Naui Rescue 1bl69

(15 co. ft.) of capacity, with its own subme!>ible pressure gauge and regulator (figure 7-5). TIlese are usuallywom attached to the main cylinde!>, and the hose and mouthpiece compactly attached to the Be alloll~ng rapid deployment. Since tllese devices have greater capacity, they allow a diver in the event of running out of air in the main cylinder to make a nonnal controlled ascent to the surface at • the recommended rate that includes a safety stop for three to five minutes at around 5 mete!> (15 feet). The problem with either of these deVices, however, is that poorly trained or imprudent dive!> may mistake "emergency procedure" for standard procedure. Neither a

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AGURE 7-5. fUllY REDUNDANT SCUBA CAN BE ALIfESAVER.

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Spare Air'" or a redundant scuba system is in any way considered part of the routine diving air supply. These are auxiliary devices only to be used in the event of dire need. If feeling that there is plenty of air available encourages the diver to simply increase the amount of time spent underwater, or to ignore recommended dive planning activities which include air consumption calculations, and buddy agreement, then they lvill have no value as a back-up system. Many experienced dive!> point lvith pride to tlle fact that tllese redundant systems, although carried faithfully tllfOUgh many dives, remain unused.

SHARED AIR ASCENTS Although controlled, ilTUllediate independent action mal' be the best choice for a diver faced with an out-ofair situation, no one would reject air if it were available. Fortunately, in the shared experience of diving, it most often is. There is great comfort and confidence in the powerful concept of dive buddies as two mutually interdependent, ~ independent dive!> sharing time undelWater. Each diver's

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NAUI Scuba Rescue Diver

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ability is augmented by the presence of tile other, and each diver represents to the other a source of aid in an emergency. While the concept is well-accepted and almost universally practiced, the sad trutIl is that without careful planning and practice it remains only an ideal. Too frequently, divers are only "SOBs" -Same Ocean Buddies, companions tllat enter the water sequentially, then abandon each other to independent pursuits, usually only meeting again at the exit point or even out of the water. While this may be acceptable under certain circumstances, in an emergency at depth, it can be a death sentence for the distressed diver. NAUI Worldwide recommends that divers make the ideal concept of a buddy the reality of their diving activities. It is nowhere more important than in the ability to share air undelwater (figure 7-6) .

the divers must become familiar with each other's equipment, talk about training, and can judge the confidence of the other diver, important activities in their own right. Most emergency plans include using an altemate second stage, and most dive training organizations and dive operators throughout the world now consider canying an altemate second stage mandatory. This requirement is usually satisfied witll a so-called "octopus" regulator, a redundant scuba system, or a BC-integrated second stage. Some divers will carry more than one altemative system, and some diving activities, notably cave penetration diving, reqUire even more extensive altemative air sources. In any event, whatever the chosen type of equipment, you and your buddy's ability to use it effectively when faced lvith a frightening underwater crisis will mean tile difference between success and possible grave harm.

MUTUAL EMERGENCY PLANNING

ALTERNATE SECOND STAGE AIR SHARING TECHNIQUES

All effective buddy briefings must include discussion and agreement on the method to employ in case either diver runs out of air. In reaching consensus on method,

fiGURE 7-8. SUCCESSfUL SHARED AIR ASCENTS REGIN WITH GOOD RUDDY DIVING TECHNIQUE.

98

The follOWing scenarios are for discussion purposes only. There is no "one correct method" of air sharing and no one can learn to use scuba eqUipment exclUSively from reading about it. No matter how well the process is understood intellectually, intensive practice of an agreed upon method, under controlled conditions, and under the supervision of a qualified instructor is mandatory for initial proficiency. Certified divers are encouraged to practice sharing air skills regularly with their customary buddy on dry land or under confined water conditions, to insure that tllese critical skills remain vital and useful. .'

When the needy diver signals that air is needed: I. Immediately offer the altemate second stage, watching the diver to make sure that the mouthpiece is purged before a breath is taken. If not, the diver will inhale water which will most likely lead to panic and either a frantic effort to regain tile surface or an attack on tile donor. Be prepared.

Chapter 7- Dealing With An DUI·Of·Air Emergency

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:2. AGURE H. fOR YOUR BUDDY TO BE AN EffECTIVE SOURCE Of AIR IN AN EMERGENCY, YOU MUST KNOW WHERE TO LOOK fOR HELP. THE "GOLDEN TRIANGLE" POSITION fOR AN AlTERNATE SECOND STAGE IS GENERALLY fAMILIAR TO ALL DIVERS.

2. When the needy diver is breathing from the alternate second stage, make eye and signal for an "OK" response. Once given, maintain eye , and establish control by grasping tile diver's BC or ann with the right hand. The needy diver does likewise, creating a "Roman Handshake," or just holding on to tile donor. 3. After a few stabilizing breaths have been taken by the needy diver, signal for an ascent to tile surface. Use the left hand to control the BC valve to maintain a steady ascent at the recommended rate. If tile needy diver is under control, and if the remaining air supply pennits. a safety stop may be made.

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When the needy diver signals that air is needed: 1. Immediately offer the primary mouthpiece to the needy diver, insuring tilat it is in an upright position to avoid tile diver having to use it "upside down" and risk a,pirating water.

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AGURE J·B. THE GREAT ADVANmGE Of AN OCTOPUS DR OTHER ArnR· NATED SECOND SlNlE TECHNIQUE IS THAT BOTH DIVERS HAVE AIR "ON DEMAND" WITHOUT INTERRUPTION.

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Switch to your BC mounted mouthpiece. 2. When the needy diver is breathing from the offered second stage, make eye and signal for an "OK" response. Once given, maintain eye , and establish control by grasping the diver's BC or arnl with the right hand. The needv diver does likewise, creating a "Roman Handshake," or just holding on to the donor. 3. After a few stabilizing breaths have been taken by the needy dim, signal for an ascent to the surface. Before the ascent, vent the air, if any, from your own Be to prel"ent it from expanding rapidly in shallower water making the ascent too rapid. It may be necessary to remove the mouthpiece momentarily to do til is, or anotiler dump valve may be easily accessible. in any case, maintain reassuring eye with the needy diver throughout the process. When ready, begin the ascent. If the needy diver is under control, and if the remaining air supply penn its, a safety stop may be made.

97


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When the needy diver signals tllat air is needed: 1. immediately offer either the redundant scuba mouthpiece. 2. When the needy diver is breathing from the redundant second stage, make eye and signal for an "OK" response. If using a Spare Air~ or another detachable redundant scuba system, tlle divers should ascend togetller making eye , but need not be in physical with each other throughout tlle ascent. If using a pony system, maintain eye , and establish control by grasping the diver's BC or aml with the right hand. 'l1Je needy diver does likewise, creating a "Roman Handshake," or just holding on to the donor. 3. After a few stabilizing breaths have been taken by the needy diver, signal for an ascent to tlle surface. Use the left hand to control the BC valve to maintain asteady ascent at the recommended rate. If the needy diver is under control, and if the remaining air supply pennits, a safety stop may be made.

BUDDY BREATHING "Buddy-breathing," (figure 7-9) once the standard technique for any out-of-air emergency, is currently being supplanted by any of the alternate air source methods outlined above. in fact, NAUI Worldwide moved away from teaching the technique, preferring instead to concentrate on easier to leam and perform emergency skills like the use of an altemate air source. Though for many divers, buddy breathing is an antiquated technique, when divers depended on a chancy reserve valve-system to signal the beginning of an ascent, the skill has been used to save lives. If this is your chosen method of sharing air, it is imperative that all divers with whom you may pair acknowledge their own proficiency in the technique. Without well-rehearsed, carefully practiced skill in

98

technique, however, attempting to employ buddy-breathing underwater is an invitation to disaster. l\vo highly agitated divers must be able to coordinate their movements and air demands under extremely trying conditions while ascending for the skill to work. This cannot happen with simple, casual interest in the skill.

BUDDY BREATHING METHOD When the needy diver signals that air is needed: I. Immediately take a breath, ing the mouthpiece to the needy diver by the hose so the purge valve is accessible to the needy diver. Exhale slowly while the needy diver is breathing. 2. After clearing the moutllpiece and taking an initial breath or two, tlle needy diver es the regulator back to the donor, who again clears the mouthpiece, usually with an exhalation of the rest of the reserved breath, takes a full breatll, exhales nonnally, then takes another and es the mouthpiece back to the needy diver who has maintained a long, slow exhalation throughout the wait. 3. When both divers are stabilized in the rhythm of ing the regulator, the donor signals for an ascen~ and when agreed to, the divers ascend continuing the process. If the divers are under control, and if the remaining air supply pemlits, a safety stop may be made.

PROBLEMS WITH SHARING AIR The chief problem with sharing air is that, no matter how well trained the divers are, it is an extremely difficult and stressful situation. The possibility of panic always attends running out of air underwater. This panic has two sources, only one of which is susceptible to mental control. Training and practice will help divers achieve self-discipline and confidence in their ability to perform skills, but there is no way to prevent the inexorable build-up of carbon dioxide in the circulatory sys-

Chapter ]. Dealing With An Dut·Of·Air Emergency

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tern from triggering the need to breathe, and if delayed long enough, the drive to bolt for the surface. ~ In any sharing air event, physiological changes in iiilI the distressed diver's metabolic and respiration rates, make the need for air that much more crucial. Extreme stress elevates the heart rate, constricts blood vessels, tenses muscles, and releases adrenaline and other chemicals into the body. All of tllese phy~ical changes come on top of severe mental agitation, no matter how well-trained and confident in tlle chosen technique a diver may be. SRD and ASRDs need to be vigilant to the fact that even under successful air sharing scenarios, where the needy diver appears stabilized and under comrol at any point in the ascent, the possibility of a panicked flight or attack always lurks in the background. Experienced NAUI Worldwide use the eyes as the mirrors of the problems that divers may be having, and thus, all of the scenarios described above include the onition to maintain eye throughout the ascent. Noticing the diver's eyes growing wider are signs of increasing apprehension, and distress. Dealing with the issues of controlling a diver who is attempting to reach the surface despite being provided..ilir, or fending off a mindless, panic-driven attack are the subject of the next chapter. After panic, tlle worst problem associated with an out-of-air emergency is that it is possible for there to be two divers without air! Towards the end of a dive, bar-

ring some eqUipment malfunction, botll divers' air supplies are lower. With one diver breathing at a rate sufficient to run out, it is possible that in the stressful encounter, the remaining air in the donor's cylinder will be used before reaching the surface. This is the best argument for a redundant scuba system back·up. Having a distinct air supply to complete the ascent is as gratifying as not haVing one is daunting. Increasing numbers of divers are adopting this fail-safe position, carrying either Illultiple cylinders with separate regula· tors, or substantial auxiliary air supplies in an ample pony bottle with its own SPG and regulator. SRD and ASRDs, particularly those interested in working in the recreational diving industry as gUides, or becoming instructors, should consider these options seriously.

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99

CHAPTER

Underwater Rescue


In this chapter you will: I. Review the concept of "responsibility" and "duty" as they apply to certified Scuba Rescue Divers and Advanced Scuba Rescue Divers. 2. Learn to assess the risk to yourself while considering the need to perform an underwater rescue of another diver in distress. 3. Learn procedures for use underwater to rescue a responsive victim and an unresponsive victim. 4. Learn what to do when confronted with a panicked diver underwater. 5. Learn what to do when attacked by a panicked diver underwater. Undenvater rescue is dangerous. The risk of injury to a would-be rescuer, despite training and skill proficiency is always high. B€yond the physical danger, any rescue entails the chance of failure that can have profound psychological and emotional effects on the rescuer whose attempt to help has gone awry. Moreover, rescuers are exposed to considerable legal liabilities no matter how appropriate their actions, despite even a relatively successful outcome. Even so, the motivation to risk grave harm to help another person is always irable, and fortunately, fundamental to human character.

As an SRD or ASRD, absent some pre-arranged, documented assumed burden with anotiler diver or divers, such as when acting in a well-defined position as a diving leader, you have no responsibility to risk yourself for another diver In other words, your proficiency and certification in rescue skills creates no obligation on your part to endanger yourself by using those skills when diving. Thus, the techniques and skills you learn in an NAUI Worldwide rescue course are only learned to make you a better informed, more profiCient diver. In truth, even your tacit agreement lvith your buddy to be mutually responsible for each other is a strictly voluntary

102

bargain which eitiler party can choose to break at will. As loose as your responsibility as a diver may be, however, if you choose to act, you create and assume a duty to perfonn to the standards to which you were trained, and to the absolute best of your ability. Once you begin to effect a rescue, unless continuing will clearly cause you grievous harm, you have the obligationto persevere until the situation is satisfactorily resolved, or so long as you are able.

All rescues must begin with the difficult question, "Am Iwilling to assume tile risks of this rescue?" Unless the answer is clearly yes, you must not act. Answering the question honestly requires you to make a frank assessment of the situation and its risks, and to consider your ability and the likely outcome of the response you are trained to make. There is no point in creating a second victim, however well-meaning or highly motivated you may be. Every water rescue carries tile inherent risk of drowning for all concerned. Participation in an underwater rescue exposes all involved to highly increased risks of pressure-related injuries and illnesses. All of these risks must be considered. Your air supply and air consumption rate are of primary imlJOrt.1nce in deciding whetiler to attempt an undenvater rescue. This is particularly true if tile diver in distress is out of air, or if the incident takes place at deeper depths or later in the dive. Arescuer is s~biect to the same stress-related factors as any other diver faced with a threatening situation, and will use air just as quickly. It is a dangerous error to sacrifice prudence to urgency. Circumstances also affect a rescuer's initial assessment. If the person in distress is in a situation for which you have not been trained, you are most often better off getting more qualified personnel than risking yourself. For example, you see your buddy penetrate an underwater wreck on a dive planned as an outside tour. You lvisely elect to wait outside tile entry point. After several minutes, you hear frantic tapping from within.

Chapter 8- Underwater Rescue

Unless you are qualified in the specialized techniques of overhead environments specific to wreck-diving, and properly equipped for the penetration, your best course of action would be to seek aid for the diver from some better source. As hard as it might be to make that decision, evelY minute you waste agonizing over what to do brings the (possibly) trapped diver, and you, closer to the end of a limited air supply. Without proper training, eqUipment and a pl~m, entering the wreck is more likely to result in two casualties than a successful rescue. Another important question to answer before attempting to aid another diver in distress is where the buddy may be? Adiver frantically swimming up to the surface may need help to avoid an injUly, but what if that diver has left another diver unconscious on the bottom, who needs more immediate assistance and is ascending to seek aid? Diving is a shared actiVity. As a rescue diver, consider this before acting. There could easily be a buddy who is in greater danger. Finally, unless you are a diving leader or are diving \\~thout any supervision, tl1ere may well be a more qualified, duty-bound diver present to effect the rescue. It may even be that the rescue is in progress, and your actions will hinder it. Exan1ine the prior exmnple of a diver swimming upward to tl1e surface again. While the diver may be risking m1 overexpm1sion injUly or decompression sickness, if the person is out of air, stopping their emergency swinmling ascent is clearly not helpful. 111e diving leader may have in fact notioed tlle person's predicamelll, and elected to allow them to ascend, follmving the diver to the surface to assist there. Or the ascending diver may be the leader going to the sUiface to aid a person in distresl there. The point is simple: carefully consider what you think you see before you act. Without the whole picture, you may do more haml tllan good.

Avictim struggling \vith a problem underwater is more dangerous to a rescuer than one that is unconscious. An unconscious diver is not likely to attack and drown someone attempting to render assistance.

Approach any diver in distress underwater with extreme caution. AlSess your personal risks carefully before attempting to take action, m1d be prepared to disengage if the diver turns on you. If possible, after identifying the problem, communicate a solution to the diver who can then relieve the difficulty on her own, while you watch and assist as reqUired. Frequently, merely stopping the diver's antics, ing the person gently with an underann assist while the problem is resolved and the situation calms, \vill do the job (figure 8-1). On the other hand, once you decide to intervene, do so forcefully. Do not make some minor adjustment to the situation, then expect the diver to "pick up the slack." For instmlce, noticing a diver with a weight belt that has slid past the hip bones and is tangled with a misplaced dive tool, or draped around the mlkles, don't merely pull the weight belt free, hand it back to the diver and resume your dive. Take the time to monitor tl1e diver while the belt is replaced and secured. If need be, do it for the person. Half-measures, however well-meaning, are no assistance at all. It is a serious mistake to assume that a diver in difficulty is capable of dealing \vith the problem once you have helped them get a little bit under control. Your effort should not end until the diver signals that he is once again "OK" after your assistance, and your best judgement tells you the person is truly "OK." After an underwater incident, there is nothing wrong \vith signaling the other diver to ascend if you have any doubt

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103


3. If the mouthpiece is in place, leave it in. If it is

about the person's ability to continue the activity. Once you are reassured on the surface, the dive may continue.

An unresponsive diver unde"vater will drown without your immediate assistance. Unfortunately, this may also be the case even wiUl your help. Realize that whatever has happened to Ule person you find, nothing that can happen to them as a result of your rescue efforts, even a diving illness or oUler injUry, is more important than the chance of survival getting them to the surface and to emergency medical care as qUickly as possible represents. 1. Su,,'ey the scene and assess your personal safety. Is there any ob\10US danger that has injured the person, and can it injure you? Where is the buddy and the group, if any? 2. Approach the apparently unconscious diver cautiously, and attempt to gel a response by tapping the diver on the shoulders, or shaking the victim. Are the mouthpiece and face mask in place? Are there any exhalation bubbles?

104

out, leave it out. Do the sanle with the face mask. 4. Remove the diver's ballast. (If the victim is wearing a lot of weight to offset a buoyant dry suit, for instance, it may be better to leave the weight in place to better control the \1ctim's buoy,mcy.) 5. Begin ascending with the diver. Position yourself behind the diver. If the mouthpiece is in place, keep a finger on it to maintain its pOSition, but do not push the purge button. Use your left hand to control your BC, adding or releasing air to maintain the reconunended ascent rate. 6. Upon breaking the surface, inflate your BC and drop your ballast, maintaining the victim at the surface. Follow the procedures for surface rescue from this point. Under some circumstances, it may be better to make the unresponsive diver buoyant at depth, and follow the person to the surface. These cirtumstances include times when you are in close proximity to the exit, such as a surface vessel on station with qualified personnel aboard, or when you feel that the individual's size and or weight is too much to physically handle. In these instances, follow the procedures above through number three, Ulen: 4A. Remove ule diver's ballast, and put enough air into the victim's BC to begin to move ule person off the bottom. (If Ule victim is in a dry suit, and there is no BC, use Ule dly suit inflatOl:)

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Chapter 8- Underwater Rescue

SA. Continue to surface the person, a5cending at the normal ascent rate, holding on to the unconscious diver's equipment until the victim's buoyancy is too great to control. 6A. LeI go when you can no longer hold the victim back, and continue your ascent at the appropriate rate until you are on the surface and can resume aiding the person.

For most people, there is nothing so frightening as breatillessness underwater. Having a physical and mental component, panic can strike any diver. Other divers may experience acute irrational fear for any number of reasons from sudden claustrophobia to inert gas narcosis. Whatever the reason for the diver's distress, a panicked individual underwater can easily, albeit inadvertently, harm himself and anyone attempting to render assistance.

Anyone seen underwater stripping off and discarding the face mask, or spitting out the second stage mouthpiece is almost always getting ready to bolt to tile surface in panic. Seeing any diver struggling with equipment, pulling at quick-release buckles or trying to part belts or straps instead of unfastening them, is most likely on the verge if not in the throes of panic. 1f you are close enough to put the apparently panicked diver's regulator back into the mouth, do so. But truthfully, the chances of doing tilis successfully are slim. Observe the person for a few seconds. Notice, if possible, the individual's eyes. Rounded, "saucer" eyes, or "bug-eyes" are invariably t~ltales of extreme fear and impending panic. From a distance, a panicky diver may be "frozen" tense, or making erratic movements or gestures. Most often a panicked diver will seem to be "climbing and clawing" back to the surface. Graceful swimming

motions are impossible since the diver is in the grip of unreasoning fear, desperately fleeing the oppressive water for the air. If you notice someone beginning to show signs of panic under.vater, and you are close enough to intervene, do so witil great caution. The best thing that you can do is to get the person to calm done. An open handed "WAIT" or "STOP" signal, followed by a calming touch, and the gesture to exhale, can forestall panic if the attack is breathing related. The long, slow exhalation \\111 help to ventilate carbon dioxide from tile diver's system, reducing the feeling of breathlessness over a relatively short period. Obviously, if tile problem is caused by an attack of claustrophobia, or fear of some marine creature, the effect of deep exhalation will not be as calming.

The most honest answer to the question of whether or not you are likely to be safe trying to prevent a panicked dim from bolting to the surface is O. If you are close enough to try to slow tile person's flight, realize that you will most likely not be able to without great difficult)' and struggle, but it is possible. Unfortunately, the person bolting may have run out of air, and stopping the individual, unless you are willing, ready and able to

liIJ 105


Ii"'!""'I share air and the victim is thinking clearly enough to ~ take It,

exactly the wrong thing to do. On the other hand, if you are relatively certain that the individual has air supply, and are willing to take the risk to attempt to slow the ascent, the key is in flaring your fins to create drag. If the ascent becomes too rapid, and you are endangered, release your grip and follow at a normal rate. When you reach the surface, be prepared to resume the rescue once the diver sufficiently tires. IS

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Under most circumstances, monitoring a diver's rapid, panicked ascent is the only course of action you will have the opportunity to take. Survey the area for the diver's buddy, if it is not you, to make sure that the out of control diver has not already attacked and injured someone else now greatly in need of assistance. Once you see that the diver is out of control and going to the surface, calm yourself down, and make a controlled ascent at the recommended rate. The diver will need assistance at the surface, and you will only be able to provide it if you surface properly, and most importantly, at a safe distance from the panicked diver In the event that the diver makes it to the surface conscious, the person in all likelihood will still be greatly distressed and agitated. Coming up near enough to be grabbed will only cause you harm. Look up and around as you ascend to make sure that the diver you are folloWing has not shifted attention to you.

IN

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The phrase "underwater attack" may conjure up black and white films or images of some modem spy novel, but being set upon by a diver who sees your air supply as his own at depth is certainly not entel1aining. Nor is the direct threat to your life imaginary. You should do whatever you must in order to break free from an unreasoning, panicked attacker underwater Be aware that this is a life or death struggle from the

108

FGURE 85. f mACKED :!NOm 'ATER, USE YOUR lEGS mFREE YOURSElf

moment you are beset. Expect no quarter or relief, simply escape as best you can. \Vhether on the surface or undel\vater, tlus often means using the legs, the strongest muscles in the extremities, to kick and push tlle attacker off (figure 8-5). If you are able to get free, and the attack was driven by air hungel; it is likely to be only a few brief moments before the person becomes extremely calm, either ing out or expiring. You can then monitor their ascent or help them ascend, so that you can help them on the surface.

There is little if anything you can do to prevent a panicked diver from getting to the surface quickly under most circumstances. More often than. not, the diver who boltl willnol be within touching distaI~ce. Even so, getling close to a diver who is in this predicament is a dangerous prospect. k; strong as the motivation to help another person may be within any human, it is never stronger than desire to survive.

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107

CHAPTER

Diving Maladies


LEARNING GOALS In this chapter you will: 1. Review the different types of lung over-expansion injuries. 2. Learn the signs and symptoms associated with lung over-expansion injuries. 3. Understand decompression sickness (DCS). 4. Learn the signs and symptoms associated with DCS. 5. Be introduced to the basic principles of neurological assessment.

IiIJ

110

"Diving maladies" is the generic tenn for the illnesses and injuries to which divers are susceptible as a result of breathing compressed gas under water. It includes all barotrauma, i.e., injuries caused by the direct and indirect effeCtl of pressure. Simple direct pressure injuries, colloquially known as "squeezes and blocks," are discussed in Chapter Five. The tenn diving maladies also refers to decompression illnesses: the group of injuries generally caused by air escaping from lungs due to ill health or damage by overexpansion; and to decompression sickness ("The Bends"), the result of uncontrolled release of dissolved gas, for the most part nitrogen, into the blood and tissue. The great majority of divers never even witness, let alone experience a pressure-related injUly or malady. Despite this, the chance of injury during diving, or the risk of a diving malady, can never be completely eliminated from any dive. In addition, since diving maladies in particular are statistical in nature, given enough dives, they can, and eventually will occur. They are possible even on well-planned, well-executed dives made by healthy, well-trained divers under ideal conditions. As daunting as these facti may seem to a non-diver, knowledgeable divers understand that they can do a great deal to reduce the risks of their participation. Your involvement in this course is one part of preparing yourself to qUickly recognize and to respond SWiftly and effectively to any of these unfortunate eventl.

PULMONARY BAROTRAUMA In a healthy person (figure 9-1), lung injury from scuba diving is almost always tile result of an inadvertent error on a diver's part. The mechanism by which lungs are injured is simple: expanding breathing medium, generally normal air, escapes from a small tear in the lung when routine exhalation is either suspended or interrupted, usually during an ascent, or when pressure on delicate lung tissues is strong enough. The possibility of lung overexpansion is the reason scuba divers are so vigorously taught to "never hold your breath." During ascent, air in the pliant tissues of the lungs will expand in inverse proportion to the ambient water pressure. This expansion takes place at any depth, but is most dramatic in the range of greatest pressure reduction, between the surface and 10 meters (33 fsw) (one and two atmospheres of absolute pressure lata]). As ambient pressure is reduced and air within the diver's lungs expands, nonnal breathing exhaustl this expanded air and the lungs remain well within criticallimitl of their elasticity.

SIGNS US. SYMPTOMS SIP% IE OD~el YDlr. SymPlom~

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Circulation of Air Sac Arterial

FIGURE g.1. GRAPHIC OF LUNGS

Airway

Chapter g- Diving Maladies

3

If breathing is interrupted during ascent by the diver's will (breath-holding) or by chance (by a sneeze or cough), or expanding pressure on the pubnonaty system is inadvertently applied (for instance by a mucous plug from congestion), lung tissue may tear. If it does, an amount of gas can escape from the lungs into the body or circulatory system. Depending on where the gas lodges, and to a lesser extent, on how much gas escapes, a more or less serious further injury can occur. All lung overexpansion injuries are serious in that simple, Single injuries are rare. More often, there are a set of injuries tllat result from the single lung tear. Anyone suspected of having suffered a lung overexpansion injury should, at the very least, be monitored closely for signs of increasing severity, and should refrain from diving until thoroughly examined and approved for diving by a qualified physician.

TYPES OF LUNG OVEREXPANSION INJURIES

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Asmall amount of air that escapes from a lung tear and lodges beneath the skin, generally in the area of the shoulders along tlle collar bone, is called "subcutaneous emphysema," literally "beneath-the-skin trapped air causing abnonnal distension of tissue" (figure 9-2). Distinguished by little, if any, discomfort, signs include the crackling and bubbling sound caused by tlle air migrating tllfough tlle tissue when touched extell1ally This is the least serious fOll1l of lung overexpansion injUiy.

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Sometimes the air released from a lung overexpansion injury lodges in the thoracic (chest) cavity that is filled with the heart and otjJer organs above th'e diaphragm (figure 9-2) Air in this area can displace the organs, including the heart, impeding circulation and making breathing difficult. This is a serious medical condition that reqUires emergency medical treatment that may include draining the air from the

body caVity. Victims should be monitored closely for signs of shock, circulatory or respiratOly distress.

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IP~t11D1 A If a lung overexpansion injury is so severe that a

great deal of air escapes from the lung, or if the injury persists unnoticed over time, it is possible for tlle lung to collapse (figure 9-2). In this scenario, air pressure on the outside of the lung is greater than air pressure within the damaged, leaking lung. Like a suddenly deflated balloon, the lung separates from the pleural lining. This can be extremely painful, and can cause acute breathing distress. Pneumothorax is a potentially life-threatening condition that reqUires immediate evacuation to an emergency medical facility. The transport should preferably be made by emergency medical specialists capable of providing advanced life should the need arise, but in any case, the victim needs immediate help.

IP

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c=

Gl

Ironically, the most severe consequences of lung overexpansion injUry, an arterial gas embolus, requires the least amount of free gas (figure 9-2). Air escapes from the lung and enters the circulatOly system, making its way into the arterial flow. This air can be carried by the blood throughout the body, occluding the smallest supply vessels (arterioles). However, it is a blockage in the brain that is most potentially hamlfu!. The occlusion grows more serious as the resulting irritation to the interior of the blood vessel is attacked by the body's normal defense mechanisms. The vessel walls swell and dead white blood cells collect in the area, eventually creating a larger embolus. Deprived by tlle growing blockage of nourishing oxygen, carried by tlle hemoglobin in the blood, ischemia develops in the brain tissue. Brain cells die rapidly if ischemia is even momentarily prolonged. Permanent irreversible brain damage results with effects that can include partial or complete lateral paralysis, varying degrees of neurological defiCit, resulting in cognitive and sensory impairment or loss, and death.

111


Arterial Gas Embolism

Mediastinal Emphysema

,,

, ,

I

Pneumothorax

Subcutaneous Emphysema"

fiGURE 9-2_ LUNG OVEREXPANSION INJURIES

UNDERSTANDING DECOMPRESSION SICKNESS While lung overexpansion injuries result primarily from easily understood and identifiable causes related to

112

clear physical concepts of pressure and its effects, the cause of decompression sickness is far less open to simple analysis. Decompression sickness results from the rapid release of dissolved inert breathing gas, usually nitrogen, the chief component of air. Just as carbon dioxide is dissolved in a carbonated

Chapter g- Diving Maladies

beverage, nitrogen dissolves in blood and tissue. In fact, as you read this, nitrogen in equal partial pressure to the nitrogen in the air in which you are immersed ~Uld which you breathe, is dissolved in your body. Were the pressure around you to change, or the density and pressure of the air you are breathing change, the dissolved gas in you would equilibrate witil the new factors. Under water on scuba, under increased ambient pressure and breathing denser gas on demand, your tissue and blood equilibrate over time until the amount of gas dissolved in tilem is appropriate for the circumstances. The longer you spend under water, the more gas dissolves, until the tissues and fluids of your body are completely saturated; that is, can hold no more gas in solution at that ambient pressure. It takes far longer than the average scuba dive for all the tissues in the body to achieve this saturated state. However, not all of the body's tissues take up g,ll at equal rates. Some tissues begin to approach saturation relatively quickly, in a matter of minutes, while others may only take hours, and still others far longer In any case, no matter what the level of saturation achieved, it is important that tile rate at which the dissolved nitrogen is released from the tissues is not so rapid as to allow it to quickly from solution to the gaseous state before reaching the arterovenous capillal)' bed in the lungs. In other words, if, just like the carbonated beverage alluded to earlier, the "lid comes off tile bottle too qUickly," it can bubble over. Such bubbLing in the tissue and circulatol)' system will invariably damage surrounding tissue (figure 9-3). l1le damage can cause more or less severe (usually) t-centered pain, pennanent neurological damage tilat can include senso!)' impaimlent or complete loss, complete or partial paral}~is, generally in symmetrical quadrants, gross mobilit)' impainnents ("staggers"), severe respiratol)' distress ("chokes") or complete respiratol)' andlor cardiac failure and death. The speed with which pressllJ:€ is reduced after exposure detemlines the amount of bubbling that will occur, and to a large extent the amount of danlage incurred and likelihood of sUIvival. In sunmlal)', decompression sickness ~ comes from the combination of staying down too long, ~ too deep and coming back to the surface too quickly - a

vein

Nitrogen bubble blockage in capillaries

1:: •

c-

fiGURE 0-3. OCS RESULTS FROM INERT CAS BUBBLES FORMING IN TlIE BLOOD AND/OR TISSUE DURING DECOMPRESSION.

good argument to confine diVing activities to conservative use of recommended recreational exposure'S as presented in NAUI Worldwide dive tables. Factors other than pressure and depth also affect the amount of dissolved nitrogen in the body, thus inlluencing the probability of decompression sickness. Chief among these are temperature and diver work. Colder liqUid will hold more dissolved gas. An uncapped carbonated beverage will lose its sparkle much more rapidly at room temperature than if it is refrigerated. Acolder diver will also be able to dissolve more nitrogen. Diver work also ,tffects tile level of nitrogen saturation achieved by holding more of the gas in muscle fibers enlarged by strenuous effort. Circulation to and from the swollen tissues is reduced, reducing offgassing by a factor not ed for in the nomlal exposure tables. These situational factors demand consideration in one's dive planning to reduce the likelihood of contracting decompression sickness. NAUI Worldwide recommends increasing the time interval one group for any dive on which the diver feels cold to for additional nitrogen that may be retained on a repetitive dive (any dive made within 24 hours of another). We also recommend increasing the time interval by one group for any dive that is perceived as strenuous. In addition, on any dive in which rou grow cold, consider the nature of hypothermia, and the poSSibility that it is more prudent to sit out a repetitive dive to once again achieve comfortable thermal balance.

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Decompression Sickness Theory

-A

B

-

c

o

E

Nitrogen dissolved in tissue will form bubbles when the difference belWeen the internal pressure 01 the diver and the ambient pressure increases 100 Quickly or sharply. This may happen when a dN9r ascends 100 last or has absorbed a large amount of nitrogen through prolonged or increased exposure. or due 10 environmental or individual physiologic laClors. These bubbles are microscopic in size at first and are believed to originate Irom tiny gas pockets in the walls of tissues (A). Excess nitrogen during decompression dissolves into the microscopic pockets. causing them 10 enlarge and extend into the circulatory path (6) until they finally break tree and become !loy bubbles (C-D), or they may continue to grow Within the tissue ilself (E). When they grow large enough 10 press on naIVe tissue or disrupt circulation, pain or symptoms result. During an ascent, the volume of a microscopIC bubble increases due to Boyle's Law. Gas pressure within the bubble decreases and the gradient (diHerence in pressure) between gas dissolved in surrounding tissue and lhe bubble increases. More gas is then drawn InlO the bubble causing it to grow larger. Therefore, bubbles not only grow because of Boyle's Law, but because 01 the inward diffusion of gas. Recompression, on the other hand, compresses bubbles and increases their internal pressure. Nitrogen then diffuses out 01 the bubbles back into solution in the tissues. Oxygen applied at increased pressures during recompression therapy augments the process by nourishing bubble-damaged tissues and helping to drive excess nitrogen Irom the system.

FIGURE 9-4. GRAPHIC OF DeS

TYPES OF DECOMPRESSION SICKNESS Discussion of decompression sickness (DCS) has usually centered on the relative severity of typeS, but in reality, all decompression sickness is equally severe, and to a rescue diver, such considerations make no difference. In tlle field, academic distinctions are less important than appropriate action. Any evidence of decompression sickness requires an immediate response and swift medical intervelllion that probably \vill include recompression tllerapy. In addition, distinguishing between the types of decompression sickness is strictly a theoretical exercise since tlle existence of any symptoms probably indicates tllat other asymptomatic bubbling (so called "silent bubbling") is present in some other area. Because of the way nitrogen bubbles act witllin the body, as highly attractive areas for released nitrogen, the possibility of asymptomatic bubbles becoming larger and crossing the tllreshold of feeling is high. Rescue divers should treat all identified decompression sickness as a potentially life-threatening condition.

"s in

~ I Skin bends may mean simple itchy skin of no consequence after hyperbaric chamber exposure, or a rashy

114

marbling, commonly on your torso, that may warn of serious decompression sickness.

lOb

."

Limb bends (t pain) is a common manifestation of DCS. The shoulder and elbow ts are common sites in recreational divers, while lower extremity pain is more likely in commercial divers and tunnel workers. Pain can be vague and mild, to piercing and severe. The limb usually looks nonnal, and usually is not tender. Sometinles inflating a blood pressure cuff around the affected limb reduces tlle pain, depending on the delay and whether the pain is due !o t effects or to nerve irritation from neurological \lends.

Neurological bends is also a common fonn of Des. Effects vary greatly. seemingly minor problems of weakness, numbness, and "pins and needles" in your arms and legs can be mean serious problems with your spinal cord. An often neglected symptom is extreme fatigue, although fatigue is not only a neurological entity. In the most serious cases, urination may become difficult

Chapter 9- Diving Maladies

fIGURE 0·5. KNOWING KOW TO CONDUCT AfiELD NEURDLOGICAL EXAM CAN MAKE THE DiffERENCE IN THE OUTCOME Of AN INJURED DIVER'S RECOVERY.

or impossible, and you may lose bowel or sexual function. You may become paralyzed or die. With decompression sickness of the brain, you may have headache, visual changes, paralysis of one side of your body, changes in mental and emotional functioning, difficulty concentrating, or changes in personality. There is some discussion of whether, and to what extent, there are long term brain changes with repeated exposure to decompression stress, even decompression stress that does not result in known decompression sickness.

rn

"Inner Ear BeMs' Inner ear bends is sometimes called "staggers," because vestibular damage can produce vertigo (a whirling sensation), making you move unsteadily. Other vestibular symptoms are hearing loss, ringing in your ears, and nausea.

Chnke~ Chokes is pulmonalY decompression sickness, a rare form of DCS that is more common in aviation. Bubbles block circulation tp your lungs. Chokes is characterized by difficulty breathing, pain under your breastbone (sternum), a cough, and a feeling or actuality of choking. Your lungs lose their ability to filter bubbles, and more serious symptoms may begin as bubbles start reaching your arterial circulation.

fIGURE 0-8. LEARNING TO PERfORM ACOMPETENT, CONCISE NEU· ROLOGICAL EXAM TAKES TRAINING AND PRACTICE.

SIGNS AND SYMPTOMS OF DIVING MALADIES Pulmonary barotrauma and decompression sickness are potentially life-threatening conditions. In the field, there is no time, nor is there ally reason once you have reasonably identified the problem, to delay appropriate treatment and an immediate call for evacuation to a hyperbaric medical facility for profeSSional diagnosis and treatment. React immediately to the following Signs: • Unconsciousne&s undelWater, immediately upon surfacing or sudden unconsciousness up to 24 hours after diving • Disruption in thought processes after diving, including unusual or bizarre behavior, sudden aggressiveness or ivity, anxiety or anxiousness, speech deficits, confusion or disorientation. • Breathing difficulty, including gasping, shortness of breath or chest pain or respiratory pain after diving.

115


• Apparent problems with bowel or bladder function including i ues of frequency and perfonnance. • Mobility problems after diving including any paralysis, problems with gait or balance, weakness, unusual fatigue, • sensory changes after diving including specific or advancing numbness or tingling in any part of the body, impainnents in hearing, \1sion or tactile sensation or severe nausea or dizziness. • Convulsion or seizure after diving.

TIe TrG ble ilh Smplo s The obvious trouble \vith symptoms for a SRD or ASRD is that, unless they happen to you or are severe and accompanied by apparent difficulties, they are easy for a diver to ignore. More often than not, most divers will do just that, even though training and common sense would dictate otherwise. There are many reasons Ii"I"'I for denial of a diving malady, but for the most part they ~ are the result of fear and embarrassment or ignorance. Most divers who are experiencing symptoms the effects of which are noticeable will gladly submit to examination and treatment. But some divers will resist even in spite of knowing better, and in others, there may be some question as to whether or not they are indeed the victims of a diving malady. Whatever the reason may be in a specific instance makes no difference to a SRD or ASRD who notices a diver who may be a victim. Your role \vill be to assess the problem carefully and then react appropriately.

n IU b:1 As a certified SRD or ASRD, whether in a leadership

position, or just acting as another diver, you can use your NAUI World\vide affiliation to help gain another diver's confidence and trust in your judgment. Pointing out your observations to a possibly affected diver, you need to convince the person to let you perfonn a more extensive, appropriate examination (see "Neurological Assessment" below) to determine whether you are correct. That this detennination is to tlle diver's eventual benefit, however, is often not a persuasive argument to gain cooperation.

118

Instead of trying to cajole the person into doing what you want by explaining the righteousness of your position, or the superiority of your knowledge, point out tlle possible consequences of ignoring a diving malady. It is easy enough to make someone understand that they are making the choice between the possibility of suffering pennanent danlage that can include severe disability, and avoiding it. If after the issues are explained to the person in a low-key, matter of fact way, there is still no cooperation, it is important that you document your effort to try to help the situation. If there is someone in overall charge of the activity, like a diving leader or boat captain, ask this person to attempt gaining the possible victim's cooperation. Discuss your observations with the person in front of the affected diver, and point out your belief that the diver is making a mistake. In this case, the leader or captain will frequently intervene, and assume responsibility for insisting that the diver cooperate. Even so, these individuals are not law enforcement officers generally, and even were this the case, no one can compel a conscious, lucid individual of the majority age to submit to eXall1ination or treatment. What the supeli'isory people will do in this case, and what you may do if there is no higher authority available, is ask the person to waive the offer of treatment, and assume responsibility for anything that may happen as a result. If the individual refuses to submit to an examination or treatment, and refuses to acknowledge the demurral in writing, it is important to document the refusal. Enlist the help of any other divers or people around to do mis. Write down the infonnation about the dive, the person's name, date and time, and what leads you to suspect there may be a problem. Do this in front of the affected diver, and read the statement out loud to others present, asking the victim to sign it once again in front of the witness(es) present. If the person again refuses, ask the witness(es) to sign acknowledgments that you did indeed present the option for eXall1ination and treatment, and that you were refused more than once. If your suspicions prove correct and the diver is severely injured, your efforts to examine and treat the person will be part of the public record of the event.

[btl


Neurological Assessment The two most serious diving maladies: Des and AGE, affect the nervous system and brain. nless uley present dramatically, through unconsciousness or life~ threatening signs, they are often subtle, symptomatic ;iii events that are diffIcult to assess and distinguish from each other. Divers may feel unusually tired after a relatively easy dive. Someone may opt out of a repetitive dive because of "not feeling like it," ulough previously very enthusiastic. Adiver may have a severe headache that could easily be a sinus squeeze, or shoulder pain ~ that can just as likely be from lifting heavy diving equipment as from anything else. At other times, the events of a dive will drive the need to make a more ulorough examination of a diver or buddy pair, although no apparent problems exist. NAUl Worldwide recommends examining all divers who have made an emergency ascent of any type, whether individual (swimming or buoyant), or while sharing air by any method. Divers who have exceeded the planned dive profile (too deep or too long, especially on a repetitive dive), omitted mandatory decompression or who have slllfaced rapidly due to poor buoyancy control, will benefit from repeated neurological assessment to reveal a developing malady (figure 9-5). Other divers may have aborted a dive because they were not feeling well, or developed a block during a multi-level dive, or had difficulty equaliZing pressure after entry. These divers, too, may benefit from an examination. Learning to perfonn a competent, concise neurological examination for the effects of DCS or AGE can be a course in itself (figure 9-6). !fyou are involved in an ASRD program, it is likely that training in this aspect of diver first aid and rescue is included. Whether it is or not, however, it is important to understand the basic concepts of the examination for this course.

m

2.

3.

4.

5.

6.

7.

8.

that you have received pernlission to pelfornl it, the date time, diver's name, and anything relevant that justify perfonning the examination such as dive profile or circumstances, observed signs or reported symptoms. Make the diver comfortable, and respect privacy. Position the diver to avoid the effects of motion if on a moving platfolln, and out of the wind and weaUler if possible. Use humor and professionalism to put the diver at ease, without making light of Ule situation. Be Sj tematic. Begin your exalltination at one end of the body, usually Ule head, and work your way towards the other end. Record observations as you progress, or better, have someone available to document findings for you. Obselve and question carefully. Make sure that findings are not a chronic conditions of the diver. Without a baseline of Ule diver's condition, you have no way of knowing if your observations are related to the diving event. Some people are hearing impaired before diving, or may have a limp or pronounced weakness in one limb. Do not expect to find anything wrong, or not to. Deal strictly with what you discover without speculation. Seek to I1Ile out possibilities. Make the diver understand that one examination is only the beginning of the process that should include at least one re-examination after an interval of about 20 minutes, and monitoring in the interim. Under most circumstances, a diver strongly suspected of having any diving injury should be discouraged from making a repetitive dive. If one diver in a buddy team may be a victim, so may the other diver.

•

BASIC PRINCIPLES OF NEUROLOGICAL ASSESSMENT 1. Record your examination, including the facts

PERFORMING THE EXAM I. Check the Vitals: Respiration, Pulse A. Respiration 1. Ilate: Nonnal about 12 - 20

117


a. Rapid >25/minule b. Slow < 10 /minute 2. Depth a. Deep b. Shallow c. Lopsided' 3. Quality a. Difficult, labored' b. Wheezing, gurgling' c. Gasping, choking' d. Easy B. Pulse 1. Rate: Nonnal for most adults 60-so beats/minute in adults. Women's pulses tend to be faster. 2. Quality a. Slower: <60 beats/minute (present in endurance athletes) b. Moderately increased >SO to 100 c. Quick, rapid, running> 100 to 140+' II. Observe the patient: Obvious signs of injury/pain A. Bleeding 1. From the mouth, ears' 2. Wounds B. Favoring one side or the other C. Eye movement 1. Pupils equal a. One pupil dilated' b. Equally reactive to light 2. Eye movement and focus a. Equal b. Unequal' III. Check the "S's": Senses, Sensation, Strength, Sensibility A. The Five Senses 1. Hearing: acuity, symmetry 2. Sight: acuity, symmetry, sensitivity to light 3. Tactile 4. Smell (Question if there are any unusual smells present.) 5. Taste (Ask if there are any unusual tastes in the mouth.) B. Sensation: Definite or Progressive Lateral or

118

Quadrantial Numbness or l1ngling' 1. Check for feeling: up and down tile limbs, torso, scalp 2. Check the face 3. Check the palms, soles of the feet C. Strength: Marked Lateral or Quadrantial Weakness' \. Grip 2. Biceps 3. Quadriceps/Hamstring 4. Ankles 5. Toes D. Sensibility I. Temperature perception 2. Facial Movement: laughter 3. Consciousness: through conversation a. Identity, place, time, events: dive profile, dive history b. Emotional state IV. Check Gait and Balance (Difficult to perform on a moving platformlboat) A. Symmetrical movement 1. Difficulty walking a slraight line 2. Consider circumstanoes B. Asymmetrical movement' 1. Limping: is it usual? 2. Dragging one foot' 3. Pronounced difficulty walking' 4. Unable to stand straight or maintain nonnal posture or position' C. Balance Tests ("Drunk check") 1. Touch the nose with the .eyes closed while leaning back •• 2. Walk heel to toe, turn sharply, return The presence of one or more of the marked items (*) indicators is generally sufficient reason to begin to treal the victim immediately with oxygen, and depending on the situation, to activate tile emergency medical system to arrange for professional assessment and treatment. Oxygen should be applied for as long as the supply lasts and at as high an inspired partial pressure as can be istered with the eqUipment on hand. If there is any improvement after about 15 minutes


on Qi,ygen, it is probable that your suspicions are correct. If you have not already done so, activate the EMS. If there is no improvement, re-evaluate the diver to see if tllere has been any change in condition from the earlier examination. If not, it is likely that the diver can cease breathing the oxygen, however, it cannot hurt to continue. Given the events leading to the initial suspicions, making a repetitive dive is probably ill-advised even if only contraindicated by unusual levels of stress. Symptoms of decompression sickness can appear up to 24, and in extreme cases, 48 hours after diving, tllOugh they generally occur within four to six hours of leaVing the water. Symptoms of lung overexpansion injuries, and especially AGE usually present immediately upon surfacing. Your certification as an SRD or ASRD does not guarantee you immunity from any diving problem, injury or particular malady. Should you suspect that you may be injured, deal immediately with the problem. Don't take "No" for an answer, even if from yourself. The downside of a so-called "false alaml" is using some time, and Il€rhaps incurring some expense in requesting professional evaluation. The drawbacks of not doing so can be catL~trophic .

...

118

CHAPTER

Treatment 01 Diving Maladies


LEARNING GOALS In this chapter you will: 1. Be introduced to the use of oxygen for first aid treatment of diving injuries. 2. Understand why o''Ygen is beneficial in the first aid treatment of diving injuries. 3. Learn the precautions that apply when handling pure oxygen. 4. Be introduced to the different types of oxygen delivery systems. 5. Be introduced to the use of recompression chambers in the treatment of diving injuries. 6. Read about a t)lJical treatment of a diving injury.

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122

There is no difference in theory or practice of immediate emergency care when confronted witil a diver believed to be injured by lung overexpansion or by Des. In either case, the recommended treatment is exactly the same: swift istration of pure oxygen to the victim at as high an inspired partial pressure as can be mallltained for as long as it takes to get the victim to more qualified emergency medical care providers and to a recompression faCility. Because it is the premier treatment for diving maladies, all NAUl Worldwide certified rescue divers should also be trained in the field istration of oxygen. This training is available from a wide variet)' of sources, including skilled NAUI Worldwide , other rescue and emergency medical training agencies. In addition, we recommend that ample O2 and a trained provider be readily available at every diving event. IVhether a SRD or ASRD needs to invest in a personal O2 delivery system will depend upon their level of diving involvement, and the kind of diving in which they generally participate. All dive rescuers, however, should be familiar with the emergency eqUipment on hand at any dive site, including available o''Ygen istration equipment and supply, in case a mishap does occur. No matter what the diving venue, be it local or an exotic destination, most diving operators are glad to provide a qualified individual lvitil a basic orientation to the emergency eqUipment present. Taking the time to gain

this knowledge in advance can save critical minutes in case of an accident. Gaining familiarity with available emergency equipment, and ensuring that appropriate oxygen istration equipment and supply is readily available are also important responsibilities of a diving leader. Finally, any diver who chooses to dive in an area where oxygen is unobtainable, or there is problematic access to appropriate treatment for a diving malady is assuming a significant additional risk that is probably lII1necessary. Oxygen should be available everywhere organized diving takes place, and as the standard of care for diving maladies, should be included in every excursion plan.

WHY OXYGEN? Although oxygen is only one component in tile air we breathe, O2 is the only gas in tile mix tilat is used in the body. Nitrogen and tile other inert gases in air for the most part serve only to dilute the oxygen to tolerable levels, and to make up the volume necessary to maintain lung inflation. Only oxygen enables critical metabolic processes to occur, notably the utilization of glucose and glycogen to "power" the oells of the body. Without ample 0,.' cells remain lvithout nourishment, and in short

AGlIHE 111-1. CAIlIfUI. OMNG PRAl:Tm, INCI.lIIIlNG PlANNINlHIlR, AND MAKING ASAf£1Y S11JP OF 3-5 MIMIlIS AT OIl'lH OF 5METBlS (15 fIfI), CAN HHP AVlIfl) DCS.

Chapter 1O· Treatment of Diving Maladies

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FIGURE 10·2. UTILIZING O2 DURING ADIVING RESCUE WILL HElP THE VICTIM'S CHANCES DF SURVIVAL IF ADIVING MALADY IS INVOlliED. PRDPER DzHANDLING AND PRECAUTIDNS MUST BE EMPLDYED AT ALL TIMES.

the most crucial collection of all the body's cells, the brain. Yet we have also learned tllat inspiring a high partial pressure of oxygen (approaching 1.6 ATA) can cause toxic reactions. Why, then, is oxygen tlle first aid treatment of choice for diving maladies? The answer lies within the nature of the injuries suffered ~L\ a result of a diving illness (Figure 10- I) We have learned that the worst outcome of a lung overexpansion injUly is an arterial gas embolus, a bubble of air that lodges in the blood vessels supplying the brain, irritating the area and blocking downstream blood flow. Since no new oxygen is delivered past the blockage, cell death is inevitable. Actually, unless the plug is in such a critical location that it rapidly causes the victim's death, a terrible but distinct possibility, there is likely some blood flow past the injured site. Unfortunately, the amount of oxygen carried to the cells on the other side of the blockage is generally insufficient to prevent cell damage without tlle enrichment of a higher inspired partial pressure of oxygen tban can be obtained from normal air. To oversimplify tlle complex process of intravascular gas dynamics and metabolism, the higher partial pressure of oxygen delivered to the site helps to remove nitrogen from the area by pushing it out and replacing

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, FIGURE 1D·3. THE SAME REQUIREMENTS FOR CLEANLINESS AND CAREFUL HANDLING APPLY TO THIS CYliNDER AS TO THE SMALLER ONE THAT INDIVIDUAL DIVERS MAY ELECT TO CARRY.

c::::L

c:=

tlhe offending gas with itself The oxygen also nourishes the damaged tissue at the site, and whatever blood tlut flows past the site carries a higher oxygen load as well, helping to relieve ischemia. The same reasons pertain to decompression sickness. In this case, oxygen is to some extent even more ameliorative since the bubble problem is more pervasive throughout the body. As a result, mild cases of Des sometimes seem to be "cured" by relatively brief periods of breathing pure oxygen. (The operative words here are seem and cured.) In addition, diving maladies are ultimately tissue injuries. All such injuries lead to some degree of shock, the body's natural reaction to tissue damage. Blood pressure tends to drop, and as a result, there is less nourishment delivered to the cells. Increasing the amount of oxygen available helps offset the damage caused by injury decreased perfusion

HANDLING OXYGEN Regardless of the type of O2 istration equip- Ii"I""I ment or the amount of supply available, oxygen must be ~

123


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handled with care (Figure 10-2). Odorless, tasteless and colorless, often the only indication of an oxygen leak is a massive explosion and fire. Ironically, 0, is not flammable. It is, however, the critical component, along with heat, that enables other items to burn. It is so effective that some material introduced into an oxygenrich environment will literally burst into flame. As a result, all implements to be used around 0, should be "oxygen-clean;" the paraphernalia associated with oxygen storage and istration must be cleaned to be free of any residues of grease, oils or solvents (Figure 10-3). Petroleum products are also dangerous fire hazards around oxygen, this includes common items like petroleum jelly, sometimes improperly used instead of pure silicone grease to lubricate diving equipment. Even excessive accumulations of body oils, or items that store and discharge static electricity can be dangerous around 0,. Any impurities or contaminants in a flow of oxygen can potentially cause fire or even explosion. Some simple precautions for handling oX'j'gen include: l. Never shake, drop or mishandle oxygen cylinders. 2. Check contents by reading the gauge only, not by opening the cylinder. If tile gauge is not functioning, have the system checked and re-filled. 3. No smoking, or open flames around 0, equipment, especially whenever oxygen is being used. 4. Avoid all}1hing that may spark when working with oxygen. Items include devices such as unshielded electric pumps or wool blankets or clothing that may discharge static electricity.

TYPES OF O2 DELIVERY SYSTEMS The goal of 0, first aid for a diving malady is to provide an injured diver with as high a partial pressure of inspired oxygen as is available for as long as it takes to get the victim to professional care. Obviously then, the amount of oxygen necessary will depend on the diving event, and in particular, its pl'Oximity to professional care. This factor is harder to assess than one would think.

124

FIGURE 10-4. ADEMAND SYSTEM, SUCH AS THIS, PROVIDES THE HIGHEST PERCENTAGE OF INSPIRED OXYGEN TO A VICTIM IN THE FIELD BEING GIVEN FIRST AID.

Even if diving in the middle of a large city, the time it takes to transport a victim to a recompression facility is much more likely to be measured in hours than minutes. Another factor to consider is that diving is a shared activity. An event that could easily lead to injury, such ;LI an out of air emergency, can affect two divers. Having to choose which of two injured divers to help is not a welcome task. But having to share an oX'j'gen supply that may only offer momentary relief to one diver is equally unwelcome. Most professionally organized dives will have ample oxygen available in consideration of these contingencies. When diving in buddy pairs, however, or with a small group of friends, the amount of 0, to carry is more of a quandary. The amount of 0, is also dictated by the kind of delivery eqUipment that is available. i\3"a convenient rule of thumb, at least a 30 minute supply of oxygen should be available to aid an injured diver. There is now available a device that allows emergency oxygen to be "rebreathed." It uses the same principles employed in underwater rebreathing equipment and can significantly extend the duration of 0, supply. Common oxygen istration equipment for diving falls into two categories: constant flow and demand (Figure 10-4). Constant (free) flow systems are eitiler on/off or adjustable. The adjustable system is

Chapter 10- Treatment of Diving Maladies

Cylinder Type

Liter Volume

Time per Cylinder

C

200

40 minutes

Portable kits, generatty carried in pairs.

0

350

70 minutes

As above, and suitable for smalt dive groups if more than one

Application

delivery system is included.

E

626

125 minutes

As above, and suitable for smalt dive groups if more than one delivery system is included.

M

3000

App. 10 hrs.

Boat or trainin tacilit su

I.

TABLE 10·1.

equipped with a gauge that allows the flow to be regulated. This is much more desirable than an all or nothing valve. Consequently, although simple on/off kits and face masks are readily available for home use for a variety of medical conditions, these devices are not recommended for diving emergencies. Using an adjustable valve free flow system, a setting ~ of about five liters per minute istered to an iliiil,J injured diver will raise tlle partial pressure of inspired oxygen sufficiently to benefit the diver. But just how much benefit is obtained will depend greatly on the type of istration equipment available. TIle simplest device is a nasal cannula, plastic tubing equipped with two prongs that are inserted into the nostrils, and an elastic strap to secure the appliance to tlle head. Oxygen lIows into the tubing, and is inhaled through the nostrils along Witll ambient air. If the

fIGURE 10-5. APOCKET MASK ALLOWS ARESCUER TO MAINTAIN AN EffECTIVE SEAL MORE EASILY, AND PROVIDES A BARRIER TO POSSIBLE CONTAGION fROM THE VICTIM.

individual is a mouth breather, little oxygen is available. If the diver stops breathing as a result of the injuI)', no oxygen is delivered, unless tlle rescuer giving rescue breatlling or istering breaths dUring R is wearing tlle nasal cannula. Anasal cannula increases the percentage of oxygen inspired to about 28 to 36 percent by volume. If only a cannula is available, divers might consider using Nitrox (oxygen enriched air) if available as a plentiful substitute tllat will give about the smne inspired percentage, and Witll tile added adv;mtage of breathing on demand. APocket Mask (Figure 10-5) is a good alternative for istering O2 to a breathing or non-breathing victim since it makes a much tighter seal on the victim's face, covering both tile mouth and nose. In so doing, a higher partial pressure of oxygen is available to the injured diver In addition, there is a one-way valve which acts as a barrier between the rescuer and the victim, lessening the remote but ever-present possibility of disease transmission. Breaths can be istered through the mask, which also has an inlet point for constant flow 02. Using a Pocket Mask with a free flow system set at about 10 liters/minute, an injured diver can receive approXimately 75 to 80 percent pure 02. Note, however, tilat at the recommended flow rate, the table times above should be halved. Three other types of face mask are frequently used with a constant flow system: the standard, partial rebreather and non-rebreather masks. Standard face masks fit loosely over the wearer's face, and have open vents located to either side of tile nose pocket, resulting in a relatively poor seal. Under ideal conditions, and with a liter flow rate exceeding 10 per minute, a standard face mask delivers about 40 percent pure oxygen to a breathing victim. Because of the seal's problems, these

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FIGURE 16-8. NEVER HESITATE TO GIVE OXYGEN IF ADIVING MAlADY IS SUSPECTED.

masks are considerably less effective under windy conditions, making them considerably less useful for most diving emergencies. The partial rebreather is similar to a standard face mask with the addition of a reservoir bag that must be partially filled prior to using the mask on the victim. The rebreather mask allows expired air to mix with the incoming oxygen, necessitating a 10 to 12 liter per minute flow rate to avoid carbon dioxide build-up within the mask. Under field conditions, a partial rebreather mask can supply a victim up to 50 percent inspired oxygen at ambient pressure. The non-rebreather mask also has a reservoir bag, but like tlle Pocket Mask, it is eqUipped with a one-way exhaust valve. This raises the percentage of oxygen given to a breatlling victim to about tlle same level as tlle Pocket Mask, around 75 percent. APocket Mask or a rebreather are preferred choices for istering oxygen from a free flow system to the victim of a diVing malady. Unlike constant flow systems, where gas is flOWing Ii"'l"""I at all times, a demand oxygen system is similar to a ~ scuba system: on breathing demand, the second stage delivers pure oxygen to the victim at ambient atmospheric pressure. Since the oxygen is given in a more

128

regulated fashion, a smaller supply will last considerably longer. Ademand system also gives a victim as much as 100 percent pure oxygen, the most desirable outcome for diving first aid - so long as the victim is breathing. In fact, there is a strong posSibility that the victim of a diving malady will not be breathing. [n this case, even a demand s}~tem will not provide any real aid to tlle person. Under these circumstances, a Pocket Mask and constant flow system used while istering rescue breathing or R is the best choice available to most rescuers. NAUIlVoridwide takes the position that no SRD or ASRD or any other diver is to employ techniques or equipment for which they are not specifically trained under any circumstances regardless of its availability at an accident site. Certified medical personnel deal with the problem of a non-breathing victim that requires oxygen by using a demand oxygen system equipped with a positive pressure delivery valve. These valves, similar to the familiar purge valve of scuba regulator are set to limit the pressure delivered into the victim so as to avoid the vel)' real possibility of lung damage that can result from overinflation. These systems are also best used with intubation, an inv~Llive medical procedure that places a tube into the victim's airway to insure that oxygen is delivered to the lungs as opposed to the stomach. Positive pressure O2 istration equipment and associated intubation are far beyond the usual definitions of first aid; however, many diving events have professional medical personnel as partiCipants. If the equipment were available in these instances, it could be used to save a life. At the sanle time, positive pressure systems that are misused could have just the opposite effect.

RECOMPRESSION THERAPY: THE NECESSARY SECOND STEP More often than not, a seriously injured diver will reqUire life that includes rescue breathing, cardiopulmonary resuscitation or both during evacuation regardless of the swift istration of oxygen.

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Chapter 10- Treatment of Diving Maladies

ro

For all the good that oxygen can do for a diving malady, whatever type it may be, it would be a fatal error to conclude that oxygen is in itself a cure for these problems. Oxygen is merely the beginning first aid treatment, and relatively easy to ister in the field. Unfortunately, there is no cure for diving maladies, only relief from the worst symptoms and the hope for no residual effects. This hope is only a reasonable expectation with rapid access to recompression tilerapy, and often, repeated therapy sessions (Figure 10-7). In its simplest form, recompression therapy for diving is the application of increased atmospheric pressure to an injured diver with the goal being to relieve symptoms by forcing tile offending nitrogen back into solution in bodily fluid and tissue in the case of DCS and AGE, and to as much as possible reduce tile size of any bubbles that remain to prevent further tissue damage. Concurrently, the increased partial pressure of oxygen in the hyperbaric environment helps to relieve the ill effects of oxygen starvation suffered by tile cells in the case of (primarily) AGE and DCS. Besides the application of increased direct pressure, recompression therapy also includes carefully controlled and monitored periods of breathing pure oxygen while in the pressure vessel. During these treatments, pure O2 is istered at the elevated atmospheric pressure within the chanlber to help f1ush residual nitrogen gas out of the tissues. Recompression therapy is a complex, equipmentintensive process perfonned by specially trained technicians under medical supervision. Because of the highly specialized nature of the aid and the apparatus itself, it is not readily available at most medical facilities however well-eqUipped and staffed they may otherwise be. Given the fact that permanent disability and death can easily result from an untreated diving malady, knOWing how to get an injured victim to appropriate care is crucial information for rescuers. ASRDs and SRDs should be familiar with the location and referral procedures for the recompression facilities in the areas where they dive if they are to be effective rescuers. The Divers Alert Network (DAN) maintains a listing of recompression facilities worldWide, and this information is also invariably available from local diving leaders as well.

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AGURE 111-7. PROFESSIONAl MEDICAL ASSESSMENT PRIOR TO RECOMPRESSION THERAPY IS THE NECESSARY SECONO STEP FIIR ADIVER SUFfERING FROM ADIVING MAlAOY

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A"Typical" Multi-lock Multi-Place Recompression Chamber Timely recompression is the cmcial detemlining factor in survival and in the chance of permanent injury from a diving malady. Though no recompression chambel~ (Figure 10-8) can be called typical, there are certain minimum standards tilat make individual facilities more or less suitable to treat diving maladies. These standards have developed over time, and represent the benefits of experience. At the same time, if a "perfect" chrunber is unavailable, and recompression is indicated for a seriously injured dive1; do not delay care. Mono-place chrullbers, even portable facilities suitahle for single dive1~, can save lives. Treatment decisions like these belong to responding emergency medical care profesSionals. Chambers most suitable for treating divers recognize that diving is a shared activity. As such, they have the capaCity to treat more than one injured person at a time. They are also of relatively high pressure capaCity, usually capable of recompression to beyond 6 ata. This figure represents the "depth" at which AGE-suspected patients are begun on treatment under most widely accepted medial protocols. In addition to the capaCity to treat more than one victim (multi-place), 1l1ultilock chambers have the capability of itting and

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External Depth Gauges - Inner Lock Oxygen Analyzer Bunk External Depth Gauges - Outer Lock

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Communications Sound Powered Phones

A&URE 10·8. BECOMPBESSION CHAM8E8

removing medical staff and other personnel to the treatment vessel while it remains under pressure. This significantly enhances the utility of the treatment facility, and the safety of working personnel. By utilizing a design that includes at least two separate pressurization systems with interlocking hatchways and ages, personnel can enter and leave the main treatment area without having to "surface" a victim in the midst of treatment. Also, staff need not suffer through long periods of compression and decompression to serve as treatment aides. They are not "locked in for the duration." These chambers are also equipped with various other features, like medical "locks" where drugs, food and water can be ed through the pressure vessel into the treatment area without a long process of compression since the med-Iock has small volume, and with good radio communications facilities to allow staff and patients under pressure to clearly converse with those outside the chamber.

128

Other desirable features include built-in breathing systems (BIBS) which allow exterior supplied therapy O2 to be istered within the chamber without significantly increasing the risk of fire that storing additional large quantities of ol-'}'gen within the hyperbaric environment would represent. In the U.S., most multi-place recompression facilities are equipped with automatic fire suppression mechanisms, since this is one of the principal d;Ulgers posed by the high pressure e!1vironmenl. Achamber treatment represents a cOnsiderable investment in time, personnel and mechanical resources. Besides the injured diver, there is usually a physician or emergency medical technician and one or more other "tenders" inside the faCility. Outside, there are at least two other chamber operating technicians monitoring the levels of gas within the chamber including paJ1iai pressures of ambient nitrogen, oxygen and carbon dioxide, and the exposure times of interior personnel. The fact that tenders and medical personnel are not scuba diving does not relieve them from the same

Chapter 10- Treatment 01 Diving Maladies

KtJ Without risks that face from the effects of pressure. careful monitoring of staff profiles, they too can divers

become victims of a diving malady without ever entering the water. As one can imagine, mobilizing the staff and maintaining tile facility in good operating condition is an expensil'e process. As a result, recompression treatment can be quite costly. Most medical coverage does not include this cost. Supplementary insurance, such as available from diving-related organizations, notably DAN, is highly recommended for active divers. This is especially true in light of tile fact that up to 80 percent of divers who suffer a diving malady did everytlling right.

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I

CHAPTER

Surtace Rescue


LEARNING GOALS In this chapter you will: I. Learn to assess the risk to yourself while considering the need to perfoml a surface rescue of another diver in distress. 2. Understand the priorities of surface rescue. 3. Review in-water rescue breatlling procedures and techniques. 4. Leam what to do when confronted witll a panicked diver at tlle surface. 5. Review transporting, removing, and cal1)'ing an injured diver. Unfortunately, most diving incidents or accidents do nbt occur directly at the dive's exit point. This fact makes s~lface assistance and rescue skills essential for any resdie diver. Surface rescue skills encom a wide range of profiaiencies from the ability to tow a seriously injured diver and perfonll in-water rescue breathing, to the techniques for properly removing injured or distressed divers from the water onto a boat, platfoml or beach.

ASSESSING RISK

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32

Only the most naive person would believe that surface rescue is less dangerous than undel\vater rescue, or t1Jat a diving incident or accident is over because the participants are on the surface. Professionals know that tllere is as much chance of injury or drowning to any r~cue qiver as there is to any victim at any point during a rescue. Act accordingly. Consider your own safety througHout any rescue (figure 11-4). No water rescue is ever completed until there is no longer any risk of dlolVtling -and tllat means that all persons are safely ovt of the water and receiving appropriate aid. All of tlle same risks of undel\vater rescue are included in the surface component of aiding another diver. TIlese include the possibility of drol11ling, the increased risk of decompression sickness from strenuous exercise (if the rescuer has been scuba diving), and physical injury that can include eve1)1hing from cuts and bruises to

pemlanent musculoskeletal damage, even a heart attack. For these reasons, careful assessment of tlle siruation and your ability to intervene must be made. Only you lvill know if your physical ability :md training are able to meet the challenges presented by a specific situation. Therefore, only you can make tlle considered decision to intervene based on careful weighting of those ingredients, your chances of success and other variables like the additional aid available represented by other divers and bystanders.

THE APPROACH TIle moments you take to plan your approach to a victim on the surface lvill often determine the success of the eventual outcome. Deciding the correct action will depend on tlle condition of the diver you are aiding. Is the diver conscious, unconscious, obviously ill or injured, relatively calm, agitated or completely out of control? Any gradation of the preceding is possible, and any victim's condition can change rapidly. Consider someone who sulfaces quickly after an out of air emergency, gives the "OKAY" signal, then immediately loses consciousness. Or a buddy who becomes unduly stressed or aspirates a drop of water and begins to choke while swimming back to tlle boat. Both situations will require intervention, but the latter is more dangerous to tlle res-

RGURE 11·1. GETIlNG AN INJURED DIVER TO THE SURFACE IS ONLY THE BEGINNING.

Chapter 11- Surtace Rescue

RGURE 11·2. ACAUTIOUS APPROACH IS THE BEGINNING OF A SUCCESSFUL RESULI

FIGURE 11·3. IF POSSIBLE, USE ADEVICE TO EXTEND YOUR DIS· TANCE FROM ADISTRESSED DIVER TO MORE EFFI· CIENTLY ASSIST BE READY TO RElEASE INSTANTlY, IF NECESSARt

SURFACE RESCUE PRIORITIES

help. Tell the diver to put more ail' into tile BC, and demonstrate that you are doing the same. It may be possible to lead the diver back to tile exit point by simply remaining at a distance and continuing to swim towards the exit while talking to the diver. This technique can also be effective with a panicked, but buoyant diver attempting to get at you on tile surface. Continue to S\vim away from the person and towards the exit (figure 11-3).

Ensure Buoyancy

Ensure Breathing

The number one issue in surface rescues is to ensure that the victim remains on the surface (figure 11-1). Under most circumstances, this means relieVing the victim and then yourself of ballast. Under the best conditions, the victims will do this themselves. Since "best conditions" rarely pertain to real-life problems, it is much more likely that tile rescuer will have to do this for tile person in distress. If the victim is conscious, do not immediately approach the diver. Getting within the diver's range of action can be dangerous to you (figure 11-2). Instead, attract the diver's attention, and calmly and forcefully order the individual to "Drop (your) weights!" several times until it becomes c1ealloto you tilat it has happened, or that it is not going to happen. In the latter situation, if tile diver is apparently floating well, not struggling to maintain position on the surface, maintain your distance and speak to the victim calmly. Ask what the problem is, and what you can do to

An unconscious diver face down at the surface will drown as surely as one at depth if water is aspirated. A non-breathing victim will suffocate as qUickly on the surface, at depth, or at home in bed. Once breathing stops, no matter where, when or why, death is imminent. As a rescue diver, after insuring tilat the victim will remain on the surface, restoring or aiding breathing is tile next priority. New techniques and protocols for aiding non-breathing victims of drowning or tilose whose breathing ceases under any circumstances are constantly being promulgated and tested. Anecdotal evidence aside, many innovative techniques, procedures or practices remain largely unrecognized by medical authorities. You may learn of procedures that would seem intuitively to be better than those that are more accepted and practiced. Despite the intuition, unless you have perfected the technique and are certified in its use, and the technique is recognized as

cuer because tile conscious diver may do anything -including hann the person(s) attempting to render aid or effect a rescue.

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effective by appropriate authorities, your decision to employ it is fraught with risk of personal liability, in litigious societies, no matter what the outcome of the action. Protocols for in-water rescue breathing are numerous. The number of breaths per minute recommended varies, as do the proposed techniques one should employ. In any event, NAUI Worldwide recommends that rescue divers choose an acceptable method from the ones that follow, and become completely adept in practice. Note that practice must include using the chosen technique while towing under the stressful conditions likely to attend a surface rescue. While dry-land practice will foster efficient technique, it is no substitute for simulated practice in the water. This is especially true for performing rescue breathing while towing. Whatever technique you choose, you must be able to maintain it consistently for the time necessary to retulll the victim to the exit point and into the hanel, of emergency medical personnel whenever possible (figure 11-4). It will be difficult to detennine under some conditions whether or not rescue breathing is required. If in doubt, give breaths. Unlike unnecessarily perfolllling cardiopulmonary resuscitation, you can do no harm to a victim by providing rescue breathing so long as you perform the technique properly. If your chosen method requires equipment, such as a Pocket Mask* or face shield, it is incumbent upon you to carry one on every dive if you are to be an effective rescuer should the occasion arise. Consider this when choosing one method over another, or become qualified in more than one technique.

~ MOUTH TO MOUTH RESCUE BREATHING Effective mouth to mouth rescue breathing requires that the victim and rescuer maintain stable (figure 11-5). The rescuer should link the left arm under the victim's left arm. Remove the victim's mask and snorkel, if any. If the rescuer's mask does not inhibit getting close enough to ister breatllS, it may be left in place. Othef\vise, it too should be removed. (Vision impaired rescuers who

34

fIGURE 114. MAINTAINING ANON·BREATHING OlVER AT THE SUR· fACE AND EffECTING ARESCUE THAT REMOVES BOTH THE RESCUER AND OlVER SAfELY fROM THE WATER IS THE GOAL have corrective lenses mounted in tlleir diving masks should insure that the masks tlley choose allow tllem to perfOllll effectively if discarding the mask is not an option.) Pinch the victim's nose closed lvith the right hand, and open tlle aif\vay by extending the head backward. Insure that you neither sink the victim, nor hyper extend and injure the neck. Roll the victim's head towards you, and make a good seal over the victim's lips. Give two deliberate breaths, observing the chest's movement .to gauge effect. In rough water; this will be difficult to s€e. In fact, it may be necessary to time breaths to coincide with the moments when waves wash over the rescuer's and victim's heads. By maintaining the mouth to mouth during immersions, the rescuer helps insure that the victim's aif\vay remains uncompromised by water. Maintain a rate of 2deliberate breaths every J0 seconds, or I breath every five seconds while towing the victim back to the dive's exit point. The choice of rhythm will depend on your ability to persevere longer with either. If done properly, progress towards the boat

Chapter 11· Surlace Rescue

AGURE 11-5. TO WORK EfFECTIVElY, THE RESCUER MUST BE ABlf TO MAINTAIN AN EFf£CTIVE SEAL, ENSURING THAT BREATHS ARE ACTUAllY BBNG RE£BVEO.

or beach will be not be hindered by having to ister rescue breathing while towing. [n any circumstance, it is better to continue forward slowly at a steady pace while providing necessary breathing aid, than it is to exhaust oneself quickly and ultimately fail to complete the tow (figure 11-6).

MOUTH TO SNORKEL RESCUE BREATHING This is a much diJTerent technique to master than mouth to mouth rescue breathing. It has significant advantages over other techniques under some conditions. By using a snorkel, chance of direct transmission of any blood-bome patllogen is reduced. The significant drawback of mouth to snorkel breathing is the difficulty of establishing an effective seal under the conditions of a rescue. Only dedicated, frequent practice will master this technique. Unlike mouth to mouth positioning, with mouth to snorkel breathing, the rescuer is behind the victim. After tlle snorkel is completely free of water, insert the mouthpiece into the victim's mouth between the fingers of the rescuer's hand that is ing the victim's head. The fingers are used to seal the mouthpiece into the victim's mouth, and if dexterous enough, to pinch

AGURE l1·B. POSITIONING YOURSElF PROPERLY, CONSIDERING THE CONDITIONS AND THE DISTANCE, AVAIlABILITY OF OTHER ASSISTANCE AND OTHER VARIABLES WILL lfAD TO SUCCESS. THINK, THEN ACT.

off the nose to effect the seaL Obviously, wearing mittens makes this one-handed technique impossible (figure 11-7). A1tematively, the victims mask can be left in place to seal the nose. In any event, the chin is held stable by the encircling arm's hand that is effecting the seaL The rescuer gives two full, deliberate breaths, just as in mouth to mouth. And just as in mouth to mouth, the effect of tlle breaths may be difficult to discem. In calm water it may be possible for the rescuer to feel the victim's expired air coming from the tip of the snorkel against the cheek. Using the snorkel introduces another element of difficulty for the rescuer since there is an amount of dead air space within the tube, and this space may become laden with carbon dioxide from the victim's exhalation. There is little that can be done to avoid this build-up of camon dioxide. Rough water may also force tlle rescuer to secure the free end of the snorkel between breaths. Hard "J' shaped snorkels are much more difficult to use than flexible ended ones, and therefore, not recommended. Asnorkel with a purge valve must have its surge valve sealed and sometimes is just inappropriate because it will release air rather than deliver it to the victim.


FIGURE 11-7. MOUTH·TO·SNORKEl BREATHING Will ONLY WORK IN THE FIElD IF THE RESCUER PRACTICES THE TECHNIQUE FREQUENTLY.

Despite the drawbacks noted, the use of a snorkel to ister rescue breathing can be effective. The technique positions the rescuer behind Ole victim, as opposed to the alongside placement in mouth to mouth, making towing easier. As with mouth to mouth, the rate of breaths can be either 2every 10 seconds, or I breath evelY five seconds. It is best for rescuers to practice diligently with the ratio that they find most comfortable and that will best enable them to perform for the longest time. Once a technique is chosen as preferred, practice it regularly! (figure 11-8) If apparatus is required, practice an altemate technique in case the device is lost, damaged or forgotten.

spend practicing using the device will make a big difference in your effectiveness with it (figure 11-8). Primarily used in conjunction with R and choking incidents on land, Pocket Masks have a flexible plastic skirt that will effect a seal on virtually any face. They are also equipped with a one way valve Olat prevents any material that may be expelled from Ole victim from coming into with the rescuer. It is important that the rescuer monitor the intelior of the mask to detemline that it remains clear of such material. As WiOl mouOl to snorkel rescue breathing, the barrier aspect of a Pocket Mask may increase the willingness of rescuers to render Olis crucial selvice to victims \vith whom 01ey are unfrulliliar. 111is in itself makes a Pocket Mask a good choice for inclusion in a rescuer's BC pocket. The technique for using the mask is generally a modification of the chin lift method for extending the aitway. Rescuers can hold the head steady and maintain the mask in position while istering breatlls throughout a tow. Working from alongside or behind the victim, tlle rescuer stays beneath tlle victim, ing the victim's head on the rescuer's chest, or in the crook of either aml. Witll the mask covering the nose and mouth, there is no need to close off the nose, nor protect the airway from water incursion so long as the seal is kept. Although it is easy to achieve a water-tight seal quickly, keeping the mask in position while giving breaths and towing is still a series of maneuvers that will require endurance. No rescue breaOling technique can be perfected and useful for an extended period in the field without extensive practice on a regul.ar basis. "

DEALING WITH PANIC AT THE SURFACE

~ POCKET MASK RESCUE BREATHING Pocket Masks are an excellent alternative for rescue breathing in that they can quickly and easily make an effective water tight seal over a victim's nose and mouth under almost any conditions. However. like any other technique, the amount and quality of the time you

38

If the diver is apparently p,Ulicked and unable to maintain position at the surface, and you feel that your intervention is necessary to prevent a drowning, realize that in doing so you are risking your own drowning and injury. Apanicked diver at the surface will do anything to escape the difficulty, even if the ultimate effect is to prolong or worsen the situation.

Chapter 11· Surface Rescue

fiGURE 11·8. THIS TECHNIQUE WORKS WELL-SO LONG AS YOU HAVE THE MASK WITH YOU ON EVERY DIVE!

Panic precludes rational thought or planned action. Therefore, plan YOllf actions especially carefully! (figure 11-9) Though every situation is unique, the panicked diver will almost always attack YOllf head and neck since this is the part of you above the water. Unfortunately, these areas are extremely vulnerable to injUly Eyes, ears, nose, mouth and throat provide convenient handholds to a panicked person. Aface mask, snorkel or regulator provide no real protection since they are easily stripped, but by keeping a tight hold on YOllf mask and regulator you may be able to protect delicate areas and keep breathing in the event that the victim begins to push you dOWllunderwater. Despite this, it is far better to avoid getting caught in the first place (figure I1-10). If you can get to the victim from behind, or approach the victim from beneath to drop tile person's ballast, do so. It will only take seconds in most cases. Once the weights are gone, it is unlikely that the person will sink, and wailing out the panic from a safe distance will relieve the situation with little additional risk to yourself. If you are unfortunately caught, you will need to be prepared to act swiftly and forcefully to release yourself from the person.

ESCAPE If you are caught, you will need to insure that you can breathe. In most situations, just tuck YOllf head

fIGURE 11·9. UNLESS ADIVER RESPONDS WITH AN "OK" ASSUME HE OR SHE WILL PANIC If APPROACHED.

to keep YOllf regulator in place (figure 11-12). Escape is usually the result of a swift, decisive and forceful effort to release yourself. This will often happen most easily by dropping quickly beneath the surface while acting strongly against the victim's grip on you. It is also ~ unlikely that a drowning diver will pursue you underwater (figure 11-13). Much as one may hate to it it, you are in a life and death struggle if captured by a panicked diver. As a resul~ the usual reluctance of a rational person to do violence to another is best suspended until you are once again sure of your 01111 sulVival. This may mean striking the victim, or othel\vise causing the person pain by twisting fingers or whatever it may take to break free. Once free, you have another chance of aiding the person. Until you are free, you are both in danger of drowning.

m

DEFENSE An irrational distressed diver at the surface is very likely to attack anyone lvithin reach. If no one is close enough, then the panicked diver will try to get to the closest person available. This is most likely to be the rescuer responding to the person's distress. It is essential to keep the victim away from you for both YOllf own safety, and to be able to aid the panicked person. Maintain position facing the person, and lay back keeping your legs extended towards tile victim (figure 11·11). No matter what the condition of YOllf upper

131


ACUilE 11·1D. APANICKBJ DIVER AT THE SURFACE IS OANCBlOUS -JlROTECT YOURSELf mOM HARM.

body, your leg; will be stronger than your arms. More importantly, your leg; are invariably longer than anyone's reach. As a result, you can more easily fend off any lunging attacks with your legs than with your amlS and hands, and you will better protect your face and head from the attacker's grip. It could easily be a fatal error, however, to underestimate tlle speed and deternlination with which a distressed diver can circumvent your defenses and gain hold. If not, as previously stated, do whatever you have to do to escape.

ASSESSING THE PROBLEM In the water, making an astute diagnosis of the nature of the problem is less important than resolving the immediate difficulty and remOVing the person from the water. Even so, the easiest and best way to learn what may be wrong with someone is to ask as long as that is an option. This obviously presumes consciousness and coherence on the victim's part. If either is missing, emergency medical assistance is required. Do not delay calling for it: if another diver is available, have the person relay the message to whoever has access to communications tllat there is a life threatening emergency in progress, and that evacuation is necessary. If the diver is apparently unconscious at the surface,

ACURE 11·11. MAINTAIN YOUR DISTANCE AND BE IN AREAOHO· ESCAPE POSITION BEfORE YOU APPROACH ACONSCIOUS DIVER IN TROUBLE.

approach cautiously to insure your own safety. Roll the diver over if found face down, and attempt to get a response verbally and physically by tapping and shaking in the same way one would upon discovering an unconscious victim ashore. If there is no response, take appropriate action including initiating rescue breathing if necessary, and begin towing the victim to assistance.

EQUIPMENT CONSIDERATIONS Along tow back to a boat or beach \vith a disabled diver while haVing to ister rescue breathing is an physical challenge. Under most circumstances, stripping a buoyant victim of the cylinder and Be is a good idea. However, if the diver is discovered unconscious at the surface or becomes unconscious in the course of the rescue, medical and legal authorities'ivilllikely pursue an investigation that will include examining the victim's eqUipment If you do decide to strip the diver of gear, consider insUring its buoyancy to enable easier recovery later if there is no one available to aid you at tlle moment. If diving in a group, detail one person to take charge of recovering the eqUipment while the distressed diver is being transported back to the exit. Instruct this individual to make no modifications in the rig, simply to bring it back and surrender it to you or appropriate authorities.

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Chapter 11- Surface Rescue

fiGURE 11-12. TUCK YOUR CHIN, DROP QUICKLY AND PUSH UP ON THE VICTIMS ELBOWS. THEN SWIM AWAY..

TOWING If the diver's mask is empty of water, leave it in place to keep water from entering the nose. If it is full, remove it -rescue breathing will probably be necessary. Towing or assisting an injured, tired or unconscious diver is an important skill learned in every basic scuba or snorkeling certification course. Perlorming these skills under the stressful necessity of aiding someone in real difficulty is very different than paddling a classmate around a pool. Wind, waves, cold, anxiety and perhaps fright, will all attend your exertions. With this in mind, knowing that you are physically able to make the considerable efforts that will be reqUired will increase your confidence and ability.

Cylinder Valve, BC or Exposure Suit Tow This is the generally considered the easiest technique to use when the victim is conscious and breathing, such as when assisting a fatigued or cramped diver. If not excessive, the victim's weight belt may be left in place, and the BC inflated to provide additional buoyancy as required. If a long towing effort is anticipated (figure 11-14), and the diver is in a sufficiently buoyant exposure suit, the cylinder and/or the BC may be removed along \Iith the ballast. The technique for towing the victim is the same in any case, differing only in where the rescuer places the gripping hand: cylinder valve (figlll'e 11-16),

fiGURE 11-13. RELEASE THE VICTIM'S WEIGHTS, PUSH AWAY AT THE HIPS, TUCK YOUR CHIN AND DROP BENEATH THEM. THEN SWIM AWAY.

BC shoulder or strap or the collar of the diver's exposure suit. The rescuer may use either hand, and may switch hands during the course of the tow at will. The rescuer can tow while keeping the regulator in place, or use a snorkel or breathe unassisted as desired. The rescuer is usually face-up in the water with the towing hand extended, palm up, grasping some part of the victim's equipment. The victim is conscious, lying faceup on the surface. If possible, the victim can help progress by filming along with the rescuer. The rescuer will usually find it beneficial to alter the frequency and style of kicking throughout the tow at intervals better to avoid succumbing to fatigue. Switching sides and hands will also help keep pelfollTIance acceptable. Be on the lookout for additional help at all times (figure 11-15). It also important to look in the direction of travel periodically in order to stay on course.

"Wheelbarrow" Push Another technique useful for a conscious, breathing victim, the "wheelbarrow" push, (figure 11-17) places the rescuer face down at the feet of a disabled diver. The distressed diver's soles rest on the shoulders of the rescuer, with the rescuer usually maintaining a grip on


nGURE 11·14. ALONG TDW TO THE EXIT MAY BE HAMPERED BY THE VICTIM'S GEAR. CONSIDER STRIPPING I~ AND YOUR OWN, TO MAKE THE TOW FASTER.

the victim's ankles or calves. The victim is buoyant, supine and face-up. The rescuer, while using either snorkel or regulator as the case mal' be, fins the disabled diver back to the exit maintaining a prone position throughout the tow, except for occasional navigational checks and momenta!)' assessments of the victim.

"Oo·si·do" Tow This is the standard technique used for towing an unconscious, possibly now breathing victim when antic· ~ ipating "mouth to mouth" rescue breadling, or when ~ a rescuer feels it is necessary because of dle need to monitor the victim closely. In the "do-si-do" position the rescuer is alongside the victim (figure ii-18). The rescue is perfonned while facing the victim throughout the tow. Either arm of the rescuer is linked with the closer ann of the victim. The rescuer may maintain an additional grip on the victim's equipment if it is left in place, or dle linked anns may be sufficient. If rescuer breaths are necessary, the grip need not be changed. The rescuer need only to roll the victim inward to reach the mouth. The free hand is used to close off the nostrils, and to position the head to insure the airway is open.

fiGURE 11-15. REGARDLESS Of HOW AT YOU MAY BE, TWO OR MORE RESCUERS CAN HElP SOMEONE BACK TO THE EXIT POINT MUCH fASTER THAN ASINGLE DIVER. GET HElP WHENEVER YOU CAN.

AUXILIARY SURFACE RESCUE AIDS While a fit rescue diver and a handy victim are the only required elements in a successful surface rescue, hav· ing auxiliary equipment available Cilll greatly decrease the risk entailed ,md make success much more likely.

Boats Small boats abound where diving taking takes place. Using one in an emergency, however, presumes that dle operator is competent. You can help insure this is dle case if you become profiCient at boat handling by taking an approved boating course from any source. Such courses are available free or for a nominal charge from local or national agencies. .. Using a boat during a rescue Cilll introduce another element of risk, especially if it is a power-driven craft. Smaller vessels \vith outboard motors are the easiest to hillldle, if familiar with their characteristics, and will also generally be the easiest to board illl injured diver onto. Even so, the dangers of operating a small boat around a group of divers in the water, especially dUring an emer· gency, are many. Hitting a diver \vidl the boat or its propeller \vill cause a serious, possibly fatal injury. Most of r."r'1 dle time, when attempting a rescue utilizing a small boat, ~


m

FIGURE 11·16. THE CYLINDER VALVE CAN MAKE AN EFFECTIVE HANDLE FOR ASHORT TOW.

it is better to row than to use power (figure 11-19). The popularity of inllatable craft, and the likelihood that someone in the area of the accident has one readily available, however make these vessels obvious choices for rescue work. Fast, stable and vi11ually unsinkable, a properly equipped, well-handled inllatable can be a valuable rescue tool. Most recreational vessels larger than about 5meters 05 feet) and boats with inboard engines, however configured, are usually not suitable for dive rescue work, except in the hands of trained professionals. In that case, the needs of rescue activities, from easy water access to speed and extensive first aid and communication resources, and trained personnel, are undoubtedly present. An injured diver is fortunate if professional rescuers are the first responders to a diving mishap that is reported to the authorities. It is more likely, however, that you will be on tile scene first l Arescue diver participating in the situation prior to professionals' arriving, is, depending on the legal and professional status of the responders, best advised to follow their directions consistent with the rescuer's diving expertise.

Paddlec~alt

and Dive Kayaks

Paddlecraft of any type can make excellent, albeit relatively slow, rescue platfonns (figure 11-20)

FIGURE 11·17. AWHEELBARROW PUSH IS HELPFULIF THE VICTIM IS CONSCIOUS, AND CAN BREATHE EASILY WITHOUT ASSISTANCE. BECAUSE THE RESCUER IS FACE· DOWN MOST OF THE TIME, IT IS NOT ATECHNIQUE FOR AVICTIM THAT NEEDS MONITORING.

Providing buoyancy and a far swifter and less tiresome way to move an injured individual than merely by swimming, assuming they can be boarded easily, dive kayaks, row boats or other styles of rowing vessels can be useful to a rescuer. At the velY least, a nearby rowboat can be sent ahead to locate more help, notify appropriate rescue authorities or fetch additional eqUipment if loading an injured diver aboard is not an option because of the limitations in the boat's size or stability. Most people operating oar-driven craft have taken the time to learn how to perfornl some crucial maneuvers with them, notably righting a capsized vessel. If you are not confident in these abilities, avoid using this type of boat.

Pe~sonal Wale~ C~alts Personal water craft (PWCs) commonly called "jetskis" and the like also have a place in a diving emergency. So much so, in fact, that many professional rescue organizations are investing in them as equipment. Fast, maneuverable and in later generations, spacious and well-configured for rescue work, tilese devices

141


FIGURE l1-1B. THE "OO-SI·OO" IS PROBABLY THE MOST COMMONlY USED TOWING TECHNIQUE BECAUSE IT ALLOWS THE RESCUER TO MONITOR THE VICTIM MOST EFFECTIVELY THROUGHOUT THE TOW. THE TECHNIQUE IS ALSO THE MOST COMMONLY USED WHEN RENDERING RESCUE BREATHING.

have many advantages over more traditiomli boats. At the same time, their speed advantages and high maneuverability mitigate against using them if you are not experienced. Being hit by a PIVe is the same as being hit by any other boat, and tile probability of serious or fatal injury is high as boating statistics reveal. Be that as it may, the burgeoning popularity of PIVes makes it almost certain that one will be in the area to provide some assistance if you are diving near any recreational shore. Keep in mind tilat these are still boats, no matter how accessible they may seem. and that as such, only appropriate training can insure that you will be able to safely use them in an emergency. There are a lvide variety of specifically designed water rescue tools that mal' be readily available at the scene of a diving emergency, pal1icularly one that occurs during a beach dive. These include floats, rescue tubes, rescue cans, paddle boards and surf mats. Any of these can provide lifesaVing aid during a rescue. Each, however, has different characteristics and mal' be more or less useful depending on your familiarity witil the appropriate procedures for the device, and your awareness of its limitations (figure 11-21).

""/---, FIGURE 11-19_ ASMAll BOAT IS AN EXCEUENT RESCUE PLATFORM IN THE RIGHT HANDS. BOAT HANOUNG SKillS, OR THEIR LACK, WIU AFFECT SUCCESS.

You will practice with some of these aids in your rescue course. In each case, you are only limited by your expertise and resourcefulness in deploying the device if it is available at the scene of an acnlal emergency. In fact, tilis is the key to using any rescue tool. It is more useful to focus on the goal: removing a person from imminent danger or getting an injured person to safety, than to belabor the techniques for using a particular style of float or the relative merits of a throwbag over a rescue tube or can. Proficiency can only be derived from practice no matter what the tool mal' be. And having the tool at hand is critical to its use. For instance, personal floatation devices (PFOs) , commonIv called "lifejackets," are mandatory equipment on any boat, and are as good at providing buoyancy for an injured diver as tile)' are if donned when a boat is sinking. Agroup of these strung together by their own straps can instantly create a "rescue raft"' that lvill elevate a diver in the water, decreasing the drag and resistance of a towed person or creating an intennediate step before having to lift a person over the side of a vessel. Even inflatable pool to}~ can contribute to the ease and efficiency of moving an injured or unconscious individual in tile water, or from water to boat or to land.


FIGURE 11-20. ASMALL BOAT PROVIDES ADRY PLATFORM FROM WHICH TO RENDER AID TO AVICTIM.

MOVING AN INJURED OlVER

rn

Know your physical limitations before attempting to move or lift any object or person. Injuring yourself helps no one, least of all you l Accepted first aid protocols advise never moving an injured person unless that person is in immediate danger. The danger of drowning makes moving victims of diving accidents out of the water, either onto a vessel or to shore, mandatOly. The need to move injured divers is further underscored by the fact that as yet there is no effective method to ister cardiopulmonary resuscitation (R) in tile water, and tilat this is frequently necessary aid for a diving victim. If additional rescuers are present one rescuer should take responsibility for maintaining head, neck and spine position and for directing the other rescuers to effect the rotation of the victim. The only possible exception to the necessity to move the victim out of the water is in a case where spinal injury may be present. Some situations that can cause accidents that may have spinal injury as a component are shore diving in heavy surf, slip and fall injuries with equipment that cause head or neck trauma, or entry/ladder accidents where a diver may inadvertently land on another diver causing head or neck injury. These accidents are extremely rare, and with caution and common sense eminently avoidable, but if such an injury is suspected, wait for professional rescuers to move the victim whenever possible (figure 11-22). If

FIGURE 11-21. NO MATTER WHAT EQUIPMENT MAY BE AVAILABLE, IT IS ULTIMATELY THE RESCUER'S SKIU AND INGENUITY THAT DETERMINES THE OUTCOME OF THE EVENI

FIGURE 11·22. INGENUITY AND TEAMWORK ARE NEEDED TO EFFECTIVELY REMOVE AN INCAPACITATED VICTIM FROM THE WATER.

movement is necessary, such as when a diver is found floating face down in the surf, follow the guidelines below for stabilizing the head throughout tile maneuver. Afundamental principle of transporting victims with suspected spinal injuries is to immobilize tileir head, neck and spine in the position in which they were found before any attempt to move them occurs. This means being proficient in the use of cervical collars and


other immobilizing devices, such as backboards and litters. Achallenge exists when a rescuer is alone and has no additional equipment but is faced with a suspected spinal injury victim who is in tile immediate danger of drowning - movement then becomes tile only choice. Turning an unresponsiveface-dollll! viclimwilb a possible spinal injury as a lone rescuer I. If in calm walm; approacb Ibe victim carefully 10 avoid causing 1l/lnecessalJ' movemenl. Position yourselfallbe bead and place one band ollibe victim's uppm' back belween Ibe sboulders and in-line wilb Ibeir spine. In Ibis way yourforetlrm wilt be in position to Ibe viclim's bead as Ibey rolate on Ibeir longitudinal axis and mainlain ils posilion in-line wilb Ibe spine. 2. Once in position use your free band 10 jJusb downward on one oftbe victim's sboulders to CC/use tbem to rolate around your ing arm. /I wilt be necessC11JI 10 use enougb force 10 generate momenlum tbat will can)' Ibe rolation pasllbe mid-poinl. IfIbile mainlaining tbe bead and ;pine alignment again use your free band 10 reael! across and calcb Ibe victim's rising sboulder 10 complele Ibe rolation. At Ibis poinl you can check breatbing and if rescue brealbs are necessary, use a modifiedjaw tbrusl tbal you learnetl in your R training 10 open and mail/lain till airway. 3. If additional rescuers are presenl, one l'esCUBl' sbould lake responsibilily for mainlaining bead, neck and spine posilion and for directing Ibe olber resCllm's 10 effecllhe rOlalion oftbe viclim.

REMOVING AVICTIM FROM THE WATER One unavoidable problem that pertains to removing a diving victim from the water is that it will almost certainly be necessary to interrupt rescue breatiling for tile time it will take to remove tile person from the water.

This makes a good plan and willing aides even more crucial since getting someone out of the water on to a vessel by yourself is extremely difficult at best, if not impossible. As a rescue diver, it makes good sense to consider how you would accomplish a removal in an emergency on any dive. Thinking about these issues is an important part of a rescuer's pre-dive contingency planning, as is identifying any other of a dive party who may be potential helpers -{)r liabilities. There is no limit to the ingenuity that a rescuer may need to accomplish an effective removal of a victim from the water on to a boat or to shore. The follOWing techniques are recommendations that can prove effective under some circumstances. Not every possibility will work every time, and not every one will work equally well under all conditions. The very nature of diving, subject as it is to the vagaries of weather and water, make issuing a blanket prescription for action impossible. As with other rescue problems, it often helps to focus first on the goal, in this case: removing the diver from the water qUickly with as little movement to the individual as can be accomplished.

Buoyancy Bounce This is a technique suitable for boarding victims into a small boat when forced to do so on your own. Leave tile buoyant victim attached to the side of the vessel while you board. Once aboard, free the victim from the tether used, and grasp the exposure suit or the Be at the shoulders or lower at the arm pits, if possible, with the diver facing tile vessel's side or boarding point. Bounce tile victim down again t his own buoyancy, but avoid submerging the face. 'lime your effort to coincide \vith the buoyant force of the water, and forcefully continue pulling the diver up over the side of the boat or platform as natural buoyancy expels the victim from tile water. This will work if you can lever the victim's upper body out of the water. At that point, stabilize the victim, and then reach down and grab the seat of the exposure suit to complete the lift.

Chaplep 11- Supface Rescue

FIGURE 11·23. WEN IF AUTIER OR BACKBOARD IS AVAIlABlE, WHEN ASPINAl. INJURY MAY BE PRESENT, IT TAKES COOPBl· ~ A1l0N AND TEAMWORK TO MAINTAIN THE VICTIM IN A aIII STABLE POSITION DURING REMOVAL mOM THE WATBl.

Rescue liners and back boards If available, tllese devices make lifting a victim out of the water much easier (figure 11-23). They also have the added advantage of being able by design to stabilize the victim's head and limbs, thus helping to reduce tlle possibility of further injUry. It is relatively easy to place a person in the water onto a backboard since buoyancy aids the effort, but if there is only one person in the water with the victim, you are likely to find yourself four arms short! This is even more the case if rescue breathing is necessary. If there is help available, one person can maintain breathing until the point that the person leaves the water, hopefully resuming it within seconds when the victim is aboard. If the removal is to shore, then rescue breathing need never be interrupted for any length of time. In any event, place the victim in the device by sinking the board beneath the person who is supine in the water. In the case of a rescue littler, this may take some effort since they are typically ~uipped with floatation. Once the person is in the litter, it may be bfted vertically out of the water by hands aboard the boat. On the boat, there is no need to remove the victim from litter. It serves as a convenient stretcher while transporting the victim. If it is necessalY to move the

victim to emergency medical care or a trans-shipment point by conventional automobile, you may have no choice but to remove the person from tlle litter. Like litters, backboards are convenient means of moving an injured person, and also make provision for stabilizing the head and neck. Less bulky than a rescue litter, a back board is easy to store, and also to constl1lct. Asimple plywood form for the most part, with hand holds and strap attachments cut into it, a brief afternoon's work can produce one as serviceable as any that may be commercially available. Loading a person on to a backboard is even easier than into a rescue litter since there are no side rails to contend with. The board is merely slid up under the victim, and then the person is secured. If being brought aboard a boat, the stem platfonn, if available, makes a convenient fulcl1lmwith which to lever the board onto the boat. Aides on the vessel can grasp tbe board and pull it up on tlle deck out of the traffic flow. Again, rescue breatlling need only be momentarily interrupted, if at all. Whether it is a backboard or a litter it will probably be equipped with straps to be used for securing the victim to it. Crisscrossing, tllat is making an "X" with tlle straps, over the upper torso and at the knees or tllighs will improve the security provided by the straps. It is also a good idea to use a separate strap at the forehead and chin along Witll the appropriate stabilizers to immobilize tlle head, and at the waist and ankles. Then for good measure a separate strap around and under the soles of the feet to prevent in lengthlvise slippage as the victim is hauled out of the water.

TERRAIN ISSUES Docks, beaches, rocky shorelines, all may be the point that a victim must be brought to for emergency medical care (figure 11-24). Few of these are constructed, deSigned or fonned with this in mind. Climbing over rocks in dive booties, or attempting to maintain a victim in a level position on a steep incline can be physically impossible. Consider these problems in advance of haVing to solve them in an emergency. Such issues

IirI ~


FIGURE 11·25. SURF ALSO INCREASES THE STRESS OF ARESCUE ATIEMPT AND SHOULD BE CONSIDERED DURING THE DIVE PLANNING PROCESS.

ROORE 11·24. APICTURESQUE AREA MAY BE ANIGHTMARE FOR OM RESCUE. SCOUT YOUR DIVING LOCATIONS CAREfUUY, AND KNOW WHAT SBMCES AND ASSISTANCE ARE AVAIlABlf WHEN CONSIDERING OVERAll RISK.

can influence your choice of dive sites or evacuation points. If a more suitable place is minutes farther, it may be a better choice even if not the closest. Injuring oneself is also far more likely when the circumstances of a rescue, which include the stress of having to care for a seriously ill or incapacitated person, are made significantly more difficult by the area in which you have to work (figure 11-25).

PARBUCKLING This is a relatively easy and inexpensive method to have in place aboard a boat or at a dock where diving is a customary activity. Depending on physics, ingenuity and cooperation, the technique has been used for Iiteral-

Iy thousands of years around the world to lift everything from classical architectural column to casks of wine. It relies on using straps, ropes, or netting in a sling arrangement around a cylindrical object, in our case an injured person, and then rolling the object up and incline or lifting the load vertically. Attachment points on the destination hold several lines or straps, the long ends of which are let down into tile water and arranged beneath the victim at convenient intervals. 11le arms are secured to the chest or sides to prevent injury. (Obviously, rolling the person up tile side of a moving boat if a spinal injury is suspected is not recommended.) The free ends of the straps are ed back up to those on the dock or boat. On cue, tile people aboard begin recovering tile lines, rolling tile individual up and out of the water. This works bes\ if there are other people aboard besides the haulers boat 10 help tile person over the gunnel or railing. This way no one has to let a line go to get a hand on the victim, and there is less chance of hurting the person in the transfer from the lift method to the deck. If the technique is done \vith netting, tile load is spread much more evenly under the victim (figure 11-25). There is also less of a chance of a line slipping on the person and catching the throat, or of a limb becoming entangled. If rope is used, it is usually better to double the rope to create a loop, then the loop under the


person and back up to the haulers. The two free ends are of the loop are secured on the deck or dock, and the loops help spread the load better (figure 11-26). Even better is nylon web belt material because the \\1dth improves and resists slipping.

On land, however, where the carry will be relatively flat, a handy old door can be a lifesaver, even for a single rescuer. You are far less likely to injure someone you may have to drag to safety if you can place a barrier between the ground and the person.

FOUND OBJECTS

CARRIES AND LIFTS

Just about an}1hing flat, rigid, \\1de and long enough to a person can become a handy litter, backboard or stretcher during a rescue emergency. This includes surfboards, floats, paddle boards or what have you. Using such items, though, can present another eleL\::!;;oI ment of risk to the victim. Not designed specifically for the purpose, keeping someone from slipping off and causing further injury is a problem that needs to be solved beforehand. In most boating situations, ample amounts of rope are available to help secure people to these objects, however, unless adept at tying bowlines, non-slipping, non-binding, or other suitable knots, you may in fact be injuring a person unwittingly. Slipping all one's weight down on a thin line will undoubtedly cause bruises at least. Serious injury can also result if the line is wrapped around a delicate part of the anatomy not meant to carry the bulk of a person. Use methods like these cautiously at best.

m

The average person weighs from 62 to 70 kilos (J 40155 Ibs). How much can you honestly lift and carry for any length of time? In all likelihood the answer is considerably less. Be that as it may, however, if conducting a rescue, you may have to lift or carry a victim up a ladder, or out of the water. This will require technique more than brute strength. Though having both available is far better than eitller one, if you were only strong in this case, you and the victim would be better off!

Climbing Lills It may sometimes be necessary to remove an individual from the water by yourself up a ladder. This may be easier than it sounds because for the most part, you are relying on some of the strongest muscles in your body, your legs, to accomplish the work. The biggest Ii"'!""I problem you 11111 face in tllis circumstance is securing the ~ person to you if they are unable to aid in the dilemma. If

FIGURE 11-2B. LONG LENGTHS OF WEIGHT BELT MATERIAL ARE EASY TO STORE IN AN EMERGENCY KIT, AND CAN BE INVALUABLE IN REMOVING A VICTIM FROM THE WATER.


FIGURE 11·27. THE LADDER LIFT HAS THE ADVANTAGE OF USING THE LEG MUSCLES TO LIFT THE WElGHl

this is the case, a Ladder Lift or BC Carry can still be effected. In a Ladder Lift, the individual is facing the rescuer, with the anTIS around the rescuers neck. Consciousness helps, allowing the victim to hold on to the rescuer. If not, having the ladder at IIle victim's back will usually keep them from falling so long as the arms are draped over the rescuer's shoulders. The rescuer places the knee up into the groin of the victim, carefully using the thighs as altemating "elevators" to continue to lift the person up to the top of the ladder. This does require aml strength and a good grip to hold onto the ladder as the climb is made (figure 11-27). ABC Carry is one where the victim, in only a BC and exposure suit, weights and cylinder having been previously removed, is carried up a ladder or ramp on the rescuer's back. The rescuer "puts on" the BC along with the victim. Most BCs have anlple room in the arm holes to do this. Wearing the victim like a backpack, the rescuer carries or lifts the person up the ladder or ramp, or can even walk with the person on the back by only leaning forward to lift the victim's feet clear of the floor. If the victim is significantly taller than the rescuel; walking willl the victim in a BC carty will not work we]] (figure 11-28).

FIGURE 11·28. MOST ReS HAVE ARM HOLES LARGE ENOUGH TO ACCOMPLISH THIS CARR~

Carries On Shore or From the Water Getting a victim onto land from the water is as simple as walking out carrying the person on your shoulders or in your amlS if the victim is small and light enough. If not, some technique is necessary. 'I\vo good ones are the traditional Firefighter's Carry and another useful variation called the Pack Strap Carry. AFirefighter's Carry is easier to start in the water than on land. In chest deep water (figure 11-29), the rescuer dips under the victim who is floating on the back. In one motion, the rescuer rises up undemeath the person and rolls them so that IIle bulk of the victim's weight rests across the rescuer's shoulders. The legs and arms dangle down on either side of IIle rescuer's head and neck, and one hand secures the arms and the other a leg. If necessary, threading one arm between the victim's leg and reaching across the rescuer's chest allows the rescuer to secure the victim by grasping the arm or wrist with the hand of IIle arm between the victim's legs. In this manner, the rescuer has one hand free if need be. If the victim must be positioned for the Firefighter's Carry on land, it is far easier to do so if the person is standing. If not, consider another method. There is high chance of back injllly to a rescuer who tries to lift a supine person from the floor to shoulder level.


work just fine for moving the person if the rescuer is able.) The rescuer stands in front of the victim, bringing the victim's arms over the rescuer's shoulders and holding the wrists with one hand to keep the victim positioned on the rescuer's back. The problem arises when the victim is much taller than the rescuer since the feet and ankles will drag on tlle ground. Again, bending forward may help.

DRAGGING AVICTIM AGURE 11-29. IN AARffiGHTER'S CARRY, IT IS MUCH fASlBl TO HOIST THE VICTIM IN CHEST OR WAIST DEEP WMIII WHBlE BUOYANCY AIDS THE UFI

If a rescuer cannot lift a victim alone, dragging may accomplish the job of removing the victim from the threat of drowning. Reach under the victim from behind and grasp under the anns. If a spinal injUl)' may be present, use the foreanns to stabilize the head and neck, and simply drag the victim backwards. Look out behind yourself from time to time to avoid rocky areas or other hazards. It may be necessary to alter your route to a longer one in order not to do more haml to tlle victim. Even \vith the best intentions, rescuers should be aware that there is a likelihood of inflicting some damage on a victim that is dragged. The best one can do is to try to minimize this by leaving the exposure suit, particularly booties, in place.

Bank Drags

FIGURE 11·30. APACK STRAP CARRY IS ALSO EASIER IF STARTffi IN CHEST OR WAIST DEEP WATER. LEANING FOR· WARD FROM THE WAIST WILL LIfT THE VICTIM CLEAR OF THE GROUND. APack Strap Carty, on Ule otller hand, is easier to effect since the victim's weight is ed almost entirely by Ule rescuer's legs. (figure 11-30). In this technique, ule victim is on the rescuer's back "piggy-back" style, save that the victim's legs can drag on tlle ground. (If tlle victim is conscious, by the way, "piggy-back" can

It can happen that where you exit the water is at a steep incline. In Ulis case, it may be impossible to drag a diver up the bank to safety. In this case, a Bank Drag can be effective in removing the victim from the danger presented by surf or a rising tide. Position yourself behind the victim, grasping them around the chest while they are in a seated position. With your back to the bank, straighten your legs until you are upright, and rock back on your heels. The victim will fall on top of you. Recover, and repeat the maneuver repeatedly, womling your way up the bank as best you can. This will be difficult for the rescuer since the progress \vill be slow, but it will get you and the victim up the hill and away from the water.


SHORE CARRIES WITH HELP

[tJ

Once ashore with a victim, a rescuer can usually depend on willing help from ersby to move a victim further, however willingness does not imply competence. How effective the aid you receive will be is in direct relation to how quickly and how well you can instruct onlookers to provide you with appropriate help. More or less aid than required will add another burden onto the rescuer. Unless a person ashore is clearly more qualified than you, for instance a law enforcement officer or certified first responder, maintain your authority and direct others to aid you as you need. If people are unwilling to help, don't waste time in argument. This may also be the case when dealing with a language barrier. If you cannot make yourself understood, continue doing what needs to be done: ing emergency medical help, and focusing your attention on the victim's needs. There may in fact be no opportunity to carry the victim once ashore. The need for R may make it impossible for the rescuer to leave the victim. In a remote area, if the victim is breathing, leaving to call for emergency medical help and evacuation is a terrible judgement call that some rescuers will have to make. Anything can happen in tlle interim.

diver to be able to reach under the person, and once positioned, stand up to effect the carry. Rescuers are cautioned to maintain an erect posture when performing this maneuver, and lift witll the large muscles of the legs to avoid back injury.

Two-Person Carry

Three-Person Carry

If the victim is responsive and can stand, albeit \\1th some difficulty, transport by two people is relatively easy (figure 11-3 I). The carriers stand to either side of the victim, and lock anns, wrist to wrist (as in a "Roman Handshake") or grasping hands, whichever will be stronger for the participants. These ed arms are placed beneath the victim's buttocks, and the otller anns go around the victim's back. If conscious, the diver should be asked to place his amlS over either rescuers shoulders, and sit back on the clasped anns. Once in the "chair" just created, the rescuers can move the victim easily, so long as their strength holds out. AlIvo-Person Carry can also work with asemi-conscious or unconscious but breathing victim. In this case, the anns are clasped beneatll tlle victim who is supine. The rescuers will kneel on one knee to either side of the

If rescue breathing is necessal)', a Three-Person Carry can be useful to transport the victim while istering breaths. This technique can also be used as a last resort if a possible spinal injury is present since there are extra hands available to stabiliz~ the head. lIvo rescuers are positioned on tlle sanie side of the supine victim. One is at about the shoulder level, the other around the area of the hips The tllird person is on the opposite side, around mid-torso. The rescuers reach beneath the victim and grasp each other's anns altemately, locking into a web position at the hips, mid-back and shoulders. TIle "top" rescuer uses the crossing amlto stabilize the head and neck, preferably already encased in a collar. If breatlling assistance is required, tllis rescuer provides it. Anotller of the three rescuers must then direct the progress of the carry, and wam of any obstructions.

FIGURE 11·31. TWO PEOPLE CAN MOVE AVICTIM FAIl MORE QUICKLY AND EFFECTIVElY THAN ON~ HOWEVER, CONSIDER THE VICTIM'S POSSIBl1 PROBLEMS, PARTICULARLY SPINAL CORD INJURY, BEFORE MOVING IN ANY FASHION.


Four·Person Carry This is a modification of the Three·Person Cany that adds the additional strength of a fourth rescuer. Stagger the four rescuers two to a side, and interlock arms as appropriate. Smaller rescuers are best placed on opposite sides of the victim to balance the strength disparities. If there are more than four rescuers available, not an unusual event with a large dive group, rotate positions with fresh rescuers at intervals ratller than trying to include more hands at a time. The latter just gets confusing, and coordination becomes difficult.

CHAPTER

Diver First Ai~


LEARNING GOALS In this chapter you will: I. Review the basic principles of first aid. 2. Learn first aid for common diving injuries. 3. Learn first aid for injuries from marine animals. 4. Understand the symptoms and treatment for "bad air," 5. Learn what to do for seasickness. 6. Leam the proper response to life-threatening emergencies. Being able to provide immediate on-scene care to the victim of a diving malady or diving related accident is a fundamental part of rescue skills. In addition to the information and skills necessary for providing usual first aid to an injured person, a Diving First Aid Provider must have specialized knowledge in order to deal effectively with injuries that can occur due to involvement in scuba and skin diving. Proficiencies in injury and illness areas apart from traditional first aid include competence in dealing with the unique problems of the direct and indirect effects of pressure, gas toxicity and marine animal wounds and marine toxins including those from venomous animals and from ingesting tainted seafood, and marine wound infections (figure 12-1). In addition, there are a con-

fiGURE 12·1. THE MOST EXOTIC MARINE ANIMALS ARE GENERAl· lY ONLY HAZARDOUS If MOLESTED OR INGESTED. AVDlDlNG MOST INJURIES IS THEREfORE THE DIVER'S CHDICE.

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AGURE 12-2. ABOARDING lADDER IN AROUGH SEA IS APOTEN· TIAl SOURCE Of INJURl

stellation of scuba and skindiving participation related injuries that are endemic to exposure to the environment. These encom problems like chilling and overheating, sunburn and seasickness. Other problems indigenous to diving activity are strains, sprains and blunt instrument trauma including fractures, conClISsions and severe contusions related to mishandling heavy eqUipment and slips and falls (figure 12-2). Finally, though a "wound is a wound," a wound under the circumstances of a diving excursion can be far more serious than one under more normal conditions. Victims of diving injuries or accidents in the diving environment may be far, either in tenns of time or distance or both, from emergency medical care. Standard first aid procedures may need to be modified to accommodate tilis, and to accommodate tfJe additional predicaments of working in and around water. This greatly increases the gravity of even relatively minor problems, especially when diving in remote areas or exotic locales. Like acquiring mastery of diving skills, becoming expert in first aid skills requires commitment of time and resouroes. Coaching and infonnation such as you will receive in this AU! Worlffivide rescue course, and your full participation in the practice scenarios your instructor will conduct are only the first step. You lvill need to

Chapter 12- Diver First Aid

continue your education in these fields apart from this class, and you will need to upgrade and refine your skills regularly tilrough additional courses, independent study and practice skill sessions with professional staff and on your own. The following information is essentially a review of some of tbe prominent first aid areas that are important to your training as a rescue diver.

THE BASIS OF FIRST AID Unless you are working specifically as a rescue diver, diving instmctor or divemaster in a certified, paid capacity by prior agreement with a diver or a group of divers, your use of first aid skills is completely voluntary and at your discretion. You have no more obligation to intervene to help an injured diver or other person whom you encounter than you do to risk yourself by attempting to rescue someone. But a certified rescue diver who makes the decision to intervene must perform to the level of knowledge and competence that could be rea~ sonably expected of a similarly trained person in that situation. In otber wordl, you need not do anything, but if you do, you must do your best according to what you know and can do. In general, you are most likely to proVide first aid care to your dive buddy, or to another member of a diving group in which you participate. The care you provide must be no more than you are trained for, nor any less than you have learned. This can sometimes create a dilemma for the layperson with a wide knowledge and interest. You may well be familiar with techniques that go beyond usual definitions of first aid. In a situation where applying these would seem to be the correct cboice, your decision to use them is fraught with potential problems for you and for tile person upon whom you are "experimenting." Harsh as it may seem, you are wrong and may face civil, even criminal penalties, even if yOLl are ultimately proven rigbt if you exceed the level of care or intervention for which you are certified and trained. (For a more complete discussion of tbese and other issues of liability, see Chapter 15.)

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THE FIRST RESPONDER AT ADIVING ACCIDENT As a rescue diver, you will most likely be the first responder on the scene of a diving accident. As with any

unusual diving incident or accident, your primary concern must be your personal safety. Whether rescuing another diver or prOViding first aid to an injured one, it is foolish to risk yourself thoughtlessly. Considering these issues in relation to first aid, some concerns beyond the usual tbinking of a diver enter tbe picture. Your primary survey of a diving victim for whom you would proVide care must include considering how to isolate yourself from bodily flUids, primarily blood, that may be present on and around the Injured diver. This may be difficult to assess in the water, but will still pertain. Although there is no known case of disease transmission of a blood-bome pathogen as a result of dive rescue or istering in-water rescue breathing, t1lere have been cases of disease transmission involVing first aid proViders, professional emergency medical specialists, EMS first responders, emergency room personnel and other medical proViders. Coming in with pathogenic substances can easily be avoided in the diving environment in the same way t1lat they can be avoided ashore. The first issue is awareness. The pOSSibility of an injured person, even one whom you know well, being infected with a serious disease must always be presumed. Handle all patients to whom you render aid in tile same way. Use surgical or other appropriate gloves when dealing with any wounds (figure 12-3). Avoid direct with any bodily flUids. Whenever possible, use a pocket mask or otller barrier device if istering rescue breaths or dUring R. Wear eye protection as well, if possible. Of course, gloves, eye protection and a surgical mask are especially necessary if dealing with a major bleeding wound or any injury or apparent disease situation that involves volumes of fluid loss. This can include the effects of seasickness or common food-poisoning, or problems stemming from marine animal . If you are exposed to any bodily substances from your involvement in a diving emergency, wash the area

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immediately Witil soap and water. If possible, change clotiling immediately that has become contaminated while you are aiding another person. Isolate these items until tiley can be thoroughly washed and disinfected, or discard them appropriately in a marked container for bio-hazardous waste. The sanle procedures pertain to any equipment, bandages or other items that you may use in the course of an incident. Report any exposure you may have had to responding EMS providers. If you are not advised by these persons to seek immediate medical attention for possible contamination, do so on your own as soon as you are relieved of caring for the victim. Infonn your doctor of the exposure, and request assessment. Until you are sure that you remain uninfected, avoid possibly infectious with others. This includes unprotected sexual activity Some jurisdictions have laws or regulations governing exposure to blood-borne pathogens. AI, a Diving First Aid Provider, you need to be familiar, and to comply with, any of these rules that may pertain to your activities.

GENERAL DIVE FIRST AID PRINCIPLES 1. Survey tile scene: is it safe for you to intervene

2. 3.

4.

5.

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and/or are you willing to assume the risks of doing so, and are you appropriately trained and able to provide necessary assistance? If necessary, activate the Emergency Medical System. Perfonn a secondary survey of the victim to assess what the obvious problem is, and to discover any other problems from which the victim may be suffering. Provide appropriate aid and care, including Basic Life like rescue breathing and R while awaiting EMS or during transport as required. Report your findings and actions to the EMS first responders who relieve you. This includes the circumstances of the event, dive profile, and identification and/or the results of your interview of the diver's buddy if it is not you.

FIGURE 12·3. USE ITEMS UKE RUBBER GLOVES ANO EYE PROTECTION WHEN PROVIDING ASSISTANCE TO ABLEEDING VICTIM.

FIRST AID FOR COMMON DIVING INJURIES External Wounds External wounds are injuries that include a break in tile skin. They may be various cuts, punctures, abrasions or tears, and are almost always accompanied by some amount of bleeding. Because of this, they must be handled carefully to avoid infection to the site, and to the first aid provider. In diving, wounds can come from many sources. Acut from a dive tool or other shall) object (incision wound or puncture wound), a dive cylinder or weight belt that falls and tears skin or from a diver falling while geared up or against a hard object on a moving platform (laceration), a scrape against coral or. rock or skinned knee from tripping on a dock (abr.asion [figure 12-4]), or torn skin from being caught by machinery like a boat propeller or an unfortunate encounter with a marine animal (avulsion). In general, first aid treatment for wounds includes two major activities: stopping or controlling bleeding and cleaning and disinfecting the area. How to accomplish them will valY with the severity and circumstances of the wound. Appropriate first aid will include anything from a dab of hydrogen peroxide and antibiotic ointment alld all adhesive balldage for a minor cut on a finger to pres-


FIGURE 12·4. SOME SPECIES OF SHARKS DO NOT HAVE TEETH. THElR SKIN CAN CAUSE ABRASIONS IF WlTH BARE SKIN IS MADE.

sure bandaging, treatment for life-threatening shock and evacuation for emergency surgical care for a major wound or amputation accompanied by heavy bleeding. Controlling Bleeding I. Find the source. 2. Apply direct pressure with a clean dressing. Avoid direct with blood. 3. Elevate the area if possible. 4. Do not remove saturated dressings; add more. 5. Leave embedded objects in place. 6. If bleeding does not stop or is of great volume, locate the appropriate pressure point and apply direct pressure. 7. If bleeding is of such volume as to be life-threatening (severe arterial or venous damage), the wound is on a limb, and medical aid is distant, apply a tourniquet as a last resort. Minor wounds should be cleaned with soap and water and a clean cloth. Use alcohol around the wound (not in the wound!) to clean tlle surrounding area. Do not apply iodine, Mercurochrome or Merthiolate to an open wound. You may use a small mTIount of antibiotic topical if the circumstances warrant, as when the wound was caused by an animal sting or other organic matter may be in the wound. In general, all animal wounds, even if small, should be evaluated by a physician.

AGURE 12·5. WHILE SHARK ATTACKS ARE EXTREMElY RARE, A SHARK Bm WIll REQUIRE ARST AID TO CONTROL BlfEDlNG AND SHOCK.

Minor wounds that include the thumb or other areas of the hand where nerve dmnage may occur should also be seen by a physiciml, as should deep penetrating wounds. After dressing with a sterile pad, bandage the area. Covering of small cuts is unnecessary after the first 24 hours, however, divers should refrain from diving until the wound closes to avoid tlle possibility of infection from organic material in water. If bleeding soaks through the dressing, add another dressing, ratller than removing and replacing. This will only re-open the wound, and may promote infection. If a dressing must be removed, soak the item in hydrogen peroxide or clean, warm water until it is loosened. severe wounds will always be accompanied by shock, a life-threatening condition that requires immediate emergency medical care (figure 12-5). Monitor the victim constantly since life including rescue breathing and R may be required. If a toumiquet is applied as a last resort, leave it in place until advised to remove it by medical authorities. Do not clean or handle a severe wound. Leave tllis to a professional. If help is distan~ remove clothing around the wound and clean tlle surrounding areas as best you can. Control bleeding mld get tlle victim to emergency care.

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INTERNAL WOUNDS Bruises (contusions) can cause internal bieeding, a life-threatening emergency. The effects of lung overexpansion injuries or decompression sickness can also do this. If internal bleeding is suspected for any reason, or a diving malady may be present, get the victim to a doctor as soon as possible, treating the diving malady as detailed in Chapter 10. For external bruises, appiy ice to the injury to reduce sweliing and alieviate pain. Piace a cloth barrier between the ice and the wound. Compression on the wound site wili also help relieve swelling. If the bruise is extensive or circumstances warrant, check the area for a fracture. All suspected fractures require medical evaluation.

HEAD INJURIES lilly head injury that includes unconsciousness for any length of time, changes in personality or function or includes bleeding from the nose or ears or fluid from the ears requires immediate medical attention. This may be the result of concussion, a blow to the head that causes the brain to jar, or a skuli fracture. Abrief neurological assessment is warranted for any severe head trauma even if consciousness is never lost. Spinal or cerebral damage may be present. Other indicators of serious head injury include headache, amnesia, vision disturbances, dizziness, nausea and weakness, seizures or speech difficulty. Ahead injury of this magnitude can be life-threatening. Act accordingly. If the victim is conscious, give nothing to eat or drink, and maintain them in a semi-sitting position to reduce blood pressure in the skuli until medical care is available. Scalp wounds that may accompany this will bleed severely. If a fracture or depressed skuli fracture (apparently unbroken bone) is present, do not apply direct pressure to the wound site. Cover the area and ice around the wound. Get help.

158

FIGURE 12·B. IMMOBILIZING AFRACTURE UNTIl APERMANENT CAST CAN BE SET CAN BE ACCOMPLISHED WITH A VARIETY OF MATERIALS.

FRACTURES Broken bones, particularly ankles and toes, and wrists and fingers are common around diving. The former from walking or running around barefoot in an unsteady, unfamiliar environment such as aboard boats, and the latter from falls that may include wearing or handling diving equipment. In any event, ali fractures require medical attention with the possible exception of a simple broken lesser toe. These may best be taped to the adjacent digit, treated for swelling with.ice, and if the individual desires on his own, aspirin. "Finning lvith a broken toe is painful, but people have different thresholds of discomfort. Finger fractures should be seen by a doctor to insure that full usage is eventually regained. Immobilize the finger, ice as appropriate and seek medical aid (figure 12-6). Serious fractures include those limbs with multiple breaks, those likely to be accompanied by major internal bleeding or organ injury (flailed chest, broken ribs, socalled "green stick" fractures, and impact and shatter fractures), and fractures that break the skin (compound


fractures). These all require medical attention. Fractures will sometimes produce shock, and if tlle result of serious accident, are often accompanied by other severe injuries. The history of the event lvill provide a clue to the first aid provider of the likelihood of more serious problems being present. Immobilizing the fractured part while transporting the individual to medical care, and treating any attendant wound is reconmlended.

CRAMPS

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Cramps can come from several diving related problems such as unaccustomed exertions or movements associated lvitll Slvimming or finning, muscular stress and spasm due to cold or fear, or even dehydration. In any event, in-water cramps can be so severe that they may disable a diver. Fortunately, muscular cramps are easy to treat oneself, or with the aid of a buddy (figure 12-7). The method for releasing common leg cramps is to stretch the affected muscle in the opposite direction, releasing tlle cranlp. For instance, a cramp in the call is treated by grasping the fin tip and pulling it back towards the knee. Cramps in the quadriceps at the front of the thigh will generally respond to pointing your toes down. Problems with cramps can, however, recur if the cause is recurrent stress of the affected muscle. This can be the case if one is out-of-shape for diving, or even if relatively fit and over exerting oneself due to circumstances like an unfamiliar activity or unexpected current. Using a different kick, and rotating among them, can help to prevent leg cramps from recurring by not stressing the same muscle in the same way. Abdominal cramps can be caused by anytlling from food poisoning to digestive gas accumulation (so-called "gut squeeze") to common menses. Whatever the reason, extreme discomfort during diving can cause accidents, so act accordingly. In tlle first two causes, prevention is the key. The third is a judgement call on the diver's part. [n general, if one is taking medication to relieve menstrual pain, diving is temporarily contraindicated.

R&URE 127. ONLY THE ONER KNOWS HOW SEVERE THE CRAMP MAY BE, ANO WHETHER OR NOT TO TERMINATE THE DIVE. FOLLOW YOUR BUDDY'S lEAD IN THESE CIRCUMSTANCES.

Divers can be subject to especially serious cases of food poisoning from ingesting fish. Again, prevention is the key: know the source of fish you may eat, and be certain that it is fresh and has been handled and stored lvith care. The most common kind of "fish poisoning" comes from improperly stored fish. Called scombroid after the class of finned fishes like mackerel, its symptoms include dizziness, nausea, vomiting and diarrhea. These are obviously contraindicative to diving, not only because of the dehydrating effect, but because concentration is severely hampered. Give possibly fish poisoned individuals nothing by mouth except water and watch them carefully. If symptoms do not abate after the initial attack, usually within 24 hours, or if the victim is experiencing severe dehydration, a trip to the emergency room is called for. Some reef-dwelling fish, favorite game of many spear fishing entllUsiasts, ingest toxins from fish that feed on the reef and are in tum eaten by larger predators. These toxins accumulate in tlle flesh of the fish

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and survive cooking. Called ciguatera poisoning, ilS symptoms are usually delayed for 3 and up to 12 hours after eating and symptoms vary with the individual. They can include: numbness and/or tingling around the mouth, a reversal of the sense of hot and cold, t and muscle aching and vomiting and diarrhea. Other possible symptoms run the gamut from general weakness and dizziness to chills and headache. In most instances there is relief in a few days, but weakness, itching and pain can and has persisted for months. There is opportunity for first aid response because of the delay in the onset of symptoms and often it is not associated with a recent meal, but is mistaken for the flu. Local knowledge can help avoid this type of poisoning and avoiding eating the flesh from large tropical species of fish can also help.

BURNS Bums are extremely painful injuries, and can also be life-threatening if extensive. The threat of infection is unusually high with severe bums since the skin, the body's protective coating, is compromised. Bums can come from two souroes: heat or chemicals. Sunburn is a radiation bum (figure 12-8). Severe bums over 3% or more of the body surface area, a whole ann, head or face for instance, are considered major, as are bums 111at go completely around a limb and thus, can impair circulation. Classified according to depth to which the skin is burned, first degree bums are the mildest affecting only the outer layer of the skin, and usually only including reddening of the skin. Once blistering occurs, a second degree bum is present. Third degree bums include deep skin destruction and even charring. Respiratory bums, those within the throat, nasal ages or lungs can occur from heat or from chemicals and are life-threatening. The airway can be shut down by swelling. Hospitalization is required. All serious bums need emergency medical attention. Extensive bums lvill always lead to shock. Monitor 1I1e bum victim carefully since olller aid, even life can become necessary. Avoid handling a burned area. If

180

RGIJR£ 12-8. 11lf PROlJFfIWlON OF SUN BlDCKlNG lOTlONS MAKES AVOIDING 11lf IlAMAGING EffICTS Of EXPOSIJR£ ASIM· Pl£ MATTIIl OF lAKING PROPBl PRECAUTIONS.

it is necessary to remove clothing, cut it free rather than drag it across 1I1e injUl)' site. If tlle burn is minor, cool tlle injury lvith cold water and sterile compresses, and bandage lightly or leave exposed if tlle skin is not damaged. Do not open blisters. Bandage around them to prevent them from being rubbed. If the bum includes other skin injury, such as a wound, seek medical attention. Bumed victims will chill easily, and severe bums can be accompanied by hypothennia. With these ancillary effeclS, it is easy to see why burns are pernicious. Although bums are rare diving injuries, they are not unusual around machinery. Most divers use boalS to enjoy the activity, and engines are hot. Be cautious. Like accidenlS, the best bums are tllose that never happen.

MARINE ANIMAL INJURIES Media aside, there are few marine animals that attack divers \vith any frequency, and even those notorious ones, sharks for instance, are usually far more interested in other things tllan you. in addition, tlleir congregating habilS and usual behavior are widely known. Divers who seek out the thrill of encountering


FIGURE 12-9. LOOKS AND REPUTATION EXAGGERAT£ THE RISK OF BEING BmEN BY THE BARRACUDA.

large pelagic creatures, sometimes even including feeding the animals, are aware in advance of the risks they are taking and willing to assume them. If they are injured in the process, however, it may be up to you as a rescuer to deal with the injury, and possibly the creature or its mates as well. Most animal injuries are actually tlle result of blundering divers' encountel~ with tlle animal's natural defenses. Divers know not to stick tlleir hands into dark holes undel\vater, for instance, lest they encounter a biting creature, but some still do. Removing the hand from the crevice lvitll an animal attached by tlle teetll is not Iifetllreatelling in itself, but the natural reaction to flee, Cilll easily be. Neglecting to exhale during tlle sprint to the surface, or at least completely disregarding tlle recommended ascent rate and lvinding up witll a diving malady or lung overexpilllSion injury is possible. 11le bite becomes secondaI)' tllough contributory. Even so, divers 11111 be injured by Mimals from time to time (figure 12-9).

Bite Divers should investigate illld be prepared for injuries from any dangerous marine animals in the areas where they intend to dive. Local dive operators will usually have extensive knowledge of hazardous local creatures and the best means of dealing lvith accidents that involve them. Seek this infonnation.

It is also an excellent idea to learn about the area you intend dive first hand by ing a diving party organized by a local dive shop. TIle guide on this excursion will most likely be a good source of infonnation on any particular hazards indigenous to the area, including those represented by marine life. All bites carry a high probability of infection from organic material. Flush the wound and seek medical attention as discussed previously under wounds. The notable exception is a bite from a venomous sea snake such as found in the PacifiC, or increasingly, tlle western Caribbean spreading out from the eastern end of the Panilllla Canal, or from a freshwater viper like tllose found in the river deltas of the southeastem United States. Bites from the sea snake carl)' neurotoxins that can quickly paralyze and kill a victim. Life to sustain the victim's circulation and breatlling during transport to emergency medical care lvill undoubtedly be necessary. There is notlling else a first aid provider can do, other than to wash the area, keep the victim calm and comfortable, and monilor the progress of the venom by noting the swelling_ At some point, life may become necessary_

Stin s. U~ChiqS,

Jell~ish

dRays

Stings Cilll occur from sea urchins or jellyftsh, usually, or inadvertently stepping on a ray as il basks in the wann shallows. TIus can be avoided by doing the "stingray shuftle" as you walk in the shallows (ftgure 12-10). Urchin spines break off easily and can remain imbedded in the wound until absorbed by the body. "Tattooing," pennanent stippling of the area, can occur because of the pigment in tlle spines, but since it is usually on tlle bottom of the foot, is not a great cosmetic issue. Though not a serious injury, urchin spines hurt. Wash the area with as hot water as the victim can stand, and apply vinegar or meat tenderizer to the wound site to relieve burning and itching that will accompany the sting. Soaking in hot water, but not hot enough to itself bum the skin, but as hot as can be tolerated, for twenty to thirty minutes, is reconunended for stings from venomous fish. Jellyfish sting, particularly those of me colonial ani-

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FIGURE 12·10. SHUFFLING YOUR FEET Will FRIGHTEN STING RAYS AWA~

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mal, tlle Portuguese Man-o-war, a large siphonophore, can be serious enough to cause shock if enough of tlle body area is affected (figure 12-1 I). The marks will appear lacy and red, generally criss-crossing the site with welts. Scrape the remainder of any organic materiaI from ilie site with a credit card, dive tool or the like. Do not use your hand since you will be stung by the residual stinging cells (nematocysts), as will the victim upon whose skin they lie! Once the organic matter is completely removed, flush ilie area wiili hot water, ilien use vinegar or meat tenderizer to prevent further injury. Monitor ilie site for signs of infection as it heals. If accompanied by a wound, seek medical attention. Since the tentacles, actually the colonies of the animal that culminates in the sail, can hang 5or more meters (15 feet) below the surface, divers can be badly stung on ilie head, face and neck. Treatment is ilie same, but more difficult since delicate areas of tlle face can be affected. Fortunately, ilie dil'e mask protects ilie eyes and nose, but ilie lips around the regulator are susceptible to severe injury, and handling ilie tentacles will also cause the injury to spread, even into the eyes. This is extremely serious and requires medical attention. Sting rays really do not sting so much as react to molestation. Stepped upon, a long saw-toothed cartilage barb, normally sheathed in ilie skin at ilie base of ilie spine where ilie tail begins, whips up causing a more or less deep, ragged wound with venom present. There is extreme pain and burning. Clean and treat ilie wound as any oilier, but use hot water soaking as first aid for ilie envenomation. Get medical attention.

AGURE 12·11. JEllY ASH STINGS CAN PRODUCE AWIDE RANGE OF SYMPTOMS FROM lOCAll1HllTCHlNG TO CARDIAC ARRESI

GAS TOXICITY "Bad air" is rare, but can occur (figure 12-12). Bad air is usually air iliat contains an unacceptably high level of carbon monoxide, or may contain oil or otller contaminants. In any case, breatlling this underwater can cause grave harm, as breathing CO can at the surface, too. Carbon monoxide binds lightly with hemoglobin in the bloodstream, reducing its ability to carry oxygenlo the tissues. Symptoms include dizziness, nausea, vomiting, disorientation, muscle weakness, chest pain, headache and tinnitus. If it sounds like oilier diVing maladies, you've been paying attention. ~ortunately, the first aid treatment is also exactly the sanre, as is the next step. Give tlle I~ctim oxygen at as high an inspired partial pressure as can be attained, and send the person to an emergency medical center.

SEASICKNESS This is a debilitating misery for many dil'ers. Susceptibility to seasickness probably also keeps many who would otheflvise enjoy diving from even considering


•

f.---. ,

FIG 12·12 THE EASIEST WAY TO AVOID THE MOST COMMON PROBLEMS OF GAS TOXICITY IS TO ENSURE THAT YOU NEVER DIVE WITH QUESTIONABlf AIR.

the activity. In any case, there is little that can be done for a seasick individual apart from removing them from the environment that is leading to their discomfort (fig~ ure 12-13). Standing under a tree (solid ground) will work. Other than that, tmUlY seasickness nostrums are available over-the-counter. Some only work if they are taken before one becomes ill, since keeping anything down afte1\vards is unlikely. Dehydration can result from severe seasickness, and diVing is therefore, not recommended. Encouraging a seasickness victim to get in the water to relieve illness is usually unwise since it will rarely help the problem, the person is in a weakened state and probably not concentrating very well on anything but escaping the sick feeling being eX~rienced. Recommended home remedies include everything from soda crackers and ginger tea to acupressure. If ever you discover one that wocks, use it. Keep the victim as warm, comfortable and hydrated as possible, and explain the difference between windward and leeward for the comfort and convenience of companions. Fresh air is always helpful, and will keep areas indoors and below decks from becoming uninhabitable by anyone else.

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FIG 12·13 SEASICKNESS CAN STRIKE EVEN THE MOST EXPERIENCED PERSONS. SEEK FRESH AIR ON THE lfEWARO SIDE OF THE BOAT.

LIFE-THREATENING EMERGENCIES Unfortunately, there are times when the first aid work of the rescue diver is concerned with life-threatening emergencies. The remote location of even near shore dive sites, diving'S unaVOidable statistical risks, the propensity for human error and the consequences of mistakes in the aquatic environment and the heightened possibility for serious injury and illness tllat results from infrequent participation in strenuous exercise all contribute to this fact. Shallow-waler blackout, drowning, near drowning and secondary drowning, heart attack, stroke, convulsion, sudden death syndrome, diving maladies, lung overexpansion injuries and decompression sickness can and do occur, and it is a rescue diver or divers and other diving companions who most frequently first come to a victim's aid. First aid in case of these mishaps centers around ing life. While rescue breathing has been discussed, and cardiopulmonary resuscitation referred to, tlle next chapter puts these activities and first aid in general, into a modem paradigm appropriately called, "The Chain of Survival." But early recognition that one of these conditions may be presenl is the allimportant first step to helping a victim survive.

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I


Hearl Attacks Acute Myocardial Infarction (M!) was first identified as a disease rather than a consequence of aging early in this century, but only became a leading cause death in the latter half of the century. Epidemiologists argue the reasons for this rise in the problem, but most agree tllat poor diet, a generally sedentary lifestyle and stress are implicated along with some hereditary factors. Regardless, recognizing that an individual may be having a heart attack is the first and probably most important step towards saving a victim's life. Most people who succumb to heart attack deny or Ii"r'1 ignore the symptoms for an average of about two hours ~ before seeking aid. Many of these persons would undoubtedly survive if seen qUickly by an emergency physician. Heart attacks generally occur with acute chest pain, but often begin more subtly with a feeling of fullness or burning sensation in the chest that resembles acute indigestion. MI can also be indicated by radiating pain tllat begins in or around the left chest area and affects the arm, shoulder and jaw. Sweating, dizziness and nausea may also be present. Such symptoms are not terribly different, save for degrees of paralysis or numbness, that may be indicative of decompression sickness. Where decompression sickness, however will respond to oxygen, heart attack, although oxygen is usually istered, will not abate with its application. In any event, deciding between heart attack and decompression sickness is not an issue that a Diver First Aid Provider need be concerned with. RecogniZing that a heart attack may be occurring is. It is unlikely that the victim will not need life . Be prepared to prol1de it.

Stroke Acerebral accident that is characterized by blockage of a blood vessel and/or may include bleeding from the rupture of a cerebral blood vessel, the symptoms of stroke are the sanle as those of an arterial gas embolism. Again, telling the difference between the two is beyond the capacity of training for first aid, however, if the signs, symptoms and circumstances warrant, always suspect AGE in the diving environment. The initial treat-

184

ment for either condition is the same in any case, oxygen, life as reqUired and immediate evacuation to a medical facility. At that point, if AGE cannot be ruled out, recompression therapy will surely be started.

Drowning, Near Drowning and Secondary Drowning Although covered preViously as a rescue topic, it is important to understand the seriousness of the medical side of drowning, and the need for immediate emergency care and monitoring. Drowning is fatal. Near drowning is to almost die from drowning, and can lead to Secondary Drowning, itself life-threatening. Lung tissue is coated with a natural chemical, surfactant, that helps the delicate tissue maintain stability. This chemical is compromised by the aspiration of sea water. When it is, the lung tissue can be ovelwhelmed by fluid or easily infected by virus or bacteria (pneumonia). Asaved nealcdrowning victim can easily succumb to Secondary Drowning, suffering severe pulmonary insufficiency several hours after the incident.

BLANKETS, STRETCHERS AND FOUND OBJECTS As 111th removing an injured victim from tile water, anything available can be pressed into service, but having a real stretcher at hand as opposed to plank found on the beach is far better. Many rescuers are now carrying a roll-up litter that can easily transport a victim placed in it. Asimple canvas rectangle with hand straps sewn on, these litters can be very useful to have in even a minimal rescue kit. Popular beaches will almost always have litters or stretchers, and professional lifeguards to use tllem. Almost any beach frequented by people will have a blanket on it that can be put to good use. Place tile victim in the blanket carefully by rolling tile person to one side, and sliding an accordion folded edge of the blanket as far beneatll tile person as can be acccmplished gently. Let the person down onto tile back,


[t]

and then roll the victim in the opposite direction to reveal the folded edge of the blanket. Straighten the blanket so Olat there is enough to grip on either side of the victim. WiOI Ole person centered as squarely on the blanket as possible, roll the edges of the blanket under again to give rescuers a better handhold. Position rescuers as for a two, three or four person carry Lift in coordination, and move the victim. Again guard against back injury by maintaining an erect posture while lifting.

185

CHAPTER

The Chain 01 Survival in Diving Accidents


LEARNING GOALS In this chapter you will: I. Learn about the "links" in the "Chain of Survival." 2. Review the procedures for perfornling Cardio-PulmonaJY Resuscitation (R) . 3. Review the procedures for relieVing an obstructed ailway. 4. Understand the problems of performing compressions. 5. Understand the problems that are generally associated with R. 6. Be introduced to tlle effects of cold water on drowning victims.

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Successful rescue, remOVing a person from imminent hann, is only tlle first step in saving the life of a ~ diVing accident victim. Excepting instances of assistance, fortunately the most common of rescues, diving victims are frequently seriously injured. RemOVing the victim from the danger presented by water, and then getting the person to necessary medical care go hand in hand. In the interim, keeping the victim alive until the arrival of EMS or during transport to a medical facility is the job of the rescuer. There is no factor as detennining of Slllvival as the speed witllwhich emergency medical care is initiated (figure 13-1). Rather than tllink of this as the exclusive province of emergency medical techniciaJls, nurses or doctors, hOlvever, the NAUI Worlffivide certified SRD or ASRD needs to include her expertise and training in the unbroken chain of immediate care that is crucial to saving a life. For diving rescue, the links in this chain include: • swift recognition of a life-threatening condition in or under the water • rapid effective intervention and resolution of the presenting problem • immediate slllface assessment and appropriate aid including establishing buoyancy aJld insuring breatlling while removing tlle victim from tlle water • activation of the emergency medical system at the first opportunity • first aid, usually including oxygen istration,

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188

FIGURE 13-1. EVEN IF THE INJURED DIVER IS CONSCIOUS AT THE SURFAC~ THE POSSIBILITY OF LIFE-THREATENING EMERGENCY OE'lllOPING IS HIGH.

reqUired basic life and R • early defibrillation when appropriate • emergency medical care and advanced cardiac life • immediate, medically supervised recompression TIle follOlving is a review of the techniques of R for infonnational pU'lloses. Emergency medical autllorities review and establish new protocols for rescue breathing, R, defibrillation and emergency first aid and cardiac care regularly. NAUI Worldlvide rescue divers should maintain current certification and proficiency in tlle techniques in order to perform adequately in case of need.

CARDIOPULMONARY RESUSCITATION The object of R is to maintain the oxygenation of vital organs, primarily the brain and heart, when the heart stops by combining rescue breathing lvith external heart compressions. By forcing blood through the circulatory system and air into the lungs, a victim in cardiac arrest may be maintained by a qualified first aid provider until the victim's heart and lungs resume function, or until more qualified medical care providers arrive to assess and aid the victim, or until the first aid proVider is unable to continue because of exhaustion.

1m

Chapter 13· The Chain of Survival in Diving Accidents

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Tissue damage and deatll cannot be delayed indefinitely by R even if perfectly perfonned since there are many more complex functions to life than simply supplying oxygen to primary organs. In fact, R is only effective at sustaining life for a relatively short time, and without defibrillation, especially in cases of heart attack, may not be effective at all. Perfectly pelfomled extemal chest compressions only supply about one tllird of the nonnal flow of blood. Rescue breathing unsupplemented by oxygen istration only delivers about 16% oxygen to a victim, the amount remaining in expired air. Nonetheless, rapid inception of R is the only chance tllat the victim has, and is the accepted protocol for emergency care at the level at which SRDs or ASRDs operate. To have any chance of success, R must begin as soon after the heart ceases to function as is possible. The longer the wait, the dramatically less chance of survival of the victim. Seconds can be crucial, and R initiated after 10 minutes of no heart beat is for the most part useless. Almost half of cardiac victims who receive R within 4 minutes of the heart stopping, and then advanced care within the next 8 minutes will survive. Response times like tllese, however, are rare outside a hospital setting. On the more positive side, about I in 5victims that receil'e R within 10 minutes and advanced care within the next fifteen, do sUlVive. Except in dive training, an exceptionally low risk aspect of recreational diving, or in near shore diving in well-populated areas selVed by extensively developed, well-trained and -equipped emergency medical care systems, such response times are unlikely.

PERFORMING R

Before beginning (the rescuer must detennine it is necessary. The victim should not be breathing, nor have a detectable pulse. You should never perfonn R on a victim lvith a pulse. 1. Attempt to rouse the victim by tapping on the

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HGURE 13·2. CHECK FOR THE PULSE FOR AT [fAST 5SECONDS.

collar bones and calling out to the victim. If there is no response, and it has not already happened, activate the EMS system. An unconscious diving victim needs rapid emergency medical care no matter what the problem. 2. Open the aiIway by tilting the head back and lifting the chin. Look at the victim's chest while listening ,md feeling for breathing lvith your face close to the victim's for 5seconds. If the victim is breathing, monitor the person while awaiting emergency aid. If this is possible, use the ratio of I breatll to every 5 compressions. 3 If the victim is not breatlling, give two, deliberate breaths of approximately I to 2seconds duration while obselving tile chest to see if it lises, and pinching tile nose closed to insure tllat air entel~ the victim. If presen~ a Pocket Mask or similar device may be employed. If oxygen is presen~ use it. If tlle breaths do not apparently enter the 11etim, re-tilt the head and ~heck tlle ailwav, and attempt two more breaths. 4. Check for a pulse by sliding your index and middle finger down on the same side of the victim upon which you are kneeling, and attempting to locate the carotid pulse in the

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189


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AGURE 13·3. PROPER HAND POSITIONING IS CRUCIAL TO MINIMIZING INJURY TO THE VICTIM, AND TO MAINTAINING CIRCUlATION.

groove at the side of the throat. Check for the pulse for at least 5 seconds (figure 13-2). 5. if there is a pulse, continue rescue breatiling at tile rate of one deliberate breatil eve!)' 5seconds. Check tile victim's pulse eve!)' minute to insure that tile heart is still beating. Continue until emergency medical help arrives or the victim begins breathing unassisted or you are exhausted. 6. If tilere is no pulse, begin chest compressions. Find the hand position by placing your middle finger on tlle victim's chest at the bollom of the rib cage closest to you, and then slide the finger up towards the center of tile victim's chest until you reach tile notch. With your middle finger in the notch, place the palm of the hand closest to the victim's head adjacent to the index finger of the hand locating the notch (figure 13-3). The heel of tile hand will be on the stemum about two finger lvidtilS from the notch in the victim's chest. Interlock tile fingers of the locating hand lvith the hand on tile chest, and begin compressing. 7. Attempt to compress the chest about Illz to 2 inches in adults lvitil tile anns straight and the shoulders over the hands. Motion should be smootil and piston-like. In adults, a rate of 80 compressions per minute is recommended. Give

170

fiGURE 13·4. UNLESS AIR IS ENTERING THE VICTIM, NO AMOUNT Of R WIU HELP. ENSURE THE AIRWAY IS CLEAR BY OBSERVING THE VICTIM'S CHEST INflATION WHILE PERfORMING RESCUE BREATHING OR R.

two deliberate breaths after each 15 compressions. 8. After 4sets of compressions and breaths, (about 1 minute) re-check the pulse. If there is a pulse, continue rescue breathing at the rate of one breath every 5seconds unless the victim begins breatlling without assistance. If there is no pulse, restart R compressions. Re-check the pulse again eve!)' two or three minutes thereafter. Two crucial conditions must be met for R to be considered successful: I. Air must be introduced into tlle lungs 2. The stemum must be sufficiently compressed to force blood through the body (figu~ 13-5).

Aproblem that may be encountered is when a foreign body lodges in the throat obstructing the airway. This mal' be the result of vomit, or of ingesting something such as the whole or parts (bite tabs) of the mouthpiece on the regulator'S second stage, or both. In this case, the airway must be cleared before perfonning R (or rescue breathing). Acombination of abdominal thrusts and finger sweeps is recommended. ~

m

Chapter 13- The Chain of Survival in Diving Accidents

I. aleCk jor bretllbillg by lookillg. lislellillg, alld jeelillgjor 510 10 seaJllds.

2. Make sure Iba/the (Jitlll(l)! is clear; Ii/I head back

as ,IJOI/'II. Give II/V jllll, deliberale bret/lbs.

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J C1xd el/lvlidpllisejor 5 10 10 secollds. if 110 plllse, proceed 10 lbe lIerl slep. albemise COIItinue with mouth-Io-moulh respiration

5. /)0 15 rompressiolls alld Ilro brealbs Repeal Ibis cycle 4 limes. Jar aboul one minute.

4. Posilioll s1JOlllders OI'eI !Jalllk; localillg Ibe compression /l.

6. ClleCk jor bret/lbillg alld pllisejor 5 10 10 sWllds; continue fiJith more sets ofcomprariSio1lS (lnd breaths

if' WCessflfJl. FIGURE 13-5. All RESCUE DIVERS NEED TO MAINTAIN CURRENT CERTIFICATION IN R.

171


-

Sometimes it is the victim's tongue that is lodged in the back of the throat preventing air entering. If this is the case, finger sweeps, or finger sweeps and ahdominal thrustl can usually dislodge it (figure 13-4).

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ABDOMINAL THRUSTS With the victim lying on the back and the rescuer straddling, the rescuer places the hands below the rib cage above the abdomen at the base of the diaphragm and thrusts forcefully upward. The maneuver is repeated several times, and is an attempt to use air trapped in the lungs to expel the blockage by forcing the diaphragm to compress the lungs. Re-check the mouth visually, but be cautious of using a finger sweep unless the object is identified visually. A"blind" poke can well again lodge whatever may have been expelled. If air still cannot be forced into the victim, repeat the thrusts.

Problems with Compressions Injury to the chest and ribs is the most common problem with istering R, and is largely unavoidable. What can be done, however, to minimize the chance that injUry will be severe is to place the hands carefully each time the chest is to be compressed to avoid driVing the tip of the sternum into the lungs. Sometimes injuries to organs other than the lungs can occur as a by-product of improperly performed chest compressions. l1lese injuries include lacerations of the spleen and liver, as well as punctures to the lungs. These can be minimized by insuring that compressions are perfonned straight up and down, rather than angling into the victim, and by avoiding pressing too deeply into the chest.

Problems with R in General The biggest problem from a victim's standpoint is that tilere is little likelihood that R by itself will actually save the person's life. From the rescuer's standpoint, the biggest problem is fear. Rescuers are often reluctant to begin R for a

172

variety of reasons, most of them stemming from various apprehensions. The fear of hamling the victim, the fear of contracting a disease and the fear of failure, are all cited in studies of people's responses to emergencies. Of these all, the fear of disease or contamination is the most rational, and can be prevented by observing precautions like bodily fluid isolation using gloves and whenever available, an appropriate mask. Fearful or not, failure is assured if no attempt to aid a victim is made. And there is no greater harm to be done to the victim than death, a state the unfortunate person has already entered without any assistance from the rescuer. Other problems that can occur include gastric distension from overly enthusiastic breaths or breathing into a partially obstructed airway, gastric acid aspiration from tile rescuer inadvertently forcing vomit into the victim's lungs or from the victim vomiting while lying on the back or forcing water into tile lungs by performing rescue breathing or R on an individual with water in the airway, an unfortunate consequence found in drowning victims. Using the usual precautions of looking into tile victim's mouth, maintaining an open airway, observing the chest for the effects of istered breaths, making an effective seal each time a breath is istered, especially when performing rescue breathing in the water, and cleaning the victim's mouth if vomitus is present will obviate tilese issues for the rescuer.

COLD WATER DROWNING

,"

Much has been made about the effects on humans of coldwater and the miraculous revivals of individuals who have drowned therein after seemingly impossibly long periods of time. Acold-water drowning victim is a good candidate for R if: • immersion has not exceeded 60 minutes • the victim is young (under about 10 years of age) ~ • R will not unduly delay necessary re-wamling • the procedure will not put rescuers unduly at risk

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173

CHAPTER

Accident Management

NAUI Scuba Rescue Dive~

LEARNING GOALS In this chapter you will: 1. Learn the basic questions a rescuer should ask to begin planning to manage an accident 2. Be introduced to the systems on which emergency communications rely. 3. Learn tlle "4 A,s" of rescue. 4. Understand emergency management and evacuation procedures. 5. Be introduced to tlle issues of victim transfer during evacuation. As Witll any successful diving excursion, a successful

rescue and the subsequent survival of the victim, begins witll a detailed contingency plan. While rescue is essentially a creative act, having the elements available to syntllesize to meet the existing needs is the result of careful foretll0ught in assembling necessary items. Those iteITIS include everything from tlle first aid kit and oi-)'gen istration equipment available, to the training in tlle use of tll0se implements, and the identification and direction of available personnel resources. No single plan element is any more important than any other in that the absence of even one can hamper or destroy tlle chance of success. Shakespeare's adage "For want of a nail ... " is as tme in rescue as it was in the loss of a kingdom. At the same time, well-meaning rescue divers may be far "oveIrepared" for tlle l)1Je of diving anticipated. 'JYpically appearing at a dive site with duffel bags full of specialized gear, these "techno" rescuers seem more prepared for an anned assault than a scuba dive, especially since the vast majority of dives are trouble-free! Striking the balance between the two extremes of having too much or too little on hand to do the job that may arise, and as importantly, suitable for your level of expertise and involvement is the first part of accident management

EMERGENCY PLANNING BEFORE THE DIVE ~

IaiiilI

178

Identifying the needs you may have to meet beforehand helps to insure that you will be equipped and prepared to react in an emergency. You will need to

fIGURE 14-1. ANY lARGE SCALE DIVING OPERATION, WRATEVER ITS PURPOSE, SHOULD HAVE ARESCUE PlAN IN PlACE THAT INCLUDES TRAINED RESERVE PERSONNEl.

answer several important questions to fully anticipate what might be needed later. Chief among these is your position in the dive. As a diving leader with some duty to react to a problem, your preparation is depended on by the people paying you, be they students or other divers. As an SRD diving with a buddy as part of a largeI; profeSSionally led diving excursion, there is clearly less expected of you - though chance may well make you the person initially respondIng to a diving incident or accident l Because of the disparity that can exist, it is wise to begin your planning by asking basic questions: • What public or private resources may be available to aid an injured diver in case of an accident? (figure 14-1). • How can these resources be activated, and how long will it take at the outside estimate to have them on scene, or to transport a victim to required care?

Chapter t4- Accident Management

FIGURE 14-2. PORTABLE RECOMPRESSION CHAMBERS SUCH AS THIS CAN MAKE THE DlFmlENCE WHEN DIVING IN AREMOTE AREA FAR fROM SOURCES OF AID.

• Is there anything about the dive's participants, planned activity, timing or location that indicates an unusual need for vigilance or preparation? • who is responsible for the overall planning and execution of the event, and to what extent am [ expected to participate beyond my usual planning and preparation as an individual diver? • What additional risk factors, if any, are present on this dive?

Communications No matter what the level of availability of aid, ing it in a timely manner is often the singlemost crucial activity that a rescue plan entails. All diving is remote in that there are, as yet, no telephones undelWater! In a diving accident, the victim's survival depends on immediate care followed by swift emergency medical treatment (figure 14-2). Reliable communication with appropriate care providers or profeSSional rescue units is of vital imparlance (figure 14-3). ~ Marine communications depend primarily on three ailI different systems, all of whicll can access the same resources. VHF Marine Band radios are limited to line of sight ranges up to about 20-25 nautical miles depending on several factors. These include the height of the transmitter's and receiver's antennas, the power of tile base

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FIGURE 14-3. THE FASTER THAT PROFESSIONAL SERVICES CAN BE NOTIFIED OF YOUR NEED FOR ASSISTANCE, THE BffiER THE CHANCES OF ASUCCESSFUL OUTCOME.

station, legally limited to 25 watts but often working at less than optimal effiCiency due to factors like corrosion and battery power, and atmospheric and environmental conditions. Single Side Band (SSB) communications offer far longer ranges, but in of dive rescue, may be less useful in that ing a rescue resource several hundred miles away for anything other than medical advice does little to aid a victim On the other hand, SSB, like amateur radio (so-called HAM radio), can easily interface with the telephone system. It is possible to use SSB if available, if normal VHF is not effective, to local resources in this way. Finally, the ubiqUitous cellular telephone, some with dedicated marine networks, also has its place in offshore diving (figure 144). Rather than using the usually low-power handheld unit, however, the stronger base-station type model that is found permanently mounted in automobiles is a good addition for a dive boat. Rescuers should be familiar with standard radio communications protocols, and if not licensed themselves, had best operate such equipment under the authority of duly licensed individuals. Shore-based or inland diving eventl also need effective communications with emergency care providers. The public telephone system in tile U.S. is extensive, but obviously a great deal of diving goes on outside the U.S.

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177


Other countries' phone s}~tems are often equally-well developed, but may be unfamiliar in their operation and in their currency. Language barriers may also pertain. All of these factors should be resolved in advance. DiVing around national seashores is usually controlled by the U.S. Park Selvice, a well-organized, responsive organization of professionals. Access to the park rangers could well be tlle first step in activating a successful res~ cue. Many parks rely on Citizen's Band radio for extended communications, or at least monitor those frequencies for emergency response.

m

Equipment What you wilt need as a rescuer is similar to what you will need as a well-prepared divel; but also includes tools specific to the possible tasks the rescue may include. These can be an}1hing from oxygen and first aid kits, to emergency communications devices, rescue litters, throw bags (figure 14-5), emergency signaling devices suitable for the area or anything else tllat you may be required to use. This will of course depend on your level of responsibility for the otller divers in the group. As a leader, you will be depended upon to have it all in place. As a rescue divel; you need only carry what you feel you might need for your personal use and possibly to aid a buddy with whom you may be diving. Even though your responsibility may not extend to others in the group, your skills and training can help to relieve the group's leader in case of an emergency. It is wise to become familiar with the resources tlut are in r=-2"iJlace for rescue on any diving excursion in which you ~ participate better to be in a position to offer aid in an emergency. Introduce yourself to the people in charge of the event as a rescue trained and certified person. Asking to look over the emergency kits, including first and oxygen, is most likely to be agreed to since professionals kilow that effective assistance is an important asset in an emergency. Then too, given the statistical nature of diving maladies, and that even diving professionals are subject to the sanle human frailties as anyone else, the group leader is not immune from being the victim of an accident. Your skills may well make the difference in the

178

RGURE 14-4. IN DIVING AREAS CLOSE TO lARGE POPUlATION CENTERS, THE EffECTIVENESS OF MOBllf PHONE MAY SUFFER UNlfSS THE INFRASTRUCTURE IS UP TO TlIE OEMANOS.

FIGURE 14-5. LOW-TECH AND RELlABlf, ATHROW BAG CAN BE INVALUABlf IN EXTENDING ARESCUER'S REACH TO ACONSCIOUS VICTIM, OR TO ANOTHER RESCUER AIDING AN UNCONSCIOUS DIVER AT THE SURFACE.

outcome of that person's rescue. All diving leaders would do well to consider this.

Other Trained Personnel Diving attracts a wide variety of people from many different professional venues. Not surprisingly, many of the paJticipan15 at any large scale diving event have

Chapter 14- Accident Management

rn

medical backgrounds or are trained in aspects of emergency response from crowd control to evacuation. Whether as physicians or nurses, or as municipal employees like police or firefighters, these individuals can be invaluable in an emergency situation. They will have the training and the experience to provide assistance in many ways. TIley can provide care beyond first aid, for instance, or be competent to direct emergency responders in their evacuation efforts. In any case, identifying tllese people and including them in an informal, mental emergency plan is a wise exercise that can save valuable time later.

Emergency Management Procedures Once resources have been identified, procedures need to be developed that will allow necessary responses to now smoothly and eFriciently. The paramount consideration in fonnulating this skeleton plan is the I.\:::!;;;;;I safety of the participants. No rescue plan or protocol that places rescuers unduly at risk is acceptable for any reason. Trading the well-being of a rescuer for the possible well-being of a victim is a poor gamble. The sad trutll is that not every rescue can be made, nor every victim saved. Difficult as the choice may be, it can be more appropriate to wait for professional rescuers tllan to enter the water to aid someone. This is often the case with a missing diver overdue by more than minutes, one who may have ventured into an overhead environment without proper training or eqUipment or one who has far exceeded planned time or depth limits. The dive that caused the problem, if such is the case, is the same dive that the rescuer is planning to make to aid the person. No rescue can be effected without a coherent, wellconstructed plan. Fonnulating one on the spot will take time, but it is time well-spent. Consider the time for planning as pM of the rescue effol1 in the same way that taking a moment to put on swim fins and a mask and to grab a noat or rescue sling prior to jumping in to aid a diver in distress at the slllface is. Without spending the critical planning time, the rescue is likely to go awry.

m

.

THE 4A'S OF RESCUE Assess Appoint Act Assessing what needs to happen at a rescue site is no simple matter. Unlike reacting to distress yourself, you are assuming responsibility for the direction and welfare of others. Their confidence in your ability will help tllem to perf01111 appropriately in the sanle way that tlleir lack of confidence in your plan or assessment will undennine their effectiveness. As with individual intervention, plan for the least amount of activity necessary to achieve the goal. Marshall and commit resources carefully. Using the same example of a diver in distress at the surface, if there are three rescue qualified divers available, including yourself, having everyone in tlle water at the same time may leave the situation unstable. What if the diver's buddy is underwater and needs help? What if another dive team surfaces far off and signals distress? If there are several people available at the site, it is always a wise decision to have someone recording the event. Documentation at the accident will definitely help emergency care providers triage the victim more effectively, and speed care. [t will also make a difference later during any outside assessment of your actions or the actions of anyone else who participated. Instruct a diver or otller person present who is in no way related to the victim or rescuers to record simply what happens, noting who, what, when and how for each step of the rescue. When the victim is out of the water, have this person accompany you and record the interview, if any, and

178


AGURE 14-B. WHEN SEflIOUS INJURIES ARE PRESENT, THE PROPER EQUIPMENT, SUCH AS ABACKBOARD FOR APOSSIBLE SPINAL INJURY, SHOULD BE EMPLOYED WHENEVER POSSIBLE.

the intelView of the diver's buddy or anyone else present who can shed light on the events. Names and addresses of persons intelViewed should be included. Otller items that need to be recorded include the time the incident occurred, the sequence of events and any care provided or offered to the victim or anyone else who was part of the event. Document refusals as well.

EVACUATION PROCEDURES More often than not, the victim of diving accident is picked up at or nearby the dive site by emergency medical providers, professional rescuers or both. Depending on the venue of tlle dive, these personnel may arrive by land, sea or air. Each mode of transportation has unique requirements from the rescue coordinator's standpoint, but all have a common goal: swift removal of a seriously injured individual to an appropriate emergency medical facility without causing tlle victim flllther hann. Your role in achieving this goal will val)' greatly

180

with the circumstances of the event (figure 14-6). ~Iost of the time, tlle professionals who arrive on scene will direct the action from that point on. Even so, knOWing how things are likely to go will help you to insure that things go as smoothly as possible from the standpoint of the initial rescuer. Besides this, there may be actions that you or others under your control take that will shorten the response time or otherwise speed the process. In the same way that you need to assess what is needed for the rescue, yOU must assess what is the most expeditious way to get an injured diver to needed care. It is entirely possible that waiting for an ambulance to arrive at the dive boat's usual dock is less efficient tllaIl having the boat dock at the nearest marina aIld taking a ta.xi or a conunandeered pick-up truck to a nearby medical center. Given radio communications, cellular telephone selVice and the like, emergency medical personnel can also be easily routed an}~vhere. Patients can always be moved closer to home or to a favored prOVider when their condition is stabilized, but delaying treatment can turn a patient into a fatality. Traffic patterns are also affected by holiday schedules, public events, and the time of the day. An ambulaIlce will move faster th;Ul nonml traffic in rush hour, but far slower than a helicopter even at a greater distance. Tune to treatment is the governing decision fac- ~ tor, not geographic proximity. In this sanle vein, it is essential that the emergency medical dispatcher with whom you speak understand, that the victim has suffered a water-related or diving accident. Giving that infollllation \\ill enable the person to make a better choice of medical destinations for the victim (figure 14-7). If there is apparently no under~tanding of the.vlctim's unique needs from the initial , ask io speak with a medical supelvisor who is much more likely to understand. If that doesn't work, refer the supervisor to DAi'J's emergency number where treatment protocols can be authoritatively explained. If possible, get the victim moving towards care while this all takes place.

Assisting the Diver Durmg the Evacuation If circumstances allow it, haVing someone accompanyan injured diver to the care site is highly recom-

Chapter 14· Accident Management

fiGURE 14·7. WHILE YOUR QUICK REACTION AT THE SM Of A RfSCUE IS CRUCIA~ ITS EVENTUAL OUTCOME MAY MOVE OUT Of YOUR CONTROL TO PROfESSIONAL ASSISTANCE AND EVACUATION SElNICES. PLAN fOR ASMOOTH TRANSmON.

mended. This person should bring a copy o[ the record that was made o[ the events of tile incident, if possible, or may be entrusted with the original if the rescue coordinator feels that it will be returned. If the victim will be transported by you, it is always better to have other persons accompany you and the victim to attend to any emergencies that may arise in the course of the transport. TIlese events can include the need for life- or continuing first aid so the individual chosen to accompany should have these skills ~ or the ability to pilot tile vehicle so you can care for the victim.

Victim Transport and Transfer Ii"fI"1

W

Rough handling of any diving accident victim can be an invitation to disaster. Jt may hasten shock or lead to cardiac arrest because of the diver's diminished capacity. Oxygen being provided to tile victim may be interrupted momentarily, but should be continued, if necessalY, until the victim is transferred to medical personnel who assume control.

The injured diver with a suspected diVing malady should generally be maintained in a horizontal position. Consider this when choosing a vehicle for transport. If life including R becomes necessaJy, having the victim in the back seat of a compact car may make it impossible. Having to stop enroute to the hospital will delay treatment, but may sometimes be unavoidable due to this necessity. If the victim is leaving the dive site unaccompanied, pin the infonnation about the incident, including ~ the patient's information, the sequence of events and ~ appropriate information into the blanket around Ii"'I""'1 the victim. Notify the receiving authorities that it is ~ there so that it can be immediately removed and utilized to continue the victim's care. Most of the time, the rescue coordinator will stand back from the actual transfer of tile victim. On a boat, the captains and crews of both vessels are generally far better trained and equipped for this highly specialized task than the SRD or ASRD. But generally does not mean invariably. You may have more experience or a better understanding of what needs to happen than do responders at any point in any incident. Never assume that the responder's uniform confers common sense or unusual skills or knowledge upon them, or tilat they are immune to mistakes. Would this were the case. Your responsibility as a rescue coordinator or rescuer is to the well-being of the victim and all who participate on the victim's behalf. Inte~)ersonal communication skills aside, do not be shy about advising a apparently misguided professionals efforts if you know better! That caveat notwithstanding, it is usually better from everyone's standpoint to let the professionals direct the transfer. The following are proVided for infornlational PU~)OS es only.

Boat 10 Boat Transfer The chief problem in moving people and eqUipment [rom one vessel to another offshore is that neither vessel will stay still, even if they are lashed tightly together In fact, tile size and types of the vessels involved may make fastening them together impossible in any case. If so, it may be necessary to actually trans-

181


fer victims from the boat to the water, and then to the boat. This is obviously highly dangerous for all concemed, and generally only attempted as a last resort. Under such circumstances it might be preferable to have a medic board tlle vessel with the victim as it makes its own way to harbor. If the boats can come alongside efficiently, the transfer will usually take place at a point where the deck levels are relatively parallel. An exception may be made when the rescue vessel has a crane onboard that can be used to pick up a litter with a victim lashed into it, and bring it across. Short of this, handing the victim over the side to waiting pel~onnel on another boat is a precarious procedure under the best circumstances. While the respective captains may be highly skilled, it is also possible that the captain on the dive boat will be the victim. Hopefully, a well-qualified mate will be on hand to take over. If not, the task may fall to the rescuer. In that event, it may be preferable to request a stand-in boat handler from the responding vessel rather than risk substantial harm to any of the cooperating personnel, or real damage to either or both vessels.

Boat to Dock Transfer This is obviously a much simpler and far preferable process than moving a victim from one boat to anotller. Even so, accidents can happen. Avoid most of these by following some simple rules: • Know where everyone aboard is, and make sure the side of the vessel that will come alongside tlle dock is clear. • Make sure tllatthe vessel is completely secure before attempting to transfer the victim or go ashore to meet responding aid proViders. • Insure that the victim is monitored tlll'oughout the process, and so long as the individual is in your custody and control.

Boat to Shore Transfer Sometimes a small boat, especially one with a relatively flat bottom, can be very effective in getting a diving accident victim qUickly to treabnent. In this activity, knowledge of the road system and the coastal shore line

182

is invaluable. Transfer the victim into the small boat, from the larger, or into the small boat initially if necessary care, including possibly needed life , can be provided there. Insure that emergency medical providers are notified, and are familiar with the area to which you are transpOtting the victim. Estimate how long the trip will take you, and work out some altemate means of communication between tlle main vessel, the small boat and the emergency responders. Handheld radios or cellular telephones are excellent for these purposes. Bring tlle small boat directly to the shore, grounding it if necessary. If not anticipating haVing sufficient aid at tlle shore, bring assistants along in the small boat consistent with its safe loading and accepted maritime practice including carrying appropriate lifesaving equipment. Wait until directed by authorities to debark the vessel; ladders or ramps should be securely in place under most circumstances.

Air Evacuation Having a victim airlifted from a remote dive site near a jungle air strip is, fortunately, in the realm of fantasy for most. The reality of such events is immeasurably more frightening than fascinating. It is much more likely that a victim will succumb under such circumstances than survive. Air evacuation from a near shore air smp is, however, a real pOSSibility in many popular diving areas. The main precaution to take in this case is to insure tllat the pilot of the aircraft understands that maintaining tlle victim of a diving malady at as Iowan altitude above sea level as practical for safe flight, is mandatory. WitllOUt pressurization to keep the victim as close tp·sea level ambient pressure as possible is likely to severely i~orsen tlle victinl'S condition. Also, using a small plane makes lying the victim down in tlle prefwed position and providing life , if needed, difficult if not completely impossible. Having to make this kind of decision is, at best, uncomfortable: tlle victim may expire if not evacuated, but if evacuated under tllese conditions is at greater risk.

Helicopters Helicopters significantly increase the ability to deliv-

Chapte~

er emergency aid to otherwise inaccessible locations, and also signifiGUltly expand the possibilities for medical evacuation by air. Able to retrieve seriously injured or disabled persons from land, sea or boat, the modem helicopter equipped as an airborne ambulance is a wonderful tool that has saved many lives that would otherwise have been lost (figure 14-8). But many helicopter cre\l~ and others involved in rescue mission have also been lost, some of these due to avoidable errors. Rescue helicopters are built for speed and maneuverability, generally equipped with sophisticated guidance and tracking systems, stellar communications ability and staffed by highly skilled, superbly trained technicians and pilots. Dive boats, or parking lots, usual pickup sites, aren't as well fitted-out, or as well staffed. Because of this, most of the time it is imperative that rescuers and rescue coordinators scrupulously follow the directions of the crew for recovering any victim. The problem is magnified when tile ground personnel are not in with the aircraft. The following are general guidelines, only.

Airlift from aVessel 'nle aircraft will most controllable when moving ahead into the \I~nd. The vessel should make due speed in this direction, or come to tilis direction when the helicopter is on scene. All external antelmas, outriggers, flag poles and masts that can be removed should be. The deck area around tile victim's pick up area should cleared ,md free of all loose eqUipment. No persOimel except tilOse directly involved in tile transfer should be present in tile area. Those in the area should be equipped Witil ear and shatterproof, well-secured eye protection, if possible. (Diving masks are generally not recommended for tilis purpose.) Rescue helicopters will often lower a coordinator or rescue specialist onto a vessel to direct the loading and lifting of an injured person. If so, follow this person's directions exactly. • The aircraft will lower a litter basket into which the victim should be secured. No one should touch the litter ~ before it has ed the deck to avoid possible shock ~ from static electricity created by the aircraft's rotor. Once the litter is grounded, it should be detached from

14- Accident Management

the cable, and the cable allowed to be recovered by the aircraft. Never secure the cable to tile vessel as this can literally pull the aircraft from the sky, Once the patient is secure, signal the helicopter to once again assume a hovering position over the vessel. Again let the lift cable ground out against the vessel or its railing before attempting to handle it. Once it has grounded, re-attach the cable to the litter basket, and stand clear. If there are lines attached to the basket, they may be handled by deck crew to keep the litter from spinning. Never secure these lines to your person, or wrap them around your limbs. When the extent of the line is reached, simply let go.

Airlift from the water Sometimes, due to the environmental conditions or the nature of the vessel, it is impractical or unduly dangerous to attempt to recover a victim from the deck of a vessel offshore. These circumstances can include rough seas, poor visibility, the presence of masts or rigging that makes it impossible for the helicopter to approach reliably or a combination of these factors and others. If a small craft is available, the victim may be lowered into it, and tied to the stem of the vessel by a long line, however caution must be taken to insure that the speed with which tile larger vessel is maintaining position is reduced sufficiently to prevent the small boat from being swamped. Also, the movement of the small boat in rough sea conditions may make this impractical. If small boat transfer is not an option, the helicopter may ask that the victim be placed in the water for recovery [rom there. This is a last ditch maneuver, and only recommended if there is no alternative and the victim is likely to die without immediate evacuation. If the victim is to be placed in the water, clearly, buoyancy is an issue. In addition, it may be necessary for the victim to be accompanied. Thus, it is entirely possible that a situation that includes a second victim will develop. Using a long line around the companion and the victim to keep them attached to the vessel until the lift is mandatory. The helicopter recommending this procedure\vill usually have aboard a highly skilled, trained rescue swimmer whose job it will be to secure the victim

183


RGURE 14·8. THE CHANCE FOR GRAVE HARM TO All CONCERNED MAKES HElICOPTER EVACUATION THE STRICT PROVINCE OF PROFESSIONAL RESCUERS. FOllOW DIRECTIONS SCRUPUlOUSll

to the lifting cable, and possibly to the rescue swimmer, so that they will be lifted back into the helicopter either in tandem or sequentially. Arescuer that was in the water with the victim initially, if any, should leave the process and get back to the boat as soon as the rescue swimmer arrives to take control. Sometimes the rescue swimmer will be in the water waiting for the victim. If this is the case, no one from the vessel should enter the water along with the victim unless getting the victim overboard requires someone adjacent to the vessel. Even so, this function may best be served by the professional. The vessel operator must observe extreme caution if people are to be put over the side, securing the engines, and allowing the vessel to drift. If this is done, the chances of separation from those is in the water is high, hence using lines as recommended, however, if rough conditions prevail it is likely that the vessel's rate of drift due to the wind will be rapid. If so, anyone in the water attached to the boat can easily be drowned. Considering all the negative possibilities, it is easy to see why these kinds of operations are best left to the control of highly trained professionals. Even under the best conditions, too many things can go wrong.

184

.'

utes

185

CHAPTER .

'"

,

.

•

.

Legal and Ethical Issues of Rescue and ~ . ' .~~ Emergency Care

.


LEARNING GOALS In this chapter you will: 1. Understand the fundamental issues of liability. 2. Learn the definition of negligence. 3. Be introduced to the concepts of "Standard of Care" and "Duty." 4. Learn about assumption of risk as it applies to your actions during a rescue. 5. Leam about insurance and the concept of the "Good Samaritan" The role you play at a diving event, your training and the level of your skills, and your willingness to use them will dictate what iUnount of responsibility you must be prepared to assume in any rescue. To a large ,~ extent, these same factors will detennine your personal ~ risk of a lawsuit that may result from a rescue in which you partiCipate. As a diving leader, you may be ultimately responsible for the welfare of a group of students or divers paying you for your services. If so, those services must meet the high standards of a NAUI Worldwide member. Your training and preparedness to avoid problems can only be exceeded by your expertise and ability to SWiftly intelvene, and as much as possible to correctly resolve any incidents or accidents that do unfOitunately occur. As an SRD or ASRD diving solely with a buddy or among a group of divers, your responsibility is far more limited, however you are bound by no less a moral, and to some extent, legal obligation to perform to the best of your ability. The cl1lcial difference is tllat as a recreational diver, regardless of yoUI' level of training or profiIi"!"""I ciency or certification in rescue skills or techniques, you ~ have no duty whatsoever to employ them to aid another diver, or to act at the behest of others, even professionals in charge of diving event, to the same end. Unless there is some duty created by your status as a recognized professional in the field, and your prior written or tacit agreement, your interventions are strictly voluntary. 77Je concepl ojDU7Y is cenlral 10 required aclion jar a resCUel: If Ihere is no dUly, you are nol obligaled 10 inlervene, and may nol be held legally responsible jarYOUI' decision.

188

The buddy relationship, howevel; may be construed as a tacit (unwritten, but knowingly accepted as common knowledge) agreement.

LIABILITY Before explOiing these concepts furthel; it is best to understand the fundamental issues of liability and suits for negligence in generaL Dishe:utening, though it may seem, in a litigious society like the U.S.A., iUlyone can be sued by anyone for anything. Plaintiffs can alwa)~ bring lawsuits against defendants. The ChiUlces of prevailing to a legal judgement in any lall~uit, howevel; are greatly mitigated by the facts and whether or not tlley are construed as satiSfying the requirements of existing law to render a verdict for or against a plaintiff. In cases pertaining to diving rescue, the plaintiff can be the victim, or representatives of the victim that have or had some interest in the victim. In other words, either the victim, or the victim's survivors, the family left to deal with the person's demise or injUry, feel that the defendant's actions contrihuted to the victim's injUry or loss, and seek compensation as a result Liability is a general tenn for legal obligation, a responsibility. In cases pertaining to rescue, the defendant is generally sued or, in rare cases, charged with negligence. Legally, negligence occurs when there is a failure to exercise tlle degree of care considered reasonable under the circumstances, which results in an unintended, but foreseeable injury to another party. In cases where a clear duty to act was ignored, criminal negligence may be charged. Thus, negligence can be eitller civil (between persons) or criminal (an act against the state). Criminal negligence is not exclusive of civil negligence, and criminal charges can be brought by the state even if the victim or others choose not to begin a lawsuit for civil negligence. Criminal charges sustained in court result in fines andlor imprisonment. Generally, howevel; diVing-related lawsuits fall into the civil categOly. If the plaintiff prevails, some monetary compensation is awarded which the defendant, 01' the defendant's insurer, is reqUired to pay. In cases where death results, awards

Chapter 15- legal and Ethical Issues 01 Rescue and Emergency Care

to plaintiffs can be substantial. The defendant's ability to pay is never considered, only the degree to which the defend~U1t was responsible for the plaintiff's problem.

criminal for Ato drive an unsafe car on public roads, but tlle damage tllat resulted occurred on private property, the parking lot, hence tllere was no injury to the state. As a rescue diver, how do you avoid becoming embroiled in a complicated mess like this 1 Read on.

NEGLIGENCE In order for a plaintiff to win a lawsuit for negligence, four important, issues must be proven in U.S. and many other countries' courts: • That there existed a duty to act on the part of the defendant towards the plaintiff • That the duty was breached, tllat is not fulfilled • That the breach of duty was the proximate cause of an actual injury to the plaintiff • That the injury resulted in damages to the plantiff To make the concept clear, consider the following anecdote: Friend Aoffers Friends Band Ca lift to supennarket in his car. Friend Ahas been told by a garage mechanic that his automobile's brakes needed repair, but he wanted to wait until payday to have them fixed. On the way to the supennarket, Pis brakes fail, and the vehicle skids into an intersection. Fortunately, no cars are coming. B elects to continue to the supennarket with A, but C decides to walk the rest of the way since the car is obviously unsafe. Sure enough, on the way into the parking lot, Aagain loses control, but this time the car hits a pole and Bis injured. Carrives on the scene, and seeing B hurt, faints and his head strikes the curb. Band Cboth go to the hospital. Was Anegligent in relation to B1 Was Anegligent in relation to C? Is Aliable for B's or C's injury? What does this have to do with rescue diving? As with many legal issues, the answers to these questions lie within the presentation of the facts to the court, and the credibility of the witnesses. It could be said that Ais negligent towards B, except for the fact that Bassumed the responsibility for being in an unsafe automobile. It could be said that Ais negligent towards Cin that he hit his head because of the accidental injury to B, except that Ahad no way of foreseeing that Cwould faint if he saw an injury. It might have been

STANDARD OF CARE AND DUTY Never exceeding your training and ability in the course of a rescue in which you participate is a good way to protect yourself from liability as a result of your actions. Although a SRD or ASRD is not obligated to respond unless acting in a professional capaCity as a diving leader, if one chooses to respond, a duty is created. That duty is to act to the best of your ability, consistent with your level of training and expertise, and to the same standards of conduct that any other person with your training and ability would meet. It will be important to be able to document your actions, and to be able to point confidently to the fact that you did the victim no further hann. This is a fundamental idea in all first aid, and consequently, central to any first aider's defense against negligence. No voluntary participants in a rescue, even those that have provided emergency care such as R, have been successfully sued in U.S. courts as a result of their actions. Since no other person is you, nor obviously was you at the time of the incident, your actions and activities will be examined based on a recreation of the events gleaned from the testimony of witnesses, and any other documentation that you can present. Once tlle facts are established as best they can be at some point in time far after tlle event, your behavior will be compared to what the "reasonably prudent individual" in your circumstances would have done. This is a matter of trying to establish in court, generally through the testimony of expert witnesses, what the standard is for persons in your position. Since you are dealing with opinions, there can be conflict. 111e plaintiffs experts will undoubtedly feel that you did not act appropriately, while any experts that you may

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consult and elect to present, will clearly feel differently. The court will ultimately decide whose experts' opinions are more credible. This will all take time, and in court proceedings, time is inevitably costly. Defending yourself against a lawsuit will be time and resource consuming no matter what the outcome. Sometimes, the threat of a lawsuit whose outcome is always uncertain is sufficient for a defendant, or a defendant's insurer to tl)' to settle with the plaintiff before, or even during the trial. It is obvious that avoiding a lawsuit for negligence is far preferable to defending oneself against one. A good way of doing this, otller than the others stated, is to work hard to maintain and improve your skills and ability. Continue your rescue, first aid and dive training under professional supervision. NAUI Worldwide ASRD certification expires. Most first aid and R certifications are also time limited, or have activity requirements. Meeting these in spirit as well as fact will help protect you against legal action. More importantly, keepIng your skills sharp will better enable you to use them when they are needed with less risk to yourself, and more likelihood of success for those whom you aid.

ASSUMPTION OF RISK AND YOUR ACTIONS IN ARESCUE All divers knowingly assume risk since diving is a risk-laden activity. People injured while diving are generally knowledgeable of the possibility of injuty, as proven by the fact that they participate freely and execute written waivers to that effect For the most part, it is reasonable to assume that an unconscious person in the water wants to be rescued, and wants to have aid provided to help the diver recover or survive. Problems can arise when the unconscious diver has a family member or other companion at the dive that refuses treatment on the injured person's behalf. But the problem is not the rescuer's! Rather, it is the individual who is refusing on the other person's behalf. k; a rescue diver, you are obligated to continue care for the person to the best of your ability once you start, are relieved by a more qualified authority or are exhausted. Without a

190

written authorization from the victim giving the companion the legal power to make care decisions in the victim's stead, a so-called "Medical Proxy," you must not allow another to deter your efforts. Aconscious victim, however, even in a life-threatening condition, has the right to refuse aid, treatment or examination. If this does occur, you should carefully document the refusal, and have the refusal witnessed by other who are present and unconnected to either you or the victim. Explain to the victim that you believe there is grave danger in this waiver of care, and the possible consequence of the refusal. If the victim chooses to assume the risk after being so infonned, that is the diver's prerogative. You have fulfilled your obligation.

Assistants Another facet in the assumption of risk concerns the risks that others may take under your supervision, even if it is voluntal)'. If you take control of a resclle and in the course of it direct otllers to act, to some extent you are responsible for their actions, and to a large extent, you are responsible for their safety. If they perfornl inappropriately and their actions result in further harm to the victim, it may well be considered your fault If assistants that you direct get hurt in the process, you may also be blanled by them or their survivors. Be wary of asking anyone to perform feats of brave I)' however willingly they may do so. Be equally wal)' of trying tllem yourself, or of believing in the stated abilities or competencies of anyone aiding you.

"

INSURANCE AND "THE GOOD SAMARITAN" Insurance for rescue divers outside the diving leadership realm is difficult to come by, if available at all. Unless yoUI' rescue actions are part of some professional obligation that you hold, most insurance companies will not be willing to accept the possible liabilities of your voluntal)' actions performing a rescue. There may be some portion of some other insurance policy that you hold, however, that could be construed to do tilat, but

Chapter 15- Legal and Ethical Issues 01 Rescue and Emergency Care

this is a legal question that is unlikely to be answered until the time it has to be. Certainly asking the insurer in advance for an interpretation of tile policy in writing is possible, but expecting a favorable result would be highly optimistic at best. This fact may be a good reason to consider striving to qualify as a AUI World\\~de leader at some level. All I AUI Worldwide can purchase excellent insurance coverage sponsored by the organization that will cover all of their diving related activities, even those in which they are acting as voluntary participants. Acquiring the myriad skills of a NAUI Worldwide leader will have great impact on your life and on your diving outlook and ability. Short of dedicating yourself to achieving NAUI Worldwide hip and becoming a diving leader, as a volunteer you may be protected in your rescue actions by the legal concept of "the Good Samaritan." Many jurisdictions recognize in their law that unselfishly helping a stranger in distress is a worthwhile activity for which one should suffer no harm. "Good Samaritans" who act appropriately and in good faith according to the standards of care and duty outlined previously are protected from liability as a result of their interventions. To depend on this concept, however, it would be wise to investigate how it applies to dive rescue in the area in which you participate.

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191

NAUI Scuba Rescue Dive~

Index A Abdominal cramps 159 Accident management dealing with aftermath of diving rescue 13, 83 duty, assumption of risk, and 18, 190 equipment and.... .. 178 insurance and .. 190 location information and .. .41, 177 A1cohol ...24 dehydration and 24 Alternate air sources alternate second stage and 96, 97 and preparation 40, 41, 48, 81, 83, 178 Ascent, Emergency 93 Assisting .5, 8, 139 Assumption of, accident management and 18, 190 As~a...................................................

....w

B Barotrauma 11 0 BC see bouyancy compensator BC carry, surface rescue and 148 Bends, skin, decompression sickness and 114 Bites, marine life problems and 161 Blackout, shallow-water 75 Blankets, surface rescue and 164 Bleeding, first aid fo1.. 157 Blocks .. .55-56 Boats .. 140 motor. .. power .. ......... 140 Buoyancy compensator problems with. .. 58, 87 Breathing .. .74, 84-85 stabilizing....... . 88 stress and . 84

192

Bronchitis al contraindication to diving Bubbles, excessive, undelWater distress and Buddy system alternate air sources and .. emergency shared air ascent.. leader in neurological examination and stress and

21 86, 116 98 98-99 178 117 .82

c

Cardiopulmonary resuscitation (R) decompression illness and 126, 134, 143, 163, 168 Carries 147 surface rescue and 147-151 Chokes, decompression sickness and 115 Cold water 65 decompression illness and 113 drowning and 172 Colds as contraindication to diving 23 Continuing education 5 diving fitness and 52, 65 contraindications to .52 contraindications to undeIWater activities and 20-28, 52 Coordination, assessment of, 42, 46 Coughing 21, 24, 74-75 R .l25, 126, 136, 150, 156, 168,169 Current 69-71 geographic 69,70 longshore 70 rip 70 tidal : 69

o Decompression i1lness Decompression illness (DCI) arterial gas embolism and first aid for... near drowning and neurological examination and providing life and recompression therapy fo1..

23, 24 .75, Ill, 123, 164 123 163 117 .l26, 156, 164 114, 126,127,164

INDEX

rescue breathing out of water and . 150 responding to 137, 176 shock and 157 subcutaneous emphysema and 111 decompression illness and 23-24 Decompression sickness 23, 59, 110, 113, 115 dehydration and... .. 24, 63-64, 159, 163 fish poisoning and 150 Dehydration 24, 63-64, 159, 163 Depth 38, 40, 87 Distress 94, 99, 102 defIllltlOn 0 f 80 stress and 78 Diver 132-133 responsive 103, 150 unconscious 75, 88, 103 Diver's Alert Network 127 Diving diving fitness and 52, 65, 76 Diving injuries burns and 160 common, first aid fo1.. 156 concussions and 158 cramps and 159 fISh pOisonmg . . an d 159 fractures and 158 gas toxicity and............ .. 162 heart attack and 163 near drowning and 163 seizures and 22, 158 stroke and 163 wounds and 45,154 Diving publications 41 diving rescue and 168 Documentation 179, 189 of neurological examiootion, decompression illness and 117 Doors, surface rescue and 133 do-si-do two and 140 Drags, surface rescue and 149

Dry suits problems with

.. .

..59 56, 104

......

E Education continuing .4, 155 safety through ..70, 133 elevator 87 Emergencies .92, 125 accident prevention and 34, 41, 46,52,92 equipment and...... .. 122 out-of-ai1............... .. 92 rescue and........... .. 14, 125 responding to .. .127, 137, 176 sharing air procedures and .. 96,98 emergency communication and 177 emergency swimming............ .. 93 Emphysema.......................... .. 20, 111 Entanglement, visibility and. .. 68 Environmental hazards cold water and...................... .. 65, 172 freshwater and. 162 oceans and................................ 69 overhead 40, 74, 93, 103, 179 rivers and ..62,71,72 Equipment problems with 57, 138 Eyes 67,99, 105, 137 protection of, air evacuation and 180, 182

F Face Mask decompression illness and First aid . primary survey in... .. secondary survey in Fitness........................ Fractures, first aid for

..

..125 ..154 155 156 .................. 20 , 28 , 52 158-160

G Grates, river diving hazards

72

193


H

R

Hypertension Hyperventilation Hypoventilation

27 ...75 74

Ice Independent ascents Infections, temporary contraindications

..40, 66 93-95 23

J Jellyfish

................................................................... 161

L Lifts, surface rescue and

148

M Mask rescue loss of scuba mask partial rebreather Medications

.. ..

125, 126 5 I25 24, 25

N Near drowning, first aid for ... Negligence, avoiding, accident. Nitrox .

..

164 .......... 189 ...................39,40

o Over-the-counter medications........ .. .45 Over-weighting.......... . .. 60 Oxygen, istration of.... .. 124 Panic................. . 105, 106, 136, 137 surface rescue and 136, 137 Parbuckling, getting victim aboard boat and 146 Pneumothorax .. 111 Pocket Mask .. 125, 126, 135, 137 Poisoning, food . 159 fish............... . 160 Prescription medications 45

194

Recompression tllerapy, decompression illness and ........ 126 redundant scuba ·..95, 96 Regulators octopus 96 problems with .. 62 Removal of diver to shore, surface rescue and 145 removal of, surface rescue and 147-151 Repetitive dives .42 Rescue breathing.......... . 134, 168-170 in-water 133-135 using Pocket Mask in 136 Rip currents 70 Risk assumption of 18 assumption and rescue.... . 190 management.. 14 River diving .. 72 obstructions and .. 72

s Seasickness .. 24, 162 Seizures.............. . 22, 158 Self-rescue, in-water distress at surface and 6 Shallow-water blackout .75 Shock ::: 123 Signals, hand, recreational diving ..47 Skip-breathing.............. . .74 Snorkel, rescue breathing and 135 SPG .36, 37, 92 Spinal cord injuly 144, 145, 163 Squeezes......... . 55 gut .. .56 hood 56

INDEX

mask

56

sinus Stress Stroke

.56, 117 \2, 80-84

164

Surf surface rescue and

71

\46

Surface rescue

132

T TB

21

Telephone, cellular, emergency

44, 45, \77, 180

Tidal currents

69

Tobacco as contraindication to diving

25

Towing, assisting, and surface resuce.............. . 139 Transfer.. 181,182 Trim problems dry suits and 1\Jberculosis...........

.

6\ .21

u Undel\vater rescue, emergency ascent and

102-107

w Weirs, river diving and Wounds, fi rst aid for..

72 156, \58

•

195

TEXTBOOKS THAT TAKE DIVER EDUCATION SERIOUSLY. new navigation featu~es folios

headings

tab system

Page numbers are color coded Chapter titles are color coded and taband easy to see, making naviulated, making the course material gation q u > < : easily accessible.

............

Clear headings on every page improve access to specific subjects.

-------------

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Clear leaming goals are outlined for each section.

The entire book is filled with full color photos, illustrations, and information graphics-all designed to reinforce the reader's learning experience.

Key points are noted by highlighted text. Notations are categorized by type and reinforced with icons.

Learning goals set /foreach section.

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Each chapter is color coded to Visually organize the information.

~ Take note of this infonnation-it ~ forms the basis for the final exam. Ii!""'I Information that will help you ~ complete the workbook. In~lcates warning or safe~'

CD.

infonnalion. responsible diling ~ practices. ~ In~icates

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