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There is a tendency for euphoria to develop while motor skills and reasoning abilities deteriorate. The result is that in many cases the pilot may become seriously hypoxic without appreciating that there is a problem. To the observer tachypnea, cyanosis, mental confusion and loss of muscle coordination are obvious. To the pilot however, the only symptoms may be slight dyspnea, dizziness, fatigue, decreasing vision and finally loss of muscular control. Night vision can be impaired at as low as ft.

Tolerance to hypoxia varies from individual to individual and from time to time. Tolerance can be increased by continual exposure to high altitudes and varies with the level of the hemoglobin and the oxygen carrying capacity of the blood. It is decreased by fatigue, cold and poor physical conditioning. Even at 5, ft. Hypoxic hypoxia is due to a decrease in the oxygen available to the body such as typically occurs with altitude. Hypemic hypoxia is caused by a reduction in the oxygen carrying capacity of the blood for any reason.

It also occurs when hemoglobin is saturated by gases for which it has a higher affinity, the most common of which is carbon monoxide. This is not only produced by exhaust leaks into the cockpit but also by cigarette smoking. Stagnant hypoxia is a less common problem caused by a reduction in total cardiac output, pooling of the blood or restriction of blood flow.

Heart failure, shock, continuous positive pressure breathing and Gforces in flight can create stagnant hypoxia. Local stagnant hypoxia can occur with tight and restrictive clothing or, in the cerebral circulation, in association with vasoconstriction due to respiratory alkalosis provoked by hyperventilation.

Histotoxic hypoxia refers to poisoning of the respiratory cytochrome system by chemicals such as cyanide or carbon monoxide but it can also be caused by the effects of alcohol. Needless to say a pilot in poor physical condition, recovering from a hangover and smoking while in flight can quickly become an unfortunate statistic!

In the seated position the lungs, due to the pull of gravity, are stretched at the apices and condensed at the bases. At the same time, the blood supply is least at the apices and greatest at the bases. Thus in the area where the alveolar ventilation is best, perfusion is least and at the bases the opposite is true.

Only in the mid section of the lung is there an ideal ventilation – perfusion ratio. Under positive G, the situation is exaggerated and if it is of long duration in crews breathing oxygen, rapid absorption from the alveoli tends to cause basilar atelectasis. Hyperventilation may be described as a respiratory rate excessive for the body’s oxygen requirements. It may be voluntary or involuntary and can occur in relation to many different activities.

In the pilot the most common precipitating causes are anxiety, fear, excessive concentration on a flight procedure and as a reaction to pain or illness.

Hyperventilation may be obvious, as in the case of children preparing to compete in underwater swimming, or it may be covert as for example when the respiratory rate increases from a required 12 per minute to an excessive 15 per minute and remains elevated for a prolonged time. Whatever the cause the results are the same.

Carbon dioxide, the most potent stimulus to respiration, is blown off in excessive amounts. The PACO2 falls and respiratory alkalosis develops. The cerebral vessels become constricted and subjectively the pilot often notices a feeling of dizziness, a coldness and tingling around the lips and a feeling as though there was a band around the head. Nausea may be present. Peripherally there is vasodilatation and stimulation of sensory nerves causing a sensation of pins and needles in the hands and in the feet.

If hyperventilation continues carpopedal spasm develops and the subject may become unconscious and develop frank tetany. With the breath held the carbon dioxide levels build up once more and the symptoms disappear in reverse order.

Obviously such a chain of events can lead to an accident. This has been documented in some incidents in young fighter pilots or untrained private pilots who have inadvertently flown into bad weather and have kept the microphone button depressed, broadcasting their breath patterns up to their final moment. Hyperventilation is often suspected in unexplained accidents. If one considers the symptoms of hypoxia and hyperventilation it will be seen that they are very similar.

Although it is usually in military pilots that problems arise with hypoxia at levels above 30, ft. The Concorde, for example, cruises above 60, ft. Cabin pressurization in these aircraft ensures that the partial pressure of oxygen is adequate and it is rare for the cabin pressure to be above 7, ft. See Fig. However, it is wise to remember that passengers with chronic lung diseases or serious anemia, particularly those who are smokers, may be significantly hypoxic even at this altitude.

More dangerous however is the situation which develops when cabin pressure suddenly fails, usually due to the loss of a window or door. The result is rapid decompression with a sudden increase in the cabin altitude to match the ambient altitude. In aircraft such as the Concorde the windows have been made particularly small to lessen this effect but in older aircraft more serious problems have occurred. The immediate effect of decompression is a loud noise, condensation of water vapour causing a mist and a shower of dust and small particles.

The temperature falls dramatically. The resultant cabin pressure may actually fall below that of the ambient pressure due to “aerodynamic suck”. This refers to the Venturi effect created by the speed of the aircraft through the air.

The initial hazard to aircraft safety is hypoxia. The crew are unlikely to be wearing oxygen masks at the time of the incident and, if the final cabin altitude is high, the time of useful consciousness may be very short see Figure 8.

It may actually be lower than would be anticipated because of the sudden escape of expanding gas from the lungs due to the reduced ambient pressure. This causes reversal of the oxygen diffusion gradient across the alveolar membrane and oxygen passes back into the lung from the blood. At 35, ft. Airlines make provision for this eventually by providing pilots with “quick-donning” oxygen masks, which can be donned in 5 seconds or less. At sea level this is – 47 x 0.

The respiratory quotient R on a pure carbohydrate diet is 1. On a balanced diet of carbohydrate, protein and fat, R is generally about 0. We have already commented on the decrease in atmospheric pressure which occurs with altitude.

Boyle’s Law states that, at constant temperature, the volume of a gas varies inversely with the pressure. If the pressure of gas is halved, its volume is doubled.

Application of this simple law to the closed body cavities quickly indicates where problems are likely to occur. By far the most common problems are with the middle ear.

It resembles a box, closed by a flexible diaphram at one end and drained by the Eustachian tube narrow tube at the other. The eustachian tube however is not rigid or symmetrical throughout its length and becomes slit-like at its outlet in the nasopharnyx. On ascent expanding trapped air usually escapes easily and the only thing noticed is a periodic “popping” due to movements of the drum as pressure equalizes.

On descent however equalization of pressure through the slit-like outlet is much more difficult and a negative pressure can build up in the middle ear. This leads to a decrease in hearing and to pain. The ear can be cleared by opening and closing the mouth, thus activating the tensor tympani muscle and dilating the tube, or by inflation by a Valsalva maneuver.

In an U. The pressure in the middle ear on descent may then become so low relative to the outside pressure that exudation and hemorrhage may take place and ultimately the eardrum may burst. Excessive valsalva maneuvers however may force bacteria into the middle ear, leading to infection. When an ear blocks and cannot be cleared by the usual maneuvers, the best way to deal with the situation is to reascend and start a slower descent. This is not always possible. During World War II the pilots of vertical diving Stukas had constant ear problems and their flight surgeons solved these by periodically incising the drums!

Nowadays this is not recommended! A particular problem occurs when pilots flying at high altitude on oxygen retire to sleep soon after landing. The middle ear is full of soluble oxygen rather than inert introgen which is absorbed during sleep.

On awakening they have earache due to the indrawn drums. This is called “oxygen ear”. Other air spaces are equally affected. The nasal sinuses are a common source of pain as may be poorly filled teeth if the filling has not been carefully inserted and a gas space remains below it.

These various symptoms are referred to as “barotraumas” and toothache of this type is known as “barodontalgia”.

The best approach to these conditions is knowledge and prevention. Fortunately most professional pilots are well aware of the problems and avoid flying when they are congested.

A common irritating, embarrassing and potentially serious problem is gas in the bowel. This expands rapidly as might be expected and, if it cannot be passed, may lead to severe pain. Chewing gum, air swallowing, carbonated drinks and beer in the passenger all add to the gas, as do various gas producing foods.

Passengers with ostomy bags or various types of bowel obstruction are particularly likely to have problems. Boyle’s Law must be kept in mind if you are involved in the transport by air of patients requiring cuffed tubes of any type or if casts or pneumatic dressings are being used. Cuffs should be inflated with saline or water rather than air before the trip.

The “Bends” or “Caisson disease” has been recognized since in association with “hard hat” divers or men working under pressurized conditions. By the end of WWI the possibility of decompression sickness in aviators was predicted and once high altitude balloon flights were undertaken the prediction was fulfilled.

The cause of decompression sickness is the formation of gas bubbles in the body and the physical law was described by Henry. Henry’s Law states that the quantity of gas that goes into solution at a given temperature is dependent upon its solubility characteristics and is proportional to the partial pressure of that gas over the surface of the liquid.

Hence as the pressure falls, the amount of gas which can be held in solution is reduced. The dominant gas in the atmosphere we breathe is nitrogen. It is inert and the body is saturated with it at ground level. During rapid ascent the reduction of barometric pressure creates a condition whereby the inert gas tension in the tissues is greater than the external barometric pressure. This condition is called super-saturation.

At this point, in association with bubble nuclei produced by muscle shear forces or turbulent blood flow, bubbles of nitrogen can be formed in the tissues and in the body fluids. It is these bubbles which give rise to decompression sickness. The symptoms of decompression sickness are described as the four “C’s”. These are Creeps, Cramps, Chokes and Collapse”.

This “formication” is believed to be caused by the formation of tiny bubbles. Smaller joints may be affected and it is not uncommon to first notice the symptoms in joints which have previously been injured. The pain is deep and aching in character and varies from mild to severe.

It is made worse by movement of the joints and is sometimes improved by pressure on the area. It is a much more serious disorder caused by multiple pulmonary gas emboli. The subject complains of substernal chest pain, dyspnea and a dry, non-productive cough. If altitude is maintained “Collapse” will inevitably occur. The treatment is immediate descent which is generally effective. Neurological decompression sickness is the most dangerous form and often has a very serious prognosis.

It may be responsible for permanent neurological deficits particularly if hyperbaric treatment is not immediately available. In the aviator brain injuries, although uncommon, are most frequent. In divers the spinal cord type is most frequent. The reason for this variance is not known. In the brain type visual disturbances scotoma, tunnel vision, diplopia etc.

Physical signs are spotty and diffuse, both motor and sensory. The signs may be thought to be hysterical but collapse may occur. In the spinal cord the most common onset is of numbness or paraesthesia in the feet. A complete transverse spinal cord lesion may occur as bubbles obstruct the blood supply and infarct the cord. Fortunately serious decompression sickness is uncommon in commercial aviation.

Generally the altitude threshold is above 18, ft. Above 26, ft. It is much more often seen therefore in high altitude military pilots whose cockpit pressurization profiles are lower than those in commercial aircraft.

There are various factors which affect it. The incidence increases with age, there being a threefold increase between the year old and the year old age groups. Nitrogen is well dissolved in fat, so obesity is a factor.

It is probably more common in women than men. It is more common with exercise at altitude, with rapid ascents, with re-exposure to altitude at frequent intervals and at low temperatures. The after effects of alcohol and intercurrent infection both increase the susceptibility. It is important to keep in mind the relationship between SCUBA diving and decompression sickness in aviators. SCUBA divers use compressed air in their tanks and are often exposed to two or more atmospheres of pressure, supersaturating the tissues.

If they fly within twelve hours of emerging from diving at standard depths, decompression sickness has been recorded at altitudes as low as 10, ft. Where they have been diving at depths which require decompression stops on the way to the surface, they should not fly for a minimum of 48 hours. Although serious problems are uncommon, it is necessary to be aware of the danger to recognize it, particularly with neurological symptoms. Occasionally a medical emergency results when a diver ascends to the surface too rapidly, causing a bubble formation.

In such cases the diver must be reexposed to a greater pressure as quickly as possible and then brought back to the surface. Sometimes the diver is too ill to undertake another dive and must be transported to a hyperbaric chamber for treatment as quickly as possible. Pilots transporting such individuals should be cautioned that increases in altitude will worsen the patient’s condition.

If pressurized aircraft are not available, flights should be made at the lowest safe altitude. Recompression treatment tables are outlined in textbooks of Diving medicine.

Doctors often feel that an understanding of acceleration G and the effects of gravity g are only of importance to aerobatic or high performance aircraft pilots.

This is a mistake. Because we are normally terrestrial creatures, bonding to the earth has taught us that gravity exerts a downward pull. In an aircraft however, G-forces are often upward or outward and as they are associated with changes in both acceleration and direction, what is experienced is a resultant force.

It is these forces and their effects on the vestibular organs which give rise to our recognition of position in space. In the review of orientation the importance of this will be explained. Speed is the rate of movement of a body while velocity is a vectorial quantity made up of both speed and direction. Acceleration G is a change in velocity either in direction or in magnitude.

It is described in three axes in relation to the body, x, y and z. Considerable confusion can arise if a clear distinction is not made between the applied acceleration and the resultant inertial force as these, by definition, always act in diametrically opposite directions.

The physiological effects of G vary with its magnitude, duration and axis of application and are modified by the area over which it is applied and the site. Tolerance to acceleration varies from day to day and is modified by body build, muscular tone and experience.

It is decreased by poor health or conditioning, fatigue, hypoxia and alcohol. It can be increased by continued exposure and education. Pilots exposed to heavy G loads soon learn to use a modified Valsalva manoeuvre with controlled breathing and muscle contraction to increase their tolerance the M1 manoeuvre. G-suits mechanically increase resistance to positive Gz by exerting pressure on the lower limbs and the abdomen to prevent pooling of blood.

Unfortunately there is no mechanical device to counteract negative Gz. Positive Gz forces the pilot into the seat, draining the blood towards the lower part of the body. A lb. This interferes with muscular movement, aircraft control and the ability to change position or to escape in an emergency.

As G comes on and blood is drained from the head, the first symptom is visual. This leads to “grey-out”, a condition in which peripheral vision is progressively lost and central vision begins to lose its acuity. As the G load increases the retinal arterial flow is further reduced until “black-out” occurs. At this point, although vision is absent, the cerebral blood flow is often maintained and the pilot may remain conscious.

At G however most pilots become unconscious unless they are protected. This is referred to as G-LOC. G-Loss of consciousness. When the G load is reduced, consciousness will be regained although there is often a brief period of confusion before full awareness is reached. This has been determined as the cause of several accidents in high performance aircraft. Negative Gz, acting from the foot to the head, is poorly tolerated by the body and in most cases the threshold is below -5 Gz.

As might be expected the visual symptom is “red-out” as blood is forced towards the head and into the retinal arterioles. Excessive -Gz leads to hemorrhages into the conjunctiva and ultimately into the brain. A special form of G is known as “jolt”. Jolt is the rate of change of acceleration. It is descriptively used in relation to short, sharp accelerations. This type of shock can give rise to serious spinal injuries and must be minimized in the design of ejection seats.

Brief alternating positive and negative Gz forces are experienced in turbulence and may be a serious problem when flying light aircraft in hot weather or flying high speed aircraft at low levels.

G-forces not only interfere with precise flying but are also a potent source of fatigue. Tolerance to transverse G Gx is much higher. It is for this reason that the astronauts in the early vehicles were placed in a recumbent position during lift-off. Gy is not of great enough amplitude to cause problems in consciousness and is not a problem with modern day aircraft. At present, head restraint is the only problem experienced with Gy.

To the earth bound individual, orientation means being aware of one’s body position relative to the earth. Gravity acts towards the centre of the earth and is recognized as down. The aviator however lives in a different world, a world in which proprioceptive senses may give rise to false information.

At the top of a loop for example, where centrifugal force replaces gravity, down appears to be up and up appears to be down!

Disorientation, in the pilot’s sense, sometimes described as “vertigo” is to be unable to locate oneself in space and can be one of the most terrifying and lethal of experiences.

We orient ourselves by vision, the vestibular system and by proprioceptive nerve data. The mental images of orientation that we derive from these impulses are learned from birth and relate to our terrestrial habitat. So strong are these sensations that it is possible to produce nausea by placing us in an environment where what we see is different to what we feel. This is the theoretical basis of motion sickness and will be described later.

Vision is the strongest orienting sense, and the one to which we turn when other senses fail. It is functionally divided into two parts. One, employing central foveal vision and sharp focus, is concerned with object recognition and is used together with learned conditioned reflexes in instrument flight.

The other, ambient orientation, is peripheral, less acute and is directly connected to vestibular function. That the two parts of vision are independent can be observed in a driver who reads a map and follows the road at the same time.

Although we can orient ourselves and function normally when the vestibular apparatus is absent or ablated, without vision orientation is much more difficult. However vision can also give rise to illusions both of location and of movement. The vestibular system has three functions. It acts to stabilize vision via the oculo-vestibular reflexes, to orient the body in relation to movement in the environment and to give a perception of motion.

These functions are performed by two 1. Each vestibule see Fig. Each canal lies in a separate plane of space: one is horizontal, one vertical and one lateral. The canals sense angular accelerations in the planes of yaw, pitch and roll respectively. They are connected at each end to the utricle, a dilated central area in which are the ampullae.

In the ampullae delicate hair cells topped by a gelatinous cupola project into the endolymph and move with it like river bottom plants in a current.

The utricle is connected to the saccule and in the floor of these chambers are the macula sacculi. The macula in the utricle lies in the horizontal plane and that in the saccule lies in the vertical plane. The maculae consist of hair cells projecting into the endolymph and covered by a gelatinous membrane containing tiny calcium carbonate crystals.

They are referred to as otoliths and act as linear accelerometers. The vestibular apparatus has connections to the visual cortex, to the innervation of the extra-ocular muscles and to the vestibular nuclei in the cerebrum. Try holding your hand up in front of your face and then moving it from side to side.

The movement does not have to be fast before focused vision of the fingers is lost. Holding the hand still however and moving the head from side to side allows sharp focus to be maintained at much greater rates.

Occulovestibular reflexes make this possible. Proprioception is of only secondary importance to vision on the ground, but is much less reliable in the air. While flying, centripetal and centrifugal forces compete with gravity and proprioception may be confused. Although proprioception enables the pilot to stabilize his body in the cockpit and gives valuable clues to changing directions and attitudes in visual flying conditions, in instrument conditions “flying by the seat of the pants” can rapidly become lethal.

All crashed within seconds! These may be foveal or vectional, that is concerned with central vision or orientation vision. Main article: Hawaii R6D-1 crash. Main article: Altensteig mid-air collision. Main article: B disappearance. Main article: Pacoima mid-air collision. Main article: Cebu Douglas C crash. Main article: Aqaba Valetta accident. Main article: Tybee Island mid-air collision. Main article: Mars Bluff B nuclear weapon loss incident.

Main article: United Airlines Flight Main article: Okinawa F crash. Retrieved 17 December Archived from the original on Retrieved — via Canada. Archived from the original on May 20, Retrieved 9 July Retrieved Archived from the original PDF on Retrieved 1 October Daily Herald, Provo. Fulwider Winter—Spring The Humboldt Historian : 5—7.

Los Angeles Times. Atglen, Pennsylvania. Archived from the original on 23 September Nuclear Weapons Accidents”, Lulu Publishing, www. Retrieved on Lifeboat In Danger’s Hour. ISBN Royal National Lifeboat Institution. Retrieved 17 June The Right Stuff. After Effects Ready! The new version of After Effects features Multi-Frame Rendering, which allows AE to render multiple frames at the same time to speed up rendering!

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