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Military medical services in Canada. Part III: prevention and research By Jim Garner In any war in which Canadians have been involved in this century, the mili¬ tary health care system has used far more resources
hospitals, doctors,
to cure sickness and accident victims than to succour the wounded. To the military surgeon, the worst enemy is not the fellow with the gun on the other side of the hill; it is his old peacetime adversaries. As is often the case, the best figures come from the US. The US army files show battle injuries ranging from 100 men per 1000 per year in the Civil War down to 18.25 in the Korean War. The figure for World War II was 23.08. Nonbattle injuries for World War II were 71 per 1000 per month in the US, rising to 99 per month in the European theatres. Admissions to hospital for diseases in World War II ranged from 621 per 1000 per year in the US to 938 in the Burma-ChinaIndia theatre. In Korea the disease ad¬ mission figure was 694.
nurses, ambulances
The overriding function of military medicine is to ensure the effective functioning of the human part of the military machine. Therefore, a prime use of medical resources is to prevent diseases and accidents. To this end, unit medical officers are directed to spend a good part of their time on preventive medicine; there are annual checkups for men over 40, pilots of any age and others who are thought to need them. There are programs for immunization and Canadian Forces Medical Services (CFMS) has a body of hygiene technicians who carry out the normal duties of public health inspectors. But the military doctors would like to intervene earlier in the sickness-disease process. They point to many of the problems caused because, they say, equipment designers forget that the weapon, or the vehicle, has to be oper¬ ated by a human being. During the later stages of the Viet-
nam war, was
the US put into service what
supposed to be the best fighterbomber ever designed, the F-lll. It had swing-wings to make it both ex¬ tremely fast and highly maneuverable at low speed. But after a few months the loss rate was so high the plane had to be withdrawn.
Here's the medical clincher to the rate was high, not through enemy action but because the F-lll was so difficult to fly. Before the plane could be put back into serv¬ ice, the designers had to redesign the controls. Military equipment seems to have a built-in tendency to hazard. Even a simple jeep is several times more dan¬ gerous than your family car. It flips more easily. The Canadian government has chosen not to spend the $200 or $300 it would cost to equip each one with roll bars, so seat belts would merely represent an extra danger. Even travelling rightside up is a hazard, for
story: the loss
physical Though flying and diving seem two opposite endeavours, both require fit, alert personnel and research in pressure and mental. To deal with the effects on divers of physical pressure, hyperbaric chambers, such as the one on right, have been devel¬ oped to treat those who surface too quickly and suffer the classic diving complaint of nitrous oxide bubbles in the bloodstream .
.
the 'bends\
CMA JOURNAL/JULY 12, 1975/VOL. 113 41
nothing but his own good grip a passenger's being catapulted through the doorless side. A tank should be a safer vehicle on the road who's going to play chicken with 50 tonnes of thick steel? But, at speed, it bounces around, and the inside is a mass of metal projections. "It's a menace," says Col. LA. Mar¬ riott, director of preventive medicine in the Department of National De¬ fence. The tank cannot now be redesigned and new ones are not forthcoming, ac¬ cording to Defence Minister James Richardson. The answer is a light helmet, now under development at the Defence and Civil Institute of Environ¬ mental Medicine in Downsview, Ont. The helmet will provide protection against head battering and also against the considerable noise generated inside the tank. At present crews wear modi¬ fied aircraft-type earphones which pro¬ vide communication and noise protec¬ tion but are not wholly satisfactory. The line of duty there is
to
prevent
Canadian servicemen are called upon operate in some pretty hostile environments. Aircrew may suffer loss of pressurization at 12 000 m. Divers may be subject to five or six atmospheres of pressure below water. There are personnel in the deserts of Egypt, the jungles of southeast Asia and the tundra of the Northwest Territories. In these circumstances, military medicine becomes a study of how to keep human beings operating effectively. A brief list drawn up by Col. Marriott of un¬ usual strains to which man is subjected in modern weapons systems includes, besides noise, changes in temperature and pressure, accelerative forces, unsuitable workspaces, jet lag and the demands on physical and mental endurance likely to be made in military to
operations.
Marriott made some pithy observa¬ tions about attitudes towards physical endurance. "Military people tend to think of their machines only. They just won't admit they themselves could be fallible," he said. Flight surgeon Lt. Col. William McArthur, a flight surgeon commanding the medical com¬ ponent of the Canadian contingent in Egypt, knows well the fallibility: "Every air accident is caused by a human failure somewhere. If a pilot misreads his altimeter and flies into the ground, the human failure is apparent. But if a wing falls off, it is also a human
failure in design or in the maintenance
or
manufacturing or operations reference to a wing's
phase." Despite his "failing off" McArthur believes
mech-
anical aspects of today's aircraft are highly reliable. His job is to ensure reliability in the air and maintenance crews. This calls for a getting-to-know-
you process. The flight surgeon must become the trusted medical adviser. A crew member who is unfit whether from physical or emotional causes shouldn't fly. But they love flying and fear being grounded; as a result they tend to hide their symptoms. Some flight surgeons learn to fly; indeed many have been pilots who sub¬ sequently took medical training. Bill McArthur is one of the latter, and he finds among the most agreeable parts of his job to be just sitting around with pilots, yarning away about aircraft types, past air shows and the delights of Cold Lake, Downsview, Winnipeg or Shearwater. It's at relaxed times like these that a pilot may casually .
mention this little thing that's been bothering him. and often the prob¬ lem is minor, the man's doubts can be taken away and he becomes fully ef¬ fective again. Aircrew get a stringent annual check¬ up and they are required to maintain a high standard of physical fitness. Failure to do so means a lowered med¬ ical category, and that means they can't ..
fly. Diving is an opposite occupation to flight, yet the CFMS doctors attached to maritime bases find a certain corre¬ lation between diving and aviation med¬ icine. There are the same requirements for physical and mental health and for understanding the people who carry out the work. Airmen and divers are operating close to the limits of human
tolerance; it is the function of medicine
to know
where those limits
are
and to
The Carl Gustav antitank weapon is fired close to the ear of infantry soldiers using it. In such proximity, the shock wave offers a high probability of ruptured eardrum. In circumstances in which weapon would be used, it is unlikely personnel would take time to insert and adjust ear
protectors.
keep the operatives within them. And divers, again, must be fit. rifle there are four or five others who Fitness is not a universal military are cooks, clerks, truck drivers, sigcondition, though, and in an infantry nallers or even doctors. For every man division, for every man who carries a who flies a fighter-bomber, there are
Even peacetime military life has unusual hazards. Driving a jeep without roll bars over this kind of country in Cyprus is distinctively less safe than driving the family car up to the cottage, even without the possibility that the patrol could find itself between Greek and Turkish elements in a local flareup.
CMA JOURNAL/JULY 12, 1975/VOL. 113 43
CFMS has access to research by medical components of NATO allies. Highspeed photograph shows .30 calibre US army bullet at 750 m/s. Within one more millisecond apple will disintegrate explosively. Increased muzzle velocities of modern rifles cause exponentially greater damage than did the weapons of 10 years ago.
dozen
on the ground. For every man (and many of those have sedentary occupations), there are two or three ashore in support. And, depend¬ ing on rank and occupation, a man or
a
at sea
woman can
remain in the service until
past 50.
Service personnel are choosing the "diseases of choice" that the De¬ partment of National Health and Wel¬ fare is so concerned about in the gen¬ eral population (now it has to foot the bill). What you have is a body of peo¬ ple, average age maybe in the middle 30s, gregarious by nature, some with access to duty-free alcohol and ciga¬ rettes (even in Canada, bar prices in military messes are low) and many in same
sedentary occupations.
Most of the troops are married so there is little control over their diets. Even with those who live in barracks, control is minimal. "We live in a de¬ mocracy, and we don't feel we can compel service people to eat whatever we think is good for them," explains Surgeon General R/Admiral R.H. Roberts. "For instance, we don't withhold butter, but we do make sure margarine is available and that they are given proper dietary information." Information on lifestyle is a part of preventive medicine largely left to the initiative of individual medical officers. And, of course, each has his opinion. Further, he has to convince his com¬ manding officer of the merits of any lifestyle programs because the CO is the authority (see part II for details on organization); even in purely medi¬ cal matters the medical officer is, in theory, only an adviser. Thus it is not surprising to find cer¬ tain obvious programs well received.
Commanding proposals to
officers are receptive to cut down on obesity: a fat soldier is an offence to the military notion of smartness. There is an overall
timum efficiency. But the army doctors were able to control the situation, and when Montgomery called on the Cana¬ dians for a maximum effort at Caen they were able to give it. It's in such field operations that health education is so essential. The role of CFMS is to provide technical advice and supervision, rather than to itself effect all the preventive measures necessary. The troops themselves have to bury their garbage, wash their hands, see they get sufficient rest, avoid con¬ taminated water supplies and generally follow healthy principles. Much of the supervision is per¬ formed by the trained hygiene technicians attached to CFMS. In Canada they function very much as public health inspectors (the Canadian Public Health Association has agreed to ac¬ cept their qualifications plus 3 months'
experience as equivalent to a diploma as a public health inspector). In the field their duties become
more
onerous,
especially in some of the UN peacekeeping missions in developing coun¬
tries. Take, for instance, the Suez Canal operation. Egypt is not the healthiest place to live. supplies are unrestandard of physical fitness which dic- liable Localtowater a western GI tract, most¬ and, tates that any forces' member under country suffers a 45 must be able to run 2x/i km in 12 ly unpotable. The major problem in schistosomiasis. Ac¬ minutes. to a study by the Walter Reed On the other hand, it is government cordingResearch Army Institute, Washington, policy to supply duty-free cigarettes Egypt has an abundance of malaria, and alcohol to troops stationed outside Canada. Local commanders do make typhoid, hepatitis, TB, measles, mumps, chickenpox, diphtheria, tetanus, para¬ the effort to persuade their subordin- sites and nearly all the other diseases ates to drink and smoke in moderation, known to mankind. No recent cases of but often the facilities for entertain¬ ment are limited, leading to a greater cholera, piague, yellow fever or smallpox are recorded, but the study sug¬ emphasis on partying. these may be "underreported". The US Air Force recently admitted gests Of the so-called diseases of civilizaalcoholism in that service is two to Egypt has one in abundance three times greater than in civil life. tion, accidents. All the Canadian medical officers I a drive There is no driving test and through Cairo makes Montreal asked said they had no reason to sup- or Vancouver traffic seem a sepose there is more alcoholism in the date experience. Canadian quiet, are troops services than among civilians. told by their commanders mostly to Health education, according to Col. avoid driving through Cairo. Marriott, needs to be low-key or inLast year the demands of interna¬ visible to be credible, but certain kinds tional politics brought a contingent of of health education are essential for a Canadian soldiers to Egypt. They were field force if it is to remain effective. down on the Cairo racetrack, along put In 1944, says Col. Marriott, the Japanese army failed to take proper with a few tents. antimalaria precautions. The result was Sweet waters to blame the force lost its effectiveness and was It will be remembered that the newsunable to prevent the allied 14th army papers in Canada carried statements by (which did take precautions) from a medical officer that care for the throwing it out of Burma. troops was inadequate. Nobody denies In the same year another field force that these statements had a certain suffered a severe outbreak of gastro¬ validity at the time they were made. enteritis. This was the Canadian 2nd The Canadian contingent had a bout corps which at the time was penned of gastrointestinal trouble, soon overin at the Normandy beachhead. There come. were a great many men on a small For western stomachs to function amount of real estate, and for a couple safely in Egypt requires more than weeks the army was at less than op¬ usual attention to preventive medicine.
46 CMA JOURNAL/JULY 12, 1975/VOL. 113
contingent now shares a housing complex with Polish and Egyptian sol¬ diers at an old Royal Air Force base on the canal. The water supply is drawn from the infamous Sweetwater Canal, so-named by generations of derisive British soldiery for qualities other than sweetness. Although the Egyptians put the supply through a chlorinating plant, checks by Canadian Forces Med¬ ical Services' personnel indicate E. coli in some samples. Jerricans of potable
The
water
are
trucked around the Canadian
quarters. Travel from meal to meal The troops are constantly urged not to eat or drink anything locally. This means that when driving to outlying detachments Suez, Cairo, Port Said and the Golan Heights journeys have to be timed to arrive at a United Nations mess hall at mealtimes. Buying local food for preparation in the Cana¬ dian messes is a problem. Eggs are fine; vegetables are washed in a solu¬ tion of 200 ppm chlorine and rinsed in a solution 0.4 to 0.8 ppm. The contingent employs a couple hundred local workers. Sixty-seven of them are classed as food handlers. Most communicable disease control is by the regular immunizations. The forces are routinely kept up to date
against smallpox, typhoid, tetanus, diphtheria, poliomyelitis and yellow fever. Other immunizations cholera, typhus, plague, hepatitis are given only as seen necessary. "We don't believe in overimmunizing," says Col. Marriott.
'Pinkies' In Egypt the arrivals ("pinkies") are checked over and the hygiene techs administer whatever extra needles are needed. The particular communicable diseases from which military groups have traditionally suffered are less of a problem in Egypt. There are few prostitutes in Ismalia, where most of the 1030 Canadians are located. This may surprise those of our ex-RAF readers who remember Egypt in the days of King Farouk, but presidents Nasser and Sadat have introduced a stricter concept of Moslem morality. Of course when there is a demand, there is a service, which is one reason that regular weekend leave parties travel from Ismalia to the Hilton in Cairo. The waitresses in the coffeeshop are attractive and friendly, and there are entrepreneurs outside who will buy Canadian cigarettes, whisky and dollar bills, or sell perfume, taxirides to the
Pyramids
and
women.
Local food handlers hired by the CF must undergo x-ray and stool examinations twice monthly as do the Canadian cooks.
The consequences, if any, are as to be syphilis as gonorrhea, unlike the 1:8 ratio current in Canada. The flies of Egypt have been a theme for inspired profanity almost since the invention of speech. Protec¬ tion against insect-born diseases (apart from a prophylactic against malaria) depends on screening and spraying. The law allows use of DDT there, but in fact CFMS personnel use other broadspectrum insecticides. In hot weather every mess is sprayed every
likely
URINE EXTRACTS1 "When the patient is too young to talk, the urine can say it all." Greifer, Professor Ira. Urinalysis in the 70's. 1973
m
5JJB) MULTISTIX provides the broadest chemical profile ever offered by reagent strip analysis. In one 60-second "dip and read" test, it provides seven different results from one reagent strip.
You read more body language
MULTISTIX Reagent Strips tor Urinalysis
Ames Company Miles Laboratories JA
m
©1975
Division, Rexdale, Ontario.
Ltd.,
night. Besides flies and malaria-infected mosquitoes, Egypt has other delights for the military visitor. There are ratlittle snakes with tlesnakes, asps nasty, poisonous bites scorpions and rabid dogs. There are two versions of rabies, known as "dumb" and "furious", and the important thing they have in common is they are both lethal. CFMS keeps antisera for all known
local venoms. Mundane but necessary Above these exotic perils, it seems almost mundane to mention the stand¬ ard environmental medicine practised by CFMS. But there are regular inspections of rooms and work areas for health hazards. A slip-free workshop floor, proper shielding for cutting tools, levels of illumination these are part of the job, too. "Preventive medicine can be frustrat-
CMA JOURNAL/JULY 12, 1975/VOL. 113 47
.@w sinemeE (levodopa and carbidopa combination)
INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. DOSAGE SUMMARY Therapy must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Because of the enhancement of levodopa effects provided by SINEMET*, titration and adjustment of dosage sheuld be made In small steps, without exceeding recommended dosage ranges. Therapy in Patients not receiving Levodopa: Initially 1/2 tablet once or twice a day, increase by 'A tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodopa: Discontinue Ievociopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. Please consult monograph for complete information including initial dosage, transfer from levodopa or other agents, adjustment and maintenance. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, 'which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history or melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and obeerve patients for unusual adverse reactions. With Anes-
thetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other SerIous ReactIons: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness. Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behavior, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica', increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dormatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. SpecialSenses: blurred vision, diplopia, dilated pupils, activation of latent Homer's syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. FOR COMPLETE PRESCRIBING INFORMATION PLEASE REFER TO PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST HOW SUPPLIED Ca8804-Tablets SI NEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded M5D654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100.
O MERCK I S HARP I & DOHME CANADA LIMITED
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50 CMA JOURNAL/JULY 12, 1975/VOL. 113
(Mc-973)
ing," says Lt. Col. McArthur. "If you've done the job properly, it's hard to prove you've done it." Research Back in Ottawa, Col. Marriott's duties include environmental, as well as preventive, medicine. This means he has the directorship of the minimal research effort maintained by the CFMS. "Our opportunities for research in clinical medicine are limited," he said. "We can read the journals just as well as anybody." In fact, the Defence Research Board allocates only about $10 000 a year to clinical research. But this goes a remarkably long way, simply because the personnel and equipment for much of the research are there anyway and don't have to be specially budgeted. Col. Marriott describes his situation as being the envy of every epidemiologist. He has, in effect, a closed community of 78 000 people with complete records on each one. "We have the GP in the system," he points out, to emphasize the completeness of the records. But to be useful for research, the records have to be in a form which makes for ready classification. To date they have not been; all this will change when the present project to computerize the records is completed. Then Marriott will be able to do retrospective research, using as a data base 78 000 men and women with totally complete medical and personal histories. Canada also maintains a minimal research effort in nuclear, biological and chemical warfare. This, Col. Marriott stresses, is purely defensive - to provide the service with the knowledge it needs to protect itself from these forms of attack. CFMS also has an input into the work carried out at the Defence and Civil Institute of Environmental Medicine (DCIEM). This institute, formed a few years ago by the joining of defence and civil research efforts, has an annual budget of $4.5 million and employs 78 service and 150 civilian people at its Downsview location. Among the 100 projects currently under way are the layout for a new bridge for an icebreaker, solar heating for homes, Arctic dehydration and a mobile garbage-disposal-water-purification combination. The institute is jointly controlled by the surgeon general and the Canadian Forces chief of research and development. Preventive medicine and research complement the actual delivery of health care to the Canadian Forces, and, as the ads say, watch this space in the next issue of CMA I.E
"ii^iiWKiSi?^
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Military medical services in Canada. Part III: prevention and research By Jim Garner In any war in which Canadians have been involved in this century, the mili¬ tary health care system has used far more resources
hospitals, doctors,
to cure sickness and accident victims than to succour the wounded. To the military surgeon, the worst enemy is not the fellow with the gun on the other side of the hill; it is his old peacetime adversaries. As is often the case, the best figures come from the US. The US army files show battle injuries ranging from 100 men per 1000 per year in the Civil War down to 18.25 in the Korean War. The figure for World War II was 23.08. Nonbattle injuries for World War II were 71 per 1000 per month in the US, rising to 99 per month in the European theatres. Admissions to hospital for diseases in World War II ranged from 621 per 1000 per year in the US to 938 in the Burma-ChinaIndia theatre. In Korea the disease ad¬ mission figure was 694.
nurses, ambulances
The overriding function of military medicine is to ensure the effective functioning of the human part of the military machine. Therefore, a prime use of medical resources is to prevent diseases and accidents. To this end, unit medical officers are directed to spend a good part of their time on preventive medicine; there are annual checkups for men over 40, pilots of any age and others who are thought to need them. There are programs for immunization and Canadian Forces Medical Services (CFMS) has a body of hygiene technicians who carry out the normal duties of public health inspectors. But the military doctors would like to intervene earlier in the sickness-disease process. They point to many of the problems caused because, they say, equipment designers forget that the weapon, or the vehicle, has to be oper¬ ated by a human being. During the later stages of the Viet-
nam war, was
the US put into service what
supposed to be the best fighterbomber ever designed, the F-lll. It had swing-wings to make it both ex¬ tremely fast and highly maneuverable at low speed. But after a few months the loss rate was so high the plane had to be withdrawn.
Here's the medical clincher to the rate was high, not through enemy action but because the F-lll was so difficult to fly. Before the plane could be put back into serv¬ ice, the designers had to redesign the controls. Military equipment seems to have a built-in tendency to hazard. Even a simple jeep is several times more dan¬ gerous than your family car. It flips more easily. The Canadian government has chosen not to spend the $200 or $300 it would cost to equip each one with roll bars, so seat belts would merely represent an extra danger. Even travelling rightside up is a hazard, for
story: the loss
physical Though flying and diving seem two opposite endeavours, both require fit, alert personnel and research in pressure and mental. To deal with the effects on divers of physical pressure, hyperbaric chambers, such as the one on right, have been devel¬ oped to treat those who surface too quickly and suffer the classic diving complaint of nitrous oxide bubbles in the bloodstream .
.
the 'bends\
CMA JOURNAL/JULY 12, 1975/VOL. 113 41
nothing but his own good grip a passenger's being catapulted through the doorless side. A tank should be a safer vehicle on the road who's going to play chicken with 50 tonnes of thick steel? But, at speed, it bounces around, and the inside is a mass of metal projections. "It's a menace," says Col. LA. Mar¬ riott, director of preventive medicine in the Department of National De¬ fence. The tank cannot now be redesigned and new ones are not forthcoming, ac¬ cording to Defence Minister James Richardson. The answer is a light helmet, now under development at the Defence and Civil Institute of Environ¬ mental Medicine in Downsview, Ont. The helmet will provide protection against head battering and also against the considerable noise generated inside the tank. At present crews wear modi¬ fied aircraft-type earphones which pro¬ vide communication and noise protec¬ tion but are not wholly satisfactory. The line of duty there is
to
prevent
Canadian servicemen are called upon operate in some pretty hostile environments. Aircrew may suffer loss of pressurization at 12 000 m. Divers may be subject to five or six atmospheres of pressure below water. There are personnel in the deserts of Egypt, the jungles of southeast Asia and the tundra of the Northwest Territories. In these circumstances, military medicine becomes a study of how to keep human beings operating effectively. A brief list drawn up by Col. Marriott of un¬ usual strains to which man is subjected in modern weapons systems includes, besides noise, changes in temperature and pressure, accelerative forces, unsuitable workspaces, jet lag and the demands on physical and mental endurance likely to be made in military to
operations.
Marriott made some pithy observa¬ tions about attitudes towards physical endurance. "Military people tend to think of their machines only. They just won't admit they themselves could be fallible," he said. Flight surgeon Lt. Col. William McArthur, a flight surgeon commanding the medical com¬ ponent of the Canadian contingent in Egypt, knows well the fallibility: "Every air accident is caused by a human failure somewhere. If a pilot misreads his altimeter and flies into the ground, the human failure is apparent. But if a wing falls off, it is also a human
failure in design or in the maintenance
or
manufacturing or operations reference to a wing's
phase." Despite his "failing off" McArthur believes
mech-
anical aspects of today's aircraft are highly reliable. His job is to ensure reliability in the air and maintenance crews. This calls for a getting-to-know-
you process. The flight surgeon must become the trusted medical adviser. A crew member who is unfit whether from physical or emotional causes shouldn't fly. But they love flying and fear being grounded; as a result they tend to hide their symptoms. Some flight surgeons learn to fly; indeed many have been pilots who sub¬ sequently took medical training. Bill McArthur is one of the latter, and he finds among the most agreeable parts of his job to be just sitting around with pilots, yarning away about aircraft types, past air shows and the delights of Cold Lake, Downsview, Winnipeg or Shearwater. It's at relaxed times like these that a pilot may casually .
mention this little thing that's been bothering him. and often the prob¬ lem is minor, the man's doubts can be taken away and he becomes fully ef¬ fective again. Aircrew get a stringent annual check¬ up and they are required to maintain a high standard of physical fitness. Failure to do so means a lowered med¬ ical category, and that means they can't ..
fly. Diving is an opposite occupation to flight, yet the CFMS doctors attached to maritime bases find a certain corre¬ lation between diving and aviation med¬ icine. There are the same requirements for physical and mental health and for understanding the people who carry out the work. Airmen and divers are operating close to the limits of human
tolerance; it is the function of medicine
to know
where those limits
are
and to
The Carl Gustav antitank weapon is fired close to the ear of infantry soldiers using it. In such proximity, the shock wave offers a high probability of ruptured eardrum. In circumstances in which weapon would be used, it is unlikely personnel would take time to insert and adjust ear
protectors.
keep the operatives within them. And divers, again, must be fit. rifle there are four or five others who Fitness is not a universal military are cooks, clerks, truck drivers, sigcondition, though, and in an infantry nallers or even doctors. For every man division, for every man who carries a who flies a fighter-bomber, there are
Even peacetime military life has unusual hazards. Driving a jeep without roll bars over this kind of country in Cyprus is distinctively less safe than driving the family car up to the cottage, even without the possibility that the patrol could find itself between Greek and Turkish elements in a local flareup.
CMA JOURNAL/JULY 12, 1975/VOL. 113 43
CFMS has access to research by medical components of NATO allies. Highspeed photograph shows .30 calibre US army bullet at 750 m/s. Within one more millisecond apple will disintegrate explosively. Increased muzzle velocities of modern rifles cause exponentially greater damage than did the weapons of 10 years ago.
dozen
on the ground. For every man (and many of those have sedentary occupations), there are two or three ashore in support. And, depend¬ ing on rank and occupation, a man or
a
at sea
woman can
remain in the service until
past 50.
Service personnel are choosing the "diseases of choice" that the De¬ partment of National Health and Wel¬ fare is so concerned about in the gen¬ eral population (now it has to foot the bill). What you have is a body of peo¬ ple, average age maybe in the middle 30s, gregarious by nature, some with access to duty-free alcohol and ciga¬ rettes (even in Canada, bar prices in military messes are low) and many in same
sedentary occupations.
Most of the troops are married so there is little control over their diets. Even with those who live in barracks, control is minimal. "We live in a de¬ mocracy, and we don't feel we can compel service people to eat whatever we think is good for them," explains Surgeon General R/Admiral R.H. Roberts. "For instance, we don't withhold butter, but we do make sure margarine is available and that they are given proper dietary information." Information on lifestyle is a part of preventive medicine largely left to the initiative of individual medical officers. And, of course, each has his opinion. Further, he has to convince his com¬ manding officer of the merits of any lifestyle programs because the CO is the authority (see part II for details on organization); even in purely medi¬ cal matters the medical officer is, in theory, only an adviser. Thus it is not surprising to find cer¬ tain obvious programs well received.
Commanding proposals to
officers are receptive to cut down on obesity: a fat soldier is an offence to the military notion of smartness. There is an overall
timum efficiency. But the army doctors were able to control the situation, and when Montgomery called on the Cana¬ dians for a maximum effort at Caen they were able to give it. It's in such field operations that health education is so essential. The role of CFMS is to provide technical advice and supervision, rather than to itself effect all the preventive measures necessary. The troops themselves have to bury their garbage, wash their hands, see they get sufficient rest, avoid con¬ taminated water supplies and generally follow healthy principles. Much of the supervision is per¬ formed by the trained hygiene technicians attached to CFMS. In Canada they function very much as public health inspectors (the Canadian Public Health Association has agreed to ac¬ cept their qualifications plus 3 months'
experience as equivalent to a diploma as a public health inspector). In the field their duties become
more
onerous,
especially in some of the UN peacekeeping missions in developing coun¬
tries. Take, for instance, the Suez Canal operation. Egypt is not the healthiest place to live. supplies are unrestandard of physical fitness which dic- liable Localtowater a western GI tract, most¬ and, tates that any forces' member under country suffers a 45 must be able to run 2x/i km in 12 ly unpotable. The major problem in schistosomiasis. Ac¬ minutes. to a study by the Walter Reed On the other hand, it is government cordingResearch Army Institute, Washington, policy to supply duty-free cigarettes Egypt has an abundance of malaria, and alcohol to troops stationed outside Canada. Local commanders do make typhoid, hepatitis, TB, measles, mumps, chickenpox, diphtheria, tetanus, para¬ the effort to persuade their subordin- sites and nearly all the other diseases ates to drink and smoke in moderation, known to mankind. No recent cases of but often the facilities for entertain¬ ment are limited, leading to a greater cholera, piague, yellow fever or smallpox are recorded, but the study sug¬ emphasis on partying. these may be "underreported". The US Air Force recently admitted gests Of the so-called diseases of civilizaalcoholism in that service is two to Egypt has one in abundance three times greater than in civil life. tion, accidents. All the Canadian medical officers I a drive There is no driving test and through Cairo makes Montreal asked said they had no reason to sup- or Vancouver traffic seem a sepose there is more alcoholism in the date experience. Canadian quiet, are troops services than among civilians. told by their commanders mostly to Health education, according to Col. avoid driving through Cairo. Marriott, needs to be low-key or inLast year the demands of interna¬ visible to be credible, but certain kinds tional politics brought a contingent of of health education are essential for a Canadian soldiers to Egypt. They were field force if it is to remain effective. down on the Cairo racetrack, along put In 1944, says Col. Marriott, the Japanese army failed to take proper with a few tents. antimalaria precautions. The result was Sweet waters to blame the force lost its effectiveness and was It will be remembered that the newsunable to prevent the allied 14th army papers in Canada carried statements by (which did take precautions) from a medical officer that care for the throwing it out of Burma. troops was inadequate. Nobody denies In the same year another field force that these statements had a certain suffered a severe outbreak of gastro¬ validity at the time they were made. enteritis. This was the Canadian 2nd The Canadian contingent had a bout corps which at the time was penned of gastrointestinal trouble, soon overin at the Normandy beachhead. There come. were a great many men on a small For western stomachs to function amount of real estate, and for a couple safely in Egypt requires more than weeks the army was at less than op¬ usual attention to preventive medicine.
46 CMA JOURNAL/JULY 12, 1975/VOL. 113
contingent now shares a housing complex with Polish and Egyptian sol¬ diers at an old Royal Air Force base on the canal. The water supply is drawn from the infamous Sweetwater Canal, so-named by generations of derisive British soldiery for qualities other than sweetness. Although the Egyptians put the supply through a chlorinating plant, checks by Canadian Forces Med¬ ical Services' personnel indicate E. coli in some samples. Jerricans of potable
The
water
are
trucked around the Canadian
quarters. Travel from meal to meal The troops are constantly urged not to eat or drink anything locally. This means that when driving to outlying detachments Suez, Cairo, Port Said and the Golan Heights journeys have to be timed to arrive at a United Nations mess hall at mealtimes. Buying local food for preparation in the Cana¬ dian messes is a problem. Eggs are fine; vegetables are washed in a solu¬ tion of 200 ppm chlorine and rinsed in a solution 0.4 to 0.8 ppm. The contingent employs a couple hundred local workers. Sixty-seven of them are classed as food handlers. Most communicable disease control is by the regular immunizations. The forces are routinely kept up to date
against smallpox, typhoid, tetanus, diphtheria, poliomyelitis and yellow fever. Other immunizations cholera, typhus, plague, hepatitis are given only as seen necessary. "We don't believe in overimmunizing," says Col. Marriott.
'Pinkies' In Egypt the arrivals ("pinkies") are checked over and the hygiene techs administer whatever extra needles are needed. The particular communicable diseases from which military groups have traditionally suffered are less of a problem in Egypt. There are few prostitutes in Ismalia, where most of the 1030 Canadians are located. This may surprise those of our ex-RAF readers who remember Egypt in the days of King Farouk, but presidents Nasser and Sadat have introduced a stricter concept of Moslem morality. Of course when there is a demand, there is a service, which is one reason that regular weekend leave parties travel from Ismalia to the Hilton in Cairo. The waitresses in the coffeeshop are attractive and friendly, and there are entrepreneurs outside who will buy Canadian cigarettes, whisky and dollar bills, or sell perfume, taxirides to the
Pyramids
and
women.
Local food handlers hired by the CF must undergo x-ray and stool examinations twice monthly as do the Canadian cooks.
The consequences, if any, are as to be syphilis as gonorrhea, unlike the 1:8 ratio current in Canada. The flies of Egypt have been a theme for inspired profanity almost since the invention of speech. Protec¬ tion against insect-born diseases (apart from a prophylactic against malaria) depends on screening and spraying. The law allows use of DDT there, but in fact CFMS personnel use other broadspectrum insecticides. In hot weather every mess is sprayed every
likely
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night. Besides flies and malaria-infected mosquitoes, Egypt has other delights for the military visitor. There are ratlittle snakes with tlesnakes, asps nasty, poisonous bites scorpions and rabid dogs. There are two versions of rabies, known as "dumb" and "furious", and the important thing they have in common is they are both lethal. CFMS keeps antisera for all known
local venoms. Mundane but necessary Above these exotic perils, it seems almost mundane to mention the stand¬ ard environmental medicine practised by CFMS. But there are regular inspections of rooms and work areas for health hazards. A slip-free workshop floor, proper shielding for cutting tools, levels of illumination these are part of the job, too. "Preventive medicine can be frustrat-
CMA JOURNAL/JULY 12, 1975/VOL. 113 47
.@w sinemeE (levodopa and carbidopa combination)
INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. DOSAGE SUMMARY Therapy must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Because of the enhancement of levodopa effects provided by SINEMET*, titration and adjustment of dosage sheuld be made In small steps, without exceeding recommended dosage ranges. Therapy in Patients not receiving Levodopa: Initially 1/2 tablet once or twice a day, increase by 'A tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodopa: Discontinue Ievociopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. Please consult monograph for complete information including initial dosage, transfer from levodopa or other agents, adjustment and maintenance. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, 'which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history or melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and obeerve patients for unusual adverse reactions. With Anes-
thetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other SerIous ReactIons: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness. Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behavior, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica', increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dormatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. SpecialSenses: blurred vision, diplopia, dilated pupils, activation of latent Homer's syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. FOR COMPLETE PRESCRIBING INFORMATION PLEASE REFER TO PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST HOW SUPPLIED Ca8804-Tablets SI NEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded M5D654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100.
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50 CMA JOURNAL/JULY 12, 1975/VOL. 113
(Mc-973)
ing," says Lt. Col. McArthur. "If you've done the job properly, it's hard to prove you've done it." Research Back in Ottawa, Col. Marriott's duties include environmental, as well as preventive, medicine. This means he has the directorship of the minimal research effort maintained by the CFMS. "Our opportunities for research in clinical medicine are limited," he said. "We can read the journals just as well as anybody." In fact, the Defence Research Board allocates only about $10 000 a year to clinical research. But this goes a remarkably long way, simply because the personnel and equipment for much of the research are there anyway and don't have to be specially budgeted. Col. Marriott describes his situation as being the envy of every epidemiologist. He has, in effect, a closed community of 78 000 people with complete records on each one. "We have the GP in the system," he points out, to emphasize the completeness of the records. But to be useful for research, the records have to be in a form which makes for ready classification. To date they have not been; all this will change when the present project to computerize the records is completed. Then Marriott will be able to do retrospective research, using as a data base 78 000 men and women with totally complete medical and personal histories. Canada also maintains a minimal research effort in nuclear, biological and chemical warfare. This, Col. Marriott stresses, is purely defensive - to provide the service with the knowledge it needs to protect itself from these forms of attack. CFMS also has an input into the work carried out at the Defence and Civil Institute of Environmental Medicine (DCIEM). This institute, formed a few years ago by the joining of defence and civil research efforts, has an annual budget of $4.5 million and employs 78 service and 150 civilian people at its Downsview location. Among the 100 projects currently under way are the layout for a new bridge for an icebreaker, solar heating for homes, Arctic dehydration and a mobile garbage-disposal-water-purification combination. The institute is jointly controlled by the surgeon general and the Canadian Forces chief of research and development. Preventive medicine and research complement the actual delivery of health care to the Canadian Forces, and, as the ads say, watch this space in the next issue of CMA I.E
