scubadoc Ten Foot Stop

May 31, 2009

Undersea and Hyperbaric Medicine Board Review Course

Filed under: News — admin @ 10:05 am

The University of Pennsylvania School of Medicine (jointly sponsored by DAN) is conducting a Undersea and Hyperbaric Medicine Board Review Course in Philadelphia, PA on 8/21-8/23/2009.

Presented by the Institute for Environmental Medicine/Division of Hyperbaric Medicine, this conference is designed to prepare physicians eligible to take the ABPM of ABEM subspecialty exam in Undersea and Hyperbaric Medicine.  Upon completion of the program, learners should be able to:

- Describe the physics of, and human physiological responses to, immersion and high-pressure environments
- Describe the pathophysiology and treatment of medical conditions resulting from diving accidents and injuries associated with changes in pressure
- Understand and describe the medical assessment of fitness for diving process
- Discuss the mechanisms of action, complications, and contraindications of hyperbaric oxygen therapy
- Describe the pathophysiology and treatment of medical conditions in which hyperbaric oxygen therapy is indicated
- Effectively use this overview to prepare for the subspecialty board examination in Undersea and Hyperbaric Medicine

To download a course brochure and registration form, please visit:

Yours in diving safety,

DAN Medical Services


May 30, 2009

To Pee or Not To Pee?

Filed under: Article, Publication — admin @ 11:42 am

To Pee or Not To Pee?

Here is an article that I wrote some years ago for Scuba Diving Magazine.

By Ernest S Campbell, MD

What Makes Divers Want to Pee While Diving?

When diving, I suddenly get the urge to pee, even though I voided only minutes before. Why do I need to pee so soon?
via e-mail

This physiological phenomenon is known as immersion diuresis, a fancy term for your body’s response to feeling under pressure. Blood is shifted to your body’s core, and the hypothalamus gland thinks this means your total fluid volume is too high and instructs your kidneys to make urine. What can you do to avoid immersion diuresis?

Avoid diuretics like caffeine before you dive.

Intentionally dehydrating yourself might seem like a good idea, but dehydration increases fatigue and predisposes you to decompression sickness.

Try to stay warm. A side effect of your body’s response to cold is the production of urine. Wearing a hooded vest under your wetsuit may save you from having to empty your bladder when you least want to. On the boat, stay out of the wind, bundle up and wear a hat.

Be healthy, sober and rested. A variety of over-the-counter and prescription drugs can interfere with your body’s heat conservation mechanisms, typically by preventing the constriction of blood vessels near the skin. Antihistamines are particularly suspect. Alcohol is worse.

Although adipose tissue insulates well, allowing fat people to tolerate cold water immersion longer than lean people, it’s better to be physically fit.

The Science of Warming Your Wetsuit

You try to hold it in, but can’t. Desperate, you pee in your wetsuit. You hope no one will notice. But what can you do? Drink less water?

No, drink more.

The Dehydration Factor

Deliberately dehydrating yourself, in the hope you can hold it until the surface interval, just makes the embarrassment problem worse.

Because of immersion diuresis and your involuntary reaction to cold, chances are you’ll have to pee anyway.

Dehydration makes the result stronger in odor and color.

The Embarrassment Factor

There is a well-worn joke that divers belong to two schools regarding peeing in their wetsuit: Those who do and those who lie about it. If you do have to pee in your wetsuit, know this:

If you’re well-hydrated, your urine will be nearly clear and odorless. Almost like water. So who’s to know?

There’s no health risk to peeing in your wetsuit. Most people don’t realize that urine is sterile, unless you already have an infection of the urinary tract. The worst you have to fear is a case of diaper rash if the urine stays against your skin several hours, and this too is less of a problem when your urine is diluted. Solution: Open your wetsuit under water and rinse it between dives.

The Warmth Factor

True or false? Urinating in a wetsuit is a quick way to warm up. False, and here’s why: You may feel warm initially, but it will actually lower your body’s warmth. And, if you’re wearing a tight-fitting wetsuit that doesn’t flush easily, a semi-dry or dry suit, then this warming-up technique loses a lot of its appeal.

What To Do with a Wetsuit that Stinks

It couldn’t be helped. You felt the urge to pee during a dive, and so you did. Now you’re afraid your wetsuit will stink. What should you do?

Give it a hot rinse. This is the most important part of regular stink prevention. Walk right past the rinse tank where other divers are busy dunking their suits in the filth rinsed off other gear, and go back to your room at the resort or home and rinse it in hot, fresh water. The easiest way to do this is to take your suit in the shower with you. Hot water is better than lukewarm water for breaking down salts from the ocean and from your body.

Hang it. After rinsing, hang your suit to dry on a wide wooden or plastic hanger, preferably one made for wetsuits. Use a wide hanger to keep the front and back of the suit apart so it can dry more quickly.

Soap it. Every once in a while give your suit a soapy bath. Scrub it well inside and out. Use a sponge on the slick neoprene and a soft-bristled brush on any nylon linings. Just about any kind of soap will work to kill the odor, but some are better than others. The best soaps for the job are commercially available “wetsuit shampoos” (check your local dive store) or a gentle baby shampoo. Next best are regular bath soaps and shampoos. Dish and laundry soaps are too harsh to use regularly on your wetsuit, but will do the job in a pinch. Never have your suit dry cleaned.

Deodorize it. If your suit still reeks, you might want to deodorize it. “Sink the Stink”  is an all-natural deodorizer made specifically for de-stinking wetsuits.


May 29, 2009

Scuba Diving with Cirrhosis and Ascites

Filed under: Article, Publication — admin @ 3:12 pm

Cirrhosis and Ascites

Here’s a query from a scuba instructor:

57 year old male, history of alcoholism & suffering cirrohsis of the liver. Very large, distended belly ( has the largest “outie” belly button you’ve ever seen! ), but otherwise not obese. Passed the N.A.U.I. pool test better than most of his classmates. Claims his drinking days are past & has non-diving physician, unrestricted approval to participate. No other medical contraindications noted on the standard N.A.U.I. medical questionaire. He is an educated man ( prof. engineer ) with previous sport diving experience years ago… What is your advice?

It is highly likely that your diver has ascites (large quantities of free fluid in his abdomen surrounding his organs). In addition to his umbilical hernia (which can rupture easily under these circumstances) which has occurred in response to the excess pressure of the fluid - it is also highly likely that he has esophageal varices or dilated blood vessels in the lower end of his gullet.

Due to the effects of immersion on the blood supply of the body, during a dive blood is shunted from the periphery into the blood vessels of the gastrointestinal tract, liver and spleen. This would cause dilation and possible rupture of the esophageal varices with massive hemorrhage. Add to this the acid reflux changes that occur about the cardia (lower end of the gullet and upper stomach) due to the action of Boyle’s law during ascent and we have a set up for rupture of not only the varices but the stomach.

This not just a theoretical possibility but has been reported.

Massive variceal bleeding caused by scuba diving.
Am J Gastroenterol. 2000 Dec;95(12):3677-8.
Nguyen MH, Ernsting KS, Proctor DD.

Finally, cirrhosis of the liver to the extent that it causes ascites can have significant mental effects of obtundation of the intellect. Hepatic encephalopathy can cause apathy, confusion, disorientation, drowsiness and slurred speech. This alone would be dangerous enough to disallow diving.

Because of what I consider significant risk, I would not certify this person as fit to dive.

May 27, 2009

Great Article From Undercurrent: New Way to Find Lost Divers

Filed under: Article, News, Publication — admin @ 9:36 am

A Better Way to Find Lost Divers

Mike Ball’s invention: special buoys and “dummy divers”

from the May, 2009 issue of Undercurrent

Like many Great Barrier Reef-based dive operations, Mike Ball Dive Expeditions has not been immune from the past few years’ incidents of paying customers getting lost on dives and spending hours at sea before getting rescued. In our March issue, we reported on the two American divers who got separated from Mike Ball’s Spoilsport and treaded water for seven hours. To prevent repeats of that incident, Mike Ball Expeditions has been testing a new method for locating missing divers at sea. Trevor Jackson, the Spoilsport captain who led the tests, sent us this report.

Imagine being lost from your dive boat. You can see it in the distance searching, moving from side to side on the horizon. But it’s so far away, the effort to get to it is fruitless. Your hopes sink with the sun and pretty soon it’s dark. With no chance of being spotted for another 12 hours, your thoughts turn to survival, keeping warm, staying together, and conserving energy. Not a situation anyone would want to find himself in.

Recent infamous events here in Queensland, where two divers spent the night drifting around the Reef in the dark last year [Editors: see our report on that in the July 2008 issue of Undercurrent], prompted me to review what we aboard Spoilsport would do if we were faced with every dive boat’s nightmare - - divers who don’t return. So I decided on a practical experiment.

Early one morning, I made a fake human, dressed it in dive gear and threw it in the water before any crew had come on deck. I told the lookout on duty later to ignore the “diver,” and to give the crew no assistance later on when we went to find it. I let two and a half hours go by. We completed the early dive, and then I alerted the crew that we had a “lost diver,” who was last seen entering the water a few hours ago. An initial concentrated search of the horizon produced nothing. The diver was gone from sight.

Captain Jackson and His BuoysWe then tied a weight belt to a life jacket and threw it in. There was a fair bit of wind and tide about, so the jacket would give us an indication of where to start looking. Surprisingly, the jacket took off in a direction contrary to where we believed the diver might be. Five minutes later we threw another weighted jacket in, followed by another a bit later. Pretty soon, the three jackets were forming a line leading toward the horizon. I instructed the helmsmen of both our dinghies to drive parallel to that line and head out for about a mile. Our fake diver was found, 27 minutes after the drill started and a mile from the boat; completely invisible to the eye and at 90 degrees to where we had initially expected him to be.

The experiment was both pleasing and sobering. The striking thing was that, despite what the conditions seemed to indicate, the diver wasn’t going in the direction we had assumed. We decided to build permanent markers to help locate drifting divers and store them on board Spoilsport for such an event. The result was the specially configured floats which you see in the photo on page 12. They include a strobe, built-in radar reflector and a flag, for use both day and night in any conditions.

We ran regular drills with the buoys to see how well and how consistently they worked. The more we practiced, the more convinced we were that the buoys were going to be a real revelation. The buoys were not only giving us direction but the rate of drift as well. If we knew approximately when the divers went missing, we could apply a little rudimentary math and figure out how far out they were also.

After starting a drill one day, I grabbed one of the crew and said ‘Come on, let’s try something new.” The dummy diver had been lost for an hour, and we had launched the two buoys 10 minutes apart. Because they were drifting now at the same speed as the diver, we could use the gap between them to get a reasonable idea of how far out we would need to go to find our dummy. Lining up the two buoys in the dinghy, we drove at top speed between the two and timed the ride - - it took 40 seconds to meet our diver. Because the buoys drift at the same rate as a diver, it was then simply a matter of dividing the time the divers were lost by the time interval between when the two buoys were launched. In other words, 60 minutes divided by 10 minutes, equaling six. We then multiplied the time it took for
us to speed between the buoys, 40 seconds by 6, or 240 seconds. All we had to do then was keep the buoys in line and speed out in the right direction for 240 seconds, and our divers should be there, or at least pretty close by.

Despite what the conditions seemed to indicate, the diver wasn’t going in the direction we had assumed.

Over a year has passed since those drills. In dozens of tests, the buoys have given us the direction and distance of our lost diver dummies with stunning accuracy. There are certain conditions in which the buoys don’t work as efficiently but with constant practice and a good measure of common sense, we’ve trained all our crew to use the buoys to regularly locate dummies missing for up to two hours and at ranges up to three miles.

The safety of our guests and crew is of paramount importance here at Mike Ball, as it is for any professional liveaboard on the water. Based on those dummy trials, I know that in the event of an emergency requiring us to locate a diver missing on the surface, we are now one step ahead of the game.

Forward this article to a dive buddy
See Also: Guidelines for the Abandoned Diver

Diving Accident Management

Filed under: Article, Publication — admin @ 8:45 am

Gestión de Accidentes de Buceo
A Power Point Presentation in Spanish

This page is compiled and maintained
by Ernest S Campbell, MD, FACS

Introduction Rescue Resuscitation Position Oxygen
IV fluids Medications InWaterTreatment Transportation Summary


It is desirable to have a standard approach to the initial management (i.e. first-aid) of an injured diver.

Coincidentally, a diver may have a non-diving related illness or injury, but in general, symptoms and signs following a dive are likely to be due to that dive.


An injured diver must be removed from the water as quickly as possible. If the diver is unconscious and beneath the surface of the water, then they should be surfaced and decompressed in the head upright, normal anatomic position with special attention being paid by the rescuer to the maintenance of a patent airway. Surfacing feet first would delay the initiation of mouth to mouth for a short period. Air would continue to be forced from the lungs by ascent either way you raise the diver. PADI states that head up is the appropriate method. On the surface, the ‘do-ci-do’ left sided position is what is being taught for mouth to mouth initiation of breathing.

Getting the unconscious diver to the surface as fast as reasonably possible, head up and with the regulator in place would be my recommendation. NOAA does not address this in their new manual and I cannot find any reference to position of retrieval
in the Navy manual.

For other articles about diving safety see

A SCUBA diver in this context should have their regulator placed in their mouth, but no attempt at “purging” gas into the injured diver should be made. Divers using rebreathing systems, full-face masks, band masks or helmets should be “flushed-through’ with fresh gas, preferably from an alternative emergency gas supply, before swimming them to the surface or recovering them to a platform or bell. Specific techniques for recovery of a diver into and resuscitation of a diver in a bell or hyperbaric rescue vessel are needed and must be practiced.

In the absence of such a platform, the injured diver should be made positively buoyant by removing their weight-belt and perhaps by inflating their buoyancy-compensator (providing it neither limits access for the rescuer nor causes the injured diver to float “face-down’). The injured diver’s air tank should be left in-situ as it acts as a keel. The rescuer should adjust their own buoyancy by buoyancy-compensator inflation and not by dropping their weight-belt in case they lose hold of the injured diver and have to recover them again from underwater.

The utility of expired-air-resuscitation (EAR) in the water, either directly or via a snorkel, is debatable. Certainly there is a significant difference between conducting EAR in a swimming pool and in the ocean in this context, effective in-water EAR is only possible with continual practice in the ocean and, in general, an injured diver’s best interests are usually served by protecting their airway and getting them out of the water as quickly as possible.

Effective EAR and chest compression ( which obviously should not be attempted in the water ) are life-saving if cardiorespiratory arrest occurs, regardless of the cause of the injury.

Techniques should not vary between the diver who has drowned and the diver who has been envenomated, nor should it be altered for a hypothermic diver (in whom it must never be abandoned until after re-warming has been completed).


If any form of decompression illness (DCI) is suspected, then the diver must be laid flat and not allowed to sit-up or stand as this may cause bubbles to distribute from the left ventricle and aorta to the brain. Although such posture-induced phenomena are unusual (rare), they have a very poor outcome. This posture must be maintained until the injured diver with DCI is inside a recompression chamber (RCC). A headdown posture is no longer advocated as it may increase the return of and subsequent “arterialization” of venous bubbles, it causes cephalic-venous engorgement such that subsequent middle-ear inflation (e.g. in a RCC during treatment) is very difficult, it limits access for resuscitation and assessment, and, in animal-model studies it actually retards the recovery of brain function in comparison to the horizontal posture.


With the exception of oxygen toxicity, administration of 100% oxygen is useful in all diving accidents. Although divers who have pulmonary oxygen toxicity need to breathe a PiO2 of less than 0.6 Bars, many of those who have had an oxygen-induced convulsion will subsequently become hypoxic and need oxygen administration.

To administer 100% oxygen, a sealing anesthetic-type mask is needed (unless a mouthpiece and nose-clip in a conscious diver or an endotracheal tube is used) and a circuit with high gas flow-rates and a gas reservoir must be used. Air breaks, to retard pulmonary damage, may be needed, but should be minimized as must all other interruptions. This is one of the reasons why oral rehydration is not particularly useful.

It is noteworthy that administration of 100% oxygen is the definitive treatment of the salt-water aspiration syndrome and most pulmonary barotrauma, including the majority of pneumothoraces. Indeed, chest cannulation is rarely needed.

IV fluids

As with oxygen, aggressive intravenous rehydration is probably of benefit to all injured divers, even those who have drowned. Certainly, such therapy is of considerable benefit in DCI. Isotonic solutions should be used. Glucose solutions should be avoided as they have been shown to increase damage in neurological trauma.

An indwelling catheter should be inserted (filled with water, not air) and an accurate fluid balance is essential. A persistent poor urinary output despite adequate fluid replacement may indicate either persistent hemoconcentration or bladder dysfunction. Either indicates severe DCI and warrants both bladder catheterization and further fluid replacement.


There are no drugs of proven benefit in the treatment of DCI. Corticosteroids, anti-platelet drugs, aspirin have been tried without success. Lignocaine has been shown to improve neurological outcome of DCS, particularly when added to oxygen. Diazepam is used to prevent and treat oxygen convulsions and to control vestibular symptoms. It makes titration of treatment almost impossible because it masks the symptoms. Indomethacin is useful only when used in combination with prostaglandin and heparin.

Nasal decongestants and analgesics are useful in many divers with aural barotrauma, and, rarely, antibiotics may be indicated.

Some chemotherapy is useful for marine animal injuries. Many coelenterate (jelly-fish) tentacle nematocysts are inactivated by being doused with vinegar. Fish-sting pain is markedly reduced by immersion of the sting-site in hot water.

Box jellyfish stings
Box jelly fish injury
Box jellyfish
Box jelly fish

Compression-immobilization bandages should be used where possible. Analgesia often requires regional or local anesthetic-blockade and there are specific anti-venoms available for the box jelly fish (Sea wasp), the stone fish and for sea snakes

In-Water Treatment

In-water treatment of DCI is practiced and advocated by some, but is logistically difficult, requires dedicated and effective equipment (e.g. full-face mask; umbilical and breathing system cleaned for oxygen; cradle, chair or platform that can be lowered to the desired depth; warm, calm water without current and dangerous marine animals; and, adequate supplies of oxygen), and clearly should not be used for unconscious, confused or nauseated divers. In general, the diver should be retrieved as quickly as possible to a definitive treatment facility.


As for any retrieval of an injured person, stabilization of the diver must precede transportation. This will include resuscitation, delivery of oxygen, insertion of an intravenous line, correction of hypothermia (in divers in the field this should be based on passive re-warming using dry clothes and blankets) or hyperthermia (most likely in closed-diving systems and again the response will need to be specifically developed and practiced), control of hemorrhage and splinting of fractures. A record of oxygen administration and fluid balance is essential.

If DCI is suspected, then the retrieval must not exceed 1000 ft above sea level. A transportable recompression chamber is ideal, but hyperbaric transportations are logistically difficult and considerable time-savings are needed to justify this activity. Many aircraft can be pressurized to “sea-level’ during flight, although this usually limits the altitude at which they can fly (and hence makes the retrieval slower and more fuel-expensive). Unpressurized aircraft are intrinsically unsuitable and must fly at less than 1000 feet, which is often not possible. Road transport may also be inappropriate depending upon the road’s altitude, contour and surface.

It is desirable to have a standard approach to the initial management (i.e. first-aid) of an injured diver. An injured diver must be removed from the water as quickly as possible. An injured diver usually requires oxygenation and rehydration. Attention to these, and early adequate retrieval can significantly improve outcome.

Management where no chamber is available

a. 100% O2 by tight-fitting mask in all cases. Continue to treat and transport even if becomes asymptomatic!
b. Oral fluids - 1 liter (non-alcoholic)per hour.
c. IV fluids as soon as possible. Avoid over-loading. One to 2 liters in first hour, then 100 cc per hour. Glucose containing fluids should not be given in the event of neurological DCS. Hyperglycemia increases the chance of neurological damage.
-Ringer’s solution without dextrose. Hartmann’s, Lactated Ringer’s or Normal saline preferred.
-Normal saline
-LMW Dextran (Dextran 40, Rheomacrodex) in saline (alters the charge of the RBC, preventing Rouleaux formation). 500 cc twice daily. Beware of adverse effects of anaphylaxis and pulmonary edema.
d. Medications
1. Glucocorticoids in neurological DCS.
2. Diazepam (Valium) 10-15 mg IV or per rectum to control seizures and severe vertigo.
3. Aspirin is given by some.
4. Lidocaine is being used by some but is still not yet proven.
e. Catheterization for the paraplegic. Use water in the balloon rather than air. Protect pressure points.
f. Pleurocentesis, if indicated.
Transport, transport, transport! Fly in aircraft pressurized at sea level or as low as possible. Beware driving through mountain passes. Have diver accompanied by a person familiar with the facts.

May 19, 2009

“Dive Away” Diving and Diving Medicine CME Conference - Fiji, South Pacific — August 27 - September 5, 2009

Filed under: News — admin @ 1:48 pm

Hi all,

I want to let you know that there are only a couple of spots left to
have you join us for the 18th International Diving, Diving-Medicine
Conference this year being jointly sponsored by the department of
hyperbaric medicine at LBMMC, The Undersea and Hyperbaric Medical
Society and the American College of Emergency Medicine. This year, the
conference is being held in:

Fiji, South Pacific!

The conference dates are August 27 - September 5, 2009.

The course will be held on the secluded island of Beqa in the heart of
the South Pacific. Fiji is the “Soft Coral Capital of the World” and
has world class diving/snorkeling. The resort and island have fantastic
facilities and lots of activities for non-divers (guided hikes, world
class surfing, sailing, big game fishing, fantastic bird watching,
waterskiing, kayaking, aromatherapy massage, Fijian cultural programs,
Kava ceremonies, Beqa fire walkers, etc.)
Fiji is legendary for its friendly and welcoming indigenous culture.

Please see the “Dive Away” Fiji, South Pacific brochure included in this
email for more information and request a registration form to sign up.

There is a limited amount of rooms available and this conference is
ALMOST SOLD OUT, so don’t delay and sign up today to secure a spot!

Brochures and registration forms are also available through the
Hyperbaric Medicine Department at Long Beach Memorial Medical Center:
(562) 933-6950 or by replying to this email.

We look forward to having you join us August 27 - September 5, 2009 in
Fiji. It promises to be a great time.

Best wishes and safe diving,

The “Dive Team”
Long Beach Memorial Medical Center
Long Beach, CA

Alan Lewis, MD
Stuart Miller, MD

SMiller1@memorialcare.orgMichael Strauss, MD
Jeff Bozanic, PhD

Safety in the Hyperbaric Environment

Filed under: Article, Publication — admin @ 1:40 pm

Safety First: In the Hyperbaric Environment

Paul J. Shefflied, PhD, CasP, CHT
Robert B. Sheffield, BA, CHT

The rapid growth in hyperbaric medicine facilities in the United States and throughout the world has created a demand for large numbers of new employees, some of whom have no experience and little training. This has heightened the concern for patient safety.
Each individual who works at the hyperbaric facility must know the potential for mishaps and use that information to safely operate the chamber and its support equipment. Although the hyperbaric medicine community enjoys an enviable safety record, it is important to periodically review hyperbaric mishaps and consider the lessons learned from prior experience so we can avoid repeating them. There are five basic safety issues addressed herein: integrity of the pressure vessel, safe gas handling practices, decompression safety, fire safety, and staff training.

See the remainder of this article at

Scuba diving accident kills man off coast of Barnegat

Filed under: Article, News, Publication — admin @ 10:47 am

Monday, May 18, 2009

Star-Ledger Staff

A recreational dive-boat crew retrieved a 42-year-old diver who lost consciousness in the ocean some 30 miles east of Barnegat but were unable to save him, the Coast Guard said.

Gene Wite of Middleton, Del., was found unconscious 125 feet below the surface off the Ocean County coast around 2:15 p.m. Saturday and was pulled aboard the Tuna Seizure, according to the Coast Guard.

Crew members of the boat, which is homeported in Brielle, tried unsuccessfully to resuscitate Wite, Coast Guard Petty Officer Crystal Kneen said. Wite had been on his second dive of the day.

It took 32 minutes for a Coast Guard rescue helicopter to fly Wite to a landing pad in Pomona. Emergency medical personnel subsequently pronounced him dead.

Kneen said she didn’t know what caused Wite lose to consciousness or what caused his death. Choppy seas Saturday rose to crests of 3 to 4 feet, and fog kept visibility to less than three miles.

Scott Wigert, dockmaster for the Brielle Yacht Club, did not know Wite but said he likely would have been an experienced diver because 125 feet is very deep — especially off New Jersey’s coast, where visibility is limited. He said recreational divers often explore shipwrecks.

The Tuna Seizure does not dock at the Brielle Yacht Club. Wigert said he wasn’t sure which marina the boat uses in Brielle, but he was familiar with it and said it is about 37 feet long.

Deaths from recreational dives are not uncommon, even among seasoned divers, Wigert said.

“It’s a risky business. It happens to the best of them,” he said. “Usually the guy runs out of air.”

Karen Keller may be reached at (732) 293-4925 or

We will start providing accounts of diving accidents for the educational value for divers.

May 16, 2009

Hyperbaric Oxygenation Reports Sent by Sunny Sonnenrein

Filed under: News, Publication — admin @ 10:54 am

Can hyperbaric oxygenation decrease doxorubicin hepatotoxicity and improve regeneration in the injured liver?
MED   09-27   200919288285  NDN- 230-0963-0060-6

AUTHORS- Firat, Ozgur; Kirdok, Ozgur; Makay, Ozer; Caliskan, Cemil; Yilmaz, Funda; Ilgezdi, Savas; Karabulut, Bulent; Coker, Ahmet; Zeytunlu, Murat

JOURNAL NAME- J Hepatobiliary Pancreat Surg
PP 346-52
DOCUMENT TYPE- Journal Article
ISSN- 1436-0691
CORPORATE AUTHOR- Department of General Surgery, Ege University Hospital, 3rd Floor, Bornova, 35100, Izmir, Turkey.

BACKGROUND/PURPOSE: Portal vein embolization is used in the treatment of hepatocellular cancer, with the purpose of enhancing resectability. However, regeneration is restricted due to hepatocellular injury following chemotherapeutics (e.g. doxorubicin). The aim of this study was to investigate whether hyperbaric oxygenation (HBO) can alleviate the hepatotoxicity of chemotherapy and improve regeneration in the injured liver.

METHODS: Rats were allocated to four experimental groups. Group I rats were subjected to right portal vein ligation (RPVL); rats in groups II and III were administered doxorubicin prior to RPVL, with group III rats being additionally exposed to HBO sessions postoperatively; group IV rats was sham-operated. All rats were sacrificed on postoperative day 7, and liver injury was assessed by measuring alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Protein synthetic ability was determined based albumin levels and liver regeneration by the mitotic index (MI).

RESULTS: The AST and ALT values of group II rats were significantly higher than those of group I, but not those of group III. Rats treated with doxorubicin and HBO (groups II and III) showed slightly but not significant differences in albumin levels than those subjected to only RPVL or sham-operated. The MI was significantly increased in groups I, II, and III, with the MI of group III rats significantly higher than those of group I rats.

CONCLUSIONS: Based on our results, we conclude that HBO treatment has the potential to diminish doxorubicin-related hepatotoxicity and improve regeneration in the injured liver.

*HBO and doxorubicin given together has caused death in rats (probably from cardiac toxicity), and cisplatin with HBO weakens the tensile strength of healing wounds in mice.


Carbon monoxide poisoning
MED   09-28   200919416624  NDN- 230-0966-3698-3

AUTHORS- Sinding, Marianne; Friis-Mooller, Nina

JOURNAL NAME- Ugeskr Laeger
PP 1298
DOCUMENT TYPE- English Abstract; Journal Article
ISSN- 1603-6824
CORPORATE AUTHOR- Roskilde Sygehus, Medicinsk Afdeling.

Carbon monoxide (CO) is a colourless, smell free, toxic gas. CO poisoning is treated by the administration of 100% oxygen, and in some cases by the administration of hyperbaric oxygen (HBO). In Denmark, 250-325 cases of CO poisoning are treated annually, of which a few percent receive HBO. However, there are discrepancies between the various current guidelines for the treatment of CO poisoning, in particular with respect to the indication for HBO. We describe the treatment of CO poisoning in a family of six members exposed to CO from indoor barbecuing.

See also:

  1. Carbon Monoxide Poisoning

    Web page describing the risks of CO poisoning and diving. - 23k - Cached - Similar pages
  2. Smoking and Diving

    I’m not aware of any studies relating to CO (carbon monoxide) retention but it certainly is a consideration in not smoking just before diving. - 32k - Cached - Similar pages
  3. Recent HBO References

    Carbon monoxide poisoning. Early awareness and intervention can save lives. Carbon monoxide poisoning and treatment with hyperbaric oxygen in the - 35k - Cached - Similar pages
  4. Carbon Monoxide Poisonimg

    Carbon monoxide poisoning is a rare cause of problems when diving, it does occur Carbon monoxide in diving is the product of incomplete combustion of - 11k - Cached - Similar pages
  5. Hyperbaric Oxygen Treatment, Abstract and Full Text of JAMA Article

    hyperbaric oxygen in suspected carbon monoxide poisoning. JAMA. of normobaric and hyperbaric oxygen for acute carbon monoxide intoxication. Lancet. - 92k - Cached - Similar pages

Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management.
MED   09-27   200919099288  NDN- 230-0964-1476-1

AUTHORS- Boyer, Alexandre; Vargas, Frederic; Coste, Fanny; Saubusse, Elodie; Castaing, Yves; Gbikpi-Benissan, Georges; Hilbert, Gilles; Gruson, Didier

JOURNAL NAME- Intensive Care Med
PP 847-53
DOCUMENT TYPE- Journal Article
ISSN- 1432-1238
CORPORATE AUTHOR- Medical Intensive Care Unit, Ho.pital Pellegrin-Tripode, Place Amoelie Raba Loeon, 33076 Bordeaux cedex, France.

PURPOSE: Surgical treatment is crucial in the management of necrotizing soft tissue infections (NSTIs). The aim of this study was to determine the influence of surgical procedure timing on hospital mortality in severe NSTI.

METHODS: A retrospective study including 106 patients was conducted in a medical intensive care unit equipped with a hyperbaric chamber Data regarding pre-existing conditions, intensive care and surgical management were included in a logistic regression model to determine independent factors associated with hospital mortality.

RESULTS: Overall hospital mortality was 40.6%. In multivariate analysis, underlying cardiovascular disease, SAPS II, abdominoperineal compared to limb localization, time from the first signs to diagnosis <72 h, and time from diagnosis to surgical treatment >14 h in patients with septic shock were independently associated with hospital mortality.

CONCLUSION: In patients with NSTI and septic shock, hospital mortality is influenced by the timing of surgical treatment.


Pre-dive normobaric oxygen reduces bubble formation in scuba divers.
MED   09-27   200919219451  NDN- 230-0964-1119-7

AUTHORS- Castagna, Olivier; Gempp, Emmanuel; Blatteau, Jean-Eric

JOURNAL NAME- Eur J Appl Physiol
PP 167-72
DOCUMENT TYPE- Journal Article
JOURNAL CODE- 100954790
ISSN- 1439-6327
CORPORATE AUTHOR- Institute of Naval Medicine, BP 610, 83800, Toulon Army, France.

Oxygen pre-breathing is routinely employed as a protective measure to reduce the incidence of altitude decompression sickness in aviators and astronauts, but the effectiveness of normobaric oxygen before hyperbaric exposure has not been well explored. The objective of this study was to evaluate the effect of 30-min normobaric oxygen (O(2)) breathing before diving upon bubble formation in recreational divers.

Twenty-one subjects (13 men and 8 women, mean age (SD) 33 +/- 8 years) performed random repetitive open-sea dives (surface interval of 100 min) to 30 msw for 30 min with a 6-min stop at 3 msw under four experimental protocols: “air-air” (control), “O(2)-O(2)”, “O(2)-air” and “air-O(2)” where “O(2)” corresponds to a dive with oxygen pre-breathing and “air” a dive without oxygen administration. Post-dive venous gas emboli were examined by means of a precordial Doppler ultrasound.

The results showed decreased bubble scores in all dives where preoxygenation had taken place (p < 0.01). Oxygen pre-breathing before each dive (“O(2)-O(2)” condition) resulted in the highest reduction in bubble scores measured after the second dive compared to the control condition (-66%, p < 0.05). The “O(2)-air” and “air-O(2) “conditions produced fewer circulating bubbles after the second dive than “air-air” condition (-47.3% and -52.2%, respectively, p < 0.05) but less bubbles were detected in “air-O(2) “condition compared to “O(2)-air” (p < 0.05).

Our findings provide evidence that normobaric oxygen pre-breathing decreases venous gas emboli formation with a prolonged protective effect over time. This procedure could therefore be beneficial for multi-day repetitive diving.

* It has not been shown that reduction in VGE provides a decrease in decompression sickness. Reference the Deep Stop workshop held at the UHMS meeting last June


Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis.
MED   09-27   200919393420  NDN- 230-0962-5077-7

AUTHORS- Flanagan, Carrie E; Daramola, Opeyemi O; Maisel, Robert H; Adkinson, Cher; Odland, Rick M

JOURNAL NAME- Otolaryngol Head Neck Surg
PP 730-4
DOCUMENT TYPE- Journal Article
ISSN- 0194-5998
CORPORATE AUTHOR- University of Minnesota Medical School, Hennepin County Medical Center, Minneapolis, MN; Department of Otolaryngology-Head and Neck Surgery, Hennepin County Medical Center, Minneapolis, MN.

OBJECTIVE: To review our management of cervical necrotizing fasciitis (CNF) with the use of adjunctive hyperbaric oxygen therapy (HBO).

STUDY DESIGN: Case series with chart review.

SUBJECTS AND METHODS: Evaluation of ten patients with CNF between 2001 to 2006.

RESULTS: There were five male and six female patients. Mean age was 43 +/- 11 years. Eight cases resulted from an odontogenic source. Comorbidities included diabetes mellitus, hypertension, and substance abuse. All patients had computed tomography scans performed, received intravenous antibiotics, and underwent surgical debridement. Eight patients underwent surgery within 24 hours. The average number of debridements was 2.2 +/- 0.8. Hospitalization was twice as long for diabetic patients (15.5 +/- 8.16 days) compared with nondiabetic patients (7.5 +/- 1.6 days, P = 0.029). Nine patients had HBO therapy. Combined data revealed a possible decrease in length of hospitalization with HBO therapy (P < 0.001). No mortality was documented.

CONCLUSION: In addition to early and aggressive medical management and surgical debridement, this study suggests that HBO therapy is a beneficial adjunct by potentially decreasing length of hospitalization. Randomized trials are still needed to demonstrate its efficacy.


Treatment of radiation retinopathy following plaque brachytherapy for choroidal melanoma.
MED   09-28   200919349865  NDN- 230-0966-2802-2

AUTHORS- Wen, Joanne C; McCannel, Tara A

JOURNAL NAME- Curr Opin Ophthalmol
PP 200-4
DOCUMENT TYPE- Journal Article
ISSN- 1531-7021
CORPORATE AUTHOR- Department of Ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-7000, USA.

PURPOSE OF REVIEW: Radiation retinopathy and maculopathy are predictable complications resulting from exposure to any source of radiation, including external beam and plaque brachytherapy. Most choroidal melanomas are currently treated with plaque brachytherapy. However, the ensuing complications frequently compromise posttreatment vision. The purpose of this review is to discuss recent studies on the management of radiation retinopathy and maculopathy.

RECENT FINDINGS: Intravitreal bevacizumab, intravitreal triamcinolone and laser photocoagulation appear to transiently decrease macular edema, although improvements in visual acuity are limited. In successful studies, recurrent treatments were needed to sustain the effects. Case studies of photodynamic therapy, oral pentoxyphylline and hyperbaric oxygen treatment describe positive results, but further studies are required. One study suggests that laser photocoagulation may be useful in prophylactically treating radiation retinopathy.

SUMMARY: Currently, there are no proven treatments for radiation retinopathy or maculopathy. The current treatment methods require frequent administration with variable improvement in visual acuity.

Ern Campbell, MD

May 9, 2009

New PFO Closure Device Reported

Filed under: Article, News — admin @ 10:32 am

LAS VEGAS, NV (May 8, 2009) — A new device designed to close a common heart defect known as a patent foramen ovale (PFO) is safe and effective at 90-days follow up, according to a new study released today at the Society for Cardiovascular Angiography and Interventions (SCAI) 32nd Annual Scientific Sessions in Las Vegas.

PFO is a common condition in which a hole that connects the two upper chambers of the heart (atria) during fetal development fails to close properly after birth. About 25 percent of the general population has PFO, which is associated with an increased risk of stroke. PFO may also be associated with migraines and decompression illness in divers.

The FlatStent EF, developed by Coherex Medical,Inc., is unique because it is implanted within the PFO tunnel, leaving a minimal amount of the device exposed to circulation, which could reduce the risk of blood clots. The mechanism of action of the FlatStent EF should limit the incidence of other major complications associated with septal patching devices currently in use, such as erosion, persistent arrhythmia, and valve apparatus distortion.

In the study, 29 of 41 patients (70.7%) who received the FlatStent EF(TM) PFO Closure System had complete PFO closure immediately following implantation. After 90 days, 17 of 19 patients (89%) had complete or clinical closure. The remaining 22 patients had not yet completed the 90-day follow up exam.

“The FlatStent is designed to be safer and easier to use than current PFO closure systems,” said Horst Sievert, MD, professor of internal medicine, cardiology and vascular medicine at the Cardiovascular Center in Frankfurt, Germany, and the study’s principal investigator. “Given the number of patients living with PFO, the results of this study show promise in providing additional treatment options that could help prevent stroke and other conditions associated with PFO.”

In the study, no device-related complications were reported. The 100-patient, multicenter registry study is designed to evaluate 30, 90 and 180-day safety and performance.

Patent Foramen Ovale

Best Publishing Company for educational resources for both diving and diving medicine and hyperbaric medicine…. New book PFO and the Diver at and Assessment of Diving Medical Fitness for Scuba Divers and Instructors!!!! PFO (Patent foramen ovale) is a persistent opening in the wall of the heart which did not close completely after birth (opening required before birth for transfer of oxygenated blood via the umbilical cord). This opening can cause a shunt of blood from right to left , but more often there is a movement of blood from the left side of the heart (high pressure) to the right side of the heart (low pressure).

People with shunts are less likely to develop fainting or low blood pressure with diving than are obstructive valve lesions (such as mitral valve stenosis or aortic stenosis), but are more likely to develop fluid accumulation in the lungs from heart failure and severe shortness of breath from the effects of combined exercise and water immersion.

Ordinarily, the left to right shunt will cause no problem; the right to left shunt, if large enough, will cause low arterial O2 tension (hypoxia) and severely limited exercise capacity. In divers there is the risk of paradoxical embolism of gas bubbles (passage of bubbles into the arterial circulation) which occur in just about all divers in the venous circulation during decompression.

Blood can flow in both directions with Intra-atrial shunts at various phases of the cardiac cycle and some experts feel that a large atrial septal defect (PFO) is a contra-indication to diving. In addition, a Valsalva maneuver, used by most divers to equalize their ears during descents and ascents, can increase venous atrial pressure to the point that it forces blood containing bubbles across the PFO into the arterial circulation. Thus the usual filtering process of the lungs is by-passed.

Dr. Fred Bove, a Temple University cardiologist, did a search of the literature for patent foramen ovale in relation to diving and diving risks. His conclusion of a meta analysis of 1400 injured divers in about 2.5 million divers (DAN, 1991) in whom the risk of DCS is about 0.05% in the diving population, was that the risk ratio for decompression sickness is increased by a factor of about three for individuals with PFO, and is reduced by a factor of about 2 in individuals who do not have a PFO. It would appear that the risk is low and the significance of the small differences is questionable.

Echocardiography is the tool of choice in making the diagnosis of PFO. However, it’s probably not a good idea to do an echocardiogram on all divers because of the cost/benefit ratio. If you personally are concerned or are having some of the symptoms of decompression illness that are undeserved, then a bubble contrast echocardiogram should be done. Bubble contrast echocardiography appears to be the most sensitive method for detecting a shunt while color flow doppler appeared to be a poor means of detecting the shunt in a transthoracic echo.

There have been recent reports of an association between cerebral emboli, migraines with aura and right to left shunts (PFO).

Philip Foster et al, in the Journal of the Aerospace Medical Association, has an elegant article “Patent Foramen Ovale and paradoxical Systemic Embolism: A Bibliographic Review” in which is presented in a single document a summary of the original findings and views from authors in this field. It is a comprehensive review of 145 peer-reviewed journal articles related to PFO that is intended to encourage reflection on PFO detection methods and on the possible association between PFO and stroke.

The article abstract and related articles can be seen at this address:

Patent Foramen Ovale Closure - A button closure (Amplatzer) is performed trans venously without entering the chest. About four weeks after the surgery, another echocardiogram is done to verify that the device is still in position.

After two-three weeks there is an overgrowth of endothelial cells covering the device, reducing the risk of infection.

After six to eight weeks the connective tissue has completely filled the spaces in the device and it becomes invisible to ultrasound. Return to diving is usually in six weeks (Wilmshurst), given the full recovery to the satisfaction of the cardiologist/surgeon. Others require a longer wait of twelve weeks.

See article by Wilmshurst, et al at .
Google Links, PFO and Scuba Diving


Int J Sports Med. 2009 Feb;30(2):150-3. Epub 2008 Sep 4.Click here to read Links
Erratum in:
Int J Sports Med. 2009 Feb;30(2):153.

Relation between right-to-left shunts and spinal cord decompression sickness in divers.

Institute of Naval Medicine, French Navy, Toulon, France.

The role of right-to-left shunting (RLS) in spinal cord decompression sickness (DCS) remains uncertain and could differ according to the distribution of lesion in spinal cord with a higher risk of upper spinal cord involvement in divers presenting a large patent foramen ovale. The aims of this study were to assess the prevalence of RLS with transcranial doppler ultrasonography in 49 divers referred for spinal cord DCS and compare it with the prevalence of RLS in 49 diving controls, and to determine a potential relation between RLS and lesion site of spinal cord. The proportion of large RLS was greater in DCS divers than in healthy control divers (odds ratio, 3.6 [95 % CI, 1.3 to 9.5]; p = 0.017). Shunting was not associated with the increased incidence of cervical spinal cord DCS (OR, 1.1 [95 % CI, 0.3 to 3.9]; p = 0.9) while a significant relationship between large RLS and spinal cord DCS with thoracolumbar involvement was demonstrated (OR, 6.9 [95 % CI, 2.3 to 20.4]; p < 0.001). From the above results, we conclude that the risk of spinal cord DCS in divers with hemodynamically relevant RLS is higher than in divers without RLS, particularly in their lower localization.

PMID: 18773377 [PubMed - indexed for MEDLINE]

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