Panic With A Twist


The 28-year-old naval aviator Tomcat pilot appeared chagrined as he entered my flight surgeon office on the aircraft carrier. His demeanor lacked the typical elan of a tactical jet pilot; the love of flying that we see in the attached video was absent from his eyes and voice.

“Doc,” he said, “I think I’m afraid to fly.”

“How does a trained naval aviator with over 600 hours total flight time, 300 in the Tomcat, suddenly become afraid to fly?” I wondered, especially one with an above-average flight performance record.

He described a pattern of anxiety dating back 18 months to an episode while flying level at 16,000 feet. He had suddenly felt hot, flushed, and nauseated; but the symptoms abated when he removed his oxygen mask and decreased the cockpit air temperature. (The fact that he waited for 18 months and several more episodes before reporting to the flight surgeon says something about the inherent fear that most aviators harbor about flight surgeons. A stroke of the doctor’s pen can end a flying career.)

Six months later while flying over water he experienced another attack. Again he felt hot and flushed, and severely apprehensive over his ability to control the airplane. He became intensely anxious over the welfare of the radar intercept officer in the back seat, whose life depended on the pilot’s ability to fly the jet. Our pilot remained anxious until landing was assured, and then the symptoms went away.

Two more episodes occurred in the subsequent year, each time on a long cross-country flight at altitude in bad weather. Each time, he became hot and flushed, and felt a powerful desire to divert and land the airplane. He completed the missions only by intense concentration on the flying tasks. But as soon as landing was certain, his symptoms disappeared.

I asked him the usual questions. No, he did not have any serious life stressors. His five-year marriage had gone through a tough period — including a two-month separation — but had weathered the storm through counseling. He was able to compartmentalize, a vital trait for aviators wherein they concentrate only on flying without intrusion by thoughts of other aspects of their lives. He denied nocturnal panic attacks, and stated that aside from recent pre-flight anxiety he only experienced the symptoms while flying at a distance from a landing site.

Then he mentioned some other symptoms, visual and physical disturbances while flying. He would see “shooting stars” in the periphery of his vision, and feel dizzy and disoriented. Those symptoms would occur only when he rotated his head while pulling positive Gs in a high performance maneuver. (The video sequences between 1:16 and 2:05 show that environment from inside the cockpit.) The symptoms would abate when he straightened his head. He said that those symptoms, like the anxiety, had gotten worse over time.

I figured this aviator had a limited symptom panic disorder, but I could not reconcile that diagnosis with the visual and physical symptoms. I referred him to an aviation neurologist for further evaluation. After a series of tests, the neurologist discovered that the aviator had congenital narrowing of his left vertebral artery. (Most people have two normal-sized vertebral arteries that join to form the basilar artery that brings blood to the brain stem, which controls vital life functions.) This aviator’s physical symptoms were caused by occlusion of his one good vertebral artery with head turning in a high-G flight profile, interrupting blood flow to his basilar artery. His anxiety symptoms were secondary to his physical anomaly, because he recognized but did not understand the threat to his ability to control the aircraft.

We managed to salvage this pilot’s career by getting him reassigned to non-tactical naval aircraft, where he would not be subjected to high-G flight maneuvers. Relieved of his anxiety-producing symptoms, he once again was free to relish the beauty of flight.

What Do They Raise In Arizona, Doc?

“That guy can really land the airplane.” 
 

Midway through the Navy initial flight training syllabus at NAS Whiting Field I was “that guy,” and about as cocky as a man can get. When I overheard the runway duty officer (RDO) on the radio complimenting my touch-and-goes at the outlying field in the Florida panhandle, the exhilaration of the flying phase of my student naval flight surgeon program reached its peak. To be singled out as an “ace” by the guys who do it for real, well…priceless.
Pride goeth…  I wrote that here last month. 
I’m older and wiser now than in the spring of 1992, when much of my world revolved around the next flight, the next takeoff, the next landing, the next debrief; and ultimately the first solo flight in that most fun airplane, the T-34C Mentor. For a recycled middle-aged ER doc, my life was hot stuff.
“Do one more and then head back,” said my on-wing flight instructor from the back seat. He hadn’t spoken much during the seven prior touch-and-go landings, and I’d almost forgotten that he was in the airplane; more like a sack of potatoes in the rear than a veteran pilot mentoring the s**t-hot doc pilot in the front seat.

The single engine turboprop aircraft accelerated under full power to traffic pattern altitude, whereupon I cranked it into a 45-degree angle of bank turn per the standard Navy racetrack landing pattern.

Diagram from www.tpub.com

 

In my head I recited the mnemonic for the landing procedure: Flop, chop, check, drop.
1) Flop. Roll into a steep bank 180 degree turn.
2) Chop. Retard the throttle to landing pattern power setting.
3) Check. Monitor the airspeed bleed-down into the safe zone for lowering the gear and flaps.
4) Drop. Extend the landing gear and deploy the flaps, further slowing the aircraft to pattern standards. 
I executed a precise roll-out at 180 degrees of turn, and completed the landing checklist on my downwind leg parallel to the runway. At the abeam point, I flopped into another steep bank turn and set the throttle for the final approach. Past the 90 degree point, losing exactly the right amount of altitude, I rolled out to straight and level flight to see the runway in front of me. Then it was a simple matter of controlling airspeed with pitch, and altitude with power until I arrived over the runway threshhold, chopped the remaining power, and allowed the airplane to settle gently onto the asphalt.
He shoots, he scores! Touchdown! Grand Slam! (So what if it’s a mixed metaphor? This is flying, man!)
As soon as the tires kissed the pavement, I pushed the throttle full forward, gently eased back the stick, and lifted the airplane back into the air.
“Nice job,” the instructor said. “Let’s go home.”
I continued on the upwind to departure altitude, and then started a turn back toward Whiting Field. The airplane didn’t accelerate like I’d expected, but it was late June — hot and humid. Just the density altitude, I thought. (Airplanes don’t perform well on a hot, humid day when the atmosphere is similar to thinner air at higher altitudes.) My self-aggrandizing cockiness ignored a deep inner voice: Might be density altitude effect in a normally aspirated piston-engine single like your old 172, but in a turboprop? Think again, Hot Shot.
I leveled off at the prescribed cruise altitude. To maintain the desired airspeed, the engine required more throttle than usual. I still thought it was density altitude. Like flying back in Arizona, density altitude can sure diminish an aircraft’s performance.
Then I heard the instructor’s voice in my headset. “Hey, Doc. Where are you from?”
“Arizona,” I said. He must be thinking about density altitude as well.
“What do they raise in Arizona, Doc?”
“Cattle,” I said in a proud voice. I came from a ranching family.
“Do they raise anything else in Arizona, Doc?”
I thought for a moment. “Crops,” I said. “Cotton, citrus, that sort of thing.”
“What else do they raise in Arizona, Doc?”
“We have copper mines,” I said. “Tourism is big.”
“Do they raise anything else?”
I was at a loss. “Pretty much it,” I said.
“How about the landing gear?”
I shifted my gaze to the landing gear handle. Sure enough, it perched in the “down and locked” position from landing. Chagrined, I jerked it up, and felt the landing gear raise. The aircraft performance zipped up as well. No longer flying “dirty,” and relieved of the excess drag from the extended landing gear, it purred along like a contented cat. We completed the return to Whiting Field in silence. That landing approach may have been less than perfect. 
There was no density altitude problem in the aircraft that day. Just a dense student naval flight surgeon who still had a lot to learn — about flying, and about life.

Fam 1 – Learning to Fly Navy

To a man (and woman), Navy Flight Surgeon Class 92002 all yearned for one special day. It seemed to hover forever over the horizon as we marched (literally) through officer indoctrination. It appeared to recede into the clouds as we sat through tedious medical didactics on the physiology of flight and other dry topics. As Florida panhandle winter gave way to spring, we gazed out the windows of our stuffy NAS Pensacola classroom and indulged our fancies; not for graduation day, but for the day we would close the medical books and transition to nearby NAS Whiting Field for the final phase of flight surgeon education — flight training.

Future naval aviators undergo their primary flight training at Whiting Field. For the doctor students of Flight Surgeon Class 92002, Whiting Field was Mecca. Unlike the other services, the Navy put student flight surgeons through the exact initial flight curriculum as student naval aviators. Our pilgrimage to that sacred airfield was not to engage in additional medical training, but to realize our fantasies of soaring on mighty wings — a thrill our civilian medical counterparts could not fathom.
The gurus of Naval Air reasoned that flight surgeons, to be effective in their duties, must understand the rigors and challenges, and the thrill, of the flight environment. You just don’t get that sensitivity from reading about it. At Whiting Field, we would be dispersed among the three resident training squadrons, sharing classroom and flight time with Navy and Marine Corps future aviators — our future patients. Not only would we learn the fundamentals of aviation, we would also fly the Navy’s trainer — at that time the T-34C single engine turboprop. (Beyond familiarizing us with the stresses of flight, the T-34 would instill in some of us a career long quest for “stick time,” to get our hands on the controls and actually fly whatever Navy aircraft we happened to occupy at the time.) In primary training at Whiting, the curriculum consisted of a series of familiarization flights (“Fams”). Each fam progressed from basic to complex skills, culminating at the pinnacle: Fam 14 – Solo Flight. A fortunate few of us might get enough sorties (weather always a factor in Florida spring) and aviate well enough to demonstrate that we had the right stuff to fly Fam 14 – commanding the airplane without an instructor on board. With my civilian commercial pilot and flight instructor certificates tucked in my wallet, I felt certain to be one of the lucky few to execute Fam 14.
I soon learned that Navy flight training — in spite of my several hundred hours of civilian flight time — would be no walk in the park, much less a turn around the pattern at my former home airport in Scottsdale, AZ. Naval Air makes training and proficiency a serious challenge, unlike the civilian flight school (one of the best) that I had attended ten years previously. At Whiting, ground school gave us a more rigorous academic challenge than medical school. We memorized aircraft systems to greater detail than we’d ever devoted to human anatomy (except, perhaps, the reproductive systems). We could not expect to sit in the cockpit of a real T-34C until we demonstrated blindfolded knowledge of the location of all flight controls and gages in a series of “static” exercises in a mock-up cockpit. Before we could move on to the flight line, we must man the same simulator to demonstrate rote knowledge of the full preflight, engine start, pre-takeoff and post-landing procedures, including parroting the exact verbiage of the checklists.
By the time we went out to the tarmac for our first sortie in the real bird, we knew all there was about its anatomy and physiology. Or so we thought.
Finally, after three weeks of non-stop class and book study, we donned our flight suits and boots, checked out helmets and parachute harnesses, and headed (swaggered) to the flight line for our first escape from the “surly bonds of earth.”
I feel the need, for speed.
We were each assigned to an “on-wing” flight instructor. Mine did not like flight surgeons. He never said so. Didn’t have to. You just know.
After a tense preflight brief, I approached the airplane with my instructor close at hand. First I had to complete the preflight check that I had memorized in consummate detail during the ground instruction phase. It went well until the part that requires the pilot to open the cowling and inspect the engine and its components. I took my time as I made a show of meticulous attention to detail on each item. Then I turned to my on-wing, who I thought by now must have recognized that I was no rookie on a flight line. “Looks okay,” I said.
“Is it airworthy, Doc?”
“Looks good to me.”
“You sure about that, Doc?” A sneer barely showed on the corner of his mustachioed upper lip.
Oh-oh, what am I missing? All at once anxious, I took out my pocket checklist and reinspected the entire engine assemblage, this time verifying each step as written in the manual. I found nothing out of order. This arrogant aviator is just messing with me. “It’s airworthy,” I said.
“You’d risk your life to fly this airplane, Doc?”
Realizing that I needed to sound more confident than I felt, I replied in a strong voice. “It’s ready to fly.”
“Okay, Doc, let’s fly.” Then he reached into the engine compartment and, with a flourish that only a naval aviator could perfect, picked his watch off the engine block and strapped it back on his wrist.
Every flight begins with a thorough preflight. Lesson learned.
And yet another lesson re-learned: Pride goeth…

SNFS 92002

First week of January, 1992, Student Naval Flight Surgeon class #92002 convened in an aging, stuffy classroom at the Navy Aviation Medicine Institute (NAMI) in Pensacola, FL. Outside, a winter chill filled the morning air. Those of us who had expected a balmy sojourn on the Gulf Coast would have to wait a few months for the seasons to change. Winters in Pensacola can be relatively frigid — at least to an Arizona native who spent most of his life in the desert. By month’s end we would get to know the cold up close and personal when we immersed ourselves in water and land survival training.
The course consisted of three phases: 1) Officer indoctrination plus water and land survival training; 2) Academic aviation medicine and physiology; 3) Flight training. For the last phase, we would move to nearby Whiting Field Naval Air Station to participate in the same primary flight training as student naval aviators. Those of us who met the grade would even get to solo fly the T-34C Mentor turboprop trainer. Since I already had a civilian commercial pilot and flight instructor ticket, I looked forward to that day. The chance to fly naval aircraft was a tangible motivator for me to leave a successful civilian practice and sign up for this gig in the first place.

Our class numbered about 30 souls. Roughly two-thirds were early career naval medical officers, fresh out of internships at Bethesda, Portsmouth, or Balboa. Many of them knew each other already, and quickly formed into small social groups. The sole woman, and only non-physician, in the class was a budding aviation physiologist with a passion for kayaking. She attracted several of the single young males in the group, but only to the point of learning that a) she had a boyfriend, and b) she could take any of them down at any time.
The remaining third were mid-career life changers like me. (Although I was the only one with no prior military experience.) Believing we were having more fun than the younger crowd, we soon formed our own social group. Several had been recalled from the reserves for Desert Storm and decided to stay on active duty. A few had no choice, as their civilian practices had dried up during their absences. Still others, myself included, had signed on for the adventure, and of course, the flying.
We in the “mature” group relished the transition from the vagaries of civilian medical practice to our new status as officers and gentlemen. Most of us would have qualified under DSM-IV psychiatric diagnostic criteria for “Narcissistic personality traits, not constituting a disorder.” (Some observers might wonder about the modifier.) We swaggered about in our new uniforms, enjoyed lunch and afternoon libations in the Officers Club, and proudly returned courteous salutes from juniors as we strolled about the base. 
The great naval adventure began in earnest the next day when we reported  to Naval Aviation Schools Command for our officer indoctrination and survival training, the first real tests of our right stuff. To a man (and woman) we rolled into the course with childlike enthusiasm. Few of us would be disappointed at the end.
Somewhere beneath that early passion lurked a vague realization that we had signed on to the “highway to the danger zone.” One reason the Navy trains flight surgeons is to prepare them for their role in fostering aviation safety and preventing mishaps. 
Engaged as we were in those first days of elan, how could we suspect that within the year one of our own would be dead, himself a victim of an aviation mishap. 

Where Do We Get Such…?

EXT. USS SAVO ISLAND, BRIDGE WING – DAY

RADM GEORGE TARRANT

Where do we get such men? They leave this ship and they do their job. Then they must find this speck lost somewhere on the sea. When they find it they have to land on it’s pitching deck. Where do we get such men?

MAN ON LOUDSPEAKER

Launch jets!

Thus ended the 1954 film, “The Bridges at Toko-Ri,” starring William Holden as a reserve Naval aviator recalled from his law practice for the Korean War; Grace Kelly as his not-so typical Navy wife (She broke the rules to join him in Yokosuka, Japan.); Mickey Rooney as Chief Mike Forney, a Navy enlisted helicopter pilot; and Frederic March as RADM Tarrant. The movie is based on James Michener’s novel of the same title, written well before women broke into tactical naval aviation.


As a Navy flight surgeon, I’ve known many naval aviators over the last two decades. I’ve shared their wardrooms, their ready rooms, their squadron spaces, and their aircraft. I’ve been through their survival training, initial flight training, recurrent training, and NATOPS quals. (I once earned a bona-fide F-14 NATOPS qual.) I’ve sat with them on Human Factors Boards, FNAEBS, and Mishap Investigation Boards. I’ve signed their annual exams, cared for their physical and mental well-being, and that of their families, given them down chits and up chits, and processed a variety of waivers.


And, I’ve flown with them in just about every platform they operate (P-3  and F/A-18 being notable exceptions).


I’ve enjoyed stick time in dual-controlled naval aircraft, including the Blue Angels’ famous “Fat Albert.” I’ve set up bombing runs in the venerable A-6 Intruder, searched for bogies in the back of an E-2 Hawkeye, done high pops in the S-3 Viking, and performed airborne intercepts in the F-14 Tomcat. I’ve flown close to the ground in the dark wearing night vision goggles in the H-60 Seahawk.  I’ve soloed in the T-34B Mentor.


Thirty times I’ve been with them as they landed those planes on that pitching aircraft carrier deck. That includes one dark, cloudy Adriatic night in the back seat of a Tomcat that boltered several times before safely trapping aboard. (CAG had some choice words for me after that flight.)


As I enter the twilight of my Navy Medicine career, its single most satisfying experience is my association with Naval Air. That was why I made the leap from civilian practice, and I’ve never been disappointed. (Except for not getting enough flight time, of course.) I love aviation and I relish flying. So no surprise that I’m thrilled to be part of this elite community, to have felt the head rush of transition from single engine Cessnas to tactical jets!


But it’s not all about the flying. It is very much more about the people. Indeed, where do we get such men? And such women?


Some of the finest men and women I’ve ever known wear those U.S. Navy wings of gold. Their indomitable spirit would infect even the most cynical of hearts. Their commitment, focus, and dedication to mission would surpass many a driven businessman. Their love for life and for fellow man would overshadow even a wide-eyed optimist.


“I could die tomorrow.”  I’ve heard Naval Aviators accused of using that phrase for wanton self-aggrandizement. The community is not perfect, nor do I mean to blindly glorify its members. But to this observer that phrase actually reflects an essential aspect of the aviator spirit. Certainly life should be cautiously managed, to include careful planning and deliberate risk mitigation. But we cannot reduce risk to zero, and we cannot outsmart life. Ultimately we must live and enjoy life as if we were to die tomorrow. We strive to achieve what Maslow called “self-actualization.” I know few other communities that capture that self-actualization any better than my friends and colleagues in Naval Aviation.


I’m proud to be a part of the Naval Air community. That’s why I love to don my flight suit, why I will always sport brown shoes with my khakis, and why I proudly pin my own wings of gold above the ribbons and that other warfare device on my left uniform chest.  For me, those wings represent peak experiences, not only of slipping the surly bonds of earth and touching the face of God, but also of being a better man for knowing those who do it as a vocation.