In Under the Headphones we’ll be discussing clinically relevant information of use to all. If you've got a better way of doing something then let us know!
Each presentation has PowerPoint slides, with corresponding Word documents containing references, learning objectives, questions and answers.
When looking at the PP presentations, each one has "speaker's notes" in the "notes view" of PP. These notes expand on the text presented in the slides, and can be presented "cold" if needed by an audiologist if asked on short notice to provide an in-service to colleagues. The "speaker's notes" provide expanded information based on the slides shown to the audience. A suggested narrative dialog is provided for the speaker in the "notes view".
Feel free to use these presentations to educate residents, nurses, teachers, physicians, etc. They are not copyrighted, and can be modified to meet your target audience. I hope you find them helpful and beneficial.
These were created as part of the "Capstone" requirement for the AuD degree from Central Michigan University/Vanderbilt Bill Wilkerson Distance Learning Doctor of Audiology Program.
Angela Williamson, Au.D., LtCol, USAF, BSC
Aug 2002
Lt Col Carolyn Bennett compiled a brochure in Microsoft Word format (zipped). LtCol Angela Williamson writes this essay:
Within days of the release of “Blackhawk Down”, the movie by director Ridley Scott, people across America were talking about it and it how it was the most accurate portrayal of battle scenes yet produced by Hollywood. The gritty reality of the movie with the feel of being inside the battle drew many people to the theater to see for themselves what might have actually happened on that day in 1993 in Mogadishu.
The events were based on reality. The reality was stark. 18 dead Americans, 500 dead Somalis, numerous Americans wounded, one briefly held captive. I went to see the movie, knowing that it would be moving and evoke strong emotions, as young American men were placed in a situation that would ultimately be a fight for their lives. The movie was indeed intense, with few scenes that allowed the audience to relax and sit back from the “edge of their seats”.
One particular scene stays with me weeks after seeing the movie. Two young men are hunkered down behind barricades, trying to defend a perimeter point. They are armed with M-16s and are engaged in taking and returning fire. One soldier, crouched next his buddy, instructs him not to “shoot that thing right beside me, I’m half-deaf as it is”. Another burst of incoming fire, the buddy returns fire, with the M-16 barrel just inches from the head of the first soldier. At a break in the firing, the second soldier asks a question to the first…he looks at him, and indicates that he can’t hear anything. The expression on his face is puzzlement; he can’t hear what being said to him as he has suffered severe acoustic trauma from the estimated 160dB Peak Pressure of noise from the M16. The audience around me laughed at his confusion. I cringed.
Throughout the remaining scenes in the movie, the young soldier who sustained a significant, and likely permanent, hearing loss becomes the comic relief of the movie. His buddies try to pantomime instructions to him, he is unable to hear himself talk, and risks exposing the soldier’s position by yelling to his comrades. His confusion and frustration at suddenly becoming essentially deaf is heartbreaking, and could have cost him his life.
For several days after watching the movie I wondered, how would the audience have reacted had the soldier been suddenly blinded by an accident? Would they have laughed as they watched him stumble and grope to his destination? I think not. I think he would have had the sympathy of the audience, and they would have hoped for his safe extraction. Because hearing loss is hidden, essentially unrecognized by others, it is not realized by most that it remains one of the largest chronic health problems for Americans. Hearing is such a part of our daily experience, often the sense of hearing is taken for granted until it is lost, yet hearing is what links us to our family, our friends, our environment, our pagers, our cell-phones, our microwaves, our music, our work, our fun. I think you get my point. Hearing is what ties us into our world, our interests, and our relationships.
Ear damage from noise exposure is the second leading cause of hearing loss in America. The number one cause is natural aging. We can’t do anything about the aging process of our bodies, but we can do something about noise exposure and limit the effect that noise has on our hearing. Noise exposure is pervasive in our society, starting with many common toys that emit sounds louder than the 85dBA exposure limit recommended by the National Institutes of Occupational Safety and Health. In other words, we don’t allow workers to be exposed to sounds louder than 85dBA without the use of ear protection, yet many everyday sounds such as leaf blowers, snowmobiles, power tools and popular children’s toys have been found to emit sounds up to 135dBA. The month of May has been designated “Better Speech and Hearing Month” and allows us time to promote hearing health, and to promote awareness of noise in our daily life as well as the potentially devastating effects it can have on our communication abilities.
The wounded depicted in the movie Blackhawk Down were numerous. But uncounted, and essentially unnoticed, were the soldiers and Marines who suffered permanent, noise induced hearing loss that will affect the quality of their lives for the rest of their lives. Take your hearing ability seriously, don’t allow yourself to become the butt of the joke because of a disability that is unseen. Turn it down, put on ear protection when engaged in noisy hobbies or work, and think about the toys you buy for your children and grandchildren, the potential harm that may be done to their hearing. We each get only one set of ears, protect them so they work well as long as you need them, and you’ll need them forever. It’s really not funny.
Angela Williamson, LtCol, USAF, BSC
Licensed Audiologist
Director, Hearing Conservation Center
Robins AFB, GA
The following letter is posted with permission of both parties involved in the dialog:
Original Message:
Sent: Saturday, November 03, 2001 11:51 AM
I’m an active duty Air Force member with 19 years of acive duty. While my speciality is not medically related, (I am an Explosive Ordnance Disposal Technician) I have been introduced to the unwonderful world of “military audiology” after I developed severe tininitus two years ago. I am very happy to have stumbled across your web page and to see that there are professionals in military service who are interested in caring for military members.
When my tinnitus developed I was treated most poorly and negligently by my “health care” providers at my local Air Force Base. The ENT canceled my appointments and at one time didn’t return my calls (against the TRICARE 48 hour rule) he avoided me to his utmost until I gave up on him, which was actually in my best interest. The Audiologist was most negative in me seeking help elsewhere aside from “you'll just have to live with it.” And likewise, the further I was from her “care” and observation, the better things became!
Luckily, my 19 years of service taught me to be proactive. I researched as much as possible and contacted the American Tinitus Association—who in turn offered me a list of tinnitus “specialists.” It was here in the civilian community that I received TRT (Tinnitus Retraining Therapy) to my great satisfaction. My out of pocket expenses were around $3,500, which included 2 full days of testing and counseling and white noise generators. Money well spent! While my military ENT who “practices” about one mile from my home would not see me at all after my initial appointment, the TRT practicioner was always available by phone—and sometimes in my distress (and there was alot of it)—the concerend reassuring guidance was most important to my recovery. Something woefully missing form the military ENT/Audiologist.
I write you this letter for several reasons:
And please, please, inform your members, that a military person suffering from severe tinnitus is not an inconvenience, or a malingerer. We didn’t get this from raping and pilaging but from faithful discharging of our military duties (as in my 19 years of explosives work) I believe the military “family” needs to support each other, starting with the health care providers.
Thank you for reading this letter,
MSgt “Mike”
Reply From: Chandler, David COL WRAMC-Wash DC
Sent: Friday, November 16, 2001 1:10 PM
Dear AF MSgt:
Thank you for your recent correspondence and for your candor in sharing a most frustrating problem. After 23 years of experience, I appreciate that your situation is common to many and is likely just the “tip of the iceberg”.
Army Audiology has long recognized the inadequacy of tinnitus treatment—not only within DoD Healthcare Facilities—but across the profession. Physicians are frustrated by the fact that they can’t objectively “examine” tinnitus, and it’s hard to hit what you can’t see. Subsequently, many physicians and audiologists have a poor understanding of how to deal with problematic tinnitus. This is why our Center is pursuing a research project with U of Maryland Medical School to investigate the use of TRT at 3 major DoD medical centers across the US (WRAMC, Wilford Hall, and San Diego Naval).
I will use your email, along with similar accounts from others, to further underscore the importance of pursuing this project. Hopefully, your situation will be of benefit to another service member in the future. Thank you again for your correspondence.
COL David Chandler
Director, Army Audiology & Speech Center
Walter Reed Army Medical Center
202-782-6644
Maj Joe Narrigan (Bolling AFB, DC) offers a PowerPoint presentation on hearing conservation's contribution to readiness. Here's a web-based version. Maj Narrigan also presents information on Peak SPL measurements of the M-1 Rifle (Adobe Acrobat format).
Maj Linda Ruckriegel (Hill AFB, UT) assembled this Microsoft PowerPoint presentation targeted towards the Primary Care Provider. It provides a nice, simple overview of the hearing conservation mission. Here's a web-based version.
LtCol Carolyn Bennett and Capt Lesly Loiseau (USAF) have co-authored an informative pamphlet titled: You and Your Hearing Aid. The document is presented here as an Adobe Acrobat file. Intended for patients, the pamphlet discusses:
This
well-designed pamphlet was published by the Crew System Interface
Division of the Air Force Research Laboratory (AFRL). Illustrations
and page layout by Gary Rankin, Systronics Inc. 04-October-2000
Mr Troels Loyborg, of CHPPM-EUR,
provides an illustration he uses to summarize noise related hearing
loss at a glance. He uses it at the end of various hearing
conservation presentations. Click on the small image for a larger
view. 19-September-2000
Have you clinical audiologists been watching with envy as our civilian counterparts fit their patients with digitally programmable technology? Have you said to yourself, "Wow, I wish I could get technically state of the art hearing aids for my active duty patients"? But, as we know, the VA contract currently doesn't include digitally programmable hearing aid circuits. I have run across a way in which you can provide your patients with a circuit that is on VA contract, and is digitally programmable.
Authorized Hearing Services (1-800-247-4741) is on the VA contract. They provide traditional class A, D and compression circuits. In addition to that, they offer the ReSound Tradition circuit as an option. This circuit is programmed at the factory based on the audiogram you supply; it then can be modified 7 different ways with a screw-set adjustment. A circuit that can be manipulated manually eliminates the need for a dedicated programmer, a Hi-Pro box or dedicated cords. This makes is easier for our Active Duty patients as they PCS from site to site to obtain follow up care from each of us, as well as our sister services. If you are interested in obtaining crisp, clear amplification with excellent signal to noise ratios, I would encourage you to check out AHS' Tradition circuit.
I conducted a very unofficial poll of my colleagues at Lackland AFB, Eglin AFB and Travis AFB and found that none of these locations were fitting active duty with Hi-Pro programming. Reasons cited were cost of the equipment and cost of the circuits. I believe our hearing impaired active duty patients deserve the best technology we can provide them, and wholeheartedly believe that digital and digitally programmable circuits are the waves of the future. Check out what AHS can provide. Is anyone aware of other great sounding circuits available to us?
Comments from my fellow clinicians would be welcome.
How do you determine if a worker's hearing protection is effective? I'm sure you all check the fit of the hearing protective device (HPD) and ensure the worker is using the appropriate insertion technique. Are you also calculating the at-the-ear exposure level? According to OSHA, when a worker has a STS, the effectiveness of the HPD must be calculated to ensure the at-the-ear time-weighted average (TWA) is no more than 85 dB. Furthermore, HSI inspectors expect to see these calculations in the medical records of all patients with STSs. Now that does not mean that the HCDC/HCC audiologist has to do the calculations. However, I have found that most units are not calculating HPD effectiveness, so it comes down to us, the audiologists, to ensure it gets done.
So, how do you determine HPD effectiveness? It's very easy to do if you have all the data. You need to know the particular HPD, the NRR of that HPD, and the worker/shop TWA. The problem comes with the TWA. At HCDC locations where all you get is the medical record, you will have to search for the TWA. If the worker has exposures other than noise, an AF Form 2755, will be in the medical record and will have the TWA listed. Workers exposed only to noise will not have the AF Form 2755 in the record. If the HCDC is expected to calculate HPD effectiveness, then the unit must supply the TWA on the AF Form 1672.
Now that you have all the data, you can plug the numbers into an equation. OSHA recommends several ways to do this. NIOSH also has several methods for calculating it. The easiest method is: TWA - (NRR - 7). I recommend using the NRR obtained at Wright-Patterson stated on the Approved HPD listing. The TWA should be the A-weighted TWA. If the number is under 85 dB, the HPD is effective.
You may be asking yourself, why do I have to write out a mathematical equation in the medical record. I can speak personally that the HSI team expects to see calculations in individual medical records. LtCol Linda Rollins was one of my inspectors at Kelly AFB, and she was pleasantly surprised to see we were doing it right. She had seen many cases of people documenting that the protection was adequate, but were not showing how they had determined that. She wanted to see the process itself.
The best way to ensure the HPD effectiveness calculation takes place is for the unit to do it. Whenever a patient shows a STS an annual audio, they should be referred to Public Health for education and refit of HPDs anyway. Perhaps you can convince them to do the calculations also. They could add a few lines to their SF 600 overprints so all they have to do is fill in blanks or circle items. Something like this would be sufficient:
S: Type HPD used:
____ V51R
____ Triple Flange
____ EAR
____ Muffs
____ Comm headsets
____ Other
O: HPD effectiveness:
TWA dBA - (NRR - 7)
_____ - (____ - 7)
under 85 dBA? ___yes ___no
A: HPD effective? ___yes ___no
P: Change HPD to: ____dual protection ___wear HPD correctly
P: Wear HPD around all noise, occupational and recreational.
There are other, perhaps more effective, methods for calculating HPD effectiveness. However, they are usually more time consuming and require more data than may be readily available. Neither OSHA nor the HSI states who is responsible for the calculation. It just has to get done. As you can see, it's an easy process. Why not meet OSHA guidelines and score a few brownie points with the HSI? If you would like more information on this or alternate methods, please call me or send me an e-mail.