scubadoc Ten Foot Stop

July 31, 2005

The Best of ‘Ten Foot Stop’, Pulmonary Embolus, Diving and Anticoagulation

Filed under: Uncategorizedscubadoc @ 11:16 am

Fitness to dive post pulmonary embolus after an airplane flight? What pulmonary assessment would be necessary? History of two episodes of DCI in the past.

Answer[s]:
From Jim Caruso, MD:
This is a very timely question given the inter-relationship of long travel to dive sites and the occurrence of PEs [pulmonary emboli]. I do not believe there is any cookbook approach to these patients and important factors such as age, health status and meds must be considered.
Certainly the usual V/Q and PFT studies are important. If the patient is to be anti-coagulated, that could be very dangerous on dive station. I would try to keep the INR to a minimum but your first priority is to minimize the risk of a repeat PE.

Since air-trapping is a primary concern in diving (like asthma or emphysema) and PEs can cause infarcts but have no specific pathology that predisposes a person to a greater risk of an air-trapping problem, I do not have any other blanket recommendations for evaluating such patients that is diver specific. My big concern would be recurrent PEs, especially since diving often involves travel and dive sites are often remote where medical care is nil.

From Allen Dekelboum, MD:

Although this is not in my area of expertise, I am concerned about why the PE occurred following flying. Was it due to stasis in the lower extremities on long flights. I think this is a rhetorical question and not necessarily the questioners personal problem, although I could be mistaken. Also he himself has had two episodes of DCI in remote areas. What kind of diving is
he doing?
I would be interested in knowing his hematologic status, re., clotting, etc. Is there any permanent damage from the PE? Pulmonary studies including diffusion studies would be indicated.

From Dr. Ed Kay:
If still on Coumadin I would warn of increased risk should DCS occur. If the individual understands the theoretical increased risks, I would return to diving with “informed consent”.
If not on Coumadin, or if individual elects to dive with risk factor of anticoagulant I would make sure lung parenchyma has returned to normal with PFTs and Spiral CT. I see no reason to limit diving if everything checks out OK.

From Martin Quigley, MD:
As I’m sure you are aware, there is little (or nothing) in the standard diving medicine texts (e.g. Bennett and Elliott) and the US Navy and NOAA Diving Manuals concerning diving after pulmonary embolism. I don’t think any formalized testing is generally required before a return to diving. I’d wait 6-12 weeks after the acute PE, and obviously all anticoagulation would have had to have been completed before diving could be considered.
The only assessment I’d do would be to ensure that there was no limitation of exercise tolerance (have the prospective diver walk up a couple of flights of stairs - or even better have the diver wear scuba gear (no fins) while climbing stairs). If there was any limitation of exercise tolerance, then there might be a role for formalized pulmonary function testing. The answer doesn’t seem very scientific, but my guess would be that diving after a PE doesn’t present significant limitations.

From Dr. Richard Moon, Duke University and DAN: The main issues would be: (1) Residual cardiopulmonary effects, if any (e.g. pulmonary hypertension) and (2) Anticoagulation.
With regard to (1) pulmonary hypertension would be exacerbated by immersed exercise, particularly in cold water, and could conceivably lead to pulmonary edema. If symptoms/signs resolved satisfactorily with no evidence of pulmonary hypertension on chest radiograph, then this should not be an issue. Another possible residual effect could be an increase in respiratory dead space due to residual hypoperfusion of a lung segment/lobe. Diving itself is associated with increased dead space (see Salzano JV et al, Physiological responses to exercise at 47 and 66 ATA. J Appl Physiol 57:1055-1068, 1984, Mummery HJ et al. The effects of age and exercise on physiological dead space during simulated dives at 2.8 ATA. J Appl Physiol 2003, in press - the text can be downloaded in .PDF format from the American Physiological Society website). If the dead space were already high due to the residual PE effects, then the addition of diving could cause the person to require a significantly higher ventilation to maintain isocapnia.

If the person is still taking anticoagulants, then it goes without saying that the effects of otic/sinus barotrauma could be exacerbated. Also, local hemorrhage is a feature of both inner ear and spinal cord DCS. If the diver is unlucky enough to experience either of these, then a more severe result might ensue.

From scubadoc:
We periodically receive letters requesting information about diving and anti-coagulation. We present the following information to the diver (or the doctor) and expect them to make their own decisions about diving. Having had many very unpleasant encounters with coumadin in my past surgical life - I’m quite skittish of allowing a person to dive while on the drug.
Several things come to mind that should be addressed before allowing return to diving or certification to dive in candidates with PTE.
First, pulmonary testing should be done to rule out any air-trapping or reduction in lung function as pulmonary embolism is capable of causing lung damage with scarring and loss of pulmonary reserve. Normal PFTs [helium loop?] and spiral CT scan might allow diving if all is OK. Diving with 60% pulmonary function would be borderline should a stressful situation arise requiring increased cardiopulmonary reserve. Pulmonary hypertension that is not symptomatic on the surface might lead to right heart overload and failure when the effects of immersion are present.
Secondly, coumadin is an extremely dangerous drug in that it can allow relatively minor trauma to turn into disastrous situations from hemorrhage; namely the minor trauma of sinus, ear and lung barotrauma that can occur with every dive. This would be the main reason to disallow diving. An effort should be made to rule out causes of thrombosis, such as abnormal proteins.
Thirdly, there is some indication that anticoagulants may actually worsen neurologic outcome in decompression accidents by causing hemorrhagic lesions to worsen (Bove, 1997, p.198.). There are no studies on this subject - only isolated reports of the use of coumadin in PTE in a person after having had neurological DCS. (Spadaro, Moon, Fracica: Life threatening PTE in neurological decompression illness. Undersea Biomed Res 19 (Suppl): 41-42, 1992.)
For more information you may want to visit our web page at http://www.scuba-doc.com/antcoag.htm .

From Dr. CJ Edge, UKSDMC
It’s interesting reading the replies re PE and diving. I’ve actually had an episode of multiple PEs post long haul flight in 1995 on coming back from a dive trip to the Maldives. I (being a physician) didn’t recognise the symptoms for 2 days after getting the severe pleuritic pain on inspiration and put it down to a pneumonia.
The answer in terms of what should happen is, to my mind, fairly clear cut. V/Q scan or spiral CT will show the extent of the problem. Haematological studies should be carried out, looking principally for the common problems i.e. factor V Leiden, prothrombin gene mutation, factor S and/or C deficiency etc. Family history may be important. Anticoagulation should be undertaken, keeping the INR 2-2.5 for an initial period of 3 months, provided that there are no contributing haematological abnormalities, such as those mentioned above, that are found (if there are, the whole question is more complex). Diving can then be resumed after 3 months. I don’t believe that increases in residual volume etc. are relevant; one generally doesn’t know what these parameters were before the problem arose, which is the important issue. However, to “cover one’s back” one could repeat the spirometry including helium dilution tests and CO diffusion if one was really concerned (I didn’t have this).
In this particular case, the person had had two episodes of DCI beforehand. I believe that this is relevant only to indicate that probably the person is dehydrated, as many divers are in tropical situations, and that the PE is a manifestation of dehydration and immobility (part of Virchow’s triad).
I advise all divers in such a situation to take a factor Xa inhibitor prior to travelling for > 4H flight, to drink plenty and especially not to let themselves get dehydrated when diving. I do this, I’m diving again and I’ve had no further problems.
Addendum: It may be worth pointing out that one can carry out an INR measurement at home now using the new kits. Therefore it may be safer for divers to be on warfarin than it was in the past. The INR should be kept between 2 and 2.5; any level greater than 3 can lead to an unacceptable risk of spontaneous haemorrhage.

July 29, 2005

Finding stuff on scubadoc Diving Medicine

Filed under: Uncategorizedscubadoc @ 10:54 am

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Medical Center

July 28, 2005

Bookmarks Worth Keeping!

Filed under: Uncategorizedscubadoc @ 9:06 am

Doc Vikingo’s Good Guy Resource for Divers
http://tinyurl.com/9usp6

DAN Report on DCI, 2004
http://tinyurl.com/arhqs

CDC Centers for Disease Control and Prevention, References and Resources
http://www.cdc.gov/travel/reference.htm

Emporiatrics: An Introduction to Travel Medicine
http://tinyurl.com/859ft

Travel Medicine, PJ Online
http://tinyurl.com/a2lo9

Travel Medicine: Helping Patients Prepare for Trips Abroad
http://tinyurl.com/9yxae

MedEd Online
http://www.mededonline.org/

Scuba Diving Accidents and Hyperbaric News from Google

Filed under: Uncategorizedscubadoc @ 8:36 am

PADI Gold Palm scuba instructor, tourist diver drown scuba diving
CDNN - New Zealand
Mayumi Fukuda, 25, a Japanese scuba diving instructor employed by PADI Gold Palm Pastime Volunteer rescue divers found Morita on the day of the accident.

Scuba Victim Flown To Marquette General
WLUC-TV - Negaunee,MI,USA
The victim of a scuba diving accident in St. Ignace was flown by Coast Guard helicopter to Marquette General Hospital Wednesday.

Bungling diver swims into mouth of shark
Xinhua - China
Chinese man accidentally swam onto the tooth of a shark whilst scuba-diving in by the park, however, it was the first time that such an accident had happened.

FSU diving team joins search for missing girl
Tallahassee.com - Tallahassee,FL,USA
A team of scuba-diving scientists from FSU’s pioneering Underwater Crime already have participated in numerous criminal and accident investigations, including

Man dies after dive at Trout Lake Park
London Free Press - London,Ontario,Canada
WOODSTOCK — A Kitchener man hurt in a diving accident at Trout Lake Park has died, the park’s second Two scuba divers died at the park during a winter dive.

Woman Survives Local Scuba Scare
WZZM - Grand Rapids,MI,USA
A West Michigan native, scuba diving in Lake Michigan over the weekend, had a close they were in the process of repairing the pipe when the accident occurred.

HBOT To Treat Chronic Conditions
Canada Free Press - Canada
What treatment would you choose, a leg amputation or increased amount of oxygen? amputation because of a failure to use hyperbaric oxygen therapy (HBOT).

North Las Vegas hospital entering phase two of $9.6 million
Las Vegas Sun - Las Vegas,NV,USA
The hyperbaric chambers are pressurized, enclosed capsules that provide double the oxygen level than a an average of one to two hours of treatment in the

Cash crisis shuts MS centre
Norfolk Eastern Daily Press - Norfolk,England,UK
The therapy centre provided hyperbaric oxygen treatment, physiotherapy, counselling, dietary advice and yoga, and was the only one of its type in a radius of

He got out just in time.
Times Herald-Record - Middletown,NY,USA
Thursday night to Westchester, where he could get specialized treatment. Without oxygen, you stop breathing. In hyperbaric therapy, the patient is placed in a

Travis hospital’s hyperbaric chamber helps to quickly cure wounds
Fairfield Daily Republic - Fairfield,CA,USA
The patients inside are put in masks or hoods to breath 100 percent oxygen. The Air Force originally started using hyperbaric treatment to treat those who

Healing Under Pressure
TheHorse.com - Lexington,KY,USA
wounds, can turn around quickly with oxygen treatment.”. can get expensive with one treatment session running medical schools have hyperbaric facilities, however

Saipan lawmakers want scuba divers to pay for decompression
CDNN - New Zealand
A decompression chamber is a machine used to treat a person suffering from what is called decompression sickness — a disorder that affects deep-sea divers.

Diver, 24, identified
Exmouth Journal - UK
Two other female divers, both from Torbay, were also treated for the effects of decompression sickness after being involved in the tragedy.

Diver who resurfaced too quickly at Sandsprit Park is flown to
Stuart News (subscription) - Stuart,FL,USA
Authorities said the diver might have suffered from decompression sickness, also known as “the bends.” It occurs when nitrogen bubbles build up in a diver’s

Man airlifted following diving accident
RTE Interactive - Ireland
A diver has been airlifted from Dublin Bay to hospital in Galway this afternoon after becoming ill with the decompression sickness known as the bends.

(Really) Risky Business
Fast Company - USA
Unless divers spend time in shallower water letting gas bleed out of their system, they will suffer decompression sickness, more commonly known as “the bends

Two rescue divers hospitalised in Galway
RTE Interactive - Ireland
hospital in Galway. Rescue services say the men may be suffering from the decompression sickness known as the bends. They were taken

HBOT To Treat Chronic Conditions
Canada Free Press - Canada
During that time it has saved the lives of many divers stricken by decompression sickness (the bends) when they’ve surfaced too quickly.

Minister warns divers of bends
Fiji Times - Fiji
Mr Naivalu said decompression sickness was an emerging public health problem in the Northern Division especially in Bua province where many people dove for

Travis hospital’s hyperbaric chamber helps to quickly cure wounds
Fairfield Daily Republic - Fairfield,CA,USA
The Air Force originally started using hyperbaric treatment to treat those who suffered from altitude-induced decompression sickness.

Patent Foramen Ovale Closure Devices
Journal of American Medical Association (subscription) - Chicago,IL,USA
23 PFO closure devices have also been used to prevent decompression sickness in divers and to manage right-to-left shunting in patients with right-sided

July 27, 2005

Board certified hyperbaric and wound care specialist physician boarded in UHMS and CWS.

Filed under: Uncategorizedscubadoc @ 5:55 pm
St. John’s Pleasant Valley Hospital, Hyperbaric and Chronic Wound Care Center, 2309 Antonio Street, Camarillo, CA 93010 is currently seeking a board certified hyperbaric and wound care specialist physician boarded in UHMS and CWS.
We can offer 2-3 shifts per week and possibly more.
Our shifts are generally 8-10 hours per day.
We are a busy center with approx 20-25 wound care patients per day and approx 10 HBO patients per day.
We are single or double covered depending on the census.
Shifts will be available October 2005
Please contact John Tesman, MD @ 805.389.5800 ext 6712 or send CV to:
JRTMDSB@cox.net or JOHN.TESMAN@chw.edu

July 25, 2005

HYPERBARIC PROGRAM MANAGER-CHT’s

Filed under: Uncategorizedscubadoc @ 6:33 pm

HYPERBARIC PROGRAM MANAGER-CHT’s

New, multiplace facility being added on to an existing monoplace facility in Marietta, Georgia

COBB HYPERBARIC MEDICINE at KENNESTONE

55 WHITCHER STREET, Suite 200

MARIETTA, GA 30060-1168

We are seeking experienced, well-qualified individuals to join an existing practice. The Program Manager must have experience as Safety Director and with management and marketing.

Competitive salary Excellent Benefit Package

Please call:
Helen B. Gelly, MD

770-422-4268 or email: hbowound@aol.com

UHMS News - Don Chandler Retiring at end of 2007.

Filed under: Uncategorizedscubadoc @ 3:14 pm
Don Chandler, our Executive Director has announced his plans to retire at the end of 2007. A Search Committee has been formed that is chaired by our President-Elect, Dr. Bret Stolp. Based upon previous searches, it is anticipated that the search will b a lengthy one, thus we are now accepting applications.
One point needs to be clear to all applicants. The corporate office will not remain in Dunkirk, Maryland. The geographic location of the office at the time a successful applicant will assume the duties of Executive Director has not yet been decided. A Relocation Committee has been formed and a decision for relocating the corporate office is expected to be made no later than June, 2006. Applicants need not inquire about the geographic location of the corporate office until the committee has made its recommendation to the UHMS Board of Directors and the Board has approved a new location.
An undergraduate degree from an accredited institution is required. Graduate and post-graduate degree(s) is/are desired but not required. A successful candidate will possess a good working knowledge of diving medicine and hyperbaric medicine.
Experience managing a non-profit organization will be a plus. Please list in the cover letter, salary requirements and any particular terms of employment that are deemed essential. Group life insurance, 50% of health insurance, and a limited 403-B investment plan are provided.
Interested parties should send a resume and cover letter, in Word format and attached to an email, to: donchandler@uhms.org
If an applicant does not have access to email, he/she may mail the application to:
Undersea and Hyperbaric Medical Society
(Personal for Don Chandler)
P.O. Box 1020
Dunkirk, MD 20754

DAN Will Conduct A Diver Medical Technician Course in November

Filed under: Uncategorizedscubadoc @ 2:44 pm

Through a joint effort of Divers Alert Network and the Duke University Medical Center, DAN will host its fifth Diver Medical Technician (DMT) course in November.

Eric Douglas, Director of Training at DAN, said he expected a full complement of 12 participants for the six-day event, which runs Nov. 6-11. Participants will spend four days at DAN Headquarters and two at the Duke hyperbaric chamber.

Douglas said diver medical technicians (DMTs) serve at the critical first step in the diving medicine chain, caring for injured divers on the scene and acting as tenders in the hyperbaric chamber. ‘Many of the participants in these programs are diving safety officers with dive teams or tenders associated with hyperbaric chambers,’ Douglas said. ‘But a good number of them have also been dive professionals interested in advancing their knowledge of dive medicine so they can better tend to the divers in their care.’

Skill training includes all DAN’s current training programs, with specialized training in use of the otoscope and field neurological surveys. Attendees who complete the course receive DMT certification through the National Board of Diving and Hyperbaric Medical Technology (NBDHMT). This course has a prerequisite of EMT-B or paramedic and diver certification.

The course offers lectures presented by internationally known faculty, hands-on practical skills, and the experience gained through 14 hours of clinical time in the Duke Center for Hyperbaric Medicine and Environmental Physiology. It gives participants an opportunity to learn both at DAN Headquarters and at the Duke Hyperbaric Center.

Capt. Brian T. Wilson, who attended a recent course, commended the program. ‘I have been to many schools, since it is my job being as training officer for the county, and as a firefighter in the USAF Reserves,’ said Wilson, an officer from Forsyth County, Ga. Fire Dept. ‘This class was very well thought out, and the instructors were very knowledgeable in their respective fields.’

For further information about the November course, check the DAN website
www.DiversAlertNetwork.org http://www.DiversAlertNetwork.org/> or
contact Douglas, at 1-800-446-2671 ext. 553 or via email at edouglas@dan.duke.edu
mailto:edouglas@dan.duke.edu> . And for information about courses offered at DEMA, visit the Coming Events section of the website.

Dan Leigh, DAN

survey looks at scuba diving practices and any injuries that result from diving

Filed under: Uncategorizedscubadoc @ 9:20 am

July 25, 2005

Dear Scuba Diver:

I need your help. I am writing to ask you to participate in a anonymous research survey. This survey looks at scuba diving practices and any injuries that result from diving. I am an Emergency Medicine resident and an avid dive enthusiast, I am conducting research into dive related injuries and diver safety, and asking scuba divers from the United States to respond. This short survey is administered through the Internet and will take about 10 minutes of your time.

This project was approved by the Institutional Review Board (the committee that oversees research at this institution) at the Resurrection Medical Center in Chicago, Illinois. If you are willing to help with this study, please complete the questionnaire via the link below and return it as directed. One option (unlinked to responses) at the end of the survey provides space for an email address entry for notification of results if you would like a copy.

Thanks and safe diving! This survey automatically ends on 9/30/05

Adam Beckett, DO

docadzz312003@yahoo.com

Link to the survey:

https://fs6.formsite.com/RMCEMRP/form298218861/secure_index.html

July 24, 2005

Blonde Humor from ’scubadoc

Filed under: Uncategorizedscubadoc @ 4:05 pm

A blonde lady motorist was about two hours from San Diego when she was flagged down by a man whose truck had broken down. The man walked up to the car and asked, “Are you going to San Diego?”
“Sure,” answered the blonde, “do you need a lift?”
“Not for me. I’ll be spending the next three hours fixing my truck. My problem is I’ve got two chimpanzees in the back which have to be taken to the San Diego Zoo. They’re a bit stressed already so I don’t want to keep them on the road all day. Could you possibly take them to the zoo for me? I’ll give you $100 for your trouble.”
“I’d be happy to,” said the blonde. So the two chimpanzees were ushered into the back seat of the blonde’s car and carefully strapped into their seat belts. Off they went. Five hours later, the truck driver was driving through the heart of San Diego when suddenly he was horrified!! There was the blonde walking down the street and holding hands with the two chimps, much to the amusement of a big crowd. With a screech of brakes he pulled off the road and ran over to the blonde.
“What the heck are you doing here?” he demanded, “I gave you $100 to take these chimpanzees to the zoo.”
“Yes, I know you did,” said the blonde, but we had money left over . . . . . . so now we’re going to Sea World.

Reactivated and Maintained by Centrum Nurkowe Aquanaut Diving