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Clinical Vignette: Spatial Disorientation

Clinical Vignette: Spatial Disorientation. MAJ Tim Cho and LCDR Jim Gilson Occupational/Aerospace Medicine Residents.

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Clinical Vignette: Spatial Disorientation

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  1. Clinical Vignette: Spatial Disorientation MAJ Tim Cho and LCDR Jim Gilson Occupational/Aerospace Medicine Residents

  2. MAJ TIM CHO, LCDR JIM GILSON AND ALL OTHERS INVOLVED IN THE PLANNING, DEVELOPMENT, AND PRESENTATION OF THIS LIVE CME EDUCATIONAL ACTIVITY PROVIDE THE FOLLOWING DISCLOSURE INFORMATION: “NOTHING TO DISCLOSE”

  3. OUTLINE • Introduction • Clinical Presentation • History • Differential Diagnosis • Review of Systems • Physical examination • Investigations • Patient Course • Discussion • References • Questions/Comments

  4. INTRODUCTION • Spatial Orientation relies on visual cueing, a functioning vestibular organ system, and proprioception • Spatial disorientation occurs when the pilot’s perception of direction (attitude) is miscued to the actual surrounding • Somatogyral (semicircular canals) and somatogravic (utricle and saccule) illusions occur • This is a clinical vignette that teaches us to appreciate the complexities of Spatial Disorientation

  5. CLINICAL PRESENTATION(History) • 31 year old active duty Apache instructor pilotpresents with a chief complaint of a tumblingsensation when the air-craft is in pitch. He is a reliable historian and recollects the initial and transient sensation whendeployed 2 years ago, however upon PCS’ing to FortRucker, AL, the sensation has now become a distraction when flying, resulting in him being more anxious.

  6. CLINICAL PRESENTATION(History) • Pertinent (+): sensation of tumbling when the aircraft is in pitch, anxiety, headaches • Pertinent (-): no acute illness, no drug or ETOH history, no blurry vision/double vision, no ringing of the ears, no musculoskeletal weakness, no cardiac history, no medication, psychiatric or motion sickness history, no disorientation when rotating

  7. CLINICAL PRESENTATION(Differential Diagnosis) • vertigo • benign paroxysmal positional vertigo • migraine headaches • anxiety • vestibular neuronitis • labyrinthitis • acoustic neuroma • inner ear anomaly

  8. CLINICAL PRESENTATION(Review of Systems and Physical Exam) • General Appearance: WD, WN M in NAD • Cranial II- XII: WNL • Sensation: WNL • Motor: WNL • Coordination/Cere-bellum: WNL • Gait and Stance: WNL • Reflexes: WNL • HEENT: chronic wisdom teeth pain • Cardiovascular: unremarkable • Pulmonary: unremarkable • Gastrointestinal: unremarkable • Genitourinary: unremarkable • Skin: unremarkable • Musculoskeletal: unremarkable • Neurological: positional vertigo • Psychiatric: unremarkable

  9. CLINICAL PRESENTATION(Investigations)

  10. CLINICAL PRESENTATION(MSDD) Control Subject Centrifugal Force Resultant Gravito-inertial Force Gravity

  11. CLINICAL PRESENTATION(Patient Course) • April 2014: • ENT/Otolaryngology Examination • July 2014: • NAMI Neurology examination • MSDD • August 2014: • Battalion staff • Restricted flying w/IP • December 2014: • Eye Movement De-sensitization and Reprocessing (EMDR) therapy, • Wisdom teeth pulled out

  12. DISCUSSION • Lesson Learned • On-going case • Leadership support combined with medical management is a viable course of action • Tri-service waiver process • Vertigo • The way forward • Additional cueing to close the gap between perceived and true orientation of pilot and environment

  13. AEROMEDICAL WAIVERS (Vertigo)

  14. REFERENCES Davis, J. R., Johnson, R. & Stepanek, J. (4th ed.). (2008). Fundamentals of aerospace medicine.Lippincott Williams & Wilkins.Federal Aviation Administration. (n.d.). Aerospace medicine dispositions. Retrieved from https://www.faa.gov/about/office_org/headquarters_offices/avs/United States Airforce. (n.d.). Air force waiver guide. Retrieved from www.wpafb.af.milUnited States Army. (n.d.). Flight surgeon’s aeromedical checklists & references. Retrieved from https://vfso.rucker.amedd.army.milUnited States Navy. (n.d.). Aeromedical reference and waiver guide. Retrieved from http://www.med.navy.mil/sites/nmotc/nami/arwg/ *Special thank you to, CAPT(ret.) Rupert and Casey

  15. Questions? Comments?

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