NAVY MEDICINE July-August 1992 'B11M'E'D Ce{e6rates its 150tli !Jlnniversary 1842-1992 Surgeon General of the Navy NAVY MEDICINE Chief, BUMED VADM Donald F. Hagen, MC, USN Vol. 83, No. 4 July-August 1992 Deputy Surgeon General Deputy Chief, BUMED eor.,. Chief, Medical RADM Robert W. Higgins, MC, USN From the Surgeon General I Navy Medicine at 15.0 Department Rounds 2 Corpsman Awarded Silver Star Edftor J. Caldwell Jan Kenneth Herman 4 NAMI Moves Into Next Century C. Lee ~ntEdltor VIrginia M. Novinski Features 6 The People Puzzle Edlor181 ~nt CDR L. Harmon, MSC, USN Nancy R. Keesee LCDR M.E. Quisenberry, NC, USN LCDR P. Denzer, MSC, USN LT K. Magnusson, MSC, USN HMC(A W) S.K. Scofield, USN 10 The Origins of BUMED: Fleet Support and Fiscal Responsibility D. C. Smi1h, Ph. D. NAVY IIEDICINE. VoL 13. No. 4. PSSN 0185·8211 USPS 31 8-070) Ia publlalled bimonthly lly 11e o.s--nt of the 16 Combat Fitness Retraining Program: An Idea Whose Navy, .,_u of Medicine and Surgery (BUMEO OIH), Time Has Come w.tllngton. DC 20372·5120. Second-claM poatage paid 81 W88111ngton. 0C. and IICidllonlll rneiHng olllcea. CDR W. W. McDaniel, MC, USNR POSTMASTER: llancl - changaa to Navy -lclne -of Naval~ and Forma Center. ATTN: Code 18 View From the Cot: Patients Opinions of Medical Care 301. 5101 Teor ,...,,.,., Philedelpllla. PA 11120. During Desert Shield/ Storm POUCY: Nwy lledlclne Ia 11e a111c1a1 publlcallon of 11e Navy Madlcel Deperlment. •• l-.clecllor Medical Depart CAPT J.R. Wheeler, MSC, USNR -'...,_... end <**Ina p;clualDi-'lnlonnatlon Nla· S. Noble ... 10 III8CIIclne. ~-and lie ..., "-"" acianca Opinlona ..-c1 - ._ of lie auflora and do net 23 Occupational Medicine and Training of Family Practice Residents -'Y ...-the clllclel poaRion of the~ of lie Navy. lie .,_, of Medicine and Surgery, or any CAPT T. W. Henn, MC, USN Ollar.,_n_..,....,......oragenc:y. Trade..,__ UMIIIor ~c~e~•c. .o n only and do not,._.,enc~c~qe­ 25 Chronology: Navy Medicine July-August 1942 c-i"neb eynd 1 1Seu Dragpeeryl1. mAalnlltl oouf g1l1le NNwavyy ollre tdhlec ianue . .m.a.y o fc Mitea clol·r J. Mitchum •~ from dlractlvaa. aullorlly lor action aiiOukl 11a ol*lnad from lie cllad ......,__ Professional DISTIHUTION: Nwy ~ lacllalrtllutaciiOacllva duly 31 The Personality Disorder Patient in the Military Health Clinic Madlcal Dapartmanl paraonnal via the Slandard Navy Dlalrl CDR S. W. Raczek, MC, USN llullon Uat. Tlla IOHowlng dlalrtllullon Ia aulllorlzad: ona copy lor aacll Madlcal, Denial. Medical Sarvlca. and Nu-Corpa LCDR T.G. Patten, MSC, USN oilier. ona copy lor MCII 10 anll.-cl Madlcal ~nt ~ Aaq-10 lnCt.a8a or~ the number of 36 Suicide Prevention: A Case Study Analysis allollad coplaa IIIOuld lla tor.rdad 10 Navy lladicJnevla the LCDR S.R. Menenberg, NC, USN local-nd. NAVY IIEDICINE Ia publlallacl ..o m appropriated lunda by LCDR D.A. Munson, NC, USN authority of the Bureau of Macllclne and Surgery In accord· anca with Navy Publlcallona and Printing RatulatiOne P-35. Notes and Announcements Tlla Sac..-ry of the Navy .... clalarmlnad ltlllllllla publlca 39 In Memoriam: CAPT R.L. Christy, Jr., MC, USN lon Ia -ryI n the tranaactlon of .,.,.,_. raqulrad by lllw of lie Dapa.-of the Navy. Funcla lor printing Ilia 40 Naval Medical Research and Development Command Highlights pullllc8llon ,_ baM apprCMCI by lie Navy Pu-na and Printing Poflc:y Corn-Artlc:laa. ....... and A Look Back c~hal1gaa ma oyf ltlhae I ONrawveyr.d aaud . 1.0. .li oef EMdalclollrc. lnNaa atf'n/ dll aSduircgieMry, 41 Navy Medicine 1942 (8UMED OIH). W.-giOn. DC 20372·5120. T...,._ (Area Code 202) 1113-1237. 1153·1217; Aulovon 2114-1237. 2114-1217. Conlrlllutlona from lie laid-wa1coma and d lla publiallad •IIPIIC8 parmlla, IUIIjaciiO adlllng and pcaal• lila allrldgmant For aala by lla Suparlntandan1 of Documenta. U.S. COVER: On 31 Aug 1842, Congress passed legislation reorganizing the Qo..,onmant Printing 01t1ca. W_,lngiOn. DC 20402. Navy into five bureaus. As the only original bureau still in existence, BUM ED celebrates its I 50th birthday. Story on page 10. Cover art by Moses Jackson, NSHS, Bethesda, MD. NAVMED P-5018 From the Surgeon General Navy Medicine at 150 0 n 31 Aug 1842, the Congress of the United States passed a Navy appropriations bill creating the Bureau of Medicine and Surgery. The purpose behind the bill was the obvious need for the Navy to be able to maintain a healthy fighting force. One hundred and fifty years later, that need still exists, and as recent world events have already shown, Navy medicine is doing an exceptional job fulfilling it. During the past 2 years, we have flexed our ability to support the operational forces like never before. Wherever we've been called to serve-whether in the sands of Southwest Asia during Operations Desert Shield/Storm, in Bangla desh, the Philippines, or Cuba during humanitarian assistance missions, or simply in our routine support of fleet operations- Navy medicine has met the challenge, and done what we do best, providing quality care to the people of the Navy and Marine Corps. What has made me especially proud is that we've been able to do all this while still keeping our commitment to take care of our Navy and Marine Corps families and retirees. The quality of the Navy hospitals and clinics which serve these beneficiaries is higher than it's ever been. In fact, when compared to civilian hospitals and other military treatment facilities, Navy hospitals consist ently receive higher scores from independent accreditation agencies. Those scores are unbiased indicators of the tremendous quality and dedication of our Navy medical personnel. In the years ahead, Navy medicine will undoubtedly be going through some changes; however, I am convinced that these changes will only help to ultimately improve the quality of service, will improve the access our beneficiaries have to health care, and increase our emphasis on preventive health care services. Within our own community, we have rededicated our commitment to providing each person within the Navy Medical Department the professional opportunities for a rewarding and fulfilling career. The plans and initiatives we are launching now will guide Navy medicine safely into the 21st century. Thank you for the significant contribution each of you makes toward continu ing the tradition of excellence which was begun I 50 years ago this month. CHARLIE GOLF ONE. VADM Donald F. Hagen, MC July-August 1992 MG Mike Myatt, commanding general, 1st Marine Division, presents the Sliver Star to HM3 Martin. Department Rounds Corpsman A Navy hospital corpsman as signed to a Marine Corps unit at Camp Pendleton, CA, is the recipient of the highest commendation presented to a medic for heroic actions during Operation Desert Storm. In a Awarded ceremony marked with traditional pomp and circumstance, HM3 Anthony Martin, 28, was presented the Silver Star for "conspicuous gal lantry and intrepidity in action." Martin's version of the story is Silver Star somewhat more modest. "I was just doing my job," said the Milwaukee, WI, native before the presentation. "I look back on the day now and can't believe I did what I did and didn't get hit." What this shy 6-foot 4-inch, 240- pound corpsman did was deliver the lives of nine marines. 2 NAVY MEDICINE Martin demonstrates how he carried LCPL Muslcant from the baHiefleld. The tale begins more than a year ago wound, a large jagged hole in his left MG Mike Myatt, who commanded in the AI Wafra oil fields during the thigh and a torn artery, was the worst. the 1st Marine Division in Operation battle to liberate Kuwait. According to The young marine, on hand to see his Desert Storm, said nine marines are the citation which accompanies the friend receive the commendation, alive today because of Martin. "'Doc' Silver Star, Company L, 3rd Battalion remembered the day. is a term of endearment earned by of the 9th Marines came under an "It felt like my leg fell off," Musicant corpsmen who support marines," enemy mortar attack 24 Feb 1991 said of the incident. "I knew I was Myatt said after pinning the medal on while rounding up surrendering Iraqi going to die. You lose that much blood Martin's chest. "Doc Martin, you are a troops. Disregarding his own safety, and you just know that you're going to very special part of our corps." Martin, then an E-3, ran amidst die. When Tony picked me up, I was Martin would have preferred a incoming Iraqi rounds, answering really surprised my leg came with me. I smaller gathering for the presentation cries for help from fellow marines. thought it had been blown off." (more than a thousand marines were in "When the mortar rounds hit," Mar With enemy gunfire raining around attendance). According to Myatt, tin remembers, "I heard Musicant and him, Martin hauled Musicant's bleed their presence was testimony to the L T Jones yelling for help. I was scared ing body, complete with battle gear feelings marines have for their corps but I had to help them. I wasn't wor and a radio, over his shoulder, and men. o ried about me. If I got hit, I got hit." bolted for the shelter of an armored - Story and photos by Joy Caldwell, Public LCPL Richard Musicant, I LT Mat vehicle with medical supplies on Affairs Office, Naval Hospital, San Diego, CA thew Jones, and SGT John White were board. "I just kind of high-stepped 92134. hit by shrapnel from the same mortar across the battlefield," Martin said. "I round. Of the three, Musicant's guess I was pretty busy that day." July-August 1992 3 NAMI Moves Into Next Century f f There is not another recom Decompression sickness is caused gases the patient is breathing and have pression chamber like this by the formation of bubbles of inert the capability to monitor and control one in the Navy Medical gas, usually nitrogen, within the the temperature inside the chamber. Department," said HMCM(DV) body's tissues. Rapid lowering of There is also an electrocardiogram Wayne Shurtz, Naval Aerospace Med ambient pressure, such as during (EKG) heart monitoring system. ical Institute's (NAMI) senior diving ascent in flying or diving, leads to an With a camera inside the chamber, medical technician. increase in dissolved nitrogen reaching and the small television monitor and Shurtz is speaking about the new a threshold level and appearing as video cassette recorder outside the state-of-the-art recompression bubbles. chamber, the patient's treatment can chamber housed in NAMI's Aviation N AM I had a recompression be monitored and recorded. "This Physiology Training Unit, Building chamber before, but it was made in the would be useful for training purposes 3845. ''This will bring NAMI into the 1930's, lacking many of the modern and for reviewing and documenting next century as far as recompression touches present on the new chamber. the patient's progress and treatment," chambers go," continued Shurtz. The "Because of the design of the new said Shurtz. recompression chamber (a steel vessel chamber, a gurney will fit inside," said To make the patient as comfortable where the internal pressure can be Shurtz. "This will enhance the as possible while being treated, an increased in equivalent feet of sea patient's safety; before a gurney would entertainment system is also included. water (FSW) or pounds per square not fit and that patient had to be bod A patient can listen to music or watch inch (PSI) causing the bubbles to be ily carried into the old chamber. We television during treatment. recompressed}, treats decompression didn't have as much control of the Other features include an oxygen sickness (DCS), arterial gas embolism patient as we would have liked to hood rather than an oxygen mask. The (AGE), carbon monoxide poisoning, ensure safety," he added. hood, a clear bubblelike apparatus and other diseases that benefit by There is an extensive patient moni that fits over the patient's head, con exposure to high concentrations of toring system. Personnel can actually nects with the oxygen hose inside oxygen under pressure. monitor the atmosphere and analyze the chamber, enabling the patient to 4 NAVY MEDICINE f breathe oxygen while wearing the hood. "The hood is for those people who have problems wearing an oxygen mask," said Shurtz. ,This also helps if the patient is treated for a long time; a mask can be very uncomfortable." In case of a fire inside the chamber, the sprinkler system will spray 200 gal lons of pressurized water into the vessel. A state-of-the-art communication Through the combined effort of EDU, service is also available to the public system is another added feature. If the Public Works, and NAMI, the new on a humanitarian basis in the event of main communication system goes out, facility cost $325,000. threat to life and limb, but an appro a self-generated sound-powered phone NAMI's primary mission regarding priate evaluation to determine the is available. This is a backup system the hyperbaric system is to support bona fide nature of the emergency that will allow the patient to communi physiology training, operational fly must be accomplished prior to accept cate with the medical personnel out ing, and Navy diving operations. ing a civilian patient. Additionally, the side the chamber. However, military members, their recompression chamber is geographi Under the guidance of the Experi dependents, and retirees suffering cally situated so that it is the only facil mental Diving Unit (EDU) in Panama from DCS and air gas embolism as a ity from Mobile, AL, to Panama City, City, FL, NAMI divers and Public result of sport diving may be brought FL, capable of adequately treating Works personnel installed the to the recompression chamber for decompression sickness or embolism chamber at considerable savings to the treatment. The recompression resulting from diving. o Navy. Independent contract consider chamber is staffed with fully qualified -Story by Claudia Lee, NAMl Public ations were $750,000-$950,000. Navy diving medical personnel. The Affairs, Pensacola, FL 32508. July-August 1992 5 Features The People Puzzle CDR Layton Harmon, MSC, USN LCDR Mary Ellen Quisenberry, NC, USN LCDR Pat Denzer, MSC, USN LT Kevin Magnusson, MSC, USN HMC(AW) Scott K. Scofield, USN Have you wondered how those people at BUMED The manpower system consists of essentially two com (Bureau of Medicine and Surgery) decide how ponents: manpower requirements and manpower authori many people you have in your hospital or clinic? zations (billets). Have you ever wondered why you have certain physician specialists and not others? Maybe you've wondered how Requirements the detailers come up with all those choice duty opportuni Manpower requirements quantitatively and qualita ties. Have you ever wondered what those manpower peo tively define the most effective and efficient methods of ple were saying when they talk billets, authorizations, performing assigned missions and functions. Stated differ end-strength, manpower, inventory, promotion opportun ently, given a naval hospital, how many people do we need ity, DOPMA, and a myriad of other terms. and what skills should they have in order to get the job This article will acquaint you with what we refer to as the done? The answer to that question provides the baseline "People Puzzle." This may be one of the most misunder manpower requirements for the facility. stood and maligned of all processes within the Navy. Our Manpower requirements are established through a vari desire is to inform, answer questions, and enlist your help ety of programs and methods. Of particular interest to in making the process work for everyone. The People Navy medicine, though, is the Shore Manpower Require Puzzle has essentially three parts: manpower, personnel, ments Program comprised of the Efficiency Review (ER) and distribution. process. The ER process is the primary method currently employed by Navy medicine to state our shore-based man Manpower power requirements. Although the terms ~manpower" and "personnel" are The ER process reviews and assesses work load in terms often used interchangeably, they are not synonymous. In of the activity's mission, functions, and tasks; objectively fact, the terms refer to two systems that are entirely differ reviews and determines the equipment and processes ent. In the broadest sense, the manpower system is the necessary for the activity to efficiently and effectively dis template upon which the personnel system operates. As charge its mission and tasks; determines the number and you would expect, the trip from the floors of Congress to defines the skills and mix of military, civilian, and/ or the floors of a medical or dental treatment facility is a long contractor manpower resources required based upon and convoluted one. measured/validated work load/tasks. 6 NAVY MEDICINE Manpower requirements provide a credible baseline for An end-strength number or target is established through planning, programming, and budgeting for total force the processes described above and reflects the number of manpower resources to support the operating forces and individuals authorized to be on active duty at the end of a the shore establishment under wartime and peacetime con fiscal year. With this target in hand, each corps' personnel ditions. planner identifies current number of people on board, projects losses by grade and specialty, and then develops a Authorizations plan to reach the end-strength target. The strength plan Billets authorized are the link between manpower contains historical information regarding the structure of requirements, Congressional appropriations, and person the corps and anticipated changes (gains and losses) based nel inventory. Billets authorized describe qualitative data on correspondence, orders, etc. The basic formula for necessary for stating manpower in terms meaningful for end-strength is: training, strength planning, and distribution of personnel. End-strength = begin strength + gains - losses As an example, assume that Naval Hospital "X" has an established requirement for two cardiovascular surgeons The end-strength for one fiscal year becomes the begin and it has decided to program two billets against those ning strength for the next. Losses are established by letters requirements. Once programmed, the billets ensure that of request and orders for resignation, release, or retire fully qualified cardiovascular surgeons are ordered to NH ment. Gains are identified through evaluation of various "X" (as inventory allows), that strength planners develop accession sources. Programs such as direct procurement, plans to maintain an adequate number of cardiovascular the Armed Forces Health Professions Scholarship Pro surgeons to meet the need, and that training plans are gram (AFHPSP), the Nurse Candidate Program (NCP), evaluated and modified, as necessary, to produce the cor enlisted commissioning programs, etc., contribute to the rect number of cardiovascular surgeons. gains variable in the end-strength equation. Manpower requirements represent the validated need to fully satisfy approved missions and functions for a given Accession Plans work load. Manpower authorizations (billets), on the Accession programs such as AFHPSP and NCP are other hand, represent an actual allocation of resources to a long-range plans which look at future accession needs. requirement. In general, total manpower requirements for Each program has its own plan which finds its basis in the the Navy exceed the money available to support that level future end-strength projections. They provide a steady, of manpower. Billets, therefore, are used to identify man reliable source of new accessions each year and form the power requirements that are resourced. foundation for our annual recruiting plans. Recruiting. The end-strength equation is completed by Personnel recruiting. Beginning strength has been established, projected losses and programmed gains identified, and we Once authorized billets have been established, we turn now have a projected end-strength with no recruiting activ our efforts to filling those authorizations with people. ity. The difference between this projected end-strength and Personnel planning is complex because it occurs on several our end-strength target becomes our total recruiting goal. levels and over several fiscal years with each level compli Goals are then established for each specialty within a corps menting and matching the others. The basis for all person according to need. nel plans is the strength plan. Other plans include accession, promotion, training, and redesignation (aug Promotion Plans mentation) plans. Promotion plans are developed annually in July I Au gust and are projected for 5 years. The promotion plan is Strength Plans constructed I Y2-2 years before execution, e.g., the FY93 Strength plans are developed quarterly, submitted to promotion plan was developed in July 1991; selections BUPERS (Bureau of Naval Personnel), and become the were made during FY92 for promotions which will begin I basis for personnel planning across the entire Navy. Oct 1992 (FY93). Guidance for promotion planning comes July-August 1992 7 from Congress, DOD, and Navy and includes guidelines Distribution for flowpoint (the average number of years from the ensign date-of-rank to the next grade), promotion opportunity Personnel distribution is an extremely dynamic under (the percentage opportunity within zone), and authoriza taking. Federal law governs matters such as total number tions (the numbers allowed within a specific grade). of personnel authorized, service obligations, retirement DOPMA vs. non-DOPMA Control. The Defense Offi eligibility, involuntary release from active duty, and com cer Personnel Management Act (DOPMA), effective Sep pensation. The Chief of Naval Operations authorizes the tember 1981, established policies specifically related to number of positions available for distribution. As men Officer Personnel Management. The DOPMA section tioned before, the manpower authorization for each activ most related to this article specifically addresses the "con ity is both a quantitative and qualitative expression of its trol" grades of LCDR, CDR, and CAPT. DOPMA was requirements. Billets can be moved from one activity to established to standardize force structure, promotion another as requirements change; however, the total opportunity, and flowpoint. DOPMA groups within the number of billets cannot exceed the Chief of Naval Opera Medical Department include the Nurse Corps and Medical tions' authorization. Billet changes can only be made by Service Corps. Control grades are usually "vacancy filled," the claimant responsible for the activity. meaning the number selected for promotion is based on the Filling authorized Medical Department billets, i.e., the number of losses to that grade. DOPMA guidelines for distribution process, involves coordination by several peo flowpoint and opportunity compared to actual flowpoint ple. The BUPERS Medical Department Officer Distribu and opportunity are provided in Table I for each Medical tion Branch (PERS-4415) has direct responsibility for all Department Corps, fiscal years 92 and 93. Medical Department officers; however, distribution deci Non-DOPMA communities, of which there are two, the sions are often made after consultation with BUMED, the Medical Corps and the Dental Corps, are not constrained individual activity, and specialty advisors. PERS-4415 in the size of their control grades. DOD guidance directs does not, however, add, delete, relocate, or change billets. that these corps shall maintain a "pyramidal" shape, flags That is a manpower function. at the top and lieutenants at the bottom, and that 6 years The distribution process is a vacancy driven system. time-in-grade shall be the window of eligibility. This Vacancies are prioritized for fill in accordance with estab results in a flowpoint which is comparable to DOPMA lished Surgeon General/ Chief of Naval Personnel policies controlled communities. and activity requirements. Current prioritization for fill is: Training Plans • Congressionally mandated facilities (staffing levels set Training plans are based on the "needs of the Navy." by Congress regardless of billet authorization). We've all heard that, but what does it mean? In this case, • Operational/ OCONUS facilities. the needs of the Navy are defined by billets authorized and • Isolated CONUS facilities (located in medically under billet subspecialty codes. Prior to developing any training served areas, e.g., Twentynine Palms). plan, a ''billet run" is obtained which lists all billets for a • Teaching and training facilities, Headquarters and Joint specific corps defined by subspecialty code. This gives us a Staff. picture of what our "needs" are. Next we do a "body run" • All others. by subspecialty code. Matching the billet run with the body run helps us identify our training needs. Other considera Once a vacant billet has been identified and prioritized, the tions made while developing the training plan include assignment and placement officers coordinate efforts to personnel currently in training, personnel projected for find an available person who is best qualified to fill the training, projected gains and losses by specialty for coming billet. The needs of the service are balanced against the years, and other identified requirements. Defined needs career needs and desires of the individual. are then compared to the number of training slots availa Placement officers represent the needs of the service and ble, and decisions are made regarding how many people act as the command's advocate to assure that the available will be selected for training during the coming year. officer is the best qualified to fill the billet. Additionally, they provide information to assignment officers regarding Redesignation Plans priorities for fill and claimant/ command requirements. Each community has a prescribed number of regular They evaluate proposals for billet fills by analyzing the officers. By law, the Navy has a limit on total number of qualifications of the officer being proposed against the regular officers allowed. Redesignation boards are con requirements of the billet. They also determine if the pro vened twice a year in April and October. Prior to the posed officer has completed the prescribed tour length at board, each community reviews the total number of regu this present duty station and is available for reassignment. lar officers on active duty and the number of projected If any discrepancies occur during this evaluation process, regular officer losses. The difference becomes the plan for the placement officer discusses the proposal with the redesignation. assignment officer. Once the placement officer determines 8 NAVY MEDICINE