient with the

best possible barrier against pathogenic bacteria in the

environment and against bacteria from the surgical

team. The following steps comprise the generally

accepted method for the surgical hand scrub.

1. Before beginning the hand scrub, don a surgical

cap or hood that covers all hair, both head and

facial, and a disposable mask covering your

nose and mouth.

2. Using approximately 6 ml of antiseptic

detergent and running water, lather your hands

and arms to 2 inches above the elbow. Leave

detergent on your arms and do not rinse.

3. Under running water, clean your fingernails and

cuticles, using a nail cleaner.

4. Starting with your fingertips, rinse each hand

and arm by passing them through the running

water. Always keep your hands above the level

of your elbows.

5. From a sterile container, take a sterile brush and

dispense approximately 6 ml of antiseptic

detergent onto the brush and begin scrubbing

your hands and arms.

6. Begin with the fingertips. Bring your thumb and

fingertips together and, using the brush, scrub

across the fingertips using 30 strokes.

7. Now scrub all four surface planes of the thumb

and all surfaces of each finger, including the

webbed space between the fingers, using 20

strokes for each surface area.

8. Scrub the palm and back of the hand in a circular

motion, using 20 strokes each.

9. Visually divide your forearm into two parts,

lower and upper. Scrub all surfaces of each

division 20 strokes each, beginning at the wrist

and progressing to the elbow.

10. Scrub the elbow in a circular motion using 20

strokes.

11. Scrub in a circular motion all surfaces to

approximately 2 inches above the elbow.

12. Do not rinse this arm when you have finished

scrubbing. Rinse only the brush.

13. Pass the rinsed brush to the scrubbed hand and

begin scrubbing your other hand and arm, using

the same procedure outlined above.

14. Drop the brush into the sink when you are

finished.

15. Rinse both hands and arms, keeping your hands

above the level of your elbows, and allow water

to drain off the elbows.

16. When rinsing, do not touch anything with your

scrubbed hands and arms.

17. The total scrub procedure must include all

anatomical surfaces from the fingertips to

approximately 2 inches above the elbow.

2-34
18. Dry your hands with a sterile towel. Do not

allow the towel to touch anything other than

your scrubbed hands and arms.

19. Between operations, follow the same handscrub procedure.

Gowning and Gloving

If you are the scrub corpsman, you will have

opened your sterile gown and glove packages in the

operating room before beginning your hand scrub.

Having completed the hand scrub, back through the

door holding your hands up to avoid touching anything

with your hands and arms. Gowning technique is

shown in the steps of figure 2–4. Pick up the sterile

towel that has been wrapped with your gown (touching

only the towel) and proceed as follows:

1. Dry one hand and arm, starting with the hand

and ending at the elbow, with one end of the

towel. Dry the other hand and arm with the

opposite end of the towel. Drop the towel.

2. Pick up the gown in such a manner that hands

touch only the inside surface at the neck and

shoulder seams.

3. Allow the gown to unfold downward in front of

you.

2-35

Figure 2–4.—Gowning.
4. Locate the arm holes.

5. Place both hands in the sleeves.

6. Hold your arms out and slightly up as you slip

your arms into the sleeves.

7. Another person (circulatory) who is not

scrubbed will pull your gown onto you as you extend

your hands through the gown cuffs.

Continue the process by opening the inner glove

packet on the same sterile surface on which you opened

the gown. The entire gloving process is shown in the

steps of figure 2–5.

1. Pick up one glove by the cuff using your thumb

and index finger.

2. Touching only the cuff, pull the glove onto one

hand and anchor the cuff over your thumb.

3. Slip your gloved fingers under the cuff of the

other glove. Pull the glove over your fingers and

hand, using a stretching side-to-side motion.

2-36

Figure 2–5.—Gloving.
4. Anchor the cuff on your thumb. With your

fingers still under the cuff, pull the cuff up and

away from your hand and over the knitted cuff

of the gown.

5. Repeat the preceding step to glove your other

hand.

6. The gloving process is complete.

To gown and glove the surgeon, follow these steps:

1. Pick up a gown from the sterile linen pack. Step

back from the sterile field and let the gown

unfold in front of you. Hold the gown at the

shoulder seams with the gown sleeves facing

you.

2. Offer the gown to the surgeon. Once the

surgeon’s arms are in the sleeves, let go of the

gown. Be careful not to touch anything but the

sterile gown. The circulator will tie the gown.

3. Pick up the right glove. With the thumb of the

glove facing the surgeon, place your fingers and

thumbs of both hands in the cuff of the glove and

stretch it outward, making a circle of the cuff.

Offer the glove to the surgeon. Be careful that

the surgeon’s bare hand does not touch your

gloved hands.

4. Repeat the preceding step for the left glove.

Cleaning the Operating/

Treatment Room

Cleanliness in the operating room is an absolute

must. Cleaning routines must be clearly understood

and carefully followed. The cause of postoperative

wound infections have, on occasion, been traced to the

operating room. Since no two patients are alike and all

patients have their own “resident” bacteria, every

surgical case must be considered to be contaminated.

At the beginning of each day, all the fixtures,

equipment, and furniture in each operating room will

be damp-dusted with an antiseptic germicide solution.

During the operation, keep the room clean and orderly

at all times. Should sponges be dropped on the floor, or

if blood or other body fluids spill, clean the area

immediately using a disinfectant germicide solution

and a clean cloth. Between operations, clean all used

items. The area of the floor occupied by the surgical

team must be cleaned using the wet vacuum method. If

a wet vacuum is not available, mops may be used, but a

clean mop head must be used following each

operation. Gowns and gloves must be removed before

leaving the room. All linens and surgical drapes must

be bagged and removed from the room. All trash and

disposable items must be bagged and taken from the

room. All instruments must be washed by gloved

hands or placed in perforated trays and put through a

washer/sterilizer.

At the completion of the day’s operations, each

operating room should be terminally cleaned using an

antiseptic germicide solution and the following tasks

accomplished.

• Clean all wall- or ceiling-mounted equipment.

• Clean all spotlights and lights on tracks.

• Thoroughly scrub all furniture used in the room,

including the wheels.

• Clean metal buckets and other waste receptacles

and, if possible, put them through the

washer/sterilizer.

• Clean scrub sinks.

• Machine scrub the entire floor in each room. If a

machine is not available, use a large floor brush.

• Suction up the disinfectant germicide solution

that is used on the floor, using a wet vacuum. If

mops are used, make sure a clean mop head is

used for each room.

NOTE: The use of mops in the operating room

is the LEAST DESIRABLE method of

cleaning.

MANAGEMENT OF INFECTIOUS

WASTE

LEARNING OBJECTIVE: Identify

medical waste sorting, packaging, handling,

and disposal procedures.

Concern about potentially adverse effects of

infectious waste on public health and the environment

has gained widespread media attention. While

scientific evidence shows that infectious waste is no

greater threat to the environment or public health than

residential solid waste, medical facilities are perceived

to be a source of pollution. It is, therefore, imperative

that a medical facility establish an effective plan for

dealing with infectious waste. This plan should

include the segregation, packing and handling,

storage, transportation, treatment, and disposal of such

2-37
debris. The management plan should establish

recordkeeping systems and personnel training

programs, and should incorporate the minimally

acceptable management standards for Navy MTFs and

DTFs (as contained in BUMEDINST 6280.1,

Management of Infectious Waste).

INFECTIOUS WASTE

Infectious waste is liquid or solid waste containing

pathogens in sufficient numbers and of sufficient

virulence to cause infectious disease in susceptible

hosts exposed to the waste. Several examples are:

• sharps (needles, scalpel blades),

• microbiology waste (cultures, stocks containing

microbes),

• pathological waste (human tissue, body parts),

• liquid waste (blood, cerebrospinal fluid), and

• medical waste from isolation rooms.

TREATMENT AND DISPOSAL METHODS

FOR INFECTIOUS WASTE

Several steps should be used in the treatment and

disposal of infectious waste. These steps include the

identification of waste; segregation, sorting, packaging,

2-38

Types of Infectious Waste Methods of Treatment Methods of Disposal

Microbiological Steam sterilization 1

Chemical disinfection 2

Incineration 3

Sanitary landfill

Pathological 5 Incineration 3&4

Cremation

Sanitary landfill

Burial 6

Bulk blood and other

potentially infectious

liquids

Gelatinization 6 Sanitary sewer 7

Sanitary landfill 8

Sharps in sharps containers Steam sterilization

Incineration

Sanitary landfill

Sanitary landfill

1 For effective sterilization, the temperature must be maintained at 121E C (250E F) for at least 90 minutes, at 15 pounds

per square inch of gauge pressure. Bacillus stearothermophilus spore strips must be used weekly to test the sterilization

process.

2 Chemical disinfection is most appropriate for liquids.

3 Ash remaining after incineration may go directly to the sanitary landfill, unless state or local regulations require

testing the ash for characteristics of hazardous waste.

4 Disposal of placentas by grinding with subsequent discharge to a sanitary sewer is acceptable unless prohibited by

county or local laws/regulations.

5 Burial or cremation is acceptable.

6 Must be further treated by steam sterilization or incineration.

7 Discharge to a sanitary sewer is acceptable unless prohibited by county or local laws/regulations.

8 Must be treated by steam sterilization or incineration before landfill disposal.

Table 2–2.—Treatment and Disposal Methods for Infectious Waste
handling, transporting, and treating of waste; and,

finally, disposal of the waste. The treatment and

disposal methods shown in table 2–2 are the minimally

acceptable standards.

SUMMARY

This chapter has introduced you to many basic

patient-care procedures and philosophies, such as

patient rights and responsibilities, professional

conduct, reporting and assessment procedures, patient

education, and patient safety precautions.

Additionally, you have learned about inpatient care

and the various types of patients you will encounter as

a Hospital Corpsman. Finally, you have been

introduced to standard rules of hygiene, aseptic

techniques, and the management of medical waste.

Having a good grasp of these areas of patient care will

give you a good base from which you can grow as a

Hospital Corpsman.

2-39

CHAPTER 3

FIRST AID EQUIPMENT, SUPPLIES, RESCUE, AND

TRANSPORTATION

This chapter will discuss first aid equipment and

supplies, and the rescue and transportation of the

injured patient. As a Hospital Corpsman, you will be

expected to recognize the uses and application

procedures for dressings and bandages, and to be able

to identify the protective equipment needed in specific

emergencies, along with where and when to use it.

In this chapter, you will learn the phases of a rescue

operation and the stages of extrication. You will also

learn the precautionary steps that must be taken in

special rescue situations. You will learn to recognize

the different patient-moving devices and lifting

techniques. Additionally, this chapter will familiarize

you with the various forms of emergency

transportation, and you will learn to identify essential

basic life support supplies on Navy ambulances.

Finally, this chapter will give you the preparatory, en

route, and turnover procedures for patients being

transported to medical treatment facilities.

FIRST AID EQUIPMENT AND

SUPPLIES

LEARNING OBJECTIVE: Identify initial

equipment and supply needs.

In a first aid situation, the Corpsman must always

be ready to improvise. In many field emergency

situations, standard medical supplies and equipment

may not be immediately available, or they may run out.

When medical supplies and equipment are available,

they will probably be found in an ambulance or in the

field medical Unit One Bag.

Navy ambulances are stocked in accordance with

BUMEDINST 6700.42, Ambulance Support. Table

3-1 lists equipment currently required for EMT-Basic

level ambulances. Table 3-2 lists the contents of an

emergency bag that a Hospital Corpsman might find in

an ambulance.

When assigned to Marine Corps Units, Hospital

Corpsmen carry their medical equipment and supplies

in a special bag. It is referred to as a “Unit One Bag.”

The Unit One Bag is made of nylon, weighs about 9

pounds, has an adjustable carrying strap, and contains

four strong compartments. The contents of the Unit

One Bag are listed below in table 3–3.

Unique operational requirements or command

decisions may modify the make-up of these lists. As a

Corpsman, it is up to you to be familiar with the

emergency medical equipment at the command, since

a call may come at a moment’s notice and you may

have to use these items to help save or sustain a life.

DRESSINGS AND BANDAGES

LEARNING OBJECTIVE: Recognize the

uses and application procedures for dressings

and bandages.

There are many different types of dressings and

bandages. You should be familiar with the various

standard dressings and bandages, their respective

functions, and their proper application in first-aid and

emergency situations.

DEFINITION OF A DRESSING

A dressing is a sterile pad or compress (usually

made of gauze or cotton wrapped in gauze) used to

cover wounds to control bleeding and/or prevent

further contamination. Dressings should be large

enough to cover the entire area of the wound and to

extend at least 1" in every direction beyond the edges.

If the dressing is not large enough, the edges of the

wound are almost certain to become contaminated.

Figure 3–1 shows several commonly used styles of

dressings.

Any part of a dressing that is to come in direct

contact with a wound should be absolutely sterile (that

is, free from microorganisms). The dressings that you

will find in first aid kits have been sterilized. However,

if you touch them with your fingers, your clothes, or

any other unsterile object, they are no longer sterile. If

you drag a dressing across the victim’s skin or allow it

3-1
3-2

ESSENTIAL EQUIPMENT FOR AMBULANCES

EMT-BASIC LEVEL

General Category

of Equipment

Detailed Breakdown Comments

Patient transfer litter • Collapsible-wheeled litter

Ventilation and airway

equipment • Portable suction apparatus

• Portable fixed oxygen equipment

• Oxygen administration equipment

• Bag-valve mask

• Airways

• Respirator (optional)

• Wide-bore tubing, rigid pharyngeal curved suction cup

• Variable flow regulator, humidifier (on fixed equipment)

• Adequate length tubing, masks (adult, child, and infant sizes;

transparent, non-rebreathing, venture and valveless nasal

prongs)

• Hand-operated, self-reexpanding bag (adult and infant sizes,

$0.85), accumulator (Fi02, 0.9), clear mask (adult, child, and

infant sizes), valve (clear, easily cleanable, operable in cold

weather)

• Nasopharyngeal, oropharyngeal (adult, child, and infant

sizes)

• Volume-cycled valve, on-off operation, 100% oxygen, 40-50

psi pressure

Immobilization devices

(splints) • Traction (adult and pediatric sizes)

• Extremity immobilization devices

•

• Backboards (long, short, and

clamshell)

• Lower extremity, limb-support slings, padded ankle hitch,

padded pelvic support, traction strap

• Joint above and joint below fracture, rigid support,

appropriate material (cardboard, metal, pneumatic, wood,

plastic, etc.)

• Joint above and point below fracture site. Chin strap (should

not use for head immobilization), hand holds for moving

patient, short (extrication: head-to-pelvis length), long

(transport: head-to-feet length)

Bandages • Burn sheets

• Triangle bandages

• Dressings

• Roller bandages

– Soft

– Elastic

• Vaseline gauze

• Adhesive tape

• Two clean (not sterile)

• Eight, three safety pins each

• Sterile, large and small

•

– Sterile, 4" or larger

– Nonsterile, 4" or larger

• Sterile, 3" × 8" or larger

• 2" or larger

Pneumatic Antishock

Garment (MAST) • Compartmentalized (legs and abdomen

separate), control valves (closed/open),

inflation pump, lower leg to lower rib

cage (does not include chest)

Obstetrical equipment • Sterile obstetrical kit

• Aluminum foil roll

• Towels, 4" × 4" dressing, umbilical tape type, bulb syringe,

clamps for cords, sterile gloves, blanket

• Enough to cover a newborn

Miscellaneous • Sphygmomanometer

• Stethoscope

• Heavy bandage scissors for cutting

clothing, belts, boots, etc.

• Mouth gags (commercial or tongue

blades covered with gauze)

• C-collar

• Flashlight

Radio communication • Two-way communication (EMT to

physician)

• Portable cellular telephone (optional)

• Radio UHF (ultra-high frequency) or VHF (very-high

frequency)

Table 3-1.—Essential Equipment for Ambulance ETM-Basic Level
to slip after it is in place, the dressing is no longer

sterile.

Should an emergency arise when a sterile dressing

is not available, the cleanest cloth at hand may be

used—a freshly laundered handkerchief, towel, or

shirt, for instance. Unfold these materials carefully so

that you do not touch the part that goes next to the skin.

Always be ready to improvise when necessary, but

never put materials directly in contact with wounds if

those materials are likely to stick to the wound, leave

lint, or be difficult to remove.

DEFINITION OF A BANDAGE

Standard bandages are made of gauze or muslin

and are used over a sterile dressing to secure the

dressing in place, to close off its edge from dirt and

germs, and to create pressure on the wound and control

bleeding. Abandage can also support an injured part or

secure a splint. The most common types of bandages

are the roller and triangular bandages.

Roller Bandage

The roller bandage, shown in figure 3–2, consists

of a long strip of material (usually gauze, muslin, or

elastic) that is wound into a cylindrical shape. Roller

bandages come in various widths and lengths. Most of

the roller bandages in the first aid kits have been

sterilized, so pieces may be cut off and used as

compresses in direct contact with wounds. If you use a

piece of roller bandage in this manner, you must be

careful not to touch it with your hands or with any other

unsterile object.

GENERAL APPLICATION.—In applying a

roller bandage, hold the roll in the right hand so that the

loose end is on the bottom; the outside surface of the

loose or initial end is next applied to and held on the

body part by the left hand. The roll is then passed

around the body part by the right hand, which controls

the tension and application of the bandage. Two or

three of the initial turns of a roller bandage should

overlie each other to properly secure the bandage (see

figure 3–3).

In applying the turns of the bandage, it is often

necessary to transfer the roll from one hand to the

3-3

AMBULANCE EMERGENCY BAG CONTENTS

Regular drip IV

tubing

Ambu bag Syrup of Ipecac

Mini drip IV tubing Trach adaptor Ace® wrap

IV extension tubing Suction tubing Klings®

19-gauge butterflies Straight &

Y-connector

Arm slings

18-gauge Medicut® Toomey syringe Safety pins

16-gauge Medicut® 10cc syringe Tongue blades

Tourniquet 20-gauge needles Tape

Adult oxygen mask Alcohol swabs Stethoscope

Nasal cannula Examination

gloves

4 x 4’s

Oxygen tubing Sodium Chloride

ampules

Lubricant

Airways (various

sizes)

Ammonia ampules Grease pencil

Table 3-2.—Ambulance Emergency Bag Contents

UNIT ONE BAG CONTENTS

One roll wire fabric, 5" x 36" One tourniquet

Two bottles of aspirin, 324 mg,

100s

One pair scissors, bandage

Three packages of morphine

inj., 1/4 g, 5s

Six packages of plastic strip

bandages, 6s

One bottle tetracaine

hydrochloride ophthalmic sol.

Three bottles

povidone-iodine solution,

1/2 fl oz

One airway, plastic, adult/

child

One thermometer, oral

Two packages atropine inj.,

12s

One card of safety pins,

medium, 12s

Two muslin triangular

bandages

Two books field medical

cards

Two medium battle dressings,

7 1/4" x 8"

One surgical instrument

set, minor surgery

Eight small battle dressings

4" x 7"

One pencil, black lead,

mechanical

One roll adhesive tape,

3 in x 5 yds

Two packages gauze,

rolled, 3 in x 5 yds

Table 3–3.—Unit One Bag Contents

Figure 3–1.—Commonly used styles of dressings.
other. Bandages should be applied evenly, firmly, but

not too tightly. Excessive pressure may cause

interference with the circulation and may lead to

disastrous consequences. In bandaging an extremity, it

is advisable to leave the fingers or toes exposed so the

circulation of these parts may be readily observed. It is

likewise safer to apply a large number of turns of a

bandage, rather than to depend upon a few turns

applied too firmly to secure a compress.

In applying a wet bandage, or one that may become

wet, you must allow for shrinkage. The turns of a

bandage should completely cover the skin, as any

uncovered areas of skin may become pinched between

the turns, with resulting discomfort. In bandaging any

extremity, it is advisable to include the whole member

(arm or leg, excepting the fingers or toes) so that

uniform pressure may be maintained throughout. It is

also desirable in bandaging a limb that the part is

placed in the position it will occupy when the dressing

is finally completed, as variations in the flexion and

extension of the part will cause changes in the pressure

of certain parts of the bandage.

The initial turns of a bandage on an extremity

(including spica bandages of the hip and shoulder)

should be applied securely, and, when possible, around

the part of the limb that has the smallest circumference.

Thus, in bandaging the arm or hand, the initial turns are

usually applied around the wrist, and in bandaging the

leg or foot, the initial turns are applied immediately

above the ankle.

The final turns of a completed bandage are usually

secured in the same manner as the initial turns, by

employing two or more overlying circular turns. As

both edges of the final circular turns are exposed, they

should be folded under to present a neat, cufflike

appearance. The terminal end of the completed

bandage is turned under and secured to the final turns

by either a safety pin or adhesive tape. When these are

not available, the end of the bandage may be split

lengthwise for several inches, and the two resulting

tails may be secured around the part by tying.

ROLLER BANDAGE FOR ELBOW.—A spica

or figure-eight type of bandage is used around the

elbow joint to retain a compress in the elbow region

and to allow a certain amount of movement. Flex the

elbow slightly (if you can do so without causing further

pain or injury), or anchor a 2- or 3-inch bandage above

the elbow and encircle the forearm below the elbow

with a circular turn. Continue the bandage upward

across the hollow of the elbow to the starting point.

Make another circular turn around the upper arm, carry

it downward, repeating the figure-eight procedure, and

gradually ascend the arm. Overlap each previous turn

about two-thirds of the width of the bandage. Secure

the bandage with two circular turns above the elbow,

and tie. To secure a dressing on the tip of the elbow,

reverse the procedure and cross the bandage in the back

(fig. 3–4).

3-4

Figure 3–2.—Roller bandages.

Figure 3–3.—Applying a roller bandage.
ROLLER BANDAGE FOR HAND AND

WRIST.—For the hand and wrist, a figure-eight

bandage is ideal. Anchor the dressing, whether it is on

the hand or wrist, with several turns of a 2- or 3-inch

bandage. If on the hand, anchor the dressing with

several turns and continue the bandage diagonally

upward and around the wrist and back over the palm.

Make as many turns as necessary to secure the

compress properly (fig. 3–5).

ROLLER BANDAGE FOR ANKLE AND

FOOT.—The figure-eight bandage is also used for

dressings of the ankle, as well as for supporting a

sprain. While keeping the foot at a right angle, start a

3-inch bandage around the instep for several turns to

anchor it. Carry the bandage upward over the instep

and around behind the ankle, forward, and again across

the instep and down under the arch, thus completing

one figure-eight. Continue the figure-eight turns,

overlapping one-third to one-half the width of the

bandage and with an occasional turn around the ankle,

until the compress is secured or until adequate support

is obtained (fig. 3–6).

ROLLER BANDAGE FOR HEEL.—The heel

is one of the most difficult parts of the body to bandage.

Place the free end of the bandage on the outer part of

the ankle and bring the bandage under the foot and up.

Then carry the bandage over the instep, around the

heel, and back over the instep to the starting point.

Overlap the lower border of the first loop around the

heel and repeat the turn, overlapping the upper border

of the loop around the heel. Continue this procedure

until the desired number of turns is obtained, and

secure with several turns around the lower leg (fig.

3–7).

ROLLER BANDAGE FOR ARM AND

LEG.—The spiral reverse bandage must be used to

cover wounds of the forearms and lower extremities;

3-5

Figure 3–4.—Roller bandage for the elbow.

Figure 3–5.—Roller bandage for the hand and wrist. Figure 3–7.—Roller bandage for the heel.

Figure 3–6.—Roller bandage for the ankle and foot.
only such bandages can keep the dressing flat and

even. Make two or three circular turns around the

lower and smaller part of the limb to anchor the

bandage and start upward, going around making the

reverse laps on each turning, overlapping about

one-third to one-half the width of the previous turn.

Continue as long as each turn lies flat. Continue the

spiral and secure the end when completed (fig. 3–8).

FOUR-TAILED BANDAGE.—A piece of roller

bandage may be used to make a four-tailed bandage.

The four-tailed bandage is good for bandaging any

protruding part of the body because the center portion

of the bandage forms a smoothly fitting pocket when

the tails are crossed over. This type of bandage is

created by splitting the cloth from each end, leaving as

large a center area as necessary. Figure 3–9A shows a

bandage of this kind. The four-tailed bandage is often

used to hold a compress on the chin, as shown in figure

3–9B, or on the nose, as shown in figure 3–9C.

BARTON BANDAGE.—The Barton bandage is

frequently used for fractures of the lower jaw and to

retain compresses to the chin. As in the progressive

steps illustrated in figure 3–10, the initial end of the

roller bandage is applied to the head, just behind the

right mastoid process. The bandage is then carried

under the bony prominence at the back of the head,

upward and forward back of the left ear, obliquely

across the top of the head. Next bring the bandage

downward in front of the right ear. Pass the bandage

obliquely across the top of the head, crossing the first

turn in the midline of the head, and then backward and

downward to the point of origin behind the right

mastoid. Now carry the bandage around the back of the

head under the left ear, around the front of the chin, and

under the right ear to the point of origin. This

procedure is repeated several times, each turn exactly

overlaying the preceding turn. Secure the bandage

with a pin or strip of adhesive tape at the crossing on

top of the head.

Triangular Bandage

Triangular bandages are usually made of muslin.

They are made by cutting a 36- to 40-inch square of a

piece of cloth and then cutting the square diagonally,

thus making two triangular bandages (in sterile packs

on the Navy’s medical stock list). A smaller bandage

3-6

Figure 3–8.—Roller bandage for the arm or leg.

Figure 3–9.—Four-tailed bandages: A. Four-tailed bandage;

B. Four-tailed bandage applied to chin; C. Four-tailed

bandage applied to nose.

Figure 3–10.—Barton bandage.
may be made by folding a large handkerchief

diagonally. The longest side of the triangular bandage

is called the base; the corner directly opposite the

middle of the base is called the point; and the other two

corners are called ends (fig. 3–11).

The triangular bandage is useful because it can be

folded in a variety of ways to fit almost any part of the

body. Padding may be added to areas that may become

uncomfortable.

TRIANGULAR BANDAGE FOR HEAD.—

This bandage is used to retain compresses on the

forehead or scalp. Fold back the base about 2 inches to

make a hem. Place the middle of the base on the

forehead, just above the eyebrows, with the hem on the

outside. Let the point fall over the head and down over

the back of the head. Bring the ends of the triangle

around the back of the head above the ears, cross them

over the point, carry them around the forehead, and tie

in a SQUARE KNOT. Hold the compress firmly with

one hand, and, with the other, gently pull down the

point until the compress is snug; then bring the point up

and tuck it over and in the bandage where it crosses the

back part of the head. Figure 3–12 shows the proper

application of a triangular bandage for the head.

TRIANGULARBANDAGEFORSHOULDER.—

Cut or tear the point, perpendicular to the base, about

10 inches. Tie the two points loosely around the

patient’s neck, allowing the base to drape down over

the compress on the injured side. Fold the base to the

desired width, grasp the end, and fold or roll the sides

toward the shoulder to store the excess bandage. Wrap

the ends snugly around the upper arm, and tie on the

outside surface of the arm. Figure 3–13 shows the

proper application of a triangular bandage for the

shoulder.

TRIANGULAR BANDAGE FOR CHEST.—

Cut or tear the point, perpendicular to the base, about

10 inches. Tie the two points loosely around the

patient’s neck, allowing the bandage to drape down

over the chest. Fold the bandage to the desired width,

carry the ends around to the back, and secure by tying.

Figure 3–14 shows the proper application of a

triangular bandage for the chest.

TRIANGULAR BANDAGE FOR HIP OR

BUTTOCK.—Cut or tear the point, perpendicular to

the base, about 10 inches. Tie the two points around the

thigh on the injured side. Lift the base up to the

waistline, fold to the desired width, grasp the ends, fold

or roll the sides to store the excess bandage, carry the

ends around the waist, and tie on the opposite side of

the body. Figure 3–15 shows the proper application of

a triangular bandage for the hip or buttock.

TRIANGULAR BANDAGE FOR SIDE OF

CHEST.—Cut or tear the point, perpendicular to the

base, about 10 inches. Place the bandage, points up,

under the arm on the injured side. Tie the two points on

top of the shoulder. Fold the base to the desired width,

carry the ends around the chest, and tie on the opposite

side. Figure 3–16 shows the proper application of a

triangular bandage for the side of the chest.

TRIANGULAR BANDAGE FOR FOOT OR

HAND.—This bandage is used to retain large

compresses and dressings on the foot or the hand. For

the foot: After the compresses are applied, place the

foot in the center of a triangular bandage and carry the

point over the ends of the toes and over the upper side

of the foot to the ankle. Fold in excess bandage at the

side of the foot, cross the ends, and tie in a square knot

3-7

Figure 3–11.—Triangular bandage.

Figure 3–12.—Triangular bandage for the head.
in front. For the hand: After the dressings are applied,

place the base of the triangle well up in the palmar

surface of the wrist. Carry the point over the ends of

the fingers and back of the hand well up on the wrist.

Fold the excess bandage at the side of the hand, cross

the ends around the wrist, and tie a square knot in front.

Figure 3–17 shows the proper application of a

triangular bandage for either the foot or the hand.

CRAVAT BANDAGE.—A triangular bandage

can be folded into a strip for easy application during an

emergency. When folded as shown in figure 3–18, the

bandage is called a cravat. To make a cravat bandage,

bring the point of the triangular bandage to the middle

of the base and continue to fold until a 2-inch width is

obtained. The cravat may be tied, or it may be secured

with safety pins (if the pins are available).

3-8

Figure 3–13.—Triangular bandage for the shoulder.
When necessary, a cravat can be improvised from

common items such as T-shirts, bed linens, trouser

legs, scarves, or any other item of pliable and durable

material that can be folded, torn, or cut to the desired

size.

Cravat Bandage for Head.—This bandage is

useful to control bleeding from wounds of the scalp or

forehead. After placing a compress over the wound,

place the center of the cravat over the compress and

carry the ends around to the opposite side; cross them,

continue to carry them around to the starting point, and

tie in a square knot.

Cravat Bandage for Eye.—After applying a

compress to the affected eye, place the center of the

cravat over the compress and on a slant so that the

lower end is inclined downward. Bring the lower end

around under the ear on the opposite side. Cross the

ends in back of the head, bring them forward, and tie

them over the compress. Figure 3–19 shows the proper

application of a cravat bandage for the eye.

3-9

Figure 3–14.—Triangular bandage for the chest.

Figure 3–15.—Triangular bandage for the hip or buttock.
Cravat Bandage for Temple, Cheek, or

Ear.—After a compress is applied to the wound, place

the center of the cravat over it and hold one end over

the top of the head. Carry the other end under the jaw

and up the opposite side, over the top of the head, and

cross the two ends at right angles over the temple on the

injured side. Continue one end around over the

forehead and the other around the back of the head to

meet over the temple on the uninjured side. Tie the

ends in a square knot. (This bandage is also called a

Modified Barton.) Figure 3–20 shows the proper

application of a cravat bandage for the temple, cheek,

or ear.

Cravat Bandage for Elbow or Knee.—After

applying the compress, and if the injury or pain is not

too severe, bend the elbow or knee to a right-angle

position before applying the bandage. Place the

3-10

Figure 3–16.—Triangular bandage for the side of the chest.

Figure 3–17.—Triangular bandage for the foot or hand.

Figure 3–18.—Cravat bandage.
middle of a rather wide cravat over the point of the

elbow or knee, and carry the upper end around the

upper part of the elbow or knee, bringing it back to the

hollow, and the lower end entirely around the lower

part, bringing it back to the hollow. See that the

bandage is smooth and fits snugly; then tie in a square

knot outside of the hollow. Figure 3–21 shows the

proper application of a cravat bandage for the elbow or

knee.

Cravat Bandage for Arm or Leg.—The width of

the cravat you use will depend upon the extent and area

of the injury. For a small area, place a compress over

the wound, and center the cravat bandage over the

compress. Bring the ends around in back, cross them,

and tie over the compress. For a small extremity, it

may be necessary to make several turns around to use

all the bandage for tying. If the wound covers a larger

area, hold one end of the bandage above the compress

and wind the other end spirally downward across the

compress until it is secure, then upward and around

again, and tie a knot where both ends meet. Figure

3–22 shows the proper application of a cravat bandage

for the arm, forearm, leg, or thigh.

Cravat Bandage for Axilla (Armpit).—This

cravat is used to hold a compress in the axilla. It is

similar to the bandage used to control bleeding from

the axilla. Place the center of the bandage in the axilla

over the compress and carry the ends up over the top of

the shoulder and cross them. Continue across the back

and chest to the opposite axilla, and tie them. Do not tie

3-11

HMF0319

Figure 3–19.—Cravat bandage for the eye.

Figure 3–20.—Cravat (Modified Barton) bandage for the temple, cheek, or ear.
too tightly or the axillary artery will be compressed,

adversely affecting the circulation of the arm. Figure

3–23 shows the proper application of a cravat bandage

for the axilla.

BATTLE DRESSING

A battle dressing is a combination compress and

bandage in which a sterile gauze pad is fastened to a

gauze, muslin, or adhesive bandage (fig. 3–24). Most

Navy first aid kits contain both large and small battle

dressings of this kind.

RESCUE AND TRANSPORTATION

LEARNING OBJECTIVE: Identify

protective equipment items that are used during

patient rescues, and recall how and when each

protective equipment item should be used.

It is a basic principle of first aid that an injured

person must be given essential treatment before being

moved. However, it is impossible to treat an injured

person who is in a position of immediate danger. If the

victim is drowning, or if his life is endangered by fire,

steam, electricity, poisonous or explosive gases, or

other hazards, rescue must take place before first aid

treatment can be given.

The life of an injured person may well depend

upon the manner in which rescue and transportation to

a medical treatment facility are accomplished. Rescue

operations must be accomplished quickly, but

unnecessary haste is both futile and dangerous. After

rescue and essential first aid treatment have been

given, further transportation must be accomplished in

a manner that will not aggravate the injuries. As a

Corpsman, it may be your responsibility to

direct—and be the primary rescuer in—these

operations. The life and safety of the victim and the

members of the rescue team may rest on your

decisions.

In this section, we will consider the use of

common types of protective equipment; rescue

procedures; special rescue situations; ways of moving

3-12

Figure 3–21.—Cravat bandage for the elbow or knee.

Figure 3–22.—Cravat bandage for the arm, forearm, leg, or thigh.

Figure 3–23.—Cravat bandage for the axilla.
the patient to safety; and procedures for transporting

the injured after first aid has been given.

PROTECTIVE EQUIPMENT

The use of appropriate items of protective

equipment will increase your ability to effect rescue

from life-threatening situations. Protective equipment

that is generally available on naval vessels and some

shore activities include the oxygen breathing

apparatus (OBA); hose (air line) masks; protective

(gas) masks; steel-wire lifelines; and devices for

detecting oxygen insufficiency, explosive vapors, and

some poisonous gases.

Oxygen Breathing Apparatus

An oxygen breathing apparatus (OBA) is provided

for emergency use in compartments containing toxic

gases. The apparatus is particularly valuable for

rescue purposes because it is a self-contained unit. The

wearer is not dependent upon outside air or any type of

air line within the effective life of the canister.

There are several types of OBAs, but they are all

similar in operation. Independence of the outside

atmosphere is achieved by having air within the

apparatus circulated through a canister. Within the

canister, oxygen is continuously generated. The

effective life of the canister varies from 20 to 45

minutes, depending on the particular apparatus and the

type of work being done. One of the newer types of

OBA is designed so that you can change canisters

without leaving the toxic atmosphere.

If you are to enter an extremely hazardous area,

you should also wear a lifeline. The lifeline should be

tended by two persons, one of whom is also wearing a

breathing apparatus.

Never allow oil or grease to come in contact with

any part of an OBA. Oxygen is violently explosive in

the presence of oil or grease. If any part of the

apparatus becomes contaminated with oil or grease

smudges, clean it before it is stowed. Care should be

taken to prevent oil or oily water from entering the

canister between the time it is opened and the time of

disposal.

Hose (Air Line) Masks

Hose masks are part of the allowance of all ships

having repair party lockers. They are smaller than the

oxygen breathing outfits and can, therefore, be used by

persons who must enter voids or other spaces that have

very small access hatches. The hose or air line mask

consists essentially of a gas mask facepiece with an

adjustable head harness and a length of airhose. Note

that the air line mask uses air rather than pure oxygen.

It must NEVER be connected to an oxygen bottle,

oxygen cylinder, or other source of oxygen. Even a

small amount of oil or grease in the air line could

combine rapidly with the oxygen and cause an

explosion.

Safety belts are furnished with each air line mask

and MUST BE WORN. Alifeline must be fastened to

the safety belt; and the lifeline should be loosely lashed

to the airhose to reduce the possibility of fouling. The

airhose and lifeline must be carefully tended at all

times so that they do not become fouled or cut. The

person wearing the air line mask and the person

tending the lines should maintain communication by

means of standard divers’ signals.

Protective (Gas) Masks

Protective masks provide respiratory protection

against chemical, biological, and radiological warfare

agents. They do not provide protection from the

effects of carbon monoxide, carbon dioxide, and a

number of industrial gases. Protection from these

gases is discussed in the section, “Rescue from

Unventilated Compartments,” later in this chapter.

In emergencies, protective masks may be used for

passage through a smoke-filled compartment or for

3-13

Figure 3-24.—Battle dressing.
entry into such a compartment to perform a job that can

be done quickly (such as to close a valve, secure a fan,

or de-energize a circuit). However, they provide only

limited protection against smoke. The length of time

you can remain in a smoke-filled compartment

depends on the type of smoke and its concentration.

The most important thing to remember about

protective masks is that they do not manufacture or

supply oxygen. They merely filter the air as it passes

through the canister.

Lifelines

The lifeline is a steel-wire cable, 50 feet long.

Each end is equipped with a strong hook that closes

with a snap catch. The line is very pliable and will slide

freely around obstructions. See figure 3–25.

Lifelines are used as a precautionary measure to

aid in the rescue of persons wearing rescue breathing

apparatus, hose masks, or similar equipment. Rescue,

if necessary should be accomplished by having another

person equipped with a breathing apparatus follow the

lifeline to the person being rescued, rather than by

attempting to drag the person out. Attempts to drag a

person from a space may result in fouling the lifeline

on some obstruction or in parting the harness, in which

case it would still be necessary to send a rescue person

into the space.

An important point to remember is that a stricken

person must never be hauled by a lifeline attached to

the waist. The victim may be dragged along the deck a

short distance, but his weight must never be suspended

on a line attached to the waist. If not wearing a harness

of some kind, pass the line around the chest under the

armpits and fasten it in front or in back.

When tending a lifeline, you must wear gloves to

be able to handle the line properly. Play out the line

carefully to keep it from fouling. Try to keep the

lifeline in contact with grounded metal; do not allow it

to come in contact with any energized electrical

equipment.

Detection Devices

The detection devices used to test the atmosphere

in closed or poorly ventilated spaces include the

oxygen indicator, for detecting oxygen deficiency;

combustible-gas indicators, for determining the

concentration of explosive vapors; and toxic-gas

indicators, such as the carbon monoxide indicator,

for finding the concentration of certain poisonous

gases. The devices are extremely valuable and should

be used whenever necessary. However, they MUST

BE USED ONLY AS DIRECTED. Improper

operation of these devices may lead to false assurances

of safety or, worse yet, to an increase in the actual

danger of the situation. For example, the use of a flame

safety lamp in a compartment filled with acetylene or

hydrogen could cause a violent explosion.

RESCUE PROCEDURES

LEARNING OBJECTIVE: Recognize the

phases of rescue operations and the stages of

extrication.

If you are faced with the problem of rescuing a

person threatened by fire, explosive or poisonous

gases, or some other emergency, do not take any action

until you have had time to determine the extent of the

danger and your ability to cope with it. In a large

number of accidents, the rescuer rushes in and

becomes the second victim. Do not take unnecessary

chances! Do not attempt any rescue that needlessly

endangers your own life!

Phases of Rescue Operations

In disasters where there are multiple patients (as in

explosions or ship collisions), rescue operations

should be performed in phases. These rescue phases

apply only to extrication operations.

The first phase is to remove lightly pinned

casualties, such as those who can be freed by lifting

boxes or removing a small amount of debris.

3-14

Figure 3–25.—Steel wire lifeline.
In the second phase, remove those casualties who

are trapped in more difficult circumstances but who

can be rescued by use of the equipment at hand and in a

minimum amount of time.

In the third phase, remove casualties where

extrication is extremely difficult and time consuming.

This type of rescue may involve cutting through decks,

breaching bulkheads, removing large amounts of

debris, or cutting through an expanse of metal. An

example would be rescuing a worker from beneath a

large, heavy piece of machinery.

The last phase is the removal of dead bodies.

Stages of Extrication

The first stage of extrication within each of the

rescue phases outlined above is gaining access to the

victim. Much will depend on the location of the

accident, damage within the accident site, and the

position of the victim. The means of gaining access

must also take into account the possibility of causing

further injury to the victim since force may be needed.

Further injury must be minimized.

The second stage involves giving lifesaving

emergency care. If necessary, establish and maintain

an open airway, start artificial respiration, and control

hemorrhage.

The third stage is disentanglement. The careful

removal of debris and other impediments from the victim

will prevent further injury to both the victim and the

rescuer.

The fourth stage is preparing the victim for

removal, with special emphasis on the protection of

possible fractures.

The final stage, removing the victim from the

trapped area and transporting to an ambulance or

sickbay, may be as simple as helping the victim walk

out of the area or as difficult as a blanket dragged out of

a burning space.

Special Rescue Situations

LEARNING OBJECTIVE: Recognize the

procedural and precautionary steps that must

be taken in various rescue situations.

The procedures you follow in an emergency

situation will be determined by the nature of the

disaster or emergency you encounter. Some of the

more common rescue situations and the appropriate

procedures for each are outlined below.

RESCUE FROM FIRE.—If you must go to the

aid of a person whose clothing is on fire, try to smother

the flames by wrapping the victim in a coat, blanket, or

rug. Leave the head UNCOVERED. If you have no

material with which to smother the fire, roll the victim

over—SLOWLY—and beat out the flames with your

hands. Beat out the flames around the head and

shoulders, then work downward toward the feet. If the

victim tries to run, throw him down. Remember that

the victim MUST lie down while you are trying to

extinguish the fire. Running will cause the clothing to

burn rapidly. Sitting or standing may cause the victim

to be killed instantly by inhaling flames or hot air.

CAUTION: Inhaling flames or hot air can kill

YOU, too. Do not get your face directly over the

flames. Turn your face away from the flame when

you inhale.

If your own clothing catches fire, roll yourself up

in a blanket, coat, or rug. KEEP YOUR HEAD

UNCOVERED. If material to smother the fire is not

available, lie down, roll over slowly, and beat at the

flames with your hands.

If you are trying to escape from an upper floor of a

burning building, be very cautious about opening

doors into hallways or stairways. Always feel a door

before you open it. If the door feels hot, do not open it

if there is any other possible way out. Remember, also,

that opening doors or windows will create a draft and

make the fire worse. So do not open any door or

window until you are actually ready to get out.

If you are faced with the problem of removing an

injured person from an upper story of a burning

building, you may be able to improvise a lifeline by

tying sheets, blankets, curtains, or other materials

together. Use square knots to connect the materials to

each other. Secure one end of the line around some

heavy object inside the building, and fasten the other

end around the casualty under the arms. You can lower

the victim to safety and then let yourself down the line.

Do not jump from an upper floor of a burning building

except as a last resort.

It is often said that the “best” air in a burning room

or compartment is near the floor, but this is true only to

a limited extent. There is less smoke and flame down

low, near the floor, and the air may be cooler. But it is

also true that carbon monoxide and other deadly gases

are just as likely to be present near the floor as near the

3-15
ceiling. Therefore, if possible, use an oxygen

breathing apparatus or other protective breathing

equipment when you go into a burning compartment.

If protective equipment is not available, cover your

mouth and nose with a wet cloth to reduce the danger of

inhaling smoke, flame, or hot air.

CAUTION: A WET CLOTH GIVES YOU

NO PROTECTION AGAINSTPOISONOUS

GASES OR LACK OF OXYGEN!

RESCUE FROM STEAM-FILLED SPACES.—

It is sometimes possible to rescue a person from a space

in which there is a steam leak. Since steam rises,

escape upward may not be possible. If the normal exit

is blocked by escaping steam, move the casualty to the

escape trunk or, if there is none, to the lowest level in

the compartment.

RESCUE FROM ELECTRICAL CONTACT.—

Rescuing a person who has received an electrical

shock is likely to be difficult and dangerous. Extreme

caution must be used, or you may be electrocuted

yourself.

CAUTION: YOU MUST NOT TOUCH

THE VICTIM’S BODY, THE WIRE, OR

ANY OTHER OBJECT THAT MAY BE

CONDUCTING ELECTRICITY.

First of all, look for the switch. If you find the

switch, turn off the current immediately. Do not waste

too much time hunting for the switch: Every second is

important.

If you cannot find the switch, try to remove the

wire from the victim with a DRY broom handle,

branch, pole, oar, board, or similar NONCONDUCTING object. It may be possible to use a DRY

rope or DRY clothing to pull the wire away from the

victim. You can also break the contact by cutting

the wire with a WOODEN-HANDLED axe, but

this is extremely dangerous because the cut ends of

the wire are likely to curl and lash back at you

before you have time to get out of the way. When

you are trying to break an electrical contact, always

stand on some nonconducting material such as a

DRY board, DRY newspapers, or DRY clothing.

See figure 3–26.

RESCUE FROM UNVENTILATED COMPARTMENTS.—Rescuing a person from a void,

double bottom, gasoline or oil tank, or any closed

compartment or unventilated space is generally a very

hazardous operation. Aboard naval vessels and at

naval shore stations, no person is permitted to enter any

such space or compartment until a damage control

officer (DCO), or some person designated by the DCO,

has indicated that the likelihood of suffocation,

poisoning, and fire or explosion has been eliminated as

far as possible. The rescue of a person from any closed

space should therefore be performed under the

supervision of the DCO or in accordance with the

DCO’s instructions. In general, it is necessary to

observe the following precautions when attempting to

rescue a person from any closed or poorly ventilated

space:

• If possible, test the air for oxygen deficiency,

poisonous gases, and explosive vapors.

• Wear a hose (air line) mask or oxygen breathing

apparatus. The air line mask is preferred for use

in spaces that may contain high concentrations

of oil or gasoline vapors. Do not depend upon a

protective mask or a wet cloth held over your

face to protect you from oxygen deficiency or

poisonous gases.

• Before going into a compartment that may

contain explosive vapors, be sure that people are

stationed nearby with fire-extinguishing

equipment.

3-16

Figure 3–26.—Moving a victim away from an electrical line.
• When going into any space that may be deficient

in oxygen or contain poisonous or explosive

vapors, be sure to maintain communication with

someone outside. Wear a lifeline, and be sure

that it is tended by a competent person.

• Do not use, wear, or carry any object or material

that might cause a spark. Matches, cigarette

lighters, flashlights, candles or other open

flames, and ordinary electrical lights must

NEVER be taken into a compartment that may

contain explosive vapors. The kind of portable

light used by cleaning parties in boilers, fuel

tanks, and similar places may be taken into a

suspect compartment. This is a steam-tight,

glove-type light whose exposed metal parts are

either made of nonsparking alloy or protected in

some way so they will not strike a spark.

An electrical apparatus or tool that might spark

must never be taken into a compartment until a DCO

has indicated that it is safe to do so. When electrical

equipment is used (e.g., an electric blower might be

used to vent a compartment of explosive vapors), it

must be explosion proof and properly grounded.

If you go into a space that may contain explosive

vapors, do not wear clothing that has any exposed

spark-producing metal. For example, do not wear

boots or shoes that have exposed nailheads or rivets,

and do not wear coveralls or other garments that might

scrape against metal and cause a spark.

A particular caution must be made concerning the

use of the steel-wire lifeline in compartments that may

contain explosive vapors. If you use the line, be sure

that it is carefully tended and properly grounded at all

times. When other considerations permit, you should

use a rope line instead of the steel-wire lifeline when

entering compartments that may contain explosive

vapors.

RESCUE FROM THE WATER.—You should

never attempt to swim to the rescue of a drowning

person unless you have been trained in lifesaving

methods—and then only if there is no better way of

reaching the victim. A drowning person may panic and

fight against you so violently that you will be unable

either to carry out the rescue or to save yourself. Even

if you are not a trained lifesaver, however, you can help

a drowning person by holding out a pole, oar, branch,

or stick for the victim to catch hold of, or by throwing a

lifeline or some buoyant object that will support the

victim in the water.

Various methods are used aboard ship to pick up

survivors from the water. The methods used in any

particular instance will depend upon weather

conditions, the type of equipment available aboard the

rescue vessel, the number of people available for

rescue operations, the physical condition of the people

requiring rescue, and other factors. In many cases it

has been found that the best way to rescue a person

from the water is to send out a properly trained and

properly equipped swimmer with a lifeline.

It is frequently difficult to get survivors up to the

deck of the rescuing vessel, even after they have been

brought alongside the vessel. Cargo nets are often

used, but many survivors are unable to climb them

without assistance. Persons equipped with lifelines

(and, if necessary, dressed in anti-exposure suits) can

be sent over the side to help survivors up the nets. If

survivors are covered with oil, it may take the

combined efforts of four or five people to get one

survivor up the net.

A seriously injured person should never, except in

an extreme emergency, be hauled out of the water by

means of a rope or lifeline. Special methods must be

devised to provide proper support, both to keep the

victim in a horizontal position and to provide

protection from any kind of jerking, bending, or

twisting motion. The Stokes stretcher (described later

in this chapter) can often be used to rescue an injured

survivor. People on the deck of the ship can then bring

the stretcher up by means of handlines. Life

preservers, balsa wood, unicellular material, or other

flotation gear can be used, if necessary, to keep the

stretcher afloat.

MOVING THE VICTIM TO SAFETY

LEARNING OBJECTIVE: Recognize the

different patient-moving devices and lifting

techniques that can be used in patient rescues.

In an emergency, there are many ways to move a

victim to safety, ranging from one-person carries to

stretchers and spineboards. The victim’s condition and

the immediacy of danger will dictate the appropriate

method. Remember, however, to give all necessary

first aid BEFORE moving the victim.

3-17
Stretchers

The military uses a number of standard stretchers.

The following discussion will familiarize you with the

most common types. When using a stretcher, you

should consider a few general rules:

• Use standard stretchers when available, but be

ready to improvise safe alternatives.

• When possible, bring the stretcher to the

casualty.

• Always fasten the victim securely to the

stretcher.

• Always move the victim FEET FIRST so the

rear bearer can watch for signs of breathing

difficulty.

STOKES STRETCHER.—The Navy service

litter most commonly used for transporting sick or

injured persons is called the Stokes stretcher. As

shown in figure 3–27, the Stokes stretcher is

essentially a wire basket supported by iron rods. Even

if the stretcher is tipped or turned, the casualty can be

held securely in place, making the Stokes adaptable to

a variety of uses. This stretcher is particularly valuable

for transferring injured persons to and from boats. As

mentioned before, it can also be used with flotation

devices to rescue injured survivors from the water. It is

also used for direct ship-to-ship transfer of injured

persons. Fifteen-foot handling lines are attached to

each end for shipboard use in moving the victim.

The Stokes stretcher should be padded with three

blankets: two of them should be placed lengthwise (so

that one will be under each of the casualty’s legs), and

the third should be folded in half and placed in the

upper part of the stretcher to protect the head and

shoulders. The casualty should be lowered gently into

the stretcher and made as comfortable as possible. The

feet must be fastened to the end of the stretcher so that

the casualty will not slide down. Another blanket (or

more, if necessary) should be used to cover the

casualty. The casualty must be fastened to the stretcher

by means of straps that go over the chest, hips, and

knees. Note that the straps go OVER the blanket or

other covering, thus holding it in place.

ARMY LITTER.—The Army litter, shown in

figure 3–28, is a collapsible stretcher made of canvas

and supported by wooden or aluminum poles. It is very

useful for transporting battle casualties in the field.

However, it is sometimes difficult to fasten the

casualty onto the Army litter, and for this reason its use

is somewhat limited aboard ship. The litter legs keep

the patient off the ground. The legs fit into the

restraining tracks of a jeep or field ambulance to hold

the litter in place during transport.

MILLER (FULL BODY) BOARD.3⁄4The Miller

Board (fig 3-29) is constructed of an outer plastic shell

with an injected foam core of polyurethane foam. It is

impervious to chemicals and the elements and can be

used in virtually every confined-space rescue and

vertical extrication. The Miller Board provides for full

body immobilization through a harness system,

including a hood and two-point contact for the head

(forehead and chin) to stabilize the head and cervical

spine. The board’s narrow design allows passage

through hatches and crowded passageways. It fits

3-18

Figure 3–27.—Stokes stretcher.

Figure 3–28.—Opening an Army litter.
within a Stokes (basket) stretcher and will float a

250-pound person.

IMPROVISED STRETCHERS.—Standard

stretchers should be used whenever possible to

transport a seriously injured person. If none are

available, it may be necessary for you to improvise.

Shutters, doors, boards, and even ladders may be used

as stretchers. All stretchers of this kind must be very

well padded and great care must be taken to see that the

casualty is fastened securely in place.

Sometimes a blanket may be used as a stretcher, as

shown in figure 3–30. The casualty is placed in the

middle of the blanket in the supine position. Three or

four people kneel on each side and roll the edges of the

blanket toward the casualty, as shown in figure 3–30A.

When the rolled edges are tight and large enough to

grasp securely, the casualty should be lifted and carried

as shown in figure 3–30B.

Stretchers may also be improvised by using two

long poles (about 7 feet long) and strong cloth (such as

a rug, a blanket, a sheet, a mattress cover, two or three

gunny sacks, or two coats). Figure 3–31 shows an

improvised stretcher made from two poles and a

blanket.

CAUTION: Many improvised stretchers do not

give sufficient support in cases where there are

fractures or extensive wounds of the body. They

should be used only when the casualty is able to stand

some sagging, bending, or twisting without serious

consequences. An example of this type of improvised

stretcher would be one made of 40 to 50 feet of rope or

1-1/2-inch firehose (fig. 3–32).

Spineboards

Spineboards are essential equipment in the

immobilization of suspected or real fractures of the

spinal column. Made of fiberglass or exterior

plywood, they come in two sizes, short (18" × 32") and

long (18" × 72"), and are provided with handholds and

straps. Spineboards also have a runner on the bottom

to allow clearance to lift (fig. 3–33).

A short spineboard is primarily used in extrication

of sitting victims, especially in automobile wrecks

(where it would be difficult to maneuver the victim out

of position without doing additional damage to the

spine). The long board makes a firm litter, protecting

the back and neck, and providing a good surface for

3-19

HMf0329

Figure 3–29.—Miller (full body) Board.

Figure 3–30.—Blanket used as an improvised stretcher.
CPR and a good sliding surface for difficult

extractions.

The short and long boards are often used together.

For example, at an automobile accident site, the

Corpsman’s first task is to assess the whole situation

and to plan the rescue. If bystanders must be used, it is

essential that they be briefed in thorough detail on what

you want them to do. After all accessible bleeding has

been controlled and the fractures splinted, the short

spineboard should be moved into position behind the

victim. A neck collar should be applied in all cases and

will aid in the immobilization of the head and neck.

The head should then be secured to the board with a

headband or a 6-inch self-adhering roller bandage.

The victim’s body should then be secured to the board

by use of the supplied straps around the chest and

thighs. The victim may then be lifted out. If, however,

3-20

Figure 3–31.—Improvised stretcher using blankets and poles.

Figure 3–32.—Improvised stretcher using rope or firehose.

Figure 3–33.—Spineboards.
the victim is too large, or further immobilization of the

lower extremities is necessary, the long spineboard

may be slid at a right angle behind the short

spineboard, and the victim maneuvered onto his side

and secured to the longboard.

The possible uses of the spineboard in an

emergency situation are limited only by the

imagination of the rescuers.

Emergency Rescue Lines

As previously mentioned, the steel-wire lifeline

can often be used to haul a person to safety. An

emergency rescue line can also be made from any

strong fiber line. Both should be used only in extreme

emergencies, when an injured person must be moved

and no other means is available. Figure 3–34 shows an

emergency rescue line that could be used to hoist a

person from a void or small compartment. Notice that

a running bowline is passed around the body, just

below the hips, and a half hitch is placed just under the

arms. Notice also that a guideline is tied to the

casualty’s ankles to prevent banging against bulkheads

and hatchways.

Rescue Drag and Carry Techniques

There will be times when you, as a Corpsman, will

be required to evacuate a sick or injured person from an

emergency scene to a location of safety. Casualties

carried by manual means must be carefully and

correctly handled, otherwise their injuries may become

more serious or possibly fatal. Situation permitting,

evacuation or transport of a casualty should be

organized and unhurried. Each movement should be

performed as deliberately and gently as possible.

Manual carries are tiring for the bearer(s) and

involve the risk of increasing the severity of the

casualty’s injury. In some instances, however, they are

essential to save the casualty’s life. Although manual

carries are accomplished by one or two bearers, the

two-man carries are used whenever possible. They

provide more comfort to the casualty, are less likely to

aggravate his injuries, and are also less tiring for the

bearers, thus enabling them to carry him farther. The

distance a casualty can be carried depends on many

factors, such as

• strength and endurance of the bearer(s),

• weight of the casualty,

• nature of the casualty’s injury, and

• obstacles encountered during transport.

You should choose the evacuation technique that

will be the least harmful, both to you and the victim.

When necessary and appropriate, use a one-rescuer

technique (several of which are described in the

following section). Two-rescuer techniques and the

circumstances under which those techniques are

appropriate are also listed below.

ONE-RESCUER TECHNIQUES.—If a victim

can stand or walk, assist him to a safe place. If there are

no indications of injury to the spine or an extremity but

the casualty is not ambulatory, he can be carried by

means of any of the following:

• Fireman’s Carry: One of the easiest ways to

carry an unconscious person is by means of the

fireman’s carry. Figure 3–35 shows the steps of this

procedure.

• Pack-strap Carry: With the pack-strap carry,

shown in figure 3–36, it is possible to carry a heavy

person for some distance. Use the following procedure:

1. Place the casualty in a supine position.

2. Lie down on your side along the casualty’s

uninjured or less injured side. Your shoulder

should be next to the casualty’s armpit.

3. Pull the casualty’s far leg over your own,

holding it there if necessary.

3-21

Figure 3–34.—Hoisting a person.
4. Grasp the casualty’s far arm at the wrist and

bring it over your upper shoulder as you roll and

pull the casualty onto your back.

5. Raise up your knees, holding your free arm for

balance and support. Hold both the casualty’s

wrists close against your chest with your other

hand.

6. Lean forward as you rise to your feet, and keep

both of your shoulders under the casualty’s

armpits.

Do not attempt to carry a seriously injured person

by means of the pack-strap carry, especially if the

arms, spine, neck, or ribs are fractured.

• Arm Carry: The technique for a one-person arm

carry is shown in figure 3–37. However, you should

never try to carry a person who is seriously injured with

this method. Unless considerably smaller than you are,

you will not be able to carry the casualty very far using

this technique.

• Blanket Drag: The blanket drag, shown in

figure 3–38, can be used to move a person who, due to

the severity of the injury, should not be lifted or carried

by one person alone. Place the casualty in the supine

position on a blanket and pull the blanket along the floor

or deck. Always pull the casualty head first, with the

head and shoulders slightly raised so that the head will

not bump against the deck.

3-22

Figure 3–35.—Fireman’s carry.

Figure 3–36.—Pack-strap carry.
A variant of the blanket drag is the clothes drag,

where the rescuer drags the victim by the clothing on

the victim’s upper body.

• Tied-hands Crawl: The tied-hands crawl,

shown in figure 3–39, may be used to drag an

unconscious person for a short distance. It is

particularly useful when you must crawl underneath a

low structure, but it is the least desirable because the

victim’s head is not supported.

To be carried by this method, the casualty must be

in the supine position. Cross the wrists and tie them

together. Kneel astride the casualty and lift the arms

over your head so that the wrists are at the back of your

neck. When you crawl forward, raise your shoulders

high enough so that the casualty’s head will not bump

against the deck.

TWO-RESCUER TECHNIQUES.—If the

casualty is ambulatory, you and your partner should

assist him to safety. However, if the victim has either a

spinal injury or a fractured extremity, there are a

number of two-rescuer techniques that can be used to

move him to safety.

• Chair Carry: The chair carry can often be used to

move a sick or injured person away from a position of

danger. The casualty is seated on a chair, as shown in

figure 3–40, and the chair is carried by two rescuers.

This is a particularly good method to use when you must

carry a person up or down stairs or through narrow,

winding passageways. This carry must NEVER be

used to move a person who has an injured neck,

back, or pelvis.

• Arm Carry: The two-person arm carry, shown

in figures 3–41 and 3–42, can be used in some cases to

move an injured person. However, this carry should

not be used to carry a person who has serious

wounds or broken bones.

Another two-person carry that can be used in

emergencies is shown in figure 3–43. Two rescuers

position themselves beside the casualty, on the same

side, one at the level of the chest and the other at the

thighs. The rescuers interlock adjacent arms as shown,

while they support the victim at the shoulders and

knees. In unison, they lift the victim and roll his front

toward theirs. This carry must not be used to move

seriously injured persons.

3-23

Figure 3–37.—One-person arm carry.

Figure 3–38.—Blanket drag.

Figure 3–39.—Tied-hands crawl.
TRANSPORTATION OF THE

INJURED

LEARNING OBJECTIVE: Recognize the

different forms of emergency transportation,

and identify essential BLS equipment and

supplies on Navy ambulances.

Thus far we have dealt with emergency methods

used to move an injured person out of danger and into a

position where first aid can be administered. As we

have seen, these emergency rescue procedures often

involve substantial risk to the casualty and should be

used only when clearly necessary.

Once you have rescued the casualty from the

immediate danger, SLOW DOWN! Casualties should

not be moved before the type and extent of injuries are

evaluated and the required emergency medical

treatment is given. (The exception to this occurs, of

course, when the situation dictates immediate

movement for safety purposes. For example, it may be

necessary to remove a casualty from a burning vehicle.

The situation dictates that the urgency of casualty

movement outweighs the need to administer

emergency medical treatment.)

From this point on, handle and transport the

casualty with every regard for the injuries that have

been sustained. In the excitement and confusion that

almost always accompany an accident, you are likely

to feel rushed, wanting to do everything rapidly. To a

certain extent, this is a reasonable feeling. Speed is

essential in treating many injuries and in getting the

casualty to a medical treatment facility. However, it is

not reasonable to let yourself feel so hurried that you

3-24

Figure 3–40.—Chair carry.

Figure 3–41.—Two-person arm carry.

Figure 3–42.—Two-person arm carry (alternate).
become careless and transport the victim in a way that

will aggravate the injuries.

Emergency Vehicles

In most peacetime emergency situations, some

form of ambulance will be available to transport the

victim to a medical treatment facility. Navy

ambulances vary in size and shape from the old “gray

ghost” to modern van and modular units. Although

there are many differences in design and storage

capacity, most Navy ambulances are equipped to meet

the same basic emergency requirements. They contain

equipment and supplies for emergency airway care,

artificial ventilation, suction, oxygenation,

hemorrhage control, fracture immobilization, shock

control, blood pressure monitoring, and poisoning.

They will also contain litters, spineboards, and other

supplies and equipment as mandated in BUMEDINST

6700.42. (Table 3–1, at the beginning of this chapter,

lists the currently required equipment for EMT-Basic

level ambulances, and table 3–2 lists the contents of an

emergency bag that a Hospital Corpsman might find in

that ambulance.)

Deployed units at sea and in the field and certain

commands near air stations will also have access to

helicopter MEDEVAC support. Helicopters are ideal

for use in isolated areas but are of limited practical use

at night, in adverse weather, under certain tactical

conditions, or in developed areas where building and

power lines interfere. In addition to taking these

factors into consideration, the Corpsman must decide

if the victim’s condition is serious enough to justify a

call for a helicopter.

Some injuries require very smooth transportation

or are affected by pressure changes that occur in flight.

The final decision will be made by the unit

commander, who is responsible for requesting the

helicopter support.

Preparing the Patient for Transport

LEARNING OBJECTIVE: Recall

preparatory, en route, and turnover

procedures for patients being transported to

medical treatment facilities.

Once emergency medical care has been completed

on-scene, the patient must be transferred to the medical

treatment facility. A process known as packaging

provides the means of properly positioning, covering,

and securing the patient to avoid any unnecessary

aggravation to the patient’s condition. (Covering helps

maintain the patient’s body temperature, prevents

exposure to the elements, and provides privacy.) Do

not “package” a badly traumatized patient; it is more

important to transport the critical or unstable patient to

the medical treatment facility quickly. The most

important aspect of each rescue or transfer is to

complete it as safely and efficiently as possible.

Care of Patient en Route

The emergency care a Corpsman can offer patients

en route is limited only by the availability of supplies,

the level of external noise and vibrations, and the

degree and ingenuity the Corpsman possesses.

3-25

Figure 3–43.—Two-person arm carry (alternate).
Care at the Medical Treatment

Facility

Do not turn the victim over to anyone without

giving a complete account of the situation, especially if

a tourniquet was used or medications administered. If

possible, while en route, write down the circumstances

of the accident, the treatment given, and keep a log of

vital signs. After turning the patient over to the

medical treatment facility, ensure that depleted

ambulance supplies are replaced so that the vehicle is

in every way ready to handle another emergency.

SUMMARY

This chapter covered first aid equipment and

supplies, and rescue and transportation of the injured

patient. You should now be able to recognize the

various types of dressings and bandages, as well as how

and when to apply them. You should be familiar with

protective equipment, rescue operations, the stages of

extrication, and the precautionary steps that must be

taken in special rescue situations. Additionally, you

should be acquainted with the different patient-moving

devices and lifting techniques. Further, you should be

able to identify essential basic life support equipment

and supplies on Navy ambulances, and you should be

able to recognize different forms of emergency

transportation. Finally, you should now be able to recall

preparatory, en route, and turnover procedures for

patients being transported to medical treatment

facilities.

3-26
CHAPTER 4

EMERGENCY MEDICAL CARE PROCEDURES

For a Navy Corpsman, the terms “first aid” and

“emergency medical procedures” relate to the

professional care of the sick and injured before in-depth

medical attention can be obtained. Appropriate care

procedures may range from providing an encouraging

word to performing a dramatic struggle to draw a person

back from the brink of death. Always remember,

however, that first aid measures are temporary

expedients to save life, to prevent further injury, and to

preserve resistance and vitality. These measures are

not meant to replace proper medical diagnosis and

treatment procedures. Hospital Corpsmen will be able

to provide the competent care that makes the

difference between life or death, temporary or

permanent injury, and rapid recovery or long-term

disability if they

• understand the relationship between first aid and

proper medical diagnosis and treatment,

• know the limits of the professional care

Corpsmen can offer, and

• keep abreast of new emergency medical

equipment.

GENERAL FIRST AID RULES

LEARNING OBJECTIVE: Recall

general first aid rules.

There are a few general first aid rules that you

should follow in any emergency:

1. Take a moment to get organized. On your way

to an accident scene, use a few seconds to remember the

basic rules of first aid. Remain calm as you take charge

of the situation, and act quickly but efficiently. Decide

as soon as possible what has to be done and which one of

the patient’s injuries needs attention first.

2. Unless contraindicated, make your preliminary

examination in the position and place you find the

victim. Moving the victim before this check could

gravely endanger life, especially if the neck, back, or

ribs are broken. Of course, if the situation is such that

you or the victim is in danger, you must weigh this threat

against the potential damage caused by premature

transportation. If you decide to move the victim, do it

quickly and gently to a safe location where proper first

aid can be administered.

3. In a multivictim situation, limit you r

preliminary survey to observing for airway patency,

breathing, and circulation, the ABCs of basic life

support. Remember, irreversible brain damage can

occur within 4 to 6 minutes if breathing has stopped.

Bleeding from a severed artery can lethally drain the

body in even less time. If both are present and you are

alone, quickly handle the major hemorrhage first, and

then work to get oxygen back into the system. Shock

may allow the rescuer a few minutes of grace but is no

less deadly in the long run.

4. Examine the victim for fractures, especially in

the skull, neck, spine, and rib areas. If any are present,

prematurely moving the patient can easily lead to

increased lung damage, permanent injury, or death.

Fractures of the hip bone or extremities, though not as

immediately life-threatening, may pierce vital tissue or

blood vessels if mishandled.

5. Remove enough clothing to get a clear idea of

the extent of the injury. Rip along the seams, if possible,

or cut. Removal of clothing in the normal way may

aggravate hidden injuries. Respect the victim’s

modesty as you proceed, and do not allow the victim to

become chilled.

6. Keep the victim reassured and comfortable. If

possible, do not allow the victim to see the wounds. The

victim can endure pain and discomfort better if

confident in your abilities. This is important because

under normal conditions the Corpsman will not have

strong pain relief medications right at hand.

7. Avoid touching open wounds or burns with your

fingers or unsterile objects, unless clean compresses

and bandages are not available and it is imperative to

stop severe bleeding.

8. Unless contraindicated, position the

unconscious or semiconscious victim on his side or

back, with the head turned to the side to minimize

choking or the aspirating of vomitus. Never give an

unconscious person any substance by mouth.

4-1
9. Always carry a litter patient feet first so that the

rear bearer can constantly observe the victim for

respiratory or circulatory distress.

TRIAGE

LEARNING OBJECTIVE: Recognize

the protocols for tactical and nontactical

triage.

Triage, a French word meaning “to sort,” is the

process of quickly assessing patients in a

multiple-casualty incident and assigning patient a

priority (or classification) for receiving treatment

according to the severity of his illness or injuries. In the

military, there are two types of triage, tactical and

nontactical, and each type uses a different set of

prioritizing criteria. The person in charge is responsible

for balancing the human lives at stake against the realities

of the tactical situation, the level of medical stock on

hand, and the realistic capabilities of medical personnel

on the scene. Triage is a dynamic process, and a patient’s

priority is subject to change as the situation progresses.

SORTING FOR TREATMENT (TACTICAL)

The following discussion refers primarily to

battalion aid stations (BAS) (where neither helicopter

nor rapid land evacuation is readily available) and to

shipboard battle-dressing stations.

Immediately upon arrival, sort the casualties into

groups in the order listed below.

Class I Patients whose injuries require minor

professional treatment that can be done on

an outpatient or ambulatory basis. These

personnel can be returned to duty in a short

period of time.

Class II Patients whose injuries require immediate

life-sustaining measures or are of a moderate

nature. Initially, they require a minimum

amount of time, personnel, and supplies.

Class III Patients for whom definitive treatment can

be delayed without jeopardy to life or loss

of limb.

Class IV Patients whose wounds or injuries would

require extensive treatment beyond the

immediate medical capabilities. Treatment

of these casualties would be to the

detriment of others.

SORTING FOR TREATMENT

(NONTACTICAL)

In civilian or nontactical situations, sorting of

casualties is not significantly different from combat

situations. There are four basic classes (priorities) of

injuries, and the order of treatment of each is different.

Priority I Patients with correctable life-threatening

illnesses or injuries such as respiratory

arrest or obstruction, open chest or

abdomen wounds, femur fractures, or

critical or complicated burns.

Priority II Patients with serious but non-lifethreatening illnesses or injuries such as

moderate blood loss, open or multiple

fractures (open increases priority), or eye

injuries.

Priority III Patients with minor injuries such as soft

tissue injuries, simple fractures, or minor

to moderate burns.

Priority IV Patients who are dead or fatally injured.

Fatal injuries include exposed brain

matter, decapitation, and incineration.

As mentioned before, triage is an ongoing process.

Depending on the treatment rendered, the amount of

time elapsed, and the constitution of the casualty, you

may have to reassign priorities. What may appear to be

a minor wound on initial evaluation could develop into

a case of profound shock. Or a casualty who required

initial immediate treatment may be stabilized and

downgraded to a delayed status.

SORTING FOR EVACUATION

During the Vietnam war, the techniques for

helicopter medical evacuation (MEDEVAC) were so

effective that most casualties could be evacuated to a

major medical facility within minutes of their injury.

This considerably lightened the load of the Hospital

Corpsman in the field, since provision for long-term

care before the evacuation was not normally required.

However, rapid aeromedical response did not relieve

the Corpsman of the responsibility for giving the best

emergency care within the field limitations to stabilize

the victim before the helicopter arrived. Triage was

seldom needed since most of the injured could be

evacuated quickly.

New developments in warfare, along with changes

in the theaters of deployment, indicate that the

helicopter evacuation system may no longer be viable

4-2
in future front-line environments. If this becomes the

case, longer ground chains of evacuation to the

battalion aid station or division clearing station may be

required. This will increase the need for life-stabilizing

activities before each step in the chain and in transit.

Evacuation triage will normally be used for personnel

in the Class II and Class III treatment categories, based

on the tactical situation and the nature of the injuries.

Class IV casualties may have to receive treatment at

the BAS level, and Class I personnel will be treated on

the line.

Remember, triage is based on the concept of saving

the maximum number of personnel possible. In some

cases, a casualty may have the potential to survive, but

to ensure that casualty's survival, the treatment

necessary may require a great deal of time and

supplies. As difficult as it may be, you may have to

forsake this patient to preserve the time and supplies

necessary to save others who have a greater potential

for survival.

PATIENT ASSESSMENT IN THE FIELD

LEARNING OBJECTIVE: Recognize the

assessment sequence for emergency medical

care in the field, and identify initial equipment

and supply needs.

Patient assessment is the process of gathering

information needed to help determine what is wrong

with the patient. Assessments that you conduct in the

field (at the emergency scene) or during transport are

known as a field assessments.

Field assessments are normally performed in a

systematic manner. The formal processes are known

as the primary survey and the secondary survey. The

primary survey is a rapid initial assessment to detect

and treat life-threatening conditions that require

immediate care, followed by a status decision about the

patient’s stability and priority for immediate transport

to a medical facility. The secondary survey is a

complete and detailed assessment consisting of a

subjective interview and an objective examination,

including vital signs and head-to-toe survey. (Both

types of surveys will be discussed in more detail later

in this chapter.)

BEFORE ARRIVAL AT THE SCENE

Before or during transit to an emergency scene,

you may learn about the patient’s illness or injury.

Although this information could later prove to be

erroneous, you should use this time to consider what

equipment you may need and what special procedures

you should use immediately upon arrival.

ARRIVAL AT THE SCENE

When you arrive at an emergency scene, you need

to start gathering information immediately. First,

make sure the scene is safe for yourself, then for the

patient or patients. Do not let information you received

before your arrival form your complete conclusion

concerning the patient's condition. Consider all related

factors before you decide what is wrong with the

patient and what course of emergency care you will

take.

You can quickly gain valuable information as to

what may be wrong with the patient. Observe and

listen as you proceed to your patient. Do not delay the

detection of life-threatening problems. Be alert to

clues that are obvious or provided to you by others.

Some immediate sources of information may come

from the following:

• The scene3⁄4Is it safe or hazardous? Does the

patient have to be moved? Is the weather severe?

• The patient3⁄4Is the patient conscious, trying to

tell you something, or pointing to a part of his

body?

• Bystanders3⁄4Are they trying to tell you

something? Listen. They may have witnessed

what happened to the patient or have pertinent

medical history of the patient (for example, prior

heart attacks).

• Medical identification device3⁄4Is the patient

wearing a medical identification device (necklace

or bracelet)? Medical identification devices can

provide you with crucial information on medical

disorders, such as diabetes.

• Mechanism of injury3⁄4Was there a fire? Did

the patient fall or has something fallen on the

patient? Is the windshield of vehicle cracked or

the steering wheel bent?

• Deformities or injuries3⁄4Is the patient lying in

a strange position? Are there burns, crushed

limbs, or other obvious wounds?

• Signs3⁄4What do you see, hear, or smell? Is there

blood around the patient? Has the patient

vomited? Is the patient having convulsions?

Are the patient’s clothes torn?

4-3
PRIMARY SURVEY

As stated earlier, the primary survey is a process

carried out to detect and treat life-threatening

conditions. As these conditions are detected,

lifesaving measures are taken immediately, and early

transport may be initiated. The information acquired

before and upon your arrival on the scene provides you

with a starting point for the primary survey. The

primary survey is a “treat-as-you-go” process. As each

major problem is detected, it is treated immediately,

before moving on to the next.

During the primary survey, you should be

concerned with what are referred to as the ABCDEs of

emergency care: airway, breathing, circulation,

disability, and expose.

A=Airway. An obstructed airway may quickly

lead to respiratory arrest and death.

Assess responsiveness and, if

necessary, open the airway.

B=Breathing. Respiratory arrest will quickly lead

to cardiac arrest. Assess breathing,

and, if necessary, provide rescue

breathing. Look for and treat

conditions that may compromise

breathing, such as penetrating

trauma to the chest.

C=Circulation. If the patient’s heart has stopped,

blood and oxygen are not being sent

to the brain. Irreversible changes

will begin to occur in the brain in 4 to

6 minutes; cell death will usually

occur within 10 minutes. Assess

circulation, and, if necessary,

provide cardiopulmonary resuscitation (CPR). Also check for profuse

bleeding that can be controlled.

Assess and begin treatment for

severe shock or the potential for

severe shock.

D=Disability. Serious central nervous system

injuries can lead to death. Assess the

patient’s level of consciousness and,

if you suspect a head or neck injury,

apply a rigid neck collar. Observe

the neck before you cover it up. Also

do a quick assessment of the

patient’s ability to move all

extremities.

E=Expose. You cannot treat conditions you have

not discovered. Remove clothing–

especially if the patient is not alert or

communicating with you–to see if

you missed any life-threatening

injuries. Protect the patient’s

privacy, and keep the patient warm

with a blanket if necessary.

As soon as the ABCDE process is completed, you

will need to make what is referred to as a status

decision of the patient’s condition. A status decision is

a judgment about the severity of the patient’s condition

and whether the patient requires immediate transport

to a medical facility without a secondary survey at the

scene. Ideally, the ABCDE steps, status, and transport

decision should be completed within 10 minutes of

your arrival on the scene.

SECONDARY SURVEY

The object of a secondary survey is to detect

medical and injury-related problems that do not pose

an immediate threat to survival but that, if left

untreated, may do so. Unlike the primary survey, the

secondary survey is not a “treat-as-you-go” process.

Instead, you should mentally note the injuries and

problems as you systematically complete the survey.

Then you must formulate priorities and a plan for

treatment.

The secondary survey for a patient who presents

with medical illness is somewhat different from that of

an injured patient. Usually the trauma assessment is

about 20 percent patient interview and 80 percent

physical exam. On the other hand, the medical

assessment is 80 percent patient interview and 20

percent physical exam. Both the physical exam and

patient interview should always be done for all medical

and trauma patients.

NOTE: Remember, if the patient’s condition

deteriorates, it may not be possible to complete

the secondary survey before starting to

transport the patient.

Subjective Interview

The subjective interview is similar to the

interview physicians make before they perform a

physical examination. The main objective of the

interview is to gather needed information from the

patient. Other objectives of the interview are to reduce

4-4
the patient’s fear and promote cooperation. Whenever

possible, conduct the subjective interview while you

are performing the physical examination.

Relatives and bystanders at the emergency scene

may also serve as sources of information, but you

should not interrupt interviewing the patient to gather

information from a bystander. If the patient is

unconscious, you may obtain information from

bystanders and medical identification devices while

you are conducting the physical examination.

When conducting a patient interview, you should

take the following steps:

1. Place yourself close to the patient. Position

yourself, when practical, so the patient can see

your face. If at all possible, position yourself so

that the sun or bright lights are not at your back.

The glare makes it difficult for the patient to

look at you.

2. Identify yourself and reassure the patient.

Identify yourself and maintain a calm,

professional manner. Speak to the patient in

your normal voice.

3. Learn your patient’s name. Once you learn

the patient’s name, you should use it during the

rest of your interview. Children will expect you

to use their first name. For military adults, use

the appropriate rank. If civilian, use “Mr.” or

“Ms.” unless they introduce themselves by their

first name.

4. Learn your patient’s age. Age information

will be needed for reports and communications

with the medical facility. You should ask

adolescents their age to be certain that you are

dealing with a minor. With minors, always ask

how you can contact their parent or guardian.

Sometimes this question upsets children

because it intensifies their fear of being sick or

injured. Be prepared to offer comfort and assure

children that someone will contact their parents

or guardians.

5. Seek out what is wrong. During this part of the

interview, you are seeking information about the

patient’s symptoms and what the patient feels or

senses (such as pain or nausea). Also, find out what

the patient’s chief complaint is. Patients may give

you several complaints, so ask what is bothering

them most. Unless there is a spinal injury that has

interrupted nerve pathways, most injured

individualswill be abletotell you of painful areas.

6. Ask the PQRST questions if the patient is

experiencing pain or breathing difficulties.

P=Provocation3⁄4What brought this on?

Q=Quality3⁄4What does it feel like?

R=Region3⁄4Where is it located?

R=ReferralDoes it go anywhere (e.g., “into

my shoulder”)?

R=RecurrenceHas this happened before?

R=ReliefDoes anything make it feel better?

S=SeverityHow bad is it on a scale of 1 to

10?

T =TimeWhen did it begin?

7. Obtain the patient’s history by asking the

AMPLE questions.

A=Allergies3⁄4Are you allergic to any

medication or anything else?

M=MedicationsAre you currently taking

any medication?

P=Previous medical history3⁄4Have you been

having any medical problems? Have you been

feeling ill? Have you been seen by a physician

recently?

L=Last meal3⁄4When did you eat or drink last?

(Keep in mind, food could cause the symptoms

or aggravate a medical problem. Also, if the

patient requires surgery, the hospital staff will

need to know when the patient has eaten last.)

E=Events3⁄4What events led to today’s

problem (e.g., the patient passed out and then

got into a car crash)?

Objective Examination

The objective examination is a comprehensive,

hands-on survey of the patient’s body. During this

examination, check the patient’s vital signs and

observe the signs and symptoms of injuries or the

effects of illness.

When you begin your examination of the patient,

you should heed the following rules:

1. Obtain the patient’s consent (if the patient is

alert).

2. Tell the patient what you are going to do.

4-5
3. Always assume trauma patients have a spinal

injury, especially unconscious trauma patients,

unless you are certain you are dealing with a

patient free from spinal injury (e.g., a medical

patient with no trauma).

HEAD-TO-TOE SURVEY.—The head-to-toe

survey is a systematic approach to performing a

physical examination. This survey is designed so

nothing important is missed during the examination of

the patient. There may be variations in the head-to-toe

survey depending on local guidelines. Traditionally,

the examination is started with the head. However,

most medical authorities now recommend that the

neck be examined first in an effort to detect possible

spinal injuries and any serious injury to the trachea that

may lead to an airway obstruction.

During the head-to-toe survey, you should

• look for discolorations, deformities,

penetrations, wounds, and any unusual chest

movements;

• feel for deformities, tenderness, pulsations,

abnormal hardness or softness, spasms, and skin

temperature;

• listen for changes in breathing patterns and

unusual breathing sounds; and

• smell for any unusual odors coming from the

patient’s body, breath, or clothing.

The head-to-toe survey may appear to be a long

process, but as you practice the procedure you will find

that it can be done in just a few minutes. All necessary

personal protective equipment, such as exam gloves

and eye protection, should be worn during your

examination.

Begin the survey by kneeling at the side of the

patient’s head. Quickly take an overview of the

patient’s body (i.e., general appearance, demeanor,

behavior, skin color and characteristics, etc.), then

perform the 26 steps described in the following

sections.

Step 1.—Check the cervical spine for point

tenderness and deformity. To perform this

procedure, gently slide your hands, palms up, under

both sides of the patient’s neck. Move your fingertips

toward the cervical midline. Check the back of the

neck from the shoulders to the base of the skull. Apply

gentle finger pressure. A painful response to this

pressure is point tenderness.

If there are signs of possible spinal injury, such as

midline deformities, point tenderness, or muscle

spasms, stop the survey and provide stabilization of the

head and neck.

NOTE: If a rigid cervical collar is to be

applied, make sure you have examined the

posterior, anterior, and sides of the neck before

applying the collar.

Step 2.—Inspect the anterior neck for

indications of injury and neck breathing. This

procedure consists of exposing the anterior neck to

check for injury and to detect the presence of a surgical

opening (stoma) or a metal or plastic tube

(tracheostomy). The presence of a stoma or

tracheostomy indicates the patient is a neck breather.

Also, if you have not already done so in the primary

survey, check for a medical identification necklace. A

necklace may state the patient has a stoma or

tracheostomy.

Look for signs of injury, such as the larynx or

trachea deviated from the midline of the neck, bruises,

deformities, and penetrating injuries. Also, check for

distention of the jugular vein. If the jugular vein is

distended, there may be an airway obstruction, a

cervical spine injury, damage to the trachea, or a

serious chest injury. All of these conditions require

immediate medical care.

After the anterior neck is inspected and if a spinal

injury is suspected, apply a rigid cervical or extrication

collar. If the patient is unconscious, assume the patient

has a spinal injury.

Step 3.—Inspect the scalp for wounds. Use

extreme caution when inspecting the scalp for wounds.

Pressure on the scalp from your fingers could drive

bone fragments or force dirt into wounds. Also, DO

NOT move the patient’s head, as this could aggravate

possible spinal injuries. To inspect the scalp, start at

the top of the head and gently run your gloved fingers

through the patient’s hair. If you come across an injury

site, DO NOT separate strands of the hair. To do this

could restart bleeding. When the patient is found lying

on his back, check the scalp of the back of the head by

placing your fingers behind the patient’s head. Then

slide your fingers upward toward the top of the head.

Check your fingers for blood. If a spinal or neck injury

is suspected, delay this procedure until the head and

neck have been immobilized. Furthermore, if you

suspect a neck injury, DO NOT lift the head off the

ground to bandage it.

4-6
NOTE: You may find upon inspection that the

patient is wearing a hairpiece or wig. Hairpieces

and wigs may be held in place by adhesive, tape,

or permanent glue, so DO NOT remove them

unless you suspect profuse bleeding.

Attempting removal may aggravate injury or

restart bleeding.

Step 4.—Check the skull and face for

deformities and depressions. As you feel the scalp,

check for depressions or bony projections. Visually

examine facial bones for signs of fractures. Unless

there are obvious signs of injury, gently palpate the

cheekbones, forehead, and lower jaw.

Step 5.—Examine the patient’s eyes. After

examining the face and scalp, move back to a side

position. Begin your examination of the eyes by

looking at the patient’s eyelids. Do not open the

eyelids of patients with burns, cuts, or other injuries

to the eyelid(s). Assume there is damage to the eye

and treat accordingly. If eyelids are not injured, have

patients open their eyes. To examine the eyes of

unconscious patients, gently open their eyes by

sliding back the upper eyelids. Keep in mind,

pressure applied to the eyelid may cause further

injury. When the eye has been opened, visually check

the globe of the eye.

Step 6.—Check the pupils for size, equality, and

reactivity. Using a penlight or flashlight, examine

both eyes. Note pupil size and if both pupils are equal

in size. Also, see if the pupils react to the beam of light.

Note a slow pupil reaction to the light. Look for eye

movement. Both eyes should move as a pair when they

observe moving persons or objects.

NOTE: Check unconscious patients for contact

lenses. Prompt removal of contact lenses is

recommended. If removal of the lens is

impractical, close the patient's eyes so the

contact lenses stay lubricated.

Table 4-1 lists pupil characteristics you may

encounter and the possible causes of abnormalities.

Step 7.—Inspect the inner surfaces of the eyelids.

If there is no obvious injury to the eye, gently pull the

upper lid up and the lower eyelid down, and check the

color of the inner surface. Normally, the inner surfaces

of the eyelids are pink. However, with blood loss they

become pale; with jaundice, the surface is yellow. The

inner surface of the eyelid is an excellent location to

detect cyanosis (skin discoloration due to lack of

oxygen), especially for patients with dark skin

pigmentation. Cyanosis is denoted by a blue color.

Step 8.—Inspect the ears and nose for injury

and the presence of blood or clear fluids. Without

rotating the patient’s head, inspect the ears and nose for

cuts, tears, or burns. Use a penlight to look in the ears

and nose for blood, clear fluids, or bloody fluids.

Blood in the ears and clear fluids (cerebrospinal fluid)

in the ears or nose are strong indicators of a skull

fracture. Also, check for bruises behind the ears,

commonly referred to as Battle’s sign. Bruises behind

the ears are strong indicators of skull fracture and

cervical spine injury. Burned or singed nasal hairs

indicate possible burns in the airway.

Step 9.—Inspect the mouth. Look inside the

mouth for signs of airway obstruction that may not

have been observed during the primary survey (e.g.,

loose or broken teeth, dentures, and blood). When you

inspect the mouth, remember not to rotate the patient’s

head.

Step 10.—Smell for odd breath odors. Place

your face close to the patient’s mouth and nose and

note any unusual odors. A fruity smell indicates

diabetic coma or prolonged vomiting and diarrhea; a

petroleum odor indicates ingested poisoning; and an

alcohol odor indicates possible alcohol intoxication.

4-7

PUPIL

CHARACTERISTICS

POSSIBLE CAUSE OF

ABNORMALITY

Dilated and unresponsive • Cardiac arrest

• Influence of drugs (e.g., LSD

and amphetamines)

Constricted and

unresponsive • Central Nervous System

disease or disorder

• Influence of narcotics (e.g.,

heroin, morphine, or

codeine)

Unequal • Stroke

• Head injury

Lackluster (dull) and

pupils do not appear to

focus

• Shock

• Coma

Table 4-1.—Listing of Pupil Characteristics and the Possible

Cause of Abnormality
Step 11.—Inspect the chest for wounds. Expose

the chest. For unconscious and trauma patients, you

should completely remove clothing to expose the

chest. (Try to provide as much privacy as possible for

patients.) Look for obvious chest injuries, such as cuts,

bruises, penetrations, objects impaled in the chest,

deformities, burns, or rashes. If puncture or bullet

wounds are found, check for exit wounds when

inspecting the back.

Step 12.—Examine the chest for possible

fracture. Before you begin examining the chest for

fractures, warn the patient that the examination may be

painful. Begin your examination by gently feeling the

clavicles (collarbones). Next, feel the sternum

(breastbone). Then examine the rib cage by placing

your hands on both sides of the rib cage and applying

gentle pressure. This process is known as

compression. If the patient has a fracture,

compression of the rib cage will cause pain. Finally,

slide your hands under the patient’s scapulae (shoulder

blades) to feel for deformities or tenderness.

Point tenderness, painful reaction to compression,

deformity, or grating sounds indicate a fracture. If air

is felt (like crunching popcorn) or heard (crackling

sounds) under the skin, this indicates that at least one

rib is fractured or that there is a pneumothorax

(punctured lung). You may also observe air escaping

the chest cavity and the wound when the patient has a

punctured lung.

Step 13.—Check for equal expansion of the

chest. Check chest movements and feel for equal

expansion by placing your hand on both sides of the

chest. Be alert to sections of the chest that seem to be

“floating” (flail chest) or moving in a direction

opposite to the rest of the chest during respiration.

Step 14.—Listen for sounds of equal air entry.

Using a stethoscope, listen to both sides of the anterior

and lateral chest. The sounds of air entry will usually

be clearly present or clearly absent. The absence of air

movement indicates an obstruction, injury, or illness to

the respiratory system. Bubbling, wheezing, rubbing,

or crackling sounds may indicate the patient has a

medical problem or a trauma-related injury.

Step 15.—Inspect the abdomen for wounds.

Look for obvious signs of injury (e.g., abdominal

distension, cuts, bruises, penetrations, open wounds

with protruding organs (evisceration), or burns) in all

four quadrants and sides.

Step 16.—Palpate the abdomen for tenderness.

Look for attempts by the patient to protect his abdomen

(e.g., patient drawing up the legs). Gently palpate the

entire abdomen. If the patient complains of pain in an

area of the abdomen, palpate that area last. Do not

palpate over an obvious injury site or where the patient

is having severe pain. While palpating the abdomen,

check for any tight (rigid) or swollen (distended) areas.

Performing abdominal palpation is important because

tender areas do not normally hurt until palpated. Note

if pain is localized, general, or diffused.

Step 17.—Feel the lower back for point

tenderness and deformity. Gently slide your hands

under the void created by the curve of the spine. Apply

gentle pressure to detect point tenderness or any

deformities.

NOTE: This examination of the lower back

may be performed later, when the patient’s

entire back is exposed in preparation to being

placed on a backboard or stretcher.

Step 18.—Examine the pelvis for injuries and

possible fractures. Examine the pelvic area for

obvious injuries. Next, gently slide your hand down

both sides of the small of the patient’s back and apply

compression downward and then inward to check the

stability of the pelvic girdle. Note any painful

responses or deformities. If a grating sound is heard,

the injury may involve the hip joint, or the pelvis may

be fractured.

Step 19.—Note any obvious injury to the genital

region. Look for obvious injuries, such as bleeding

wounds, objects impaled in the area, or burns. Also,

check for priapism in male patients. Priapism is a

persistent erection of the penis often brought about by

spinal injury or certain medical problems, such as

sickle cell crisis.

Step 20.—Examine the lower extremities. DO

NOT move, lift, or rearrange the patient’s lower

extremities (legs and feet) before or during the

examination as further injury to the patient may occur.

Check for signs of injury by inspecting each limb, one

at a time, from hip to foot. Rearrange or remove

clothing and footwear to observe the entire

examination site. Pants should be removed in a

manner that does not aggravate injuries. Cutting along

the seams to remove pants is the best method. If the

injury is not obvious, remove the shoe(s) and palpate

any suspected fracture sites for point tenderness.

Before palpating the site, warn the patient that this

examination may cause pain. Before the patient is

4-8
moved, all suspected or known fractures should be

stabilized (with splints, traction splints, or the like).

Step 21.—Check for a distal pulse and capillary

refill. To make sure there are no circulatory problems

in the legs or feet, check the distal pulse and capillary

refill. The distal pulse is a pulse taken at the foot or

wrist. It is called distal because the pulse is located at

the distal end of the limb. The distal pulse of the foot,

also referred to as pedal pulse, may be taken at either

of two sites: the posterior tibial pulse (located behind

the medial ankle) or the dorsalis pedis pulse (located

on the anterior surface of the foot, lateral to the large

tendon of the great toe).

You should compare the quality of the pulses in

each lower limb. Absence of a distal pulse usually

indicates that a major artery supplying the limb has

been pinched or severed. This condition may be

caused by a broken or displaced bone end or a blood

clot. An absent or weak distal pulse may also result

from splints or bandages being applied too tightly.

Check capillary refill by squeezing a toe (usually,

the big toe) with your thumb and forefinger. The skin

and nail where pressure is applied should blanch

(lighten). When you release the pressure, the color

(blood) should return immediately. If it takes more

than 2 seconds for the color to return, capillary refill is

considered delayed.

NOTE: After splints or bandages are applied,

check capillary refill to make sure circulation

has not been impaired.

Step 22.—Check for nerve function and

possible paralysis of the lower extremities

(conscious patient). Check the lower extremities of

conscious patients for nerve function or paralysis.

First, touch a toe and ask the patient which toe it is. Do

this to both feet. If the patient cannot feel your touch or

if the sensations in each foot are not the same, assume

that nerve damage in the limb or a spinal injury has

occurred.

If sensations appear normal and no injuries are

present, have the patient wave his feet. Finally, ask the

patient to gently press the soles of his feet against your

hand. The inability of the patient to perform any of

these tasks indicates the possibility of nerve damage.

When nerve damage is suspected, assume the patient

has a spinal injury.

Step 23.—Examine the upper extremities for

injury. Check for signs of injury to the upper

extremities (arms and hands) by inspecting each limb,

one at a time, from clavicle to fingertips. Rearrange or

remove items of clothing to observe the entire

examination site. Check for point tenderness,

swelling, or bruising. Any of these symptoms may

indicate a fracture. Immobilize any limb where a

fracture is suspected.

Step 24.—Check for a distal pulse and capillary

refill. To make sure the circulation to the upper

extremities has not been compromised, confirm distal

(radial) pulse. Initial check of radial pulse was

performed during the primary survey. Check capillary

refill of fingers or palm of hand (see step 21 for

procedure). If there is no pulse or if capillary refill is

delayed, the patient may be in shock or a major artery

supplying the limb has been pinched, severed, or

blocked.

Step 25.—Check for nerve function and

possible paralysis of the upper extremities

(conscious patient). Check the upper extremities of

conscious patients for nerve function or paralysis.

Have the patient identify the finger you touch, wave his

hand, and grasp your hand. Do this to both hands. If

the patient cannot feel your touch or the sensations in

each hand are not the same, assume nerve damage in

the limb or a spinal injury has occurred.

WARNING: Be alert for a rapid onset of

difficult breathing or respiratory arrest.

These conditions may occur to patients who

have sustained a cervical injury.

Step 26.—Inspect the back and buttocks for

injury. If there is no indication of injury to the skull,

neck, spine, or extremities, and you have no evidence

of severe injury to the chest or abdomen, gently roll the

conscious patient as a unit toward your knees and

inspect the surface of the back for bleeding or obvious

injuries. The back surface may be inspected prior to

positioning the patient for transport or delayed until the

patient is transferred to a spineboard or other

immobilization device.

VITAL SIGNS.Vital signs (which generally are

taken after primary, secondary, and head-to-toe

surveys have been completed) include taking the

patient’s pulse, respiration, blood pressure, and

temperature. Depending on local protocols, the

patient’s level of consciousness as well as eye pupil

size and reactivity may be recorded with vital signs.

Skin characteristics, such as temperature, color, and

4-9
moistness or dryness, can also be conveniently

determined at this time.

Pulse.—When taking a patient’s pulse, you should

be concerned with two factors: rate and character. For

pulse rate, you will have to determine the number of

beats per minute. Pulse rate is classified as normal,

rapid, or slow. A normal pulse rate for adults is

between 60 to 80 beats per minute. Any pulse rate

above 100 beats per minute is rapid (tachycardia),

while a rate below 60 beats per minute is slow

(bradycardia).

NOTE: An athlete may have a normal at-rest

pulse rate between 40 and 50 beats per

minute. This is a slow pulse rate, but is not an

indication of poor health.

Pulse character is the rhythm and force of the

pulse. Pulse rhythm is evaluated as regular or

irregular. When intervals between beats are constant,

the pulse is regular, and when intervals are not

constant, the pulse is described as irregular. Pulse

force refers to the pressure of the pulse wave as it

expands the artery. Pulse force is determined as full or

thready. A full pulse feels as if a strong wave has

passed under your fingertips. When the pulse feels

weak and thin, the pulse is described as thready.

The pulse rate and character can be determined at a

number of points throughout the body. The most

common site to determine a patient’s pulse is the

radial pulse. The radial pulse (wrist pulse) is named

after the radial artery found in the lateral aspect of the

forearm.

Respiration.—Respiration is the act of breathing.

A single breath is the complete process of breathing in

(inhalation) followed by breathing out (exhalation).

When observing respiration in connection to vital

signs, you should be concerned with two factors: rate

and character.

Respiration rate is the number of breaths a patient

takes in 1 minute. The rate of respiration is classified

as normal, rapid, or slow. The normal respiration rate

for an adult at rest is 12 to 20 breaths per minute. A

rapid respiration rate is more than 28 respirations per

minute, and a slow respiration rate is less than 10

breaths per minute. A rapid or slow respiration rate

indicates the patient is in need of immediate medical

attention and should be transported to a medical

treatment facility as soon as possible.

Respiration character includes rhythm, depth,

ease of breathing, and sound. Respiration rhythm

refers to the manner in which a person breathes.

Respiration rhythm is classified as regular or irregular.

A regular rhythm is when the interval between breaths

is constant, and an irregular rhythm is when the

interval between breaths varies.

Respiration depth refers to the amount of air

moved between each breath. Respiration depth is

classified as normal, deep, or shallow.

Ease of breathing can be judged while you are

judging depth. Ease of breathing may be judged as

labored, difficult, or painful.

Sounds of respiration include snoring,

wheezing, crowing (birdlike sounds), and gurgling

(sounds like breaths are passing through water).

You should count respirations as soon as you have

determined the pulse rate. Count the number of breaths

taken by the patient during 30 seconds and multiply by

2 to obtain the breaths per minute. While you are

counting breaths, note the rhythm, depth, ease of

breathing, and sounds of respiration.

Blood Pressure.—The measurement of the pressure

blood exerts against the wall of blood vessels is known as

blood pressure. The pressure created in the arteries when

the heart pumps blood out into circulation (heart beat) is

called the systolic blood pressure. The pressure

remaining in the arteries when the heart is relaxed

(between beats) is called the diastolic blood pressure.

The systolic pressure is always reported first and the

diastolic pressure second (e.g., 120 over 80).

Blood pressure varies from one person to another

and is measured with a stethoscope and a

sphygmomanometer (BP cuff). Low blood pressure

(hypotension) is considered to exist when the systolic

pressure falls below 90 millimeters of mercury (mm

Hg) and/or the diastolic falls below 60. “Millimeters

of mercury” refers to the units of the BP cuff’s gauge.

High blood pressure (hypertension) exists once the

pressure rises above 150/90 mm Hg. Keep in mind that

patients may exhibit a temporary rise in blood pressure

during emergency situations. More than one reading

will be necessary to determine if a high or low reading

is only temporary. If a patient’s blood pressure drops,

the patient may be going into shock. You should report

major changes in blood pressure immediately to

medical facility personnel.

Tempera ture.—Body temperatures are

determined by the measurement of oral, rectal, axillary

4-10
(armpit), and aural (ear) temperatures. In emergency

situations, taking a traditional body temperature may

not be indicated, so a relative skin temperature may be

done. A relative skin temperature is a quick

assessment of skin temperature and condition. To

assess skin temperature and condition, feel the

patient’s forehead with the back of your hand. In doing

this, note if the patient’s skin feels normal, warm, hot,

cool, or cold. At the same time, see if the skin is dry,

moist, or clammy. Also check for “goose pimples,”

indicating chills.

BASIC LIFE SUPPORT

LEARNING OBJECTIVE: Recall basic life

support techniques for upper airway

obstruction, respiratory failure, and cardiac

arrest.

Basic life support is the emergency technique for

recognizing and treating upper airway obstruction and

failures of the respiratory system and heart. The

primary emphasis should be on the ABCs of basic life

support: maintaining an open airway to counter upper

airway obstruction; restoring breathing to counter

respiratory arrest; and restoring circulation to counter

cardiac arrest.

UPPER AIRWAY OBSTRUCTION

The assurance of breathing takes precedence over

all other emergency measures. The reason for this is

simple: If a person cannot breathe, he cannot survive.

Many factors may cause a person’s airway to

become fully or partially obstructed. A very common

cause of obstruction with both adults and children is

improperly chewed food that becomes lodged in the

airway (an event commonly referred to as a “cafe

coronary”). Additionally, children have a disturbing

tendency to swallow foreign objects while at play.

Another cause for upper airway obstruction occurs

during unconsciousness, when the tongue may fall

back and block the pharynx (fig. 4-1). When the upper

airway is obstructed, the heart will normally continue

to beat until oxygen deficiency becomes acute.

Periodic checks of the carotid artery must be made to

ensure that circulation is being maintained.

Partial Airway Obstruction

The signs of partial airway obstruction include

unusual breath sounds, cyanosis, or changes in

breathing pattern. Conscious patients will usually

make clutching motions toward their neck, even when

the obstruction does not prevent speech. Encourage

conscious patients with apparent partial obstructions

4-11

Figure 4-1.—Tongue blocking airway.
to cough. If the patient is unable to cough, begin to

treat the patient as if this were a complete obstruction.

(This also applies to patients who are cyanotic.)

Complete Airway Obstruction

Conscious patients will attempt to speak but will

be unable to do so. Nor will they be able to cough.

Usually, patients will display the universal distress

signal for choking by clutching their neck. The

unconscious patient with a complete airway

obstruction exhibits none of the usual signs of

breathing: rise and fall of the chest and air exchange

through the nose and/or mouth. A complete blockage

is also indicated if a correctly executed attempt to

perform artificial ventilation fails to instill air into the

lungs.

Opening the Airway

Many problems of airway obstruction, particularly

those caused by the tongue, can be corrected simply by

repositioning the head and neck. If repositioning does

not alleviate the problem, more aggressive measures

must be taken.

POSITIONING THE PATIENT.When a

patient is unresponsive, you must determine if he is

breathing. This assessment requires the patient to be

positioned properly with the airway opened.

Before repositioning patients, it is imperative that

you remember to check them for possible spinal

injuries. If there is no time to immobilize these injuries

and the airway cannot be opened with the victim in the

present position, then great care must be taken when

repositioning. The head, neck, and back must be

moved as a single unit. To do this, adhere to the

following four steps (see figure 4-2).

Step 1—Kneel to the side of the victim in line with

the victim’s shoulders, but far enough away so that the

victim’s body will not touch yours when it is rolled

toward you. Straighten the victim’s legs, gently but

quickly. Then move the victim’s closer arm along the

floor until it reaches straight out past the head.

Step 2—Support the back of the victim’s head with

one hand while you reach over with the other hand to

grasp under the distant armpit.

Step 3—Pull the patient toward you while at the

same time keeping the head and neck in a natural

straight line with the back. Resting the head on the

extended arm will help you in this critical task.

Step 4—Roll the patient onto his back and

reposition the extended arm.

Once the patient is supine with the arms alongside

the body, you should position yourself at the patient’s

side. By positioning yourself at the patient’s side, you

can more easily assess whether the patient is breathing.

If the patient is not breathing, you are already

positioned to perform artificial respirations (also

referred to as rescue breathing) and chest compressions.

Either one of two maneuvers—the head tilt-chin

lift maneuver or the jaw-thrust maneuver—may be

used to open an obstructed airway. When performing

these maneuvers, you may discover foreign material or

vomitus in the mouth that needs to be removed. Do not

spend very much time to perform this task. Liquids or

semiliquids should be wiped out with the index and

middle finger covered by a piece of cloth. Solid

material should be extracted with a hooked index

finger.

HEAD TILT-CHIN LIFT MANEUVER.—The

head tilt-chin lift maneuver is the primary method used

to open the airway. To perform the head tilt-chin lift

maneuver, place one of your hands on the patient’s

forehead and apply gentle, firm, backward pressure

using the palm of your hand. Place the fingers of the

other hand under the bony part of the chin. Lift the chin

forward and support the jaw, helping to tilt the head

back. See figure 4-3. This maneuver will lift the

patient’s tongue away from the back of the throat and

provide an adequate airway.

PRECAUTIONS: When performing the

head tilt-chin lift maneuver, do not press too

deeply into the soft tissue under the chin.

Undue pressure in this location may obstruct

the airway. In addition, make sure the mouth is

kept open so exhalation and inhalation are not

hindered.

JAW-THRUST MANEUVER.—The jaw-thrust

maneuver is considered an alternate method for

opening the airway. This maneuver is accomplished by

kneeling near the top of the victim’s head, grasping the

angles of the patient’s lower jaw, and lifting with both

hands, one on each side. This will displace the

mandible (jawbone) forward while tilting the head

backward. Figure 4-4 illustrates the jaw-thrust

maneuver. If the lips close, retract the lower lip with

your thumb. If mouth-to-mouth breathing is necessary,

close the nostrils by placing your cheek tightly against

them.

4-12
NOTE: The jaw-trust technique without head

tilt is considered the safest approach to

opening the airway of patients with suspected

neck injuries because it usually can be done

without extending the neck.

4-13

Figure 4-2.—The four steps to reposition the victims of spinal injuries.

Figure 4-3.—Head tilt-chin lift maneuver. Figure 4-4.—Jaw-thrust maneuver.
Foreign-Body Airway Obstruction

Management

Foreign-body airway obstruction should be

considered in any victim—especially a younger victim

–who suddenly stops breathing, becomes cyanotic, or

loses consciousness for no apparent reason.

The Heimlich maneuver (subdiaphragmatic

abdominal thrusts) is recommended for relieving

foreign-body airway obstruction. By elevating the

diaphragm, the Heimlich maneuver can force air from

the lungs to create an artificial cough intended to expel

a foreign body obstructing the airway. Each individual

thrust should be administered with the intent of

relieving the obstruction. It may be necessary to repeat

the thrust several times to clear the airway. Five thrusts

per sequence is recommended.

When you perform this maneuver, you should

guard against damage to internal organs, such as

rupture or laceration of abdominal or thoracic viscera.

To minimize this possibility, your hands should never

be placed on the xiphoid process of the sternum or on

the lower margins of the rib cage. They should be

below this area but above the navel and in the midline.

Regurgitation may occur as a result of abdominal

thrusts. Be prepared to position the patient so

aspiration does not occur.

HEIMLICH MANEUVER WITH VICTIM

STANDING OR SITTING.—To perform the

Heimlich maneuver with victim standing or sitting,

stand behind the victim, wrap your arms around the

victim’s waist, and proceed as follows:

Step 1—Make a fist with one hand.

Step 2—Place the thumb side of the fist against the

victim’s abdomen, in the midline slightly above the

navel and well below the tip of the xiphoid process.

Step 3—Grasp the fist with the other hand and

press the fist into the victim’s abdomen with a quick

upward thrust. See figure 4-5.

Step 4—Repeat the thrusts and continue until the

object is expelled from the airway or the patient

becomes unconscious. Each new thrust should be a

separate and distinct movement.

HEIMLICH MANEUVER WITH VICTIM

LYING DOWN.—To perform the Heimlich

maneuver with victim lying down, proceed as follows:

Step 1—Place the victim in the supine position

(face up).

Step 2—Kneel astride the victim’s thighs and

place heel of one hand against the victim’s abdomen,

in the midline slightly above the navel and well below

the tip of the xiphoid.

Step 3—Place the second hand directly on top of

the first.

Step 4—Press into the abdomen with a quick

upward thrust. See figure 4-6.

4-14

Figure 4-5.—Administering the Heimlich maneuver to a

conscious victim who is standing.

Figure 4-6.—Administering the Heimlich maneuver to an

unconscious victim who is lying down.
If you are in the correct position, you will have a

natural midabdominal position and are unlikely to

direct the thrust to the right or left. A rescuer too short

to reach around the waist of an unconscious victim can

use this technique. The rescuer can use their body

weight to perform the maneuver.

CHEST THRUSTS WITH VICTIM

STANDING OR SITTING.—This technique is used

only in the late stages of pregnancy or in the markedly

obese victim. To perform chest thrusts with victim

standing or sitting, proceed as follows:

Step 1—Stand behind the victim, with your arms

directly under the victim’s armpits, and encircle the

victim’s chest.

Step 2—Place the thumb side of your fist on the

middle of the victim’s sternum (breastbone), taking

care to avoid the xiphoid process and the margins of the

rib cage.

Step 3—Grab your fist with the other hand and

perform backward thrust until the foreign body is

expelled or the victim becomes unconscious. See

figure 4-7.

CHEST THRUSTS WITH VICTIM LYING

DOWN.—Chest thrusts should be used only for victims

in the late stages of pregnancy and when the Heimlich

maneuver cannot be applied effectively to the

unconscious, markedly obese victim. To perform chest

thrusts with victim lying down, proceed as follows:

Step 13⁄4Place the victim on his back and kneel

close to the victim’s side.

Step 2––Place the heel of your hand on the lower

portion of the sternum (in the same manner as you

would when performing chest compressions).

Step 3––Deliver each thrust firmly and distinctly,

with the intent of relieving the obstruction.

MANUAL REMOVAL OF FORE IGN

BODY.—A foreign body can be removed by

performing a “finger sweep.” This procedure,

however, must be performed on unconscious

victims only (though not on seizure victims). To

perform a finger sweep, proceed as follows:

Step 1––With the victim’s face up, open the

victim’s mouth by grasping both the tongue and lower

jaw between the thumb and fingers and lifting the jaw.

This action draws the tongue away from the back of the

throat and away from a foreign body that may be

lodged there. This step alone may partially relieve the

obstruction.

Step 2––Insert the index finger of the other hand

down along the inside of the cheek and deeply into the

throat to the base of the tongue.

Step 3––Use a hooking action to dislodge the

foreign body and maneuver it into the mouth so that it

can be removed. See figure 4-8.

4-15

Figure 4-7.—Administering the chest thrust to a conscious

victim who is standing. Figure 4-8.—Finger sweep.
It is sometimes necessary to use the index finger to

push a foreign body against the opposite side of the

throat to dislodge and remove it. Be careful not to

force the object deeper into the airway. If the foreign

body comes within reach, grasp and remove it.

BREATHING

The second aspect of basic life support is to restore

breathing in cases of respiratory arrest. Failure of the

breathing mechanism may be caused by various

factors. They include complete airway obstruction,

insufficient oxygen in the air, inability of the blood to

carry oxygen (e.g., carbon monoxide poisoning),

paralysis of the breathing center of the brain, and

external compression of the body. Respiratory arrest is

usually but not always immediately accompanied by

cardiac arrest. Periodic checks of the carotid pulse

must be made, and you must be prepared to start

cardiopulmonary resuscitation (CPR).

Signs of respiratory arrest are an absence of

respiratory effort, a lack of detectable air movement

through the nose or mouth, unconsciousness, and a

cyanotic discoloration of the lips and nail beds.

Determining Breathlessness

To assess the presence or absence of breathing

(fig. 4-9), you should use the following procedures:

Step 13⁄4Place your ear over the patient’s mouth

and nose, while maintaining an open airway.

Step 23⁄4While observing the patient’s chest,

• look for the chest to rise and fall,

• listen for air escaping during exhalation, and

• feel for the flow of air.

Recovery Position

If the patient is unresponsive, has no evidence of

trauma, and is obviously breathing adequately, place

the patient in the “recovery position.” See figure 4-10.

In the recovery position, the airway is more likely to

remain open, and an unrecognized airway obstruction

caused by the tongue is less likely to occur. It is

important to continue close observation of the patient

who has been placed in the recovery position until he

becomes responsive.

To place a patient in the recovery position, roll the

patient onto his side so that the head, shoulders, and

torso move simultaneously without twisting. If the

patient has sustained trauma or trauma is suspected,

the patient should NOT be moved.

Artificial Ventilation

If a patient is in respiratory arrest, artificial

ventilations must be started immediately. Any delay

could result in brain damage or death. The purpose of

artificial ventilation is to provide air exchange until

natural breathing is re-established. Artificial

ventilation should be given only when natural

breathing has been suspended; it must not be given to

a person who is breathing naturally. Do not assume

that a person’s breathing has stopped merely because

the person is unconscious or has been rescued from

water, from poisonous gas, or from contact with an

electric wire.

Techniques of artificial ventilation include

mouth-to-mouth, mouth-to-nose, mouth-to-stoma,

and mouth-to-mask. These techniques as they apply

to adult patients are discussed in the following

sections.

MOUTH-TO-MOUTH.—Artificial ventilation

with the mouth-to-mouth technique is a quick,

effective way to provide oxygen to the patient. The

exhaled air contains enough oxygen to supply the

patient’s needs.

To perform mouth-to-mouth ventilation, the

airway must be open. To open the airway, perform the

head tilt-chin lift or jaw-thrust maneuver. If there is no

spontaneous breathing, start artificial ventilation by

pinching the nose closed with your thumb and index

4-16

Figure 4-9.—Determining breathlessness.
finger. Take a deep breath and seat your lips around the

patient’s mouth (creating an airtight seal), and give two

slow ventilations (1 1⁄2 to 2 seconds per breath). See

figure 4-11. Allow enough time for the lungs to deflate

between ventilations. If the patient still does not

respond, continue mouth-to-mouth ventilations at the

rate of 10 to 12 ventilations per minute or one breath

every 5 seconds. Periodically, check the pupils for

reaction to light; constriction is a sign of adequate

oxygenation.

NOTE: When performing artificial ventilation

and the lungs cannot be inflated adequately,

repeat head tilt-chin lift or jaw-thrust

maneuver, and again attempt ventilation. If the

lungs still do not inflate adequately, assume the

airway is obstructed by a foreign object.

MOUTH-TO-NOSE.—Mouth-to-nose

ventilation is effective when the patient’s mouth

cannot be opened (lockjaw), extensive facial or dental

injuries occur, or an airtight seal of the mouth cannot be

achieved. Figure 4-12 shows an example of this

procedure.

To administer this technique, tilt the head back

with one hand on the patient’s forehead and use the

other hand to lift the jaw (as in the head tilt-chin lift

maneuver). Close the victim’s mouth. Take a deep

breath, seal your lips around the patient’s nose, and

give two ventilations. Allow the victim’s lungs to

deflate passively after each ventilation. If the victim

does not respond, then you must fully inflate the lungs

at the rate of 10 to 12 ventilations per minute or one

breath every 5 seconds until the victim can breathe

spontaneously.

MOUTH-TO-STOMA.—A casualty who has

had surgery to remove part of the windpipe will breathe

through an opening in the front of the neck called a

stoma. Cover the casualty's mouth with your hand,

take a deep breath, and seal your mouth over the stoma.

Breathe slowly, using the procedures for

mouth-to-mouth breathing. Do not tilt the head back.

(In some situations, a person may breathe through the

stoma as well as his nose and mouth. If the casualty’s

chest does not rise, cover his mouth and nose, and

continue breathing through the stoma.)

MOUTH-TO-MASK.—The mouth-to-mask

breathing device includes a transparent mask with a

one-way valve mouth piece. The one-way valve

directs the rescuer’s breath into the patient’s airway

while diverting the patients’s exhaled air away from

the rescuer. Some devices have an oxygen adaptor that

permits the administration of supplemental oxygen.

4-17

Figure 4-10.—A patient in the recovery position.

Figure 4-11.—Mouth-to-mouth ventilation.

Figure 4-12.—Mouth-to-nose ventilation.
Mouth-to-mask is a reliable form of ventilation

since it allows the rescuer to use two hands to create a

seal. Follow the steps below to perform the

mouth-to-mask technique.

Step 1—Place the mask around the patient’s

mouth and nose, using the bridge of the nose as a guide

for correct position. Proper positioning of the mask is

critical because gaps between the mask and the face

will result in air leakage.

Step 2––Seal the mask by placing the heel and

thumb of each hand along the border of the mask and

compressing firmly to provide a tight seal around the

margin of the mask.

Step 3––Place your remaining fingers along the

bony margin of the jaw and lift the jaw while

performing a head tilt.

Step 4––Give breaths in the same sequence and at

the same rate as in mouth-to-mouth resuscitation;

observe the chest for expansion.

Gastric Distention

Sometimes during artificial ventilation, air is forced

into the stomach instead of into the lungs. The stomach

becomes distended (bulges), indicating that the airway

is blocked or partially blocked, or that ventilations are

too forceful. This problem is more common in children

but can occur with adults as well. A slight bulge is of

little worry, but a major distention can cause two serious

problems. First, it reduces lung volume: the distended

stomach forces the diaphragm up. Second, there is a

strong possibility of vomiting.

The best way to avoid gastric distention is to

position the head and neck properly and/or limit the

volume of ventilations delivered.

NOTE: THE AMERICAN RED CROSS

(ARC) STATES THAT NO ATTEMPT

SHOULD BE MADE TO FORCE AIR FROM

THE STOMACH UNLESS SUCTION

EQUIP- MENT IS ON HAND FOR

IMMEDIATE USE.

If suction equipment is ready and the patient has a

marked distention, you can turn the patient on his side

facing away from you. With the flat of your hand, apply

gentle pressure between the navel and the rib cage. Be

prepared to use suction should vomiting occur.

CIRCULATION

Cardiac arrest is the complete stoppage of heart

function. If the patient is to live, action must be taken

immediately to restore heart function. The symptoms

of cardiac arrest include absence of carotid pulse, lack

of heartbeat, dilated pupils, and absence of breathing.

A rescuer knowing how to administer

cardiopulmonary resuscitation (CPR) greatly

increases the chances of a victim’s survival. CPR

consists of external heart compression and artificial

ventilation. External heart compression is performed

on the outside of the chest, and the lungs are ventilated

by the mouth-to-mouth, mouth-to-nose, mouth-tostoma, or mouth-to-mask techniques. To be effective,

CPR must be started within 4 minutes of the onset of

cardiac arrest. The victim should be supine on a firm

surface.

CPR should not be attempted by a rescuer who has

not been properly trained. If improperly done, CPR

can cause serious damage. It must never be practiced

on a healthy individual. For training purposes, use a

training aid instead. To learn this technique, see your

medical education department or an American Heart

Association- or American Red Cross-certified

Hospital Corpsman, nurse, or physician.

One-Rescuer CPR

The rescuer must not assume that a cardiac arrest

has occurred solely because the victim is lying on the

floor and appears to be unconscious. First, try to rouse

the victim by gently shaking the shoulders and trying

to obtain a response (e.g., loudly ask: “Are you OK?”).

If there is no response, place the victim supine on a

firm surface. Always assume neck injuries in

unconscious patients. Kneel at a right angle to the

victim, and open the airway using the head tilt-chin lift

or jaw-thrust methods described previously. Attempt

to ventilate. If unsuccessful, reposition the head and

again attempt to ventilate. If still unsuccessful, deliver

five abdominal thrusts (Heimlich maneuver) or chest

thrusts to open the airway. Repeat the thrust sequence

until the obstruction is removed.

DETERMINING PULSELESSNESS.—Once

the airway has been opened, check for the carotid

pulse. The carotid artery is most easily found by

locating the larynx at the front of the neck and then

sliding two fingers down the side of the neck toward

you (fig. 4-13). The carotid pulse is felt in the groove

between the larynx and the sternocleidomastoid

4-18
muscle. If the pulse is present, ventilate as necessary.

If the pulse is absent, locate the sternum and begin

chest compressions.

PROPER POSITIONING OF HANDS ON

STERNUM.—To locate the sternum, use the middle

and index fingers of your lower hand to locate the

lower margin of the victim’s rib cage on the side closest

to you (fig. 4-14). Then move your fingers up along the

edge of the rib cage to the notch where the ribs meet the

sternum in the center of the lower chest. Place your

middle finger on the notch and your index finger next

to it. Place the heel of your other hand along the

midline of the sternum next to your index finger.

Remember to keep the heel of your hand off the

xiphoid (tip of the sternum). A fracture in this area may

damage the liver, causing hemorrhage and death.

CHEST COMPRESSIONS.—Place the heel of

one hand directly on the sternum and the heel of the

other on top of the first. Interlock your fingers or

extend them straight out and KEEPTHEM OFFTHE

VICTIM’S CHEST! Effective compression is

accomplished by locking your elbows into position,

straightening your arms, and positioning your

shoulders directly over hands so that the thrust for each

chest compression is straight down on the sternum.

See figure 4-15. The sternum should be depressed

approximately 1 1⁄2 to 2 inches (for adults). Release

chest compression pressure between each

compression to allow blood to flow into the chest and

heart. When releasing chest compression pressure,

remember to keep your hands in place on the chest.

Not only will you feel less fatigue if you use the

proper technique, but a more effective compression

4-19

Figure 4-13.—Locating the carotid pulse.

Figure 4-14.—Proper position of hands on the sternum for

chest compressions.

Figure 4-15.—Proper position of the rescuer.
will also result. Ineffective compression occurs when

the elbows are not locked, the rescuer is not directly

over the sternum, or the hands are improperly placed

on the sternum.

PERFORMANCE AND REASSESSMENT OF

CPR.—When one rescuer performs CPR, the ratio of

compressions to ventilations is 15 to 2, and it is

performed at a rate of 80 to 100 compressions per

minute. Vocalize: “one and, two and, three and,...”

until you reach 15. After 15 compressions, you must

give the victim two slow ventilations (1 1⁄2 to 2

seconds). Continue for four full cycles. Quickly check

for the carotid pulse and spontaneous breathing. If

there are still no signs of recovery, continue CPR with

compressions. Reassess the patient every few minutes

thereafter.

If a periodic check reveals a return of pulse and

respiration, discontinue CPR and place the victim in

the recovery position. Continue monitoring the victim

and be prepared to restart CPR .

Two-Rescuer CPR

If there are two people trained in CPR on the scene,

one should perform chest compressions while the other

performs ventilations. The compression rate for

two-rescuer CPR is the same as it is for one-rescuer

CPR: 80 to 100 compressions per minute. However,

the compression-ventilation ratio is 5 to 1, with a pause

for ventilation of 1 1⁄2 to 2 seconds consisting primarily

of inspiration. Exhalation occurs during chest

compressions.

Two-rescuer CPR should be performed with one

rescuer positioned at the chest area and the other positioned

beside the victim’s head. The rescuers should be on

opposite sides of the victim to ease position changes when

one rescuer gets tired. Changes should be made on cue

without interrupting the rhythm.

The victim’s condition must be monitored to assess

the effectiveness of the rescue effort. The person

ventilating the patient assumes the responsibility for

monitoring pulse and breathing. To assess the

effectiveness of the partner’s chest compressions, the

rescuer should check the pulse during compressions. To

determine if the victim has resumed spontaneous

breathing and circulation, chest compressions must be

stopped for 5 seconds at the end of the first minute (20

cycles) and every few minutes thereafter.

NOTE: Although it has fallen out to favor

with some agencies, two-person CPR remains

a viable method of resuscitation.

CPR for Children and Infants

CPR for children (1 to 8 years old) is similar to that

for adults. The primary differences are that the heel of

only one hand is used to apply chest compressions, and

ventilations are increased to a rate of 20 breaths per

minute (once every 3 seconds). Chest compressions

are performed on the lower half of the sternum

(between the nipple line and the notch). The chest

should be depressed approximately one-third to

one-half (about 1 to 1 1⁄2 inches) the total depth of the

chest.

For infants (under 1 year old), CPR is performed

with the infant supine on a hard, flat surface. The hard

surface may be the rescuer’s hand or arm, although

using the arm to support the infant during CPR enables

the rescuer to transport the infant more easily while

continuing CPR. See figure 4-16. Once the infant is

positioned on a hard surface, the airway should be

opened using the head tilt-chin lift or jaw-thrust

maneuver. Both maneuvers, however, must be

performed very carefully and gently to prevent

hyperextension of the infant’s neck. Pulselessness is

determined by palpating the brachial artery (fig. 4-17).

If the infant has no pulse and is not breathing, CPR

must be started immediately.

To perform CPR on an infant, place your mouth

over the infant’s nose and mouth, creating a seal. Give

two slow breaths (1 to 1 1⁄2 seconds per breath) to the

infant, pausing after the first breath to take a breath.

Pausing to take a breath after the first breath of each

pair of breaths maximizes oxygen content and

4-20

Figure 4-16.—Infant supported on rescuer’s arm, and proper

placement of fingers for chest compressions.
minimizes carbon dioxide concentration in the

delivered breaths. Perform chest compressions by

using two fingers to depress the middle of the sternum

approximately 1⁄2 to 1 inch. See figures 4-16 and 4-18

for proper finger positioning for chest compressions.

For both infants and children, the compression rate

should be at least 100 compressions per minute.

Compressions must be coordinated with ventilations at

a 5-to-1 ratio. The victim should be reassessed after 20

cycles of compressions and ventilations

(approximately 1 minute) and every few minutes

thereafter for any sign of resumption of spontaneous

breathing and pulse. If the child or infant resumes

effective breathing, place the victim in the recovery

position.

SHOCK

LEARNING OBJECTIVE: Recognize the

signs and symptoms of shock, and determine

treatment by the type of shock presented.

Shock is the collapse of the cardiovascular system,

characterized by circulatory deficiency and the

depression of vital functions. There are several types

of shock:

• Hypovolemic shock–caused by the loss of

blood and other body fluids.

• Neurogenic shock–caused by the failure of the

nervous system to control the diameter of blood

vessels.

• Cardiogenic shock–caused by the heart failing

to pump blood adequately to all vital parts of the

body.

• Septic shock–caused by the presence of severe

infection.

• Anaphylactic shock–caused by a

life-threatening reaction of the body to a

substance to which a patient is extremely

allergic.

Multiple types of shock may be present in varying

degrees in the same patient at the same time. The most

frequently encountered and most important type for

the Hospital Corpsman to understand is hemorrhagic

shock, a type of hypovolemic shock which will be

discussed later in this chapter.

Shock should be expected in all cases of major

injury, including gross hemorrhage, abdominal or

chest wounds, crash or blast injuries, extensive

large-muscle damage (particularly of the extremities),

major fractures, traumatic amputations, or head

injuries, or in burns involving more than 10 percent of

the body surface area.

SYMPTOMS OF SHOCK

The symptoms of shock vary from patient to

patient and even within an individual during the course

of illness. Evaluation of the whole situation is more

important than one particular sign or symptom.

Degrees of Shock

Table 4-2 provides a generalized overview of the

degrees of shock and their symptoms correlated to the

approximate volume deficit.

4-21

Figure 4-17.—Palpating brachial artery pulse in an infant.

Figure 4-18.—Locating proper finger position to perform

chest compressions in infants.
Shock Control and Prevention

The essence of shock control and prevention is to

recognize the onset of the condition and to start

treatment before the symptoms fully develop. The

following are general signs and symptoms of the

development of shock (see figure 4-19):

• Restlessness and apprehension are early

symptoms, often followed by apathy.

• Eyes may be glassy and dull. Pupils may be

dilated. (These are also the symptoms of

morphine use.)

• Breathing may be rapid or labored, often of the

gasping, “air hunger” type. In the advanced

stages of shock, breathing becomes shallow and

irregular.

• The face and skin may be very pale or ashen

gray; in the dark complexioned, the mucous

membranes may be pale. The lips are often

cyanotic.

• The skin feels cool and is covered with clammy

sweat. The skin’s coolness is related to a

decrease in the peripheral circulation.

• The pulse tends to become rapid, weak, and

thready. If the blood pressure is severely

lowered, the peripheral pulse may be absent.

The pulse rate in hemorrhagic shock may

reach 140 or higher. In neurogenic shock,

however, the pulse rate is slowed, often

below 60.

• The blood pressure is usually lowered in

moderately severe shock; the systolic

pressure drops below 100, while the pulse

rises above 100. The body is compensating

for circulatory fluid loss by peripheral

vasoconstriction. This process tends to

maintain the blood pressure at a nearly

normal level despite a moderately severe loss

of circulating blood volume. A point comes,

however, when decompensation occurs, and

a small amount of additional blood loss will

produce a sudden, alarming fall in blood

pressure.

• There may be nausea, vomiting, and dryness

of the mouth, lips, and tongue.

• Surface veins may collapse. Veins normally

visible at the front of the elbow, forearms,

4-22

Approximate

Deficit (ml)

Decrease in Blood

Volume % Degree Signs

0-500 0-10 None None

500-1200 10-25 Mild Slight tachycardia

Postural changes in blood pressure

Mild peripheral vasoconstriction

Increased respirations

1200-1800 25-35 Moderate Thready pulse 100-120

Systolic blood pressure 90-100

Marked vasoconstriction

Labored breathing

Diaphoresis (profuse perspiration)

Anxiety and restlessness

Decreased urine output

1800-2500 35-50 Severe Thready pulse > 120

Systolic blood pressure < 60

Weakened respirations

Increased diaphoresis

Changes in levels of consciousness

No urine output

Table 4-2.—Correlation of Magnitude of Volume Deficit and Clinical Presentation
and the back of the hands will be hard to

distinguish.

• There are frequent complaints of thirst. Even the

severely wounded may complain of thirst rather

than pain.

• The kidneys may shut down. Urine formation

either ceases or greatly diminishes if the systolic

blood pressure falls below 80 for long periods of

time.

• The person may faint from inadequate venous

blood return to the heart. This may be the result

of a temporary gravitational pooling of the blood

associated with standing up too quickly.

HYPOVOLEMIC SHOCK

Hypovolemic shock is also known as oligemic or

hematogenic shock. The essential feature of all forms

of hypovolemic shock is loss of fluid from the

circulating blood volume, so that adequate circulation

to all parts of the body cannot be maintained.

Hemorrhagic Shock

In cases where there is internal or external

hemorrhage due to trauma (hemorrhagic shock), there

is a loss of whole blood, including red blood cells. The

diminished blood volume causes a markedly lessened

cardiac output and reduced peripheral circulation.

This results in reduction of oxygen transported to the

tissues (hypoxia); reduction of perfusion, the

circulation of blood within an organ; and reduction of

waste products transported away from the tissue cells.

Under these conditions, body cells are able to carry on

their normal functions for only a short period of time.

The body tries to restore the circulatory volume by

supplying fluid from the body tissues. The result is a

progressive fall in the hematocrit (ratio of red blood

cells to plasma) and in the red blood cell count.

Burn Shock

In burn shock, on the other hand, there is a

progressive increase in the hematocrit and red blood

cell count. This increase is due to hemoconcentration

from loss of the plasma fraction of the blood into and

through the burned area.

NEUROGENIC SHOCK

Neurogenic shock, sometimes called vasogenic

shock, results from the disruption of autonomic

nervous system control over vasoconstriction. Under

normal conditions, the autonomic nervous system

keeps the muscles of the veins and arteries partially

contracted. At the onset of most forms of shock,

further constriction is signaled. However, the vascular

muscles cannot maintain this contraction indefinitely.

A number of factors, including increased fluid loss,

central nervous system trauma, or emotional shock,

can override the autonomic nervous system control.

The veins and arteries immediately dilate, drastically

expanding the volume of the circulatory system, with a

corresponding reduction of blood pressure.

Simple fainting (syncope) is a variation of

neurogenic shock. It often is the result of a temporary

gravitational pooling of the blood as a person stands

up. As the person falls, blood again rushes to the head,

and the problem is solved. Neurogenic shock may also

be induced by fear or horror, which will override the

autonomic nervous system control.

Shell shock and bomb shock are other variations of

neurogenic shock that are important to the Hospital

Corpsman. These are psychological adjustment

reactions to extremely stressful wartime experiences

and do not relate to the collapse of the cardiovascular

system. Symptoms range from intense fear to complete

dementia and are manifestations of a loss of nervous

control. Care is limited to emotional support of the

patient and his evacuation to the care of a psychiatrist

or psychologist.

4-23

Figure 4-19.—Symptoms of shock.
CARDIOGENIC SHOCK

Cardiogenic shock is caused by inadequate

functioning of the heart, not by loss of circulating

blood volume. If the heart muscle is weakened by

disease or damaged by trauma or lack of oxygen (as in

cases of pulmonary disease, suffocation, or myocardial

infarction), the heart will no longer be able to maintain

adequate circulatory pressure, even though the volume

of fluid is unchanged. Shock will develop as the

pressure falls. Heart attack is an extreme medical

emergency all Hospital Corpsmen must be ready to

handle. It will be discussed in greater detail in the

“Common Medical Emergencies” section of this

chapter.

SEPTIC SHOCK

Septic shock usually does not develop for 2 to 5

days after an injury and the patient is not often seen by

the Corpsman in a first aid situation. Septic shock may

appear during the course of peritonitis caused by

penetrating abdominal wounds or perforation of the

appendix. Gross wound contamination, rupture of an

ulcer, or complications from certain types of

pneumonia may also cause septic shock. Septic shock

is the result of vasodilation of small blood vessels in

the wound area, or general vasodilation if the infection

enters the bloodstream. In addition to increasing

circulatory system volume, the walls of the blood

vessels become more permeable, which allows fluids

to escape into the tissues. This type of shock carries a

poor prognosis and should be treated under the direct

supervision of a medical officer.

ANAPHYLACTIC SHOCK

Anaphylactic shock occurs when an individual is

exposed to a substance to which his body is

particularly sensitive. In the most severe form of

anaphylactic shock, the body goes into an almost

instantaneous violent reaction. A burning sensation,

itching, and hives spread across the skin. Severe

edema affects body parts and the respiratory system.

Blood pressure drops alarmingly, and fainting or coma

may occur.

The causative agent may be introduced into the

body in a number of ways. The injection of medicines

(especially penicillin and horse- or egg-cultured

serums) is one route. Another method is the injection

of venoms by stinging insects and animals. The

inhalation of dusts, pollens, or other materials to which

a person is sensitive is a third route. Finally, a slightly

slower but no less severe reaction may develop from

the ingestion of certain foods and medications.

Specific treatment of venoms and poisons will be

discussed in chapter 5, “Poisoning, Drug Abuse, and

Hazardous Material Exposure.”

GENERAL TREATMENT PROCEDURES

Intravenous fluid administration is the most

important factor in the treatment of all types of shock

except cardiogenic shock. Ringer’s lactate is the best

solution to use, although normal saline is adequate

until properly cross-matched whole blood can be

administered. The electrolyte solutions replace not

only the lost blood volume, but also lost extracellular

fluid that has been depleted. If the shock is severe

enough to warrant immediate administration of

intravenous fluids, or if transportation to a medical

facility will be delayed and a medical officer is not

available to write an administrative order, be

conservative: Start the intravenous fluids and let them

run at a slow rate of 50 to 60 drops per minute. If

intravenous solutions are unavailable or transportation

to a medical treatment facility will be delayed, and

there are no contraindications (such as gastrointestinal

bleeding or unconsciousness), you may give the

patient an electrolyte solution by mouth. An

electrolyte solution may be prepared by adding a

teaspoon of salt and half a teaspoon of baking soda to a

quart or liter of water. Allow the patient to sip the

solution.

Other treatment procedures for shock are as

follows:

• Maintain an open airway. Oxygen may also be

administered if proper equipment is available.

• Control hemorrhages.

• Check for other injuries that may have been

sustained. Remove the victim from the presence

of identifiable causative agents.

• Place the victim in a supine position, with the

feet slightly higher than the head (shock

position). Certain problems, such as breathing

difficulties or head injuries, may require other

positioning.

• Reduce pain by splinting fractures, providing

emotional support, and attending to the victim’s

comfort. Unless contraindicated, aspirin may be

dispensed.

• Conserve the patient’s body heat.

4-24
• Avoid rough handling of the victim, and

transport to a medical treatment facility.

• If transportation to a definitive care facility will

be lengthy or delayed, seek the radio or phone

advice of a medical officer on whether to give

fluids by mouth or to start an intravenous line. If

this consultation is impossible, use your own

judgment. In the case of cardiogenic shock, DO

NOT start intravenous fluids since blood volume

is sufficient and only function is impaired.

• Constantly monitor the patient and record vital

signs every 15 minutes so that you are able to

keep track of the patient’s progress.

PNEUMATIC COUNTER-PRESSURE

DEVICES (MAST)

Commonly known as Medical Anti-Shock

Trousers or Military Anti-Shock Trousers (MAST),

pneumatic counter-pressure devices are designed to

correct or counteract certain internal bleeding

conditions and hypovolemia. The garment does this by

developing an encircling pressure up to 120 mm Hg

around both lower extremities, the pelvis, and the

abdomen. The pressure created

• slows or stops venous and arterial bleeding in

areas of the body enclosed by the pressurized

garment;

• forces available blood from the lower body to the

heart, brain, and other vital organs;

• prevents pooling of blood in the lower

extremities; and

• stabilizes fractures of the pelvis and lower

extremities.

Some indications for use of the pneumatic

counter-pressure devices are when

• systolic blood pressure is less than 80 mm Hg,

• systolic blood pressure is less than 100 mm Hg

and the patient exhibits the classic signs of

shock, or

• fracture of the pelvis or lower extremities is

present.

Although the only absolute contraindication in the

use of these devices is in the case of pulmonary edema,

other conditional contraindications include congestive

heart failure, heart attack, stroke, pregnancy,

abdominal evisceration, massive bleeding into the

thoracic cavity, and penetrating wounds where the

object is still impaled in the victim.

Application of the anti-shock garment is a simple

procedure, but it requires some important preliminary

steps. When the garment is laid out flat, ensure that

there are no wrinkles. If the patient is to remain

clothed, remove all sharp and bulky objects from the

patient’s pockets. Take vital signs before applying the

MAST garment. When applying the garment, inflate

sufficiently so the patient’s systolic blood pressure is

brought to and maintained at 100 mm Hg. Once the

garment is inflated, take the patient’s vital signs every

5 minutes. The garment should be removed only under

the direct supervision of a physician.

BREATHING AIDS

LEARNING OBJECTIVE: Recognize

breathing aids and their uses.

As a Hospital Corpsman, you should become

familiar with the breathing aids that may be available

to help you maintain an open airway and to restore

breathing in emergency situations. Breathing aids

include oxygen, artificial airways, bag-valve mask

ventilator, pocket face mask, and suction devices.

USE OF OXYGEN (O2)

In an emergency situation, you will probably have

a size E, 650-liter cylinder of oxygen available. The

oxygen cylinder is usually fitted with a yoke-style

pressure-reducing regulator, with gauges to show tank

pressure and flow rate (adjustable from 0 to 15 liters

per minute). A humidifier can be attached to the

flowmeter nipple to help prevent tissue drying caused

by the water-vapor-free oxygen. An oxygen line can

be connected from the flowmeter nipple or humidifier

to a number of oxygen delivery devices that will be

discussed later.

When available, oxygen should be administered,

as described below, to cardiac arrest patients and to

self-ventilating patients who are unable to inhale

enough oxygen to prevent hypoxia (oxygen

deficiency). Hypoxia is characterized by tachycardia,

nervousness, irritability, and finally cyanosis. It

develops in a wide range of situations, including

poisoning, shock, crushing chest injuries,

cerebrospinal accidents, and heart attacks.

4-25
Oxygen must never be used near open flames since

it supports burning. Oxygen cylinders must be handled

carefully since they are potentially lethal missiles if

punctured or broken.

ARTIFICIAL AIRWAYS

The oropharyngeal and nasopharyngeal airways

are primarily used to keep the tongue from occluding

(closing) the airway.

Oropharyngeal Airway

The oropharyngeal airway can be used only on

unconscious victims because a conscious person will

gag on it. This airway comes in various sizes for

different age groups and is shaped to rest on the

contour of the tongue and extend from the lips to the

pharynx. Selecting the correct size oropharyngeal

airway is very important to its effectiveness. An

airway of proper size will extend from the corner of the

patient’s mouth to the tip of the earlobe on the same

side of the patient’s face.

One method of insertion is to depress the tongue

with a tongue blade and slide the airway in. Another

method is to insert the airway upside down into the

victim’s mouth; then rotate it 180° as it slides into the

pharynx (fig. 4-20).

Nasopharyngeal Airway

The nasopharyngeal airway may be used on

conscious victims since it is better tolerated because it

generally does not stimulate the gag reflex. Since it is

made of flexible material, it is designed to be

lubricated and then gently passed up the nostril and

down into the pharynx. If the airway meets an

obstruction in one nostril, withdraw it and try to pass it

up the other nostril. See figure 4-21 for proper

insertion of the nasopharyngeal airway.

BAG-VALVE MASK VENTILATOR

The bag-valve mask ventilator (fig. 4-22) is

designed to help ventilate an unconscious victim for

long periods while delivering high concentrations of

oxygen. This system can be useful in extended CPR

attempts because, when using external cardiac

compressions, the cardiac output is cut to 25 to 30

percent of the normal capacity, and artificial

ventilation does not supply enough oxygen through the

circulatory system to maintain life for a long period.

Various types of bag-valve-mask systems that

come in both adult and pediatric sizes are in use in the

Navy. Essentially, they consist of a self-filling

ventilation bag, an oxygen reservoir, plastic face

masks of various sizes, and tubing for connecting to an

oxygen supply.

4-26

Figure 4-20.—The rotation method of inserting an

oropharyngeal airway.

Figure 4-21.—Proper insertion of a nasopharyngeal airway.

Figure 4-22.—Bag-valve mask ventilator.
Limitations of the Bag-Valve

Mask Ventilator

The bag-valve mask ventilator is difficult to use

unless the user has had sufficient practice with it. It

must not be used by inexperienced individuals. The

system can be hard to clean and reassemble properly;

the bagging hand can tire easily; and an airtight seal at

the face is hard to maintain, especially if a single

rescuer must also keep the airway open. In addition,

the amount of air delivered to the victim is limited to

the volume that the hand can displace from the bag

(approximately 1 liter per compression).

Procedures for Operating the Bag-Valve

Mask Ventilator

To use the bag-valve mask ventilator, hook the bag

up to an oxygen supply and adjust the flow in the range

of 10 to 15 liters per minute, depending on the desired

concentration (15 liters per minute will deliver an

oxygen concentration of 90 percent). After opening

the airway or inserting an oropharyngeal airway, place

the mask over the face and hold it firmly in position

with the index finger and thumb, while keeping the jaw

tilted upward with the remaining fingers (fig. 4-23).

Use the other hand to compress the bag once every 5

seconds. Observe the chest for expansion. If none is

observed, the face mask seal may not be airtight, the

airway may be blocked, or some component of the

bag-valve mask ventilator may be malfunctioning.

POCKET FACE MASK

A pocket face mask designed with an oxygen-inlet

flow valve for mouth-to-mask ventilation can be used

to give oxygen-enriched artificial ventilation.

Although a pocket face mask system cannot achieve

oxygen concentrations as high as the bag-valve mask

system, it has the advantages of providing greater air

volume (up to 4 liters per breath) and of being much

easier to use (since both hands are free to maintain the

airway and keep the mask firmly in place). See figure

4-24. The pocket face mask also acts as a barrier

device. It prevents the rescuer from coming in contact

with the patient’s body fluids and breath, which are

possible sources of infection.

To use the pocket face mask, stand behind the head

of the victim, and open the airway by tilting the head

backward. Place the mask over the victim’s face (for

adults, the apex goes over the bridge of the nose; for

infants, the apex fits over the chin, with the base resting

on the bridge of the nose). Form an airtight seal

between the mask and the face, and keep the airway

open by pressing down on the mask with both thumbs

while using the other fingers to lift the jaw up and back.

Ventilate into the open chimney of the mask.

4-27

Figure 4-23.—Bag-valve mask ventilator in use.

Figure 4-24.—Providing mouth-to-mask ventilations with

pocket face mask.
Oxygen can be added by hooking the valve up to an

oxygen supply. Since the rescuer’s breath dilutes the

oxygen flow in artificial ventilation, adjust the flow

rate to increase oxygen concentration. At 5 liters per

minute, the oxygen concentration will be

approximately 50 percent. At 15 liters per minute, this

concentration will increase to 55 percent.

The mask has an elastic strap so it can be used on

conscious, self-ventilating patients to increase oxygen

concentration.

SUCTION DEVICES

The patient’s airway must be kept clear of foreign

materials, blood, vomitus, and other secretions.

Materials that remain in the airway may be forced into

the trachea and eventually into the lungs. This will

cause complications ranging from severe pneumonia

to a complete airway obstruction. Use suction to

remove such materials.

In the field, a Hospital Corpsman may have access

to a fixed (installed) suction unit or a portable suction

device. Both types of suction devices are equipped

with flexible tubing, suction tips and catheters, and a

non-breakable collection container.

Maintenance of suction devices consists of testing

the suction pressure regularly and cleaning the device

after each use.

Before using a suction device, always test the

apparatus. Once the suction pressure has been tested,

attach a suction catheter or tip. Position the patient on

his side, and open the patient’s mouth. This position

permits secretions to flow from the patient’s mouth

while suction is being delivered. Use caution in

patients with suspected neck or spinal injuries. If the

patient is fully and securely immobilized on a

backboard, the backboard may be tilted to place the

patient on his side. If you suspect such injuries but the

patient is not immobilized, suction as best you can

without turning the patient. Carefully insert the suction

tip or catheter at the top of the throat (fig. 4-25). DO

NOT push the tip down into the throat or into the

larynx. Apply suction, but for no more than a few

seconds, since supplemental oxygen or ventilations

cease while suctioning, keeping oxygen from the

patient. Suction may be repeated after a few breaths.

CRICOTHYROIDOTOMY

A cricothyroidotomy, often called an emergency

tracheotomy, consists of incising the cricothyroid

membrane, which lies just beneath the skin between

the thyroid cartilage and the cricoid cartilage. In most

cases, the cricothyroid membrane can be easily located

by hyperextending the neck so that the thyroid notch

(Adam’s apple) becomes prominent anteriorly.

Identify the position of the thyroid notch with the index

finger. This finger descends in the midline to the

prominence of the cricoid cartilage. The depression of

the cricothyroid membrane is identified above the

superior margin of the cricoid cartilage (fig. 4-26).

Make a small lateral incision at the base of the thyroid

cartilage to expose the cricothyroid membrane. Excise

this membrane (taking care not to go too deeply) and

insert a small-bore air line into the trachea.

4-28

Figure 4-25.—Proper insertion of suction tip.

Figure 4-26.—Anatomical structures of the neck to identify

the cricothyroid membrane.
An alternate method is to use a 12- to 16-gauge

intercatheter. Locate the cricothyroid membrane as

described above and insert the needle into the trachea.

Immediately upon penetration of the cricothyroid

membrane, thread the plastic catheter into the trachea

and remove the needle. Then connect the catheter to an

oxygen line for translaryngeal oxygen jet insufflation.

Do not attempt a cricothyroidotomy except as a

last resort when other methods of opening the

airway have been unsuccessful.

SOFT TISSUE INJURIES

LEARNING OBJECTIVE: Recognize the

different types of wounds, and determine

management and treatment procedures for

open and internal soft-tissue injuries.

The most common injuries seen by the Corpsman

in a first aid setting are soft tissue injuries with the

accompanying hemorrhage, shock, and danger of

infection. Any injury that causes a break in the skin,

underlying soft tissue structures, or body membranes

is known as a wound. This section will discuss the

classification of wounds, the general and specific

treatment of soft tissue injuries, the use of dressings

and bandages in treating wounds, and the special

problems that arise because of the location of wounds.

CLASSIFICATION OF WOUNDS

Wounds may be classified according to their

general condition, size, location, the manner in which

the skin or tissue is broken, and the agent that caused

the wound. It is usually necessary for you to consider

these factors to determine what first aid treatment is

appropriate for the wound.

General Condition of the Wound

If the wound is fresh, first aid treatment consists

mainly of stopping the flow of blood, treating for

shock, and reducing the risk of infection. If the wound

is already infected, first aid consists of keeping the

victim quiet, elevating the injured part, and applying a

warm wet dressing. If the wound contains foreign

objects, first aid treatment may consist of removing the

objects if they are not deeply embedded. DO NOT

remove objects embedded in the eyes or the skull, and

do not remove impaled objects. Stabilize impaled

objects with a bulky dressing before transporting the

victim.

Size of the Wound

In general, since large wounds are more serious

than small ones, they usually involve more severe

bleeding, more damage to the underlying organs or

tissues, and a greater degree of shock. However, small

wounds are sometimes more dangerous than large ones

since they may become infected more readily due to

neglect. The depth of the wound is also important

because it may lead to a complete perforation of an

organ or the body, with the additional complication of

entrance and exit wounds.

Location of the Wound

Since a wound may involve serious damage to the

deeper structures, as well as to the skin and the tissue

immediately below it, the location of the wound is

important. For example, a knife wound to the chest

may puncture a lung and cause interference with

breathing. The same type of wound in the abdomen

may result in a dangerous infection in the abdominal

cavity, or it might puncture the intestines, liver,

kidneys, or other vital organs. A knife wound to the

head may cause brain damage, but the same wound in a

less vital spot (such as an arm or leg) might be less

important.

Types of Wounds

When you consider the manner in which the skin or

tissue is broken, there are six general kinds of wounds:

abrasions, incisions, lacerations, punctures, avulsions,

and amputations. Many wounds, of course, are

combinations of two or more of these basic types.

ABRASIONS.—Abrasions are made when the

skin is rubbed or scraped off. Rope burns, floor burns,

and skinned knees or elbows are common examples of

abrasions. This kind of wound can become infected

quite easily because dirt and germs are usually

embedded in the tissues.

INCISIONS.—Incisions, commonly called cuts,

are wounds made by sharp cutting instruments such as

knives, razors, and broken glass. Incisions tend to

bleed freely because the blood vessels are cut cleanly

and without ragged edges. There is little damage to the

surrounding tissues. Of all classes of wounds,

incisions are the least likely to become infected, since

4-29
the free flow of blood washes out many of the

microorganisms (germs) that cause infection.

LACERATIONS.—These wounds are torn,

rather than cut. They have ragged, irregular edges and

masses of torn tissue underneath. These wounds are

usually made by blunt (as opposed to sharp) objects. A

wound made by a dull knife, for instance, is more likely

to be a laceration than an incision. Bomb fragments

often cause lacerations. Many of the wounds caused

by accidents with machinery are lacerations; they are

often complicated by crushing of the tissues as well.

Lacerations are frequently contaminated with dirt,

grease, or other material that is ground into the tissue.

They are therefore very likely to become infected.

PUNCTURES.—Punctures are caused by objects

that penetrate into the tissues while leaving a small

surface opening. Wounds made by nails, needles, wire,

and bullets are usually punctures. As a rule, small

puncture wounds do not bleed freely; however, large

puncture wounds may cause severe internal bleeding.

The possibility of infection is great in all puncture

wounds, especially if the penetrating object has tetanus

bacteria on it. To prevent anaerobic infections,

primary closures are not made in the case of puncture

wounds.

AVULSIONS.—An avulsion is the tearing away

of tissue from a body part. Bleeding is usually heavy.

In certain situations, the torn tissue may be surgically

reattached. It can be saved for medical evaluation by

wrapping it in a sterile dressing and placing it in a cool

container, and rushing it—along with the victim–to a

medical facility. Do not allow the avulsed portion to

freeze, and do not immerse it in water or saline.

AMPUTATIONS.—A traumatic amputation is

the nonsurgical removal of the limb from the body.

Bleeding is heavy and requires a tourniquet (which

will be discussed later) to stop the flow. Shock is

certain to develop in these cases. As with avulsed

tissue, wrap the limb in a sterile dressing, place it in a

cool container, and transport it to the hospital with the

victim. Do not allow the limb to be in direct contact

with ice, and do not immerse it in water or saline. The

limb can often be successfully reattached.

Causes of Wounds

Although it is not always necessary to know what

agent or object has caused the wound, it is helpful.

Knowing what has caused the wound may give you

some idea of the probable size of the wound, its general

nature, the extent to which it is likely to become

contaminated with foreign matter, and what special

dangers must be guarded against. Of special concern

in a wartime setting is the velocity of wound-causing

missiles (bullets or shrapnel). A low-velocity missile

damages only the tissues it comes into contact with.

On the other hand, a high-velocity missile can do

enormous damage by forcing the tissues and body

parts away from the track of the missile with a velocity

only slightly less than that of the missile itself. These

tissues, especially bone, may become damage-causing

missiles themselves, thus accentuating the destructive

effects of the missile.

Having classified the wound into one or more of

the general categories listed, the Corpsman will have a

good idea of the nature and extent of the injury, along

with any special complications that may exist. This

information will aid in the treatment of the victim.

MANAGEMENT OF OPEN SOFT-TISSUE

INJURIES

There are three basic rules to be followed in the

treatment of practically all open soft tissue injuries: to

control hemorrhage, to treat the victim for shock, and

to do whatever you can to prevent infection. These will

be discussed, along with the proper application of first

aid materials and other specific first aid techniques.

Hemorrhage

Hemorrhage is the escape of blood from the

vessels of the circulatory system. The average adult

body contains about 5 liters of blood. Five hundred

milliliters of blood, the amount given by blood donors,

can usually be lost without any harmful effect. The

loss of 1 liter of blood usually causes shock, but shock

may develop if small amounts of blood are lost rapidly,

since the circulatory system does not have enough time

to compensate adequately. The degree of shock

progressively increases as greater amounts of blood

escape. Young children, sick people, or the elderly

may be especially susceptible to the loss of even small

amounts of blood since their internal systems are in

such delicate balance.

Capillary blood is usually brick red in color. If

capillaries are cut, the blood oozes out slowly. Blood

from the veins is dark red. Venous bleeding is

characterized by a steady, even flow. If an artery near

the surface is cut, the blood, which is bright red in

color, will gush out in spurts that are synchronized with

the heartbeats. If the severed artery is deeply buried,

4-30
however, the bleeding will appear to be a steady

stream.

In actual practice, you might find it difficult to

decide whether bleeding is venous or arterial, but the

distinction is not usually important. The important

thing to know is that all bleeding must be controlled as

quickly as possible.

External hemorrhage is of greatest importance to

the Corpsman because it is the most frequently

encountered and the easiest to control. It is

characterized by a break in the skin and visible

bleeding. Internal hemorrhage (which will be

discussed later) is far more difficult to recognize and to

control.

Control of Hemorrhage

The best way to control external bleeding is by

applying a compress to the wound and exerting

pressure directly to the wound. If direct pressure does

not stop the bleeding, pressure can also be applied at an

appropriate pressure point. At times, elevation of an

extremity is also helpful in controlling hemorrhage.

The use of splints in conjunction with direct pressure

can be beneficial. In those rare cases where bleeding

cannot be controlled by any of these methods, you

must use a tourniquet.

If bleeding does not stop after a short period, try

placing another compress or dressing over the first and

securing it firmly in place. If bleeding still will not

stop, try applying direct pressure with your hand over

the compress or dressing.

Remember that in cases of severe hemorrhage, it is

less important to worry too much about finding

appropriate materials or about the dangers of infection.

The most important problem is to stop rapid

exsanguination. If no material is available, simply

thrust your hand into the wound. In most situations,

direct pressure is the first and best method to use in the

control of hemorrhage.

Pressure Points

Bleeding can often be temporarily controlled by

applying hand pressure to the appropriate pressure

point. A pressure point is the spot where the main

artery to an injured part lies near the skin surface and

over a bone. Apply pressure at this point with the

fingers (digital pressure) or with the heel of the hand.

No first aid materials are required. The object of the

pressure is to compress the artery against the bone, thus

shutting off the flow of blood from the heart to the

wound.

There are 11 principal points on each side of the

body where hand or finger pressure can be used to stop

hemorrhage. These points are shown in figure 4-27. If

bleeding occurs on the face below the level of the eyes,

apply pressure to the point on the mandible. This is

shown in figure 4-27A. To find this pressure point,

start at the angle of the jaw and run your finger forward

along the lower edge of the mandible until you feel a

small notch. The pressure point is in this notch.

If bleeding is in the shoulder or in the upper part of

the arm, apply pressure with the fingers behind the

clavicle. You can press down against the first rib or

forward against the clavicle; either kind of pressure

will stop the bleeding. This pressure point is shown in

figure 4-27B.

Bleeding between the middle of the upper arm and

the elbow should be controlled by applying digital

pressure to the inner (body) side of the arm, about

halfway between the shoulder and the elbow. This

compresses the artery against the bone of the arm. The

application of pressure at this point is shown in figure

4-27C. Bleeding from the hand can be controlled by

pressure at the wrist, as shown in figure 4-27D. If it is

possible to hold the arm up in the air, the bleeding will

be relatively easy to stop.

Figure 4-27E shows how to apply digital pressure

in the middle of the groin to control bleeding from the

thigh. The artery at this point lies over a bone and quite

close to the surface, so pressure with your fingers may

be sufficient to stop the bleeding.

Figure 4-27F shows the proper position for

controlling bleeding from the foot. As in the case of

bleeding from the hand, elevation is helpful in

controlling the bleeding.

If bleeding is in the region of the temple or the

scalp, use your finger to compress the main artery to

the temple against the skull bone at the pressure point

just in front of the ear. Figure 4-27G shows the proper

position.

If the neck is bleeding, apply pressure below the

wound, just in front of the prominent neck muscle.

Press inward and slightly backward, compressing the

main artery of that side of the neck against the bones of

the spinal column. The application of pressure at this

point is shown in figure 4-27H. Do not apply pressure

at this point unless it is absolutely essential, since there

4-31
is a great danger of pressing on the windpipe, thereby

choking the victim.

Bleeding from the lower arm can be controlled by

applying pressure at the elbow, as shown in figure

4-27I.

As mentioned before, bleeding in the upper part of

the thigh can sometimes be controlled by applying

digital pressure in the middle of the groin, as shown in

figure 4-27E. Sometimes, however, it is more effective

to use the pressure point of the upper thigh, as shown in

figure 4-27J. If you use this point, apply pressure with

4-32

Figure 4-27.—Pressure points.
the closed fist of one hand and use the other hand to

give additional pressure. The artery at this point is

deeply buried in some of the heaviest muscle tissue in

the body, so a great deal of pressure must be exerted to

compress the artery against the bone.

Bleeding between the knee and the foot may be

controlled by firm pressure at the knee. If pressure at

the side of the knee does not stop the bleeding, hold the

front of the knee with one hand and thrust your fist hard

against the artery behind the knee, as shown in figure

4-27K. If necessary, you can place a folded compress

or bandage behind the knee, bend the leg back, and

hold it in place by a firm bandage. This is a most

effective way of controlling bleeding, but it is so

uncomfortable for the victim that it should be used

only as a last resort.

You should memorize these pressure points so that

you will know immediately which point to use for

controlling hemorrhage from a particular part of the

body. Remember, the correct pressure point is that

which is (1) nearest the wound, and (2) between the

wound and the main part of the body.

It is very tiring to apply digital pressure, and it can

seldom be maintained for more than 15 minutes.

Pressure points are recommended for use while direct

pressure is being applied to a serious wound by a

second rescuer. Using the pressure-point technique is

also advised after a compress, bandage, or dressing has

been applied to the wound, since this method will slow

the flow of blood to the area, thus giving the direct

pressure technique a better chance to stop the

hemorrhage. The pressure-point system is also

recommended as a stopgap measure until a pressure

dressing or a tourniquet can be applied.

Elevation

The elevation of an extremity, where appropriate,

can be an effective aid in hemorrhage control when

used in conjunction with other methods of control,

especially direct pressure. This is because the amount

of blood entering the extremity is decreased by the

uphill gravitational effect. Do not elevate an extremity

until it is certain that no bones have been broken or

until broken bones are properly splinted.

Splints

Another effective method of hemorrhage control

in cases of bone fractures is splinting. The

immobilization of sharp bone ends reduces further

tissue trauma and allows lacerated blood vessels to

clot. In addition, the gentle pressure exerted by the

splint helps the clotting process by giving additional

support to compresses or dressings already in place

over open fracture sites.

Later in this chapter we will go into the subject of

splinting in greater detail.

Tourniquets

A tourniquet is a constricting band that is used

to cut off the supply of blood to an injured limb.

Use a tourniquet only as a last resort and if the

control of hemorrhage by other means proves to be

difficult or impossible. A tourniquet must always

be applied above the wound (i.e., toward the trunk),

and it must be applied as close to the wound as

practical.

Basically, a tourniquet consists of a pad, a band,

and a device for tightening the band so that the blood

vessels will be compressed. It is best to use a pad,

compress, or similar pressure object, if one is

available. The pressure object goes under the band and

must be placed directly over the artery or it will

actually decrease the pressure on the artery, allowing a

greater flow of blood. If a tourniquet placed over a

pressure object does not stop the bleeding, there is a

good chance that the pressure object is in the wrong

place. If placement is not effective, shift the object

around until the tourniquet, when tightened, will

control the bleeding.

Any long flat material may be used as the band. It

is important that the band be flat: belts, stockings, flat

strips of rubber, or neckerchiefs may be used; however,

rope, wire, string, or very narrow pieces of cloth should

not be used because they can cut into the flesh. A short

stick may be used to twist the band, tightening the

tourniquet. Figure 4-28 shows the proper steps in

applying a tourniquet.

To be effective, a tourniquet must be tight

enough to stop the arterial blood flow to the limb. Be

sure, therefore, to draw the tourniquet tight enough

to stop the bleeding. Do not make it any tighter than

necessary, though, since a tourniquet that is too tight

can lead to loss of the limb the tourniquet is applied

to.

After you have brought the bleeding under control

with the tourniquet, apply a sterile compress or

dressing to the wound and fasten it in position with a

bandage.

4-33
Here are the points to remember about using a

tourniquet:

1. Use a tourniquet only as a last resort! Don’t

use a tourniquet unless you can’t control the

bleeding by any other means.

2. Don’t use a tourniquet for bleeding from the

head, face, neck, or trunk. Use it only on the

limbs.

3. Always apply a tourniquet above the wound

and as close to the wound as possible. As a

general rule, do not place a tourniquet below the

knee or elbow except for complete amputations.

In certain distal areas of the extremities, nerves

lie close to the skin and may be damaged by the

compression. Furthermore, rarely does one

encounter bleeding distal to the knee or elbow

that requires a tourniquet.

4. Be sure you draw the tourniquet tight enough to

stop the bleeding, but don’t make it any tighter

than necessary. The pulse beyond the tourniquet

should disappear.

5. Don’t loosen a tourniquet after it has been

applied. Transport the victim to a medical

facility that can offer proper care.

6. Don’t cover a tourniquet with a dressing. If it is

necessary to cover the injured person in some

way, make sure that all the other people

concerned with the case know about the

tourniquet. Using crayon, skin pencil, or blood,

mark a large “T” and the time the tourniquet was

applied on the victim’s forehead or on a medical

tag attached to the wrist.

MANAGEMENT OF INTERNAL

SOFT-TISSUE INJURIES

Internal soft-tissue injuries may result from deep

wounds, blunt trauma, blast exposure, crushing

accidents, bone fracture, poison, or sickness. They

may range in seriousness from a simple contusion to

life-threatening hemorrhage and shock.

Visible Indications

Visible indications of internal soft-tissue injury

include the following:

• Hematemesis (vomiting bright red blood)

• Hemoptysis (coughing up bright red blood)

• Melena (excretion of tarry black stools)

• Hematochezia (excretion of bright red blood

from the rectum)

• Hematuria (passing of blood in the urine)

• Nonmenstrual (vaginal bleeding)

• Epistaxis (nosebleed)

• Pooling of the blood near the skin surface

Other Symptoms

More often than not, however, there will be no

visible signs of injury, and the Corpsman will have to

infer the probability of internal soft-tissue injury from

other symptoms such as the following:

• Pale, moist, clammy skin

• Subnormal temperature

• Rapid, feeble pulse

• Falling blood pressure

• Dilated, slowly reacting pupils with impaired

vision

• Tinnitus

• Syncope

• Dehydration and thirst

• Yawning and air hunger

• Anxiety, with a feeling of impending doom

4-34

Figure 4-28.—Applying a tourniquet.
Immediate Treatment

There is little that a Corpsman can do to correct

internal soft-tissue injuries since they are almost

always surgical problems. The Hospital Corpsman’s

goal must be to obtain the greatest benefit from the

victim’s remaining blood supply. The following steps

should be taken:

1. Treat for shock.

2. Keep the victim warm and at rest.

3. Replace lost fluids with a suitable blood volume

expander. DO NOT give the victim anything to

drink until the extent of the injury is known for

certain.

4. Give oxygen, if available.

5. Splint injured extremities.

6. Apply cold compresses to identifiable injured

areas.

7. Transport the victim to a medical treatment

facility as soon as possible.

SPECIAL CONSIDERATIONS IN

WOUND TREATMENT

There are special considerations that should be

observed when treating wounds. The first of these is

immediate treatment to prevent shock. Next, infection

should be a concern: Look for inflammation and signs

of abscess. Hospital Corpsmen should be aware of

these conditions and have the knowledge to treat them.

Shock

Shock is likely to be severe in a person who has lost

a large amount of blood or suffered any serious wound.

The causes and treatment of shock are explained

earlier in this chapter.

Infection

Although infection may occur in any wound, it is a

particular danger in wounds that do not bleed freely, in

wounds in which torn tissue or skin falls back into

place and prevents the entrance of air, and in wounds

that involve the crushing of tissues. Incisions (in

which there is a free flow of blood and relatively little

crushing of tissues) are the least likely to become

infected.

Battle wounds are especially likely to become

infected. They present the problem of devitalized

(dead or dying) tissue; extravasated blood (blood that

has escaped its natural boundaries); foreign bodies

such as missile fragments, bits of cloth, dirt, dust; and a

variety of bacteria. The devitalized tissue proteins and

extravasated blood provide a nutritional medium for

the support of bacterial growth and thus are conducive

to the development of serious wound infection.

Puncture wounds are also likely to become infected by

the germs causing tetanus.

COMMON INFECTION-CAUSING BACTERIA.—

There are two types of bacteria that commonly cause

infection in wounds: aerobic and anaerobic. Aerobic

bacteria live and multiply in the presence of air or free

oxygen, while anerobic bacteria live and multiply only

in the absence of air.

Aerobic Bacteria.—The principal aerobic

bacteria that cause infection, inflammation, and

septicemia (blood poisoning) are streptococci and

staphylococci, some varieties of which are hemolytic

(destroy red blood cells). The staphylococci and

streptococci may be introduced at the time of

infliction, or they may be introduced to the wound later

(at the time of first aid treatment or in the hospital if

nonsterile instruments or dressings are employed).

Anaerobic Bacteria.—Anaerobic bacteria are

widespread in soil (especially manured soil). While

not invasive, anaerobic bacteria contribute to disease

by producing toxins and destructive enzymes, often

leading to necrosis and/or gangrene of the infected

area.

MINOR WOUND CLEANING AND

DRESSING.—Wash minor wounds immediately with

soap and clean water; then dry and paint them with a

mild, nonirritating antiseptic. Apply a dressing if

necessary. In the first aid environment, do not attempt

to wash or clean a large wound, and do not apply an

antiseptic to it since it must be cleaned thoroughly at a

medical treatment facility. Simply protect it with a

large compress or dressing, and transport the victim to

a medical treatment facility. After an initial soap and

water cleanup, puncture wounds must also be directed

to a medical treatment facility for evaluation.

Inflammation

Inflammation is a local reaction to irritation. It

occurs in tissues that are injured, but not destroyed.

Symptoms include redness, pain, heat, swelling, and

sometimes loss of motion.

4-35
The body’s physiologic response to the irritation is

to dilate local blood vessels, which increases the blood

supply to the area. The increased blood flow, in turn,

causes the skin to appear red and warmer. As the blood

vessels dilate, their injured walls leak blood serum into

surrounding tissues, causing edema and pain from

increased pressure on nerve endings. In addition,

white blood cells increase in the area and act as

scavengers (phagocytes) in destroying bacteria and

ingesting small particles of dead tissue and foreign

matter.

Inflammation may be caused by trauma or

mechanical irritation; chemical reaction to venom,

poison ivy, acids, or alkalies; heat or cold injuries;

microorganism penetration; or other agents such as

electricity or solar radiation.

Inflammation should be treated by the following

methods:

• Remove the irritating cause.

• Keep the inflamed area at rest and elevated.

• Apply cold for 24 to 48 hours to reduce swelling.

Once swelling is reduced, apply heat to soft

tissues, which hastens the removal of products

of inflammation.

• Apply wet dressings and ointments to soften

tissues and to rid the area of the specific causal

bacteria.

Abscesses

An abscess is a localized collection of pus that

forms in cavities created by the disintegration of tissue.

Abscesses may follow injury, illness, or irritation.

Most abscesses are caused by staphylococcal

infections and may occur in any area of the body, but

they are usually on the skin surface.

A furuncle (boil) is an abscess in the true skin

caused by the entry of microorganisms through a hair

follicle or sweat gland. A carbuncle is a group of

furuncular abscesses having multiple sloughs, often

interconnected under the true skin. When localized,

there are several “heads.” Symptoms begin with

localized itching and inflammation, followed by

swelling, fever, and pain. Redness and swelling

localize, and the furuncle or carbuncle becomes hard

and painful. Pus forms into a cavity, causing the skin to

become taut and discolored.

Treatment for furuncles and carbuncles includes

the following:

• DO NOT squeeze! Squeezing may damage

surrounding healthy tissue and spread the

infection.

• Use aseptic techniques when handling.

• Relieve pain with aspirin.

• Apply moist hot soaks/dressings (110°F) for 40

minutes, three to four times per day.

• Rest and elevate the infected body part.

• Antibiotic therapy may be ordered by a

physician.

• Abscesses should be incised after they have

localized (except on the face) to establish

drainage. Abscesses in the facial triangle (nose

and upper lip) should be seen by a physician.

SPECIAL WOUNDS AND THEIR

TREATMENT

LEARNING OBJECTIVE: Recall

medical precautions and wound-treatment

procedures for the following list of wounds:

animal bites, eye wounds, head wounds,

facial wounds, abdominal wounds, crushing

injuries, and the removal of foreign objects.

As a Hospital Corpsman, you should find most

general wounds very easy to diagnose and treat. There

are other wounds, however, that require special

consideration and treatment. They are discussed

below.

Eye Wounds

Many eye wounds contain foreign objects. Dirt,

coal, cinders, eyelashes, bits of metal, and a variety of

other objects may become lodged in the eye. Since

even a small piece of dirt is intensely irritating to the

eye, the removal of such objects is important.

However, the eye is easily damaged. Impairment of

vision (or even total loss of vision) can result from

fumbling, inexpert attempts to remove foreign objects

from the eye. The following precautions must be

observed:

• DO NOT allow the victim to rub the eye.

4-36
• DO NOT press against the eye or manipulate it

in any way that might cause the object to become

embedded in the tissues of the eye. Be very

gentle; roughness is almost sure to cause injury

to the eye.

• DO NOT use such things as knives, toothpicks,

matchsticks, or wires to remove the object.

• DO NOT UNDER ANY CIRCUMSTANCES

ATTEMPT TO REMOVE AN OBJECT

THAT IS EMBEDDED IN THE EYEBALL

OR THAT HAS PENETRATED THE EYE!

If you see a splinter or other object sticking out

from the eyeball, leave it alone! Only specially

trained medical personnel can hope to save the

victim’s sight if an object has actually penetrated

the eyeball.

Small objects that are lodged on the surface of the

eye or on the membrane lining the eyelids can usually

be removed by the following procedures:

1. Try to wash the eye gently with lukewarm,

sterile water. A sterile medicine dropper or a

sterile syringe can be used for this purpose.

Have the victim lie down, with the head turned

slightly to one side as shown in figure 4-29.

Hold the eyelids apart. Direct the flow of water

to the inside corner of the eye, and let it run

down to the outside corner. Do not let the water

fall directly onto the eyeball.

2. Gently pull the lower lid down, and instruct the

victim to look up. If you can see the object, try to

remove it with the corner of a clean

handkerchief or with a small moist cotton swab.

You can make the swab by twisting cotton

around a wooden applicator, not too tightly, and

moistening it with sterile water.

CAUTION: Never use dry cotton anywhere

near the eye. It will stick to the eyeball or to the

inside of the lids, and you will have the problem

of removing it as well as the original object.

3. If you cannot see the object when the lower lid is

pulled down, turn the upper lid back over a

smooth wooden applicator. Tell the victim to

look down. Place the applicator lengthwise

across the center of the upper lid. Grasp the

lashes of the upper lid gently but firmly. Press

gently with the applicator. Pull up on the

eyelashes, turning the lid back over the

applicator. If you can see the object, try to

remove it with a moist cotton swab or with the

corner of a clean handkerchief.

4. If the foreign object cannot be removed by any

of the above methods, DO NOT MAKE ANY

FURTHER ATTEMPTS TO REMOVE IT.

Instead, place a small, thick gauze dressing over

both eyes and hold it in place with a loose

bandage. This limits movement of the injured

eye.

5. Get medical help for the victim at the earliest

opportunity.

Head Wounds

Head wounds must be treated with particular care,

since there is always the possibility of brain damage.

The general treatment for head wounds is the same as

that for other fresh wounds. However, certain special

precautions must be observed if you are giving first aid

to a person who has suffered a head wound.

• NEVER GIVE ANY MEDICATIONS.

• Keep the victim lying flat, with the head at the

level of the body. Do not raise the feet if the face

is flushed. If the victim is having trouble

breathing, you may raise the head slightly.

• If the wound is at the back of the head, turn the

victim on his side.

• Watch closely for vomiting and position the head

to avoid aspiration of vomitus or saliva into the

lungs.

4-37

Figure 4-29.—Irrigating the eye.
• Do not use direct pressure to control hemorrhage

if the skull is depressed or obviously fractured.

Facial Wounds

Wounds of the face are treated, in general, like

other fresh wounds. However, in all facial injuries

make sure neither the tongue nor injured soft tissue

blocks the airway, causing breathing obstruction.

Keep the nose and throat clear of any obstructing

materials, and position the victim so that blood will

drain out of the mouth and nose.

Facial wounds that involve the eyelids or the

soft tissue around the eye must be handled carefully

to avoid further damage. If the injury does not

involve the eyeball, apply a sterile compress and

hold it in place with a firm bandage. If the eyeball

appears to be injured, use a loose bandage.

(Remember that you must NEVER attempt to

remove any object that is embedded in the eyeball

or that has penetrated it; just apply a dry, sterile

compress to cover both eyes, and hold the compress

in place with a loose bandage).

Any person who has suffered a facial wound that

involves the eye, the eyelids, or the tissues around the

eye must receive medical attention as soon as possible.

Be sure to keep the victim lying down. Use a stretcher

for transport.

Chest Wounds

Since chest injuries may cause severe breathing

and bleeding problems, all chest injuries must be

considered as serious conditions. Any victim showing

signs of difficulty in breathing without signs of airway

obstruction must be inspected for chest injuries. The

most serious chest injury that requires immediate first

aid treatment is the sucking chest wound. This is a

penetrating injury to the chest that produces a hole in

the chest cavity. The chest hole causes the lung to

collapse, preventing normal breathing functions. This

is an extremely serious condition that will result in

death if not treated quickly.

Victims with open chest wounds gasp for breath,

have difficulty breathing out, and may have a bluish

skin color to their face. Frothy-looking blood may

bubble from the wound during breathing.

The proper treatment for a sucking chest wound is

as follows:

1. Immediately seal the wound with a hand or any

airtight material available (e.g., ID card). The

material must be large enough so that it cannot

be sucked into the wound when the victim

breathes in.

2. Firmly tape the material in place with strips of

adhesive tape and secure it with a pressure

dressing. It is important that the dressing is

airtight. If it is not, it will not relieve the victim’s

breathing problems. The object of the dressing

is to keep air from going in through the wound.

NOTE: If the victim’s condition

suddenly deteriorates when you apply

the seal, remove it immediately.

3. Give the victim oxygen if it is available and you

know how to use it.

4. Place the victim in a Fowler’s or semi-Fowler’s

position. This makes breathing a little easier.

During combat, lay the victim on a stretcher on

the affected side.

5. Watch the victim closely for signs of shock, and

treat accordingly.

6. Do not give victims with chest injuries anything

to drink.

7. Transport the victim to a medical treatment

facility immediately.

Abdominal Wounds

A deep wound in the abdomen is likely to

constitute a major emergency since there are many

vital organs in this area. Abdominal wounds usually

cause intense pain, nausea and vomiting, spasm of the

abdominal muscles, and severe shock. Immediate

surgical treatment is almost always required;

therefore, the victim must receive medical attention at

once, or the chances of survival will be poor. Give only

the most essential first aid treatment, and concentrate

your efforts on getting the victim to a medical

treatment facility. The following first aid procedures

may be of help to a person suffering from an abdominal

wound:

• Keep the victim in a supine position. If the

intestine is protruding or exposed, the victim

may be more comfortable with the knees drawn

up. Place a coat, pillow, or some other bulky

cloth material under the knees to help maintain

this position. DO NOT ATTEMPT TO PUSH

THE INTESTINES BACK IN OR TO

MANIPULATE THEM IN ANY WAY!

4-38
• If bleeding is severe, try to stop it by applying

direct pressure.

• If the intestines are not exposed, cover the

wound with a dry sterile dressing. If the

intestines are exposed, apply a sterile compress

moistened with sterile water. If no sterile water

is available, clean sea water or any water that is

fit to drink may be used to moisten the compress.

Figure 4-30 shows an abdominal wound with the

intestine protruding. Figure 4-31 shows the

application of compresses large enough to cover

the wound and the surrounding area. The

compress should be held in place by a bandage.

Fasten the bandage firmly so that the compress

will not slip around, but do not apply any more

pressure than is necessary to hold the compress

in position. Large battle dressings are ideal.

• Treat for shock, but do not waste any time doing

it. The victim must be transported to a hospital at

the earliest possible opportunity. However, you

can minimize the severity of shock by making

sure that the victim is comfortably warm and

kept in the supine position. DO NOT GIVE

ANYTHING TO DRINK. If the victim is

4-39

Figure 4-31.—Applying compresses to a protruding abdominal wound.

Figure 4-30.—Protruding abdominal wounds.
thirsty, moisten the mouth with a small amount

of water, but do not allow any liquid to be

swallowed.

• Upon the direction of a medical officer, start an

intravenous line.

Crush Injuries

Force can be transmitted from the body's exterior

to its interior structure, leaving the skin intact, with a

simple bruise as the only external evidence of trauma.

This force can cause internal organs to be crushed or to

rupture and bleed. When this happens, it is called a

crush injury. Organs such as the liver and spleen

contain a lot of blood. When crushed, these organs

bleed severely, and this severe internal bleeding can

cause shock. Contents of hollow organs (e.g., urine or

digested food) can leak into the body cavities, causing

severe inflammation and tissue damage. Bones can

also be broken along with muscles, and nerves

damaged. Assessment and treatment for the Hospital

Corpsman can be difficult when a crush injury is

involved. Treat symptomatically and evacuate to the

nearest medical treatment facility as soon as possible.

Removing Foreign Objects

Many wounds contain foreign objects. Wood or

glass splinters, bullets, metal fragments, bits of wire,

fishhooks, nails, tacks, cinders, and small particles

from grinding wheels are examples of the variety of

objects or materials that are sometimes found in

wounds. When such objects are near the surface and

exposed, first aid treatment includes their removal.

However, first aid treatment does not include the

removal of deeply embedded objects, powdered glass,

or any widely scattered material of this nature. You

should never attempt to remove bullets, but you should

try to find out whether the bullet remains in the victim.

Look for both entrance and exit wounds. The general

rule to remember is this: Remove foreign objects from

a wound when you can do so easily and without

causing further damage; but NEVER HUNT FOR OR

ATTEMPT TO REMOVE DEEPLY BURIED OR

WIDELY SCATTERED OBJECTS OR

MATERIALS, except in a definitive care environment.

The following procedure may be used to remove a

small object from the skin or tissues if the object is near

the surface and clearly visible:

1. Cleanse the skin around the object with soap and

water and paint with any available skin

antiseptic solution.

2. If necessary, pierce the skin with a sharp

instrument (a needle, razor, or sharp knife that

has been sterilized by passing it through a flame

several times).

3. Grasping the object at the end, remove it.

Tweezers, small pincers, or forceps may be used

for this purpose. (Whatever instrument you use

should first be sterilized by boiling if at all

possible.)

4. If the wound is superficial, apply gentle pressure

to encourage bleeding.

5. Cover the wound with a dry, sterile dressing.

If the foreign object is under a fingernail or toenail,

you may have to cut a V-shaped notch in the nail so that

the object can be grasped by the forceps. Do not try to

dig the object out from under the nail with a knife or

similar instrument.

Acurved or barbed object (such as a fishhook) may

present special problems. Figure 4-32 shows one

method of removing a fishhook that has become

embedded in the flesh. As you can see from figure

4-32A, the barb on the hook prevents its direct

removal. However, if you push the hook forward

through the skin, as shown in figure 4-32B, you can

clip off the barb with a wire cutter or similar tool, as

shown in figure 4-32. The remainder of the fishhook

4-40

Figure 4-32.—Removing a fishhook.
can then be withdrawn in the manner indicated in

figure 4-32D.

Animal Bites

A special kind of infection that must be guarded

against in case of animal bites is rabies (sometimes

called “hydrophobia”). This disease is caused by a

virus that is present in the saliva of infected animals.

The disease occurs most commonly in wild animals,

but it has been found in domestic animals and

household pets. In fact, it is probable that all mammals

are susceptible to it. The virus that causes rabies is

ordinarily transmitted by a bite, but it can be

transmitted by the saliva of an infected animal coming

in contact with a fresh wound or with the thin mucous

membrane of the lips or nose. The virus does not

penetrate normal unbroken skin. If the skin is broken,

DO NOT attempt wound closure.

If rabies develops in man, it is usually fatal. A

preventive treatment is available and it is very

effective, but only if it is started shortly after the bite.

This treatment is outlined in BUMEDINST 6220.6.

Since the vaccine can be obtained only at a medical

treatment facility or a major ship, any person bitten by

an animal must be transferred quickly to the nearest

treatment facility for evaluation, along with a complete

report of the circumstances surrounding the incident.

Remember, prevention is of utmost importance.

Immediate local treatment of the wound should be

given. Wash the wound and the surrounding area

carefully, using sterile gauze, soap, and sterile water.

Use sterile gauze to dry the wound, and then cover the

wound with a sterile dressing. DO NOT use any

chemical disinfectant. Do not attempt to cauterize the

wound in any way.

All of the animal’s saliva must be removed from

the victim’s skin to prevent further contamination of

the wound.

CAUTION: DO NOT allow the animal’s

saliva to come in contact with open sores or

cuts on your hands.

When a person has been bitten by an animal, every

effort must be made to catch the animal and to keep it

confined for a minimum of 8 to 10 days. DO NOT kill

it if there is any possible chance of catching it alive.

The symptoms of rabies are not always present in the

animal at the time the bite occurs, but the saliva may

nevertheless contain the rabies virus. It is essential,

therefore, that the animal is kept under observation

until a diagnosis can be made. The rabies treatment is

given if the animal develops any definite symptoms, if

it dies during the observation period, or if for any

reason the animal cannot be kept under observation.

Remember that any animal bite is dangerous and

MUST be evaluated at a treatment facility.

WOUND CLOSURE

LEARNING OBJECTIVE: Recognize the

different types of suture material and their

uses; recall topical, local infiltration and

nerve-block anesthetic administration

procedures; and identify the steps in wound

suturing and suture removal.

The care of the wound is largely controlled by the

tactical situation, facilities available, and the length of

time before proper medical care may be available.

Normally, the advice to the Corpsman regarding the

suturing of wounds is DO NOT ATTEMPT IT.

However, if days are expected to elapse before the patient

can be seen by a surgeon, the Corpsman should know

how to use the various suture procedures and materials,

and how to select the most appropriate of both.

Before discussing the methods of coaptation

(bringing together), some of the contraindications to

wound closing should be described.

• If there is reddening and edema of the wound

margins, infection manifested by the discharge

of pus, and persistent fever or toxemia, DO NOT

CLOSE THE WOUND. If these signs are

minimal, the wound should be allowed to “clean

up.” The process may be hastened by warm,

moist dressings, and irrigations with sterile

saline. These aid in the liquefaction of necrotic

wound materials and the removal of thick

exudates and dead tissues.

• If the wound is a puncture wound, a large gaping

wound of the soft tissue, or an animal bite, leave

it unsutured. Even under the care of a surgeon, it

is the rule notto close wounds of this nature until

after the fourth day. This is called “delayed

primary closure” and is performed upon the

indication of a healthy appearance of the wound.

Healthy muscle tissue that is viable is evident by

its color, consistency, blood supply, and

contractibility. Muscle that is dead or dying is

comparatively dark and mushy; it does not

4-41
contract when pinched, nor does it bleed when

cut. If this type of tissue is evident, do not close

the wound.

• If the wound is deep, consider the support of the

surrounding tissue; if there is not enough support

to bring the deep fascia together, do not suture

because dead (hollow) spaces will be created. In

this generally gaping type of wound, muscles,

tendons, and nerves are usually involved. Only a

surgeon should attempt to close this type of

wound.

NOTE: To a certain extent, firm pressure

dressings and immobilization can obliterate

hollow spaces. If tendons and nerves do not

seem to be involved, absorbable sutures may

be placed in the muscle. Be careful to suture

muscle fibers end-to-end and to correctly

appose them. Close the wound in layers. This

is extremely delicate surgery, and the

Corpsman should weigh carefully the

advisability of attempting it–and then only if

he has observed and assisted in numerous

surgical operations.

If the wound is small, clean, and free from foreign

bodies and signs of infection, steps should be taken to

close it. All instruments should be checked, cleaned,

and thoroughly sterilized. Use a good light and

position the patient on the table so that access to the

wound will be unhampered.

The area around the wound should be cleansed and

then prepared with an antiseptic. The wound area

should be draped, whenever possible, to maintain a

sterile field in which the Corpsman will work. The

Corpsman should wear a cap and mask, scrub his hands

and forearms, and wear sterile gloves.

Suture Materials

In modern surgery, many kinds of ligature and

suture materials are used. All can be grouped into two

classes: nonabsorbable sutures and absorbable

sutures.

NONABSORBABLE SUTURES.—These are

sutures that cannot be absorbed by the body cells and

fluids in which they are embedded during the healing

process. When used as buried sutures, these sutures

become surrounded or encapsulated in fibrous tissue

and remain as innocuous foreign bodies. When used as

skin sutures, they are removed after the skin has

healed. The most commonly used sutures of this type

and the characteristics associated with each are listed

below.

• Silkfrequently reacts with tissue and can be

“spit” from the wound.

• Cotton3⁄4loses tensile strength with each

autoclaving.

• Linen3⁄4is better than silk or cotton but is more

expensive and not as readily available.

• Synthetic materials (e.g., nylon, dermalon)

are excellent, particularly for surface use. They

cause very little tissue reaction. Their only

problem seems to be the tendency for the knots to

come untied. (Because of this tendency, most

surgeons tie 3 to 4 square knots in each such

suture.) Nylon is preferred over silk for face and

lip areas because silk too often causes tissue

reactions.

• Rust-proof metal (usually stainless steel wire)

has the least tissue reaction of all suture

materials and is by far the strongest. The primary

problems associated with it are that it is more

difficult to use because it kinks and that it must

be cut with wire cutters.

ABSORBABLE SUTURES.—These are sutures

that are absorbed or digested during and after the

healing processes by the body cells and tissue fluids in

which they are embedded. It is this characteristic that

enhances their use beneath the skin surfaces and on

mucous membranes.

Surgical gut fulfills the requirements for the

perfect sutureease of manufacture, tensile strength,

and variety availablemore often than any other

material.

• Manufacture of catgut: Though it is referred to

as “catgut,” surgical gut is derived from the

submucosal connective tissue of the first

one-third (about 8 yards) of the small intestine of

healthy government-inspected sheep. The

intestine of the sheep has certain characteristics

that make it especially adaptable for surgical use.

Among these characteristics is its uniformly

fine-grained tissue structure and its great tensile

strength and elasticity.

• Tensile strength of catgut: This suture material

is available in sizes of 6-0 to 0 and 1 to 4, with 6-0

being the smallest diameter and 4 being the

largest. The tensile strength increases with the

diameter of the suture.

4-42
• Varieties of catgut: Surgical gut varies from

plain catgut (the raw gut that has been gauzed,

polished, sterilized, and packaged) to chromic

catgut (that has undergone various intensities of

tanning with one of the salts of chromic acid to

delay tissue absorption time). Some examples of

these variations and their absorption times

follow in table 4−3.

Suture Needles

Suture needles may be straight or curved, and they

may have either a tapered round point or a cutting edge

point. They vary in length, curvature, and diameter for

various types of suturing. Specific characteristics of

suture needles are listed below.

• Size: Suture needles are sized by diameter and

are available in many sizes.

• Taper point: Most often used in deep tissues,

this type needle causes minimal amounts of

tissue damage.

• Cutting edge point: This type needle is

preferred for suturing the skin because of the

needle's ability to penetrate the skin's toughness.

• Atraumatic (atraloc, wedged): These needles

may either have a cutting edge or a taper point.

Additionally, the suture may be fixed on the end

of the needle by the manufacturer to cause the

least tissue trauma.

Preparation of Casualty

Before suturing the wound(s) of any victim, the

following steps should be taken to prepare the casualty.

1. Examine the casualty carefully to determine

what materials are needed to properly close the

wound.

a. Select and prepare sterile instruments,

needles, and suture materials.

b. Position the patient securely so that access

to the wound and suture tray is optimal. It is

usually not necessary to restrain patients for

suturing.

c. Make sure a good light is available.

2. Strictly observe aseptic wound preparation. Use

mask, cap, and gloves. Thorough cleaning and

proper draping are essential.

3. Select an anesthetic with care. Consider the

patient’s tolerance to pain, time of injury,

medications the patient is taking or has been

given, and the possible distortion of the tissue

when the anesthetic are infiltrated.

SELECTION OF ANESTHESIA.—The most

common local anesthetic used is Xylocaine, which

comes in various strengths (0.5%, 1%, 2%) and with or

without epinephrine. Injectables containing

epinephrine must never be used on the fingers, toes,

ears, nose–any appendage with small vessels–because

of the vasoconstricting effect of the epinephrine.

Epinephrine is also contraindicated in patients with

hypertension, diabetes, or heart disease.

The three methods of anesthestia administration

are topical, local infiltration, and nerve block. Topical

anesthetics are generally reserved for ophthalmic or

plastic surgery, and nerve blocks are generally

accomplished by an anesthesiologist or anesthetist for

the surgical patient. For a Corpsman, topical

anesthesia is limited to the instillation of eye drops for

mild corneal abrasions after all foreign bodies have

been removed. DO NOTattempt to remove embedded

foreign bodies. Nerve blocks are limited to digital

blocks wherein the nerve trunks that enervate the

fingers or toes are anesthetized. The most common

method of anesthesia used by a Corpsman is the

infiltration of the anesthetizing agent around a wound

or minor surgical site.

ADMINISTRATION OF ANESTHESIA.—

Performing a digital block is a fairly simple procedure,

but it should not be attempted except under the

supervision of a medical officer or after a great deal of

practice. The first step is cleansing the injection site

with an antiseptic solution. The anesthetizing agent is

then infiltrated into the lateral and medial aspects at the

base of the digit with a small bore needle (25- or

26-gauge), taking care not to inject into the veins or

arteries. Proper placement of the anesthesia should

result in a loss of sensitivity in a few minutes. This is

tested by asking the patient if he can distinguish a sharp

4-43

Type Gut Absorption Time

A: Plain 10 days

B: Mild chromic 20 days

C: Medium chromic 30 days

D: Extra chromic 40 days

Table 4-3.—Absorption Times of Various Types of Surgical

Gut
sensation or pain when a sharp object is gently applied

to the skin.

Administering local anesthesia is similar except

you are anesthetizing nerves immediately adjacent to

where you will be working instead of nerve trunks.

There are two generally accepted methods of

infiltrating the anesthesia. One is through the skin

surrounding the margin of the wound and the other is

through the wound into the surrounding tissue. In

either case, sufficient quantities must be infiltrated to

effect anesthesia approximately 1⁄2 inch around the

wound, taking care not to inject into a vein or artery.

CAUTION: The maximum recommended

amount of Xylocaine to be used is 50 cc for a

1% solution or the equivalent.

General Principles of Wound Suturing

Wounds are closed either primarily or secondarily.

A primary closure takes place within a short time of

when the wound occurs, and it requires minimal

cleaning and preparation. Asecondary closure, on the

other hand, occurs when there is a delay of the closure

for up to several days after the wound's occurrence. A

secondary closure requires a more complex procedure.

Wounds 6 to 14 hours old may be closed primarily if

they are not grossly contaminated and are meticulously

cleaned. Wounds 14 to 24 hours old should not be

closed primarily. When reddening and edema of the

wound margins, discharge of pus, persistent fever, or

toxemia are present, do not close the wound.

Do not use a primary closure for a large, gaping,

soft-tissue wound. This type of wound will require

warm dressings and irrigations, along with aseptic care

for 3 to 7 days to clear up the wound. Then a secondary

wound closure may be performed.

The steps to perform a delayed wound closure are

outlined below.

1. Debride the wound area and convert circular

wounds to elliptical ones before suturing.

Circular wounds cannot be closed with

satisfactory cosmetic results.

2. Try to convert a jagged laceration to one with

smooth edges before suturing it. Make sure that

not too much skin is trimmed off; that would

make the wound difficult to approximate.

3. Use the correct technique for placing sutures.

The needle holder is applied at approximately

one-quarter of the distance from the blunt end of

the needle. Suturing with a curved needle is

done toward the person doing the suturing.

Insert the needle into the skin at a 90° angle, and

sweep it through in an arclike motion, following

the general arc of the needle.

4. Carefully avoid bruising the skin edges being

sutured. Use Adson forceps and very lightly

grasp the skin edges. It is improper to use

dressing forceps while suturing. Since there are

no teeth on the grasping edges of the dressing

forceps, the force required to hold the skin

firmly may be enough to cause necrosis.

5. Do not put sutures in too tightly. Gentle approximation ofthe skinis allthatis necessary. Remember

that postoperative edema will occur in and about the

wound, making sutures tighter. Figure 4-33

illustrates proper wound-closure techniques.

6. If there is a significant chance that the sutured

wound may become infected (e.g., bites,

delayed closure, gross contamination), place an

iodoform (anti-infective) in the wound. Or

place a small rubber drain in the wound, and

remove the drain in 48 hours.

7. When suturing, the best cosmetic effect is

obtained by using numerous interrupted simple

sutures placed 1/8 inch apart. Where cosmetic

result is not a consideration, sutures may be

slightly farther apart. Generally, the distance of

the needle bite from the wound edges should be

equal to the distance between sutures.

8. When subcutaneous sutures are needed, it is

proper to use 4-0 chromic catgut.

9. When deciding the type of material to use on

skin, use the finest diameter that will satisfactorily hold the tissues. Table 4-4 provides

guidance as to the best suture to use in selected

circumstances.

10. When cutting sutures, subcutaneous catgut

should have a 1/16-inch tail. Silk skin sutures

should be cut as short as is practical for removal on

the face and lip. Elsewhere, skin sutures may have

longer tails for convenience. A tail over 1⁄4 inch is

unnecessary, however, and tends to collect

exudate.

11. The following general rules can be used in

deciding when to remove sutures:

a. Face: As a general rule, 4 or 5 days. Better

cosmetic results are obtained by removing

every other suture and any suture with

4-44
redness around it on the third day and the

remainder on the fifth day.

b. Body and scalp: 7 days.

c. Soles, palms, back, or over joints: 10 days,

unless excess tissue reaction is apparent

around the suture, in which case they should

come out sooner.

d. Any suture with pus or infection around it

should be removed immediately, since the

suture's presence will make the infection

worse.

e. When wire is used, it may be left in safely for

10 to 14 days.

ORTHOPEDIC INJURIES

Many kinds of accidents cause injuries to bones,

joints, or muscles. In giving first aid or emergency

treatment to an injured person, you must always look

for signs of fractures (broken bones), dislocations,

sprains, strains, and contusions.

An essential part of the emergency treatment for

fractures consists of immobilizing the injured part with

splints so that the sharp ends of broken bones will not

move around and cause further damage to nerves,

blood vessels, or vital organs. Splints are also used to

immobilize severely injured joints or muscles and to

prevent the enlargement of extensive wounds. You

must have a general understanding of the use of splints

before going on to learn the detailed first aid treatment

for injuries to bones, joints, and muscles.

SPLINTS

LEARNING OBJECTIVE: Recognize the

different types of splints that are available,

and determine how and when they should be

used.

In an emergency, almost any firm object or

material will serve as a splint. Thus, umbrellas, canes,

rifles, tent pegs, sticks, oars, wire mesh, boards,

corrugated cardboard, and folded newspapers can be

used as splints. A fractured leg may sometimes be

splinted by fastening it securely to the uninjured leg.

Whenever available, use manufactured splints such as

pneumatic splints or traction splints.

Requirements

Splints, whether manufactured or improvised,

must fulfill certain requirements. They should be

lightweight, strong, fairly rigid, and long enough to

reach past the joints above and below the fracture.

They should be wide enough so that the bandages used

to hold them in place will not pinch the injured part.

Splints must be well padded on the sides touching the

body; if they are not properly padded, they will not fit

well and will not adequately immobilize the injured

part. If you have to improvise the padding for a splint,

you may use clothing, bandages, cotton, blankets, or

any other soft material. If the victim is wearing heavy

clothes, you may be able to apply the splint on the

outside, allowing the clothing to serve as at least part of

the required padding. Fasten splints in place with

4-45

Wound Suture Material/Size

Children under 3 years 6-0

All other faces 5-0

Body 4-0

Feet, elbows, knees #34 or #36 wire, or 4-0

Child’s scalp 4-0

Adult’s scalp 3-0

Lip 6-0 or 5-0

Table 4-4.—Suture Guide

Figure 4-33.—Suturing.
bandages, strips of adhesive tape, clothing, or other

suitable materials. If possible, one person should hold

the splints in position while another person fastens

them.

Application

Although splints should be applied snugly, they

should never be tight enough to interfere with the

circulation of the blood. When you are applying

splints to an arm or a leg, try to leave the fingers or toes

exposed. If the tips of the fingers or toes become blue

or cold, you will know that the splints or bandages are

too tight. You should examine a splinted part

approximately every half hour and loosen the

fastenings if the circulation appears to be impaired.

Remember that any injured part is likely to swell, and

splints or bandages that are otherwise applied correctly

may later become too tight.

MANAGEMENT OF BONE

INJURIES

LEARNING OBJECTIVE: Select the

appropriate stabilization and treatment

procedure for the management of bone

injuries.

A break in a bone is called a fracture. There are

two main kinds of fractures. A closed fracture is one

in which the injury is entirely internal; the bone is

broken but there is no break in the skin. An open

fracture is one in which there is an open wound in the

tissues and the skin. Sometimes the open wound is

made when a sharp end of the broken bone pushes out

through the flesh; sometimes it is made by an object

such as a bullet that penetrates from the outside.

Figure 4-34 shows closed and open fractures.

Open fractures are more serious than closed

fractures. They usually involve extensive damage to

the tissues and are quite likely to become infected.

Closed fractures are sometimes turned into open

fractures by rough or careless handling of the victim.

It is not always easy to recognize a fracture. All

fractures, whether closed or open, are likely to cause

severe pain and shock; but the other symptoms may

vary considerably. A broken bone sometimes causes

the injured part to be deformed or to assume an

unnatural position. Pain, discoloration, and swelling

may be localized at the fracture site, and there may be a

wobbly movement if the bone is broken clear through.

It may be difficult or impossible for the victim to move

the injured part; if able to move it, there may be a

grating sensation (crepitus) as the ends of the broken

bone rub against each other. However, if a bone is

cracked rather than broken through, the victim may be

able to move the injured part without much difficulty.

An open fracture is easy to recognize if an end of the

broken bone protrudes through the flesh. If the bone

does not protrude, however, you might see the external

wound but fail to recognize the broken bone.

General Guidelines

If you are required to give first aid to a person who

has suffered a fracture, you should follow these general

guidelines:

• If there is any possibility that a fracture has been

sustained, treat the injury as a fracture until an

X-ray can be made.

• Get the victim to a definitive care facility at the

first possible opportunity. All fractures require

medical treatment.

• Do not move the victim until the injured part has

been immobilized by splinting (unless the move

is necessary to save life or to prevent further

injury).

4-46

Figure 4-34.—Fractures: A. Closed; B. Open.
• Treat for shock.

• Do not attempt to locate a fracture by grating the

ends of the bone together.

• Do not attempt to set a broken bone unless a

medical officer will not be available for many

days.

• When a long bone in the arm or leg is fractured,

the limb should be carefully straightened so that

splints can be applied, unless it appears that

further damage will be caused by such a

maneuver. Never attempt to straighten the limb

by applying force or traction with any

improvised device. Pulling gently with your

hands along the long axis of the limb is

permissible and may be all that is necessary to

get the limb back into position.

• Apply splints. If the victim is to be transported

only a short distance, or if treatment by a medical

officer will not be delayed, it is probably best to

leave the clothing on and place emergency

splinting over it. However, if the victim must be

transported for some distance, or if a

considerable period of time will elapse before

treatment by a medical officer, it may be better to

remove enough clothing so that you can apply

well padded splints directly to the injured part. If

you decide to remove clothing over the injured

part, cut the clothing or rip it along the seams. In

any case, be careful! Rough handling of the

victim may convert a closed fracture into an

open fracture, increase the severity of shock, or

cause extensive damage to the blood vessels,

nerves, muscles, and other tissues around the

broken bone.

• If the fracture is open, you must take care of the

wound before you can deal with the fracture.

Bleeding from the wound may be profuse, but

most bleeding can be stopped by direct pressure

on the wound. Other supplemental methods of

hemorrhage control are discussed in the section

on wounds of this chapter. Use a tourniquet as a

last resort. After you have stopped the bleeding,

treat the fracture.

Now that we have seen the general rules for

treating fractures, we turn to the symptoms and

emergency treatment of specific fracture sites.

Forearm Fracture

There are two long bones in the forearm, the radius

and the ulna. When both are broken, the arm usually

appears to be deformed. When only one is broken, the

other acts as a splint and the arm retains a more or less

natural appearance. Any fracture of the forearm is

likely to result in pain, tenderness, inability to use the

forearm, and a kind of wobbly motion at the point of

injury. If the fracture is open, a bone will show

through.

If the fracture is open, stop the bleeding and treat

the wound. Apply a sterile dressing over the wound.

Carefully straighten the forearm. (Remember that

rough handling of a closed fracture may turn it into an

open fracture.) Apply a pneumatic splint if available;

if not, apply two well-padded splints to the forearm,

one on the top and one on the bottom. Be sure that the

splints are long enough to extend from the elbow to the

wrist. Use bandages to hold the splints in place. Put

the forearm across the chest. The palm of the hand

should be turned in, with the thumb pointing upward.

Support the forearm in this position by means of a wide

sling and a cravat bandage, as shown in figure 4-35.

The hand should be raised about 4 inches above the

level of the elbow. Treat the victim for shock and

evacuate as soon as possible.

Upper Arm Fracture

The signs of fracture of the upper arm include pain,

tenderness, swelling, and a wobbly motion at the point

4-47

Figure 4-35.—First aid for a fractured forearm.
of fracture. If the fracture is near the elbow, the arm is

likely to be straight with no bend at the elbow.

If the fracture is open, stop the bleeding and treat

the wound before attempting to treat the fracture.

NOTE: Treatment of the fracture depends

partly upon the location of the break.

If the fracture is in the upper part of the arm near

the shoulder, place a pad or folded towel in the armpit,

bandage the arm securely to the body, and support the

forearm in a narrow sling.

If the fracture is in the middle of the upper arm, you

can use one well-padded splint on the outside of the

arm. The splint should extend from the shoulder to the

elbow. Fasten the splinted arm firmly to the body and

support the forearm in a narrow sling, as shown in

figure 4-36.

Another way of treating a fracture in the middle of

the upper arm is to fasten two wide splints (or four

narrow ones) about the arm and then support the

forearm in a narrow sling. If you use a splint between

the arm and the body, be very careful that it does not

extend too far up into the armpit; a splint in this

position can cause a dangerous compression of the

blood vessels and nerves and may be extremely painful

to the victim.

If the fracture is at or near the elbow, the arm may

be either bent or straight. No matter in what position

you find the arm, DO NOT ATTEMPT TO

STRAIGHTEN IT OR MOVE IT IN ANY WAY.

Splint the arm as carefully as possible in the position in

which you find it. This will prevent further nerve and

blood vessel damage. The only exception to this is if

there is no pulse distal to the fracture, in which case

gentle traction is applied and then the arm is splinted.

Treat the victim for shock and get him under the care of

a medical officer as soon as possible.

Thigh Fracture

The femur is the long bone of the upper part of the

leg between the kneecap and the pelvis. When the

femur is fractured through, any attempt to move the

limb results in a spasm of the muscles and causes

excruciating pain. The leg has a wobbly motion, and

there is complete loss of control below the fracture.

The limb usually assumes an unnatural position, with

the toes pointing outward. By actual measurement, the

fractured leg is shorter than the uninjured one because

of contraction of the powerful thigh muscles. Serious

damage to blood vessels and nerves often results from a

fracture of the femur, and shock is likely to be severe.

If the fracture is open, stop the bleeding and treat

the wound before attempting to treat the fracture itself.

Serious bleeding is a special danger in this type of

injury, since the broken bone may tear or cut the large

artery in the thigh.

Carefully straighten the leg. Apply two splints,

one on the outside of the injured leg and one on the

inside. The outside splint should reach from the armpit

to the foot. The inside splint should reach from the

crotch to the foot. The splints should be fastened in five

places: (1) around the ankle; (2) over the knee; (3) just

below the hip; (4) around the pelvis; and (5) just below

the armpit (fig. 4-37). The legs can then be tied

together to support the injured leg as firmly as possible.

It is essential that a fractured thigh be splinted

before the victim is moved. Manufactured splints, such

as the Hare or the Thomas half-ring traction splints, are

best, but improvised splints may be used. Figure 4-37

shows how boards may be used as an emergency splint

for a fractured thigh. Remember, DO NOT MOVE

THE VICTIM UNTIL THE INJURED LEG HAS

BEEN IMMOBILIZED. Treat the victim for shock,

and evacuate at the earliest possible opportunity.

Lower Leg Fracture

When both bones of the lower leg are broken, the

usual signs of fracture are likely to be present. When

only one bone is broken, the other one acts as a splint

and, to some extent, prevents deformity of the leg.

However, tenderness, swelling, and pain at the point of

4-48

Figure 4-36.—Splint and sling for a fractured upper arm.
fracture are almost always present. A fracture just

above the ankle is often mistaken for a sprain. If both

bones of the lower leg are broken, an open fracture is

very likely to result.

If the fracture is open, stop the bleeding and treat

the wound. Carefully straighten the injured leg. Apply

a pneumatic splint if available; if not, apply three

splints, one on each side of the leg and one underneath.

Be sure that the splints are well padded, particularly

under the knee and at the bones on each side of the

ankle.

A pillow and two side splints work very well for

treatment of a fractured lower leg. Place the pillow

beside the injured leg, then carefully lift the leg and

place it in the middle of the pillow. Bring the edges of

the pillow around to the front of the leg and pin them

together. Then place one splint on each side of the leg

(over the pillow), and fasten them in place with strips

of bandage or adhesive tape. Treat the victim for shock

and evacuate as soon as possible. When available, you

may use the Hare or Thomas half-ring traction splints.

Kneecap Fracture

The following first aid treatment should be given

for a fractured kneecap (patella):

Carefully straighten the injured limb. Immobilize

the fracture by placing a padded board under the

injured limb. The board should be at least 4 inches

wide and should reach from the buttock to the heel.

Place extra padding under the knee and just above the

heel, as shown in figure 4-38. Use strips of bandage to

fasten the leg to the board in four places: (1) just below

the knee; (2) just above the knee; (3) at the ankle; and

(4) at the thigh. Do not cover the knee itself. Swelling

is likely to occur very rapidly, and any bandage or tie

fastened over the knee would quickly become too tight.

Treat the victim for shock and evacuate as soon as

possible.

Clavicle Fracture

A person with a fractured clavicle usually shows

definite symptoms. When the victim stands, the

injured shoulder is lower than the uninjured one. The

victim is usually unable to raise the arm above the level

of the shoulder and may attempt to support the injured

shoulder by holding the elbow of that side in the other

hand. This is the characteristic position of a person

with a broken clavicle. Since the clavicle lies

immediately under the skin, you may be able to detect

the point of fracture by the deformity and localized

pain and tenderness.

If the fracture is open, stop the flow of blood and

treat the wound before attempting to treat the fracture.

Then apply a sling and swathe splint as described

below (and illustrated in figure 4-39).

Bend the victim’s arm on the injured side, and

place the forearm across the chest. The palm of the

hand should be turned in, with the thumb pointed up.

The hand should be raised about 4 inches above the

level of the elbow. Support the forearm in this position

by means of a wide sling. A wide roller bandage (or

any wide strip of cloth) may be used to secure the

victim’s arm to the body (see figure 4-35). A

figure-eight bandage may also be used for a fractured

clavicle. Treat the victim for shock and evacuate to a

definitive care facility as soon as possible.

4-49

Figure 4-37.—Splint for a fractured femur.

Figure 4-38.—Immobilization of a fractured patella.
Rib Fracture

If a rib is broken, make the victim comfortable and

quiet so that the greatest dangerthe possibility of

further damage to the lungs, heart, or chest wall by the

broken endsis minimized.

The common finding in all victims with fractured

ribs is pain localized at the site of the fracture. By

asking the patient to point out the exact area of the pain,

you can often determine the location of the injury.

There may or may not be a rib deformity, chest wall

contusion, or laceration of the area. Deep breathing,

coughing, or movement is usually painful. The patient

generally wishes to remain still and may often lean

toward the injured side, with a hand over the fractured

area to immobilize the chest and to ease the pain.

Ordinarily, rib fractures are not bound, strapped,

or taped if the victim is reasonably comfortable.

However, they may be splinted by the use of external

support. If the patient is considerably more

comfortable with the chest immobilized, the best

method is to use a swathe (fig. 4-40) in which the arm

on the injured side is strapped to the chest to limit

motion. Place the arm on the injured side against the

chest, with the palm flat, thumb up, and the forearm

raised to a 45° angle. Immobilize the chest, using wide

strips of bandage to secure the arm to the chest.

Do not use wide strips of adhesive plaster applied

directly to the skin of the chest for immobilization

since the adhesive tends to limit the ability of the chest

to expand (interfering with proper breathing). Treat

the victim for shock and evacuate as soon as possible.

Nose Fracture

A fracture of the nose usually causes localized pain

and swelling, a noticeable deformity of the nose, and

extensive nosebleed.

Stop the nosebleed. Have the victim sit quietly,

with the head tipped slightly backward. Tell the victim

to breathe through the mouth and not to blow the nose.

If the bleeding does not stop within a few minutes,

apply a cold compress or an ice bag over the nose.

Treat the victim for shock. Ensure the victim

receives a medical officer’s attention as soon as

possible. Permanent deformity of the nose may result

if the fracture is not treated promptly.

Jaw Fracture

A person who has a fractured jaw may suffer

serious interference with breathing. There is likely to

be great difficulty in talking, chewing, or swallowing.

Any movement of the jaw causes pain. The teeth may

be out of line, and there may be bleeding from the

gums. Considerable swelling may develop.

4-50

Figure 4-39.—Sling for immobilizing fractured clavicle.

Figure 4-40.—Swathe bandage of fractured rib victim.
One of the most important phases of emergency

care is to clear the upper respiratory passage of any

obstruction. If the fractured jaw interferes with

breathing, pull the lower jaw and the tongue well

forward and keep them in that position.

Apply a four-tailed bandage, as shown in figure

4-41. Be sure that the bandage pulls the lower jaw

forward. Never apply a bandage that forces the jaw

backward, since this might seriously interfere with

breathing. The bandage must be firm so that it will

support and immobilize the injured jaw, but it must not

press against the victim’s throat. Be sure that the

victim has scissors or a knife to cut the bandage in case

of vomiting. Treat the victim for shock and evacuate as

soon as possible.

Skull Fracture

When a person suffers a head injury, the greatest

danger is that the brain may be severely damaged;

whether or not the skull is fractured is a matter of

secondary importance. In some cases, injuries that

fracture the skull do not cause serious brain damage;

but brain damage canand frequently doesresult

from apparently slight injuries that do not cause

damage to the skull itself.

It is often difficult to determine whether an injury

has affected the brain because the symptoms of brain

damage vary greatly. A person suffering from a head

injury must be handled very carefully and given

immediate medical attention.

Some of the symptoms that may indicate brain

damage are listed below. However, you must

remember that all of these symptoms are not always

present in any one case and that the symptoms that do

occur may be greatly delayed.

• Bruises or wounds of the scalp may indicate that

the victim has sustained a blow to the head.

Sometimes the skull is depressed (caved in) at

the point of impact. If the fracture is open, you

may find glass, shrapnel, or other objects

penetrating the skull.

• The victim may be conscious or unconscious. If

conscious, the victim may feel dizzy and weak,

as though about to faint.

• Severe headache sometimes (but not always)

accompanies head injuries.

• The pupils of the eyes may be unequal in size and

may not react normally to light.

• There may be bleeding from the ears, nose, or

mouth.

• The victim may vomit.

• The victim may be restless and perhaps confused

and disoriented.

• The arms, legs, face, or other parts of the body

may be partially paralyzed.

• The victim’s face may be very pale, or it may be

unusually flushed.

• The victim is likely to be suffering from shock,

but the symptoms of shock may be disguised by

other symptoms.

It is not necessary to determine if the skull is

fractured when you are giving first aid to a person who

has suffered a head injury. The treatment is the same in

either case, and the primary intent is to prevent further

damage to the brain.

Keep the victim lying down. If the face is flushed,

raise the head and shoulders slightly. If the face is pale,

have the victim lie so that the head is level with, or

slightly lower than, the body. Watch carefully for

vomiting. If the victim begins to vomit, position the

head to prevent choking on the vomitus.

If there is serious bleeding from the wounds, try to

control that bleeding by the application of direct

pressure, using caution to avoid further injury to the

skull or brain. Use a donut-shaped bandage to gently

surround protruding objects. Never manipulate those

objects.

• Be very careful about moving or handling the

victim. Move the victim no more than is

4-51

Figure 4-41.—Four-tailed bandage for the jaw.
necessary. If transportation is necessary, keep

the victim lying down.

• In any significant head or facial injury, assume

injury to the cervical spine. Immobilization of

the cervical spine is indicated.

• Be sure that the victim is kept comfortably

warm, but not too warm.

• Do not give the victim anything to drink. DO

NOT GIVE ANY MEDICATIONS. See that

the victim receives a medical officer’s attention

as soon as possible.

Spinal Fractures

If the spine is fractured at any point, the spinal cord

may be crushed, cut, or otherwise damaged so severely

that death or paralysis will result. However, if the

fracture occurs in such a way that the spinal cord is not

seriously damaged, there is a very good chance of

complete recovery, provided that the victim is

properly cared for. Any twisting or bending of the neck

or backwhether due to the original injury or

carelessness from handling lateris likely to cause

irreparable damage to the spinal cord.

The primary symptoms of a fractured spine are

pain, shock, and paralysis. Pain is likely to be acute at

the point of fracture. It may radiate to other parts of the

body. Shock is usually severe, but (as in all injuries)

the symptoms may be delayed for some time.

Paralysis occurs if the spinal cord is seriously

damaged. If the victim cannot move the legs, feet, or

toes, the fracture is probably in the back; if the fingers

will not move, the neck is probably broken. Remember

that a spinal fracture does not always injure the spinal

cord, so the victim is not always paralyzed. Any

person who has an acute pain in the back or the neck

following an injury should be treated as though there is

a fractured spine, even if there are no other symptoms.

Emergency treatment for all spinal fractures,

whether of the neck or of the back, has two primary

purposes: (1) to minimize shock, and (2) to prevent

further injury to the spinal cord. Keep the victim

comfortably warm. Do not attempt to keep the victim

in the position ordinarily used for the treatment of

shock, because it might cause further damage to the

spinal cord. Just keep the victim lying flat and do NOT

attempt to lower the head.

To avoid further damage to the spinal cord, DO

NOT MOVE THE VICTIM UNLESS IT IS

ABSOLUTELY ESSENTIAL! If the victim’s life is

threatened in the present location or transportation is

necessary to receive medical attention, then, of course,

you must move the victim. However, if movement is

necessary, be sure that you do it in a way that will cause

the least possible damage. DO NOT BEND OR

TWIST THE VICTIM’S BODY, DO NOT MOVE

THE HEAD FORWARD, BACKWARD, OR

S IDEWAYS, AND DO NOT UNDER ANY

CIRCUMSTANCES ALLOW THE VICTIM TO

SIT UP.

If it is necessary to transport a person who has

suffered a fracture of the spine, follow these general

rules:

• If the spine is broken at the neck, the victim must

be transported lying on the back, face up. Place

pillows or sandbags beside the head so that it

cannot turn to either side. DO NOT put pillows

or padding under the neck or head.

• If you suspect that the spine is fractured but do

not know the location of the break, treat the

victim as though the neck is broken (i.e., keep the

victim supine). If both the neck and the back are

broken, keep the victim supine.

• No matter where the spine is broken, use a firm

support in transporting the victim. Use a rigid

stretcher, or a door, shutter, wide board, etc. Pad

the support carefully, and put blankets both

under and over the victim. Use cravat bandages

or strips of cloth to secure the victim firmly to the

support.

• When placing the victim on a spineboard, one of

two acceptable methods may be used. However,

DO NOT ATTEMPT TO LIFT THE

VICTIM UNLESS YOU HAVE ADEQUATE

ASSISTANCE. Remember: Any bending or

twisting of the body is almost sure to cause

serious damage to the spinal cord. Figure 4-42

shows the straddle-slide method. One person

lifts and supports the head while two other

persons each lift at the shoulders and hips,

respectively. A fourth person slides the

spineboard under the patient. Figure 4-43 shows

the proper procedure in performing the log-roll

method. The victim is rolled as a single unit

towards the rescuers, the spineboard is

positioned, and the victim is rolled back onto the

spineboard and secured in place. If there are at

least four (preferably six) people present to help

lift the victim, they can accomplish the job

without too much movement of the victim’s

4-52
body. NEVER attempt to lift the victim,

however, with fewer than four people.

• Evacuate the victim very carefully.

Pelvic Fracture

Fractures in the pelvic region often result from

falls, heavy blows, and accidents that involve

crushing. The great danger in a pelvic fracture is that

the organs enclosed and protected by the pelvis may be

seriously damaged when the bony structure is

fractured. In particular, there is danger that the bladder

will be ruptured. There is also danger of severe

internal bleeding; the large blood vessels in the pelvic

region may be torn or cut by fragments of the broken

bone.

The primary symptoms of a fractured pelvis are

severe pain, shock, and loss of ability to use the lower

part of the body. The victim is unable to sit or stand. If

the victim is conscious, there may be a sensation of

“coming apart.” If the bladder is injured, the victim’s

urine may be bloody.

Do not move the victim unless ABSOLUTELY

necessary. The victim should be treated for shock and

4-53

Figure 4-43.—Log-roll method of moving spinal cord injury victim onto a backboard.

Figure 4-42.—Straddle-slide method of moving spinal cord

injury victim onto a backboard.
kept warm but should not be moved into the position

ordinarily used for the treatment of shock.

If you must transport the victim to another place,

do it with the utmost care. Use a rigid stretcher, a

padded door, or a wide board. Keep the victim supine.

In some cases, the victim will be more comfortable if

the legs are straight, while in other cases the victim will

be more comfortable with the knees bent and the legs

drawn up. When you have placed the victim in the

most comfortable position, immobilization should be

accomplished. Fractures of the hip are best treated

with traction splints. Adequate immobilization can

also be obtained by placing pillows or folded blankets

between the legs as shown in figure 4-44 and using

cravats, roller bandages, or straps to hold the legs

together, or through the use of MAST garments.

Fasten the victim securely to the stretcher or

improvised support, and evacuate very carefully.

MANAGEMENT OF JOINT

AND MUSCLE INJURIES

LEARNING OBJECTIVE: Select the

appropriate stabilization and treatment

procedure for the management of joint and

muscle injuries.

Injuries to joints and muscles often occur together,

and it is sometimes difficult to tell whether the primary

injury is to a joint or to the muscles, tendons, blood

vessels, or nerves near the joint. Sometimes it is

difficult to distinguish joint or muscle injuries from

fractures. In case of doubt, alwaystreat any injury to a

bone, joint, or muscle as though it were a fracture.

In general, joint and muscle injuries may be

classified under four headings: (1) dislocations, (2)

sprains, (3) strains, and (4) contusions (bruises).

Dislocations

When a bone is forcibly displaced from its joint,

the injury is known as a dislocation. In some cases, the

bone slips back quickly into its normal position, but at

other times it becomes locked in the new position and

remains dislocated until it is put back into place.

Dislocations are usually caused by falls or blows but

occasionally by violent muscular exertion. The most

frequently dislocated joints are those of the shoulder,

hip, fingers, and jaw.

A dislocation is likely to bruise or tear the muscles,

ligaments, blood vessels, tendons, and nerves near a

joint. Rapid swelling and discoloration, loss of ability

to use the joint, severe pain and muscle spasms,

possible numbness and loss of pulse below the joint,

and shock are characteristic symptoms of dislocations.

The fact that the injured part is usually stiff and

immobile, with marked deformation at the joint, will

help you distinguish a dislocation from a fracture. In a

fracture, there is deformity between joints rather than

at joints, and there is generally a wobbly motion of the

broken bone at the point of fracture.

As a general rule, you should not attempt to reduce

a dislocationthat is, put a dislocated bone back into

placeunless you know that a medical officer cannot

be reached within 8 hours. Unskilled attempts at

reduction may cause great damage to nerves and blood

vessels or actually fracture the bone. Therefore, except

in great emergencies, you should leave this treatment

to specially trained medical personnel and concentrate

your efforts on making the victim as comfortable as

possible under the circumstances.

The following emergency measures will be

helpful:

1. Loosen the clothing around the injured part.

2. Place the victim in the most comfortable

position possible.

3. Support the injured part by means of a sling,

pillows, bandages, splints, or any other device

that will make the victim comfortable.

4. Treat the victim for shock.

5. Get medical help as soon as possible.

You should NEVER attempt to reduce the more

serious dislocations, such as those of the hip.

However, if it is probable that the victim cannot be

treated by a medical officer within a reasonable time,

you should make a careful effort to reduce certain

4-54

Figure 4-44.—Immobilizing a fractured pelvis.
dislocations (such as those of the jaw, finger, or

shoulder) if there is no arterial or nerve involvement

(pulse will be palpable and there will be no numbness

below the joint). Treat all other dislocations as

fractures, and evacuate the victim to a definitive care

facility.

DISLOCATION OF THE JAW.—When the

lower jaw is dislocated, the victim cannot speak or

close the mouth. Dislocation of the jaw is usually

caused by a blow to the mouth; sometimes it is caused

by yawning or laughing. This type of dislocation is not

always easy to reduce, and there is considerable danger

that the operator’s thumbs will be bitten in the process.

For your own protection, wrap your thumbs with a

handkerchief or bandage. While facing the victim,

press your thumbs down just behind the last lower

molars and, at the same time, lift the chin up with your

fingers. The jaw should snap into place at once. You

will have to remove your thumbs quickly to avoid

being bitten. No further treatment is required, but you

should warn the victim to keep the mouth closed as

much as possible during the next few hours. Figure

4-45 shows the position you must assume to reduce a

dislocated jaw.

DISLOCATION OF THE FINGER.—The

joints of the finger are particularly susceptible to

injury, and even minor injuries may result in prolonged

loss of function. Great care must be used in treating

any injury of the finger.

To reduce a dislocation of the finger, grasp the

finger firmly and apply a steady pull in the same line as

the deformity. If it does not slip into position, try it

again, but if it does not go into position on the third

attempt, DO NOT TRY AGAIN. In any case, and

whether or not the dislocation is reduced, the finger

should be strapped, slightly flexed, with an aluminum

splint or with a roller gauze bandage over a tongue

blade. Figure 4-46 shows how a dislocated finger can

be immobilized by strapping it to a flat, wooden stick,

such as a tongue depressor.

DISLOCATION OF THE SHOULDER.—

Before reduction, place the victim in a supine position.

After putting the heel of your foot in the victim’s

armpit, grasp the wrist and apply steady traction by

pulling gently and increasing resistance gradually.

Pull the arm in the same line as it is found. After

several minutes of steady pull, flex the victim’s elbow

slightly. Grasp the arm below the elbow, apply traction

from the point of the elbow, and gently rotate the arm

into the external or outward position. If three reduction

attempts fail, carry the forearm across the chest and

apply a sling and swathe. An alternate method

involves having the patient lie face down on an

examining table with the injured arm hanging over the

side. Apply prolonged, firm, gentle traction at the

wrist with gentle external rotation. A water bucket

with a padded handle placed in the crook of the

patient’s elbow may be substituted. Gradually add

sand or water to the bucket to increase traction.

Grasping the wrist and using the elbow as a pivot point,

gently rotate the arm into the external position.

Sprains

Sprains are injuries to the ligaments and soft

tissues that support a joint. A sprain is caused by the

violent wrenching or twisting of the joint beyond its

normal limits of movement and usually involves a

momentary dislocation, with the bone slipping back

into place of its own accord. Although any joint may

4-55

Figure 4-45.—Position for reducing a dislocated jaw. Figure 4-46.—Immobilizing a dislocated finger.
be sprained, sprains of the ankle, wrist, knee, and

finger are most common.

Symptoms of a sprain include pain or pressure at

the joint, pain upon movement, swelling and

tenderness, possible loss of movement, and

discoloration. Treat all sprains as fractures until ruled

out by X-rays.

Emergency care for a sprain includes application

of cold packs for the first 24 to 48 hours to reduce

swelling and to control internal hemorrhage; elevation

and rest of the affected area; application of a snug,

smooth, figure-eight bandage to control swelling and

to provide immobilization (basket weave adhesive

bandages can be used on the ankle); a follow-up

examination by a medical officer; and X-rays to rule

out the presence of a fracture.

NOTE: Check bandaged areas regularly for

swelling that might cause circulation

impairment and loosen bandages if necessary.

After the swelling stops (24 to 48 hours), moist heat

can be applied for short periods (15 to 30 minutes) to

promote healing and reduce swelling. Moist heat can be

warm, wet compresses, warm whirlpool baths, etc.

CAUTION: Heat should not be applied until

24 hours after the last cold pack.

Strains

Injuries caused by the forcible overstretching or

tearing of muscles or tendons are known as strains.

Strains may be caused by lifting excessively heavy

loads, sudden or violent movements, or any other

action that pulls the muscles beyond their normal

limits.

The chief symptoms of a strain are pain, lameness

or stiffness (sometimes involving knotting of the

muscles), moderate swelling at the place of injury,

discoloration due to the escape of blood from injured

blood vessels into the tissues, possible loss of power,

and a distinct gap felt at the site.

Keep the affected area elevated and at rest. Apply

cold packs for the first 24 to 48 hours to control

hemorrhage and swelling. After the swelling stops,

apply mild heat to increase circulation and aid in

healing. As in sprains, heat should not be applied until

24 hours after the last cold pack. Muscle relaxants,

adhesive straps, and complete immobilization of the

area may be indicated. Evacuate the victim to a

medical facility where X-rays can be taken to rule out

the presence of a fracture.

Contusions

Contusions, commonly called bruises, are

responsible for the discoloration that almost always

accompanies injuries to bones, joints, and muscles.

Contusions are caused by blows that damage bones,

muscles, tendons, blood vessels, nerves, and other

body tissues. They do not necessarily break the skin.

The symptoms of a contusion or bruise are familiar to

everyone. There is immediate pain when the blow is

received. Swelling occurs because blood from the broken

vessels leaks into the soft tissue under the skin. At first

the injured place is reddened due to local skin irritation

from the blow. Later the characteristic “black and blue”

marks appear. Perhaps several days later, the skin turns

yellowish or greenish before normal coloration returns.

The bruised area is usually very tender.

As a rule, slight bruises do not require treatment.

However, if the victim has severe bruises, treat for

shock. Immobilize the injured part, keep it at rest, and

protect it from further injury. Sometimes the victim

will be more comfortable if the bruised area is

bandaged firmly with an elastic or gauze bandage. If

possible, elevate the injured part. A sling may be used

for a bruised arm or hand. Pillows or folded blankets

may be used to elevate a bruised leg.

ENVIRONMENTAL INJURIES

LEARNING OBJECTIVE: Recall the

classification and evaluation process for

burns, and determine the appropriate

treatment for each type of burn.

Under the broad category of environmental

injuries, we will consider a number of emergency

problems. Exposure to extremes of temperature,

whether heat or cold, causes injury to skin, tissues,

blood vessels, vital organs, and, in some cases, the

whole body. In addition, contact with the sun’s rays,

electrical current, or certain chemicals causes injuries

similar in character to burns.

THERMAL BURNS

True burns are generated by exposure to extreme

heat that overwhelms the body’s defensive

mechanisms. Burns and scalds are essentially the same

injury: Burns are caused by dry heat, and scalds are

caused by moist heat. The seriousness of the injury can

4-56
be estimated by the depth, extent, and location of the

burn, the age and health of the victim, and other

medical complications.

Classification of Severity

Burns are classified according to their depth as

first-, second-, and third-degree burns (as shown in

figure 4-47).

FIRST-DEGREE BURN.—With a first-degree

burn, the epidermal layer is irritated, reddened, and

tingling. The skin is sensitive to touch and blanches

with pressure. Pain is mild to severe, edema is

minimal, and healing usually occurs naturally within a

week.

SECOND-DEGREE BURN.—A second-degree

burn is characterized by epidermal blisters, mottled

appearance, and a red base. Damage extends intobut

not throughthe dermis. Recovery usually takes 2 to

3 weeks, with some scarring and depigmentation. This

condition is painful. Body fluids may be drawn into

the injured tissue, causing edema and possibly a

“weeping” fluid (plasma) loss at the surface.

THIRD-DEGREE BURN.—Athird-degree burn

is a full-thickness injury penetrating into muscle and

fatty connective tissues, or even down to the bone.

Tissues and nerves are destroyed. Shock, with blood in

the urine, is likely to be present. Pain will be absent at

the burn site if all the area nerve endings are destroyed,

and the surrounding tissue (which is less damaged)

will be painful. Tissue color will range from white

(scalds) to black (charring burns). Although the

wound is usually dry, body fluids will collect in the

underlying tissue. If the area has not been completely

cauterized, significant amounts of fluids will be lost by

plasma “weeping” or by hemorrhage, thus reducing

circulation volume. There is considerable scarring and

possible loss of function. Skin grafts may be

necessary.

Rule of Nines

Of greater importance than the depth of the burn in

evaluating the seriousness of the condition is the extent

of the burned area. A first-degree burn over 50 percent

of the body surface area (BSA) may be more serious

than a third-degree burn over 3 percent. The Rule of

Nines is used to give a rough estimate of the surface

area affected. Figure 4-48 shows how the rule is

applied to adults.

Other Factors

A third factor in burn evaluation is the location of

the burn. Serious burns of the head, hands, feet, or

genitals will require hospitalization.

The fourth factor is the presence of any other

complications, especially respiratory tract injuries or

other major injuries or factors.

4-57

Figure 4-47.—Classification of burns. Figure 4-48.—Rule of Nines.
The Corpsman must take all these factors into

consideration when evaluating the condition of the

burn victim, especially in a triage situation.

First Aid

After the victim has been removed from the source

of the thermal injury, first aid should be kept to a

minimum.

• Maintain an open airway.

• Control hemorrhage, and treat for shock.

• Remove constricting jewelry and articles of

clothing.

• Protect the burn area from contamination by

covering it with clean sheets or dry dressings.

DO NOTremove clothing adhering to a wound.

• Splint fractures.

• For all serious and extensive burns (over 20

percent BSA), and in the presence of shock, start

intravenous therapy with an electrolyte solution

(Ringer’s lactate) in an unburned area.

• Maintain intravenous treatment during

transportation.

• Relieve mild pain with aspirin. Relieve

moderate pain with cool, wet compresses or ice

water immersion (for burns of less than 20

percent BSA). Severe pain may be relieved with

morphine or demerol injections. Pain resulting

from small burns may be relieved with an

anesthetic ointment if the skin is not broken.

Aid Station Care

Once the victim has arrived at the aid station,

observe the following procedures.

• Continue to monitor for airway patency,

hemorrhage, and shock.

• Continue intravenous therapy that is in place, or

start a new one under a medical officer’s

supervision to control shock and replace fluid

loss.

• Monitor urine output.

• Shave body hair well back from the burned area,

and then cleanse the area gently with disinfectant

soap and warm water. Remove dirt, grease, and

nonviable tissue. Apply a sterile dressing of dry

gauze. Place bulky dressings around the burned

parts to absorb serous exudate.

• All major burn victims should be given a booster

dose of tetanus toxoid to guard against infection.

Administration of antibiotics may be directed by

a medical officer or an Independent Duty

Corpsman.

• If evacuation to a definitive care facility will be

delayed for 2 to 3 days, start topical antibiotic

therapy after the patient stabilizes and following

debridement and wound care. Gently spread a

1/16-inch thickness of Sulfamylon or

Silvadene over the burn area. Repeat the

application after 12 hours, and then after daily

debridement. Treat minor skin reactions with

antihistamines.

SUNBURN

Sunburn results from prolonged exposure to the

ultraviolet rays of the sun. First- and second-degree

burns similar to thermal burns result. Treatment is

essentially the same as that outlined for thermal burns.

Unless a major percentage of the body surface is

affected, the victim will not require more than first aid

attention. Commercially prepared sunburn lotions and

ointments may be used. Prevention through education

and the proper use of sun screens is the best way to

avoid this condition.

ELECTRICAL BURNS

Electrical burns may be far more serious than a

preliminary examination may indicate. The entrance

and exit wounds may be small, but as electricity

penetrates the skin it burns a large area below the

surface, as indicated in figure 4-49. ACorpsman can do

little for these victims other than monitoring the basic

life functions, delivering CPR, treating for shock if

necessary, covering the entrance and exit wounds with

a dry, sterile dressing, and transporting the victim to a

medical treatment facility.

Before treatment is started, ensure that the victim

is no longer in contact with a live electrical source.

Shut the power off or use a nonconducting rope or stick

to move the victim away from the line or the line away

from the victim. See figure 3-26.

CHEMICAL BURNS

When acids, alkalies, or other chemicals come in

contact with the skin or other body membranes, they

4-58
may cause injuries that are generally referred to as

chemical burns. For the most part, these injuries are

not caused by heat but by direct chemical destruction

of body tissues. Areas most often affected are the

extremities, mouth, and eyes. Alkali burns are usually

more serious than acid burns because alkalies

penetrate deeper and burn longer.

When such burns occur, the following emergency

procedures must be carried out immediately:

1. Quickly flush the area with large amounts of

water, using a shower or hose, if available. Do

not apply water too forcefully. Flood the area

while the clothing (including shoes and socks) is

being removed and continue often removal.

NOTE: There are two exceptions to the

above: (1) In alkali burns caused by dry lime,

the mixing of water and lime creates a very

corrosive substance. Dry lime should be

brushed away from the skin and clothing,

unless large amounts of water are available for

rapid and complete flushing. (2) In acid burns

caused by phenol (carbolic acid), wash the

affected area with alcohol because phenol is

not water soluble; then wash with water. If

alcohol is not available, flushing with water is

better than no treatment at all.

2. After thorough washing, neutralize any

chemical remaining on the affected area.

WARNING: DO NOT attempt to neutralize a

chemical unless you know exactly what it is

and what substance will neutralize it. Further

damage may be done by a neutralizing agent

that is too strong or incorrect.

For acid burns, make a solution of 1 teaspoon of

baking soda to a pint of water and flush it over

the affected area. For alkali burns, mix 1 or 2

teaspoons of vinegar to a pint of water and flush

it over the affected area.

3. Flush the area again with water and gently pat

dry with a sterile gauze. Do not rub the area.

4. Transport the victim to a medical treatment

facility.

When treating chemical burns to the eye, the one

and only emergency treatment is to flush the eye(s)

immediately with large amounts of water or a sterile

saline solution. Irrigate acid burns to the eyes for at

least 5 to 10 minutes with at least 2000 ml of water.

Irrigate alkali burns to the eyes for at least 20 minutes.

Because of the intense pain, the victim may be unable

to open the eyes. If this occurs, hold the eyelids apart

so that water can flow across the eye.

A drinking fountain or field “water buffalo” may

be used to supply a steady stream of water. Hold the

victim’s head in a position that allows water to flow

from the inside corner of the eye toward the outside.

Do not allow the water to fall directly on the eye, and

do not use greater force than is necessary to keep the

water flowing across the eye.

CAUTION: Never use any chemical antidotes

such as baking soda or alcohol in treating

burns of the eye, and do not try to neutralize

chemical agents.

After thorough irrigation, loosely cover both eyes

with a clean dressing. This prevents further damage by

decreasing eye movement.

The aftercare for all chemical burns is similar to

that for thermal burns: Cover the affected area and get

the victim to a medical treatment facility as soon as

possible.

WHITE PHOSPHORUS BURNS

A special category of burns that may affect

military personnel in a wartime or training situation is

that caused by exposure of white phosphorus (WP or

Willy Peter). First aid for this type of burn is

4-59

Figure 4-49.—Electrical burns.
complicated by the fact that white phosphorus particles

ignite upon contact with air.

Superficial burns caused by simple skin contact or

burning clothes should be flushed with water and treated

like thermal burns. Partially embedded white

phosphorus particles must be continuously flushed with

water while the first aid provider removes them with

whatever tools are available (i.e., tweezers, pliers,

forceps). Do this quickly, but gently. Firmly or deeply

embedded particles that cannot be removed by the first

aid provider must be covered with a saline-soaked

dressing, and this dressing must be kept wet until the

victim reaches a medical treatment facility. The wounds

containing embedded phosphorus particles may then be

rinsed with a dilute, freshly mixed 1% solution of copper

sulfate. This solution combines with phosphorus on the

surface of the particles to form a blue-black cupric

phosphite covering, which both impedes further

oxidation and facilitates identification of retained

particles. Under no circumstances should the copper

sulfate solution be applied as a wet dressing. Wounds

must be flushed thoroughly with a saline solution

following the copper sulfate rinse to prevent absorption

of excessive amounts of copper. (Copper has been

associated with extensive intravascular hemolysis.) An

adjunct to the management of phosphorus burn injuries is

the identification of the retained phosphorescent particles

in a darkened room during debridement.

NOTE: Combustion of white phosphorus

results in the formation of a severe pulmonary

irritant. The ignition of phosphorus in a closed

space (such as the BAS tent or sickbay) may

result in the development of irritant

concentrations sufficient to cause acute

inflammatory changes in the tracheobronchial

tree. The effects of this gas, especially during

debridement, can be minimized by placing a

moist cloth over the nose and mouth to

inactivate the gas and by ventilating the tent.

HEAT EXPOSURE INJURIES

LEARNING OBJECTIVE: Identify the

signs, symptoms, and emergency treatment

of heat cramps, heat exhaustion, and heat

stroke.

Excessive heat affects the body in a variety of

ways. When a person exercises or works in a hot

environment, heat builds up inside the body. The body

automatically reacts to get rid of this heat through the

sweating mechanism. This depletes water and

electrolytes from the circulating volume. If they are

not adequately replaced, body functions are affected,

and, initially, heat cramps and heat exhaustion

develop. If the body becomes too overheated or water

or electrolytes too depleted, the sweat-control

mechanism of the body malfunctions and shuts down.

The result is heat stroke (sunstroke). Heat exposure

injuries are a threat in any hot environment, but

especially in desert or tropical areas and in the boiler

rooms of ships. Under normal conditions, it is a

preventable injury. Individual and command

awareness of the causes of heat stress problems should

help eliminate heat exposure injuries.

Heat Cramps

Excessive sweating may result in painful cramps

in the muscles of the abdomen, legs, and arms. Heat

cramps may also result from drinking ice water or other

cold drinks either too quickly or in too large a quantity

after exercise. Muscle cramps are often an early sign

of approaching heat exhaustion.

To provide first aid treatment for heat cramps,

move the victim to a cool place. Since heat cramps are

caused by loss of salt and water, give the victim plenty

of cool (not cold) water to drink, adding about one

teaspoon of salt to a liter or quart of water. Apply

manual pressure to the cramped muscle, or gently

massage it to relieve the spasm. If there are indications

of anything more serious, transport the victim

immediately to a medical treatment facility.

Heat Exhaustion

Heat exhaustion (heat prostration or heat collapse)

is the most common condition caused by working or

exercising in hot environments. In heat exhaustion,

there is a serious disturbance of blood flow to the brain,

heart, and lungs. This causes the victim to experience

weakness, dizziness, headache, nausea, and loss of

appetite. The victim may faint but will probably regain

consciousness as the head is lowered, which improves

the blood supply to the brain. Signs and symptoms of

heat exhaustion are similar to those of shock; the

victim will appear ashen gray, the skin cool, moist, and

clammy and the pupils may be dilated (fig. 4-50). The

vital signs usually are normal; however, the victim

may have a weak pulse, together with rapid and

shallow breathing. Body temperature may be below

normal.

4-60
Treat heat exhaustion as if the victim were in

shock. Move the victim to a cool or air-conditioned

area. Loosen the clothing, apply cool wet cloths to the

head, axilla, groin, and ankles, and fan the victim. Do

not allow the victim to become chilled. (If this does

occur, cover with a light blanket and move into a

warmer area.) If the victim is conscious, give a

solution of 1 teaspoon of salt dissolved in a liter of cool

water. If the victim vomits, do not give any more

fluids. Transport the victim to a medical treatment

facility as soon as possible. Intravenous fluid infusion

may be necessary for effective fluid and electrolyte

replacement to combat shock.

Heat Stroke

Sunstroke is more accurately called heat stroke

since it is not necessary to be exposed to the sun for this

condition to develop. It is a less common but far more

serious condition than heat exhaustion, since it carries

a 20 percent mortality rate. The most important feature

of heat stroke is the extremely high body temperature

(105°F, 41°C or higher) accompanying it. In heat

stroke, the victim suffers a breakdown of the sweating

mechanism and is unable to eliminate excessive body

heat build up while exercising. If the body temperature

rises too high, the brain, kidneys, and liver may be

permanently damaged.

Sometimes the victim may have preliminary

symptoms such as headache, nausea, dizziness, or

weakness. Breathing will be deep and rapid at first,

later shallow and almost absent. Usually the victim

will be flushed, very dry, and very hot. The pupils will

be constricted (pinpoint) and the pulse fast and strong

(fig. 4-50). Compare these symptoms with those of

heat exhaustion.

When providing first aid for heat stroke, remember

that this is a true life-and-death emergency. The longer

the victim remains overheated, the more likely

irreversible brain damage or death will occur. First aid

is designed to reduce body heat fast.

Reduce heat immediately by dousing the body

with cold water or by applying wet, cold towels to the

whole body. Move the victim to the coolest place

available and remove as much clothing as possible.

Maintain an open airway. Place the victim on his back,

with the head and shoulders slightly raised. If cold

packs are available, place them under the arms, around

the neck, at the ankles, and in the groin. Expose the

victim to a fan or air conditioner, since drafts will

promote cooling. Immersing the victim in a cold water

bath is also very effective. If the victim is conscious,

give cool water to drink. Do not give any hot drinks

or stimulants. Discontinue cooling when the rectal

temperature reaches 102°F; watch for recurrence of

temperature rise by checking every 10 minutes.

Repeat cooling if temperature reaches 103°F rectally.

Get the victim to a medical facility as soon as

possible. Cooling measures must be continued while

the victim is being transported. Intravenous fluid

infusion may be necessary for effective fluid and

electrolyte replacement to combat shock.

Prevention of Heat Exposure Injuries

LEARNING OBJECTIVE: Determine the

steps needed to prevent heat exposure

injuries.

The prevention of heat exposure injuries is a

command responsibility, but the medical department

plays a role in it by educating all hands about the

medical dangers, monitoring environmental health,

and advising the commanding officer.

On the individual level, prevention centers on water

and salt replacement. Sweat must be replaced ounce for

ounce; in a hot environment, water consumption must

be drastically increased. Salt should be replaced by

eating well-balanced meals, three times a day, salted to

taste. In the field, “C” rations contain enough salt to

sustain a person in most situations. DO NOT use salt

tablets unless specified by a physician. DO NOT

consume alcoholic beverages.

At the command level, prevention centers on an

awareness of the environment. The Wet Bulb Globe

4-61

Figure 4-50.—Heat exhaustion and heat stroke.
Temperature (WBGT) must be monitored regularly,

and the results interpreted with the Physiological Heat

Exposure Limit (PHEL) chart before work assignments are made. In addition, unnecessary heat sources,

especially steam leaks, must be eliminated, and vents

and exhaust blowers must be checked for adequate

circulation. The results will be a happier, healthier, and

more productive crew.

COLD EXPOSURE INJURIES

LEARNING OBJECTIVE: Identify the

signs, symptoms, and emergency treatment

of each type of cold exposure injury.

When the body is subjected to extremely cold

temperatures, blood vessels constrict, and body heat is

gradually lost. As the body temperature drops, tissues

are easily damaged or destroyed.

The cold injuries resulting from inadequate

response to the cold in military situations have spelled

disaster for many armiesthose of Napoleon and

Hitler in their Russian campaigns, for example. The

weather (i.e., temperature, humidity, precipitation, and

wind) is the predominant influence in the development

of cold injuries. Falling temperature interacting with

high humidity, a wet environment, and rising wind

accelerates the loss of body heat.

Other factors that influence the development of cold

injuries are the individual's level of dehydration, the

presence of other injuries (especially those causing a

reduction in circulatory flow), and a previous cold injury

(which increases susceptibility by lowering resistance).

In addition, the use of any drug (including alcohol) that

modifies autonomic nervous system response or alters

judgment ability can drastically reduce an individual’s

chance for survival in a cold environment.

Like heat exposure injuries, cold exposure injuries are

preventable. Acclimatization, the availability of warm,

layered clothing, and maintenance of good discipline and

training standards are important factors. These are

commandnot medicalresponsibilities, but the

Corpsman plays a crucial role as a monitor of nutritional

intake and personal hygiene (with emphasis on foot care)

and as an advisor to the commanding officer. ACorpsman

is also responsible for acquainting the troops with the

dangers of cold exposure and with preventive measures.

Two major points must be stressed in the

management of all cold injuries: Rapid rewarming is

of primary importance, and all unnecessary manipulations of affected areas must be avoided. More will be

said about these points later.

In military operations the treatment of cold injuries is

influenced by the tactical situation, the facilities available

for the evacuation of casualties, and the fact that most

cold injuries are encountered in large numbers during

periods of intense combat when many other wounded

casualties appear. Highly individualized treatment under

these circumstances may be impossible because

examination and treatment of more life-endangering

wounds must be given priority. In a high-casualty

situation, shelter cold-injury victims, and try to protect

them from further injury until there is sufficient time to

treat them.

All cold injuries are similar, varying only in the

degree of tissue damage. Although the effects of cold

can, in general, be divided into two types—general

cooling of the entire body and local cooling of parts of the

bodycold injuries are seldom strictly of one type or the

other; rather, these injuries tend to be a combination of

both types. Each type of cooling, however, will be

discussed separately in the sections that follow.

General Cooling (Hypothermia)

General cooling of the whole body is caused by

continued exposure to low or rapidly falling

temperatures, cold moisture, snow, or ice. Those

exposed to low temperatures for extended periods may

suffer ill effects, even if they are well protected by

clothing, because cold affects the body systems slowly,

almost without notice. As the body cools, there are

several stages of progressive discomfort and disability.

The first symptom is shivering, which is an attempt to

generate heat by repeated contractions of surface

muscles. This is followed by a feeling of listlessness,

indifference, and drowsiness. Unconsciousness can

follow quickly. Shock becomes evident as the victim’s

eyes assume a glassy stare, respiration becomes slow

and shallow, and the pulse is weak or absent. As the

body temperature drops even lower, peripheral

circulation decreases and the extremities become

susceptible to freezing. Finally, death results as the

core temperature of the body approaches 80°F.

The steps for treatment of hypothermia are as

follows:

1. Carefully observe respiratory effort and heart

beat; CPR may be required while the warming

process is underway.

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2. Rewarm the victim as soon as possible. It may

be necessary to treat other injuries before the

victim can be moved to a warmer place. Severe

bleeding must be controlled and fractures

splinted over clothing before the victim is

moved.

3. Replace wet or frozen clothing and remove

anything that constricts the victim’s arms, legs,

or fingers, interfering with circulation.

4. If the victim is inside a warm place and is

conscious, the most effective method of

warming is immersion in a tub of warm (100° to

105°F or 38° to 41°C) water. The water should

be warm to the elbownever hot. Observe

closely for signs of respiratory failure and

cardiac arrest (rewarming shock). Rewarming

shock can be minimized by warming the body

trunk before the limbs to prevent vasodilation in

the extremities with subsequent shock due to

blood volume shifts.

5. If a tub is not available, apply external heat to

both sides of the victim. Natural body heat (skin

to skin) from two rescuers is the best method.

This is called “buddy warming.” If this is not

practical, use hot water bottles or an electric

rewarming blanket. Do not place the blanket or

bottles next to bare skin, however, and be

careful to monitor the temperature of the

artificial heat source, since the victim is very

susceptible to burn injury. Because the victim is

unable to generate adequate body heat,

placement under a blanket or in a sleeping bag is

not sufficient treatment.

6. If the victim is conscious, give warm liquids to

drink. Never give alcoholic beverages or allow

the victim to smoke.

7. Dry the victim thoroughly if water is used for

rewarming.

8. As soon as possible, transfer the victim to a

definitive care facility. Be alert for the signs of

respiratory and cardiac arrest during transfer,

and keep the victim warm.

Local Cooling

Local cooling injuries, affecting individual parts

of the body, fall into two categories: freezing and

nonfreezing injuries. In the order of increasing

seriousness, they include chilblain, immersion foot,

superficial frostbite, and deep frostbite. The areas

most commonly affected are the face and extremities.

CHILBLAIN.—Chilblain is a mild cold injury

caused by prolonged and repeated exposure for several

hours to air temperatures from above freezing 32°F

(0°C) to as high as 60°F (16°C). Chilblain is

characterized by redness, swelling, tingling, and pain

to the affected skin area. Injuries of this nature require

no specific treatment except warming of the affected

part (if possible use a water bath of 90°F to 105°F),

keeping it dry, and preventing further exposure.

IMMERSION FOOT.—Immersion foot, which

also may occur in the hands, results from prolonged

exposure to wet cold at temperatures ranging from just

above freezing to 50°F (10°C). Immersion foot is

usually seen in connection with limited motion of the

extremities and water-soaked protective clothing.

Signs and symptoms of immersion foot are

tingling and numbness of the affected areas; swelling

of the legs, feet, or hands; bluish discoloration of the

skin; and painful blisters. Gangrene may occur.

General treatment for immersion foot is as follows:

1. Get the victim off his feet as soon as possible.

2. Remove wet shoes, socks, and gloves to

improve circulation.

3. Expose the affected area to warm, dry air.

4. Keep the victim warm.

5. Do not rupture blisters or apply salves and

ointments.

6. If the skin is not broken or loose, the injured part

may be left exposed; however, if it is necessary

to transport the victim, cover the injured area

with loosely wrapped fluff bandages of sterile

gauze.

7. If the skin is broken, place a sterile sheet under

the extremity and gently wrap it to protect the

sensitive tissue from pressure and additional

injury.

8. Transport the victim as soon as possible to a

medical treatment facility as a litter patient.

FROSTBITE.—Frostbite occurs when ice

crystals form in the skin or deeper tissues after

exposure to a temperature of 32°F (0°C) or lower.

Depending upon the temperature, altitude, and wind

speed, the exposure time necessary to produce

frostbite varies from a few minutes to several hours.

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The areas most commonly affected are the face and

extremities.

The symptoms of frostbite are progressive.

Victims generally incur this injury without being

acutely aware of it. Initially, the affected skin reddens

and there is an uncomfortable coldness. With

continued heat loss, there is a numbness of the affected

area due to reduced circulation. As ice crystals form,

the frozen extremity appears white, yellow-white, or

mottled blue-white, and is cold, hard, and insensitive

to touch or pressure. Frostbite is classified as

superficial or deep, depending on the extent of tissue

involvement.

Superficial Frostbite.—In superficial frostbite

the surface of the skin will feel hard, but the underlying

tissue will be soft, allowing it to move over bony

ridges. This is evidence that only the skin and the

region just below it are involved. General treatment for

superficial frostbite is as follows:

1. Take the victim indoors.

2. Rewarm hands by placing them under the

armpits, against the abdomen, or between the

legs.

3. Rewarm feet by placing them in the armpit or

against the abdomen of the buddy.

4. Gradually rewarm the affected area by warm

water immersion, skin-to-skin contact, or hot

water bottles.

5. Never rub a frostbite area.

Deep Frostbite.—In deep frostbite, the freezing

reaches into the deep tissue layers. There are ice

crystals in the entire thickness of the extremity. The

skin will not move over bony ridges and will feel hard

and solid.

The objectives of treatment are to protect the

frozen areas from further injury, to rapidly thaw the

affected area, and to be prepared to respond to

circulatory or respiratory difficulties.

1. Carefully assess and treat any other injuries

first. Constantly monitor the victim’s pulse and

breathing since respiratory and heart problems

can develop rapidly. Be prepared to administer

CPR if necessary.

2. Do not attempt to thaw the frostbitten area if

there is a possibility of refreezing. It is better to

leave the part frozen until the victim arrives at a

medical treatment facility equipped for

long-term care. Refreezing of a thawed

extremity causes severe and disabling damage.

3. Treat all victims with injuries to the feet or legs

as litter patients. When this is not possible, the

victim may walk on the frozen limb, since it has

been proven that walking will not lessen the

chances of successful treatment as long as the

limb has not thawed out.

4. When adequate protection from further cold

exposure is available, prepare the victim for

rewarming by removing all constricting

clothing such as gloves, boots, and socks. Boots

and clothing frozen on the body should be

thawed by warm-water immersion before

removal.

5. Rapidly rewarm frozen areas by immersion in

water at 100°F to 105°F (38°C to 41°C). Keep

the water warm by adding fresh hot water, but do

not pour the water directly on the injured area.

Ensure that the frozen area is completely

surrounded by water; do not let it rest on the side

or bottom of the tub.

6. After rewarming has been completed, pat the

area dry with a soft towel. Later it will swell,

sting, and burn. Blisters may develop. These

should be protected from breaking. Avoid

pressure, rubbing, or constriction of the injured

area. Keep the skin dry with sterile dressings

and place cotton between the toes and fingers to

prevent their sticking together.

7. Protect the tissue from additional injury and

keep it as clean as possible (use sterile dressings

and linen).

8. Try to improve the general morale and comfort

of the victim by giving hot, stimulating fluids

such as tea or coffee. Do not allow the victim to

smoke or use alcoholic beverages while being

treated.

9. Transfer to a medical treatment facility as soon

as possible. During transportation, slightly

elevate the frostbitten area and keep the victim

and the injured area warm. Do not allow the

injured area to be exposed to the cold.

4-64
Later Management of Cold Injuries

LEARNING OBJECTIVE: Determine the

steps needed for the later management of

cold-exposure injuries.

When the patient reaches a hospital or a facility for

definitive care, the following treatment should be

employed:

1. Maintain continued vigilance to avoid further

damage to the injured tissue. In general, this is

accomplished by keeping the patient at bed rest

with the injured part elevated (on surgically

clean sheets) and with sterile pieces of cotton

separating the toes or fingers. Expose all lesions

to the air at normal room temperature. Weight

bearing on injured tissue must be avoided.

2. Whirlpool baths, twice daily at 98.6°F (37°C)

with surgical soap added, assist in superficial

debridement, reduce superficial bacterial

contamination, and make range of motion

exercises more tolerable.

3. Analgesics may be required in the early postthaw days but will soon become unnecessary in

uncomplicated cases.

4. Encourage the patient to take a nutritious diet

with adequate fluid intake to maintain hydration.

5. Perform superficial debridement of ruptured

blebs, and remove suppurative scabs and

partially detached nails.

MORPHINE USE FOR PAIN RELIEF

LEARNING OBJECTIVE: Recall

morphine dosage, administration routes,

indications, contraindications, and

casualty marking procedures.

As a Corpsman, you may be issued morphine for

the control of shock through the relief of severe pain.

You will be issued this controlled drug under very strict

accountability procedures. Possession of this drug is a

medical responsibility that must not be taken lightly.

Policies pertaining to morphine administration are

outlined in BUMEDINST 6570.2, Morphia Dosage

and Casualty Marking.

MORPHINE ADMINISTRATION

Morphine is the most effective of all pain-relieving

drugs. It is most commonly available in premeasured

doses in syrettes or tubexes. Proper administration in

selected patients relieves distressing pain and assists in

preventing shock. The adult dose of morphine is 10 to

20 mg, which may be repeated, if necessary, in no less

than 4 hours.

Morphine has several undesirable effects,

however, and a Corpsman must thoroughly understand

these effects. Morphine

• is a severe respiratory depressant and must not

be given to patients in moderate or severe shock

or in respiratory distress.

• increases intracranial pressure and may induce

vomiting. These effects may be disastrous in

head injury cases.

• causes constriction of the pupils (pinpoint

pupils). This effect prevents the use of the

pupillary reactions for diagnosis in head injuries.

• is cardiotoxic and a peripheral vasodilator.

Small doses of morphine may cause profound

hypotension in a patient in shock.

• poisoning is always a danger. There is a narrow

safety margin between the amounts of morphine

that may be given therapeutically and the

amounts that produce death.

• causes considerable mental confusion and

interferes with the proper exercise of judgment.

Therefore, morphine should not be given to

ambulatory patients.

• is a highly addictive drug. Morphine should not

be given trivially and must be rigidly accounted

for. Only under emergency circumstances

should the Corpsman administer morphine.

Rigidly control morphine administration to

patients in shock or with extensive burns. Because of

the reduced peripheral circulation, morphine

administration by subcutaneous or intramuscular

routes may not be absorbed into the bloodstream, and

pain may persist. When pain persists, the uninformed

often give additional doses, hoping to bring about

relief. When resuscitation occurs and the peripheral

circulation improves, the stored quantities of morphine

are released into the system, and an extremely serious

condition (morphine poisoning) results.

4-65
When other pain-relieving drugs are not available

and the patient in shock or with burns is in severe pain,

20 mg of morphine may be given intramuscularly

(followed by massage of the injection site). Resist the

temptation to give more, however. Unless otherwise

ordered by a medical officer, doses should not be

repeated more than twice, and then at least 4 hours

apart.

If the pain from a wound is severe, morphine may

be given when examination of the patient reveals no

• head injury;

• chest injury, including sucking and nonsucking

wounds;

• wounds of the throat, nasal passages, oral cavity,

or jaws wherein blood might obstruct the airway;

• massive hemorrhage;

• respiratory impairment, including chemical

burns of the respiratory tract (any casualty

having fewer than 16 respirations per minute

should not be given morphine);

• evidence of severe or deepening shock; or

• loss of consciousness.

CASUALTY MARKING

Morphine overdose is always a danger. For this

reason, plainly identify every casualty who has received

morphine. Write the letter “M” and the hour of injection

on the patient’s forehead (e.g., M0830) with a skin

pencil or semi-permanent marking substitute. Attach

the empty morphine syrette or tubex to the patient’s shirt

collar or another conspicuous area of the clothing with a

safety pin or by some other means. This action will alert

others that the drug has been administered. If a Field

Medical Card is prepared, record the dosage, time, date,

and route of administration.

COMMON MEDICAL EMERGENCIES

LEARNING OBJECTIVE: Choose the

appropriate treatment and management

techniques for the common medical

emergencies.

This section of the chapter deals with relatively

common medical emergencies a Hospital Corpsman

may face. Generally speaking, these particular

problems are the result of previously diagnosed

medical conditions; so, at least for the victim, they do

not come as a complete surprise. Many of these

victims wear a medical identification device (necklace

or bracelet), or carry a medical identification card that

specifies the nature of the medical condition or the type

of medications being taken. In all cases of sudden

illness, search the victim for a medical identification

device.

SYNCOPE

Uncomplicated syncope (fainting) is the result of

blood pooling in dilated veins, which reduces the

amount of blood being pumped to the brain. Causes of

syncope include getting up too quickly, standing for

long periods with little movement, and stressful

situations. Signs and symptoms that may be present

are dizziness; nausea; visual disturbance from

pupillary dilation; sweating; pallor; and a weak, rapid

pulse. As the body collapses, blood returns to the head,

and consciousness is quickly regained. Revival can be

promoted by carefully placing the victim in the shock

position or in a sitting position with the head between

the knees. Placing a cool, wet cloth on the patient’s

face and loosening their clothing can also help.

Syncope may also result from an underlying

medical problem such as diabetes, cerebrovascular

accident (stroke), heart condition, or epilepsy.

DIABETIC CONDITIONS

Diabetes mellitus is an inherited condition in

which the pancreas secretes an insufficient amount of

the protein hormone insulin. Insulin regulates

carbohydrate metabolism by enabling glucose to enter

cells for use as an energy source. Diabetics almost

always wear a medical identification device.

Diabetic Ketoacidosis

Diabetic ketoacidosis most often results either

from forgetting to take insulin or from taking too little

insulin to maintain a balanced condition. Diabetics

may suffer from rising levels of glucose in the blood

stream (hyperglycemia). The rising levels of glucose

result in osmotic diuresis, an increased renal excretion

of urine. Serious dehydration (hypovolemia) may

result. Concurrently, the lack of glucose in the cells

leads to an increase in metabolic acids in the blood

(acidosis) as other substances, such as fats, are

metabolized as energy sources. The result is gradual

central nervous system depression, starting with

symptoms of confusion and disorientation, and leading

4-66
to stupor and coma. Blood pressure falls, and the pulse

rate becomes rapid and weak. Respirations are deep,

and a sickly sweet acetone odor is present on the

breath. The skin is warm and dry.

NOTE: Diabetic victims are often mistakenly

treated as if intoxicated since the signs and

symptoms presented are similar to those of

alcohol intoxication.

The diabetic under treatment tries to balance the

use of insulin against glucose intake to avoid the above

problems. The victim or the victim’s family may be

able to answer two key questions:

1. Has the victim eaten today?

2. Has he taken the prescribed insulin?

If the answer is yes to the first and no to the second

question, the victim is probably in a diabetic coma.

Emergency first aid centers around ABC support,

administration of oral or intravenous fluids to counter

shock, and rapid evacuation to a medical officer’s

supervision.

Insulin Shock

Insulin shock results from too little sugar in the

blood (hypoglycemia). This type of shock develops

when a diabetic exercises too much or eats too little

after taking insulin. Insulin shock is a very serious

condition because glucose is driven into the cells to be

metabolized, leaving too little glucose in circulation to

support the brain. Brain damage develops quickly.

Signs and symptoms of insulin shock include

• pale, moist skin;

• dizziness and headache;

• strong, rapid pulse; and

• fainting, seizures, and coma.

Treatment is centered on getting glucose into the

system quickly to prevent brain damage. Placing sugar

cubes under the tongue or administering oral liquid

glucose are the most beneficial treatments. Transport

the victim to a medical treatment facility as soon as

possible.

NOTE: If you are in doubt as to whether the

victim is in insulin shock or a ketoacidotic

state, give them sugar. Brain damage develops

very quickly in insulin shock and must be

reversed immediately. If the victim turns out

to be ketoacidotic, a condition that progresses

slowly, the extra sugar will do no appreciable

harm.

CEREBROVASCULAR ACCIDENT

A cerebrovascular accident, also known as stroke

or apoplexy, is caused by an interruption of the arterial

blood supply to a portion of the brain. This

interruption may be caused by arteriosclerosis or by a

clot forming in the brain. Tissue damage and loss of

function result.

Onset of a cerebrovascular accident is sudden,

with little or no warning. The first signs include

weakness or paralysis on the side of the body opposite

the side of the brain that has been injured. Muscles of

the face on the affected side may be involved. The

patient’s level of consciousness varies from alert to

unresponsive. Additionally, motor functions

including vision and speechon the affected side are

disturbed, and the throat may be paralyzed.

Emergency treatment for a cerebrovascular

accident is mainly supportive. Special attention must

be paid to the victim’s airway, since he may not be able

to keep it clear. Place the victim in a semi-reclining

position or on the paralyzed side.

• Be prepared to use suction if the victim vomits.

• Act in a calm, reassuring manner, and keep any

onlookers quiet since the victim may be able to

hear what is going on.

• Administer oxygen to combat cerebral hypoxia.

• Carefully monitor the victim’s vital signs and

keep a log. Pay special attention to respirations,

pulse strength and rate, and the presence or

absence of the bilateral carotid pulse.

• Transport the victim to a medical treatment

facility as soon as possible.

ANAPHYLACTIC REACTION

This condition, also called anaphylaxis or

anaphylactic shock, is a severe allergic reaction to

foreign material. The most frequent causes are

probably penicillin and the toxin from bee stings,

although foods, inhalants, and contact substances can

also cause a reaction. Anaphylaxis can happen at any

time, even to people who have taken penicillin many

times before without experiencing any problems. This

condition produces severe shock and cardiopulmonary

failure of a very rapid onset. Because of the rapidity

4-67
and severity of the onset of symptoms, immediate

intervention is necessary. The general treatment for

severe anaphylaxis is the subcutaneous injection of

0.3 cc of epinephrine and supportive care.

The most characteristic and serious symptoms of

an anaphylactic reaction are loss of voice and difficulty

breathing. Other typical signs are giant hives,

coughing, and wheezing. As the condition progresses,

signs and symptoms of shock develop, followed by

respiratory failure. Emergency management consists

of maintaining vital life functions. Summon the

medical officer immediately.

POISONS/DRUG ABUSE/HAZARDOUS

MATERIALS

As a Hospital Corpsman, you could encounter

special situations that include poisoning, suspected

drug abuse, or exposure to hazardous materials.

Knowledge of these conditionsalong with the ability

to assess and treat themis essential. These situations

are discussed in detail in chapter 5, “Poisoning, Drug

Abuse, and Hazardous Material Exposure.”

HEART CONDITIONS

A number of heart conditions are commonly

referred to as heart attacks. These conditions include

angina pectoris, acute myocardial infarction, and

congestive heart failure. Together these heart

conditions are the cause of at least half a million deaths

per year in our country. Heart conditions occur more

commonly in men in the 50-to-60-year age group.

Predisposing factors are the lack of physical

conditioning, high blood pressure and blood

cholesterol levels, smoking, diabetes, and a family

history of heart disease.

Angina Pectoris

Angina pectoris, also known simply as angina, is

caused by insufficient oxygen being circulated to the

heart muscle. This condition results from a spasm of

the coronary artery, which allows the heart to function

adequately at rest but does not allow enough

oxygen-enriched blood to pass through the heart to

support sustained exercise. When the body exerts

itself, the heart muscle becomes starved for oxygen.

The result of this condition is a squeezing, substernal

pain that may radiate to the left arm and to the jaw.

Angina is differentiated from other forms of heart

problems because the pain results from exertion and

subsides with rest. Many people who suffer from

angina pectoris carry nitroglycerin tablets. If the

victim of a suspected angina attack is carrying a bottle

of these pills, place one pill under the tongue. Relief

will be almost instantaneous. Other first aid

procedures include providing supplemental oxygen,

reassurance, comfort, monitoring vital signs, and

transporting the victim to a medical treatment facility.

Acute Myocardial Infarction

Acute myocardial infarction results when a

coronary artery is severely occluded by

arteriosclerosis or completely blocked by a clot. The

pain associated with myocardial infarction is similar to

that of angina pectoris but is longer in duration, not

related to exertion or relieved by nitroglycerin, and

leads to death of heart-muscle tissue. Other symptoms

are sweating, weakness, and nausea. Additionally,

although the patient’s respirations are usually normal,

his pulse rate increases and may be irregular, and his

blood pressure falls. The victim may have an

overwhelming feeling of doom. Death may result.

First aid for an acute myocardial infarction

includes

• reassurance and comfort while placing the

victim in a semi-sitting position;

• loosening of all clothing;

• carefully maintaining a log of vital signs, and

recording the history and general observations;

• continuously monitoring vital signs and being

prepared to start CPR;

• starting a slow intravenous infusion of 5%

dextrose solution in water;

• administering oxygen; and

• quickly transporting the victim to a medical

treatment facility.

Congestive Heart Failure

A heart suffering from prolonged hypertension,

valve disease, or heart disease will try to compensate

for decreased function by increasing the size of the left

ventricular pumping chamber and increasing the heart

rate. This condition is known as congestive heart

failure. As blood pressure increases, fluid is forced out

of the blood vessels and into the lungs, causing

pulmonary edema. Pulmonary edema leads to rapid

shallow respirations, the appearance of pink frothy

4-68
bubbles at the nose and mouth and distinctive rattling

sounds (known as rales) in the chest. Increased blood

pressure may also cause body fluids to pool in the

extremities.

Emergency treatment for congestive heart failure

is essentially the same as that for acute myocardial

infarction. Do not start CPR unless the patient’s heart

function ceases. If an intravenous line is started, it

should be maintained at the slowest rate possible to

keep the vein open since an increase in the circulatory

volume will make the condition worse. Immediately

transport the patient to a medical treatment facility.

CONVULSIONS

Convulsions, or seizures, are a startling and often

frightening phenomenon. Convulsions are

characterized by severe and uncontrolled muscle

spasms or muscle rigidity. Convulsive episodes occur

in one to two percent of the general population.

Although epilepsy is the most widely known form

of seizure activity, there are numerous forms of

convulsions that are classified as either central nervous

system (CNS) or non-CNS in origin. It is especially

important to determine the cause in patients who have

no previous seizure history. This determination may

require an extensive medical workup in the hospital.

Since epilepsy is the most widely known form of

seizure activity, this section will highlight epileptic

seizure disorders.

Epilepsy, also known as seizures or fits, is a

condition characterized by an abnormal focus of

activity in the brain that produces severe motor

responses or changes in consciousness. Epilepsy may

result from head trauma, scarred brain tissue, brain

tumors, cerebral arterial occlusion, fever, or a number

of other factors. Fortunately, epilepsy can often be

controlled by medications.

Grand mal seizure is the more serious type of

epilepsy. Grand mal seizure may bebut is not

alwayspreceded by an aura. The victim soon comes

to recognize these auras, which allows him time to lie

down and prepare for the seizure’s onset. A burst of

nerve impulses from the brain causes unconsciousness

and generalized muscular contractions, often with loss

of bladder and bowel control. The primary dangers in a

grand mal seizure are tongue biting and injuries

resulting from falls. A period of sleep or mental

confusion follows this type of seizure. When full

consciousness returns, the victim will have little or no

recollection of the attack.

Petit mal seizure is of short duration and is

characterized by an altered state of awareness or partial

loss of consciousness, and localized muscular

contractions. The patient has no warning of the

seizure’s onset and little or no memory of the attack

after it is over.

First aid treatment for both types of epileptic

seizure consists of protecting the victim from

self-injury. Additional methods of seizure control may

be employed under a medical officer’s supervision. In

all cases, be prepared to provide suction to the victim

since the risk of aspiration is significant. Transport the

patient to a medical treatment facility once the seizure

has ended.

DROWNING

Drowning is a suffocating condition in a water

environment. Water seldom enters the lungs in

appreciable quantities because, upon contact with

fluid, laryngeal spasms occur, and these spasms seal

the airway from the mouth and nose passages. To

avoid serious damage from the resulting hypoxia,

quickly bring the victim to the surface and

immediatelyeven before the victim is pulled to

shorestart artificial ventilation. Do not interrupt

artificial ventilation until the rescuer and the victim are

ashore. Once on dry ground, quickly administer an

abdominal thrust (Heimlich maneuver) to empty the

lungs, and then immediately restart the ventilation

until spontaneous breathing returns. Oxygen

enrichment is desirable if a mask is available.

Remember that an apparently lifeless person who

has been immersed in cold water for a long period of

time may be revived if artificial ventilation is started

immediately.

PSYCHIATRIC EMERGENCIES

A psychiatric emergency is defined as a sudden

onset of behavioral or emotional responses that, if not

responded to, will result in a life-threatening situation.

Probably the most common psychiatric emergency is

the suicide attempt. A suicide attempt may range from

verbal threats and suicidal gestures to a successful

suicide. Always assume that a suicide threat is real; do

not leave the patient alone. In all cases, the prime

consideration for a Hospital Corpsman is to keep

patients from inflicting harm to themselves and to get

them under the care of a trained psychiatric

professional. When dealing with suicidal gestures or

attempts, treat any self-inflicted wounds appropriately.

4-69
In the case of ingested substances, do not induce

vomiting in a patient who is not awake and alert. For

specific treatment of ingested substances, refer to the

section on poisons in chapter 5.

There are numerous other psychiatric conditions

that would require volumes to expound upon. In

almost all cases, appropriate first aid treatment

consists of a calm, professional, understanding

demeanor that does not aggravate or agitate the patient.

With an assaultive or hostile patient, a “show of force”

may be all that is required. Almost all cases of

psychiatric emergencies will present with a third

party]often the family or friend of the patientwho

has recognized a distinct change in the behavior

pattern of the patient and who is seeking help for them.

DERMATOLOGIC EMERGENCIES

Most dermatologic cases that present as

emergencies are not real emergencies. The patient

perceives them as such because of the sudden

presentation and/or repulsive appearance or excessive

discomfort. Treat most dermatologic conditions

symptomatically. The major exception to

symptomatic treatment is toxic epidermal necrolysis

(TEN).

Toxic epidermal necrolysis is a condition

characterized by sudden onset, excessive skin

irritation, painful erythema (redness of skin produced

by congestion of the capillaries), bullae (large

blisters), and exfoliation of the skin in sheets. TEN is

also known as the scalded skin syndrome because of

its appearance. TEN is thought to be caused by a

staphylococcal infection in children and by a toxic

reaction to medications in adults.

Since skin is the largest single organ of the body

and serves as a barrier to infection, prevention of

secondary skin infection is very important. Treatment

of skin infections consists of isolation techniques,

silver nitrate compresses, aggressive skin care,

intravenous antibiotic therapy and, in drug-induced

cases, systemic steroids.

EMERGENCY CHILDBIRTH

Every Hospital Corpsman must be prepared to

handle the unexpected arrival of a new life into the

world. If the Corpsman is fortunate, a prepackaged

sterile delivery pack will be available. This pack will

contain all the equipment needed for the normal

delivery of a healthy baby. If the pack is not available,

a Hospital Corpsman will require imaginative

improvisation of clean alternatives.

When faced with an imminent childbirth, the

Hospital Corpsman must first determine whether there

will be time to transport the expectant mother to a

hospital. To help make this determination, the

Corpsman should try to find out

• if this will be the woman’s first delivery (first

deliveries usually take much longer than

subsequent deliveries);

• the time between contractions (if less than 3

minutes, delivery is approaching);

• if the mother senses that she has to move her

bowels (if so, then the baby’s head is well

advanced down the birth canal);

• if there is crowning (bulging) of the orifice

(crowning indicates that the baby is ready to

present itself); and

• how long it will take to get to the hospital.

The Corpsman must weigh the answers to these

questions and decide if it will be safe to transport the

patient to the hospital.

Prior to childbirth, a Corpsman must quickly “set

the stage.” The mother must not be allowed to go to the

bathroom since straining may precipitate delivery. Do

not try to inhibit the natural process of childbirth. The

mother should lie back on a sturdy table, bed, or

stretcher with a folded sheet or blanket placed under

her buttocks for absorption and comfort. Remove all

the patient’s clothing below the waist, bend the knees,

move the thighs apart, and drape her lower extremities

with clean towels or sheets. Don sterile gloves, or, if

these are not available, rewash your hands.

In a normal delivery, your calm professional

manner and sincere reassurance to the mother will

reduce her anxiety and make the delivery easier for

everyone. Help the woman rest and relax as much as

possible between contractions. During a contraction,

deep, open-mouth breathing will relieve some pain and

straining. As the child’s head reaches the area of the

rectum, the mother will feel an urgent need to defecate.

Reassurance that this is a natural feeling and a sign that

the baby will be born soon will help alleviate her

apprehension.

Watch for the presentation of the top of the baby’s

head. Once the head appears, take up your station at

the foot of the bed and gently push against the head to

keep it from emerging too quickly. Allow it to come

4-70
out slowly. As more of the head appears, check to be

sure that the umbilical cord is not wrapped around the

neck. If it is, either gently try to untangle the cord, or

move one section over the baby’s shoulder. If neither

of these actions is possible, clamp the cord in two

places, 2 inches apart, and cut it. Once the baby’s chin

emerges, support the head with one hand and use the

bulb syringe from the pack to suction the nostrils and

mouth. Before placing the bulb in the baby’s mouth or

nose, compress it; otherwise, a forceful aspiration into

the lungs will result. The baby will now start a natural

rotation to the left or right, away from the face-down

position. As this rotation occurs, keep the baby’s head

in a natural relationship with the back. The shoulders

appear next, usually one at a time.

NOTE: From this point on, it is essential to

remember that the baby is VERY slippery, and

great care must be taken so that you do not

drop it. The surface beneath the mother should

extend at least 2 feet out from her buttocks so

that the baby will not be hurt if it does slip out

of your hands. Keep one hand beneath the

baby’s head, and use the other hand to support

its emerging body.

Once the baby has been born, suction the nose and

mouth again if breathing has not started. Wipe the

baby’s face, nose, and mouth clean with sterile gauze.

Your reward will be the baby’s hearty cry.

Clamp the umbilical cord as the pulsations cease.

Use two clamps from the prepackaged sterile delivery

pack, 2 inches apart, with the first clamp 6 to 8 inches

from the navel. Cut the cord between the clamps. For

safety, use gauze tape to tie the cord 1 inch from the

clamp toward the navel. Secure the tie with a square

knot. Wrap the baby in a warm, sterile blanket, and log

its time of arrival.

The placenta (afterbirth) will deliver itself in 10 to

20 minutes. Massaging the mother’s lower abdomen

can aid this delivery. Do not pull on the placenta. Log

the time of the placenta’s delivery, and wrap it up for

hospital analysis.

Place a small strip of tape ( 1⁄2 -inch wide), folded

and inscribed with the date, time of delivery, and

mother’s name, around the baby’s wrist.

COMPLICATIONS IN CHILDBIRTH

Unfortunately, not all deliveries go smoothly. The

following sections cover various complications in

childbirth.

Breech Delivery

A breech delivery occurs when the baby’s legs and

buttocks emerge first. Follow the steps for a normal

delivery, and support the lower extremities with one

hand. If the head does not emerge within 3 minutes, try

to maintain an airway by gently pushing fingers into

the vagina. Push the vagina away from the baby’s face

and open its mouth with one finger. Get medical

assistance immediately.

Prolapsed Cord

If the cord precedes the baby, protect it with moist,

sterile wraps. If a physician cannot be reached quickly,

place the mother in an extreme shock position. Give

the mother oxygen, if available, and gently move your

gloved hand into the vagina to keep its walls and the

baby from compressing the cord. Get medical

assistance immediately.

Excessive Bleeding

If the mother experiences severe bleeding, treat

her for shock and give her oxygen, if available. Place

sanitary napkins over the vaginal entrance and rush her

to a hospital.

Limb Presentation

If a single limb presents itself first, immediately

get the mother to a hospital.

SUMMARY

A medical emergency can occur at anytime. You

must be prepared to act expeditiously and confidently,

whether you are in a combat situation, on board a naval

vessel, or at the Navy Exchange. This chapter covers

the preliminary steps you should follow when

managing sick or injured patients. The preliminary

emergency steps include triage, patient assessment,

and, when needed, basic life support. Other related

topics covered in this chapter are breathing aids, shock,

diagnosis and emergency treatment procedures for

medical conditions and injuries, morphine use for pain

relief, and other common emergencies. In the

following chapters, diagnosis and emergency

treatment procedures for medical conditions and

injuries will be discussed.

4-71

CHAPTER 5

POISONING, DRUG ABUSE, AND HAZARDOUS

MATERIAL EXPOSURE

As a Hospital Corpsman, you may encounter

patients as the result of poisoning, drug overdose, or

exposure to hazardous materials. Such patients may

initially present with no symptoms or with varying

degrees of overt intoxication. The asymptomatic

patient may have been exposed to or ingested a lethal

dose of a substance but not exhibit any manifestations

of toxicity. A patient with mild symptoms may

deteriorate rapidly, so observe them closely.

Potentially significant exposures should be observed

in an acute care facility whenever possible.

Remember, though: We are not always in a hospital

environment, and we must be prepared to deal with

each situation when and wherever it should present

itself.

In this chapter, we will discuss the assessment and

treatment for ingested, inhaled, absorbed, and injected

poisons. Drug abuse assessment and treatment

procedures, patient handling techniques, and the

recognition of hazardous material (HAZMAT)

personal safety guidelines and information sources

will also be covered. The last part of the chapter will

cover rescue, patient care, and decontamination

procedures for patients exposed to HAZMAT.

NOTE: Prior to deployments and operational

commitments, commands are strongly

recommended to contact the area

Environmental Preventive Medicine Unit

(EPMU) for current, specific, medical

intelligence, and surveillance data. With this

information at hand, the local preventive

medicine authority can identify, prevent, and

treat conditions not common to the homeport

area. The cognizant EPMU will provide data

through MEDIC, (Medical, Environmental,

Diagnosis, Intelligence and Countermeasure). Formally called a Disease Risk

Assessment Profile (DISRAP), MEDIC is a

comprehensive, constantly updated

management tool. MEDIC is an invaluable

aid for identifying at-risk communicable

diseases, immunization requirements, and—

as applies especially to this chapter—local

pests and environmental dangers.

POISONING

LEARNING OBJECTIVE: Recall

assessment and treatment procedures for

ingested, inhaled, absorbed, and injected

poisons

A poison is a substance that, when introduced into

the body, produces a harmful effect on normal body

structures or functions. Poisons come in solid, liquid,

and gaseous forms, and they may be ingested, inhaled,

absorbed, or injected into the system.

Every chemical in a sufficient dose can cause toxic

effects in a human—or in any organism. The amount

or concentration of a chemical and the duration of

exposure to it are what determine the chemical’s dose

and toxicity. A 16th century quotation from Paracelsus

states, “Dose alone makes a poison. . . .All substances

are poisons, there is none which is not a poison. The

right dose differentiates a poison and a remedy. ”

A poisoning is defined as the presence of signs or

symptoms associated with exposure or contact with a

substance. If there are no clinical manifestations or

toxic effects, the incident is simply an “exposure” or a

contact with a potentially poisonous substance. Just

being exposed to a chemical does not mean that a

poisoning has or will occur. It is a matter of dose and

a few other variables (e.g., age, sex, individual

resistance, or state of health) that determine if, or what,

toxic effects will occur.

ASSESSMENT AND TREATMENT

OF PATIENT

In most cases, ASSESSMENT AND TREATMENT

OF THE PATIENT IS MORE IMPORTANT THAN

EFFORT TO IDENTIFY AND TREAT A SPECIFIC

POISON. Supportive therapy—managing the ABCs

(Airway, Breathing, and Circulation) of basic life

support and treating the signs and symptoms—is safe

and effective in the vast majority of poisonings.

Extraordinary means to enhance elimination of the

poison (hemodialysis and hemoperfusion) are seldom

needed. Except for agents with a delayed onset of

5-1
toxicity (such as acetaminophen), most ingested

poisons produce signs and symptoms in less than 4

hours, and most efforts to decontaminate the gut

(remove an ingested poison) have little value more

than 1 hour after ingestion.

In acute poisonings, prompt treatment is indicated.

After the patient has been evaluated and stabilized,

general poison management can be initiated. There are

six steps in the initial evaluation and follow-on poison

management:

1. Stabilization, which consists of a brief

evaluation and assessment directed toward

identifying the measures required to maintain life

and prevent further deterioration of the patient.

• Observe the ABC + D & E (Drug-induced

central nervous system (CNS) depression,

and undressing/uncovering to Expose the

patient for disabilities (injuries) to ensure

areas of contact or exposure to a chemical

can be seen.)

• Check the pupils for size and reactivity to

light, and do a basic neurologic exam.

• Administer oxygen as needed, IV line for

fluids.

• Watch for signs and symptoms of

anaphylaxis.

2. Evaluation, which must be performed once the

patient is stabilized.

• Include a full history, physical exam, and

ordering of appropriate tests (i.e., labs, EKG,

x-rays) directed toward identification of

toxic agent, evaluating the severity of toxic

effects, and searching for trauma and

complications.

• Periodically reassess the patient. Look for

changes. Monitor vital signs, urine output,

and cardiac rhythm.

• Record your findings (including time), and

respond to important changes appropriately.

3. Prevention or limitation of absorption,

through skin decontamination, flushing of eyes,

ventilation, stomach emptying, administration

of charcoal and cathartics, and whole bowel

irrigation.

4. Elimination enhancement, through serially

administered activated charcoal, ion-trapping

(pH adjustment of the urine to promote

excretion of certain poisons), hemodialysis, and

hemoperfusion (similar to hemodialysis, but

used for larger size molecules).

5. Administration of specific antidotes. Less

than 5 percent of poisons have specific

antidotes. All patients who present should

receive glucose, thiamine, and naloxone.

Consider supplemental oxygen.

6. Continuing care and disposition, including a

period of observation and education (i.e., poison

prevention) or psychiatric counseling.

Establish follow-up.

THE DIAGNOSIS OF POISONING

In most situations, the treatment of a poisoning

victim will be under the direction of a medical officer.

However, in isolated situations, a Hospital Corpsman

must be ready to treat the victim.

Poisoning should be suspected in all cases of

sudden, severe, and unexpected illness. You should

investigate such situations by ascertaining, as quickly

and thoroughly as possible, the answers to the

following questions:

• What are the signs and symptoms of the illness?

• What was happening before the illness

occurred? (Remember, there may have been a

chronic exposure over time with the signs and

symptoms just becoming apparent.)

• What substances were in use? Could more than

one substance have been involved?

• Is there a container of the suspected substance?

If so, how much was there initially, and how

much is there now? (If possible, bring the

container to the treatment facility. The label will

often identify the contents and the recommended

precautions and treatment. The label may also

list a contact number for emergency advice.

Remember, though, that other people—

including you—may become contaminated

through contact with the container. Handle it

carefully.)

• What was the duration of exposure? When did it

happen?

• What is the location of the bite or injury (if

applicable)?

• Has this happened before?

5-2
• Are there other people involved?

• Does the patient have a significant past medical

history?

• Is the patient’s condition improving/

deteriorating?

The presence of a toxic syndrome or toxidrome can

help establish that a poison has been involved by

suggesting the class of poison(s) to which the patient may

have been exposed. Table 5-1 provides a list of commonly

encountered toxidromes, their sources and symptoms.

The “non-syndrome syndrome” is of special

importance. The only method to recognize the potential

for a delayed onset poisoning to occur is to suspect the

possibility from the history or presentation of a person.

In some cases, the individual’s affect or behavior may

provide a clue. In other cases, the examiner must rely on

clinical experience or even a hunch.

GENERAL TREATMENT

Once poisoning has been established, the general

rule is to quickly remove as much of the toxic

substance from the victim as possible. The method of

removal of the poison varies depending upon how the

poison was introduced:

• Ingested poisons: There is a choice between

emetics and gastric lavage, followed by

adsorbents and cathartics.

• Inhaled poisons: Oxygen ventilation is the

method of choice.

• Absorbed poisons: Removal of the poison is

primarily attained by cleansing the skin.

• Injected poisons: Antidotal medications are

recommended.

INGESTED POISONS

Ingested poisons are those poisons which have

been consumed, whether accidentally or intentionally,

by the victim. Ingestion is the most common route of

exposure to toxic materials in the home.

The local actions of an ingested poison can have

irritant, acidic (corrosive), or basic (caustic) effects at

the site of contact.

5-3

Syndrome Sources Signs & Symptoms

narcotic opiates, benzodiazepines, barbiturates Abeady eyes,@ sunglasses, decreased blood pressure,

CNS and respiratory depression

withdrawal alcohol, barbiturates, benzodiazepines,

narcotics, sedative-hypnotics

diarrhea, dilated pupils, goose bumps, increased heart

rate, tearing, yawning, stomach cramps, hallucinations

sympathomimetic t he o p h ylli ne, ca f fei ne, LSD, PCP,

amphetamine, cocaine, decongestants

CNS excitation (confusion, incoordination, agitation,

hallucination, delirium, seizures), increased blood

pressure and heart rate

anticholinergic antihistamines, atropine, scopolamine,

antidepressants, anti-Parkinson L,

antipsychotics, antispasmodics, mushrooms, hallucinogens, antidepressants

dry skin, increased heart rate, dilated pupils, fever,

urinary retention, decreased bowel sounds, CNS

excitation

cholinergic organophosphates, carbamates, physostigmine, neostigmine, endrophoniumASLUDGE@: increased salivation, lacrimation,

urination, defecation, GI cramping, emesis; CNS

(headache, restless, anxiety, confusion, coma,

seizures); muscle weakness and fasciculations

non-syndrome

syndrome

various chemicals with delayed onset due to

biotransformation, depletion of natural

detoxifying agent, accumulation of dose or

effect

fromAnothing@to minor complaints that initially appear

to be trivial

Table 5-1.—Commonly Encountered Toxidromes
NOTE

There are two important categories of substances which act locally on the skin, eyes, or

mucous membranes and cause damage

through direct contact. These are acids (corrosives) and bases (caustics). Although these

two categories are distinct and there are significant differences in the physiological effects of contact with them, the term

“corrosive” is recognized as a generic term

for the action that occurs upon contact with either an acid or a base. The terms “corrosive”

and “noncorrosive,” as used in this chapter,

should be understood to represent the generic

and not the specific. When specifically discussing acids or bases in this chapter, the

terms “acid” or “base” (or “alkali”), respectively, will be used.

Ingested substances can be absorbed into the body

and transported to a distant site with systemic

action(s). In such situations, the poisonous substance

may cause few effects—or even no effect—at the site

of contact or absorption, but it may have severe

systemic effects.

Ingestion of substances that do not produce local

effects can be divided into two types:

• nontoxic substances (latex paint, dirt, silica gel,

spider plant), and

• potentially toxic substances (poisonous fish,

medications, heavy metals (lead, mercury),

pesticides, and personal care products).

Episodes involving the ingestion of non-toxic

substances do not require decontamination of the gut.

(Swallowing a non-toxic foreign body, however, like a

coin or button battery in a child, may result in choking

and require prompt medical intervention.)

The toxicity range of absorbed poisons extends

from essentially non-toxic to extremely toxic

(remember Paracelsus’ “dose”). Ingestion of

substances with a low order of toxicity may result in

the production of only minor systemic effects (nausea,

vomiting, diarrhea), effects that are mild, self-limiting,

and do not require significant medical intervention.

NOTE: Do not induce unnecessary vomiting

to discourage a patient from repeating a

voluntary ingestion again.

Noncorrosives

The many different noncorrosive substances have

the common characteristic of irritating the stomach.

They produce nausea, vomiting, convulsions, and

severe abdominal pain. The victim may complain of a

strange taste, and the lips, tongue, and mouth may look

different than normal. Shock may also occur.

Examples of noncorrosives are listed in table 5-2.

First aid for most forms of noncorrosive poisoning

centers on quickly emptying the stomach of the

irritating substance. The following steps are suggested:

1. Maintain an open airway. Be prepared to give

artificial ventilation.

2. Dilute the poison by having the conscious

victim drink one to two glasses of water or milk.

3. Empty the stomach using emetic, gastric lavage,

adsorbent, and/or cathartic.

a. Giving an emetic is a preferred method for

emptying the contents of the stomach. It is

5-4

Irritant Sources of Contact

Arsenic Dyes, insecticides, paint, printer=s ink,

wood preservatives

Copper Antifoulant paint, batteries, canvas

preservative, copper plating, electroplating, fungicides, insecticides, soldering, wood preservatives

Iodine Antiseptics

Mercury Bactericides, batteries, dental supplies

and appliances, disinfectants, dyes,

fungicides, ink, insecticides, laboratories, photography, wood preservatives

Phosphorus Incendiaries, matches, pesticides, rat

poison

Silver nitrate Batteries, cleaning solutions, ink,

photographic film, silver polish,

soldering

Zinc Disinfectants, electroplating, fungicides, galvanizing, ink, insecticides,

matches, metal plating and cutting,

paint, soldering, wood preservatives

Table 5-2.—Common Stomach Irritants and Possible Sources

of Contact
quick and—except in cases of caustic or

petroleum distillate poisoning, or when an

antiemetic has been ingested—can be used

in almost every situation when the victim is

conscious. In most situations, a Hospital

Corpsman will have access to syrup of

Ipecac. This emetic acts locally by irritating

the gastric mucosa and centrally by

stimulating the medullary vomiting center in

the brain. The usual adult dose is 15-30 cc,

and the dose for a child (age 1 to 12 years) is

15 cc. The dosage should be followed

immediately by a glass of water. Most

people will vomit within 30 minutes. The

amount of stomach contents (and poison)

recovered will vary. In an emergency room,

the medical officer can rapidly induce

vomiting by the injection of various

medications. If nothing else is available,

tickle the back of the victim’s throat with

your finger or a blunt object. This procedure

should induce vomiting.

b. Trained personnel may use gastric lavage by

itself or after two doses of Ipecac syrup has

failed to induce vomiting. After passing a

large—caliber nasogastric tube, aspirate the

stomach contents. Next, instill 100 ml of

normal saline into the stomach, then aspirate

it out again. Continue this flushing cycle

until the returning fluid is clear. Gastric

lavage is preferred when the victim is

unconscious or—as in the case of strychnine

poisoning—is subject to seizures.

c. Activated charcoal (AC) adsorbs many

substances in the gut and prevents

absorption into the body. After the

substance is adsorbed to the AC, the bound

substance moves through the gut and is

eliminated with the production of a

charcoal-black bowel movement. AC may

be administered after emesis or lavage, or it

may be used alone.

d. A cathartic (magnesium sulfate or sorbitol)

may be used to “speed” the movement of the

bound substance and minimize absorption.

4. Collect the vomitus for laboratory analysis.

5. Soothe the stomach with milk or milk of

magnesia.

6. Transport the victim to a definitive care facility

if symptoms persist.

Corrosives

Acids and alkalies (bases) produce actual chemical

burning and corrosion of the tissues of the lips, mouth,

throat, and stomach. Acids do most of their damage in

the acidic stomach environment, while alkalies

primarily destroy tissues in the mouth, throat, and

esophagus. Stains and burns around the mouth, and the

presence of characteristic odors provide clues as to an

acid or base ingestion. Swallowing and breathing may

be difficult, especially if any corrosive was aspirated

into the lungs. Stridor, a high-pitched sound coming

from the upper airway, may be heard. The abdomen

may be tender and swollen with gas, and perforation of

the esophagus or stomach may occur. NEVER

ATTEMPT TO TREAT AN ACID OR BASE

INGESTION BY ADMINISTERING A

NEUTRALIZING SOLUTION BY MOUTH.

GIVE WATER ONLY, UNLESS DIRECTED BY A

POISON CONTROL CENTER (PCC) OR

MEDICAL OFFICER. Monitor the ABC+D&Es,

and watch for signs of shock.

Examples of corrosive agents and sources of

contact are listed in table 5-3.

When providing treatment for the above poisons,

DO NOT INDUCE VOMITING. The damage to the

mouth and esophagus will be compounded. In

addition, the threat of aspiration during vomiting is too

great. Gastric lavage could cause perforation of the

esophagus or stomach. Therefore, use it only on a

doctor’s order. First aid consists of diluting the

corrosive and keeping alert for airway potency and

shock. If spontaneous vomiting occurs, administer an

antiemetic.

Irritants

Substances such as automatic dishwasher

detergent, diluted ammonia, and chlorine bleach can

produce local irritation to the mucous membranes and

potentially cause mild chemical burns. The pH of

irritants may be slightly acidic or basic. If a person has

ingested an irritant, direct the patient to spit the product

out and rinse the mouth repeatedly with water. Spit the

rinse water out also. Do NOT administer anything

other than water unless directed by a PCC or medical

officer.

Petroleum Distillates or Hydrocarbons

Volatile petroleum products (such as kerosene,

gasoline, turpentine, and related petroleum products

5-5
like red furniture polish) usually cause severe

chemical pneumonia as well as other toxic effects in

the body. Symptoms include abdominal pain, choking,

gasping, vomiting, and fever. Often these products

may be identified by their characteristic odor. Mineral

oil and motor oil are not as serious since they usually

do nothing more than cause diarrhea.

When providing treatment for the ingestion of

petroleum distillates, DO NOT INDUCE

VOMITING unless told to do so by a physician or

poison control center. Vomiting may cause additional

poison to enter the lungs. However, the quantity of

poison swallowed or special petroleum additives may

make gastric lavage or the use of cathartics advisable.

If a physician or poison control center cannot be

reached, give the victim 30 to 60 ml of vegetable oil.

Transport the victim immediately to a medical

treatment facility.

Food Poisoning

Food poisoning can occur from ingesting animal

or plant materials, or even from the chemicals that are

used in raising, processing, or preserving crops and

livestock. Although illness associated with a

contaminated water supply could be considered a type

of food poisoning, this issue will not be addressed.

Most bacterial and viral food poisonings appear

within 8 hours of ingesting food. The signs and

symptoms of poisoning include nausea, vomiting,

diarrhea, muscle aches, and low-grade fever. The

general treatment is supportive and directed at

preventing dehydration through the administration of

fluids. If diarrhea persists more than 24 hours, or if the

patient is unable to keep fluids down, further definitive

medical care is necessary. Food poisoning can also

occur from ingestion of parasites.

Marine food-borne illnesses from ingesting fish

and shellfish is a concern especially when traveling to

new destinations. Wherever you are in the world, you

should learn which local seafood is known to be safe

and which present the potential for harm. Table 5-4

lists some of toxins found in fish and shellfish and their

potential sources.

Mussels, clams, oysters, and other shellfish often

become contaminated with bacteria during the warm

months of March through November (in the northern

hemisphere). Numerous varieties of shellfish should

not be eaten at all. Therefore, wherever you are in the

world, you should learn which local seafoods are

known to be safe and which present the potential for

harm.

5-6

Agent Sources of Contact

Hydrochlori

c

Electroplating, metal

cleaners, photoengraving

Nitric Industrial cleaners,

laboratories,

photoengraving, rocket

fuels

ACIDS

Oxalic Cleaning solutions, paint

and rust removers, photo

developer

Sulfuric Auto batteries, detergents,

dyes, laboratories, metal

cleaners

ALKALIES

Ammonia Galvanizers, household

cleaners, laboratories,

pesticides, rocket fuels

Lime Brick masonry, cement,

electroplating, insecticides,

soap, water treatment

Lye Bleaches, degreasers,

detergents, laboratories,

paint and varnish removers

Carbolic Disinfectants, dry batteries,

paint removers, photo

materials, wood

preservatives

Creosol Disinfectants, ink, paint

and varnish removers,

photo developer, stainers

PHENOLS

Creosote Asbestos, carpentry, diesel

engines, electrical shops,

furnaces, lens grinders,

painters, waterproofing,

wood preservatives

Table 5-3.—Examples of Common Acids, Alkalies, and

Phenols, with Possible Sources of Contact
Most fish poisonings occur from eating fish that

normally are considered to be safe to eat. However,

fish can become poisonous at different times of the

year because of their consumption of poisonous algae

and plankton (red tide) that occur in certain locations.

The signs and symptoms of red tide paralytic shellfish

poisoning are tingling and numbness of the face and

mouth, muscular weakness, nausea and vomiting,

increased salivation, difficulty in swallowing, and

respiratory failure. Primary treatment is directed at

evacuating the stomach contents as soon as possible. If

the patient has not vomited, select the appropriate

method to remove the stomach contents by either syrup

of Ipecac or gastric lavage. If respiratory failure

develops, support ventilation and other life-sustaining

systems as needed.

Examples of fish that are known to be poisonous

AT ALL TIMES are shown in figure 5-1.

The symptoms of shellfish and fish poisoning are

tingling and numbness of the face and mouth, muscular

weakness, nausea and vomiting, increased salivation,

difficulty in swallowing, and respiratory failure.

Primary treatment is directed toward evacuating

the stomach contents. If the victim has not vomited,

cause him to do so. Use syrup of Ipecac, gastric lavage,

or manual stimulation; then administer a cathartic. If

respiratory failure develops, give artificial ventilation

and treat for shock.

INHALATION POISONS

In the Navy, and in other industrial settings in

general, inhalation is the most common route of

exposure to toxic substances. The irritants and

corrosives mentioned in tables 5-2 and 5-3 are more

often a source of poisoning by means of inhalation

rather than by ingestion. An inhaled poison can act

directly on the upper respiratory tract or lungs with

immediate, delayed, or chronic effects, or the

substance can use the pulmonary system to gain entry

into the body, be absorbed into the blood, and cause

toxic effects (systemic toxicity) at a distant site of

action.

The handling of large quantities of petroleum

products (fuel oil and gasoline, in particular)

constitutes a special hazard, since all of these products

give off hazardous vapors. Other poisonous gases are

by-products of certain operations or processes:

exhaust fumes from internal combustion engines;

fumes or vapors from materials used in casting,

molding, welding, or plating; gases associated with

bacterial decomposition in closed spaces; and gases

that accumulate in voids, double bottoms, empty fuel

5-7

Toxin Source

Ciguatoxin

(cholinergic

effects)

tends to be found in fish from coral

reefs, including barracuda, grouper,

red snapper, parrot fish

Scombrotoxin

(histamine-like

reaction)

tuna, bonito, skipjack, mackeral,

mahi mahi

Saxitoxin

(neurologic

effects)

bivalve shellfish (mussels, clams,

scallops) accumulate toxin from

dinoflagellate during red tides

causing Aparalytic shellfish

poisoning@

*Tetrodotoxin

(neurotoxin)

*Neurotoxin

bacteria found in puffer fish,

California newt, eastern salamander

Moray eel

* toxic at all times

Table 5-4.—Examples of Toxins from Fish Known to be

Poisonous

PUFFER

TRIGGERFISH

PARROT FISH

PORCUPINE FISH

FILEFISH

SURMULLET OR GOATFISH

SURGEONFISH

HM3f0501

Figure 5-1.—Poisonous fish.
tanks, and similar places. Some sources of inhalation

chemical poisoning are listed in table 5-5.

NOTE: Inhaled substances can cause

olfactory fatigue. After a few minutes of

exposure, the smell is no longer detected,

fooling the individual into believing the

substance is no longer there and, thus, no

longer a danger.

Carbon monoxide is the most common agent of gas

poisoning. It is present in exhaust gases of internal

combustion engines as well as in sewer gas, lanterns,

charcoal grills, and in manufactured gas used for

heating and cooking. It gives no warning of its

presence since it is completely odorless and tasteless.

The victim may lose consciousness and suffer

respiratory distress with no warning other than slight

dizziness, weakness, and headache. The lips and skin

of a victim of carbon monoxide poisoning are

characteristically cherry red. Death may occur within

a few minutes.

Most inhalation poisoning causes shortness of

breath and coughing. The victim’s skin will turn blue.

If the respiratory problems are not corrected, cardiac

arrest may follow.

Inhaling fine metal fumes can cause a special type

of acute or delayed poisoning. These metal fumes are

generated from heating metal to boiling and

evaporation during hot metal work in such operations

as metal cutting or welding. The resulting illness is

called metal fume fever (MFF). In the Navy, the most

common cause of MFF is the inhalation of vaporized

zinc found in the galvanized covering of iron/steel.

Proper local and general ventilation and/or the use of

respiratory protection are necessary to prevent this

illness.

The first stage of treatment for an inhalation

poisoning is to remove the victim from the toxic

atmosphere immediately. WARNING: Never try to

remove a victim from the toxic environment if you do

not have the proper protective mask or breathing

apparatus, or if you are not trained in its use. Too often,

well-intentioned rescuers become victims. If help is

not immediately available, and if you know you can

reach and rescue the victim, take a deep breath, hold it,

enter the area, and pull the victim out. Next,

1. start basic life support (the ABC+D&Es);

2. remove or decontaminate the clothing (if

chemical warfare agents or volatile fuels were

the cause);

3. keep the victim quiet, treat for shock, and

administer oxygen; and

4. transport the victim to a medical treatment

facility for further treatment.

ABSORBED POISONS

Some substances may cause tissue irritation or

destruction by contact with the skin, eyes, and lining of

5-8

Inhaled Substance Source of Exposure

Acetone, isopropyl

alcohol, amyl acetate

Nail polish remover

Aliphatic

hydrocarbons

Fuels, Stoddard solvent,

PD-680, mineral spirits,

naphtha

Butane AThrow-away@ lighters

Carbon dioxide Fire suppression/fighting,

evaporation of dry ice, wells

and sewers

Carbon monoxide Fires, lightning, heating and

fuel exhausts

Chlorinated

hydrocarbons

Shoe polish

Chlorine Water purification, sewage

treatment

Chlorofluorocarbons

(CFCs)

Refrigerants, degreasers,

propellants (old)

Hydrogen sulfide Sewer, decaying materials,

CHT system

Methylethylketone Paint

Methylene chloride Paint stripper, solvent, dyes

N-hexane Rubber cement

Nitrous oxide Aerosol can propellant

Tetrachloroethylene

(perchloroethylene)

Dry cleaning

Toluene Plastic adhesive, acrylic

paint, shoe polish

Trichloroethane

(methylchloroform)

Solvent, degreaser

Table 5-5.—Sources of Inhalation Poisoning
the nose, mouth, and throat. These substances include

acids, alkalies, phenols, and some chemical warfare

agents. Direct contact with these substances will cause

inflammation or chemical burns in the affected areas.

Consult the “Chemical Burns” section of chapter 4 and

the “Chemical Agents” section of chapter 8 of this

manual for treatment.

INJECTED POISONS AND

ENVENOMATIONS

Injection of venom by stings and bites from

various insects and arthropods, while not normally

life-threatening, can cause acute allergic reaction that

can be fatal. Poisons may also be injected by snakes

and marine animals.

Bee, Wasp, and Fire Ant Stings

Stings from bees, wasps, and ants account for more

poisonings than stings from any other insect group.

Fortunately, they rarely result in death. The vast

majority of stings cause a minor local reaction at the

injection site, with pain, redness, itching, and swelling.

These symptoms usually fade after a short time. A

small percentage of these stings can cause an allergic

victim severe anaphylactic reactions, presenting with

itching, swelling, weakness, headache, difficulty

breathing, and abdominal cramps. Shock may follow

quickly, and death may occur.

The following first aid measures are recommended

for all but minor, local reactions to bites or stings:

1. Closely monitor vital signs (and the whole

patient), and remove all rings, bracelets, and

watches.

2. Remove stingers without squeezing additional

venom (remaining in poison sacs attached to

stingers) into the victim. To do this, scrape along

the skin with a dull knife (as if you were shaving

the person). The dull blade will catch the stinger

and pull it out.

3. Place an ice cube or analgesic-corticosteroid

cream or lotion over the wound site to relieve

pain. Do NOT use “tobacco juice,” saliva, or

other concoctions.

4. For severe allergic reactions (generalized

itching or swelling, breathing difficulty, feeling

faint or clammy, unstable pulse or blood

pressure), immediately give the victim a

subcutaneous injection of 1:1000 aqueous

solution of epinephrine. Dosage is 0.5 cc for

adults and ranges from 0.1 to 0.3 cc for children.

5. Patients with severe allergic reactions should be

evacuated immediately to a medical facility.

Scorpion Stings

About 40 species of scorpions (fig. 5-2) exist in

America. Centruroides exilicauda may cause severe

effects. Most dangerous species are found from North

Africa to India. Scorpion stings vary in severity,

depending on the species of the scorpion and the

amount of poison actually injected. They cause severe

pain in the affected area.

Mild reactions may include local swelling, skin

discoloration, swollen lymph nodes near the sting area,

itching, paresthesias (“pins and needles,” numbness),

and even nausea and vomiting. The duration of

symptoms is less than 24 hours.

The following first aid treatment should be given

for scorpion stings:

1. Place ice over the sting site (cool the area for up

to 2 hours). Do NOT use tobacco juice, saliva,

or other concoctions.

2. Elevate the affected limb to approximately heart

level.

3. Give acetaminophen for minor pain.

4. Calcium gluconate, 10 ml of 10 percent

solution, may be given intravenously to relieve

muscle spasms.

5. Valium may be used to control excitability and

convulsions.

6. An antivenom is available for severe bites by

Centruroides exilicauda (also called “bark

scorpion,” it is the scorpion found in Mexico

and the American southwest). It is available

from the Antivenom Production Laboratory,

Arizona State University, Tempe, Arizona

85281, phone (602) 965-6443 or (602)

965-1457, and from Poison Control in Phoenix,

phone (602) 253-3334.

CAUTION: Morphine and meperidine

hydrochloride may worsen the respiratory

depression from the venom of

Centruroides exilicauda.

5-9
Spider Bites

Spiders in the United States are generally

harmless, with several exceptions. The most notable

are the black widow (Latrodectus mactans) and brown

recluse (Loxosceles reclusa, also found in South

America) spiders. Their bites are serious but rarely

fatal. Wandering spiders (Phoneutria species, found in

South America), funnel web spiders (Atrax species,

found in Australia), and more widely distributed

spiders of the Chiracanthium species may also cause

moderate to severe human reactions. Check current

MEDIC CD-ROM for management of specific

situations and venues.

The female black widow spider is usually

identified by the red hourglass-shaped spot on its belly

(fig. 5-2). Its bite causes a dull, numbing pain, which

gradually spreads from the region of the bite to the

muscles of the entire torso. The pain becomes severe,

and a board-like rigidity of the abdominal muscles is

common. Nausea, vomiting, headache, dizziness,

difficulty in breathing, edema, rash, hypertension, and

anxiety are frequently present. The bite site can be

very hard to locate (there is little or no swelling at the

site), and the victim may not be immediately aware of

having been bitten. The buttocks and genitalia should

be carefully examined for a bite site if the suspected

victim has recently used an outside latrine. The

following first aid treatment steps are suggested:

1. Place ice over the bite to reduce pain.

2. Hospitalize victims who are under 16 or over 65

(for observation).

3. Be prepared to give antivenom in severe cases.

The brown recluse spider (fig. 5-2) is identified by

its violin-shaped marking. Its bite may initially go

unnoticed, but after several hours, a bleb develops over

the site, and rings of erythema begin to surround the

bleb. Other symptoms include skin rash, fever and

chills, nausea and vomiting, and pain. A progressively

enlarging necrotic (dead tissue) ulcerating lesion (with

a crusty black scab) eventually develops.

Intravascular hemolysis (breakdown of the blood) is

most often seen in children and may be fatal.

Antivenom is not currently available.

Treatment for brown recluse spider bites includes

the following:

• Debridement of lesion, followed by peroxide

cleansing and Burrow’s solution soaks

• Application of polymyxin-bacitracin-neomycin

ointment and sterile dressing

• Dapsone 50-100 mg twice a day is used to

promote healing in some cases, but only after

screening for G6PD deficiency. Other

antibiotics may be used to treat infection, and

steroids to reduce inflammation

NOTE: Glucose-6-phosphate dehydrogenase

(G6PD) deficiency is a common human

enzyme deficiency. A G6PD deficiency can

cause a harmful reaction to a number of

medications, including dapsone.

• Based upon medical consultation, excision of

the lesion and optional commencement of

corticosteroid therapy

Centipede Bites

Centipedes can attain sizes of over one foot in

length! Their bite, though rare, leaves two tiny red

marks and causes redness and swelling. Severe pain,

swelling, and inflammation may follow, and there may

be headache, dizziness, vomiting, irregular pulse,

muscle spasm, and swollen lymph nodes. No

long-term effects are usually seen. Treat discomfort

with acetaminophen, cool packs, and elevation of the

affected limb to heart level.

5-10

THE “BLACK WIDOW” SPIDER

A. TOP VIEW B. UNDERSIDE

SCORPION BROWN RECLUSE

HM3f0502

Figure 5-2.—Black widow and brown recluse spiders and

scorpion.
Snakebites

Poisonous snakes are found throughout the world,

with the exception of certain islands and the Antarctic.

There are five venomous families of snakes.

• Viperidae–includes rattlesnakes, moccasins,

South American lance-headed vipers and

bushmaster, Asian pit vipers, African and Asian

vipers and adders, the European adder, and

saw-scaled viper (Middle-eastern). Kills mainly

by coagulopathy (a blood clotting disorder) and

shock.

• Elapidae–Includes cobras, kraits, mambas, and

coral snakes. Kills from neurotoxic venom that

can cause respiratory failure, paralysis, and

cardiac failure.

• Hydrophidae–Includes sea snakes and

venomous snakes from the islands of the

southern Pacific Ocean, including Australia,

New Zealand, and New Guinea. Also kills from

neurotoxic venom.

• Colubridae–Includes most of the common

nonvenomous species, as well as the boomslang,

and vine/twig/bird snake (Africa); Japanese

yamakagashi; Southeast Asian red-necked

callback. Venom’s method of toxic action varies

according to type of snake.

• Atractaspididae–Includes the burrowing

asps/mole vipers, stiletto snakes, and adders.

Venom’s method of toxic action varies

according to type of snake.

Within the United States, poisonous snakes are

Crotalids (rattlesnakes, copperheads, and moccasins)

and the Elapids (coral snakes).

CROTALIDS.—Crotalids are of the Viperidae

(viper) family and are called “pit vipers” because of the

small, deep pits between the nostrils and the eyes (fig.

5-3). They have two long, hollow fangs. These fangs are

normally folded against the roof of the mouth, but they

can be extended when the snake strikes. Other

identifying features of the Crotalids include thick bodies;

slit-like pupils of the eyes; and flat, triangular heads. The

most identifying feature of a pit viper is the relative width

of the snake’s head compared to the thickness of the body.

The head will be much wider than the body, giving the

appearance of an arrowhead. The difference in size is so

obvious that identification of a snake as a pit viper can

usually be made from a safe distance.

Further identification can be made by examining

the wound for signs of fang entry in the bite pattern. Pit

viper bites leave two puncture marks (sometimes only

one, and sometimes more). Nonvenomous snakes (for

example, garter snakes) leave a series, often in a curve

or semi-circle, of tiny scratches or punctures.

Individual identifying characteristics include rattles

on the tails of most rattlesnakes, and the cotton-white

interior of the mouths of moccasins.

ELAPIDS.—Coral snakes are of the family

Elipidae and related to the cobra, kraits, and mamba

snakes in other parts of the world (fig. 5-4). Corals,

which are found in the Southeastern United States, are

comparatively thin snakes with small bands of red,

black, and yellow (or almost white). Some

5-11

NOSTRIL

PIT

VERTICAL

PUPIL

VENOM

SAC

RATTLESNAKE

COPPERHEAD

MOCCASIN

BITE PATTERN

HM3f0503

FANG

Figure 5-3.—American pit vipers.
nonpoisonous snakes have similar coloring, but in the

North American coral snake, the red band always

touches the yellow band, and the bands go all the way

around the body. (In some of the nonvenomous,

similarly colored varieties, the bands are only on the

back and sides, not the belly.) There is an old saying

that only applies to NORTH American coral snakes:

“Red on yellow, kill a fellow; red on black, venom

lack.” The coral snake has short, hollow fangs that

chew into its victim and introduce the poison. Coral

snake venom is dangerous, so if the skin is broken,

give antivenom before envenomation is evidenced

by symptoms or findings.

Venom, which is stored in sacs in the snake’s head,

is introduced into a victim through hollow or grooved

fangs. An important point to remember, however, is

that a bitten patient has not necessarily received a dose

of venom. The snake can control whether or not it will

release the poison and how much it will inject. As a

result, while symptoms in a poisonous snakebite

incident may be severe, they may also be mild or not

develop at all.

SIGNS AND SYMPTOMS OF SNAKEBITE.— In a snakebite situation, every reasonable

effort should be made to positively identify the culprit,

since treatment of a nonpoisonous bite is far simpler

and less dangerous to the victim than treatment of a

poisonous bite. However, unless the snake can be

POSITIVELY identified as nonpoisonous,

CONSIDER ALL SNAKEBITES AS

POISONOUS! SEEK CONSULTATION FROM

EXPERT SOURCE.

Signs and symptoms of venomous snakebite may

include

• a visible bite on the skin (possibly no more than a

local discoloration);

• pain and swelling in the bite area (may develop

slowly, from 30 minutes to several hours);

• continued bleeding from site of bite (often seen

with viper bites);

• rapid pulse;

• labored breathing;

• progressive weakness;

• dim or blurred vision;

• nausea and vomiting;

• seizures; or

• drowsiness (or loss of consciousness).

Usually enough symptoms present themselves

within an hour of a poisonous snakebite to erase any

doubt as to the victim’s having been envenomated or

5-12

CORAL SNAKE

COBRA- ASIA, AFRICA

KRAIT- INDIA, S. E. ASIA

MAMBA- AFRICA BITE PATTERN

HM3f0504

Figure 5-4.—Corals, cobras, kraits, and mambas.
not. The victim’s condition provides the best

information as to the seriousness of the situation.

The aims of first aid for envenomated snakebites

are to reduce—not stop—the circulation of blood

through the bite area, delay absorption of venom,

prevent aggravation of the local wound, maintain vital

signs, and transport the victim as soon as possible to an

MTF with minimum movement.

TREATMENT OF SNAKEBITES.—The

proper steps in the treatment of snakebites are listed

below.

1. Try to identify the snake. Positive identification

is important to selecting the correct antivenom

for the treatment of the patient.

NOTE: Do not risk further injury by trying to

kill the snake.

2. Certain suction extractors have benefit (for

example, the Sawyer extractor), especially if

used within the first 3 minutes. If available

immediately, use the extractor and leave it on for

30 minutes. The cups may fill up. Empty and

re-use them as necessary.

3. GENTLY wash the wound with soap and water

(it may remove some of the venom). Do NOT

rub vigorously, as it may cause the venom to be

absorbed more rapidly.

4. Place the victim in a comfortable position.

5. Tell the patient to remove any jewelry

(especially rings and bracelets, as these may

impede blood flow if there is swelling of the

extremities). Assist, if necessary.

6. Start an IV line.

7. Monitor vital signs (including ABC+D&Es)

closely, responding appropriately as necessary.

8. Until evacuation or treatment is possible, ensure

the victim lies quietly and does not move any

more than necessary.

9. Do not allow the victim to smoke, eat, or drink

any fluids. (Water is permissible if you

anticipate more than several hours will pass

before arriving at a hospital and being able to

establish an IV line.)

10. Transport the victim to a hospital or other

appropriate facility.

11. Place a lymphatic (light) constriction on the

extremity (if the bite is on an extremity). The

goal is to obstruct lymphatic—not blood-flow.

(See instructions below.) DO NOT USE A

TOURNIQUET!

12. Splint the extremity at the level of the body

(heart). DO NOT ELEVATE THE

EXTREMITY!

13. Hospitalize and observe all snakebites for at

least 24 hours.

In the case of spitting cobras (found in Africa,

Thailand, Malaysia, Indonesia, and the Philippines),

which attempt to spray venom into victims’ eyes, rinse

the eyes with large volumes of water (neither a blast

nor a trickle, and not with hot water). Apply

antibacterial (tetracycline or chloramphenicol) eye

ointment, and apply a patch with just enough pressure

to keep the eyelid from blinking.)

Other aid will be mainly supportive:

• Check pulse and respiration frequently. Give

artificial ventilation, if necessary.

• Treat for shock, including IV fluids (normal

saline or lactated Ringer’s solution).

• When possible, clean the area of the bite with

soap and water, and cover the wound to prevent

further contamination.

5-13

LYMPHATIC CONSTRICTION

INSTRUCTIONS

An appropriate lymphatic constriction device is a

blood pressure cuff, inflated to the diastolic blood

pressure (so the blood can be felt flowing past the

cuff). Other devices may be used, but IT IS

IMPORTANT THAT BLOOD CIRCULATION TO THE BITE AREA BE

MAINTAINED.

Constriction should be fully released every 30

minutes for 15 seconds. If the constriction

pressure cannot be carefully controlled, THE

MAXIMUM TOTAL TIME OF USE OF THE

CONSTRICTION DEVICE IS 2 HOURS.

(Thus, three 15-second breaks, and the fourth

time the cuff, belt, or band remains OFF.)

NOTE: If you use a blood pressure cuff (or

device that you KNOW is not constricting

more than an Ace7 bandage on a sprain), you

may continue to apply constriction until the

patient reaches a hospital.
• Give acetaminophen for pain if delay in hospital

treatment is anticipated.

Antivenom.—Antivenom (also called antivenin)

is available for many snakes, and is indicated for

severe envenomations by Viperidae family snakes and

most envenomations by snakes of the other poisonous

families. Antivenom is best given as soon as possible

after an envenomation, but may be of value up to a few

days after a bite.

If possible, antivenom specific to the snake should

be used. Otherwise, a “polyspecific” antivenom may

be used. READ THE PACKAGE INSERT OF THE

ANTIVENOM FOR VALUABLE INFORMATION.

Epinephrine and diphenhydramine must be available,

as allergic reactions (including anaphylaxis) to

antivenom have occurred (they are often prepared

from horse serum, which some people are allergic to).

Antivenom is diluted (for example, 1:10) and

given at 5 ml/minute IV, and the dose is based on

stopping the progression of signs and symptoms, not

the victim’s body weight (the children’s dose is the

same as the adult dose). For neurotoxic snakebites, if

there is no improvement in 30 minutes, the dose should

be repeated. For Viperidae (which can cause bleeding

disorders), spontaneous bleeding should stop after

sufficient antivenom is given; continue giving

antivenom until bleeding stops and progression of

swelling is retarded. Because you may need to

administer antivenom a number of times, one vial may

not be enough to treat a patient.

Antivenom is available via PCCs and hospitals. It

may also be available at zoos and embassies.

The “Don’ts” of Snakebite Treatment.–The

following are the “don’ts” when it comes to treatment

of snakebite.

• DO NOT use any ice or cooling on the bite.

• DO NOT use a tourniquet. Obstructing blood

flow can make local tissue injury much worse.

• DO NOT use electric shock.

• DO NOT make any cuts or incisions in the

wound. Cuts at the bite site may impede

circulation and promote infection and make

local tissue injury much worse.

• DO NOT give victim alcohol or narcotics.

Further information may be obtained on an

emergent basis from a PCC or from Arizona Poison

Control, (520) 626-6016.

Bites, Stings, and Punctures from Sea Animals

A number of sea animals are capable of inflicting

painful wounds by biting, stinging, or puncturing.

Except under rare circumstances, these stings and

puncture wounds are not fatal. Major wounds from

sharks, barracuda, moray eels, and alligators can be

treated by controlling the bleeding, preventing shock,

giving basic life support, splinting the injury, and

transporting the victim to a medical treatment facility.

Minor injuries inflicted by turtles and stinging corals

require only that the wound be thoroughly cleansed

and the injury splinted.

JELLYFISH INJURIES.—Other sea animals

inflict injury by means of stinging cells located in

tentacles. This group includes the jellyfish and the

Portuguese man-of-war (fig. 5-5). The tentacles

(which may be impossible to see, even in relatively

clear water) release poison or tiny stingers through

which poison is injected into the victim. Jellyfish

stings may cause symptoms ranging from minor

irritation (pain and itching) to death. Contact with the

tentacles produces burning pain, a rash with small

hemorrhage in the skin, and, on occasion, shock,

muscular cramping, nausea, vomiting, and respiratory

and cardiac distress. Treatment for minor jellyfish

injuries consists of pouring sea water over the injured

area and then removing the tentacles with a towel or

gloves. Next, pour rubbing alcohol, formalin, vinegar,

meat tenderizer, or diluted ammonia over the affected

area to neutralize any remaining nematocysts (minute

stinging structures). Finally, cover the area with any

dry powder (to which the last nematocysts will

5-14

JELLYFISH

PORTUGUESE MAN-OF-WAR

HM3f0505

Figure 5-5.—Jellyfish and Portuguese Man-of-war.
adhere), and then scrape off with a dull knife. Apply

cool packs and hydrocortisone cream.

Some jellyfish (notably, the Portuguese

man-of-war, the box jellyfish, and certain jellyfish

from northeastern Australia) may cause serious

injuries and even have the potential to be lethal. In

cases where the kind of jellyfish that caused the sting is

either unknown or is known to have been from a box

jellyfish or Portuguese man-of-war, the injury should

be treated as a serious one, regardless of initial

symptoms. The following steps should be taken in the

case of serious jellyfish stings.

1. Retrieve the victim from the water if necessary.

2. Send others for an ambulance and antivenom.

(Antivenom is available for box jellyfish stings.

It is from sheep, and should be given in all

serious stings.)

3. Pour vinegar liberally (2 liters) over the sting

area for at least 30 seconds to inactivate stinging

cells that may remain.

4. Remove any remaining tentacles carefully.

(Excessive manipulation may cause rupture of

nematocysts and further poison release.)

Carefully (and gently) use a towel if necessary,

or use a dull knife edge (as described above to

remove arthropod stingers).

5. Apply a compression bandage to stings

covering more than half of one limb or causing

altered consciousness.

6. Start an IV.

7. Remain with the victim, and monitor vital signs

(the ABCs and consciousness, responding

appropriately (possibly including CPR) and as

necessary).

8. Transport the patient to a hospital as quickly as

possible.

9. Opiate analgesics (morphine or meperidine)

may be necessary for pain relief.

“SPINE” INJURIES.—Spiny fish, stingrays,

urchins, and cone shells inject their venom by

puncturing with spines (fig. 5-6). General signs and

symptoms include swelling, nausea, vomiting,

generalized cramps, diarrhea, muscular paralysis, and

shock. General emergency care consists of prompt

flushing with cold sea water to remove the venom and

to constrict hemorrhaging blood vessels. Next,

debride the wound of any remaining pieces of the

spine’s venom-containing integumentary sheath. Soak

the wound area in very hot water (110°F/43° C) for 30

to 60 minutes to neutralize the venom. Finally,

completely debride the wound, control hemorrhage,

suture, provide tetanus prophylaxis and a

broad-spectrum antibiotic, and elevate the extremity.

For minor injuries, a steroid cream to the wound area

may relieve discomfort. For serious injuries—wounds

that are deep, very painful, or causing the patient

distress—stabilize the patient and transport

immediately to a hospital.

In the case of contact with stonefish, scorpionfish,

zebra, or lionfish, immerse the wound in very hot water

for a minimum of 30 minutes until the pain is

decreased. Inject emetine hydrochloride directly into

the wound within 30 minutes, and provide meperidine

(or other opiate) for pain. Monitor the victim’s vital

signs closely. Obtain antivenom (from local zoos or

aquariums) for all serious cases.

SEA SNAKE INJURIES.—Sea snakes are found

in the warm water areas of the Pacific and Indian

Oceans. Their venom is VERY poisonous, but their

fangs are only 1/4 inch long. The first aid outlined for

land snakes also applies to sea snakes.

DRUG ABUSE

LEARNING OBJECTIVE: Recall drug

abuse assessment and treatment procedures

and patient handling techniques.

Drug abuse is the use of drugs for purposes or in

quantities for which they were not intended. Drugs of

5-15

HM3f0506

Figure 5-6.—Stingray sting.
abuse may be swallowed, inhaled, snorted (or by nose

drops), injected, or even absorbed through the skin,

rectum, or vagina. When abused, therapeutic drugs

become a source of “poison” to the body. Drug abuse

can lead to serious illness, dependency, and death.

Death is usually because of acute intoxication or

overdoses.

Drugs of abuse can be classified in many different

ways. This chapter will classify drugs of abuse based

on the symptoms they produce: CNS depression, CNS

stimulation, and hallucinations. The CNS depressants

include narcotics, ethanol, barbiturates, nonbarbiturate sedative-hypnotics (including benzodiazepines). The CNS stimulants include caffeine,

nicotine, amphetamines, and cocaine. The

hallucinogens include LSD, PCP, and marijuana.

Table 5-6 lists many of the most frequently abused

drugs with their recognizable trade names, some

commonly used street names, and observable

symptoms of abuse.

The following sections contain specific

information about commonly abused drugs, as

classified in table 5-6, including availability and

methods of administration.

NARCOTIC INTOXICATION

Unfortunately, narcotic abuse is common,

although it is rare among military personnel. This

group of drugs includes the most effective and widely

used pain killers in existence. Prolonged use of

narcotic drugs, even under medical supervision,

inevitably leads to physical and psychological

dependence. The more commonly known drugs within

this group are opium, morphine, heroin, codeine, and

methadone (a synthetic narcotic). In addition, Darvon 7

and Talwin7 are included in this group because of their

narcotic-like action. Next to cocaine (discussed later),

heroin is the most popular narcotic drug because of its

intense euphoria and long-lasting effect. It is far more

potent than morphine but has no legitimate use in the

United States. Heroin appears as a white, gray, or tan

fluffy powder. The most common method of using

heroin is by injection directly into the vein, although it

can be sniffed. Codeine, although milder than heroin

and morphine, is sometimes abused as an ingredient in

cough syrup preparations. Symptoms of narcotic drug

abuse include slow, shallow breathing; possible

unconsciousness; constriction (narrowing) of the

pupils of the eyes to pinpoint size; drowsiness;

confusion; and slurred speech.

The narcotic user, suddenly withdrawn from

drugs, may appear as a wildly disturbed person who is

agitated, restless, and possibly hallucinating. Initial

symptoms start within 2 to 48 hours and peak at about

72 hours. Although these signs and symptoms are not

life-threatening, most users will state that they feel so

bad they wish they were dead. The signs and symptoms

of withdrawal immediately stop upon re-administering

a narcotic and withdrawing the drug by tapering the

dose over several days.

ALCOHOL INTOXICATION

Alcohol is the most widely abused drug today.

Alcohol intoxication is so common that it often fails to

receive the attention and respect it deserves. Although

there are many other chemicals that are in the chemical

grouping of “alcohols,” the type consumed by people

as a beverage (in wines, beers, and distilled liquors) is

known as ethyl alcohol, ethanol, grain alcohol, or just

“alcohol.” It is a colorless, flammable, intoxicating

liquid, classed as a drug because it depresses the

central nervous system, affecting physical and mental

activities.

Alcohol affects the body of the abuser in stages.

Initially, there is a feeling of relaxation and well-being,

followed by confusion with a gradual disruption of

coordination, resulting in inability to accurately and

efficiently perform normal activities and skills.

Continued alcohol consumption leads to a stuporous

state of inebriation that results in vomiting, an inability

to walk or stand, and impaired consciousness (sleep or

stupor). Excessive consumption can cause loss of

consciousness, coma, and even—in extreme cases —

death from alcohol poisoning.

The potential for physical and psychological

addiction is very high when alcohol is abused. The

severely intoxicated individual must be closely

monitored to avoid inhalation of vomit (aspiration) and

adverse behavioral acts to the patient or others.

Withdrawal from alcohol is considered to be

life-threatening and should be appropriately treated in

a healthcare facility. Individuals withdrawing from

alcohol are at a greater risk of serious complications or

death than those withdrawing from narcotics. The

effects of alcohol withdrawal include severe agitation,

anxiety, confusion, restlessness, sleep disturbances,

sweating, profound depression, delirium tremens

(“DTs,” a particular type of confusion and shaking),

hallucinations, and seizures.

5-16
5-17

A. NARCOTICS

Agent Trade Name Some Street Names Symptoms of Abuse

Morphine

Diacetylmorphine

Codeine

Meperidine

Methadone

Propoxyphene

Pentazocine

............................................

Heroin

............................................

Demerol

Dolphine

Darvon

Talwin

“H”, Miss Emma, smack

“H”, horse, junk, smack, stuff, whack

Dolly

•Lethargy

•Drowsiness

•Confusion

•Euphoria

•Slurred speech

•Flushing of the skin on face, neck,

and chest

•Nausea and vomiting

•Pupils constricted to pinpoint size

B. ALCOHOL

(Ethyl)

Agent Trade Name Some Street Names Symptoms of Abuse

Alcohol (ethyl) Ethanol Liquors, beer, wines •Slurred speech

•Incoordination

•Confusion

•Tremors

•Drowsiness

•Agitation

•Nausea and vomiting

•Respiratory depression

•Hallucinations

•Possible coma

C. STIMULANTS

(Uppers)

Agent Trade Name Some Street Names Symptoms of Abuse

Amphetamine

Cocaine

Dextroamphetamine

Methamphetamine

Methylphenidate

Benzedrine

............................................

Dexadrine

Methadrine

Ritalin

Bennies, pep pills, ups, cartwheels

Crack, coke, snow, gold dust, rock,

freebase, snort, hubba hubba, flake

Dexies

Speed, meth, crystal, diet pills, crank

•Excitability

•Rapid and unclear speech

•Restlessness

•Tremors

•Sweating

•Dry lips and mouth

•Dilated pupils

•Loss of consciousness

•Coma

•Hallucinations

D. BARBITURATES

(Downers, dolls, barbs, rainbows)

Agent Trade Name Some Street Names Symptoms of Abuse

Phenobarbital

Amobarbital

Pentobarbital

Secobarbital

............................................

Amytal

Nembutal

Seconal

Goofballs, phennies

Blues, blue birds, blue devils, downers

Yellows, yellow jackets

Reds, red devils, seggy

Same as those noted in alcohol

intoxication, plus pupils may be

dilated.

Table 5-6.—Classification of Abused Drugs
5-18

E. OTHER SEDATIVES & HYPNOTICS

(Downers)

Agent Trade Name Some Street Names Symptoms of Abuse

Glutethimide

Chlordiazepoxide

Meprobamate

Methaqualone

Doriden

Librium

Miltown, Equanil

Quaalude, Sopor

Goofers

Ludes, sopors

Same as those noted in alcohol and

barbiturate intoxication.

F. HALLUCINOGENS

Agent Trade Name Some Street Names Symptoms of Abuse

Lysergic acid diethylamide

Mescaline

Phencyclidine (PCP)

Psilocin, psilocybin

............................................

..............................................

Peyote

LSD, acid, sunshine

Peyote, mesc

Angel dust, hog, peace pills

Buttons, mesc, magic

mushrooms

•Trance-like state

•Anxiety

•Confusion

•Tremors

•Euphoria

•Depression

•Hallucinations

•Psychotic manifestations

•Suicidal or homicidal tendencies

G. CANNABIS

Agent Trade Name Some Street Names Symptoms of Abuse

Cannabis Marijuana Pot, grass, weed, joint, tea,

reefer, rope, Jane, hay, dope

•Euphoria

•Excitability

•Increased appetite

•Dryness of mouth

•Odor of burned rope on breath

•Intoxication

•Laughter

•Mood swings

•Increase in heart rate

•Reddening of eyes

•Loss of memory

•Distortion of time and spatial

perception

H. INHALANTS

Agent Trade Name Some Street Names Symptoms of Abuse

Amyl nitrate

Butyl nitrate

Other volatile chemicals:

Cleaning fluid, furniture

polish, gasoline, glue,

hair spray, nail polish

remover, paint thinner,

correction fluid

Snappers, poppers

Locker room, rush

•Dazed, temporary loss of contact with

reality

•Possible coma

•Swollen membranes in mouth and nose

•“Funny numb feeling”

•“Tingling” inside the head

•Changes in heart rhythm

•Possible death

Table 5-6.—Classification of Abused Drugs—Continued
BARBITURATE INTOXICATION

Benzodiazepines have largely replaced

barbiturates, or “downers,” as sedatives, hypnotics

(sleeping pills), or anxiolytic (anti-anxiety) agents.

Barbiturates are still used to treat various seizure

disorders. They are classified based on their duration

of action: ultra-short acting, short acting, intermediate

acting, and long acting. Barbiturate use classically

causes various degrees of CNS depression with

nystagmus (eyes moving up and down, or side-to-side

involuntarily), vertigo (sensation of the room

spinning), slurred speech, lethargy, confusion, ataxia

(difficulty walking) and respiratory depression.

Severe overdose may result in coma, shock, apnea

(stopped breathing), and hypothermia. In

combination with ethanol or other CNS depressants,

there are additive CNS and respiratory depression

effects.

Prolonged use of barbiturates can lead to a state of

physical and psychological dependence. Upon

discontinued use, the dependant person may go into

withdrawal. Unlike narcotic (opiate) withdrawal,

barbiturate withdrawal is LIFE THREATENING!

Depending on type of barbiturate, signs and symptoms

start within 24 hours. The withdrawal syndrome

includes nausea, vomiting, sweating, tremors

(trembling or shaking), weakness, insomnia, and

restlessness. These clinical findings progress to

apprehension, acute anxiety, fever, increased blood

pressure, and increased heart rate. If untreated, severe

and life-threatening effects include delirium,

hallucinations, and seizures. The signs and symptoms

will stop upon re-administration of the barbiturate and

by tapering the dose slowly over several days.

NONBARBITURATE SEDATIVEHYPNOTIC INTOXICATION

Nonbarbiturate sedative-hypnotics (a “hypnotic”

is a sleeping pill) have actions very similar to the

barbiturates. However, they have a higher margin of

safety; overdose and addiction require larger doses and

addiction requires a longer time period to occur. Like

the barbiturates, when combined with ethanol or other

depressants, there are addictive CNS- and

respiratory-depression effects. Most of the traditional,

nonbarbiturate sedative-hypnotics are either no longer

available (Methaquaalone, Ethchlorovynol,

Glutethimide) or rarely used today (chloral hydrate)

because of their profound “hangover effect.” Newer

sedative-hypnotics are emerging for the temporary

treatment of insomnia. Benzodiazepines are widely

used to treat seizure disorders, anxiety, muscle spasms,

and insomnia.

STIMULANT INTOXICATION

The stimulants (“uppers”) directly affect the

central nervous system by increasing mental alertness

and combating drowsiness and fatigue. One group of

stimulants, called amphetamines, is legitimately used

in the treatment of conditions such as mild depression,

obesity, and narcolepsy (sleeping sickness).

Amphetamines are also commonly abused.

Usually referred to as stimulants, speed, or uppers,

amphetamines can be taken orally, intravenously, or

smoked as “ice.” Amphetamines directly affect the

central nervous system by increasing mental alertness

and combating drowsiness and fatigue. They are

abused for their stimulant effect, which lasts longer

than cocaine.

Amphetamines cause central nervous system

stimulation with euphoria, increased alertness,

intensified emotions, aggressiveness, altered

self-esteem, and increased sexuality. In higher doses,

unpleasant CNS effects of agitation, anxiety,

hallucinations, delirium, psychosis, and seizures can

occur. When stimulants are combined with alcohol

ingestion, patients have increased psychological and

cardiac effects.

Signs and symptoms associated with amphetamine

use include mydriasis (dilated pupils), sweating,

increased temperature, tachycardia (rapid pulse), and

hypertension. Patients seeking medical attention

usually complain of chest pain, palpitations, and

shortness of breath.

“Heavy use” (involving large quantities) of

amphetamines is physically addicting, and even “light

use” (involving small amounts) can cause

psychological dependence. Tolerance to increasingly

higher doses develops and withdrawal can occur from

these levels. Abruptly stopping chronic amphetamine

use does not cause seizures or present a

life-threatening situation. The withdrawal is typically

characterized by apathy, lethargy, muscle aches,

stomachaches, increased appetite, anxiety, sleep

disturbances, and depression with suicidal tendencies.

Cocaine, although classified as a narcotic, acts as a

stimulant and is commonly abused. It is relatively

ineffective when taken orally; therefore, the abuser

either injects it into the vein or “snorts” it through the

5-19
nose. Its effect is much shorter than that of

amphetamines, and occasionally the abuser may inject

or snort cocaine every few minutes in an attempt to

maintain a constant stimulation and prevent

depression experienced during withdrawal (comedown). Overdose is very possible, often resulting in

convulsion and death.

The physical symptoms observed in the cocaine

abuser will be the same as those observed in the

amphetamine abuser.

HALLUCINOGEN INTOXICATION

The group of drugs that affect the central nervous

system by altering the user’s perception of self and

environment are commonly known as hallucinogens.

Included within this group are lysergic acid

diethylamide (LSD), mescaline, dimethoxymethylamphetamine (STP), phencyclidine (PCP), and

psilocybin. They appear in several forms: crystals,

powders, and liquids.

The symptoms of hallucinogenic drugs include

dilated pupils, flushed face, increased heartbeat, and a

chilled feeling. In addition, the person may display a

distorted sense of time and self, show emotions

ranging from ecstasy to horror, and experience

changes in visual depth perception.

Although no deaths have resulted from the drugs

directly, hallucinogen-intoxicated persons have been

known to jump from windows, walk in front of

automobiles, or injure themselves in other ways

because of the vivid but unreal perception of their

environment.

Even though no longer under the direct influence

of a hallucinogenic drug, a person who has formerly

used one of the drugs may experience a spontaneous

recurrence (flashback) of some aspect of the drug

experience. The most common type of flashback is the

recurrence of perceptual distortion; however, victims

of flashback may also experience panic or disturbing

emotion. Flashback may be experienced by heavy or

occasional users of hallucinogenic drugs, and its

frequency is unpredictable and its cause unknown.

CANNABIS INTOXICATION

Cannabis sativa, commonly known as marijuana,

is widely abused and may be classified as a mild

hallucinogen. The most common physical appearance

of marijuana is as ground, dried leaves, and the most

common method of consumption is smoking, but it can

be taken orally. A commercially prepared product of

the active ingredient in marijuana, tetrahydrocannabinol (THC), is dronabinol (Marinol R) available

in the U.S. as a controlled Schedule II drug.

Dronabinol is used for the treatment of nausea and

vomiting in chemotherapy patients. It may also be

useful in the treatment of acute glaucoma, asthma, and

nausea and vomiting from other chronic illnesses. The

individual response to the recreational use of

marijuana varies and depends on the dose, the

personality and expectation of the user, and the setting.

Unexpected ingestion, emotional stress, or underlying

psychiatric disorders can increase the possibility of an

unfavorable reaction.

After a single inhaled dose of marijuana, a

subjective “high” begins in several minutes and is gone

within four hours. Marijuana causes decreased pupil

size and conjunctivitis (reddening of the white of the

eye). Smoking marijuana can increase the heart rate

(tachycardia) for about two hours. It can slightly

increase systolic blood pressure in low doses and can

lower blood pressure in high doses. An increased

appetite and dry mouth are common complaints after

marijuana use.

Social setting influences the psychological effects

associated with “usual doses” of marijuana smoking.

Smoking in a solitary setting may produce euphoria,

relaxation, and sleep. In a group setting, increased

social interaction, friendliness, and laughter or

giddiness may be produced. Subjectively, time moves

slower, images appear more vivid, and hearing seems

keener. High doses can cause lethargy, depersonalization, pressured speech, paranoia, hallucinations, and

manic psychosis (imagining everything is wonderful

in a way that is out of reality).

INHALANT INTOXICATION

Inhalants are potentially dangerous, volatile

chemicals that are not meant for human consumption.

They are found in consumer, commercial, and

industrial products intended for use in well-ventilated

areas. The vapors they produce can be extremely

dangerous when inhaled inadvertently or by design.

Substances in this category include adhesives

(synthetic “glues”), paint, wet markers, lighter fluids,

solvents, and propellants in aerosol spray cans, and air

fresheners. Inhalants can be abused by “sniffing”

5-20
(inhaling through the nose directly over an open

container), “bagging” (holding an open bag or

container over the head), or “huffing” (pouring or

spraying material on a cloth that is held over the mouth

and inhaling through the mouth). These methods

usually use a bag or other container to concentrate and

retain the propellant thereby producing a quick “high”

for the abuser.

Persons who regularly abuse inhalants risk

permanent and severe brain damage and even sudden

death. The vapors from these volatile chemicals can

react with the fatty tissues in the brain and literally

dissolve them. Additionally, inhalants can reduce the

availability and use of oxygen. Acute and chronic

damage may also occur to the heart, kidneys, liver,

peripheral nervous system, bone marrow, and other

organs. Sudden death can occur from respiratory arrest

or irregular heart rhythms that are often difficult to

treat even if medical care is quickly available.

Signs and symptoms of inhalant abuse closely

resemble a combination of alcohol and marijuana

intoxication. Acute symptoms are very short-lived and

are completely gone within two hours. Physical

symptoms of withdrawal from inhalants include

hallucinations, nausea, excessive sweating, hand

tremors, muscle cramps, headaches, chills and

delirium tremens. Thirty to forty days of

detoxification is required, and relapse is frequent.

HANDLING DRUG-INTOXICATED

PERSONS

As in any emergency medical situation, priorities

of care must be established. Conditions involving

respiratory or cardiac failure must receive immediate

attention before specific action is directed to the drug

abuse symptom. General priorities of care are outlined

below:

• The ABCs + D & E: check for adequacy of

airway, breathing, and circulation, signs of

drug/chemical (“D”) induced altered mental

status, and hidden injuries or contact with a

poison revealed by exposing (“E”) parts of the

body covered with clothing or other articles.

Watch for shock! Give appropriate treatment.

• If the victim cannot be aroused, place him on his

side so secretions and vomitus can drain from the

mouth and not be aspirated into the lungs.

• All adult patients with an altered mental status

should receive dextrose after blood sugar

testing, thiamine, naloxone, and oxygen.

• If recommended by the PCC or medical officer,

place the patient on a cardiac monitor and/or

obtain specimens for comprehensive laboratory

work-up (blood and urine).

• If recommended by the PCC or medical officer,

decontaminate the gut. (This decontamination

should be accomplished ONLY if the victim is

conscious and the drug was RECENTLY

TAKEN ORALLY.)

• Prevent the victim from self-injury while highly

excited or lacking coordination. Use physical

restraints only if absolutely necessary (i.e., upon

failure of chemical restraints).

• Calm and reassure the excited patient by “talking

them down” in a quiet, relaxed, and sympathetic

manner.

• Gather materials and information to assist in

identifying and treating the suspected drug

problem. Spoons, paper sacks, eyedroppers,

hypodermic needles, and vials are excellent

identification clues.

• The presence of capsules, pills, drug containers,

needle marks (tracks) on the patient’s body, or

paint or other substance around the mouth and

nose, are also important findings of substance

abuse.

• A personal history of drug use from the patient or

those accompanying the patient is very

important and may reveal how long the victim

has been abusing drugs, approximate amounts

taken, and time between doses. Knowledge of

past medical problems, including history of

convulsions (with or without drugs) is also

important.

• Transport the patient and the materials collected

to a medical treatment facility.

• Inform MTF personnel and present the materials

collected at the scene upon arrival at the facility.

5-21
HAZARDOUS MATERIAL EXPOSURE

LEARNING OBJECTIVE: Recognize

hazardous material personal safety

guidelines and hazardous material

information sources.

Hazardous materials are substances with the

potential of harming people or the environment.

Hazardous materials can be gaseous, liquid, or solid,

and can include chemical or radioactive materials.

(Radiological exposure will be covered in depth in

chapter 8 of this manual. Radioactive materials are

regulated by specific instructions/directives.) The

most common substances involved in incidents of

hazardous material (HAZMAT) exposure are volatile

organic compounds, pesticides, ammonia, chlorine,

petroleum products, and acids.

Your initial action at the scene of a hazardous

materials incident must be to assess the situation, since

your safety—as well as that of the public and any

patients—is of primary concern. You must first

determine the nature of the HAZMAT, then establish a

safety zone. Only after these things have been

accomplished can a victim who has been exposed to

hazardous materials be rescued, transported to an

appropriate facility, and properly decontaminated.

The Department of Transportation (DOT)

publication, Emergency Response Guidebook (ERG

series, published every four years), RSPA P5800.8, is a

useful tool for first responders during the initial phase

of a hazardous materials/dangerous goods incident.

ERG series addresses labeling, identification, toxicity,

safety/contamination zones, and decontamination

procedures. IT IS IMPERATIVE THAT ALL

PERSONNEL INVOLVED WITH HAZMAT

INCIDENT RESPONSE BE FAMILIAR WITH

THIS PUBLICATION. It is also available on the

Internet at http://hazmat.dot.gov/gydebook.htm.

DETERMINING THE NATURE OF THE

HAZARDOUS MATERIAL

When an incident involving the exposure of

hazardous material occurs, it is of prime importance to

any rescue operation to determine the nature of the

substance(s) involved. All facilities that produce

HAZMAT are required by law to prominently display

this information, as is any vehicle transporting it. Any

carton or box containing such material must also be

properly labeled. The name of the substance may also

be displayed, along with a required four-digit

identification number (sometimes preceded by the

letters UN or NA).

The various kinds of hazardous materials usually

have different labels to assist in their identification.

These are generally diamond-shaped signs that have

specific colors to identify the type of HAZMAT

involved. Table 5-7 provides a list of the Department

of Transportation (DOT)-mandated classifications of

hazardous materials.

The ERG series provides a list of hazardous

materials and appropriate emergency response actions.

The Guidebook is primarily a tool to enable first

responders to quickly identify the specific or generic

classification of the material(s) involved in the

incident, and to protect themselves and the general

public during the initial phase of the incident.

SAFETY GUIDELINES

Your first objective should be to try to read the

labels and identification numbers FROM A

DISTANCE. If necessary, use binoculars. DO NOT

go into the area unless you are absolutely certain that

has been no hazardous spill. Relay any and all

information available to your dispatch center where it

can be used to identify the HAZMAT.

Once the HAZMAT has been identified, it can be

classified as to the danger it presents (i.e., toxicity

level). Based on this classification, the appropriate

specialized equipment (known as personal protective

equipment, or PPE) can be determined to provide

adequate protection (i.e., protection level) from

5-22

HAZMAT Type Label Description

Explosives solid orange color

Nonflammable gases solid green color

Flammable liquids solid red color

Flammable solids white and red stripes

Oxidizers & peroxides solid yellow color

Poisons & biohazards solid white color

Radioactive materials half white/half yellow with black

radiation symbol

Corrosives half white/half black

Other usually white

Table 5-7.—Hazardous Materials Warning Labels
secondary contamination to rescue personnel and

healthcare providers.

Toxicity Levels

The National Fire Protection Association (NFPA)

has developed a system for indicating the health,

flammability, and reactivity hazards of chemicals. It is

called the NFPA 704 Labeling System and is made up

of symbols arranged in squares to comprise a

diamond-shaped label (fig. 5-7). Each of the four

hazards is indicated by a different colored square:

• Red indicates the flammability.

• Yellow indicates the reactivity.

• White indicates any special hazards.

• Blue indicates health hazards.

• The health hazard levels are

• 4 - deadly,

• 3 - extreme danger,

• 2 - hazardous,

• 1 - slightly hazardous, and

• 0 - normal material.

Protection Levels

The protection levels, B, C, and D—indicate the

type and amount of protective equipment required in a

given hazardous circumstance, with level A being the

most hazardous.

• Level A - positive pressure-demand, full-face

piece self-contained breathing apparatus

(SCBA) or positive pressure-demand supplied

air respirator with escape SCBA; fully

encapsulating, chemical-resistant suit; inner

chemical-resistant gloves; chemical-resistant

safety boots/shoes; and two-way radio

communication.

• Level B - positive pressure-demand, full-face

piece SCBA or positive pressure-demand

supplied air respirator with escape SCBA;

chemical-resistant clothing (overalls and

long-sleeved jacket with hooded one- or

two-piece chemical splash suit or disposable

chemical-resistant one-piece suit);

chemical-resistant safety boots/shoes; hard hat;

and two-way communication.

• Level C - full-face piece, air-purifying

canister-equipped respirator; chemical-resistant

clothing (overalls and long-sleeved jacket with

hooded one- or two-piece chemical splash suit or

disposable chemical-resistant one-piece suit);

inner and outer chemical-resistant gloves;

chemical-resistant safety boots/shoes; hard hat;

and two-way communication.

• Level D - Coveralls, safety boots/shoes, safety

glasses or chemical splash goggles, and hard hat.

You are required to wear gloves at all four

protection levels. If the correct type of glove to be used

is not known, use neoprene or rubber, and avoid using

latex or vinyl. In any instance, contact with HAZMAT

should be avoided or minimized, and proper

5-23

WHITE

BLUE YELLOW

RED

HEALTH HAZARD FIRE HAZARD

FLASH POINTS 4- DEADLY

3- EXTREMELY HAZARDOUS

2- HAZARDOUS

1- SLIGHTLY HAZARDOUS

0- NORMAL MATERIAL

4- BELOW 73 F

3- BELOW 100 F

2- BELOW 200 F

1- ABOVE 200 F

0- WILL NOT BURN

REACTIVITY

4- MAY DETONATE

3- SHOCK AND HEAT

MAY DETONATE

2- VIOLENT CHEMICAL CHANGE

1- UNSTABLE IF HEATED

0- STABLE

SPECIFIC HAZARD

OXIDIZER

ACID

ALKALI

CORROSIVE

USE NO WATER

RADIATION HAZARD

OX

ACID

ALK

COR

W

0

0

0

0

HM3f0507

Figure 5-7.—NFPA 704 labeling system.
decontamination should be performed promptly.

Protect feet from contact with chemical by using a

disposable boot/shoe cover made from appropriate

material.

Site Control

For management purposes, site control is divided

up into three sections.

• Exclusion Zone (Hot Zone): The area where

the contamination has occurred. The outer

boundary of the exclusion zone should be

marked either by lines, placards, hazard tape

and/or signs, or enclosed by physical barriers.

Access control points should be established at

the periphery of the exclusion zone to regulate

the flow of personnel and equipment.

Remember also to remain upwind of the danger

area, and avoid low areas where toxic

gases/vapors may tend to settle.

• Contamination-Reduction Zone (Warm

Zone): The transition area between the

contaminated area and the clean area. This zone

is designed to prevent the clean support zone

from becoming contaminated or affected by

other site hazards. Decontamination of

personnel/equipment takes place in a designated

area within the contamination-reduction zone

called the “contamination-reduction corridor.”

• Support Zone: The location of the

administrative and other support functions

needed to keep the operations in the exclusion

and contamination- reduction zones running

smoothly. The command post supervisor should

be present in the support zone. Personnel may

wear normal work clothes within this zone.

Figure 5-8 shows the three management sections

of a hazard zone.

RESCUE AND PATIENT CARE

PROCEDURES

LEARNING OBJECTIVE: Recall rescue,

patient care, and decontamination

procedures for patients exposed to

hazardous material.

After a safety zone has been established—and

regardless of your level of training—you should

follow the procedures outlined below:

• Help isolate the incident site and keep the area

clear of unauthorized and unprotected

personnel.

• Establish and maintain communications with

your dispatcher.

• Stay upwind and upgrade from the site, and

monitor wind and weather changes.

• Don’t breathe any smoke, vapors, or fumes.

5-24

CONTAMINATION-REDUCTION ZONE

>> WARM ZONE <<

EXCLUSION ZONE

>> HOT ZONE <<

Victim(s)

COMMAND

CENTER

WIND

SUPPORT

ZONE

HM3f0508

Figure 5-8.—Hazard zone management sections
• Don’t touch, walk, or drive through the spilled

materials, since these will increase the area of the

spill.

• Don’t eat, drink, or smoke at the site; don’t touch

your face, nose, mouth, or eyes. (These are all

direct routes of entry into your body.)

• Eliminate any possible source of ignition (e.g.,

flares, flames, sparks, smoking, flashes,

flashlights, engines, portable radios).

• Notify your dispatcher and give your location.

Request the assistance of the HAZMAT

response team.

• If possible, identify the hazardous material and

report it to the dispatcher.

• Observe all safety precautions and directions

given by the on-site HAZMAT expert. All

orders should be given and received face to

face.

• Stay clear of restricted areas until the on-site

HAZMAT expert declares them to be safe.

Rescue from Exclusion Zone (Hot Zone)

The most dangerous element of any HAZMAT

incident—both to the exposed victims and the

rescuers—is the rescue from the hot zone. Rescue

operations should always be performed using

appropriate protective equipment (PPE). You must

never enter the area unless you have been

appropriately trained to do so. Let the experts

handle this aspect of the rescue, but be prepared to

provide supportive care once the victim is clear of the

contaminated area.

As soon as the patient has been removed to safety,

you should follow normal primary and secondary

survey procedures, including interviews of the patient

and bystanders. Observe the patient and provide basic

life support. Give the patient supplemental oxygen,

and monitor vital signs closely.

Patient Decontamination Procedures

Decontamination is the process of removing or

neutralizing and properly disposing of contaminants

that have accumulated on personnel and equipment.

Decontamination protects site personnel by

minimizing the transfer of contaminants, helps to

prevent the mixing of incompatible chemicals, and

protects the community by preventing uncontrolled

transportation of contaminants from the site. All

personnel, clothing, and equipment that leave the

contamination area (exclusion zone) must be

decontaminated to remove any harmful chemicals that

may have adhered to them. Some decontamination

methods include those listed below.

• Dilution: the flushing of the contaminated

person or equipment with water.

• Absorption: the use of special filters and

chemicals to absorb the hazardous material.

• Chemical washes: specific chemicals used to

neutralize the hazardous material.

• Disposal and isolation: the proper disposal of

contaminated materials instead of attempting to

decontaminate them.

Dilution is the most frequently appropriate method of

decontamination.

Decontamination requires the use of PPE,

although the level of protection required may be less

once the victim is out of the hot zone. A victim who is

exposed to a gas may not require actual

“decontamination” after rescue and only require

cessation of exposure and an opportunity to breathe

fresh air. However, if a victim is soaked with a liquid,

the HAZMAT may pose an ongoing risk to the victim

and to the rescuers or medical personnel. IT IS

IMPORTANT TO ALWAYS ASSUME THAT THE

VICTIM HAS BEEN CONTAMINATED WITH

SOMETHING THAT COULD HARM YOU AND

OTHERS UNTIL DETERMINED OTHERWISE.

Do not be foolish or bold and presume that you or

others will not be exposed and harmed!

Once the victim is medically evaluated, carefully

remove any solid material that remains on the patient’s

clothing. Be alert not to get any on yourself. If the

material is dry, immediately remove the victim’s

clothing while avoiding or minimizing contact with the

HAZMAT or loss of the HAZMAT from the clothing.

Unless specifically contraindicated by the hazardous

nature of the HAZMAT and directed by the incident

commander or the supporting medical advisor, flush

the patient’s skin, clothing, and eyes with water. To the

maximum extent possible, control or retain the runoff

(which is contaminated) which will be containerized

for proper disposal. Remove all of the victim’s

clothing, shoes, and jewelry. Place everything that

may have contacted the HAZMAT in a special

container. Mark the container as contaminated.

Continue flushing the skin with water for at least 20

5-25
minutes. Again, try to retain the runoff. Using

available items like towels or clean rags, mechanically

remove the HAZMAT by wiping; avoid rubbing the

skin too vigorously. Dry the skin and provide

uncontaminated dry clothing or coverings.

The nature of the HAZMAT involved and the

threat to the health of others (rescue team, other

victims, medical personnel, transport crew)

determines the degree of decontamination necessary

before treatment or transporting the patient. Generally,

it is preferred that decontamination be accomplished

before treatment or transport. However, the patient’s

immediate medical condition may be more serious

than the contamination itself. For example, ingested

HAZMAT may pose little immediate threat to nearby

personnel, but be an imminent threat to the victim’s

life. Therefore, the consequences of delaying the

emergency care of the patient’s injuries to accomplish

gut decontamination must be carefully evaluated. In

some cases, decontamination and emergency medical

care can be carried out simultaneously. In rare

instances of great urgency, the victim may require

transportation to the hospital before decontamination.

In these unusual cases, notify both the hospital and

transportation crew of the patient’s medical condition

and contamination. Depending on the situation, the

transportation crew will have to appropriately prepare

to carry and care for the contaminated victim;

otherwise, the crew themselves could be contaminated

and/or be affected by the contamination. For example,

the transport crew may need to wear level A or B suits

and/or respirators. Remember, if the victim is

contaminated and the transport requires personal

protective devices, it is likely that the vehicle will be

contaminated and require appropriate decontamination. There is also a potential to contaminate the

receiving medical facility and its staff.

Diagnosis, Treatment, and Transport

As soon as the victim has been removed to safety,

follow normal primary and secondary survey

procedures, including interviews of the patient and

bystanders. Observe the patient and provide the ABCs

of basic life support (airway, breathing, circulation)

and add “D” and “E” for disability and exposure. Look

for signs of trauma and provide proper exposure (i.e.,

remove clothing) to fully assess the victim. Monitor

vital signs and the victim closely! As a guideline, give

the patient supplemental oxygen (4 to 6 liters per

minute), and start an IV at an area of skin not exposed

to the hazardous material (or at least that has been

thoroughly decontaminated).

If the HAZMAT victim has swallowed a known or

identified toxic material, treat the victim as a poisoned

patient using the information provided above. Dress

wounds and prepare the patient for transport to a

medical treatment facility.

Finally, transport the victim to a medical treatment

facility for complete medical evaluation and treatment.

Care should be taken during transport to stabilize the

victim by maintaining normal body temperature,

administering oxygen, and treating shock.

SUMMARY

In this chapter, we discussed the assessment and

treatment for poisoning, drug abuse, and hazardous

material exposure, along with the rescue and

decontamination procedures for patients exposed to

HAZMAT. In our rapidly changing environment, we

must be up to date on the latest changes in assessment

and treatment for these conditions. You may stay

informed through contact with the local Poison

Control Center, MEDIC releases, or via the World

Wide Web on the Internet.

5-26
CHAPTER 6

PHARMACY AND TOXICOLOGY

As you advance in rate, you will become more and

more involved in the administration of medicines.

Although drugs and their dosages are prescribed by

medical officers and other authorized prescribers, you,

as the Hospital Corpsman, are involved in their

administration. It is necessary for you to learn drug

sources, composition, methods of preparation and

administration, and physiologic and toxicologic

action. This chapter covers pharmacology, toxicology,

medication calculations, pharmaceutical preparations,

and prescriptions.

PHARMACOLOGY

LEARNING OBJECTIVE: Recall the

subsciences of pharmacology, drug

standards, medication administration

methods, and factors that affect dosage.

Pharmacology is the science that deals with the

origin, nature, chemistry, effects, and uses of drugs.

The subsciences of pharmacology and their specific

areas of concentration are as follows:

• PHARMACOGNOSY—the branch of

pharmacology that deals with biological,

biochemical, and economic features of natural

drugs and their constituents.

• PHARMACY—the branch of pharmacology

that deals with the preparation, dispensing, and

proper use of drugs.

• POSOLOGY—the science of dosages.

• PHARMACODYNAMICS—the study of drug

action on living organisms.

• PHARMACOTHERAPEUTICS—the study

of the uses of drugs in the treatment of disease.

• TOXICOLOGY—the study of poisons, their

actions, their detection, and the treatment of the

conditions produced by them.

The science of treating disease by any method that

will relieve pain, cure disease, or prolong life is called

therapeutics. Therapeutics does not deal solely with

giving or taking medicine. This field also includes

many other methods, such as radiological treatment,

diathermy, and hydrotherapy.

DRUG STANDARDS

The texts dealing with pharmaceutical

preparations include the United States Pharmacopeia

and National Formulary (USP-NF), which provides

standards for drugs of therapeutic usefulness and

pharmaceutical necessity. Inclusion of drugs into this

compendium is based on therapeutic effectiveness and

popularity. The USP-NF provides tests for drug

identity, quality, strength, and purity.

Drug Facts and Comparisons and the Physicians’

Desk Reference (PDR) have multiple indexes of

commercially available drugs. Both are used as

advertising outlets for various drug manufacturers. A

comprehensive description of each pharmaceutical

preparation (including composition, action and use,

administration and dosage, precautions and side

effects, dosage forms available, and the common

(generic) drug names) is provided in both publications.

These two publications are used as references for

in-depth information on pharmaceutical products by

healthcare providers and pharmacy personnel.

Remington: The Science and Practice of

Pharmacy is probably the most widely used

text/reference in American pharmacies. It contains all

areas relevant to the art/science of pharmacy. The

Pharmacological Basis of Therapeutics (Goodman

and Gilman) is a textbook of pharmacology,

toxicology, and therapeutics. This work is known as

the “blue bible” of pharmacology.

MEDICATION ADMINISTRATION

The quantity and frequency of a drug’s

administration to a patient depend on several factors,

as does the method of that medication’s administration. This section will cover some of the factors

affecting dosage calculations and methods of

administration.

6-1
Dosage

The amount of medication to be administered is

referred to as the dose. The study of dosage and the

criteria that influence it is called posology. The doses

given in the United States Pharmacopeia and National

Formulary (USP-NF) are average therapeutic doses

and are known as “usual adult doses.” The following

terms are used in connection with doses.

THERAPEUTIC DOSE.—Therapeutic dose is

also referred to as the normal adult dose, the usual dose

or average dose. It is the amount needed to produce the

desired therapeutic effect. This therapeutic dose is

calculated on an average adult of 24 years who weighs

approximately 150 pounds.

DOSAGE RANGE.—Dosage range is a term that

applies to the range between the minimum and

maximum amounts of a given drug required to produce

the desired effect. Many drugs (such as penicillin)

require large initial doses that are later reduced to

smaller amounts. Closely associated with “dosage

range” are the terms minimum dose (the least amount

of drug required to produce a therapeutic effect),

maximum dose (the largest amount of drug that can be

given without reaching the toxic effect), and toxic dose

(the least amount of drug that will produce symptoms

of poisoning).

MINIMUM LETHALDOSE.—Minimum lethal

dose is the least amount of drug that can produce death.

Factors Affecting Dosage

The two primary factors that determine or

influence the dosage of a medication are the age and

weight of the patient.

AGE.—Age is the most common factor that

influences the amount of drug to be given. An infant

requires a lower dose than an adult. Elderly patients

may require a higher or lower dose than the average

dose, depending upon the action of the drug and the

condition of the patient.

The rule governing calculation of pediatric

(child’s) doses, Young’s Rule, is expressed as follows:

The age in years of the child is the numerator, and

the age plus 12 is the denominator. This fraction is

multiplied by the normal adult dose.

WEIGHT.—In the calculation of dosages, weight

has a more direct bearing on the dose than any other

factor, especially in the calculation of pediatric doses.

The rule governing calculation of pediatric doses

based on weight is Clark’s Rule, expressed as follows:

The child’s weight in pounds is the numerator, and the

average adult weight (150 pounds) is the denominator.

This fraction is multiplied by the adult dose.

OTHER FACTORS THAT INFLUENCE

DOSAGE.—Other factors that influence dosage

include the following:

• Sex—Females usually require smaller doses

than males.

• Race—Black individuals usually require larger

doses, and Asians require smaller doses than

Caucasians.

• Occupation—Persons working in strenuous

jobs may require larger doses than those who sit

at a desk all day.

• Habitual use—Some patients must take

medications continuously, causing their bodies

to build up tolerance to the drug. This tolerance

may require larger doses than their initial doses

to obtain the same therapeutic effect.

• Time of administration—Therapeutic effect

may be altered depending upon time of

administration (e.g., before or after meals).

6-2

age in years

age in years +12

× adult dose = child' s dose

Example: The adult dose of aspirin is 650 mg.

What is the dose for a 3-year-old child?

3

3 + 12

mg

15 × = 130 mg

650

weight in pounds

150

× adult dose = child' s dose

60 lbs

150 lbs × 650 mg = 260 mg

Example: The adult dose of aspirin is 650 mg.

What is the dose for a child weighing 60 pounds?
• Frequency of administration—Drugs given

frequently may need a smaller dose than if

administered at longer intervals.

• Mode of administration—Injections may

require smaller doses than oral medications.

Methods of Administering Drugs

Drugs may be introduced into the body in several

ways, each method serving a specific purpose.

ORAL.—Oral administration of medications is

the most common method. Among the advantages of

administering medication orally (as opposed to other

methods) are the following:

• Oral medications are convenient.

• Oral medications are cheaper.

• Oral medications do not have to be pure or

sterile.

• Awide variety of oral dosage forms is available.

Oral medication administration may be

disadvantageous for the following reasons:

• Some patients may have difficulty swallowing

tablets or capsules.

• Oral medications are often absorbed too slowly.

• Oral medications may be partially or completely

destroyed by the digestive system.

Other methods of administration closely

associated with oral administration are sublingual and

buccal. Sublingual drugs are administered by placing

the medication under the tongue. The medication is

then rapidly absorbed directly into the blood stream.

An example of a sublingual drug is nitroglycerin

sublingual tablets (for relief of angina pectoris).

Buccal drugs are administered by placing the

medication between the cheek and gum. Buccal drugs,

like sublingual drugs, are quickly absorbed directly

into the blood stream. An example of a drug that may

be given buccally is the anesthetic benzocaine.

PARENTERAL.—Parenteral medications are

introduced by injection. All drugs used by this route

must be pure, sterile, pyrogen-free (pyrogens are

products of the growth of microorganisms), and in a

liquid state. There are several methods of parenteral

administration, including subcutaneous, intradermal,

intramuscular, intravenous, and intrathecal or

intraspinal.

Subcutaneous.—The drug is injected just below

the skin’s cutaneous layers. Example: Insulin.

Intradermal.—The drug is injected within the

dermis layer of the skin. Example: Purified protein

derivative (PPD).

Intramuscular.—The drug is injected into the

muscle. Example: Procaine penicillin G.

Intravenous.—The drug is introduced directly

into the vein. Example: Intravenous fluids.

Intrathecal or Intraspinal.—The drug is

introduced into the subarachnoid space of the spinal

column. Example: Procaine hydrochloride.

INHALATION.—Inhalation is a means of

introducing medications through the respiratory

system in the form of a gas, vapor, or powder.

Inhalation is divided into three major types:

vaporization, gas inhalation, and nebulization.

Vaporization.—Vaporization is the process by

which a drug is changed from a liquid or solid to a gas

or vapor by the use of heat (such as in steam

inhalation).

Gas Inhalation.—Gas inhalation is almost

entirely restricted to anesthesia.

Nebulization.—Nebulization is the process by

which a drug is converted into a fine spray by the use of

compressed gas.

TOPICAL.—Topical drugs are applied to a

surface area of the body. Topically applied drugs serve

two purposes:

• Local effect: The drug is intended to relieve

itching, burning, or other skin conditions

without being absorbed into the bloodstream.

• Systemic effect: The drug is absorbed through

the skin into the bloodstream.

Examples of topical preparations are ointments,

creams, lotions, and shampoos.

RECTAL.—Drugs are administered rectally by

inserting them into the rectum. The rectal method is

preferred to the oral route when there is danger of

vomiting or when the patient is unconscious,

uncooperative, or mentally incapable. Examples of

rectal preparations are suppositories and enemas.

VAGINAL.—Drugs are inserted into the vagina to

produce a local effect. Examples of vaginal

preparations are suppositories, creams, and douches.

6-3
DRUG CLASSIFICATIONS

LEARNING OBJECTIVE: Recall drug

groups, the generic and trade names of

drugs listed in each drug group, and

recognize each drug’s use.

The definition of a drug is any chemical substance

that has an effect on living tissue but is not used as a

food. Drugs are administered to humans or animals as

an aid in the diagnosis, treatment, or prevention of

disease or other abnormal condition; for the relief of

pain or suffering; and to control or improve any

physiologic or pathologic condition. Drugs are

classified according to set criteria and fall into three

specific areas: general, chemical, and therapeutic.

• General—Drugs are grouped according to their

source, whether animal, vegetable, or mineral in

origin.

• Chemical—Drugs are grouped by their

chemical characteristics.

• Therapeutic (Pharmacological)—Drugs are

grouped according to their action on the body.

NOTE: Some drugs may have more than

one action.

Drug Nomenclature

Drugs normally have three names: chemical,

generic, and trade (brand).

• Chemical name relates to the chemical and

molecular structure. An example is

2,4,7-triamino-6-phenylpteridine.

• Generic name is often derived from the

chemical name. Generic name is the common

name of the drug. An example is triamterene.

(Note the underlining of the chemical name

above.)

• Trade name is the proprietary name given by

the manufacturer. Trade name is referred to as

the brand name. An example is Dyrenium®, a

brand of triamterene made by SmithKline

Beecham.

Drug Groups

The types of drugs discussed in this chapter and the

correlating drugs in common use described in

appendix IV are grouped according to

pharmacological classes. Only a brief summary is

possible here, and the Corpsman who desires a more

complete description of each drug should refer to the

USP -NF, Drug Facts and Comparisons, the

Physicians’ Desk Reference, or other drug reference

books.

ASTRINGENTS.—Astringents are drugs that

cause shrinkage of the skin and mucous membranes.

Astringents are mainly used to stop seepage, weeping,

or discharge from mucous membranes. (See appendix

IV, page 1.)

EMOLLIENTS.—Emollients are bland or fatty

substances that may be applied to the skin to make it

more pliable and soft. They may also serve as vehicles

for application of other medicinal substances.

Emollients are available as ointments, creams, or

lotions. (See appendix IV, page 1.)

EXPECTORANTS AND ANTITUSSIVES.—

Expectorants and antitussives are commonly used in

the symptomatic treatment of the common cold or

bronchitis. (See appendix IV, page 1.) Expectorants

are more accurately known as bronchomucotropic

agents. These agents assist in the removal of secretions

or exudate from the trachea, bronchi, or lungs. They

act by liquefying viscid mucous or mucopurulent

exudates. Therefore, they are used in the treatment of

coughs to help expel these exudates and secretions.

Antitussives are agents that inhibit or suppress the act

of coughing. Other cold and allergy relief preparations

are discussed later in this chapter.

NASAL DECONGESTANTS.—Nasal decongestants reduce congestion and the swelling of mucous

membranes. They are used for the temporary relief of

nasal congestion due to the common cold, nasal

congestion associated with sinusitis, and to promote

nasal or sinus drainage. Nasal decongestants are also

used to relieve eustachian tube congestion. Nasal

decongestants are often combined with antihistamines,

antitussives, and expectorants to relieve the symptoms

of colds, allergies, and sinusitis. Some of the more

frequently used drug combinations are covered in

appendix IV, page 2.

ANTIHISTAMINES.—Antihistamines are used

to counteract the physical symptoms that histamines

cause. Histamine, a substance released by mast cells

distributed in connective tissues usually near blood

vessels, promotes some of the reactions associated

with inflammation and allergies, such as asthma and

hay fever. Antihistamines may cause drowsiness, so

6-4
patients should be warned against driving or operating

machinery while taking this type of medication. (See

appendix IV, page 2.)

HISTAMINE H2 RECEPTOR ANTAGONISTS.— Histamine H2 receptor antagonists block

histamines that cause an increase of gastric acid

secretion in the stomach. Histamine H2 receptor

antagonists are effective in preventing complications

of peptic ulcer disease and alleviating symptoms of

this disease. (See appendix IV, page 2.)

ANTACIDS.—Antacids are drugs used to

counteract hyperacidity in the stomach. Normally,

there is a certain degree of acidity in the stomach. An

excess of acid can irritate the mucous membranes and

is commonly known as indigestion, heartburn, or

dyspepsia. In some disease states, the gastrointestinal

tract may become excessively acidic (very low pH),

causing diarrhea or leading to peptic ulcer formation.

Antacids may interfere with the body’s ability to use

many drugs. For this reason, oral drugs normally

should not be taken within 2 hours of taking an antacid.

(See appendix IV, page 3.)

NOTE: It is important for you to be aware of

the significance of the sodium content of most

antacids, particularly for cardiac patients or

patients on a low-sodium diet.

ANTISEPTICS, DISINFECTANTS, AND

GERMICIDES.—These agents are primarily

intended for the prevention of infections by destroying

bacteria or preventing their growth. The differences

among them are based primarily on degree of activity

and how they are used. Antiseptics suppress the

growth of microorganisms. Germicides kill

susceptible organisms. Disinfectants are agents used

to disinfect inanimate objects and are primarily

germicidal in their action. All of these agents are for

external use only, unless otherwise indicated. (See

appendix IV, pages 3 and 4.)

SULFONAMIDES.—Sulfonamides were the

first effective chemotherapeutic agents to be available

in safe therapeutic dosage ranges. They were the

mainstay of therapy of bacterial infections in humans

before the introduction of the penicillins in 1941.

Sulfonamides are synthetically produced and are

effective against both gram-positive and

gram-negative organisms. (See appendix IV, page 5.)

PENICILLINS.—Penicillin is one of the most

important antibiotics. It is derived from a number of

Penicillium molds commonly found on breads and

fruits. The mechanisms of action for the penicillins is

the inhibition of cell wall synthesis during the

reproductive phase of bacterial growth. It is one of the

most effective and least toxic of the antimicrobial

agents. (See appendix IV, page 5.)

CEPHALOSPORINS.—The cephalosporins are

a group of semisynthetic derivatives of cephalosporin

C, an antimicrobial agent of fungal origin. They are

structurally and pharmacologically related to the

penicillins. Because the cephalosporins are

structurally similar to the penicillins, some patients

allergic to penicillin may also be allergic to cephalosporin drugs. The incidence of cross-sensitivity is

estimated to be 5 to 16 percent.

This family of antibiotics is generally divided into

generations:

• First generation — cefazolin sodium (Ancef®,

Kefzol®)

• Second generation — cefoxitin sodium

(Mefoxin®)

• Third generation — cefotaxime sodium

(Claforan®)

The main differences among the groups is the

change in the antibacterial spectrum. The third

generation agents have a much broader gram-negative

spectrum than the earlier generations.

Examples of various cephalosporins are listed in

appendix IV, page 6.

TETRACYCLINES .—Tetracyclines,

introduced in 1948, were the first truly broad-spectrum

antibiotics. They include a large group of drugs with a

common basic structure and chemical activity. The

most important mechanism of action of the

tetracyclines is the blocking of the formation of

polypeptides used in protein synthesis. Because of

their broad spectrum of activity, tetracyclines are most

valuable to treat mixed infection, such as chronic

bronchitis and peritonitis; however, they are drugs of

choice for only a few bacterial infections. Tetracycline

is also used as a topical preparation to treat acne.

The tetracyclines are relatively nontoxic, the most

common side effects being mild gastrointestinal

disturbances. Allergic reactions and anaphylaxis are

rare. Administration to children and pregnant women

is not indicated because it may produce discoloration

of the teeth and depress bone marrow growth. The

major hazard of tetracycline therapy is the overgrowth

of resistant organisms, especially Candida and

staphylococci.

6-5
Tetracyclines should not be administered with

milk, milk products, antacids or iron preparations; they

combine with metal ions to form nonabsorbable

compounds.

Examples of tetracyclines in common use are

listed in appendix IV, page 6.

AMINOGLYCOSIDES.—Aminoglycosides are

a group of drugs that share chemical, antimicrobial,

pharmacologic, and toxic characteristics, and that are

effective against most gram-positive and gramnegative organisms. Their method of action is by

inhibiting protein synthesis. Aminoglycosides can

cause varying degrees of ototoxicity and nephrotoxicity, depending on the particular agent and the

dose. Toxicity is more prevalent in the very young or

old, in the presence of renal impairment or

dehydration, or with the use of diuretics. Because of

their high toxicity, aminoglycosides are not

recommended when the infective organism is

susceptible to less toxic preparations.

Examples of several aminoglycosides are listed in

appendix IV, page 7.

MACROLIDES.—Macrolide antibiotics constitute

a large group of bacteriostatic agents that inhibit protein

synthesis. They are effective against gram-positive

cocci, Neisseria, Hemophilus, and mycobacteria. All are

similar to penicillin in their antibacterial spectra, and are

often used in patients who are sensitive to penicillin. (See

appendix IV, pages 7 and 8.)

ANTIFUNGALS.—Antifungal agents inhibit or

suppress the growth systems of fungi, dermatophytes,

or Candida. Antifungals have not been developed to

the same degree as antibacterial agents. Most fungi are

completely resistant to the action of chemicals at

concentrations that can be tolerated by the human cell.

Since there are only a few available for internal use,

most antifungal agents are topical. The antifungal

agents that are available for systemic use generally

produce hepatic or renal dysfunction or other serious

side effects. Because of these side effects, systemic

antifungals should be limited to serious or potentially

fatal conditions. Therapy that includes topical

preparations may be provided in conjunction with oral

or parenteral antifungal agents.

Examples of several antifungal agents are listed in

appendix IV, page 8.

ANTIPARASITICS.—Antiparasitics are agents that

are destructive to parasites. Parasitic infections or

infestations account for the largest number of chronic

disabling diseases known. They are especially prevalent in

the tropics or subtropics and in lesser-developed countries

where overcrowding and poor sanitation exist. Parasitic

infections include protozoal infections (malaria, amebiasis,

andto alesser extent,trichomoniasis), helminthicinfections

(intestinal worms), and ectopara- sites. Ectoparasites, such

as head lice and crab lice, although not disabling, are

considered a nuisance and can transmit disease.

Examples of antiparasitics in common use are

listed in appendix IV, page 9.

LAXATIVES.—Laxatives are drugs that facilitate

the passage and elimination of feces from the colon and

rectum. They are indicated to treat simple constipation

and to clean the intestine of any irritant or toxic

substances (catharsis). Laxatives may also be used to

soften painfully hard stools and to lessen straining of

certain cardiac patients when defecating. They are

contraindicated in certain inflammatory conditions of

the bowel, bowel obstruction, and abdominal pain of

unknown origin, and should not be used in the presence

of nausea and vomiting. Laxatives are classified as

irritant, bulk, emollient, or stool softeners. Frequent or

prolonged use of any laxative may result in dependence.

(See appendix IV, pages 9 and 10.)

ANTIDIARRHEALS.—Antidiarrheals are drugs

that are effective in combating diarrhea. Diarrhea is

defined as an abnormal frequency and liquidity of fecal

discharge. This condition may result from food

poisoning, parasitic infestation of the bowel, and

gastrointestinal diseases. (See appendix IV, page 10.)

DIURETICS.—The kidney is the primary organ

that excretes water-soluble substances (urine) from the

body. Diuretics are agents that increase the rate of

urine formation. These agents are useful in treating

hypertension and edematous conditions, such as

congestive heart failure and acute pulmonary edema.

However, loss body fluids due to use of diuretics can

seriously deplete electrolytes from the system, and

care should be taken to monitor and replenish lost

sodium and potassium through diet and supplement

therapy. (See appendix IV, page 10 and 11)

NON-NARCOTIC ANALGESICS, ANTIPYRETICS, AND ANTI-INFLAMMATORY

AGENTS.—Non-narcotic analgesics are drugs that

relieve pain without producing unconsciousness or

impairing mental capacities. Antipyretics relieve or

reduce fevers. Anti-inflammatory agents counteract

or suppress inflammation or the inflammatory process.

Many of the drugs discussed in appendix IV, page 11,

were developed with two or more of these properties.

6-6
CENTRAL NERVOUS SYSTEM STIMULANTS.—Certain drugs stimulate the activity of

various portions of the central nervous system (CNS).

The Manual of the Medical Department (MANMED)

is explicit as to the usage of these drugs in the Navy.

Primary indications for this class of drugs are

narcolepsy, hyperkinesis, and attention deficit

disorders in children. Central nervous system

stimulants are generally contraindicated in patients

with hypertension, arteriosclerosis, symptomatic

cardiovascular disorders, agitated states, glaucoma, or

history of drug abuse. (See appendix IV, page 12.)

CENTRAL NERVOUS SYSTEM DEPRESSANTS.—Central nervous system (CNS) depressants

range in depressive action from mild sedation to deep

coma, differing mainly in rapidity, degree, and

duration of action. Any of these CNS depressants may,

in sufficient doses, cause respiratory depression.

Alcohol use while taking CNS depressants should be

avoided. Many of the central nervous system

depressants are controlled medications. Refer to the

MANMED for control, custody, and accountability

guidelines for controlled substances.

Barbiturates comprise a widely used group of

CNS depressants. They are used mainly as

sedative-hypnotics, anticonvulsants, anesthetics for

short anesthesia, and may be used in combination with

analgesics to enhance their analgesic effect.

NOTE: Barbiturates may be habit forming.

See appendix IV, page 12, for examples of central

nervous system depressants.

OPIUM AND OPIUM ALKALOIDS.—The

activity of opium is primarily due to its morphine

content. The major medical use of opium has been for

its antiperistaltic activity, particularly in diarrhea.

Opium alkaloids, e.g., morphine and codeine, have

replaced opium in medical use. Members of this drug

group are used as analgesics, cough sedatives, and for

certain types of diarrhea. (See appendix IV, pages 12

and 13.)

NOTE: Warn patients taking opium or opium

alkaloids that drowsiness, dizziness, and

blurring of vision may occur. For this reason,

they should not drive or perform other tasks

that require alertness. Also, caution patients

against consuming alcohol and other CNS

depressants. Patients should notify their

physician immediately if shortness of breath

or difficulty in breathing occurs.

PSYCHOTHERAPEUTIC AGENTS.—

Tranquilizers and mood modifiers are the two primary

groups of psychotherapeutic agents. Psychotherapeutic agents are classified as major tranquilizers,

minor tranquilizers, and mood modifiers. The mood

modifiers have replaced amphetamines as treatment of

choice for depressive states. (See appendix IV, pages

13 and 14.)

SKELETAL MUSCLE RELAXANTS.—

Skeletal muscle relaxants are used in connection with

the treatment of muscle spasm due to various

conditions. They may also be used to produce

muscular relaxation during surgical anesthesia.

Skeletal muscle relaxants may cause drowsiness and

impair performance of tasks that require alertness.

(See appendix IV, page 14.)

CARDIOVASCULAR AGENTS.—Cardiovascular agents affect the action of the circulatory

system. Most of these agents are highly specialized.

(See appendix IV, pages 14 and 15.)

VASOCONSTRICTORS.—Vasoconstrictors

produce constriction of the blood vessels with

consequent rise in blood pressure. (See appendix IV,

page 15.)

ANTICOAGULANTS.—Anticoagulants delay

or prevent blood coagulation. Before an anticoagulant

agent is prescribed and its dosage determined,

laboratory testing of the patient’s blood-clotting

capabilities should be performed.

Examples of commonly used anticoagulants are

listed in appendix IV, page 15.

VITAMINS.—Vitamins are unrelated organic

substances that occur in many foods and are necessary

for the normal metabolic functioning of the body.

Vitamins may be water-soluble or fat-soluble. The

majority of vitamins are water-soluble. Water-soluble

vitamins are excreted in the urine and are not stored in

the body in appreciable quantities. The fat-soluble

vitamins (A, D, E, and K) are soluble in fat solvents and

are absorbed along with dietary fats. Fat-soluble

vitamins are not normally excreted in the urine and

tend to be stored in the body in moderate amounts.

See appendix IV, page 16, for a listing of several of

the major vitamins and their respective properties.

GENERAL AND LOCAL ANESTHETICS.—

Generally speaking, anesthesia means “without

feeling.” Consequently, we apply the word to drugs

that produce insensibility to pain. The field of

anesthesia is a highly specialized one.

6-7
General anesthetics are usually gas or vapor and

are administered by inhalation. Anesthesiology is a

highly specialized field, and the administration of a

general anesthetic should never be undertaken without

the supervision of a medical officer. There may be

times, however, when you, as a Hospital Corpsman,

are called upon to assist by administering general

anesthesia. You should, therefore, acquaint yourself

with the most commonly used general anesthetics and

their respective properties.

Local anesthetics produce loss of sensation to

pain in a specific area or locality of the body, without

loss of consciousness or mental capacity. The majority

of these drugs are administered parenterally or

topically.

See appendix IV, pages 17 and 18, for a listing of

several of the most commonly used anesthetics.

OXYTOCICS.—Oxytocics are drugs that

produce a rhythmic contraction of the uterus. Their

action is selective for the uterus, although other

smooth muscles are affected. (See appendix IV, page

18.)

Biological Agents

Biological agents are prepared from living

organisms or their products. The chief purpose served

by these preparations in the Navy is the immunization

of personnel against infectious disease. They may,

however, be used in the treatment of disease or act in a

diagnostic capacity. Dosage and routes of

administration are described in BUMEDINST 6320.1.

Biologicals include serums, viruses, toxins,

antitoxins, antigens, and bacterial vaccines.

Manufacturers of these products must be licensed

by the Secretary of the Treasury. Their products are

monitored by the U.S. Public Health Service.

The label that must be placed on each package will

bear the name, address, and license number of the

manufacturer. It will also list the name of the product,

lot number, date of manufacture (or expiration), period

of potency, and the minimum potency (or the fact that

there is no standard of potency).

FACTORS TO BE REMEMBERED

CONCERNING BIOLOGICALS.—Most immunizing agents that are used in routine procedures may

be obtained through normal supply channels. (Yellow

fever vaccine must be ordered from activities that have

been designated as supply points for this biological.)

Biologicals must be stored in a cool, dry, and

preferably dark place. (Yellow fever vaccine must be

maintained in a frozen state until prepared for use.) All

biological products should be examined periodically,

and a thorough examination for deterioration will be

held immediately preceding their use.

EXAMINATIONS OF PARENTERAL

SOLUTIONS.—Solutions are examined at least three

times at the activity at which they are ultimately used:

1. Upon receiving the solution.

2. Periodically while in storage.

3. Immediately preceding use. Parenteral

solutions, unless the label states otherwise, must

be free of turbidity or undissolved material. All

solutions should be inverted and gently swirled

to bring any sediment or particulate matter into

view. A well-illuminated black or white

background will facilitate this examination.

Parenteral solutions may be unfit for use because of

• deterioration from prolonged storage,

• accidental contamination occurring upon

original packaging, or

• defects that may develop in containers or seals.

There is no set rule that can be applicable in

regards to any of these factors. Therefore, to ensure

suitability for use, a regimented program of inspection

is necessary.

IMMUNIZING AGENTS.—Following is a

descriptive list of the most common immunizing

agents used by the U.S. armed forces to inoculate

military personnel against disease.

Diphtheria Antitoxin.—Diphtheria antitoxin is a

transparent or slightly opalescent liquid, nearly

colorless, and has a very slight odor due to its

preservative. It is a sterile solution of antitoxic

substances obtained from the blood serum or plasma of

a healthy horse immunized against diphtheria toxin.

Tetanus Antitoxin.—Tetanus antitoxin is a sterile

solution of antitoxic substances that are usually

obtained from the blood serum or plasma of a healthy

horse that has been immunized against tetanus toxin or

toxoid. Tetanus antitoxin contains not more than 0.4

percent cresol or 0.5 percent phenol as a preservative.

It is slightly opalescent with a yellow, brown, or

greenish color, depending upon the manufacturer.

There will be a slight odor of the preservative used.

Tetanus Toxoid.—Tetanus toxoid is a sterile

solution of the growth of the tetanus bacillus,

6-8
Clostridium tetani, which has been treated with

formaldehyde. It is a brownish yellow or slightly

turbid liquid, usually having the distinctive odor of

formaldehyde.

Alum Precipitated Diphtheria and Tetanus

Toxoids and Per tussis Vaccines Combined

(DPT).— This is a markedly turbid, whitish liquid. It

is nearly odorless or may have a slight odor of the

preservative. It is a sterile suspension of the precipitate

obtained by treating the mixture of diphtheria toxoid,

tetanus toxoid, and pertussis vaccine with alum and

combining in such proportions as to ensure an

immunizing dose of each in the total dosage as listed on

the label.

Cholera Vaccine.—Cholera vaccine is a

suspension of killed cholera, Vibrio comma, in a

suitable diluent, usually normal saline. The vaccine

presents a turbid appearance, and there may be a slight

odor due to the preservative. On storage, autolysis

may occur so that the vaccine may become almost as

clear as water.

Poliovirus Vaccine.—There are two kinds of

polio vaccine: Inactivated poliovirus vaccine (IPV),

which is the shot recommended in the United States

today, and a live, oral polio vaccine (OPV), which

consists of drops that are swallowed. Until recently,

OPV was recommended for most children in the

United States. OPV helped us rid the country of polio,

and it is still used in many parts of the world.

Both vaccines give immunity to polio, but OPV is

better at keeping the disease from spreading to other

people. However, for a few people (about one in 2.4

million), OPV actually causes polio. Since the risk of

getting polio in the United States is now extremely low,

experts believe that using oral polio vaccine is no longer

worth the slight risk, except in limited circumstances.

Inactivated poliovirus vaccine (IPV) must be

stored between 2B

C and 8BC (24BF and 46BF). The

vaccine is clear and colorless, and it should be

administered intramuscularly or subcutaneously.

ORAL POLIOVIRUS VACCINE MUST

NEVER BE ADMINISTERED PARENTERALLY.

To maintain potency, OPV must be stored in the freezer

compartment of the refrigerator. It should be noted that

certain forms of this vaccine will remain fluid at

temperatures above -14B

C. If frozen, after thawing,

agitate the vaccine to ensure homogeneity of its

contents before use. Once the temperature rises above

0B

C, the vaccine MUST BE USED WITHIN 7 DAYS.

During this period, it must be stored below 10B

C.

Yellow Fever Vaccine.—This vaccine is a dull,

light orange, flaky or crust-like desiccated mass that

requires rehydration immediateley before use. It must

be stored at or below 0B

C until rehydration is effected

with sterile sodium chloride injection USP.

Plague Vaccine.—The vaccine for plague is a

sterile suspension of killed plague bacilli in an isotonic

solution. The strain of bacilli used has been selected for

its high antigenic efficiency. The vaccine is a turbid,

whitish liquid with little or no odor. The presence of any

precipitate is reason to suspect contamination.

Influenza Virus Vaccine.—The influenza virus

vaccine is prepared from the allantoic fluid of

incubated fertile hen eggs. It is a slightly hazy fluid,

the result of minute amounts of egg protein. Its color

varies from gray to very faint red, depending upon the

method of manufacture.

The duration of immunity is probably no longer

than a few months, which necessitates repeating the

inoculation before the expected seasonal occurrence.

Do not inoculate individuals who are known to be

sensitive to eggs or egg products, or personnel

suffering from upper respiratory infections.

Dried Smallpox Vaccine.—This vaccine is

prepared directly from calf lymph, purified,

concentrated, stabilized, and dried by lyophilization.

Dried smallpox vaccine is much more stable than the

conventional liquid. When stored at or below 25EC, it

retains its full potency for 18 months. When

reconstituted and stored below 4EC (preferably 0EC),

it retains its full potency for 3 months.

Smallpox is no longer considered to be a threat to

world health, and immunizations against it are no

longer required. However, a general knowledge of the

disease and its prevention is important.

Anthrax Vaccine.—The anthrax vaccine for

humans licensed for use in the United States is a

cell-free filtrate vaccine (using dead as opposed to live

bacteria). Inspect the vaccine visually for particulate

matter and discoloration before administration.

Anthrax vaccine should be stored between 2EC and

8EC (refrigerator temperature); it must not be frozen.

Do not use the vaccine if the expiration date listed on

the package has expired.

The vaccine should be administered only to

healthy men and women from 18 to 65 years of age. It

should NOT be administered to pregnant women.

6-9
The immunization consists of three subcutaneous

injections given 2 weeks apart, followed by three

additional subcutaneous injections given at 6, 12, and

18 months. Annual booster injections of the vaccine

are required to maintain immunity.

TOXICOLOGY

LEARNING OBJECTIVE: Identify how

poisons are introduced into the body and the

factors that affect their toxicity.

Toxicology is the science of poisons, their actions,

their detection, and the treatment of the conditions

produced by them. A poison is a substance that, when

inhaled, swallowed, absorbed, applied to the skin, or

injected into the body in relatively small amounts, may

cause damage to structures or disturbances of function.

Poisons act by changing the normal metabolism of

cells or by actually destroying them.

The effects of poisons may be local or remote, and

in some instances, poisons can produce both effects. A

local effect is produced when a poison only affects the

area in which it is applied. Aremote effectis produced

when a poison affects parts of the body that are remote

to the site of application or point of introduction.

Poisons sometimes show no effect—or only a slight

effect—until several doses have been taken. Then,

suddenly, an effect is produced that nearly equals that

produced by taking the whole amount at one time. This

is known as a cumulative effect.

The toxicity of poisons depends upon their method

of introduction into the body and how fast they are

absorbed by the body. For example, snake venom

taken into the mouth or into the stomach during first aid

treatment of snakebite is not ordinarily harmful, but

snake venom injected parenterally is extremely

poisonous.

Various conditions affect an individual’s reaction

and susceptibility to poisons. For instance, some

individuals by nature are unusually sensitive to certain

poisons (such as venom from bee stings), while others

possess a natural tolerance. Additionally, the age of

the victim can affect the severity of the poisoning.

Young children, for example, are normally more

susceptible to poisons than adults. Habitual use of

certain poisons, such as narcotics, may cause

individuals to become accustomed to a poison’s

effects, even though the amount taken by these

individuals would ordinarily be considered lethal.

This habitual use of poisons, however, may result in a

sudden hypersensitivity that could be deadly. The

actions of poisons may also be considerably modified

by disease, some diseases increasing and others

lessening the action of poisons.

Poisons are eliminated from the body by way of the

kidneys, liver, gastrointestinal tract, and skin. Poisons

are eliminated either unchanged or in the form of other

compounds. These compounds are the result of

chemical changes made in various body organs and

tissues.

For a more in-depth understanding of the various

types of poisoning and their emergency treatment

procedures, see chapter 5, “Poisoning, Drug Abuse,

and Hazardous Material Exposure.”

PHARMACY

LEARNING OBJECTIVE: Recall the

various pharmaceutical weight and

measurement systems, and determine

medication dosage by using the conversion

process or the percentage and ratio

calculations.

As you progress in your career as a Hospital

Corpsman, you will be assigned duties in specialized

departments throughout the hospital and especially

aboard ship. Not only will your responsibilities

increase, but your training will become more and more

diversified.

One of the departments to which you may be

assigned is the pharmacy, where you will assist in

preparing and dispensing medicines. This section will

give you a basic introduction to the field of pharmacy

and help prepare you for these responsibilities.

METROLOGY AND CALCULATION

Metrology, called the arithmetic of pharmacy, is

the science of weights and measures and its application

to drugs, their dosage, preparation, compounding, and

dispensing.

It is absolutely vital for Hospital Corpsmen to

thoroughly understand the principles and applications

of metrology in pharmacy. Errors in this area endanger

the health—even the life—of the patient.

6-10
The Metric System

The metric system is the official system of weights

and measures used by Navy Pharmacy Departments

for weighing and calculating pharmaceutical

preparations. The metric system is becoming the

accepted system throughout the world. Hospital

Corpsmen need to be concerned primarily with the

divisions of weight, volume, and linear measurement

of the metric system. Each of these divisions has a

primary or basic unit and is listed below:

• Basic unit of weight is the gram, abbreviated “g”

• Basic unit of volume is the liter, abbreviated “l”

• Basic linear unit is the meter, abbreviated “m”

By using the prefixes deka, hecto, and kilo for

multiples of, respectively, ten, one hundred, and one

thousand basic units, and the prefixes micro, milli,

centi, and decifor one-ten thousandth, one- thousandth,

one-hundredth, and one-tenth, respectively, you have

the basic structure of the metric system. By applying the

appropriate basic unit to the scale of figure 6-1, you can

readily determine its proper terms. For example, using

the gram as the basic unit of weight, we can readily see

that 10 g equals 1 dekagram, 100 g equals 1 hectogram,

and 1000 g is referred to as a kilogram. Conversely,

going down the scale, 0.1 g is referred to as a decigram,

0.01 g is called a centigram, and 0.001 g is a milligram.

The Apothecary System

Although fast becoming obsolete, the apothecary

system for weighing and calculating pharmaceutical

preparations is still used and must be taken into

consideration. It has two divisions of measurement:

weight and volume. In this system, the basic unit of

weight is the grain (abbreviated “gr”), and the basic

unit of volume is the minim (abbreviated “m”).

The Avoirdupois System

The avoirdupois system is a system used in the

United States for ordinary commodities. The basic units

of the avoirdupois system are dram (27.344 grains),

ounce (16 drams), and pound (16 ounces).

Table of Weights and Measures

See table 6-1, a table of weights and measures;

study it thoroughly.

Converting Weights and Measures

Occasionally, there are times when it will be

necessary to convert weights and measures from one

system to another, either metric to apothecary or vice

versa. Since patients can hardly be expected to be

familiar with either system, always translate the

dosage directions on the prescription into a household

equivalent that they can understand. Household

measurements are standardized, on the assumption

that the utensils are common enough to be found in any

home. Table 6-2 is a table of household measures, with

their metric and apothecary equivalents.

CAUTION: For the conversion of specific

quantities in a prescription or in converting a

pharmaceutical formula from one system to

another, exact equivalents must be used.

CONVERSION

As stated earlier, in the practice of pharmacy it may

be necessary to convert from one system to another to

dispense in their proper amounts the substances that

have been ordered. Although the denominations of the

metric system are not the same as the common

systems, the Bureau of International Standards has

established conversion standards that will satisfy the

degree of accuracy required in almost any practical

situation. Ordinary pharmaceutical procedures

generally require something between two- and

three-figure accuracy, and the following tables of

conversion (tables 6-3 and 6-4) are more than

sufficient for practical use. Naturally, if potent agents

are involved, you must use a more precise conversion

factor for purposes of calculation.

6-11

HM3F0601

GRAM

METER

LITER

KILO

HECTO

DEKA

ONE LINE

deci

centi

milli

DECIMAL LINE

100

1,000

10

1

01

001

1/10

1/100

1/1000

1.

Figure 6-1.—Graph comparing the metric system with the

decimal equivalent.
6-12

Table 6-1.—Measuring Equivalents
PERCENTAGE CALCULATIONS

Percentage means “parts per hundred” or the

expression of fractions with denominators of 100.

Thus, a 10 percent solution may be expressed as 10%,

10/100, 0.10, or 10 parts per 100 parts.

It is often necessary for the pharmacist to

compound solutions of a desired percentage strength.

Percentage in that respect means parts of active

ingredient per 100 parts of total preparation.

Following are the three basic rules to remember in

solving percentage problems:

1. To find the amount of the active ingredient

when the percentage strength and the total

quantity are known, multiply the total weight

or volume by the percent (expressed as a

decimal fraction).

6-13

Metric Apothecary Household

5 ml 1 fl dr 1 teaspoonful*

10 ml 2 fl dr 1 dessertspoonful

15 ml 4 fl dr 1 tablespoonful

(1⁄2 fl oz)

30 ml 8 fl dr 2 tablespoons

(1 fl oz)

60 ml 2 fl oz 1 wineglassful

120 ml 4 fl oz 1 teacupful

240 ml 8 fl oz 1 tumblerful

480 ml 16 fl oz 1 pint

960 ml 32 fl oz 1 quart

*Official U.S.P. teaspoonful is 5 ml.

Table 6-2.—Table of Metric Doses with Approximate Equivalents

Conversion Table

for Weights and Liquid Measures

1 grain = 0.065 gram or 65 milligrams

1 gram = 15.432 grains

1 milliliter = 16.23 minims

1 fluid ounce = 29.57 milliliters

Table 6-3.—Conversion Table for Weights and Liquid

Measures

Examples of Weight and Liquid Conversions

gr to g gr/15.432 = g

ml to fl oz ml/29.57 = fl oz

minims to ml minims/16.23 = ml

mg to gr mg/65 = gr

g to gr g x 15.432 = gr

fl oz to ml fl oz x 29.57 = ml

ml to minims ml x 16.23 = minims

gr to mg gr x 65 = mg

Table 6-4.—Examples of Weight and Liquid Conversions

Example: Substance X contains 38% fat. How many

grams of fat are required to prepare 120 g of substance X?

Solution: 38% is expressed as a decimal fraction

(0.38) and multiplied by the amount of the finished

product required.

120 g

x .38

960

360

45.60 g , the weight of fat needed.
2. To find the total quantity of a mixture when

the percentage strength and the amount of

the active ingredient are known, divide the

weight or volume of the active ingredient by the

percent (expressed as a decimal fraction).

3. To find the percentage strength when the

amount of the active ingredient and the total

quantity of the mixture are known, divide the

weight or volume of the active ingredient by the

total weight or volume of the mixture. Then

multiply the resulting answer by 100 to convert

the decimal fraction to percent.

ALTERNATE METHODS FOR SOLVING

PERCENTAGE PROBLEMS

The alternate method for solving percentage

problems, illustrated below, incorporates the three

rules discussed above into one equation. This method

is often preferred since it eliminates errors that may

result from misinterpreting the values given in the

problem.

% strength = Amt of active ingredient x 100(%)

Total amt of preparation

A variation of the alternate percentage equation,

illustrated below, uses “parts per hundred” instead of

percent, with X used as the unknown.

Amt of active ingredient = Parts of active ingredient

Amt of total preparation 100 parts (total mixture)

RATIO AND PROPORTION

CALCULATIONS

Ratio is the relationship of one quantity to another

quantity of like value. Example ratios are 5:2, 4:1.

These ratios are expressed as “5 to 2” and “4 to 1,”

respectively. A ratio can exist only between values of

the same kind, as the ratio of percent to percent, grams

to grams, dollars to dollars. In other words, the

denominator must be constant.

6-14

Example: If a mixture contains 20% of substance Y,

how many grams of the 20% mixture would contain 8 g

of Y?

Solution: 20% is expressed as a decimal fraction

(0.20). Divide the weight (8 g) by the percent, thus:

40.0 g , the weight of 20%

.20 ) 8.00 mixture that would

8 0 contain 8 g of

00 substance Y.

Example: Find the percentage strength of Z if 300 g

of a mixture contains 90 g of substance Z.

Solution:

0.3 g , is the percent of Z

300 ) 90.00 expressed as a decimal

90 fraction

00

0.3 x 100(%) = 30% of Z in the mixture

Example #2: Calculate the amount of active ingredient

in 300 g of a 5% mixture of active ingredient B.

Solution: Convert 5% to a decimal fraction (0.05).

Substitute the known values in the equations, and use X

for the amount of the unknown ingredient .

0.05 = X/300 X = 15 g

Example #1: Calculate the percent of A in a solution if

120 g of that solution contains 6 g of A.

Solution: Substitute the known values in the equation

and use X for the percent (the unknown factor).

X = 6/120 x 100(%) = 5 (%)

Therefore, X=5, which is the percent strength of the

solution.

Example: Ascertain the percent B in a mixture of

600 g that contains 15 g of B.

Solution:

=

X = 2.5, the parts of active ingredient

per 100 parts of total mixture, or

2.5%

15

600 = X100

600X = 1500

X =

1500

600
Proportion is two equal ratios considered

simultaneously. An example proportion is

1:3::3:9

This proportionis expressed as “1isto 3 as 3isto 9.” Since

the ratios are equal, the proportion may also be written

1:3 = 3:9

Terms of Proportion

The first and fourth terms (the terms on the ends)

are called the extremes. The second and third terms

(middle terms) are called the means.

In a proportion, the product of the means equals the

product of the extremes; therefore, when three terms are

known,the fourth (or unknown)term may be determined.

Application of Proportion

The important factor when working proportions is

to put the right values in the right places within the

proportion. By following a few basic rules, you can

accomplish this without difficulty and solve the

problem correctly.

In numbering the four positions of a proportion

from left to right (i.e., first, second, third, and fourth,

observe the following rules):

• Let X (the unknown value) always be in the

fourth position.

• Let the unit of like value to X be the third

position.

• If X is smaller than the third position, place the

smaller of the two leftover values in the second

position; if X is larger, place the larger of the two

values in the second position.

• Place the last value in the first position. When

the proportion is correctly placed, multiply the

extremes and the means and determine the value

of X, the unknown quantity.

6-15

When we add water to a solution, the strength is

diluted; consequently, the 70% strength of this

solution will be lessened when we add the extra

150 ml of water. Therefore, of the two remaining

given quantities (650 ml and 500 ml), the smaller

(500 ml) will be placed in the second position,

leaving the quantity 650 ml to be placed in the first

position:

2nd position: 500 ml

1st position: 650 ml

The proportion appears as follows:

650 : 500 :: 70 : X

Multiplying the extremes and the means, we arrive

at:

650X = 35,000, or X = 53.8

When 150 ml of water is added to 500 ml of 70%

alcohol, the result is 650 ml of 53.8% solution.

Example #1: What is the percent strength of 500 ml of

70% alcohol to which 150 ml of water has been added?

Solution: When adding 150 ml to 500 ml, the total

quantity will be 650 ml; consequently, our four values

will be 500 ml, 650 ml, 70%, and X (the unknown

percent). Following the rules stated above, the problem

will appear as follows:

4th position: X (%)

3rd position: 70% (like value to X)

Example #2: When 1000 ml of 25% solution is

evaporated to 400 ml, what is the percent strength?

Solution:

4th position: X(%)

3rd position: 15% (like value to X)

When we evaporate a solution, it becomes stronger.

Therefore, the larger of the two remaining given

values (1000 ml and 400 ml), will be placed in the

second position, leaving the quantity 400 ml to be

placed in the first position:

2nd position: 1000 ml

1st position: 400 ml

The proportion appears as follows:

400 : 1000 :: 15 : X

Multiplying the extremes and the means, we arrive

at:

400X = 25,000, or X = 62.5

When 1000 ml of water is evaporated to 400 ml, the

result is a 62.5% solution.
Ratio Solutions

Ratio solutions are usually prepared in strengths as

follows: 1:10, 1:150, 1:1000, 1:25000, etc., using even

numbers to simplify the calculations. When a solution

is made by this method, the first term of the ratio

expresses the part of the solute (the substance

dissolved in a solvent), while the second term

expresses the total amount of the finished product.

Rules for solving ratio-solution problems are as

follows:

W/W (weight/weight) solution: Divide the total

weight (grams) of solution desired by the larger

number of the ratio, and the quotient will be the

number of grams of the solute to be used.

W/V (weight/volume) solution: Divide the total

volume (in milliliters) of solution desired by the larger

number of the ratio, and the quotient will be the

number of grams of the solute needed.

V/V (volume/volume) Solution: Divide the total

volume (in milliliters) of the solution desired by the

larger number of the ratio, and the quotient will be the

number of milliliters of the drug to be used.

Percentage solutions from stock and/or ratio

solutions:

PHARMACEUTICAL PREPARATIONS

LEARNING OBJECTIVE: Recall the

composition and physical characteristics of

commonly used pharmaceutical preparations.

While assigned to a pharmacy or naval vessel, you

may be required to make pharmaceutical preparations.

The following sections will acquaint you with the

composition and physical characteristics of some of

these preparations.

Elixirs

Elixirs are aromatic, sweetened hydroalcoholic

solutions containing medicinal substances. The color

of elixirs varies according to the nature of the

ingredients; some are artificially colored.

Suspensions

Suspensions are coarse dispersions comprised of

finely divided insoluble material suspended in a liquid

medium. To keep the insoluble material suspended, a

third agent, called a suspending agent, is required. The

process of mixing or combining the ingredients to form

a suspension is called reconstitution.

Ointments

Ointments are semisolid, fatty, or oily preparations

of medicinal substances. These preparations are of

such a consistency as to be easily applied to the skin

and gradually liquefy or melt at body temperature.

Ointments vary in color according to their ingredients.

The base of an ointment is generally greasy in texture,

6-16

Example: How many grams of KMNO4 are needed

to make 500 g of a 1:2000 solution?

Solution:

500 ÷ 2000 = 0.25 g of drug needed

500 - 0.25 = 499.75 g of solvent needed

500.00 g total solution

Example: How many grams of bichloride of mercury

are needed to prepare 500 ml of a 1:1000 solution?

Solution:

500 ÷ 1000 = 0.50 g of drug needed

Add sufficient solvent to make 500 ml of solution.

Example: From a 1:10 solution of silver nitrate in

water, prepare 60 ml of a 1.5% solution of the same

ingredients.

Solution: A 1:10 (W/V) solution contains 1 g of

solute and enough solvent to total 10 ml of solution

(finished product). Therefore, 1 ml of the solution

would contain 0.1 g of the solute. Since it is required that 0.9 g of the solute be used to prepare

60 ml of the required strength, use 9 ml of the stock

solution and enough solvent (water) to make the total

volume measure 60 ml.

Example: How many milliliters of HCl are needed to

prepare a 1:250 solution with a total volume of 500

ml?

Solution:

500 ÷ 250 = 2.0 ml of drug needed
and the medicinal substances combined with it are

always intended to be very fine particles, uniformly

distributed.

Suppositories

Suppositories are solid bodies intended to

introduce medicinal substances into the various

orifices of the body (rectum, vagina, and urethra). The

ingredients are incorporated in a base that melts at

body temperature.

Capsules

Capsules are gelatin shells containing solid or

liquid medicinal substances to be taken orally. A

common type of capsule contains medicine in the form

of a dry powder that is enclosed in transparent cases

made of gelatin. Capsules are sized by universally

designated numbers: 5, 4, 3, 2, 1, 0, 00, 000. The

number 5 has the capacity of about 65 mg of powder

(such as aspirin) and the number 00 capsule contains

about 975 mg of the same substance. Only sizes 3

through 00 are available through the Federal Stock

System.

PHARMACEUTICAL INSTRUMENTS

LEARNING OBJECTIVE: Identify

commonly used pharmaceutical instruments

and describe the purpose of each.

In the process of preparing some pharmaceutical

preparations, you may need to use specialized

instruments. To acquaint you with some of the more

commonly used pharmaceutical instruments, the

following sections will give you a description of each

instrument and explain its purpose. See figure 6-2 for

an illustration of each instrument discussed.

Pharmaceutical Balances

Two types of pharmaceutical balances are in

common use in the Navy: torsion balances (shown in

figure 6-2) and electronic balances (not shown). These

balances are classified as either “Class A” or “Class

B.” Class A balances are used for weighing loads from

120 mg to 120 g. All dispensing pharmacies are

required to have at least one Class A balance on hand at

all times. Class B balances weigh loads of more than

648 mg, and they must be conspicuously marked

“Class B.” Class B balances are optional equipment in

the pharmacy.

Ribbed Funnel

Ribbed funnels are utensils used in the filtering

process. They are most commonly made of glass, but

other substances (tin, copper, rubber) are occasionally

used. The funnel is shaped so that the inside surface

tapers at a 60E angle, ending in a tapered delivery

spout. The inside surface is “ribbed” to allow air to

escape from between the glass and the filtering

medium (improving the filtration process).

Erlenmeyer Flask

The Erlenmeyer flask is a glass container with

metric measurements inscribed on it. It is used for

mixing and measuring various medicinal ingredients.

Mortar and Pestle

These two items always go together, one being

useless without the other. The mortar is basically a

heavy bowl, with one distinct property: the inside

concavity is geometrically hemispheric. The

accompanying pestle is primarily a handtool that has a

tip made of identical material as the mortar, and its

convexity forms a perfect hemisphere. The reason for

the two opposing hemispheres is to provide an even

grinding surface. Mortars and pestles are made of

glass, metal, or unglazed pottery called wedgewood.

Glass is used when triturating (reducing substances to

fine particles or powder by rubbing or grinding) very

pure products (such as eye ointments), and when the

preparations contain stains.

NOTE: Metal mortars and pestles should

never be used when the drugs are likely to react

with the metals.

Spatula

The spatula is a knifelike utensil with a rounded,

flexible, smoothly ground blade, available in various

sizes. The spatula is used to “work” powders,

ointments, and creams in the process of levigation (the

rubbing, grinding, or reduction to a fine powder with or

without the addition of a liquid) and trituration. It is

also used to transfer quantities of drugs from their

containers to the prescription balance. Spatulas should

not be used to pry open cans or as knives for opening

boxes. Once the surface is scratched or the edges bent,

6-17
the spatula is ruined, and it becomes useless for

pharmacy work.

Graduates

Graduates are conical or cylindrical clear glass

containers, graduated in specified quantities and used

to measure liquids volumetrically. Measuring should

always be done at eye level.

DRUG INCOMPATIBILITIES,

CONTRAINDICATIONS, AND ADVERSE

EFFECTS

Occasionally, the drugs we use to improve a

person’s condition may not work in the manner

intended. The outcome may be contrary to that which

was expected, and, indeed, could even cause harm to

the patient. It is important to be aware of symptoms

that may indicate a drug is not doing its job properly.

Incompatibilities

LEARNING OBJECTIVE: Identify the

three classifications of drug incompatibility,

and recall what causes these drug

incompatibilities to occur.

There are instances when a drug used

simultaneously with another drug or substance does

not perform as it was intended. These drugs or

substances may be incompatible together and,

therefore, should not be administered at the same time.

A drug incompatibility can also occur when drugs are

compounded together in the pharmacy. There are three

classes of drug incompatibilities: therapeutic,

physical, and chemical. In the following sections, each

class of drug incompatibility is discussed.

THERAPEUTIC INCOMPATIBILITIES.—

Therapeutic incompatibilities occur when agents

6-18

HM3F0802

MORTAR

AND

PESTLE

SPATULA GRADUATE

(CONICAL)

GRADUATE

(CYLINDRICAL)

PRESCRIPTION

BALANCE

1

2

3

4

5

6

7

8

1/2

1/2

1/4

OZ. PT.

Figure 6-2.—Pharmaceutical instruments.
antagonistic to one another are prescribed together.

Such circumstances seldom occur, but when they do,

the Hospital Corpsman should bring the perceived

incompatibility to the attention of the physician. The

pharmaceutical agents may have been used together

for one agent to modify the activity of the other. The

physician will verify the prescription as necessary.

PHYSICAL INCOMPATIBILITIES.—

Physical incompatibilities are often called pharmaceutical incompatibilities and are evidenced by the

failure of the drugs to combine properly. It is virtually

impossible for uniform dosages of medicine to be

given from such solutions or mixtures. Ingredients

such as oil and water (which are physically repellant to

each other) and substances that are insoluble in the

prescribed vehicle are primary examples of physical

incompatibilities.

CHEMICAL INCOMPATIBILITIES.—

Chemical incompatibilities occur when prescribed

agents react chemically upon combination to alter the

composition of one or more of the ingredients

(constituents).

MANIFESTATIONS OF INCOMPATIBI ITY.—

The following list outlines the various ways

incompatibility between or among drug agents may be

manifested. The respective type of incompatibility is

also noted.

• Insolubility of prescribed agent in vehicle

(physical)

• Immiscibility of two or more liquids (physical)

• Precipitation due to change in menstrum that

results in decreased solubility (called salting

out) (physical)

• Liquification of solids mixed in a dry state

(called eutexia) (physical)

• Cementation of insoluble ingredients in liquid

mixtures (physical)

• Evolution in color (chemical)

• Reduction or explosive reaction (called

oxidation) (chemical)

• Precipitation due to chemical reaction

(chemical)

• Inactivation of sulfa drugs by procaine HCl

(therapeutic)

Although it is, of course, impossible to eliminate

all drug-agent incompatibilities, some combinations

may respond to one of the following corrective

measures.

• Addition of an ingredient that does no alter the

therapeutic value (such as the addition of an

ingredient to alter solubility of an agent)

• Omission of an agent that has no therapeutic

value or that may be dispensed separately

• Change of an ingredient (e.g., substitution of a

soluble form of an ingredient for an equivalent

insoluble form)

• Change of a solvent

• Utilization of special techniques in compounding

Contraindications

LEARNING OBJECTIVE: Recall drug

contraindications, adverse drug reactions,

and interactions.

A contraindication is any condition the patient

might display that makes a particular treatment or

procedure inadvisable. These conditions include, but

are not limited to, the disease process and other

administered medications.

Adverse Drug Reactions

Adverse drug reactions may occur when a drug,

administered in a dose appropriate for human

prophylaxis, diagnosis, or therapy, has an unintended

and noxious effect on the patient receiving it. As a

Hospital Corpsman, you must be aware of the

possibility of adverse effects of medications so that

you can prevent an occurrence, or at least minimize the

impact on the patient.

Drug Interactions

Patients may receive more than one medication at

a time (as happens frequently in the case of

hospitalized patients). Combining medications can

cause the individual drugs to interact with each

other—either positively or negatively—to produce an

outcome that would not have occurred if each drug had

been administered singly. Such interactions may affect

the intensity of a drug’s response, the duration of its

effect, and side effects that may occur. As stated

above, drug interactions can be positive as well as

6-19
negative, and two or more medications are often

administered to achieve a greater therapeutic effect.

Information Concerning Drug

Contraindications, Adverse Reactions, and

Interactions

Descriptions of drug contraindications, adverse

reactions, and interactions may be found in several

publications, most notably the Physicians’ Desk

Reference. However, the most important location for

finding this information is the manufacturer’s package

insert and associated literature that accompanies each

drug.

PRESCRIPTIONS

LEARNING OBJECTIVE: Recall the

parts of a prescription, authorized

prescribers and how prescriptions are

written, filled, verified, labeled, and filed.

The most important tool used by the pharmacy is

the prescription. A prescription is a written or

computerized order from a healthcare provider

(prescriber) directing the pharmacy to compound and

dispense a drug or medication for a patient to use.

Of special importance is your understanding and

conformance to the following protocols:

• All information pertaining to a prescription is

confidential and should not be divulged to any

persons not specifically involved in the

treatment.

• No prescription or any of its parts may be applied

or transferred to any person other than the patient

specified.

To fill a prescription correctly, you must

thoroughly understand the prescription writing and

filling process. Because regulations and policies

governing pharmacies sometimes change, it is

important for you to be familiar with pharmacy

policies in the Manual of the Medical Department

(MANMED), NAVMED P-117. The MANMED is the

basic guide to pharmacy operations.

PARTS OF THE PRESCRIPTION

Currently, there are two standardized forms used

for prescriptions: the DoD Prescription, DD Form

1289 (fig. 6-3) and the Polyprescription, NAVMED

6710/6 (fig. 6-4). Information placed on these forms

must be either typewritten or legibly handwritten in ink

or indelible pencil. In addition to these two forms,

many of today’s fixed medical facilities (e.g., naval

hospitals and medical clinics) now have automated

pharmacy systems that allow healthcare providers to

enter prescription requests into computers in their

offices instead of handwriting prescriptions.

Prescriptions, written or computerized, have, for the

most part, the same information requirements. The

only major difference is that automated prescriptions

do not require the prescriber’s signature.

DD 1289 is used extensively for outpatient

prescriptions. For this reason, the key parts of DD

1289 will be discussed in the following sections. See

figure 6-3 for examples of specific block entries.

Patient Information Block

In the patient information block, located at the top

of the DD 1289, the patient’s full name and date of birth

are required. At most medical facilities, however,

additional patient information is added to this block.

This additional information usually includes the

patient’s duty station; social security number with

family member prefix; rate; and branch of service.

Medical Facility and Date Block

The medical facility block, located below the

patient information block, should contain the name of

the medical facility or ship where the prescription was

written. Completion of this block is important if the

source of the prescription needs to be traced.

The date block, located to the right of the medical

facility block, should contain the date in which the

prescription was written.

Prescription Block

The large block in the center of the DD 1289 is the

prescription block. It contains four parts: the

superscription, the inscription, the subscription, and

the signa.

SUPERSCRIPTION.—The superscription “Rx”

means “take” or “take thou” or, in effect, “I want this

patient to have the following medication.”

INSCRIPTION.—The inscription is that part of

the prescription that lists the names and quantities of

the ingredients to be used. This part of the prescription

6-20
is of utmost importance, since the spelling of many

unrelated drugs is similar. Whenever there is doubt

as to the drug or the amount listed in the

inscription, the individual filling the prescription

should always verify the inscription with the

prescriber.

NOTE: The drug should be written

generically, and the dosage size or strength

written metrically.

SUBSCRIPTION.—The subscription follows

the inscription and is that part of the prescription that

gives directions to the compounder.

6-21

HM3F0603

Figure 6-3.—DOD Prescription form.
SIGNA.—The signa, not to be confused with the

prescriber’s signature, is the part of the prescription

that gives the directions for the patient. This portion is

preceded by the abbreviation “Sig.”

Prescriber Signature Block

Finally, the prescriber signature block, located at

the bottom of the form, must contain a legible

signature of the prescriber, as well as the prescriber’s

full name, rank, corps, and service, stamped, typed, or

handprinted. Mimeographed, preprinted, or

rubber-stamped prescriptions may be used, but

signatures must be original and in the handwriting of

the prescriber. Facsimiles are not acceptable.

AUTHORIZED PRESCRIBERS

According to the MANMED, the following

persons are authorized to write prescriptions:

• Medical and Dental Corps Officers

• Medical Service Corps optometrists, physician

assistants, and podiatrists

• Civilian physicians employed by the Navy

• Independent duty Hospital Corpsmen

• Nurse practitioners (may prescribe when

authorized in writing by the commanding

officer)

• Nurse anesthetists and midwives (may prescribe

within the scope of their practice when

authorized in writing by the CO or delegated

representative)

Prescriptions written by civilian prescribers, other

than those employed by the Navy, may be filled for

authorized beneficiaries, provided the prescribed item

is on the medical facility’s formulary (a published

listing of medications) and the prescribed quantity is

within limitations established by the command.

With the exception of the polyprescription,

prescriptions are limited to one item per prescription.

The quantity of the drug prescribed should be a

reasonable amount needed by the patient. Excessive or

unrealistic quantities should not be prescribed.

Erasures on prescriptions are prohibited, and

interlineations (information inserted between lines of

writing) must be initialed.

6-22

Figure 6-4.—Polyprescription form.
Finally, persons authorized to prescribe cannot

write prescriptions for themselves or members of their

immediate families.

FILLING PRESCRIPTIONS

When you receive a prescription for filling, you

should follow certain basic steps to make sure that the

right patient gets the right medicine in the right amount

in the right way. There are no shortcuts—in the

pharmacy things are done right or not at all!

Prescription Verification

First of all, satisfy yourself that the prescription

you have received is a bonafide one and that the person

you have received it from is entitled to have it filled by

your pharmacy. You don’t need to be tedious about

verification. The simplest and best way is to ask for an

ID card and verify the expiration date on the ID card.

Study the prescription carefully and make sure that

the drug prescribed is reasonable, that its amount or

dosage is realistic in consideration of the patient’s age,

and that the quantity of the medication is practical. A

prescription calling for 1,000 tetracycline tablets or a

pint of paregoric, for example, warrants further

inquiry.

If, in the process of verification, you feel that there

is a discrepancy, an ambiguity, or an incompatibility, or

for any reason you find it is necessary to consult the

prescriber, never allow the patient to suspect that

anything is amiss. You should never fill a prescription

you do not completely understand or that you feel is

incorrect. What appears to be an overdose may be the

desired dose for a specific patient, but the prescriber

will appreciate being called for verification.

When you are sure you understand the prescription

and are satisfied that it is in all respects correct, you

should give its filling your undivided attention. Most

mistakes are made when the person filling the

prescription is either interrupted while doing so or is

trying to accomplish more than one task at a time.

During the process of filling a prescription, the

label on the containers used in filling the prescription

should be verified at least three times. Initially, the

label should be read when the container is taken from

the shelf. Then it should be read again when the

contents are removed from the container. And finally,

the container’s label should be read before it is

returned to the shelf. By following these three

verification steps for each prescription you fill, you

will reduce the possibility of making a prescription

error.

Prescription Labeling

Proper labeling of a prescription is as important as

filling it correctly. It is reasonable to assume that if a

great deal of accuracy is necessary to properly

compound a prescription, it is just as important that the

patient take the correct amount of medication in the

right manner to receive its maximum benefits.

Improperly written or misunderstood directions on a

prescription label can be disastrous. Make sure all

labels are typed clearly and their directions translated

into simple layman’s language. Keep in mind that the

prescription label serves two purposes. First and most

important, it gives the patient directions pertaining to

the medication; second, in case of misuse or error, it is

the quickest means by which the contents of the

prescription container, the person who wrote the

prescription, and the person who filled it can be traced.

Consequently, the following information, illustrated in

figure 6-5, should always be on the label:

• The name and phone number of the dispensing

facility

• A serialized number that corresponds with the

number on the prescription form, (see figure 6-3)

• The date the prescription is filled

• The patient’s name

• The directions to the patient, transcribed

accurately from the prescription, in clear,

concise layman’s language

• The prescriber’s name and rate or rank

• The initials of the compounder

• Authorized refills, if any

• The expiration date, if applicable

• Name, strength, and quantity of medication

dispensed

NOTE: Pharmaceutical preparations

should be identified and labeled with the

generic name. However, trade or brand

names may be used if the trade or brand

name is actually on the container.

Other information that may need to be attached to

the prescription container are labels reading “Shake

Well Before Using” or “For External Use Only.”

“Poison” labels should be omitted when a preparation

6-23
is intended for external use, as many physicians prefer

the “For External Use Only” labels.

After the prescription is labeled, check the

ingredients again by some systematic method to ensure

accuracy.

As an added precaution and to aid expeditious

identification of drugs in case of undesirable effects,

note the manufacturer and the lot number of the

proprietary drug dispensed on the prescription form

(fig. 6-3). This procedure, however, does not apply to

medications consisting of a mixture of several

ingredients. The initials or the code of the person

filling the prescription must also be written on the

prescription form (fig. 6-3).

FILING PRESCRIPTIONS

Prescriptions that have been filled must be

maintained in one of several separate files:

• Schedule II and III narcotics—Prescriptions

containing narcotics are numbered

consecutively, preceded by the letter “N,” and

filed separately.

• Alcohol—These prescriptions are numbered

consecutively, preceded by the letter “A,” and

filed separately.

• Schedule III (nonnarcotic), IV, and V

drugs—These prescriptions are part of and are

numbered in the same manner as the general

files; however, they are maintained separately.

• General files—All other prescriptions are

numbered consecutively and filed together.

Currently, prescriptions are required to be kept on

file for at least 2 years after the date of issue.

REGULATIONS AND

RESPONSIBILITIES PERTAINING TO

CONTROLLED SUBSTANCES,

ALCOHOL, AND DANGEROUS DRUGS

LEARNING OBJECTIVE: Recall

Hospital Corpsman responsibilities and

accountability pertaining to controlled

substances; identify controlled substance

schedules; and recall controlled substance

security, custody, inventory, and survey

procedures.

Hospital Corpsmen who handle controlled

substances and other drugs are held responsible for the

proper distribution and custody of those substances

and drugs. Nowhere is the demand for strict integrity

more important. Misuse, abuse, loss, and theft of these

substances have always, sooner or later, ended in

tragedy and severe consequences. No one has ever

profited by their misappropriation.

It behooves every Hospital Corpsman to

thoroughly understand the responsibility concerning

the custody and handling of controlled substances and

other drugs and to be familiar with the regulations and

laws pertaining to them.

RESPONSIBILITY

Although the MANMED specifically assigns

custodial responsibility for controlled substances,

alcohol, and dangerous drugs to a commissioned

officer (and more specific control to the Nursing

Service), you, as a Hospital Corpsman, have the

responsibilities of administering and securing them

properly. All controlled substances and other drugs are

to be kept under lock and key. Neither keys nor drugs

should ever be entrusted to a patient.

ACCOUNTABILITY

Hospital Corps personnel are held accountable for

drugs entrusted to them. Great care should be

exercised to prevent the loss or unauthorized use of

drugs. No drug should be administered without proper

authority. In addition, U.S. Navy Regulations forbid

the introduction, possession, use, sale, or other transfer

of marijuana, narcotic substances, or other controlled

substances.

6-24

NAVAL HOSPITAL

BETHESDA, MD 20814

(keep out of reach of children)

John R. Doe, HM2, USN

Take one (1) tablet every 12 hours if needed

for cold symptoms.

Dimetapp #30 Dr. Johnson

No Refills

Phone

295-2113

295-550

4/28/99kk

117765

HM3F0605

Figure 6-5.—Prescription label.
CONTROLLED SUBSTANCE SCHEDULES

Controlled substances and drugs require special

handling and security measures. The Controlled

Substance Act of 1970 established five schedules

(categories) related to a drug’s potential for abuse,

medical usefulness, and degree of dependency, if

abused.

Controlled substances may migrate between

schedules, and new products may be added. These

changes will be promulgated by the Navy Materiel

Support Command in the Medical and Dental Materiel

Bulletin.

Schedule I

Schedule I substances have high abuse potential

and no accepted medical use (e.g., heroin, marijuana,

LSD).

Schedule II

Schedule II substances have high abuse potential

and severe psychological and/or physical dependence

liability. Examples of schedule II substances include

narcotics, amphetamines, and barbiturates.

Prescriptions for schedule II substances can never be

ordered with refills and must be filled within 7 days of

the date originally written.

Schedule III

Schedule III substances have less abuse potential

than schedule II substances and moderate dependence

liability. Examples of schedule III substances include

nonbarbiturate sedatives, nonamphetamine

stimulants, and medications that contain a limited

quantity of certain narcotics. Prescriptions must be

filled within 30 days of the date written and may be

refilled up to five times within 6 months.

Schedule IV

Schedule IV substances have less abuse potential

than schedule III substances and limited dependence

liability. Prescriptions must be filled within 30 days of

the date written and may be refilled up to five times

within a 6-month period.

Schedule V

Schedule V substances have limited abuse

potential. Schedule V substances are primarily

antitussives or antidiarrheals that contain small

amounts of narcotics (codeine). Prescriptions must be

filled within 30 days of the date written and may be

refilled up to five times within 6 months.

DANGEROUS DRUGS

Poisonous drugs, chemicals, and similar

substances are classified as dangerous drugs. Because

these substances are powerful, their containers should

have a distinctive color, size, or shape, and the

container should be placed in a special storage area so

they are not mistaken for other drugs. In addition, the

following safeguards should be enforced:

• Label all containers of dangerous substances

appropriately.

• Store caustic acids (such as glacial acetic,

sulfuric, nitric, concentrated hydrochloric, or

oxalic acids) in appropriate containers, and do

not issue to wards or outpatients.

• Account for and issue methyl alcohol

(methanol) to be used by medical activities in the

same manner as other controlled substances.

Methanol should not be stored, used, or

dispensed by the pharmacy, ward, or outpatient

treatment facility.

SECURITY AND CUSTODY OF

CONTROLLED SUBSTANCES

Schedule I and II controlled substances and ethyl

alcohol require vault or safe storage and inventory by

the Controlled Substance Inventory Board (discussed

in more detail in the section entitled “Inventory of

Controlled Substances”). Working stock may be kept

in a locked area within the pharmacy. A copy of the

safe combination must be kept in a sealed envelope

deposited with the CO or representative.

Schedule III, IV, and V controlled substances

require locked cabinet security for storage of bulk

drugs. A minimum amount of working stock may be

dispersed among other pharmacy stock, provided the

pharmacy stock itself is secure. Otherwise, all stock in

this category must be kept in locked cabinets.

Custodial responsibility for controlled substances,

ethyl alcohol, and dangerous drugs at naval hospitals is

entrusted to a commissioned officer or a civilian

pharmacist who is appointed in writing by the CO. At

remote branch clinics that do not have a commissioned

officer or a civilian pharmacist, the CO will designate

6-25
in writing a member of the branch clinic as custodian.

On board large naval vessels, the CO will appoint an

officer of the Medical Department or another officer in

writing as the bulk custodian. This officer will be

responsible for, and maintain custody of, all bulk

controlled substances. On board smaller naval vessels,

access to controlled substances is limited to the bulk

custodian and the senior medical department

representative (SMDR). Only individuals whose

official duties require access to such spaces are

provided the safe combinations.

INVENTORY OF CONTROLLED

SUBSTANCES

Monthly (or more frequently, if necessary), the

Controlled Substances Inventory Board takes an

unannounced inventory of controlled substances.

NOTE: An exception to this frequency may

be made for ships with an Independent Duty

Corpsman. On these ships, the inventory may

be conducted on a quarterly basis if there have

been no transactions of controlled substances

(including filled prescriptions or receipts of

items requisitioned from supply).

The CO appoints the members of the board in writing.

The board consists of three members, at least two of

whom are commissioned officers. After the board

conducts the inventory, it submits a report to the CO.

The officer having custodial responsibility cannot be a

member of the board. On small ships and installations,

the SMDR may be a board member. For further

guidance on controlled substance inventory procedures,

refer to NAVMEDCOMINST 6710.9, Guidelines for

Controlled Substances Inventory.

SURVEY OF CONTROLLED SUBSTANCES

Schedule I and II controlled substances, ethyl

alcohol, and locally controlled drugs that have become

outdated, deteriorated to the point of not being usable,

are of questionable purity or potency, or have had their

identity compromised, must be reported to the CO. If

destruction is indicated and directed by the CO,

destruction must be accomplished in the presence of a

member of the Controlled Substance Inventory Board.

A certification of destruction form contains the

complete nomenclature and quantity of the substances

to be destroyed together with the method of destruction

to be used. After certification is completed, approved

by the CO, and signed by the members witnessing the

destruction, the certification of destruction is retained

and filed as required by current instructions. The

destroyed substances should then be removed from the

stock records and the controlled substance log.

SUMMARY

Inpatients and the majority of outpatients will

receive pharmaceutical products as part of their

treatment. As a healthcare provider who may

administer these products or fill prescriptions, it is

crucial for you to have a good foundation of knowledge

in pharmacology, toxicology, and the proper handling

of prescriptions and controlled substances. This

chapter touched on each of these topics to assist you in

your duties. However, you should consult the

recommended publications, such as the Manual of the

Medical Department, Drug Facts and Comparisons,

and the Physicians’ Desk Reference, to provide you

with the guidance and knowledge you will need to

provide the best possible care for your patients.

6-26
CHAPTER 7

CLINICAL LABORATORY

A basic knowledge of clinical laboratory

procedures is critical for all Hospital Corpsmen,

particularly those working at small dispensaries and

isolated duty stations without the supervision of a

medical officer. A patient’s complaint may be of little

value by itself, but coupled with the findings of a few

easily completed laboratory studies, a diagnosis can

usually be surmised and treatment initiated.

Hospital Corpsmen who can perform blood and

urine tests and interpret the results are better equipped

to determine the cause of illness or request assistance.

Since they can provide a more complete clinical

picture to the medical officer, their patients can be

treated sooner.

In this chapter, we will discuss laboratory

administrative responsibilities, ethics in the laboratory,

the microscope, blood collection techniques, and

step-by-step procedures for a complete blood count and

urinalysis. Also included are basic testing procedures

for bacteriologic, serologic, and fungal identification.

THE HOSPITAL CORPSMAN AND THE

CLINICAL LABORATORY

LEARNING OBJECTIVE: Recall

clinical laboratory administrative

procedures and ethics policy.

The Hospital Corpsman is not expected to make

diagnoses from test findings or to institute definitive

treatment based upon them. However, with the

availability of modern communications facilities,

having the results of these tests available will greatly

assist the Corpsman in giving a clearer clinical picture

to the supporting medical officer.

Needless to say, accuracy, neatness, and attention

to detail are essential to obtain optimum test results.

Remember also that these tests are only aids to

diagnosis. Many other clinical factors must be taken

into consideration before treatment may be started.

ADMINISTRATIVE PROCEDURES AND

RESPONSIBILITIES

The ability to perform clinical laboratory tests is a

commendable attribute of the Hospital Corpsman.

However, the entire testing effort could be wasted if

proper recording and filing practices are ignored and

the test results go astray. As a member of the medical

team, it is your responsibility to make sure that

established administrative procedures are followed

with regard to accurate patient and specimen

identification. It is your further responsibility to

ensure laboratory reports in your department are

handled and filed properly.

Since the test results are a part of the patient’s

clinical picture, their precision and accuracy are vital.

Test results have a vital bearing upon the patient’s

immediate and future medical history. They are,

therefore, made part of the patient’s health record

(inpatient or outpatient). Laboratory reports of

inpatients are placed in the inpatient health record,

while laboratory reports of outpatients are placed in the

outpatient health record.

Laboratory Request Forms

The armed forces have gone to great lengths to

produce workable, effective laboratory forms that

serve their purpose with a minimum of confusion and

chance for error. These forms are standard forms (SF)

in the 500 series. Their primary purpose is to request,

report on, or record clinical laboratory tests. With the

exception of SF-545 (Laboratory Report Display), SF

laboratory forms are multicopied and precarbonized

for convenience. The original copy of the laboratory

report forms are attached to the SF-545 (located inside

the patient’s heath record), and the carbon copy

becomes part of the laboratory’s master file. For a

complete listing of SF forms and their purposes, refer

to the Manual of the Medical Department

(MANMED), NAVMED P-117.

SF laboratory request forms are not the only means

by which healthcare providers can order laboratory

tests. Many of today’s naval medical facilities have

computerized laboratory systems. Computerized

laboratory systems enable healthcare providers to

enter laboratory test requests into computers located in

7-1
their spaces. Once healthcare providers enter their test

requests, patients may report immediately to the

Laboratory Department, where specimens are

obtained and tests are performed.

Use of Laboratory Request Forms

Write information on the SF laboratory request

forms in black or blue-black ink. Use a separate SF

laboratory request form for each patient and for each

test. Document the patient’s full name, family member

prefix and social security number, rate/rank,

dependency status, branch of service, and status in the

“Patient Identification” block. Also identify the ward

or department ordering the test in this block. See figure

7-1 for an illustration of the Urinalysis request form,

SF-550. Computer-generated laboratory test requests

require the same patient identification data as SF

laboratory requests.

Since the results of the requested laboratory test

are usually closely associated with the patient’s health

and treatment, the requesting healthcare provider’s

name should also be clearly stated in the “Requesting

Physician’s Signature” block on the request form

(fig. 7-1). The doctor requesting the urinalysis should

sign in this block. Alternatively, you may type/print

the doctor’s name in the block and initial the entry to

authenticate it. This practice ensures that the report

will get back to the provider as soon as possible.

Enter the requested test in the “Remarks” block

(e.g., “Clean catch midstream to R/O urinary tract

infection”). Because the data requested, the date

reported, and the time of specimen collection are

usually important in support of the clinical picture,

these pieces of information should be clearly written

on the request in the areas provided for them (fig. 7-1).

Patient and Specimen Identification

Before accepting laboratory request forms and

specimens in the laboratory, check patient

identification information on both the request form and

the specimen container label for completeness and

legibility. Proper documentation of patient

identification information on these items can prevent a

great number of errors. Also, make sure the

specimen(s) submitted is in fact the specimen of the

patient submitting it. You need not stand over the

patient while the specimen is being collected;

however, keep in mind that for certain tests (such as

drug or alcohol screening tests) individuals may

attempt to substitute specimens.

7-2

HM3f0701

Figure 7-1.—SF-550, Urinalysis Request Form.
Filing Laboratory Forms

After healthcare providers have reviewed

laboratory test reports, they will initial the form.

Initialing the form indicates the healthcare provider has

reviewed the test results. After the healthcare provider

releases the laboratory report, it should be filed in the

patient’s inpatient or outpatient health record, as

appropriate. If a standard form is used to record test

results, it should be attached chronologically to the

SF-545, Laboratory Report Display, inside the patient’s

health record. The SF-545 functions as a display form

for multiple laboratory reports. See figure 7-2. Use the

preglued areas provided on the lab forms. However,

since the glue is notorious for losing its grip after a

while, you may use tape or staples to attach the form to

the SF-545. Each SF-545 can accommodate a limited

number of laboratory reports, so do not overcrowd the

display form. When the SF-545 is full, add a new

SF-545 to the health record and place it in front of the

old SF-545. In this way, the most current lab reports will

remain in chronological order.

Automated or computer-generated laboratory test

reports, depending on the form’s size, may be either

mounted on the SF-545 or placed adjacent to the

SF-545 in the health record. Keep in mind that these

automated or computer-generated forms should also

be filed chronologically.

ETHICS AND GOOD PRACTICES IN THE

LABORATORY

The nature of laboratory tests and their results

must be treated as a confidential matter between the

patient, the healthcare provider, and the performing

technician. Chapter 16 of the MANMED outlines the

Navy’s ethics policy with regard to disclosure of the

contents of a patient’s medical record, including lab

reports. It is good practice to prevent unauthorized

access to these reports, to leave interpretation of the

test results to the attending provider, and to refrain

from discussing the results with the patient.

BLOOD COLLECTION

LEARNING OBJECTIVE: Identify the

correct steps to perform blood collection by

the finger puncture method and

venipuncture method, and recall Standard

Precautions and other safety precautions

that apply to blood collection.

There are two principal methods of obtaining

blood specimens: the finger puncture method and the

venipuncture method. For most clinical laboratory

tests requiring a blood specimen, venous blood

obtained by venipuncture is preferred. Blood collected

by venipuncture is less likely to become contaminated,

and the volume of blood collected is greater. Infection

control practices, equipment requirements, and

step-by-step instructions on performing both of these

blood collection methods will be discussed in the

following sections.

STANDARD PRECAUTIONS

Under the concept of “Standard Precautions”

outlined by the Centers For Disease Control and

Prevention (CDC), blood and other bodily fluids

should be considered as potentially infectious. To

protect medical personnel from direct contact with

blood during phlebotomy (blood collection), gloves

are required to be worn. Gloves should be disposed of

after each patient.

Needles and sharps used in the blood collection

process should be handled with extreme caution and

disposed of in biohazard sharps containers. Sharps

containers should be conveniently located near

phlebotomy work sites.

Absorbent materials, such as cotton 2 x 2’s used to

cover blood extraction sites, normally contain only a

small amount of blood and can be disposed of as

general waste. However, if a large amount of blood is

absorbed, the absorbent material should be placed in a

biohazard waste container and treated as infectious

waste.

Clean phlebotomy work site equipment and

furniture daily with a disinfectant.

FINGER PUNCTURE

The finger puncture method is used when a patient

is burned severely or is bandaged so that the veins are

either covered or inaccessible. Finger puncture is also

used when only a small amount of blood is needed.

Materials Required for Finger Puncture

Procedure

To perform a finger puncture, the following

materials are required:

• Sterile gauze pads (2" x 2")

7-3
7-4

HM3f0702

1 2 3 4 5 6 7

LABORATORY REPORT DISPLAY

Figure 7-2.—SF-545, Laboratory Report Display.
• 70% isopropyl alcohol or povidone-iodine

solution pads

• Blood lancets

• Capillary tubes

• Bandages

Arrange your equipment in an orderly manner and

have it within easy reach. Also, wash your hands

before and after each procedure.

Finger Puncture Procedure

To perform a finger puncture, follow the steps

given below.

1. Explain the procedure to the patient.

2. Using the middle or ring finger, massage or

“milk” the finger down toward the fingertip.

Repeat this “milking” five or six times.

3. Cleanse the fingertip with an alcohol pad or

povidone-iodine solution and let dry.

4. Take a lancet and make a quick deep stab on the

side of the finger (off-center). To obtain a large

rounded drop, the puncture should be across the

striations of the fingertip. See figure 7-3.

5. Wipe away the first drop of blood to avoid

dilution with tissue fluid. Avoid squeezing the

fingertip to accelerate bleeding as this tends to

dilute the blood with excess tissue fluid, but

gentle pressure some distance above the

puncture site may be applied to obtain a free

flow of blood.

6. When the required blood has been obtained,

apply a pad of sterile gauze and instruct the

patient to apply pressure, then apply a bandage.

When dealing with infants and very small

children, the heel or great toe puncture is the best

method to obtain a blood specimen. This method is

performed in much the same way.

VENIPUNCTURE (VACUTAINER

METHOD)

The collection of blood from veins is called

venipuncture. For the convenience of technician and

patient, arm veins are best for obtaining a blood

sample. If arm veins cannot be used due to interference

from bandage or IV therapy, thrombosed or hardened

veins, etc., consult your supervisor for instructions on

the use of hand or foot veins.

NOTE: Do not draw blood from an arm with

IV fluid running into it. Choose another site.

The IV fluid will alter tests results.

Materials Required for Venipuncture

Procedure

To perform a venipuncture, the following

materials are required:

• Sterile gauze pads (2" x 2")

• 70% isopropyl alcohol or povidone-iodine

solution pads

• Tourniquet

• Vacutainer needles and holder

• Vacutainer tube appropriate for the test to be

performed

Arrange your equipment in an orderly manner and

have it within easy reach. Also, wash your hands

before the procedure.

Venipuncture Procedure

Position the patient so that the vein is easily

accessible and you are able to perform the

venipuncture in a comfortable position. Always have

the patient either lying in bed or sitting in a chair with

the arm propped up.

7-5

PREFERRED

TECHNIQUE

HM3f0703

POOR

TECHNIQUE

Figure 7-3.—Finger puncture.
WARNING

Never perform a venipuncture with the

patient standing up. If patients should faint,

they could seriously injure themselves.

Also, safeguards should be in place to

prevent patients from falling forward when

they are seated.

To perform venipuncture, follow the steps given

below.

1. Explain the procedure to the patient.

2. Apply tourniquet around the arm approximately

2 to 3 inches above the antecubital fossa (the

depression in the anterior region of the elbow,

see figure 7-4) with enough tension so that the

VEIN is compressed, but not the ARTERY. A

BP cuff (sphygmomanometer) may be used

instead of a tourniquet if a patient is difficult to

draw.

3. Position the patient’s arm extended with little or

no flexion at the elbow.

4. Locate a prominent vein by palpation (feeling).

If the vein is difficult to find, it may be made

more prominent by massaging the arm with an

upward motion to force blood into the vein.

5. Cleanse the puncture site with a 70% alcohol

pad or povidone-iodine solution and allow to

dry.

CAUTION: After cleaning the puncture

site, only the sterile needle should be allowed

to touch it.

6. “Fix” or hold the vein taut. This is best

accomplished by placing the thumb under the

puncture site and exerting a slight downward

pressure on the skin or placing the thumb to the

side of the site and pulling the skin taut laterally

(fig. 7-4).

7. Using a smooth continuous motion, introduce

the needle, bevel side up, into the side of the vein

at about a 15-degree angle with the skin

(fig. 7-4).

8. Holding the vacutainer barrel with one hand,

push the tube into the holder with the other hand

and watch for the flow of blood into the tube

until filling is completed.

9. Once all the specimens have been collected,

hold the vacutainer with one hand and release

the tourniquet with the other.

10. Place a sterile gauze over the puncture site and

remove the needle with a quick, smooth motion.

11. Apply pressure to the puncture site and instruct

the patient to keep the arm in a straight position.

Have the patient hold pressure for at least 3

minutes.

12. Take this time to invert any tubes that need to

have anticoagulant mixed with the blood.

13. Label specimens.

14. Reinspect the puncture site to make sure

bleeding has stopped, and apply a bandage.

7-6

NEEDLE BEVEL UP

SKIN

15 O

ANTECUBITAL

FOSSA

HM3f0704

VEIN

Figure 7-4.—Venipuncture.
THE MICROSCOPE

LEARNING OBJECTIVE: Identify the

parts of the microscope, and determine their

functions.

Before any attempts are made to view blood

smears, urinary sediments, bacteria, parasites, etc., it is

absolutely essential that beginners know the

instrument with which they will be spending

considerable time—the microscope. The microscope

is a precision instrument used extensively in clinical

laboratories to make visible objects too small to be

seen by the unaided eye. Most laboratories are

equipped with binocular (two-eyepiece) microscopes,

but monocular microscopes are also commonly used.

The type of microscope most often used in the

laboratory is referred to as the compound microscope.

See figure 7-5. A compound microscope contains a

system of lenses of sufficient magnification and

resolving power (ability to show, separate, and

distinguish) so that small elements lying close together

in a specimen appear larger and distinctly separated. In

the following sections, the compound microscope’s

framework, illumination system, magnification

system, and focusing system will be discussed.

FRAMEWORK

The framework of the compound microscope

consists of four parts: the arm, the stage, the

mechanical stage, and the base (fig. 7-5).

Arm

The arm is the structure that supports the

magnification and focusing system. It is the handle by

which the microscope is carried.

Stage

The stage is the platform on which a specimen is

placed for examination. In the center of the stage is an

aperture or hole that allows the passage of light from

the condenser.

7-7

EYEPIECES

BODY TUBE

ARM

MECHANICAL STAGE

COARSE CONTROL KNOB

FINE CONTROL KNOB

BASE

INTERNAL

LIGHT SOURCE

CONDENSER

IRIS DIAPHRAGM

STAGE

OBJECTIVES

REVOLVING

NOSEPIECE

HM3f0705

Figure 7-5.—Compound microscope.
Mechanical Stage

The mechanical (movable) stage holds the

specimen in place and is the means by which the

specimen may be moved about on the stage.

Base

The base is the structure on which the microscope

rests.

ILLUMINATION SYSTEM

Ideal illumination of a specimen viewed under the

microscope requires even light distribution. The

objectives must also be entirely filled with light from

the condenser. To fulfill these requirements, the

illumination system of the compound microscope

consists of three parts: an internal light source, a

condenser, and an iris diaphragm. See figure 7-5.

Internal Light Source

The internal light source is built into the base of the

microscope. It provides a precise and steady source of

light into the microscope.

Condenser

The condenser is composed of a compact lens

system and is located between the light source and

stage. The condenser concentrates and focuses light

from the light source directly through the specimen.

Iris Diaphragm

An iris diaphragm located on the condenser

controls the diameter of the light source’s beam. To

improve resolution, the operator should adjust the

opening of the iris diaphragm to approximately the

same size as the face of the objective lens. In addition

to the diaphragm on the condenser, an iris diaphragm

may be located on the internal light source. This iris

diaphragm controls the amount of light sent to the

condenser from the internal light source.

MAGNIFICATION SYSTEM

The magnification system of the compound

microscope contains at least two lens systems. The

two lens systems are mounted on either end of a tube

called the body tube. The lens nearest the object is

called the objective lens, and the lens nearest the eye is

the ocular lens or eye piece. See figure 7-5.

Objective Lenses

On a compound microscope, there is usually a set

of three objective lenses (or “objectives”). This set of

objectives is the component most responsible for the

magnification and resolution of detail in a specimen.

Each objective lens has a different focus distance and

magnification power. A set of objectives normally

consists of a low-power lens (approximate focus 16 mm,

magnification 10X), a high-power lens (approximate

focus 4 mm, magnification 45X), and an

oil-immersion lens (approximate focus 1.8 mm,

magnification 100X). Objective lenses are color

coded for easy recognition: 16 mm-10X (green),

4 mm-45X (yellow), and 1.8 mm-100X (red).

Revolving Nosepiece

The revolving nosepiece contains openings into

which objective lenses are fitted, and revolves

objectives into desired position.

Body Tube

The body tube is a tube that permits light to travel

from the objective to the ocular lens.

Ocular Lenses

Ocular lenses, or eyepieces, are located on top of

the body tube and usually have a magnification power

of 10X. To calculate the total magnification of a

specimen, you multiply the magnification power of the

objective by the magnification power of the ocular

lens. Examples of total magnifications are provided in

table 7-1.

FOCUSING SYSTEM

Focusing is accomplished by moving the stage up

or down with the coarse and fine control knob

(fig. 7-5). Whether the stage needs to be raised or

lowered depends on the focal length of the objective

7-8

Objective

Lens

Color

Code

10X

Ocular

Total

Magnification

16 mm-10X

4 mm-45X

1.8 mm-100X

Green

Yellow

Red

10X

10X

10X

100X

450X

1000X

Table 7-1.—Examples of Total Magnifications
being used. For example, the high-powered objective

of short focal length (4 mm) will need the stage raised

so the objective is very close to the specimen, while the

low-powered objective of a longer focal length (16 mm)

will need the stage lowered so the objective is farther

from the specimen.

The coarse control knob is used initially to bring

the specimen’s image into approximate focus. Once

this is accomplished, the fine control knob sharpens

the image.

Coarse Control Knob

The coarse control knob is the larger and inner

knob. Rotating the coarse control knob allows the

image to appear in approximate focus.

Fine Control Knob

The fine control knob is the smaller and outer

knob. Rotating this control knob renders the image

clear and well-defined.

FOCUSING THE MICROSCOPE

The process of focusing consists of adjusting the

relationship between the optical system of the

microscope and the object to be examined so that a

clear image of the object is obtained. The distance

between the upper surface of the glass slide on the

microscope stage and the faces of the objective lens

varies depending upon which of the three objectives is

in the focusing position. It is a good practice to obtain a

focus with the low-power objective first, then change

to the higher objective required to avoid accidentally

damaging the objective lens, the specimen, or both.

Most modern microscopes are equipped with parfocal

objectives (meaning that if one objective is in focus,

the others will be in approximate focus when the

nosepiece is revolved). With the low-power objective

in focusing position, observe the following steps in

focusing.

1. Seat yourself behind the microscope, then lower

your head to one side of the microscope until

your eyes are approximately at the level of the

stage.

2. Using the coarse adjustment knob, lower the

body tube until the face of the objective is within

1/4 inch of the object. Most microscopes are

constructed in such a way that the low-power

(green) objective cannot be lowered and make

contact with the object on the stage.

3. While you are looking through the ocular, you

should use the coarse adjustment knob to

elevate the body tube until the image becomes

visible. Then use the fine adjustment knob to

obtain a clear and distinct image. Do not move

the focusing knob while changing lenses.

4. If the high-power objective (yellow) is to be

used next, bring it into position by revolving the

nosepiece (a distinct “click” indicates it is in

proper alignment with the body tube). Use the

fine adjustment knob only to bring the object

into exact focus.

5. If specimen is too dark, you can increase

lighting by opening the iris diaphragm of the

condenser.

6. The oil-immersion objective (red) is used for

detailed study of stained blood and bacterial

smears. Remember that the distance between

objective lens and object is very short, and great

care must be employed so the specimen is not

damaged. After focusing with the high-power

objective and scanning for well-defined cells,

raise the objective, place a small drop of

immersion oil, free of bubbles, on the slide,

centering the drop in the circle of light coming

through the condenser. Next, revolve the

nosepiece to bring the oil-immersion objective

into place, and, by means of the coarse

adjustment knob, slowly lower the body tube

until the lens just makes contact with the drop of

oil on the slide. The instant of contact is

indicated by a flash of light illuminating the oil.

The final step in focusing is done with the fine

adjustment knob. It is with this lens in particular

that lighting is important. The final focus, clear

and well-defined, will be obtained only when

proper light adjustment is made.

CARE OF THE MICROSCOPE

The microscope is an expensive and delicate

instrument that should be given proper care.

Moving or transporting microscopes should be

accomplished by grasping the arm of the scope in one

hand and supporting the weight of the scope with the

other hand. Avoid sudden jolts and jars.

Keep the microscope clean at all times; when not in

use, microscopes should be enclosed in a dustproof

cover or stored in their case. Remove dust with a camel

hair brush. Lenses may be wiped carefully with lens

7-9
tissue. When the oil-immersion lens is not being used,

remove the oil with lens tissue. Use oil solvents (such

as xylene) on lenses only when required to remove

dried oil and only in the minimal amount necessary.

Never use alcohol or similar solvents to clean lenses.

COMPLETE BLOOD COUNT

LEARNING OBJECTIVE: Identify the

five parts of a complete blood count, and

recognize the testing procedures for the

following: Unopette® Red Blood Cell

Count, Microhematocrit, Unopette White

Blood Cell Count, and Differential White

Blood Cell Count.

A complete blood count consists of the following

five tests:

• Total red blood cell (RBC) count

• Hemoglobin determination

• Hematocrit reading

• Total white blood cell (WBC) count

• Differential white blood cell count

The complete blood count, commonly referred to

as a CBC, is used in the diagnosis of many diseases.

Blood collected for these tests are capillary or

peripheral blood and venous blood. CBCs may be

performed either manually or by using automated

hematology analyzers. The manual method is used in

isolated locations and on board some naval vessels

where a hematology analyzer installation is not

practical. For this reason, and because machines break

down on occasion, the manual method will be covered

in the following sections.

COUNTING BLOOD CELLS

To manually count red blood cells (erythrocytes)

and white blood cells (leukocytes), you will need a

microscope and an instrument called a

hemacytometer. See figure 7-6. The hemacytometer

is a thick glass slide with three raised parallel platforms

on the middle third of the device. The central platform

is subdivided by a transverse groove to form two

halves, each wider than the two lateral platforms and

separated from them and from each other by moats.

The central platforms each contain a counting chamber

and are exactly 0.1 mm lower than the lateral

platforms.

Each counting chamber has precisely ruled lines

etched into the glass, forming a grid. This grid or

ruled area is so small that it can only be seen with the

aid of a microscope. The grid used by most

laboratories is the Improved Neubauer Ruling. See

figure 7-7 for an example of the Improved Neubauer

Ruling. The Improved Neubauer Ruling is 3 by 3 mm

(9 mm2

) and subdivided into nine secondary squares,

each 1 by 1 mm (1 mm2

).

A thick cover glass, ground to a perfect plane,

accompanies the counting chamber (fig. 7-6).

Ordinary cover glasses have uneven surfaces and

should not be used. When the cover glass is in place on

the platform of the counting chamber, there is a space

exactly 0.1 mm thick between it and the ruled platform.

Counts of red blood cells and white blood cells are

each expressed as concentration: cells per unit volume

of blood. The unit of volume for cell counts is

expressed as cubic millimeters (mm3

) because of the

linear dimensions of the hemacytometer chamber.

TOTAL RED BLOOD CELL COUNT

The total red blood cell (erythrocyte) count is the

number of red cells in one cubic millimeter of blood.

The normal red blood cell count is as follows:

Adult male............. . .4.2 to 6.0 million per mm3

Adult female ............ .3.6 to 5.6 million per mm3

Newborn. ............... .5.0 to 6.5 million per mm3

7-10

COVER

GLASS

RAISED

PLATFORMS

COUNTING

CHAMBERS

MOATS

TOP VIEW

COVER GLASS DEPTH OF CHAMBER = 0.1MM

RAISED PLATFORM RAISED PLATFORM

RULED

PLATFORM

SIDE VIEW HM3f0706

Figure 7-6.—Top and side views of a hemacytometer.
As we said earlier, the red cell count is used in the

diagnosis of many diseases. For example, a red cell

count that drops below normal values may indicate

anemia and leukemia. On the other hand, a red cell

count that rises above the normal values may indicate

dehydration.

The Unopette® Method is used to manually count

red blood cells. Material requirements and the

step-by-step procedures for performing this procedure

are provided in the following sections.

Materials Required for Unopette Procedure

The Unopette procedure consists of a disposable

diluting pipette system that provides a convenient,

precise, and accurate method for obtaining a red blood

cell count. To perform a red blood cell count using the

Unopette method, you will need to obtain the

following materials:

• A disposable Unopette (see fig. 7-8) for RBC

counts. The Unopette consists of

—a shielded capillary pipette (10 microliter (Fl)

capacity), and

—a plastic reservoir containing a premeasured

volume of diluent (1:200 dilution).

• Hemacytometer and coverglass

• Microscope with light source

• Hand-held counter

• Laboratory chit

Unopette Procedure

The Unopette procedure for counting red blood

cells is as follows:

1. Puncture the diaphragm in the neck of the

diluent reservoir with the tip of the capillary

shield on the capillary pipette. See figure 7-9.

2. After obtaining free-flowing blood from a

lancet puncture of the finger, remove the

protective plastic shield from the capillary

pipette. Holding the capillary pipette slightly

above the horizontal, touch the tip to the blood

source (see fig. 7-10, view A). The pipette will

7-11

3mm

3mm

1mm

1mm

HM3f0707

Figure 7-7.—Improved Neubauer Ruling.

CAPILLARY

PIPETTE SHIELD

CAPILLARY PIPETTE

PLASTIC RESERVOIR

WITH DILUENT

HM3f0708

Figure 7-8.—Unopette® for RBC count.
fill by capillary action. When blood reaches the

end of the capillary bore in the neck of the

pipette, filling is complete and will stop

automatically. The amount of blood collected

by the capillary tube is 10 Fl. Wipe any blood

off the outside of the capillary tube, making sure

no blood is removed from inside the capillary

pipette. (An alternative source of blood is a

thoroughly mixed fresh venous blood sample

obtained by venipuncture. See figure 7-10,

view B.)

3. With one hand, gently squeeze the reservoir to

force some air out, but do not expel any diluent

(fig. 7-11). Maintain pressure on the reservoir.

With the other hand, cover the upper opening of

the capillary overflow chamber with your index

finger and seat the capillary pipette holder in the

reservoir neck (see fig. 7-11).

4. Release pressure on the reservoir and remove

your finger from the overflow chamber opening.

Suction will draw the blood into the diluent in

the reservoir.

5. Squeeze the reservoir gently two or three times

to rinse the capillary tube, forcing diluent into

but not out of the overflow chamber, releasing

pressure each time to return diluent to the

reservoir. Close the upper opening with your

index finger and invert the unit several times to

mix the blood sample and the diluent. See

figure 7-12.

6. For specimen storage, cover the overflow

chamber of the capillary tube with the capillary

shield.

7-12

CAPILLARY

PIPETTE SHIELD

DIAPHRAGM

HM3f0709

Figure 7-9.—Puncturing the diaphragm of diluent with the

capillary pipette shield.

A

B HM3f0710

Figure 7-10.—Drawing blood into the Unopette capillary

tube: A. From a finger puncture; B. From a venous blood

sample.

HM3f0711

CAPILLARY OVERFLOW

CHAMBER

Figure 7-11.—Preparing reservoir to receive blood from the

capillary tube.
7. Immediately prior to cell counting, mix again by

gentle inversion, taking care to cover the upper

opening of the overflow chamber with your

index finger.

8. Place the coverglass on the hemacytometer

counting chamber, making sure coverglass is

clean and free of grease. (Fingerprints must be

completely removed.)

9. Remove the pipette from the reservoir. Squeeze

the reservoir and reseat the pipette in the reverse

position, releasing pressure to draw any fluid in

the capillary tube into the reservoir. Invert and

fill the capillary pipette by gentle pressure on the

reservoir. After discarding the first 3 drops, load

(charge) the counting chamber of the

hemacytometer by gently squeezing the

reservoir while touching the tip of the pipette

against the edge of the coverglass and the

surface of the counting chamber (fig. 7-13). A

properly loaded counting chamber should have

a thin, even film of fluid under the coverglass

(fig. 7-14, view A). Allow 3 minutes for cells to

settle. If fluid flows into the grooves (moats) at

the edges of the chamber or if air bubbles are

seen in the field, the chamber is flooded and

must be cleaned with distilled water, dried with

lens tissue, and reloaded (fig. 7-14, view B). If

the chamber is underloaded, carefully add

additional fluid until properly loaded.

10. Place the loaded hemacytometer into a petri dish

with a piece of dampened tissue to keep the

hemacytometer from drying out (fig. 7-15).

Allow 5 to 10 minutes for the cells to settle.

11. Once the cells have settled, place the

hemocytometer on the microscope. Use the

low-power lens to locate the five small fields (1,

2, 3, 4, and 5) in the large center square bounded

by the double or triple lines. See figure 7-16.

Each field measures 1/25 mm2

, 1/10 mm in

depth, and is divided into 16 smaller squares.

These smaller squares form a grid that makes

accurate counting possible.

12. Switch to the high-power lens and count the

number of cells in field 1. Move the

hemacytometer until field 2 is in focus and

repeat the counting procedure. Continue until

the cells in all five fields have been counted.

Note the fields are numbered clockwise around

the chamber, with field 5 being in the center.

7-13

HM3f0712

Figure 7-12.—Mixing blood sample and diluent.

HM3f0713

Figure 7-13.—Loading the counting chamber.
Count the fields in this order. To count the cells

in each field, start in the upper left small square

and follow the pattern indicated by the arrow in

field 1 of figure 7-16. Count all of the cells

within each square, including cells touching the

lines at the top and on the left. Do not count any

cells that touch the lines on the right or at the

bottom.

13. Total the number of cells counted in all five

fields and multiply by 10,000 to arrive at the

number of red cells per cubic millimeter of

blood.

NOTE: The number of cells counted in each

field should not vary by more than 20. A

greater variation may indicate poor

distribution of the cells in the fluid, resulting in

an inaccurate count. If this happens, the test

must be repeated.

HEMOGLOBIN DETERMINATION

A routine test performed on practically every

patient is the hemoglobin determination. Hemoglobin

determination, or hemoglobinometry, is the

measurement of the concentration of hemoglobin in

the blood. Hemoglobin’s main function in the body is

to carry oxygen from the lungs to the tissues and to

assist in transporting carbon dioxide from the tissues to

the lungs. The formation of hemoglobin takes place in

the developing red cells located in bone marrow.

Hemoglobin values are affected by age, sex,

pregnancy, disease, and altitude. During pregnancy,

gains in body fluids cause the red cells to become less

concentrated, causing the red cell count to fall. Since

hemoglobin is contained in red cells, the hemoglobin

concentration also falls. Disease may also affect the

values of hemoglobin. For example, iron deficiency

anemia may drop hemoglobin values from a normal

value of 14 grams per 100 milliliters to 7 grams per 100

milliliters. Above-normal hemoglobin values may

occur when dehydration develops. Changes in altitude

affect the oxygen content of the air and, therefore, also

affect hemoglobin values. At higher altitudes there is

less oxygen in the air, resulting in an increase in red cell

counts and hemoglobin values. At lower altitudes

there is more oxygen, resulting in a decrease in red cell

counts and hemoglobin values.

7-14

COVER

GLASS

COUNTING

CHAMBERS

PROPERLY

LOADED

A

HM3f0714

FLOODED

AIR

BUBBLES UNDERLOADED

B

Figure 7-14.—Loading hemacytometer: A. Hemacytometer

properly loaded; B. Hemacytometer improperly loaded.

Example: Total number of cells counted = 423.

Multiply:

423 x 10,000 = 4,230,000

Total red cell count = 4,2300,000 cells/mm3

HM3f0715

Figure 7-15—Loaded hemacytometer placed inside petri dish.
7-15

HEMACYTOMETER (COUNTING CHAMBER)

IMPROVED NEUBAUER RULING

A-B-C-D

1-2-3-4-5

ARE FIELDS USED IN DOING THE WHITE BLOOD CELL COUNT.

ARE FIELDS USED IN DOING THE RED BLOOD CELL COUNT.

(Letters, numbers, and arrows are not actually seen in the counting

chamber. They are for illustration only. Circles depict areas seen

through the microscope.)

Low power (100X)

High dry (400X)

Each of these small

squares is 1/25 mm square

(50 ) μ

A B

C D

5

4 3

1 2

HM3f0716

This space is one

square mm. On the

hemacytometer its

depth is 1/10 of a

mm. For content

of this space,

multiply by 10 to

get content of

one cubic mm.

Figure 7-16.—Hemacytometer counting chamber.
The normal values for hemoglobin determinations

are as follows:

Methods for hemoglobin determination are many

and varied. The most widely used automated method is

the cyanmethemoglobin method. To perform this

method, blood is mixed with Drabkin’s solution, a

solution that contains ferricyanide and cyanide. The

ferricyanide oxidizes the iron in the hemoglobin,

thereby changing hemoglobin to methemoglobin.

Methemoglobin then unites with the cyanide to form

cyanmethemoglobin. Cyanmethemoglobin produces a

color which is measured in a colorimeter,

spectrophotometer, or automated instrument. The color

relates to the concentration of hemoglobin in the blood.

Manual methods for determining blood hemoglobin

include the Haden-Hausse and Sahli-Hellige methods.

In both methods, blood is mixed with dilute hydrochloric

acid. This process hemolyzes the red cells, disrupting the

integrity of the red cells’ membrane and causing the

release of hemoglobin, which, in turn, is converted to a

brownish-colored solution of acid hematin. The acid

hematin solutionisthen compared with a color standard.

HEMATOCRIT (PACKED CELL VOLUME)

DETERMINATION

The hematocrit or packed cell volume (PCV)

determines the percentage of red blood cells (RBCs) in

whole blood.

The normal hematocrit value for men is 42% to

52%; for women, 37% to 47%; and for newborns, 53%

to 65%. When hematocrit determinations are below

normal, medical conditions such as anemia and

leukemia may be present. Above-normal hematocrit

determinations indicate medical conditions like

dehydration, such as occur in severe burn cases.

Currently, automated hematology analyzers

supply most hematocrits. However, when hematology

analyzers are not available, hematocrit determinations

can be manually performed by the microhematocrit

method or macrohematocrit method. Both methods

call for the blood to be centrifuged, and the percentage

of packed red cells is found by calculation.

The microhematocrit method is the most accurate

manual method of determining blood volume and

should be used whenever feasible. Material

requirements and the step-by-step procedures for

performing the microhematocrit method will be

covered in the following sections.

Materials Required for Microhematocrit

Procedure

To perform a hematocrit using the microhematocrit method, the following materials are

required.

• Capillary tubes, plain or heparinized

• Modeling clay sealant

• Microhematocrit centrifuge

• Microhematocrit reader

Microhematocrit Procedure

To perform the microhematocrit method, you

should follow the steps listed below:

1. Fill t he ca pilla r y t u be tw o -t hi r d s t o

three-quarters full with well-mixed, oxalated

venous blood or fingertip blood. (For fingertip

blood use heparinized tubes, and invert several

times to mix.)

2. Seal one end of the tube with clay.

3. Place the filled tube in the microhematocrit

centrifuge, with the plugged end away from the

center of the centrifuge.

4. Centrifuge at a preset speed of 10,000 to 12,000

rpm for 5 minutes. If the hematocrit exceeds 50

percent, centrifuge for an additional 3 minutes.

5. Place the tube in the microhematocrit reader.

Read the hematocrit by following the

manufacturer ’s instructions on the

microhematocrit reading device.

TOTAL WHITE BLOOD CELL COUNT

The total white cell (leukocyte) count determines

the number of white cells per cubic millimeter of

blood. A great deal of information can be derived from

white cell studies. The white blood cell count (WBC)

and the differential count are common laboratory tests,

and they are almost a necessity in determining the

nature and severity of systemic infections. Normal

WBC values in adults range from 4,500 to 11,000 cells

per cubic millimeter; in children the range is from

5,000 to 15,000 cells per cubic millimeter; and in

7-16

Grams per

100 ml blood Percent

Woman............................12.5 to 15.................83 to 110

Men....................................14 to 17..................97 to 124

Newborn infants................17 to 23..................97 to 138
newborns the range is from 10,000 to 30,000 cells per

cubic millimeter.

White blood cell counts are performed either

manually or with automated hematology analyzers.

Only the manual method will be covered in this

chapter. After a brief discussion on abnormal white

blood cell counts, we will cover the Unopette method

for manually counting white blood cells.

Abnormal White Cell Counts

When white cell counts rise above normal values,

the condition is referred to as leukocytosis.

Leukocytosis frequently occurs when systemic or

local infections (usually due to bacteria) are present.

Counts for infections are highly variable. Examples of

some infections and their representative white cell

counts are as follows:

Pneumonia—20,000 to 30,000/mm3

Meningitis—20,000 to 30,000/mm3

Appendicitis—10,000 to 30,000/mm3

Dyscrasia (the diseased condition) of

blood-forming tissues, such as occurs in leukemia (due

to a malfunctioning of lymph and marrow tissues) also

results in leukocytosis, with extremely high white cell

counts. These white cell counts sometimes exceed

1,000,000/mm3

.

Other physiological conditions that can cause

leukocytosis and a white cell count as high as

15,000/mm3 may occur as follows:

• Shortly after birth

• During late pregnancy

• During labor

• Accompanying severe pain

• After exercise or meals

• After cold baths

• During severe emotional upset

An abnormally low count, known as leukopenia,

may be caused by the following conditions:

• Severe or advanced bacterial infections (such as

typhoid, paratyphoid, and sometimes

tularemia), or when the bacterial infection has

been undetected for a period of time (as with

chronic beta streptococcal infections of the

throat).

• Infections caused by viruses and rickettsiae,

such as measles, rubella, smallpox (until the 4th

day), infectious hepatitis, psittacosis, dengue,

tsutsugamushi fever, and influenza (when it may

fall to 1,500/mm3

, or shift to leukocytosis if

complications develop).

• Protozoal infections (such as malaria) and

helminthic infections (such as trichinosis). (For

example, with victims of malaria, slight

leukocytosis may develop for a short time during

paroxysm (the sudden intensification of

symptoms). Shortly thereafter, however,

leukopenia ensues.)

• Overwhelming infections when the body’s

defense mechanisms break down.

• Anaphylactic shock

• Radiation

Materials Required for Unopette Procedure

The Unopette method uses a disposable diluting

pipette system that provides a convenient, precise, and

accurate method for obtaining a white blood cell count.

When the Unopette method is used, whole blood is

added to a diluent. The diluent lyses (destroys) the red

blood cells, but preserves the white blood cells. Once

the red cells are completely lysed, the solution will be

clear. The diluted blood is then added to a

hemacytometer. Once the hemacytometer is loaded,

the cells should be allowed to settle for 10 minutes

before counting proceeds.

The following materials are required to perform a

white blood cell count using the Unopette method:

• Disposable Unopette for WBC counts, which

consists of

—a shielded capillary pipette (20 microliter (Fl)

capacity), and

—a plastic reservoir containing a premeasured

volume of diluent (1:100 dilution).

• Hemacytometer and coverglass

• Microscope with light source

• Hand-held counter

• Laboratory chit

7-17
Unopette Procedure

The Unopette disposable diluting pipette system

used to count WBCs is almost identical in shape and

application to the Unopette system for RBC counts.

The only major difference is that the reservoir contains

a different diluent and the capillary pipette capacity

differs (RBC 10 Fl and WBC 20 Fl). To assist you in

performing the Unopette procedure for WBCs, we will

refer to illustrations for the Unopette procedure for

RBCs in this section.

The Unopette procedure for counting white blood

cells is as follows:

1. Puncture the diaphragm in the neck of the

reservoir with the tip of the capillary pipette

shield. See figure 7-9.

2. After you obtain free-flowing blood from a

lancet puncture of the finger, remove the

protective plastic shield from the capillary

pipette. Hold the capillary pipette slightly

above the horizontal and touch the tip to the

blood source (fig. 7-10, view A). The pipette

will fill by capillary action. When blood reaches

the end of the capillary bore in the neck of the

pipette, filling is complete and will stop

automatically. The amount of blood collected

by the capillary tube is 20 Fl. Wipe any blood

off the outside of the capillary tube, making sure

no blood is removed from inside the capillary

pipette. (An alternative source of blood is a

thoroughly mixed fresh venous blood sample

obtained by venipuncture. See figure 7-10,

view B.)

3. With one hand, gently squeeze the reservoir to

force some air out, but do not expel any diluent

(fig. 7-11). Maintain pressure on the reservoir.

With the other hand, cover the upper opening of

the capillary overflow chamber with your index

finger and seat the capillary pipette holder in the

reservoir neck (fig. 7-11).

4. Release pressure on the reservoir and remove

your finger from the overflow chamber opening.

Suction will draw the blood into the diluent in

the reservoir.

5. Squeeze the reservoir gently two or three times

to rinse the capillary tube, forcing diluent into

but not out of the overflow chamber, releasing

pressure each time to return diluent to the

reservoir. Close the upper opening with your

index finger and invert the unit several times to

mix the blood sample and diluent. See

figure 7-12.

6. For specimen storage, cover the overflow

chamber of the capillary tube with the capillary

shield.

7. Immediately prior to cell counting, mix again by

gentle inversion, taking care to cover the hole

with your index finger.

8. Place the coverglass on the hemacytometer

counting chamber, making sure the coverglass is

clean and grease-free. (Fingerprints must be

completely removed.)

9. Remove the pipette from the reservoir. Squeeze

the reservoir and reseat the pipette in the reverse

position. Release pressure to draw any fluid in

the capillary tube into the reservoir. Invert and

fill the capillary pipette by gentle pressure on the

reservoir. After discarding the first 3 drops, load

(charge) the counting chamber of the

hemacytometer by gently squeezing the

reservoir while touching the tip of the pipette

against the edge of the coverglass and the

surface of the counting chamber (fig. 7-13). A

properly loaded counting chamber should have

a thin, even film of fluid under the coverglass

(fig. 7-14, view A). Allow 3 minutes for the

cells to settle. If fluid flows into the grooves

(moats) at the edges of the chamber or if you see

air bubbles in the field, the chamber is flooded

and must be cleaned with distilled water, dried

with lens tissue, and reloaded (fig. 7-14, view

B). If the chamber is underloaded, carefully add

additional fluid until properly loaded.

10. Place the loaded hemacytometer into a petri dish

with a piece of dampened tissue to keep the

hemacytometer from drying out (fig. 7-15).

Allow 5 to 10 minutes for the cells to settle.

11. Once the cells have settled, place the

hemacytometer on the microscope. Using the

high-power objective, count the WBCs in the

four corner fields of the hemacytometer

chamber (fields A, B, C, and D of figure 7-16).

Each field is composed of 16 small squares. To

count the cells in each field, start in the upper left

small square and follow the pattern indicated by

the arrow in field B of figure 7-16. Count all of

the cells within each square, including cells

touching the lines at the top and on the left. Do

not count any cells that touch the lines on the

right or at the bottom.

7-18
12. When all the cells in the 4 fields have been

counted, multiply the count by 50. This will

give you the total number of white cells per

cubic millimeter of blood.

DIFFERENTIAL WHITE BLOOD

CELL COUNT

A total white blood cell count is not necessarily

indicative of the severity of a disease, since some

serious ailments may show a low white cell count. For

this reason, a differential white cell count is performed.

A differential white cell count consists of an

examination of blood to determine the presence and

the number of different types of white blood cells. This

study often provides helpful information in

determining the severity and extent of an infection,

more than any other single procedure used in the

examination of the blood.

The role of white blood cells, or leukocytes, is to

control various disease conditions. Although these

cells do most of their work outside the circulatory

system, they use the blood for transportation to sites of

infection.

Five types of white cells are normally found in the

circulating blood. They are

• eosinophils,

• basophils,

• neutrophils,

• lymphocytes, and

• monocytes.

Cell Identification

To perform a differential white cell count, you

must be able to identify the different types of white

cells. The ability to properly identify the different

types of white cells is not difficult to develop, but it

does require a thorough knowledge of staining

characteristics and morphology (the study of the form

and structure of organisms). This knowledge can be

gained only by extensive, supervised practice.

To acquaint you with the developmental stages of

each type of leukocyte, a colorized illustration

(fig. 7-17) has been provided. This illustration also

displays the developmental stages of the red blood

cell (erythrocyte) and the blood platelet cell

(thrombocyte). To further assist you, identifying

characteristics of each type of leukocyte as they

appear on a stained blood smear will be covered in the

following sections.

Laboratories use a blood smear to obtain a

differential white cell count. To prepare a blood

smear, a blood specimen is spread across a glass slide,

stained to enhance leukocyte identification, and

examined microscopically. Material requirements

and the step-by-step procedure for performing a blood

smear will be covered later in this chapter.

NEUTROPHILS.—Neutrophils account for the

largest percentage of leukocytes found in a normal

blood sample, and function by ingesting invading

bacteria. On a stained blood smear, the cytoplasm of a

neutrophil has numerous fine, barely visible

lilac-colored granules and a dark purple or reddish

purple nucleus (see figure 7-17). The nucleus may be

oval, horseshoe, or “S”-shaped, or segmented

(lobulated). Neutrophils are subclassified according

to their age or maturity, which is indicated by changes

in the nucleus. The subclassifications for neutrophilic

cells are metamyelocyte, band, segmented, and

hypersegmented.

Neutrophilic Metamyelocyte.—A neutrophilic

metamyelocyte, also called a “juvenile” cell, is the

youngest neutrophil generally reported. The nucleus

is fat, indented, and is usually “bean”-shaped or

“cashew nut”-shaped (fig. 7-17).

Neutrophilic Band.—A neutrophilic band,

sometimes called a “stab” cell, is an older or

intermediate neutrophil. The nucleus has started to

elongate and has curved itself into a horseshoe or

S-shape. As the band ages, it matures into a

segmented neutrophil (fig. 7-17).

Segmented Neutrophil.—A segmented

neutrophil is a mature neutrophil. The nucleus of a

segmented neutrophil is separated into two, three,

four, or five segments or lobes (fig. 7-17).

7-19

Example: 25 cells in field #1

23 cells in field #2

26 cells in field #3

26 cells in field #4

100 total cells in all fields

Multiply:

100 x 50 = 5,000

Total white cell count = 5,000 cells/mm3
7-20

MONOBLAST LYMPHOBLAST MYELOBLAST RUBRIBLAST

PROMEGAKARYOCYTE PROLYMPHOCYTE PROGRANULOCYTE

NEUTROPHILIC MYELOCYTE

BASOPHILIC

MYELOCYTE

EOSINOPHILIC

MYELOCYTE

EOSINOPHILIC

METAMYELOCYTE

EOSINOPHILIC

BAND

RUBRICYTE

METARUBRICYTE

EOSINOPHIL

RETICULOCYTE

ERYTHROCYTE BASOPHIL

MEGAKARYOCYTE

THROMBOCYTE HYPERSEGMENTED

NEUTROPHIL

LYMPHOCYTE

SEGMENTED NEUTROPHIL

NEUTROPHILIC METAMYELOCYTE

NEUTROPHILIC BAND

BASOPHILIC

METAMYELOCYTE

MONOCYTE

PROMONOCYTE

PRORUBRICYTE

BASOPHILIC

BAND

I

M

M

A

T

U

R

E

C

E

L

L

S

M

A

T

U

R

E

RETICULO-ENDOTHELIAL CELL

LIVER-SPLEEN (PARENT CELL OF ALL BLOOD CELLS)

MESENCHYME

BLOOD ISLANDS-YOLK SAX

E

M

B

R

Y

O

DEVELOPMENT OF BLOOD CELLS X 1500

HM3F0717

Figure 7-17.—Development of blood cells.
Hypersegmented Neutrophil.—A hypersegmented neutrophil is a mature neutrophil. The

nucleus of a hypersegmented neutrophil is divided

into six or more segments or lobes (fig. 7-17).

EOSINOPHIL.—Eosinophils aid in detoxification. They also break down and remove protein

material. The cytoplasm of an eosinophil contains

numerous coarse, reddish-orange granules, which are

lighter colored than the nucleus (fig. 7-17).

BASOPHIL.—The function of basophilic cells is

unknown. It is believed, however, that basophilic cells

keep the blood from clotting in inflamed tissue.

Scattered large, dark-blue granules that are darker than

the nucleus, characterize the cell as a basophil

(fig. 7-17). Granules may overlay the nucleus as well

as the cytoplasm.

LYMPHOCYTE.—The function of lymphocytes is

also unknown, but it is believed that they produce

antibodies and destroy the toxic products of protein

metabolism. The cytoplasm of a lymphocyte is clear sky

blue, scanty, with few unevenly distributed, azurophilic

granules with a halo around them (fig. 7-17). The nucleus

is generally round, oval, or slightly indented, and the

chromatin (a network of fibers within the nucleus) is

lumpy and condensed at the periphery.

MONOCYTE.—The monocyte, the largest of the

normal white blood cells, destroys bacteria, foreign

particles, and protozoa. Its color resembles that of a

lymphocyte, but its cytoplasm is a muddy gray-blue

(fig. 7-17). The nucleus is lobulated, deeply indented

or horseshoe-shaped, and has a relatively fine

chromatin structure. Occasionally, the cytoplasm is

more abundant than in the lymphocyte.

Materials Required for the Differential

Count Procedure

To perform a differential count, the following

materials are required:

• Four plain glass microscope slides, clean and dry

• Wright-Giemsa stain solution (follow

manufacturer’s directions for use and storage)

• Staining containers

• Deionized or distilled water

• Microscope with light source

• Immersion oil

• Blood cell counter

Differential Count Procedure

The procedure for the differential white cell count

is done in 4 steps:

Step 1: Making the blood smear

Step 2: Staining the cells

Step 3: Counting the cells

Step 4: Reporting the count

Each step of this procedure will be discussed in the

following sections.

MAKING THE BLOOD SMEAR.—The

simplest way to count the different types of white cells

is to spread them out on a glass slide. The preparation

is called a blood smear. There are two methods of

making a blood smear: the slide method (covered in

this chapter) and the cover glass method.

It is very important to make a good blood smear. If

it is made poorly, the cells may be so distorted that it

will be impossible to recognize them. You should

make at least two smears for each patient, as the

additional smear should be examined to verify any

abnormal findings.

To prepare a blood smear for a differential count,

follow the steps below:

1. Using a capillary tube, collect anticoagulated

blood from a venous blood sample.

2. Deposit a drop of blood from capillary tube onto

a clean, grease-free slide. Then place the slide

on a flat surface, blood side up.

3. Hold a second slide between your thumb and

forefinger and place the edge at a 23-degree

angle against the top of the slide that holds the

drop of blood (see figure 7-18, view A). Back

the second slide down until it touches the drop of

blood. The blood will distribute itself along the

edge of the slide in a formed angle (see

figure 7-18, view B).

4. Push the second slide along the surface of the

other slide, drawing the blood across the surface

in a thin, even smear (see figure 7-18, view C).

If this is done in a smooth, uniform manner, a

gradual tapering effect (or “feathering”) of the

blood will occur on the slide. This “feathering”

of the blood is essential to the counting process

and is the principal characteristic of a good

blood smear (see figure 7-18, view D). When

7-21
you are making the smear, prevent blood from

reaching the extreme edges of the slides.

Allowing the smear to reach the edges of the

slide will aggravate the tendency of large cells to

stack up on the perimeter of the smear. A smear

with wavy lines or blanks spots should be

discarded, and a new smear made.

5. Once the blood smear is made, let it dry (it will

take a few minutes). Then write the patient’s

name in pencil on the bottom edge of the slide,

as illustrated in figure 7-18, view D). Proceed to

step 2, staining the cells.

STAINING THE CELLS.—Once a blood smear

is made, it should be stained. Staining the blood smear

highlights the differences among the different types of

leukocytes for easier recognition during the counting

process. The most popular stain used for this purpose

is Wright’s stain. Wright’s stain is a methyl alcohol

(methanol) solution of an acid dye and a basic dye. The

acid dye in Wright’s stain is known as eosin and is red

in color. The basic dye in Wright’s stain is known as

methylene blue and is blue in color. Generally, white

cells are identified by their affinity to the dye they

prefer. For example, cells that prefer the acid dye

(eosin) are called eosinophils. Other cells that prefer

the basic dye are called basophils.

WARNING

Wright’s staining solution contains methanol, which

is considered a hazardous material. It is classified as

flammable, a poison, and an irritant. Methanol must

be kept away from heat, sparks, and open flames.

Good ventilation in usage areas is paramount since

exposure to vapors can irritate eyes, nose, throat, and

mucous membranes of the upper respiratory tract.

When not in use, methanol containers should be

closed tightly and stored upright to prevent leakage.

Gloves and protective clothing (e.g., lab coat or

apron) and eyewear should be worn to avoid contact

with the solution. Absorption through skin can cause

permanent blindness. Death may result from

ingestion or exposure to high vapor concentrations of

methanol.

There are a variety of staining products on the

market today. Some of these staining products have

combined Wright’s solution with other staining

solutions, such as Giemsa stain. When using a new

product, you should always review the manufacturer’s

usage and safety recommendations.

The staining process that we will cover in this

chapter is known as a quick stain. A quick stain has

very few equipment requirements and only a few

procedural steps. An example of a quick stain is One

Step II Wright-Giemsa Stain Solution® by Criterion

Sciences. To stain a blood smear with this product,

follow the steps below.

1. Prepare two staining containers by filling one

with One Step II stain solution and the other

with deionized or distilled water. The use of tap

water instead of deionized or distilled water is

not recommended since the pH of tap water

varies. If tap water is used, its pH should

between 5.8 and 7.03.

2. Immerse the slide (blood smear) in the stain for

15 to 30 seconds. (To prevent debris or

precipitate from contaminating the slide, do not

add new stain to old.)

3. Remove the slide and allow excess stain to drain

from the edge of the slide.

4. Immerse the slide in the deionized or distilled

water for 5 to 15 seconds. (Change the water

7-22

Frost, John

A

B

C

D

HM3f0718

Figure 7-18.—Making a blood smear: A. Placing second slide

at a 23Eangle; B. Blood distributing itself along second slide’s

edge; C. Drawing blood across surface of slide; D. Example

of a properly prepared blood smear.
when it becomes dark blue or when film forms

on the surface.) NOTE: Rinse time is critical

and must be shorter than the stain time.

5. Drain excess water and wipe the back of the

slide to reduce background color.

6. Place slide in horizontal position on table and

allow to air dry. NOTE: Do not accelerate

drying time by placing slide on a warmer or in

front of a fan. The film of water on the slide is

important for the color development.

7. Once the slide is dry, proceed to step 3, counting

the cells.

COUNTING THE CELLS.—Once the blood

smear has been stained, it is placed under a

microscope, and the differential count is conducted.

To perform a differential white cell count, you

should follow the steps listed below:

1. Place the slide under the microscope. Switch

the oil immersion objective (red) (100X) into

position above the stage. Turn the coarse

adjustment to raise the oil immersion objective

about 1 inch above the opening in the stage.

Open the condenser and switch on the

microscope light.

2. Place a large drop of immersion oil on the thin

area of the blood smear. See figure 7-19.

3. Hold the slide so the thin area is on your left.

Then fix the slide firmly in the jaws of the

mechanical (movable) stage. Move the

mechanical stage so the drop of oil on the slide is

directly over the bright light coming up from the

condenser.

4. Using the coarse control knob, you should now

slowly lower oil immersion objective into the

drop of oil (on the slide). When the objective is

in the drop of oil, continue turning the coarse

adjustment until the objective is touching the

glass slide.

5. Now, while continually looking through the

eyepiece, VERY SLOWLY rotate the coarse

adjustment toward you until you see some cells.

After you have brought the cells into view with

the coarse adjustment, bring the cells into

perfect focus by rotating the fine adjustment.

NOTE: Always rotate the fine adjustment back

and forth when identifying cells. This step will

help you see the various layers of the cell and

thereby help you to identify the different types

of white cells.

6. Count 100 consecutive white cells, pressing the

correct key on the cell counter for each type of

white cell identified. (If the cell counter is not

available, record cell type and number of cells

encountered on a piece of paper.) Follow path

similar to one illustrated in figure 7-20 to count

cells.

7. Total each type of white cell. If you count 20

lymphocytes among the 100 cells, the

differential count for lymphocytes is 20%.

Continue this process until your count totals

100%. This differential count is referred to as a

relative count. Another differential count that

may be requested is an absolute count. To

perform an absolute count, multiply the total

white cell count by the individual cell

percentages. See the example below.

7-23

DROP OF IMMERSION OIL

HM3f0719

THIS THIN AREA OF THE

BLOOD SMEAR IS FOR

IDENTIFYING THE CELLS

Figure 7-19.—Placement of immersion oil on blood smear.

HM3f0720

Figure 7-20.—Counting path for differential count.

Example:

Patient has a total white cell count of 8,000.

Differential count shows 20% leukocytes.

Multiply:

8,000 x 0.20 (20%) = 1,600

Patient has 1,600 lymphocytes/mm3
NOTE: When performing the white cell

count, you may observe abnormal white

cells such as distorted lymphocytes,

smudge cells, and disintegrated cells.

Distorted lymphocytes, which appear

squashed or distorted, are caused by

excessive pressure on the cell during the

process of making the smear. Distorted

cells should be recorded as normal

lymphocytes. Smudge cells are white

cells that have ruptured and only the

nucleus remains. A few smudge cells may

be found in a normal blood smear.

Smudge cells should not be added to the

count or recorded. Disintegrated cells

are ruptured cells, but the nucleus and

cytoplasm still remain. Disintegrated

cells should not be counted as one of the

100 cells, but should be recorded on the

report as “disintegrated cells.”

8. Once the differential count is completed,

proceed to step 4, reporting the count.

NOTE: If it is desirable to save a smear

for reexamination, remove the immersion

oil by placing a piece of lens tissue over

the slide and moistening the tissue with

xylene. Draw the damp tissue across the

slide, and dry the smear with another

piece of lens paper.

REPORTING THE COUNT.—When you have

calculated the differential count, the report is given

according to either the Schilling classification or

filament and nonfilament classification methods.

We will be covering the Schilling classification, since

it is the simplest and most popular method.

The Schilling Classification.—The Schilling

classification was established when Victor Schilling, a

German hematologist, noticed that in many diseases

there is an increase in the percentage of immature

neutrophils. The blood chart he developed reported the

percentages of the different neutrophilic cell types and

(in part) was arranged in the following manner:

Normal

%

Myelocytes Metamyelocytes Band CellsSegmented

Cells

0 0 2 to 6 55 to 75

Note that the immature cells are on the left side of

the chart. If percentages of immature cell increased,

Schilling referred it as a “shift to the left.” When the

shift to the left was accompanied by a low white cell

count, Schilling called it a “degenerative shift to the

left.” A degenerative shift to the left is seen in such

diseases as typhoid fever. This shift is caused by a

depression of the cell factories in the bone marrow.

When the shift to the left is accompanied by a high

white cell count, it is called a “regenerative shift to the

left.” A regenerative shift to the left is seen in such

diseases as pneumonia. This shift is caused by a

stimulus of the cell factories in the bone marrow.

A “shift to the right” implies an increase in

hypersegmented neutrophils. It may be seen in

pernicious anemia, an anemia caused by the

malabsorption of vitamin B12.

The Schilling classification for an adult differential white cell count is provided below in table 7-2.

NOTE: Normal values for differential

counts vary with the age of the patient.

For example, children’s blood normally

contains 0% to 2% basophils, 0% to 5%

eosinophils, 25% to 75% neutrophils,

30% to 70% lymphocytes, and 0% to 8%

monocytes. Normal values may also be

adjusted by hospitals that have evaluated

the normal differential value for their

local population.

General Interpretations of Leukocyte

Changes.—Together, the total white cell count and

differential count aid physicians in interpreting the

severity of infections. Some general interpretations of

leukocyte changes are as follows:

• Leukocytosis with an increase in the percentage

of neutrophils indicates a severe infection with a

7-24

Cell Normal %

Neutrophilic myelocytes 0

Neutrophilic metamyelocytes 0

Neutrophilic band cells 2 to 6

Neutrophilic segmented cells 55 to 75

Lymphocytes 20 to 35

Monocytes 2 to 6

Eosinophilic segmented cells 1 to 3

Basophilic segmented cells 0 to 1

Table 7-2.—Schilling Classification of the Differential White

Cell Count
good response of the bone marrow. The primary

bacteria-destroying cells (known as phagocytes)

are the neutrophils, and the bone marrow should

supply large numbers of these to combat the

infection. The greater the “shift to the left”

(increase in immature neutrophils), the more

severe the infection. The appearance of

numerous juvenile cells (metamyelocytes)

indicates irritation of the bone marrow with

regeneration. If the infection continues and the

patient’s resistance declines, the shift advances

further to the left. If improvement ensues, the

shift declines and recedes to normal.

• A falling white cell count with the number and

maturity of neutrophils progressing toward

normal indicates recovery.

• A continued “shift to the left” with a falling total

white cell count indicates a breakdown of the

body’s defense mechanism and is a poor

prognosis.

• The percentage of eosinophils, lymphocytes,

and monocytes generally decreases in acute

infections.

• In tuberculosis, an increase in monocytes

(monocytosis) indicates activity in the infected

area. An increase in lymphocytes (lymphocytosis) indicates healing.

• Eosinophils increase in parasitic infections and

allergic conditions.

BACTERIOLOGY

LEARNING OBJECTIVE: Recall

bacteria classifications, common bacteria,

and procedural steps for making smears,

Gram staining, and reading and reporting

smears.

Bacteriology is the study of bacteria. Of primary

interest to Hospital Corpsman is medical bacteriology,

which deals with the bacteria that cause disease in man.

Bacteria are prokaryotic microorganisms of the

kingdom Protista. They reproduce asexually by

transverse binary fission in which the cell divides into

two new cells. Bacteria are found almost everywhere,

and the human body harbors vast numbers. Many

bacteria are beneficial and essential to human life; only

a few are harmful to man.

BACTERIA CLASSIFICATION

Since there are thousands of types of bacteria, a

method of classification is essential. Bacteria are

classified according to their respective

• disease-producing ability,

• growth requirements,

• morphologic characteristics,

• colonial morphology,

• toxins produced, and

• Gram’s stain reaction.

Disease-Producing Ability

The disease-producing ability of bacteria is

referred to as either pathogenic or nonpathogenic.

Pathogens are bacteria that cause diseases, and

nonpathogens are harmless bacteria. Bacteria that are

essential to our body are, in their proper environment,

called common or normal flora. For example, alpha

streptococcus in the throat is common flora, but when

it is found elsewhere (such as in the blood stream,

possibly as a result of tooth extraction), it may cause

diseases such as septicemia and endocarditis.

Growth Requirements

The four growth requirements for bacteria are

• temperature,

• oxygen,

• nutrition, and

• moisture.

TEMPERATURE REQUIREMENTS.—

Temperature requirements are divided into the

following three categories.

• Psychrophilic—bacteria that reproduce best at

15EC to 20EC

• Mesophilic—bacteria that reproduce best at

20EC to 45EC

• Thermophilic—bacteria that reproduce best at

50EC to 55EC

OXYGEN REQUIREMENTS.—The amount of

oxygen needed for an organism to grow or reproduce

varies with the type of organism. Aerobes are

organisms that reproduce in the presence of oxygen.

Obligate aerobes are organisms that grow only in the

7-25
presence of free oxygen. Anaerobes are organisms

that do not reproduce in the presence of oxygen, and

obligate anaerobes are organisms that grow only in

the absence of free oxygen and are killed if exposed to

free oxygen. Facultative organisms are organisms

that grow in the presence of free oxygen and in an

oxygen-free atmosphere. Microaerophilic

organisms are organisms that grow only in low

amounts of free oxygen.

NUTRITION REQUIREMENTS.—Nutrition

requirements for the various types of bacteria depends

on what their particular environment provides.

Autotrophic bacteria are self-nourishing, and

heterotrophic bacteria are not self-sustaining.

MOISTURE REQUIREMENTS.—Moisture is

indispensable for bacterial growth.

Morphologic Characteristics

The structural (or morphologic) characteristics of

bacteria are based on three distinct shapes or

categories:

• Coccus(pl. cocci)—spherical, appears singly, in

pairs, chains, clusters, or packets.

• Bacillus (pl. bacilli)—rod-shaped, appears

singly, in chains, or in palisades.

• Spirillum (pl. spirilla)—spiral-, corkscrew-, or

comma-shaped, appearing singly only.

Three special structures, present on some bacteria,

aid in the classification process of bacteria. The

special structures are the capsule, the spore, and the

flagellum. The capsule is a gummy, gelatinous, or

mucoid structure surrounding certain bacteria. The

spore is an inactive, resting, and resistant form

produced within the organism, usually as a result of

unfavorable environmental conditions. The third and

final special structure is the flagellum, a hairlike

structure that provides motility.

Colonial Morphology

A colony is a cohesive mass composed of many

millions of bacterial cells, growing on or in a medium

(such as blood agar, a gel enriched with blood that is

used in the preparation of solid culture media for

microorganisms) as a result of the multiplication and

division of a single cell. The size, color, shape, edge,

topography, consistency, and odor of the colony vary

with each organism.

Toxins Produced

Generally, toxins produced are waste products of

metabolism in a bacterial cell. Some bacteria produce

toxins that attack red blood cells in a culture medium

such as blood agar. Examples of toxins produced by

bacteria are listed below:

• Alpha hemolysin—produces partial hemolysis

(the disruption of the integrity of the red cell

membrane causing release of hemoglobin) and

changes the medium to a green color.

• Beta hemolysin—completely lyses the RBC,

leaving a clear zone of hemolysis.

• Endotoxin (low potency)—comprises part of

the cell wall and is released as the bacterial cell

spontaneously destroys itself with

self-generated enzymes (a process known as

autolysis).

• Exotoxin (high potency)—derives from the

bacteria during its growth but is found outside

the bacterial cell in the surrounding medium.

Exotoxins are highly poisonous, soluble, and

protein in nature.

Gram’s Stain Reaction

To differentiate and identify bacteria, you must

make them visible by staining. The staining

procedure, devised by Dr. Hans Christian Joachim

Gram, stains microorganisms such as bacteria with

crystal violet, treats them with 1:15 dilution of strong

iodine solution, decolorizes them with ethanol or

ethanol-acetone, and counterstains them with a

contrasting dye, usually safranin. Microorganisms

that retain the crystal violet stain (a dark blue-black

color) are said to be gram-positive, and those that lose

the crystal violet stain by decolorization but stain with

counterstain (a deep pink or reddish color) are said to

be gram-negative.

COMMON BACTERIA

Bacteria are named by genus and species. The first

word (capitalized) indicates the genus; the second

word (not capitalized) indicates the species, a

subdivision of the genus. For example:

GENUS SPECIES

Neisseria gonorrhoeae

7-26
Table 7-3 will familiarize you with commonly

encountered bacteria. This table lists the bacteria’s

morphologic shape, Gram stain response, genus and

species, and the type of infection it produces.

BACTERIOLOGIC METHODS

There are a variety of methods used in the

laboratory to identify bacteria. However, only a few of

these bacteriologic methods can be performed in

isolated duty locations or on board naval vessels. One

of these methods is the smear. The smear permits

healthcare personnel to examine specimens

microscopically. Material requirements and the

step-by-step procedures for making smears is covered

in the following sections.

Smear

A smear is the procedure in which a specimen–a

body fluid or a discharge–is spread across a glass slide

for microscopic examination. To enhance the

visualization of microorganisms on the smear, Gram

staining (introduced earlier in this chapter) is used.

Once the smear is stained, it is ready to be examined

under the microscope. Normally, smears are examined

by laboratory technicians who prepare reports of their

findings.

MATERIALS REQUIRED FOR SMEAR.—To

perform a smear, the following materials are required:

• Glass slide

7-27

COMMON BACTERIA

Morphologic

Shape

GramPositive or

-Negative

Genus & Species Type of Infection

Streptococcus pneumoniae Pneumonia

Positive

Streptococcus pyogenes (Beta

Streptococci Group A)

Strep throat

Cocci

Staphylococcus aureus Boils, furuncles, osteomyelitis,

pneumonia, septicemia,

endocarditis, and impetigo

Neisseria gonorrhoeae Gonorrhea

Negative Neisseria meningitidis

(meningococcus)

Meningitis

Corynebacterium

diphtheriae

Diphtheria

Bacilli

Positive

Clostridium

(all are anaerobic and

spore producers)

• perfringens (welchii)

• tetani

• botulinum

Gas gangrene

Tetanus

Botulism

Yersinia (Pasteurella) pestis Bubonic plague

Negative Brucella abortus Brucellosis

Bordetella pertussis Whooping cough

Table 7-3.—Common Bacteria
• Microscope

• Wooden applicator stick

• Saline solution

• Forceps

• Bunsen burner

PROCEDURE FOR MAKING SMEARS.—To

prepare smears for microscopic examination, follow

these steps:

1. Spread the specimen with a wood applicator

stick across a slide that has been cleaned with

alcohol or acetone and polished with lens paper.

The smear should be thin and uniformly spread.

If the smear is opaque, it is too thick and should

be emulsified with a drop or two of saline.

2. Label the smear and circle the material to be

stained with a diamond point pen for easier

identification and location of the material after

staining.

3. Let the smear air dry. Do not use forced heat

drying; forced drying will distort bacterial cells

and other materials.

4. Hold the smear with forceps and fix the smear

by passing it through a flame (smear side up)

three or four times. Avoid overheating the

smear; overheating will cause cellular wall

destruction.

5. Let the slide cool. Once the slide is cooled, it is

ready to be stained.

Gram’s Stain

As previously explained, the most common

staining procedure used in bacteriologic work is the

Gram stain. This method yields valuable information

and should be used on all smears that require staining.

Gram’s stain is also used for examining cultures to

determine purity and for identification purposes.

PRINCIPLE OF GRAM STAINING.—As

touched on previously, the crystal violet stain, the

primary stain, stains everything in the smear blue. The

Gram’s iodine acts as a mordant, a substance that

causes the crystal violet to penetrate and adhere to the

gram-positive organisms. The acetone-alcohol

mixture acts as the decolorizer that washes the stain

away from everything in the smear except the

gram-positive organisms. The safranin is the

counter-stain that stains everything in the smear that

has been decolorized: pus cells, mucus, and

gram-negative organisms. The gram-negative

organisms will stain a much deeper pink than the pus

cells and mucus will stain even lighter pink than the

pus cells.

MATERIALS REQUIRED FOR GRAM

STAINING.—To Gram stain a smear, the following

materials are required:

• Gram stain kit, which consists of:

—Crystal violet stain

—Iodine or stabilized iodine (mordant)

—Acetone-alcohol decolorizer

—Safranin stain

• Staining rack

• Blotting paper or paper towel

PROCEDURE FOR GRAM STAINING

SMEARS.—After smears have been dried,

heat-fixed, and cooled, proceed as follows:

1. Place the slide on a staining rack. Then flood

slide with primary stain (crystal violet). Let

stand 1 minute.

2. Remove the primary stain by gently washing

with cold tap water.

3. Flood the slide with mordant (iodine or

stabilized iodine) and retain on slide for 1

minute.

4. Remove mordant by gently washing with tap

water.

5. Tilt slide at a 45-degree angle and decolorize

with the acetone-alcohol solution until the

solvent that runs from the slide is colorless (30

to 60 seconds).

6. Wash the slide gently in cold tap water.

7. Flood the slide with counter-stain (safranin) and

let stand for 30 to 60 seconds.

8. Wash slide with cold tap water.

9. Blot with blotting paper or paper towel or allow

to air dry.

10. Examine the smear under an oil immersion

objective.

Reading and Reporting Smears

Place a drop of oil on the slide and, using the oil

immersion objective of the microscope, read the

7-28
smear. All body discharges contain extraneous

materials, such as pus cells and mucus. Of interest,

however, are the types of bacteria that may be present.

The stained smear reveals only two features: the

morphology and the staining characteristics of the

bacteria present. Positive identification requires

cultures and further studies.

Hospital Corpsmen should report only what

they see. For example, “Smear shows numerous

gram-negative bacilli.” If two or more types of

bacteria are seen in a smear, the rule is to report them in

order of predominance. For example:

“1. Numerous gram-positive cocci in clusters

2. Few gram-negative bacilli”

Gram-positive organisms are easy to see because

they stain a deep blue or blue-black. Gram-negative

organisms stain a deep pink, but since the background

material is also pink, minute and detailed inspection is

necessary before reporting the results.

In the presence of gonorrhea, the smear will reveal

large numbers of pus cells with varying numbers of

intracellular and extracellular gram-negative,

bean-shaped cocci in pairs. Such a finding could be

considered diagnostic. It is important to point out that

only a few of the thousands of pus cells on the slide

may contain bacteria, and sometimes it requires

considerable search to find one.

SEROLOGY

LEARNING OBJECTIVE: Recall

principles and procedures for the Rapid

Plasma Reagin (RPR) Card Test and the

Monosticon DRI-DOT® Slide Test.

Serology consists of procedures by which antigens

and reacting serum globulin antibodies may be

measured qualitatively and quantitatively. Serologic

tests have been devised to detect either antigens

present or antibodies produced in a number of

conditions. Most tests are based on agglutination

reactions between an antigen and a specific antibody.

An antigen is a substance that, when introduced

into an individual who does not already possess that

substance, may stimulate the individual’s cells to

produce specific antibodies that react to this substance

in a detectable way. The five basic characteristics of an

antigen are that it must be foreign to the body, it must

possess a high molecular weight, it must be

structurally stable, it must be complex, and it must

have a high specificity to stimulate tissues to produce a

defensive protein substance called an antibody.

Antibodies are the specific defensive proteins

produced when an antigen stimulates individual cells.

Antibodies are produced by the host in response to the

presence of an antigen and are capable of reacting with

antigens in some detectable way.

The antigen-antibody reaction takes place when

a reaction occurs between specific antibodies in the

plasma and the antigen present on cell surfaces.

Principles and procedures of two serologic tests,

the rapid plasma reagin (RPR) card test and the

Monosticon DRI-DOT® Slide Test are covered in the

following sections.

RAPID PLASMA REAGIN (RPR)

CARD TEST

The RPR Card test is a sensitive, easily performed

screening test for syphilis. The test is performed on

unheated plasma or serum. Everything needed for the

test is in a kit that is available commercially. This test

kit is very useful aboard ship and at small stations.

Principle of the RPR Card Test

In the RPR Card test method of syphilis detection, a

specific antigen (carbon-particle cardiolipin) detects

“reagin,” a substance present in the serum of persons

who are infected with syphilis. Specimens that contain

reagin cause formation of particles (called flocculation)

or coagulation of the carbon particles to occur on the

RPR Card antigen. Reactive specimens appear as black

clumps against a white background. Nonreactive

specimens appear as an even, light-gray color.

Materials Required for RPR Test

To perform an RPR Card test, the following

materials are required:

• Serum sample—venous blood collected in tubes

without anticoagulant. NOTE: Use clear,

unhemolyzed serum that has been separated

from the blood cells as soon after collection as

possible.

• RPR Card Test Kit, which consists of the

following components:

—RPR Card antigen suspension

7-29
—Plastic dispensing bottle

—20-gauge, galvanized needle, blunt cut

—Test cards

—Pipette/stirrers, 50 microliter (Fl)

• One 1 ml tuberculin syringe

• Distilled water

• Mechanical rotator (adjusted to 100 rpm)

• RPR Card Test Control Cards (each consisting of

three labeled test areas containing lyophilized

(meaning a stabilized preparation of a biological

substance, such as blood, that has been frozen

rapidly and then dehydrated under a high

vacuum) control specimens with designated

patterns of reactivity: Reactive, ReactiveMinimal-to-Moderate, and Nonreactive.)

NOTE: RPR Card Test Antigen and

Control Cards must be stored at 4EC when

not in use. Both items are stable until the

expiration date. Store “in use” antigen

suspension in the dispensing bottle at

4EC. The antigen suspension is stable for

3 months or until the expiration date,

whichever occurs first.

Preliminary Preparations for RPR Test

The following preliminary preparations must be

performed before RPR testing can begin:

1. Remove the antigen suspension vial and one

control card envelope from the refrigerator.

Allow the items to warm to room temperature.

2. Resuspend the contents of the vial by vigorously

shaking the antigen vial.

3. Snap the neck of the vial.

4. Attach the needle (provided in the kit) to a 1 ml

tuberculin syringe. Slowly draw up into the

syringe from the vial approximately 1 ml of the

antigen suspension.

5. Hold the syringe perpendicular to the surface

and count the number of drops dispensed from a

0.5 ml volume. Allow the drops to fall into the

antigen vial. NOTE: The needle is accurate if

30 drops, plus or minus 1 drop, are dispensed

from the 0.5 ml volume.

6. Slowly expel the remainder of the antigen

solution in the syringe back into the antigen vial.

7. Remove the needle from the syringe. Place the

needle on the tapered fitting of the plastic

dispensing bottle (provided in the kit).

8. Slowly withdraw all the contents of the antigen

vial by collapsing the dispensing bottle and

using it as a suction device.

9. Allow the rotator to warm up for 5 to 10

minutes; adjust to 100 rpm.

RPR Test Procedure

To detect syphilis using the RPR Card test, follow

the steps below:

1. Open the foil package and remove the control

card.

2. Use a pipette/stirrer to reconstitute each control

card circle with 0.5 ml of distilled water.

3. Mix solution in control card circle with

pipette/stirrer until the dehydrated control

specimen is dissolved. Spread specimen over

entire area of circle. Use a separate

pipette/stirrer for each circle.

4. Draw the patient’s sample by holding the

pipette/stirrer between the thumb and forefinger

near the stirring or sealed end and squeeze. Do

not release pressure until the open end is below

the surface of the specimen, then release

pressure to draw up the sample.

5. Hold the pipette/stirrer in a vertical position,

directly over the card test area where the

specimen is to be delivered; squeeze

pipette/stirrer, allowing 1 drop to fall onto the

test area.

6. Invert the pipette/stirrer and, with the sealed

end, spread specimen within the circle. Discard

the pipette/stirrer when done.

7. Continue the steps above until one or two test

cards are filled with patient’s samples.

8. Gently shake the antigen dispensing bottle

before use. Hold the bottle in the vertical

position and dispense several drops into the

dispensing bottle cap to ensure the needle

passage is clear. Allow 1 “free-falling” drop to

fall onto each test area. Do not stir; the mixing

of antigen suspension and specimen is

accomplished by rotation.

9. Put the card(s) on the rotator and cover with the

humidifying cover. Rotate cards for 8 minutes

7-30
at 100 rpm. To help differentiate nonreactive

from reactive results, you should briefly rotate

and tilt the card by hand (3 or 4 back-and-forth

motions).

10. Immediately read the card macroscopically

(with the unaided eye) in the “wet” state under a

high-intensity lamp.

11. Compare the patient’s tests to the controls for

correct interpretations. The reactive control

should show small to large clumps. The

nonreactive control should show no clumping or

very slight roughness. The reactive-minimalto-moderate control should show slight but

definite clumping.

12. Report the test as

• reactive, if agglutination or flocculation is

present, or

• nonreactive, if no agglutination is present.

NOTE: The RPR Card test is used as a

screen for syphilis. If a patient’s RPR is

reactive, the patient should be sent to a

laboratory to have a FTA-ABS

(Fluorescent Treponemal Antibody

Absorption Test) performed. The

FTA-ABS, a more precise test, is used to

confirm primary, secondary, and late

syphilis.

MONOSTICON DRI-DOT SLIDE

TEST

Mononucleosis imitates many diseases so well that

diagnosis is confirmed only by selective serologic

testing. The Monosticon DRI-DOT Slide Test is an

accurate, 2-minute disposable test designed to detect

the presence of infectious mononucleosis antibodies in

serum, plasma, or whole blood.

Principle of the Monosticon DRI-DOT

Slide Test

The Monosticon DRI-DOT Slide Test consists of

specially prepared, stable sheep and/or horse

erythrocyte antigen (dyed) and guinea pig antigen on a

disposable slide. When serum, plasma, or whole blood

is mixed with these antigens on the slide, the test result

for infectious mononucleosis will be positive or

negative. A positive result is indicated by

agglutination and a negative result is indicated by no

agglutination.

Materials Required for Monosticon

DRI-DOT Slide Test

To perform the Monosticon DRI-DOT Slide Test,

the following materials are required:

• Serum or plasma specimen

• Monosticon DRI-DOT Test kit, which consists

of:

—Monosticon DRI-DOT Test slides

—Positive I.M. (infectious mononucleosis)

serum control

—Negative I.M. serum control

—Dropper bottle

—Dispenstirs® (designed to deliver a 0.03 ml

drop)

• Distilled water

• Centrifuge

• DRI-DOT slide holder (available commercially,

but not necessary to perform test)

Controls for Monosticon DRI-DOT

Slide Test

Both a positive and negative control are included

in each kit to check the effectiveness of the reagents.

The positive I.M. serum control (human) is a dilution

of human sera (sing. serum) containing the specific

heterophile antibody of infectious mononucleosis.

The negative I.M. serum control (human) is a dilution

of human sera containing no detectable antibody to

infectious mononucleosis. Both controls have been

dried and placed in a vial with color-coded cap and

label. Since both controls are of human origin, they are

potentially infectious and must be handled with care.

Both controls (positive and negative) should be

tested before performing test with serum, plasma, or

whole blood. Controls are prepared in the same manner

as serum and plasma test described in the next section,

but instead of adding serum or plasma to the slide, the

control is added. Before each control is used, it must be

reconstituted with 0.5 ml of distilled water. If results of

the control tests are not as expected, do not use the test

kit.

7-31
Monosticon DRI-DOT Slide Test Procedure

To detect mononucleosis using the Monosticon

DRI-DOT Slide Test, follow the steps below.

1. Centrifuge the blood specimen for 10 minutes to

obtain the plasma or serum to be tested.

2. Fill the dropper bottle with distilled water.

3. Remove the disposable slide by tearing the

envelope where indicated. (Remove only

enough slides to perform the tests at hand.)

4. Set the slide in a holder or on a flat surface.

5. Place one drop of water from the dropper bottle

next to but not on the blue dot within the circle

on the slide.

6. Use a Dispenstir to squeeze the closed end

between thumb and forefinger, and place the

open end into the plasma or serum to be tested.

Release pressure to draw up the specimen into

the Dispenstir.

7. Hold the Dispenstir perpendicularly over the

buff-colored dot (guinea pig antigen) within the

circle of the slide. Place one drop of specimen

onto the dot.

8. Use the flared end of the Dispenstir to mix the

water, specimen, and the guinea pig antigen

(bluff-colored dot) thoroughly.

9. Blend this mixture thoroughly with the blue dot

(horse/sheep antigen).

10. Rock the slide (or slide holder) back and forth

gently in a figure-8 motion for 2 minutes so that

the liquid slowly flows over the entire area

within the circle.

11. After 2 minutes, read the results under a strong,

glaring light.

12. Report test as

• positive, if agglutination is present, or

• negative, if no agglutination is present.

See figure 7-21 for an illustration of positive and

negative test results.

NOTE: A positive test result usually

occurs between the fourth day and the

twenty-first day of illness, and may

persist for several months.

FUNGUS TEST

LEARNING OBJECTIVE: Recall how

potassium hydroxide (KOH) preparation is

used in the detection of fungi.

Fungi (sing. fungus) are chlorophyll-free,

heterotrophic (not self-sustaining) of the same family

of plants (i.e., Thyllophyta) as algae and lichens. They

reproduce by spores that germinate into long filaments

called hyphae. As the hyphae continue to grow and

branch, they develop into a mat of growth called the

mycelium (pl. mycelia). From the mycelium, spores

are produced in characteristic patterns. These spores,

when dispersed to new substances, germinate and form

new growths. Reproduction is often asexual, usually

by budding (as in yeast), but certain fungi have sexual

reproduction.

Common superficial infections of the skin caused

by fungi are athlete’s foot and ringworm of the scalp.

A simple and frequently used method of detecting

fungi is the potassium hydroxide (KOH)

preparation. Fungi are seen in clustered round buds

with thick walls, accompanied by fragments of

7-32

POSITIVE - AGGLUTINATION NEGATIVE - NO AGGLUTINATION

HM3f0721

Figure 7-21.—Illustration of positive and negative Monosticon DRI-DOT Slide Test Results.
mycelia. Scrapings from the affected area of the skin

are mounted in 10% KOH for positive laboratory

diagnosis.

To detect fungi in infected tissue using the KOH

preparation, follow the steps below.

1. Place skin, hair, or nail scrapings from the

affected area on a glass slide and add one drop of

10% KOH. (Dissolve 10 g of KOH in 100 ml of

distilled water.)

2. Place a coverslip on the preparation.

3. Warm the preparation gently over a flame, being

careful not to boil it, and allow it to stand until

clear. Do not allow the preparation to dry out.

4. Examine the p repa ration by using the

high-power objective on microscope with

subdued light.

• Fungi on the skin and nails appear as

refractile fragments of hyphae.

• Fungi in the hair appear as dense clouds

around the hair stub or as linear rows inside

the hair shaft.

URINALYSIS

LEARNING OBJECTIVE: Recall the

three types of urine specimens, the methods

used to preserve urine specimens, and the

procedure for performing a urinalysis.

Since the physical and chemical properties of

normal urine are constant, abnormalities are easily

detected. The use of simple tests provides the

physician with helpful information for the diagnosis

and management of many diseases.

This section deals with the three types of urine

specimens, methods used to preserve urine specimens,

the procedure for performing a routine and

microscopic examination of urine specimens, and

some of the simpler interpretations of the findings.

URINE SPECIMENS

Urine specimens for routine examinations must be

collected in aseptically clean containers. Unless

circumstances warrant, avoid catheterization because

it may cause a urinary tract infection. Specimens of

female patients are likely to be contaminated with

albumin and blood from menstrual discharge, or with

albumin and pus from vaginal discharge. For

bacteriologic studies, care must be taken to ensure that

the external genitalia have been thoroughly cleansed

with soap and water. The patient must void the initial

stream of urine into the toilet or a suitable container

and the remainder directly into a sterile container. All

urine specimens should either be examined when

freshly voided, or refrigerated to prevent decomposition of urinary constituents and to limit bacterial

growth. In the following sections, we will cover three

types of urine specimens: random, first morning, and

24-hour.

Random Urine Specimen

A random urine specimen is urine voided without

regard to the time of day or fasting state. This sample is

satisfactory for most routine urinalyses. It is the least

valid specimen, since test results may reflect a

particular meal or fluid intake.

First Morning Urine Specimen

The first morning urine specimen is the first urine

voided upon rising. It is the best sample for routine

urinalysis, because it is usually concentrated and more

likely to reveal abnormalities. If positive results are

obtained from the first morning specimen, the

physician may order a 24-hour specimen for

quantitative studies.

Twenty-Four Hour Urine Specimen

The 24-hour urine specimen measures the exact

output of urine over a 24-hour period. Use the

following steps to collect this specimen.

1. Have patient empty bladder early in the morning

and record time. Discard this urine.

2. Collect all urine voided during next 24 hours.

3. Instruct patient to empty bladder at 0800 the

following day (end of 24-hour period). Add this

urine to pooled specimen.

Refrigerate specimen during collection, and,

depending on the test being performed, add a

preservative to the first specimen voided.

The normal daily urine volume for adults ranges

from 800 to 2000 ml, averaging about 1,500 ml. The

amount of urine excreted in 24 hours varies with fluid

intake and the amount of water lost through

perspiration, respiration, and bowel activity. Diarrhea

7-33
or profuse sweating reduces urinary output; a

high-protein diet tends to increase it. Daytime urine

output is normally two to four times greater than

nighttime output.

PRESERVATION OF URINE SPECIMENS

To delay decomposition of urine, use the following

methods of preservation:

• Refrigeration

• Preservatives

—Hydrochloric acid

—Boric acid

—Glacial acetic acid

Other preservatives used include formaldehyde,

toluene, and thymol. The preservative used must be

identified on the label of the container. If no

preservative is used, this, too, should be noted.

NOTE: Before adding a preservative to a

urine specimen, contact the laboratory

performing the test to find out what

preservative to use and the quantity to

add. Preservative requirements vary from

laboratory to laboratory.

ROUTINE URINE EXAMINATION

A routine urinalysis includes the examination of

physical characteristics, chemical characteristics, and

microscopic structures in the sediment. A sample for

urinalysis (routine and microscopic) should be at least

15 ml in volume (adult), and either a random or first

morning specimen. Children may only be able to

provide a small volume, but 10-15 ml is preferred.

Physical Characteristics

Physical characteristics evaluated during a routine

urinalysis include color, appearance, and specific

gravity.

COLOR.—The normal color of urine varies from

straw to light amber. Diluted urine is generally pale;

concentrated urine tends to be darker. The terms used

to describe the color of urine follow.

• Colorless

• Light straw

• Straw

• Dark straw

• Light amber

• Amber

• Dark amber

• Red

The color of urine may be changed by the presence

of blood, drugs, or diagnostic dyes. Examples are:

• red or red-brown (smokey appearance), caused

by the presence of blood.

• yellow or brown (turning greenish with yellow

foam when shaken), caused by the presence of

bile.

• olive green to brown-black, caused by phenols

(an extremely poisonous compound, used as an

antimicrobial agent).

• milky white, caused by chyle. (Chyle, which

consists of lymph and droplets of triglyceride, is

a milky fluid taken up by lacteal vessels from the

food in the intestine during digestion.)

• dark orange, caused by Pyridium® (a topical

analgesic used in the treatment of urinary tract

infections).

• blue-green, caused by methylene blue (used as a

stain or dye for various diagnostic tests).

APPEARANCE.—Urine’s appearance may be

reported as clear, hazy, slightly cloudy, cloudy, or very

cloudy. Some physicians prefer the term “turbidity”

instead of “transparency,” but both terms are

acceptable.

Freshly passed urine is usually clear or

transparent. However, urine can appear cloudy when

substances such as blood, phosphates, crystals, pus, or

bacteria are present. A report of transparency is of

value only if the specimen is fresh. After standing, all

urine becomes cloudy because of decomposition, salts,

and the action of bacteria. Upon standing and cooling,

all urine specimens will develop a faint cloud

composed of mucus, leukocytes, and epithelial cells.

This cloud settles to the bottom of the specimen

container and is of no significance.

SPECIFIC GRAVITY.—The specific gravity of

the specimen is the weight of the specimen compared

to an equal volume of distilled water. The specific

gravity varies directly with the amount of solids

dissolved in the urine and normally ranges from 1.015

to 1.030 during a 24-hour period.

7-34
The first morning specimen of urine is more

concentrated and will have a higher specific gravity

than a specimen passed during the day. A high fluid

intake may reduce the specific gravity to below 1.010.

In the presence of disease, the specific gravity of a

24-hour specimen may vary from 1.001 to 1.060.

Specific gravity is measured with an index

refractometer, available as standard equipment at most

duty stations. See figure 7-22. The index refractometer may be held manually or mounted on a stand like

a microscope. The specific gravity of urine is

determined by the index of light refraction through

solid material.

Measure the specific gravity with an index

refractometer in the following manner:

1. Hold the index refractometer in one hand. Use

the other hand and an applicator stick to place a

drop of urine on the glass section beneath the

coverglass.

2. Hold the refractometer so that the light reflects

on the glass section, and look into the ocular

end. Read the number that appears where the

light and dark lines meet. This is the specific

gravity.

Chemical Characteristics

Chemical characteristics evaluated during a

routine urinalysis include pH, protein, glucose,

ketones, and blood. Some laboratories also include

tests for bilirubin, urobilinogen, and nitrite, depending

on the test strip used. Currently, most medical

facilities use the Multistix® and Color Chart, which

detects pH, protein, glucose, ketones, blood, bilirubin,

and urobilinogen. The Multistix is a specially

prepared multitest strip. The strip is simply dipped

into the urine specimen and compared to the color

values for the various tests on the accompanying chart.

The color chart also indicates numerical pH values,

which should be reported.

Microscopic Examination of Urine Sediment

Microscopic examination of urine sediment is

usually performed in addition to routine procedures.

This examination requires a degree of skill acquired

through practice under the immediate supervision of

an experienced technician. The specimen used for

microscopic examination should be as fresh as

possible. Red cells and many formed solids tend to

disintegrate upon standing, particularly if the

specimen is warm or alkaline.

PREPARING SPECIMENS FOR MICROSCOPIC EXAMINATION.—To prepare urine

specimens for microscopic examination, follow the

steps below.

1. Stir the specimen well.

2. Pour 15 ml of urine into a conical centrifuge

tube, and centrifuge at 1,500 rpm for 5 minutes.

3. Invert the centrifuge tube and allow all of the

excess urine to drain out. Do not shake the tube

while it is inverted. Enough urine will remain

in the tube to resuspend the sediment. Too much

urine will cause dilution of the sediment,

making an accurate reading difficult.

4. Resuspend the sediment by tapping the bottom

of the tube.

5. With a medicine dropper, mount one drop of the

suspension on a slide and cover it with a

coverslip.

6. Place the slide under the microscope, and scan

with the low-power objective and subdued

lighting.

7. Switch to the high-power objective for detailed

examination of a minimum of 10 to 15 fields.

CLINICALLY SIGNIFICANT FINDINGS.—

Leukocytes, erythrocytes, and casts may all be of

clinical significance when found in urine sediment.

Leukocytes.—Normally, 0 to 3 leukocytes per

high-power field will be seen on microscopic

examination. More than 3 cells per high-power field

probably indicates disease somewhere in the urinary

tract. Estimate the number of leukocytes present per

high-power field and report it as the “estimated

number per high-power field.”

Erythrocytes.—Red cells are not usually present

in normal urine. If erythrocytes are found, estimate

their number per high-power field and report it.

Erythrocytes may be differentiated from white cells in

several ways:

• White cells are larger than red cells.

7-35

HM3f0722

Figure 7-22.—Index refractometer.
• When focusing with the high-power lens, the red

cells show a distinct circle; the white cells tend to

appear granular with a visible nucleus.

• One drop of 5% acetic acid added to the urine

sediment disintegrates any red cells, but it does

not affect the white cells (except that the nuclei

become more distinct).

Casts.—These urinary sediments are formed by

coagulation of albuminous material in the kidney

tubules. Casts are cylindrical and vary in diameter.

The sides are parallel, and the ends are usually

rounded. Casts in the urine always indicate some form

of kidney disorder and should always be reported. If

casts are present in large numbers, the urine is almost

sure to be positive for albumin.

There are seven types of casts. They are as

follows:

• Hyaline casts are the most frequently occurring

casts in urine. Hyaline casts can be seen in even

the mildest renal disease. They are colorless,

homogeneous, transparent, and usually have

rounded ends.

• Red cell castsindicate renal hematuria. Red cell

casts may appear brown to almost colorless and

are usually diagnostic of glomerular disease.

• White cell casts are present in renal infection

and in noninfectious inflammation. The

majority of white cells that appear in casts are

hypersegmented neutrophils.

• Granular casts almost always indicate

significant renal disease. However, granular

casts may be present in the urine for a short time

following strenuous exercise. Granular casts

that contain fine granules may appear grey or

pale yellow in color. Granular casts that contain

larger coarse granules are darker. These casts

often appear black because of the density of the

granules.

• Epithelial casts are rarely seen in urine because

renal disease that primarily affects the tubules is

infrequent. Epithelial casts may be arranged in

parallel rows or haphazardly.

• Waxy casts result from the degeneration of

granular casts. Waxy casts have been found in

patients with severe chronic renal failure,

malignant hypertension, and diabetic disease of

the kidney. Waxy casts appear yellow, grey, or

colorless. They frequently occur as short, broad

casts, with blunt or broken ends, and often have

cracked or serrated edges.

• Fatty casts are seen when there is fatty

degeneration of the tubular epithelium, as in

degenerative tubular disease. Fatty casts also

result from lupus and toxic renal poisoning. A

typical fatty cast contains both large and small

fat droplets. The small fat droplets are

yellowish-brown in color.

SUMMARY

Clinical laboratory medicine is a very dynamic

field of medicine, with new testing procedures and

equipment being invented all the time. The goal of this

chapter is to introduce you to some basic laboratory

tests that do not require state-of-the-art equipment and

that can be easily performed in isolated duty stations

and aboard naval vessels. These tests will assist you in

establishing diagnoses and will enable you to provide

the best possible medical care for your patients.

7-36
CHAPTER 8

MEDICAL ASPECTS OF CHEMICAL,

BIOLOGICAL, AND RADIOLOGICAL WARFARE

In this chapter we will discuss the history of

chemical, biological, and radiological (CBR) warfare,

and the recognition and treatment of CBR-produced

conditions. We will also discuss the Medical

Department’s role in meeting the medical aspects of CBR

defense, which includes protection from CBR hazards,

mass casualty decontamination, decontamination

stations, and supplies for decontamination. Table 8-1

provides a summary of CBR symptoms and treatments.

CHEMICAL WARFARE

LEARNING OBJECTIVE: Select the

appropriate treatment and decontamination

procedure for chemical, biological, or

radiological exposures.

The use of chemical agents in warfare, frequently

referred to as “gas warfare,” is defined as the use of

chemical agents in gaseous, solid, or liquid states to

harass personnel, produce casualties, render areas

impassable or untenable, or contaminate food and

water. The chances of surviving a chemical attack are

increased as knowledge of the nature of the agents and

of the use of correct protective measures is increased.

HISTORY

The first large-scale use of chemical agents came

in World War I when, in 1915, the Germans released

chlorine gas against the Allied positions at Ypres,

Belgium. Over 5,000 casualties resulted. There were

other gas attacks by both combatant forces during

World War I, and it is well documented that

approximately one-third of all American casualties in

this conflict were due to chemical agent attacks.

During the interval between World Wars I and II,

each of the major powers continued to develop its

capability for chemical warfare, in spite of a ban by the

Geneva Treaty. In isolated cases in the late 1930s,

toxic chemicals were used; however, they were not

used during World War II. Nor were toxic chemicals

authorized for use in Korea, Vietnam, or Desert Storm.

Defoliants and riot-control agents were used with

some degree of effectiveness in the jungles

of Vietnam, in tunnel and perimeter-clearing

operations.

DISPERSAL

Chemical agents are dispersed by modern

weapons for strategic as well as tactical purposes.

However, the areas of their use are limited by the range

of the weapons or aircraft used by the combatant force.

A naval unit afloat finds itself in a unique situation

with respect to defending against toxic chemical

agents. Agents can be released as clouds of vapor or

aerosol. These can envelope the exterior of a vessel

and penetrate the hull of the ship. Extensive

contamination can result from such an attack, and the

ship must be decontaminated while the personnel

manning it continue to eat, sleep, live, and fight on

board.

To properly meet the medical needs of the ship, the

medical officer or Hospital Corpsman on independent

duty must organize the Medical Department well in

advance of the actual threat of a chemical agent attack.

All hands must be indoctrinated in the use of protective

equipment and self-aid procedures, and close liaison

and planning must be maintained with damage control

personnel responsible for area decontamination.

SELF-PROTECTION AND TREATMENT

In a chemical attack, the first priority is to ensure

your own survival so that you may then treat casualties.

There are several items available to help you survive a

chemical attack, and you should know how to use

them. Along with protective clothing, there is a

protective mask, which should be put on at the first

indication of a chemical attack. The mask will filter

out all known chemical agents from the air and allow

you to work in a chemically contaminated area. A

chemical agent on the skin can be removed effectively

by using the M291 skin decontamination kit (fig. 8-1).

The M291 skin decontamination kit replaces the

M258A1 (fig. 8-2). Upon receipt of the M291,

discontinue use of the M258A1.

8-1
8-2

Table 8-1.—Summary of CBR Agents, Effects, and Treatment
Chemical agents penetrate ordinary clothing rapidly.

However, significant absorption through the skin

requires a period of minutes. The effects of clothing

penetration may be reduced by quickly removing the

contaminated clothing and neutralizing the chemical

agent onthe skin by washing, blotting, or wipingit away.

Prompt decontamination (decon) of the skin is

imperative. Decon of chemical agents on the skin within

1 minute after contamination is perhaps 10 times more

effective than if decontamination is delayed 5 minutes.

Detailed instructions on the use of skin decontamination

kits can be found in the NAVMED P-5041, Treatment of

Chemical Agent Casualties and Conventional Military

Chemical Injuries, and in the kits themselves.

Finally, there are two types of antidote

autoinjectors—atropine and 2-PAM Cl—for your own

8-3

HM3F0801

Figure 8-1.—M291 skin decontamination kit.

HM3F0802

COVER

FOLDED WIPE

(DRY)

STRAP

CASE

FOLDED WIPE

(WET)

NYLON PACKET WITH

THREE AMPULES

THREE DECON-2 PAKETS

Figure 8-2.—M258A1 skin decontamination kit.
use if you become a nerve-agent casualty. The

autoinjectors will be discussed later in this chapter.

Familiarize yourself with your equipment. Know how

it works before you need it.

DECONTAMINATION

The guiding principle in personnel decontamination is to avoid spreading contamination to clean

areas and to manage casualties without aggravating

other injuries.

Casualty Priorities

It will often be necessary to decide whether to

handle the surgical condition or the chemical hazard

first. If the situation and the condition of the casualty

permit, decontamination should be carried out first.

The longer the chemical remains on the body, the more

severe will be the danger of spreading the chemical to

other personnel and equipment.

The following order of priority for first aid and

decontaminating casualties is recommended:

1. Control of massive hemorrhage

2. First aid for life-threatening shock and wounds

3. Decontamination of exposed skin and eyes

4. Removal of contaminated clothing and

decontamination of body surfaces (if not in a

toxic environment)

5. Adjustment of patient’s mask, if mask is

necessary

6. First aid in less severe shock and wounds

The basic steps in sorting and handling casualties

are indicated in figure 8-3. This plan should be

modified to fit specific needs.

8-4

C A

A

B B

E

D

HM3F0803

DIRTY

CLEAN

WOUNDED

CLEAN

CLEAN

CLEAN

TREATMENT

ADDITIONAL MEDICAL AID.

AWAITING EVACUATION.

CONTAMINATED

EMERGENCY

DIRTY

IMPROVISED AREA OR

SPECIALLY DESIGNATED

FACILITY FOR EMERGENCY

OPERATIONS ON CONTAMINATED WOUNDED WHO ARE

DECONTAMINATED WHEN

INDICATED.

CLEAN

CONTAMINATED

CONTAMINATED EMERGENCY

CONTAMINATED

WOUNDED

FREE VENTILATION; SOME COVER.

REMOVE CONTAMINATED OUTER

CLOTHING, GEAR, AND BLANKETS.

SPEED IN UNDRESSING DESIRABLE.

CHANGE TO CLEAN LITTER, BLANKETS. SKIN PENCIL AREAS OF

CONTAMINATION. UNDRESSERS,

BEARERS MASKED AND PROTECTED.

DIRTY

SENTRY

MAY BE WARMED. UNDERCLOTHES

REMOVED AND PASSED FORWARD OR

PLACED IN FREQUENTLY EMPTIED

SACKS OR BINS. OINTMENT OR SOAP

AND WATER TO SKIN AREAS BELIEVED

EXPOSED. WASHING FACILITIES.

ATTENDANTS MASKED, PROTECTED.

ALL CASES AND

RECORDS RECEIVED.

Figure 8-3.—Basic steps in sorting and handling casualties.
Decontamination Station Organization

In general, the decontamination station, or “dirty”

area, receives casualties contaminated with a chemical

agent. The arrangement of this area will vary with the

site of the medical unit and the facilities available for

decontamination.

Each ship will have a minimum of at least two

decontamination stations, insofar as the hull design

permits. The “dirty” areas should be topside or in some

well-ventilated space. Personnel manning these areas

should be provided with protective equipment.

In the “dirty” area, casualties will be decontaminated, undressed, showered, and passed along to

clean areas. Both areas should be clearly marked as either

“clean” or “contaminated,” as appropriate. Decontamination kits, protective ointment, and an abundant supply

of soap and water must be provided. In addition, standard

first-aid items should be on hand. When possible,

improvise supports (e.g., small boxes, blocks of wood,

etc.) for stretchers to keep them raised off the deck.

Handling of Contaminated Casualties

The spread of contamination to uncontaminated

personnel or to spaces not set aside to receive contamination must be avoided. Contaminated personnel,

clothing, or equipment must be kept out of uncontaminated areas since the subsequent decontamination of

such spaces is quite difficult. Contaminated clothing

and gear must be placed in designated dump areas and,

whenever practically possible, kept in metal cans with

tightly fitting covers.

Supplies

The Medical Officer or Senior Medical Department Representative (SMDR) is responsible for

maintaining adequate supplies for decontamination

and treatment of CBR casualties. Medical decontamination supplies are supplied to ships on a

personnel -strength basis, as listed in current Authorized

Medical Allowance List (AMAL).

The decontamination supply cabinets will be kept

locked, and the keys will be in custody of the Damage

Control Assistant (DCA). Cabinets and chests will

be stenciled with a red cross and marked

“DECONTAMINATION MEDICAL SUPPLIES.”

CHEMICAL AGENTS

Chemical agents are grouped under several

classifications. The broadest classification we will use

is based on the general effect produced (i.e., severe

casualty, harassment, or incapacitation). Within each

general group, there are further breakdowns, the most

convenient of which (from a medical point of view) is

the classification by physiologic effect. Chemical

agents may also be classified as lethal or nonlethal.

Nonlethal agents will not kill you. Lethal agents are

those that result in a 10 percent or greater death rate

among casualties. They are further classified as

persistent or nonpersistent, depending on the length of

time they retain their effectiveness after dissemination.

In the following paragraphs, we discuss the agents

that produce the greatest number of fatalities and

casualties among personnel who have been exposed to

them.

Nerve Agents

Nerve agents produce their effect by interfering

with normal transmission of nerve impulses in the

parasympathetic autonomic nervous system.

Physically, nerve agents are odorless, almost colorless

liquids, varying greatly in viscosity and volatility.

They are moderately soluble in water and fairly stable

unless strong alkali or chlorinating compounds are

added. They are very effective solvents, readily

penetrating cloth either as a liquid or vapor. Other

materials, including leather and wood, are fairly well

penetrated. Butyl rubber and synthetics, such as

polyesters, are much more resistant.

Pharmacologically, the nerve agents are

cholinesterase inhibitors (interfering with normal

transmission of nerve impulses in the parasympathetic

autonomic nervous system). Their reaction with

cholinesterase tends to be irreversible, and reaction

time varies with the agent.

SIGNS AND SYMPTOMS OF EXPOSURE.—

Nerve-agent intoxication can be readily identified by

its characteristic signs and symptoms. If a vapor

exposure has occurred, the pupils will constrict,

usually to a pinpoint. If the exposure has been through

the skin, there will be local muscular twitching where

the agent was absorbed. Other symptoms will include

rhinorrhea, dyspnea, diarrhea and vomiting,

convulsions, hypersalivation, drowsiness, coma, and

unconsciousness.

TREATMENT.—Specific therapy for nerve

agent casualties is atropine, an acetylcholine blocker.

When exposed, each member of the Navy and Marine

Corps is issued three 2 mg autoinjectors of atropine

and three 600 mg autoinjectors of 2-PAM Cl. DO

8-5
NOT give nerve agent antidotes for preventive

purposes before contemplated exposure to a nerve

agent.

The atropine autoinjector consists of a hard plastic

tube containing 2 mg (0.7 ml) of atropine in solution

for intramuscular injection. It has a pressure-activated

coiled-spring mechanism that triggers the needle for

injection of the antidote solution. These injectors are

designed to be used by individuals on themselves when

symptoms appear. For medical personnel, the required

therapy is to continue to administer atropine at

15-minute intervals until a mild atropinization occurs.

This can be noted by tachycardia and a dry mouth.

Atropine alone will not relieve any respiratory muscle

failure. Prolonged artificial respiration may be

necessary to sustain life.

A second autoinjector containing oxime therapy

(using pralidoxime chloride, or 2-PAM Cl) can also be

used for regeneration of the blocked cholinesterase.

Since 2-PAM Cl is contained in the kit of autoinjectors,

additional oxime therapy is not generally medically

recommended for those who have already received

t reatment by autoinjection. The 2 -PAM Cl

autoinjector is a hard plastic tube that, when activated,

dispenses 600 mg of 2-PAM Cl (300 mg/ml) solution.

It also has a pressure-activated coiled-spring

mechanism identical to that in the atropine

autoinjector.

Self-Aid.—If you experience the mild symptoms

of nerve-agent poisoning, you should

IMMEDIATELY hold your breath and put on your

protective mask. Then, administer one set of (atropine

and 2-PAM Cl) injections into your lateral thigh

muscle or buttocks, as illustrated in figures 8-4 and

8-5. Position the needle end of the atropine injector

against the injection site and apply firm, even pressure

(not jabbing motion) to the injector until it pushes the

needle into your thigh (or buttocks). Make sure you do

not hit any buttons or other objects. Using a jabbing

motion may result in an improper injection or injury to

the thigh or buttocks.

Hold the atropine injector firmly in place for at

least 10 seconds. The seconds can be estimated by

counting “one thousand one, one thousand two,” and

so forth. Firm pressure automatically triggers the

coiled mechanism and plunges the needle through the

clothing into the muscle and at the same time injects

the atropine antidote into the muscle tissue.

Next, inject yourself in the same manner with the

2-PAM Cl injector, using the same procedure as you

did for the atropine. This will now complete one set of

nerve-agent antidotes. Attach the used injectors to

your clothing (fig. 8-6) (to indicate the number of

injections you have already received).

After administering the first set of injections, wait

10 to 15 minutes (since it takes that long for the

antidote to take effect) before administering a second

set, if needed. If the symptoms have not disappeared

within 10 to 15 minutes, give yourself the second set of

injections. If the symptoms still persist after an

additional 15 minutes, a third set of injections may be

given by nonmedical personnel.

After administering each set of injections, you

should decontaminate your skin, if necessary, and put

on any remaining protective clothing.

8-6

HIP

BONE

LATERAL

THIGH

MUSCLE

INJECTION

SITE

HM3F0804

Figure 8-4.—Thigh injection site.

INJECTION

SITE

INJECTION

SITE

MAIN

NERVE HM3F0805

Figure 8-5.—Buttocks injection site.
Buddy Aid.—If you encounter a service member

suffering from severe signs of nerve-agent poisoning,

you should provide the following aid:

• Mark the casualty, if necessary. Do not fasten the

hood.

• Administer, in rapid succession,three sets of the

nerve-agent antidotes. Follow the procedures

for administration as described previously in the

self-aid section.

NOTE: Use the casualty’s own

autoinjectors when providing aid. Do not

use your injectors on a casualty. If you do,

you may not have any antidote available

when needed for self-aid.

Blister Agents (Vesicants)

Blister agents, or vesicants, exert their primary

action on the skin, producing large and painful blisters

that are incapacitating. Although vesicants are classed

as nonlethal, high doses can cause death.

Common blister agents include mustard (HD),

nitrogen mustard (HN), and Lewisite (L). Each is

chemically different and will cause significant specific

symptoms. They are all similar in their physical

characteristics and toxicology. Mustards are

particularly insidious because they do not manifest

their symptoms for several hours after exposure. They

attack the eyes and respiratory tract as well as the skin.

There is no effective therapy for mustard once its

effects become visible. Treatment is largely

supportive: to relieve itching and pain, and to prevent

infection.

MUSTARD (HD) AND NITROGEN

MUSTARD (HN).—HD and HN are oily, colorless or

pale yellow liquids, sparingly soluble in water. HN is

less volatile and more persistent than HD but has the

same blistering qualities.

Signs and Symptoms of Exposure.—The eyes

are the most vulnerable part of the body to mustard gas.

Contamination insufficient to cause injury elsewhere

may produce eye inflammation. Because the eye is the

most sensitive part of the body, the first noticeable

symptoms of mustard exposure will be pain and a

gritting feeling in the eyes, accompanied by spastic

blinking of the eyelids and photophobia. Vapor or

liquid may burn any area of the skin, but the burns will

be most severe in the warm, sweaty areas of the body:

the armpits, groin, and on the face and neck. Blistering

begins in about 12 hours but may be delayed for up to

48 hours. Inhalation of the gas is followed in a few

hours by irritation of the throat, hoarseness, and a

cough. Fever, moist rales, and dyspnea may develop.

Brochopneumonia is a frequent complication. The

primary cause of death is massive edema or

mechanical pulmonary obstruction.

Treatment.—There is no specific antidotal

treatment for mustard poisoning. Physically removing

as much of the mustard as possible, as soon as possible,

is the only effective method for mitigating symptoms

before they appear. All other treatment is

symptomatic, that is, the relief of pain and itching, and

control of infection.

LEWISITE (L).—Lewisite is an arsenical (an

arsenic-based compound). This blistering compound

is a light- to dark-brown liquid that vaporizes slowly.

Signs and Symptoms of Exposure.—The vapors

of arsenicals are so irritating that conscious persons are

immediately warned by discomfort to put on the mask.

No severe respiratory injuries are likely to occur,

except in the wounded who are incapable of donning a

mask. The respiratory symptoms are similar to those

produced by mustard gas. While distilled mustard and

nitrogen mustard cause no pain on the skin during

absorption, Lewisite causes intense pain upon contact.

Treatment.—Immediately decontaminate the

eyes by flushing with copious amounts of water to

remove liquid agents and to prevent severe burns.

Sodium sulfacetamide, 30 percent solution, may be

8-7

HM3F0806

Figure 8-6.—One set of used autoinjectors attached to a pocket

flap.
used to combat eye infection within the first 24 hours

after exposure. In severe cases, morphine may be

given to relieve pain.

In cases of systemic involvement, British AntiLewisite (BAL), dimercaprol, is available in a peanut

oil suspension for injection. BAL is a specific

antiarsenical that combines with the heavy metal to

form a water-soluble, nontoxic complex that is

excreted. However, BAL is somewhat toxic, and an

injection of more than 3 mg/kg will cause severe

symptoms.

Aside from the use of dimercaprol for the systemic

effects of arsenic, treatment is the same as for mustard

lesions.

Blood Agents

Blood agents interfere with enzyme functions in

the body, i.e., block oxygen transfer. Hydrocyanic acid

(AC) and cyanogen chloride (CK) are cyanidecontaining compounds commonly referred to as blood

agents. These blood agents are chemicals that are in a

gaseous state at normal temperatures and pressures.

They are systemic poisons and casualty-producing

agents that interfere with vital enzyme systems of the

body. They can cause death in a very short time after

exposure by interfering with oxygen transfer in the

blood. Although very deadly, they are nonpersistent

agents.

SIGNS AND SYMPTOMS OF EXPOSURE.—

These vary with concentration and duration of

exposure. Typically, either death or recovery takes

place rapidly. After exposure to high concentrations of

the gas, there is a forceful increase in the depth of

respiration for a few seconds, violent convulsions after

20 to 30 seconds, and respiratory failure with cessation

of heart action within a few minutes.

TREATMENT.—There are two suggested

antidotes in the treatment of cyanides: amyl nitrite in

crush ampules (provided as first aid) and intravenous

sodium thiosulfate solution.

In an attack, if you notice sudden stimulation of

breathing or an almond-like odor, hold your breath and

don your mask immediately. In treating a victim, upon

notification by competent authority that there are no

blood agents remaining in the atmosphere, crush two

ampules of amyl nitrite in the hollow of your hand and

hold it close to the victim’s nose. You may repeat this

procedure every few minutes until eight ampules have

been used. If the atmosphere is contaminated and the

victim must remain masked, insert the crushed

ampules into the mask under the face plate.

Whether amyl nitrite is used or not, sodium

thiosulfate therapy is required after the initial

lifesaving measures. The required dose is 100 to 200

mg/kg, given intravenously over a 9-minute period.

The key to successful cyanide therapy is speed;

cyanide acts rapidly on an essential enzyme system.

The antidotes act rapidly to reverse this action. If the

specific antidote and artificial respiration are given

soon enough, the chance of survival is greatly

enhanced.

Choking or Lung Agents

The toxicity of lung agents is due to their effect on

lung tissues; they cause extensive damage to alveolar

tissue, resulting in severe pulmonary edema. This

group includes phosgene (CG) and chlorine (Cl), as

well as chloropicrin and diphosgene. However, CG is

most likely to be encountered, and its toxic action is

representative of the group.

Phosgene is a colorless gas with a distinctive odor

similar to that of new-mown hay or freshly cut grass.

Unfortunately, even at minimal concentrations in the

air (i.e., below the threshold of olfactory perception),

CG can cause damage to the eyes and throat. Generally

speaking, CG does not represent a hazard of long

duration; therefore, an individual exposed to a

casualty-producing amount should be able to smell it.

SIGNS AND SYMPTOMS OF EXPOSURE.—

There may be watering of the eyes, coughing, and a

feeling of tightness in the chest. More often, however,

there will be no symptoms for 2 to 6 hours after

exposure. Latent symptoms are rapid, shallow, and

labored breathing; painful cough; cyanosis; frothy

sputum; clammy skin; rapid, feeble pulse; and low

blood pressure. Shock may develop, followed by

death.

TREATMENT.—Once symptoms appear,

complete bed rest is mandatory. Keep victims with

lung edema only moderately warm, and treat the

resulting anoxia with oxygen. Because no specific

treatment for CG poisoning is known, treatment has to

be symptomatic.

Incapacitating Agents

Incapacitating agents, which are mainly

comprised of psychochemicals, produce mental

confusion and an inability to function intelligently.

8-8
The psychochemicals temporarily prevent an

individual from carrying out assigned actions. These

agents may be administered by contaminating food or

water, or they may be released as aerosols. The

following are characteristics of the incapacitants:

• High potency (i.e., an extremely low dose is

effective) and logistic feasibility

• Effects produced mainly by altering or

disrupting the higher regulatory activity of the

central nervous system

• Duration of action comprising hours or days,

rather than momentary or transient action

• No permanent injury produced

SIGNS AND SYMPTOMS OF EXPOSURE.—

The first symptoms appear in 30 minutes to several

hours and may persist for several days. Abnormal,

inappropriate behavior may be the only sign of

intoxication. Those affected may make irrational

statements and have delusions or hallucinations. In

some instances, the victim may complain of dizziness,

muscular incoordination, dry mouth, and difficulty in

swallowing.

The standard incapacitant in the United States is

3-quinuclidinyl benzilate (BZ), a cholinergic blocking

agent, which is effective in producing delirium that

may last several days. In small doses it will cause an

increase in heart rate, pupil size, and skin temperature,

as well as drowsiness, dry skin, and a decrease in

alertness. As the dose is increased to higher levels,

there is a progressive deterioration of mental

capability, ending in stupor.

TREATMENT.—The first aid is to prevent

victims from injuring themselves and others during the

toxic psychosis. Generally, there is no specific therapy

for this type intoxication. However, with BZ and other

agents in the class of compounds known as glycolates,

physostigmine is the drug treatment of choice. It is not

effective during the first 4 hours following exposure;

after that, it is very effective as long as treatment is

continued. However, treatment does not shorten the

duration of BZ intoxication, and premature

discontinuation of therapy will result in relapse.

Riot-Control/Harassment Agents

“Riot-control agents” is the collective term used to

describe a collection of chemical compounds, all

having similar characteristics which, though relatively

nontoxic, produce an immediate but temporary effect

in very low concentrations. These agents are used to

harass enemy personnel or to discourage riot actions.

Generally, patients require no therapy; removal from

the environment is sufficient to effect recovery in a

short time.

There are two classes of riot-control/harassment

agents: lacrimators and vomiting agents.

LACRIMATORS.—Lacrimators (or tear gases)

are essentially local irritants that act primarily on the

eyes. In high concentrations, they also irritate the

respiratory tract and the skin. The principal agents

used are chloracetophenone (CN) and

orthochlorobenzilidine malanonitrile (CS). Although

CS is basically a lacrimator, it is considerably more

potent than CN and causes more severe respiratory

symptoms. CN is the standard training agent and is the

tear gas most commonly encountered because it is not

as potent. CS is more widely used by the military as a

riot-control agent.

Protection against all tear agents is provided by

protective masks and ordinary field clothing secured at

the neck, wrists, and ankles. Personnel handling CS

should wear rubber gloves for additional protection.

Signs and Symptoms of Exposure.—

Lacrimators produce intense pain in the eyes with

excessive tearing. The symptoms following the most

severe exposure to vapors seldom last over 2 hours.

After moderate exposure, they last only a few minutes.

Treatment.—First aid for lacrimators is generally

not necessary. Exposure to fresh air and letting wind

blow into wide open eyes, held open if necessary, is

sufficient for recovery in a short time. Any chest

discomfort after CS exposure can be relieved by

talking.

An important point to remember is that this

material adheres tenaciously to clothing, and a change

of clothing may be necessary. Do not forget the hair

(both head and facial) as a potential source of

recontamination.

VOMITING AGENTS.—Vomiting agents

comprise the second class of agents in the riot-control

category. The principal agents of this group are

diphenylaminochloroarsine (Adamsite (DM)),

diphenylchloroarsine (DA), and diphenylcyanoarsine

(DC). They are used as training and riot-control

agents. They are dispersed as aerosols and produce

their effects by inhalation or by direct action on the

eyes. All of these agents have similar properties and

pathology.

8-9
Signs and Symptoms of Exposure.—Vomiting

agents produce a strong pepper-like irritation in the

upper respiratory tract, with irritation of the eyes and

lacrimation. They cause violent uncontrollable

sneezing, coughing, nausea, vomiting, and a general

feeling of malaise. Inhalation causes a burning

sensation in the nose and throat, hypersalivation, and

rhinorrhea. The sinuses fill rapidly and cause a violent

frontal headache.

Treatment.—It is of the utmost importance that

the mask be worn in spite of coughing, sneezing,

salivation, and nausea. If the mask is put on following

exposure, symptoms will increase for several minutes

in spite of adequate protection. As a consequence,

victims may believe the mask is ineffective and

remove it, further exposing themselves. While the

mask must be worn, it may be lifted from the face

briefly, if necessary, to permit vomiting or to drain

saliva from the face piece. Carry on duties as

vigorously as possible. This will help to lessen and

shorten the symptoms. Combat duties usually can be

performed in spite of the effects of vomiting agents if

an individual is motivated.

First aid consists of washing the skin and rinsing

the eyes and mouth with water. A mild analgesic may

be given to relieve headache. Recovery is usually

spontaneous and complete within 1 to 3 hours.

SCREENING SMOKES.—Screening smokes fit

in with riot-control agents. Their primary use is to

obscure vision and to hide targets or areas. When used

for this purpose outdoors, they are not generally

considered toxic. However, exposure to heavy smoke

concentration for extended periods, particularly near

the source, may cause illness or death. Under no

circumstances should smoke munitions be activated

indoors or in closed compartments.

Symptomatic treatment of medical problems or

discomfort resulting from exposure to screening

smokes will generally suffice.

WHITE PHOSPHORUS.—White phosphorus

(WP) is a pale, waxy solid that ignites spontaneously

on contact with air to give a hot, dense, white smoke

composed of phosphorus pentoxide particles. While

field concentrations of the smoke may cause

temporary irritation to the eyes, nose, and throat,

casualties from the smoke have not occurred in combat

operations. No treatment is necessary, and

spontaneous recovery is rapid once the patient is

removed from the WP source.

White phosphorus smoke not only creates an

obscuring smoke, but it also has a secondary effect

upon personnel if it contacts the skin. When burning

particles of WP embed in the skin, they must be

covered with water, a wet cloth, or mud. A freshly

mixed 0.5 percent solution of copper sulfate (which

produces an airproof black coating of copper

phosphide) may be used as a rinse but must not be used

as a dressing. The phosphorus particles must be

removed surgically.

BIOLOGICAL WARFARE

Epidemics arising from natural causes have

plagued military forces for centuries and in many

instances have determined the outcome of campaigns.

Recognition of this drain on personnel undoubtedly

has led to attempts to produce illness in epidemic

proportions, through pollution of water and food

supplies as well as through other means. The

dissemination of disease-producing organisms has

never been employed on any significant scale as a

weapon of war.

HISTORY

Biological warfare has become a very real

possibility since World War II because of the advance

of knowledge in the various biological science fields.

Many countries have indulged in research on the use of

microorganisms as a weapon of war, and in the hands

of an unscrupulous enemy, antianimal and antiplant

agents could be powerful instruments of war, reducing

or destroying a nation’s food supply. In this chapter,

however, we are concerned only with agents that

would be effective against populations. Although their

effectiveness has never been established by actual use

in war, they are considered to have grave military

capabilities.

DISPERSAL

Biological warfare has certain aspects in common

with chemical warfare in that biological agents can be

dispersed in the air and travel downwind in the same

manner as a gas cloud. These agents may be inhaled

unless a protective mask is worn, and they may cause

disability or death. They are capable of contaminating

clothing, equipment, food, and water supplies. Some

types of agents may persist in the target area for

considerable periods of time.

8-10
Biological agents, unlike most war gases or

vapors, cannot be detected by the physical senses or by

chemical detectors. Their presence or identity can be

determined only by laboratory examination of air

samples or contaminated objects. The time between

exposure and onset of disease symptoms will usually

be a matter of days rather than hours, as is the case with

most chemical agents. Though they may be exposed to

the same dosage of biological agent, not all personnel

will be affected the same way. Some may become

seriously ill, while others may have a very mild attack.

Still others may escape the disease entirely.

PROTECTION

In this section, we will discuss both individual and

group protection, as well as the methods of protecting

food and water supplies.

Individual Protection

The natural resistance of the body and its

maintenance in the best possible physical condition

constitute important lines of defense against biological

agents. Immunity and good health alone, however,

cannot be expected to triumph over massive

onslaughts of biological agents. These agents may

have been tailored to create varying degrees of

incapacitation, including death. To reduce the

effectiveness of such attacks, the military provides

protective equipment and a series of protocols to its

members. In general, these measures closely parallel

those provided for defense against chemical attack.

PORTALS OF ENTRY.—Inhalation of airborne

organisms is considered the greatest potential hazard

in biological warfare. The protective mask is an

important piece of defensive equipment. A mask that

is in good condition and has been properly fitted will

greatly reduce the possibility of your inhaling

infectious material. Since you cannot detect the

presence of biological agents, the use of the mask and

other protective equipment will depend upon early

warning.

To produce disease, biological agents must gain

entrance into the body. A concentration of biological

agents on the skin might, in time, be transferred to a

portal of entry. Any type of clothing will provide some

protection by reducing the quantity of agents coming

in contact with the skin. The degree of protection

afforded is dependent upon how well the fabric stops

penetration and the number of layers of clothing being

worn. Since this protective effect is due to the

mechanical filtering or screening action of the cloth, it

is important that shirt and jacket collars be fastened.

Sleeves should be rolled down and cuffs buttoned,

trouser cuffs stuffed inside tops of boots or socks, and

all other garment openings tied or otherwise secured.

Following this procedure will minimize the entry of

airborne organisms and reduce the risk of bodily

contact with biological agents that may be present on

the surface of the ground or in the air.

EQUIPMENT AND ACTION.—Military

headgear helps safeguard the hair from heavy

contamination, and ordinary gloves or mittens provide

protection for the hands. The type of clothing issued

for protection against chemical agents is impregnated

with an impermeable barrier and provides a higher

degree of protection than the ordinary uniform.

Whenever it is available, it should be used.

Upon notification of an attack with biological

agents, or before entering an area known to be

contaminated by them, the following steps should be

taken:

1. Put on protective mask and check it for correct

fit.

2. Button clothing. Tie clothing at wrists and

ankles with string or extra shoelaces. Put on

special protective clothing, if available.

3. Put on gloves, if available.

4. While in the contaminated area, maintain the

provisions outlined above.

Upon leaving the area, proceed with decontamination measures to the extent the situation permits.

Group Protection

In biological as well as chemical and radiological

warfare, a tightly constructed shelter offers great

protection. The shelter must be pressurized to prevent

entrance of the microorganisms. Pressurization is

accomplished by introducing filtered air into the

shelter. If the shelter is reasonably tight, this incoming

air will force exhausted and/or contaminated air

outward. Nonpressurized buildings, shelters, or field

fortifications provide only limited protection from

aerosols. Eventually, microorganisms will penetrate

through cracks, creating a respiratory hazard requiring

the use of a protective mask. As in the case of other

protective equipment, the sooner a shelter is used

following contamination, the more effective the

shelter will be in arresting or staying in contact with

biological agents.

8-11
Protection of Food and Water

Food and water supplies are especially susceptible

to deliberate contamination. Civilian supplies— which

all too frequently do not receive careful supervision

and protection—must always be suspected of

accidental or deliberate contamination. It should also

be emphasized that water is not necessarily pure just

because it comes from a faucet. In some countries pure

water is the exception rather than the rule. The safest

rule is to consume only food and drinks received from

military sources. Procedures for protection of the

water supply and routines for inspection and

decontamination are well defined in the military and, if

diligently observed, will protect from deliberate

contamination.

FOOD.—In the event of a known or suspected

biological attack, all exposed or unpackaged foods not

in critical supply should be destroyed. In most

instances, food can be rendered safe for consumption

by application of moist-heat cooking procedures. In

some instances, deep-fat cooking is adequate. Some

foods, however, cannot be sterilized because the

treatment would render them unacceptable for

consumption.

WATER.—Chlorination is by far the almost

universal method of purifying water, and it destroys

most of the biological agents. Boiling may be required

to ensure proper decontamination in exceptional cases.

The military establishes water points in the field

whenever possible. The equipment location at these

points provides for filtration as well as chlorination

and, when properly operated, is effective in removing

organisms that produce disease. Some biological

agents cannot be destroyed by normal waterpurification techniques. When biological agents are

known to have been used, all drinking water must be

boiled. In the preparation of water for large numbers,

the boiling procedure should be supervised. Water

boiling may, of necessity, become an individual

responsibility and may be so directed.

For small groups of people, the Lyster bag is

provided as a suitable container for the storage of water

that has already been treated. Water that has not been

made potable previously is purified in the Lyster bag

by means of chemicals. Water purification procedures

are discussed in detail in the Preventive Medicine

Manual, NAVMED P-5010.

DECONTAMINATION

Personal decontamination following actual or

suspected exposure to biological agents will depend

upon the existing tactical situation and the facilities

available. If the situation permits, contaminated

clothing should be carefully removed and the body

washed thoroughly with soap and water before

donning fresh clothing. Specific attention should be

given to decontamination and treatment of skin

lesions.

Normally, each individual is responsible for his

own decontamination. If a person is physically unable

to decontaminate himself, this process has to be

performed by other available personnel. Since illness

resulting from exposure to biological warfare may be

delayed because of the incubation period, decontamination may occur before the individual becomes ill.

Decontamination of the wounded is the responsibility

of Medical Department personnel. When the situation

and the condition of the casualty permit, decontamination should come first. However, massive hemorrhage, asphyxia, or other life-endangering conditions

naturally receive priority.

In general, all candidates for decontamination

should first have all exposed areas thoroughly washed

with soap and large amounts of water, the mask

adjusted, and all contaminated clothing removed. The

casualty may then be moved to a clean area where the

wounds can be treated.

Decontamination procedures are the same as those

used for casualties of chemical warfare.

RADIOLOGICAL WARFARE

Radiological—the “R” in CBR—warfare is more

frequently referred to as nuclear warfare. The

principles of treatment of casualties, as developed

from previous experiences in conventional warfare,

are applicable in the treatment of casualties produced

by radiological warfare. With the exception of

ionizing radiation effects, the type of injuries produced

in nuclear warfare are similar to those of conventional

warfare. Standardized techniques of treatment must be

adopted for all types of casualties so the greatest

number of patients can receive maximum medical care

in the shortest period of time with the greatest

economy of medical personnel and equipment.

8-12
HISTORY

The death and devastation evidenced by the first

and only use of nuclear power in wartime (in

Hiroshima and Nagasaki, Japan, at the end of World

War II) has, to date, kept it from being used again.

Although a nuclear nonproliferation treaty has been

signed by most of the major powers, nuclear weaponry

is still a part of the arsenal of many countries of the

world, some of which, if given the opportunity and

excuse, would not hesitate to employ it to achieve

victory at any cost.

History has shown that nuclear warfare is capable

of producing a large disparity between the available

medical care and the number of casualties requiring

care. The capabilities of medical facilities and

personnel must be surveyed to determine how and

where they can best be utilized. Both professional and

nonprofessional personnel must be trained in

additional skills related as far as possible to their

primary duties. Within medical organizations,

efficiency will depend upon controlled patient flow,

adequate supplies, and continuing essential

housekeeping and administrative functions. To meet

the requirements, it is essential that all medical service

personnel be trained to assume some additional

responsibilities.

EXPOSURE FACTORS

Teams entering contaminated areas to either

remove casualties or work in decontamination stations

have two major concerns. The first concern is the

prevention of their own contamination, and the second

is the prevention or reduction of radioactive exposure.

Contamination can be avoided by decontaminating

patients and equipment before handling, wearing

appropriate protective clothing and equipment,

avoiding highly contaminated areas, and strictly

observing personal decontamination procedures.

Exposure to radiation should also be avoided or

minimized. Alpha and beta particles and gamma rays

are emitted from radioactive contaminants and present

a direct risk to the health and safety of personnel in the

contaminated area. This risk can be avoided (or at least

minimized) by following some simple guidelines and

using common sense. Time, distance, and shielding

are the major elements that guide actions to avoid

exposure.

Time

Radioactive decay and the decomposition of

fallout products progress rapidly in the early hours

after a nuclear blast, and the hazards to rescue workers

can be reduced considerably if operations can be

delayed until natural decay has reduced the level of

radioactivity. Use teams trained in the use of survey

instruments since they will determine the intensity of

radiation and mark perimeters of danger zones.

Limiting the time of exposure is essential if total

avoidance is not possible. Rotating personnel entering

an exposure risk area, planning actions to minimize

time in the area, and prompt decontamination reduce

the total time the individual is exposed, thereby

reducing the dose of radiation absorbed by the body.

Distance

Both radioactive particles and electromagnetic

waves (gamma rays) lose energy and consequently

lose their ability to harm tissue as they travel away

from their source. Therefore, the farther one is from

the source, the more the danger of an exposure is

minimized.

Shielding

Shielding is an essential component in preventing

radiation exposure. Alpha and beta particles have very

little penetrating power, and the intact skin forms an

adequate barrier in most cases. Gamma radiation has

much greater penetrating power and presents the

greatest risk of exposure and damage to tissue.

Lead is the most effective shielding material.

Wood, concrete, other metals, and heavy clothing will

somewhat reduce the amount of gamma radiation that

reaches the body. Most particle exposure is the result

of inhalation or ingestion, although radiation particles

may enter the body through burned, abraded or

lacerated skin. In avoiding particle exposure, full

personnel-protective clothing and a protective mask

with hood provides the best protection. The protective

mask and foul-weather gear will provide lesser but

adequate protection. In cases where no protective

breathing devices are available, some protection is

afforded by breathing through a folded towel,

handkerchief, or several surgical masks. Avoid

hand-to-mouth contact, eating, or smoking in

contaminated areas.

8-13
EFFECTS ON PERSONNEL

The injuries to personnel resulting from a nuclear

explosion are divided into three broad classes: blast

and shock injuries, burns, and ionizing radiation

effects.

Apart from the ionizing radiation effects, most of

the injuries suffered in a nuclear weapon explosion

will not differ greatly from those caused by ordinary

high explosives and incendiary bombs. An important

aspect of injuries in nuclear explosions is the

“combined effect,” that is, a combination of all three

types of injuries. For example, a person within the

effective range of a weapon may suffer blast injury,

burns, and also from the effects of nuclear radiation. In

this respect, radiation injury may be a complicating

factor, since it is combined with injuries due to other

sources.

Blast and Shock Wave Injuries

Injuries caused by blast can be divided into

primary (direct) blast injuries and secondary (indirect)

blast injuries.

Primary blast injuries are those that result from

the direct action of the air shock wave on the human

body. These injuries will be confined to a zone where

fatal secondary blast and thermal damage may be

anticipated. Therefore, most surviving casualties will

not have the severe injuries that result from the direct

compressive effects of the blast wave.

Secondary blast injuries are caused by collapsing

buildings and by timber and other debris flung about by

the blast. Persons may also be hurled against

stationary objects or thrown to the ground by the high

winds accompanying the explosions. The injuries

sustained are thus similar to those due to a mechanical

accident: bruises, concussions, cuts, fractures, and

internal injuries.

At sea, the shock wave accompanying an

underwater burst will produce various “mechanical”

injuries. These injuries will resemble those caused

aboard ship by more conventional underwater

weapons, such as noncontact mines and depth charges.

Instead of being localized, however, they will extend

over the entire vessel.

Equipment, furniture, gas cylinders, boxes, and

similar gear, when not well secured, can act as missiles

and cause many injuries.

Burn Injuries

A weapon detonated as an air burst may produce

more burn casualties than blast or ionizing radiation

casualties. Burns due to a nuclear explosion can also

be divided into two classes: direct and indirect burns.

Direct burns(usually called flash burns) are the result

of thermal (infrared) radiation emanating from a

nuclear explosion, while indirect burns result from

fires caused by the explosion. Biologically, they are

similar to any other burn and are treated in the same

manner.

Since all radiation travels in a straight line from its

source, flash burns are sharply limited to those areas of

the skin facing the center of the explosion.

Furthermore, clothing will protect the skin to some

degree unless the individual is so close to the center of

the explosion that the cloth is ignited spontaneously by

heat. Although light colors will absorb heat to a lesser

degree than dark colors, the thickness, air layers, and

types of clothing (wool is better than cotton) are far

more important for protection than the color of the

material.

Eye Burns

In addition to injuries to the skin, the eyes may also

be affected by thermal radiation. If people are looking

in the general direction of a nuclear detonation, they

may be flash blinded. This blindness may persist for

20 to 30 minutes.

A second and very serious type of eye injury may

also occur. If people are looking directly at the fireball

of a nuclear explosion, they may receive a retinal flash

burn similar to the burn that occurs on exposed skin.

Unfortunately, when the burn heals, the destroyed

retinal tissue is replaced by scar tissue that has no

light-perception capability, and the victims will have

scotomas, blind or partially blind areas in the visual

field. In severe cases, the net result may be permanent

blindness. The effective range for eye injuries from the

flash may extend for many miles when a weapon is

detonated as an air burst. This effective range is far

greater at night when the pupils are dilated, permitting

a greater amount of light to enter the eye.

Radiation Injuries

Radioactivity may be defined as the spontaneous

and instantaneous decomposition of the nucleus of an

unstable atom with the accompanying emission of a

particle, a gamma ray, or both. The actual particles and

8-14
rays involved in the production of radiation injuries are

the alpha and beta particles, the neutron, and the

gamma ray. These particles and rays produce their

effect by ionizing the chemical compounds that make

up the living cell. If enough of these particles or rays

disrupt a sufficient number of molecules within the

cell, the cell will not be able to carry on its normal

functions and will die.

ALPHA.—Alpha particles are emitted from the

nucleus of some radioactive elements. Alpha particles

produce a high degree of ionization when passing

through air or tissue. Also, due to their large size and

electrical charge, they are rapidly stopped or absorbed

by a few inches of air, a sheet of paper, or the

superficial layers of skin. Therefore, alpha particles do

not constitute a major external radiation hazard.

However, because of their great ionization power, they

constitute a serious hazard when taken into the body

through ingestion, inhalation, or an open wound.

BETA.—Beta particles are electrons of nuclear

origin. The penetration ability of a beta particle is

greater than an alpha particle, but it will only penetrate

a few millimeters of tissue and will most probably be

shielded out by clothing. Therefore, beta particles, like

alpha particles, do not constitute a serious external

hazard; however, like alpha particles, they do

constitute a serious internal hazard.

NEUTRONS.—Neutrons are emitted from the

nucleus of the atom. Their travel is therefore

unaffected by the electromagnetic fields of other

atoms. The neutron is a penetrating radiation which

interacts in billiard-ball fashion with the nucleus of

small atoms like hydrogen. This interaction produces

high-energy, heavy-ionizing particles that can cause

significant biological damage similar to that produced

by alpha particles.

GAMMA RAYS.—Gamma rays are electromagnetic waves. Biologically, gamma rays are

identical to x-rays of the same energy and frequency.

Because they possess no mass or electrical charge, they

are the most penetrating form of radiation. Gamma

rays produce their effects mainly by knocking orbital

electrons out of their path—thereby ionizing the atom

so affected—and imparting to the ejected electron.

Neutrons and gamma rays are emitted at the time of the

nuclear explosion, along with light. Gamma rays and

beta particles are present in nuclear fallout along with

alpha particles from unfissioned nuclear material.

Neutrons and gamma rays are an important medical

consideration in a nuclear explosion since their range

is great enough to produce biologic damage, either

alone or in conjunction with blast and thermal injuries.

PROTECTION AND TREATMENT

Preparations for the protection and treatment of

projected casualties of a nuclear attack must be made

in advance of any such assault.

Action before Nuclear Explosion

If there is sufficient warning in advance of an

attack, head as quickly as possible for the best shelter

available. This is the same procedure as would be used

during an attack by ordinary, high-explosive bombs.

At the sound of the alarm, get your protective mask

ready. Proceed to your station or to a shelter, as

ordered. If you are ordered to a shelter, remain there

until the “all clear” signal is given.

In the absence of specially constructed shelters

during a nuclear explosion ashore, you can get some

protection in a foxhole, a dugout, or on the lowest floor

or basement of a reinforced concrete or steel-framed

building. Generally, the safest place is in the basement

near walls. The next best place is on the lowest floor in

an interior room, passageway, or hall, away from the

windows and, if possible, near a supporting column.

Avoid wooden buildings when possible. If you have no

choice, take shelter under a table or bed rather than

going out into the open. If you have time, draw the

shades and blinds to keep out most of the heat from the

blast. Only those people in the direct line of sight of

thermal emission will be burn casualties; that is,

anything that casts a shadow will afford protection.

Tunnels, storm drains, and subways can also provide

effective shelter.

In the event of a surprise attack, no matter where

you are—out in the open on the deck of a ship, in a ship

compartment, out in the open ashore, or inside a

building—drop to a prone position in a doorway or

against a bulkhead or wall. If you have a protective

mask with you, put it on. Otherwise, hold or tie a

handkerchief over your mouth and nose. Cover

yourself with anything at hand, being especially sure to

cover the exposed portions of the skin, such as the face,

neck, and hands. If this can be done within a second of

seeing the bright light of a nuclear explosion, some of

the heat radiation may be avoided. Ducking under a

table, desk, or bench indoors, or into a trench, ditch, or

vehicle outdoors, with the face away from the light,

will provide added protection.

8-15
Treatment of Nuclear Casualties

Most injuries resulting from the detonation of a

nuclear device are likely to be mechanical wounds

resulting from collapsing buildings and flying debris,

and burns caused by heat and light liberated at the time

of detonation.

A burn is a burn, regardless of whether it is caused

by a nuclear explosion or by napalm, and its

management remains the same. This is also true of

fractures, lacerations, mechanical injuries, and shock.

In none of these is the treatment dictated by the cause.

For most of the conventional injuries, standard

first-aid procedures should be followed.

The following word of caution should be

considered when you are treating wounds and burns:

Dressings for wounds and burns should follow a

closed-dressed principle, with application of an

adequate sterile dressing using aseptic techniques.

Make no attempt to close the wound, regardless of its

size, unless authorized by a physician. If signs of

infection and fever develop, give antibiotics. When a

physician is not available to direct treatment, the

Corpsman should select an antibiotic on the basis of

availability and appropriateness, and administer three

times the recommended amount. If the antibiotic does

not control the fever, switch to another. If the fever

recurs, switch to still another. Overwhelming

infection can develop rapidly in the patients due to

burns or damage from radiation. Whenever a

broad-spectrum antibiotic is given, administer oral

antifungal agents.

To date, there is no specific therapy for injuries

produced by lethal or sublethal doses of ionizing

radiation. This does not mean that all treatment is

futile. Good nursing care and aseptic control of all

procedures is a must. Casualties should get plenty of

rest, light sedation if they are restless or anxious, and a

bland, nonresidue diet.

DECONTAMINATION

If you suspect that you are contaminated, or if

detection equipment indicates you are, report to a

personnel decontamination facility as soon as possible.

Facilities

In a large-scale nuclear catastrophe, there may be

numerous casualties suffering not only from

mechanical injuries and thermal burns, but from

radiation injuries and psychological reactions as well.

The medical facility should consist of a personnel

monitoring station, both clean and contaminated

emergency treatment stations, a decontamination

station, a sorting station, and various treatment

stations. It should be set up so that personnel must pass

through a monitoring station prior to sorting for

medical care. If there is a need for decontamination,

the casualty should be routed through the

decontamination station on the way to the sorting

station. The physical layout should be arranged so that

no casualty can bypass the monitoring station and go

directly to a treatment station. Also, casualties who are

contaminated should be unable to enter clean areas

without first passing through a decontamination

station. The medical facility flow chart shown in

figure 8-3 illustrates an appropriate schema for

handling those exposed to nuclear radiation.

TEAMS.—Patients brought in by the rescue

teams or arriving on their own should first proceed

through the monitoring station to determine whether or

not they are contaminated with radioactive material.

No medical treatment should be instituted in the

monitoring station. Only personnel who have had

training and experience as members of Radiological

Safety/Decontamination teams or as members of

Damage Control parties should be assigned to the

monitoring station. Those operating the monitoring

station should have a basic knowledge of and

experience with radiac instruments. Of the personnel

available to the treatment facility, several of those most

experienced and knowledgeable in radiological safety

and radiation protection should be assigned

supervisory jobs in the decontamination station. Also,

it is highly desirable to have some personnel with

operating room experience to decontaminate patients

with traumatic injuries. It is not necessary for the other

personnel working in the decontamination station to

have any appreciable training or experience other than

that given when the medical facility is put into

operation.

MONITORS.—After the patients are monitored,

they are directed or taken down one of four avenues,

depending upon their physical conditions. Those

requiring immediate lifesaving measures should be

considered contaminated and routed directly through

the monitoring station to the contaminated emergency

treatment station. Definitive monitoring for these

individuals may be performed at the decontamination

station. Both treatment stations are set up much the

same and should have only those facilities necessary

for immediate lifesaving forms of treatment.

Personnel working in these stations should be better

8-16
versed in emergency first-aid care than those used for

monitoring and for rescue teams, but they need not be

trained in radiation monitoring.

SORTING.—After emergency lifesaving

procedures have been attended to, casualties from the

clean emergency treatment station should be taken

directly to the sorting station, and those from the

contaminated treatment station should be taken to the

decontamination station. Casualties not requiring

immediate emergency treatment should be taken or

sent from the monitoring station directly to the sorting

station or to the decontamination station, whichever is

appropriate. The decontamination station should be

set up to take, hold, and dispose of all contaminated

clothing and to supply clean replacement clothing after

the casualty has been decontaminated. Monitoring

equipment will also be required, as will showering and

washing facilities, and some capability for surgical

(e.g., wound) decontamination when necessary.

Cleaning

Early removal of radioactive “contamination” will

reduce radiation burns, radiation dosage, and the

chances of inhaling or ingesting radioactive material.

There are two rules to be remembered in the removal of

radioactive contamination:

• Contamination is easily spread, so “spot”

cleaning must be attended to before general

decontamination procedures are started.

• Removal of radioactive contamination is best

accomplished with soap and water.

SPOT CLEANING.—Cotton swabs or gauze

may be used to decontaminate moist areas. Use

gummed tapes to decontaminate dry areas. If, after the

first cleansing, decontamination is inadequate, the

process should be repeated three to five times. If

contamination persists, a preparation consisting of a

mixture of 50 percent detergent and 50 percent

cornmeal, with enough water added to make a paste,

should be tried. The contaminated area should be

scrubbed (preferably with a soft-bristle surgical brush)

for 5 minutes, then rinsed.

GENERAL CLEANING.—After the hot spots

have been removed, the second step is to shower with

soap and water. Scrub the entire body, including the

hair and nails. After the shower, monitor again; if any

contamination remains, repeat spot cleaning and

shower procedures. If the hair is contaminated,

shampoo it several times. If it becomes apparent that

shampooing has not removed the radioactive material,

cut the hair as close to the scalp as necessary to remove

the radioactive material.

If areas become tender from excessive washing, it

may be necessary to restore some of the skin oils by

gently rubbing in a small amount of lanolin or ordinary

hand or face cream. This will soothe the skin and

prepare it for further decontamination if additional

steps are necessary. Decontamination should be

continued until the radioactivity has been reduced to

the “safe” level set by the responsible Medical

Department representative. Wounds or body parts that

resist decontamination may have to be covered and the

patient referred to a higher-level medical treatment

facility.

UNCONTAMINATED AREAS.—Protect any

uncontaminated cut, scratch, or wound with an

impermeable tape or other suitable material while

decontaminating the rest of the body. If a wound is

already contaminated, the simplest and least drastic

decontamination method available should be tried

first, always by trained medical personnel. First, the

wound should be carefully bathed or flushed with

sterile water, and a reasonable amount of bleeding

should be encouraged. Following decontamination,

standard triage procedures are used.

Additional information pertaining to the initial

management of irradiated or radioactively

contaminated individuals may be obtained from the

current version of BUMEDINST 6470.10, Initial

Management of Irradiated or Radioactively

Contaminated Personnel.

Contaminated Material and Supplies

Radiological material may be removed but not

destroyed. Water then becomes a special problem.

Distillation frees water of radioactive material,

providing emergency drinking water. Water coming

from an underground source usually is free from

radioactive materials and is therefore usable; however,

water coming from a reservoir that has to depend upon

a surface watershed for its source may not be usable.

Fortunately, regular water-treatment processes that

include coagulation, sedimentation, and filtration will

remove most fallout material, and if the reservoir water

can be properly treated, it will be usable again. But for

safety’s sake, never drink untested water.

SUPPLIES AND FOOD.—Supplies and food

can be protected from residual radiation by storage in

dust-proof containers. Although the outside of the

8-17
containers may become contaminated, most of this

radioactive material can be removed by washing. The

container can then be opened and the contents removed

and used without fear of causing significant

contamination.

The outer wrappings on medical supplies and the

peelings on fruit and vegetables also afford protection

to their contents. After carefully removing the outer

coverings and checking the contents, it may be found

that these materials will be safe to use.

CLOTHING.—Contaminated clothing should be

handled with care. Such clothing should never be

casually placed on furniture, hung on walls, or dropped

on floors, but, instead, should be stored in garbage cans

or disposable containers. If these are not available,

contaminated clothing should be placed on pieces of

paper large enough to be rolled and secured. Grossly

contaminated clothing should be properly disposed of

by an authorized method, such as burial at sea or in

deep pits or trenches, whichever is appropriate. If

clothing is in short supply, lightly contaminated

clothing may be salvaged by special laundering. Three

washings in hot water with detergent should be

sufficient. To be sure that this procedure has freed the

clothing from radioactive material, each article should

be monitored before it is released for reuse. Rubber

and plastic materials are readily decontaminated in a

warm detergent wash.

SUMMARY

In this chapter we discussed the recognition and

treatment of chemical, biological, and radiological

(CBR) hazards, and the Medical Department’s role in

meeting the medical aspects of CBR defense. These

included protection from CBR hazards, mass-casualty

decontamination, decontamination stations, and

supplies for decontamination.

8-18
CHAPTER 9

DIET AND NUTRITION

This chapter is concerned with the nutritional

requirements for the healthy person, and for the sick,

wounded, and convalescing patient. Research has

confirmed that good health depends in part upon the

availability of essential nutrients the body requires

throughout life. The well-nourished individual is

usually mentally alert, is at a maximum of physical

capability, and has a high resistance to disease. The

daily basic minimum nutritional requirements must be

met and often supplemented during periods of illness

to meet the changing needs of the body and its ability to

use foods. Therefore, the diet is an important factor in

the therapeutic plan for each patient.

The important role of nutrition in overall health is

widely recognized. As a member of the Navy, you must

be healthy to perform your professional duties. Part of

maintaining a healthy lifestyle starts with eating a

well-balanced diet and maintaining a good fitness

regimen. Many people in the Navy and Marine Corps do

not maintain a proper daily diet. As a Hospital

Corpsman, you may be responsible for providing

nutritional counseling and, perhaps, even motivation.

You have an added responsibility to observe for

additional nutritional needs and omissions and to advise

your shipmates when necessary. If you stay healthy and

energetic, the knowledge and experience you share and

the example you set may help your shipmates adopt and

maintain a healthier lifestyle.

Balancing energy intake and expenditure can be

difficult, both when activity levels are high as well as

when they are very low. Typically, body weight remains

constant when energy intake equals expenditure (fig.

9–1). The energy balance equation can be “unbalanced”

by changing energy intake, energy expenditure, or both.

To gain or lose 1 pound requires that approximately 3,500

extra calories be consumed or burned.

FOOD CLASSIFICATION

LEARNING OBJECTIVE: Identify the

components of good nutrition.

Foods are substances from animal and plant

sources that yield heat and energy when ingested and

absorbed by the body. Food nutrients build and renew

tissues and regulate the body processes. The unit

commonly used for describing energy intake and

energy expenditure is the calorie. Good food sources

contain substantial amounts of nutrients in relation to

caloric content and provide upwards of 10 percent of

the U.S. Recommended Dietary Allowance for each

specific nutrient. Most people can get enough of each

required nutrient daily by eating a wide variety of

foods.

PROTEINS

Proteins are the “building blocks” of the body and

provide important required nutritive elements.

Proteins are needed for growth, maintenance, and

replacement of body cells, and they form hormones

and enzymes used to regulate body processes. Extra

protein is either used to supply energy or is changed

into body fat. Found in both the animal and plant

kingdoms, all proteins are composed of amino acids.

Some amino acids are absolutely essential to maintain

life and are necessary for repair, growth, and body

development. Of the approximately 20 amino acids,

9-1

INTAKE=3000 KCAL OUTPUT=3000 KCAL WEIGHT GAIN=0

INTAKE=4000 KCAL OUTPUT=2000 KCAL WEIGHT GAIN=+

INTAKE=2000 KCAL OUTPUT=3000 KCAL WEIGHT GAIN= _

HM3f0901

Figure 9–1.—Balancing energy intake.
our body can produce all but nine. These nine amino

acids are termed “essential amino acids.” We must get

them from food, and we need all nine at one time so our

body can use them effectively.

Proteins, which promote tissue growth and

renewal, have long been recognized as the main

structural unit of all living cells. Each gram (g) of

protein yields 4 calories in the process of metabolism.

Although proteins yield energy, they are an expensive

source. If sufficient carbohydrates are not supplied,

the body will use protein for energy requirements.

This protein may be obtained from muscle tissue,

producing the “wasting effect” of long-term starvation

and some diseases.

A constant protein source is required in the daily

diet. The normal daily protein intake for adults should

be 0.8 gram per kilogram (g/kg) (2.2 lbs) of body

weight, or 12 percent of the total caloric intake.

Pregnant women require an additional 10 grams of

protein a day over the normal daily intake.

Proteins play an important role in recovering from

fractures, burns, and infections. They are also

important in healing wounds and recovering from

surgical procedures. In cases of recovery, protein

intake should be increased in accordance with the

severity of the condition, and carbohydrates and fats

can be added liberally. While proteins can supply

energy, they are not a main source of energy like

carbohydrates and fat.

Ideally, the patient should receive protein by

mouth; however, it is sometimes necessary to meet the

minimum requirements parenterally. Glucose

parenteral solution, given during an acute emergency

period, will prevent some loss of protein. Protein

deficiency may stunt growth, promote a secondary

anemia, or induce nutritional edema. Dietary sources

of protein and the nine essential amino acids are milk,

yogurt, eggs, meats, fish, cheese, poultry, peanut

butter, legumes, and nuts. Protein from plant sources is

best when combined with animal protein, such as milk

plus peanut butter, or when legumes are combined with

grains, such as Navy beans plus rice.

FATS

The chief functions of fats are to supply energy and

transport fat-soluble vitamins. Each gram of fat yields

9 calories. Fats provide the most concentrated source

of calories (and, therefore, energy) of all the food

nutrients. Fats are found in both the animal and

vegetable kingdoms. Fatty acids and glycerol are the

end products of the digestion of fats.

Many fats act as carriers for the fat-soluble

vitamins A, D, E, and K. They also act both as a

padding for vital organs, particularly the kidneys, and

as subcutaneous tissue to help conserve body heat. Fat

is stored as adipose (fatty) tissue to form a reserve

supply in time of need. Dietary fats delay gastric

emptying and promote a feeling of fullness. Excess

calories from fats may produce obesity, the forerunner

of arteriosclerosis, hypertension, gallbladder disease,

and diabetes. A diet high in fat, especially saturated fat

and cholesterol, contributes to elevated blood

cholesterol levels in many people. Adults over the age

of 30 should have a serum cholesterol level of less than

200 mg/dl. Health experts agree that less than 30

percent of our total calories per day should come from

fat. Saturated fat intake should be no more than 10

percent of the total calories.

Reducing dietary fat is also a good way to limit

calories. Decreased fat intake results in fewer calories

without a reduction of most nutrients. Too little fat in

the diet may lead to being underweight, having

insufficient padding for the vital organs, and lowered

energy. Butter, margarine, cream cheese, fatty meats,

whole milk, olives, avocados, egg yolks, nuts,

commercial bakery products, and vegetable oils are all

sources of dietary fat.

CARBOHYDRATES

Carbohydrates (sugar and starches) are the most

efficient sources of energy and are known as the “fuel

of life.” They are abundantly found in most plant food

sources. Complex carbohydrates (starches) are in

breads, cereals, pasta, rice, dry beans and peas, and

other vegetables, such as potatoes and corn. Simple

carbohydrates are found in sugars, honey, syrup, jam,

and many desserts. The new nutritional guidelines

established by the Food and Drug Administration

(FDA) recommend that complex carbohydrates and

naturally occurring sugars (found primarily in fruit)

make up approximately 50 percent of one’s total

caloric intake. The FDA also recommends that refined

and processed sugars make up no more than 10 percent

of the calories in one’s diet.

Each gram of carbohydrate yields 4 calories in the

process of its metabolism. Carbohydrates must be

reduced to glucose before the body can use them.

Carbohydrates are stored in the muscles to fuel their

movement, and in the liver as glycogen, which is then

9-2
broken down and released as glucose at the exact rate

needed by the body. This latter mechanism is

controlled largely by insulin from the pancreas.

During fasting, liver glycogen is rapidly depleted,

leading the body to use its fat for energy. Carbohydrates that are not needed for energy are converted to

and stored as adipose (fat) tissue.

The main functions of carbohydrates are to

• furnish the main source of energy for

muscular work and nutritive processes,

• help maintain body temperature,

• form reserve fuel,

• assist in oxidation of fats, and

• spare protein for growth and repair.

MINERALS

Although mineral elements constitute only a small

portion of the total body weight, they enter into the

activities of the body to a much greater degree than

their weight would indicate. Certain mineral elements

are essential for specific body functions. While it is not

yet known exactly how many of the mineral elements

are indispensable to the body functions, seemingly

small changes of mineral concentration can be fatal.

These essential inorganic elements contribute

overwhelmingly to the skeletal framework of the body

and teeth, and they are an essential part of many

organic compounds.

Minerals form an integral part of basic cell

structure and circulate in body fluids. They also

exercise specific physiologic influences on the

function of body tissues. For mineral needs to be met

satisfactorily, consumption of each element must be

sufficient to cover body tissue requirements and to

meet changing physiological needs. At one time, it

was erroneously believed that any diet adequate in

other respects would also provide an adequate intake

of essential minerals. This is not so. Foods vary

greatly in their mineral—as well as their overall

nutritional—content, depending on growing

conditions, storage, and preparation procedures.

Among the major minerals are calcium, phosphorus,

iron, potassium, zinc, and magnesium. Table 9–1 lists

the essential elements, the foods that contain them, and

their functions.

VITAMINS

Vitamins are essential compounds that are present

in food in minute quantities. Although vitamins do not

furnish energy or act as tissue-building materials, they

do act as catalysts in many body chemical reactions

and are necessary for normal metabolic functions,

growth, and the health of the human body. Their

absence results in malnutrition and specific deficiency

diseases. Vitamin chemistry is complex and

nutritional experimentation is difficult, so our

knowledge of them is being continually supplemented

and revised. It is quite possible that additional

vitamins will be discovered or that some of those

already recognized may prove to contain more than

one factor.

Vitamins are so widely distributed in food that a

properly prepared normal diet usually provides an

adequate amount. Vitamins can be destroyed during

the preparation or preservation of certain foods;

however, manufacturers frequently add vitamins to

their products to replace those destroyed or removed in

processing. Since fat-soluble vitamins can be stored in

the body, it is possible to develop hypervitaminosis by

consuming excessive amounts of these nutrients, and

death may result in extreme cases. Fat-soluble

vitamins include A, D, E, and K.

• Vitamin A is involved in the formation and

maintenance of healthy skin, hair, and mucous

membranes. Vitamin A helps us to see in dim

light and is necessary for proper bone growth,

tooth development, and reproduction. Good

sources of vitamin Ainclude yellow, orange, and

dark green vegetables; fruits; and liver, eggs,

cheese, butter, and milk.

• Vitamin D promotes calcium and phosphorus

absorption and is required for the formation of

healthy bones and teeth. Good sources include

fortified milk, egg yolk, liver, tuna, and cod liver

oil. Vitamin D is produced in the body on

exposure to sunlight.

• Vitamin E protects vitamin A and essential fatty

acids from oxidation in the body cells and

prevents breakdown of body tissues. Good

sources include vegetable oils, fortified cereals,

whole-grain cereals and bread, nuts, wheat

germ, and green leafy vegetables.

• Vitamin K includes a group of vitamins that

promote normal clotting of the blood and helps

maintain normal liver functions. Good sources

9-3
are green leafy vegetables, liver, soybean, and

other vegetable products.

Water-soluble vitamins, such as vitamin C and the

B-complex vitamins, are not stored in the body to any

great extent. Rather, they are used as necessary by the

body, and any amounts that remain are excreted in the

urine. As a result, these vitamins must be replenished

daily to ensure optimum health.

• Vitamin C (ascorbic acid) is necessary for

normal growth and cell activity and is important

for maintaining blood vessel strength. It helps

the body resist upper respiratory infections and

is necessary for the proper development of teeth

and gums. Wounds and burns require vitamin C

for healing. A deficiency of ascorbic acid causes

an individual to bruise easily. A severe

deficiency leads to a condition known as scurvy.

Good sources include citrus fruits, raw leafy

vegetables, and tomatoes.

• Vitamin B (Complex) includes more than 12

separate B vitamins. Some of the more common

B vitamins are

9-4

Element Rich Sources Function in the Body

Iodine Seafood, water, and plant life in nongoiterous

regions, and iodized salt

Assists in normal functioning of

the thyroid gland.

Sodium Table salt, seafood, animal products, and foods

processed with sodium

Regulates osmotic pressure, pH

balance, and heartbeat.

Potassium Avocados, bananas, oranges, potatoes, tomatoes,

nuts, meat, coffee, tea, milk, and molasses

Regulates osmotic pressure and

pH balance. A constituent of all

cells.

Magnesium Nuts, whole-grain cereals, legumes, and

vegetables

Assists in maintaining mineral

balance.

Calcium Milk, yogurt, cheese, some green vegetables,

molasses, sardines, and salmon

Assists in blood coagulation;

regulates heartbeat, aids in

regulating mineral metabolism

and muscle and nerve response. A

constituent of bones and teeth.

Phosphorus Milk, yogurt, poultry, fish, meats, cheese, nuts,

cereals, and legumes

Aids in metabolizing organic

foodstuffs and maintains pH

balance. A constituent of bones

and teeth.

Iron Liver, egg yolks, oyster, legumes, whole or

fortified grains, dark and green vegetables, and

dried fruit

Helps carry oxygen throughout the

body. A constituent of hemoglobin, blood, and tissue.

Chlorine Table salt, seafoods, and animal products Regulates osmotic pressure. A

constituent of gastric acid.

Sulphur Protein foods Promotes hair and nail formation

and growth. A constituent of all

body tissue.

Copper Liver, kidney, nuts, dried legumes, some shellfish,

and raisins

Aids in the use of iron in hemoglobin synthesis.

Zinc Meat, liver, eggs, seafood (especially oysters),

milk, and whole-grain products

Regulates growth, taste acuity,

and appetite. A constituent of

enzymes.

Table 9–1.—Mineral Elements in Nutrition
—Thiamin (B1) is necessary for normal

growth, normal carbohydrate metabolism

and normal functioning of the heart,

nerves, and muscles. Thiamin deficiency

results in retarded growth and nerve

disorders, and a condition known as

beriberi. Good sources include pork, fish,

eggs, and whole-grain cereals.

—Riboflavin (B2) is required for normal

growth, vigor, healthy skin and mucosa,

and normal eye function. Riboflavin is

found in milk products, green leafy

vegetables, and eggs. Other good sources

of vitamin B2 are the organ meats, heart,

kidney, and liver.

—Niacin (B3) is necessary for normal

growth and skin health, normal

functioning of the stomach and intestines,

nervous and circulatory systems, and for

carbohydrate, fat, and protein

metabolism. The best sources are meat,

liver, poultry, and peanuts.

—Pyridoxine (B6) is necessary for fat,

carbohydrate, and protein metabolism,

and is sometimes used to treat nausea in

pregnancy. Sources include liver, yeast,

wheat germ, pork, potatoes, and milk.

Vitamin B6 is usually prescribed with

Isonizid (INH) treatment since INH often

causes a pyridoxine deficiency.

—Cyanocobalamin (B12) is necessary

for the health of nervous tissue and assists

in iron metabolism and the maturation

process of red blood cells. B12 is used to

prevent pernicious anemia. The best

sources are liver and kidneys, milk, eggs,

fish, and cheese.

See Appendix IV for more information on

vitamins.

VITAMIN AND MINERAL SUPPLEMENTS

Vitamin supplements are usually not necessary if a

diet includes a wide variety of foods. Exceptions may

occur in prenatal diets in which iron is low, as well as in

patients who are deficient in a specific vitamin.

Vitamin supplements should be taken only on a

physician or dietitian’s recommendation.

Vitamin and mineral supplements are being widely

used by physically active people because of all the

performance-enhancing claims made by supplement

manufacturers. It is estimated that 40–50 percent of

athletes use some form of vitamin/mineral

supplements. Some doses range from amounts similar

to the Recommended Dietary Allowances (RDA) up to

levels many times the RDA. Supplements are useful

under a variety of conditions, such as if an individual

• has an existing vitamin or mineral deficiency;

• has poor nutrient intake and/or dietary habits; or

• is exposed to extreme environmental conditions,

such as altitude.

Often, laxatives are prescribed in conjunction with

some medical treatments and may cause decreased

absorption of vitamins,loss ofminerals and elec-trolytes, or

inhibition of glucose uptake. Therefore, any patient on

laxatives should be carefully monitored, and supplementary

nutritives should be administered as necessary.

Taking a general multivitamin supplement appears

to be without measurable performance enhancing

effects in healthy, well-nourished, physically active

personnel. Similarly, no improvements in muscle

strength or endurance have been noted in strength

athletes, such as body builders, who tend to use

megadoses of vitamin and mineral supplements. The

indiscriminate use of high-potency vitamins and

minerals is of growing concern since excessive

amounts of vitamins and/or minerals can be harmful

and may result in nutrient imbalances. Excessive

intake of some vitamin and mineral supplements can

result in adverse—and possibly toxic–side effects.

WATER

Water is often called the “forgotten nutrient.”

Water is needed to replace body fluids lost primarily in

urine and sweat. A person can survive weeks without

food but only days without water. Water makes up 70

percent of body weight and is found in every cell in the

body. It is the medium through which nutrients are

transported from the digestive tract to the cells where

they are needed. Water is also the medium through

which the by-products of cell metabolism are

removed.

Water also serves as the medium in which the

chemical processes of life take place. It is normally

taken into the body in beverages, soups, and in the form

of solid foods. Fluid needs are increased with

sweating, vomiting, diarrhea, high-protein diets, and

in hot environments. An insufficient intake may cause

dehydration, evidenced by loss of weight, increased

body temperature, and dizziness.

9-5
GUIDE TO GOOD EATING

LEARNING OBJECTIVE: Recall the

elements of the USDA Food Guide Pyramid

and recommended dietary guidelines.

Calculating a therapeutic diet can be complicated

and is best left to dietitians. It is now common practice

for dietitians or dietary kitchens to select foods for

diets using the food groups outlined in figure 9–2, the

Food Guide Pyramid. These foods are classified

according to their nutritional value and the number of

servings that should be eaten each day.

THE FOOD GUIDE PYRAMID

The Food Guide Pyramid emphasizes foods from

the five food groups shown in the sections of the

pyramid. Each of these groups provides some, but not

all, of the nutrients we require. For good health we

need them all. For everyday living, the simplest and

most practical plan is to follow those same guidelines,

selecting from the various food groups the type and

amount of food recommended.

DIETARY GUIDELINES

The food pyramid graphically communicates the

message of the Dietary Guidelines for Americans.

Diets should be built upon a base of complex

carbohydrates and less fats. The placement of the food

groups starting at the base of the pyramid conveys the

current recommendations. These recommendations

are as follows:

• Eat more grains, vegetables, and fruits

• Eat moderate amounts of lean meats and dairy

foods

• Use sweets, fats, and oils sparingly

9-6

FATS, OILS, & SWEETS

USE SPARINGLY

MILK, YOGURT,

& CHEESE

GROUP

2-3 SERVINGS

VEGETABLE

GROUP

3-5

SERVINGS

KEY

FAT (NATURALLY OCCURRING AND ADDED)

SUGARS (ADDED)

THESE SYMBOLS SHOW FATS, OILS,

AND ADDED SUGARS IN FOODS.

MEAT, POULTRY, FISH

DRY BEANS, EGGS

& NUTS GROUP

2-3 SERVINGS

FRUIT

GROUP

2-4 SERVINGS

BREAD, CEREAL,

RICE, PASTA

GROUP

6-11

SERVINGS

HM3f0902

Figure 9-2.—Food Guide Pyramid.
Generally accepted guidelines suggest that you eat

a diet that is high in complex carbohydrates and low in

protein and fat. Your diet should consist of at least five

combined servings of fruits and vegetables each day.

Avoid fat when possible. Eat at regular intervals when

possible, and avoid snacking late at night. For detailed

information on nutrition, consult Navy Nutrition and

Weight Control Guide, NAVPERS 15602; and the Fat,

Cholesterol and Calorie List for General Messes,

NAVSUP 580.

DIET THERAPY

LEARNING OBJECTIVE: Select the

appropriate diet for various medical

conditions.

It is often necessary to cater to a patient’s appetite,

since many individuals become especially hard to

please when sick. In some disease states, such as

cancer, patients experience marked taste changes.

Because of the importance of the nutritional elements

in feeding the sick, try to carry out the patient’s wishes

whenever possible. A tactful and observant Hospital

Corpsman can be of great benefit to the physician and

dietitian in carrying out the dietary regimen. You must

be aware of what comprises a well-balanced diet and

should be able to recognize when dietary adjustments

need to be made in special situations. This is important

to meet the changing needs of the diseased body’s

ability to make use of foods.

The patient should be made to feel that the utmost

cleanliness and care have been observed in the

preparation and service of their food. The patient’s

face and hands should be cleaned before food is served,

and the lips and teeth cleaned before and after the meal.

If the mouth is dry, it should be moistened periodically.

When special or modified diets are ordered, check

the contents of the tray with the written orders. An

error in serving a special diet may cause discomfort,

serious illness, or even death.

OBJECTIVES OF DIET THERAPY

The objectives of diet therapy are as follows:

• To increase or decrease body weight

• To rest a particular organ

• To adjust the diet to the body’s ability to use

certain foods

• To produce a specific effect as a remedy (e.g.,

regulation of blood sugar in diabetes)

• To overcome deficiencies by the addition of food

rich in some necessary element (e.g.,

supplementing the diet with iron in treating

macrocytic anemia)

• To provide ease of digestion by omitting

irritating substances, such as fiber, spices, or

high-fat foods

TYPES OF DIETS

Diets used in the treatment of disease are often

spoken of by specific names that show a special

composition and often indicate the purpose for which

the diet is intended.

Regular Diet

The regular diet is composed of all types of foods

and is well balanced and capable of maintaining a state

of good nutrition. It is intended for convalescing

patients who do not require a therapeutic diet.

Modified or Therapeutic Diets

Modified or therapeutic diets are modifications of

the regular diet and are designed to meet specific

patient needs. These include

• method of preparation (e.g., baking, boiling, or

broiling),

• consistency (e.g., ground or chopped),

• total calories (e.g., high or low calorie),

• nutrients (e.g., altering carbohydrate, protein,

fat, vitamins, and minerals), and

• allowing only specific foods (e.g., diabetic diet).

SOFT DIET.—The soft diet is soft in texture and

consists of liquids and semi-solid foods. It is indicated

in certain postoperative cases, for convalescents who

cannot tolerate a regular diet, in acute illnesses, and in

some gastrointestinal disorders. A soft diet is an

intermediate step between a liquid and regular diet and

is low in connective tissue and indigestible dietary

fiber. Little or no spices are used in its preparation.

The soft diet includes all liquids other than

alcohol, and foods that may be incorporated into a soft

9-7
diet include well-cooked cereals, pastas, white bread

and crackers, eggs, cottage cheese, tender meat, fish,

poultry, and vegetables (including baked, mashed, and

scalloped potatoes). Vegetables can be puréed and

meats ground for dental patients. Permitted desserts

are custards, gelatin puddings, soft fruits, and simple

cakes and cookies. Foods prohibited in a soft diet

include fried foods, raw vegetables, and nuts.

LIQUID DIET.—A liquid diet consists of foods

that are in a liquid state at body temperature. This type

of diet is indicated in some postoperative cases, in

acute illnesses, and in inflammatory conditions of the

gastrointestinal (GI) tract. It is important that feedings

consisting of 6 to 8 ounces or more be given every 2 to

3 hours while the patient is awake.

Liquid diets are usually ordered as clear, full, or

dental liquid. A clear liquid diet includes clear broth,

black tea or coffee, plain gelatin, and clear fruit juices

(apple, grape, and cranberry), popsicles, fruit drinks,

and soft drinks. This diet is inadequate in all nutrients.

A full liquid diet includes all the liquids served on a

clear liquid diet, with the addition of strained cream

soups, milk and milk drinks, ice cream, puddings, and

custard. The full liquid diet is inadequate in iron,

niacin, and possibly Vitamin A and thiamin. A dental

liquid diet includes regular foods blended and strained

in liquid form and all foods allowed on clear and full

liquid diets. Vitamin and mineral supplements may be

necessary with the dental liquid diet if the

recommended amounts of food are not tolerated.

HIGH-CALORIE DIET.—The high-calorie diet

is of a higher caloric value than the average patient

normally requires. A high-calorie diet is indicated

when an increase of total calories is required by

malnourished, underweight, postsurgical, or

convalescing patients, especially those recovering

from acute illnesses such as infections, burns, and

fevers. The increase in calories is obtained by

supplementing or modifying the regular diet with

high-calorie foods or commercial supplements, by

giving larger portions, or by adding snacks. It is given

to meet a need for energy caused by the more rapid

metabolism that accompanies certain diseases

(especially fever, hyperthyroidism, poliomyelitis, and

tuberculosis). In the liquid or soft diet, adding fats and

carbohydrates increases the caloric value. The

high-calorie diet is often ordered along with high

protein. Proteins are added to prevent depletion of

proteins in the plasma (a condition known as

hypoproteinemia). As the patient progresses, a more

solid diet is given.

Good sources of high-calorie foods are whole

milk, cream, sweets, butter, margarine, fried foods,

gravy, sauces, and ice cream. Between-meal feedings

consisting of milk, milkshakes, cheese, cookies, or

sandwiches are recommended, but these feedings

should not interfere with the patient’s appetite at

mealtime.

HIGH-PROTEIN DIET.—As previously stated,

protein is essential for tissue growth and regeneration.

A high-protein diet is indicated in almost all illnesses

(e.g., nephrosis, cirrhosis of the liver, infectious

hepatitis, burns, radiation injury, fractures, some GI

disorders, conditions in which the protein blood level

is low, and in preoperative and postoperative cases).

In some acute illnesses and disorders, such as

infectious hepatitis, GI disorders, and postoperative

conditions, patients may be unable to consume solid

foods or the daily requirement of protein and calories

because of pain or nausea. In these cases, intravenous

fluids with nutrient additives are required for the

patient to receive the required amount of protein.

Protein-calorie deficiency is a definite factor in

postoperative wound disruption. This disruption can

best be prevented by preemptive nutritional measures

before surgery. Antibody production will be decreased

if the patient receives inadequate protein. Remember,

the daily recommended intake of proteins for adults is

at least 0.8 g/kg of body weight (approximately 56 g).

A high-protein diet should provide a minimum of 1.5 g

of protein per kg of body weight (approximately

105 g). The seriously burned and radiation injury

patients should receive at least 3.0 g/kg daily.

Supplement the regular diet with high-quality

protein foods, such as meat, fish, cheese, milk, and

eggs.

LOW-CALORIE DIET.—The low-calorie diet

is useful in the treatment of obesity, but it may also be

used to control weight in medical conditions such as

arthritis, hypertension, diabetes, cardiac disease, or

hypothyroidism. Aloss of 1 to 2 pounds per week is the

medically acceptable limit for weight reduction. A

low-calorie diet consists of 1,000 to 1,800 calories per

day. Calorie levels are determined by physicians and

dietitians to help meet specific individual patient

weight-loss goals. The daily intake of proteins should

be at least 0.8 g/kg of standard body weight.

Supplemental vitamins may be ordered if the

prescribed diet is less than 1,200 calories.

Patients on low-calorie diets should be instructed

by the dietitian (if available) or other medical

9-8
personnel knowledgeable in proper eating habits. The

dietitian conducts patient interviews to learn the

patient’s eating behaviors, usual portions, preparation

of foods, meal patterns, nutritional adequacy, exercise,

and so forth. Individual programs should then be

recommended to assist patients to attain and maintain

their ideal weight.

The Handbook of Clinical Dietetics, published by

the American Dietetic Association, lists the following

formula for determining ideal body weight. For

females, the basic weight for 5 feet is 100 pounds. Add

5 pounds for every inch over 5 feet. For males, the

basic weight for 5 feet is 106 pounds, with 6 pounds

added for every inch over 5 feet. Adjustments must be

made for body build. Reduce desired weight by 10

percent for a small frame; increase it by 10 percent for a

large frame. Total caloric requirements are based on

ideal body weight plus activity.

Many patients on low-calorie diets experience

hunger. To satisfy this hunger or appetite, low-calorie

foods such as raw vegetables, broth, black coffee or

tea, and other unsweetened or diet beverages should be

provided. Water and sodium need not be restricted

unless there are cardiac complications or edema, and

the restrictions are ordered by the physician.

LOW-PROTEIN DIET.—As the name implies,

the low-protein diet is made up of foods that furnish

only small amounts of protein and consist largely of

carbohydrates and fats (e.g., foods such as

marshmallows, hard candy, and butter). This diet is

used in renal diseases associated with nitrogen

retention or liver disorders. Limited amounts of

protein are sometimes advocated in certain kidney

diseases (such as chronic nephrotic edema).

Low-protein diets for renal failure are usually

restricted in sodium and potassium, because these two

elements are not excreted properly during this

condition. In some cases of chronic renal

insufficiency, the protein content of the diet is varied,

usually between 40 and 60 g per day, so that there will

be sufficient complete protein to maintain nitrogen

equilibrium.

In some metabolic disturbances, such as amino

acids in the urine, protein restriction may be of

therapeutic value.

HIGH-RESIDUE DIET.—The high-residue

(high-bulk, high-fiber, high-roughage) diet is

indicated in atonic constipation, spastic colon, irritable

bowel syndrome, and diverticulosis. This diet

encourages regular elimination by stimulating muscle

tone, creating softer and larger stools that are more

easily propelled through the colon, thereby reducing

the pain and cramping that accompany spastic colon or

irritable bowel syndrome.

The patient is given a regular diet, with the

inclusion of high-residue foods. The main sources of

fiber are whole-grain breads and cereals, bran cereals,

fresh fruits, and vegetables that are raw or cooked until

tender. Whole grain breads and cereals that contain

wheat bran have a greater laxative effect than fruits and

vegetables, because the bran acts to absorb water

within the colon, creating a bulk effect. Fiber intake

should be increased gradually to minimize potential

side effects of bloating, cramps, and diarrhea. At least

one serving of 100 percent wheat bran cereal is

recommended daily. Cereals such as raisin bran, Bran

Flakes®, Shredded Wheat®, and oatmeal may be used

occasionally, but they contain less than half the amount

of fiber found in All-Bran® or Bran Buds®. Fresh

fruits and vegetables with edible skins, such as apples

and grapes, are higher in fiber content than canned

fruits or vegetables and their juices.

Dietary intake of refined sugars and starches

should be decreased because they are poor sources of

fiber. Also, limit white flour products, refined cereals,

pies, cakes, and cookies.

Too little fluid in the high-residue diet may cause

dehydration and lead to constipation. The patient must

drink at least eight 8-ounce glasses of water or other

fluids daily, particularly when consuming the

recommended amount of bran. Drinking too much

alcohol, beverages containing caffeine (such as coffee,

cola, tea, and soft drinks), however, can irritate a

sensitive colon and can cause dehydration. When

possible, use decaffeinated coffee. One or two glasses

of water in the morning help to stimulate peristalsis.

Excessive intake of foods like dried beans, fruits with

seeds and skins, nuts, popcorn, and strong spices may

cause irritability, especially during the inflammation

period of colon disease states. These foods should be

individualized to the patient.

When one is progressing from a low-residue diet

after an acute infection or diverticulitis, increase fiber

in the diet gradually. Start by adding one serving of

100 percent bran cereal and three servings of

whole-grain bread to the low-residue menu pattern.

Gradually increase the amount of raw vegetables and

fresh fruits to at least four servings per day.

LOW-RESIDUE DIET.—The low-residue diet is

indicated in ulceration, inflammation, and other

9-9
gastric disorders (such as partial intestinal obstruction

or diverticulitis). It is also used in certain postoperative states that affect any part of the GI tract, e.g., a

hemorrhoidectomy. Low-residue diets are also used in

treating dysenteries of long duration.

The purpose of this diet is to provide nonstimulating, non-irritating, and easily digested

material that leaves little residue, thus avoiding

mechanical irritation of the GI tract. Various

commercially prepared low-residue elemental diet

supplements may be given to provide complete

nutrition.

LOW-SODIUM DIET.—A low-sodium diet

consists of foods containing a very small percentage of

sodium, with no salt added in preparation or by the

patient. It is impossible to prepare an absolutely

sodium-free diet.

The low-sodium diet is indicated when edema is

present, in renal diseases, hypertension, and certain

cardiac conditions.

The nephrotic patient is often unable to excrete

sodium in a normal manner because the kidneys’

retention of sodium leads to edema. Alow-sodium diet

is thus indicated, with no restriction on salt-free

liquids. Such patients should be encouraged to drink

2,000 to 3,000 milliliters (ml) of low-sodium fluids

daily.

The allowance of sodium in a strict low-sodium

diet is 250 to 1,000 mg daily. The allowance of sodium

in a moderate low-sodium diet is 2,000 mg or 2 g.

Regular diets with no salt added contain 2.4 to 4.5 g of

sodium.

Any diet in which the amount of sodium is

drastically reduced has possible side effects. The

patient who is on this diet regimen must be constantly

observed—particularly in warm climates—for

lassitude, complaints of weakness, anorexia, nausea

and vomiting, mental confusion, abdominal cramps,

and aching skeletal muscles. Electrolyte imbalances

can have serious consequences. If you observe

symptoms such as those described above, notify a

medical officer.

BLAND DIET.—A bland diet may be helpful for

gastritis, hyperacidity, hemorrhoids, peptic ulcers, and

other GI disorders. Dietary management of patients

with chronic ulcer disease has been the subject of much

controversy. Bland diets have traditionally been used

for these patients. However, experiments show that

there is no significant difference in the response of

patients with an active duodenal ulcer to a bland diet.

Known irritants to the gastric mucosa include alcohol,

black pepper, caffeine, chili powder, cocoa, coffee,

certain drugs, and tea.

Emphasizing how to eat is as important as

indicating what foods to eat, since there are individual

responses to bland diets. Offer the following

suggestions to the patient:

• Avoid worry and emotional upsets at mealtime

• Chew food well and eat slowly

• Rest before and after meals

• Avoid foods of extreme temperatures

If fruits and juices between meals cause distress,

try including them with meals. Meals must be kept

small to reduce gastric acidity and distention. Among

foods to avoid in the bland diet are

• fatty meats,

• fried foods,

• whole-grain breads and cereals,

• dried beans and peas,

• cabbage-family vegetables,

• chocolate,

• nuts and seeds, and

• carbonated beverages, caffeine, coffee, and tea.

Patients on a bland diet may use spices and

condiments such as allspice, cinnamon, mace, paprika,

sage, thyme, catsup, cranberry or mint jelly, and

extract and flavorings without chocolate or vinegar.

The bland diet allows a more liberal food selection

than other restrictive diets. This diet reduces the

number of meals to three, and increases the quantity of

foods given. Individualize the diet to the patient.

The “Regular-No Stimulants Diet” (also called

“liberal bland”), a type of bland diet, eliminates only

those items that have been shown scientifically to

irritate the gastric mucosa (i.e., alcohol, black pepper,

caffeine, chili powder, cocoa, coffee, certain drugs,

and tea).

Decaffeinated coffee may be restricted in most

types of bland diets. Recent studies show that it causes

increased gastric acid secretion and esophageal

pressure causing gastric acid reflux in the esophagus.

Decaffeinated coffee is only offered on the bland diet

9-10
and the regular-no stimulants diet if it is tolerated by

the patient.

Chronic and excessive use of antacids to treat

hyperacidity and related conditions may result in

thiamin deficiency, presumably because of alkaline

destruction of thiamin within the bowel lumen.

Excessive intake of milk with antacids may cause

systemic alkalosis and hypercalcemia. Milk may be

contraindicated in patients with allergic reactions or

lactose intolerance.

LOW-CARBOHYDRATE, HIGH-PROTEIN

DIET.—Alow-carbohydrate, high-protein diet is used

in the treatment of hypoglycemia. This diet limits

simple carbohydrates that are quickly absorbed into

the blood. A marked rise in blood sugar stimulates the

pancreas to overproduce insulin, which leads to a

hypoglycemic state as too much sugar is transported

out of the blood.

Individualize the diet to the patient, since

hypoglycemic reactions may occur at any time for

various reasons. For example, meal skipping,

inadequate calorie intake with excessive energy

expenditure, and drinking alcohol may precipitate a

low-blood-sugar reaction.

The foods may be divided into three to six or more

small meals. Liberal amounts of protein and fat are

used, as they are more slowly digested and absorbed.

The diet includes meats, fish, poultry, cheese, eggs,

fats, low-starch vegetables, and limited amounts of

unsweetened fruit and juices, breads, cereals, and

high-starch-content vegetables (like corn, peas, and

potatoes). Because milk contains the sugar lactose,

limit it to 2 cups a day for an adult.

Sweets such as candy, sugar, jams, jellies, soft

drinks, and pastries should be avoided to help prevent

hypoglycemic reactions. They should be consumed

only when necessary to quickly increase blood-sugar

levels during a hypoglycemic reaction. If reactions are

frequent, it is helpful to carry hard candy for quick and

easy use. Handy high-protein snacks to help prevent

hypoglycemic reactions may include cheese, peanut

butter, milk, and hard-boiled eggs.

SUMMARY

Fulfilling the daily requirement of eating a wide

variety of foods, in the correct amounts, will contribute

directly to a healthy lifestyle. Well-nourished

crewmembers with good health are much more able to

resist infections, are able to sleep soundly and awake

with a pleasant demeanor. By using your knowledge of

diet therapy and nutrition to train and treat your crew,

your job will be made significantly easier.

9-11

CHATER 10

EMERGENCY DENTAL CARE AND PREVENTIVE

MEDICINE

TERMINAL OBJECTIVE: Be familiar with

the subject matter and technical publications

relating to emergency dental care and preventive

medicine.

Because of the nature of our rating and the many

responsibilities placed upon us, Hospital Corpsmen

must have a general understanding of many areas of

medicine. Emergency dental care and preventive

medicine practices are two of those areas. Both of

these subjects are extremely important, but because

they are both already discussed in great detail in other

Navy publications, this chapter will present only a

brief overview of them. Emergency Dental Care is

covered in Section I, and Preventive Medicine is

addressed in Section II. For in-depth information,

refer to the publications outlined respectively in

table 10-1.

SECTION I

EMERGENCY DENTAL CARE

In the absence of a dental officer you, as the

medical department representative (MDR), will be

required to perform basic emergency dental first aid

associated with the most common oral conditions and

injuries. While this section will introduce you to the

basics of dental anatomy and histology, dental

terminology, oral diseases and injuries, and the dental

record, you will find in-depth discussion of these areas

in the DT and HM Advancement Handbooks; chapter 6

of Dental Technician Training Manual, Volume 1,

NAVEDTRA 12572; and in chapter 6 of the Manual of

the Medical Department, NAVMED P-117.

The primary function of this emergency dental

care is to alleviate pain, arrest hemorrhage, or prevent

further or complicating injury to dental structures.

Ensuring that the entire crew is in good dental health

before deployment will prevent most dental-related

problems. Therefore, predeployment examinations

are very important.

You must administer only emergency dental care.

Refer routine cases to a dental treatment facility, and

refer any cases treated by nondental personnel for

follow-up at the earliest opportunity.

DENTAL ANATOMY AND HISTOLOGY

To provide emergency dental care, you will need to

be familiar with dental anatomy and histology. The

following sections will provide you with basic

information; however, if you require more detailed

10-1

Dental

DT Advancement Handbook

HM Advancement Handbook

Dental Technician Training Manual, Vol. 1,

NAVEDTRA 12572

Dental Technician Training Manual, Vol. 2,

NAVEDTRA 12573

Manual of the Medical Department,

NAVMED P-117, chapter 6

Various BUMED notes and instructions

Various SECNAV and OPNAV notes and

instructions

Preventive Medicine

HM Advancement Handbook

Manual of Naval Preventive Medicine,

NAVMED P-5010

Control of Communicable Diseases Manual,

NAVMED P-5038

Naval Supply Publication 486

Various BUMED notes and instructions

Various SECNAV and OPNAV notes and

instructions

Table 10-1.—Publication List
information on dental anatomy and histology, consult

the Dental Technician Training Manual, Volume 1,

NAVEDTRA 12572, or contact your local dental

treatment facility for references.

Dental Anatomy

The adult mouth normally has 32 permanent teeth.

On board ship, you will usually be able to refer a

patient to a dentist for a dental problem. When you do

have to make such a referral, you must be able to

correctly describe the problem and its location (e.g.,

which tooth, which surface of the tooth, etc.) in

appropriate dental terminology. Because referrals are

infrequent, this required information will not be

covered here. However, the information is available in

detail in the Dental Technician Training Manual,

Volume 2, NAVEDTRA 12573.

Dental Histology

Dental anatomy deals with the external form and

appearance of the teeth. Dental histology studies the

tissues and internal structure of the teeth, along with

the tissues that surround and support them. It will be

helpful to have a knowledge of dental histology in case

you need to provide emergency dental treatment.

Dental Terminology

Knowledge of dental terminology is important to

interpret emergency treatment plans prepared by

dentists and to prepare consultation sheets for referral

to dental treatment facilities. Make sure you use

standard dental abbreviations when recording entries

in a patient’s dental record. You will find some

important basic dental-related words and definitions in

the next section, “Oral Diseases and Injuries.” Both

the Dental Technician Training Manual Volume 2,

NAVEDTRA 12573, and the Manual of the Medical

Department, NAVMED P-117, will provide you with a

more in-depth listing of dental terminology.

ORAL EXAMINATION

Before performing an oral examination, you

should review the patient’s medical and dental

histories. Note the medications the patient is currently

taking. The dental health questionnaire should be

updated if any significant changes in the patient’s

health status have occurred since the form was last

updated by the patient.

When you examine the oral cavity, use a thorough

and systematic approach. You must have a knowledge

of the normal dental anatomy and histology to

recognize oral diseases and injuries. The chief

complaint that brought the patient to seek treatment

will fall into the category of either an oral disease or

condition or an oral injury.

The following are brief descriptions of the major

oral diseases or conditions and oral injuries that may be

seen during an oral examination.

• Dental caries are the result of localized decay of

the calcified tissues of teeth. Bacterial plaque is

the most common cause of dental caries.

Bacteria release acids and other toxins that

attack tooth enamel and produce carious lesions

called cavities.

• Acute pulpitis is a severe inflammation of the

tooth pulp. Usually, it is the result of dental

caries.

• A periapical abscess usually results from an

infection of the tooth pulp, often developing as a

result of unchecked pulpitis.

• Gingivitis is an inflammation of the gingival

tissue. The most frequent cause of marginal

gingivitis is poor oral hygiene.

• Necrotizing ulcerative gingivitis (NUG) is a

severe inflammation of the gingival tissue. NUG

may be also referred to as trench mouth. NUG

is not contagious.

• Periodontitis is an inflammatory condition that

involves the gingivae, the crest of the alveolar

bone, and the periodontal membrane above the

alveolar crest.

• Aperiodontal abscess is caused by an infection

in the periodontal tissues.

• Pericoronitis is an inflammation of the gingiva

around a partially erupted tooth. It may also

result from constant contact between the tissue

flap and a tooth in the opposing arch.

• Stomatitis is an inflammation of the oral

mucosa.

• Recurrent labial herpes is an infection that

produces a fever blister or cold sore. Such a

lesion is usually found on the lip.

• Postoperative hemorrhage may occur any time

from a few hours to several days after a tooth

extraction. The bleeding from the extraction site

may be light or heavy. Treat all abnormal

postextraction bleeding as serious.

10-2
• Alveolar osteitis, also known as dry socket,

results when a normal clot fails to form in the

socket of a recently extracted tooth. Since this

condition is usually very painful, always

consider it a serious emergency.

• Pain in fractured teeth usually results from the

irritation of the pulp tissue. Additional information concerning the types of fractures is

contained in chapter 6 of the Dental Technician

Training Manual, Volume 1, NAVEDTRA

12572.

DENTAL RECORD

Each service member’s military dental treatment

record consists of a Dental Record Jacket, NAVMED

6150/21-30, containing dental treatment forms. The

form used to record dental treatment is EZ603A. It is

imperative that all forms documenting patient care

contain adequate treatment information. Additional

information concerning dental forms is contained in

chapter 2 of the Dental Technician Training Manual,

Volume 2, NAVEDTRA 12573; and chapter 6 of the

Manual of the Medical Department, NAVMED P-117.

SECTION SUMMARY

When dental emergencies occur and dental

facilities are not readily available, medical personnel

are expected to perform basic emergency dental care.

This section has provided basic information on

fundamental dental histology and a variety of dental

conditions. We also discussed the importance of dental

record maintenance and dental forms used by medical

personnel.

SECTION II

PREVENTIVE MEDICINE

Prevention and control of disease are considered the

most desirable means of maintaining good health.

Information included in this overview should provide you

with a general knowledge of the principles and practices of

the Navy’s Preventive Medicine afloat and ashore. This

information is discussed in detail in the Manual of Naval

Preventive Medicine, NAVMED P-5010.

SANITATION

Sanitation is defined as the formulation and

application of measures designed to protect (military)

public health, and the disposal of waste. The goal of

the Navy’s sanitation program is to provide personnel

with a clean and healthy work and living environment.

Personal Hygiene

Because of the close living quarters in the Navy,

particularly aboard ships, personal hygiene is of

utmost importance: Uncleanliness or disagreeable

ordor will surely affect the morale of your shipmates.

Disease and other health problems can spread and

rapidly affect an entire compartment or division. Good

personal hygiene promotes health and prevents

disease. You are responsible for presenting health

education training programs to the personnel in your

unit, including information on the basics of personal

hygiene, and proper exercise, sleep, and nutritional

requirements.

Sanitation of Living Spaces

You, as the MDR, perform sanitation inspections

and provide recommendations to the commanding

officer. The living spaces, their inspection, and living

space cleaning and maintenance practices are

discussed in detail in the Manual of Preventive

Medicine, NAVMED P-5010.

HABITABILITY

Factors that can effect habitability of working and

berthing spaces are air ventilation, heating, and air

conditioning.

Measurements of thermal stress are used to monitor

environmental conditions in which personnel work, live,

and exercise. Monitoring environmental conditions is

crucial to maintaining a safe environment for personnel.

For more detailed information on the items discussed in

this section, you should refer to Manual of Naval

Preventive Medicine, NAVMED P-5010.

VECTOR AND PEST CONTROL

A vector is any animal capable of transmitting

pathogens or producing human or animal discomfort

or injury. Some of the commonly encountered vectors

are insects, arthropods (insects with hard, jointed

exoskeleton and paired, jointed legs), and rodents.

Pests, on the other hand, are organisms (insects,

rodents, fungi, bacteria, snakes, etc.) that adversely

affect military operations and the well-being of man

and animal; attack real property, supplies, and

equipment; or are otherwise undesirable. For more

detailed information on the items discussed in this

10-3
section, you should refer to Manual of Naval

Preventive Medicine, NAVMED P-5010.

FOOD-SERVICE SANITATION

Food-borne illnesses represent an ever-present

threat to the health and morale of our military

personnel. To prevent food-borne illnesses, you will

need to ensure that all foods are procured from

approved sources and processed, prepared, and served

with careful adherence to recommended sanitary

practices. When assigned as a medical department

representative for a command or station, you may be

given the responsibility of inspecting food,

food-service facilities, and investigating food-borne

illness outbreaks.

For guidance on safe time limits for keeping food,

proper storage temperatures, and storage life of

perishable and semi-perishable items, refer to tables in

Naval Supply Publication 486.

Training and Hygiene of Food-Service

Personnel

Food-service personnel should be thoroughly

indoctrinated in personal hygiene and food sanitation

procedures and in the methods and importance of

preventing food-borne illness. Requirements for food

service training are addressed in Food Service

Training Program, SECNAVINST 4061.1.

Food-Service Inspection Report

Navy and Marine Corps food-service facilities are

required to be inspected by a medical department

representative, together with the food-service manager

or officer or designated representative. The findings of

the inspection are reported on a NAVMED Form

6240/1, Food Service Sanitation Inspection. A system

has been established in which maximum defect points

are awarded for each stated requirement. The

inspector assigns an appropriate number of defect

points up to the maximum possible and computes a

sanitary compliance score (SCS). Complete

step-by-step procedures for filing the report and

computing the SCS are provided in the Manual of

Naval Preventive Medicine, NAVMED P-5010.

IMMUNIZATIONS AND COMMUNICABLE

DISEASES

Navy and Marine Corps personnel are exposed to a

wide variety of environmental conditions, including

climatic extremes, stressful situations, and close living

quarters. Many of these personnel travel to foreign

lands where conditions may not only be unsanitary, but

where a high level of disease may also exist.

Preventive medicine’s major role is to minimize

disability by emphasizing immunization programs.

Immunizations

Vaccines used to protect Navy and Marine Corps

personnel against certain diseases before exposure to

infection are called prophylactic immunizations.

Prophylactic immunizations are limited to very serious

diseases for which effective and reliable immunizing

agents have been developed.

Immunizations procured for the Armed Forces are

required to meet the minimum standards set by the

Department of Health and Human Services (DHHS).

Immunizations for Military Personnel

Navy and Marine Corps personnel are required to

be ready to deploy on a moment’s notice. To make sure

personnel are prepared for deployment, you should

review their immunization records on a routine basis,

and, before deployments, also review BUMEDINST

6230.15, Immunizations and Chemoprophylaxis.

Initial and booster dosages and routes of administration are dictated by the vaccine manufacture, the U.S.

Public Health Service Immunization Practices

Advisory Committee (ACIP), or both.

Communicable Diseases

Communicable diseases, as the name implies, are

diseases that may be transmitted from a carrier to a

susceptible host. They may be transmitted from an

infected person or animal or indirectly through an

intermediate host, vector, or inanimate object. The

illness produced is the result of infectious agents

invading and multiplying in the host, or from the

release of their toxins (poisons).

An important step in the control of communicable

disease is the expedious preparation and submission of

the Medical Event Report. Instructions and

requirements for reporting to local, state, national, and

international health authorities can be found in the

preface of the Control of Communicable Diseases

Manual, NAVMED P-5038. In addition, you should

follow instructions for the Medical Event Report

(MER), BUMEDINST 6220.12, when reporting

10-4
communicable diseases affecting Navy and Marine

Corps personnel.

WATER SUPPLY

A hygienically safe and continuously dependable

water supply is a necessity of life. Drinking water

should be free of disease-producing organisms,

poisonous chemicals, as well as from objectionable

color, odor, and taste. For more detailed instruction on

these topics, you should review the Manual of Naval

Preventive Medicine, NAVMED P-5010.

Water Supply Ashore

With rare exceptions, Navy and Marine Corps

activities ashore within the continental limits of the

United States are situated where a municipal water

supply is available. BUMEDINST 6240.1, Standards

for Potable Water, sets drinking water standards for

U.S. naval establishments worldwide, both ashore and

afloat.

Water Supply in the Field

Hospital Corpsmen are frequently called upon to

approve field water sources and to recommend

disinfection methods before water is considered safe to

drink. Consider water acquired in the field as unsafe

until it has been disinfected and tested. Approval of

water sources should be based on a thorough

surveillance of available water sources.

WATER QUANTITY REQUIREMENTS.—

The daily water requirements for personnel in the field

vary with a number of factors, including the season of

the year, geographical location, and the tactical

situation. Personnel who do not drink enough water

can quickly become dehydrated both in extremely hot

or extremely cold climates.

WATER TREATMENT.—Water treatment is the

process of purifying water to make it potable (safe to

drink). Various processes can be used to purify water.

These processes include aeration, coagulation,

flocculation, filtration, reverse osmosis, and

disinfection, all of which are discussed in depth in

NAVMED P-5010.

Water Supply Afloat

Potable water for shipboard use comes from one of

several sources: the ship’s distillation plant,

shore-to-ship delivery, or ship-to-ship transfer. The

ship’s medical department is responsible for

determining the quality of the water. The ships

engineering section determines the quantity stored or

produced, and performs the actual chlorination or

bromination.

Water Testing

Naval vessels follow water testing requirements

and procedures outlined in the latest edition of

Standard Methods for the Examination of Water and

Wastewater, published by the American Public Health

Association (APHA), American Water Works

Association (AWWA), and the Water Pollution

Control Federation (WPCF).

Manufacture and Handling of Ice

Most ships and shore activities use ice machines to

make ice. To reduce bacterial growth, ice used around

food or in food or drink must be made from potable

water. All ice must be prepared in a sanitary manner

and afforded the same protection as potable water. The

medical departments aboard ships are required to

include ice samples in any bacteriological analyses

they perform on water.

WASTEWATER TREATMENT AND

DISPOSAL

Wastewater is the spent water of a ship, base,

industrial plant, or other activity. This spent water

contains wastes, such as soil, detergent, and sewage.

The proper disposal of these waste materials is one of

the most important measures for controlling

water-borne diseases, such as cholera and typhoid

fever.

Wastewater Treatment and Disposal

Systems Ashore

The use of approved municipal or regional

wastewater collection and disposal systems is the

preferred method for disposing of wastes from shore

activities. Accordingly, municipal or regional

wastewater disposal systems are used by Navy shore

activities whenever feasible.

Wastewater Treatment and Disposal

Systems Afloat

The overboard discharge of untreated sewage from

DoD ships within the navigable waters of the United

10-5
States and the territorial seas (within three nautical

miles of shore) is prohibited by federal law. To comply

with the law, naval vessels are being equipped with

marine sanitation devices (MSDs) that either treat

sewage before discharge or collect and hold it until it

can be properly disposed of through dockside sewer

connections or pumped overboard in unrestricted

waters. For more detailed instruction on these topics,

you should review Manual of Naval Preventive

Medicine, NAVMED P-5010.

SECTION SUMMARY

This section discussed basic information

pertaining to sanitation, habitability management, pest

and vector control, food-borne illness, food-service

sanitation, food-service inspections, and food-borne

illness outbreak investigations.

We also discussed communicable diseases, water

supply, and wastewater treatment and disposal

procedures. This section discussed information on the

safe and proper handling of potable water, bacteriological tests, treatment, and disinfection. A general

review of wastewater treatment and disposal procedures

for shore and afloat activities was also included in this

section.

SUMMARY

This chapter has provided a general overview on a

variety of fundamental dental conditions and

preventive medicine situations. Because of the nature

of our rating and the many responsibilities placed upon

us, Hospital Corpsmen must have a general understanding of many areas of medicine. Dentistry and

preventive medicine practices are two of those areas.

For additional detailed information on these subjects,

you should refer to the references listed at the

beginning of this chapter.

10-6
CHAPTER 11

PHYSICAL EXAMINATIONS

The Department of Defense has established

uniform physical standards for all members of the

military service. Physical examinations are conducted

to interpret each individual’s physical qualification for

initial entry, mobilization, retention, assignment to

special duties, and training programs that lead to

enlistment and commissioning. The purpose of the

examination is to identify physical defects and

psychological problems that would compromise a

member’s ability to perform duties normally assigned.

Physical standards are intended to preclude acceptance

of those individuals who present contagious or

infectious hazards to other personnel, would be unable

to perform assigned duties, or who have conditions

likely to be aggravated by naval service.

The purpose of this chapter is to review the various

types of physical examinations and their requirements,

provide a general understanding of how physical

examination forms and reports are completed, and

cover some of the testing procedures and equipment

for which you may be responsible. In your capacity as

a Hospital Corpsman, you will function as both clerical

and medical assistant to the medical examiner. To do

this properly, you should be familiar with

administrative regulations that apply to physical

examinations. You should also ensure the patient’s

health record is correct and complete, all tests and

laboratory results are recorded, and the completed

report of medical examination and history are properly

filed in the member’s health record.

TYPES OF PHYSICAL EXAMINATIONS

LEARNING OBJECTIVE: Differentiate

between the types of physical examinations.

Physical examinations, whether routine or special

duty, are mandatory for members at certain times

during their military careers. The first of these

examinations is the entrance (enlistment, appointment,

or commissioning) physical examination, and the last

is the physical examination that occurs upon

separation from the service. In addition to these two,

there may be several others, depending on the length of

the member’s service or special duty requirements.

Physical examinations of Marine Corps and Navy

personnel, active and reserve, are performed by Navy

medical officers or other credentialed providers. If a

Navy medical officer or credentialed provider is not

available, the medical examination may be performed

by a Department of Defense (DoD) physician or

credentialed civilian contracted physician. Dental

examinations are normally performed by Navy dental

officers. For further information on dental

examinations for naval reserve personnel, refer to the

Manual of the Medical Department (MANMED),

NAVMED P-117.

Most physical examinations will require special

studies (tests). Some of these special studies (which

will be performed in advance of the physical

examination by the medical examiner) may include

laboratory tests to detect syphilis (RPR), HIV, and

cholesterol levels; optometric evaluation to determine

visual acuity; audiometric testing for hearing

capabilities; and dental examination to determine

dental fitness. For more information on special study

requirements for each type of physical examination,

refer to the MANMED and directives that address

specific physical examinations.

ROUTINE PHYSICAL EXAMINATIONS

Essentially, there are four types of routine physical

examinations you should know about. They are the

entrance, periodic, reenlistment, and separation

physicals. The MANMED provides specific

instructions on how and when each type of physical is

to be conducted.

Entrance (Enlistment, Appointment, and

Commissioning) Physical Examination

The Department of Defense (DoD) establishes the

standards for entry into military service (DoD

Directive 6130.3). Entry physical standards for

training programs leading to officer appointment are

more stringent than the basic physical qualifications

for enlistment or commissioning. This policy ensures

qualification of the member at the time of his

appointment.

11-1
Entrance physical examinations are normally

performed at Military Entrance Processing Stations

(MEPS). Entrance physical examination results are

documented on the Report of Medical Examination

(SF-88) and Report of Medical History (SF-93). The

original completed physical examination forms are

permanently filed in the member’s health record.

Copies of the completed examination forms are filed

by the examining facility for a specified period of time.

(See MANMED for current physical examination

disposition requirements.) This policy applies to all of

the physical examinations service members may have

throughout their career. The forms used for the

entrance physical (SF-88 and SF-93) are also used for

many of the routine and special duty physical

examinations that will be discussed in more detail later

in this chapter.

Periodic Physical Examination

The purpose of the periodic examination is to

determine physical qualification for retention on

active duty and to maintain current medical data

regarding physical qualification of personnel.

Retention standards are not the same as entrance

standards; the prime consideration for retention is the

ability to continue active service. The periodic

physical examination evaluates the member’s current

state of health. The examination also includes

documentation of chronic or unresolved medical

complaints from injuries or illnesses incurred during

military service or complaints or injuries that may have

existed before induction. The periodic physical

examination is conducted at the intervals prescribed in

the MANMED.

If the examining medical officer determines a

defect exists that he cannot adequately evaluate, a

consultation or referral for further evaluation may be

initiated. If the defect is severe enough, the member

may be referred to a medical board. Amedical board is

convened to evaluate and report on the diagnosis;

prognosis for return to full duty; plan for further

treatment, rehabilitation, or convalescence; estimate

the length of further disability; and provide medical

recommendations for disposition of the service

member being evaluated.

A member may be considered physically qualified

(PQ) despite the presence of certain medical

conditions. However, if it is clearly determined that

the condition interferes with the member’s capability

of functioning in the naval service effectively, the

member may be processed for an administrative or

medical discharge. Additional guidance is provided in

the Military Personnel Manual (MILPERSMAN) and

applicable Navy and Marine Corps directives.

Reenlistment Physical Examination

The purpose of the reenlistment physical

examination is to determine if service members are

physically qualified to be retained on active duty. A

complete medical examination is not required if there

is a valid examination (i.e., entrance, periodic, or

special duty physical) in the service member’s service

record. The reenlistment physical consists of a

medical record review and documentation of medical

conditions that may need consideration or further

inquiry by healthcare providers. The service member

will also be interviewed by a healthcare provider.

Reenlistment criteria specified in the MANMED

should be followed during the health record review and

the interview of patient.

The results of the reenlistment physical

examination are recorded on form SF-600, Chronological Record of Medical Care. The healthcare provider

will indicate on the SF-600 if the service member is

physically qualified for reenlistment. After the

physical examination is completed, the SF-600 will be

filed in the member’s health record.

Separation Physical Examination

Before being released from active duty, members

receive a thorough physical examination. If the

separation is the result of an evaluation by a medical

board, the medical board report serves as the document

for the physical examination.

Members who separate from the service—for any

reason (i.e., retirement, end-of-enlistment, or

administrative discharge)—are required to read the

following statement at the time of their physical

examination:

You are being examined because of your

separation from active duty. If you feel you

have a serious defect or condition that

interferes, or has interfered, with the

performance of your military duties, advise

the examiner. If you are considered by the

examiner to be not physically qualified for

separation, you will be referred for further

evaluation, and, if indicated, appearance

before a medical board. If, however, you are

found physically qualified for separation, any

defects will be recorded in item 74 of the

11-2
SF-88 or on an SF-600. Such defects, while

not considered disqualifying for military

service, may entitle you to certain benefits

from the Department of Veterans Affairs

(DVA). If you desire further information in

this regard, contact the DVA office nearest

your home after your separation.

In the case of a service member separating from the

Navy or Marine Corps before completion of 90 days of

service, a similar statement as above must be read by

the separating member. Refer to article 15-29 of the

MANMED for this statement. In either case the

separating member will be requested to sign the

following entry in item 73 on the SF-88 or the SF-600.

I have been informed of and understand the

provisions of article XX-XX of the Manual of

the Medical Department.

Refusal of the member to sign this statement will

not delay separation. Rather, the examiner will note in

item 73 of the SF-88 or on the SF-600 that the

provisions of MANMED article XX-XX have been

fully explained to the member, who declined to sign a

statement to that effect. Give each member released

from active duty a signed, legible copy of the SF 88 or

SF-600.

SPECIAL DUTY PHYSICAL

EXAMINATIONS

Military personnel who are assigned to or applying

for special duty such as aviation duty, diving duty,

submarine duty, etc., are required to meet physical

requirements above the basic entrance examination

requirements. In addition, personnel are required to

have a special duty physical if they have psychosocial

considerations, are exposed to extreme physical

hazards, or if they are to be assigned to sites with

inadequate medical facilities. Other special duties

requiring preplacement examinations include

handling explosives, operating explosives vehicles,

and duty as a fire fighting instructor. Specific details

for each type of special duty physical examination is

delineated in the MANMED.

As with routine physicals, special duty physical

examinations are performed by medical officers or

DoD civilian physicians. For operational units

(squadrons or groups), the medical officer assigned

will normally perform special duty examinations. If

there is not a unit medical officer, a medical officer

assigned to a supporting clinic, hospital, or related

operational unit should perform the examination.

Physician assistants (PAs) and nurse practitioners may

perform special duty examinations if a medical officer

or DoD physician is not available or if the examination

workload is too great. When a PA or nurse practitioner

performs special duty examinations, the examination

MUST be countersigned in block 80 of the SF 88 by a

physician.

Physical examinations for special duty applicants

must be completed before reporting for their special

duty assignment. If a service member is determined by

the medical examiner to be “not qualified for special

duty,” the member can usually remain in the service

but will not be given special duty assignments. To

maintain special duty status, service members may

have more frequent physical examinations than service

members not on special duty status. Validity periods

for special duty physicals are discussed in the

MANMED. Also, refer to Navy directives that apply

to specific special duty examinations for current

information on physical qualifications.

OVERSEAS/OPERATIONAL SUITABILITY

SCREENING EXAMINATIONS

Upon receipt of accompanied orders overseas or to

a remote assignment, the member and, as applicable,

his family members will be screened to determine their

physical and psychological suitability for transfer.

Service members and families who are not screened—

or who are improperly screened—can arrive at a duty

station with requirements beyond the capability of the

local medical, dental, educational, or community

facilities. This may result in decreased quality of life,

early return from assignment, billet gaps, etc. Proper

screening helps ensure a positive and productive tour

for the service member. All screening should be

completed within 30 days of receipt of orders.

OCCUPATIONAL HEALTH MEDICAL

SURVEILLANCE EXAMINATIONS

The Navy uses many materials in its work places,

some of which are potentially hazardous to personnel.

To minimize the risk associated with these hazardous

substances, the Navy developed the Navy

Occupational Safety and Health (NAVOSH) Program,

OPNAVINST 5100.23. Within the NAVOSH Program

is the Medical Surveillance Program. The Medical

Surveillance Program provides physical examination

and medical monitoring guidelines for personnel who

are exposed to or work with hazardous materials.

11-3
Medical surveillance examinations assess the

health status of individuals as it relates to their work.

Although these exams are not physical examinations

as described in this chapter, they are actually

surveillance examinations that produce specific

information with regard to an individual’s health

during actual or potential exposure to hazardous

materials (i.e., the Asbestos Medical Surveillance

Program [AMSP]). Specific guidance on the Asbestos

Medical Surveillance Program is provided in

OPNAVINST 5100.23. Another example of a medical

surveillance program is the Occupational Noise

Control and Hearing Conservation Program.

Personnel who work in areas of high sound generation

(e.g., flight deck of carrier) must be evaluated

periodically for hearing loss. Specific guidance on the

Occupational Noise Control and Hearing

Conservation Program is provided in

NAVMEDCOMINST 6260.5 and OPNAVINST

5100.23.

MEDICAL BOARD EXAMINATIONS AND

REPORTS

Medical review boards are the single most

important factor in determining fitness for duty in

today’s Navy. Medical boards are convened and

reviews are conducted to determine the various

degrees of fitness for military service. Local

(re)evaluations are scheduled to assess patient

progress and length of limited duty, or need for a

formal evaluation at NAVPERSCOM or the Physical

Evaluation Board (PEB). The following examples

illustrate the legal guidelines, requirements, and job

descriptions for the different types of medical boards

and describe the duties of the personnel responsible.

Abbreviated Temporary Limited Duty (TLD)

Medical Board Report

The abbreviated board report is used only when a

member is expected to return to full duty after an

adequate period of treatment. Processing time should

not exceed 6 working days, and under most

circumstances, the report should be completed in 3

working days. The board report is a local action taken

by an appropriate medical or dental officer and does

not require external departmental review by

NAVPERSCOM. The form (NAVMED 6100/5) used

for this report is a multi-copy form. It is a vehicle for

recording basic medical findings, plans, and

expectations in terms of prognosis and length of

medical restriction of activity. It also provides for

parent command acknowledgment and comment. This

form serves as excellent input for the “putting

performance into practice” form in the member’s

health record; however, it is not a substitute for

detailed documentation of conditions in the member’s

health record. The Abbreviated TLD Medical Board

Report(NAVMED 6100/5) is to be used when all of the

following criteria are met:

• The member is enlisted in the U.S. Navy or

Marine Corps.

• The member suffers from an uncomplicated

illness or injury which makes them temporarily

unable to fully perform duties to which they are

assigned or expected to be assigned, but will

most likely be fit for full duty after an adequate

period of treatment not exceeding 8 months.

• The member’s health or clinical record contains

adequate documentation on the nature and

circumstances of the illness or injury, its course,

prognosis, and treatment.

Patient (Re)evaluation/TLD Duration

Once a member has been placed on TLD, the

physician, dental officer, or Independent Duty

Corpsman (IDC) (when in an independent operational

duty environment), will

• conduct a detailed treatment/rehabilitation

assessment and develop a treatment/ rehabilitation plan;

• ensure follow-up evaluations every 2 months,

documenting at each evaluation objective

findings of continued unsuitability, progress

toward recovery, findings and recommendations

of specialty evaluations, modifications to the

treatment/ rehabilitation plan, and prognosis for

return to worldwide assignability; and

• o btai n a p p r o val f r om NAVPERSCOM

(NPC-821) or CMC (MMSR-4), via the patient

administration Limited Duty (LIMDU)

Coordinator for periods of TLD less than 8

months, or via a formal board (NPC-821 or

MMSR-4) for periods longer than 8 months.

Approval must be obtained via formal board if the initial

recommended period of TLD exceeds 8 months, and the

total period a member can be on LIMDU must not

exceed 16 months.

11-4
Uncorrected Condition

If the servicemember’s condition cannot be

corrected during the initial or subsequent period of

TLD and treatment, or if it is clear that the condition

will continually interfere with or preclude his ability to

function effectively in an operational arena or to

deploy worldwide, notify the transferring or parent

command and NAVPERSCOM. Subsequent to the

second period of TLD, if appropriate, a Physical

Evaluation Board (PEB) will adjudicate the case. If the

PEB (in Washington, DC) finds the member “fit to

continue Naval Service,” NAVPERSCOM will direct

the command to initiate appropriate administrative

action, which may include a recommendation of

administrative separation (per MILPERSMAN

1910-120).

Formal Board Report

If conditions warrant (i.e., when the period of

recovery is expected to exceed 8 months), the

physician or dental officer will dictate a formal board

report in accordance with SECNAVINST 1850.4 and

MANMED, chapter 18, for submission to NAVPERSCOM (NPC-821). The LIMDU Coordinator is

responsible for reviewing the medical board, verifying

the content and that the processing time is consistent

with current policy. However, a command

endorsement is not required on a formal board.

COMPLETING REQUIRED FORMS

LEARNING OBJECTIVE: Select the

appropriate form(s) used for physical

examinations and recall how each form

should be completed.

While there are several forms used to record

physicals, the scope and purpose of the physical

dictates which form or forms should be used. For

example, the preplacement and annual physical

evaluation of food service personnel or personnel

exposed to hazardous materials can, in most cases, be

adequately documented on an SF 600. This section

discusses the most commonly used physical examination forms.

REPORT OF MEDICAL EXAMINATION,

SF 88

The SF 88, Report of Medical Examination, is the

principal document for recording a complete physical

examination (figs. 11-1 and 11-2). The SF 88 is, like

most medical documentation, a legal document.

Entries on the form must be legible. If you make a

typographical or clerical error, correct the entry by

drawing a single line through the erroneous entry,

initialing above the error, and making the corrected

entry in the same block. If space is not available in that

block, make the corrected entry in block 42

(identifying the erroneous entry by number). Chapter

16 of the MANMED provides specific details on

information for each block to complete this form

properly.

Stamps are used routinely by many naval medical

facilities to incorporate routine information or data

onto medical documents, as illustrated in blocks 50 and

73 of figures 11-1 and 11-2. The use of stamps must,

however, be in accordance with physical examination

directives and the MANMED.

REPORT OF MEDICAL HISTORY, SF 93

The purpose of Standard Form (SF) 93, Report of

Medical History, is to provide a complete personal

medical history and to serve as a source of information

that supplements information reported on the SF 88.

The SF 93 provides a current, concise, and

comprehensive record of a service member’s personal

medical history before entering the service and any

subsequent changes in the member’s medical status.

After the military entrance examination, any

subsequent medical examinations that require the use

of the SF 88 will also require an SF 93 to be completed.

Any medical information entered by patients on the SF

93 is made only to document changes in medical

history since their last physical examination. If no

changes have occurred since the previous SF 93 was

generated, the examiner should enter “no significant

interval history” in block 25.

When you prepare the SF 93, complete items 1

through 7 in the same manner as you did the SF 88 (fig.

11-3). This information can be handwritten or typed.

Inform examinees that they are responsible for

completing items 8 through 25 (figs. 11-3 and 11-4).

Item 8 should contain a handwritten statement from

examinees regarding their present state of health and

any medications they may be taking. Items 9 through

24 are checked either “yes,” “no,” or “don’t know” by

the examinees. Assist examinees by explaining

unfamiliar medical terminology that appears on these

items. Helping them complete the form will ensure an

accurate accounting of the member’s medical history.

Keep in mind that the SF 93 is information of

11-5
11-6

HM3f1101

, Jr.

Jack R. Frost, Sr. (Father) , 1616 Abalone Lane,

Figure 11-1.—Example of completed front side of SF 88.
11-7

Figure 11-2.—Example of completed back side of SF 88.
11-8

HM3f1103

Figure 11-3.—Example of front side of SF 93.
11-9

HM3f1104

Figure 11-4.—Example of back side of SF 93.
significant or chronic disorders instead of one-time

events of minor illnesses or disorders.

An essential part of a complete physical

examination is the review of patient’s medical history.

The medical examiner is responsible for reviewing

items 9 through 24 of the SF 93. After reviewing these

items, the medical examiner uses item 25 to elaborate

on all “yes” responses (fig. 11-4). Examiners

document conditions considered disqualifying as

“CD” and those considered not disqualifying as

“NCD.” Examiner’s signature and identification

information should be documented at the bottom of the

back side of the SF 93.

SPECIAL DUTY MEDICAL ABSTRACT,

NAVMED 6150/2

The NAVMED 6150/2, Special Duty Medical

Abstract, is a record of physical qualifications, special

training, and periodic examinations of members

designated to perform special duty, such as aviation,

submarine, and diving. When members complete

special duty physical examinations and special

training, they should have entries made on their

NAVMED 6150/2. NAVMED 6150/2 entries require

the approval of a medical officer or designated

specialty medical service corps officer (i.e., aerospace

physiologist for aerospace physiology training).

If a special-duty-qualified service member is

found to be physically or mentally unfit, the service

member’s special duty status will be suspended either

temporarily or permanently. The reason(s) for the

member’s suspension and period of suspension are

recorded on the NAVMED 6150/2. Special pay

disbursements are often based on a member’s physical

and mental qualifications or continued requalification

for performance in a special duty.

PHYSICAL EXAM TESTING

PROCEDURES AND EQUIPMENT

LEARNING OBJECTIVE: Recall visual

acuity, color vision, audiometric, and EKG

test equipment and procedures.

Some of the basic procedures used to gather

information for a physical examination are taught in

Hospital Corpsman “A” School (e.g., vital signs,

venipuncture, and height and weight measurements).

However, other tests require advanced technical

expertise, such as serological testing, and pressure and

oxygen-tolerance testing. Some testing procedures

may be learned by on-the-job training (OJT) or by

short courses of instruction. These testing procedures

and the equipment used will be discussed in this

section.

VISUAL ACUITY

Visual acuity testing determines the ability of the

eye to discriminate fine detail. It is the most important

test of eye function. Throughout the Navy, there are

two accepted methods for testing visual acuity: the

Snellen chart and Jaeger cards, and the Armed Forces

Vision Tester. The Snellen chart and Jaeger cards are

used together to test visual acuity. The Snellen charts

test distant visual acuity; the Jaeger cards are used to

evaluate near visual acuity. The Armed Forces Vision

Tester checks both distant and near visual acuity, and

assists in evaluating other optical conditions.

The first step in testing for visual acuity is to find

out if the patient wears corrective eyewear. On the day

of their visual acuity testing, patients should bring in

their glasses. Contact lenses are not recommended for

use during visual acuity testing. Contact lenses cause

an increase in time needed for testing purposes, and

they tend to be an inconvenience for both the patient

and healthcare provider. Acuity testing is performed

with and without the glasses on, and the results are

documented in blocks 59 and 61 on the SF 88. Visual

acuity requirements are discussed in the MANMED.

Snellen Charts

Probably the most familiar of the visual testing

equipment, Snellen charts, are the preferred method

for testing distant visual acuity. Snellen charts can test

both monocular and binocular visual acuity.

Operational guidelines for Snellen charts are provided

by the chart’s manufacturer. Your local military

optometrist or eye clinic can also provide you

operational guidelines for Snellen charts. Specific

details and current conditions for testing with Snellen

charts are as follows:

• If the examinee wears corrective lenses, have

them remove the lenses before the examination.

Test the examinee first without corrective lenses,

and then with the corrective lenses in place.

• Hang the chart on the wall so the 20/20 line is 64

inches from the floor. Direct the examinees to

stand 20 feet from the chart. Test each eye

11-10
individually, then both eyes together. Do not

allow the examinee to squint or tilt his head.

• With the graduation of the size of the letters

advocated by Snellen, the visual acuity is

expressed according to his classical formula V =

d/D, where “d” is the distance at which the letters

are read, is divided by “D” the distance at which

the letters should be read. Then record the

smallest line read on the chart from the 20-foot

distance as the vision; e.g., 20/20, 20/200.

Jaeger Cards

When the Armed Forces Vision Tester is not

available, Jaeger cards are used to test near vision.

There are six paragraphs on each card. Each paragraph

is printed in a different size type and labeled as J-1 (the

smallest print size), J-2,..., up to J-6.

When testing with these cards, you should hold the

card at a distance of 14 to 16 inches from the examinee

and tell the examinee to read the paragraphs. Record

the visual acuity as the smallest type he can

comfortably read and record the distance (e.g., J-2 at

14 inches).

NOTE: The distance of the card from the

examinee may be converted to centimeters,

but ensure the results of the test are also

recorded in centimeters. Consistency is the

key.

Armed Forces Vision Tester

The Armed Forces Vision Tester (AFVT) is a

semiportable machine that has the capability to test

near and distant visual acuity, horizontal and vertical

phorias, and stereopsis (depth perception). It consists

of two rotating drums that hold illuminated slides. The

handles on the side of the machine rotate the drums to

change the slides. A scoring key and instruction

manual are provided with the machine.

COLOR VISION TESTING

The Manual of the Medical Department requires

that all applicants for the naval service receive a color

vision test. The Navy has two methods of testing color

discrimination: the Farnsworth Lantern Test

(FALANT) and the pseudoisochromatic plates (PIP).

The FALANT is the preferred test, and in many cases it

is the test prescribed by the MANMED as the only

acceptable method for testing color vision.

Farnsworth Lantern Test

The purpose of the Farnsworth Lantern Test is to

evaluate color perception. The Farnsworth Lantern is a

machine with a light source directed at the examinee.

What the examinee sees is two lights in a vertical

plane. These lights appear in two of three possible

colors, either red, green, or white, shown in varying

combinations. The examinee is asked to identify the

color combinations from top to bottom at a distance of

8 feet; the examiner rotates the drum to provide the

different combinations. The examinee must identify a

total of nine different combinations.

On the first run of nine lights, if the examinee

correctly identifies all nine, the FALANT is passed. If

the examinee incorrectly identifies any of the lights,

two additional runs of nine lights are performed

without interruption. The score is the average number

of incorrectly identified lights of the second two runs.

If the average score is 1 or less, the FALANT is passed.

If the score is 2 or more, the FALANT is failed. If the

score is 1.5, the test should be repeated after a 5-minute

break. Do not retest scores of 2 or more since this will

invalidate the test procedure.

NOTE: If examinees wear corrective lenses

for distant vision, they should wear them

during this test.

Pseudoisochromatic Plates

If the FALANT is not available, pseudoisochromatic plates (PIP) are used to determine color

vision. Personnel so tested must be retested with the

FALANT at the first activity they report to that has a

Farnsworth Lantern. Two tests are available, the

18-plate test and the 15-plate test, each of which

includes one demonstration plate not used for scoring.

When administering the PIP examination, you

should hold the plates 30 inches from the examinee.

Allow 2 seconds for each plate identification, and do

not allow the examinee to touch the plates. To pass the

18-plate test, the examinee must identify a minimum of

14 of the 17 test plates; for the 15-plate test, a minimum

of 10 of the 14 test plates. Record the score in block 64

of the SF 88 as PASSED PIP or FAILED PIP. Include

the number of correct responses (e.g., PASSED PIP 17

of 17 or FAILED PIP 10 of 17).

AUDIOGRAM

An audiogram is a record of hearing thresholds an

individual has for various sound frequencies. By

11-11
evaluating an individual’s frequency thresholds,

hearing deficiencies can be detected. To test an

individual’s frequency thresholds, the technician will

use an instrument called an audiometer (manual or

computerized). Audiometers used by the Navy are

calibrated to American National Standards Institute

(ANSI) specifications.

Upon entry into the service, a baseline audiogram

is performed and recorded on a DD 2215. Subsequent

audiometric test results are recorded on a DD 2216 and

performed as directed by OPNAVINST 5100.19 and

the MANMED. Audiometric testing shall be

performed only by personnel who have attended an

audiometric training course and have been certified.

All audiometric tracings or readings recorded on the

SF 88 or other medical documentation should contain

the certification number of the person performing the

audiometric test.

ELECTROCARDIOGRAM

An electrocardiogram is a record of electrical

impulses made by the heart. Electrocardiograms are

produced by an instrument called an electrocardiograph. The electrocardiograph is used to examine and

record electrical impulses produced by the contraction

of the heart muscle. Abbreviated either EKG or ECG,

the electrocardiogram is interpreted by a physician or

cardiologist to determine the heart rate and rhythm,

and evidence of any heart damage, especially damage

associated with a heart attack.

EKGs are currently performed as part of the

physical examination once the member reaches the age

of 40, and routinely thereafter. Otherwise, EKGs are

performed only as clinically indicated or required for

special duty. Refer to BUMED instructions for current

periodicity information on EKG testing. The Naval

Medical Department routinely uses EKGs with 12

leads for physical examinations performed on Navy

and Marine Corps personnel.

SUMMARY

A general review has been provided to you on

various types of physical examinations, their

requirements, and the documentation procedures of

commonly used physical examination forms. We have

also discussed physical examination testing equipment

and procedures that evaluate vision, hearing, and

cardiac function.

The physical examination is a key component of

the Navy Medical Department’s efforts to maintain the

health of Sailors and Marines during times of war and

peace. The importance of the physical examination

cannot be overstated. The combination of medical

history, medical testing, and medical examination

furnishes the healthcare provider with a complete

picture of the individual’s health. Any indications of

medical problems can be evaluated and managed more

expediently and effectively through the use of the

physical examination. Your assistance with medical

testing and your detailed document management will

ensure the patient receives the best possible medical

evaluation by the medical examiner. More in-depth

information is contained in the Manual of the Medical

Department, NAVMED P-117.

11-12
CHAPTER 12

HEALTH RECORDS

Just as the Personnelman is responsible for the

preparation and maintenance of the service record, so

you, the Hospital Corpsman, are responsible in the

same way for health records. A health record is the

official medical history of Navy and Marine Corps

personnel and eligible beneficiaries.

The military health record is an individual’s

chronological record of medical, dental, occupational

health evaluations, and treatments. The health record

is used by healthcare providers to plan and document

patient care treatment. The medical history provided

by the health record assists medical personnel who

perform physical examinations, physical fitness

evaluations, diagnosis decisions, and render care

incident to injury or disease.

The health record has significant medicolegal

value to the patient, the medical treatment facility

(MTF) and dental treatment facility (DTF), the

practitioner responsible for the patient, and the U. S.

Government. For example, if a military member or

eligible beneficiary is injured by a nonmilitary

individual (e.g., car accident) and the naval hospital

provides medical care, the naval hospital would, in

turn, bill the nonmilitary individual or his insurance

company (third-party payer) for the medical services it

provided the injured military member or beneficiary.

To justify the naval hospital’s billing, send copies of

medical documents from the injured individual’s

health record pertaining to the injury and subsequent

treatment(s) to the third-party payer. Third-party

payers depend substantially upon the information

recorded in the medical record. Also, various officials

and boards (i.e., special duty boards and medical

boards) refer to information furnished by the health

record in determining physical fitness or physical

disability.

The health record provides statistical data for

medical research, utilization management, risk

management, and quality assurance. For all the

reasons mentioned here, accurate and complete record

entries and proper medical record maintenance are of

the utmost importance.

This chapter will discuss the requirements for

opening, maintaining, verifying, and closing active

duty and reserve personnel health records. Use of

medical forms and form filing procedures will also be

covered. For further details and up-to-date guidelines

on health record management, as well as differences

between medical records established by deployable

units or under combat conditions, refer to chapter 16 of

the Manual of the Medical Department (MANMED)

and pertinent instructions or notices.

PRIMARY AND SECONDARY

MEDICAL RECORDS

LEARNING OBJECTIVE: Identify the

various types of primary and secondary

medical records, and recall the usage of

each type.

Primary medical records are the original records

established to document the continuation of care to

service members (active and retired) and their

beneficiaries. Secondary medical records are

established by a patient’s healthcare provider and

contain specific medical information needed by that

healthcare provider. Secondary medical records are

maintained separate from the primary medical record.

PRIMARY MEDICAL RECORDS

Three major categories of primary medical records

are health records (HRECs), outpatient records

(ORECs), and inpatient records (IRECs). Dental

records (DRECs) are part of HRECs and ORECs.

Health Record

The HREC is a file of continuous care given to active

duty members and documents all their outpatient care.

While the HREC primarily documents ambulatory

(outpatient) care, copies of inpatient narrative summaries

and operative reports are also placed in the HREC to

provide continuity of healthcare documentation.

Outpatient Record

The OREC is a file of continuous care that

documents ambulatory treatment received by a person

other than an active duty person.

12-1
Inpatient Record

The IREC is a medical file that documents care

provided to a patient (inpatient) assigned to a

designated inpatient bed in an MTF or ship.

SECONDARY MEDICAL RECORDS

Secondary medical records are separate from the

primary medical record and must follow the guidelines

established by the MANMED and the local medical

records committee. These records are kept in a

separate file secured in a specialty clinic or department

of fixed MTFs (e.g., naval hospitals and branch

medical clinics). The secondary medical records

include convenience records, temporary records, and

ancillary records.

Because primary healthcare providers of active

duty personnel must be aware of their crew’s medical

status at all times, temporary and ancillary records will

not be opened or maintained for active duty personnel.

The exceptions to this policy are records for

obstetrics/gynecology (OB/GYN), family advocacy,

and psychology and psychiatry clinical records.

The healthcare provider creating a secondary

medical record should write a note stating the nature of

the secondary record, the patient’s diagnosis, and the

clinic or department name, address, and telephone

number on the NAVMED 6150/20, Summary of Care,

of the patient’s primary medical record. The

healthcare provider should make a second note entry

on the NAVMED 6150/20 when the secondary record

is closed.

Convenience Record

A convenience record contains excerpts from a

patient’s primary record and is kept within the MTF by

a treating clinic, service, department, or individual

provider for increased access to the information.

When the convenience record’s purpose has been

served, the establishing clinic, service, department, or

provider purges the record from its file, compares it to

the primary medical record, and adds any medical

documents that are not already in the primary medical

record.

Temporary Record

A temporary record is an original medical record

established and retained in a specialty clinic, service,

or department in addition to the patient’s primary

medical record. Its purpose is to document a current

course of treatment. The temporary medical record

becomes a part of the primary medical record when the

course of treatment is concluded. This record is most

commonly established in OB/GYN for a prenatal

patient.

Ancillary Record

Ancillary records consist of original healthcare

documentation withheld from a patient’s primary

HREC or OREC. In certain cases it may be advisable

to not file original treatment information in the primary

treatment record, but instead place this information

into a secondary medical record, to which the patient,

parent, or guardian has limited access. Examples of

such instances include information that is potentially

injurious to the patient, or information that requires

extraordinary degrees of protection (such as

psychiatric treatment or instances of real or suspected

child or spouse abuse, etc).

THE MEDICAL RECORD

LEARNING OBJECTIVE: Recall

custody guidelines for medical records.

All medical records are the property of the U.S.

Government and must be maintained by MTFs (naval

hospitals, medical clinics, and medical departments of

ships, submarines, aviation squadrons, and isolated

duty locations) that have primary cognizance over the

care of the patient. Medical records are of continuing

long-term interest to the government and the patient

and must be maintained within an MTF. Patients may

not retain original HRECs, ORECs, or dental records.

Hand-carrying medical records by unauthorized

individuals (e.g., spouses or siblings of the patient)

without written permission is prohibited.

HEALTH RECORD CUSTODY

The HREC is retained in the custody of the medical

officer on the ship, submarine, or aviation squadron to

which the member is assigned. For those ships,

submarines, and aviation squadrons that do not have

medical officers, the health record may be placed in the

custody of the medical department representative

(MDR) at the discretion of the commanding officer

(CO). Examples of MDRs are Independent Duty

Corpsman or Squadron Corpsman. When Medical

12-2
Department personnel are not assigned, the CO may

assign custody of the health records to the local

representatives of the Medical Department who

generally furnish medical support. The custody of

health record by an individual is not permitted.

Health records are subject to inspection at any time

by the commanding officer, superiors in the chain of

command, the fleet medical officer, or other authorized

inspectors. The health record is for official use only,

and adequate security and custodial care are required.

There are many methods of providing adequate

security and custodial control of health records. In

general, health records should be stored in such a

manner as to be inaccessible to the crew or general

public. No records or record pages should be left

unattended. This precaution also helps to prevent loss

or misplacement of records.

Medical Department personnel will maintain a

Health Records Receipt, File Chargeout, and

Disposition Record, NAVMED 6150/7, for each health

record in their custody. The completed charge out form

should be retained in the file until the record is

returned.

Medical officers or MDRs are responsible for the

completeness of required health record entries while

the record remains in their custody.

CROSS-SERVICING HEALTH RECORDS

The HREC of a Navy or Marine Corps member is

normally serviced by personnel of the Medical

Department of the Navy. However, if a Navy or

Marine Corps member is performing an assignment

with the Army or the Air Force, the health record may

be serviced by Army or Air Force Medical Department

personnel. This management of the health record may

be done if the attendant service interposes no objection

and considers the procedure feasible. Reciprocal

procedures for servicing the health records of Army or

Air Force personnel by personnel of the Medical

Department of the Navy will be maintained whenever

feasible, and if requested by authorized representatives

of those services.

DEALING WITH LOST, DESTROYED, OR

ILLEGIBLE HEALTH RECORDS

When a HREC is lost or destroyed, the HREC

custodian will open a replacement health record. The

designation “REPLACEMENT” will be prominently

entered on the jacket and all forms replaced. A brief

explanation of the circumstances requiring the

replacement and the date accomplished should be

entered on SF 600, Chronological Record of Medical

Care. If the missing record is subsequently recovered,

the information or entries in the replacement record

will be inserted in the original record.

The HREC or any part of it should be duplicated

whenever it becomes illegible or deteriorates to the

point that it may endanger its future use or value as a

permanent record. The duplicate record or duplicate

portion must reproduce as closely to the original as

possible. Pay particular attention to detail when you

transcribe this information. When you duplicate an

entire health record, place the designation

“DUPLICATE RECORD” prominently on the front of

the jacket above the wo rding OUTPAT IENT

MEDICAL RECORD.

When you duplicate only part of the record,

identify the individual forms by printing

“DUPLICATE” at the bottom of each form. Enter the

circumstances necessitating the duplication and the

date accomplished on an SF 600. Microfiche all forms

replaced for protection and preservation, and make the

envelope a permanent part of the medical record. On

front of the envelope, record the member’s full name,

FMP (family member prefix) and SSN, date of birth,

and list the original forms contained in the envelope.

If microfilming is not available to the MTF, place

the original health forms (except forms contaminated

with mold or mildew) inside a plain envelope for

preservation and make them part of the permanent

record. On the front of the envelope, record the

member’s identifying data (same as microfiche

envelope) and list the contents of the envelope. Mark

the envelope “ORIGINAL MEDICAL RECORDS

—PERMANENT” and file as the bottommost item in

part 2 of the 4-part health record jacket.

DISPOSING OF HEALTH RECORDS

DURING HOSPITALIZATION

When a patient is transferred to an MTF, the HREC

should accompany the patient. If members are

admitted to a military hospital while away from their

command, their HRECs should be forwarded as soon

as possible to the hospital. If a discharged member is

directed to proceed home and await final action on the

recommended findings of a physical evaluation board,

an entry to this effect should be recorded in the HREC.

If a member is admitted to a civilian hospital for

treatment involving brief periods of hospitalization,

12-3
the HREC should be retained by the activity until

disposition is completed. The HREC will then be

forwarded to the cognizant office of medical affairs or

to the activity designated by the Commandant of the

Marine Corps (CMC) for Marine Corps members. In

instances where the parent activity retains the HREC, a

summary of the hospitalization will be entered on an

SF 600 when the member returns to duty.

When a member is hospitalized at a medical

facility of a foreign nation, an entry of this fact should

be made in the HREC. The HREC should be retained

on board and continued until the patient either returns

to duty or is transferred to another U.S. Navy vessel or

U.S. military activity. Upon departure of the vessel

from the port, the HREC should be delivered to the

commanding officer for inclusion in the member’s

service record for forwarding to the nearest U.S.

embassy or consulate.

SECURITY AND SAFEKEEPING OF

MEDICAL RECORDS

LEARNING OBJECTIVE: Recall

security and safekeeping procedures for

medical records.

Each MTF or medical department develops

policies to ensure that medical records are secure and a

patient’s privacy is protected. Security and

safekeeping are major concerns and responsibilities of

staff handling medical records. The medical record

contains information that is personal to patients,

treated as privileged information, and protected by the

Privacy Act of 1974. The Privacy Act of 1974 protects

a patient’s right to privacy in respect to personal

medical information. The Privacy Act permits only the

patients and their legal representatives to obtain this

information.

Medical facilities or departments should take

precautions to avoid compromise of medical

information during the movement and storage of

medical records. Medical records should be handled

by only authorized medical service personnel.

Records should be stored in a locked area, room, or file

to ensure safekeeping, unless there is a 24-hour watch

in the records room. Refer to the MANMED for more

detailed guidelines on medical record security and

safekeeping.

RELEASING MEDICAL INFORMATION

LEARNING OBJECTIVE: Recognize

guidelines for releasing medical

information.

The Surgeon General (also titled Director, Naval

Medicine) is the official responsible for administering

and supervising the execution of SECNAVINST

5211.5, Department of the Navy Privacy Act Program

(PAP), as it pertains to the Health Care Treatment

Record System. Additionally, the Office of the

Surgeon General authorizes requests for access and

amendment to naval members’ medical and dental

records.

Commanding officers of Navy MTFs are

designated as local systems managers for medical

records maintained and serviced within their activities.

Local systems managers are authorized to release

information from health records located within the

command if proper credentials have been established.

The requesting office or individual will be advised that

such information is private and must be treated with

confidentiality. In all cases where information is

disclosed, an entry must be made on OPNAV Form

5211/9, Record of Disclosure-Privacy Act of 1974, and

should include the date, nature and purpose of the

disclosure, and the name and address of the person or

agency receiving the information. Maintain a copy of

any such disclosure requests.

GUIDELINES FOR RELEASING MEDICAL

INFORMATION

In the following paragraphs, we cover the policy

for release of record transcripts. As will be noted, the

appropriate rule for release to be implemented depends

upon the intended recipient of the record transcript.

1. Release to the Public. Information contained

in medical records of individuals who have undergone

medical or dental examination or treatment is personal

to the individual and considered private and privileged

in nature. Consequently, disclosure of such information

to the public would constitute an unwarranted invasion

of personal privacy. Such information is exempt from

release under the Freedom of Information Act.

However, MTF commanding officers may release

some information to the public or the press without the

patient’s or patient’s next of kin’s (NOK) consent. This

12-4
information is the patient’s name; grade or rate; date of

admission or disposition; age; sex; component, base,

station, or organization; and general condition.

2. Release to the Individual Concerned. Release

of healthcare information to the individual concerned

(patient) falls within the purview of the Privacy Act and

not the Freedom of Information Act. When individuals

request information from their medical record, it will be

released to them unless, in the opinion of the releasing

authority, it might prove injurious to their physical or

mental health. In such an event, the releasing authority

will request authorization from the patients to send their

medical information to their personal physician.

3. Release to Representatives of the Individual

Concerned. Upon the written request from patients,

healthcare information will be released to their

authorized representatives. If an individual is mentally

incompetent, insane, or deceased, the NOK or legal

representative must authorize the release in writing.

NOK or legal representatives must submit adequate

proof that the member or former member has been

declared mentally incompetent or insane, or furnish

adequate proof of death if such information is not on

file. Legal representatives must also provide proof of

appointment, such as a certified copy of a court order.

4. Release to Other Government Departments

and Agencies. When requested, healthcare

information will be released to other government

departments. These government departments and

agencies must have a legitimate need for the

information as listed in the “Routine Uses” section of

the Medical Treatment Records System, which is

annually set forth in SECNAVNOTE 5211, Systems of

Personal Records Authorized for Maintenance Under

the Privacy Act of 1974, 5 USC 552a (PL 93-579).

If the releasing authority is in doubt whether the

requesting department has a legitimate need for the

information, it will ask the requesting department to

specify the purpose for which the information will be

used. In some cases, the requesting department should

be advised that the information will be withheld until

the written consent of the individual concerned is

obtained.

RELEASING MEDICAL INFORMATION TO

FEDERAL AND STATE AGENCIES

In honoring proper requests, the releasing

authority should disclose only information relative to

the request. In the following three instances, for

example, departments and agencies, both federal and

state, may have a legitimate need for the information:

1. Health care information is required to process a

governmental action involving an individual. (The

Veterans Administration and the Bureau of Employees’

Compensation process claims in which the claimant’s

medical or dental history is relevant). If an agency

requests health care information solely for employment

purposes, a written authorization is required from the

individual concerned.

2. Health care information is required to treat an

individual in the department’s custody. (Federal and

state hospitals and prisons may need the medical or

dental history of their patients and inmates.)

3. Release to federal or state courts or other

administrative bodies. The preceding limitations are

not intended to prevent compliance with lawful court

orders for health records in connection with civil

litigation or criminal proceedings, or to prevent release

of information from health records when required by

law. If you have doubts about the validity of record

requests, ask the Judge Advocate General (JAG) for

guidance.

RELEASING MEDICAL INFORMATION

FOR RESEARCH

Commanding officers of MTFs are authorized to

release information from medical records located

within the command to members of their staff who are

conducting research projects. Where possible, the

names of parties should be deleted. Other requests

from research groups should be forwarded to Bureau

of Medicine and Surgery (BUMED) for guidance.

FILING HEALTH RECORDS

LEARNING OBJECTIVE: Recall filing

procedures for health records.

The Navy Medical Department uses the Terminal

Digit Filing System (TDFS) to file health records. In

this system, health records are filed according to the

terminal digits (last two numbers) of the service

member’s social security number (SSN), color coding

of the health record jacket, and use of a block filing

system.

To understand the TDFS filing system, you will

need to view the SSN in a different way. As you know,

12-5
the nine digits of the SSN are divided into three number

groups for ease in reading. This practice reduces the

chance of transposing numbers. For example, in the

TDFS system the SSN 123-45-6789 is visually

grouped and read from right to left (instead of left to

right), as follows:

On the health record, the family member prefix

(FMP) is added to the patient’s social security number.

The FMP is a system used by the Navy to show a

beneficiary’s relationship to the sponsor. For instance,

the FMP for active duty personnel is 20, while the FMP

for a spouse is 30 (fig. 12-1).

Under the Terminal Digit Filing System, the

central files are divided into 100 approximately equal

sections. Each section is identified by a maximum of

100 file guides bearing the 100 primary numbers, 00

consecutively through 99. Each of these 100 sections

contain records whose terminal digits correspond to

the section’s primary number (fig. 12-1). For

example, every record with the SSN ending in 56 is

filed in section 56.

Within each of these 100 sections, health records

are filed in numerical sequence according to their

secondary numbers. The secondary number is the

pair of digits immediately left of the primary number

(fig. 12-1).

To make filing of health records easier, health

record jackets are color-coded. The second to the last

digit of the SSN is preprinted on the jacket. The color

of the health record jacket corresponds to the

preprinted digit as follows:

Centralized files having records based upon more

than 200 SSNs, or a file of more than 200 records, may

need to use the TERTIARY (third) NUMBER in filing.

In a properly developed and maintained terminal-digit,

color-coded and block-filing system, it is almost

impossible to misfile a record. A record misfiled with

respect to the left digit of its primary number (for

example, a 45 that has been inserted among the 55s)

will attract attention because of its different record

jacket color. A record jacket misfiled in respect to the

right primary number (for example, a 45 that has been

inserted among the 42s) causes a break in the diagonal

pattern formed by the blocking within a color group.

Authorized exemptions from the requirements of

the TDFS are discussed in detail in the MANMED.

OPENING HEALTH RECORDS

LEARNING OBJECTIVE: Determine

when a health record should be opened,

and select the appropriate record jacket

and sequence of medical forms to be placed

within a new record.

This section will discuss the opening of active duty

HRECs. HRECs are opened when an individual

becomes a member of the Navy and Marine Corps,

when a member on the retired list is returned to active

duty, or when the original record has been lost or

destroyed.

When establishing the four-part health record, the

appropriate military health record jacket and required

forms must be current and assembled in accordance

with current directives.

OPENING HEALTH RECORDS FOR

ACTIVE DUTY OFFICERS

Recruiting offices open HRECs for civilian

applicants who are accepted for an officer

12-6

Primary Group Secondary Group Third Group

89 67 123-45

PRIMARY NUMBER

SECONDARY NUMBER

FIRST PART: TERTIARY NUMBER

SECOND PART: TERTIARY NUMBER

( 123-45* )

FAMILY MEMBER PREFIX (FMP) CODE

00-123-45-67-89

HM3f1201

Figure 12-1.—Example of social security number grouping

and family member prefix.

Preprinted Digit Jacket Color

0

1

2

3

4

5

6

7

8

9

Orange

Green

Yellow

Gray

Tan

Blue

White

Almond

Pink

Red
appointment. The health record is then forwarded to

the new officer’s first duty station.

Midshipmen or former enlisted members

appointed to commissioned officer or warrant officer

grade continue to use their existing HREC. The MTF

having custody of the record at the time of acceptance

of appointment will make necessary entries to indicate

the new grade and the designator or MOS. Also, the

record custodian should prepare summary information

entries on SF 600 and NAVMED 6150/4 to include

date, place, and grade to which the member was

appointed.

Health records of civilian candidates selected for

appointment to the Naval Academy should be prepared

at the Naval Academy at the time of appointment.

Health records for civilian applicants selected for

officer candidate programs should be opened upon

enrollment in the program.

OPENING HEALTH RECORDS FOR

ACTIVE DUTY ENLISTED PERSONNEL

The HREC is opened by the activity executing the

enlistment contract upon original enlistment in the

Navy or Marine Corps. An exception to this rule

involves service members who are enlisted or inducted

and ordered to immediate active duty at a recruit

training facility. In this instance, the HREC will be

opened by either the Naval Training Center (NTC) or

Marine Corps Recruit Depot, as appropriate. Copies of

the service member’s SF 88, Report of Medical

Examination, and SF 93, Report of Medical History,

are sent to the appropriate NTC or recruit depot, and

added to other applicable HREC forms in the

member’s HREC.

OPENING HEALTH RECORDS FOR

RESERVISTS

The Naval Reserve Personnel Center (NRPC),

New Orleans, is the HREC custodian for inactive

reserve personnel. In addition, NRPC is responsible

for the records’ preparation and maintenance. When

inactive reservists are called to active duty and their

HRECs have not been received by their duty station, a

request for their records should be initiated. Requests

for Navy personnel are sent to NRPC. Marine Corps

personnel requests are sent to the Marine Corps

Reserve Support Center. For Navy and Marine

Corps service members who were discharged before

31 January 1994, requests should be sent to the

National Personnel Records Center (NPRC) for

record retrieval. For service members who were

discharged after 31 January 1994, requests for record

retrieval are sent to the Department of Veterans

Affairs (DVA). Addresses of each of these activities

are listed in the MANMED.

PREPARING THE HEALTH RECORD

JACKET

A new military health record jacket, NAVMED

6150/20-29, should be prepared when an HREC is

opened or when the existing jacket has been damaged

or is deteriorating to the point of illegibility. The old

jacket should be destroyed following replacement.

Preparing the Outside Front Cover and

Inside Back Cover

A felt-tip or indelible black-ink pen should be

used to record all identifying data, except in the “Pencil

Entries” block on the upper left of the outer front cover

of the HREC. As indicated, information in this block

should be written in pencil, so it can be updated or

changed. Figure 12-2 illustrates the completed outside

front cover and inside back cover of a military health

record jacket.

RECORD NUMBERING.—Each health record

jacket has the second to the last digit of the SSN

preprinted on it. The preprinted digit also matches the

last digit of the form number (e.g., the preprinted digit

on NAVMED 6150/26 is 6). The color of the treatment

record jacket corresponds to the preprinted digit. In

preparing a member’s treatment record jacket, select a

prenumbered NAVMED 6150/20-29 jacket by

matching the second to the last number of the

member’s SSN.

SOCIAL SECURITY NUMBER.—Enter the

rest of the member’s SSN on the top of the inside back

cover. For members who do not have an SSN (e.g.,

foreign military personnel), use NAVMED 6150/29 as

the treatment record jacket. A“substitute” SSN should

be created for these members by assigning the numbers

“9999" as the last four digits of the SSN and assigning

the first five digits in number sequence (e.g., first SSN

000-01-9999, the second SSN 000-02-9999). Place a

piece of black cellophane tape over the number that

corresponds to the last digit of the SSN in each of the

two number scales on the inside back cover of the

HREC (fig. 12-2).

FAMILY MEMBER PREFIX.—Enter the

member’s family member prefix (FMP) code in the

two diamonds preceding the SSN on the top of the

12-7
inside back cover. Enter the FMP code of 20 for all

Navy and Marine Corps members. Enter an FMP code

of 00 for all foreign military personnel.

PATIENT’S NAME.—Enter the member’s full

name (last, first, middle initial, in that order) in the

upper-right corner. Indicate no middle name by the

abbreviation “NMN.” If the member uses initials

instead of first or middle names, show this by

enclosing the initials in quotation marks (e.g., “J”

“C”). Indicate titles, such as JR, SR, and III, at the end

of the name. The name may be handwritten on the line

provided or imprinted on a self-adhesive label and

attached to the jacket in the patient identification box.

ALERT BOX—In the lower center area of the

outside front cover, indicate in the alert box whether

the member has drug sensitivities or allergies by

entering an “X” in the appropriate box. If there are no

allergies or sensitivities, leave it blank.

RECORD CATEGORY.—Indicate the

appropriate record category by entering an “X” in the

box marked “Health Record” on the outside front

cover, just below the “Pencil Entries” block. Then

attach 1⁄2- inch red tape to the record category block on

the right edge of the inside back cover of the jacket; this

indicates it’s an active duty record.

PATIENT SERVICE AND STATUS.—Below

the record category box is the patient service and status

box. Mark an “X” in the appropriate service block.

SPECIAL CATEGORIES OF RECORDS.—

Identify the records of personnel assigned to special

duty or medical surveillance programs (e.g., personnel

reliability program, flight status, or the Asbestos

Medical Surveillance Program) by marking an “X” at

the appropriate special category entry listed below the

record category type.

Identify flag officers and general officers by

stamping or printing “FLAG OFFICER” or

12-8

Figure 12-2.—Sample of completed outside front cover and inside back cover of a health record jacket (NAVMED 6150/26.)
“GENERAL OFFICER,” as appropriate, on the lower

portion of the patient identification box. If a patient

identification label is used, print or stamp the

appropriate identification below the label.

PENCILENTRIES.—Following the instructions

on the front cover, pencil in the appropriate title (i.e.,

grade or rate, if on active duty; preferred form of

address, if retired or civilian), and include the current

command (if active duty).

RECORD RETIREMENT TAPE BOX.—

Leave the record retirement tape box on the inside back

cover blank.

BAR CODE.—Some Navy medical facilities

have bar coding capabilities. The bar code label

indicates the patient’s FMP, SSN, record type, and

record volume number. Affix the label to the front of

the record jacket in the box right of the alert box. If the

bar code is part of the patient identification label (such

as the patient identification label produced by the

Composite Health Care System (CHCS) computers),

place this label in the patient identification box.

LABELS.—Use of a self-adhesive label with the

name of the MTF, ship, or other units having custodial

responsibility for the record is optional. Ship or MTF

logos are permitted as long as the necessary patient

identifying information is not obscured. For further

details see the appropriate MANMED article covering

this subject.

Preparing the Inside Front Cover

Enter the following information in pencil on the

inside front cover of the HREC jacket. Record the

information in the inside of the front cover in pencil to

permit changes and updating.

• Date of arrival

• Projected departure date

• Home address and telephone number

• Duty station and telephone number

Preparing the Middle Section

The middle section of the HREC contains a

preprinted DD 2005, Privacy Act Statement—Health

Care Records, on the front side. When opening an

HREC, the service members are asked to read the

Privacy Act Statement. After the members have read

the statement, they will need to sign, date, and include

their SSN at the bottom of the form. Signing this

statement indicates the service members understand

their right to confidentiality in regard to the medical

documentation placed in their HREC.

On the reverse of the middle section is a Disclosure

Accounting Record. This form should be annotated

whenever the HREC is released to any individual or

agency outside the MTF.

SEQUENCE OF HEALTH RECORD FORMS

When assembling an HREC, you should arrange

the forms in chronological order by date. The most

current document should be placed on top, and the least

current documents below it. The HREC contains

dividers that partition the record into four parts. A

sequential listing of medical forms to be filed in each

section is provided in table 12-1. The titles for each

part of the HREC are as follows:

Part 1. Record of Preventive Medicine and

Occupational Health

Part 2. Record of Medical Care and Treatment

Part 3. Physical Qualifications

Part 4. Record of Ancillary Studies, Inpatient

Care, and Miscellaneous Forms

HEALTH RECORD FORMS

LEARNING OBJECTIVE: Recall the

purpose and completion procedures for the

health record forms discussed in this

section.

In the last section, you learned there are many

medical forms placed in the health record. Also, you

learned each form has a specific location within the

record. The methods for the management of major

areas of health care, both ashore and afloat, are rapidly

changing. The Composite Health Care System

(CHCS), a secure, computer-based system, is now the

primary means that healthcare practitioners use to

schedule and process patient visits, track medical

results, order labs and x-rays, and process orders for

medications. CHCS is especially valuable for

pier-side healthcare providers and furnishes a much

higher standard for patient care.

Computerized medical documentation (e.g.,

laboratory test results, emergency room reports, etc.)

12-9
12-10

Table 12-1.—Sequential List of Health Record Forms
has become commonplace. However, the Navy

Medical Department continues to use many

government printed forms (e.g., NAVMED, DD, and

SF). This section will cover selected (governmentprinted) medical forms, their purpose, and procedures

for completing them.

Healthcare providers should enter their signature

and identification data in the HREC in black or

blue-black ink. Type, print, or stamp provider’s name,

grade or rating, and social security number below their

signature. Stamped facsimile signatures are NOT to be

used on any medical form in the HREC. The signing

individual assumes responsibility for the correctness

of the entry for which they sign.

All medical forms require an accurate and

complete documentation of patient identification data.

Patient identification data on medical documentation

is critical. Complete and accurate documentation of

patient identification data helps to ensure the

documents are placed in the correct patient’s record.

Three methods are currently used to place patient

identification on medical documents:

• embossed medical card,

• automated forms, and

• handwritten entries.

Embossed medical cards are used to imprint

patient identification data on medical forms. Printouts

of automated (computerized) forms should provide the

information listed in table 12-1. Handwritten patient

identification data should be entered in spaces at the

bottom of the form. Each method should contain, at a

minimum, the patient identification data listed in table

12-2.

SUMMARY OF CARE (NAVMED 6150/20)

The Summary of Care (fig. 12-3) contains a

summation of relevant problems and medications that

significantly affect the patient’s health status. Properly

maintained, the Summary of Care form aids healthcare

providers by allowing them quick access to pertinent

medical factors that may affect how they manage a

patient’s medical care. This form is a permanent part

of the HREC.

Entries on the NAVMED 6150/20 should include

significant medical and surgical conditions, allergies,

untoward reactions to medication, and medications

currently using or recently used. The Summary of

Care form should be reviewed, and, if necessary,

revised during the patient’s visit. The NAVMED

6150/20 should also be reviewed during yearly

verification and before HREC transfers.

The Summary of Care form is divided into five

sections: significant health problems, hospitalization/

surgery, medical alert, medications, and health

maintenance.

• Significant health problems section: Enter

only significant medical conditions in this section.

Significant medical conditions include chronic diseases

(such as hypertension, diabetes, arthritis, etc.) and acute

recurrent illnesses (such as recurrent urinary tract

infections, recurrent otitis media, recurrent bronchitis,

etc.)

• Hospitalization/surgery section: Enter

significant surgical conditions. Include all procedures

requiring general or regional anesthesia and any

procedures likely to have a long-term effect on the

patient’s health status.

• Medical alert section: Note any allergies and

significant reactions to drugs in the medical alert

section. Record also in this section relevant alcohol and

tobacco use.

• Medications section: Record all currently or

recently used medications.

• Medical maintenance section: This section of

the NAVMED 6150/20 contains a variety of medical

information. It contains health maintenance functions,

such as mammograms, chest X-rays, EKGs, and pap

smears. Enter the date of the health maintenance

functions in pencil, so it can be updated. Include in this

section occupational health surveillance activities, such

12-11

Item # Patient Identification Data

1 Full name (last, first, middle)

2 FMP + SSN

3 Date of birth (YY-MM-DD)

4 Sex of patient (M or F)

5 Sponsor (self)

6 Sponsor’s Agency or military service

(USN, USMC, USCG,...)

7 Patient’s paygrade (e.g., E7, O2)

8 MTF maintaining record (e.g., NH

Pensacola, etc.)

Table 12-2.—Patient Identification Data
12-12

Figure 12-3.—Summary of Care, NAVMED 6150/20.
as involvement in the Asbestos Program, the Hearing

Conservation Program, or exposure to lead. Include

also the following laboratory tests: blood type, G6PD,

and sickle trait.

CHRONOLOGICAL RECORD OF

MEDICAL CARE (SF 600)

The Chronological Record of Medical Care, SF 600,

provides a current, concise, and comprehensive record of

a member’s military medical history (fig. 12-4, view A

and B). Use the SF 600 for all outpatient care and file in

the HREC. Record all visits, including those that result in

referrals to other MTFs, on the SF 600. Each person

making an entry on the form must sign the entry and

include his identification information (full name, grade

or rate, profession [e.g., MC, NC, etc.], and SSN), either

hand printed, typed, or stamped.

Properly maintained, the SF 600 facilitates the

evaluation of a patient’s physical condition and

reduces correspondence necessary to obtain medical

records. Appropriate use of the form also eliminates

unnecessary repetition of expensive diagnostic

procedures and serves as an invaluable permanent

record of medical evaluations and treatments.

Completing the SF 600

Entries made on the SF 600 can be typewritten

when practical. However, entries normally are

handwritten with black or blue-black ink pens. When

initiating an SF 600, patient identification data should

be completed. Also, type or stamp the date

(DD-MMM-YY) and the name and address of the

activity responsible for the entry.

Use both sides of each SF 600. Preparation of a

new SF 600 is not necessary each time the person is

seen in a different MTF. If only a few entries are

recorded on the SF 600 at the time of a move, stamp the

designation and location of the receiving MTF below

the last entry and use the rest of the page to record

subsequent visits. If the back of the SF 600 is not used,

then the back needs to be crossed out and the words

“This side not used,” printed in the middle of the form.

SF 600s are continuous and include the following

information: complaints, duration of illness or injury,

physical findings, clinical course, results of laboratory

or other special examinations, treatment (including

operations), physical fitness at the time of disposition,

and disposition. The subjective complaint,

observation, assessment, and plan (SOAP) format may

be used for entries so long as the required information

in table 12-3 is included.

Enter the following information indicated on table

12-3 on the patient’s SF 600.

Record each visit and the complaint described,

even if a member is returned to duty without treatment.

Also, document if a patient leaves before being seen.

Other SF 600 Entries

Other SF 600 entries include the following:

• Imminent hospitalization

• Special procedures and therapy

• Sick call visit

12-13

ITEM REMARKS

Date A c om plete date m u st be

included with every entry in the

HREC. When an undated page is

misfiled, it is difficult to replace

in proper sequence. Use the

three-letter abbreviation for the

month on all dates (e.g., 27 Apr

96).

MTF name Name of hospital, clinic, or ship

Clinical

department or

service

(e.g., Military Sick Call,

Orthopedic Department.,

etc.)

Chief complaint or

purpose of visit

(e.g., headache, PRT

screening, etc.)

Objective findings

Diagnosis or

medical

impression

Studies ordered

and results

(e.g., laboratory, X-ray, etc.)

Therapies

administered

Patient

disposition,

recommendations,

and patient

instructions

(e.g., SIQ for 24 hours, referral

to specialty clinic, etc.)

Healthcare

provider ’s name

and signature

Include the provider’s grade or

rate, profession (e.g., MC, NC),

and SSN

Table 12-3.—Required Information on an SF 600
12-14

Figure 12-4.—Chronological Record of Medical Care, SF 600: A. Front view.
12-15

Figure 12-4.—Chronological Record of Medical Care, SF 600: B. Back view.
• Injuries or poisonings

• Line-of-duty inquiries

• Binnacle list and sick list

• Reservist check-in and check-out statements

IMMINENT HOSPITALIZATION.—When an

admission of a patient is imminent, admission notes

can be made on an SF 600. However, the use of the SF

509, Medical Record-Progress Report, is preferred.

The SF 509 form is routinely used for inpatient

admission notes and are filed in the patient’s IREC.

Record referred or postponed inpatient admissions on

the SF 600.

SPECIAL PROCEDURES AND THERAPY.—

When patients are seen repeatedly for special

procedures or therapy, such as physical and

occupational therapy, renal dialysis, or radiation, note

the therapy on the SF 600 and record interim progress

statements. Initial notes, interim progress notes, and

any summaries may be recorded on any appropriate

authorized form, but should be referenced on SF 600.

Write a final summary when special procedures or

therapy are ended. This summary should include the

result of evaluative procedures, the treatment given,

the reaction to treatment, the progress noted, condition

on discharge (when applicable), and any other

pertinent observations.

SICK CALL VISITS.—Whenever a member is

evaluated at sick call, an entry will be made on an SF

600 reflecting the complaints or conditions presented,

pertinent history, treatment rendered, and disposition.

INJURY OR POISONING.—In the event of

injury or poisoning, record the duty status of the

member at the time of occurrence and the

circumstances of occurrence per the guidelines in

BUMEDINST 6300.3, Inpatient Data System.

LINE-OF-DUTY INQUIRIES.—When a

member of the naval service incurs an injury that might

result in permanent disability or results in his physical

inability to perform duty for a period exceeding 24

hours, an entry should be made concerning line-of-duty

misconduct. Such entries should include facts, such as

time of injury, date, place, names of persons involved,

and the circumstances surrounding the injury.

A line-of-duty inquiry is conducted to establish

whether the injuries the patient sustained are the result

of misconduct on the part of the member or others. For

more details on line-of-duty inquiries, see the Manual

of the Judge Advocate General (JAGMAN).

BINNACLE LIST AND SICK LIST.—When a

member’s name is placed on the Binnacle List for

treatment, make an entry on the SF 600 showing date,

diagnosis, and a summary of treatment.

When an active duty member is placed on the Sick

List, the medical department representative (MDR)

should enter information on the SF 600 about the

nature of the disease, illness, or injury; pertinent

history or circumstances of occurrence; treatment

rendered; and disposition.

SERIOUSLY ILL/VERY SERIOUSLY ILL

(SI/VSI) LIST.—Place personnel whose illness or

injuries are severe on the SI/VSI List (as defined in

MILPERSMAN 4210100) and make appropriate

notification.

RESERVIST CHECK-IN AND CHECK-OUT

STATEMENTS.—Naval Reserve personnel who are

checking in, or out on orders for annual training (AT),

active duty for training (ADT), or inactive duty

training travel (IDTT)) should sign the following

statements. The statements should be entered on an

SF 600 and signed by the reserve member and the

MDR.

For personnel checking in:

I certify that there have been no

significant changes in my physical

condition since my last physical

examination or annual certification.

Furthermore, I certify that I have no

illness or injury that would preclude me

from performing this period of (circle

one) AT, ADT, IDTT.

(Member’s and MDR’s signature and date)

For personnel checking out:

I certify that I have/have not incurred or

aggravated any injuries or illnesses

during the period of Naval Reserve

service.

(Member’s and MDR’s signature and date)

Special SF 600s

Two special SF 600s will be covered in the section.

Both forms perform specific functions.

SPECIAL-HYPERSENSITIVITY SF 600.—

Indicate any hypersensitivity to drugs or chemicals on

a separate SF 600 (fig. 12-5). The SF 600 will be

marked “SPECIAL-HYPERSENSITIVITY” at the

12-16
bottom of the page. Appropriate entries regarding the

hypersensitivity should be made on the SF 601

(Immunization Record), SF 603 (Dental Report),

NAVMED 6150/10-19 (HREC jacket), and the

NAVMED 6150/20 (Summary of Care).

BLOOD GROUPING AND TYPING

RECORD.—The Blood Grouping and Typing

Record, which is generated at the member’s initial

entry processing point, is an SF 600 overprint.

Information on the Blood Grouping and Typing

Record identifies the individual by the appropriate

ABO group and Rh type (positive or negative). Testing

results are documented on the form and the original

laboratory request filed with the SF 545, Laboratory

Result Display, in the member’s HREC. The Blood

Grouping and Typing Record may also contain a

syphilis screening test and other screening test for the

presence of certain diseases.

IMMUNIZATION RECORD (SF 601)

The purpose of the SF 601 form (fig. 12-6) is to

record prophylactic (disease preventive) immunizations; sensitivity tests; reactions to transfusions, drugs,

sera (sing. serum), and food; known allergies; and

blood-typing. The SF 601 contains specified blocks

for various immunizations, such as yellow fever

vaccine, typhoid vaccine, and influenza vaccine.

Preparing and Maintaining SF 601

An immunization record is prepared and maintained for each person with an HREC. Information on

the SF 601 is recorded in designated blocks. When

space is exhausted in any single category, prepare a

new SF 601 and file in the HREC in chronological

order. Verify previous entries and bring the most

current immunizations forward. Retain the old SF 601

beneath the new SF 601. Replacement of the SF 601 is

not required because of a change in grade, rating,

name, or status of member. Never maintain the SF 601

separate from the HREC. Information recorded on the

SF 601 is normally needed for government

international travel, such as unit deployments or

directed governmental travel.

Immunization Entries

The name of the medical officer or MDR

administering the immunization or test or determining

12-17

Figure 12-5.—Standard Form 600, Special-Hypersensitivity.
12-18

Figure 12-6.—Immunization Record, SF 601: A. Front view.
12-19

Figure 12-6.—Immunization Record, SF 601: B. Back view.
the nature of the sensitivity reaction should be typed or

stamped on the SF 601 form. Signatures are not

required; however, when signatures are used, make

sure you can read them.

The medical officer or Medical Department

representative administering the immunization is

responsible for completing entries in the appropriate

sections of SF 601. For smallpox (if administered),

cholera, yellow fever and anthrax immunizations,

record the manufacturer’s name and batch or lot

number.

NOTE: The specific protocol for recording

anthrax immunizations is outlined in

SECNAVINST 6230.4.

Type any hypersensitivity to drugs or chemicals

under “Remarks and Recommendations” in capital

letters (e.g., “HYPERSENSITIVITY TO ASPIRIN,”

“HYPERSENSITIVE TO LIDOCAINE”). This entry

is in addition to a similar entry required on the SF 603,

the SF 600 Special-Hypersensitivity form, and the

NAVMED 6150/20 retained permanently in the

HREC.

When recording positive results (10 mm or more

induration) of the tuberculin skin test (PPD), refer to

the Tuberculosis Control Program instruction,

BUMEDINST 6224.8, for guidance.

Disposing of SF 601

When a service member is released from active

duty or separated from the service, the SF 601 is to

remain with the HREC.

INTERNATIONAL CERTIFICATES OF

VACCINATION (PHS-731)

All personnel performing international travel

should be immunized in accordance with

NAVMEDCOMINST 6230.15, Immunizations and

Chemoprophylaxis, and the current edition of FM

8-33/NAVMED P-5038, Control of Communicable

Diseases of Man. Service members should have a

properly completed and authenticated PHS-731 form

(International Certificates of Vaccination) in their

possession. The PHS-731 form is issued to service

members for independent international travel. This

form, kept by the individual, is a personal record of

immunizations. The PHS-731 is not to be filed in the

HREC at any time. Any immunizations recorded on

the PHS-731 should be transcribed onto the SF 601.

According to international rules, entries on the

PHS-731 require authentication for immunizations

against smallpox (if administered), yellow fever,

cholera, and anthrax. Authentication (proof the

immunization has been given) is accomplished by

stamping each entry with the Department of Defense

(DoD) immunization stamp and by the healthcare

provider’s signature. The signature block may be

stamped or typewritten and authenticated with the

healthcare provider’s signature.

ABSTRACT OF SERVICE AND MEDICAL

HISTORY (NAVMED 6150/4)

This form provides a chronological history of the

ships and stations to which a member has been

assigned for duty and treatment, and an abstract of

medical history for each admission to the Sick List.

A NAVMED 6150/4 (fig. 12-7) is prepared upon

opening the health record, and it remains with the

health record regardless of any change in the member’s

status. Continuation sheets are incorporated whenever

a current abstract is completely filled. Complete

columns of the NAVMED 6150/4 as follows:

• Ship or Station column. Enter the name of the

ship or command to which the member is

attached for duty or treatment.

• Diagnosis, Diagnosis Number, and Remarks

column. Enter the diagnosis title and

International Classification of Diseases (ICDA)

number each time final disposition from the Sick

List is made. When there is more than one

diagnosis for a single admission, record each

diagnosis.

• Date column. Indicate in the “From” and “To”

subcolumns all dates of reporting and

detachment for duty or dates of admission and

discharge from the Sick List. Upon transfer for

temporary duty (TDY), make an entry only if the

HREC accompanies the individual to the place

of TDY.

NAVMED 6150/4 is retained as a permanent part

of the HREC. When the record is closed, make an entry

indicating the date, title of servicing activity, and

explanatory circumstances.

Upon discharge and immediate reenlistment, or

change in status, an appropriate entry to this effect

should be made on the current NAVMED 6150/4.

Subsequent chronological entries are continued on the

same form.

12-20
RECORD OF OCCUPATIONAL EXPOSURE

TO IONIZING RADIATION (DD FORM 1141)

This form is initiated when military personnel are

first exposed to ionizing radiation (with the exception

of patients incurring such radiation while undergoing

diagnostic treatment). This form becomes a

permanent part of the member’s health record.

Instructions for preparing DD Form 1141 are on

the back of the form. Further instruction concerning

the applicability and use of the form are contained in

12-21

Figure 12-7.—Abstract of Service and Medical History, NAVMED 6150/4.
the Radiation Health Protection Manual, NAVMED

P-5055.

ADJUNCT HEALTH RECORD FORMS AND

REPORTS

This section provides instruction for using certain

forms in the health record instead of transcribing their

data to the SF 600, Chronological Record of Medical

Care.

Narrative Summary (SF 502)

The purpose of the SF 502 is to summarize clinical

data relative to treatment received during periods of

hospitalization. The narrative summary should

include all procedures and diagnoses, and must agree

with information listed on the Inpatient

Admission/Disposition Report (NAVMED 6300/5)

and any information listed in the operation report.

The SF 502 should include the following

information:

• Reason for hospitalization, including a brief

clinical statement of the chief complaint and

history of the present illness.

• All significant findings.

• All procedures performed and treatment given,

including patient’s response, complications, and

consultations.

• The condition and relevant diagnosis at the time

of patient’s transfer or discharge.

• Discharge instructions given to patients or their

families (i.e., physical activity permitted,

medication, diet, and follow-up care).

• List of principal providers or attending

physicians and their signatures.

A completed copy of the SF 502 should

accompany patients who are transferred to another

medical facility. Upon discharge from the hospital, a

copy of the SF 502 should be taken to the member’s

parent command. The SF 502 informs the command of

any limitations, medications, and follow-up care the

service member may need. After command use, the

SF 502 should be placed into the member’s HREC. For

more detailed instruction on the use of the SF 502, refer

to the MANMED.

Abbreviated Clinical Record (SF 539)

The SF 539 may be used as a substitute for the

narrative summary for those admissions of a minor

nature that require less than 48 hours of

hospitalization. Acopy of SF 539 should be filed in the

HREC.

Consultation Sheet (SF 513)

The SF 513 is used for outpatients who need to be

referred to other healthcare providers or specialists,

such as gynecologists, internists, optometrists, etc.

The primary patient assessment should be entered onto

the form. Include as well the results of examinations

and tests on the SF 513. The patient remains the

responsibility of the referring provider until the

specialist takes over the care. In some cases, the

specialist will perform an examination or procedure

and refer the patient back to the original provider for

continued care. The original consultation form stays in

the HREC.

Medical Board Report (NAVMED 6100/1)

Whenever a member of the naval service is

reported on by a medical board, place a legible copy of

the report in the health record instead of transcribing

the clinical data to the SF 600. Make a notation on the

current SF 600 to indicate the clinical data is contained

in the copy of the Medical Board Report incorporated

in the health record, when the Medical Board Report is

forwarded to the Navy Department for review and

appropriate disposition. Enter a report of the

departmental action on the current SF 600.

Eyewear Prescription (DD Form 771)

The purpose of DD form 771, Eyewear

Prescription (fig. 12-8), is to order corrective

prescription eyewear. Depending on its edition date

(any of which is authorized), the DD form 771 may

consist of a 3-copy carbon form (for use with pen), a

2-part carbonless form (printed on a tractor-feed

printer) (fig. 12-8A), or a computer-generated form

using virtual copies (fig. 12-8B). The original of the

form will be sent to the optical laboratory, and a copy of

the form will be placed in the patient’s HREC. As with

other standard forms, the DD 771 is frequently

submitted via computer modem or fax, depending on

availability.

Three major areas covered by the DD Form 771 are

patient information, prescription information, and

12-22
miscellaneous information. These three areas are

discussed as follows:

1. Patient Information: The specific information

required is the patient’s name, rank, SSN, duty

station, mailing address, and military status.

This information is required to establish

eligibility and provide the requesting activity

with an address for the patient upon receipt of

the completed eyeglasses.

2. Prescription Information: Since the spectacle

prescription is the technical portion of the order

form, you should complete it with great care,

ensuring that the prescription is transferred in its

entirety. The essential elements of the

prescription are interpupillary distance, frame

size, temple length, plus and minus designators

for both sphere and cylinder powers, segment

powers and heights, prism, and prism base. It is

not necessary to calculate decentration in the

single vision or multifocal portions of the order.

It is also unnecessary to try to transpose any

prescription into plus or minus cylinder form.

Leave the prescription as is, copy it onto the DD

Form 771, and note in the remarks section that

the prescription has been copied and is in the

HREC.

3. Miscellaneous Information: This area is

reserved for any information you feel the Navy

Optical Laboratory may need. Information the

laboratory may need includes special

fabrication requirements, such as multifocal

lenses, or proof of eligibility for specialized

eyewear, such as aviator sunglasses. Standard

issue items can be determined from

NAVMEDCOMINST 6810.1, Ophthalmic

Services.

DD Forms 771 should be typewritten or computer

printed whenever possible. This practice eliminates

12-23

Figure 12-8.—Eyewear Prescription, DD Form 771: A. Computer-printed edition; B. Computer-generated edition.
any errors by misreading an individual’s handwriting.

It is critical you take the time to correctly order

spectacles. Omission of any information or entering

erroneous information will result in a delay at the

fabricating facility or a patient’s receiving an incorrect

pair of eyeglasses, or both.

If you cannot read what has been written on an

eyewear prescription, you should contact the optometrist

for clarification. In the case where the optometrist cannot

be contacted, as a last effort you can send a photostatic

copy of the prescription to the optical laboratory, rather

than transcribing information of which you are unsure.

Make sure that the copy of the prescription is

accompanied by a completed DD Form 771.

VERIFYING HEALTH RECORDS

LEARNING OBJECTIVE: Identify

health record items that should be reviewed

during an annual verification.

Health records are verified annually by medical

personnel having custody of the record. Health records

should also be reviewed when service members report

and detach from their command, and at the time of their

physical examinations.

Each record should be carefully reviewed, and any

errors or discrepancies should be corrected. Items to

be reviewed during an annual verification include:

form placement, forms order (chronological), and

completeness and accuracy of patient identification

data on the record jacket and on each piece of medical

documentation. In addition, verify that the Privacy Act

Statement has been signed, the Summary of Care form

is updated (as necessary), blood group and Rh factor

are documented, and currency of immunizations and

accuracy of allergy documentation are complete.

Upon completion of an annual HREC verification,

you should make an SF 600 entry and black-out the

corresponding year block on the front leaf of the jacket

with a black felt-tip pen. With this procedure, records

that have not been verified during the calendar year can

be identified readily and the annual verification

accomplished.

CLOSING HEALTH RECORDS

LEARNING OBJECTIVE: Recall

closing procedures for health records.

A member’s health record is to be closed under the

following circumstances:

• Death or declared death

• Discharge

• Resignation

• Release from active duty

• Retirement

• Transfer to the Fleet Reserve or release to

inactive duty

• Missing or missing in action (MIA)(when

officially declared as such)

• Desertion (when officially declared as such)

• Disenrollment as an officer candidate or

midshipman

When closing an HREC, make sure the record is in

order, that there are no loose papers, and all

identification data is consistent. Record closing entry

on the NAVMED 6150/4, Abstract of Service and

Medical History. Include the date of separation, title of

servicing activity, and any explanatory circumstances.

Upon final discharge or death, send the entire

HREC and dental record to the command maintaining

the member’s service record (no later than the day

following separation) for inclusion in and transmittal

with the member’s service record. Make sure the

original of the separation physical examination

documents are included in the HREC before delivery

to the command maintaining the member’s service

record, such as the PSD, PSA, etc. In case of death,

send a copy of the death certificate along with the

transmitted records.

A copy of the HREC is provided free of charge to

members who requests one upon their release,

discharge, or retirement.

MISSING OR MISSING-IN-ACTION

MEMBERS

Whenever a member disappears and the available

information is insufficient to warrant an administrative

determination of death, enter a summary of the

12-24
relevant circumstances on the SF 600. Include

circumstances about the presumed disappearance of

the individual, then status (missing or missing in

action), and supporting documentation. Close the

record and handle it as you would records for members

being discharged from the service.

DESERTION

When a member is officially declared a deserter,

explain this fact on the SF 600 and the NAVMED

6150/4. Deliver member’s HREC and dental treatment

record to the member’s commanding officer (CO) for

inclusion in and transmittal with the member’s service

record for both Navy and Marine Corps personnel.

When a deserter is apprehended or surrenders, the

CO of the activity having jurisdiction is required to

submit a request for the member’s records to Bureau of

Naval Personnel (BUPERS) or Commandant of the

Marine Corps (CMC), as appropriate.

RETIREMENT

When a member of the naval service is placed on

the retired list or Fleet Reserve List, close the HREC as

you would on a discharge. However, upon request of

the retiring member, a new medical record (OREC) is

established. A copy of the retiring member’s active

duty HREC may be incorporated into a new

NAVMED 6150/20-29 folder. Make an entry on an

SF 600 in the HREC and in the new OREC, stating the

date the HREC was closed.

DISABILITY SEPARATION OR

RETIREMENT

The MTF should send a copy of the HREC of a

member being separated for disability to the DVA

(Department of Veteran Affairs) regional officer

nearest to where the member will be residing. Send the

medical record directly from the MTF to the DVA, so

the record can be considered as a primary source of

evidence in processing a claim for veteran’s benefits.

A record carried by the member is considered

secondary evidence and is not used to process a claim.

Send the record with the VA 526, Claim of Benefits, so

the regional office can initiate the claim.

Members separating from the service and eligible

for veteran’s benefits should be provided a copy of

their HREC on request. Members should be counseled

to request a copy in the event they may make a claim

for veteran’s benefits in the future. Always offer to

send a copy of their HREC to the regional DVA office

for them.

SUMMARY

As a Hospital Corpsman, you will be responsible

for managing health records. Health records are a vital

tool in the healthcare delivery process. It is of the

utmost importance that you learn and follow

guidelines for establishing, handling, maintaining, and

closing health records. Keep in mind, your handling of

the health record can affect others. A well-maintained

health record furnishes healthcare providers with

current medical data, enabling the provider to give

each patient timely and comprehensive medical care.

Confidential treatment of a patient’s medical

information honors the patient’s privacy and is in

keeping with legal regulations. Following the

guidelines in this chapter will assist you in properly

managing health records under your care.

12-25

CHAPTER 13

SUPPLY

The responsibility of accounting for assets within

the Department of the Navy comes down from the

Secretary of the Navy (SECNAV) to the commanding

officers of field activities throughout the Navy.

Commanding officers must ensure proper fiscal

administration by the directives, principles, and

policies prescribed by the Comptroller of the Navy.

The Naval Supply Systems Command (NAVSUP)

is responsible for administering supply management

policies, to include cataloging, standardization,

inventory control, storage, issue, and disposal of naval

material. You, as a Hospital Corpsman, must be

familiar with the methods of procuring and accounting

for naval materials.

In this chapter we will discuss the proper

procedures to use in estimating supply needs,

procuring supplies and material, and accounting for

supplies and operating funds. The last section of the

chapter deals with contingency supply blocks and their

maintenance.

NAVSUP MANUALS, PUBLICATIONS,

AND DIRECTIVES

LEARNING OBJECTIVE: Recognize the

purpose and content of key supply manuals

and instructions.

To function well in the Navy supply system, you

must be familiar with the NAVSUP manuals,

publications, and directives that outline policy and

procedures for different areas of supply. These

manuals, publications, and directives are available in

the Naval Logistics Library located on the NAVSUP

homepage, www.navsup.navy.mil.

ALTERNATIVE TITLES FOR NAVSUP

PUBLICATIONS

NAVSUP publications may be referred to in four

different ways. For example, the Operating

Procedures Manual Military Standard Requisitioning

and Issue Procedure, and Military Standard

Transaction Reporting and Accounting Procedure

(MILSTRIP/MILSTRAP), NAVSUP P437, may be

referred to in various publications and directives as

NAVSUP Publica tion 437, NAVSUP P -437,

NAVSUP Pub 437, or NAVSUP 437. However, when

referencing this publication (or other NAVSUP

publications), cite it as “NAVSUP P-437” (and the

applicable paragraph number).

CHANGES TO PUBLICATIONS

Regardless of how well you have learned to use the

various supply publications, if they aren’t kept up to

date, you may encounter problems when you attempt to

order an item. Also, you may be unaware of an item

that has been recalled. Enter changes promptly when

they are received to ensure that the latest information is

being used. Always read accompanying instructions

before making changes.

NAVAL SUPPLY SYSTEMS COMMAND

(NAVSUP) MANUAL

The NAVSUP manual is designed to institute

standardized supply procedures and consists of the

following four volumes:

Volume I C Introduction to Supply

Volume II C Supply Ashore

Volume III C Retail Clothing Stores and

Commissary Stores

Volume IV C Transportation of Property

OPERATING PROCEDURES MANUAL FOR

MILITARY STANDARD REQUISITIONING AND

PROCEDURES (NAVSUP P-437) AND MILITARY

STANDARD TRANSACTION REPORTING AND

ACCOUNTING PROCEDURES (MILSTRIP/

MILSTRAP)

The MILSTRIP/MILSTRAP manual issues policy

on the MILSTRIP/MILSTRAP system. This

publication takes precedence over conflicting

provisions contained in other supply system manuals

or directives. The manual covers system management,

13-1
requisitioning procedures for ashore activities,

inventory control, financial matters, and other topics.

The publication provides forms, formats, and codes,

and serves as a comprehensive reference for persons

involved in preparing or processing MILSTRIP

documents. Since NAVSUP P-437 is not distributed

afloat, afloat MILSTRIP/MILSTRAP operations are

incorporated into NAVSUP P-485.

MILSTRIP/MILSTRAP DESK GUIDE,

NAVSUP P-409

The NAVSUP P-409 was published as a handy

reference for personnel responsible for originating and

processing MILSTRIP/MILSTRAP documents, since

NAVSUP P-437 is a large, comprehensive, threevolume publication. This small booklet contains

common definitions, coding structures, and abbreviated code definitions used on a day-to-day basis.

Blank space is provided for entering commonly used

routing identifiers, funding codes, project codes, and

locally assigned codes.

AFLOAT SUPPLY PROCEDURES,

NAVSUP P-485

The Afloat Supply Procedures, NAVSUP P-485,

establishes policies for operating and managing afloat

supply departments and activities. It helps supply

personnel understand and perform their individual

tasks. Although this publication is designed primarily

for nonautomated supply procedures, a significant

amount of the information it contains also applies to

automated systems.

The procedures contained in this publication are

the minimum essential for acceptable supply

management and are mandatory unless specifically

stated as optional. The publication encompasses the

procedures outlined in the NAVSUP Manual, volumes

I, II, and V, and NAVSUP P-437 as they apply to afloat

situations. It covers organization and administration,

material identification, material procurement, material

receipt, custody and stowage, material expenditure

and shipment, inventory management, transportation,

and special material.

NAVYMEDICAL AND DENTALMATERIAL

BULLETIN, NAVMEDLOGCOM

NOTICE 6700

The Navy Medical and Dental Material Bulletin,

NAVMEDLOGCOM NOTICE 6700, is issued monthly

via the NAVMEDLOGCOM homepage, www-nmlc.

med.navy.mil, by the Commander, Naval Medical

Logistics Command. It contains information of

importance and interest to medical supply departments,

such as changes in stock numbers, addition and deletions,

availability of excess equipment, and notification of

material unfit for use and disposal instruction. Revisions

to this publication should be read carefully for any

changes to your files or references.

APPROPRIATIONS AND OPERATING

BUDGETS

LEARNING OBJECTIVE: Recognize

how appropriations and operating budgets

are conducted.

An appropriation is referred to in the NAVCOMPT

Manual as “. . . [an authorization] by an act of Congress

to incur obligations for specified purposes and to make

payments therefor out of the Treasury.” The Navy uses

appropriations received to pay for the construction of

new ships, to fund the cost of operations and

maintenance for the existing fleet, and to pay for

training, personnel pay, and to operate shore

establishments that support the fleet.

TYPES OF APPROPRIATIONS

Three types of appropriations are used by the

Navy, depending upon the purpose for which the

appropriation is issued. Most appropriations are for

one fiscal year (FY). The FY runs from 01 October of a

year to 30 September of the following year. The

federal government uses this time period for budgeting

normal operating costs of the armed services,

including the Navy. Other types of appropriations may

be granted without a time limitation or for a specific

time that may exceed 1 year.

Annual Appropriations

Annual appropriations are provided for active

and reserve military personnel expenses, as well as

for operation and maintenance expenses. The

appropriations become available for obligation and

expenditure at the beginning of the fiscal year

designated in the Appropriations Act. Obligations

may be incurred only during this designated fiscal

year; however, the obligated funds remain available

for the payment of such obligations for an additional 5

years. At the end of the additional 5-year period, fund

13-2
distribution differs, depending on the purpose of the

appropriation.

Continuing Appropriations

A continuing appropriation, also referred to as a

no-year appropriation, is one that is available for

incurring obligations until the funding is exhausted or

until the purpose for which it was made is

accomplished without a fixed-period restriction.

Examples of continuing appropriations are Military

Construction Navy (construction projects that are

planned up to 5 years ahead) and revolving funds such

as the Defense Business Operating Funds (DBOF) (a

projection of the predicted cost to operate the Navy).

Continuing appropriations become available for

obligation and expenditure at the beginning of the FY

following the passage of the Appropriations Act or

may become immediately available when so specified

in the Act. When the purpose of a continuing

appropriation has been accomplished administratively

or by Congress, DoD transfers an amount equal to the

total of unliquidated obligations, less the total of

reimbursements to be collected, to the surplus of the

Treasury.

Multiple-Year Appropriations

Generally, multiple-year appropriations are made

for appropriations that require a long lead time for

planning and execution, such as procurement of

aircraft, missiles, and ships. Multiple-year appropriations become available for obligation and

expenditure at the beginning of the fiscal year

(1 October) designated in the appropriation, unless

otherwise stated in the Act. They are available for

incurring obligations only during the FYs specified in

the Act. However, they are available for paying such

obligations for an additional 5 years.

At the end of the last FY included in the

appropriation, when the appropriation expires for

obligation purposes, the balance is transferred to the

Treasury.

OPERATING BUDGETS

The operating budget is the annual budget of an

activity and is assigned by the Chief of Naval

Operations (CNO), Fiscal Management Division, to

major claimants. A major claimant is an office,

command, or Headquarters Marine Corps. The

claimant is designated as the administering office

under the operation and maintenance appropriation.

Holders of operating budgets have the option of

granting a degree of financial responsibility to

subordinates by issuing operating targets (OPTARs).

OPTARs are generally apportioned in four equal

quarterly divisions that represent the maximum

amount that can be spent for each quarter of the FY. By

using this system, facilities are able to manage and

effectively control the expenditure of funds. This

system prevents overexpenditure of funds early in the

fiscal year and helps prevent financial problems at the

end of the year. Unused quarterly funds may be carried

over to the next quarter simply by adding them to the

new quarterly apportionment. At the end of the fourth

quarter, all accounts are balanced and closed; new

expenditures are not authorized until appropriated

funds are made available for the new fiscal year.

Funds allotted to the medical department to

purchase needed items are called the operating target

(OPTAR). Medical OPTAR funds are the funds used to

fulfill the following five major requirements:

• Authorized Medical Allowance List (AMAL).

The AMAL is the minimum amount of medical

material to be maintained on board a ship or on

order at any given time. The amount of material

as noted in an AMAL is designated by BUMED

for each class of ship and is based on past

experience. Recommendations for changes to

the AMAL should be forwarded through the

chain of command to BUMED.

• Authorized Dental Allowance List (ADAL).

The ADAL is the minimum amount of dental

material to be maintained on board a ship or on

order at any given time. The amount of material

as noted in an ADAL is designated by BUMED

for each class of ship and is based on past

experience. Recommendations for changes to

the ADAL should be forwarded through the

chain of command to BUMED.

• Type Commander’s (TYCOM) Requirements. To supplement the AMAL, TYCOMs

may have additional requirements to maintain

units in a high state of readiness and allow units

to be self-supporting in an emergency, such as a

natural disaster or humanitarian mission.

TYCOM requirements for medical considerations relate to such items as gun bags, airways,

litters, and battle dressing supplies.

13-3
• Special Mission Usage. These missions include

but are not limited to humanitarian, civilian

rescue, and drug interdiction operations.

• Administrative Requirements. The purchase

of consumable or medical OPTAR restricted

items may be made from the medical OPTAR

with the approval of the executive officer.

Medical books and publications listed in

NAVMEDCOMINST 6820.1 may also be

purchased with this OPTAR.

FEDERAL SUPPLY CATALOG SYSTEM

LEARNING OBJECTIVE: Recall the

terms associated with the Federal Supply

System and how to use the Federal Supply

Catalog.

The Department of Defense Supply System

contains more than 4 million items; of this total the

Navy stocks more than 1 million items. To order

supplies effectively from this system, you must have a

basic understanding of the DoD supply system

terminology and structure. This includes the naming,

description, classification, and numbering of all items

carried under centralized control of the United States

Government. Only one identification number is used

for each item, from purchase to final disposal.

TERMINOLOGY

To effectively procure and account for naval

materials, you will need to be familiar with

terminology commonly used in the supply system.

Some of the terms with which you should be familiar

are discussed below:

BULK STOCK Material in full, unbroken

containers available for future

use.

CONSUMABLE Supplies that are consumed or

disposed of after use.

EQUIPAGE Items that require management

control afloat because of high

unit cost, vulnerability to

pilferage, or indispensability to

the ship=s mission.

CONTROLLED

EQUIPAGE

Items of equipage that require

special management control

because the material is essential

for the mission or the protection

of life, is relatively valuable, or

easily converted to personal use.

EQUIPMENT Any functional unit of hull,

mechanical, electrical, ordnance,

or electronic material, operated

singly or as a component of a

system or subsystem. Equipment is considered nonconsumable.

MATERIAL All supplies, repair parts,

equipment, and equipage used in

the Navy/Marine Corps.

NONCONSUMABLESupplies and materials that are

not consumed or disposed of

after their use. Buildings and

equipment are nonconsumable

items.

REPAIR PART Any item that has an application

and appears in an allowance

parts list (APL), stock number

sequence list (SNSL), integrated

stock list (ISL), Naval Ship

Systems Command drawings, or

a manufacturer=s handbook.

RESERVE

STOCK

Items on hand and available for

issue for a specific purpose, but

not for general use (for example,

decontamination supplies).

STANDARD

STOCK

Material under the control of an

inventory manager and

identified by a National Item

Identification Number (NIIN).

The NIIN is the last nine-digits of

the Federal Stock Number.

STOCK

NUMBER

The smallest quantity of a supply

item.

FEDERAL SUPPLY CLASSIFICATION

SYSTEM

The Federal Supply Classification System is

designed to permit the classification of all items of

supply used by the federal government. Each item of

supply will be included in one—AND ONLY

ONE—FSC. The FSC is made up of 2 two-digit

13-4
numeric codes: the federal supply group and the

federal supply class. The federal supply group

identifies, by title, the commodity area covered by the

classes within each group.

An example of a Federal Supply Group and its

classes is as follows:

NATIONAL STOCK NUMBERS

Every item in the Federal Supply Catalog is

identified by a 13-digit stock number referred to as

National Stock Number (NSN). The national stock

number (NSN) for an item of supply consists of a

four-digit federal supply classification (FSC group and

class) and a nine-digit national item identification

number (NIIN). The NIIN consists of a two-digit

national codification bureau (NCB) code and seven

digits that, in conjunction with the NCB code, identify

each NSN item in the Federal Supply Distribution

System.

The National Item Identification Number is a

nine-digit number that identifies each item of supply

used by the Department of Defense. Although the

NIIN is part of the NSN, it is used independently to

identify an item within a classification. Unlike the

FSC, the NIIN is assigned serially, without regard for

the name, description, or classification of the item.

An example NSN is: 3110-00-123-4567

NAVY ITEM CONTROL NUMBERS

Navy Item Control Numbers (NICN) identify

items of material (such as pencils, staplers, sutures,

and medications) that are not included in the FSC but

are stocked in the Navy supply system. These numbers

are 13-digits and are assigned by inventory control

managers.

LOCAL ITEM CONTROL NUMBERS

Technically, any item identification number

assigned by an activity for its own use is a Navy Item

Control Number. To distinguish between NICNs that

are authorized in supply transaction documents and

those that are not, the term Local Item Control Number

(LICN) is often used. A full explanation of the

composition of NIINs, NICNs, and LICNs is contained

in Afloat Supply Procedures, NAVSUP P-485.

COGNIZANCE SYMBOLS

Although cognizance symbols are not part of the

NSN, they are used as supply management codes that

identify the Navy inventory manager for the specific

category of material requisitioned. This symbol

consists of two parts, one numeric and one alphabetic.

For example, the symbol for all Navy-owned bulk

medical material is “9L.”

FEDERAL SUPPLY CATALOG, MEDICAL

MATERIAL SECTION

The Federal Supply Catalog contains all standard

stock items available to agencies of the United States

Government. It furnishes identification and

management data for single-manager supply items.

The sections of the catalog that are of special interest to

the Hospital Corpsman are those dealing with medical

items, as listed in the NAVSUP P-485, volume I,

chapter 2. Each subsection deals with specific

categories of material.

The following is a description of the subsections of

Federal Supply Catalog, Medical Material, 6500

section:

• Introduction—provides a general overview of

the contents and use of the catalog.

• Alphabetical Index—contains a list of item

names, colloquial names, synonyms, common

names, and trade names, referenced to index

numbers, that help locate an item within the

subsection.

• Glossary of Colloquial Names and

Therapeutic Index (6505/6508 subsection

only)—contains colloquial names, synonyms,

and trade names arranged in alphabetical order

and cross-referenced to appropriate National

Item Names. Items are also classified by

therapeutic use.

13-5

Group 65

Medical, Dental, and

Veterinary Supplies and

Equipment

6505 - Drugs Biological, and

Official Reagents

6508 - Medicated Cosmetics

and Toiletries

6510 - Surgical Dressing

Material

3110

|

Federal

Supply

Classification

(FSC)

00-

|

National

Codification

Bureau Code

123-4567

|

National Item

Identification

Number (NIIN)
• Identification List (IL)—contains the

following four sections:

1. Preface—Each subsection contains a preface

that includes special instructions pertaining to

that individual subsection.

2. Alphabetical Index—This list of National Item

Names is cross-referenced to index numbers to

help locate an item when the NSN is not known.

3. National Stock Number Index—This list of

NSNs is arranged in numerical order and

referenced to index numbers to help locate an

item within a subsection.

4. List of Items index number—Some items are

illustrated for clarity. Each item listed includes

action codes; handling and/or storage codes, if

any; NSN; and a brief description of the item.

• Action Codes—Additions, deletions, or

revisions of published data are identified as

follows:

• Index Numbers—Items are presented in

alphabetical order; index numbers are assigned

in ascending sequence within each pamphlet.

They are used solely as a locator device and not

in place of NSNs.

• National Stock Number Index—NIINs are

listed in numerical order.

• Descriptive Data—Important distinguishing

characteristics are stated in this section.

• Description—Information which appears

below the item name and above the box in which

the index number, NSN, and data are arranged.

Operational data may appear as a footnote such

as “cold weather use only.”

• Notes—Information regarding item

special storage and handling procedures

are as follows:

• Navy Management Data List—This list

contains all items in the subsection and shows

unit of issue, price, and authorized substitutions.

A separate Navy Management Data List is

published for each Identification List.

PROCUREMENT

LEARNINGOBJECTIVE: Recognize the

various supply levels, and recall requisition

form completion and processing procedures.

Procurement is the act of obtaining materials or

services. Material may be procured by requisition

(items with federal stock numbers) or open purchase

(items without federal stock numbers, procured from

nonfederal sources). Requisitions are most frequently

used, but open purchase is used for procuring

13-6

N-new C indicates items not previously

included in the basic publica -

tion, change bulletin, or

change notice; or reinstatenment of a previously deleted

item.

C-change C indicates a change in data

since the previous publication.

D-deletion C indicates an item that is no

longer available.

B C corrosive or poisonous material

C C contains one or more component

items of the nature described under

“R” below; used in connection with

assemblies only

F C subject to damage by freezing

G C requires refrigeration between 2E to

8EC (35E to 46EF)

I C flammable or oxidizing materials

M C an item containing potentially

recoverable precious metals

P C an item with potency period or

expiration date

Q C drugs or other item requiring security

storage and Schedule III, IV, and V

R C alcohol, alcoholic beverages,

precious metals, or other substances

requiring vault storage and Schedule

II

W C item must be kept frozen for

preservation
nonstandard material and emergency items. In this

section, we will cover supply levels, supply level

terminology, requisition, requisition documents,

purchase procedures, and the Uniform Material

Movement and Issue Priority System (UMMIPS).

LEVELS OF SUPPLY

There must be some control over the level or

quantity of supplies kept by medical departments.

Without controls, policy changes or poor ordering

procedures may result in some items being in short

supply, while other items are stockpiled in quantities

that would not be consumed for several years. To avoid

such occurrences, it is necessary to develop rules

governing stock levels.

Supply Level Terminology

Supply levels may be expressed in one of two

ways: in numerical terms and in terms of months of

usage. Numerical is expressed as the total amount of

supplies on hand. Months of usage is the most

commonly used measurement of supply levels. It is the

best method to use in accounting for the amount of

items that are used on a monthly basis. In expressing

the supply level of any stock item, four measurements

may be used: operating level, safety level, storage

objective, and requisitioning objective.

OPERATING LEVEL.—This measurement

indicates the quantity of an item that is required to

sustain operations during the interval between

requisitions or the receipt of scheduled successive

shipments of supplies. The operating level should be

based upon the length of the replenishment cycle. For

example, if requisitions are submitted every 2 months,

the operating level would be the quantity of the item

that is consumed every 2 months. This level will vary

for different items.

SAFETY LEVEL.—This measurement indicates

the quantity of an item, over and above the operating

level, that should be maintained to ensure that

operations will continue if replenishment supplies are

not received on time, or if there is an unpredictably

heavy demand for supplies. This measurement simply

provides a margin of safety.

STOCKAGE OBJECTIVE.—This measurement indicates the minimum quantity of a stock item

that is required to support current operations. It is the

sum of the operating level and the safety level. For

example, if the operating level of an item is 80 units

and the safety level is 20 units, the stockage objective

would be to maintain 100 units of that item in stock at

all times.

REQUISITIONING OBJECTIVE.—This

measurement indicates the maximum quantity of a

stock item that should be kept on hand and on order to

support operations. It is the sum of the operating and

safety levels and the quantity of an item that will be

consumed in the interval between the submission of a

requisition and the arrival of the supplies. Figure 13-1

illustrates the relationship between the various levels

of supply.

Usage Data

The most accurate guide in determining supply

requirements is past experience, as reflected in

accurate stock records. Stock record cards (which will

be discussed in detail later in the chapter) should be

kept current to assist in the material usage notes. Stock

records should tell you how much of each item has

been used in the past. From this past usage data, you

can make a reasonable projection of future usage rates.

SAMS (SNAP Automated Medical System) is an

additional management tool. SAMS is the current

approved shipboard computer program used to track

all aspects of medical supply.

REQUISITIONS

A requisition is an order from an activity that is

requesting material or services from another activity.

Except for certain classes of material listed in

NAVSUP P-485 and P-437, all items ordered from the

Navy Supply System, other military installations, the

Defense Logistics Agency (DLA), and the

Government Services Administration (GSA) will be

procured using the MILSTRIP system. MILSTRIP

requisitioning is based upon the use of a coded,

single-line-item document for each supply transaction

discussed in the paragraphs that follow.

DoD Single-Line Item Requisition System

Document (Manual), DD Form 1348

DD Form 1348 (fig. 13-2) is used as a requisition;

requisition follow-up, modification, or cancellation;

and tracer request on overdue shipments sent by

insured, registered, or certified mail. This form is

available in two-, four-, and six-part sets as follows:

• The two-part set is used by nonautomated ships

for requisition follow-up, modification, or

cancellation, and tracer requests;

• the four-part set is used for requisitioning from

shore activities; and

13-7
• the six-part set is used for requisitioning from

other nonautomated ships (and from automated

ships, when required).

Non-NSN Requisition (Manual),

DD Form 1348-6

DD Form 1348-6 (fig. 13-3) is a six-part form used

to requisition material that cannot be identified by an

NSN, NATO stock number, or NICN other than

permanent “LL”-coded NICNs. The form consists of

two sections. The upper section includes essentially

the same data elements as DD Form 1348. The lower

section includes 10 data blocks for additional

identification data.

Single-Line Item Consumption/Requisition

Document (Manual), NAVSUP Form 1250-1

NAVSUP Form 1250-1 (fig. 13-4) is a seven-part

multipurpose form used as a consumption document.

It is also used as a MILSTRIP requisitioning document

by nonautomated ships for procuring material or

services from another ship, naval supply centers, naval

supply depots, and Navy Inventory Control Point

(NAVICP) Philadelphia.

Requisition and Invoice/Shipping Document,

DD Form 1149

DD Form 1149 (fig. 13-5) is prepared for certain

items that are excluded from MILSTRIP. These items

are listed in NAVSUP P-485 and P-437. DD Form

13-8

Quantity of material

required to sustain

operations in the

interval between

requisitions or the

arrival of successive

shipments

Quantity required to

permit continued operations during interruptions of replenishment or

unpredictable demands

Quantity of material

consumed during normal

order and shipping time

OPERATING

LEVEL OF

SUPPLY

SAFETY

LEVEL OF

SUPPLY

STOCKAGE

OBJECTIVE

REQUISITIONING

OBJECTIVE

HM3f1301

Figure 13-1.—Levels of supply.

HM3f1302

Figure 13-2.—MILSTRIP requisition document: DD Form 1348.
1149 may be used as a requisitioning document or a

receipt document. As a requisitioning document, use

this form to procure GSA contract items such as

medical books, journals, and standard and nonstandard

BUMED-controlled items requiring local purchase

action.

BUMED-CONTROLLED ITEMS

BUMED-controlled items are essential to preserve

life (medications), are easily pilferable (hemostats,

etc.), and/or have a high acquisition or replacement

cost (CAT scan, X-Ray equipment). Requisition

standard stocked BUMED-controlled items on DD

Form 1348, and forward the request through the chain

of command to the Naval Medical Logistics Command

(NAVMEDLOGCOM) for technical review.

PROFESSIONAL BOOKS AND

PUBLICATIONS

The listing of all books and publications that are

required to be maintained at an activity can be found in

NAVMEDCOMINST 5600.1 and NAVMEDCOMINST 6820.1. GSA periodically makes open-end

contracts that cover the procurement of books. All

professional books and publications are procured

under the provisions of these contracts.

PURCHASES

Ships’ supply officers and commanding officers of

ships without Supply Corps officers may obtain

supplies or services by purchase on the open market.

13-9

A.B. SMITH, LT, SC, USN

HM3f1303

NOTE: DD FORM 1348-6 is a 6-part snap-out form with multicolored interleaved copies.

It is perforated at fold line to permit folding to size of a requisition.

Figure 13-3.—Example of a Non-NSN Requisition (DD Form 1348-6).
Purchases are made by one of the following three

methods:

1. Purchase order for purchases not in excess of

$25,000 CONUS or $50,000 outside CONUS.

2. Imprest fund (funds authorized by TYPE

commander for immediate purchases) for cash

purchases of $500 or less.

3. Orders under indefinite delivery-type contracts

and blanket purchase agreements (BPAs) that

have been negotiated by shore activities.

A single requirement may NOT be divided with

more than one purchase action for the purpose of

avoiding monetary limitations. Procedures for

purchases by ashore activities are provided in

NAVSUPINST 4200.85.

13-10

HM3f1304

6196 0692 B 6206 000 02 6196-3456

BLOCK 016 8 942 6 264

V 0515 2 OE01 Z00 0 P3 1R0 00

J 9N 5 9 2 0 00 1 6 0 4 8 9 5 EA 2 1 3 2 264 CR

A0A R7P3 V05152 6196 3456 R V 05851 B 9N IK5 06

Walter T. Door

Figure 13-4.—MILSTRIP requisition document: NAVSUP Form 1250-1.

R52192 USS JOHN PAUL JONES (DDG-32)

N00244 NSC SAN DIEGO, CA

SUPPLY OFFICER

USS JOHN PAUL JONES (DDG-32)

FPO SAN FRANCISCO, CA

1791804.702D 000 53824 B 060957 2D R52192 003041----NU

SEE

BELOW

SERVICES AND MATERIALS FOR REPAIR OF:

3001 IBM ELECTRIC TYPEWRITERS,

Ser. Nos. 14-667421, 15-66744

3002 REMINGTON ELECTRIC TYPEWRITER,

Ser. No. 336601

JOB 1 $60.00

JOB 1 40.00

REQN. SER. NO.

10 FEB 1998 R52192-3041-

SEE

BELOW

A. B. SMITH, LT, SC, USN

HM3f1305

13

S/N 0102 - LF - 011 - 1801

Figure 13-5.—Requisition and Invoice/Shipping Document, DD Form 1149 (multiple requests).
UNIFORM MATERIAL MOVEMENT AND

ISSUE PRIORITY SYSTEM (UMMIPS)

The UMMIPS system assigns priorities to material

movement. Issuing these priorities is a integral and

vital part of MILSTRIP. In the movement and issue of

material, it is necessary to establish a common basis to

determine the relative importance of competing

demands for resources of logistics systems. The

method for determining the relative importance and

urgency of logistics requirements is provided by the

priority designator (PD), a two-digit code that ranges

from 01 (highest) to 15 (lowest). The priority

designator is determined from the urgency of need

designator (UND) and the Force/Activity Designator

(F/AD), as shown in table 13-1.

Force/Activity Designator (F/AD)

F/AD is a Roman numeral (I-V) that identifies and

categorizes a force or activity on the basis of its

military importance as shown below:

Urgency of Need Designator (UND)

The Urgency of Need Designator (UND) consists

of an uppercase letter “A,” “B,” or “C.” It is selected to

indicate the relative urgency of a force’s or activity’s

need for a required item of material. Assignment of

UND is the responsibility of the force or activity

making the requisition and is derived according to

NAVSUP P-485. UNDs and their associated definitions are as follows:

13-11

URGENCY OF NEED DESIGNATORS*

Unable to

Perform

Mission

Impaired

Operational

Capability

Routine

Force/Activity

Designators*

AB C

I In Combat 1 4 11

II Positioned for Combat 2 5 12

III Positioned to Deploy/Combat 3 6 13

IV Other Active & Selected

Reserve Forces

7 9 14

V All Other 8 10 15

Numeric Priorities

*For additional detailed guidance concerning Force/Activity Designators and Urgency

of Need Designators, see OPNAVINST 4614.1.

Table 13-1.—Listing of Priority Designators

I In Combat

II Positioned for Combat

III Positioned to Deploy/Combat

IV Other Active and Selected Reserve Forces

V All Other

UND Definition

A (1)

(2)

(3)

Requirement is immediate.

Without material, the activity is

unable to perform one or more of its

primary missions.

The condition noted in (2) above

has been reported by established,

not operationally ready supply/

casualty report (NORS/CASREPT) procedures.

B (1)

(2)

(3)

Requirement is immediate or it is

known that such a requirement

will occur in the immediate

future.

The activity’s ability to perform

one or more of its primary

missions will be impaired until

the material is received.

Deals with Q-COSAL Reactor

Plant components.

C (1)

(2)

Requirement is routine.

Combat Logistics force.
Priority Designator (PD)

PD is a two-digit number (01-highest to 15-lowest)

determined by using the table of priority designator

shown in table 13-1. For example, if your ship is

assigned an F/AD of III and your requirement is of a

routine nature, assign priority 13.

In addition to providing standardized criteria for

assigning priorities, UMMIPS provides acceptable

maximum processing times for use by supply activities

in furnishing material. Processing time standards and

additional codes used in MILSTRIP and UMMIPS are

included in NAVSUP P-485. For additional detailed

guidance concerning Force/Activity Designator and

Urgency of Need Designator, see OPNAVINST

4614.1.

PREPARING A MILSTRIP

REQUISITION

LEARNING OBJECTIVE: Recognize

MILSTRIP requisition procedures and how

they are used for material receipt, custody,

and stowage.

MILSTRIP uses coded data for processing

requisitions with automatic data processing

equipment. No matter what type of requisitioning

document you use, use extreme care in selecting and

entering the coded data elements. These codes apply to

all levels of supply. Although they are too numerous

for all to be included in this chapter, the codes can be

found in the appendices of NAVSUP P-485. The

following general rules apply to MILSTRIP

requisition:

• Enter data by ball-point pen or typewriter. Do

not use pencil; pencil marks can cause errors

when the requisition is processed through mark

sensing equipment.

• Data should be entered between the “tic” marks

on the form. However, it is mandatory that

entries be included within the data fields to

which they pertain.

• To eliminate confusion between the numeral

zero and the letter “O,” use the communications

zero (φ) on MILSTRIP requisitions when zeros

are applicable.

Specific details for completing DD Form 1348 and

NAVSUP Form 1250-1 can be found in NAVSUP

P-485.

MATERIAL RECEIPT, CUSTODY, AND

STOWAGE

For every procurement action taken, there is a

receipt action that follows. Once the supplies are

received, they must be identified, checked, and

distributed to the appropriate storeroom or department,

and documentation as to their receipt, custody and

stowage must be accomplished.

Material Receipt

As in every situation, responsibility for actions

taken must be assigned to key personnel. In the receipt

of government-owned materials, responsibility for

receipts takes on an added importance because of the

many types of material receipts and the required

accountability.

Receipt Documentation

There are several types of receipt papers, and

which type is used depends upon the manner in which

the material was requested, the issuing activity, and the

modes of transportation used in delivery. The most

commonly encountered receipt is the DoD Single Line

Item Release/Receipt Document, DD Form 1348-1,

(fig. 13-6). Regardless of the type of receipt document,

the end-use receiver must

1. date the document upon receipt,

2. circle the quantity accepted, and

3. sign the document to indicate receipt.

Receiving Procedures

Small quantities of stores received on a daily basis

require no special preparations for receipt. Stock large

quantities of stores in a central area out of the traffic

flow and hold there until preliminary identification

and package count are completed. Then sort them

according to the department or storeroom to which

they will be distributed.

Report of Discrepancy

Item or packaging discrepancies attributable to the

shipper (including contractors, manufacturers, or

vendors) should be reported on the Report of

13-12
Discrepancy (ROD), SF 364, by the receiving activity.

The purpose of the ROD is to determine the cause of

the discrepancy, effect corrective action, and prevent

recurrence. When both item discrepancies and

packaging discrepancies are noted on the same

shipment, both blocks on the top of SF 364 should be

checked and the types of discrepancies noted. The

types of discrepancies required to be reported are

described in chapter 4 of NAVSUP P-485. Detailed

instructions for preparing and distributing of RODs are

contained in the current version of SECNAVINST

4355.18.

Custody

The term custody refers to the responsibility for

proper care, stowage, and use of Navy material and

records pertaining to such. Stored material is required

to be kept under lock and key, except when the material

is too numerous or too large to make such stowage

impractical. Lock storeroom spaces securely when not

in use.

Stowage

Material in storerooms and other designated

stowage areas should be arranged to

• ensure maximum use of available space,

• provide orderly stowage and ready accessibility,

• prevent damage to spaces or injury to personnel,

• reduce the possibility of material loss or damage,

• make it easy to issue the oldest stock first, and

• make it easy to inventory.

The preceding criteria and a “common-sense”

approach will enable storeroom personnel to achieve

stowage efficiency. To the maximum extent that

available space permits, you should adhere to the

following guidelines when stowing material:

• Locate heavy bulk material and materials

handling equipment near hatches or doors to

minimize the physical effort required for

loading, stowage, and breakout.

13-13

HM3F1306

1

Figure 13-6.—DoD Single Item Release/Receipt Document, DD Form 1348-1.
• Locate light bulky materials in storerooms with

high overhead clearances for maximum use of

available space.

• Segregate materials that are dissimilar in type or

classification.

• Locate frequently requested materials as close as

possible to the point of issue.

• Locate shelf-life items in a readily accessible

area to facilitate periodic screening.

• Install appropriate stowage aids (flashlight,

paper, and pencil) in spaces where they are

readily accessible.

• Make aisles at least 30 inches wide, if possible.

• Arrange material with identification labels

facing outward to make issue and inventory

easy.

• Avoid multiple locations for the same item.

If you follow the preceding criteria and guidelines,

you should have no problems in maintaining your

spaces and issuing and inventorying materials.

SPECIAL STOWAGE OF ITEMS

At times, you will have items that require special

stowage. The Naval Ships’Technical Manual (NSTM)

and the Hazardous Materials Information System

(HMIS), DoD 6050.5, outline the requirements for

shipboard stowage of dangerous materials and lists the

materials under each classification. We will now cover

the classifications of material and discuss storage

requirements for special types of material.

Hazardous Material

Hazardous material includes all types of

compressed gases and materials that present a fire

hazard or are otherwise dangerous. Paint and oil

constitute the bulk of material in this category. Paint

and flammable liquid storerooms are normally

provided with alarm and CO2 smothering systems that

can be activated by automatic temperature-sensitive

devices inside storerooms and by manual controls

outside storerooms. A flooding system operated

manually outside storerooms is an additional safety

factor. These storerooms are located, when practical,

below the full-load water line, near either end of the

vessel, but not adjacent to a magazine. They are

equipped with watertight doors that must be locked

and dogged when not in use.

Compressed Gases

Stow compressed gases on the weather deck, and

securely fasten them in a vertical position. Protect the

cylinder valves from accumulations of ice and snow,

and screen the cylinders from direct rays of the sun.

NAVSUP P-485 contains more specific information

concerning handling compressed gas cylinders.

Acid

Liquid acid, unless classified as safe material, is

stowed in an acid locker. Acid lockers are leak-proof

and lead-lined boxes, chests, or lockers specifically

designed for stowing bottles or carboys of acid.

Medical acids may be stored in a medical storeroom.

Alcohol

Alcohol should be stowed in a locked container in

the paint and flammable liquid storeroom, to which

only the supply officer (or other officer designated in

writing by the commanding officer) has the key or

combination.

SHELF-LIFE MATERIAL

Shelf-life material is subject to deterioration.

These items are assigned a shelf-life code listed in the

NMDL. The code denotes the shelf-life span of

material from the date of manufacture to the date of

disposal, or date of testing according to the inventory

manager’s instructions to extend the shelf life. Type I

codes (alpha) apply to items for which shelf life cannot

be extended. Type II codes (numeric) apply to items

for which shelf life may be extended.

OTHER REPAIR PARTS

Repair parts should be stored in their original

containers. With today’s improving techniques and the

material used in packaging, repair parts may be stored

for a considerable time without damage from dust,

shock, or humidity.

STOREROOMS

When you are in charge of a storeroom, you are

also responsible for maintaining cleanliness of the

space. Before you secure each night, sweep the

storeroom and remove all trash. Periodically clean

bins, shelves, ventilation ducts, and fans.

13-14
The overall condition of your space is also your

responsibility. Rust is an ever-present enemy, and

constant vigilance is required to keep it under control.

Rust spots should be chipped, wire brushed or sanded,

primed, and spot painted. Tighten loose bolts promptly

to prevent possible damage to the storeroom or its

contents. Examine pipes, valves, electrical systems,

watertight fittings, and fire-fighting equipment daily,

and report any defect to the supply officer.

Before getting underway into open seas,

thoroughly inspect and secure storerooms to prevent

stores from shifting due to the ship’s motion. Lash

bulk stores to bulkheads, stanchions, or battens, and

secure the fronts of open bins and shelves to prevent

stores from falling out on the deck. Unless approval is

obtained from the commanding officer, do not stow

personal gear in storerooms designated for supplies.

INVENTORY

LEARNING OBJECTIVE: Recognize

specific characteristics of each type of

supply inventory, how inventories are to be

conducted, and procedures for inventory

reconciliation.

Throughout this section, we will use various terms

to refer to inventory control procedures. Some of these

terms are defined here to help you understand them and

apply them correctly. NAVSUP P-485 provides

definitions for all the terms used in inventory control.

DEFINITIONS

In the following paragraphs, we will discuss

definitions that are used in the supply system.

Inventory

Inventory is the quantity of stocks on hand for

which stock records are maintained, or the function

whereby the material on hand is physically inspected

and counted and stock records reconciled accordingly.

Order and Shipping Time

Order and shipping time refers to the time elapsing

between submitting a requisition and receiving the

material requisitioned (also called procurement lead

time).

Average Endurance Level

Average endurance level refers to the quantity of

material normally required to be on hand to sustain

operations for a stated period without resupply.

High Limit (Requisitioning Objective)

High limit is the maximum quantity of material to

be maintained on hand and on order to sustain current

operations normally for 9 months.

Low Limit (Reorder Point)

Low limit (reorder point) is the least amount of the

stock required to be left on hand before the need to

reorder is indicated.

Not Carried (NC) Items

Not carried (NC) items are items not stocked in

storerooms or for which stock records are not

maintained.

Not in Stock (NIS)

Not in stock (NIS) are items carried in stock but not

on board when demand occurs.

Demand

Demand refers to the request for an NC item that

will be procured or an issue of a stock item.

Frequency of Demand

Frequency of demand refers to the number of

requests for an item within a given time frame,

regardless of the quantity requested or issued.

Integrated Logistics Overhaul (ILO)

The ILO is an overhaul procedure divided into

several phases, designed to weed out obsolete and

unused items.

TYPES OF INVENTORIES

There are several types of inventories, each with a

specific purpose. These types of inventory are

bulkhead-to-bulkhead, specific commodity, special

material, spot, velocity, and random sampling.

13-15
Bulkhead-to-Bulkhead

A bulkhead-to-bulkhead inventory is a physical

count of all the material aboard a ship or within a

specific storeroom. A bulkhead-to-bulkhead

inventory of a specific storeroom is conducted when a

random sampling of that storeroom fails to meet the

inventory accuracy rate of 90 percent.

Specific Commodity Inventory

The specific commodity inventory is a physical

count of all items under the same cognizance symbol or

federal supply class (such as 6515/6505), or that

support the same operational function (e.g., bandages,

IV fluids, needles, etc.).

Special Material Inventory

A special material inventory requires the physical

count of all items that, because of their physical

characteristics, costs, or other reasons, are specifically

designated for separate identification and inventory

control. Special material inventories include but are

not limited to stocked items designated as classified or

hazardous. Physical inventory of such material is

required on a scheduled basis, as prescribed in the

NAVSUP P-485.

Medical supplies are examples of both the specific

commodity and special material inventories.

Spot Inventory

A spot inventory is an unscheduled type of

physical inventory to verify the existence of a specific

item. It is usually conducted when a requisition is

returned showing the item is not in stock but the stock

records indicate the item is on hand. A spot inventory

is also conducted when directed by higher authority or

when a specific item has been found to be defective.

Velocity Inventory

A velocity inventory is based on the premise that

the faster an item moves, the greater the room for error.

This type of inventory is required on items with a

relatively high turnover rate.

Random Sampling Inventory

A random sampling inventory is considered to be

part of the annual scheduled inventory program. It is

done to measure the stock record accuracy for a

segment of material on hand.

INVENTORY PROCEDURES

Proper inventory procedures mandate a complete

and correct item count. You must ensure that the total

quantity of each item is determined as accurately as

possible. Keeping in mind that inventories are

conducted to bring stock and stock records into

agreement, you can see the importance of a complete,

accurate, and legible inventory. Documents

authorized for conducting inventory counts of stock

material include NAVSUP 1075 (whether or not

maintained as locator records) and machine or

manually prepared listings. Copies of Stock Record

Card, Afloat, NAVSUP 1114, even when maintained in

storerooms, are not to be used as inventory count

documents.

Promptly upon completion of the physical

inventory and before matching inventoried quantities

against stock record balances, review the inventory

documents to ensure that

• all items scheduled for inventory have been

counted or verified as nonexistent,

• quantities counted are legibly recorded and

compatible with related units of issue,

• all locations applicable to the inventory segment

have been checked,

• “added” items are adequately identified and

legibly recorded,

• items are documented in National Item

Identification Number sequence, and

• documents are dated and initialed.

RECONCILIATION OF COUNT

DOCUMENTS AND STOCK RECORDS

Upon completion of the physical count and review

of the count documents (documents with the actual

numerical count of the items), the next step in the

inventory process is to reconcile count documents with

the stock records. This is done to determine if a

difference exists between the physical count and the

amount recorded on stock records.

When the count documents are correct and

complete, compare them, item by item, with the

applicable stock records to determine whether

differences exist. If no differences exist, post the

matched count cards or items in the inventory listing to

13-16
the applicable stock record. Enter the Julian date

(numerical day of the year) of the inventory and the

notation “INV” in the DATE & SER/WCC column,

and enter the inventory quantity in the ON-HAND

column. The inventory quantity and the on-hand

number should match. See figure 13-7. If differences

exist in the on-hand quantity, locations, or other stock

record data, reconcile such differences using the

procedures outlined in NAVSUP P-485.

STOCK RECORD CARDS

LEARNING OBJECTIVE: Recall how to

prepare and post stock record cards.

Without stock record cards, it would be impossible

to know if there were adequate stocks of material

necessary for the operation of the medical department

of a ship. Procurement of stock must be based on the

information contained on the stock record cards. Use

of approved computer programs are encouraged.

Manual stock record cards are discussed in the

paragraphs that follow.

The two stock record cards most commonly used

in recording usage data are the Stock Record Card,

Afloat, NAVSUP 1114, and the Stock Record Card.

These cards are maintained stock records for all items

of stocked material.

DESCRIPTION OF NAVSUP 1114

The pre-printed captions appearing on the top line

and at the bottom of the NAVSUP 1114 are identical to

each other, and most of the captions are familiar and

self-explanatory. Additional information on some of

the top- and second-line data elements may help you

understand the captions, as well as the source and use

of the data shown.

Material Control Code (MCC)

The material control code (MCC) is a single

alphabetic character assigned by the inventory control

manager to segregate items into more manageable

grouping of fast-, medium-, or slow-moving items, or

to relate to field activities special reporting and control

requirements. This is a first-line entry and is

mandatory for repairable items.

Allowance Parts List/Allowance Equipage List

(APL/AEL)

The APL/AELis a system for numbering the repair

parts and equipment-related consumable items. If the

13-17

HM3F1307

Figure 13-7.—Posting inventory to stock records
Integrated Stock List (ISL) indicated that more than

one AEL or APL applies to the same item, enter the

letter “M” instead of the AEL/APL number. Enter

“General Use” or “GUCL” for non-equipment-related

consumables.

Location

Location tells each area in which the item is stored.

High Limit, Low Limit, Safety Level

(HL, LL, SL)

High limit, low limit, and safety level quantities

are computed in accordance with NAVSUP P-485 and

recorded on the NAVSUP 1114.

Allowance List Quantity (A/L QTY)

Allowance list quantity (A/L QTY) is filled in for

items on the AMAL/ADAL and left blank for

non-allowance items.

Allowance Type Code (AT)

The AT code is assigned by the Integrated

Logistics Overhaul (ILO). It is a single-character

numeric code based on the item use, requirement to be

carried, or usage rates. When an item is added between

ILOs, assign the appropriate AT code.

E/R/C Codes

The E/R/C codes are used for equipage items (E),

repair parts and equipment-related consumables (R),

or for general-use consumables (C). Equipage items

(E) are for special accounting class 207 ships only.

BEG.MO.DE.

The BEG.MO.DE codes are the beginning date of

the demand period, generally the date of the last ILO.

When the original (ILO-prepared) card is filled and a

new card is prepared, bring this date forward to the new

card with the demand and frequency of demand

recorded on the original card. When a card is prepared

between ILOs, the demand date is the date of the initial

requisition.

Demand Frequency Brought Forward (DFBF)

The demand frequency brought forward (DFBF)

code is the total brought forward from a filled stock

record onto a new stock record.

URG

The URG code is a checkmark or “X” if the item is

listed in the Consolidated Afloat Requisitioning Guide

Overseas (CARGO).

MRT

The MRT code is a checkmark or “X” if the item is

listed in the SERVMART shopping list of the local

supply support activity.

Economic Order Item (EOI)

The economic order item (EOI) is a checkmark or

“X” if the item is listed as an economic order item

(low-cost item that may be ordered in a 90-day quantity

if cost does not exceed $40).

Critical Item (CI)

The critical item (CI) is a checkmark or “X” if the

item is listed as a critical item.

Military Essentiality Code (MEC)

The military essentiality code (MEC) is indicated

in the Coordinated Shipboard Allowance List

(COSAL) stock number sequence list (SNSL) for

repair parts and equipment-related consumables.

Security Classification Code (SCC)

The security classification code (SCC) is used

when applicable.

Shelf-Life Code (SLC)

The shelf-life code (SLC) is used when applicable.

Pre-Expended Bin (PEB) Item

The PEB code is a checkmark or “X” used on the

NAVSUP 1114 when the item is designated as a

pre-expended bin item (e.g., nuts, bolts), or when the

unit of issue is large.

Requisition Outstanding

The requisition outstanding code is the Julian date,

serial number, and quantity applicable to each

procurement document.

13-18
PREPARING NEW CARDS

When the original card is filled, prepare a new

card, duplicating the stock item information (except

for usage data). Enter the beginning date on the new

card. Bring forward the demand quantity and

frequency demand totals from the old card to the new

card. Also bring forward any requisitions still

outstanding. Retain the old card, and file it according

to local policy.

POSTING PROCEDURES

Post stock record cards daily as receipt and issue

documents are received. Proper posting procedures

include comparing the following data elements on

receipt documents with those on the stock record

cards:

• Cognizance symbols

• NSN

• Unit of issue

• Unit price

• Storage location

• Quantity received with quantity requisitioned

If the data elements on the receipt documents and

the stock record card are in agreement, enter the Julian

date of the receipt and the serial number of the related

requisition in the DATE & SER/WCC column. Enter

the quantity received in the RECEIPTS column, and

increase the balance in the ON-HAND column by the

quantity received. Draw a single line through the

applicable requisition data for a full receipt (see fig.

13-8). For a partial receipt, if there is a suffix code in

block 44 of DD Form 1348-1, draw a single line

through the quantity and write the outstanding quantity

next to it (fig. 13-8). If there is no suffix code in block

44, consider the requisition as complete. For supplies

received in excess of the requisitioned amount, refer to

NAVSUP P-485.

CONTROLLED SUBSTANCES

LEARNING OBJECTIVE: Recall

security and inventory procedures for

controlled substances.

Naval medical facilities dispensing pharmaceuticals range from large medical centers ashore to small

sickbays aboard ships of the fleet. The custodial

responsibility of controlled substances is vested in the

commanding officer. An officer of the Medical

Department or, in such an officer ’s absence, a

commissioned officer designated by the commanding

officer, keeps all unissued controlled substances in a

separate, locked compartment. Controlled substances

include tranquilizers, alcoholic beverages, alcohol,

hypnotics, stimulants, and narcotics that require

special custodial care. Medicinals are designated

controlled substances by the symbol “Q” or “R” in the

notes column of the Federal Supply Catalog. The Force

13-19

PARTIAL QUANTITY RECEIVED, BALANCE DUE

PARTIAL QUANTITY RECEIVED, BALANCE CANCELLED

HMf31308

25

25

26

26

27

27

28

28

29

29

30

30

31

31

32

32

33

33

34

34

35

35

36

36

37

37

40

40

41

41

42

42

43

43

44

44

45

45

38

38

39

39

QUANTITY

QUANTITY

DOCUMENT NUMBER

DOCUMENT NUMBER

DATE

DATE

SERIAL

SERIAL

REQUISITIONER

REQUISITIONER

A

SERV SERV

SUFFIX SUFFIX

A/L QTY

RECEIPTS ISSUES

AT E/R/C REG. DES.

ON HAND

NO. DQ SF DF SF URG

DATE & SER./WCC

REQUISITIONS OUTSTANDING

DUE DATE SERIAL NO. QUANTITY

4 (Manual) Buff (Rev. 18-75)

A/L QTY

RECEIPTS ISSUES

AT E/R/C REG. DES.

ON HAND

NO. DQ SF DF SF URG

DATE & SER./WCC

REQUISITIONS OUTSTANDING

DUE DATE SERIAL NO. QUANTITY

4 (Manual) Buff (Rev. 18-75)

Figure 13-8.—Posting partial quantities to stock records.
Medical Officer also has authority to designate a

medicinal as “controlled.”

BULK CUSTODIAN

The commanding officer appoints in writing a

commissioned officer to serve as the bulk custodian.

This officer is responsible for and maintains custody of

all bulk controlled substances.

SECURITY

Security of controlled substances is of utmost

importance. Therefore, access to controlled

medicinals is limited to the bulk custodian and the

senior medical department representative (SMDR).

Only individuals whose official duties require access

to such spaces will be provided the safe combinations.

ACCOUNTABILITY

The bulk custodian and the SMDR are responsible

for the receipt and custody of controlled substances.

Each unit must maintain a detailed record of the

receipt, transfer, survey, dispensing, and expenditure

of controlled substances in accordance with

MANMED, chapter 21.

INVENTORY BOARD

Monthly, or more frequently if necessary, the

Controlled Substances Inventory Board will conduct

an unannounced inventory of controlled substances.

The commanding officer appoints three members to

this board, at least two of whom are commissioned

officers. The third member is an E-7 or above. The

officer having custodial responsibility is not appointed

to the board. After the board conducts the monthly

inventory, it will submit a report to the commanding

officer.

SURVEY OF CONTROLLED SUBSTANCES

The survey or inspection of the controlled

substance inventory will be much easier if you adhere

to proper documentation procedures. Destroy

controlled substances in the presence of at least one

member of the inventory board. Make appropriate

entries to the stock records and the Controlled

Substances Log. Items are destroyed in a manner that

ensures total destruction and prevents subsequent use.

The method of destruction must meet federal, state,

and local environmental pollution control standards.

PROPERTY SURVEYS

A property survey is the procedure that is used

when Navy property or Defense Logistics Agency

material is lost, damaged, or destroyed. The purpose of

a survey is to determine who or what is responsible for

the loss, and to determine the actual loss to the United

States Government. To make a true determination, the

facts surrounding the loss or damage must be

thoroughly investigated in a timely manner. The forms

discussed in the following paragraphs are used in

connection with survey procedures.

FINANCIAL LIABILITY INVESTIGATION

OF PROPERTY LOSS, DD FORM 200

The Financial Liability Investigation of Property

Loss, DD Form 200, is used if personal responsibility

is evident, and if the commanding officer or higher

authority so directs.

For more detailed information about the survey

procedures, refer to the NAVSUP Manual, volumes I

and II.

CONTINGENCY SUPPLY BLOCKS

LEARNING OBJECTIVE: Recall

assemblage and management procedures

for medical contingency supply blocks.

At some point in your career, you may be assigned

to one of the six types (surgical, medical regulating,

preventive medicine, specialist support, special

psychiatric rapid intervention (SPRINT), or

humanitarian support) of Mobile Medical

Augmentation Readiness Teams (MMART), to a fleet

hospital, or to some other contingency-related unit.

MMARTs are specialty units that can be deployed

anywhere in the world on short notice. The Medical

Augmentation Program (MAP), BUMEDINST

6440.5, gives detailed information on policies,

procedures, and responsibilities on the various types of

teams. These specialty units require supplies and

equipment that may not be available or are in limited

supply in the area to which deployed. To circumvent

this problem, contingency supply blocks have been

established.

Contingency supply blocks consist of functionally

packaged medical and dental equipment and supplies.

Each block is assembled to meet the needs of a specific

13-20
unit. For example, a surgical supply block contains

enough equipment to establish one operating room and

sufficient supplies for 100 major surgical cases.

BUMEDINST 6440.6, Mobile Medical Augmentation

Readiness Team (MMART) Manual, contains

information about several other blocks and their

support capabilities.

ASSEMBLING THE BLOCK

The contents of each contingency supply block are

outlined in an Authorized Medical Allowance List

(AMAL) specific to that block. The Naval Medical

Logistics Command (NAVMEDLOGCOM) is

responsible for developing, publishing, maintaining,

and coordinating a comprehensive review of all

AMALs on at least an annual basis. The AMAL is the

basic source document used to sustain supply block

management. The preface of the AMAL contains

instructions for maintaining, packing, and marking the

block.

MANAGING THE BLOCK

Contingency supply blocks contain dated,

shelf-life, or deteriorative items such as

pharmaceuticals, intravenous solutions, and

prepackaged items. Proper management of the block

ensures operational readiness. Dated items in the

block must have an expiration date sufficiently far in

the future to allow for a lengthy deployment (up to 6

months). The requirement for monthly status and

quarterly readiness reports ensures the designated

supply blocks are ready for rapid deployment. This

reporting process also allows the team members to

become familiar with the contents of the block and the

operability of all equipment.

Navy medicine=s primary missionCand most

important responsibilityCis to provide combat-ready

professional medical personnel to support the Navy

and Marine Corps team. A highly effective logistic

management program is the cornerstone for any

deployed mission.

SUMMARY

In this chapter we identified Naval Supply

manuals and publications. We introduced the Federal

Supply Catalog System, and we discussed the proper

procedures used to estimate supply needs, procure

supplies and material, and account for supplies and

operating funds. We also discussed the several types of

inventory used in the Navy and the proper procedures

for conducting each inventory, as well as the

importance of stock record cards and the information

required to be recorded on them. Finally, we identified

the importance of and specific procedures for

safeguarding controlled substances.

13-21

CHAPTER 14

ADMINISTRATION

Although most of the their duties are performed in

a clinical environment, Hospital Corpsmen may be

assigned to clerical positions aboard ship, assigned to

duty with the Fleet Marine Force, or detailed to staff

duty where a knowledge of administrative procedures

and reports is a must. Handling, correcting, and using

official directives and publications are important

administrative duties. The efficiency of your office

depends upon the currency of its publications and

directives and how well you know them.

As you progress in rate and assume greater

responsibilities, you will be required to maintain the

activity’s Medical Department Journal, and various

logs, records, and directives. Additionally, you may be

required to draft, type, and file correspondence. You

will use Navy directives and publications more and

more as you learn your job. You may also be required

to maintain computer data for command use.

In this chapter we will cover medical reports, logs,

and records commonly used by the Navy Medical

Department. We will also discuss the maintenance and

disposal of instructions and notices, preparation of

correspondence, and filing procedures. Additionally,

we will discuss the organization of the Fleet Marine

Force and Fleet Hospitals. Finally, we will discuss the

steps required for the development of both a command

medical readiness plan (to include Mobile Medical

Augmentation Readiness Team (MMART) and unit

augmentation) and a joint medical operation plan.

REPORTING REQUIREMENTS

LEARNING OBJECTIVE: Recognize

Medical Department reporting requirements.

As a member of the Medical Department, whether

in a clinic, on a ship, or working sick call, your duties

may include the maintenance of various logs and the

preparation of reports required by higher authority.

These reports are in the Manual of the Medical

Department (NAVMED P-117) and in the current

version of BUMEDINST 5210.9. BUMED has

distributed numerous forms to facilitate reporting,

recordkeeping, and administrative efficiency

throughout the Medical Department. Specific

instructions for management of reports and forms are

covered in the current version of BUMEDINST

5210.9.

MEDICAL DEPARTMENT JOURNAL

Medical Department activities afloat are required

to keep a journal, referred to as the Medical

Department Journal. This journal contains a complete,

concise, chronological record of events of importance

or historical value concerning the Medical Department

(other than medical histories of individuals). It lists

personnel entered onto or deleted from the binnacle or

sick list; reports of personnel casualties, injuries, and

deaths; results of inspections of fresh provisions;

training given to nonmedical personnel; stretcher

bearers assigned; results of inspections of medical

equipment, battle dressing stations, gun bags, and

stretchers; receipt of medical supplies; and other

general information of significance. The journal is

signed daily by the senior medical officer, when

assigned, or the senior medical department

representative (SMDR). The journal is a permanent

record and is retired in accordance with the current

version of SECNAVINST 5212.5.

REPORTS TO THE OFFICER OF THE

DECK OR DAY (OOD)

In addition to being entered into the Medical

Department Journal, any other important occurrences

are reported by the senior representative of the medical

activity to the OOD (or other proper official) for entry

into the duty log or journal of the command. Items

such as injuries or death of personnel and damage,

destruction, or loss of Medical Department property

are reported. The names of patients in serious

condition are reported directly to the commanding

officer and the OOD, with the information necessary

for notification of the patient’s next of kin.

14-1
SICK CALL TREATMENT LOG

A log referred to as the Sick Call Treatment Log is

maintained for each ship or activity. The log contains

each patient’s reporting date and time, name, rate,

social security number, command, division,

complaint, diagnosis, treatment, disposition, and

departure time from sick call. When full, the log is

retired in accordance with SECNAVINST 5212.5.

BINNACLE LIST

The Binnacle List, NAVMED 6320/18, is used to

excuse an individual from duty for a period of 24 hours

or less. This report is prepared by the senior medical

department representative on board and should be

submitted to the commanding officer no later than

0930 each day. This form contains a list of individuals

recommended to be excused from duty because of

illness. The list is approved by the commanding

officer, and no names may be added without the CO’s

permission.

MORNING REPORT OF THE SICK

The Morning Report of the Sick, NAVMED

6320/19, is used to excuse an individual from duty for a

period of more than 24 hours. This report contains a

list of the sick and injured, including names,

diagnoses, and conditions. It is prepared by the senior

medical department representative on board and is

submitted to the commanding officer by 1000 daily.

When it is necessary to excuse someone from duty

after the Morning Report of the Sick is submitted, add

the patient’s name to the Binnacle List, and submit the

appropriate report to the commanding officer. If a

patient is still unfit for duty when the next Morning

Report of the Sick is submitted, add his name to the

NAVMED 6320/19 as of the date on which his name

was first entered on the Binnacle List. If a satisfactory

diagnosis cannot be established, simply note

“Diagnosis undetermined” and indicate the chief

complaint. Report suspected cases of malingering to

the commanding officer.

TRAINING LOG

All lectures and training periods that are part of the

medical training program should be recorded in the

Training Log and a notation made in the Medical

Department Journal. The entries should include the

date, location, type of training (GMT, etc.) or subject

matter, and what department personnel received the

training (Engineering, Deck, etc.).

IMMUNIZATION LOG

To aid you in annotating health records and filling

out monthly medical reports, develop and maintain an

immunizations log. As the minimum, the information

should include the date; name; rank; social security

number; immunization type; duty station; and, for

personnel receiving PPDs, a contact phone number.

There should also be space for adverse reactions.

WATER TEST LOG

The purpose of the water test log is to record the

readings of daily residual chlorine or bromine levels

and the weekly bacteriological examinations required

on potable water aboard ship and in the field.

APPOINTMENT LOG

The purpose of the appointment log is to track

medical consultations and clinical appointments that

are scheduled by the Medical Department. When a

patient is unable to keep an appointment, a notation

indicating both the cancellation and rescheduling of

the appointment should be made in the log. Multiple

appointment cancellations by the same member should

be brought to the attention of the member’s chain of

command.

DIRECTIVES ISSUANCE SYSTEM

LEARNING OBJECTIVE: Recall the

policies and procedures for maintaining

directives, drafting correspondence, and

filing.

As a Hospital Corpsman in an administrative

billet, you may be responsible for maintaining your

command’s files and the CD-ROM library of Navy

directives. Refer to SECNAVINST 5215.1 for

complete details of your responsibilities.

TYPES AND PURPOSES OF DIRECTIVES

A directive may be an instruction (same as a

Marine Corps order), a notice (same as a Marine Corps

bulletin), or a change transmittal. Directives prescribe

or establish policy, organization, conduct, methods, or

14-2
procedures; require action; set forth information

essential to the effective administration or operation of

activities concerned; or contain authority or

information that must be promulgated formally.

Instruction

An instruction is a directive containing authority

or information having continuing reference value, or

requiring continuing action. It remains in effect until

superseded or otherwise canceled by the originator or

higher authority.

Notice

A notice is a directive of a one-time or brief nature,

and it always contains a self-canceling provision. A

notice has the same force or effect as an instruction.

Notices usually remain in effect for 6 months or less,

but never for longer than a year. Any requirement for

continuing action contained in a notice (such as

submitting a report, using a form, or following a

specified procedure) is canceled when the notice is

canceled, unless the requirement is incorporated into

another document (such as an instruction).

Change Transmittal

A change transmittal is used to transmit changes to

manuals, publications, instructions, or, occasionally,

notices. Each transmittal describes the nature of the

change and gives directions for making it. Changes

and corrections are made by inserting new pages,

removing obsolete pages, or making pen-and-ink

changes in the existing text. When a list of effective

pages is included with a change, it is important to

check all pages against the checklist. This procedure

enables you to determine if your publication is

complete and current. In the Marine Corps,

comparable changes are made to orders and bulletins.

MAINTAINING DIRECTIVES

Instructions are normally placed in large three-ring

binders in numerical sequence according to a standard

subject identification code number (SSIC),

consecutive number, and issuing authority. At some

activities, directives may be maintained in a CD-ROM

library. For security purposes, classified directives

and documents are generally filed in separate binders

and maintained in a safe. Because of their brief

duration, notices ordinarily do not need to be filed in

the master file (main files of instructions). If it is

necessary to file them temporarily with instructions,

tab the notices so that each one may be easily and

promptly removed as soon as its cancellation date is

reached. Copies may be filed in separate suspense

binders when necessary.

Locator Sheets

When directives must be removed from the files, a

locator sheet is made up and put in where the directive

should be in the binder. This sheet will contain the

identity of the issuing authority, the directive’s

standard subject identification code number, subject

title, date removed, and both the location of the

directive and the name of the person who has custody

of it.

Making Changes

Follow the instructions enclosed in change

transmittals to enter changes to directives. Proper

notations, such as “CH-1,” are entered in the upper

right margin of the first page of each directive changed

to indicate changes received and incorporated. For

publication-type instructions, completed changes are

noted on the record of changes sheet in the front of the

publication.

List of Effective Instructions

Each year, BUMED conducts a review of all

current instructions, then compiles and distributes a

consolidated list of effective internal and external

instructions via the internet.

CORRESPONDENCE

In addition to maintaining directives and logs and

submitting reports, the Hospital Corpsman working in

an administrative billet must be able to draft and type

correspondence correctly and neatly and be able to file

correspondence so that it may be retrieved quickly and

efficiently.

Navy official correspondence is usually prepared

in the standard naval letter format, referred to as the

standard naval letter. The standard naval letter is

also used when corresponding with certain agencies of

the United States Government. Some civilian firms

that deal extensively with the Navy also prepare

correspondence using the standard naval letter.

Instructions for typing standard naval letters are very

precise and must be followed to the last detail. All the

information to properly prepare naval correspondence

14-3
can be found in the current version of the Department

of the Navy Correspondence Manual, SECNAVINST

5216.5. You should consult this manual when you

prepare correspondence. You may use approved

computer programs for preparing correspondence.

File Number

The size and complexity of the Navy demands a

standard method for filing paperwork. This

standardization frees personnel from learning new

filing systems when moving from one activity to

another. The SSIC system of coding correspondence

through use of a four- or five-digit number

representing its subject matter provides an efficient,

consistent method of filing and retrieving documents.

SSICs are found in Department of the Navy Standard

Subject Identification Codes, SECNAVINST 5210.11.

They serve as file numbers for and are required on all

Navy and Marine Corps letters, messages, directives,

forms, and reports. SSICs will be discussed in more

detail in the upcoming section on filing.

Originator’s Code

An originator’s code, formed according to local

instructions and serving as a basic identification

symbol, appears on all outgoing correspondence. It is

usually the office symbol of the drafter, but it may be

the hull number of the drafter’s ship. For example:

LHA l8-80. This is office/department 80 of ship

LHA-18.

Serial Number

Classified correspondence must contain a serial

number. Whether unclassified correspondence is also

serialized depends on local policy. A command that

produces little correspondence probably does not need

to serialize. An activity that uses serial numbers starts

a new sequence at the beginning of each calendar year

and assigns the numbers consecutively. The serial

number, when used, is combined with the originator’s

code. The following format is used: Ser

LHAl8-80/0726. This represents the 726th piece of

correspondence produced by office/department 80 of

ship LHA-18 during the current calendar year.

There is no punctuation following the serial

number and no space before or after the slash. For

classified correspondence, the classification letter

precedes the serial number (C for Confidential, S for

Secret, T for Top Secret). For example:

Ser LHAl8-80/C16. This is the sixteenth piece of

confidential correspondence originating from

office/department 80 of LHA-18 since the beginning

of the current calendar year.

ELECTRONIC MAIL

Electronic mail (e-mail) lets individuals and

activities exchange information by computer. You

could use it for informal communications in place of

telephone calls or to transmit formal correspondence

within DoD.

FACSIMILE TRANSMISSION SERVICE

Facsimile machines (fax) provide a rapid and

reliable alternative to the mail service for transmission

of documents. Use of fax machines and other

electronic media is discussed in the Navy

Correspondence Manual.

MESSAGES

A message is a written thought or idea,

expressed as briefly and precisely as possible, and

prepared for transmission by the most suitable

means of telecommunication. Details on format,

headings, precedence, and addressal of naval

messages are contained in the current version of the

Naval Telecommunications Procedures Manual,

NTP 3.

FILING

In the previous section of this chapter, we said that

each piece of correspondence requires a file number,

derived from the Department of the Navy Standard

Subject Identification Codes, SECNAVINST 5210.11,

and referred to as the SSIC. The extent of your

knowledge of this standardization system of subject

identification will determine the efficiency with which

you will be able to retrieve a piece of correspondence

from your files.

Numerical Subjects Grouping

SSICs are broken down into 13 major groups:

1000 series—Military Personnel

2000 series—Telecommunications

3000 series—Operations and Readiness

4000 series—Logistics

5000 series—General Administration and

Management

14-4
6000 series—Medicine and Dentistry

7000 series—Financial Management

8000 series—Ordnance Material

9000 series—Ships Design and Material

10000 series—General Material

11000 series—Facilities and Activities Ashore

12000 series—Civilian Personnel

13000 series—Aeronautical and Astronautical

Material

These major groups are subdivided into primary,

secondary, and, at times, tertiary (third-level)

subdivisions. Primary subjects are designated by the

last three digits of the code number, secondary subjects

by the last two digits, and tertiary subjects by the last

digit. For example: 6224

6000 Medicine and Dentistry

6200 Preventive Medicine

6220 Communicable Diseases

6224 Tuberculosis

6100 Physical Fitness

6600 Dentistry

Detailed subdivisions can be found in

SECNAVINST 5210.11.

Classifying

Classifying, as it is used here, is the process of

determining the correct subject group or name-title

codes under which correspondence should be filed and

any subordinate subjects that should be

cross-referenced. Classifying is the most important

filing operation because it determines where

correspondence is to be filed.

The proper way to subject-classify a document so

that it can be readily identified and found when needed

is to read it carefully, analyze it, and then select the

SSIC that most closely corresponds to the subject.

Cross-Reference Filing

File most official correspondence, reports, or other

material under only one standard subject identification

code. There are times when more than one code will

apply to the contents of the correspondence. In these

cases, a system of cross-referencing is desirable to

permit you to locate the correspondence quickly. To

cross-reference, use a Cross-Reference Sheet, DD

Form 334 (filling in the required information about

the correspondence), or make a copy of the correspondence and place it in the appropriate cross

-referenced file. Instances where you need to use a

Cross-Reference Sheet are when

• a document has more than one subject;

• the subject may be interpreted in such a way that

it lends itself to filing under more than one

specific subject group;

• two or more subject identification codes pertain

to the names, places, or items appearing in the

document;

• enclosures are separated from the basic

correspondence; or

• oversize material is filed in an area that is

separate from the file for which intended.

Official Method of Filing

Loose filing of correspondence in standard file

folders is the official method because it saves time and

material. A label containing identifying data for each

folders contents is generally placed on the tab of the

folder. Five-drawer, steel, non-insulated, letter-size

cabinets are standard equipment in the Navy for filing

correspondence and documents. Material that cannot

be folded neatly in the intended file should be filed in a

suitable cabinet. Note the location of this material on

the basic document of a cross-reference sheet. Files

containing classified documents or Privacy Act data

are to be properly secured in accordance with the

current version of OPNAVINST 5510.1. Use of

computers to maintain files is also a quick method for

retrieval. However, paper and/or backup disk copies of

the computer files must also be available.

Terminating Files

General correspondence, as well as most other

files, are terminated at the end of each calendar year,

and new files are begun. Budget and accounting

records are also terminated annually, but at the end of

each fiscal year (30 September). Maintain terminated

files in the office for 1 year before they are retired to a

storage area where they are maintained until they are

eligible for destruction or transfer to a Federal Records

Center. The current version of the Disposal of Navy

and Marine Corps Records Manual, SECNAVINST

14-5
5212.5, contains detailed information about terminating files.

DISPOSITION OF RECORDS

The Department of the Navy is producing records

with increasing speed and ease. Actions and decisions,

both important and unimportant, are being

documented at every level of command. Informational

papers are being more widely distributed. The records

disposal program is designed to identify records for

permanent retention or temporary retention and later

destruction. One of the goals of the program is to

dispose each year of a volume of records at least equal

to the volume of records created during that year.

Decisions to save or not save must not be avoided

by saving all your files. No matter how firmly you

believe that disposing of a file today will mean that

someone will need it tomorrow, a decision must be

made. If you are in doubt about disposal of certain

records, avoid taking it upon yourself either to retain or

dispose of them; consult with your superiors to decide

what course of action to take. The current version of

the Disposal of Navy and Marine Corps Records

Manual, SECNAVINST 5212.5, discusses the

retention period of official files and explains whether

they should be destroyed or forwarded to a Federal

Records Center for further retention.

ELECTRONIC RECORDS

An electronic record is any information that is

recorded in a digital form that only a computer can

process. In practice, there is no difference between

managing electronic and paper records. The Navy

Correspondence Manual is an excellent guide to use

for handling electronic records.

TICKLER FILES

As we discussed earlier in this chapter, the Medical

Department is required to submit a number of reports.

These required reports are listed in OPNAVNOTE

5214 (which is published annually) and in NAVMED

P-117, chapter 23. To ensure that these reports are

submitted in a timely manner, a system has been

developed to readily identify what report is due and

when it is due. This system is known as the tickler

system. The manner in which a tickler file is made up

may vary with each command. Use a computer to save

time since there are many approved programs

available to create tickler files. Or, you may use 5" x 8"

cards with separators marked with the month (i.e.,

January through December), with the tickler card filed

in the month in which the report is due. The tickler file

may also be used as a reminder of action required on

incoming correspondence, or interim reports on a

project with a future completion date. Aboard ship, the

tickler file is also required for personnel requiring

immunizations, physical examinations, or program

evaluation. To ensure that departments submit all

reports when due, it is advisable to have a tickler

system alerting them in sufficient time before the

actual due date. This may be accomplished as follows:

• Put out a monthly listing of reports due.

• Provide each department with a copy of the

appropriate tickler card.

To be effective, the tickler file requires daily attention

and updating.

MEDICAL DEPARTMENT SUPPORT

TO THE FLEET MARINE FORCE

(FMF) AND FLEET HOSPITALS

LEARNING OBJECTIVE: Recognize the

medical organization of the Fleet Marine

Force and Fleet hospitals.

To understand the complexity of medical support

to FMF and Fleet hospitals, you must first be familiar

with its overall organization. We will first discuss the

FMF. Medical and dental personnel are not members

of the U.S. Marine Corps. They are detailed from the

Navy and assigned to the FMF, which is a balanced

force of combined air and ground troops trained,

organized, and equipped primarily for offensive

deployment. The FMF consists of a headquarters,

force troops, a force service support group (FSSG),

one or more Marine divisions, brigades, and aircraft

wings. Each of these units is assigned a specific

number of medical support personnel, providing an

interrelated network of medical support.

FMF MEDICAL SUPPORT

In general, Medical Department personnel serving

with FMF may be divided into two groups:

• Combat personnel, who provide medical and

initial first aid to prepare the casualty for further

evacuation, and

14-6
• Support personnel, who provide surgical and

medical aid to those who need early definitive

care and cannot be further evacuated.

Medical personnel are an integral part of the

combat unit to which they are assigned; they train with

their units and live with and accompany them at all

times.

All of the units comprising an FMF have Medical

Department personnel organic to them. However, the

majority of medical support comes from the medical

battalion of Force Service Support Group (FSSG). The

FSSG is a composite grouping of functional units.

These functional units provide combat service support

beyond the organic capability of all elements of FMF.

The medical battalion provides combat medical

support required for independently deployed battalion

landing teams, regimental landing teams, Marine

expeditionary units, or Marine expeditionary brigades.

The primary mission of the medical battalion is to

provide

• casualty collection,

• emergency treatment,

• temporary hospitalization,

• specialized surgery, and

• evacuation.

In addition, medical battalions must plan,

supervise, and coordinate timely preventive measures

for controlling disease.

The basic organization of a typical medical

battalion is shown in figure 14-1. A further breakdown

of the organization can be found in chapter 3 of the

Marine Corps Warfighting Publication (MCWP)

4-11.1.

FMF DENTAL SUPPORT

The mission of FMF dental units is to furnish

dental services to a Marine Expeditionary Force. By

attaching dental sections and detachments of the task

force, battalion personnel maintain dental readiness

during exercises, deployments, operations other than

war, and combat operations.

In an emergency environment, the dental

battalions primary mission is to provide dental health

maintenance, with a focus on emergency care.

Personnel from these detachments may also provide

postoperative, ward, central sterilization, and supply

room support, and other medical support as

determined to be appropriate by the medical battalion

and surgical company commanders.

FLEET HOSPITALS

Initially conceived and developed as facilities to

provide medical support during intense combat

operations, fleet hospitals are also used in lengthy

low-intensity scenarios. Fleet hospitals are

transportable, medically and surgically intensive

(capable of performing advanced medical and surgical

procedures), and deployable in a variety of operational

scenarios. Available in sizes ranging from 100 to 500

beds, these health-care assets can be used by a variety

of field commanders. Fleet hospitals are designed to

be used in long-term operations (60+ days) involving a

14-7

HM3F1401

MEDICAL BATTALION

260 BEDS

9 OPERATING ROOMS

HEADQUARTERS &

SERVICE COMPANY

SURGICAL COMPANY

60 BEDS / 3 OR's

SURGICAL COMPANY

60 BEDS / 3 OR's

SURGICAL COMPANY

60 BEDS / 3 OR's

SHOCK TRAUMA PLATOON

8 STP's / 10 BEDS EACH

HEADQUARTERS

PLATOON

HEADQUARTERS

PLATOON

HEADQUARTERS

PLATOON

TRIAGE / EVACUATION

PLATOON

TRIAGE / EVACUATION

PLATOON

TRIAGE / EVACUATION

PLATOON

SURGICAL

PLATOON

SURGICAL

PLATOON

SURGICAL

PLATOON

Figure 14-1.—Organization of a medical battalion.
sizable number of ground forces. Moderately

sophisticated care is provided, along with resuscitative

medical and surgical care, and selected specialty care.

Fleet hospitals are substantially self-supporting and

relocatable; however, relocatability varies with the

hospital size.

Mission

A fleet hospital’s mission depends on its type and

the operation in which it will be used. The type is

determined by bed size and echelon of care. Fleet

hospitals are designed and staffed to provide Echelon

III or Echelon IV levels of patient care.

Designation

Fleet hospitals designated as active duty facilities

will be manned by active duty personnel, with a

command staff assigned from one particular naval

hospital using the Medical Augmentation Program

(MAP). Naval Reserve fleet hospitals will be staffed

by preassigned Naval Reserve personnel. After

activation, fleet hospitals are deployed to an

operational theater where command and control pass

to an operational commander.

Organization

The internal organization of the fleet hospital is

similar to a shore-based MTF. It consists of the

command staff (commanding officer, executive

officer, command master chief, and special assistants)

and five directorates (nursing service, medical

services, surgical service, ancillary service, and

administrative service).

Security and Safety

A deployed fleet hospital must have a security plan

that addresses security precautions, threat response,

and disaster recovery. The security program covers

physical, informational, and classified material

aspects normally included in the area of operation

(AO) security plan. Physical security for fleet

hospitals is both internal and external.

Fleet hospitals will follow the same OPNAV safety

program as other operational units. Hospital

commanders establish a safety program and an internal

organization to address safety issues and appoint a

safety officer.

Logistics

Logistics for a fleet hospital include medical

supplies, equipment, and services. Logistical

requirements can range from acquiring raw material to

delivering medical supplies to a field hospital, or

returning medical equipment to a theater after a patient

evacuation. Tasks of fleet hospital logistics include

contracting, host-nation support, equipment management, facilities management, transportation, graves

registration, and postal service. All of the fleet hospital

supply department operations are conducted in

accordance with NAVSUP P-485.

Personnel

Staffing for active duty fleet hospitals comes from

several CONUS MTFs, while designated reserve units

staff a particular reserve fleet hospital. Each fleet

hospital has its own active manning document

(AMD). Personnel are normally issued TAD orders for

less than 180 days. If the operation exceeds 179 days,

PCS orders may be issued. Replacements are handled

the same way as in any fixed MTF.

Training

BUMED is responsible for monitoring the training

of all authorized personnel assigned to fleet hospital

mobilization billets. COMNAVSURFRESFOR is

responsible for overseeing the training of Naval

Reserve personnel assigned to staff Naval Reserve

fleet hospitals.

COMMAND MEDICAL READINESS

PLAN

LEARNING OBJECTIVE: Recall the

policies and procedures for the drafting of a

command medical readiness plan, and recall

mobile medical personnel augmentation

procedures.

As you advance in the Hospital Corps, you may be

involved in assisting in the development of a command

readiness plan. This is the process by which wartime

medical requirements are filled by active duty and

reserve personnel to bring units to their full or partial

wartime allowance.

14-8
MEDICAL AUGMENTATION PROGRAM

(MAP)

The Medical Augmentation Program is a

computer-supported program that provides medical

personnel to the operating forces during situations

requiring medical personnel augmentation (additional

personnel). Inherent in this system is the ability to

monitor wartime manning readiness and determine the

impact of future personnel requirements. The program

also allows for the planning of training for Medical

Department personnel. Other aspects that must be

considered are the establishment of training

requirements, the development of a readiness

reporting system, and the phased deployment of

personnel.

Augmentation Sources

Through MAP, the requirements of the operational

commanders are combined with the active duty

resources of the augmentation source commands. The

commands that are to be supported by MAP are

functional units, typically manned only at a minimum

level during peacetime and requiring manpower

augmentation in order to fulfill their missions during

contingency situations. Current manpower

authorization levels are not a factor in defining unit

augmentation requirements. The augmentation

sourcing units are CONUS-based medical and dental

treatment facilities. These medical and dental facilities

provide and train the augmentees. The sourcing units’

assets are matched with the augmentation

requirements.

Program Scope

The scope of the MAP is based on a worst-case

scenario involving total augmentation to meet the early

support requirements of the operational forces. This

means bringing all operational units to their full

allowances. Limited augmentation scenarios are also

within the scope of this program. Double tasking is not

permitted under the MAP. The MMART system is a

subset of the MAP and should not be viewed as a

separate entity. The MMART surgical/surgical

support teams are incorporated into the system as the

core of an LHA/LPH/LHD augment. Individuals may

have both MMART and LHA/LPH/LHD mission

assignments, but these are identical, not dual tasks.

Specific unit platforms and training requirements are

discussed in detail in the current version of Medical

Augmentation Program (MAP), BUMEDINST

6440.5.

MOBILE MEDICAL AUGMENTATION

READINESS TEAM (MMART)

The MMART system is a peacetime subset of the

MAP. The mission of an MMART is to serve as a force

of trained Medical Department personnel capable of

rapidly augmenting operational forces for limited,

short-term military operations, disaster relief

missions, fleet and FMF exercises, and scheduled

deployments. During contingencies requiring medical

augmentation, the MMART surgical and surgical

support teams become the integral augment core for

LHA/LPH/LHDs. Other MMART teams dissolve into

other augment units.

The MMART is a composite of separate teams

manned by medical and dental specialists. The nucleus

of the MMART is the surgical team. When combined,

a number of distinct specialty teams comprise a single

MMART. A full composite MMART consists of one of

each of the following component specialty teams:

• Surgical team

• Surgical support team

• Head and neck trauma team

• Neurosurgical team

• Nursing team

• Medical regulating team

• Special psychiatric rapid intervention team

(SPRINT)

• Blood bank team

• Preventive medicine team

• Disaster relief/evacuation team

An MMART may be deployed as a full composite

team. However, in most situations, an individual

specialty team or a combination of specialty teams is

all that is required. The personnel and material

organization of the MMART may be modified at

BUMED direction to meet the specific operation or

disaster mission. MMARTs are generally deployed as

intact units to an operational commander. These teams

may be augmented or reduced as necessary, but they

are deployed to a single unit. The exception to this

situation is in medical regulating teams, which are

fragmented to various ships to set up a medical

regulating communications network. For further

information about MMART, see the current version of

Mobile Medical Augmentation Readiness Team

(MMART) Manual, BUMEDINST 6440.6.

14-9
JOINT MEDICAL OPERATIONAL

PLAN

LEARNING OBJECTIVE: Identify the

steps in the development of a joint medical

operational plan.

As a Hospital Corpsman you should be able to

assist in the development of a joint medical operational

plan. This is a plan that outlines the use of medical

assets in support of tactical operations. The tactical

mission of the combat forces is the basis for all medical

planning. Medical preparation and planning must be

initiated early and must be specifically designed to

support the tactical operation.

MEDICAL ESTIMATE

A medical estimate is an estimate of personnel and

material needed to supply medical services in support of

military operations. The steps that are taken in preparing

the medical estimate include consideration of the

command mission, consideration of the factors affecting

the health services (workload, supplies, etc.), and

evaluation of proposed courses of action (i.e., listing

comparative advantages and disadvantages of each).

Medical Intelligence

The staff surgeon and dental surgeon must be

thoroughly informed of all military operations before a

proper medical estimate can be made. Some of the

items that should be considered are enemy capabilities,

friendly capabilities, and environment (terrain,

climate, etc.). This information, taken together,

becomes medical intelligence.

Patient Estimate

Based on the medical intelligence, a preliminary

patient estimate can be made of the probable number of

patients, types of patients, patient distribution, and the

areas of greatest patient density. From these

preliminary patient estimates, a calculation is made of

the number and types of medical units and the amount

and kinds of medical material which will be required.

Similar estimates, based on the anticipated health

situation, will be required for preventive medicine

units.

Evaluation of Course of Action

The staff surgeon must determine the various

courses of action that are available and the probable

effect of each enemy capability on the success of each

course of action, and weigh the advantages and

disadvantages of each course of action. The staff

surgeon will then decide which course of action

promises to be the most successful in accomplishing

the mission. A recommendation will be made to the

commander for medical requirements, along with

where, when, and how medical units should be

employed.

PLANNING FACTORS

Basic planning for medical support in joint

operations involves four major considerations:

• Plans pertaining exclusively to each medical

service

• Plans of each medical service that require

coordination with the other elements of the same

armed service

• Plans involving joint action among the services

• Plans involving coordination with allied forces

Admission Rates

One of the prerequisites for sound medical

planning is an accurate estimate of patients, calculated

by applying admission rates to personnel strengths.

Admission rates are numerical expressions of the

relative frequency with which patients are admitted to

hospitals from a specified population over a designated

period of time. The particular admission rates used in

medical planning represent average rates derived from

similar experiences in similar military operations. The

three primary categories of patients used in calculating

admission rates in an area of military operation are

wounded (battle) patients, nonbattle injury patients,

and patients who are ill.

Evacuation

Patient evacuation policy is established by the

Secretary of Defense, with the advice of the Joint

Chiefs of Staff and the recommendation of the theater

commander. The policy states, in number of days, the

maximum period of noneffectiveness (i.e.,

hospitalization) that patients may be held within the

command for treatment. Any patient who is not

expected to return to duty within the number of days

expressed in the theater evacuation policy is

14-10
evacuated. Evacuation plans are greatly influenced by

the amount and type of transportation available to

medical service.

SUMMARY

In this chapter we discussed medical reports, logs,

and records commonly used by the Navy Medical

Department. We also covered maintenance and

disposal of instructions and notices, preparation of

correspondence, and filing procedures. Additionally,

the chapter covered the Fleet Marine Force,

development of a command medical readiness plan (to

include the Mobile Medical Augmentation Readiness

Team (MMART) and unit augmentation), and

development of a joint medical operational plan.

14-11

CHAPTER 15

HEALTHCARE ADMINISTRATION

In the Medical Department, proper records

administration is very important. We are charged with

administering not only routine personnel records, but

also clinical records that may affect the rights and

benefits of patients and their dependents years beyond

retirement or discharge.

As a Hospital Corpsman, you could be assigned to

or responsible for the administrative affairs

concerning inpatients or outpatients. This chapter will

provide information on the function of healthcare

programs you may be involved with or responsible for.

We will also discuss the legal implications in medical

care, including the various aspects of consent, incident

reports, and release or nonrelease of medical information

under the Privacy and/or Freedom of Information

Acts. Further, guidance concerning your relationship

and interaction with law enforcement personnel and

the legal community will also be outlined.

PATIENT ELIGIBILITY FOR

HOSPITALIZATION AND

NONFEDERAL CARE

LEARNINGOBJECTIVE: Recognize the

policies and procedures for DEERS,

CHAMPUS, and TRICARE.

The fact that a person seeking treatment is or was

connected with the federal government does not

automatically entitle him to treatment at a naval

medical treatment facility. A number of factors

determine eligibility for certain types of medical

attention and the source and amount of remuneration

for that treatment. The following section deals with

eligibility verification by presentation of a valid ID

card and utilization of the Defense Enrollment

Eligibility System (DEERS). Further guidance can be

obtained by familiarizing yourself with the following

sources:

• NAVMEDCOMINST 6320.3, Medical and

Dental Care for Eligible Persons at Navy

Medical Department Facilities

• NAVMEDCOMINST 6320.18, Civilian Health

and Medical Program of the Uniformed Services

(CHAMPUS) Regulation

• NAVMED P-5020, Resources Management

Handbook

DEFENSE ENROLLMENT ELIGIBILITY

REPORTING SYSTEM (DEERS)

The Defense Enrollment Eligibility Reporting

System (DEERS) was developed to improve

distribution and control of military healthcare

services. Additionally, DEERS was implemented to

assist in the projection and allocation of costs for

healthcare programs and to minimize fraudulent

healthcare claims. Navy medicine’s eligibility for care

instruction, NAVMEDCOMINST 6320.3, provides

guidance as to who and under what circumstances

members can receive medical and dental care at Navy

Medical Department facilities; the extent and

conditions under which such care may be provided;

and the collection process to pay for that care.

Enrollment for all seven uniformed services (i.e.,

Army, Air Force, Marine Corps, Navy, Coast Guard,

Public Health Service, and National Oceanic and

Atmospheric Administration) is accomplished

through completion and submission of an Application

for Uniformed Services Identification and Privilege

Card, DD 1172, for a member’s dependent. When a

new ID card is obtained for the dependent, the

member’s DEERS data is updated online. If problems

exist within a patient’s database, active duty personnel

and their dependents must be referred to the sponsor’s

personnel office. Refer all other beneficiaries (e.g.,

retired personnel and their dependents) to the nearest

personnel office.

Direct Care System Procedures

In addition to providing authorization to standard

medical care through inclusion in its membership

database, DEERS now includes a dental policy based

upon beneficiary information (versus the previous

policy based on sponsor information). This change in

policy occurred in part because of the increased

accuracy of the database as well as the percentage of

personnel enrolled.

15-1
Although DEERS and the ID card system are

related, there are instances when the beneficiary is in

possession of a valid ID card and the DEERS system

shows the patient as ineligible or not in the database. In

these instances, eligibility verification using the ID

card shall not override DEERS without some other

type of collateral documentation. (See sections on

DEERS overrides and exceptions later in this chapter.)

It must be stressed that military treatment facilities

(MTFs) are to verify eligibility. Establishment of

eligibility is under the cognizance of the respective

service personnel offices.

Eligibility

Patients who present for non-emergency treatment

without a valid ID card but who are in the DEERS

database will not be provided medical care without

first signing a statement that they are eligible and

giving the reason why a valid ID card is not in their

possession. If a valid ID card is not provided within 30

calendar days, the patient is referred for billing as a

Civilian Humanitarian Non-indigent, in accordance

with the Resources Management Handbook,

NAVMED P-5020. Such billing may be delayed if the

commanding officer of the facility is convinced proof

is delayed for reasons beyond the control of the patient

or sponsor. In all cases where a patient presents

without an ID card and does not appear in the DEERS

database, non-emergency care will be denied.

REASONS FOR INELIGIBILITY.—When a

DEERS check is performed and the patient is found

ineligible for any of the following reasons, routine

non-emergency healthcare will be denied (except as

noted later in this section).

• Sponsor not enrolled in DEERS

• Dependent not enrolled in DEERS

• Ineligible due to passed terminal (end) eligibility

date

• Sponsor has separated from active duty

• Spouse is divorced from sponsor and is not

entitled to benefits as a former spouse

• Dependent child is married

UNDER NO CIRCUMSTANCES WILL THE

CLERK PERFORMING THE ELIGIBILITY

CHECK DENY THE REQUESTED CARE. Only

command-designated supervisory personnel can

perform this function.

DEERS ELIGIBILITY OVERRIDES.—The

nine “DEERS eligibility overrides” are listed below.

Unless otherwise stated, all overrides must be

supported by a valid ID card.

1. DD 1172—The patient presents an original or

copy of the DD 1172 used for DEERS

enrollment. There are specific items required

for verification, and current service directives

must be checked.

2. All Other Dependents Recently Becoming

Eligible for Benefits—Patients who become

eligible for benefits in the previous 120 days

may be treated upon presentation of a valid ID

card. For children under 10 years of age, a valid

ID card of a parent or guardian is acceptable.

Upon application for care beyond 120 days,

follow the procedure in item 1, above.

3. New Identification Card—Patients presenting

with a new valid ID card, issued within the

previous 120 days, will not be denied care.

4. Ineligible Due to ID Card Expiration—When

the database shows a patient as ineligible

because of ID card expiration, care may be

rendered as long as the patient has a new ID card

issued within the previous 120 days. After 120

days, follow the procedure in item 1, above.

5. Sponsors Entering Active Duty Status for a

Period of Greater than 30 Days—A copy of

orders ordering a reservist or guardsman to an

active duty period of greater than 30 days may be

accepted for the first 120 days of the active duty

period. After that, follow the procedure in step 1.

6. Newborns—Newborns will not be denied care

for a period of 1 year following birth. The

patient’s birth certificate suffices when

presented with a parent’s valid ID card.

7. Emergency Care—This is a medical decision

and shall be determined by criteria established

within the command.

8. Sponsor’s Duty Station is Outside the 50

United States or has an APO/FPO

Address—Dependents whose sponsors are

assigned outside the 50 United States or to a

duty station with an APO/FPO address will not

be denied care as long as the sponsor is enrolled

and eligible in DEERS.

9. Survivors—When an eligibility check

indicates that a deceased sponsor is not enrolled

15-2
in DEERS or the survivor is listed as the sponsor,

the survivor will be treated on the first visit and

referred to the appropriate personnel office for

correction of the DEERS database. For second

and subsequent visits, the survivor will be

required to follow the procedure in item 1, above.

DEERS ELIGIBILITY EXCEPTIONS.—The

following beneficiaries are categorized as “DEERS

Eligibility Exceptions.” Although authorized care,

they may not be authorized to be enrolled in the

DEERS system. These beneficiaries will NOT be

denied care based upon a DEERS check.

• Secretary of the Navy Designees—Secretary

of the Navy Designees will be treated as

indicated on their letter of designation.

• Foreign Military Personnel—These personnel

and their dependents, assigned through Personnel

Exchange Programs or other means, are or may be

eligible. Eligible members may also include

—North Atlantic Treaty Organization (NATO)

military personnel and their dependents

stationed in or passing through the United

States;

—crew and passengers of visiting military

aircraft; and

—crews of ships of NATO nations that come

into port.

Other foreign military personnel may be eligible through

Public Law or DoD agreements. As such, they will be

treated in accordance with current service directives.

Patients in other organizations, such as Red Cross

workers, Secret Service agents, Federal Aviation

Administration personnel, and some non-retiree

veterans, to name a few, are also in this category.

Ensure current eligibility requirements are met for

these personnel prior to treatment.

TRICARE

TRICARE is an enhancement of the Civilian

Health and Medical Program of the Uniformed

Services (CHAMPUS). TRICARE is a medical

benefits program established to enhance management

of care services in military medical treatment facilities

and to cost-share charges for medically necessary

civilian services and supplies required in the diagnosis

and treatment of illness or injury. TRICARE is also

utilized if the required services are not available from

the direct care system of the Department of Defense

treatment facilities or designated MTFs.

Information pertaining to eligibility, extent of

care, providers, cost, and claims is contained in the

booklet Sailing with TRICARE, for Sailors and Their

Families. A copy of this publication, along with the

TRICARE Provider Directory and other helpful

TRICARE information is available at your local

TRICARE Service Center. A wealth of guidance is

also available via the DoD TRICARE homepage,

http://www.tricare.osd.mil.

NAVY MEDICINE’S QUALITY

ASSURANCE PROGRAM

LEARNING OBJECTIVE: Recall the

philosophy of Navy medicine’s Quality

Assurance Program.

The Quality Assurance Program is used to

evaluate the degree of excellence of the results of

delivered care and to make improvements so that care

in the future will result in a higher degree of quality.

Quality assurance activities reflect what patients and

providers expect of each other. In past years, various

means of reviewing and evaluating patient care have

been introduced. In 1979, the JCAH Board of

Commissioners imposed the requirement for hospitals

to coordinate quality assurance activities and to use an

ongoing monitoring system to review and evaluate the

quality and need for care. This approach is effective in

identifying important patient-related problems and is

applicable in every healthcare delivery situation.

Many of the principles, standards, and organizational

requirements of JCAH have been adopted and are

contained in OPNAV 6320.7, Health Care Quality

Insurance Policies for Operating Forces.

BUMEDINST 6010.13, Quality Assurance Program,

lists the required elements for process improvement

(quality assurance) programs of naval hospitals,

medical clinics, and dental clinics.

PATIENT RELATIONS AND

COMMAND PATIENT CONTACT

PROGRAMS

LEARNING OBJECTIVE: Recall the

philosophy of the Patient Relations Program

and the Command Patient Contact

Program.

15-3
Navy healthcare professionals have long

understood the need for good communication and

rapport between the patient and the medical

department staff. The atmosphere in which patient

care is given has a tremendous effect on the patient’s

perception of the quality of care. The quality of

medical care rendered to Navy beneficiaries is superb;

however, too frequently the medical care is perceived

by the patient to be substandard because personnel in

patient contact points are not adequately trained in

interpersonal relations. Good patient rapport is an

essential element of health care delivery. Many

complaints voiced by patients would not occur if

personnel manning critical patient contact points

presented a courteous, positive, and knowledgeable

attitude that reflected a genuine concern for the patient.

To this end, the Patient Relations Program was

implemented through BUMEDINST 6300.10, Health

Care Relations Program. The Patient Relations

Program’s primary goal is to provide assistance by

intervention in and resolution of a patient’s complaints

or problems. The Patient Contact Program, a subset of

the Patient Relations Program, ensures an effective

means of resolving such issues before the patient

departs the facility. As an adjunct to this goal, both

programs strive to enhance the channels of

communication between the hospital and the patient

population, as well as among the hospital staff.

FAMILY ADVOCACY PROGRAM

LEARNING OBJECTIVE: Recognize

policies and procedures pertaining to the

Family Advocacy Program.

The purpose of the Family Advocacy Program is to

identify, treat, and monitor Navy personnel engaging

in spouse or child abuse/neglect (whether physical or

psychological) and sexual abuse. The program, a

responsibility of the Navy Military Personnel

Command, is guided by SECNAVINST 1752.3 and,

further, by BUMEDINST 6320.70. In each

geographical location, a Family Advocacy

Representative (FAR), usually a staff member of the

Naval Hospital, manages the program. A basewide

committee, composed of medical, line, chaplain, and

Family Service Center personnel, reviews abuse cases

and determines whether each case is established,

suspected, or unfounded. Established cases are

reported at the central registry at the Bureau of

Medicine and Surgery, where service statistics are

compiled and the future assignment of established

abusers is monitored and controlled.

DRUG AND ALCOHOL ABUSE

PREVENTION AND CONTROL

PROGRAM

LEARNING OBJECTIVE: Recognize

policies and procedures pertaining to the

Drug and Alcohol Abuse Prevention and

Control Program .

The Navy has established a “zero tolerance”

standard for drug usage. Although prevention and

punishment are still major components of the zero

tolerance policy, the major emphasis has shifted to

education and training. Routine after-care treatment of

addiction is rarely offered to individuals found abusing

drugs, and the most likely outcome of drug abuse is

appropriate disciplinary action and separation from the

service. Levels of alcohol-abuse treatment range from

shipboard education programs to inpatient admission.

Post-treatment consists of monitoring and support

groups, both of which are crucial aspects of the 1-year

after-care rehabilitation program.

All individuals with substance abuse problems—

whether alcohol- or drug-related—are totally

accountable for their actions and the consequences of

them in accordance with the Uniform Code of Military

Justice (UCMJ) and other relevant federal, state, and

local laws. See OPNAVINST 5350.4, Drug and

Alcohol Abuse Prevention and Control, and

SECNAVINST 5300.28, Military Substance Abuse

Prevention and Control, for additional information

and guidance.

Drug and alcohol abuse is costly in terms of lost

work hours and unnecessary administrative and

judicial processing and is a critical drawdown on

morale and esprit de corps. It undermines the very

fiber of professional readiness, safety, discipline,

judgment, and loyalty. It is not only the abuser who is

affected, but the abuser’s shipmates as well. “Zero

tolerance” recognizes that drug and alcohol abuse is

incompatible with the maintenance of high standards

of performance, military discipline, and readiness, and

is destructive of Navy efforts to instill pride and

professionalism in its members.

15-4
PREVENTION

Prevention programs are an important aspect of

military life. PREVENT 2000 (Personal

Responsibility and Values, Education and Training) is

a program designed specifically for the younger Sailor.

ADAMS (Alcohol and Drug Abuse, Managers and

Supervisors) is required for E-5 and above.

Most commands have full-time or collateral-duty

DAPAs, Drug and Alcohol Program Advisors, who

provide the direct liaison between law enforcement,

medical, the Family Services Center, and the

commanding officer in all matters dealing with

intervention, identification, and treatment. The DAPA

coordinates on-site training, facilitates Alcohol

Anonymous meetings, and provides referrals for

outside intervention and inpatient treatment if

indicated. Personnel can be identified to the DAPA

through aberrant behavioral patterns, suspicious

medical findings, and by self-referral to either medical

or the chaplain’s office.

CONTROL

Medical personnel become professionally

involved in substance abuse programs when called

upon to withdraw blood or urine from an individual

suspected of drug or alcohol abuse. Few areas cause as

much concern and confusion to healthcare providers as

the question of when those bodily fluids may be

lawfully extracted.

At the outset, a few basic facts must be discussed.

1. The healthcare provider should not undertake a

fluid extraction procedure when to do so is

medically contraindicated.

2. Refusal to perform an extraction in the face of

lawful authority could subject the healthcare

provider to charges of obstruction of justice or

willful disobedience of an order.

3. The healthcare provider is not an arbiter of the

law. (In other words, the admissibility of

evidence derived from a blood or urine sample is

not a matter for Medical Department personnel

to decide.)

4. Common sense and cooperation with command

and law enforcement officials should be the

guideposts in every instance where extraction of

bodily fluids is an issue.

The following are the circumstances where

withdrawal of blood or urine from active duty military

members is authorized:

• Consensual withdrawal—If an individual

expressly consents to an extraction of bodily

fluids and there is a legitimate reason for the

extraction, the healthcare provider may perform

the procedure.

• Valid medical purpose—Specimens may be

obtained from an individual for a valid medical

examination, provided the individual has

expressly or implicitly consented to the

examination.

• Competence for duty examinations—The

Competence for Duty Examination request form

(NAVMED 6120/1) contains a block for the

submitting authority to request laboratory

analysis. See figures 15–1 and 15–2. The

following procedures should be used in handling

competence for duty requests.

—The command initiating the request should

complete items 1 through 12 of the form. The

individual submitting the request must have

authority to make the request. Normally, this

will be a commanding officer, executive

officer, or command duty officer of the

initiating command.

—After proper initiation of the request, the

medical officer or other authorized healthcare

provider will complete blocks 13 through 49

on the form.

—If the command has requested laboratory

analysis, the patient should first be requested

to give written consent to the procedure. If the

patient will not give consent but will allow

extraction, the sample should be taken. If the

patient refuses consent and will physically

resist extraction, the requesting command

should be notified and no extraction

attempted unless a search authorization is

issued.

PHYSICAL READINESS PROGRAM

LEARNINGOBJECTIVE: Recognize the

policies and procedures pertaining to the

Physical Readiness Program.

15-5
The policies governing this program are outlined

in OPNAVINST 6110.1. Currently, physical readiness

testing is required for all personnel on a semi-annual

basis. Testing, education, and training advice are

provided through a network of collateral duty

command fitness coordinators. In addition to the

requirement for program implementation by each

subordinate command, Medical Department

responsibilities are

• providing technical assistance to BUPERS,

• conducting lifestyle, fitness, and obesity

research,

15-6

Figure 15–1.—NAVMED 6120/1, Competence for Duty Examination request form (front).
15-7

HM3f1502

Figure 15–2.—NAVMED 6120/1, Competence for Duty Examination request form (back).
• reviewing health status and granting waivers for

those individuals unable to safely participate in

physical fitness testing and training, and

• assisting in the development of exercise

prescriptions.

LEGAL IMPLICATIONS IN MEDICAL

CARE

LEARNINGOBJECTIVE: Recognize the

policies and procedures pertaining to

consent for medical treatment, incident

reports, and release of medical information.

There are few aspects of medical administration of

treatment that do not have some legal implications.

Every time a patient comes into contact with a facility

or its staff members, either directly or indirectly,

formally or informally, the potential for legal

entanglement exists. Although the law has become

more and more involved in the operation of hospitals,

the exercise of common sense combined with a

knowledge of those situations that require special care

will protect the hospital and its staff from most

difficulties.

This section addresses some of the situations that

regularly arise and have legal consequences, including

the policy and instructions that apply to those

situations. Keep in mind that the law is an inexact

science, subject to widely varying circumstances. The

information in this chapter cannot substitute for the

advice of an attorney. Hospital staff members are

encouraged to consult with hospital or area Judge

Advocate General (JAG) Corps officers on issues with

which they are uncomfortable.

CONSENT REQUIREMENTS FOR

MEDICAL TREATMENT

With limited exceptions, every person has the right

not to be touched without his having first given

permission. This right to be touched only when and in

the manner authorized is the foundation of the

requirement that consent must be obtained before

medical treatment is initiated. Failure to obtain

consent may result in the healthcare provider being

responsible for an assault and battery upon the patient.

Informed Consent

While the term “consent” in the medical setting

refers to a patient’s expressed or implied agreement to

submit to an examination or treatment, the doctrine of

“informed consent” requires that the healthcare

provider give the patient all the information necessary

for a knowledgeable decision on the proposed

procedure. When courts say that a patient’s consent

must be informed, they are saying that a patient’s

agreement to a medical procedure must be made with

full awareness of the consequences of the agreement.

If there is no such awareness, there has been no lawful

consent.

The duty to inform and explain rests with the

provider. THIS RESPONSIBILITY CANNOT BE

DELEGATED.

The provider must describe the proposed

procedure in lay terms so the patient understands the

nature of what is proposed. The risks of the treatment

must be explained. If there are any alternative medical

options, they should be disclosed and discussed.

For common medical procedures that are

considered simple and essentially risk free, a provider

is not required to explain consequences that are

generally understood to be remote. A determination of

what is simple and common should be made from the

perspective of appropriate medical standards. Where

the harm that could result is serious or the risk or harm

is high, the duty to disclose is greater.

Methods should be developed within each hospital

department to acquaint patients with the benefits,

risks, and alternatives to the proposed treatment. In

some departments, prepared pamphlets or information

sheets may be desirable. In others, oral

communication may be the best method. Some states

(e.g., Texas) have laws that are very specific about

what is required.

Emergency Situations

Consent before treatment is not necessary when

treatment appears to be immediately required to

prevent deterioration or aggravation of a patient’s

condition, especially in life-threatening situations, and

it is not possible to obtain a valid consent from the

patient or a person authorized to consent for the

patient. The existence and scope of the emergency

should be adequately documented.

15-8
Who May Consent

The determination of who has authority to consent

to medical treatment is based on an evaluation of the

competency of the patient. If competent, usually the

patient alone has the authority to consent. Competency

refers to the ability to understand the nature and

consequences of one’s decisions. In the absence of

contrary evidence, it may be assumed that the patient

presenting for treatment is competent. If the patient is

incompetent, either by reason of statutory

incompetence (e.g., a minor) or by reason of a physical

or mental impairment, the inquiry must turn to

whoever has the legal capacity to consent on behalf of

the patient. Parents and guardians will usually have the

authority to consent for their minor child or children.

In many states, though not all, a husband or wife may

give consent for an incompetent spouse. It is the law of

the state in which the hospital is located that controls

the question of “substitute consent.”

Forms of Consent

Consent for medical treatment should be obtained

through an open discussion between the provider and

patient during which the patient expressly agrees to the

procedure. The consent should then be documented by

having the patient sign any appropriate forms and by

the provider noting any important details of the

discussion in the medical record.

In certain limited circumstances, the consent of an

individual to simple medical treatment may be implied

from the circumstances. Implied consent arises by

reasonable inference from the conduct of the patient or

the individual authorized to consent for the patient.

Reliance on this form of consent is strongly

discouraged except in the most routine, risk-free

examinations and procedures.

Witness to Consent

Any competent adult may witness the patient’s

consent. It is preferable that the witness be a staff

member of the hospital who is not participating in the

procedure. It is not advisable for a relative of the

patient to act as a witness.

Duration of Consent

A consent is valid as long as there has been no

material change in the circumstances between the date

that consent was given and the date of the procedure. It

is desirable that a new consent be obtained if there is a

significant time lapse or if the patient has been

discharged and readmitted due to postponement of the

procedure.

INCIDENT REPORTS

When an event occurs that harms an individual,

illustrates a potential for harm, or evidences serious

dissatisfaction by patients, visitors, or staff, then a

risk-management incident has taken place. Examples

of such episodes could include the following:

• A patient’s family helps him out of bed despite

directions to the contrary by staff members. The

patient falls and is injured.

• Excessive silver nitrate is put into the eyes of a

newborn, impairing vision.

• The mother of the child complains about the care

that has been given to her child and informs a

staff member that she is going to talk to her

lawyer about what has happened.

When a member of the staff becomes aware of an

incident, he has a responsibility to make the hospital

command aware of the situation. The mechanism for

doing this is the incident report system. Incident

reports are designed to promptly document all

circumstances surrounding an event, to alert the

commanding officer, quality assurance coordinator,

and other involved administrators and clinicians of a

potential liability situation, and, in a broader sense, to

establish an information base on which to monitor and

evaluate the number and types of incidents that take

place in the facility.

Because incident reports, by their very nature,

contain a great deal of information that would be of

interest to persons filing claims or lawsuits against the

Navy for alleged substandard medical care, and

because the law recognizes the need for hospitals to

have a reliable means of discovering and correcting

problems, most states have enacted laws that make

incident reports confidential. In other words, a person

cannot obtain a copy of an incident report to help in

their legal action against the hospital.

However, incident reports can lose their

“protected” status if they are misused or mishandled. It

is important, therefore, to treat these reports like other

confidential documents. You must strictly limit the

number of copies made and the distribution of the

reports. Do not include the report in the patient’s

treatment record. The report should be limited to the

facts and must not contain conclusions. Finally, the

15-9
report should be addressed and forwarded directly to

the quality assurance coordinator of the hospital.

Further guidance concerning the Risk Management Program, the program that governs incident

reports, can be found in BUMEDINST 6010.21.

RELEASE OF MEDICAL INFORMATION

Two federal statutes, the Privacy Act and the

Freedom of Information Act (FOIA) combine to

establish the criteria for collecting, maintaining, and

releasing medical treatment records.

Freedom of Information Act

The Freedom of Information Act governs the

disclosure of documents compiled and maintained by

government agencies. A written request for

Department of the Navy records that explicitly or

implicitly refers to FOIA must be responded to in

accordance with the provisions of the Act. The

Department of the Navy will make available to any

person all documents, not otherwise exempt,

provided the requester reasonably describes the

records sought and promises to pay for reasonable

search and photocopy costs. Each naval activity is

responsible for developing procedures for ensuring

the prompt handling, retrieval, and review of

requested records. The official having responsibility

for the records has 10 working days to respond to the

requester.

A naval record will be withheld only when it is

exempt from disclosure under FOIA. One basis for

exempting a record from disclosure applies to

personnel, medical, and similar files, the release of

which would constitute a clearly unwarranted invasion

of personal privacy. This concern over clearly

unwarranted privacy intrusion is reflected in the

provisions of the Privacy Act.

Privacy Act

The public’s concern over the inner workings and

functioning of the government was the reason for the

creation of the FOIA. However, it became obvious that

a balance had to be made between the public’s right to

know and other significant rights and interests. One of

these competing interests was the protection of an

individual’s personal right to privacy. In response to

this need, the Privacy Act of 1974 was enacted. The

stated purpose of the Privacy Act is to establish

safeguards concerning the right to privacy by

regulating the collection, maintenance, use, and

dissemination of personal information by federal

agencies.

The Privacy Act requires federal agencies to

• permit an individual to know what records

pertaining to him are collected, maintained,

used, or disseminated by the agency;

• permit an individual to prevent records

pertaining to him and obtained by the agency for

a particular purpose from being used or made

available for another purpose without the

individual’s consent;

• permit an individual to gain access to

information pertaining to him in federal agency

records, have a copy made for all or any portion

thereof, and correct or amend such records;

• collect, maintain, use, or disseminate any

record of identifiable personal information in a

manner that ensures such action is for a

necessary and useful purpose, that the

information is current and accurate, and that

adequate safeguards are provided to prevent

misuse of such information;

• permit exemptions from the requirements of the

Privacy Act only in those cases where there is

specific statutory authority to do so; and

• be subject to civil suits for any damages that

occur as a result of willful or intentional

violation of any individual’s rights under the

Privacy Act.

In addition, any officer or employee of an agency

who willfully violates certain provisions of the Privacy

Act is subject to criminal prosecution and fines.

Under the Privacy Act’s provisions concerning

disclosure of information, there are several

circumstances under which naval treatment records

and their contents can be disclosed. Included are

disclosures to employees of the Department of the

Navy who have a need to know the information. Also

included are disclosures to a person under compelling

circumstances affecting health or safety, pursuant to a

court order, and to another government agency for civil

or criminal law enforcement activities. Circumstances

under which the release of medical information is

appropriate are discussed in chapter 12, Health

Records, and in the section of this chapter concerning

law enforcement personnel.

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MEDICAL CONDITIONS AND LAW

ENFORCEMENT PERSONNEL

LEARNINGOBJECTIVE: Recognize the

policies and procedures pertaining to

prisoner patients, victims of alleged sexual

assault and rape, substance abuse and

control, probable-cause searches, and

line-of-duty and misconduct investigations.

Some medical conditions, by their very

occurrence, will result in the involvement of law

enforcement personnel. Individuals who are injured

while committing a criminal offense; victims of abuse,

neglect, or assault; impaired or injured as a result of

drug abuse; or injured as a result of a traffic accident

will often be the subject of an official investigation.

Many times the investigators will want to question the

patient or the healthcare providers treating the patient.

Often, the medical records of the patient will be

requested by the authorities. Occasionally, officials

will want to take the patient into custody.

Under the Posse Comitatus Act, a federal statute

enacted in 1956 (18 U.S.C. § 1385), it is unlawful for

the U.S. military to be used to enforce or assist in the

enforcement of federal or state civil laws. There are

many exemptions to this act, but the issue for

healthcare providers is settled by asking the following

question: “Is the medical procedure being done on this

patient for a legitimate medical reason, or is it only

being performed to assist civil law enforcement?”

Provided there is a reasonable medical justification for

the procedure, the results of the procedure may be

shared with civil law enforcement officials under the

circumstances discussed below.

Cooperation with law enforcement officials, to the

extent possible, is required. Provided there are no

medical contraindications, patients who are either

suspected of having committed an offense or who are

presumed victims of criminal activity will be made

available to speak with investigators. As discussed

previously, access to medical treatment records is

governed by the Privacy Act and FOIA. Generally,

records of patients may be made available to U.S. Navy

investigators once they have established a need to

know the information. This determination will usually

be made by the hospital JAG or public affairs officer.

Other Department of Defense, federal, state, or local

law enforcement officers may have access to treatment

records if access is necessary as part of a criminal

investigation and there is no unwarranted violation of

the privacy rights of the individual involved.

Similarly, local health and social service departments

may be provided information from the record. The

same guidelines that apply to access to treatment

records apply to staff members’ discussing with

investigating officers the details of the medical

treatment provided to a patient.

DELIVERY OF A PATIENT UNDER

WARRANT OF ARREST

No patient may be released from treatment before

it is medically reasonable to do so. Once it is

determined that the individual can be released without

significant risk of harm, the following guidelines

regarding release to law enforcement authorities apply.

• Nonactive Duty Patients—When a nonactive

duty patient is released from medical treatment,

the facility no longer exercises any degree of

control, and normal legal processes will occur.

No official action by hospital personnel is

required before local authorities take custody of

the released patient. There may be occasions,

however, when law enforcement officials should

be notified of an imminent release of a patient.

• Active Duty Patients—The commanding

officer is authorized to deliver personnel to

federal law enforcement authorities who display

proper credentials and represent to the command

that a federal warrant for the arrest of the

individual concerned has been issued. There are

circumstances in which delivery may be refused;

however, guidance should be sought from a

judge advocate of the Navy or Marine Corps

when delivery is to be denied.

Normally, it is the responsibility of the permanent

command to take custody and control of an active duty

member suspected of committing an offense. If the

member is an unauthorized absentee and the command

to which he is assigned is not in the same geographic

area as the treatment facility, release of the patient

should be coordinated with the nearest Transient

Personnel Unit or Military Prisoner Escort Unit. Close

liaison with the member’s permanent command should

also be established.

In cases where delivery of an active duty patient is

requested by local civil authorities, and the treatment

facility is located within the requesting jurisdiction or

aboard a ship within the territorial waters of such

jurisdiction, commanding officers are authorized to

15-11
deliver the patient when a proper warrant is presented.

Whenever possible, a judge advocate of the Navy or

Marine Corps should be consulted before delivery. If

the treatment facility is located outside the jurisdiction

requesting delivery, only a General Courts-Martial

authority (as defined by the Uniform Code of Military

Justice, Manual for Courts-Martial, and Navy

Regulations) is authorized to arrange for delivery of

such the patient. Extradition, return agreements, and

other prerequisites to delivery will have to be

completed.

When disciplinary proceedings involving military

offenses are pending, the treatment facility should

obtain legal guidance from a judge advocate before

delivering a patient to federal, state, or local

authorities. When the commanding officer considers

that extraordinary circumstances exist which indicate

that delivery should be denied, then the Judge

Advocate General of the Navy must be notified of the

circumstances by message or phone.

PRISONER PATIENTS

Prisoner patients fall into three categories of

eligible beneficiaries:

• Enemy prisoners of war and other detained

personnel

• Nonmilitary federal prisoners

• Military prisoners

Enemy Prisoners of War and Other Detained

Personnel

Enemy prisoners of war and other detained

personnel are entitled to all necessary medical and

dental care, subject to the availability of care and

facilities.

Nonmilitary Federal Prisoners

Nonmilitary federal prisoners are authorized only

emergency medical care. When such care is being

provided, the institution to which the prisoner is

sentenced must furnish the security personnel to

ensure custody of the prisoner and safety of others in

the facility. Upon completion of emergency care,

arrangements will be made immediately to transfer

these individuals to a nonmilitary treatment facility or

for return to the institution to which sentenced.

Military Prisoners

Status of Forces policy is to protect, to the

maximum extent possible, the rights of U.S. personnel

who may be subject to criminal trial by foreign courts

and imprisonment in foreign prisons. Active duty

members are generally not separated from the service

until they have completed their term of imprisonment

and returned to the United States. During this

confinement, they will normally remain healthcare

beneficiaries.

Military prisoners (those sentenced under the

Uniform Code of Military Justice) whose punitive

discharges have been executed but whose sentences

have not expired are authorized medical and dental

care. Individuals on appellate leave, awaiting

execution of a punitive discharge, are also entitled to

care. Military prisoners whose punitive discharges

have been executed and who require hospitalization

beyond expiration of their sentences are not eligible for

care, but they may be hospitalized as civilian

humanitarian nonmilitary indigents until disposition

can be made to some other facility.

SEXUAL ASSAULT AND RAPE

Sexual assault and rape are criminal offenses,

often associated with serious injury. The management

of cases involving sexual assault and rape must be a

joint medical and legal function. A sexual assault

investigation kit, supplied by the Naval Criminal

Investigative Service, is used to gather and preserve

evidence of a crime. Included in this kit are

step-by-step procedures for the examination of the

patient, as well as a checklist of specimens to be

collected.

In order to safeguard and obtain evidence to be

used in possible legal proceedings, liaison between the

naval treatment facility, military and civil

investigative agencies, and state and local agencies

(such as Child and Spouse Protective Services) should

be established. It must be kept in mind that medical

personnel are not to judge, defend, or prosecute the

individuals involved. NAVMEDCOMINST 6310.3,

Management of Alleged or Suspected Sexual Assault

and Rape Cases, provides further guidance for the

care, evaluation, and medico-legal documentation of

the victim of an alleged rape or sexual assault.

Every effort must be made to treat the patient with

respect and courtesy and to provide appropriate

privacy. In dealing with alleged victims of sexual

15-12
assault, careful attention to psychological factors must

be given to lessen the impact of the incident. This is

especially important when a minor is involved and the

reaction of adults may be more harmful than the actual

assault itself. Tactful questioning and the use of

appropriate terminology are of extreme importance

throughout the history taking and examination.

OPNAV INST 1752.1, Sexual Assault Victim

Intervention (SAVI) Program, and SECNAVINST

5800.11, Victim and Witness Program, provide

guidance for the care and support of victims of sexual

assault.

CHILD AND SPOUSE ABUSE AND

NEGLECT

The nature of child and spouse abuse and neglect

requires a careful patient history and physical

examination to identify or rule out past and present

injuries caused by abuse or neglect. The policies and

guidelines established by the Navy Family Advocacy

Program must be followed. This program was

discussed earlier in this chapter and is outlined in

SECNAVINST 1752.3 and BUMEDINST 6320.70.

SUMMARY

Retaining our high medical standards and the

quality healthcare the fleet demands, as well as

providing care for military dependents and a constantly

expanding retiree database, requires a healthcare

administration support structure that is second to none.

DEERS management and the determination of patient

eligibility are crucial components and only two of the

areas discussed in this chapter. Also covered were many

of the health-related programs established to benefit and

support eligible recipients in the military community.

These programs are often meant to eliminate the need

for others. Good quality assurance, for example, creates

better patient relations, thereby minimizing legal

problems; substance abuse and family advocacy

programs identify problems before they become

unmanageable; and the physical readiness program

helps build a healthier Sailor, thus eliminating needless

patient visits.

This chapter also provided an overview of the

Hospital Corpsman’s responsibilities in the area of

interaction with legal authorities. Sexual assault,

spouse and child abuse, and drug and alcohol incidents

require legal and medical teamwork. Many legal

battles are lost because of failure to adhere to the

proper administrative procedures. As a Hospital

Corpsman, you must be aware of these procedures and

ensure that they are followed precisely.

15-13

CHAPTER 16

DECEDENT AFFAIRS PROGRAM

The Navy’s Decedent Affairs Program consists of

search, recovery, identification, care, and disposition of

remains of deceased personnel for whom the Department

of the Navy is responsible. The Decedent Affairs Program

is considered a highly visible and extremely sensitive

program. Arrangements for the burial of the deceased

should be conducted in an expedient but dignified manner,

and survivors of the deceased should be given the greatest

possible amount of support and assistance.

ASSIGNMENT OF RESPONSIBILITIES

LEARNING OBJECTIVE: Identify

military activities that are responsible for the

management of the Navy and Marine Corps

Decedent Affairs Program.

The overall manager of the Navy and Marine Corps

Decedent Affairs Program is the Naval Office of

Medical/Dental (MEDDEN) Affairs, located at Great

Lakes, IL. At the local level, naval hospitals and other

naval activities are responsible for inspecting remains,

briefing escorts and making travel arrangements, and (for

burial at sea) delivering remains to the point of

embarkation. Naval hospitals manage deaths that occur

at the hospital and in their local catchment (area of

responsibility) area. At small independent operational

units and on board naval vessels, the responsibility for

managing the Decedent Affairs Program falls on the

commanding officer or officer-in-charge and the senior

Hospital Corpsman. For this reason, Hospital Corpsmen

should have a working knowledge of decedent affairs

procedures, which are outlined in NAVMEDCOMINST

5360.1, Decedent Affairs Manual.

PROGRAMS

LEARNING OBJECTIVE: Recall the

purpose of the Current Death Program,

Graves Registration Program, Concurrent

Return Program, Return of Remains

Program, and the Casualty Assistance Call

Program.

To carry out the various responsibilities of the

Decedent Affairs Program, five programs have been

established. They are

• the Current Death Program,

• the Graves Registration Program,

• the Concurrent Return Program,

• the Return of Remains Program, and

• the Casualty Assistance Calls Program.

CURRENT DEATH PROGRAM

The Current Death Program provides professional

mortuary services, supplies, and related services

incident to the care and disposition of remains of

persons eligible for these services. Under this

program, remains are shipped to a place designated by

the primary next of kin (PNOK), such as a spouse or

parents, for permanent disposition. The decedent’s

personal effects will also be shipped to the legal

recipient. The Current Death Program is normally

operational on a worldwide basis during peacetime,

but may also be used during major conflicts.

GRAVES REGISTRATION PROGRAM

The Graves Registration Program (GR or

GRREG) provides for the search, recovery, evacuation

(to a temporary cemetery or a mortuary), initial

identification, disposition of personal effects found

with each deceased, and burial of deceased persons in

temporary cemeteries. This program is only

operational when authorized by the responsible

commander during major military operations. When

necessary, the GR program includes the establishment

and maintenance of temporary burial sites. Detailed

guidance on graves registration procedures are

contained in the Navy and Marine Corps publication

NAVMED P-5016/NAVMC 2509A, Handling of

Deceased Personnel in Theaters of Operation.

CONCURRENT RETURN PROGRAM

The Concurrent Return Program combines the

Current Death Program and Graves Registration

16-1
Program. This program provides for the search,

recovery, and evacuation of remains to a processing

point; identification and preparation of remains in a

mortuary; and shipment, for permanent disposition, to

a final destination designated by the PNOK. The

Concurrent Return Program normally becomes

operational when large numbers of military personnel

are committed to a strategic area.

Remains buried in temporary cemeteries (under

the GR program or in emergencies) will normally be

disinterred and evacuated under the Concurrent Return

Program if conditions and capabilities permit.

RETURN OF REMAINS PROGRAM

The Return of Remains Program provides for

permanent disposition of remains of persons buried in

temporary cemeteries who could not be evacuated

under the Concurrent Return Program. The Return of

Remains Program is activated only upon the enactment

of special legislation. This special legislation may

authorize the establishment of one or more permanent

American cemeteries in the overseas area and may

give PNOK the option of having the remains buried

therein or shipped to another place of their choosing.

When the Return of Remains Program becomes

activated, the Chief, Bureau of Medicine and Surgery

(BUMED), is responsible for advising field activities

of its activation.

CASUALTY ASSISTANCE CALLS

PROGRAM

The Casualty Assistance Calls Program (CACP) is

administered by the Commander, Naval Military

Personnel Command (COMNAVMILPERSCOM),

and the Commandant of the Marine Corps (CMC).

Although integrally related, the CACPis not part of the

Decedent Affairs Program. The CACP details a

Casualty Assistance Calls Officer (CACO), usually a

commissioned officer (although senior enlisted

personnel may be used), to personally contact the

PNOK. The CACO helps the PNOK and SNOK

(secondary next of kin—children over 18, brother,

etc.) with problems surrounding the death, and

provides information on such matters as

• disposition of remains,

• death gratuity and unpaid pay and allowances,

• personal effects of the deceased,

• settlement of the decedent’s estate (wills, bank

accounts, property, savings bonds, commercial

insurance, etc.),

• Servicemen’s Group Life Insurance (SGLI), and

• travel of dependents to grave site and to

permanent residence.

The Navy and Marine Corps Casualty Assistance

Calls Programs are operated differently. The

individual service instructions noted below should be

consulted for specifics.

• NAVPERS 15560, Naval Military Personnel

Manual (MILPERSMAN)

• BUPERSINST 1770.3, The Navy Casualty

Assistance Calls Program (CACP) Manual

• MCO P3040.4, Marine Corps Casualty

Procedures Manual (MARCORCASPROCMAN)

ELIGIBILITY FOR DECEDENT

AFFAIRS

LEARNING OBJECTIVE: Identify

individuals who are eligible for decedent

affairs benefits.

Navy and Marine Corps members who expire

while serving on active duty or active and inactive duty

for training are entitled to Decedent Affairs Program

benefits. Generally, the following persons under the

jurisdiction of the Department of the Navy are entitled

to some decedent affair benefits: dependents, retirees,

and civilian employees. For details, see

NAVMEDCOMINST 5360.1, Decedent Affairs

Manual.

NOTIFICATION OF DEATH

LEARNING OBJECTIVE: Identify forms

used to report casualties, deaths, and

personnel missing or missing in action.

As soon as possible after it is determined that a

casualty has occurred, submit a casualty report in

accordance with MILPERSMAN 4210100. When

death occurs, complete the “Personnel Casualty

Report (Death), Report Symbol NMPC 1770-4

16-2
Officer/Enlisted.” For missing personnel, complete

the “Personnel Casualty Report (Missing/Missing in

action), Report Symbol NMPC 1770-4 Officer/

Enlisted.”

PERSONNEL CASUALTY REPORT

A personnel casualty report must be completed for

the following persons who become casualties:

• Active duty Navy

• Retired Navy

• Certain former service members

• Certain military dependents

• Members of other Armed Forces

• Civilians serving with or attached to Navy

commands

• Others whose deaths occur on naval reservations

or aboard ships

When a member becomes a casualty, his

commanding officer should submit a personnel

casualty report. However, if a service member

becomes a casualty while away from his command, the

command or activity that learns of the casualty

occurring should submit the personnel casualty report.

The member’s command should supplement the

personnel casualty report that was previously

submitted by another command.

METHOD OF REPORTING CASUALTIES

Personnel casualty reports should be sent by

priority message.

Action Addressees on Personnel Casualty

Reports

The following activities should be action

addresses on personnel casualty reports:

1. Commander, Naval Military Personnel

Command

2. Chief, Bureau of Medicine and Surgery

3. Casualty Assistance Calls/Funeral Honors

Support (CAC/FHS) Program coordinators of

the area in which the primary and secondary

NOK reside, or the appropriate overseas

CAC/FHS program coordinator

4. T he Na val O f fice o f Me dical/De ntal

(MEDDEN) Affairs

Information Addressees on Personnel Casualty

Reports

The following activities should be listed as

information addresses on personnel casualty reports:

1. Secretary of the Navy

2. Navy Finance Center

3. Navy Family Allowance Activity, Cleveland (if

the member reported is in a missing status, or if

the status is being changed from missing to

deceased)

4. The CAC/FHS program coordinator of the area

in which the casualty occurred

5. The Chief of Naval Operations (if the casualty is

incidental to operations, and on all reports of

progress in searches for missing members)

6. The appropriate home port/station, type

commander, appropriate operational and

administrative commands, and the Enlisted

Personnel Management Center (EPMAC)

7. The command or activity designated by the

CAC/FHS program coordinator to provide

casualty assistance

8. The Fleet Home Town News Center

9. The Naval Safety Center

10. The Judge Advocate General

11. The Appropriate Naval Legal Service Office (if

the casualty is the result of other than natural

causes)

12. The Armed Forces Institute of Pathology

If the decedent was a Marine Corps member,

follow the notification procedures and message

formats contained in the MARCORCASPROCMAN,

MCO P3040.4.

NOTIFICATION OF NEXT OF KIN

LEARNING OBJECTIVE: Recall

notification of next of kin procedures.

In cases of death, primary next of kin are

personally notified by a uniformed Navy or Marine

16-3
Corps representative, as appropriate. Personal

notification of the PNOK will normally be made

between 0600 and 2200, except under unusual

circumstances (e.g., the new media is expected to make

a press release; or the member has been hospitalized in

serious or very serious condition within CONUS, and

the NOK is already aware of the prognosis).

When a death occurs within CONUS, it is the

responsibility of the member’s commanding officer to

make sure that personal notification is made. Outside

CONUS, the COMNAVMILPERSCOM will make

sure that personal notification is made through the

appropriate senior commander overseas.

CONFIRMATION OF THE CASUALTY

Notifications that are not made by telegram should

be confirmed by a telegram, unless the PNOK or

SNOK has specifically stated that written confirmation is not desired. This follow-up notification

should take place within 24 hours of the personal

notification.

See MILPERSMAN 4210100 for examples of

basic telegram formats for notification and

confirmation of death. The formats are presented for

guidance only, and rigid adherence is not required.

CONDOLENCE LETTER

Commanding officers are required to write a letter

to the appropriate NOK within 48 hours of a casualty.

The letter, in addition to expressions of condolence,

should contain appropriate details of the casualty;

however, no details should be included that are likely

to distress the NOK. A copy of the letter is sent to the

COMNAVMILPERSCOM and Office of the Judge

Advocate General (OJAG)—Investigations Division.

Example formats for condolence letters can be found

in the Decedent Affairs Manual.

AUTOPSY

LEARNING OBJECTIVE: Determine

under what circumstances an autopsy should

be performed.

An autopsy will be performed on the remains of all

persons who die on active duty or active duty for

training when the commanding officer (CO) deems it

necessary. The CO’s request may be self-initiated or

based upon the recommendation of an investigating

officer, other fact-finding body, or a medical officer.

An autopsy may be necessary to determine the true

cause of death, to get information for completing

military records, or to protect the welfare of the

military community.

AIRCREW AUTOPSY

The Manual of the Medical Department

(MANMED), NAVMED P-117, states that when an

aircrew member dies while serving as an aircrew

member on a military aircraft, the medical officer will

recommend to the CO that an autopsy be performed to

determine the cause of death. The cause of death in

these cases is interpreted to mean any correlation

between pathological evidence and the accident cause

factor.

REQUESTING PERMISSION FOR

AUTOPSY

When an autopsy is desired but not mandatory, the

following sentence will be incorporated in the casualty

notification message that requests disposition

instructions from the PNOK:

“In the interest of medical science and to confirm

medical diagnosis, it is requested that your telegram

include whether or not permission is granted to

accomplish mortem examination.”

NONMILITARY AND RETIRED

PERSONNEL AUTOPSY

When an autopsy is deemed necessary for retired

personnel or nonmilitary persons who die at a naval

treatment facility or on a Navy installation, written

authorization from the NOK must be obtained before

performing the autopsy. The request for permission to

perform an autopsy should be incorporated in the

casualty notification message, as noted above.

SEARCH, RECOVERY, AND

IDENTIFICATION

LEARNING OBJECTIVE: Recall

procedures used to search for, recover, and

identify remains.

The search for, recovery, and identification of

remains should be accomplished as soon as possible

16-4
and should be coordinated with an administrative

fact-finding body. Normally, the need for these

operations results from acts of violence, such as an

aircraft accident, fire, explosion, or natural disaster.

The Manual of the Judge Advocate General

(JAGMAN), JAGINST 5800.7, requires the

convening of an administrative fact-finding body

when incidents of this nature occur. This

responsibility is usually delegated to a naval activity

with necessary capabilities at or near the scene of

disaster. In establishing identification of remains,

search and recovery operations are part of the

fact-finding body’s functions, with technical

assistance furnished by appropriate medical

authorities.

SEARCH AND RECOVERY

Every effort should be made to recover all remains.

In disasters such as aircraft accidents, fires,

explosions, etc., involving the death of naval members

and members of other services, notify the Bureau of

Medicine and Surgery (BUMED) and MEDDEN

Affairs by priority message. This assures immediate

interdepartmental cooperation and the early dispatch

of necessary supplies, equipment, medical and dental

records, and technical personnel. The priority message

should include the following information:

• Name, grade or rate, and social security number

of all personnel believed dead or missing

• Names of those personnel already identified and

method of identification

• Names of those personnel tentatively already

positively identified, and whether remains are

anatomically intact

• Type and quantity of mortuary supplies, transfer

cases, chemicals, and other equipment required

• Whether technical help is desired

Do not release information to the NOK, family, or

news media unless specific instructions are received

from BUMED and MEDDEN Affairs to do so.

When search, recovery, and identification

operations continue for more than 36 hours,

chronological progress reports should be dispatched

every 24 hours to BUMED and MEDDEN Affairs,

with the appropriate information addressees directed

by NAVMEDCOMINST 5360.1.

IDENTIFICATION

When the CO is satisfied that identification has

been established beyond doubt and documented

accordingly, the remains may be considered identified.

A minimum of two statements of recognition,

substantiated by dental and/or fingerprint comparison

or intact remains, will substantiate identification

requirements.

MEDDEN Affairs will establish final conclusions

and take action required for final disposition of these

remains if shipped from outside CONUS to CONUS.

Disposition of unidentified remains will be directed by

the MEDDEN Affairs or the CMC, as appropriate.

After thorough study of all evidence, final

conclusions made by MEDDEN Affairs will result in

one of the following determinations:

• Identification of the remains

• Unidentified, but believed to be a specific

individual

• Unidentified, unknown

• Group remains, known individuals

• Group remains, unknown individuals

When an autopsy of remains is required or

requested, the identification specialist should schedule

the autopsy to be performed during the identification

process or immediately following. This will preclude

any delays in releasing the body for burial and make

sure that methods of identification are included in the

autopsy report.

Personal effects found on or with remains, after

having served all identification purposes, will be

disposed of in accordance with current instructions

contained in the Naval Supply Manual, NAVSUP

P-485, or the MARCORCASPROCMAN, MCO

P3040.4, as appropriate.

IDENTIFICATION PROBLEMS

All remains, except those that have been positively

identified and are anatomically complete, will require

additional study and processing by an identification

specialist. The MEDDEN Affairs may be requested to

provide an identification specialist to visit the activity

and make a complete review, to assure that all possible

techniques, methods, and procedures have been used

to provide a positive identification. The CMC should

be an information addressee when members of the

Marine Corps may be involved. When members of

16-5
other services are involved, BUMED and MEDDEN

Affairs should be notified by priority message to

ensure immediate interdepartmental coordination.

PROCURING MORTUARY SERVICES

LEARNING OBJECTIVE: Recall

mortuary services procurement methods, and

recognize primary and secondary burial

expenses.

Mortuary services for the remains of individuals

eligible for Decedent Affairs Program benefits outside

CONUS are specified in local instructions. Mortuary

services within CONUS are provided by naval

activities through annual contracts, individual

purchase orders, or by private arrangements.

ANNUAL CONTRACTS

Annual contracts are awarded to funeral directors

serving the local area of activities anticipating 10 or

more deaths per year.

ONE-TIME CONTRACTS

One-time contracts (individual purchase orders)

are issued by an activity to a funeral home when an

annual contract is not in effect.

PRIVATE ARRANGEMENTS

Private arrangements are made by the PNOK. The

PNOK should be advised of services and supplies

available through Navy sources and on reimbursement

limitations. Reimbursement limitations and

reimbursement forms can be obtained by contacting

MEDDEN Affairs or the local naval hospital’s

Decedent Affairs Office.

AUTHORIZED SERVICES

Annual contracts and one-time contracts cover

primary funeral expenses but do not include secondary

expenses. NOK should be tactfully encouraged to

allow the Navy to make all primary-care arrangements, since greater benefits can be furnished

throughout procedures. For more information

concerning procedures and authorized items, consult

NAVMEDCOMINST 5360.1. Primary and secondary

funeral expenses are explained in the following

sections.

Primary Expenses

Primary expenses are expenses incurred in

connection with the recovery, preparation, encasement, and burial of the remains. Primary expenses

include

• expenses incurred in the recovery and removal

of remains,

• embalmment,

• casket and shipping case,

• cremation,

• interment,

• clothing (e.g., military uniform), and

• delivery of the remains to a common carrier

terminal, a local cemetery, or crematorium.

Secondary Expenses

Secondary expenses are expenses incurred in

connection with the funeral and burial of remains.

Secondary expenses include

• funeral coach,

• transportation of relatives to the cemetery,

• gravesite,

• vault,

• funeral director’s services,

• clergyman’s services,

• opening and closing the grave,

• floral tribute, and

• obituary notices.

PREPARATION AND PROCESSING

REMAINS

LEARNING OBJECTIVE: Recall

procedures for preparing and processing

remains.

It is imperative that preservative treatment be

initiated as soon as possible after death. The naval

authority with decedent affairs responsibility should

maintain close coordination with appropriate military

or civilian authorities to ensure the prompt release and

16-6
delivery of remains to the mortuary facility. Remains

must be prepared under approved high standards of the

mortuary profession and returned to the final

destination in their most normal and lifelike

appearance.

INITIAL PREPARATION

Remains may be refrigerated for short periods

pending arrival of a transportation vessel or arrival of

the government embalmer. To minimize cellular

deterioration, remains should be refrigerated above the

freezing point at 36° to 40°F (2.2° tο 4.4°C).

OVERSEAS FACILITIES

Government mortuary facilities are located in

various overseas areas and have the responsibility to

furnish mortuary services for all eligible categories of

military and civilian personnel. The geographical

areas of responsibility are outlined in the

CINCPACINST 5360.1, Geographic Responsibilities

for Mortuary Operations. Also consult

NAVMEDCOMINST 5360.1 for locations of overseas

mortuaries.

When death occurs in overseas areas not served by

facilities listed in NAVMEDCOMINST 5360.1,

request assistance from the senior naval command. In

some areas, Department of State sources may have the

capability to render advice or assistance. The senior

naval command may also be able to arrange airlift of

remains from the place of death to a point where a

government mortuary or a commercial facility is

available, or arrange for emergency dispatch of a

qualified embalmer from an overseas government

mortuary to the place of death.

CERTIFICATE OF DEATH (OVERSEAS)

When remains are transferred from an overseas

activity to a CONUS point of entry, three signed copies

of DD Form 2064, Certificate of Death (Overseas),

must accompany the remains. Failure to include the

DD Form 2064 may cause delays in providing further

transfer within CONUS. Additionally, at least two DD

Form 565, Statement of Recognition, should be

included.

BURIAL CLOTHING

The service dress blue uniform or (if this uniform

is not available for deceased personnel) the appropriate

winter service dress uniform, with authorized insignia,

devices, badges, decorations, underwear, and hose are

the only approved items for burial, unless other items

are specifically requested by the NOK. Shoes and

headgear should also be procured when required or

requested. These items may be withdrawn from the

deceased’s personal effects or purchased from the

Navy Exchange, Navy Retail Clothing Store, or

Marine Corps Clothing Store. When not available

through these sources, procurement through

commercial sources is authorized. When suitable

items are not available for personnel who die outside

the 48 contiguous United States, the U.S. port of entry

should be contacted and given estimated uniform

sizes, as soon as possible, so burial clothing can be

purchased. Funding for uniform items is noted in

NAVMEDCOMINST 5360.1.

When requested by the NOK, remains may be

attired in a white uniform or civilian clothing

consisting of appropriate outer clothing, underwear,

hose, and, if specifically requested, shoes. Items of

clothing in the individual’s possession at the time of

death should be used if available and in satisfactory

condition.

PLACEMENT OF REMAINS IN CASKET

OR TRANSFER CASE

Normally, remains are placed in a specification

casket or transfer case in a manner that will create an

appearance of rest and composure. Precautions should

be taken to ensure maintenance of position during

transit.

Each remains returned in a transfer case will be

wrapped in a white cotton sheet plus a second

wrapping in a polyethylene cover, and sealed with

pressure-sensitive tape or heat sealed.

CASKETS

There are two sizes of caskets. Each is an

18-gauge silvertone metal sealer with a cut top. The

standard size casket has internal dimensions of 23 x

78 inches (58.4 cm x 1.98 m), while the oversize

casket has internal dimensions of 25 x 81 inches (63.5

cm x 2.06 m).

INSPECTION OF REMAINS

After processing or reprocessing and before

shipment, all remains should be inspected in

accordance with NAVMEDCOMINST 5360.1. The

decedent affairs officer (DAO) is responsible for

16-7
expediting arrangements for transportation. As such,

personnel should be available at all times, including

Saturdays, Sundays, and holidays, to perform

inspections. Before acceptance, the inspector must

make sure that all services and supplies meet current

specifications.

CREMATION

LEARNING OBJECTIVE: Recall

guidelines for requesting cremation of

remains.

When requested in writing or by telegram,

cremation is authorized, subject to compliance with

civil regulations. No overt action by naval authorities

should be made to encourage the NOK to elect

cremation. Cremation will not be permitted if any

questions exists concerning an individual’s legal right

to direct disposition of the remains.

AT-SEA DISPOSITION

LEARNING OBJECTIVE: Recall

burial-at-sea procedures.

Commanding officers who receive requests for

at-sea disposition of remains or cremains (cremated

remains) will forward the request to the appropriate

fleet commander-in-chief (CINC) and requested port

of embarkation. Fleet CINCs are authorized to

designate activities to accept remains or cremains on a

“not-to-interfere basis.” The port of embarkation will

coordinate the arrangements. Upon receipt of

authorization, the date of committal or dispersion will

be determined by the availability of resources. Except

under unusual circumstances, civilian personnel will

not be authorized to attend services aboard naval ships

at sea or aboard naval aircraft. Exceptions that cannot

be resolved at the delegated authority level will be

referred to the CNO for final determination. Refer to

NAVMEDCOMINST 5360.1 for eligibility and

specifics.

PUTREFIED REMAINS

When the mortician is unable to arrest the odor of

remains, they will not be accepted for burial at sea. The

odor generated for such remains will detract from the

dignity of the ceremony and will have a detrimental

effect on the officers and men of the vessel. Cremated

putrefied remains may be accepted.

CEREMONY RECORDS

Since civilians are not normally allowed to attend

ceremonies aboard naval ships or aircrafts,

photographs and/or video of the ceremony will be

taken. Both a letter describing the ceremony and the

burial flag will be sent to the NOK, in accordance with

NAVMEDCOMINST 5360.1.

CONSIGNMENT AND

TRANSPORTATION OF REMAINS

LEARNING OBJECTIVE: Recall

consignment policies and authorized methods

of transportation of remains.

Activities that arrange transportation have the

responsibility to provide expeditious transportation

and a confirmed schedule as soon as possible by

whatever methods meet the requirements.

Consideration should be given to any special desires of

the NOK, including releasing the remains for

transportation that they may wish to provide.

CONSIGNMENT

Remains may only be consigned to a funeral

director, the director or superintendent of a national

cemetery, or the consignee designated by the

MEDDEN Affairs for unclaimed remains. In addition

to the above consignees, cremains may be consigned to

the PNOK or person designated by the PNOK.

AUTHORIZED METHODS OF

TRANSPORTATION WITHIN THE UNITED

STATES

Authorized methods of transportation within the

United States include government air, commercial air,

chartered air taxi, and funeral coach.

Government Air

Government air is not authorized within CONUS

without approval of the CNO (OP-414). If the

circumstances indicate government air, MEDDEN

16-8
Affairs should be contacted for guidance and

assistance.

Commercial Air

Commercial air may be supplemented by either

rail or funeral coach transportation. An escort must

travel with the remains. If delays en route or changes in

schedule occur, the escort must notify the installation

arranging the transportation and the consignee.

Chartered Air Taxi

Chartered air taxi service may be authorized when

commercial air is not available to the destination and

the use of a funeral vehicle or rail would cause undue

delay.

Funeral Coach

The funeral coach method of transportation may

be used under any of the following circumstances:

• To transfer remains from the place of preparation

to another local funeral home, to a local

cemetery, or to a common-carrier terminal

• When common-carrier service is not available

• When a common carrier is available only part of

the way to the place designated by the PNOK,

then funeral coach service may be used for the

remaining portion of the transportation

authorized

• When the cost is not in excess of the commoncarrier cost

• When the cemetery cannot provide

transportation from the terminal to the cemetery,

a funeral coach may be used as a continuation of

common-carrier service when remains are

consigned directly to a national cemetery or a

Navy cemetery or plot

• To transfer remains from the common-carrier

terminal at destination to the funeral

establishment, and to deliver remains to the local

cemetery or crematory

• When requested by the NOK, and the family

member defrays costs in excess of the method

that would have been used by the government

• When the use of a common-carrier service will

involve extended layover, and this method will

expedite the arrival

TRANSPORTATION OF CREMATED

REMAINS

Cremated remains (cremains) of active duty

personnel will be hand carried by an escort, and

transported using commercial air, rail, a funeral

director’s vehicle, or other appropriate vehicle. When

an escort is not authorized, cremains may be

transported by registered mail (preferred method), air,

or surface transportation to the PNOK, or to a specified

individual designated by the PNOK.

TRANSPORTATION OF REMAINS OF

CONTAGIOUS OR COMMUNICABLE

DISEASE VICTIMS

When death is the result of a contagious or

communicable disease, remains, after embalming,

should be placed immediately in a transfer case or

casket. The transfer case or casket should be closed

immediately and a gummed 2" x 4" label, marked

“CONTAGIOUS” should be affixed to the outside of

the receptacle at the head end. Information concerning

diseases considered contagious may be obtained from

local or state health officials. When the remains carry

communicable or contagious disease, make sure that

the consignment message specifically states that death

was due to a contagious or communicable disease.

AUTHORIZED TRANSPORTATION TO OR

FROM CONUS

Remains of eligible decedents who die outside the

48 contiguous United States will be transported by the

most expeditious U.S. government means; normally,

government air (Air Mobility Command (AMC)

flights) are used. If such transportation is not

available, impractical, or would cause undue delay,

commercial air may be authorized by MEDDEN

Affairs.

OUTSIDE CONUS DESTINATIONS

When persons eligible for decedent affairs benefits

are consigned to a destination outside the 48

contiguous United States, the activity responsible for

preparation and transportation will contact the nearest

consul of the country concerned to ascertain the

requirements for entry, and assure that all requirements

are met before arranging transportation of the remains.

Failure to do so could lead to serious delays. Three

certified copies of the civilian certificate of death

should accompany the remains.

16-9
ESCORTS

LEARNING OBJECTIVE: Recall criteria

for escort selection, and identify escort duties

and responsibilities.

Escorts are provided to accompany remains to

ensure prompt, safe delivery, as a mark of respect to the

decedent, and as an indication of the Navy’s desire to

help the NOK. Only one escort is authorized. More

than one may be assigned; however, two escorts may

not serve at the same time. Problems concerning

arrangements for a Navy escort that cannot be resolved

by the responsible command should be referred to

MEDDEN Affairs or the area commander outside

CONUS. Problems concerning Marine Corps

members should be referred to CMC.

INSIDE CONUS ESCORTS

Within CONUS, escorts are detailed to accompany

the remains or cremains of each Navy and Marine

Corps decedent to their final destination. Furnishing

escorts is the responsibility of the activity arranging

transportation of the remains or cremains. When

selecting an escort for the deceased, the activity

arranging transportation is encouraged to consult the

last duty station of the deceased.

OUTSIDE CONUS ESCORTS

When remains are consigned to a place outside

CONUS where Armed Forces representatives or other

government officials are not available to receive,

transfer, or otherwise assist in transportation

arrangements, military escorts will be provided.

Unless a special escort is requested by the PNOK

and approved by MEDDEN Affairs, remains

transported by AMC aircraft from a point outside

CONUS to a CONUS port of entry will not be

accompanied by an escort. The aircraft commander

will act as the escort during the time of transport by

AMC aircraft. An escort will be detailed by the

military activity responsible for transportation

arrangements at the CONUS port of entry.

SELECTION OF ESCORTS

Any Navy or Marine Corps member on active duty

may serve as an escort. Navy and Marine Corps

members who volunteer may be accepted if they meet

the criteria for selection. Unless a special escort is

requested by the NOK, the escort selected should be of

the same branch of service, status, and paygrade of the

deceased. The escort should be a friend of the

deceased, from the same unit, and preferably of the

same religion.

SPECIAL ESCORTS

A special escort is defined as a person requested

specifically by the PNOK or by his representative, or a

person assigned by an appropriate command because

unusual circumstances prevail and such assignment is

considered in the best interest of the naval service. All

requests for special escorts must be referred to

MEDDEN Affairs.

If desired by the PNOK, a civilian or member of

another service may be assigned as a special escort. An

escort in retired or inactive status should be treated as a

civilian. All military special escorts are assigned

subject to availability as determined by their CO and,

unless closely related to the deceased, generally are not

authorized outside CONUS.

DUTIES OF THE ESCORT

A naval escort is a representative of the Navy who

will be required to perform services of a very special

and personal nature. It is very important that these

duties are thoroughly explained to the escort.

Providing instructions to the escort is the

responsibility of the command arranging for

transportation of the remains. The Manual for Escorts

of Deceased Naval Personnel, NAVPERS 15955, will

assist in this function. For additional information, you

should consult NAVMEDCOMINST 5360.1.

DISPOSITION OF PERSONAL

EFFECTS

LEARNING OBJECTIVE: Recall

disposition of personal effects policies.

All personal effects of the deceased are to be

collected and inventoried, except where the member

occupied government or public housing and the spouse

requires no assistance. In the event the spouse dies

simultaneously with the service member, the CO

cooperates with surviving relatives of the deceased and

civil authorities by providing protection for the

property of the deceased.

The CO appoints an inventory board consisting of

two members, of which one member is normally a

16-10
commissioned officer. The inventory should be

recorded on an Inventory of Personal Effects Form,

NAVSUP Form 29. An original and four copies will be

prepared and signed by the board members. The board

will send all five copies with the personal effects to the

supply officer for completion, disposition, and

signature. The supply officer returns three signed

copies. The inventory board sends one copy to the

COMNAVMILPERSCOM, files one in the service

record of the deceased, and sends one to the officer

who appointed the board.

CIVIL CERTIFICATES OF DEATH

LEARNING OBJECTIVE: Determine

when civil certificates are required and where

they should be distributed.

A civil certificate of death must be obtained if a

death occurs within one of the 50 United States or the

District of Columbia. If a death occurs outside these

areas, with the exception of Guam, a Certificate of

Death (Overseas), DD 2064, should be prepared. This

certificate is in addition to the civil certificate of death;

however, the civil certificate of death is not required in

all overseas areas. Civil authorities should be

consulted to determine local requirements. When a

death occurs at a naval activity in any state, territory, or

insular possession of the United States, the CO will

report the death to civil authorities (usually the coroner

or medical examiner). It is a general practice for

medical officers to complete a civil certificate of death

for all deaths occurring in naval medical treatment

facilities.

The medical officer or Medical Department

representative of the ship or station where the deceased

was attached will obtain the certificate from the civil

authorities. If requested by the authorities, the civil

certificate of death may be prepared and signed by a

naval officer. If problems arise in getting a certificate,

request assistance from MEDDEN Affairs. If death

occurs abroad and no naval activity is available, the

nearest consular officer should be requested to get a

certificate. The medical officer or Medical

Department representative will prepare and forward a

DD 2064 with the civil certificate of death, supporting

papers, and the closed health record.

In general (except where the state has retained

concurrent jurisdiction with the United States, civil

authorities have no jurisdiction over deaths occurring

on naval reservations. However, a transit or burial

permit should be obtained from civil authorities to

remove the remains from a naval reservation either for

shipment or burial. If death of any person for whom the

Department of the Navy is responsible occurs outside

the limits of a naval reservation, the remains normally

will not be moved until permission has been received

from civil authorities.

DISTRIBUTION OF DEATH CERTIFICATE

FOR DEATHS OCCURRING IN CONUS

When a Navy or Marine Corps death occurs in one

of the 50 United States or the District of Columbia,

follow local civil requirements. In addition, the

following procedures in table 16-1 apply:

DISTRIBUTION OF DEATH CERTIFICATE

FOR DEATHS OCCURRING OUTSIDE

CONUS

When a Navy or Marine Corps death occurs

outside the 50 United States or the District of

Columbia, follow the local civil requirements. In

16-11

For CONUS

decedents. . . Send copy of death certificate to. ..

Active Duty Commanding Officer

Naval Medical Information

Management Center

Bethesda, MD 20814

(Place one copy in member’s closed

health record.)

Inactive Duty Naval Reserve Personnel Center

4400 Dauphine Street

New Orleans, LA 70149

Active/Inactive

Marines

Commandant of the Marine Corps

(Code MSPA-1)

Department of the Navy

Washington, DC 20380

Table 16-1.—Distribution of Death Certificate for Deaths

Occurring in CONUS
addition, a DD 2064 is prepared and copies are

distributed as outlined in table 16-2.

DEATH CERTIFICATES FOR SHIPMENT

OF REMAINS

When death occurs outside CONUS, three signed

copies of DD 2064 will accompany the remains to

CONUS. When death occurs within CONUS, three

certified copies of the civil certificate of death will

accompany the remains from CONUS to outside

CONUS, in addition to all other forms required by

NAVMEDCOMINST 5360.1.

NOTE: A certificate of death should not be

prepared for persons listed as missing.

PAYMENTS AND COLLECTIONS

LEARNING OBJECTIVE: Recall funeral

payment and collection procedures.

Authorized Decedent Affairs Program expenses

are chargeable to the special open allotment held by

BUMED. In circumstances involving reimbursable

transactions, costs may also be initially charged to the

open allotment subject to reimbursement. The

allotment may be charged by any Navy or Marine

Corps activity assigned procurement or payment

responsibility. Army and Air Force activities may

charge the allotment when arranging for authorized

supplies and services at the request of a naval activity.

PRIMARY EXPENSES

If the NOK makes arrangements for disposition of

remains, rather than using services of DoD, or

completes funeral arrangements before DoD services

are offered, the amounts outlined below are allowed

toward incurred expenses. The figures quoted are

subject to change, so check the latest series of

NAVMEDCOMINST 5360.1 for the authorized

allowances, or contact the MEDDEN Affairs.

When an Armed Forces contract or mortuary is

available (and services were offered to the NOK) but

not used, an amount not to exceed what procurement

would have cost the Navy is allowed. This includes

costs the Navy would have incurred over and above

contract expenses. Contact MEDDEN Affairs for

current allowance limits.

TRANSPORTATION EXPENSES

If the NOK arranges for transportation of remains,

reimbursement may be made in an amount not to

exceed what transportation would have cost the

government. If the Navy has arranged for

transportation and the final destination cannot be

reached by common carrier, reasonable costs may be

allowed for supplemental transportation by funeral

coach or other vehicle.

SECONDARY (INTERMENT) EXPENSES

Secondary expenses will be provided to the NOK

whether the remains or cremains are interred in a

private cemetery, a national or federal government

cemetery, or in a burial at sea. The allowance paid for

each method of interment will be in accordance with

16-12

For OUTUS

decedents. . . Send copy of death certificate to. . .

Active Duty Commanding Officer

Naval Medical Information

Management Center

Bethesda, MD 20814

(The original death certificate is

placed in member’s closed health

record.)

Inactive Duty Navy personnel:

Naval Reserve Personnel Center

4400 Dauphine Street

New Orleans, LA 70149

Marine Corps personnel:

Commandant of the Marine Corps

(Code MSPA-1)

Department of the Navy

Washington, DC 20380

Other deaths The command indicated if the death

occurred aboard a ship, at a naval

station, or on a naval aircraft. For full

details, see MANMED.

Table 16-2.—Distribution of Death Certificate for Deaths

Occurring in Outside CONUS
NAVMEDCOMINST 5360.1, Decedent Affairs

Manual.

MEMORIAL SERVICE FOR

NONRECOVERABLE REMAINS

When remains of eligible military personnel,

whose determination of death has been made, are

nonrecoverable, reimbursement to the PNOK (or

designee) may be made for memorial service

expenditures. A claim for reimbursement may be

allowed if presented within the approved time frame

after notification of the NOK of the date of death. The

PNOK must submit receipted invoices or a certified

claim to MEDDEN Affairs.

HEADSTONES AND MARKERS

Personnel serving on active duty at the time of

their death are eligible for a headstone or marker

provided by the Veterans’ Administration (VA). At a

national cemetery, the director or superintendent will

make the arrangements. In naval plots and cemeteries,

the Navy will make the arrangements. In other

cemeteries, an application should be submitted to the

VA. If a commercial headstone or marker is procured,

a limited reimbursement is authorized. A memorial

marker may be provided upon request to

commemorate the death of a member whose remains

were not recovered or were buried at sea.

REIMBURSEMENT PROCEDURES

LEARNING OBJECTIVE: Recall

procedures for reimbursement of funeral

costs.

When the Navy has arranged for primary services

and transportation, a claim for payment of the

supplemental transportation charges may be submitted

to MEDDEN Affairs by the funeral director at the final

destination.

DD Form 1375, Request for Payment of Funeral

and/or Interment Expenses, should be given to the

PNOK (or PNOK’s designee) to claim reimbursement

or payment for primary expenses, transportation, and

secondary expenses.

GOVERNMENT SERVICES NOT UTILIZED

WITHIN CONUS

Claims relating to primary expenses and

transportation costs to a common-carrier terminal for

transportation to the final destination will be

forwarded to MEDDEN Affairs.

Claims relating to interment (secondary)

allowances and supplemental transportation costs will

be forwarded to MEDDEN Affairs.

GOVERNMENT SERVICES NOT UTILIZED

OUTSIDE CONUS

Area commanders outside CONUS are authorized

to make local payment of expenses incurred in areas

under their jurisdiction.

Claims in areas outside the jurisdiction of the

activities (area commanders) noted in NAVMEDCOMINST 5360.1 should be submitted to BUMED for

resolution.

GOVERNMENT SERVICES UTILIZED

When the Navy has arranged for primary services

and transportation, submit claims for payment and

reimbursement of interment costs or supplemental

transportation expenses to MEDDEN Affairs.

REPORTING EXPENSES

LEARNING OBJECTIVE: Recall

reporting procedures for funeral expenses.

Activities incurring expenses in connection with

disposition of remains of Navy and Marine Corps

personnel do not report these expenses to BUMED

except when indicated on the DD Form 2062, Record

of Preparation and Disposition of Remains (Outside

CONUS), and DD Form 2063, Record of Preparation

and Disposition of Remains (Within CONUS). In

arranging for disposition of remains of other services’

deceased personnel, activities obtaining services and

supplies from commercial sources should forward a

letter report, MED 5360-3, Report of Disposition and

Expenditures–Remains of the Dead, to the service

concerned. Costs for which the activity’s funds have

been cited should be shown on the letter report.

16-13
NATIONAL CEMETERIES

LEARNING OBJECTIVE: Recall services

that are available at national cemeteries.

Except for Arlington National Cemetery (which is

under the jurisdiction of the Department of the Army)

and a few other exceptions noted in NAVMEDCOMINST 5360.1, national cemeteries are under the

jurisdiction of the Chief Memorial Affairs Director,

Depa rtment o f Memo rial A ffai r s, Vete ran s ’

Administration, Washington, DC.

NATIONAL CEMETERY

CLASSIFICATIONS

There are three classifications of national

cemeteries:

1. Open (Active)—Cemeteries with grave spaces

available.

2. Closed (Inactive)—Cemeteries without grave

spaces available.

3. New (Inactive)—Cemeteries planned but not

yet opened.

ELIGIBILITY FOR INTERMENT

Remains of the following naval and former naval

members may be buried in any open national cemetery

except at the National Cemetery at Arlington, Virginia:

• Navy or Marine Corps member who was serving

on active duty at time of death (other than active

duty for training).

• Former Navy or Marine Corps members who

were discharged under conditions other than

dishonorable.

• Any member of a Navy or Marine Corps Reserve

organization whose death occurred under

honorable conditions while the individual was

1. On active duty for training (including

authorized travel to and from active duty

training),

2. on inactive duty training (including

authorized travel to and from such training),

or

3. hospitalized or undergoing treatment at the

expense of the government for injury or

disease incurred or contracted during the

period covered by 1 and 2, above.

• Members of the Naval Reserve Officers’

Training Corps whose death occurred under

honorable conditions while they were

1. attending an authorized training camp or

authorized training cruise,

2. performing authorized travel to and from

that camp or cruise, or

3. hospitalized or undergoing treatment at the

expense of the government of the United

States for injury or disease incurred or

contracted during the period covered by 1

and 2, above.

• Surviving spouse and minor children of

individuals covered above.

(For further information on interment eligibility at

Arlington, consult NAVMEDCOMINST 5360.1.)

At the discretion of the Chief Memorial Affairs

Director, unmarried adult children of eligible

individuals may be buried in any open national

cemetery (except Arlington) if they were totally

disabled either physically or mentally before attaining

the age of 21. The Chief Memorial Affairs Director

may also authorize the burial of unremarried widows

or widowers or eligible deceased members whose

remains were either lost at sea or buried at sea not at

their own volition, or who were officially determined

missing or missing in action and subsequently

administratively declared dead for the purpose of

terminating missing or missing-in-action status.

HONORS

Military honors for interment in national

cemeteries are the responsibility of the member’s

service. Honors for services at Arlington National

Cemetery are coordinated by the superintendent of the

cemetery with BUPERS or the CMC, as appropriate.

VAULTS

A metal, asphalt, or concrete vault may be

procured at the NOK’s expense, if it is preferred. If a

vault is privately procured, the superintendent/director

must be notified of the outside dimensions to ensure

the proper preparation of the grave. The contractor

furnishing the vault must also provide necessary

equipment and personnel for placing the vault in the

grave before the funeral service and for placement of

the vault lid after the service.

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VIEWING REMAINS

National cemeteries no longer have facilities for

viewing remains. If the NOK desires a viewing before

interment, the remains must be consigned to a local

funeral director.

SCHEDULING

Unless extraordinary circumstances exist with

respect to the condition of remains, interment in

national cemeteries will not be made on Saturdays,

Sundays, or holidays.

NAVAL PLOTS AND CEMETERIES

LEARNING OBJECTIVE: Recall policy

for interment at a naval cemetery.

With two exceptions, MEDDEN Affairs exercises

technical direction of naval plots and cemeteries.

Presently, there are only a few active naval cemeteries,

so plot availability is extremely limited. For this

reason, decedents who are eligible for interment in

national cemeteries will not normally be authorized

interment in a naval plot or cemetery. However,

exceptional or unusual circumstances will be referred

to BUMED for determination.

GROUP INTERMENTS

LEARNING OBJECTIVE: Recall

guidelines for group interments.

When remains of two or more individuals killed in

the same incident cannot be individually identified, a

priority message detailing the circumstances should be

sent to MEDDEN Affairs. MEDDEN Affairs will then

determine if there is a need for an identification

specialist to be sent. If remains cannot be individually

identified, the collective remains will be interred as a

group interment. Group interments should be made in

a national cemetery, within the 50 United States, as

close to the midpoint of the two most widely separated

homes of record of known deceased individuals

involved, or as otherwise directed by the program

managers. MEDDEN Affairs will coordinate with the

other services as required. Procedures followed in

group interments are:

1. Unidentified remains should be prepared,

wrapped and placed into the minimum number

of caskets possible without overcrowding.

Partially segregated but identifiable remains

should be wrapped separately.

2. One or more escorts should be provided, as long

as the number of escorts does not exceed the

number of deceased persons.

3. The PNOK and two blood relatives of each

deceased member in a group interment are

authorized round-trip transportation to the place

of interment at government expense.

4. The ceremonies should be conducted with full

military honors and be in accordance with the

religious preferences applicable to all

denominations represented within the group.

Photographs should be provided to the PNOK, if

desired.

5. The headstone or headstones should be

inscribed with the names of all known deceased

personnel.

SUMMARY

The Decedent Affairs Program consists of the

search, recovery, identification, care, and disposition

of remains of deceased personnel for whom the

Department of the Navy is responsible. Large medical

treatment facilities normally manage decedent affairs

mattes. However, when a death occurs at small

independent operational units, senior Hospital

Corpsmen will be responsible for the proper

management of this program. For this reason, basic

components of the Decedent Affairs Program were

covered in this chapter. For further guidance, you

should consult the Decedent Affairs Manual or contact

the Naval office of Medical/Dental Affairs, Mortuary

Affairs Section, Great Lakes, Illinois.

16-15

APPENDIX I

HISTORY OF THE HOSPITAL CORPS

UNITED STATES NAVY

ORIGIN AND DEVELOPMENT OF THE

CORPS

Few military organizations can look upon their

histories with the same degree of pride and awe as the

Navy Hospital Corps. Since the establishment of the

Navy medical department in Colonial times and the

commissioning of the Hospital Corps a century ago,

Hospital Corpsmen and their forerunners have proven

themselves ready to support Marines and Sailors by

giving them aid whenever and wherever necessary.

This level of dedication has remained a strong current

running through the Corps’ history, even as the tools

and techniques used by its members have evolved.

REVOLUTIONARY WAR

The first direction given to the organization of

Navy medicine consisted of only one article in the

Rules for the Regulation of the Navy of the United

Colonies of North America of 1775. Article 16 stated:

Aconvenient place shall be set apart for sick or

hurt men, to be removed with their hammocks

and bedding when the surgeon shall advise the

same to be necessary: and some of the crew

shall be appointed to attend to and serve them

and to keep the place clean. The cooper shall

make buckets with covers and cradles if

necessary for their use.

Interestingly, the cooper (or barrel-maker), whose skills

could be used to make bedpans, had a more detailed job

description than did any kind of trained medical

assistant.

A typical medical section was usually limited to

two, perhaps three men: the surgeon, the surgeon’s

mate, and possibly an enlisted man. The surgeon was a

physician. The surgeon’s mate, usually a doctor as

well, held status like that of a modern warrant officer

but signed on only for a particular cruise. Although

surgeons’mates were historically viewed as part of the

Medical Corps, their position and responsibilities

appear to be more equivalent to those of today’s senior

Hospital Corpsmen.

Few things changed in medical techniques and

organization between 1775 and 1814, the period

covering America’s first naval wars. Among the less

dramatic responsibilities of caring for the noncombat

ill and injured were feeding and personal care of the

sick. The simple daily ration of porridge, or “loblolly,”

was sure to be carried down to those in the medical

space by untrained attendants.

SURGEON’S MATES AND LOBLOLLY

BOYS

Congress approved an act on March 2, 1799, which

copied the words of the Continental Congress’medical

department Article 16 of 1775 exactly. As a result,

there was still no title or job description for enlisted

medical personnel. The nickname “loblolly boy” was

in common use for so many years that it became the

official title in Navy Regulations of 1814. The loblolly

boy’s job, described in the Regulations of 1818,

included the following:

The surgeon shall be allowed a faithful

attendant to issue, under his direction, all

supplies and provisions and hospital stores,

and to attend the preparation of nourishment

for the sick. . . . The surgeon’s mates shall be

particularly careful in directing the loblolly

boy to keep the cockpit clean, and every article

therein belonging to the Medical Department. .

. . The surgeon shall prescribe for casual cases

on the gun deck every morning at 9 o’clock,

due notice having been previously given by his

loblolly boy by ringing of a bell.

SURGEON’S STEWARDS AND LOBLOLLY

BOYS

A new senior enlisted medical rate, surgeon’s

steward, was introduced in the ensuing decades. The

term is first seen in 1841 in Navy pay charts, but it

appears that the new billet was only allowed on larger

ships. By April 1, 1843, the Navy Department issued

an order allowing surgeon’s stewards to be assigned to

brigs and schooners. The relative importance of

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medical Sailors was hereby increased. Surgeon’s

stewards ranked second in seniority among the ship’s

petty officers, next only after the master-at-arms.

SURGEON’S STEWARDS AND NURSES

The year 1861 brought civil war to this country,

and—due to the enormous expansion of the Navy

because of the war—changes and developments in the

medical department ensued. On June 19, 1861, a Navy

Department circular order established a new name for

the loblolly boy.

In addition to a surgeon’s steward, 1 nurse

would be allowed for ships with a complement

of less than 200; 2 nurses would be allowed for

ships with a complement of more than 200;

and sufficient nurses would be allowed on

receiving ships in a number proportionate to

the necessities of the vessel.

While the shipboard medical department changed

the titles of its personnel, new techniques in mass care

of the sick and wounded were also developed. A

captured sidewheel steamer was repaired and modified

to care for patients. Refinements to the ship included

bathrooms, kitchens, and laundries—even elevators

and the facilities to carry 300 tons of ice. On December

26, 1862, the USS Red Rover became the first Navy

vessel specifically commissioned as a hospital ship.

The medical complement included 30 surgeons and

male nurses, as well as four nuns.

APOTHECARIES AND BAYMEN

Postwar reductions in the size of the Navy brought

new classifications to enlisted medical personnel. The

title “surgeon’s steward” was abolished in favor of

three grades of apothecaries in 1866. Those selected as

apothecaries had to be graduates of a course in

pharmacy or possess the same knowledge gained

through practical experience. The Apothecary, First

Class, ranked with a warrant officer, while the second

and third classes were petty-officer equivalents. The

three rates were reduced to one petty officer

apothecary on March 15, 1869.

“Nurse,” as a title for junior enlisted medical

personnel, was replaced by the title “bayman” (defined

as one who manned the sick bay) in the early 1870s.

U.S. Navy Regulations of 1876 used the title officially,

and it remained valid for 22 more years.

An apothecary of the 1890s mixed and dispensed

all medication aboard a ship. He was responsible for

all medical department reports, supply requests, and

correspondence, and he helped maintain medical

department records. The apothecary administered

anesthesia during surgery and was the primary

instructor for new baymen.

The apothecaries’ responsibilities did not end

there, however. (See figure APP-I-1.) During

shipboard surgery, the bayman focused an electric light

on the incision site while the surgeon did his work on

what served as a combination of both writing and

operating table. He sterilized surgical instruments by

boiling them, then stored them in a solution of 5

percent phenol. Bandages and dressings were

sterilized by baking them in a coffee can in the ship’s

oven. Sick bay itself was prepared for surgery by

wiping the entire room down with a chlorine solution.

On days when the ship’s routine called for scrubbing

bags and hammocks, a bayman was responsible for

washing those of the sick. When required, he painted

the ship’s medical spaces.

During the last two decades of the 1800s, many in

the naval medical establishment called for reforms in

the enlisted components of the medical department.

Medicine had by now progressed far more as a science,

and civilian hospitals all had teaching schools for their

nurses. Foreign navies had trained medical Sailors,

and the U.S. Army had established its own Hospital

Corps of enlisted men on March 1, 1887. Navy

Surgeon General J. R. Tryon argued, in his annual

report of 1893, against the practice of assigning

landsmen to the medical department with nothing

more than on-the-job-training. He advocated the

urgent need for an organized hospital corps.

Physicians in the fleet were equally certain of the

need for changes. Surgeon C. A. Sigfried of the USS

Massachusetts made his views known in his report to

the Surgeon General in 1897.

The importance of improving the medical

department of our naval service is more and

more apparent, in view of the recent advances

in the methods and rapidity of killing and

wounding. The great want is a body of trained

bay men or nurses, and these should be better

paid and of better stamp and fiber. Now and

then we procure a good man, and proceed with

his training as a bay man. He soon finds

opportunity for betterment in some one of the

various departments of the ship, in the matter

of pay and emolument, either in some

yeoman’s billet or in some place where his

meager $18 per month can be suddenly

AI-2
increased to $30, $40, or even $60 per month.

The bay man, who should be an intelligent,

sober man, and well trained in many things

pertaining to nursing, dieting, ambulance, and

aids to wounded, and have a moderate amount

of education, finds his pay at present among

the lowest in the ship’s company; even the men

caring for storerooms get more per month.

HOSPITAL STEWARDS AND HOSPITAL

APPRENTICES

Arguments for a professional, well-trained group

of individuals to provide medical care for the Navy

finally paid off, although it took the imminent danger

of combat in the Spanish-American War to spur

Congress into action. Within a bill aimed at building

the armed forces was a section to provide for the

Navy’s long-needed Hospital Corps. It was approved

by President William McKinley on June 17, 1898.

From that date to the present, either generically or by

rating title, medical Sailors have been called “Hospital

Corpsmen.”

To ensure that the members of the new Hospital

Corps were adequately trained in the disciplines

pertinent to both medicine and the Navy, a basic school

for corpsmen was established at the U.S. Naval

Hospital Norfolk (Portsmouth), Virginia. Originally

called the School of Instruction, it opened September

2, 1902. Its curriculum included anatomy and

physiology, bandaging, nursing, first aid, pharmacy,

clerical work, and military drill. The first class of 28

corpsmen was graduated on December 15, 1902. (See

figure APP-I-2.)

The school continued for a brief time and was then

moved to the Naval Hospital in Washington, D.C.,

remaining in existence there until 1911. For the next 3

years, there was no basic school for corpsmen, but the

concept was revived in 1914. The next two Hospital

Corps Training Schools were opened in Newport,

Rhode Island, and on Yerba Buena Island, California.

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HM3FAI01

Figure APP-I-1.—An apothecary (petty officer first class) treats a shipmate aboard the USS Boston in 1888.
HOSPITAL APPRENTICES AND

PHARMACIST’S MATES

The next revision in the structure of the Hospital

Corps came by act of Congress on August 29, 1916.

Under this plan, the rates were hospital apprentices,

second class and first class (both of whom wore a red

cross on the sleeve); pharmacist’s mates, third, second,

and first; and chief pharmacist’s mate. The officer

contingent of the Hospital Corps included the two

warrant officer ranks of pharmacist and chief

pharmacist. The reorganization allowed for a massive,

fivefold increase in the size of the Hospital Corps.

At the start of 1917, the Hospital Corps counted

1,700 men in its ranks. Aconcerted effort to recruit and

train new personnel enabled the corps to reach its

authorized strength of 3 1/2 percent of the Navy and

Marine Corps, or 6,000 men. But as these plans came

to fruition, the United States entered World War I in

April. By the end of 1918, the corps peaked at about

17,000.

PHARMACIST’S MATES IN WORLD WAR I

The massive wartime expansion in Hospital Corps

strength necessitated additional schools to train the

newcomers. Hospital Corps School, Great Lakes,

Illinois, had been established in January 1913.

Wartime schools were created in Minneapolis at the

University of Minnesota, in New York at Columbia

University, and at the Philadelphia College of

Pharmacy. A school for Naval Reserve Force Hospital

Corpsmen was set up at Boston City Hospital. Other

crash-course schools for shipboard personnel were

conducted at a number of other civilian hospitals.

Hospital Corpsmen who were needed to serve as

medical department representatives on small vessels

such as destroyers were trained at the Pharmacist’s

Mate School at Hampton Roads, Virginia, the

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HM3FAI02

Figure APP-I-2.—A hospital steward (chief petty officer) and two hospital apprentices from a ship’s landing party medical section,

1905.
forerunner of the Independent Duty Hospital

Corpsman School.

Hospital Corpsmen were assigned to the multitude

of duty types and locations needed to support a Navy

involved in a world war. Naval hospitals were opened

and staffed. Ships and aircraft squadrons were given

medical support. At sea, the dangers of the new war

were ever present.

Naval training facilities and shore establishments

needed Hospital Corpsmen, as did occupation forces in

Haiti and other bases around the world. But World War

I provided the Hospital Corps a role that would afford it

some of the most dangerous challenges it would ever

face: duty with the Marine Corps.

Assignment to Marine Corps units was not

completely new. Hospital Corpsmen were serving

with Marine occupational forces in Cuba, Haiti, and

Santo Domingo at the outbreak of the war, and they had

seen other similar service. It was the change of the

Marine Corps’ role to one of expeditionary forces in a

large-scale ground war that changed what Hospital

Corpsmen would do. Sick call and preventive

medicine were continuous roles that remained

unchanged. Facing artillery, mustard gas, and machine

gunfire were new experiences.

A heritage of valorous service with the Marines

was born, as evidenced by two Hospital Corpsmen

receiving the Medal of Honor. Other decorations to

Hospital Corpsmen included 55 Navy Crosses, 31

Army Distinguished Service Crosses, 2 Navy

Distinguished Service Medals, and 237 Silver Stars. A

hundred foreign personal decorations were granted to

Navy Hospital Corpsmen, and 202 earned the right to

wear the French Fourragère shoulder aiguillette

permanently. Their 684 personal awards make the

Hospital Corps, by one account, the most decorated

American unit of World War I.

PHARMACIST’S MATES IN WORLD

WAR II

World War II became the period of Hospital Corps’

greatest manpower, diversity of duty, and instance of

sacrifice. Between 1941 and 1945, the ranks of this

small organization swelled from its prewar levels of

near 4,000 to more than 132,000 personnel. This

increase came to fulfill new responsibilities with new

technologies at new duty stations. In the face of great

adversity, the Hospital Corps would cement its

reputation for effectiveness and bravery.

The Navy’s fleet expanded to thousands of ships,

and the Marine Corps grew from a few regiments to six

divisions. A two-ocean war produced horrific

numbers of casualties, and the Hospital Corps grew to

meet the needs of casualty collection, treatment, and

convalescence. To educate the influx of new Sailors,

Hospital Corps Training School at Portsmouth,

Virginia, was augmented by a temporary school at

Naval Hospital Brooklyn, New York. The school at

Great Lakes was recreated in 1942, and others were

started at Farragut, Idaho, and at Bainbridge,

Maryland, in 1943. A separate Hospital Corps

Training School was established for women (fig.

APP-I-3) at Bethesda, Maryland, in January 1944.

Specialized schools were opened to train pharmacist’s

mates for independent duty and for service with the

Marines. Additionally, courses were established to

instruct personnel on new equipment and techniques in

dozens of developing medical fields.

Shore-based duty sent Hospital Corps personnel to

hospitals and dispensaries in the United States and

abroad. Advance-base hospitals on newly captured

Pacific islands formed a crucial link in the chain of

evacuation from battle sites. Those facilities in Hawaii or

England received casualties from their respective fronts,

and wounded service personnel recuperated in Stateside

hospitals. Hospital Corpsmen made the treatment of

American casualties possible at each of these by

providing technical support and direct patient care.

Duty on surface ships afforded Hospital Corpsmen

numerous challenges and abundant environments in

which to face them. Hospital ships required the

services of personnel in much the same way as

shore-based hospitals, except that those on ship were

afloat and subject to attack. Other classes of vessels,

such as landing ships and patrol craft (LSTs and

PCERs), became large floating clinics/ambulances

which required additional Hospital Corps personnel.

Additionally, combatant ships and transports in the

Atlantic, Pacific, and Mediterranean theaters took

casualties from ships, aircraft, and submarines

throughout the war, necessitating the service of

well-trained Hospital Corpsmen.

Approximately 300 Hospital Corpsmen sat out all

but the early days of the war when they were captured in

the Philippines by the invading Japanese. In

prisoner-of-war camps and huddled in POW “hell ships,”

they endured malnutrition, disease, torture, and brutality.

One hundred thirty-two Hospital Corpsmen died as

prisoners during World War II, a death rate almost 20

percent higher than among other American POWs.

AI-5
Hospital Corpsmen served on the beaches not only

in the island campaigns of the Pacific, but in Europe as

well. Teams of Navy medical personnel formed aid

stations with beach battalions at Sicily and Normandy,

treating Army and allied wounded under fire. Hospital

Corpsmen ensured the survival of these casualties until

they could reach hospitals in England.

Of all the Hospital Corpsmen in World War II,

Fleet Marine Force personnel endured, perhaps, the

most grueling side of war. As they swarmed numerous

beaches in the Pacific, they became targets themselves

as they braved fire to reach downed comrades. At

Guadalcanal, Tarawa, Peleliu, Saipan, Tinian,

Kwajalein, Iwo Jima, and Okinawa, Hospital

Corpsmen bled and died, often in greater numbers than

the Marines for whom they cared. Hospital Corps

casualties in the 4th Marine Division at Iwo Jima, for

example, were 38 percent.

Members of the Hospital Corps treated some

150,000 combat casualties during the war. This

number does not include thousands of others—those

plagued by disease and injured in the line of

duty—who were aided by their medical shipmates.

The cost of this service was high: 1,170 Hospital

Corpsmen were killed in action and thousands more

were wounded. But their valor was rewarded.

Hospital Corpsmen earned 7 Medals of Honor (almost

half of those awarded to Sailors in the war), 66 Navy

Crosses, 465 Silver Star Medals, and 982 Bronze Star

Medals.

A NEW HOSPITAL CORPS

Massive reorganization of the armed forces took

place after World War II. A new Department of

Defense was established, and the Army-Navy Medical

Service Corps Act removed commissioned allied

health and medical administration officers from the

Hospital Corps. This law also provided for a separate

Dental Technician rating, which remained a

component of the Hospital Corps until 1972. Women

in the Hospital Corps had previously been WAVES, a

AI-6

HM3FAI03

Figure APP-I-3.—Women entered the Hospital Corps in World War II as WAVES.
component of the U.S. Naval Reserve, but the new

legislation permitted women to enlist in the Regular

Navy.

Effective April 1, 1948, the Navy changed the

names and insignia of the Hospital Corps. The new

rating titles were hospital recruit, hospital apprentice,

hospitalman, hospital corpsmen third, second, and first

class, and chief hospital corpsman. The red Geneva

cross (fig. APP-I-4), which had marked corpsmen for

50 years, was replaced in the rating badge with the

original symbol of the winged caduceus. The rates of

senior chief and master chief hospital corpsman were

added in 1958.

HOSPITAL CORPSMEN IN KOREA

As part of a United Nations force, Marines were

committed to the Korean peninsula when South Korea

was invaded by its northern neighbor in the summer of

1950. Within the first year, Hospital Corpsmen had

participated in the dramatic landing at Inchon and the

frigid retreat from the Chosin Reservoir. Although

only one Marine division was involved in the war

between 1950 and 1953, the Hospital Corps lost 108

killed in action. Disproportionate to their numbers was

their heroism. In Korea, Hospital Corpsmen earned

281 Bronze Star Medals, 113 Silver Star Medals, and

23 Navy Crosses. All five enlisted Navy Medals of

Honor were awarded to Navy Hospital Corpsmen

serving with the Marines.

HOSPITAL CORPSMEN IN VIETNAM

American military commitment in Southeast Asia

grew in the decades following World War II. As early

as 1959, a few Hospital Corpsmen provided medical

support for U.S. military personnel as part of the

American Dispensary at the U.S. Embassy. Four years

later, in 1963, Navy Station Hospital, Saigon, was

created. Ninety Hospital Corpsmen staffed the facility,

and provided care for U.S. and allied (Australian, New

Zealand, Filipino, and South Korean) military, as well

as South Vietnamese civilians. These medical

personnel conducted routine medical care and treated

the victims of combat and terrorist actions until the

hospital was transferred to the Army in 1966.

Hospital Corpsmen were assigned aboard ships of

various kinds, providing offshore medical support to

U.S. forces. The largest commitment here was on the

hospital ships USS Repose and USS Sanctuary. Some

200 Hospital Corpsmen, representing the gamut of

technical specialties, worked on each ship. Teams of

20 Hospital Corpsmen served on LPH-class

amphibious ships. Others supported the riverine force

on APB-class base ships.

U.S. State Department initiatives and the Medical

Civic Action Program (MEDCAP) provided medical

support for Vietnamese civilians. Beyond routine aid

and treatment, the Hospital Corpsmen working

through these programs provided guidance in

sanitation and preventive medicine throughout South

Vietnam.

By far the Hospital Corps’ largest contribution in

Vietnam was with Marine Corps units. Starting with

the 50 who landed with the Marines at Da Nang in

1965, the enlisted medical component would grow to

2,700 Hospital Corpsmen assigned to 1st and 3d

Marine Divisions, 1st Marine Air Wing, and other

combat support units. Two medical battalions and two

hospital companies operated field hospitals, collecting

and clearing units, and dispensaries that treated the

flow of combat casualties from the field. Closer

support was provided at the battalion aid station (BAS)

level, where casualties could be stabilized before

evacuation to more definitive care. The BAS was often

bypassed because of the exceptional medical

evacuation capabilities of helicopter medical

evacuation (MEDEVAC).

The most dangerous role of the Hospital Corpsman

in Vietnam was in the field. Special units (such as

Navy SEAL teams and Marine reconnaissance units)

took medical Sailors with them, as did the artillery, air,

and infantry elements of the Marine Corps. Most of the

53 Hospital Corpsmen assigned to an infantry battalion

served with rifle companies, one or two men per

platoon of about 40. These Sailors patrolled with their

Marines, risked the same dangers, and rendered the aid

that saved the lives of thousands.

HOSPITAL CORPSMEN SINCE

VIETNAM

Since April 1975, Hospital Corpsmen have

continued to serve in the many “hot spots” around the

world. Fifteen Hospital Corpsmen were killed in

action when the Marine headquarters in Beirut,

Lebanon, was attacked and destroyed by a suicide

truck bomber on October 23, 1983. Hospital

Corpsmen were present at sea and ashore when the

United States took military action in Grenada, and then

again when they faced both bullets and the needs of a

starving populace in Somalia.

The 1990-91 Iraqi invasion of Kuwait gained a

strong response from the United States and the world in

the form of Desert Shield/Desert Storm. Preparations

AI-7
were made to drive the Iraqi Army out of the tiny

country, and corpsmen were readied to respond to the

needs of their shipmates. Hospital Corpsmen around

the globe reacted, as their ships, stations, and Marines

deployed or prepared to receive casualties. In fact, the

first Navy casualty of Desert Storm was a Hospital

Corpsman. Of the vast number of Naval Reservists

called to active duty, the largest single group activated

consisted of Hospital Corpsmen. Of an inventory of

just more than 12,000 Hospital Corpsmen in the Naval

Reserve, some 6,700 were recalled to active duty. The

largest group of them, about 4,600, served at medical

treatment facilities and casualty receiving centers;

approximately 1,100 went to Marine Corps units;

about 840 were attached to Fleet Hospitals Six and

Fifteen; and some 470 of the reservists were assigned

to the hospital ships Mercy and the Comfort.

HOSPITAL CORPSMEN TODAY

Today’s Hospital Corpsmen perform as assistants

in the prevention and treatment of disease and injury.

They assist with physical examinations, provide

patient care, and administer medicinals. They perform

general laboratory, pharmacy, and other patient

support services. They assist in the administrative,

supply, and accounting procedures within medical

departments ashore, afloat, and with the Marine Corps.

They instruct medical and nonmedical personnel in

first aid, self-aid, personal hygiene, and medical

records maintenance. They assist in the maintenance

of environmental health standards, and they are

prepared to assist in the prevention and treatment of

CBR casualties and in the transportation of the sick and

injured. Senior Hospital Corpsmen perform technical

planning and management functions in support of

medical readiness and quality health care delivery.

In addition to their general assignments, Hospital

Corpsmen trained as technicians perform specialized

functions within the operational forces, clinical

specialties, and administrative department, and they

may be assigned duties independent of a medical

officer. These complex duties require that each

Hospital Corpsman have broad-based training and a

versatility neither demanded nor expected of other

enlisted rating in the Navy.

Wherever you find the Navy, wherever you find

the Marine Corps, there you will find Navy Hospital

Corpsmen. In times of peace, they toil unceasingly, day

and night, providing quality care to numerous

beneficiaries. In times of war, they are on the beaches

with the Marines, employed in amphibious operations,

in transportation of wounded by air, on the battlefield,

and on all types of ships, submarines, aircraft carriers,

and landing craft. Their innumerable instances of

heroism, during which they have consciously exposed

themselves to danger to save lives, are not spectacular

because the corpsmen were required to act. Rather,

their bravery is exceptional because it was not

required, but given freely and willingly in service to

their country and their fellow humanity, above and

beyond the call of duty.

Abridged from “The U.S. Navy Hospital Corps: A

Century of Tradition, Valor, and Sacrifice,” by

HMCS(FMF) Mark T. Hacala, USNR, with permission

from the author.

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APPENDIX II

COMMONLY USED ABBREVIATIONS

AA . . . . . . . . . . . . . . Alcoholics Anonymous

ACTH .......... adrenocorticotropichormon

ADH . . . . . . . . . . . . . . antidiuretic hormone

AIDS ..... acquired immunodeficiency syndrome

B-cells....... lymphocytes produced in the bone

marrow

Ba . . . . . . . . . . . . . . . . . . . . . . . barium

Bid . . . . . . . . . . . . . . . . . . . . 2 times a day

BP . . . . . . . . . . . . . . . . . . . blood pressure

BUMED ...... Bureau of Medicine and Surgery

BUN . . blood, urea, nitrogen (test of kidney function)

BW. . . . . . . . . . . . . . . . . biological warfare

C. . . . . . . . . . . . . . . . . Celsius (centigrade)

Ca . . . . . . . . . . . . . . . . . . . . . . . calcium

CAAC....... Counseling and Assistance Center

CBC . . . . . . . . . . . . . . complete blood count

CBR . . . . . . chemical, biological, and radiological

(warfare)

cc . . . . . . . . . . . . . . . . cubic centimeter/1 ml

CCU . . . . . . . . . . . . . . . . coronary care unit

CHF . . . . . . . . . . . . . congestive heart failure

Cl . . . . . . . . . . . . . . . . . . . . . . . chlorine

CNS . . . . . . . . . . . . . . central nervous system

CO2 .................. carbon dioxide

COPD ........ chronic obstructive pulmonary

disease

CSF . . . . . . . . . . . . . . . . cerebrospinal fluid

CVA. . . . . . . . . . . . . cerebrovascular accident

CW . . . . . . . . . . . . . . . . . chemical warfare

D&C . . . . . . . . . . . . . . dilation and curettage

DC. . . . . . . . . . . . . . . . . . . . Dental Corps

DCA. . . . . . . . . . . . . damage control assistant

diff . . . . . . . . . . . . . . differential blood count

DME . . . . . . . . . . diving medical examination

DNA . . . . . . . . . . . . . . deoxyribonucleic acid

DOB . . . . . . . . . . . . . . . . . . . date of birth

DOD . . . . . . . . . . . . . Department of Defense

DTs. . . . . . . . . delerium tremens (confusion and

incoherence brought on by

withdrawal from alcohol)

Dx ...................... diagnosis

ea . . . . . . . . . . . . . . . . . . . . . . . . . each

ECG/EKG ............. electrocardiogram

EM . . . . . . . . . . . . . . . . electron microscope

ENT . . . . . . . . . . . . . . . ear, nose, and throat

F...................... Fahrenheit

FAC . . . . . . . . . . . . . . free available chlorine

FBS . . . . . . . . . . . . . . . . fasting blood sugar

FDA. . . . . . . . . . Food and Drug Administration

Fe . . . . . . . . . . . . . . . . . . . . . . . . . iron

FSC . . . . . . . . . . . . . Federal Supply Catalog

FSH. . . . . . . . . . . follicle-stimulating hormone

g/gm ....................... gram

GI . . . . . . . . . . . . . . . . . . . gastrointestinal

gr. . . . . . . . . . . . . . . . . . . . . . . . . grain

gtt . . . . . . . . . . . . . . . . . . . . . . . . drops

GTT. . . . . . . . . . . . . . . glucose tolerance test

GU . . . . . . . . . . . . . . . . . . . genitourinary

h.s. . . . . . . . . . . . . . . at bedtime (hora somni)

Hb/Hgb .................. hemoglobin

HCG . . . . . . . . . human chorionic gonadotropin

Hct . . . . . . . . . . . . . . . . . . . . . hematocrit

Hg . . . . . . . . . . . . . . . . . . . . . . mercury

HIV . . . . . . . . . human immunodeficiency virus

hpf . . . . . . . . . . high-power field (microscope)

I. . . . . . . . . . . . . . . . . . . . . . . . . iodine

I&O . . . . . . . . . . . . . . . . . intake and output

ICU . . . . . . . . . . . . . . . . Intensive care unit

IM . . . . . . . . . . . . . . . . . . . intramuscular

IPPB . . . ....... intermittent positive-pressure

breathing (asthma and

emphysema therapy)

IUD . . . . . . . . . . . . . . . . intrauterine device

IV . . . . . . . . . . . . . . . . . . . . . intravenous

AII-1
IVP . . . . . . . . . . . . . . intravenous pyelogram

JAG . . . . . . . . . . . . . Judge Advocate General

K...................... potassium

KUB. . . . . . . . . . . . kidney, ureter, and bladder

(abdominal x-ray)

l or L. . . . . . . . . . . . . . . . . . . . . . . . liter

Lab . . . . . . . . . . . . . . . . . . . . . laboratory

LES . . . . . . . . . . Leave and Earnings Statement

LH . . . . . . . . . . . . . . . . luteinizing hormone

LLQ . . . . . . . . . . . . . . . . left lower quadrant

LMP . . . . . . . . . . . . . . . last menstrual period

LP . . . . . . . . . . . . . . . . . . lumbar puncture

LUQ . . . . . . . . . . . . . . . . left upper quadrant

m ........................ meter

MANMED .... Manual of the Medical Department

MC. . . . . . . . . . . . . . . . . . . Medical Corps

MCH . . . . . . . . . mean corpuscular hemoglobin

MCHC ........... mean corpuscular hemoglobin concentration

MCV. . . . . . . . . . . . mean corpuscular volume

Med Board .......... Department of Defense

Medical Review Board

mg . . . . . . . . . . . . . . . . . . . . . milligram

MI . . . . . . . . . . . . . . . myocardial infarction

MILPERSMAN ...... Naval Military Personnel

Manual

ml . . . . . . . . . . . . . . . . . . . . . . milliliter

mm . . . . . . . . . . . . . . . . . . . . . millimeter

MO . . . . . . . . . . . . . . . . . . medical officer

MSC. . . . . . . . . . . . . . Medical Service Corps

N....................... nitrogen

Na . . . . . . . . . . . . . . . . . . . . . . . sodium

NAVEDTRA ..... Naval Education and Training

NAVFINCEN ......... Naval Finance Center

NAVMEDCOM ...... Naval Medical Command

NC . . . . . . . . . . . . . . . . . . . . Nurse Corps

NDRC ....... Naval Drug Rehabilitation Center

NEC . . . . . . . . . . Naval Enlisted Classification

ng . . . . . . . . . . . . . . . . . . . . . nasogastric

NMPC ..... Naval Military Personnel Command

npo . . . . . . . . . . nothing by mouth (nulli per os)

NRTC. . . . . . . . . . . nonresident training course

O2 ....................... oxygen

OB . . . . . . . . . . . . . . . . . . . . . obstetrics

OBA . . . . . . . . . . . oxygen breathing apparatus

OD . . . . . . . . . . . . . . right eye (oculus dexter)

OJT . . . . . . . . . . . . . . . . on-the-job training

OR. . . . . . . . . . . . . . . . . . . operating room

OS . . . . . . . . . . . . . . left eye (oculus sinister)

oz . . . . . . . . . . . . . . . . . . . . . . . . ounce

P. . . . . . . . . . . . . . . . . . . . . . phosphorus

PAYPERSMAN . . . Pay and Personnel Procedures

Manual

pc. . . . . . . . . . . . . . . after meals (post cibum)

PDB. . . . . . . . . . . . . . . paradichlorobenzene

PDR . . . . . . . . . . . Physicians’Desk Reference

PH . . . . . . . . . . . . hydrogen ion concentration

(alkalinity and acidity

measurement)

PID . . . . . . . . . . . pelvic inflammatory disease

po . . . . . . . . . . . . . . . . . . . . orally (per os)

poly............ segmented neutrophil (seg)

post-op ................. post-operative

ppd. . . . . . . . . . . . . purified protein derivative

ppm . . . . . . . . . . . . . . . . . parts per million

pre-op .................. pre-operative

prn . . . . . . . . . . . . . . asrequired (pro re nata)

PSD . . . . . . . . . Personnel Support Detachment

PVC . . . . . . . . premature ventricular contraction

q4h . . . . . . . . . . . . . . . . . . . every 4 hours

q6h . . . . . . . . . . . . . . . . . . . every 6 hours

qd . . . . . . . . . . . . . . . . . . . . . . every day

qh. . . . . . . . . . . . . . . . . . . . . . every hour

qid . . . . . . . . . . . . . . . . . . . . 4 times a day

qns . . . . . . . . . . . . . . . quantity not sufficient

qt . . . . . . . . . . . . . . . . . . . . . . . . . quart

Ra . . . . . . . . . . . . . . . . . . . . . . . radium

RBC . . . . . . . . . . . . . . . . . . . red blood cell

Rh . . Rh factor (antigen in blood of some individuals)

RLQ . . . . . . . . . . . . . . . right lower quadrant

RUQ . . . . . . . . . . . . . . . right upper quadrant

Rx ................. take (prescription)

sc/sub-q . ................ subcutaneous

SOAP notes . . . . . . . the only accepted method of

medical record entries for

the military. (Subjective;

Objective; Assessment;

Plan)

AII-2
SOB . . . . . . . . . . . . . . . . shortness of breath

stat .................... immediately

STD . . . . . . . . . . . sexually transmitted disease

T-cells.......... lymphocytes produced in the

thymus gland

TAD/TEMADD ...... temporary additional duty

TB . . . . . . . . . . . . . . . . . . . . tuberculosis

tbsp .................... tablespoon

tid . . . . . . . . . . . . . . . . . . . . 3 times a day

tpr. . . . . . . . . temperature, pulse, and respiration

TSH . . . . . . . . . . thyroid-stimulating hormone

tsp . . . . . . . . . . . . . . . . . . . . . . teaspoon

UIC . . . . . . . . . . . . . . unit identification code

URI . . . . . . . . . . . . upper respiratory infection

USP-NF .... United States Pharmacopeia-National

Formulary

VA . . . . . . . . . . . . . . Veterans Administration

VD . . . . . . . . . . . . . . . . . . venereal disease

VDRL. . .........Venereal Disease Research

Laboratory (an antibody

test for syphilis)

vs . . . . . . . . . . . . . . . . . . . . . . vital signs

WBC . . . . . . . . . . . . . . . . . white blood cell

WHO . . . . . . . . . . . World Health Organization

YOB . . . . . . . . . . . . . . . . . . . year of birth

AII-3

APPENDIX III

PREFIXES AND SUFFIXES USED IN

MEDICAL TERMINOLOGY

The following are some of the more common

prefixes and suffixes used by healthcare providers to

describe body conditions and procedures.

PREFIXES

a-; an- . . . . . . . . . . . . . . . lacking; absence of

ab- . . . . . . . . . . . . . . . . . . . . . away from

acr/o .................... extremities

ad- . . . . . . . . . . . . . . . . towards; addition of

adip/o . . . . . . . . . . . . . . . . . . . . . . . . fat

aer/o . . . . . . . . . . . . . . . . . . . . . . . . air

amphi- . . . . . . . . . . . . . . . . . . on both sides

amyl/o...................... starch

andr/o ...................... male

AIII-1

Medical terminology uses components (i.e., prefixes and suffixes) to build words that represent

medical conditions and procedures. These words can often seem intimidating until you learn how to

break them down into their component parts.

Examples of Combinations of Prefixes and Suffixes

cholecystitis = chole + cyst + itis (inflammation of the gallbladder)

• chole = gall

• cyst = bladder

• Itis = inflammation

cholelithiasis = chole + lith + iasis (condition resulting from gallstones)

• chole = gall

• lith = stone

• iasis = condition (resulting from)

odontalgia = odont + algia (tooth pain; toothache)

• odont = tooth

• algia = pain

rhinoplasty = rhino + plasty (to form or build up the nose)

• rhino = nose

• plasty = to form or build up
angi/o ...................... vessel

ankyl/o .............. crooked; bent; stiff

ante- ...................... before

anter/o; anteri/o ................. front

anti- ...................... against

aque/o ...................... water

arthr/o ...................... joint

articul/o...................... joint

atel/o.................... incomplete

audi/o ..................... hearing

aur/i . . . . . . . . . . . . . . . . . . . . . . . . ear

auto- ........................ self

axill/o...................... armpit

bacteri/o.................... bacteria

bene- ....................... good

bi/o......................... life

bi- . . . . . . . . . . . . . . . . . . . . . . . . . two

bil/i ...................... gall; bile

brachi/o . . . . . . . . . . . . . . . . . . . . . . arm

brady- ...................... slow

bucc/o ...................... cheek

calc/o ..................... calcium

capit/o ...................... head

carcin/o..................... cancer

cardi/o ...................... heart

cata- ....................... down

caud/o ............. tail; lower part of body

caus/o....................... burn

cauter/o ................... heat; burn

celi/o ................. belly; abdomen

cephal/o ..................... head

cerebell/o ................. cerebellum

cerebr/o................ brain; cerebrum

cervic/o.................. neck; cervix

chem/o................. drug; chemical

chol/e ....................... gall

chondr/o ................... cartilage

chrom/o ..................... color

chron/o ...................... time

cib/o ....................... meals

con-................... with; together

contra- .............. against; opposed to

coron/o ...................... heart

cortic/o . . . .................. cortex

cost/o ....................... ribs

crani/o ...................... skull

cry/o . . . . . .................. cold

crypt/o ..................... hidden

cutane/o ...................... skin

cyan/o. . . . . .................. blue

cyst/o . . . .................. bladder

cyt/o ........................ cell

dacry/o ...................... tear

dactyl/o. . ................ fingers; toes

de- . . . . . . . . . . . . . . . . . . . . . . . lack of

dent/i ....................... tooth

derm/o; dermat/o ................. skin

di. . . . . . . . . . . . . . . . . . . . . . . complete

dia- . . . .............. complete; through

diaphor/o .................... sweat

dist/o . . . . . . . . . . . . . . . . . . . . . . . . far

dors/o ................. back (of body)

dys- . . . . . . . . . . . . . . . . . difficult; painful

ec-; ecto- . . . .............. out; outside

em- . . . . . . . . . . . . . . . . . . . . . . . . . in

en- . . . . . . . . . . . . . . . . . . . . . . in; within

encephal/o .................... brain

endo- ...................... within

enter/o. . . ................. intestines

epi- ....................... above

erg/o . . . . . . . . . . . . . . . . . . . . . . . work

erythr/o. . . . . . . . . . . . . . . . . . . . . . . red

eso-....................... inward

estr/o ...................... female

eti/o ....................... cause

eu- . . . . . . . . . . . . . . . . . . . . . . . . good

ex- . . . . . . . . . . . . . . . . . . . . . . . . . out

exo- ...................... outside

fibr/o ............... fibers; fibrous tissue

gastr/o .................... stomach

gen/o .............. producing; beginning

germ/o . ................. sprout; seed

gingiv/o ..................... gums

gloss/o ..................... tongue

gluc/o; glyc/o . ................. sugar

gnos/o ................... knowledge

AIII-2
gravid/o .................. pregnancy

gynec/o ................ woman; female

hem/o; hemat/o ................. blood

hemi- ....................... half

hepat/o ...................... liver

hidr/o ...................... sweat

hist/o; histi/o .................. tissue

home/o .......... same; constant; unchanged

hydr/o ...................... water

hyper- ................. above; increase

hypn/o ...................... sleep

hypo- .................. under; below

hyster/o ................. uterus; womb

immun/o ............... safe; protection

in- . . . . . . . . . . . . . . . . . . . . . . . . not; in

infra-.................. below; inferior

inter- ..................... between

intra- ...................... within

is/o .................... same; equal

kary/o ..................... nucleus

kerat/o .............. horny; hard; cornea

kinesi/o................... movement

labi/o........................ lips

lacrim/o ................. tear; tear duct

lact/o ....................... milk

lapar/o .................... abdomen

laryng/o ............... larynx; voice box

later/o ....................... side

leuk/o ...................... white

lingu/o ..................... tongue

lip/o. . . . . . . . . . . . . . . . . . . . . . . . . fat

lumb/o................ lower back; loins

macro- . . . . . . . . . . . . . . . . . . . . . . large

mal- .................... faulty; poor

mamm/o..................... breast

mast/o ...................... breast

medi/o ..................... middle

melan/o ..................... black

meso- ..................... middle

meta- .............. beyond; near; change

metr/o; metri/o ................. uterus

micr/o ...................... small

mit/o ...................... thread

mon/o . . . . ............... one; single

morph/o .................. shape; form

mort/o . ..................... death

my/o ...................... muscle

myel/o ........... spinal cord; bone marrow

myos/o ..................... muscle

narc/o ................ stupor; numbness

nas/o ....................... nose

nat/i........................ birth

necr/o . ..................... death

neo- . . . . . . . . . . . . . . . . . . . . . . . . new

nephr/o ..................... kidney

neur/o . ..................... nerve

ocul/o; ophthalm/o. . . . . . . . . . . . . . . . . eye

odont/o...................... tooth

olig/o . .................. few; scanty

onc/o ................... mass; tumor

or/o ....................... mouth

orth/o . . . .................. straight

oste/o ....................... bone

ot/o . . . . . . . . . . . . . . . . . . . . . . . . . ear

ov/o . . . . . . . . . . . . . . . . . . . . . . . . egg

pachy/o .................. heavy; thick

pan- . . . . . . . . . . . . . . . . . . . . . . . . . all

para-.............. beside; near; abnormal

path/o ..................... disease

per- . . . . . . . . . . . . . . . . . . . . . . through

peri- . . . ................... around

phag/o .................. eat; swallow

pharyng/o . ................... throat

phil/o . . ........... like; love; attraction to

phleb/o ...................... vein

phob/o ....................... fear

phot/o....................... light

physi/o . . . .................. nature

pne/o . . .............. breathing; breath

pneum/o . .................... lung

poly- ................... many; much

post- ................... after; behind

pre- ....................... before

proct/o ..................... rectum

prot/o ....................... first

proxim/o ..................... near

AIII-3
pseud/o ...................... false

psych/o...................... mind

py/o . . . . . . . . . . . . . . . . . . . . . . . . pus

pyr/o ................ heat; temperature

re-. . . . . . . . . . . . . . . . . . . . . . . . . back

rect/o ...................... rectum

ren/o ...................... kidney

retro- ...................... behind

rhin/o ....................... nose

rib/o ....................... sugar

roentgen/o ................... x-rays

sarc/o ............ flesh (connective tissue)

scop/o .......... examination (usually visual)

semi- ....................... half

seps/o .................... infection

somn/o ...................... sleep

son/o ...................... sound

spher/o.............. round; globe-shaped

sphygm/o .................... pulse

spondyl/o ........... vertebrae (backbones)

stomat/o .................... mouth

sub- ................... under; below

supra- ...................... above

sym-; syn- ............... together; with

tachy- ....................... fast

tele/o .................... far; distant

thorac/o ..................... chest

top/o ............. position; location; place

tox/o; toxic/o .................. poison

trans- ...................... across

ultra- ................. beyond; excess

vas/o ................... vessel; duct

ven/o ....................... vein

ventr/o ............... belly side of body

vir/o ................... virus; poison

viscer/o ................ internal organs

vit/a; vit/o ..................... life

xanth/o ..................... yellow

xer/o . . . . . . . . . . . . . . . . . . . . . . . . dry

SUFFIXES

-ac; -al; -ar; -ary ............. pertaining to

-algia ....................... pain

-ase ...................... enzyme

-asthenia . .............. lack of strength

-blast .............. immature; embryonic

-capnia................. carbon dioxide

-cele ................... tumor; hernia

-cidal ...................... killing

-clast. . ..................... break

-coccus (pl.-cocci) ........... berry-shaped

-crine................. secrete; separate

-crit ...................... separate

-cyte ........................ cell

-cytosis ............... condition of cells

-desis ..................... binding

-ectasia; -ectasis.......... dilation; stretching

-ectomy .................. removal of

-emesis. . .................. vomiting

-emia ...................... blood

-er. . . . . . . . . . . . . . . . . . . . . . . one who

-esthesia ................... sensation

-genesis ............ condition of producing

-globin; -globulin ............... protein

-gram . . .................... record

-graph . . . ......... instrument for recording

-graphy. ............. process of recording

-ia . . . . . . . . . . . . . . . . . condition; process

-iasis . . . ............... condition (of)

-ic . . . . . . . . . . . . . . . . . . . . pertaining to

-ist ...................... specialist

-itis ................... inflammation

-lith .................. stone; calculus

-lysis . . ........... destruction; break down

-lytic .................... destruction

-malacia . . . ................ softening

-manometer ......... used to measure pressure

-megaly . . ............... enlargement

-meter................. used to measure

-oid .................... resembling

-ole .................... little; small

-ology . . ................... study of

-oma .................. growth; tumor

-opia . . .................... vision

-opsy ....................... view

-or. . . . . . . . . . . . . . . . . . . . . . . one who

AIII-4
-(o)rraphy .................. repair of

-(o)rrhea ............... flow; discharge

-osis................... condition (of)

-(o)stomy ........... creation of an opening

-(o)tomy ................. cutting into

-ous ................... pertaining to

-para ............. births (viable offspring)

-pathy ..................... disease

-penia ............... decreased number

-phagia .............. eating; swallowing

-pheresis ................... removal

-philia ............. attraction for; increase

-phobia ................... fear; dread

-phonia .................. voice; sound

-phoria ............. feeling (mental state)

-phylaxis .................. protection

-physis ................. grow; growth

-plasia ............... formation; growth

-plasty ................. form; build up

-plegia .................... paralysis

-pnea .................... breathing

-porosis .................... passage

-ptosis . . . ............. drooping; falling

-rrhea . . . . ............. discharge; flow

-sclerosis .................. hardening

-scope . . . ....... instrument used to examine

-scopy. . . ....... examination (usually visual)

-spasm ............. contraction of muscles

-stalsis . . ................ constriction

-stasis .................. control; stop

-static .............. stopping; controlling

-stenosis ............. tightening; stricture

-sthenia . . . ................. strength

-therapy ................... treatment

-thermy . . . . .................. heat

-tic .................... pertaining to

-tome ................ instrument to cut

-tomy. . . ............. process of cutting;

incision

-tresia . . . . ................. opening

-tropic; -trophy ........... growth; nutrition

-ule .................... little; small

-uric; -uria .................... urine

-y. . . . . . . . . . . . . . . . . . condition; process

AIII-5

APPENDIX IV

COMMON PHARMACEUTICALS

AIV-1
AIV-2
AIV-3
AIV-4
AIV-5
AIV-6
AIV-7
AIV-8
AIV-9
AIV-10
AIV-11
AIV-12
AIV-13
AIV-14
AIV-15
AIV-16
AIV-17
AIV-18
APPENDIX V

GLOSSARY

The following terms are explained as used in this manual and as commonly defined.

ABDUCTION—Moving an extremity away from the body.

ABRASION—An area of skin or mucous membrane worn from the body mechanically by

some unusual or abnormal process.

ABSCESS—A localized collection of pus.

ACIDOSIS—A condition resulting from acid accumulating in the body.

ADDUCTION—Bringing an extremity toward the body.

ADIPOSE—Of a fatty nature.

ADRENERGIC—Activated by, characteristic of, or secreting epinephrine or similar

substance.

ABSORBENT—A drug which “takes up” other substances by absorption.

ADSORPTION—The attachment of one substance to the surface of another.

AEROBIC—Growing only in the presence of oxygen.

AFFECT—(n.) Feeling experienced in connection with an emotion.

ALBUMINURIA—Albumin in the urine.

ALIMENTARY—Pertaining to food or digestion.

ALKALOSIS—A pathogenic condition resulting from accumulation of base in, or loss of

acid from, the body.

AMBULATORY—Walking or able to walk.

ANABOLISM—The constructive process by which the simple products of digestion are

converted by living cells into more complex compounds and living matter for cellular

growth and repair.

ANAEROBIC—Growing only in the absence of oxygen.

ANALGESIC—A drug used to relieve pain without producing unconsciousness or

impairing mental capacities.

ANATOMY—The science of the structure of the body and the relationship of its parts to

each other.

ANEMIA—A decrease in certain elements of the blood, especially red cells and

hemoglobin.

ANESTHESIOLOGIST—A physician who specializes in anesthesiology.

ANESTHESIOLOGY—A branch of medicine that studies anesthesia and anesthetics.

ANESTHETIST—A registered nurse trained in administering anesthetics.

ANISOCORIA—Unequal diameter of the pupils.

ANODYNE—A drug that relieves pain.

ANOREXIA—Loss of appetite.

ANTHELMINTIC—A drug that expels, paralyzes, or kills intestinal worms.

AV-1 .
ANTIBIOTIC—A synthetic product or a product of living microorganisms that

kills or inhibits the growth of undesirable microorganisms.

ANTIDOTE—An agent that counteracts a poison.

ANTIGEN—A substance which, under certain conditions, is capable of inducing

the formation of antibodies and reacting specifically with the antibodies in a

detectable manner.

ANTIPYRETIC—A drug that lowers elevated body temperature.

ANTISEPTIC—A drug or chemical that inhibits the growth of microorganisms

without necessarily destroying them.

APNEA—A temporary cessation of breathing.

ARTICULATION—The place of union or junction between two or more bones of

the skeleton.

ASEPTIC—Clean; free of pathogenic organisms.

ASTRINGENT—A drug or preparation that produces shrinkage of body

membranes, especially mucous membranes.

ASYMPTOMATIC—Having no symptoms.

AUSCULTATION—The act of listening for sounds within the body, with or

without a stethoscope.

AUTOLYSIS—The spontaneous disintegration of tissues or cells by the action of

their own serum or enzymes, such as occurs after death and in some pathological

conditions.

AVULSED—A forcible separation; also, a part torn from another.

AXILLARY—Pertaining to the area of the armpit.

BACTERICIDE—An agent that destroys bacteria.

BACTERIOSTATIC—An agent that inhibits the growth of bacteria.

BIOLOGICALS—Medicinal preparations made from living organisms and their

products, including serums, vaccines, antigens, and antitoxins.

BLANCHING—Turning white.

BLEB—Blister, bubble.

BRADYCARDIA—Abnormally slow heartbeat, evidenced by a pulse rate of 60 or

less.

BRADYPNEA—Abnormally slow breathing.

BUBO—An inflamed swelling of a lymphatic gland, especially in the area of the

armpit or groin.

BUCCAL—Referring to the cheek.

CARRIER—A person or animal that harbors specific infectious agents in the

absence of discernible clinical disease, and serves as a potential source of

infection for humans.

CASTS—Urinary sediments formed by coagulation of albuminous material in the

kidney tubules.

AV-2 .
CATABOLISM—A destructive process in which the complex compounds of the

digestive process are reduced to more simple substances.

CATHARTICS—Drugs that promote bowel movement.

CERVICAL—Pertaining to the neck or the neck of any organ or structure.

CHEYNE-STOKES—Breathing characterized by alternating periods of apnea

and deep respirations.

COAGULATION—Clotting.

COAPTATION—To fit together, as the edges of a wound or the ends of a fractured

bone; category of splint.

COCCYX—Tailbone.

COLATION—The process of straining or filtration.

COMMUNICABLE—Capable of being transmitted from one person to another.

COMMUNICABLE PERIOD—The period of time in which an infectious agent

may be passed from an infected animal or man to a receptive host. There may be

more than one such period of time during the course of disease.

COMMINUTION—The process of physical reduction of a substance to fine

particle size.

CONTACT—A person or animal known to have been associated with an infected

person or animal, or a contaminated environment, and to have had the

opportunity to acquire the infection.

CONTAMINATION—The presence of an infectious agent or toxin on the surface

of a body or inanimate article, such as clothing, dishes, surgical dressings or

instruments, as well as in food or water.

CONTRACTURE—A condition of muscle shortening and fibrous tissue

development that results in a permanent joint deformity.

CONTUSION—A bruise.

CORROSIVE—A substance that rapidly destroys or decomposes body tissue at

point of contact.

CREPITUS—The cracking or grating sound produced by fragments of fractured

bones rubbing together.

DEBILITY—The state of abnormal bodily weakness.

DEBRIDEMENT—The removal of all foreign matter and devitalized tissue in or

about a wound.

DECANTATION—Separating liquids from solids by letting the solids settle to the

bottom and pouring off the liquid.

DECEREBRATE—A person with brain damage that produces certain abnormal

neurologic signs.

DECORTICATION—Removing portions of the cortical substance of a structure

or organ, such as the brain, kidney, or lung.

DECUBITUS ULCER—Bed or pressure sore.

DESQUAMATE—To shed, peel, or scale off.

AV-3 .
DIASTOLE—The dilation or period of dilation of the heart, especially of the

ventricles.

DIATHERMY—The generation of heat in tissue by electric current for medical or

surgical purposes.

DISINFECTION—The killing of infectious agents outside the body by physical or

chemical means applied directly.

concurrent—Done during the treatment of a patient with a communicable

disease.

terminal—Done after a patient has been discharged or transferred.

DISINFESTATION—Aphysical or chemical means of destroying animal or insect

pests in a particular area.

DISTILLATION—Converting a liquid to a vapor by applying heat and condensing

the vapor back to liquid by cooling.

DIURESIS—Urine excretion in excess of the usual amount.

DIURETICS—Drugs that increase the secretion of urine.

DYSPNEA—Labored or difficult breathing.

ECCHYMOSIS—A small hemorrhagic spot, larger than a petechia, in the skin or

mucous membrane, forming a nonelevated, rounded or irregular, blue or

purplish patch.

ELECTROLYTE—A substance that dissociates into ions in solution or when

fused, thereby becoming capable of conducting electricity.

ELIXIR—An aromatic, sweetened, hydroalcoholic solution containing medicinal

substances.

EMBOLUS—A clot or other plug brought by the blood from another vessel and

forced into a smaller one, thereby obstructing circulation.

EMETIC—A substance that causes vomiting.

EMOLLIENT—A drug that softens, soothes, or smooths the skin or irritated

surfaces.

EMULSION—A liquid preparation containing two unmixable liquids, such as oil

and water, one of which is dispersed as globules in the other.

ENCAPSULATED—Enclosed within a capsule.

ENDEMIC—The constant presence of a disease in a given locality.

ENTERIC—Of or within the intestine.

EPIDEMIC—The outbreak of disease in a geographic area in excess of normal

expectations.

EPIDEMIOLOGY—The study of epidemics and epidemic diseases.

EPISTAXIS—Nosebleed.

EPIZOOTIC—Attacking many animals in a region at the same time.

ERADICATE—Wipe out; destroy.

ERYTHEMA—Redness.

ERYTHROCYTE—Red blood cell.

AV-4 .
EUPNEA—Ordinary, quiet breathing.

EUTAXIA—The liquification of solids mixed in a dry state.

EXSANGUINATION—Extensive loss of blood due to hemorrhage, either internal

or external.

EXTENSION—Straightening or unbending, as in straightening the forearm, leg, or

fingers.

EXTRAVASATION—A discharge or escape, such as blood from a vessel into the

tissue.

EXTRICATION—The process of freeing a victim, such as from a wrecked car or

flooded compartment.

FLEXION—Bending, as in bending an arm or leg.

FOMITE—An object, such as a book, wooden object, or an article of clothing, that

is not in itself harmful, but is able to harbor pathogenic microorganisms and thus

may serve as an agent of transmission of an infection.

FUMIGATION—The destruction of disease-producing animals or insects by

gaseous agents.

FUNGICIDE—A drug that kills fungus.

FURUNCLE—An abscess in the true skin caused by the entry of microorganisms

through a hair follicle or sweat gland.

FUSION—Melting.

GASTROSTOMY—A surgical opening from the external surface of the body into

the stomach, usually for inserting a feeding tube.

GAVAGE—Introducing a substance into the stomach through a tube.

GERMICIDE—An agent that kills germs.

GESTATION—The period of carrying developing offspring in the uterus after

conception.

GLYCOSURIA—Glucose in the urine.

GRAM-NEGATIVE—A microorganism that does not retain Gram’s crystal violet

and is stained by the counterstain.

GRAM-POSITIVE—A microorganism that is stained by Gram’s crystal violet.

HEMACYTOMETER—An instrument for estimating the number of blood cells

in a measured volume of blood.

HEMATEMESIS—Vomiting bright red blood.

HEMATOCRIT—A determination of the volume percentage of red blood cells in

whole blood.

HEMIPLEGIA—Loss of motion and sensation of one side of the body.

HEMOGLOBIN—Iron containing red pigment (heme) combined with a protein

substance (globin).

HEMOLYSIN—Substance that breaks down red blood cells, thereby liberating

hemoglobin.

HEMOPTYSIS—Coughing up bright red blood.

AV-5 .
HEMOSTATICS—Drugs that control external bleeding by forming an artificial

clot.

HISTOLOGY—The microscopic study of tissue structure.

HOST—A man or other living animal affording subsistence or lodgment to an

infectious agent under natural conditions.

HYDROTHERAPY—The scientific use of water in the treatment of disease.

HYPERGLYCEMIA—Abnormally increased content of sugar in the blood.

HYPERPNEA—Increased rate and depth of breathing.

HYPERTENSION—High blood pressure.

HYPERTHERMIA—Abnormally high body temperature, especially that induced

for therapeutic purposes.

HYPOGLYCEMIA—Low blood sugar.

HYPOPNEA—Abnormal shallowness and rapidity of breathing.

HYPOSTASIS—Poor or stagnant circulation in a dependent part of the body or

organ, as in venous insufficiency.

HYPOTENSION—Low blood pressure.

HYPOTHERMIA—Abnormally low body temperature.

HYPOVOLEMIA—Abnormally decreased volume of circulating fluid (plasma)

in the body.

HYPOXIA—Low oxygen content or tension; deficiency of oxygen in the inspired

air.

IMMISCIBLE—Incapable of being mixed.

IMMUNE PERSON—An individual who does not develop clinical illness when

exposed to specific infectious agents of a disease, due to the presence of specific

antibodies or cellular immunity.

IMMUNITY—A defense mechanism of the body which renders it resistant to

certain organisms.

INAPPARENT INFECTION—An infection with no detectable clinical

symptoms, even though the causative infectious agent may be identifiable with

laboratory examinations. It is also known as an asypmtomatic or subclinical

infection.

INCIDENCE RATE—The number of specific disease cases diagnosed and

reported in a specific population in a defined period of time. It is usually

expressed as cases per 1,000 or 100,000 annually.

INCISION—A cut, or a wound produced by cutting with a sharp instrument.

INCOMPATIBLE—Not suitable for combination or simultaneous administration.

INCONTINENT—Unable to control excretory functions.

INCUBATION PERIOD—The period of time between the initial exposure to an

infectious agent and the first clinical symptoms of the disease.

INDURATION—An abnormally hard spot or place.

AV-6 .
INFECTION—A condition resulting when pathogens enter body tissues, multiply,

and cause injury to cells.

INFECTIOUS AGENT—An organism capable of producing infection or disease.

INFECTIOUS DISEASE—A disease of man and animal resulting from an

infection.

INFESTATION—The establishment and multiplication of small animals or

arthropods (especially insects and rodents) on the body, clothing, or habitat of

individuals or animals.

INGUINAL—Pertaining to the abdomen.

INSTRUCTION—A directive containing authority or information having

continued reference value or requiring continuing action.

INTEGUMENTARY (SYSTEM)—The skin and its accessory structures,

including hair and nails.

INTRADERMAL—Into the dermis.

INUNCTION—Rubbing in.

ISCHEMIA—The lack of blood supply to specific areas due to constriction or

obstruction in the blood vessels.

ISOLATION—Procedures taken to separate infected persons or animals, dispose

of their secretions, and disinfect or sterilize the supplies, equipment, utensils,

etc., used for their care, in order to prevent the spread of disease to susceptible

persons or animals. Different procedures may be required for the specific

infectious agent involved.

ISOTONIC—A solution having the same salinity as whole blood.

KERATOLYTIC—Removes horny layers of epidermis.

LACERATED—Torn.

LACERATION—A wound made by tearing and resulting in jagged edges.

LACRIMATION—The secretion of tears.

LACRIMATORS—Tear gases.

LACTATION—The production of milk.

LATENT—Concealed; not manifest; potential.

LAVAGE—The irrigation or washing out of an organ (such as the stomach or

bowel).

LESION—Any pathological or traumatic discontinuity of tissue or loss of function

of a part.

LEUKOCYTE—White blood cell.

LEUKOCYTOSIS—Abnormally high white blood cell count.

LEUKOPENIA—Abnormally low white blood cell count.

LEVIGATION—Adding a small amount of liquid to a mortar and pestle while

triturating.

LIGAMENT—A sheet or band of tough, fibrous tissue connecting two or more

bones or cartilages, or supporting an organ, fascia, or muscle.

AV-7 .
LINIMENT—Solution or mixture of various substances in oily, alcoholic, or

emulsified form, intended for external application.

LUMBAR—Pertaining to the part of the back between the thorax and the pelvis.

LYOPHILIZATION—The creation of a stable preparation of a biological

substance (blood plasma, serum, etc.) by rapid freezing and dehydration of the

frozen product under high vacuum.

MACERATION—Softening of a solid by soaking.

MAGMAS—Thick, creamy, aqueous suspensions of inorganic substances in a very

fine state.

MALAISE—A vague feeling of bodily discomfort.

MASTICATION—Chewing.

MEDICAL ASEPTIC TECHNIQUE—The practice that prevents the spread of

pathogens from person to person, place to place, or place to person.

MELENA—Excretion of black tarry stools.

METABOLISM—The sum of all the physical and chemical processes by which

living organized substance is produced and maintained. Also, the

transformation by which energy is made available to the organism.

METAMORPHOSIS—Change of shape or structure, particularly a transition

from one development stage to another, as from larva to adult form.

METROLOGY—The science of weights and measures.

MICROORGANISM—A minute, living organism invisible to the naked eye.

MICTURATION—Voiding; urinating.

MORBIDITY RATE—An incidence rate that includes all persons in a particular

population who become ill during a specific period of time.

MORPHOLOGY—The science of forms and structure of organized beings.

MORTALITY RATE—The number of deaths, reported in a particular population,

over a specific period of time, divided by the total population, reported as deaths

per 1,000 population. If the deaths are from one cause, then it is known as a

disease-specific mortality rate.

MOTTLED—Marked with blotches or spots of different colors or shades.

MUCUS—A sticky substance secreted by mucous membranes.

MYDRIATIC—Any drug that dilates the pupil.

MYELIN—A lipid substance that forms a sheath around certain nerve fibers.

MYELINATED—Covered with a myelin sheath.

NECROSIS—The death of tissue, usually in small, localized areas.

NOSOCOMIAL—Originating in a hospital.

NOTICE—A directive of a one-time or limited nature that has a self-canceling

provision and the same force or effect as an instruction.

NUTRITION—The total process of providing the body with nutriments, and

assimilating and using them.

AV-8 .
OINTMENT—A semisolid, fatty, or oily preparation of medicinal substances for

external application.

OLFACTORY—Pertaining to the sense of smell.

OLIGEMlA—Deficiency in the volume of blood.

OPHTHALMIC—Pertaining to the eye.

ORGANISM—Any living thing.

OSMOSIS—The diffusion of fluids through a membrane or porous partition.

OSSIFICATION—Changing or developing into bone.

OXIDATION—The union of a substance with oxygen.

PALPABLE—Capable of being touched or felt.

PALPITATION—An abnormal, rapid, regular or irregular beating of the heart, felt

by the patient.

PARAPLEGIA—Loss of motion and sensation of the lower half of the body.

PARASITICIDES—Drugs that kill parasites.

PARENTERAL—Administration of drugs by injection.

PARESIS—Slight or partial paralysis.

PAROXYSM—A sudden attack, or intensification of the symptoms of a disease,

usually recurring periodically.

PATHOGEN—An organism capable of producing disease or causing infections.

PATHOGENICITY—The capability of an infectious agent to cause disease in a

susceptible host.

PERCUSSION—The act of striking a body part with short, sharp blows as an aid in

diagnosing the condition by evaluating the sound obtained.

PERIPHERAL—Outward part or surface.

PERSISTENT—Stubborn; persevering.

PETECHIA—(pl. petechiae) A round pinpoint, nonraised, purplish red spot caused

by hemorrhage in the skin.

pH—Scale measuring the acidity or alkalinity of a solution.

PHAGOCYTOSIS—The ingestion and destruction by phagocytes of cells,

microorganisms, and other foreign matter in the blood or tissue.

PHARMACOGNOSY—The study of the action of drugs and their uses.

PHYSIOLOGICAL—Characteristic of or appropriate to an organism’s

functioning.

PLEXUS—Network.

PRECIPITATION—The quality or state of being separated from solution or

suspension by chemical or physical change, usually as an insoluble amorphous

or crystalline solid.

PRONE—Lying face down.

PROPHYLACTIC—The prevention of disease; preventive treatment.

AV-9 .
PROPORTION—Two equal ratios considered simultaneously.

PROSTRATION—Utter exhaustion.

PRURITIS—Intense itching.

PSYCHOLOGICAL—Belonging to or of the nature of psychology; the mental

process.

PURULENT—Pus filled or containing pus.

PUSTULE—A small, inflamed elevation of the skin containing pus.

QUADRAPLEGIA—Loss of motion and sensation below the neck.

RALES—An abnormal sound, either moist or dry, classified by location (e.g.,

bronchial rales, laryngeal rales).

RATIO—The relationship of one quantity to another of like units.

RESERVOIR—A carrier on which an infectious agent depends primarily for

survival.

RESISTANCE—The sum total of body mechanisms that provide barriers to the

invasion of infectious agents or their toxic products.

RHINORRHEA—The free discharge of a thin nasal mucus.

RHONCHUS—(pl.rhoncii) A rattling throat sound due to partial obstruction; a dry

coarse rale in the bronchial tubes.

SACRUM—Triangular bone just below the lumbar vertebrae.

SANITIZATION—The process of cleaning with soap and water or boiling to

reduce the number of organisms to a safe level.

SEPSIS—The growth of pathogens in living tissue.

SERUM—(pl. serums or sera) The watery portion of an animal fluid remaining

after coagulation; plasma minus the clotting proteins and clotting cells.

SHOCK—Collapse of the cardiovascular system, characterized by circulatory

deficiency and depression of vital functions.

SOLUBILITY—The ability of a solid to dissolve in a given amount of solvent.

SPIRITS—Alcoholic or hydroalcoholic solutions of volatile substances.

SPORE—A microorganism in a resting or dormant state that renders it highly

resistant to destruction.

SPRAIN—Injury to the ligaments and soft tissues that support a joint.

STERILE—Free of all living organisms.

STERILIZATION—The process of destroying all organisms on a substance or

article by exposure to physical or chemical agents; the process by which all

organisms, including spores, are destroyed.

STERNUNTATORS—Vomiting agents.

STERTOROUS—Snoring-type breathing sound.

STRAIN—Forcible overstretching or tearing of a muscle or tendon.

STRIATED—Striped or streaked.

AV-10 .
STRIDOR—A harsh, high-pitched respiratory sound such as the inspiratory sound

often heard in acute laryngeal obstruction.

SUBCUTANEOUS—Under the skin.

SUBLINGUAL—Under the tongue.

SUPERFICIAL—Of or pertaining to the surface, lying on, not penetrating below.

SUPINE—Lying on the back.

SURGICAL ASEPTIC TECHNIQUE—The practice that renders and keeps

objects and areas free from all organisms.

SURGICALLY CLEAN—Clean but not sterile.

SUSCEPTIBLE—Not resistant. A person or animal who may acquire an infection

or disease when exposed to a specific agent, because his or her resistance to the

agent is lacking or reduced.

SUSPECT—A person who may have acquired a communicable disease; it is

indicated by the medical history and clinical presentation.

SUSPENSION—A coarse dispersion of finely divided insoluble material

suspended in a liquid medium.

SYNCOPE—Faintness or actual fainting.

SYNERGIST—A medicine that aids or cooperates with another.

SYRUP—Concentrated aqueous solutions of sucrose, containing flavoring or

medicinal substances.

TACHYCARDlA—Excessively rapid heart beat, usually over 100.

TAENIAFUGE—Adrug that expels tapeworms without necessarily killing them.

TENDON—A fibrous cord by which a muscle is attached to the skeleton.

THORACIC—Pertaining to or affecting the chest.

THROMBUS—A plug or clot in a blood vessel or in one of the cavities of the heart,

formed by coagulation of the blood. It remains where it was formed.

TINCTURE—Usually an alcoholic solution of animal or vegetable drugs.

TINNITUS—Ringing in the ears.

TOXEMIA—Poisonous products in the blood.

TOXICOLOGY—The science of poisons.

TOXINS—Poisons.

TRACHEOSTOMY—Surgically creating an opening into the trachea.

TRIAGE—Sorting casualties to determine priority of treatment.

TRITURATION—A process of reducing a solid to a very fine powder by grinding

in a mortar and pestle.

URTICARIA—Hives or welts.

UREMIA—A condition resulting from waste products not being removed

efficiently by the kidneys so that they remain in the blood.

VASCULAR—Pertaining to blood vessels.

AV-11 .
VASOCONSTRICTOR—An agent that constricts the blood vessels.

VASODILATOR—An agent that dilates the blood vessels.

VERMICIDE—A drug that expels worms without necessarily killing them.

VESICANT—A blistering drug or agent.

VESICATION—The process of blistering.

VESICLE—A small blister.

VIRULENCE—The degree of pathogenicity of a microorganism or its ability to

invade the tissues of the host.

WATERS—Aqueous solutions of volatile substances.

.

AV-12 .
APPENDIX VI

TRADEMARK COMPANIES

AVI-1

ACE® Becton Dickinson and Company

Achromycin® Lederle Labs

Actifed® Warner-Lambert Co.

Adrenalin Chloride® Parke-Davis

Afrin® Schering-Plough

Aftate® Schering-Plough

All-Bran® Kellogg’s®, a registered trademark of Kellogg Company

Amoxil® SmithKline Beecham

Amphojel® Wyeth-Ayerst

Anaprox® Roche Laboratories

Ancef® SmithKline Beecham

Antiminth® Pfizer

Antivert® Pfizer

Aralen® Sanofi

Atarax® Pfizer

Bactrim® Roche Laboratories

Benadryl® Warner-Lambert Co.

Betadine® Purdue Frederick

Betapen-VK® Mead Johnson

Bicillin® Wyeth-Ayerst

Bleph-10® Allergan

Bonine® Pfizer

Bran Buds® Kellogg’s®, a registered trademark of Kellogg Company

Bran Flakes® Post®, a registered trademark of Kraft Foods Inc.

Cardizem® Hoechst Marion Roussel

The following is a list of trademarks used in this manual.
AVI-2

Ceftin® Glaxo Wellcome

Chlor-Trimeton® Schering-Plough

CIDEX® Johnson & Johnson Medical, Inc.

Claforan® Hoechst Marion Roussel

Cleocin® Pharmacia & Upjohn

Colace® Roberts

Compazine® SmithKline Beecham

Coumadin® DuPont

Darvon® Teva Pharmaceuticals USA

Demerol HCl® Sanofi

Desenex® Novartis

Desoxyn® Abbott Pharmaceutical

Dexedrine® SmithKline Beecham

Diamox® Lederle Labs

Dilantin® Parke-Davis

Dispenstir® Hynson, Westcott, and Dunning, Inc.

Domeboro® Bayer Corporation

Dramamine® Pharmacia & Upjohn

Dulcolax® Novartis Consumer

Dyazide® SmithKline Beecham

Dynapen® Bristol-Myers Squibb

Dyrenium® SmithKline Beecham

E-Mycin® Knoll Labs

Ecotrin® SmithKline Beecham

Elavil® Zeneca

Elimite® Herbert Pharma

Entex®LA Proctor & Gamble Pharmaceuticals

Equanil® Wyeth-Ayerst

Ergotrate® Maleate Lilly

Eryc® Warner Chilcott Professional Products

Esidrix® Ciba-Geigy Pharmaceutical
AVI-3

Eskalith® SmithKline Beecham

Eurax® Westwood-Squibb

Ex-Lax® Novartis Consumer

Fansidar® Roche Laboratories

Feldene® Pfizer

Flagyl® Searle

Flexeril® Merck

Fluothane® Wyeth-Ayerst

Fulvicin® Schering

Gantrisin® Roche Laboratories

Gentamycin® Boehringer Ingelheim

Gris-PEG® Allergan

Haldol® Ortho-McNeil Pharmaceutical

HydroDIURIL® Merck

Hygroton® Rhone-Poulenc Rorer

Ilotycin® Dista

Indocin® Merck

Innovar® Janssen

Isoptin® Knoll Labs

Isordil® Wyeth-Ayerst

Kaopectate® Pharmacia & Upjohn

Keflex® Dista

Kefzol® Lilly

Ketalar® Parke-Davis

Lanoxin® Glaxo Wellcome

Lasix® Hoechst Marion Roussel

Librium® Roche Products

Lithonate® Solvay

Lomotil® Searle

Lotrimin® Schering-Plough

Luminal® Bayer Corporation
AVI-4

Maalox® Novartis Consumer

Maxzide® Bertek

Medicut® American Diagnostic Corporation

Mefoxin® Merck

Mellaril® Novartis Pharmaceuticals

Metamucil® Proctor & Gamble

Micatin® McNeil Consumer Products

Minocin® Lederle Labs

Mintezol® Merck

Monistat® Ortho Dermatalogical

Monosticon DRI-DOT® Organon Teknika Corporation

Motrin® McNeil Consumer

Multistix® Ames Company, a division of Miles Laboratories, Inc.

Mycelex® Bayer

Mycifradin® Sulfate Pharmacia & Upjohn

Mycostatin® Westwood-Squibb

Mylanta® Johnson & Johnson-Merck

Nebcin® Lilly

Nembutal® Abbott

Neo-Synephrine® Sanofi

Nitro-Bid® Hoechst Marion Roussel

Nitrostat® Parke-Davis

Norgesic® 3M

Novocain® Sanofi Winthrop Pharmaceuticals

Nupercainal® Ciba-Geigy

One Step II Wright-Giemsa

Stain Solution®

Criterion Sciences, a division of Cornwell Corporation

Ophthaine® Bristol-Myers Squibb

Ophthetic® Allergan

Oretic® Abbott

Parafon Forte DSC® Ortho-McNeil Pharmaceutical
AVI-5

PCE Dispertab® Abbott

Pen-Vee K® Wyeth-Ayerst

Persantine® Boehringer Ingelheim

pHisoHex® Sanofi

Pitocin® Parke-Davis

Polycillin® Mead Johnson

Primaquine® Phosphate Sanofi Winthrop Pharmaceuticals

Procan SR® Parke-Davis

Pronestyl® Bristol-Myers Squibb Company

Prozac® Dista

Pyridium® Parke-Davis Pharmaceuticals, a division of Warner-Lambert Co.

Restoril® Novartis

Rifampin® Hoechst Marion Roussel

Ritalin® Novartis

Robaxin® Robins

Robitussin DM®

Robitussin AC®

Whitehall-Robins Healthcare, a division of American Home

Products Corporation

Sani-Supp® Sandoz

Seconal® Lilly

Septra® Glaxo Wellcome

Shredded Wheat® Post®, a registered trademark of Kraft Food Inc.

Silvadene Cream® Hoechst Marion Roussel

Sodium Sulamyd® E. Fougera & Co., a division of Altana Inc.

Sorbitate® Zeneca

Sudafed® Warner-Lambert Co.

Sumycin® Apothecon

Surfak® Hoechst-Roussel

Sus-Phrine® Forest

Tagamet® SmithKline Beecham

Talwin® Sanofi Winthrop Pharmaceuticals

Thorazine® SmithKline Beecham
AVI-6

Tinactin® Schering-Plough

Tolectin® Ortho-McNeil Pharmaceutical

Trobicin® Pharmacia & Upjohn

Tylenol® McNeil Consumer

Unopette® Microcollection

System

Becton-Dickinson, a division of Becton, Dickinson and Company

V-Cillin K® Eli Lilly

Valium® Roche Products

Vancocin® Lilly

Vermox® Janssen

Vibramycin® Pfizer

Visine Eye Drops® Pfizer

Vistaril® Pfizer

Virtual Naval Hospitalä A trademark of The University of Iowa

Wycillin® Wyeth-Ayerst

Xylocaine® Astra

Zantac® Glaxo Wellcome

Zinacef® Glaxo Wellcome
REFERENCES

NOTE: Although the following references were current when this NRTC was

published, their continued currency cannot be assured. Therefore, you need to be

sure that you are studying the latest revision.

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1991.

Bates, Barbara J., et al, A Guide to Physical Examination and History Taking, 6th ed.,

J.B. Lippincott, Philadelphia, 1995.

Brown, Barbara A., Hematology: Principles and Procedures, 6th ed., Lea &

Febiger, Philadelphia, PA, 1993.

Browner, Bruce D., Lenworth M. Jacobs, and Andrew N. Pollack, Emergency Care

and Transportation of the Sick and Injured, 7th ed., Jones & Bartlett Publishers,

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Surgery, Washington, DC, December 1996.

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Providers, American Heart Association, Dallas, TX, 1994.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

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Command, Washington, DC, October 1988.

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Views and Intrusions Performed by Military Personnel, BUMEDINST

6120.20B, Chief, Bureau of Medicine and Surgery, Washington, DC, 1982.

Damage Controlman 3&2, NAVEDTRA 10572, Naval Education and Training

Professional Development and Technology Center, Pensacola, FL, May 1986.

Decedent Affairs Manual, NAVMEDCOMINST 5360.1, Commander, Naval

Medical Command, Washington, DC, September 1987.

Dental Infection Control Program, BUMEDINST 6600.10A, Chief, Bureau of

Medicine and Surgery, Washington, DC, August 1992.

AVII-1
Dental Technician Training Manual, Vol. 1, NAVEDTRA 12572, Naval Education

and Training Professional Development and Technology Center, Pensacola, FL,

October 1999.

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and Training Professional Development and Technology Center, Pensacola, FL,

October 1999.

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(AVIP), SECNAVINST 6230.4, Secretary of the Navy, Washington, DC, April

1998.

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Identification Codes (SSIC), SECNAVINST 5210.11D, Secretary of the Navy,

Washington, DC, October 1987.

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1999.

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Secretary of the Navy, Washington, DC, July 1992.

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Philadelphia, PA, 1988.

Drug and Alcohol Abuse Prevention and Control, OPNAVINST 5350.4C, Chief of

Naval Operations, Washington, DC, April 2000.

Drug Facts and Comparisons, 1996 edition, J. B. Lippincott, Philadelphia, PA,

1996.

Ellenhorn, Matthew J., Ellenhorn’s Medical Toxicology : Diagnosis and Treatment

of Human Poisoning, Lippincott,Williams &Wilkins, Philadelphia, PA, 1997.

Emergency War Surgery NATO Handbook, NAVMED P-5059, United States

Department of Defense, Washington, DC, 1988.

Family Advocacy Program, BUMEDINST 6320.70, Chief, Bureau of Medicine and

Surgery, Washington, DC, June 1999.

Family Advocacy Program, SECNAVINST 1752.3A, Secretary of the Navy,

Washington, DC, July 1996.

First Aid for Soldiers, App. A, FM21-11, Headquarters, Department of the Army,

Washington, DC, 1988.

Forms and Reports Management Program, BUMEDINST 5210.9, Chief, Bureau of

Medicine and Surgery, Washington, DC, August 1991.

Gennaro, Alfonso R., ed., Remington: The Science and Practice of Pharmacy, 19th

ed., Mack Publishing Company, Easton, PA, 1995.

Goldfrank, Lewis R., Neal E. Flomenbaum, and Neal A. Lewin, Goldfrank’s

Toxicologic Emergencies, McGraw-Hill Professional Publishing, New York,

NY, 1998.

AVII-2
Goodman, Louis S., Lee E. Limbird, and Joel G. Hardman, Goodman & Gilman’s

The Pharmacological Basis of Therapeutics, 9th ed., McGraw-Hill, New York,

NY, 1996.

Graff, Sister Laurine, A Handbook of Routine Urinalysis, J. P. Lippincott, Co.,

Philadelphia, PA, 1983.

Gray’s Anatomy, 37th ed., Churchill Livingston, Inc., New York, NY, 1989.

Guidelines for Controlled Substances Inventory, NAVMEDCOMINST 6710.9,

Commander, Naval Medical Command, Washington, DC, May 1986.

Guthrie, Helen A., Introductory Nutrition, 7th ed., Times Mirror/Mosby College

Publishing, St. Louis, MO, 1989.

Health Care Relations Program, BUMEDINST 6300.10, Chief, Bureau of

Medicine and Surgery, Washington, DC, July 1996.

Henry, John B., Clinical Diagnosis and Management by Laboratory Methods, 18th

ed., W. B. Saunders Company, Philadelphia, PA, 1991.

http://hazmat.dot.gov/gydebook.htm

http://www.tricare.osd.mil

http://www.vnh.org

Immunizations and Chemoprophylaxis, BUMEDINST 6230.15, Chief, Bureau of

Medicine and Surgery, Washington, DC, November 1995.

Informed Consent for Medical and Dental Treatment, NAVMEDCOMINST 6320.16,

Commander, Naval Medical Command, Washington, DC, August 1988.

Inhalants—The Silent Epidemic, National Inhalant Prevention Coalition, Austin,

TX, 1999.

Isselbacher, Kurt J., Eugene Braunwald, Jean D.Wilson, Joseph B. Martin, Anthony

S. Fauci, and Dennis L. Kasper, eds., Harrison’s Principles of Internal

Medicine, 13th ed., vols. 1 & 2, McGraw-Hill, Inc., New York, NY, 1994.

Kerschner, Velma L., Nutrition and Diet Therapy, 3rd ed., F. A. Davis Company,

Philadelphia, PA, 1991.

Kubler-Ross, Elisabeth, M.D., On Death and Dying: What the Dying Have to Teach

Doctors, Nurses, Clergy, and Their Own Families, Collier Books, New York,

NY, 1969.

Leiken, Jerrold B., and Frank P. Paloucek, Poisoning and Toxicology Compendium,

Lexi Comp, Hudson, OH, 1997.

M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live), Merck & Co., Inc.,

West Point, PA, 1999. [Product insert.]

Management of Alleged or Suspected Sexual Assault and Rape Cases,

NAVMEDCOMINST 6310.3, Commander, Naval Medical Command,

Washington, DC, April 1989.

Management of Infectious Waste, BUMEDINST 6280.1A, Chief, Bureau of

Medicine and Surgery, Washington, DC, June 1994.

Manual for Courts-Martial, Part 3, “Military Rule of Evidence 315, Military

Cause/Search and Seizure”; and “Military Rule of Evidence 312, Body Views

and Intrusions,” United States Army Publishing Company, 1998.

AVII-3
Manual of Clinical Dietetics, 5th ed., The American Dietetic Association, 1996.

Manual of Naval Preventive Medicine, NAVMED P-5010, Chief, Bureau of

Medicine and Surgery, Washington, DC, August 1999.

Manual of the Judge Advocate General, chap. 2, “Delivery of Patient UnderWarrant

of Arrest,” and “Line of Duty Misconduct,” JAGINST 5800.7A, Department of

the Navy Judge Advocate General, Alexandria, VA, October 1990.

Manual of the Medical Department, NAVMED P-117, Chief, Bureau of Medicine

and Surgery, Washington, DC, January 2000.

Marine Corps Warfighting Publication (MCWP) 4-11.1, Health Services Support

Operations, chapter 3, Commandant, U.S. Marine Corps, Washington, DC,

March 1998.

Medical and Dental Care for Eligible Persons at Navy Medical Department

Facilities, NAVMEDCOMINST 6320.3B, Commander, Naval Medical

Command, Washington, DC, May 1987.

Medical Augmentation Program (MAP), BUMEDINST 6440.5B, Chief, Bureau of

Medicine and Surgery, Washington, DC, February 2000.

Medical, Dental, and Educational Suitability Screening and Exceptional Family

Member Program (EFMP) Enrollment, BUMEDINST 1300.2, Chief, Bureau

of Medicine and Surgery, Washington, DC, 2000.

Medical Support in Joint Operations, NAVMED P-5047, Chief, Bureau of

Medicine and Surgery, Washington, DC, 1972.

Meeker, Margaret H., and Jane C. Rothrock, Alexander’s Care of the Patient in

Surgery, 10th ed., Mosby—Year Book, Inc., St. Louis, MO, 1995.

Military Requirements for Petty Officer Third Class, NAVEDTRA 12024, Naval

Education and Training Professional Development and Technology Center,

Pensacola, FL, 1999.

Military Substance Abuse Prevention and Control, SECNAVINST 5300.28C,

Secretary of the Navy, Washington, DC, March 1999.

MILSTRIP/MILSTRAP Desk Guide, NAVSUP P-409, Commander, Naval Supply

Systems Command, Mechanicsburg, PA, June 1998.

Mobile Medical Augmentation Readiness Team (MMART) Manual, BUMEDINST

6440.6, Chief, Bureau of Medicine and Surgery, Washington, DC, May 1993.

Mobile Medical Augmentation Readiness Team (MMART) Program, OPNAVINST

6440.1B, Chief of Naval Operations, Washington, DC, August 1991.

Monosticon DRI-DOT, Organon Teknika Corp., Durham, NC, 1986. [Product

brochure.]

Morphia Dosage and Casualty Marking, BUMEDINST 6570.2, Chief, Bureau of

Medicine and Surgery, Washington, DC, November 1994.

NATO Handbook on the Medical Aspects of NBC Defensive Operations, NAVMED

P-5059.

Naval Ships’ Technical Manuals, Commander, Naval Sea Systems Command,

Arlington, VA.

Naval Supply Systems Command (NAVSUP) Manual, vols. 2 & 5, Commander,

Naval Supply Systems Command, Mechanicsburg, PA, 1990.

AVII-4
Naval Warfare Publication: Deployable Health Service Support Platforms (NWP

4-02.4), Part A, Fleet Hospitals, Navy Tactical Support Activity, Washington,

DC, August 1996.

Navy and Marine Corps Records Disposition Manual, SECNAVINST 5212.5D,

Secretary of the Navy, Washington, DC, April 1998.

Navy Customer Service Manual, NAVEDTRA 12972, Naval Education and

Training Professional Development and Technology Center, Pensacola, FL,

1993.

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5100.23E, Chief of Naval Operations, Washington, DC, January 1999.

Nosocomial Infection Control Program, BUMEDINST 6220.9A, Chief, Bureau of

Medicine and Surgery, Washington, DC, September 1998.

O’Keefe, Michael F., ed., Brady Emergency Care, 8th ed., Prentice-Hall, Inc.,

Englewood Cliffs, NJ, 1998.

Occupational Noise Control and Hearing Conservation, NAVMEDCOMINST

6260.5, Commander, Naval Medical Command,Washington, DC, April 1984.

Olson, Kent R., Poisoning and Drug Overdose, 3rd ed., McGraw-Hill Professional

Publishing, New York, NY, 1999.

One Step II Wright-Giesma Stain Solution, Criterion Sciences, division of Cornwell

Corp., Riverdale, NJ, 1997. [Product brochure.]

Patient’s Bill of Rights and Responsibilities, enclosure (5) to Health Care Relations

Program, BUMEDINST 6300.10, Chief, Bureau of Medicine and Surgery,

Washington, DC, July 1996.[9 Jul 96]

Physical Readiness Program, OPNAVINST 6110.1F, Chief of Naval Operations,

Washington, DC, May 2000.

Physicians’Desk Reference, 53rd ed., Medical Economics Co., Montvale, NJ, 1999.

Poliovirus Vaccine Inactivated—IPOL®, Connaught Laboratories, Inc.,

Swiftwater, PA, 1997. [Product insert.]

Procedures for Administering and Treating Prisoners and Awardees,

NAVMEDCOMINST 6320.11, Commander, Naval Medical Command,

Washington, DC, October 1984.

Provision of Standbys During Medical Examinations, BUMEDINST 6320.83,

Chief, Bureau of Medicine and Surgery, Washington, DC, November 1991.

Quality Assurance (QA) Program, BUMEDINST 6010.13, Chief, Bureau of

Medicine and Surgery, Washington, DC, August 1991.

Recommended Dietary Allowances, 10th ed., Subcommittee on the Tenth Edition of

the RDAs, Food and Nutrition Board, Commission on Life Sciences, National

Research Council, 1989.

Risk Management Program, BUMEDINST 6010.21, Chief, Bureau of Medicine

and Surgery, Washington, DC, October1996.

Sailing with TRICARE, for Sailors and Their Families, TRICARE, April 1999.

Schwartz, George R., ed. in chief, and C. Gene Cayten, Mary Anne Mangelsen,

Thom A. Mayer, and Barbara K. Hanke, eds., Principles and Practice of

AVII-5
Emergency Medicine, 3rd ed., vols. 1 & 2, Lea & Febiger, Philadelphia, PA,

1992.

Seiverd, Charles E., Hematology for Medical Technologists, 5th ed., Lea & Febiger,

Philadelphia, PA, 1983.

Sexual Assault Prevention and Response, SECNAVINST 1752.4, Secretary of the

Navy, Washington, DC, September 1995.

Sexual Assault Victim Intervention (SAVI) Program, OPNAVINST 1752.1A, Chief

of Naval Operations, Washington, DC, December 1993.

Shipboard Medical Procedures Manual, COMNAVSURFLANTINST 6000.1H,

Commander, Naval Surface Force, U.S. Atlantic Fleet, Norfolk, VA, February

1997.

Standard First Aid Course, NAVEDTRA 13119, Chief, Bureau of Medicine and

Surgery, Washington, DC.

Stoklosa, Mitchell J., and Howard C. Ansel, Pharmaceutical Calculations, 10th ed.,

Lea & Febiger, Media, PA, 1996.

The Merck Manual, 16th ed., Merck & Co., Inc., Rahway, NJ, 1992.

The Navy SEAL Nutrition Guide, Department of Military and Emergency Medicine,

Uniformed Services University of Health Sciences, F. Edward Hébert School of

Medicine, 1994.

Tilton, Richard C., Albert Balows, David C. Hohnadel, and Robert F. Reiss, eds.,

Clinical Laboratory Medicine, Mosby—Year Book, Inc., St. Louis, MO, 1992.

Timby, Barbara K., Fundamental Skills and Concepts in Patient Care, 6th ed.,

Lippincott-Raven Publishers, Philadelphia, PA, 1996.

Tobacco Use in Naval Medical Department Activities, BUMEDINST 6200.12,

Chief, Bureau of Medicine and Surgery, Washington, DC, June 1990.

Treatment of Chemical Agent Casualties and Conventional Military Chemical

Injuries, NAVMED P-5041.

Turgeon, Mary Louise, Immunology and Serology in Laboratory Practice, 2nd ed.,

Mosby—Year Book, Inc., St. Louis, MO, 1996.

Typhoid Vi Polysaccharide Vaccine, Connaught Laboratories, Inc., Swiftwater, PA,

1995. [Product insert.]

Unopette Microcollection System, Becton-Dickinson, division of Becton,

Dickinson and Co., Rutherford, NJ, 1991. [Product brochure.]

Victim and Witness Assistance Program, SECNAVINST 5800.11A, Secretary of the

Navy, Washington, DC, June 1995.

AVII-6
INDEX

A

Administration, 14-1

Anatomy, 1-1

Appropriations and operating budgets, 13-2

operating budgets, 13-3

types of appropriations, 13-2

Assignment of responsibilities for decedent affairs,

16-1

At-sea disposition, 16-8

ceremony records, 16-8

putrefied remains, 16-8

Autopsy, 16-4

aircrew autopsy, 16-4

nonmilitary and retired personnel autopsy, 16-4

requesting permission for autopsy, 16-4

B

Bacteriology, 7-25

bacteria classification, 7-25

bacteriologic methods, 7-27

common bacteria, 7-26

Basic life support, 4-11

breathing, 4-16

circulation, 4-18

upper airway obstruction, 4-11

Biological warfare, 8-10

decontamination, 8-12

dispersal, 8-10

history, 8-10

protection, 8-11

Blood collection, 7-3

finger puncture, 7-3

standard precautions, 7-3

venipuncture (vacutainer method), 7-5

Blood count, complete, 7-10

counting blood cells, 7-10

differential white blood cell count, 7-19

hematocrit (packed cell volume) determination,

7-16

hemoglobin determination, 7-14

total red blood cell count, 7-10

total white blood cell count, 7-16

Breathing aids, 4-25

artificial airways, 4-26

bag-valve mask ventilator, 4-26

cricothyroidotomy, 4-28

Breathing aids—Continued

pocket face mask, 4-27

suction devices, 4-28

use of oxygen (02), 4-25

C

CBR warfare, medical aspects of, 8-1

Cell, 1-2

Characteristics of living matter, 1-2

Chemical, biological, and radiological warfare,

medical aspects of, 8-1

Chemical warfare, 8-1

chemical agents, 8-5

decontamination, 8-4

dispersal, 8-1

history, 8-1

self-protection and treatment, 8-1

Circulatory system, 1-24

blood, 1-24

blood vessels, 1-28

heart, 1-25

Civil certificates of death, 16-11

death certificates for shipment of remains, 16-12

deaths occurring in CONUS, 16-11

deaths occurring outside CONUS, 16-11

Clinical laboratory, 7-1

Closing health records, 12-24

desertion, 12-25

disability separation or retirement, 12-25

missing or missing-in-action members, 12-24

retirement, 12-25

Command Medical Readiness Plan, 14-8

medical augmentation program (MAP), 14-9

mobile medical augmentation readiness team

(MMART), 14-9

Common medical emergencies, 4-66

anaphylactic reaction, 4-67

cerebrovascular accident, 4-67

complications in childbirth, 4-71

convulsions, 4-69

dermatologic emergencies, 4-70

diabetic conditions, 4-66

drowning, 4-69

emergency childbirth, 4-70

heart conditions, 4-68

poisons/drug abuse/hazardous materials, 4-68

psychiatric emergencies, 4-69

syncope, 4-66

INDEX-1
Communication skills, 2-7

communication process, 2-7

patient contact point, 2-8

therapeutic communication, 2-9

Completing required forms, 11-5

Report of Medical Examination, SF88, 11-5

Report of Medical History, SF93, 11-5

Special Duty Medical Abstract, NAVMED 6150/2,

11-10

Consignment and transportation of remains, 16-8

authorized methods of transportation within the

United States, 16-8

authorized transportation to or from CONUS, 16-9

consignment, 16-8

outside CONUS destinations, 16-9

transportation of cremated remains, 16-9

transportation of remains of contagious or

communicable disease victims, 16-9

Contingency supply blocks, 13-20

assembling the block, 13-21

managing the block, 13-21

Controlled substances, inventory for, 13-19

accountability, 13-20

bulk custodian, 13-20

financial liability investigation of property loss, DD

Form 200, 13-20

inventory board, 13-20

property surveys, 13-20

survey of controlled substance, 13-20

Controlled substances, regulations and

responsibilities, 6-24

accountability, 6-24

controlled substance schedules, 6-25

dangerous drugs, 6-25

inventory of controlled substances, 6-26

responsibility, 6-24

security and custody of controlled substances, 6-25

survey of controlled substances, 6-26

Cremation, 16-8

D

Decedent Affairs eligibility, 16-2

Decedent Affairs Programs, 16-1

Casualty Assistance Calls Program, 16-2

Concurrent Return Program, 16-1

Current Death Program, 16-1

Graves Registration Program, 16-1

Reporting Expenses, 16-3

Return Of Remains Program, l6-2

Dental care, emergency, 10-1

Diet and nutrition, 9-1

Diet therapy, 9-7

objectives of diet therapy, 9-7

types of diets, 9-7

Digestive system, 1-49

accessory organs of digestion, 1-52

alimentary canal, 1-49

Directives issuance system, 14-2

correspondence, 14-3

disposition of records, 14-6

electronic mail, 14-4

electronic records, 14-6

facsimile transmission service, 14-4

filing, 14-4

maintaining directives, 14-3

messages, 14-4

tickler files, 14-6

types and purposes of directives, 14-2

Disposition of personal effects, 16-10

Dressings and bandages, 3-1

battle dressing, 3-12

definition of a bandage, 3-3

definition of a dressing, 3-1

Drug abuse, 5-15

alcohol intoxication, 5-16

barbiturate intoxication, 5-19

cannabis intoxication, 5-20

hallucinogen intoxication, 5-20

handling drug-intoxicated persons, 5-21

inhalant intoxication, 5-20

narcotic intoxication, 5-16

nonbarbiturate sedative-hypnotic intoxication,

5-19

stimulant intoxication, 5-19

Drug and Alcohol Abuse Prevention and Control

Program, 15-4

control, 15-5

prevention, 15-5

E

Eligibility for Decedent Affairs, 16-2

Emergency dental care, 10-1

dental anatomy and histology, 10-1

dental record, 10-3

oral examination, 10-2

Emergency medical care procedures, 4-1

Endocrine system, 1-41

adrenal glands, 1-43

gonads (testes and ovaries), 1-44

hypothalamus, 1-41

pancreas, 1-43

parathyroid glands, 1-43

INDEX-2
Endocrine system—Continued

pituitary gland, 1-42

thyroid gland, 1-42

Environmental hygiene, 2-28

aesthetics, 2-28

concurrent and terminal cleaning, 2-28

climate control, 2-28

lighting, 2-28

Environmental injuries, 4-56

chemical burns, 4-58

cold exposure injuries, 4-62

electrical burns, 4-58

heat exposure injuries, 4-60

sunburn, 4-58

thermal burns, 4-56

white phosphorus burns, 4-59

Escorts, 16-10

duties of the escort, 16-10

inside CONUS escorts, 16-10

outside CONUS escorts, 16-10

selection of escorts, 16-10

special escorts, 16-10

F

Family Advocacy Program, 15-4

Federal Supply Catalog system, 13-4

cognizance symbols, 13-5

Federal Supply Catalog, medical material section,

13-5

Federal supply classification system, 13-4

local item control numbers, 13-5

national stock numbers, 13-5

Navy item control numbers, 13-5

terminology, 13-4

Female reproductive system, 1-59

external accessory organs, 1-62

female reproductive cycle, 1-63

internal accessory organs, 1-61

ovaries, 1-60

Filing health records, 12-5

First aid equipment and supplies, 3-1

First aid rules, general, 4-1

Fleet marine force (FMF) and fleet hospitals, support

to, 14-6

fleet hospitals, 14-7

FMF dental support, 14-7

FMF medical support, 14-6

Food classification, 9-1

carbohydrates, 9-2

fats, 9-2

minerals, 9-3

Food classification—Continued

proteins, 9-1

vitamins, 9-3

vitamin and mineral supplements, 9-5

water, 9-5

Fundamentals of patient care, 2-1

Fungus test, 7-32

G

General first aid rules, 4-1

Group interments, 16-15

Guide to good eating, 9-6

dietary guidelines, 9-6

Food Guide Pyramid, 9-6

H

Hazardous material exposure, 5-22

determining the nature of the hazardous material,

5-22

rescue and patient care procedures, 5-24

safety guidelines, 5-22

Health and illness, 2-1

Healthcare administration, 15-1

Health records, 12-1

closing, 12-24

filing, 12-5

opening, 12-6

verifying, 12-24

Health record forms, 12-9

Abstract of Service and Medical History

(NAVMED 6150/4), 12-20

adjunct health record forms and reports, 12-22

Chronological Record of Medical Care, SF 600,

12-3

Immunization Record (SF 601), 12-17

Inte rnational Ce rti ficates o f Vaccination

(PHS-731), 12-20

Record of Occupational Exposure to Ionizing

Radiation (DD Form 1141), 12-21

Summary of Care, NAVMED 6150/20, 12-11

Hospital Corpsman and the clinical laboratory, 7-1

administrative procedures and responsibilities, 7-1

ethics and good practices in the laboratory, 7- 3

I

Inpatient care, 2-11

medical patient, 2-11

INDEX-3
Inpatient care—Continued

orthopedic patient, 2-19

surgical patient, 2-15

terminally ill patient, 2-23

Integumentary system, 1-22

skin function, 1-22

skin structure, 1-22

Interpersonal relations, 2-5

age, 2-6

culture, 2-5

gender, 2-6

race, 2-5

religion, 2-6

Inventory, 13-15

definitions, 13-15

procedures, 13-16

reconciliation of count documents and stock

records, 13-16

types of inventories, 13-15

J

Joints, 1-15

classifications, 1-15

joint movements, types of, 1-16

Joint medical operational plan, 14-10

medical estimate, 14-10

planning factors, 14-10

L

Legal implications in medical care, 15-8

child and spouse abuse and neglect, 15-13

consent requirements for medical treatment, 15-8

delivery of a patient under warrant of arrest, 15-11

incident reports, 15-9

medical conditions and law enforcement personnel,

15-11

prisoner patients, 15-12

release of medical information, 15-10

sexual assault and rape, 15-12

Living matter, characteristics, 1-2

Lymphatic system, 1-31

lymph nodes, 1-32

pathways of the lymphatic system, 1-31

M

Male reproductive system, 1-57

external accessory organs, 1-59

internal accessory organs, 1-58

testes, 1-58

Management of infectious waste, 2-37

infectious waste, 2-38

treatment and disposal methods for, 2-38

Medical conditions and law enforcement personnel,

15-11

child and spouse abuse and neglect, 15-13

delivery of patient under warrant of arrest,

15-11

prisoner patients, 15-12

sexual assault and rape, 15-12

Medical emergencies, common, 4-66

Medical record, 12-2

cross-servicing health records, 12-3

dealing with lost, destroyed, or illegible heath

records, 12-3

disposing of health records during hospitalization,

12-3

health record custody, 12-2

primary and secondary, 12-1

security and safekeeping of, 12-4

Microscope,7-7

care of the microscope, 7-9

focusing system, 7-8

focusing the microscope, 7-9

framework, 7-7

illumination system, 7-8

magnification system, 7-8

MILSTRIP requisition, preparing,13-12

Morphine use for pain relief, 4-65

casualty marking, 4-66

morphine administration, 4-65

Muscles, 1-17

contraction, 1-18

contraction and recovery, 1-18

extensibility and elasticity, 1-18

fatigue, 1-18

maintenance of muscle tissue, 1-18

major skeletal, 1-19

stimulus for contraction, 1-18

tissues, 1-19

tonicity, 1-18

N

National cemeteries, 16-14

eligibility for interment, 16-14

honors, 16-14

national cemetery classifications, 16-14

scheduling, 16-15

vaults, 16-14

viewing remains, 16-15

Naval plots and cemeteries, 16-15

INDEX-4
NAVSUP Manuals, Publications, and Directives, 13-1

Afloat Supply Procedures, NAVSUP P-485, 13-2

alternative titles for NAVSUP publications, 13-1

changes to publications, 13-1

MILSTRIP/MILSTRAP Desk Guide, NAVSUP

P-409, 13-2

Naval Supply Systems Command (NAVSUP)

Manual, 13-1

Navy Medical and Dental Material Bulletin, 13-2

Operating Procedures Manual, 13-1

Navy medicine’s Quality Assurance Program, 15-3

Nervous system, 1-36

autonomic nervous system, 1-40

central nervous system, 1-37

impulse transmission, 1-37

nerves, 1-37

neuron, 1-36

peripheral nervous system, 1-39

Notification of death, 16-2

method of reporting casualties, 16-3

personnel casualty report, 16-3

Notification of next of kin, 16-3

condolence letter, 16-4

confirmation of the casualty, 16-4

O

Opening health records, 12-6

active duty enlisted personnel, 12-7

active duty officers, 12-6

preparing the health record jacket, 12-7

reservists, 12-7

sequence of health record forms, 12-9

Organs, 1-6

Orthopedic injuries, 4-45

management of bone injuries, 4-46

management of joint and muscle injuries, 4-54

splints, 4-45

P

Pathogenic organism control, 2-29

medical asepsis, 2-29

surgical aseptic technique, 2-30

Patient assessment in the field, 4-3

arrival at the scene, 4-3

before arrival at the scene, 4-3

primary survey, 4-4

secondary survey, 4-4

Patient care, fundamentals of, 2-1

Patient education, 2-9

Patient eligibility for hospitalization and nonfederal

care, 15-1

Defense Enrollment Eligibility Reporting System

(DEERS), 15-1

TRICARE, 15-3

Patient Relations and Command Patient Contact

Programs, 15-3

Patient safety, 2-24

environmental safety, 2-24

general safety, 2-27

Patient, the, 2-1

rights, 2-2

responsibilities, 2-2

Payments and Collections, 16-12

headstones and markers, 16-13

memorial service for nonrecoverable remains,

16-13

primary expenses, 16-12

secondary (interment) expenses, 16-12

transportation expenses, 16-12

Personal traits, 2-4

integrity, 2-4

leadership, 2-5

personal appearance, 2-5

Pharmacology, 6-1

drug classifications, 6-4

drug incompatibilities, contraindications, and

adverse effects, 6-18

drug standards, 6-1

medication administration, 6-1

Pharmacy, 6-10

alternatemethods for solving percentage problems, 6-14

conversion, 6-11

drug incompatibilities, contraindications, and

adverse affects, 6-18

metrology and calculation, 6-10

pharmaceutical instruments, 6-17

pharmaceutical preparations, 6-16

percentage calculations, 6-13

ratio and proportion calculations, 6-14

Physical exam testing procedures and equipment,

11-10

audiogram, 11-11

color vision testing, 11-11

electrocardiogram, 11-12

visual acuity, 11-10

Physical examinations, 11-1

Physical examinations, types of, 11-1

medical board examinations and reports, 11-4

routine physical examinations, 11-1

screening examinations, 11-3

special duty physical examinations, 11-3

surveillance examinations, 11-3

INDEX-5
Physical Readiness Program, 15-5

Physiology, 1-1

Poisoning, 5-1

absorbed poisons, 5-8

assessment and treatment of patient, 5-1

diagnosis of poisoning, 5-2

general treatment, 5-3

ingested poisons, 5-3

inhalation poisons, 5-7

injected poisons and envenomations, 5-9

Position and direction, terms, 1-1

Preparation and processing remains, 16-6

burial clothing, 16-7

caskets, 16-7

certificate of death (overseas), 16-7

clothing, 16-7

initial preparation, 16-7

inspection of remains, 16-7

overseas facilities, 16-7

placement of remains in casket or transfer case,

16-7

Preparing a MILSTRIP requisition, 13-12

material receipt, custody, and stowage, 13-12

other repair parts, 13-14

shelf-life material, 13-14

special stowage of items, 13-14

storerooms, 13-14

placement of remains in casket or transfer case,

16-7

Prescriptions, 6-20

authorized prescribers, 6-22

filing prescriptions, 6-24

filling prescriptions, 6-23

parts of the prescription, 6-20

Preventive medicine, 10-3

food-service sanitation, 10-4

habitability, 10-3

immunizations and communicable diseases, 10-4

sanitation, 10-3

vector and pest control, 10-3

wastewater treatment and disposal, 10-5

water supply, 10-5

Primary and secondary medical records, 12-1

primary, 12-1

secondary, 12-2

Procuring mortuary services, 16-6

annual contracts, 16-6

authorized services, 16-6

one-time contracts, 16-6

private arrangements, 16-6

Procurement, 13-6

BUMED-controlled items, 13-9

levels of supply, 13-7

Procurement—Continued

professional books and publications, 13-9

purchases, 13-9

requisitions, 13-7

Uniform Material Movement and Issue Priority

System (UMMIPS), 13-11

Professional ethics, 2-4

Professional practice, 2-3

accountability, 2-3

patient advice, 2-3

patient behavior, 2-3

professional limitations, 2-3

Programs, Decedent Affairs, 16-1

R

Radiological warfare, 8-12

decontamination, 8-16

effects on personnel, 8-14

exposure factors, 8-13

history, 8-13

protection and treatment, 8-15

Reimbursement procedures, 16-13

government services not utilized within CONUS,

16-13

government services not utilized outside CONUS,

16-13

government services utilized, 16-13

Releasing medical information, 12-4

releasing medical information for research, 12-5

guidelines for releasing medical information, 12-4

releasing medical information to federal and state

agencies, 12-5

Reporting expenses, 16-13

Reporting and assessment procedures, 2-10

reporting, 2-10

self-questioning techniques for, 2-11

Rescue and transportation, 3-12

protective equipment, 3-13

Rescue procedures, 3-14

moving the victim to safety, 3-17

transportation of the injured, 3-24

Respiratory system, 1-32

anatomy of the respiratory system, 1-33

process of respiration, 1-36

Reporting requirements, 14-1

appointment log, 14-2

binnacle list, 14- 2

immunization log, 14-2

medical department journal, 14-1

morning report of the sick, 14-2

reports to the officer of the deck or day (OOD), 14-1

INDEX-6
Reporting requirements—Continued

sick call treatment log, 14-2

training log, 14-2

water test log, 14-2

S

Search, recovery, and identification, 16-4

identification, 16-5

identification problems, 16-5

search and recovery, 16-5

Security and safekeeping of medical records, 12-4

Sensory system, 1-45

hearing, 1-47

sight, 1-45

smell, 1-45

taste, 1-45

touch, 1-48

Serology, 7-29

Monosticon DRI-DOT slide test, 7-31

rapid plasma reagin (RPR) card test, 7-29

Shock, 4-21

anaphylactic shock, 4-24

cardiogenic shock, 4-24

general treatment procedures, 4-24

hypovolemic shock, 4-23

neurogenic shock, 4-23

pneumatic counter-pressure devices (MAST), 4-25

septic shock, 4-24

symptoms of shock, 4-21

Skeletal system, 1-6

anatomy of bones, 1-6

bone classifications, 1-7

divisions of skeleton, 1-7

Soft tissue injuries, 4-29

classification of wounds, 4-29

management of internal soft-tissue injuries, 4-34

management of open soft-tissue injuries, 4-30

special considerations in wound treatment, 4-35

special wounds and their treatment, 4-36

Soft tissue injuries—Continued

wound closure, 4-41

Stock record cards, 13-17

description of NAVSUP 1114, 13-17

posting procedures, 13-19

preparing new cards, 13-19

Supply, 13-1

Surgical aseptic technique, 2-30

T

Tissues, 1-3

connective tissue, 1-4

epithelial tissue, 1-3

muscular tissue, 1-5

nerve tissue, 1-6

Toxicology, 6-10

Triage, 4-2

sorting for treatment (nontactical), 4-2

sorting for evacuation, 4-2

U

Urinalysis, 7-33

preservation of urine specimens, 7-34

routine urine examination, 7-34

urine specimens, 7-33

Urinary system, 1-53

kidneys, 1-53

ureters, 1-56

urethra, 1-57

urinary bladder, 1-56

V

Verifying health records, 12-24

INDEX-7

Assignment Questions

Information: The text pages that you are to study are

provided at the beginning of the assignment questions.

1

ASSIGNMENT 1

Textbook Assignment: “Anatomy and Physiology,” pages 1-1 to 1-48.

1-1. When the body is in the anatomical

position, the thumbs point

1. medially

2. laterally

3. anteriorly

4. posteriorly

1-2. A person lying on his/her back is in what

position?

1. Prone

2. Erect

3. Supine

4. Lateral recumbent

1-3. The physical and chemical breakdown of

the food we eat is called

1. digestion

2. metabolism

3. anabolism

4. catabolism

1-4. The transfer of fluids across the plasma

membrane of a cell from an area of lower

concentration to an area of higher

concentration is a process known as

1. infusion

2. diffusion

3. perfusion

4. osmosis

1-5. Homeostasis is defined as

1. control of bleeding

2. absorption, storage, and use of food

products

3. self-regulated control of the body’s

internal environment

4. the power of voluntary movement

1-6. That portion of a cell containing all the

genetic material important in the cell’s 

reproduction is called the

1. plasma membrane

2. nucleus

3. cytoplasm

4. reticulated endothelium

1-7. What type of tissue is known as the lining

tissue of the body?

1. Connective

2. Areolar

3. Sebaceous

4. Epithelial

1-8. The secretion of digestive fluids and the

absorption of digested foods and liquids is

the chief function of which tissue?

1. Columnar

2. Osseus

3. Sercus

4. Squamous
2

1-9. Because this tissue is continuous

throughout the body, if an infection were

allowed to spread, it could reach every area

of the body by moving through which of

the following tissues?

1. Areolar

2. Adipose

3. Osseous

4. Fibrous

1-10. Which of the following are the two most

prominent mineral elements of bone?

1. Ossein and calcium

2. Phosphorus and calcium

3. Sodium and phosphorus

4. Periosteum and ossein

1-11. The bones of the wrist are classified as

which of the following bones?

1. Long

2. Short

3. Flat

4. Irregular

1-12. Bones of the cranium include which of the

following?

1. Maxilla

2. Occipital

3. Atlas and axis

4. All of the above

1-13. The appendicular skeleton is composed of

the bones of the

1. skull and vertebral column

2. thorax and vertebral column

3. pelvis and thorax

4. upper and lower extremities

1-14. The upper three ribs on each side are

known as which of the following types of

ribs?

1. True

2. False

3. Floating

4. Sternal

1-15. The head of the humerus is called the

1. scapula

2. acetabulum

3. glenoid falsa

4. epicordyle

1-16. The innominate bone is composed of three

parts that are united in adults to form a

cuplike structure called the

1. glenoid fossa

2. acetabulum

3. symphysis pubis

4. obturator foramen

1-17. The prominences easily felt on the inner

and outer aspects of the ankle are called

1. medial and lateral malleolus

2. medial and lateral condyles

3. greater and lesser tuberosities

4. greater and lesser trochanters

1-18. Bones that develop within a tendon are

known as which of the following?

1. Condyloid

2. Sesamoid

3. Vermiform

4. Falsiform

1-19. Moving an extremity away from the body is

called

1. flexion

2. extension

3. abduction

4. adduction
3

1-20. The act of straightening a limb is known as

1. flexion

2. extension

3. abduction

4. adduction

1-21. The primary function of the muscles

includes all of the following EXCEPT

1. providing heat during activity

2. maintaining body posture

3. producing red blood cells

4. providing movement

1-22. The ability of muscles to regain their

original form when stretched is known as

1. contractiblity

2. elasticity

3. extensibility

4. tonicity

1-23. Actin and myosin are the two protein

substances involved in

1. muscle recovery

2. muscle nourishment

3. muscle contraction

4. rigor mortis

1-24. Which of the following properties describes

the ability of muscles to respond to a

stimulus?

1. Contractility

2. Irritability

3. Extensibility

4. Tonicity

1-25. If a generally sedentary person in less than

good physical condition enters a marathon

with intent to complete the race, which of

the following outcomes can he/she be

expected to encounter?

1. If the day is cool, there will be no

significant risk

2. Any physical deficiency can be

overcome with a carbohydrate-rich

diet before the race

3. If stretching exercises are performed

before the race, he/she will be ok

4. He/she runs the risk of muscle damage

1-26. Intramuscular injections are frequently

given in which of the following muscles?

1. Trapezius

2. Pectoralis majoris

3. Deltoid

4. All of the above

1-27. Intramuscular injections are usually given

in which of the following muscles?

1. Quadriceps

2. Sartorius

3. Gastrocnemius

4. Gluteus maximus

1-28. The body’s primary thermo-regulatory

action is a function of dilating and

contracting blood vessels and the

1. stratum germinativum

2. sweat glands

3. sebaceous glands

4. melanin

1-29. The total blood volume in the average adult

is in what ranges?

1. 3 to 4 liters

2. 4 to 5 liters

3. 5 to 6 liters

4. 6 to 7 liters
4

1-30. A decreased red blood cell (RBC) count

could be the result of a medical condition

affecting the

1. compact bone

2. periosteum

3. yellow marrow

4. red marrow

1-31. Blood of the average female adult contains

(a) how many million RBCs per (b) what

unit? 

1. (a) 4.5 (b) mm3

2. (a) 6.0 (b) cm3

3. (a) 4.5 (b) 1

4. (a) 4.5 (b) low power field

1-32. A white blood cell (WBC) count of 18,000

may indicate what condition?

1. Leukocytosis

2. Normalcy

3. Infection

4. Vetiligo

1-33. In an accident victim suffering from a

fibrinogen deficiency, the rescuer may have

difficulty performing which of the actions

listed below?

1. Controlling hemorrhage

2. Immobilizing a fracture

3. Supporting respiratory function

4. Reducing a dislocation

1-34. In addition to preventing excessive blood

loss, the formation of a blood clot serves

which, if any, of the following purposes?

1. To convert fibrinogen into blood

serum to aid healing

2. To form the foundation for new tissue

growth

3. To manufacture leukocytes

4. None of the above

1-35. The valves of the heart include all of the

following EXCEPT

1. atrial

2. mitral

3. tricuspid

4. pulmonary

1-36. Oxygenated blood is carried by which of

the following vein(s)?

1. Inferior vena cava

2. Superior vena cava

3. Portal

4. Pulmonary

1-37. The contraction phase of the heart is

1. systole

2. tension

3. diastole

4. active

1-38. The pulse pressure is the difference

between which of the following

measurements?

1. Venous and arterial pressure

2. Resting and active pulse rate

3. Arterial and ventricular pressure

4. Systole and diastole

1-39. The venous system that carries digested

materials from the intestinal tract is called

the

1. portal

2. pulmonary

3. abdominal

4. pelvic

1-40. Lymph nodes participate in all of the

following functions EXCEPT

1. manufacture of white blood cells

2. filtration of bacterial debris

3. production of hormones

4. collection of large protein molecules
5

1-41. Windpipe is another term for

1. nares

2. larynx

3. trachea

4. pharynx

1-42. The primary muscle of respiration is known

as the

1. pleura

2. alveolus

3. diaphragm

4. mediastinum

1-43. Of the following nerves, which, if any,

controls the larynx during the process of

breathing?

1. Phrenic

2. Intercostal

3. Vagus

4. None of the above

1-44. A nerve cell, or neuron, is composed of all

of the following EXCEPT a/an

1. synapse

2. axon

3. cyton

4. dendrite

1-45. The impulse receptors of a nerve are called

1. dendrites

2. Schwann cells

3. ganglia

4. neurons

1-46. The space through which a nerve impulse

passes from one neuron to another is called

a/an

1. myelin sheath

2. synapse

3. axon

4. ganglion

1-47. Balance, coordination of movement, and

harmony of motion are functions of what

part of the brain?

1. Cerebral cortex

2. Cerebellum

3. Pons

4. Temporal lobe

1-48. Circulation and respiration are controlled

primarily from what area of the brain?

1. Medulla oblongata

2. Pons

3. Cerebellum

4. Cerebrum

1-49. The meninges, membrane layers covering

of the brain and spinal cord, are composed

of all of the following EXCEPT the

1. dura mater

2. pia mater

3. arachnoid

4. foramen magnum

1-50. In what part of the body is cerebral spinal

fluid produced?

1. Ventricles of the brain

2. Spinal cord

3. Meninges

4. Medulla oblongata
6

1-51. The 12 pairs of cranial and 31 pairs of

spinal nerves form what nervous system?

1. Peripheral

2. Central

3. Autonomic

4. Sympathetic

IN ANSWERING QUESTIONS 1-52

THROUGH 1-54, SELECT FROM THE LIST

ABOVE THE CRANIAL NERVE THAT

PERFORMS THE FUNCTION LISTED IN

EACH QUESTION.

1-52. Controls the muscles of the tongue.

1. A

2. B

3. C

4. D

1-53. Transmits sensation of taste.

1. A

2. B

3. C

4. D

1-54. Receives sensory input from the face.

1. A

2. B

3. C

4. D

1-55. The autonomic nervous system is

composed of two main divisions: the

1. pons and medulla oblongata

2. voluntary and involuntary systems

3. sympathetic and parasympathetic

systems

4. cerebrum and cerebellum

1-56. Conservation and restoration of energy are

the result of nerve impulses arising from

which, if any, of the following nervous

systems?

1. Sympathetic

2. Parasympathetic

3. Voluntary

4. None of the above

IN ANSWERING QUESTIONS 1-57

THROUGH 1-60, SELECT FROM THE LIST

ABOVE THE NERVOUS SYSTEM THAT IS

MOST RESPONSIBLE FOR THE SYMPTOM

OR FUNCTION GIVEN IN THE QUESTION.

1-57. Increased heart rate.

1. A

2. B

3. C

4. D

1-58. Vision.

1. A

2. B

3. C

4. D

1-59. Decreases heart rate to normal.

1. A

2. B

3. C

4. D

A. Facial

B. Trigeminal

C. Hypoglossal

D. Accessory

A. Sympathetic

B. Central

C. Peripheral

D. Parasympathetic
7

1-60. Reflex arc.

1. A

2. B

3. C

4. D

1-61. Hormones secreted by the endocrine system

are

1. secreted directly into the gland, tissue,

or organ it influences

2. directed to the gland, tissue, organ by a

duct system

3. secreted into the circulatory system

4. typically produced in large quantities

1-62. The overproduction of which hormone

leads to acromegaly?

1. Somatotropin

2. Oxytocin

3. Gonadotropin

4. Thyroxin

1-63. Which of the following diseases is

characterized by a deficiency of the

antidiuretic hormone?

1. Myxedema

2. Diabetes insipidus

3. Hyperthyroidism

4. Addison’s disease

1-64. An insufficient secretion of thyroxin is

characterized by all of the following

symptoms EXCEPT

1. weight gain

2. fatigue

3. profuse sweating

4. slowed heart rate

1-65. Calcium levels in the blood are controlled

by which of the following hormones?

1. Thyroxin

2. Vasopressin

3. Oxytocin

4. Parathormone

1-66. Electrolyte balance is a function of the

hormone produced by the

1. posterior lobe of the pituitary gland

2. anterior lobe of the pituitary gland

3. cortex of the adrenal gland

4. medulla of the adrenal gland

1-67. A metabolic response to epinephrine

includes which, if any, of the symptoms

listed below?

1. Decreased heart rate

2. Increased blood pressure

3. Respiratory distress

4. None of the above

1-68. What hormone is produced by the alpha

cells of the islands of Langerhans in the

pancreas?

1. Glucagon

2. Insulin

3. Norepinephrine

4. Androgens

1-69. The cornea is part of the protective outer

layer of the eye called the

1. sclera

2. conjunctiva

3. choroid

4. crystalline body
8

1-70. The inner part of the eye derives its

nourishment primarily from the vascular

structure of what tissue?

1. Conjunctiva

2. Sclera

3. Vitreous humor

4. Choroid

1-71. Dilation of the pupil, a muscular response

of the iris, normally occurs as a result of

what?

1. Increased intensity of light

2. Decrease intensity of light

3. Irritation to the sclera

4. Irritation to the conjunctiva

 1-72. Of the elements listed below, which makes

seeing in the dark possible?

1. Rods

2. Cones

3. Iris

4. Choroid

1-73. By what process is three-dimensional

vision produced?

1. Accommodation

2. Convergence

3. Refraction

4. Stimulation

1-74. The mechanical transmission of sound from

the tympanic membrane to the inner ear is a

function of which of the following?

1. Auditory ossicles

2. Eustachian tube

3. Bony labyrinth

4. Organ of Corti

1-75. What structure(s) of the inner ear

provide(s) neural stimuli used to maintain

equilibrium?

1. Fenestra rotunda

2. Fenestra ovalis

3. Semicircular canals

4. Organ of Corti
9

ASSIGNMENT 2

Textbook Assignment: “Anatomy and Physiology,” chapter 1—continued, pages 48-63; “Fundamentals of

Patient Care,” chapter 2, pages 2-1 through 2-39.

 2-1. The conversion of mechanical impulses

(sound waves) to neural impulses that can

be interpreted by the brain is a function of

the

1. endolymph

2. semicircular canals

3. organ of Corti

4. fenestra ovalis

2-2. The enzymatic action of amylase results in

the chemical breakdown of

1. fats to fatty acids

2. starches to fats

3. starches to complex sugars

4. proteins to complex sugars

2-3. Absorption of food occurs predominantly in

which of the following areas of the

intestines?

1. Duodenum

2. Jejunum

3. Ileum

4. Cecum

2-4. Of the organs listed below, which function

as the accessory organs of digestion for the

small intestines?

1. Pancreas, liver, villae

2. Spleen, liver, gallbladder

3. Pancreas, pylorus, spleen

4. Pancreas, liver, gallbladder

2-5. The gallbladder performs which of the

following purposes?

1. Stimulates the production of insulin

2. Stores bile

3. Metabolizes sugars

4. Produces antibodies

2-6. The functional unit of the kidney is called

the

1. nephron

2. Malpighian body

3. glomerulus

4. loop of Henle

2-7. Which of the following is/are (a)

function(s) of the kidneys?

1. To maintain acid-base balance

2. To remove certain toxic substances

3. To remove excess sugar

4. All the above

2-8. Blood concentration varies due to which, if

any, of the following factors?

1. Temperature

2. Water intake

3. State of health

4. None of the above

2-9. What is the approximate total capacity of

the adult bladder?

1. 250 ml

2. 300 ml

3. 600 ml

4. 750 ml
10

2-10. Testosterone production is a function of

which of the following glands?

1. Cowper’s

2. Prostate

3. Testes

4. Bulbourethral

2-11. Which of the following is/are considered

the primary female reproductive organs?

1. Ovaries

2. Fallopian tubes

3. Uterus

4. Endometrium

2-12. Fertilization of an ovum normally takes

place in the

1. ovaries

2. fallopian tubes

3. uterus

4. vagina

2-13. The concepts of health include

1. the absence of disease or disability

2. soundness of mind, body, and spirit

3. both 1 and 2 above

4. a feeling of euphoria

2-14. Patient rights and responsibilities are

standards addressed by what organization?

1. Commander, Navy Medical Command

(formerly Bureau of Medicine and

Surgery)

2. American Medical Association (AMA)

3. Joint Commission on Accreditation of

Healthcare Organizations (JCAHO)

4. National League of Nursing (NLN)

2-15. The limitations imposed upon a healthcare

provider are based on local regulations and

which of the following elements?

1. The rating’s occupational standards

2. The rate training manual

3. The provider’s training and experience

4. All of the above

2-16. In the healthcare field, accountability

means that providers

1. are held responsible for their actions

2. must continue their education in the

healthcare field

3. are bound by a code of ethics

4. all the above

2-17. A patient requests your advice or opinion

concerning the care or proposed care (s)he

is undergoing. Which, if any, of the

following is the appropriate response?

1. Answer honestly, to the best of your

ability

2. Refer the patient to the nurse or

physician responsible for his/her care

3. Say you'll ask your supervisor

4. None of the above

2-18. Personal and medical information learned

about a patient as the result of your position

as a Hospital Corpsman is privileged and

must not be divulged to unauthorized

individuals.

1. True

2. False
11

TO ANSWER QUESTIONS 2-19 THROUGH

2-21, SELECT FROM THE ABOVE LIST THE

STATEMENT THAT MOST ACCURATELY

DESCRIBES THE TERMS GIVEN IN THE

QUESTION. NOT ALL STATEMENTS WILL

BE USED.

2-19. Interpersonal relations.

1. A

2. B

3. C

4. D

 2-20. Culture.

1. A

2. B

3. C

4. D

 2-21. Race.

1. A

2. B

3. C

4. D

2-22. A patient who is a professed atheist is

placed on the Very Serious List (VSL) with

a poor prognosis for recovery. All of the

following actions by the staff are

considered appropriate and ethical

EXCEPT

1. informing the rest of the staff of the

patient’s nonreligious beliefs

2. informing the rest of the staff of the

patient’s condition

3. informing pastoral services (chaplain)

of the patient’s condition and

nonreligious beliefs

4. attempting to convince the patient to

accept a religious belief

2-23. The communication process takes place

only through the written or spoken word.

1. True

2. False

2-24. Communication barriers inhibit the flow of

information and may consist of which of

the following factors?

1. Decreased auditory acuity

2. Age

3. Education

4. All the above

 2-25. The most common cause of ineffective

communication and the most difficult

obstacle to identify is which of the

following barriers?

1. Psychological

2. Physical

3. Psychosocial

4. Spiritual or religious

A. Learned and shared

behavior patterns and

standards.

B. How one responds to and

regards others.

C. Inherited characteristics.

D. Belief system.
12

2-26. In the communication process, listening is a

critical skill and can be improved by

developing which, if any, of the following

attitudes and behaviors?

1. Anticipating what the patient will say

2. Minimizing distractions

3. Taking notes

4. None of the above

2-27. The purpose of therapeutic communication

includes all of the following EXCEPT

1. assessing behavior and modifying if

appropriate

2. educating a patient regarding health

and health care

3. providing information on how to get to

the appropriate clinic for treatment

4. obtaining information to determine a

patient’s illness

TO ANSWER QUESTIONS 2-28 THROUGH

2-31, SELECT FROM THE LIST ABOVE THE

TERM THAT MOST APTLY APPLIES TO

THE REQUIREMENT PRESENTED.

2-28. Developing a patient’s history of a

complaint.

1. A

2. B

 2-29. Explaining the necessities and methods of

personal hygiene to the parent of a young

patient.

1. A

2. B

 2-30. Providing self-care instructions to a patient

released to convalescent leave.

1. A

2. B

2-31. Directing the patient to the pharmacy to fill

a prescription.

1. A

2. B

2-32. Which of the following are goals of patient

health education?

1. Promoting patient self-care

2. Promoting behavior modification

3. Influencing a patient’s attitude toward

health and disease

4. All the above

2-33. Patient education is the responsibility of

1. the members of the command

education and training department

2. only the physician and nurses for the

patient

3. all members of the healthcare team

4. the outpatient staff and clinic

supervisor only

TO ANSWER QUESTIONS 2-34 THROUGH

2-38, SELECT FROM THE ABOVE LIST THE

TYPE(S) OF OBSERVATION(S) THAT MOST

ACCURATELY APPLY(S) TO THE

SCENARIO DESCRIBED IN THE QUESTION.

A. Contact point

communication

B. Therapeutic communication

Kind(s) of observation(s)

A. Subjective only

B. Objective only

C. Both subjective and

objective
13

2-34. In the emergency room, you are examining

a patient who suddenly vomits and tells you

he has been feeling nauseous for the past

several hours.

1. A

2. B

3. C

2-35. A patient claims to have swallowed many

pills and complains of sleepiness and

nausea.

1. A

2. B

3. C

2-36. An EKG performed on a patient is

interpreted as normal and the patient’s

breathing improves with oxygen therapy.

1. A

2. B

3. C

2-37. A patient complains of chest pain and has

difficulty breathing.

1. A

2. B

3. C

2-38. When picking up a patient’s dinner tray,

you notice that only the liquids have been

consumed at this meal, although the patient

has normally eaten full meals before this.

1. A

2. B

3. C

2-39. A medical patient is prescribed therapeutic

bed rest primarily for what reason?

1. To inhibit the development of

circulatory problems

2. To prevent depression and apathy

3. To prevent further damage to body

systems

4. To inhibit the development of

respiratory problems

2-40. A health care provider can reasonably

expect that all patients admitted for surgical

procedures will exhibit which of the

following characteristics?

1. Be very demanding

2. Be apathetic and passive

3. Exhibit violent behavior

4. Be fearful and anxious

2-41. SF 522, Request for Administration of

Anesthesia and for Performance of

Operations and other Procedures, is

normally signed by a parent, legal guardian,

or spouse EXCEPT when the patient is

1. able to do so

2. over 16 years of age but under 18

3. over 18 years of age but under 21

4. a member of the Armed Forces

2-42. When a regional anesthetic is administered,

the patient can expect what effect?

1. Motor, but not sensory perception will

diminish

2. Pain will be reduced or eliminated in

the body part injected or swabbed

3. Level of consciousness will decline

4. The entire body will become numb
14

2-43. In general anesthesia, a stimulation of vital

signs is evidence of what level of

anesthesia induction?

1. Stage 1

2. Stage 2

3. Stage 3

4. Stage 4

2-44. Dropping a metal basin on the operating

room floor may cause a violent response

from a general anesthesia patient in what

stage of anesthesia?

1. Stage 1

2. Stage 2

3. Stage 3

4. Stage 4

2-45. In the immediate postoperative recovery

phase, a patient’s skin color may be

indicative of all of the following EXCEPT

1. the patient’s ability to recover from the

anesthetic agent

2. postoperative hemorrhage

3. degradation of respiratory function

4. the development of shock

2-46. When permitted, postoperative patients

should be encouraged to ambulate to

improve the functions of which of the

following physiologic systems?

1. Renal system

2. Digestive system

3. Cardiopulmonary system

4. All of the above

2-47. When caring for a young, otherwise healthy

orthopedic patient requiring

immobilization, the healthcare provider can

anticipate all of the following EXCEPT

1. symptoms of emotional stress

2. frequent complaints of sore or aching

pain

3. periods of dizziness associated with

disorientation

4. a deterioration of skin tone and

function

2-48. Unless otherwise directed by the physician,

when one is applying a cast to an arm, the

patient’s wrists is generally in which of the

following positions?

1. Extended about 10 degrees

2. In the neutral position

3. Flexed about 30 degrees

4. In any of the above; specific position is

immaterial

2-49. A patient who has been fitted with a cast

should be instructed to return to the medical

treatment facility as soon as possible under

which of the following circumstances?

1. The cast becomes soiled

2. The extremity affected by the cast is

numb

3. The itching becomes unbearable

4. The cast gets wet

2-50. In the theory of death and dying, it is

suggested that most people exhibit five

stages. The stage where the terminal

patient becomes concerned about the state

of his or her affairs and family members is

known as the stage of

1. denial

2. acceptance

3. bargaining

4. depression
15

2-51. Patient falls may be avoided by taking

which of the following preventive

measures?

1. Proper use of bed/gurney siderails

2. Keeping floors dry and uncluttered

3. Instructing patients on the proper use

of walking aids (crutches, canes, etc.)

4. All of the above

2-52. Electrical and electronic equipment poses

significant injury hazards. Of the

following, which is the authorized means of

reducing this hazard?

1. Repairing frayed cords with electrical

tape to prevent shock

2. Informing the staff of defective

equipment

3. Having medical repair perform

electrical safety checks on all

equipment

4. Using only two-prong, nongrounded

electrical plugs

2-53. Skin contact burns can be caused by

icebags or hypothermia blankets.

1. True

2. False

2-54. During a fire evacuation, which of the

following procedures is NOT considered

appropriate?

1. Immediately remove patients to safety

2. Close all windows and doors

3. Turn off all oxygen equipment not

necessary to sustain life

4. Clear all possible exits

2-55. Because of its nonstatic qualities, the most

acceptable material for use in the operating

room is

1. wool

2. synthetic fabrics

3. untreated synthetic/cotton blends

4. 100% cotton

2-56. Documentation and analysis of all accidents

and injuries is provided for which of the

following reasons?

1. To forestall negligence or malpractice

suits

2. To identify and punish the responsible

person(s)

3. To identify and correct safety

deficiencies

4. All of the above

2-57. Environmental hygiene is directed toward

producing a healthy environment and

includes such practices as maintaining unit

cleanliness and

1. providing for adequate ventilation

2. limiting noise levels

3. proper disposal of soiled articles

4. all of the above

2-58. What source is considered the most

frequent reservoir of infectious agents

pathogenic to man?

1. Soil

2. Animals

3. Man

4. Plants

TO ANSWER ITEMS 2-59 THROUGH 2-62,

SELECT FROM THE ABOVE LIST THE

SITUATIONAL ELEMENT THAT MOST

CLOSELY MATCHES THE CHAIN OF

INFECTION LINK GIVEN IN THE

QUESTION AS IT APPLIES TO THE

FOLLOWING SCENARIO.

A. Corpsman’s hands

B. Patient

C. Abdominal wound

D. Furuncle
16

A corpsman assists a medical officer to perform

incision and drainage of a furuncle on a patient’s

leg. After the I&D procedure, the corpsman changes

a postsurgical abdominal dressing on the same

patient. A few days later, the surgical wound

appears red and swollen and a culture reveals a

significant staphylococcal infection.

2-59. Reservoir of the infectious agent.

1. A

2. B

3. C

4. D

2-60. Mode of transmission.

1. A

2. B

3. C

4. D

2-61. Portal of entry.

1. A

2. B

3. C

4. D

2-62. Susceptible host.

1. A

2. B

3. C

4. D

2-63. One essential practice of medical asepsis is

washing your hands before and after

changing a patient’s dressing(s).

1. True

2. False

2-64. Minimizing the spread of an infectious

disease can be accomplished by the use of

isolation techniques that may include

1. limiting patient contact

2. establishing physical barriers

3. concurrent and terminal disinfection

4. all of the above

2-65. The sterilization method of choice for most

articles used in surgery is

1. dry heat

2. steam under pressure

3. ethylene oxide gas

4. soaking in glutaraldehyde

2-66. Which of the following is an important step

in using ethylene oxide gas for

sterilization?

1. Providing protective masks to the

operators

2. Providing an aeration period

3. Including surgical blades and sutures

in the pack

4. Ensuring adequate steam pressure in

the chamber

2-67. Sterilization of individual strands of suture

is acceptable for which of the types listed?

1. All absorbable suture material

2. All nonabsorbable suture material

3. Both 1 and 2 above

4. Stainless steel sutures only

2-68. Which of the following rubber products

may be resterilized after use?

1. Disposable surgeon’s gloves

2. Latex surgical drains

3. Surgical suction tubing

4. Disposable urinary catheters
17

2-69. While adding items to a sterile field, you

think you may have dragged the corner of a

wrapper across part of the field. What

should your course of action be?

1. Do nothing. Wrappers are considered

clean

2. Tell the scrub technician so he or she

can avoid that part of the field

3. Say nothing and continue with what

you are doing

4. Dismantle the field and set up a new

field

2-70. When setting up a minor surgery case, you

notice that the instrument pack is outdated,

What should you do?

1. Unwrap and inspect the pack and if

usable, resterilize

2. Resterilize the pack without

unwrapping

3. Return it to the shelf and let someone

else take care of it

4. Use the pack; only the outside is not

sterile

2-71. The surgical hand scrub is performed to

1. chemically sterilize the hands and

forearms

2. remove all bacteria from the hands and

forearms

3. reduce bacterial to a minimum on the

hands and forearms

4. remove obvious dirt and grime from

the hands and forearms

2-72. Transient and resident bacteria are easily

removed from the skin by the friction

created during the surgical hand scrub.

1. True

2. False

2-73. What is the preferred method of cleaning an

operating room floor between operations?

1. Sponge and disinfectant

2. Broom

3. Mop

4. Wet vacuum

2-74. For effective sterilization of

microbiological infectious waste, the

temperature of the sterilizing steam must be

maintained at _____ for at least _____, at

_____ per square inch of gauge pressure.

1. 121° F, 45 minutes, 15 pounds

2. 121° C, 90 minutes, 10 pounds

3. 250° F, 90 minutes, 15 pounds

4. 250° C, 45 minutes, 10 pounds
18

ASSIGNMENT 3

Textbook Assignment: “First Aid Equipment, Supplies, Rescue and Transportation,” chapter 3, pages

3-1 to 3-26; "Emergency Medical Care Procedures," chapter 4, pages 4-1 to 4-37.

3-1. In first aid situations, the ability to

improvise is a highly desirable personal

characteristic for a Corpsman.

1. True

2. False

3-2. A typical ambulance emergency bag does

NOT contain which of the following

items?

1. Toomey Syringe

2. Atropine

3. Airways

4. Trach Adaptor

A. Spica E. Barton

B. Figure-eight F. Triangular

C. Spiral reverse G. Cravat

D. Four-tailed

IN ANSWERING QUESTIONS 3-3 THROUGH

3-9, REFER TO THE LIST ABOVE,

MATCHING THE TYPE OF BANDAGE WITH

THE BODY PART TO WHICH IT IS MOST

COMMONLY APPLIED.

 3-3. Axilla.

1. A

2. B

3. F

4. G

 3-4. Ear.

1. C

2. D

3. E

4. G

3-5. Head.

1. F

2. D

3. B

4. A

3-6. Elbow.

1. A or B

2. C or F

3. E

4. G

 3-7. Ankle.

1. D

2. C

3. B

4. A

3-8. Calf.

1. A

2. B

3. C

4. D

3-9. Chin.

1. C or A

2. D or E

3. F or G

4. G only
19

3-10. The oxygen breathing apparatus (OBA) is

a valuable adjunct in rescue operations for

what reason?

1. It can be connected directly to an

external air source

2. It provides positive pressure

ventilation for the wearer

3. It neutralizes or filters toxic gasses

4. It generates its own oxygen

3-11. When, if ever, should an oxygen source be

connected to an air line mask?

1. When entering a carbon dioxide filled

compartment or void

2. When entering a compartment or void

with fuel oil vapors

3. After the couplings have been cleaned

of all oil or grease

4. Never

3-12. The standard gas mask provides effective

protection against

1. carbon monoxide and carbon dioxide

2. low oxygen concentrations

3. both 1 and 2 above

4. chemical and biological warfare

agents

3-13. When using a lifeline to raise an

unconscious person from a compartment,

the lifeline should be attached to the victim

in what manner?

1. Around the waist and to the belt

2. Around the chest and under the arms

3. Around the hips and the wrists

4. Around the arms and the legs

IN ANSWERING QUESTIONS 3-14 AND 3-15,

REFER TO THE FOLLOWING SCENARIO. 

DETERMINE THE PHASE OF RESCUE

OPERATIONS, STAGE OF EXTRICATION,

AND/OR RESCUE PROCEDURE INDICATED

BY THE QUESTION.

3-14. Several Sailors have just been reached. 

Two are unconscious, badly burned, and

pinned under an empty wall locker. One is

dead.

1. First and third phases/first stage

2. Second phase/third stage

3. Third phase/third stage

4. First and last phases/first stage

3-15. A Sailor is injured and trapped under a

fallen metal beam that is wedged tight by a

buckled bulkhead. After unsuccessful

efforts to move the beam, special cutting

and lifting equipment is called for.

1. First phase

2. Second phase

3. Third phase

4. Last phase

Scenario

There has been a fire and explosion

aboard ship and approximately 30

Sailors are trapped below deck. To get

to the trapped Sailors, bulkheads are

being breached and a large section of

the damaged deck is being cut away. 

Firefighting teams are still fighting a

large out of control fire near where you

will be working. Passageway ventilation

systems are working to remove dense,

acrid smoke. Everyone is wearing OBA.

Several steam lines have been ruptured

and live electrical lines are sparking

throughout the area. The DCO has

determined that rescue attempts can be

conducted.
20

3-16. Five burned Sailors walked out of a

smoldering compartment. You are

administering first aid and transporting

them to sickbay.

1. First and second stages

2. Second stage only

3. First and third stages

4. Second and final stages

3-17. A Sailor whose clothes are on fire runs

toward you. A small canvas tarp is nearby.

Which of the following actions should you

take?

1. Throw the victim to the deck and

cover the victim head to foot with the

tarp

2. Beat out the flames from the head

downward to the feet

3. With the victim wrapped in the tarp,

roll the victim over very quickly

4. With the victim standing, wrap the

victim in the tarp and beat the flames

out with your hands

3-18. The ventilators suddenly shut down and

sparking has ceased. Rescuers are to enter

a darkened compartment. The DCO is

supervising the rescue effort. The rescuers

should take which of the following

precautions?

1. Check for oxygen, gasses, and

explosive vapors

2. Wear a lifeline

3. Carry and wear only nonsparking

equipment

4. Each of the above

3-19. Which of the stretchers listed below is

considered most practical when lifting a

casualty from an engine room?

1. Stokes stretcher

2. Army litter

3. Miller Board

4. Improvised blanket and line stretcher

3-20. Which of the following pieces of rescue

equipment should be used to carry a person

with a suspected back or neck injury?

1. Army litter

2. Spineboard

3. Either 1 or 2, depending on the

circumstances

4. Improvised stretcher

3-21. Probably the easiest way to carry an

unconscious person is called the

1. fireman’s carry

2. tied-hands crawl

3. blanket drag

4. chair carry

3-22. The tied-hands crawl is the most useful

when the victim

1. is too heavy to lift

2. must be move long distances

3. is seriously injured

4. must be moved under low structures

3-23. What is the most distinct advantage of the

chair carry?

1. The ease of transporting heavy

casualties

2. The ease of negotiating stairs

3. Its safety in transporting neck or back

injuries

4. Its safety in transporting pelvic

injuries

3-24. Which of the following is NOT a factor the

Corpsman considers in deciding whether

or not to recommend using a helicopter for

evacuating patients?

1. The victim's overall condition

2. The tactical situation

3. The affect of pressure changes in

flight

4. Cost
21

3-25. The primary purposes of first aid include

all the following EXCEPT to

1. provide definitive medical treatment

2. preserve resistance and vitality

3. save life

4. prevent further injury

3-26. At what point should the preliminary

examination of a casualty be done?

1. In the hospital

2. In the ambulance

3. After making the victim comfortable

4. Before moving the casualty

3-27. In a combat scenario, a casualty sustaining

numerous superficial shrapnel wounds

should be triaged into which of the

following groups?

1. Class I

2. Class II

3. Class III

4. Class IV

3-28. In a trauma related incident where a patient

has multiple injuries, you should treat

which of the following first?

1. Fractures

2. Most obvious injury

3. Most lift-threatening condition

4. Most painful condition

3-29. For warfare in the future where helicopter

evacuation may not be viable, personnel in

which of the following treatment

categories will receive evacuation triage?

1. I and II

2. II and III

3. I and IV

4. III and IV

3-30. What is the basic concept of triage?

1. To sort casualties into treatment

categories for transportation

2. To prioritize treatment categories for

surgery

3. To save the maximum number of

personnel possible

4. To assist medical personnel in saving

time and supplies

3-31. What is the purpose of field assessments?

1. To detect and treat life threatening

conditions for immediate care

2. To conduct a subjective interview and

an objective examination

3. Both a and b, above

4. To identify needed equipment and

supplies

3-32. At an emergency scene, you should

immediately take which of the following

actions?

1. Inform the person in charge that

medical personnel have arrived

2. Ensure that someone begins triage, if

needed

3. Review patient emergency assessment

procedures

4. Make sure the scene is safe for self

and patients

3-33. Which of the following actions are a main

focus of conducting a primary survey?

1. Making a status decision and

formulating priorities

2. Formulating a treatment plan and

making a status decision

3. Formulating priorities and making a

transport decision

4. Making a status decision and a

transport decision
22

3-34. At the emergency scene, you should delay

giving emergency care to life-threatening

problems until you have conducted a

thorough field assessment of the patient

and the environment.

1. True

2. False

 3-35. At an emergency scene, which of the

following is a purpose for conducting a

subjective interview?

1. To gather information from relatives

or bystanders

2. To gather information from the patient

3. To reduce patient fear and promote

cooperation

4. All of the above

3-36. What pupillary sign is an indication of a

central nervous system disorder?

1. Unequal pupils

2. Constricted pupils

3. Unresponsive pupils

4. Dull and unfocused pupils

3-37. On examination of the chest, you detect

distinct "crackling" sounds. What

condition should you immediately suspect?

1. Flail chest

2. An obstruction

3. A punctured lung

4. An illness involving the respiratory

system

3-38. An absent pedal pulse could be caused by

all of the following conditions EXCEPT

1. a broken or dislocated bone

2. delayed capillary refill

3. spints or bandages being placed too

tightly

4. a pinched or severed major artery

3-39. Evaluation of diagnostic vital signs

includes all of the following EXCEPT

1. blood pressure

2. rhythm/regularity of pulse

3. profuse perspiration

4. level of consciousness

 3-40. What term identifies the pressure of the

pulse wave as it expands the artery?

1. Pulse rhythm

2. Pulse character

3. Tachycardia

4. Pulse force

 3-41. What condition or observation may

indicate a patient is going into shock?

1. Systolic pressure below 90 mm Hg

2. Hypertension

3. Erratic breathing

4. A sudden rise in blood pressure

3-42. What is the universal distress signal

indicating an obstructed airway?

1. Spasmodic coughing

2. Clutching at the throat

3. Hyperventilation

4. Cherry-red coloration of the skin or

nail beds

3-43. To open a partially obstructed airway of a

victim with a cervical spine injury, which

of the following is considered the safest

method?

1. Jaw thrust

2. Head tilt

3. Abdominal thrust

4. Chest thrust
23

3-44. Symptoms of foreign-body airway

obstruction include which of the

following?

1. Victim stops breathing

2. Victim starts turning blue

3. Victim loses consciousness for no

apparent reason

4. All the above

3-45. Artificial ventilation is indicated in which

of the following situations?

1. To assist ventilation in partial airway

obstruction

2. In carbon monoxide poisoning

3. In lack of respiratory effort

4. In cyanosis

3-46. Dilated pupils in a patient receiving

artificial ventilation is an indication of

1. overventilation

2. adequate ventilation

3. insufficient ventilation

4. hypovolemia

3-47. Artificial ventilation of a patient with a

badly displaced mandibular fracture is best

given

1. by mouth-to-mouth ventilation

2. by mouth-to-nose ventilation

3. with an oxygen mask

4. by the back-pressure arm-lift method

3-48. The major problem you should anticipate

when relieving gastric distention is which

of the following?

1. Reduced lung volume

2. Internal bleeding

3. Vomiting

4. Cardiac arrest

3-49. When ventilating an adult using the mouthto-mask method, how do you best obtain

an airtight seal?

1. By fitting the apex of the mask over

the bridge of the nose

2. By fitting the apex of the mask over

the chin

3. By compressing the collar of an adult

mask

4. By attaching an oxygen line

3-50. What is the first step in preparing to

perform CPR?

1. Check vital signs

2. Determine unconsciousness

3. Locate the sternum

4. Establish a patent airway

3-51. The best place to find the pulse of an

unconscious patient is in which of the

following arteries?

1. Pulmonary

2. Carotid

3. Apical

4. Radial

3-52. A fracture of the xiphoid tip of the sternum

during CPR may cause significant damage

to the

1. rib cage

2. lungs

3. spleen

4. liver

3-53. In one-rescuer CPR, the proper

compression to ventilation ratio is

1. 15 to 2

2. 2 to 15

3. 1 to 5

4. 5 to 1
24

3-54. When properly performing CPR on an

adult, the depth of compressions is

1. 0.5 to 1.0 inches

2. 1.0 to 1.5 inches

3. 1.5 to 2.0 inches

4. 1.5 to 2.5 inches

3-55. Which of the following is a physiologic

result of shock?

1. Increased cardiac output

2. Hypoxia

3. Hyperperfusion of organs

4. Increased urine output

3-56. The signs and symptoms of shock include

1. hot and dry skin, dilated pupils, weak

and rapid pulse

2. hot and dry skin, constricted pupils,

strong and rapid pulse

3. cool and moist skin, dilated pupils,

weak and rapid pulse

4. cool and moist skin, constricted

pupils, strong and rapid pulse

3-57. Oligemic shock is another name for

1. cardiogenic shock

2. neurogenic shock

3. septic shock

4. hypovolemic shock

3-58. An oral electrolyte solution can be made

from a liter of water and what other

components?

1. 1.0 teaspoon of sugar + 0.5 teaspoon

of baking powder

2. 0.5 teaspoon sugar + 1.0 teaspoon

baking powder

3. 1.0 teaspoon salt + 0.5 teaspoon

baking soda

4. 0.5 teaspoon salt + 1.0 teaspoon

baking soda

3-59. Treatment for shock may include all of the

following EXCEPT

1. opening and maintaining an airway

2. oxygen therapy

3. intravenous fluid therapy

4. keeping the victim cool

3-60. Which of the following is a

contraindication for the use of Medical

Anti-Shock Trousers (MAST)?

1. Pelvic fracture

2. Pulmonary edema

3. Fractured femur

4. Depressed skull fracture

3-61. When should Medical Anti-Shock

Trousers (MAST) be removed from a

patient?

1. When blood pressure reaches 100 mm

Hg systolic

2. When intravenous fluids are started

3. In a medical treatment facility under a

medical officer’s supervision only

4. When the patient is in the ambulance

and stabilized

3-62. Which of the following is/are a

limitation(s) on the use of the bag-valve

mask ventilator?

1. Should be used only by experienced

individuals

2. Is hard to clean and reassemble

3. Seal at the face is hard to maintain

4. Each of the above

3-63. Which of the following is/are an

advantage(s) of using the pocket face mask

as opposed to the bag-valve mask?

1. Acts as a barrier device

2. Provides greater air volume

3. Achieves higher oxygen

concentrations

4. 1 and 2 only
25

3-64. Cricothyroidotomy is the process or

technique of

1. hyperextending the neck

2. creating an opening to the trachea

3. suctioning the trachea

4. inserting an esophageal obturator

airway

3-65. An avulsion injury is defined as a

1. traumatic removal of a limb

2. piercing injury that closes over

3. clean surgical cut

4. traumatic removal of tissue

3-66. In most situations, what is the best and first

method to control hemorrhage?

1. Direct pressure

2. Pressure point

3. Elevation

4. Tourniquet

3-67. The following information about pressure

points is correct EXCEPT

1. Pressure points are ideal when

bleeding must be controlled for

extended periods of time

2. Pressure is applied to the pressure

point nearest to but proximal to the

wound

3. Use of pressure point and elevation

can slow hemorrhage until a

tourniquet can be applied

4. Use of pressure point and elevation

can slow hemorrhage until a direct

pressure dressing can be applied

3-68. If one is applying a tourniquet to a

traumatic amputation of the hand, where

should the tourniquet be applied?

1. Just above the wrist

2. Just below the elbow

3. Just above the elbow

4. Across the biceps at the thickest part

3-69. When a tourniquet is used to control

bleeding, which of the following

procedures should be followed?

1. Use narrow material so the band bites

into the skin

2. Loosen the tourniquet every 15

minutes to allow blood flow

3. Tighten it only enough to stop arterial

bleeding

4. Ensure both the wound and tourniquet

are covered by the dressings

3-70. Production of bright red blood during

coughing is called

1. hematemesis

2. hemoptysis

3. hematochezia

4. epistaxis

3-71. In treating patients with suspected internal

injuries, prime consideration should be

given to all of the following EXCEPT

1. oral fluids in all cases

2. treating for shock

3. supplemental oxygen therapy

4. transporting to a medical facility as

soon as possible

3-72. To grow and multiply, anaerobic bacteria

require

1. hemolytic action

2. increased levels of oxygen

3. normal levels of oxygen

4. absence of oxygen

3-73. The body’s physiologic response to an

irritation or inflammation is characterized

by which, if any, of the following

symptoms?

1. Redness, warmth, and swelling

2. Redness, coolness, and discomfort

3. Blanching, coolness, and swelling

4. None of the above
26

3-74. A single pus-filled cavity in the true skin

of the nape of the neck would be classified

as a

1. carbuncle

2. furuncle

3. lymph node

4. phagocyte

3-75. Which of the following is proper action to

take if a metal splinter is embedded in the

left eye?

1. Remove the foreign body with sterile

forceps

2. Remove the foreign body with a dry

cotton swab

3. Patch the left eye and transport to a

medical treatment facility

4. Patch both eyes and transport to a

medical treatment facility
27

ASSIGNMENT 4

Textbook Assignment: “Emergency Medical Care Procedures,” chapter 4, pages 4-38 to 4-71; "Poisoning,

Drug Abuse, and Hazardous Material Exposure," chapter 5, pages 5-1 to 5-26.

4-1. Appropriate treatment for a sucking chest

wound includes all of the following

EXCEPT

1. giving oral fluids

2. administering oxygen therapy

3. treating for shock

4. placing the victim on the injured side

4-2. Of the following, which is an appropriate

treatment for a protruding abdominal

wound?

1. Giving oral fluids

2. Replacing the intestines in the

abdominal cavity

3. Applying a dry compress

4. Treating for shock

4-3. Which of the following statements is true

about the viral disease known as rabies?

1. It is found only in household pets

2. It is usually fatal in man

3. It is treatable with standard antibiotics

4. It is transmittable only through animal

bites

4-4. What procedure should be followed with

respect to an animal bite?

1. Cauterize to prevent infection

2. Close with nylon sutures

3. Clean with standard antiseptics

4. Clean with soap and water

4-5. Immediate suturing of a wound is

contraindicated if the wound has which of

the following characteristics?

1. It is a puncture wound

2. There is edema and/or discharge

3. It is a deep or gaping wound

4. Any of the above

4-6. An alternate name for an absorbable suture

material is

1. dermalon

2. gut

3. sick

4. nylon

4-7. In administering anesthesia, the preferred

method is to inject the agent directly into a

vein or artery located within 1/2 inch of a

wound.

1. True

2. False

4-8. Which of the following is/are a

recommended step(s) in performing a

delayed wound closure?

1. Use dressing forceps while suturing

2. Convert jagged edges to smooth before

suturing

3 For best cosmetic effect, place sutures

further apart

4. 1 and 3 only
28

4-9. Of the following statements concerning the

appropriate length for a splint, which is

accurate?

1. A splint should be long enough to

reach from the fracture to the joint

below the fracture

2. A splint should be long enough to

reach from the fracture to the joint

above and below the fracture

3. A splint should be long enough to

reach past the joints above and below

the fracture

4. The length of a splint is immaterial

4-10. After applying a splint to a fractured

forearm, you notice the fingers develop a

bluish tinge and are cool to touch. What

should you do?

1. Elevate the arm

2. Apply warm compresses

3. Loosen the splint

4. Remove the splint

4-11. What is the primary reason for splinting

fractures?

1. To prevent further injury

2. To control hemorrhage

3. To reduce swelling

4. To increase blood circulation

4-12. To fit well and provide adequate

immobilization, a splint must have which of

the attributes listed?

1. Be well padded at body contact areas

2. Be twice as wide as the injured limb

3. Be strong, rigid, and applied tightly

4. Be applied by two people

4-13. The proper first aid treatment for a fracture

of the humerus near the shoulder is to

1. apply a splint to the outside and one to

the inside of the upper arm, bandage

the arm to the body and support the

forearm in a sling

2. apply a splint to the outside of the arm,

bandage the arm to the body, and

support the forearm in a sling

3. place a pad or folded towel in the

armpit, bandage the arm to the body,

and support the forearm in a sling

4. splint the arm in the position you find

it and bandage the arm securely to the

body

 4-14. When applying a splint to immobilize a

fractured patella, where should you place

extra padding?

1. Around the knee and under the

buttocks

2. Under the knee and above the heel

3. Under the knee and under the thigh

4. Around the knee and under the calf

4-15. What is the most important consideration in

treating a mandibular fracture?

1. Immediate immobilization

2. Ensuring a patent airway

3. Realignment of the jaw

4. Control of pain

4-16. Of the following actions, which is of prime

importance when dealing with a head

injury?

1. Determine if the skull is fractured

2. Assume cervical spine damage

3. Administer pain medication

4. Remove impaled objects
29

4-17. How should a suspected spinal fracture

victim be transported?

1. Ensure immobilization on a rigid

backboard

2. Place a pillow or adequate padding

under the neck

3. Transport in the shock position

4. Do all of the above

4-18. Deformity at a joint, coupled with pain,

discoloration, and immobility of and

around the joint, is characteristic of which

of the following disorders?

1. Dislocation

2. Simple fracture

3. Compound fracture

4. Displaced fracture

4-19. Of those listed below, which joints are the

most frequently dislocated?

1. Sternal ribs, finger, and jaw

2. Knee, hip, and elbow

3. Knee, hip, shoulder, and jaw

4. hip, shoulder, fingers and jaw

4-20. To reduce a dislocated jaw, you should do

which of the following?

1. Pull the chin forward and down

2. Have a victim open his or her mouth

several times to affect reduction

3. Grasp behind the front teeth and pull

forward

4. Press down behind the last molars and

lift the chin

4-21. In general, sprains and strains are injuries

to

1. joints and muscles

2. nerves and blood vessels

3. bones and blood vessels

4. bones and nerves

4-22. The treatment for strains and sprains

includes all of the following EXCEPT

1. radiographic evaluation

2. immediate application of moist heat

3. immobilization and rest

4. elevation

IN ANSWERING QUESTIONS 4-23

THROUGH 4-25, USE THE “RULE OF NINES”

AND FIGURE 4-48 IN THE TEXT TO

DETERMINE THE EXTENT OF INJURY BY

BODY SURFACE AREA, AND SELECT THE

MOST APPROPRIATE ANSWER FROM THE

LIST ABOVE BASED ON THE

INFORMATION GIVEN IN THE QUESTION.

4-23. A steam burn to the face, chest, abdomen,

and both arms.

1. A

2. B

3. C

4. D

4-24. A sunburn to the back of both legs, both

arms, and the back.

1. A

2. B

3. C

4. D

A. 18%

B. 27%

C. 31.5%

D. 36%
30

4-25. A thermal burn to the left arm and front of

the left leg.

1. A

2. B

3. C

4. D

4-26. First-aid treatment for extensive second

degree burns should include which of the

following treatments?

1. Anesthetic ointments and transport

only

2. Debridement of the wound and dry

dressings

3. Intravenous infusion and analgesia

4. Anesthetic ointments and analgesia

4-27. Morphine is an acceptable analgesic in

patients with which of the following

symptoms?

1. Head injuries

2. Profound respiratory distress

3. Advanced shock

4. Painful skin burns

4-28. The usual treatment for chemical burns is to

flush with copious amounts of water. The

two exceptions to this rule are in the case of

which of the following chemicals?

1. Phosphoric acid and lye

2. White phosphorus and carbolic acid

3. Dry lime and carbolic acid

4. Sulfuric acid and carbolic acid

4-29. A dilute solution of which of the listed

substances will neutralize alkali burns to

the skin?

1. Alcohol

2. Phenol

3. Vinegar

4. Baking soda

4-30. First aid treatment of white phosphorus

burns with partially embedded particles

includes

1. wet dressings of copper sulfate

2. superficial debridement while flushing

with water

3. neutralization with a dilute vinegar

solution

4. neutralization with a dilute solution of

baking soda

4-31. Signs and symptoms of heat exhaustion

include a weak rapid pulse, nausea,

headache, and

1. constricted pupils

2. greatly increased body temperature

3. cool, moist, and clammy skin

4. flushed, red face

4-32. The incidence of heat exposure injuries can

be minimized by all of the following

EXCEPT

1. education of personnel

2. environmental monitoring

3. daily salt tablets

4. maintenance of exhaust blowers and

vents

4-33. What is the most effective method of

rewarming a victim of hypothermia?

1. “Buddy warming”

2. Covering the victim with blankets or a

sleeping bag

3. Hot water bottles at the neck, armpits,

groin, and the chest

4. Immersion in a tub of warm water

4-34. An antiseptic emollient cream should be

applied to which, if any, of the following

cold injuries?

1. Chilblain

2. Immersion foot

3. All frostbites

4. None of the above. Cold injuries

should be kept dry
31

4-35. For which, if any, of the following reasons

should a frostbite injury remain frozen?

1. To minimize the severity of pain

2. Where there is a possibility of

refreezing

3. To prevent shock

4. Never. Frostbite should always be

rewarmed as quickly as possible

4-36. Which of the following is/are a

recommended step(s) in treating deep

frostbite?

1. Slowly rewarm frozen areas

2. Break blisters to speed healing

3. Gently rub injured areas to promote

blood circulation

4. Comfort victim with hot tea or coffee

4-37. A Corpsman may administer morphine to

which of the following patients?

1. With a head injury

2. In shock

3. With burns from inhaled chemicals

4. Hemorrhaging

4-38. Reversal of a syncopal episode can often be

accomplished by what action?

1. Sitting with the head between the

knees

2. Sitting upright

3. Lying down with the head and

shoulders slightly elevated

4. Lying down in the reverse shock

position

4-39. Which of the following methods is the

quickest and easiest way of determining if

an unconscious person is a diabetic?

1. Check for signs of ketoacidosis

2. Determine blood sugar levels

3. Look for signs of insulin use

4. Search for a Medic Alert tag, bracelet,

or card

4-40. Of the following actions, which is the

immediate treatment for insulin shock?

1. Administer an injection of insulin

2. Place sugar under the victim’s tongue

3. Start an intravenous solution of normal

saline

4. Administer oxygen

4-41. In addition to monitoring vital signs and

making the patient comfortable, treatment

for a stroke includes which of the following

procedures?

1. Administering analgesics to relieve

pain

2. Giving oxygen therapy

3. Giving a rapid infusion of a 5 percent

dextrose solution

4. Giving a 0.3cc injection of epinephrine

for vasoconstriction

4-42. Initial first aid treatment for an attack of

angina pectoris includes reassurance,

monitoring of vital signs, and

1. initiating CPR

2. giving sublingual nitroglycerin

3. advise the patient to return to duty

when pain abates

4. giving a 0.3cc of epinephrine IM to

increase heart rate

4-43. First aid treatment for acute myocardial

infarction without cardiac arrest includes all

of the following EXCEPT

1. giving oxygen therapy

2. monitoring vital signs

3. starting an intravenous infusion of only

normal saline

4. transporting to a medical treatment

facility
32

4-44. Proper first aid treatment for a patient

suffering a convulsive seizure episode

consists of which of the following

procedures?

1. Protecting the victim from injury

2. Immediately starting CPR

3. Muscle massage during periods of

rigidity

4. Injecting 75 to 100 mg of Demerol IM

to effect relaxation

4-45. The most common psychiatric emergency

is probably the suicide gesture or attempt. 

Basic treatment consists of all of the

following EXCEPT

1. presenting a calm and understanding

presence

2. leaving the victim alone to reflect on

his or her actions

3. assuming all suicide threats are real

4. treating self-inflicted wounds as any

other wound

4-46. When, during childbirth, the baby’s head

presents, why should you apply gentle

pressure to the head?

1. To prevent an explosive delivery

2. To avoid compressing the umbilical

cord

3. To compress the cord to stimulate the

infant’s vital function

4. To allow you time to suction the

mouth and nose of the infant

4-47. When should the infant’s mouth and nose

be suctioned?

1. If spontaneous respirations do not

occur

2. When the chin clears the vaginal canal

3. After the child has completely

emerged

4. After clamping and cutting the

umbilical cord

4-48. Emergency first aid treatment for a

prolapsed cord during childbirth includes

all of the following EXCEPT

1. decompressing the cord as much as

possible

2. giving oxygen therapy

3. placing the mother in the shock

position

4. clamping and cutting the umbilical

cord when it presents

4-49. If a prolapsed cord occurs, which of the

following actions should you take?

1. Give the mother oxygen

2. Place the mother in an extreme shock

position

3. Get medical assistance

4. Each of the above

4-50. Poisoning is defined as contact with or

exposure to a toxic substance.

1. True

2. False

4-51. A patient presents with dilated pupils,

fever, dry skin, urinary retention, decreased

bowel sounds, and increased heart rate. 

What toxidrome does this set of symptoms

suggest?

1. Narcotic

2. Anticholinergic

3. Withdrawal

4. Non-syndrome syndrome

4-52. Which of the following is the method of

choice for a Corpsman to use to induce

vomiting?

1. 15-30 cc of syrup of Ipecac

2. 2 teaspoonfuls of dry mustard in water

3. 2 teaspoonfuls of an active charcoal

slurry

4. To tickle the back of the victim’s

throat
33

4-53. Of the following, which is the most likely

area of damage in a victim who has

ingested a strong alkali?

1. Stomach

2. Esophagus

3. Liver

4. Colon

4-54. Treatment of a victim who ingested a

strong acid includes intravenous infusion

therapy and

1. inducing vomiting

2. diluting the stomach contents with

water

3. neutralizing the stomach contents with

a weak sodium bicarbonate solution

4. gastric lavage

4-55. Which of the following substances, upon

ingestion, poses a threat of chemical or

aspiration pneumonia?

1. Acid compounds

2. Alkali compounds

3. Petroleum distillates

4. Any of the above

4-56. If you are unable to reach the poison

control center or a physician for specific

instructions, how should you treat a victim

who has ingested turpentine?

1. Induce vomiting and observe

2. Give 1 to 2 ounces of vegetable oil

orally

3. Neutralize the poison with vinegar and

water

4. Give 1 to 2 tablespoonfuls of milk of

magnesia

4-57. Of the following, which, if any, is

considered the most common agent in

inhalation poisoning?

1. Carbon dioxide

2. Carbon monoxide

3. Freon

4. None of the above

4-58. Treatment for an inhalation poisoning

victim includes all of the following

EXCEPT

1. removal from the contaminated

atmosphere

2. administration of oxygen

3. administration of stimulants

4. treatment for shock

4-59. A patient presents exhibiting signs of

anaphylactic reaction to a bee or wasp

sting. Of the following, which is NOT

considered appropriate treatment?

1. Removal of patient’s jewelry

2. Subcutaneous injection of epinephrine

3. Warm packs over the sting site

4. Removal of the stinger by scraping

with a dull knife

4-60. The victim of a scorpion sting may safely

be given any of the following

pharmaceuticals EXCEPT

1. Demerol or morphine

2. Calcium gluconate

3. Valium

4. All the above are acceptable

4-61. Symptoms of a black widow spider bite

may include severe pain, dyspnea, and

1. obvious swelling

2. abdominal rigidity

3. a necrotizing lesion

4. fever and chills

4-62. Excision and corticosterod therapy is early

treatment for the bite of which of the

following?

1. Scorpions

2. Black widow spiders

3. Brown recluse spiders

4. Snakes
34

4-63. What is the key identifying feature of the

coral snake that distinguishes it from other

snakes with similar markings?

1. The yellow band is always next to the

red band

2. The red band is always next to the

black band

3. It has a distinctive bite pattern

4. It has deep pits below the eyes

4-64. On patrol, a member of your unit receives a

rattlesnake bite just below the elbow. What

first aid treatment should you perform?

1. Place a tourniquet 1 inch proximal to

the bite site

2. Place a constricting band 2 inches

proximal to the bite site

3. Place a constricting band 2 inches

distal to the bite site below the elbow

4. Both 2 and 3 above

4-65. Jellyfish nematocysts can be neutralized

with which of the following substances?

1. Formalin

2. Dilute ammonia

3. Vinegar

4. Any of the above

4-66. The most widely abused drug(s) is/are

1. ethanol

2. opiates

3. barbiturates

4. amphetamines

4-67. Signs and symptoms of stimulant

intoxication include all of the following

EXCEPT

1. hyperactivity

2. increased appetite

3. dilated pupils

4. increased body temperature

 4-68. A person may display which of the

following symptom(s) after using a

hallucinogenic drug?

1. Pin-pointed pupils

2. Decreased heartbeat

3. Flushed face

4. Both 2 and 3 above

 4-69. Marijuana falls into which of the following

categories of drugs?

1. Barbiturate

2. Physically addicting

3. Hallucinogen

4. Harmless

4-70. Persons who regularly abuse inhalants risk

which of the following injuries?

1. Severe brain damage

2. Damaged internal organs

3. Death

4. Each of the above

4-71. In caring for drug-intoxicated persons, the

Corpsman should perform what actions as

his/her first priority?

1. Check for an adequate airway

2. Keep the victim awake

3. Induce vomiting if the victim is awake

4. Transport to a medical facility
35

IN ANSWERING QUESTIONS 4-72 AND

4-73, REFER TO THE TABLE ABOVE. 

MATCH THE TOXICITY LEVEL WITH

THE PROTECTION LEVEL REQUIRED,

AS DESCRIBED IN THE QUESTION.

 4-72. Full body protection and sealed equipment.

1. 0

2. 1 and 2

3. 3 and 4

4. 4 only

 4-73. Protection level C.

1. 0

2. 1 and 2

3. 3

4. 4

 4-74. The Corpsman should give special attention

to which of the following requirements

while working in the command sub-zone?

1. Work in low geographic areas to avoid

toxic fumes

2. Decontaminate victims and equipment

outside of the hazard zone

3. Stay upwind and upgrade of the

incident site

4. Collect a sample of the hazardous

material for later examination

4-75. What patient decontamination procedure is

the most frequently used?

1. Absorption

2. Chemical wash

3. Dilution

4. Disposal and isolation

Level Health Hazard

 0 Little or none

 1 and 2 Slight

 3 Extreme

 4 Deadly
36

ASSIGNMENT 5

Textbook Assignment: “Pharmacy and Toxicology,” chapter 6, pages 6-1 to 6-26; "Common

Pharmaceuticals," appendix IV, pages AIV-1 to AIV-18.

5-1. The actual title of the “blue bible” of

pharmacology is

1. the Physicians’ Desk Reference

2. The United States Pharmacopoeia and

National Formulary (USP-NF)

3. the Pharmacological Basis of

Therapeutics

4. Remington’s Pharmaceutical Sciences

5-2. The most common factor influencing the

amount of drug given to a patient is

1. weight

2. gender

3. age

4. route of administration

5-3. What would be the proper dose in

milliliters of ampicillin for an 8-year old

child if the adult dose is 15 ml?

1. 2

2. 6

3. 9

4. 15

5-4. What is the name of the rule used to

determine appropriate dosage of medication

based on a child’s weight?

1. Young’s Rule

2. Clark’s Rule

3. Rule of Nines

4. Minimum Rule

5-5. Determine the appropriate dose in

milligrams of medication for a child

weighing 30 pounds if the average dose for

an adult dose is 600 mg.

1. 50

2. 100

3. 120

4. 150

5-6. In computing the amount of drug to be

given to an underweight female, what

adjustments to the normal dosage would

ordinarily be made?

1. Increase the dosage because of her

weight and further increase because of

her sex

2. Increase of dosage because of her

weight but decrease because of her sex

3. Decrease of dosage because of her sex

and further decrease because of her

weight

4. Decrease of dosage because of her sex

but an increase because of her weight

5-7. A drug given repeatedly to a patient often

has to be increased in dosage to maintain

the desired effect. The need for a larger

dose is probably caused by

1. an acquired tolerance from habitual

use

2. an abnormal sensitivity

3. a cumulative effect from habitual use

4. an individual idiosyncrasy
37

5-8. The most common method of administering

medications is

1. orally

2. parentally

3. topically

4. intravenously

5-9. Which of the following is an example of a

drug injected intradermally?

1. Insulin

2. Procaine hydrocloride

3. Purified protein derivative

4. 2 or 3 above

5-10. Which of the following is NOT a way in

which drugs are grouped?

1. By chemical characteristics

2. By their brand names

3. By their source

4. By their action on the body

5-11. Which of the following is a characteristic

side effect of antihistamines?

1. Nausea

2. Drowsiness

3. Uricaria

4. Tinnitis

5-12. Agents that inhibit the growth of

microorganisms without necessarily killing

them are known as

1. germicides

2. fungicides

3. antiseptics

4. astringents

5-13. The drug group most often used to treat

dyspepsia is

1. emollients

2. astringents

3. antacids

4. adsorbents

5-14. Patients sensitive to penicillin may also

exhibit sensitivity to cephalosporins.

1. True

2. False

5-15. Milk or milk products may interfere with

the absorption of which of the following

drugs?

1. Cephalexin (Keflex)

2. Tetracycline hydrochloride

3. Streptomycin sulfate

4. Erthromycin

5-16. Macrolides are effective against which of

the following organisms?

1. Gram-positive cocci

2. Dermatophytes

3. Parasites

4. Gram-negative

5-17. Supplemental potassium may be required

with which of the following categories of

drugs?

1. Anti-inflammatories

2. Antidiahrreals

3. Antipyretics

4. Diuretics

5-18. The two most important opium alkaloids

are morphine and

1. paraldehyde

2. codeine

3. meperidine

4. cocaine

5-19. Water-soluable vitamins are not excreted in

the urine and are stored in the body in

moderate amounts.

1. True

2. False
38

5-20. As used in the Navy, what is the primary

purpose of biological agents?

1. Diagnosis

2. Resuscitation

3. Immunization

4. Pest control

5-21. Which of the following organizations is

responsible for the licensing of biological

agents?

1. Secretary of the Navy

2. Public Health Service

3. American Medical Association

4. Secretary of the Treasury

5-22. With which of the following is the yellow

fever vaccine reconstituted?

1. Sterile water, USP

2. Triple distilled water, USP

3. Sterile, 5% dextrose in water, USP

4. Sterile sodium chloride injection, USP

5-23. Which of the following vaccines should not

be administered to individuals who are

sensitive to egg products?

1. Smallpox

2. Plague

3. Influenza

4. Anthrax

5-24. A poison that is introduced into the body in

one location and affects the body in another

location is displaying what effect?

1. Local

2. Remote

3. Cumulative

4. Inhibiting

5-25. The correct abbreviations for the metric

system of primary units of measure for

weight, volume, and linear dimensions are

1. gr, 1, cm

2. gr, ml, m

3. g, 1, m

4. g, l, cm

5-26. Which of the following is equal to one onehundredth of a liter?

1. Dekaliter

2. Deciliter

3. Centiliter

4. Milliliter

5-27. The basic unit of weight in the apothecary

system is the

1. gram

2. grain

3. dram

4. milliliter

5-28. A prescription requires 2 ounces of a

substance stocked in liters. How many

milliliters are required to fill the

prescription?

1. 0.030

2. 0.060

3. 30.0

4. 60.0

5-29. A compound requires 40 grains of a

substance stocked in kilograms. How many

grams are required to prepare the

compound?

1. 0.62

2. 2.6

3. 4.2

4. 2,400.0
39

5-30. You have 360 grams of a compound. If 54

grams of the compound is silver nitrite,

what is the percentage of silver nitrite?

1. 12.5

2. 15.0

3. 17.5

4. 20.0

INFORMATION FOR ITEMS 5-31 AND 5-32 IS

AS FOLLOWS: ASSUME THAT THE

FOLLOWING IS THE CORRECT FORMULA

FOR COMPOUNDING 1,000 ML OF

POTASSIUM ARSENATE SOLUTION.

Arsenic trioxide.......................... 12.8 g

Potassium bicarbonate.................. 9.8 g

Alcohol.................................... 40.0 ml

Distilled water, q.s. to make 1000..... 0 ml

5-31. You receive a prescription for 285 ml of the

preceding formula. How many milliliters

of alcohol should you use in compounding

the prescription?

1. 9.6

2. 11.4

3. 13.6

4. 15.9

5-32. If you receive a prescription for 1,800 ml of

the preceding formula, how many grams of

arsenic trioxide will you use?

1. 7.80

2. 19.40

3. 23.04

4. 25.60

5-33. A patient is to receive 1.8 million units of

oxycillin IM. Using quantity sufficient

sterile water to reconstitute a vial of 2.4

million units to 2 ml, how much of the

solution should the patient receive?

1. 1.0 ml

2. 1.25 ml

3. 1.50 ml

4. 1.75 ml

5-34. A patient is to receive a 3/4 gr dose of

Phenobarbital. If you dissolve two 1/2 gr

tablets of Phenobarbital in 30 ml of water,

how much of the solution should the patient

receive?

1. 15.0 ml

2. 17.5 ml

3. 20.0 ml

4. 22.5 ml

5-35. How many grams of sodium chloride are

required to prepare 1 liter of a 1:5000

solution?

1. 0.2

2. 0.4

3. 2.0

4. 4.0

5-36. Of the following types of pharmaceutical

preparations, which incorporates finely

powdered medicinal substances into a fatty

base?

1. Lotion

2. Suspension

3. Ointment

4. Elixir

5-37. All pharmacies that dispense medications

are required to have what Class balance?

1. A

2. B

3. C

4. D

5-38. What drug incompatibility occurs when

agents antagonistic to one another are

prescribed together?

1. Therapeutic

2. Physical

3. Chemical

4. 1 and 3 above
40

5-39. Eutexia is an example of what type of drug

incompatibility manifestation?

1. Chemical

2. Physical

3. Therapeutic

4. 2 and 3 above

5-40. A properly administered drug dosage that

has an unintended and noxious effect on the

patient is the definition of which of the

following terms?

1. Contraindication

2. Drug interaction

3. Adverse reaction

4. Therapeutic incompatibility

5-41. In the prescription block of DD 1289, what

part lists the names and quantities of the

ingredients prescribed?

1. Superscription

2. Inscription

3. Subscription

4. Signa

5-42. If, in the course of filling a prescription,

you feel that there may be a discrepancy or

incompatibility, you should take which of

the following actions?

1. Let the patient know that you

discovered an error and will be

checking with the prescriber before

filling the prescription

2. Consult the prescriber to verify the

prescription

3. Both 1 and 2

4. Fill the prescription as written

5-43. Which of the following is a schedule III

drug?

1. Marijuana

2. An antitussive

3. Amphetamines

4. Nonbarbiturate sedative

5-44. What schedule of drug can never be

ordered with refills?

1. II

2. III

3. IV

4. V

5-45. Which of the following is a

bronchomucotropic agent?

1. Petrolatum

2. Guaifenesin

3. Benzoate

4. Phenol

5-46. Aluminum acetate, an astringent, is often

used to treat which of the following

conditions listed below?

1. Athlete’s foot

2. External otitis

3. Poison ivy

4. All of the above

5-47. In conjunction with antacids, which of the

following is used to treat duodenal ulcers?

1. Dimenhydrinate

2. Diphenhydramine hydrochloride

3. Ranitidine

4. Pseudoephedrine hydrochloride

5-48. Which of the following drugs is

administered to control motion sickness?

1. Cimetidine

2. Meclizine hydrochloride

3. Chlorpheniramine maleate

4. Dephenhydramine hydrochloride

5-49. In addition to being an antacid, magnesium

hydroxide may be used as a/an

1. emollient

2. laxative

3. demulcent

4. astringent
41

5-50. Which of the following is an ideal

emollient to protect sensitive skin from the

sun?

1. Theobroma oil

2. Lanolin

3. Zinc oxide ointment

4. Aluminum acetate

5-51. The standard by which all other antiseptics

are measured is

1. betadine

2. phenol

3. isopropyl alcohol

4. hexachlorophene

5-52. An accidential spill of phenol can be

neutralized by

1. water

2. silver nitrate

3. hydrogen peroxide

4. alcohol

5-53. The primary pharmacological action of

sulfonimides is

1. viricidal

2. parasiticidal

3. bacteriostatic

4. fungistatic

5-54. The most common use for systemic

sulfonamides is in the treatment of which of

the conditions listed below?

1. Respiratory infections

2. Urinary tract infections

3. Viral infections

4. Furunculosis

5-55. Silver sulfadiazine is used almost

exclusively in the treatment of

1. surgical wound sepsis

2. burns

3. prostatitis

4. furunculosis

5-56. Which of the following is for parenteral

administration only?

1. Dicloxicillin

2. Ampicillin

3. Penicillin V

4. Penicillin G

5-57. The drug of choice for uncomplicated

group A beta-hemolytic streptococcal

pharyngitis is

1. Penicillin V potassium

2. Nafcillin

3. Ampicillin

4. Dicloxicillin

5-58. Severe colitis and diarrhea may be adverse

side effects of which of the following?

1. Neomycin sulfate

2. Gentamicin sulfate

3. Penicillin G benzathene

4. Clindamycin hydrochloride

5-59. Which of the following is an appropriate

substitute for penicillin when penicillin is

contraindicated?

1. Doxycycline

2. Cephalexin

3. Erythromycin

4. Streptomycin

5-60. Of the following drugs, which was

developed with the sole purpose being the

treatment of gonorrhea?

1. Penicillin G benzathene

2. Nitrofurantoin

3. Spectinomycin hydrochloride

4. Doxycycline hyclate

5-61. Undeclyenic acid is used as a/an

1. disinfectant

2. antipyretic

3. analgesic

4. fungicide
42

 5-62. In addition to the treatment of Phthirus,

which of the following is effective in the

treatment of scabies?

1. Nystatin

2. Miconazole nitrate

3. Permethrin

4. Metronidazole

 5-63. Trichomonas vaginalis can be treated with

1. crotamiton

2. metronidazole

3. fansidar

4. mebendazole

 5-64. Drugs that destroy parasitic worms are

known as

1. ambecides

2. vermicides

3. germicides

4. bactericides

5-65. The drug of choice for the treatment and

management of grand mal seizures is

1. methylphenidate hydrochloride

2. phenobarbital

3. phenytoin sodium

4. any psychotropic agent

5-66. Prochlorperizine is used mainly to

1. treat symptoms of nausea and vomiting

2. alleviate symptoms of tension,

agitation, and psychosis

3. counteract the effects of alcohol

withdrawal

4. relieve respiratory distress

5-67. Muscle relaxants include all of the

following EXCEPT

1. methocarbamol

2. diazepam

3. cyclobenzaprine hydrochloride

4. temazepam

5-68. Digitoxin increases the force of cardiac

contraction by acting on the

1. vagus nerve

2. valves of the heart

3. heart muscle

4. blood vessels

5-69. Of the following, which is an appropriate

drug to administer to a patient suffering an

asthma attack?

1. Amyl nitrite

2. Epinephrine

3. Phenylephrine hydrochloride

4. Atropine

5-70. The vitamin deficiency associated with

night blindness is

1. vitamin A

2. vitamin B6

3. vitamin Bl2

4. vitamin K

5-71. A deficiency of which of the following

could lead to inflammation, cracking of the

lips, or vision problems?

1. Retinol

2. Thiamine

3. Riboflavin

4. Ascorbic acid

5-72. Which of the following is the vitamin

involved in absorption and use of calcium

and phosphorus?

1. Vitamin A

2. Vitamin B1

3. Vitamin C

4. Vitamin D

5-73. The agent used to treat pernicious anemia is

1. cyanocobalamin

2. ascorbic acid

3. vitamin D

4. vitamin K
43

5-74. The general anesthesia agent most

commonly used in dentistry is

1. halothane

2. nitrous oxide

3. lidocaine hydrochloride

4. procaine hydrochloride

5-75. On what area of the body is proparacaine

hydrochloride most widely used as a topical

anesthetic?

1. Nose

2. Ears

3. Eyes

4. Throat
44

ASSIGNMENT 6

Textbook Assignment: “Clinical Laboratory,” chapter 7, pages 7-1 to 7-36.

 6-1. Which of the following, if any, is

considered the most appropriate source for

blood specimens obtained for clinical

examination?

1. By venipuncture

2. By finger puncture

3. From an artery

4. None of the above

6-2. Using the steps below, determine the

correct sequence for obtaining blood by

finger puncture.

a. Clean finger

b. Lance finger

c. Milk finger

d. Collect specimen

e. Wipe away first drop

1. a, b, c, e, d

2. c, b, e, a, d

3. a, c, b, e, d

4. c, a, b, e, d

6-3. When performing a finger puncture, the

first drop should be wiped away to avoid

which of the following conditions?

1. Bacterial contamination

2. Clotting at the puncture site

3. Dilution of the specimen with alcohol

4. Dilution of the specimen with tissue

fluids

6-4. How would a 5 ml blood specimen be

obtained from a patient with an intravenous

antibiotic being given through the left arm

and blood being received through the right

arm?

1. Multiple finger punctures

2. Left arm

3. Right arm

4. Hand or foot

6-5. A tourniquet applied to the arm during

venipuncture should provide enough

tension to compress the artery, but not the

vein.

1. True

2. False

6-6. The correct needle position for

venipuncture is (a) what degree angle and

(b) with the bevel in what position?

1. (a) 15, (b) up

2. (a) 30, (b) up

3. (a) 15, (b) down

4. (a) 30, (b) down

6-7. A tourniquet is normally applied before and

to aid in the process of venipuncture. At

what point in the venipuncture procedure

should you remove the tourniquet?

1. Just before needle insertion

2. Just after needle insertion, but before 

vacutainer

3. Once all specimens have been

collected

4. After needle removal

6-8. The part of the microscope on which the

prepared specimen is placed for

examination is called the

1. arm

2. base

3. frame

4. stage
45

6-9. All of the following are components of the

microscope’s illumination system EXCEPT

1. internal light source

2. condenser

3. external light source

4. iris diaphragm

6-10. The total magnification available by using

the lens color coded red is

1. 1000X

2. 450X

3. 100X

4. 10X

6-11. Light travels from the objective to the

ocular lens through what component of the

microscope?

1. Body tube

2. Iris diaphragm

3. High-powered lens

4. Revolving nosepiece

6-12. What objective should be used for a

detailed study of stained bacterial smears?

1. Low power

2. High dry

3. Oil immersion

4. Either 2 or 3 above

 6-13. If necessary, which, if any, of the following

substances may be used for cleaning the

lenses on a microscope?

1. Alcohol

2. Bleach

3. Xylene

4. None of the above

 6-14. A CBC includes which of the following?

1. Total RBC count

2. Hematocrit

3. Differential WBC count

4. All of the above

 6-15. The hemacytometer is designed primarily

for what purpose?

1. To differentiate between red blood

cells and white blood cells

2. To count white blood cells

3. To count red blood cells

4. Both 2 and 3

6-16. The main reason for using the cover glass

included with the hemacytometer instead of

an ordinary cover glass is because the

hemacytometer cover glass

1. is clearer

2. has an even surface

3. is thicker

4. is less likely to break

6-17. A subnormal RBC count may indicate that

the patient has which of the following listed

conditions?

1. Leukopenia

2. Anemia

3. Dehydration

4. Uremia

 6-18. What is the total capacity of the capillary

pipette provided in a Unopette® for RBC

count?

1. 0.5μl

2. 1.0μl

3. 10.0μl

4. 100.0μl

6-19. Which of the following conditions indicates

that the counting chamber is properly

loaded?

1. There is a thin, even film of fluid

under the coverglass

2. The fluid flows into the grooves at the

edges of the chamber

3. Air bubbles are seen in the field

4. The chamber is flooded
46

6-20. What objective should be used for counting

RBCs?

1. Low power

2. High power

3. Oil immersion

4. High dry

6-21. When counting cells, to arrive at a correct

count, the cells touching the lines on

the_______ and ________are counted in

addition to all cells totally within each

square.

1. Left, top

2. Left, bottom

3. Right, top

4. Right, bottom

6-22. To arrive at the number of RBCs per mm3 ,

total the number of cells counted in the five

fields and multiply by

1. 0.1

2. 10.0

3. 100.0

4. 10,000.0

6-23. Which of the following factors affect

hemoglobin values?

1. Age

2. Sex

3. Altitude

4. All the above

6-24. Both the number of squares and the

counting procedure for WBCs is the same

as it is for RBCs.

1. True

2. False

6-25. What is the term used for the volume of

erythrocytes expressed as a percentage of

the volume of whole blood in a sample?

1. Hematocrit

2. Hemoglobin

3. Red blood count

4. Complete blood cell count

6-26. The hematocrit for a normal, healthy

female is within what range?

1. 30 to 40 percent

2. 37 to 47 percent

3. 42 to 50 percent

4. 44 to 52 percent

6-27. A shift from leukocytosis toward

leukopenia in a patient with a systemic

bacterial infection is a good sign.

1. True

2. False

6-28. Select from those listed below the term

used to describe an abnormally high WBC

count.

1. Leukocytosis

2. Erythrocytosis

3. Leukopenia

4. Pancytopenia

6-29. Which of the following conditions may

cause leukopenia?

1. Strep throat

2. Psittacosis

3. Anaphylactic shock

4. Each of the above

6-30. To arrive at the number of white cells per

mm3

 of blood, total the number of cells

counted in the four fields and multiply by

1. 0.5

2. 5.0

3. 50.0

4. 5000.0
47

6-31. A differential blood count is the percentage

of distribution in the blood of which of the

following types of cells?

1. Lymphocytes

2. Monocytes

3. Leukocytes

4. Erythrocytes

6-32. What is the function of leukocytes?

1. To carry oxygen through the blood

2. To control various disease conditions

3. To aid in clotting the blood

4. Each of the above

6-33. What type of leukocyte comprises the

largest percentage of cells in the circulating

blood?

1. Lymphocyte

2. Neutrophil

3. Erythocyte

4. Thrombocyte

6-34. When viewing a smear for a differential

count, you identify the cells with the large,

scattered dark blue granules that are darker

than their nuclei as

1. lymphocytes

2. monocytes

3. basophils

4. neutrophils

6-35. The largest of the normal WBCs is the

1. monocyte

2. lymphocyte

3. eosinophil

4. basophil

6-36. On a properly prepared slide for a

differential count, the smear will

1. extend from one side of the slide to the

other

2. be evenly distributed on the entire

slide

3. show no wavy or blank spots

4. show smooth even edges

6-37. Properly prepared differential slides require

a longer rinse time than stain time.

1. True

2. False

6-38. If a smear used in a differential count is to

be saved for reexamination, remove the

immersion oil by placing a piece of lens

tissue over the slide and moistening the

tissue with

1. alcohol

2. water

3. xylene

4. acetone

6-39. A continued shift to the left with a falling

total WBC count probably indicates

1. progress toward normal recovery

2. a decrease in immature neutrophils

3. a breakdown of the body’s defense

mechanism and is a poor prognosis

4. a decrease in parasitic and allergenic

conditions
48

TO ANSWER QUESTIONS 6-40 THROUGH

6-43, SELECT FROM THE ABOVE LIST THE

CONDITION THAT MOST APPROPRIATELY

CORRESPONDS TO THE LEUKOCYTIC

CHARACTERISTIC IN THE QUESTION.

6-40. Increased eosinophils.

1. A

2. B

3. C

4. D

6-41. Increased monocytes.

1. A

2. B

3. C

4. D

6-42. Decreased WBC count with increased

juvenile cells.

1. A

2. B

3. C

4. D

6-43. Decreased WBC count with increased

mature cells.

1. A

2. B

3. C

4. D

6-44. All of the following are classifications of

bacteria EXCEPT

1. Temperature and moisture content

2. Growth requirements and morphologic

characteristics

3. Toxins produced and diseaseproducing ability

4. Gram’s stain reaction and colonial

morphology

6-45. The difference between anaerobes and

aerobes is that anaerobes need oxygen to

reproduce.

1. True

2. False

6-46. Autotrophic bacteria require an

environment that supplies them with

nourishment.

1. True

2. False

6-47. Which of the following structures provides

some bacteria with a means of movement?

1. Capsule

2. Spore

3. Spirillum

4. Flagellum

6-48. What type of bacterial toxin completely

lyses erythrocytes?

1. Exotoxin

2. Endotoxin

3. Beta hemolysin

4. Alpha hemolysin

A. Recovery

B. Parasitic infection

C. Breakdown of the

body’s defense

D. Active tuberculosis
49

TO ANSWER ITEMS 6-49 THROUGH 6-53,

SELECT FROM THE ABOVE LIST THE

CONDITION MOST PROBABLY CAUSED BY

THE AGENT LISTED IN THE QUESTION.

6-49. Bordetella pertussis.

1. A

2. C

3. E

4. F

6-50. Streptococcus pneumoniae.

1. A

2. B

3. C

4. E

6-51. Yersinia pestis.

1. B

2. C

3. D

4. E

6-52. Clostridium perfringens.

1. A

2. C

3. D

4. F

6-53. Staphylococcus aureus.

1. A

2. D

3. E

4. F

6-54. In the Gram’s stain procedure, which of the

following chemicals acts as the mordant?

1. Crystal violet

2. Safranin

3. Iodine

4. Acetone

6-55. All of the following statements are true

about antigens EXCEPT that an antigen

1. is inherently unstable structurally

2. must be foreign to the body

3. possesses a high molecular weight

4. has a high specificity to stimulate

tissues to produce antibodies

6-56. The Rapid Plasma Reagin test for syphilis

is best used with what type of specimen?

1. Serum

2. Plasma

3. Whole blood

4. Either serum or plasma

A. Impetigo

B. Plague

C. Pneumonia

D. Gas gangrene

E. Strep throat

F. Whooping cough
50

6-57. To properly perform the RPR Card Test,

the serum sample should be from arterial

blood that has been separated from the

blood cells as soon after collection as

possible.

1. True

2. False

6-58. Which of the following actions is

considered appropriate if a patient’s RPR is

reactive?

1. Give patient penicillin

2. Send patient to lab for further testing

3. Counsel patient against engaging in

unsafe sex

4. Report results of RPR to patient’s

commanding officer

6-59. Which of the following chemical

preparations is frequently used to detect

fungi?

1. Hydrogen sulfoxide

2. Hydrogen peroxide

3. Potassium hydroxide

4. Potassium sulfate

6-60. The best urine specimen is that taken

during which of the following times?

1. First morning

2. Random

3. Fasting

4. 24 hour

6-61. For a 24-hour urine specimen collection,

which of the following statements is

INCORRECT?

1. Discard the first specimen

2. Add a preservative after the first

specimen has been obtained

3. Discard the last specimen

4. Refrigerate the specimen during the

collection period

6-62. What purpose does toluene serve when

used in conjunction with a urine specimen?

1. It increases the albumin

2. It dissolves unwanted cells

3. It protects the specimen from

decomposition

4. It dissolves the albumin

6-63. Which of the following colors would be

considered abnormal in a urine specimen?

1. Colorless

2. Amber

3. Straw

4. Red

TO ANSWER ITEMS 6-64 THROUGH 6-67,

SELECT FROM THE ABOVE LIST THE

MOST PROBABLE CAUSATIVE AGENT

THAT WOULD PRODUCE THE URINE

COLOR STATED IN THE QUESTION.

6-64. Milky.

1. A

2. B

3. C

4. D

6-65. Dark orange.

1. A

2. B

3. C

4. D

A. Pyridium®

B. Bile

C. Blood

D. Fats (chyle)
51

6-66. Red-brown.

1. A

2. B

3. C

4. D

6-67. Brown.

1. A

2. B

3. C

4. D

6-68. A report on urine transparency is valid

regardless of standing time.

1. True

2. False

6-69. The specific gravity of a liquid or solid is

the weight of the substance as compared to

an equal volume of

1. ethanol

2. methanol

3. distilled water

4. normal saline

6-70. In the microscopic examination of urine

sediment, scan the slide using the low per

objective and examine it in detail using

which of the following objectives?

1. Low power

2. High dry

3. High power

4. Oil immersion

6-71. The addition of one drop of 5 percent acetic

acid to urine sediment will disintegrate

1. white blood cells

2. mucous threads

3. casts

4. red blood cells

6-72. There are seven types of casts or sediments

found in urine. Of the four listed below,

which may be attributed to lupus?

1. Red cell casts

2. Fatty casts

3. Granular casts

4. Epithelial casts
52

ASSIGNMENT 7

Textbook Assignment: “Medical Aspects of Chemical, Biological, and Radiological Warfare,” chapter 8,

pages 8-1 to 8-18; "Diet and Nutrition," chapter 9, pages 9-1 to 9-11; "Emergency

Dental Care and Preventive Medicine," chapter 10, pages 10-1 to 10-6.

7-1. Who is responsible for area decontamination of chemical agents aboard ship?

1. Medical officer

2. Supply officer

3. Damage control personnel

4. All hands

7-2. What should be the first priority in the

treatment of chemically contaminated

casualties?

1. Control of massive hemorrhage

2. Decontamination

3. Treatment of life-threatening shock

and wounds

4. Removal of contaminated clothing

7-3. Who, if anyone, is responsible for

maintaining adequate supplies for the

decontamination and treatment of CBR

casualties?

1. Medical officer

2. Damage control officer

3. Supply officer

4. No one

7-4. Nerve agents produce their effect by

interfacing with normal transmission of

nerve impulses.

1. True

2. False

7-5. The tendency of a chemical agent to

remain effective in a contaminated area is

known as

1. lethality

2. persistency

3. volatility

4. permeability

7-6. Inhalation of nerve gas characteristically

results in which of the symptoms listed

below?

1. Local muscular twitching

2. Dry mouth

3. Pinpoint pupils

4. Pulmonary edema

7-7. In a definitive care facility, the indicated

treatment of a nerve agent victim includes

which of the following therapies?

1. 2 mg atropine and 600 mg 2-PAM

chloride every 15 minutes until

recovery

2. 2 mg atropine every 15 minutes until

the victim has a dry mouth and mild

tachycardia

3. 600 mg 2-PAM chloride every 15

minutes until the victim is conscious

4. Respiratory support only

7-8. What part of the body is most sensitive to

the effects of mustard gases?

1. Eyes

2. Lungs

3. Liver

4. Skin

7-9. Specific antidotal therapy is available for

which, if any, of the following vesicants?

1. Mustard (HD)

2. Nitrogen mustard (HN)

3. Lewisite (L)

4. None of the above
53

7-10. First aid treatment for blood agents is amyl

nitrite ampules followed by which of the

compounds listed below?

1. Oral potassium chloride

2. Oral sodium thiosulfate

3. Intravenous potassium chloride

4. Intravenous sodium thiosulfate

7-11. The symbol for phosgene gas is

1. C1

2. CN

3. CG

4. CK

7-12. Which of the following odors is an early

indication of exposure to phosgene gas in

casualty-producing amounts?

1. Bitter almonds

2. A freshly mown lawn

3. Geraniums

4. None of the above. Phosgene is

undetectable

7-13. The chemical agent that primarily affects

the higher regulatory functions of the CNS

is represented by which of the following

symbols?

1. AC

2. BZ

3. CN

4. CS

7-14. Exposure to fresh air and allowing wind to

blow across wide open eyes is generally

sufficient treatment for which of the

following agents?

1. Psychochemicals

2. Lacrimators

3. Vomiting agents

4. Glycolates

7-15. With exposure to Adamsite, which, if any,

of the following actions must be taken to

minimize or inhibit the symptoms of

exposure?

1. Don a protective mask and continue

duties as vigorously as possible

2. Give an intramuscular injection of

physostigmine

3. Give an intravenous infusion of

sodium thiosulfate

4. Do none of the above

7-16. What is the proper treatment for burning

white phosphorus particles embedded in

the skin?

1. Surgical removal followed by a

copper sulfate wet dressing

2. A copper sulfate rinse then surgical

removal

3. A copper sulfate rinse only

4. Allowing them to burn out

7-17. By what means can biological agents can

be detected?

1. Physical senses

2. Chemical detectors

3. Laboratory examination

4. All of the above

7-18. When entering an area known to be

contaminated with biological agents,

which of the following actions should be

taken?

1. Put on gloves, if available

2. Button up clothing

3. Put on a protective mask

4. Do all of the above
54

7-19. What is the appropriate procedure to

follow when biological agents are known

to have been placed in your drinking

water?

1. Double the amount of chlorine in the

water

2. Double the time the water is exposed

to the chlorine

3. Boil the water before you drink any of

it

4. Refrain from drinking the water

7-20. Presenting a serious internal radiation

hazard, alpha particles can enter the body

through which of the following?

1. The digestive system

2. The respiratory system

3. Open wounds

4. Any of the above

7-21. Of the following, which type of radiation

has the greatest penetrating power?

1. Alpha

2. Beta

3. Gamma

4. Neutron

7-22. In the event of a nuclear detonation, what

is the best position to assume?

1. Sitting, with the knees drawn up to the

chest, facing away from the blast

2. Face down, with your face covered

3. On your side, in a fetal position facing

away from the blast

4. Supine, with your face covered

7-23. The treatment of thermal burns from a

nuclear detonation differs from more

conventional burn wounds in which, if any,

of the following ways?

1. Conventional burn wounds are

generally less serious

2. Conventional burn wounds are more

likely to become infected

3. Burns resulting from a nuclear

detonation are more painful

4. There is no difference

7-24. When using antibiotics for victims of

radiation injuries, what is the

recommended dosage?

1. One-half of the normal dosage

2. The normal dosage

3. Two times the normal dosage

4. Three times the normal dosage

7-25. Approximately what number of calories

must be burned or consumed for the

average individual to lose or gain one

pound?

1. 1,500

2. 2,000

3. 3,500

4. 5,000

 7-26. Which of the following nutritive elements

are considered the "building blocks" of the

body?

1. Fats

2. Carbohydrates

3. Minerals

4. Proteins

 7-27. What happens to protein consumed that is

in excess of body requirements?

1. Used to supply energy only

2. Changed into fat only

3. Both 1 and 2

4. Excreted from the body through

elimination
55

 7-28. What total number of amino acids are

obtained solely from the food we eat?

1. 3

2. 7

3. 9

4. 11

7-29. What amount of protein should a nonpregnant person consume on a daily basis?

1. 0.8 g/kg

2. 1.2 g/kg

3. 2.2 lbs

4. There is no specific recommended

amount

 7-30. Protein deficiency can result in which of

the following conditions?

1. Nutritional edema

2. Secondary anemia

3. Restricted growth

4. Each of the above

7-31. The number of calories generated by each

gram of protein, fat, and carbohydrate,

respectively is

1. 3, 6, 4

2. 4, 9, 4

3. 6, 3, 9

4. 9, 4, 6

7-32. The serum cholesterol level of adults over

the age of 30 should be less than

1. 100 mg/dl

2. 150 mg/dl

3. 200 mg/dl

4. 300 mg/dl

7-33. Of the following, which is NOT a source

of dietary fat?

1. Rice

2. Whole milk

3. Avocados

4. Egg yolks

 7-34. Refined and processed sugars should make

up no more than what percent of an

individual’s total caloric intake?

1. 5

2. 10

3. 15

4. 20

FOR QUESTIONS 7-35 TO 7-39, USE THE

ABOVE LIST TO MATCH THE FOOD

IDENTIFIED IN EACH OF THE QUESTIONS

TO THE NUTRITIVE ELEMENT

PRIMARILY ASSOCIATED WITH IT.

7-35. Fish.

1. A

2. B

3. C

4. D

7-36. Honey.

1. A

2. B

3. C

4. D

7-37. Butter.

1. A

2. B

3. C

4. D

7-38. Eggs.

1. A

2. B

3. C

4. D

A. Complex carbohydrates

B. Simple carbohydrates

C. Proteins

D. Fats
56

7-39. Corn.

1. A

2. B

3. C

4. D

7-40. An otherwise normal, healthy diet is

always sufficient to provide an individual

with adequate levels of minerals.

1. True

2. False

7-41. Consumption of excessive amounts of

certain vitamins can, in some

circumstances, be fatal.

1. True

2. False

7-42. Which of the following is sometimes

referred to as "the forgotten nutrient"?

1. Selenium

2. Phosphorus

3. Water

4. Fructose

7-43. According to the Dietary Guidelines for

Americans, upon which of the following

dietary elements should a nutritional diet

be based?

1. Fruits and vegetables

2. Complex carbohydrates

3. Fats

4. Dairy

7-44. Fried foods, as long as they are not too

crisp, may be included in a soft diet.

1. True

2. False

7-45. When a liquid diet has been ordered by the

attending physician or dietician, the

feedings should be ____ ounces and

administered every ____ hours.

1. 4-6, 3-4

2. 6-8, 2-3

3. 8-10, 6-8

4. 10-12, 2-3

7-46. A high-calorie diet may be effected by

modifying the regular diet in which of the

following ways?

1. Adding snacks

2. Increasing portions

3. Providing commercial supplements

4. Each of the above

FOR QUESTIONS 7-47 TO 7-51, SELECT THE

DIET FROM THE LIST ABOVE THAT MOST

APPROPRIATELY MATCHES THE

MALADY IN THE QUESTION.

7-47. Malnourishment.

1. A

2. B

3. C

4. D

7-48. Hypothyroidism.

1. E

2. D

3. C

4. B

7-49. Inflammatory GI tract.

1. A

2. B

3. C

4. D

A. Liquid

B. High-calorie

C. High-protein

D. Low-calorie

E. Low-protein
57

7-50. Low production of antibodies.

1. E

2. D

3. C

4. B

7-51. Chronic nephrotic edema.

1. B

2. C

3. D

4. E

7-52. Which of the following is appropriate

procedure in the administration of a highresidue diet?

1. Ensure adequate fluid intake

2. Limit caffeine intake

3. Provide raw or tender-cooked

vegetables

4. All of the above

FOR QUESTIONS 7-53 TO 7-57, SELECT THE

DIET FROM THE LIST ABOVE THAT MOST

APPROPRIATELY MATCHES THE

MALADY IN THE QUESTION.

7-53. Peptic ulcers.

1. E

2. D

3. C

4. B

7-54. Hypertension.

1. A

2. B

3. C

4. D

7-55. Hemorrhoidectomy.

1. E

2. D

3. C

4. B

7-56. Hypoglycemia.

1. B

2. C

3. D

4. E

7-57. Spastic colon.

1. A

2. B

3. C

4. D

7-58. What is the most common cause of dental

caries?

1. Sugar

2. Lack of fluoridation

3. Infrequent dental examinations

4. Bacterial plaque

7-59. Severe inflammation of the tooth pulp is

known as

1. acute pulpitis

2. periapical absess

3. marginal gingivitis

4. necrotizing ulcerative gingivitis

 7-60. The most frequent cause of marginal

gingivitis is

1. bacteria

2. caries

3. poor oral hygiene

4. periodontitis

A. High-residue

B. Low-residue

C. Low-sodium

D. Bland

E. Low-carbohydrate, highprotein
58

 7-61. What is the most frequent cause of

periodontal abscesses?

1. A virus

2. An infection

3. Poor oral hygiene

4. Prolonged irritation

 7-62. An inflammation of the gingiva around a

partially erupted tooth is known as

1. periodontitis

2. periodontal abscess

3. stomatitis

4. pericoronitis

 7-63. An inflammation of the oral mucosa is

called

1. periocoronitis

2. gingivitis

3. stomatitis

4. periodontitis

 7-64. Labial herpes is an infection that results in

which of the following conditions?

1. Fever blisters

2. Gingivitis

3. Pericoronitis

4. All the above

7-65. Excruciating, constant pain 3 days after a

tooth extraction indicates which of the

following conditions?

1. Hemorrhage

2. Osteitis

3. Stomatitis

4. Pericoronitis

7-66. The form used to record dental treatment is

the

1. SF 600

2. SF 602

3. EZ 603A

4. NAVMED 6150/20

 7-67. In addition to maintaining and promoting

good health, personal hygiene is important

for which of the following reasons?

1. Inhibits the spread of disease

2. Promotes good morale

3. Decreases the risk of disabling disease

4. All of the above

7-68. Preventive medicine procedures in the

Navy are addressed in detail in what

publication?

1. SECNAVINST 4061.1

2. NAVMED P-5010

3. NAVMED P-5038

4. Navy Supply Publication 486

7-69. Animals that carry disease and can

transmit those diseases to human or animal

hosts to cause illness or injury are called

1. pests

2. insects

3. vectors

4. rodents

7-70. Guidance as to appropriate food storage

temperatures, storage life of perishable and

semi-perishable food items, and safe time

limits for keeping food can be found in

which of the following publications?

1. SECNAVINST 4061.1

2. NAVMED P-5010

3. NAVMED P-5038

4. Navy Supply Publication 486

7-71. All Navy and Marine Corps food-service

facilities must be inspected by a medical

department representative and food-service

department representative.

1. True

2. False
59

7-72. Immunizations used within the Armed

Forces are required to meet standards set

forth by which of the following

organizations?

1. Food and Drug Administration

2. Department of Health and Human

Services

3. Centers for Disease Control

4. National Institutes of Health

7-73. Instructions for preparing and submitting

the Medical Event Report can be found in

which of the following publications?

1. SECNAVINST 4061.1

2. NAVMED P-5010

3. NAVMED P-5038

4. Navy Supply Publication 486

7-74. As long as it is clear, tastes good, and is

free from odor, water obtained in the field

can be considered to be potable.

1. True

2. False

7-75. Marine sanitation devices (MSDs) perform

what function(s) aboard ship?

1. Treat sewage before discharge into

restricted waters

2. Collect and hold sewage for treatment

3. Treat sewage before discharge into

unrestricted waters

4. Both 2 and 3
60

ASSIGNMENT 8

Textbook Assignment: “Physical Examinations,” chapter 11, pages 11-1 to 11-12; "Health Records,"

chapter 12, pages 12-1 to 12-25; "Supply," chapter 13, pages 13-1 to 13-21.

8-1. Physical examinations of Navy and Marine

Corps personnel, whether active or reserve,

may be performed by which of the

following?

1. Navy medical officers

2. DoD physicians

3. Credentialed civilian contract

physicians

4. All the above

 8-2. What entity is responsible for setting the

physical standards for entry into the U.S.

Navy?

1. Bureau of Naval Personnel

2. Department of Defense

3. Bureau of Naval Medicine

4. Chief of Naval Operations

 8-3. In which, if any, of the following

publications will you find the prescribed

intervals for periodic physical

examinations?

1. MILPERSMAN

2. NAVMED P-5010

3. NAVMED P-117

4. None of the above

 8-4. All of the following are functions of a

medical board EXCEPT

1. evaluating and reporting on diagnosis

2. selection of personnel for special duty

3. planning for treatment, rehabilitation,

or convalescence

4. estimating the length of further

disability

 8-5. Family member screening is required even

if a servicemember is accepting

unaccompanied orders to an overseas duty

station.

1. True

2. False

8-6. Medical surveillance examinations are

required for certain occupational fields or

certain skills or jobs; e.g., people who work

with beryllium or mercury. Specific

guidelines on what tests are required and

the frequency of those tests can be found in

1. BUMEDINST 5100.1

2. COMNAVMEDCOMINST 5100.46

3. OPNAVINST 5100.23

4. SECNAVINST 6200.2

8-7. What report is used when a member is

expected to return to full duty status after

being placed on limited duty?

1. Limited Duty (LIMDU) Board

2. Formal Medical Board

3. Abbreviated Temporary Limited Duty

(TLD) Medical Board

4. Physical Examination Board (PEB)

8-8. Which of the following steps is appropriate

when a servicemember is found not fit for

duty after an initial TLD period of 6

months, but has a favorable prognosis and

is expected to be returned to duty within 4

more months?

1. Administrative separation

2. Extension of 4 months to his TLD

3. Initiation of a second and final 6-

month TLD

4. Formal medical board
61

8-9. What is the maximum length of time an

individual may be held on limited duty

without convening a formal board?

1. 8 months

2. 16 months

3. 1 year

4. 2 years

8-10. Who is responsible for verifying the

content of a medical board?

1. The attending physician

2. The LIMDU Coordinator

3. The Patient Administration Limited

Duty Coordinator

4. The convening authority

8-11. A command endorsement is required on a

formal medical board.

1. True

2. False

8-12. A Sailor reports for her periodic physical

examination and states that no changes

have occurred in her medical status since

her last physical. What entry, if any, would

be appropriate to put in block 25 of her

SF 93, Report of Medical History?

1. "N/A"

2. "No changes"

3. "No significant interval history"

4. Nothing; leave block 25 blank

8-13. One method for testing near visual acuity is

the

1. Snellen charts

2. Jaeger cards

3. Farnsworth lantern

4. pseudoisochromatic plates

8-14. The preferred method for testing color

vision is the

1. Snellen charts

2. Jaeger cards

3. Farnsworth lantern

4. pseudoisochromatic plates

8-15. EKGs are performed routinely as part of a

member’s physical examination once the

member reaches the age of 35.

1. True

2. False

 8-16. The health record of a military member

may be used for which of the following

purposes?

1. Aid in determining claims

2. Determine physical fitness

3. Provide data for medical statistics

4. Do all of the above

8-17. Of the following, which is NOT considered

a major category of the primary medical

record?

1. DREC

2. HREC

3. IREC

4. OREC

8-18. Secondary medical records, which are held

separately from primary medical records,

are not normally opened or maintained for

active duty personnel. Under which of the

following circumstances may a secondary

medical record be established for an active

member?

1. The member is to undergo surgery

2. The member is to go TAD for medical

treatment

3. The member is under investigation for

domestic abuse

4. The member is AWOL
62

8-19. What information should be included on

the NAVMED 6150/20 of a member’s

primary medical record with respect to the

existence of a member’s secondary medical

record?

1. Nature of secondary record

2. Patient’s diagnosis

3. Clinic name, address, and phone

number

4. Each of the above

8-20. Custody of health records is generally

vested in the medical department. On ships

without a medical department

representative, an individual retains custody

of the record until which of the following

times, if any?

1. Transfer

2. Transfer with verification every 6

months

3. Transfer with annual verification

4. Never

8-21. Health records are for official use only but

are subject to inspection an any time by

1. the commanding officer or his or her

superior

2. authorized medical inspectors

3. the fleet medical officer

4. any of the above

8-22. When a member is hospitalized in a foreign

nation and the ship departs port, the health

record is

1. retained on board

2. turned over to the hospital

3. forwarded to the nearest U.S. consulate

or embassy

4. turned over to another U.S. vessel in

port

8-23. Although considered privileged, release of

information in the health record is required

under the Freedom of Information Act.

1. True

2. False

8-24. Under which of the following

circumstances may an individual’s medical

information be released to his authorized

representative(s)?

1. When verbally requested by the

individual

2. Upon request of the representative

when adequate proof of the

individual’s death can be provided

3. Upon proof that the individual has

been declared mentally incompetent

4. Both 2 and 3 above

8-25. A well-known and preeminent research

group requests medical information to use

as part of the basis of a study it is

performing. What action, if any, should be

taken prior to release? 

1. Commanding officer of MTF should

release information immediately

2. Commanding officer of MTF should

check with the Judge Advocate

General for advice

3. Commanding officer of MTC should

forward the request to BUMED for

guidance

4. None; an individual’s medical

information may not be released for

research

8-26. The health record jacket of PO3 Walter T.

Door, 333-44-5555, would be what color?

1. Blue

2. Almond

3. Orange

4. Pink
63

8-27. A health record is only opened in which of

the following cases?

1. When a member returns to active duty

from the retired list

2. When the original record has been lost

3. When first becoming a member of the

naval service

4. In all the above cases

8-28. In the record category box on the health

record jacket, all active duty military

records are identified by what color tape?

1. Blue

2. Black

3. Red

4. White

8-29. The health jackets of flag or general

officers should be annotated to reflect their

rank.

1. True

2. False

8-30. When a HREC is opened on a service

member, the member should be directed to

read and sign the Privacy Act Statement

inside the back cover of the HREC.

1. True

2. False

8-31. Entries to the Chronological Record of

Medical Care, SF 600, when not

typewritten, should be made in which

color(s) of ink?

1. Blue

2. Black or blue-black

3. Red

4. Ink color is irrelevant

8-32. What is the preferred form on which to

record admission to the hospital?

1. SF 509, Medical Record-Progress

Report

2. SF 600, Chronological Record of

Medical Care

3. NAVMED 6150/4, Abstract of Service

and Medical History

4. NAVMED 6150/20, Summary of Care

IN ANSWERING QUESTIONS 8-33

THROUGH 8-36, SELECT FROM THE 

ABOVE LIST THE APPROPRIATE HEALTH

RECORD FORM FOR RECORDING THE

INFORMATION GIVEN.

8-33. Routine innoculations.

1. A

2. B

3. C

4. D

8-34. Human immune virus testing.

1. A

2. B

3. C

4. D

8-35. Sick call visits for poison ivy.

1. A

2. B

3. C

4. D

A. SF 600

B. SF 601

C. DD1141

D. NAVMED 6150/2
64

8-36. Results of radiation monitoring.

1. A

2. B

3. C

4. D

IN ANSWERING QUESTIONS 8-37

THROUGH 8-39, SELECT FROM THE ABOVE

LIST THE HEALTH RECORD FORM THAT

MOST CLOSELY RELATES TO THE

STATEMENT IN THE QUESTION.

8-37. Used for ordering corrective lenses.

1. A

2. B

3. C

4. D

8-38. May be used for an active duty patient who

is admitted to the hospital for less than 24

hours.

1. A

2. B

3. D

4. E

8-39. A record of prophylactic immunizations

and sensitivity tests.

1. A

2. B

3. C

4. D

8-40. Which of the following documents should

NEVER be filed in an individual’s HREC?

1. FM 8-33

2. PHS-731

3. SF 509

4. NAVMED 6100/1

8-41. In which of the following circumstance

should the health record be verified?

1. Upon reporting

2. Upon transfer

3. At the time of a physical examination

4. In all of the above cases

8-42. Under which of the following

circumstances would a member’s health

record NOT be closed?

1. Transfers to a new duty station

2. Transfers to the Fleet Reserve

3. Placed on the retired list

4. Declared missing in action

8-43. On which of the following documents

would a notation be made concerning an

member’s status as a deserter?

1. SF 600

2. NAVMED 6100/1

3. NAVMED 6150/4

4. Both 1 and 3

8-44. A copy of the HREC of a member

separated for disability should be given to

the member for presentation to the DVA so

that the member’s claim can be processed

expeditiously.

1. True

2. False

A. NAVMED 6150/4

B. SF 539

C. SF 601

D. DD 771
65

 8-45. Which of the following types of

appropriations is not normally used by the

Navy?

1. Multiple-year

2. Annual

3. Continuing

4. Apportioning

8-46. At the end of the second quarter, what is

done with the funds that have not been

obligated in the previous quarter?

1. The funds are carried over into the

next quarter

2. The funds are carried over into the

next year

3. The funds are returned to the Treasury

4. The funds are placed in the

command’s welfare and recreation

fund

8-47. The shipboard medical OPTAR may be

used to purchase all of the following items

EXCEPT

1. x-ray units and film processors

2. medical books and publications

3. gun bags

4. litters and stretchers

8-48. Which of the following characteristics

could designate an item as controlled

equipage?

1. High cost

2. Liable to pilferage

3. Required for ship’s mission

4. Each of the above

8-49. The first four digits of a National Stock

Number are known as the

1. Federal Supply Classification code

2. Federal Stock number

3. National Identification number

4. Cognizance symbol

8-50. How many digits are in a National Stock

Number?

1. 9

2. 10

3. 12

4. 13

8-51. In which of the following would you find

handling or storage codes, a brief

description of each item, and a crossreference of NINs and NSNs?

1. Management Data List (MDL)

2. Identification List (IL)

3. Authorized Medical Allowance List

(AMAL)

4. Naval Supply System Command

Manual

TO ANSWER ITEMS 8-52 THROUGH 8-54,

SELECT FROM THE TABLE BELOW THE

LEVEL OF SUPPLY DEFINED IN THE ITEM.

A. Stockage objective

B. Identification List (IL)

C. Operating level

D. Requisitioning objective

8-52. The quantity of an item required to support

operations between the time a requisition is

submitted and receipt of material.

1. A

2. B

3. C

4. D

8-53. The minimum amount of an item of

material required to support operations.

1. A

2. B

3. C

4. D
66

8-54. The maximum amount of material in stock

and on order to support operations.

1. A

2. B

3. C

4. D

8-55. What is the name of the standard computer

supply management system used by

shipboard medical departments?

1. Shipboard Automated Medical Supply

2. SNAP Automated Medical System

3. Supply Automated Medical System

4. Shipboard Automated Management

System

8-56. Medical journals and books may be ordered

on which of the following forms?

1. DD Form 1149, Requisition and

Invoice/Shipping Document

2. NAVSUP Form 1250-1, Single-Line

Item Requisition Document (manual)

3. DD Form 1348m, DOD Single-Line

Item Requisition Document

(mechanical)

4. DD Form 1348m, Non-NSN

Requisition (manual)

8-57. Who assigns the Urgency of Need

Designator (UND) on a requisition?

1. Activity requiring the material

2. Supply depot

3. Stock point

4. Inventory control point

8-58. What is the purpose of a Report of

Discrepancy, SF 364?

1. To determine the cause of a

discrepancy

2. To effect corrective action on a

discrepancy

3. To prevent recurrence of a discrepancy

4. To do all of the above

8-59. Whenever possible and where space

permits, aisles in stowage areas should be

at least how wide?

1. 18 in

2. 24 in

3. 30 in

4. 36 in

8-60. All of the following locations aboard ship

are appropriate stowage areas for hazardous

material EXCEPT

1. below the full-load water line

2. adjacent to a magazine

3. near either end of the ship

4. behind watertight doors

8-61. Alcohol should be stowed in a locked

container in the paint and flammable liquid

storeroom.

1. True

2. False

8-62. What is the primary purpose of an

inventory?

1. To locate missing items

2. To determine what items are in a

storeroom

3. To ensure balance on hand match

stock record cards

4. To balance the OPTAR

8-63. Differences between on-hand quantity,

location of stock, or other stock record data

should be reconciled in accordance with

what publication?

1. NAVSUP 1114

2. NAVSUP P-437

3. NAVSUP P-485

4. NAVSUPINST 4200.85
67

8-64. Once a stock record card has been totally

filled in, a new card should be prepared,

following all of the steps listed EXCEPT

1. bring forward demand quantity and

frequency demand totals from old card

2. destroy old card, in accordance with

local policy

3. bring forward any outstanding

requisitions from old card

4. enter the beginning date on the new

card

8-65. How often must inventory of controlled

substances be conducted?

1. Weekly

2. Monthly

3. Quarterly

4. Semiannually

8-66. In what document would you find the

contents of each contingency block

outlined?

1. AMAL

2. MAP

3. MMART Manual

4. SPRINT

8-67. At a minimum, how often should all

AMALs be reviewed?

1. Monthly

2. Quarterly

3. Semiannually

4. Annually
68

ASSIGNMENT 9

Textbook Assignment: “Administration,” chapter 14, pages 14-1 to 14-14; "Health Care Administration,"

chapter 15, pages 15-1 to 15-13; and "Decedent Affairs," chapter 16, pages 16-1 to

16-15.

9-1. The Medical Department Journal contains a

chronological record of events concerning

the Medical Department and should include

all of the following EXCEPT

1. reports of personnel casualties,

injuries, or deaths

2. personnel entered onto or deleted from

the binnacle list

3. medical histories of personnel

4. training lectures to stretcher bearers

9-2. NAVMED 6320/18, Binnacle List, is used

to list all personnel falling into what status?

1. Admitted to the hospital

2. Excused from duty for 24 hours or less

because of illness

3. Excused from duty for more than 24

hours because of illness

4. Who reported to sick call in the

morning

9-3. NAVMED 6320/19 Morning Report of the

Sick, must be submitted to the commanding

officer daily by what time?

1. 0800

2. 0900

3. 1000

4. 1100

9-4. A member misses his clinical appointment.

He has missed two previous appointments. 

What action, if any, should the Corpsman

maintaining the appointment log take?

1. Call the member and reschedule the

appointment

2. Notify the member's chain of

command that he has missed several

appointments

3. Do nothing; when the member is able

to reschedule, he will do so

9-5. A notice issued under the Navy Directive

Issuance System has the same force and

effect as an instruction.

1. True

2. False

9-6. In the process of making changes to

directives, which of the following

procedures should you follow?

1. Annotate the first page of the directive

with "CH-#" (# = change number) to

indicate the change has been

incorporated into the directive

2. If the directive is removed from the

binder or file, replace the directive

with a locator sheet

3. If the directive is in the form of a

publication, fill out the "Record of

Changes" sheet in the front of the book

4. Each of the above
69

9-7. Routine unclassified correspondence must

contain all of the following items in the

identification symbol EXCEPT

1. standard subject identification symbol

2. date

3. serial number

4. organization code

9-8. In what publication would you find

examples of and instructions for the proper

formatting of a naval message?

1. NTP 3

2. SECNAVINST 5210.11

3. Navy Correspondence Manual

4. Navy Message Manual

9-9. A Navy letter carries the subject

identification number 5320. What is the

major subject of the letter?

1. Military personnel

2. Operations and readiness

3. General administration and

management

4. Financial management

9-10. What is the process called that is used to

determine the correct subject group under

which documents should be filed?

1. grouping

2. coding

3. classifying

4. cross-referencing

9-11. It is prudent to cross-reference a piece of

correspondence under which of the

following circumstances?

1. The basic correspondence has separate

enclosures

2. The document has multiple subjects

3. There is more than one applicable

SSIC

4. Each of the above

9-12. Budget and accounting files are terminated

and new files begun at what time(s)?

1. Semi-annually, on 31 March and

30 September

2. Annually, at the end of the calendar

year

3. Annually, at the end of the fiscal year

4. Every 3 years

9-13. Tickler files are used to determine all of the

following EXCEPT

1. when reports are due

2. ship’s movement/port schedule

3. when physical examinations are

required

4. immunization schedules

9-14. The Marine Corps specially assigns

members to the Fleet Marine Force to serve

as medical and dental personnel

1. True

2. False

9-15. All of the following are considered part of

the primary mission of the medical

battalion EXCEPT

1. emergency treatment

2. evacuation

3. immunization

4. temporary hospitalization

9-16. Which of the following could be considered

 accurate attributes of a fleet hospital?

1. Non-deployable, permanent station for

high-intensity situations

2. Transportable, with 100 to 500 beds,

providing moderately sophisticated

care

3. Designed for short-term (less than 60

days) operations involving large

numbers of ground forces

4. Mostly self-supporting and relocatable,

with less than 100 beds
70

9-17. A fleet hospital has what number of

directorates?

1. 2

2. 3

3. 4

4. 5

9-18. The operation of fleet hospital supply

departments are conducted in accordance

with what directive?

1. NAVMED P-5010

2. BUMEDINST 6440.6

3. NAVSUP P-485

4. NAVSUP P-437

9-19. Through use of the Medical Augmentation

Program (MAP), it is possible to do all of

the following EXCEPT

1. monitor wartime manning readiness

2. augment operational medical

personnel, as necessary

3. train medical personnel

4. develop a readiness reporting system

9-20. The Mobile Medical Augmentation

Readiness Team is a peacetime version of

the Medical Augmentation Program.

1. True

2. False

9-21. Detailed information concerning MMART

can be found in what directive or manual?

1. NAVMED P-5010

2. BUMEDINST 6440.6

3. NAVSUP P-485

4. NAVSUP P-437

9-22. Before an accurate determination of the

number of personnel and amount of

material are needed for a particular military

operation, the staff surgeon and dental

surgeon must know about enemy and

friendly capabilities, as well as

environmental factors. What is this

information, taken as a whole, called?

1. Medical estimate

2. Planning factors

3. Medical intelligence

4. Command mission

9-23. Who establishes patient evacuation policy?

1. Secretary of the Navy

2. Joint Chiefs of Staff

3. Chief of Naval Medicine

4. Secretary of Defense

9-24. Eligibility for medical care at a military

medical treatment facility is established by

the ___________ and verified by the

_____________?

1. Personnel office, medical treatment

facility

2. Military treatment facility, personnel

office

3. Commanding officer, physician on

duty

4. Commanding officer, personnel officer

 9-25. In a case where DEERS determines that a

patient with a valid ID card is ineligible for

care, the ID card will always be the

determining factor. No other supporting

documents are required

1. True

2. False
71

 9-26. Which of the following beneficiaries can

receive medical care and can also be

enrolled in the DEERS system?

1. Red Cross workers

2. Secretary of the Navy designees

3. Secret Service agents

4. Newborns

 9-27. BUMED and OPNAV both have

instructions covering healthcare and quality

assurance programs?

1. True

2. False

 9-28. It is the primary function of which of the

following programs to provide a good

communication and rapport between the

patient and medical department staff?

1. The Patient Contact Program

2. The FOIA

3. The Patient Relations Program

4. The Family Advocacy Program

 9-29. What authority has the responsibility of the

Family Advocacy Program?

1. BUMED

2. NMPC

3. Family Service Center

4. BUPERS

 9-30. A committee consisting of members from

what professional areas of the Navy

reviews abuse cases?

1. Medical, line, chaplain, security

2. Medical, chaplain, security, Family

Service Center

3. Medical, line, chaplain, Family Service

Center

4. Medical, line, security, Family Service

Center

 9-31. The Navy hopes to achieve its drug free

"zero tolerance" goal by the use of which

of the following methods?

1. Detection

2. Education

3. Deterrence

4. Treatment

 9-32. What training prevention program is

specifically aimed at the junior Sailor?

1. ADAMS

2. PREVENT 2000

3. Alcoholics Anonymous

4. IMPACT

9-33. What is the primary function of a DAPA?

1. To facilitate shipboard Alcoholics

Anonymous meetings

2. To coordinate on-site training for the

crew

3. To act as the liaison between civilian

authorities and the Commanding

Officer

4. To arrange for inpatient treatment

9-34. Which of the following is a true statement

concerning competence for duty exams?

1. The Executive Officer can fill out

blocks 1 through 13 of NAVMED

6120/1

2. An Independent Duty Corpsman can

fill out blocks 12 - 49 of NAVMED

6120/1

3. The patient must give his written

consent before a sample of blood can

be obtained

4. A search authorization is required only

if the patient refuses to cooperate
72

9-35. Medical has responsibility for which

aspects of the Physical Readiness Program?

1. Testing

2. Education and training

3. Legal

4. Obesity research

9-36. The responsibility of informing a patient of

the consequences of a non-emergent

medical procedure and obtaining informed

consent from that patient lies ONLY with

the medical provider.

1. True

2. False

9-37. Of the following, who would be the best

choice to witness a patient’s consent to a

medical procedure?

1. A stranger

2. An immediate family member

3. A member of the medical team

4. A relative

9-38. Which is NOT a true statement about an

incident report?

1. They are confidential but if misused or

mishandled, they can become public

2. The reports must be limited to only

facts and a logical conclusion

3. Copies must be limited

4. They must be forwarded only to the

quality assurance coordinator

9-39. The Privacy Act governs the disclosure of

documents compiled and maintained by

government agencies.

1. True

2. False

9-40. Through use of the FOIA an individual can

gain access to information pertaining to

himself from federal agency records and

correct those records, if necessary.

1. True

2. False

FOR QUESTIONS 9-41 THROUGH 9-45, MATCH

THE INSTRUCTION WITH ITS

CORRESPONDING NUMBER. ALL ANSWERS

WILL NOT BE USED.

9-41. OPNAVINST 1752.1.

1. E

2. F

3. G

4. H

9-42. BUMEDINST 6320.70.

1. A

2. B

3. C

4. D

9-43. NAVMEDCOMINST 6320.18.

1. C

2. D

3. E

4. F

A. Risk Management Program

B. Physical Readiness Program

C. Patient Relations Program

D. Family Advocacy Program

E. CHAMPUS

F. Quality Assurance Program

G. Sexual Assault Victim Intervention

H. Victim and Witness Program
73

9-44. BUMEDINST 6010.21.

1. A

2. B

3. C

4. D

9-45. BUMEDINST 6010.13.

1. C

2. D

3. E

4. F

9-46. Which statement is true concerning the

release of an active duty patient under

arrest?

1. No official action by hospital

personnel is required before local

authorities can take custody

2. No patient may be released from

treatment before it is medically

reasonable to do so

3. The patient must be transported

directly to his parent command

4. A federal warrant must be presented

before the patient can be released to

civilian authority

9-47. The Commanding Officer is authorized to

deliver an active duty patient to civilian

authorities when a proper warrant is

presented under all of the circumstances

listed EXCEPT when

1. the ship is within the territorial waters

of the requesting jurisdiction

2. the patient refuses to leave and

requests a lawyer

3. the patient is outside the jurisdiction if

the civilian authority

4. cognizant JAG office has not been

contacted

9-48. All of the following are categories of

eligible prisoner beneficiaries EXCEPT

1. military prisoners

2. nonmilitary federal prisoners

3. prisoners of war and other detained

personnel

4. illegal aliens awaiting deporation or

processing

9-49. Which of the following personnel is

authorized emergency care ONLY?

1. Enemy prisoners of war

2. Nonmilitary federal prisoners

3. A previously active duty person past

his EAOS released from a foreign

prison

4. Personnel detained by the US

government but not yet charged with a

crime or arrested

9-50. Military prisoners are authorized care under

all of the following conditions EXCEPT

when

1. their discharge has been executed but

their sentence has not expired

2. they are on leave, awaiting discharge

3. they require continued hospitalization

after their discharge

4. they have been sentenced under the

UCMJ only

9-51. Child abuse and spouse neglect is covered

in what program?

1. SAVI

2. Family Advocacy

3. Risk Management

4. Child and Spouse Protective Services
74

9-52. The Decedent Affairs Program consists of

the search, recovery, identification, care,

and disposition of remains of deceased

personnel for whom the Department of the

Navy is responsible.

1. True

2. False

9-53. The Casualty Assistance Calls program is

administered by the which of the following

commands?

1. Commander, Naval Medical

Command

2. Commander, Naval Military Personnel

Command

3. Office of Medical Affairs

4. Commanding Officer, Naval Hospital

9-54. The Casualty Assistance Calls offier assists

the next of kin (NOK) with which of the

following item(s)?

1. Disposition of remains

2. Survivor benefits

3. Obtaining the rights and privileges that

the NOK is entitle to

4. All of the above

9-55. Which of the following programs can only

be activated upon the enactment of special

legislation?

1. Return of Remains Program

2. Concurrent Return Program

3. Graves Registration Program

4. Current Decedent Affairs Program

IN ANSWERING QUESTIONS 9-56

THROUGH 9-59, SELECT FROM THE ABOVE

LIST THE PROGRAM THAT MOST

CLOSELY RELATES TO THE STATEMENT

IN THE QUESTION.

9-56. Provides for the search, recovery,

evacuation, initial identification, and burial

in temporary cemeteries when tactical

situation does not permit concurrent return.

1. A

2. B

3. C

4. D

9-57. Provides professional mortuary services,

supplies, and related services incident to

care and disposition of remains.

1. A

2. B

3. C

4. D

9-58. Is not identified as part of the Decedent

Affairs Program.

1. A

2. B

3. C

4. D

9-59. May be activated to support large numbers

of military personnel committed to a

strategic area.

1. A

2. B

3. C

4. D

9-60. The personnel casualty report of an active

duty Navy member shall be submitted by

1. telegram

2. routine precedence message

3. speedletter

4. priority message

A. Current Decedent Affairs

Program

B. Casualty Assistance Calls

Program

C. Concurrent Return

Program

D. Graves Registration

Program
75

9-61. Within CONUS, who is responsible for

ensuring the next of kin is notified of a

member’s death?

1. Office of Medical Affairs

2. The member’s commanding officer

3. Naval Military Personnel Command

4. Commander, Naval Medical

Command

9-62. The commanding officer will write a

condolence letter to the NOK within

_____ hours of the death.

1. 24

2. 36

3. 48

4. 72

9-63. When search, recovery, and identification

operations continue for more than 36 hours,

a progress report will be made to BUMED

and MEDDEN Affairs every _____ hours.

1. 8

2. 12

3. 24

4. 36

9-64. After serving all identification purposes,

the personal effects of a deceased naval

member are disposed of as directed in the

1. NAVSUP Manual

2. Manual of the Medical Department

3. Naval Military Personnel Manual

4. JAGMAN

9-65. Who will be requested to provide an

identification specialist to examine

unidentified remains?

1. Naval Military Personnel Command

2. Commander, Naval Medical

Command

3. Geographic command

4. Naval Office of Medical/Dental

Affairs

9-66. What is the minimum number of projected

deaths per year required for awarding

contracts by naval activities for procuring

mortuary services within CONUS?

1. 15

2. 10

3. 8

4. 5

9-67. To minimize cellular deterioration, remains

should be refrigerated at _____ C.

1. 0° to 2.2°

2. 2.2° to 4.4°

3. 4.4° to 6.6°

4. 6.6° to 8.8°

9-68. How many copies of DD 2064 must

accompany remains being transferred from

an overseas activity to a CONUS point of

entry?

1. 5

2. 3

3. 2

4. 1

9-69. Once authorization has been obtained for

burial at sea, who coordinates the

arrangements?

1. Commander, Naval Medical

Command

2. Chief of Naval Operations

3. Office of Medical Affairs

4. Appropriate fleet commanders in chief

9-70. If it is desired to transport the uncremated

remains by the Air Mobility Command

(AMC) within CONUS, prior approval

must be obtained from the

1. Commander, Naval Medical

Command

2. Chief of Naval Operations

3. Secretary of the Navy

4. Naval Military Personnel Commander
76

9-71. Problems concerning arrangements for a

Navy escort within CONUS should be

referred to the

1. Naval Office of Medical/Dental

Affairs

2. Decedent Affairs Officer

3. Commandant of the Marine Corps

4. Area commander

9-72. A request by the primary next of kin

(PNOK) for a special escort must be

referred to

1. Chief of Naval Operations

2. Naval Military Personnel Command

3. Naval Office of Medical/Dental

Affairs

4. Commander, Naval Medical

Command

9-73. The maximum authorized Government

allowance for expenses toward the

interment of a deceased active duty

member in a private cemetery can be found

in which of the following publications?

1. NAVMEDCOMINST 5360.1

2. NAVPERS 15955

3. NAVSUP P-485

4. NAVMED P-5016/NAVMC 2509A

9-74. Who has jurisdiction at the Arlington

National Cemetery?

1. State government

2. Department of the Army

3. Department of the Interior

4. Office of Medical Affairs

9-75. When group burials are necessary, roundtrip transportation at government expense

to the place of burial is provided for

1. the PNOK

2. all members of the immediate family

3. the PNOK and two blood relatives

4. the PNOK and one other close relative