scubadoc Ten Foot Stop

April 30, 2007

Diving After Head Injury

Filed under: Interesting Newsscubadoc @ 10:31 am

A diver recently wrote asking about return to diving after having had a bang in the head in an automobile accident. He was briefly unconscious, had no memory loss and had not had any seizures. He was observed overnight in the ER and allowed home with negative studies to be followed by his family physician.


What Are the Problems Posed by a head injury in a diver?

Head injury generally poses two main problems with diving: post-traumatic epilepsy and changes in cognitive status.

Diving may be resumed or started after head injury if:

1.) No drugs are required

2.) There has not been loss of consciousness greater than 30 minutes

3.) There are no localizing signs

4.) There has not been amnesia longer than one hour.

What About Drugs?

Anticonvulsants should not be used with diving as they are all sedating and potentiate the effect of nitrogen narcosis, leading to disorientation at unexpectedly shallow depths. Diving may be resumed three months after the cessation of anticinvulsants without seizure activity.

What do others have to say about diving and head trauma?

Divers Alert Network has several articles about diving with head trauma. One of these is in DAN FAQ about head trauma at http://www.diversalertnetwork.org/medical/faq/faq.asp?faqid=76

Another article in the DAN website by Dr. Hugh Greer (dec.) is located at http://www.diversalertnetwork.org/medical/articles/article.asp?articleid=15

The British SubAqua Club have this to say about head trauma and diving:

BS-AC recommendations: “The length of post traumatic amnesia (PTA) including any period of unconsciousness may be used as an index to the severity of injury. Where PTA has been less than one hour, there should be a three week layoff from diving. With PTA of an hour to 24 hours, there should be a two month layoff. Where the period of PTA exceeds 24 hours, there inevitably has been severe brain damage and there is considerable likelihood of subsequent epilepsy and impaired mental functioning. A minimum period off diving of three months is suggested and cerebral function should have returned to normal.

If epilepsy should have developed as a result of injury then further diving is banned unless it was an isolated fit occurring at the time of injury. Likewise if anticonvulsant medication is being taken as a prophylactic measure, diving should be banned, but may be resumed three months after this is withdrawn if the individual never had a seizure.

Operative intervention to raise depressed bone or evacuate haematomas should disqualify for three months but otherwise may be disregarded except insofar as it may be associated with subsequent fits, anticonvulsants treatment or other factors above.”

Get the approval of your physician

You should be able to dive if you have

—the approval of your physician,

—have not had seizures

—have not had a reduction in your ability to perform the task-loading required in safe diving, self-rescue and rescue of your buddy

—and have been off medication as described above.

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Ciguatera Fish Poisoning

Filed under: Interesting Newsscubadoc @ 10:27 am


Dr. Omar Sanchez, diver/cardiologist from Argentina, sends us this article about Ciguatera revision from the Centers for Disease Control and Prevention.
Ciguatera Fish Poisoning—Texas, 1998, and South Carolina, 2004
JAMA. 2006;296:1581-1582. October 4,
EXTRACT | FULL TEXT |
Related link: Ciguatera References
=================================================

Costochondral Separation and Diving

Filed under: Interesting Newsscubadoc @ 10:20 am
Question from a reader:

After a dive I was removing my wet suit and twisted around to grab my zipper cord and had severe pain in the chest. I was given O2 on the boat with little relief and went to the doctor here in Samoa and was told not to worry. (We do not have a chamber here, but since the doctor told me not to worry, I basically tried to put it out my head).

The general pain to touch subsided after a couple of days, but an ache continued to bother me. The pain evolved into a strange combination of pains during the day. At night when I lay down, it eases up. Now, after three months of enduring all of this uneasiness in my chest, I am worried that the injury was actually related to the dive (not the act of taking off the wetsuit). I am currently feeling a general tightness around the upper right chest area, sometimes it feels like nerve pain stretching towards my shoulder from my chest, oftentimes, the pain extends to
my back and is quite uncomfortable beside and below my right shoulder blade. Massage
seems to help, but the pain soon returns.

I also sometimes have a strange tingling throughout the area below where the collarbone attaches to the chest, it feels like something is in my throat, sometimes almost a hot sensation with a taste. I have been on an acid inhibitor (nexium), so I don’t believe it is coming from my stomach. I have seen a doctor here in Samoa, but he doesn’t know much about dive medicine. I am a male, 41 years old and generally quite healthy and I stay in shape. This injury has become rather debilitating and I would like to try to do something about it. I would like some advice.
Thank you for your time.

Answer:
Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with the advice of an examining physician.

What you are describing is probably ’sternocostal or costochondral separation’, an injury that is seen fairly frequently with trauma situations but not often associated with wet suit removal. It is not serious but is difficult to diagnose or see on x-ray or other diagnostic methods and often is a diagnosis of exclusion.

The fact that it is associated with movement and pressure seems to rule out serious internal problems such as pulmonary problems, but it would be wise to have yourself checked for coronary artery disease.

One would have to agree that it most likely is not related to your dives. The condition can cause prolonged severe pain as you have noted and can often last for months. Pain syndromes can also be markedly worsened by anxiety of the unknown and one would suspect that this is having a part to play in your situation.

Here is another letter about the same subject:
I recently suffered chest pain in my right side after crashing on roller skates with my daughter (long story, but I had to prevent the 4-year-old from getting squashed). I landed on my right side with right arm stretched over my shoulder. Later in the evening (not immediately), I began to experience muscular-type pain at the interior edge of my ribcage, approximately 2″ below the sternum. I went to the doctor, and chest xrays were negative for cracks/fractures. 600mg of Ibuprofen taken a few times a day helps, but after a couple of days without, the pain begins to return. The pain is low grade with occasional sharp pain, no coughing, voice changes or shortness of breath. The injury appeared to get better, but my weight training seemed to aggrevate it. Therefore, I have rested it for over a month, but the low grade pain lingers.

While this has not impacted normal life, I have not been able to lift weights/exercise for our dive team. I’m still in good shape, but do not want to get too far gone before resuming. Based upon what I’ve read, I believe I either have a bruise, rib separation, or perhaps a cartilege stretch/tear.
I would very much appreciate information or websites that might contain information on such injuries so I might be able to accelerate the rehab. I’ve heard soft tissue rib injuries are some of the worst for rehab, but I’m willing to help the process in anyway possible. I’ve also wondered if an MRI might help diagnose the problem, or if that would even affect the recommendations.

Answer:
From your history provided this sounds like a costochondral separation, although an undisplaced rib fracture is possible. Rib fractures can take a long time to clear up (four to six weeks) and costochondral separations can take twice as long. You might want to be sure that you don’t have some other internal injury, such as liver damage (right side). It would probably ease your mind - if not your pain - to see a physician and be sure.

Here are some links:
http://www.ncemi.org/cse/cse0502.htm
http://www.cc.cc.ca.us/sportsmedicine/chest_injuries.htm

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

April 29, 2007

Ultra lightweight flexible decompression chambers

Filed under: Interesting Newsscubadoc @ 10:04 am

Here is a letter we received from Alex Burnup of the UK concerning his design of an ultra lightweight flexible decompression chamber. We present this for your information only. The utility of such a product is obvious.

Dear Doctor Campbell,

I just found your 10 foot stop site by accident when I did a Google search, as your interested in HBOT and diving you may like to look at some of my work at www.divealive.co.uk.

I design new ultra lightweight flexible decompression chambers, the current model weighs in at 66 lbs, but this is shortly to be reduced to around 55 lbs in production models, new models being worked on now will go as low as 17 lbs for a full air decompression rating with a full 2 times or more fail safety factor.

The site has 2 videos on it of the UK Navy testing, including the only ever destruction test of a chamber, which I should add failed at 12.6 bar above ambient,(183psi) when the stainless steel hatch buckled, later found to be caused by a poor weld, something soon rectified with the contractor who made it, so far we have never managed to damage the material part of the chamber and new versions will do away with the metal totally as being the weakest part of the design.

I hope you find the site interesting, at the moment I am looking for enough orders or a backer, either an existing company or an individual/individuals to set up a manufacturing plant in the USA, I seem to be getting plenty of interest from Australia and Europe but not much from the American side of the world, possible because of the belief amongst US divers that it will never happen to them, but we all know it does, I personally have used the chambers to rid myself of a Hospital Acquire Infection that very nearly killed me (8 months in Hospital), without the treatment which others in our team provided I would have died and still the staff at the hospital refuse to believe in HBOT as an effective anti bacterial treatment.

If you want any other info, just e mail, I will be glad to help out.

Yours Sincerely,

Alex Burnup

DIVEALIVE
DECOMPRESSION
CHAMBERS

Tel:- 00 (44) (0)1622 817839

Email:- a.b@divealive.co.uk

Website:- www.divealive.co.uk

Address
26 Kenward Road,
Yalding,
Kent,
ME18 6JP
UK

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

Abandoned Divers, What to do, How to Prevent

Filed under: Interesting Newsscubadoc @ 10:00 am


The Boat

* Check out the boat and boat captain before diving
* Ask questions about rescue action plans
* Ask about the history of the motor
* Ask about the credentials of the crew
* Ask about the system for counting heads (Names!)
* Find out if the boat has a functioning radio
o Request to see and hear it function
o Ask who they call for assistance
* Be alert to location of the nearest land

Important! Don’t be put off by an officious captain! Your life may be at stake. If the captain doesn’t want to cooperate - ask your dive leader to intervene or get off the boat.

The Dive

* If a drift dive, listen carefully for instructions, stay with the group
* Check for current, tide and wind conditions; imagine yourself out of sight of the boat
* Always start your dive by swimming upcurrent after orienting yourself
* Develop navigational skills. See http://snipurl.com/tcv0

Equipment possibly helpful

* Inflatable Sausage
* Reflector
* Whistle or other noise maker
* Slate
* Line

Hazards of being left behind

* Dehydration and thirst
* Hypothermia
* Severe sunburn and immersion injury
* Marine animal injury
* Drowning

Things to do

* Inflate BC
* Drop weights, preserving belt
* Inflate sausage
* Flash reflector (Someone might see it, even though you can’t see them)
* Blow whistle
* Write time, approximate location and speed of current on your slate
* If you swim, swim diagonally with the current toward any known dry land.
* Stay with others involved. Use a tie up method using empty weight belt or other straps. This gives a larger target for searchers.
* Remember that there will be rescue attempts and searchers.

‘Seven Steps to Survival’

Survival at sea depends on the recognition that you are in danger of losing your life. There are commonly described “seven steps” to survival that may make a difference in the outcome of some rather terrible situations. Even an accident fairly close inshore in cold water can quickly lead to hypothermia and drowning. The seven steps to survival are: recognition, inventory, shelter, water, food, signals and play. Of course, flotation is a prerequisite for any survival after only a short time in the water. Other factors come into play, the most important of which is unmeasurable, “the will to live”.

The seven steps to survival include recognizing that you are in peril and realizing that what you are wearing constitutes a form of shelter. Use signals in the form of mirrors, flares, colored objects or waving arms, suits or objects about to attract attention. Finally, “play” comes into action as you have memories, fantasies, prayer, tell jokes and get rid of your anger.

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Cardiocerebral Resuscitation

Filed under: Interesting Newsscubadoc @ 9:58 am

Cardiocerebral Resuscitation: An Interview with Gordon A. Ewy, MD
http://snipurl.com/pe46

The mortality rate with cardiorespiratory resuscitation is miserable and now it’s time to do away with the “giving breathes” aspect of rescuscitation - just using chest compression. This good study shows the way.

Cardiocerebral Resuscitation on Medline - Related Articles
http://snipurl.com/pfmp

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Stingray Injury

Filed under: Interesting Newsscubadoc @ 9:52 am

The most frequent injury from sea life is probably due to jellyfish stings. However, the stingray injury from a venomous barb usually requires immediate, competent medical attention because of the pain and propensity for prolonged side effects due to infection and foreign body retention.

The ubuquitous stingray belongs to the Phylum Chordata, Class Chondrichthyes. These possess a serrated bony spine at the base of the dorsal surface of the tail. An integumentary sheath discharges venom when ruptured. Most injuries occur when the ray is stepped on, the tail is thrust upward and forward and fired into the foot or leg. However, there are reported deaths from injuries to the chest, abdomen and groin areas in divers who swim closely over stingrays hidden in sand.

The venom is thermolabile (deactivated with heat) and induces severe vasoconstriction.

  • Symptoms: Intense pain is felt at the site; there is local ischemia (loss of blood supply), and edema. Edges are jagged, may contain pieces of spine and secondary infection is common. Systemic effects include salivation, sweating, vomiting, diarrhea, cramps, hypotension (low blood pressure), and cardiovascular collapse.
    • Treatment: Irrigate and remove remaining spine. Immerse in hot (45-50 C) water until pain subsides. Give local or systemic pain relief. Cleanse, debride and suture the wound. Give tetanus protection, infection prophylaxis and monitor / support cardio-respiratory system as indicated.

Question:

I was stung by a stingray ten days ago in the gulf of mexico. I was treated with tetanus and medicine for shock and allergy. Since then it seemed to be fine. The puncture wound is in the bottom of my foot.

Yesterday I noticed some localized swelling. Almost like a hematoma or abcess? Like a grape size, harder. When I walk on it it feels like I’m walking on a grape or rock. At the time it was done the medical clinic was not sure if the barb had come out or not. What should I do now?

Answer:

It is entirely possible that you have a portion of the barb or some of the proteinaceous substance surrounding the barb still in your foot. Sometimes this will not show up on x-ray and other diagnostic procedures are required.

There might be the need for surgical debridement of the wound, if this has not been done before now.

See my web site information about this at http://scuba-doc.com//hzrdmrnlf.html and at this site http://www.emedicine.com/aaem/topic421.htm .

Stingray barb

stingray wound

********************************************************************

***Steve Irwin Dies of Stingray injury to the heart.***
http://www.stuff.co.nz/stuff/0,2106,3786798a12,00.html

Ihe accident that claimed Irwin’s life appears to have involved some very bad luck. Filming in shallow water for a documentary, Irwin was attacked when he snorkelled over the top of a sting ray, which reacted unexpectedly.

Based on information from film footage of the incident, a cameraman told The Australian: “He was up in the shallow water, probably 1.5m to 2m deep, following a bull ray which was about a metre across the body - probably weighing about 100kg, and it had quite a large spine.

“It stopped and went into a defensive mode and swung its tail with the spike. It probably felt threatened because Steve was alongside and there was the cameraman ahead, and it felt there was danger and it baulked.”

By great misfortune, the ray’s barb punctured Irwin’s chest and heart. Caught on film, he was seen to pull out the barb, which would have been some 10cm long. He was recovered aboard the cover boat and, despite the arrival of a helicopter with paramedics, did not survive.

Reports of stingray injuries to the heart

Survivor of a stingray injury to the heart. Med J Aust. 2001 Jul 2;175(1):33-4.
Weiss BF, Wolfenden HD.
Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, NSW. weissbx@usa.net

Injuries to the extremities from stingray barbs are not uncommon along the Australian seaboard. Cardiac injuries from stingray barbs are rare, even worldwide, and all but one have been fatal. We report a survivor of a cardiac injury caused by a stingray barb. Penetration of a body cavity by a stingray barb requires early surgical referral and management.

The entire paper can be seen at http://snipurl.com/vy5h .

Fatal and non-fatal stingray envenomation. Med J Aust. 1989 Dec 4-18;151(11-12):621-5
Fenner PJ, Williamson JA, Skinner RA.
Ambrose Medical Group, North Mackay, Qld.

A fatality occurred in a previously healthy 12-year-old boy after a penetrating chest injury from a stingray barb. The injury occurred under freak circumstances. Death was a result of cardiac tamponade which was secondary to venom-induced, localized myocardial necrosis and spontaneous perforation, six days after the direct penetration of the right ventricle by the barb. Three other cases of less serious stingray envenomation are described which illustrate the significant localized morbidity that may occur without immediate wound exploration and toilet after adequate anaesthesia. We also report a study of a series of 100 minor stingray envenomations which, when treated, resulted in no morbidity. It is possible that local infiltration with 1% plain lignocaine may have a direct counteraction against stingray venom that remains in the wound area. Stingray venom has insidious, but powerful, localized tissue necrosing properties in humans.

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

Springhill Medical Center Chamber (Mobile, AL) Wins 10K PADI Award

Filed under: Interesting Newsscubadoc @ 9:49 am

One of the advantages of being a subscriber to Ten Foot Stop is that we occasionally have information that can lead to windfalls for you and your diving/hyperbaric endeavour.

Julio Garcia, CHT, RN writes to tell us about his wound treatment center receiving a 10K grant which was advertised on our web blog.
“I had applied for the chamber endowment fund as listed on the Ten-Foot Stop blog for PADI America and we won a 10K grant for advance hyperbaric training at Hyperbarics International. Isn’t that too cool.”

Here is the news release:

Springhill Medical Center Awarded Prestigious PADI Chamber Endowment Fund

The Professional Association of Diving Instructors (PADI) awarded more than a third of its entire Chamber Endowment Fund to the Center for Wound Care and Hyperbaric Medicine at Springhill Medical Center. PADI supports diver safety and research through its international endowment program.

The Center for Wound Care and Hyperbaric Medicine will use the funds to send medical staff members to the Undersea Medical Team Training Program in Key Largo, Florida.

“This is one of the few places we will be able to get specialized advanced training for our hyperbaric medical personnel,” said Julio R. Garcia, C.H.T., R.N., Program Director of Springhill’s Center for Wound Care and Hyperbaric Medicine. “The training will allow us to further our knowledge of dive injuries and the management of critical care patients who need our hyperbaric chambers.”

Providing hyperbaric medical support for the central Gulf Coast, Springhill’s Hyperbaric Center is the only Undersea and Hyperbaric Medicine accredited facility in the state of Alabama. In addition, Springhill is the primary hyperbaric support for Keesler Air Force Base in Biloxi, the primary evacuation and treatment site for Naval Station Pascagoula, and the primary back-up facility for Naval Station Pensacola.

PADI is the world’s largest recreational diving organization, with more than 5,300 dive centers and resorts and 130,000 dive professionals worldwide. The Chamber Endowment Fund was established to benefit recreational dive communities worldwide.

“We anticipate an increase in recreational dive activity precipitated by the sinking of the USS Oriskany off the coast of Pensacola. We will be seeing an increase in patients who require advanced knowledge in hyperbaric medicine. To meet those needs, our proposal to PADI included the request for us to attend specialized training,” Garcia said.

“We typically see approximately 10 DCI patients a year. An anticipated increase to approximately 100 DCI-related injuries annually represents a substantial strain on the hyperbarics resources available in this area,” Garcia explains.

The USS Oriskany is located 22.5 miles SSW from the coast of Pensacola. This artificial reef is now the largest along the U.S. coastline.

Many divers assume there will be a hyperbaric chamber near their diving destination, but this is not always the case. To support these critical facilities, PADI established The Chamber Endowment Fund in 2004. 

This year, more than $30,000 was available to qualified applicants, and Springhill’s Center for Wound Care and Hyperbaric Medicine received more than $10,000. The PADI Chamber Endowment Fund provides funding for projects such as:

  • Staff training and certification

  • General chamber maintenance costs

  • Equipment costs

  • New chamber construction

“The selection committee members recognized the necessity, merit and value of this training for our facility in the service of the diving community for the central Gulf Coast,” Garcia said. “We appreciate their support of the diving and hyperbaric medical community with a program such as the Chamber Endowment Fund.”

UKSDMC Depression Guidelines, Posted in October 2005

Filed under: Interesting Newsscubadoc @ 9:46 am
The UK Sport Diving Medical Committee has posted new guidelines for diving with depression and anti-depressants. In addition, there is also a questionaire form posted for follow-up of these individuals.

These can be seen at the UKSDMC web site at
http://www.uksdmc.co.uk/newsletters/UKSDMC_Depression_Guidline.doc
http://www.uksdmc.co.uk/newsletters/depression_questionaire.doc

We have reproduced these below in case you are unable to access the site.

**************************************************************************
UKSDMC Depression & Antidepressants Guideline

Depression in the UK is very common. Most cases are managed in primary care with only the most severe requiring specialist assessment & treatment. Secondary care doctors will come across patients who are taking antidepressants on a regular basis.

The aim of this guideline is to provide a basis for the assessment of divers who wish to dive whilst taking antidepressants.

Depression is a condition where the patient experiences a disorder of mood. They complain of “being down”, unhappy, sad, tearful, poor sleep, feelings of hopelessness & worthlessness, poor concentration & decision making, occasionally thoughts of self harm & suicide. These symptoms are also observed by close friends & relatives.

The cardinal diagnostic features are
Poor sleep
A black cloud hanging over the day when they waken
An inability to get pleasure from things such as hobbies that formerly provided pleasure.

The full diagnostic features are listed in ICD10
http://www3.who.int/icd/vol1htm2003/fr-icd.htm

The concerns are that a diver who is suffering from depression may not be able to function in the water due to anxiety, poor concentration & decision making, or the irrational decision to use diving as form of suicide. This would put the sufferer & his buddy at risk.

There are also concerns about theoretical risks of diving whilst taking antidepressants.

However a patient who’s depression has “lifted “ & is now clinically cured but requires antidepressants to maintain that state of well being can probably dive safely.

Divers who are taking antidepressants must satisfy the following criteria:

1.Patients should only dive on the newer antidepressants. The older tricyclics reduce the fit threshold, can cause dysrythmias & are sedative. Modern antidepressants such as the SSRIs citalopram, fluoxetine & paroxetine have a low seizure rate of Diving with Depression & Antidepressants Guideline Questionnaire

Please answer all questions below, then sign the form & return to the medical referee.
Patients name, D.0, B. address, phone number

1. Please list all medication currently taken by the patient

2. The date of starting the medication. Please confirm compliance with therapy.

3. Please confirm that the depression has lifted, that patient is on maintenance therapy & has returned to normal daily life & work.

4. Please confirm that there have been no upward mood swings

5. If the patient has been withdrawn from medication please confirm that this was at least six weeks ago & that the patient’s mental health is stable.

Signed Surgery Stamp

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

April 28, 2007

CARBON MONOXIDE REPORTING SYSTEM

Filed under: Interesting Newsscubadoc @ 6:52 pm
To UHMS Member:

I am writing to determine the level of interest with regard to the development of an online, real time, web-based reporting system for cases of carbon monoxide poisoning treated with hyperbaric oxygen in the US. If the idea moves forward, it would be developed as a joint UHMS/CDC project.

Please take 1-2 minutes to answer the questions on the brief survey

at:

http://www.surveymonkey.com/s.asp?u=755622696910

Thank you. Neil B. Hampson, MD

Past President, UHMS

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

Stingray injury (and how not to manage it!)

Filed under: Interesting Newsscubadoc @ 6:51 pm

Dr. Bruce Miller, diving dermatologist, sent us this report about how not to treat a stingray injury. [Photo by Kris Judish]

“A good friend was in Mexico wading and stepped on a small stingray. It nailed him (large red dot). The 3 smaller ones are xylocaine injection sites. He’s a big tough dude and said that it was by far the most excruciatingly painful thing he’s ever experienced.

He was sent to the doc at the hotel who hooked him up to a monitor and started an IV. Told his assistant to pour hot water on the wound so this guy pours BOILING water on it. Stopped the venom pain but caused a 2nd degree burn with a large blister. I saw him 3 days later. The area was red and somewhat tender but no streaks. I put him on cipro just in case. Apparently the doc also explored the wound but no sheath remnants.

We hear about encounters such as this at all the dive med meetings but rarely do we see it.

More about stingray injuries

STINGRAY
Phylum Chordata, Class Chondrichthyes. These possess a serrated bony spine at the base of the dorsal surface of the tail. An integumentary sheath discharges venom when ruptured.


Most injuries occur when the ray is stepped on, the tail is thrust upward and forward and fired into the foot or leg. The venom is thermolabile (deactivated with heat) and induces severe vasoconstriction.

Symptoms: Intense pain is felt at the site; there is local ischemia (loss of blood supply), and edema. Edges are jagged, may contain pieces of spine and secondary infection is common. Systemic effects include salivation, sweating, vomiting, diarrhea, cramps, hypotension (low blood pressure), and cardiovascular collapse.

Treatment: Irrigate and remove remaining spine. Immerse in hot (50 C) water until pain subsides. Give local or systemic pain relief. Cleanse, debride and suture the wound. Give tetanus protection, infection prophylaxis and monitor / support cardio-respiratory system as indicated.

Dr. Carl Edmonds sends us the following good information about the temperature of the water for relief:
“Notice in your 10 foot stop that you recommend 50 degrees C for stingray injury.

We did say, in the 70s that the temperature can go up to 50 degrees, but we were adding hot water to cold and doing it slowly. We later changed to 45 degrees because of 3 reasons

1. If you immediately immerse a limb into 50 degrees, many people find this exceptionally painful, and jump off the examination couch
2. There is a suggestion that this temperature may do tissue damage
3. It is not needed. 45 degrees works just fine.”
===================================================================================

If you don’t have a way to measure the temperature - one would suppose that it can be tested on one’s self on the back of the hand, as in testing an infants milk bottle. A rule of thumb would be “as hot as you can stand it on the back of the hand!”
===================================================================================
Re water temp for spine injuries ( including stingray)- I advise my nurses to have the water as hot as can be tolerated by the unaffected limb ( ie put both feet in!!)- usually 40-45C
Regards,
Dr Neil Banham
Emergency Physician

See also:
http://www.scuba-doc.com/hazard.htm

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

April 27, 2007

Deeper Into Diving, Second Edition

Filed under: Interesting Newsscubadoc @ 10:24 am

John Lippmann, Executive Director and Director of Training DAN-SE Asia-Pacific has sent us a copy of the revised book, “Deeper Into Diving” - which I have been avidly reading for the past several weeks. It is an update of the previous book first published in 1990 but this one includes writing by Dr. Simon Mitchell, an active physician who is certified in diving and hyperbaric medicine by the Australian and New Zealand College of Anaesthetists. The book is delightfully written so as to appeal to the every day diver, the instructor and to the medical professional needing to delve deeper into a particular subject about the medical aspects of diving. For an excellent addition to your library for diving physiology and medicine, I heartily recommend that you look into getting this book.

The book is published by J.L. Publications, a Division of Submarine Publications,
P.O. Box 387,
Ashburton, Victoria 3147, Australia.
Tel/Fax:+61-3-9886 0200.
Email: jlpubs@bigpond.net.au
Website http://www.submarinerpublications.com

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SCUBA diving for individuals with disabilities

Filed under: Interesting Newsscubadoc @ 10:23 am


We get fairly frequent requests for information concerning diving with various disabling conditions and have generally applied the knowledge known to exist for all divers to the limitations of the particular disability involved. This has in most cases been satisfactory but occasionally we run into a wall of lack of pertinent information, such as the effect of pressure on electronic implants and pumps. Cheng and Diamond published a review of potential problems that they recognized as being important to divers with disabilities in the American Journal of Physical Medicine and Rehabilitation in May of 2005 and the article is paraphrased below.

Cheng J, Diamond M.
SCUBA diving for individuals with disabilities.
Am J Phys Med Rehabil. 2005 May;84(5):369-75. Review.
http://snipurl.com/o92y

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

Recommendations of the World Congress on Drowning

Filed under: Interesting Newsscubadoc @ 10:20 am


Appendices to Recommendations of the World Congress on Drowning
Amsterdam 26 – 28 June 2002
Overview recommendations task force Diving (breath hold, scuba and hose diving)

During the World Congress on Drowning, experts of the task force Breath hold, scuba
and hose diving have finalised a consensus document on a variety of topics.
It was agreed that
1. Well-constructed national regulations have been effective where enforced and
that any significant improvements in health and safety would arise only from a
more inclusive definition of working divers and a wider application of existing
procedures.
2. Self-regulation within the world-wide recreational diving industry continues to
be the practical route for further improvement but that there is a need to counter
a perception that there is a conflict between commercial interests and safety.
3. The training agencies comply with international quality assurance and control
procedures (QA/QC) such as the International Standard ISO 9000 series and
also encourage independent monitoring to assure the effective and safe use of
existing and new procedures.
4. Subsistence fishermen who are predominantly found in the poor countries
around the world, use equipment that is minimal and that their training,
regulations and medical support appear to be zero.
To improve diving-fishermen safety and reduce drowning there is a need to
collect data on accidents and drowning among representative samples of diving
fishermen around the world.
This should be followed up with international non-governmental organisations
(NGOs), other charities and appropriate UN development initiatives so that
existing academic societies, training organisations and others could deliver
suitable medical and diving advice and training for fishermen compatible with
the limits of available local resources.
5. The collection of diver morbidity and mortality data and the associated
contributory factors for each incident is a necessary first step in reducing
drowning incidents among divers. Also needed are the denominator data that
will allow the calculation of risk.
6. Recreational divers are free to dive when, where and how they like but the diver
also has an obligation to the public. Any underwater accident to a diver can put
buddy divers and rescuers at considerable risk.
7. Greater stringency is needed in the assessment of the physical, mental and
medical fitness of all who choose to dive. A single assessment of fitness for
diving at the beginning of diver training should not be considered valid
throughout the rest of the diver’s life. Re-assessments are recommended at
intervals that may diminish with advancing years and re-assessment may also
be needed after illness or injury.
8. To give a medical opinion on a diver’s fitness, the doctor should have prior
knowledge of the unique hazards faced by a diver. Whenever possible, the
medical assessment should be conducted by a doctor acknowledged as
competent in this special subject. It is recommended the training of diving
doctors, both for the medical examination of divers and also for the treatment of
medical emergencies in diving, complies with guidance such as that published
by the European Diving Technology Committee (EDTC) and the European
Committee for Hyperbaric Medicine (ECHM). Periodical revision training is
also important.
9. The mental, physical and medical standards of fitness in each category of
diving should be harmonised internationally.
10. Greater emphasis should be placed at all levels of training on the causation and
prevention of in-water fatalities.
11. After some 3 to 5 years without regular diving, the individual should be subject
to a formal re-assessment of competence before re-entering the water.
12. The policy of training children as young as 8 years old to dive should
emphasise the immaturity of mental outlook that many young persons may have
when an emergency occurs.
13. Emergency procedures should be consistent with a variety of equipment in a
variety of configurations.
14. Programs of refresher training should be established to maximise practical re-learning
and updating of basic emergency skills. This is needed particularly
after an individual’s equipment has been modified.
15. Self-rescue and buddy-rescue procedures should be compatible with the
equipment used and the environmental conditions.
16. Training of rescuers should include the procedures for recovery of the victim
from the water into a boat and transfer of the patient from the deck of a boat to
a helicopter or some other emergency transport vehicle.
17. Hand signals and basic procedures used in diving emergencies, whether at
depth or on the surface, should be standardised and promoted through rescue
and diving agencies throughout the world.
18. Rescuers must be made aware that the treatment of drowning in a diver might
be complicated by other medical conditions such as carbon monoxide
poisoning, envenomation and omitted decompression arising from that same
dive.
19. National and international standards of medical care should be written for all
medical emergencies in diving by suitable academic bodies.
20. Drowning is mostly a diagnosis of exclusion and often is a presumptive
diagnosis based on purely circumstantial evidence. All diving-related deaths
should be thoroughly investigated, including a complete autopsy, evaluation of
the equipment and a review of the circumstances surrounding the fatality by
knowledgeable investigators with appropriate training and experience.
The post-mortem examination of a drowned diver should be conducted by a
pathologist who is knowledgeable about diving (or who is advised by a doctor
who is knowledgeable about diving).

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Driving to Higher Altitude After Diving

Filed under: Interesting Newsscubadoc @ 10:14 am

Several years ago I ran across this explanation of the physiology of driving to higher altitudes after diving and found it well written. Author unknown.

“So here’s my understanding of the physiology: Obviously, nobody worries about the altitude of their room in that high-rise Honolulu hotel. So it’s simply incorrect to say, “Never go to higher altitude after a dive.” The issue is “How much altitude?” and “How do you adjust your dive plan for anticipated changes of altitude after the dive?” Increasing altitude DOES increase the risk of decompression illness, but this risk is manageable by appropriate dive planning. The atmospheric pressure at 5000 feet (my home in Alpine Utah) is approximately 640 mm Mercury. This compares to 760 mm Hg at sea level. (The difference is the equivalent of about 5 feet of water. So when diving at altitude, you become nitrogen-saturated a little less quickly. This isn’t a big factor, and the deeper you dive, the less significant it becomes.) When you emerge from the water, there’s less pressure to hold nitrogen in solution in your blood. Example: When diving at, say, 65 feet depth at 5000 feet of altitude, you’d absorb nitrogen 5% slower. But once you emerge, there’s 15% less pressure holding the absorbed nitrogen in solution.

The pressure holding the nitrogen in solution is the critical factor in preventing decompression illness. So divers at altitude adjust their dive plan by substituting DEEPER depths for the actual depths they’ve dived. They assume they’ll absorb nitrogen faster (they don’t really). But when those numbers are plugged into the “sea level” dive table, it balances out. In other words, at 5000 feet, you assume you have 15% more nitrogen rather than 15% less pressure holding the nitrogen in solution, and it balances out. That way, you don’t need a full dive table for every altitude. So how about diving at low altitude, then driving to higher altitude later? Well, let’s assume we’re ALREADY diving at that altitude. It poses no significant risk to travel to altitude if you’ve planned your dive AS THOUGH YOU’LL BE EMERGING FROM THE WATER AT THAT ALTITUDE. Got that concept? If you compute your safe level of nitrogen saturation as if you’ll be emerging from the water at 5000 feet, how can it be more dangerous emerge from the water at sea level then drive to 5000 feet? Seems to me, the time it takes to drive to that altitude is one hell of a safety stop.

So my advice for diving, then driving to altitude is:
(1) Switch from computer to dive tables. The dive tables, properly used, will be more conservative. And they allow you to adjust for altitude.
(2) Use an altitude-adjusted depth in your dive table. Specifically, you should use the highest altitude you’ll reach within 24 hours of the dive AS THE ALTITUDE OF THE DIVE.
(3) Substitute this “drive-altitude-adjusted depth” for the actual depth of the dive in your dive table.
(4) PLAN YOUR DIVE, AND DIVE YOUR PLAN. For example, if I’m diving at 6000 feet elevation, but driving home by way of a mountain pass at 9,500 feet, I use 10,000 feet as the depth of the dive (instead of 6000). There is a table for altitude-adjusted depths at http://www.UtahDiving.com/divetabl.htm

More information about this from Jim Grier in an article he wrote for ScubaDiving .com “Tips”.
http://dive.scubadiving.com/members/divetips.php?s=517

See also:
1. history of decompression safety and dive tables
2002 Flying After Diving DEMA Flying After Diving: History, Research & Guidelines Richard Vann … 1st Report Cabin altitude 8-10,000 ft Pilot … 4 hrs after diving to 30 fsw Flight
http://www.scuba-doc.com/FADDEMA2002.ppt

2. Diving Physics
Diving Physics Register || Site Map || SiteSearch … Email || Translate || Home Diving Physics and Physiology In order … be encountered while diving, one must thoroughly understand
http://www.scuba-doc.com/physics.pdf

3. Flying After Diving-
fly too soon after diving, gives parameters for time limits and … flying. Flying after Diving* This website is written and … Campbell, MD, FACS ‘Diving Medicine’ The question is often
http://www.scuba-doc.com/flyngaft.htm

4. Microsoft Word - 3CA4866A-1252-C19C.doc
FALL PARACHUTING AFTER DIVING PROJECT REPORT Funded by U … when flying follows diving. Male volunteers completed simulated 60 ft/60 min dives followed by three hours at 25,000 ft to
http://www.scuba-doc.com/MFFAD.pdf

5. Diving At Altitude
to correct for diving at altitude DIVING MEDICINE ONLINE Diving At Altitude (A simplified method to obtain … Ware, PhD [CAUTION: Diving at altitude requires special training which
http://www.scuba-doc.com/divealt.html

6. Parameters for Flying After Diving
for Flying After Diving Flying after Diving* This website is written and … Campbell, MD, FACS ‘Diving Medicine’The question is often … to fly after diving”? The answer to the question
http://www.scuba-doc.com/fad.pdf

7. Flying After Diving
take place with diving and flying HOME > Here … Flying and Altitude Parameters for Flying After Diving Diving After Flying? DAN has … Flying After Diving Presentation, Dr. Richard
http://www.scuba-doc.com/flyafdv.html

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