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The occurrence of intravascular sickling depends on the degree of deoxygenation of the haemoglobin arrhythmia dysrhythmia discount trandate 100mg free shipping, which is largely determined by the oxygen tension and pH in the various local areas of the vascular system; the tendency to pulse pressure variation normal values trusted 100mg trandate sickling is also affected by the concentration of Hb S in the red cells blood pressure chart old purchase trandate 100mg visa, and by the presence of other haemoglobins that may interact with Hb S high blood pressure medication and sperm quality discount 100mg trandate visa. The sickling of red cells in the circulating blood has two major pathological effects: a) the deformed and elongated erythrocytes are rigid and their cell membrane is damaged; as a result, the sickled red cells are removed rapidly from the circulation by the reticuloendothelial system, producing haemolytic anaemia. Local pain, functional impairment, and other clinical manifestations are attributable to the vascular blockade. The diagnosis of sickle cell trait should be based on the following findings (including results from sickling tests): the patient should not be anaemic, and should have normal red cell morphology, normal levels of haemoglobin F, and a haemoglobin electrophoretic pattern of haemoglobins A and S in which A predominates. The requirements referring specifically to the urinary system are detailed in Annex 1, 6. Any transient condition of the urinary system should be considered a decrease in medical fitness until recovery. Proteinuria should always be an indication for additional medical investigation, but need not be disqualifying for aviation duties. Further discussion of proteinuria, and specifically albuminuria, is found in the nephrology section of this chapter. The examiner should seek urological consultation for any history of major surgery involving a partial or total excision or diversion of a urinary system organ in order to assess the condition’s propensity for sudden incapacitation. A degree of interpretation and evaluation must be exercised by the medical examiner and the medical assessor, often in collaboration with a consultant. Not only medical but also environmental and operational factors should be taken into consideration for the overall assessment of an applicant’s medical fitness. The genito urinary system is multifaceted in that vascular, hormonal, barometric and traumatic perturbations have significant influences on the overall function of its organs. From renal calculus disease to malignant transformation, the genito urinary system may have multiple diagnoses than can affect the pilot. Small stones (< 5 mm) with smooth contours can be expected to pass spontaneously, albeit with potentially incapacitating symptoms such as severe pain, nausea, profuse sweating (diaphoresis), or shock, all of which are clearly incompatible with safe flying. The incidence of upper urinary tract stones in aircrew appears, however, to be highest during the fourth and fifth decades. Symptoms may be absent or may range from the negligible to the most excruciating pain. Although an episode that proceeds slowly may be recognized by those who have previously experienced renal colic, a rapid onset may lead to incapacitation during flight. This pain may radiate anteriorly towards the abdomen, umbilicus or ipsilateral testis or labium. It may be described as paroxysmal or colicky, owing to ureteral peristalsis against an obstruction, or steady, more commonly caused by an inflammatory process. Renal colic may present with gastrointestinal symptoms such as nausea and emesis secondary to reflex stimulation of the coeliac ganglion or proximity of adjacent organs. Renal pain typically has no association with peritoneal signs or diaphragmatic irritation. This triad will result in acute ureteral symptoms, which can commonly be determined by the locus of the 1 referred pain. Mid ureteral pain may mimic appendicitis on the right (McBurney’s point) or diverticulitis on the left. Lower ureteral obstruction may induce ipsilateral scrotal or labial symptoms as in renal pain above. However, it may also cause 1 McBurney’s point: a point about 5 cm superomedial to the anterior superior spine of the ilium, on a line joining that process and the umbilicus, where pressure elicits tenderness in acute appendicitis. Patients with calculus obstruction usually have difficulty finding comfortable positions. These patients commonly sit, stand, or pace up and down the room without pain relief. Emergency urinary diversion may be necessary in the setting of an obstructive calculus with fever. Immediate intervention and rapid relief of obstruction are mandatory to prevent urosepsis and urological demise. Relief can be accomplished with ureteral stenting or placement of a percutaneous nephrostomy tube. An evaluation of the renal function based on creatinine studies and urinalysis is also necessary. Marked pyuria or bacteriuria and the presence of nitrite or leukocyte esterase should raise suspicion of an infected and possibly obstructed stone. Diagnostic procedures such as stone analysis, urine pH, 24 hour urine collection, and serum studies are necessary to understand the source of the stone disease. Urine culture should be performed even in the absence of other signs of acute infection in order to rule out an occult infectious process. Radiographic studies are also important for further functional and anatomical evaluation of a possible obstructing calculus. Calcium containing calculi may have various degrees of opacity, with calcium apatite having the highest radiodensity. This study can provide both functional and anatomical information to guide the treatment of a licence holder with a urinary calculus. Delayed contrast uptake into the renal parenchyma may reveal an acute obstructive picture commonly known as the “obstructive” nephrogram. Further radiographic signs of acute obstruction may include dilation of the collecting system, ipsilateral renal enlargement, and even forniceal rupture with urinary extravasation. Chronic obstruction may present with a dilated, tortuous ureter, renal parenchymal thinning, crescentic calyces, and a “soap bubble” nephrogram. Its current ubiquity, low risk of morbidity from contrast reactions, and speed make it an excellent choice for early diagnosis. Ultrasonography is a commonly used tool in patients that should not receive contrast or be exposed to radiation. Inciting aetiologies may include hypercalcaemia from hyperparathyroidism or other medical causes, idiopathic hypocalcuria, low urinary citrate, hyperoxaluria, and hyperuricosuria. This treatment inherently disqualifies the patient from aviation duties but allows for the rapid resolution of pain and avoids the use of oral medications, which are often difficult to administer in nauseated patients. However, their use may diminish renal blood flow and intra renal haemodynamics, which may be detrimental to renal function. Furthermore, relieving obstruction is necessary when there is evidence of progressive renal deterioration, pyelonephritis or unrelenting pain. Temporizing manoeuvres may have to be undertaken until more definitive procedures can be carried out, such as extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, or ureteroscopic stone extraction. All treatment including conservative management aimed at encouraging the natural passage of the stone, surgery, and extracorporeal shock wave lithotripsy will necessitate grounding until recovery. The most common morbidity associated with both procedures is bleeding, which is usually self limiting. Interestingly, and ironically, some studies have shown reduction in ureteral peristalsis following fluid administration, which may inhibit further passage of stone in spite of increased diuresis. Prior to issuance of a licence or permitting a licence holder to return to aviation duties, a comprehensive urological examination should be performed. The assessment should be based on the presumptive risk of in flight incapacitation. In some cases, a licence may be issued with certain operational limitations such as a commercial 2 Doppler ultrasonography: application of the Doppler Effect in ultrasound to detect movement of scatterers (usually red blood cells) by the analysis of the change in frequency of the returning echoes. It makes possible real time viewing of tissues, blood flow and organs that cannot be observed by any other method. For first time stone formers, the risk ranges from 20 to 50 per cent over the first ten years with an overall lifetime recurrence rate of 70 per cent. Luckily, however, most smaller stones and even stones up to 8–10 mm diameter will pass spontaneously in less than two weeks, despite the often incapacitating pain they produce. However, if the stones are located such that they are unlikely to pass into the calyx, the risk for incapacitation during flight is low. If the urinary studies do not reveal any underlying risk factors for recurrent stone formation, then medical certification for aviation duties may be considered.
Headache attributed to hypertension 2014 ppt order trandate 100 mg without prescription hypertensive Description: Headache heart attack remixes trusted 100 mg trandate, usually bilateral and pulsating heart attack high cheap trandate 100mg mastercard, encephalopathy should be coded as 10 quitting high blood pressure medication generic trandate 100 mg with amex. Description: Headache, usually bilateral and pulsating, Diagnostic criteria: occurring in women during pregnancy or the immediate puerperium with pre eclampsia or eclampsia. Headache fullling criterion C after resolution of the pre eclampsia or eclampsia. Headache, in a woman who is pregnant or in the to the onset of the hypertensive puerperium (up to four weeks postpartum), fulll encephalopathy ing criterion C 2. Pre eclampsia or eclampsia has been diagnosed a) headache has signicantly worsened in C. Evidence of causation demonstrated by at least parallel with worsening of the hyperten two of the following: sive encephalopathy 1. International Headache Society 2018 144 Cephalalgia 38(1) or resolution of the pre eclampsia or b) pounding or throbbing (pulsating) eclampsia quality 3. Comments: the time to onset of autonomic dysreexia after spinal cord injury is variable and has been Comments: Pre eclampsia and eclampsia appear to reported from four days to 15 years. A placenta threatening condition, its prompt recognition and ade appears essential for their development, although case quate management are critical. Their diagnosis requires blood pressure, altered heart rate and diaphoresis hypertension (>140/90 mmHg) documented on two cranial to the level of spinal cord injury. These are blood pressure readings at least four hours apart, or a triggered by noxious or non noxious stimuli, usually rise in diastolic pressure of! In addition, tissue oedema, procedures, gastric ulcer and others) but sometimes thrombocytopaenia and abnormalities in liver function somatic (pressure ulcers, ingrown toenail, burns, can occur. Although headache Comments: It has been estimated that approximately may occur under conditions of hypoglycaemia induced 30% of patients with hypothyroidism suer from 10. There is a female preponderance and often a to fasting can occur in the absence of hypoglycaemia, history of migraine. Migraine, so the signicance of these results is unclear Description: Migraine like headache, usually but not and they require conrmation in future studies. Any headache fullling criterion C Description: Diuse non pulsating headache, usually B. Acute myocardial ischaemia has been mild to moderate, occurring during and caused by fast demonstrated ing for at least eight hours. Evidence of causation demonstrated by at least two of the following: Diagnostic criteria: 1. Evidence of causation demonstrated by both of b) headache has signicantly improved or the following: resolved in parallel with improvement in 1. International Headache Society 2018 146 Cephalalgia 38(1) Failure to recognize and correctly diagnose 10. Acute mountain sickness: medical problems larly since vasoconstrictor medications. Both disorders can produce severe head pain features, neuropathology and mechanisms of injury. Reverse association homoeostasis between high altitude headache and nasal conges Description: Headache caused by any disorder of homo tion. Migraine associated with altitude: results from a population Diagnostic criteria: basedstudyinNepal. Any headache fullling criterion C relieves migraine like headaches associated with B. Clinical fea resolution of the disorder of homoeostasis tures of headache at altitude: a prospective study. Cerebral venous system and anatomical predisposition to high Comment: Although relationships between headache and altitude headache. The cerebral proposed, systematic evaluation of these relationships eects of ascent to high altitudes. Lancet Neurol has not been performed and there is insucient evidence 2009; 8: 175–191. Headaches attributed to airplane travel: a Danish Carbon monoxide may be an important molecule survey. Three subtypes of headache attribu Nocturnal awakening with headache and its rela ted to imbalance between intrasinusal and external air tionship with sleep disorders in a population pressure J Headache not associated with high prevalence of headache: a Pain 2006; 7: 37–43. Headache acteristics in obstructive sleep apnea syndrome and associated with dialysis. Arch magnesium level associated with hemodialysis head Intern Med 1990; 150: 1265–1267. Principles, uses, and in habitual snorers: frequency, characteristics, pre complications of hemodialysis. Headache with paroxysmal hypertension: a clonidine responsive complaints in relation to nocturnal oxygen satura syndrome. Hypertension is a type headache and sleep apnea in the general popu factor associated with chronic daily headache. International Headache Society 2018 148 Cephalalgia 38(1) of headache in mildly hypertensive patients. Arch characteristics and outcome after treatment with Intern Med 2001; 161: 252–255. Prevalence Headache in patients with mild to moderate hyper and outcome under thyroid hormone therapy. J Sousa Melo E, Carrilho Aguiar F and Sampaio Rocha Neurol Neurosurg Psychiatry 1971; 34: 154–156. Thedominantroleof is not necessarily an exertional headache: case increased intrasellar pressure in the pathogenesis of report. When a new headache occurs for the rst time in close temporal relation to a cranial, cervical, facial, disorder of the cranium, neck, eyes, eye, ear, nose, sinus, dental or mouth disorder ears, nose, sinuses, teeth, mouth or known to cause headache, it is coded as a secondary other facial or cervical structure headache attributed to that disorder. Degenerative changes in the cervical cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or spine can be found in virtually all people over 40 years other facial or cervical structure of age. However, large scale controlled studies have shown that such changes are equally widespread among people with and people without headache. Spondylosis or osteochondrosis are therefore not con clusively the explanation of associated headache. A Coded elsewhere: similar situation applies to other widespread disorders: chronic sinusitis, temporomandibular disorders and Headaches that are caused by head or neck trauma are refractive errors of the eyes. Headache attributed to trauma or Without specic criteria it would be possible for vir injury to the head and/or neck. It is not sucient Neuralgiform headaches manifesting with facial, merely to list manifestations of headaches in order to neck and/or head pain are classied under 13. The purpose of the criteria in this chapter is not to describe headaches in all their possible subtypes and General comment subforms, but rather to establish specic causal rela tionships between headaches and facial pain and the Primary or secondary headache or both The general rules disorders of the cranium, neck, eyes, ears, nose, sinuses, for attribution to another disorder apply to 11. For this reason it has been necessary cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or to identify strict specic operational criteria for cervi other facial or cervical structure. International Headache Society 2018 150 Cephalalgia 38(1) described in this chapter. Instead, the aim is to motivate the development of reliable and valid Comment: Most disorders of the skull. Exceptions of For these reasons, and because of the variety of cau importance are osteomyelitis, multiple myeloma and sative disorders dealt with in this chapter, it is dicult Paget’s disease. Headache may also be caused by to describe a general set of criteria for headache and/or lesions of the mastoid, and by petrositis. Headache or facial pain fullling criterion C Coded elsewhere: Headache caused by neck trauma is B. Headache attributed to trauma or disorder or lesion of the cranium, neck, eyes, ears, injury to the head and/or neck or one of its types.
Visual after images are dif ferent from retinal after images hypertension 34 weeks pregnant buy trandate 100 mg free shipping, which occur only A1 blood pressure good buy trandate 100mg cheap. These phenomena blood pressure 70 over 50 discount trandate 100mg without prescription, arising from the structure of the visual system itself blood pressure 0f 165 discount trandate 100mg without a prescription, include excessive oaters in both A. Not interrupted by pain free periods of >3 hours shooting over the visual eld of both eyes when look on! Further Comment: Other neurological disorders including rever research is needed into whether these disorders share sible cerebral vasoconstriction syndrome, posterior pathophysiological mechanisms causing visual symp reversible encephalopathy syndrome and arterial dissec toms but, meanwhile, it is hypothesized that cortical tion should be excluded by appropriate investigation. Dynamic, continuous, tiny dots across the entire photopsia, photophobia, nyctalopia and tinnitus than 1 visual eld, persisting for >3 months those without comorbid migraine. At least one other paroxysmal phenomenon asso dition, and aids physicians in recognizing it. Patients ciated with the bouts of hemiplegia or occurring complaining of visual snow as a symptom often have independently (a history of) 1. Second, in a similar argument applied to research, future studies on persistent visual symptoms need homogeneous study groups; inclusion Note: of criteria for A1. Such as tonic spells, dystonic posturing, choreoathe toid movements, nystagmus or other ocular motor A1. The possibility that it is an unusual Description: Excessive, frequent crying in a baby who form of epilepsy cannot be ruled out. Vestibular symptoms of moderate or severe inten 3 4 sity, lasting between ve minutes and 72 hours Comments: Infantile colic aects one baby in ve. At least half of episodes are associated with at Infants with colic have a higher likelihood of develop least one of the following three migrainous 5 ing 1. Migraine, the like a) unilateral location lihood of an infant with colic increases twofold. Vestibular symptoms, as dened by the Barany criterion B Society’s International Classication of Vestibular! International Headache Society 2018 194 Cephalalgia 38(1) Disorders and qualifying for a diagnosis of A1. Vestibular migraine, include: However, since they also occur with various other ves a) spontaneous vertigo: tibular disorders, they are not included as diagnostic i. Vestibular symptoms are rated moderate when they addition to visual, sensory or dysphasic aura symptoms interfere with but do not prevent daily activities and for this diagnosis. At the other end of the spec requires ve episodes of vertigo, occurring without trum, there are patients who may take four weeks warning and resolving spontaneously after minutes to to recover fully from an episode. A unilateral throbbing headache may occur Dierent symptoms may occur during dierent epi during attacks but is not a mandatory criterion. Associated symptoms may occur before, Benign paroxysmal vertigo is regarded as one of the during or after the vestibular symptoms. History and physical examinations do not suggest migraine headaches are not required for diagnosis. Therefore, the dierential diagnosis minutes and longer lasting ones of more than ve min should include other vestibular disorders compli utes) should receive both these diagnoses. Migraine is more common in patients with Meniere’s` disease than in healthy controls. In among migraine patients in Chinese neurological fact, migraine and Meniere’s` disease can be inherited departments. Fluctuating hearing loss, tinnitus Other symptoms and aural pressure may occur in A1. Persistent posi When the criteria for Meniere’s disease are met, par ` tive visual phenomena in migraine. The may include a vestibular migraine/Meniere’s` disease interrelations of migraine, vertigo, and migrainous overlap syndrome. Perenboom M, Zamanipoor Najafabadi A, Zielman R, Bisdor A, von Brevern M, Lempert T, et al. Visual sensitivity is more enhanced in migrai of the Committee for the Classication of Vestibular neurs with aura than in migraineurs without aura. J Vestib Res 2009; Vestibular migraine – validity of clinical diagnostic 19: 1–13. Migraine tion between migraine, typical migraine aura and related vestibulopathy. Menstrual appendix criteria in the third beta edition of the versus non menstrual attacks of migraine without International Classication of Headache aura in women with and without menstrual Disorders. They dene a core syndrome of tension d) forehead and facial sweating type headache. In other words, these criteria are very e) forehead and facial ushing specic but have low sensitivity. During part, but less than half, of the active time characteristics: course of A3. No nausea, vomiting, photophobia or improves sensitivity without signicant loss of speci phonophobia city, but formal eld testing has not conrmed this. Severe unilateral orbital, supraorbital and/or tem alternative criteria for tension type headache pro poral pain lasting 2–30 minutes posed in the third beta edition of the international C. Either or both of the following: classication of headache disorders: results from the 1. Severe or very severe unilateral orbital, supraorbi indomethacin tal and/or temporal pain lasting 15–180 minutes F. During part, but less than half, of the active time Alternative diagnostic criteria: course of A3. Present for >3 months, with exacerbations of ally in a dose of at least 150 mg daily and increased moderate or greater intensity if necessary up to 225 mg daily. Experts in the working group believe it d) forehead and facial sweating improves sensitivity without signicant loss of speci e) forehead and facial ushing city, but formal eld testing has not been performed to f) sensation of fullness in the ear support the change in criteria. Responds absolutely to therapeutic doses of ache attacks (alternative criteria) 1 indomethacin Alternative diagnostic criteria E. Moderate or severe unilateral head pain, with orbital, supraorbital, temporal and/or other tri Note: geminal distribution, lasting for 1–600 seconds and occurring as single stabs, series of stabs or 1. In an adult, oral indomethacin should be used initi in a saw tooth pattern ally in a dose of at least 150 mg daily and increased C. The dose by injec symptoms or signs, ipsilateral to the pain: tion is 100–200 mg. During part, but less than half, of the active time characteristics of the disorder not fully developed. International Headache Society 2018 198 Cephalalgia 38(1) without the expected responses to indomethacin, Although attacks are mostly spontaneous, they may oxygen or triptans. Recurrent stabbing head pain attacks lasting 1–10 characteristics of nine new cases. Epicrania fugax across the surface of one hemicranium, commen with backward radiation. J Headache Pain 2012; 13: cing and terminating in the distributions of dier 175. A structural lesion must be excluded by history, injury to the head and/or neck physical examination and, when appropriate, investigation. Some data suggest that headache may begin topography is a distinctive attribute that dierentiates after a longer interval. The onset and termination points head injury and headache onset is set at three months, remain constant in each patient, with pain usually but it is presumed that headaches that begin in closer moving forward from a posterior hemicranial area temporal proximity to the injury are more likely to be towards the ipsilateral eye or nose, but backward radia accurately attributed to the injury. Future studies tion is also possible from a frontal or periorbital area should continue to investigate the utility of these and towards the occipital region. Headache is reported to have developed between injury (when applicable) seven days and three months after all of the 3. Comment: the current stipulation that headache must begin (or be reported to have begun) within seven days A5. In the following suggested diag Diagnostic criteria: nostic criteria, the maximal time interval between the A. Any headache fullling criteria C and D head injury and headache onset is set at three months, B. Traumatic injury to the head has occurred, fulll but it is presumed that headaches that begin in closer ing both of the following: temporal proximity to the injury are more likely to be 1. Traumatic injury to the head has occurred, asso b) loss of memory for events immediately ciated with at least one of the following: before or after the injury 1. Headache persists for >3 months after its onset seven days and three months after all of the E.
Internal examination supplemented by histology may reveal severe coronary artery disease prehypertension prevention purchase 100 mg trandate, coronary artery thrombosis prehypertension and alcohol buy generic trandate from india, recent silent myocardial infarction blood pressure medication used for anxiety generic 100 mg trandate amex, or myocarditis — whichever heart disease had caused his death at the controls; b) if a passenger had sustained head injury of lethal severity blood pressure record chart uk purchase 100 mg trandate with mastercard, important conclusions could be drawn as to the survivability of the accident. Internal and subsequent laboratory examination, however, showing swallowed carbon in the oesophagus and stomach, inhaled carbon in the trachea and bronchi, congested oedematous lungs and a raised carboxyhaemoglobin level in the blood, would show the true cause of death as burning. The head injury might then be ascribable to heat and its interpretation would be quite different; c) a husband and wife might both appear to have sustained multiple injuries and incineration. Detailed autopsy and laboratory examinations might show the one to have died as the passenger referred to in b) above while the other, having a ruptured aorta and no evidence of survival during the post crash fire, had died from injury. It could then be held that the former had survived the latter with far reaching medico legal implications regarding the disposal of estates. An assessment of the nature and cause of injuries is required so that consideration can be given to appraising safety features within the aircraft and to improving them. Examples include penetrating head injuries or crushing fractures of the lower legs. Both of these may suggest an unsatisfactory design of the back of the seats in relation to those situated immediately behind them. On more than one occasion conclusions have been reached as to which pilot was actually at the controls of an aircraft when it crashed, based upon the nature of the injuries to the hands and wrists or feet and ankles as determined both by naked eye examination at autopsy and by radiographs. Tissues from around any such suspect wounds should be preserved by the pathologist for laboratory analysis for the appropriate trace evidence. Injuries so caused will be reflected in damage to the clothing; the dangers of premature removal of clothing purely for the purpose of identification are, thereby, emphasized. It cannot be too strongly emphasized, however, that evidence that a medical abnormality was present in a pilot is usually a long way from proof that the abnormality was either the cause of his death or connected with the accident. A list of diseases known to cause sudden complete incapacitation and death in apparently normal healthy persons can readily be prepared. It would include coronary artery disease with or without thrombosis, myocarditis and ruptured cerebral arterial aneurysm, for example. However, severe coronary artery disease and myocarditis can be present and consistent with normal function, and both are known to have an appreciable incidence in the normal population. The presence of either could be coincidental in a pilot whose aircraft had crashed because of some technical failure. Similarly, in the presence of extensive cranial injury it would be only a careful examination that would reveal a cerebral arterial aneurysm. Even if found, it might be difficult to be sure whether it had ruptured in life or had been traumatically ruptured as part of the cranial injury. The detailed autopsy and subsequent laboratory investigations advocated imply that every effort will be made to discover whether the flight crew were suffering from any disease or illness or whether they were suffering from any form of intoxication or any possible effect of having taken drugs. When all investigations have been completed and no evidence of any disease or cause for impaired function has been found, it is possible to state that this has been excluded, for practical purposes, as an event or cause of the accident. When some evidence has been found of disease or potential cause of impaired function, very careful consideration must be given to the nature of the condition, its potential for affecting function, and any discovery of an alternative hypothetical cause for the accident derived from the engineering and general investigation of the accident. When correlation of all this evidence has been effected by the Investigator in Charge, through the reports of the Human Factors Group and other groups, it will be possible to put forward any theory formed concerning human factors on the flight deck in relation to the circumstances and the cause of the accident with a balanced judgement as to its probability. Nevertheless, there are certain points that should not be overlooked in the examination of any body. A uniform pattern suggests that all the passengers were subjected to much the same type and degree of force. A typical example is the combination of cranio facial damage, seat belt injury and crushing of the lower legs associated with passenger tie down failure in the classic crash situation. Much additional information may be derived by comparing the pattern of injuries in the passengers with the pattern in the cabin crew. This could suggest some unusual incident and the interpretation of the findings depends to a large extent on accurate identification and location in the aircraft according to the passenger seating plan. The possibility of a single body showing a deviation from the norm must always be remembered. It may be the only means by which a case of sabotage or unlawful interference with the operation of the aircraft is revealed. Anomalous findings may give a clue to such accident causes as failure of the automatic pilot or attempted interference with the normal operation of the aircraft. Injuries discovered should be, whenever possible, related to specific items of equipment in the cockpit. To this end a search should be made for the presence of blood and other tissues on the seats, instruments and control columns. In certain circumstances it may be necessary to identify such evidence as being related to specific flight crew members or, conceivably, to show that the tissues are not human — for example, evidence of bird strike. Displacement of fasteners and evidence on the belts themselves may give an indication of the forces involved. It might be possible to deduce the size of the seat occupant from such measurement although it should be borne in mind that seat belt adjustments may vary considerably. Of greater importance, the overall tightness of belts should enable the investigator to distinguish between a cabin that has been prepared for an emergency landing and one in which the passengers have been sitting with their belts lightly fastened as a routine. Findings of this nature must certainly be correlated with passenger seating plans when available and with the results of the autopsy examinations. When seating plans are not available and when local or national authorities removed bodies but did not record their location, clues may often be discovered as to the seating of passengers; for example, a book or handbag found in the compartment on a seat back will suggest a probable location of its owner. Fragments of fabric, fused to aircraft structure, compared with clothing removed from bodies may permit deductions about the location of bodies — at least where the bodies came to rest, if not their seat locations. Particular attention should be given to any condition likely to have led to incapacitation in flight or to a deterioration in fitness and performance. The possible cause of incapacitation or lowered efficiency of performance is, theoretically, the range of the diseases of man but, with adequate medical supervision of crews, gross abnormalities are unlikely to be present. Many functional abnormalities, however, are not demonstrable at autopsy — epilepsy being the prime example. Visual and auditory acuity of the crew should also be noted but, again, it will be the essentially negative pathological findings in an accident suspected of having a human factor cause that will focus attention on these systems. However, well documented abnormalities of this sort are scarcely compatible with modern flight crew selection methods or effective working as part of an airline operation. It may be that information obtained from friends, relatives, acquaintances, supervisors, instructors, personal physicians and other observers as to both the recent activities and attitudes of the flight crew and to their long term personal and flying habits, general health and ordinary behaviour may provide information which is of far greater value. Human elements of perception, judgement, decision, morale, motivation, ageing, fatigue and incapacitation are often relatively intangible, yet highly pertinent variables. It should be emphasized that a positive association between any such abnormality discovered and the cause of the accident can seldom, if ever, be better than conjecture. Despite these difficulties, every effort must be made to investigate and report upon such human factors as fully as possible. It may be necessary to include a psychologist familiar with aviation in the Human Factors Group. For example, a deviation from the flight path might suggest a need for an examination for carbon monoxide intoxication; a suspect pressurization system might indicate a need to confirm or exclude hypoxia as a cause of the accident. The itemization of likely toxic causes will simplify and direct the work of the toxicologist. These are the sort of matters that emphasize the need for frequent meetings of the heads of the investigation groups and the need for adequate exchange of information at such meetings. Errors and deficiency of performance may occur whether operations are as planned, whether unexpected conditions develop, or whether emergencies arise. The cause of these errors and performance decrements may be found in: a) errors of perception. These may be related to auditory, visual, tactile or postural stimuli; b) errors of judgement and interpretation. Misjudgement of distances, misinterpretation of instruments, confusion of instructions, sensory illusions, disorientation, lapse of memory, etc. These particularly relate to timing and coordination of neuromuscular performance and technique as related to the movement of controls; Contributing causes of errors and performance deficiency may lie in such areas as: d) attitude and motivation; e) emotional affect; f) perseverance. It is in the evaluation of these potential factors that the Human Factors Group may be of invaluable assistance to the Investigator in Charge. For example, it may be suggested that the pilot was particularly irritable at the time of the flight.
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