Scubadoc’s Ten Foot Stop

June 27, 2009

Diving In Polluted Waters

Filed under: Article — admin @ 10:46 am
Diving in Polluted Waters

The Problem
Over the past ten to fifteen years the diving population has become sensitized to the potentially hazardous presence of pollution in the sea.  The ocean has been a traditional dumping ground for many types and degrees of pollutants.  Several years ago a Los Angeles Times article indicated that 2000 U.S. beaches were closed due to sewage spills.(1993).  California, as usual a leader, had 745 closures with 588 occurring in Southern California.  Consistent and regular monitoring would have probably  fond many more contaminated beaches needing closure.  There is a definite lack of any standardized program for monitoring our waterways; particular areas of concern are harbors and similar areas which do not “flush” well, rivers, especially those with high levels of industry on the shores, sewage outfalls which go out to sea but are often overloaded and areas which have the deposits of soft, silty materials dropped as the currents reduce their velocities in dispersal areas.  It has been estimated that there are on the order of 15,000 chemical spills that enter our water areas each year in the U.S. alone.  The contaminated areas are growing and now include many recreational diving areas as well as scientific study sites and search and rescue operations.

The health consequences of the water pollution have not been quantified by careful study but many local health professionals are concerned with infectious and carcinogenic disease potential for patients who are ocean swimmers, lifeguards and divers. Until adequate epidemiologic data is available the recourse would appear to be logically focused upon conservative practices in selecting dive sites and conditions.

This increase in areas of pollution is a worldwide problem and has affected many diving operations. Diving in polluted water requires that certain precautions be taken, and, in some instances, the use of sophisticated equipment and procedures.  Avoiding diving in areas with high potential for pollution, particularly after heavy rains is fundamental in urban or industrialized areas.


The main problem centers around the fact that bacterial, viral and chemical hazards can affect the human body by skin contact and entry through orifices.   The following list was produced in the NOAA Manual and the details were obtained from the medical literature.

Vibrio – 34 species of this family of bacteria are known and cholera and El Tor vibriones are among those known to be pathogenic to man.  Cholera vibriones have recently been found in Santa Monica Bay in California and have raised concerns although it is not known to have produced any disease. Other vibriones may be anaerobic and produce disease states such as purulent otitis, mastoiditis, and pulmonary gangrene.  V. Proteus found in human fecal material is a common cause of diarrheal disease.  V. Vulnificus is found in sea water.

Enterobacteria
Escherichia – found widely in nature, occasionally pathogenic to man, produces carotenoid pigments and can often be recognized by the orangish pus.  E. Coli,. which has some pathogenic strains is often found in fecal material: and can produce urinary tract infection and epidemic diarrheal disease.

Shigella – produces dysentery

Salmonella – 1000 serotypes, ingestion can produce gastroenteritis including food poisoning, typhoid and paratyphoid.

Klebsiella – can produce pneumonia, rhinitis, respiratory infection.

Legionella- causes Legionnaires disease and Potomac fever.  Perhaps inhibited in salt water.

Actinomycetes – causes a “ray fungus” actinomycosis, an infectious disease in man which inflames lymph nodes, develops abscesses, can drain into the mouth causing damage to the peritoneum, liver and lungs.

Pseudomonas- pathogenic to man, “blue pus” formed by some pseudomonas infections. This can lead to a wide variety of infections including wound sepsis, endocarditis, pneumonia and meningitis. It is known to flourish in dark, warm, damp places, i.e., inside hoses, bladder compartments and similar places that are not cleansed after being infiltrated by contaminants.

Viruses – infectious agents which can result in fevers (frequently severe), mononucleosis, and a wide range of disease states.

Parasites – many types with all manner of effects, all bad, can are found in polluted water.

Chemicals -  There are over 15,000 chemical spills in the U.S. waterways each year and many of these are releasing chemicals that are incompatible with man and the equipment that is worn.


Prevention
As detailed information becomes available on this issue divers will become sensitized to the need for preventive measures before, during and after diving.  At present the scientific and public safety diving communities are developing techniques for isolating the diver from the potential problems and decontaminating all exposed elements of the diving equipment.  It appears eminent that the recreational community will feel the need to exert greater care in the future.

It is becoming increasingly important to develop an understanding of the variations in the local conditions to which individuals expose themselves.  Some areas become particularly hazardous following heavy rains, hot weather and windstorms.  Local health authorities can usually be called for advice regarding any tests that have been performed and the results.  They should also be able to identify areas of high concentrations of pollutants that should be avoided.

When diving in areas where pollution is suspected or expected the following issues are worthy of evaluation.

1. The individual diver should consider the need for appropriate vaccinations and inoculations.  Many of the diseases can be avoided if the individual has taken the appropriate “shots”.  A few that appear worthy of consideration:
Hepatitis A and B
Cholera
Polio
Tetanus
Typhoid, Smallpox and Diphtheria

2. Pollution and filth are often associated. If the water contains obvious trash and garbage it is quite probably an unhealthful diving environment and another location should be selected.  If the water looks nasty it probably is nasty!!

3. Many diseases have an incubation period before they exhibit symptoms.  Medical advice is as close as the phone and early diagnosis and treatment can sometimes be improved if the Doctor understands that an individual may.have been submerged in polluted water.

4. Information on chemical spills can be obtained from the Chemical Transportation Emergency Center (1 800 424 9300 US).

5. “When in doubt- Check about”

A basic procedure if one feels they must dive in high risk water involves reducing the exposure of the diver.  NOAA has pioneered a sophisticated SOS (suit over suit) system that will virtually isolate the diver from any contact with the water.  This system is somewhat complex inasmuch as it requires complete system integrity from the times the diver dresses out until the system has been decontaminated following the dive.  Strict procedures are followed to ensure that the divers body does not contact the fluid in which it is immersed.

Previously, many public safety divers wore a  single dry suit and a full face mask during their dives. However, Stephen Barsky now states that Full-face masks only provide minimal protection and should only be used in environments where the pollutants are known, and do not pose a threat of death or permanent disability. In environments where the pollutants are not known, or where they lead to death or permanent disability, a helmet should be worn connected to a mating dry suit with mating dry gloves. This is considered the standard today.” (See Reference below)

If good seals are involved and the diver is effectively rinsed, scrubbed down and rinsed again prior to breaking any existing seals, the probability of exposure to the pollutants can be minimized.  Special care must be taken to clear hoses and fittings that interface with the life support system.  A failure to rinse bladders and hoses which may later be linked to the divers mouth or lungs could provide a path to the host days after the dive.  The use of snorkels, alternate air sources, oral inflation devices and hose connections should all be given careful attention since the can carry contaminants directly into the mouth.  Positive pressure, “self bailing” breathing systems have definite advantages in that they resist flooding.

Recreational divers maybe well advised to place their regulator in their mouth and their mask over their nose before entering suspect water and keeping it there until they have safely exited the water where they can remove the regulator without needing to replace it.

Polluted water is a fact of our lives.  The degree of pollution can only be mitigated through education and the “upstream” elimination of the sources of the contaminants.  The attitude that careful rinsing of diving gear is a waste of time “cuz its just going to get wet again next time it is used” should probably be replaced with the attitude that one should begin every dive with clean gear.


LINKS To Pollutant Testing

Utah Bureau of Environmental Chemistry and Toxicology
http://hlunix.hl.state.ut.us/els/chemistry/

Adapted from Glen Egstrom, Ph.D
Medical Seminars, Inc. 1992

Other References:
Colwell, et.al. Microbial Hazards Of
Diving In Polluted Waters, Maryland Sea Grant
Publication UM-SG-TS-82-01.

Diving in High-Risk Environments, 3rd Edition
by Steven M. Barsky
Amazon.com
Paperback – 197 pages 3rd edition (December 15, 1999)
Hammerhead Press; ISBN: 0967430518

June 9, 2009

Diving With Disabilities

Filed under: Article — admin @ 1:30 pm

Download pdf

A Real Diving ChallengeThis page is written and maintained by
Ernest S Campbell, MD, FACS


Have you ever been on a night dive and had your lights go out? Or, imagine yourself doing a shore dive and you find that someone has tied your feet together; just imagine the difficulty of dragging yourself in and out of the water.

These are just two of the challenges that face disabled people who want to experience the serenity and beauty of scuba diving: the blind person is forever in pitch darkness, the paraplegic faces this wall every day.

In spite of these seemingly insurmountable obstacles, there are many disabled who are participating in scuba diving programs especially designed to assist them to experience our sport safely.

Below are listed various services and contacts for disabled persons who wish to learn more about diving:

Articles

  • Dive Training for the Disabled: What is it Worth? Diver Magazine, August 1997
  • “Soaring Below”, by Vicki Stiefel.
  • ‘Alert Diver’, March/April 1996; a publication of
    DAN (Divers Alert Network)

  • “Diving With Care”,
  • Training and Medical Aspects of Diving With Disabilities,
    Kimberly P. Walker, NREMT-P, DAN Training
    Alert Diver, March-April 1996, p. 40.

  • Scuba Diving With Disabilities Robinson, Jill. & A. Dale Fox:
  • (Champagne, Illinois:  Leisure Press, a Division of Human
    Kinetics Publishers, Inc.  Box 5076 Champagne, Il 61820.  1987)
    “A valuable supplement to any diving manual or class. For the disabled diver or the instructor who wants to teach disabled divers, the book is must reading.”


Associations and Clubs and Training


Amazing Seals

amazingseals.com

St. Paul/ Minneapolis Minnesota

Masha Bowen coordinator

(651)263-9707
We have recently started this exiting new program and working with local rehabilitation centers providing scuba experience for disabled divers. We have PADI and HSA certified instructors.



Disabled Diver training in the San Diego area.

John Ellerbrock
PADI Master Instructor
Pinnacle Divers

PinnacleDiver@home.com
619.997.DIVE (3483)


Eels on Wheels Adaptive Scuba Club
Aron Waisman,
12338 Limerick Ave,
Austin, Texas, 78758
(512) 873-9121
awaisman@austin.rr.com
http://www.Eels.org

Article “Challenges of Diving With Disabilities”, by Tammie Shelton
http://scuba-doc.com/DivingDisabilities.pdf


National Instructors Association for Divers with Disabilities (NIADD), Dorothy Shrout, P.O. Box 112223, Campbell; CA 95011-2223; (408) 379-6536, (408) 244- 8652 fax
NIADD, San Jose, CA.  Contact Frank Degnan at Any Water Sports, (408)244-4433.  Frank and Dorothy Shrout organize this.


Handicapped Scuba Association, Jim Gatacre, 1104 El Prado, San Clemente, CA 92672-4637, (714) 498-6128,   HSA@HSASCUBA.COM


Houston Disabled Scuba Divers Association, 403 East Nasa Road 1, Suite 325, Webster TX 77598-5314, (713) 477-5556, swa@neosoft.com

Southern Wheelchair Adventurers Association of Galveston-Houston, 403 East Nasa Road 1, Suite 325, Webster TX 77598-5314, (713) 477-5556, (Lytle Seibert); swa@neosoft.com,


Canadian Scuba Diving Clubs for Divers with Disabilities

  • Club Challenge, 3108 Woodland Park Drive, Burlington, Ontario L7N 1L2 Canada; (905) 634-8234 (Joan Muir; Burlington), (905) 844-4160 (Annis Dixon; Oakville), (519) 658-5838 (Margaret Sanderson; Kitchener), (416) 485-7355 (Jerry Ford; Toronto)
  • Pacific Northwest Scuba Challenge Association, 14286 72nd Avenue, Surrey, British ColumbIa V3W 2R1 Canada; (604) 525-7149 (Ron Stead)
  • Persephone Scuba Diving Club, Concordia University, 7141 Sherbrooke Street West, Montreal, Quebec H4B 1R6 Canada; Louis Jankowski, Ph.D., (514) 848-3320 (office), (514) 630-1429 (home)

Diving With Disabilities
Bruce Van Hoorn
14960 Penitencia Creek Road
San Jose, CA 95132
(408)258-9789


Dis-A-Dive
Bart Schassoort
3530 Warrensville Center Road
Suite 200
Shaker Heights, OH 44122
(216)241-3483


Open Waters, Paul A. Rollins, Project Coordinator, or Steven Tremblay, Project Director, c/o Alpha One, 127 Main St., South Portland, ME 04106-2622; (800) 640- 7200 (voice or TTY) or (207) 767-2189 (voice or TTY), (207) 799-0355 fax, open_waters@alpha-one.org , http://www.alpha-one.org


The Australian Underwater Federation has published a booklet on teaching disabled divers.  It can be obtained from theAUF Office,
PO BOX 1006,
Civic Square, ACT, 2608, Australia.


IAHD, is a non-profit organization for disabled divers.
www.iahd.org and www.iahd-americas.org


Norges handikapfellesskap in Norway,
Dive Training for the disabled.
www.handikap.no
e-mail:tomm.fredriksen@handikap.no

================================================

June 2, 2009

Secrets of the Deep

Filed under: Article, Publication — admin @ 1:24 pm

Here is an interesting article in the New York Magazine about diving along the waterfront of New York City. The entire article can be seen at http://nymag.com/news/features/56609/

What lies beneath the surface of New York Harbor? For starters, a 350-foot steamship, 1,600 bars of silver, a freight train, and four-foot-long cement-eating worms.

Commercial diver Lenny Speregen and NYPD detective John Drzal.
Illustrations by Mark Nerys

(Photo: Matt Hoyle)

The steady transformation of New York’s waterfront from wasteland to playground means more of us are spending time along the city’s edge. That can lead a person to wonder: What, exactly, is down there? Until recently, we had patchy knowledge of what lies beneath the surface of one of the world’s busiest harbors. What we did know came largely from random anecdotes, and depth soundings done the way Henry Hudson did them—by rope and lead sinker. This first GPS-era picture comes from the team at Columbia University’s Lamont-Doherty Earth Observatory, who have methodically swept the lower Hudson with state-of-the-art sonar. LDEO’s Dr. Frank Nitsche stitched together their data, along with several other researchers’ work, into this elegant color-keyed map, which we’ve supplemented by talking with sea captains, historians, and the divers pictured above. There’s a whole other city down there. Here and on the following pages is your guide.

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DAN Announces New Vice President of Medical Services

Filed under: Article, News — admin @ 11:43 am


Dr. Nicholas Bird Joins DAN Staff as New Head of Medicine Department

Anyone who has called the DAN® 24-Hour Diving Emergency Hotline or used the non-emergency Medical Information Line knows the outstanding caliber of those who comprise DAN’s medical department. That legacy now continues with the addition of Dr. Nicholas Bird, DAN’s incoming vice president of medical services.

Dr. Bird joins the DAN staff in June. He comes to DAN from the Dixie Regional Medical Center in St. George, Utah, where he currently serves as the medical director of hyperbaric medicine. His acceptance of his new position at DAN follows an intensive and exhaustive months-long search by the organization to find the right candidate for the job.

“We knew the incoming VP would have some large shoes to fill,” said Dan Orr, president and CEO of DAN. “Our retiring VP of Medical Services, Joel Dovenbarger, has served this organization for almost all of its 30 years, and his contributions to its success cannot be measured. We knew it would take a special person to succeed him, and Dr. Nick Bird is that person. He’s a highly qualified and capable physician with extensive experience in hyperbaric medicine. He’s a great fit for our culture and the needs of our medical department, and he’s an active diver who understands and enthusiastically supports our mission and philosophy. We couldn’t have asked for more.”

Dr. Bird’s qualifications include a medical degree from the Royal College of Surgeons in Ireland and the completion of his family medicine residency at the University of Washington at Vancouver, as well as a fellowship in diving and hyperbaric medicine at the University of California at San Diego. He is board certified in Family Practice and Undersea and Hyperbaric Medicine. He served in the U.S. Air Force as a Flight Surgeon and was honorably discharged with the rank of Major, but not before serving as the final Commander of the Base Hospital in Jordan during Operation Iraqi Freedom.

In addition to extensive credentials, Dr. Bird’s character was also highly admired and praised by the candidate selection committee. Said Dr. Brett Hart, a member of DAN’s Board of Directors and the selection committee: “[Our] decision to support Dr. Bird’s selection as DAN’s new Vice President of Medical Services came down to three things: honor, courage and commitment. Beyond being a capable physician, he consistently demonstrated the moral character necessary to ‘do the right thing’ in terms of supporting DAN and its mission.”

Added Dick Clarke, president of National Baromedical Services and another member of the selection committee: “Dr. Nick Bird brings to DAN solid medical credentials, excellent interpersonal skills and great enthusiasm. DAN’s membership will be that much better off as a result of Dr. Bird’s close coordination of emergency evacuation and related medical care with all those who work globally on behalf of the injured diver.”

Although the start of Dr. Bird’s tenure at DAN is still a few weeks away, his enthusiasm for his new position is unmistakable. “DAN [is] integral to the diving community,” he said. “As a resource for information, a lifeline for injured divers, a conduit for research and a pioneer of safety training, DAN has distinguished itself as an industry leader.

“I am honored to have been chosen as the new VP of Medical Services and look forward to advancing DAN’s mission of dive safety. As a hyperbaric physician, I am especially interested in DAN’s goal both to establish and enhance the quality and integrity of medical care for divers in remote areas. I have joined DAN at an exciting time in the organization’s development and look forward to rolling up my sleeves and diving in.”

Dr. Bird’s addition to the DAN staff is certainly one reason it is an exciting time at DAN, and we hope you’ll join us in welcoming him both to DAN and the dive industry.

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June 1, 2009

Arterial gas embolism: a review of cases

Filed under: Article, Publication — admin @ 12:20 pm

Arterial gas embolism: a review of cases

There is an article in Anaesth Intensive Care. 2008 Jan;36(1):60-4, “Arterial gas embolism: a review of cases at Prince of Wales Hospital, Sydney, 1996 to 2006″ by Trytko BE, Bennett MH that is well written and reports on the experience of a hyperbaric facility that utilizes evidence based guidelines for HBO treatment. 

Arterial gas embolism may occur as a complication of diving or certain medical procedures. Although relatively rare, the consequences may be disastrous. Recent articles in the critical care literature suggest the non-hyperbaric medical community may not be aware of the role for hyperbaric oxygen therapy in non-diving related gas embolism. This review is part of an Australian appraisal of experience in the management of arterial gas embolism over the last 10 years. We identified all patients referred to Prince of Wales Hospital Department of Diving and Hyperbaric Medicine with a diagnosis of arterial gas embolism from 1996 to 2006. Twenty-six patient records met our selection criteria, eight iatrogenic and 18 diving related. All patients were treated initially with a 280 kPa compression schedule. At discharge six patients were left with residual symptoms. Four were left with minor symptoms that did not significantly impact quality of life. Two remained severely affected with major neurological injury. Both had non-diving-related arterial gas embolism. There was a good outcome in the majority of patients who presented with arterial gas embolism and were treated with compression.

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. http://www.sinkthestink.com/

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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?

Answer:
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.
http://snipurl.com/3s76

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
scubadoc@scuba-doc.com

Introduction Rescue Resuscitation Position Oxygen
IV fluids Medications InWaterTreatment Transportation Summary

Introduction

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.


Rescue

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 http://www.scuba-doc.com/dvsaf.html

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.


RESUSCITATION
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).


POSITION

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.


OXYGEN

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.


Medications

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.


Transportation

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.


Summary
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

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 http://www.todayswoundclinic.com/2009/05/saftey-first-in-the-hyperbaric-environment/

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