Diver Medic Course INDEX

Unit/Page

A
A MEDICS MAIN DUTIES.................................................................................... ABORT SCHEDULES............................................................................................ ADIABATIC COMPRESSION............................................................................... AIR EMBOLOUS.................................................................................................... ANALGESICS......................................................................................................... ANOXIA.................................................................................................................. ANTIBIOTICS & ANTIMICROBIAL AGENTS ................................................. ANTI-DIARRHOEALS........................................................................................... ANTIVENUM ORDERING/STORING.............................................................. ASEPTIC BONE NECROSIS................................................................................. AURAL BAROTRAUMA...................................................................................... 12358488833-

B
BAROTRAUMA..................................................................................................... 3 BAROTRAUMA OF ASCENT............................................................................... 3 BAROTRAUMA OF DESCENT............................................................................ 3 -

C
CARBON DIOXIDE RETENTION....................................................................... 4 CARBON MONOXIDE POISONING................................................................... 4 CARDIVASCULAR SYSTEM (A & P DIAGRAM)............................................. 9 CATHERISATION.................................................................................................. 5 COMPRESSION ARTHRALGIA........................................................................... 3 CORAL CUTS......................................................................................................... 8 CEREBRAL OXYGEN TOXICITY........................................................................ 4 -

D
DCI NEW TERMINOLOGY................................................................................ 2 DCI IN FLIGHT...................................................................................................... 3 DECOMPRESSION PULMONARY BAROTRAUMA........................................ 3 DENTAL BAROTRAUMA.................................................................................... 3 DIGESTIVE SYSTEM (A & P DIAGRAM).......................................................... 9 DISTRESS CALLING............................................................................................ 8 DIVING INCIDENT RECORD.............................................................................. 6 DR ABC CHART.................................................................................................... 6 DRUGS................................................................................................................... 8 DRUGS EAR....................................................................................................... 8 DRUGS GASTRO INTESTINAL TRACT.......................................................... 8DRUGS RESPIRATORY TRACT........................................................................ 8 DRUGS SKIN....................................................................................................... 8 DYSBARIC OSTEONECROSIS............................................................................ 3 DRUGS EYE........................................................................................................ 8 -

E
EAR (A & P DIAGRAM)........................................................................................ 9 -

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EAR & SINUS DYSFUNCTION............................................................................ 3 EMERGENCY RADIO FREQUENCIES............................................................... 8 EMERGENCY SCHEDULES................................................................................ 2 ESSENTIALS OF FIRST AID................................................................................ 1 ETHICS AND CONDUCT...................................................................................... 1 EXPIRY DATES...................................................................................................... 8 EXTERNAL EAR.................................................................................................... 3 EXTUBATION........................................................................................................ 6 EYE (A & P DIAGRAM)........................................................................................ 9 -

F
FACIAL SQUEEZE................................................................................................. FEMALE REPRODUCTIVE SYSTEM (A & P DIAGRAM)................................ FIRST AID OF MANEGEMENT IN DIVING ACCIDENTS................................ FLYING AFTER DIVING....................................................................................... 3932-

G
GAS BURDEN......................................................................................................... 2 GASEOUS EXCHANGE (A & P DIAGRAM)....................................................... 9 GIRDLE PAIN.......................................................................................................... 2 -

H
HAZARDS INTRAVENOUS INFUSION............................................................ 5 HEAVY EXTERNAL BLOOD LOSS..................................................................... 5 HIGH PRESSURE NERVOUS SYNDROME........................................................ 3 HOSPITAL VISITS/TRAINING............................................................................. 1 HYDROSTATIC NERVOUS SYNDROME........................................................... 3 HYPERCAPNIA (CO2 POISIONING)................................................................... 4 HYPEROXIA........................................................................................................... 4 HYPOVOALAEMIC SHOCK................................................................................ 5 HYPOXIA................................................................................................................ 4 -

I
INDICATION FOR INFUSION............................................................................... INFUSION EQUIPMENT........................................................................................ INFUSION SET UP.................................................................................................. INNER EAR............................................................................................................. INTERNAL BLEEDING.......................................................................................... INTRAVENOUS INFUSION................................................................................... INTUBATION.......................................................................................................... IV CATHETER (VENFLON) RANGE COLOUR.................................................. 55635565-

L
LIMB PAIN............................................................................................................... 2 LYMPHATIC............................................................................................................ 2 -

M
MALE REPRODUCTIVE SYSTEM (A & P DIAGRAM)..................................... 9 MANAGEMENT OF INMERSIONS PATIENTS................................................... 7 -

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MEDICAL ABBREVIATIONS................................................................................ 1MEDICAL TERMINOLOGY................................................................................... 1 MIDDLE EAR BAROTRAUMA............................................................................ 3 MIDDLE EAR DISORDERS.................................................................................. 3 MIDDLE SQUEEZE............................................................................................... 3 MOTION SICKNESS.............................................................................................. 7 MUSCULAR SYSTEM FRONT VIEW (A & P DIAGRAM)................................ 9 MUSCULAR SYSTEM REAR VIEW (A & P DIAGRAM).................................. 9 -

N
NERVOUS SYSTEM + AUTOMATIC NERVES (A & P DIAGRAM).................. NERVOUS SYSTEM (A & P DIAGRAM).............................................................. NEUROLOGICAL................................................................................................... NITROGEN NARCOSIS......................................................................................... NON-RECOMPRESSION TREATMENT............................................................... 99243-

O
OBSERVATION RECORD CHART........................................................................ 6 ORGAN POSITIONING-FRONT VIEW (A & P DIAGRAM).............................. 9 ORGAN POSITIONING REAR VIEW (A & P DIAGRAM).............................. 9 OTITIS MEDIA........................................................................................................ 3 OXYGEN TOXICITY............................................................................................... 4 OIL CONTAMINATION.......................................................................................... 7 OXYGEN TOXICITY CHART................................................................................ 4 -

P
PATENT FORAMEN OVALE.................................................................................. PERSONAL AND SATURATION HYGIENE......................................................... PHONETIC ALPHABET.......................................................................................... PULMONARY OXYGEN TOXICITY..................................................................... 2284-

R
RECOMPRESSION TREATMENT.......................................................................... REVERSED EAR...................................................................................................... RN TREATMENT TABLES...................................................................................... ROUND WINDOW RUPTURE................................................................................ 2363-

S
SEA URCHINS.......................................................................................................... 8 SECONDARY DROWNING..................................................................................... 7 SEDATIVES AND SLEEPING TABLETS............................................................... 8 SINUS SQUEEZE...................................................................................................... 3 SIZES OF E.T. TUBES.............................................................................................. 5 SKELETAL SYSTEM-FRONT VIEW (A & P DIAGRAM).................................... 9 SKELETAL SYSTEM-REAR VIEW (A & P DIAGRAM)...................................... 9 SKIN (A & P DIAGRAM)......................................................................................... 9 -

T
TEETH LAYOUT (A & P DIAGRAM).................................................................... 9 -

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THERMAL BALANCE............................................................................................ 7 THORACIC SQUEEZE............................................................................................ 3 TINNITUS................................................................................................................. 3 TOOTH CAVITIES SQUEEZE................................................................................ 3 TREATMENT DROPS (EARS)................................................................................ 2 TYPES OF DROWINING......................................................................................... 7 -

U
UDERWATER BLAST INJURIES............................................................................ 7 URINARY SYSTEM (A & P DIAGRAM)................................................................ 9 -

V
VACCINATIONS....................................................................................................... VENEPUNCTURE.................................................................................................... VENFLON................................................................................................................. VERTIGO.................................................................................................................. 8553-

Diver Medic Course SECTION ONE - INTRODUCTION Medical terminology

ABC Method sequence of operations required in cardio-pulmonary resuscitation. A stands for air, B stands for breathe and C for circulation. Abduction movement away from the midline of the body. Actual Consent consent by the adult patient, usually in oral form, accepting amergency care. This must be informed consent. Acute to have a rapid onset. Sometimes used to mean severe. Acute Myocardial Infarction (AMI) heart attack. The sudden death of heart muscle due to oxygen starvation. Usually caused by a narrowing or blockage of coronay artery supplying the myocardium. Adipose Nature of fat. Adduction movement toward to midline of the body. Alveoli microscopic air sacs of the lungs where gas exchange takes place with the circulatory system. Analgesic pain reliever. Anaphylatic Shock allergy shock. The most severe type of allergic reaction in wich a person goes into shock when he comes into contact with a substance to which he is allergic. Anatomical Position standard reference position for the body in the study of anatomy. The body is erect, facing the observer. The arms are down at the sides and the palms of the hands face forward. Aneurysm blood filled sac caused by the localised dilation of an artery or vein. The dilated or weakened section of an arterial wall. Angina Pectoris chest pains often caused by an insufficient blood supply to the heart muscle. Anoxia absence of oxygen. See hypoxia. Anorexiab Loss of appetite. Anterior front surface of the body or body part. Antiseptic substance that will stop the growth or, or prevent the activities of germs (micro organisms). Aorta major artery of systemic circulation that carries blood from the heart out to.

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Apnoea suspension of breathing. Arrhytmia disturbance of heart rate and rhythm. Artery any blood vessel carrying blood away from the heart. Aseptic clean, free of particles or dirt and debris, but not necessarily sterile. Astringent An agent causing contraction of organic tissue. Asphyxia loss of consciousness caused by too little oxygen reaching the brain. The functions of the brain, heart and lungs will cease. Atrium superior chamber of the heart. Avulsion piece of tissue or skin that is torn loose or pulled off by injury. Bacteriostatic Inhibiting the growth of bacteria. Blanch become pale. Brachial Pulse pulse produced by compressing the major artery of the upper arm. Used to detect heart action and circulation in infants. Bradycardia abnormal condition where the heart rate is very slow. The pulse rate will be below 50 beats per minute. Bronchiole small branches of the airway that carry air to and from the alveoli. Bronchus the portion of the airway connecting the trachea to the lungs (plural-bronchi). Cannula hollow tube that can be inserted into a cavity to allow for fluid to be introduced or removed. Capillary microscopic blood vessel where exchange takes place between bloodstream and body tissues. Cardiac refers to the heart. Cardiogenic Shock failure of the cardiovascular system brought about when the heart can no longer develop the pressure needed to circulate blood to all parts of the body. Cardiopulmonary Resuscitation the re-establishment of the heart and lung action, by artificial ventilation and external cardiac compression. Cardiovascular concerning the heart and blood vessels. Carotid large neck artery. One is found on each side of the neck. Its pulse is of prime importance in the primary survey and CPR.

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Catheter flexible tube passed through body channels to allow for the drainage or withdrawal of fluids. Cephalic refers to the head. Cerebrospinal Fluid clear watery fluid that helps to protect the brain and spinal cord. Cervical relating to the neck or to the interior end of the uterus. Chronic opposite of acute. It can be used to mean long and drawn out or recurring. Clavicle collarbone. Clonic Phase second phase of a convulsion seizure, with the patient exhibiting violent body jerks, drooling, and possible cyanosis. Most convulsions last 1 to 2 minutes. Coccyx lowermost bones of the vertebral column. They are fused into one bone in the adult. Coma state of complete unconsciousness Comminuted Fracture fracture where the bone is fragmented or turned to powder. Concussion mild state of stupor or temporary unconsciousness caused by a blow to the head. There is no laceration or bleeding in the brain. Contraindicated condition, sign, or symptom that mekes a particular course of treatment or procedure inadvisable. Contusion bruise. The simplest form of closed wound where blood flows between tissues causing a discolouration. Convulsion uncontrolled muscle spasm, often violent. Core Temperature body temperature measured at a central point, such as within the rectum. Cornea transparent covering over the iris and pupil of the eye. Coronary refers to the blood vessels that supply blood to the heart muscle. Many people use this term to mean heart attack. Cranium braincase of the skull. Many people use the term skull when they mean cranium. Crepitus grating noise or the sensation felt. Caused by the movement of broken bone ends rubbing together. Also a crackling sound. Crowing a typical sound made when a patient breathes. It usually indicates airway obstruction. Cyanosis when the skin colour changes to blue or grey because of too little oxygen in the blood. Cutaneous pertaining to the skin.

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Diaphramatic Breathing weak and rapid respirations with little movement of the chest wall and slight movement of the abdomen. An attempt to breathe with the diaphragm alone. Diastolic Pressure pressure exerted on the internal walls of the arteries when the heart is relaxing. Dilation to enlarge, expanding in diameter. Disinfect to destroy harmful microorganisms, but not necessarily their resistant spores Dislocation displacement (pulling out) of a bone end that forms part of a joint. Distal away from a point of reference, such as the shoulder or the hip joint. Mor distant to. Distended inflated, swollen or stretched. Dysphasia difficult or labourde breathing. Embolism movement and the lodgement of a blood clot or foreign body (fat or air bubble) inside a blood vessel. The foreign body is called an embolus. Emergency Medical Technician (EMT) professioonal level provider of emergency care. This individual has received formal training and is state certified. Emphysema the abnormal presence of air in tissues or cavities of the body. Epiglottis flap of cartilage and other tissues that is the superior structure of the larynx. It closes off the airway and diverts solids and liquids down the esophagus. Epistaxix nosebleed. Eructation belching. The escape of gas from the stomach, through the mouth. Erythema a superficial redness of the skin. Esophageal Obturator Airway (EOA) breathing tube inserted into the esophagus. The vents in the tube are positioned at the opening into the larynx. Esophagus muscular tube leading from the pharynx to the stomach. Eustachian Tube the tube connecting the middle ear to the throat. Fainting simple form of shock, occurring when tha patient has a temporary, self-correcting, loss of consciousness caused by a reduced supply of blood in the brain. Also called psychogenic shock. Fibrillation uncoordinated contractins of the myocardiuim resulting from independent individual cuscle fibre activity. Fibrin fibrous protein material formed and utilized to produce a blood clot. Fibula lateral leg bone.

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Flexion bending. To lessen the angle of a joint. Gastro used as a beginning of words in reference to the stomach. Genitalia external reproductive organs. Greenstick Fracture split along the length of a bone, giving the appearance of a green stick bent to its breaking point. Hemiparesis paralysis on one side of the body. Haematoma collection of blood under the skin or in the tissues as a result of an injured or broken blood vessel. Sometimes referred to as a blood tumor. Haemoptysis coughing up blood from the lung. Haemorrhage blood escaping from blood vessels. Haemothorax condition of blood and bloody fluids in the area between the lungs and the walls of the chest cavity. Hemiplegia paralysis of one half of the body. The lesion is on the side of the brain opposite to the side paralised. Humerus arm bone. Hypercapnia an increased amount od Carbon Dioxide in the blood. Hyperglycaemia excess of sugar in the blood. Hypertension abobe normal blood pressure. Hyperthermia greatly increased body temperature. Hyperventilation increased rate and depth of breathing. Hypoglycaemia the blood sugar level is less than normal. Hypotension below normal blood pressure. Hypothermia general cooling of the body. Hypovolaemic Shock state of shock brought about by an excessive loss of whole blood or plasma. Hypoxia inadequate supply of oxygen to the body tissues. Infarction localized death of tissue resulting from the discontinuation of its blood supply. Inferior away from the top of the body. Usually compared with another structure which is closer

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to the top (superior). Interposed Ventilation artificial ventilations provided during CPR. Ischaemia deficient blood supply. Jaw-Thrust method of opening the airway without lifting the neck or tilting the head. Jugular Veins large veins in the neck that drain blood from the head. Laceration jagged edged open wound. Larynx airway situated between the pharynx and the trachea. The voice box. Lateral to the side, away from the midline of the body. Ligament fibrous tissue that connects bone to bone. Lumbar Spine vertebrae of the lower back, consisting of 5 bones. Medial toward the vertical midline of the body. Mediastinum central portion of the chest cavity containing the heart, its greater vessels, part of the esophagus, and part of the trachea. Meninges three membranes surrounding the brain and spinal cord. Metabolic Shock state of shock due to a loss of body fluids (dehydration) and change in body chemistry. Metacarpals hand bones. Metatarsals foot bones. Myocardium heart muscle. Neurogenic Shock caused when the nervous system falls to control the diameter of the blood vessels. The vessels remain widely dilated, providing too great a volume to be filled by available blood. Nystagmus An involuntary, rapid movement of the eyeball. Oedema - dropsy. An effusion of fluid into the tissues. Oropharyngeal Airway curved breathing tube inserted into the patient's mouth. It will hold the base of the tongue forward. Paraesthesia disorder of sensation, e.g. Feeling of tingling or as of pins and needles. Paraplegia spinal lesion. From lesion below total paralysis.

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Paralysis no power or sensation or movement of any part. Patella kneecap. Penetrating Wound puncture wound with only an entrance wound. Perforating Wound puncture wound with an entrance and an exit. Pericardium sac that surrounds the heart. Peritoneum membtane that lines the abdominal cavity. Phalanges bones of the toes and fingers. Pharynx throat. Plasma fluid portion of the blood. It is blood minus blood cells and other structures (formed elements). Platelet formed elements of the blood that release factors needed for form blood clots. Pleura double membrane sac. The outer layer lines the chest wall and the inner layer covers the outside of the lungs. Pneumothorax collection of air in the chest cavity to the outside of the lungs, caused by the puncture to the chest wall or the lungs. Posterior back. Prone lying face down. Proximal close to a point of reference such as the shoulder or hip joint. Used with distal, meaning away from. Psychogenic Shock see fainting. Pulmonary refers to the lungs. Pulmonary circulation circuit of blood travelling from the right ventricle of the heart to the lungs and returning to the left atrium. Radial Pulse wrist pulse. Radius lateral forearm bone. Rectum lower portion of the large intestine ending with the anus. Respiratory Shock state of shock caused by too little oxygen in the blood. Usually due to lung failure, where the patient is unable to adequately fill the lungs.

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Retrosternal behind the sternum. Sacrum fused vertebrae of the lower back, inferior to the lumbar spine. Scapula shoulder blade. Septic Shock form of shock caused by severe infection. Toxins from the infection cause the blood vessels to dilate and plasma to be lost through vessel walls. Septum a partition between two cavities. Shock failure of the circulatory system to provide an adequate blood supply to all parts of the body. Spleen organ located to the left of the upper abdominal cavity, behind the stomach. It stores blood and destroys old blood cells. Sphygmomanometer instrument used to measure blood pressure. Sterile free of all life forms. Sternum breastbone. Stethoscope instrument used to amplify body sounds. Stokes-Adams Syndrome attacks of syncopy or fainting, due to cerebral anaemia in some cases of complete heart block. The heart stops, but breathing continues. Strain injury to muscles or tendon, caused by overexertion. Subcutaneous beneath the skin. Subjunctival Haemorrhage bleeding which occurs under the membrane lining the outer side of the eyeball. Superior toward the top of the body. Often used in reference with inferior, meaning away from the top of the body. Supine lying flat on the back. Symptom evidence of injury or illness told to you by the patient. Systemic refers to the entire body. Systolic force exerted by the blood on the artery walls when the heart is contracting. Tachycardia rapid heartbeat, usually 120 or more beats per minute. Tarsals ankle bones.

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Tendon fibrous tissue that connects muscle to bone. Therapeutics Science and art of healing and the treatment of a disease. Thoracic Cavity anterior body cavity above the diaphragm. It protects the heart and lungs. Thorax chest. Tibia medial lower leg bone. Tinnitus a ringing or roaring sound in the ears. Tonic Phase first state of a convulse seizure where the patient's body can become rigid for up to 30 seconds per episode. Can be longer in diving. Tourniquet las resort used to control bleeding. A band or belt is used to constrict blood vessels to stop the flow of blood. Trachea windpipe. Trauma injury caused by violence, shock or pressure. Triage method of sorting patients according to the severity of their injuries. Ulna medial forearm bone. Vasoconstriction narrowing of the blood vessels. Vasodilaton Enlargement of the blood vessels. Vein any blood vessel that returns blood to the heart. Ventral front of the body or body part. See anterior. Ventricle inferior chamber of the heart. Ventricles pump blood from the heart. Vertebra bone of the spinal column. Viscera internal organs. Usually refers to the abdominal organs. Vital Signs in basis DMT level care, pulse rate and character, breathing rate and character, blood pressure, and relative skin temperature. Pupil reaction. Xiphoid inferior process of the sternum.

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MEDICAL ABREVIATIONS BP CNS CPR CSF CVS EAR ECM ECG ESR Hb mm Hg PCV RBC RS WBC UPTD Blood pressure Central nervous system Cariopulmonary resuscitation Cerebrospinal fluid Cariovascular system Expired air resuscitation External cardiac massage Electrocardiogram Erythrocyte sedimentation rate Haemoglobin Milimeters of mercury (pressure) Packed cell volume Red blood corpuscle Respiratory system White blood corpuscle Unit pulmonary toxicity dose

Diver Medic Course MEDICAL TERMINOLOGY

Cerebal Renal Hepatic Gastric Medulla Cortex Idiopathic (of diseases) Functional Central nervous system Automatic nervous system brain, spinal cord, peripheral nerves branches of above, combined into relay stations, power sub-stations, for organs not under control of will. Intake, breakdown, absorption of food. Intake of air containing oxygen. Exchange of gases in the body tissues (carbon dioxide-oxygen) Heart and blood vessels, transport system Activities of the liver Treatment Hence-Chemo with drugs Physio with exercise Psycho via the mind cause unknown (terms used to describe several structures in the body, e.g. Brain) of the brain of the kidney of the liver of the stomach inner part outer part, kidney

Alimentary system Respiratory system Cardio-vascular system Biliary system Therapy

Diver Medic Course PARTS OF WORDS, WHICH MAY BE AT THE BEGINNING, IN THE MIDDLE, OR AT THE END OF THE WORD
Dura Loco Derma Stasis Therm CauScope Micro Mega Blast Ortho Pan Tox Neuro Leuco Phobia Morphi -cyst-pneu-mela-lact-hydro-synhard place of skin stand heat burn to view small large build upright whole of poison of nerves white fear from of a cell of respiration black of milk of water going together e.g. Syndrome e.g. Pneumonia e.g. Melaena-black stool, melancholiablack mood e.g. Ploy-morph e.g. Durable, indurated e.g. Locality, locomotor e.g. Dermis, hypodermic e.g. Stat. (give at once), venestasis, static e.g. Thermometer e.g. Cautery e.g. Telescope, cytoscope e.g. Microscope e.g. Mega-ton, acromegaly (disease with overgrowth of bone) e.g. Megaloblastic anaemia (disease with large blood cells) e.g. Orthopaedic, orthopnoeic e.g. Pan-hysterectomy e.g. Toxic e.g. Neuritis e.g. Leucocyte

Diver Medic Course

-lysis-myc-eu-dys-my-pyo-pererythro peri epi intra inter poly di bi mono pseudo para endo meso ecto dia anti ante post hyper breakdown of fungus easy difficult of muscle of pus through redness around upon within between many two one false beside inner middle outer across against before after above e.g. Erythema e.g. Emphysema e.g. Actinomyces, streptomycin e.g. Euphoric, euthanasia e.g. Dyspnoea

Diver Medic Course

hypo retre ultra -ology-itis-ostomy-ectomy-cele-opia-aemia-omaless than behind beyond study for inflammation cutting into cutting off swelling sight of blood tumour e.g. Diplopia

Diver Medic Course INTRODUCTION ETHICS & CONDUCT

A person who has an accident is called a Victim. Once under care of a first aider he becomes a patient (maybe because he is waiting for something to happen!). Be: Pleasant (inspire confidence & calm) Co-operative (work with team) Resourceful (adapt to situation) Self motivated (show initiative) Emotionally stable (overcome feelings) Leader (take control) Proud (neat/clean appearance) Good morals (trusted/valuables/truthful) Good habits (no smoking contaminate wounds no alcohol O2 danger) Conversation (talk properly no bad language) Listen (to others/interviews) do not say wrong things Develop calm, professional manner better patient care.

Patient has a right to refuse treatment. All examinations must be with informed consent, even minor things such as pulse taking. There are a number of situations where the medic is allowed to proceed without consent e.g. An unconscious patient. Is is assumed that the patient would give consent if able. Try to persuade by conversation. Do not argue. If serious condition Interdive's Superintendent may want patient to sign, release form or witness refusal. Privacy Do not talk to others about patient (except Supv/Doctor) may discuss causes/symptoms etc but not PT name. Records Anything written on standard forms become part of patient records may be legal document so, must be complete, accurate and original. Alcohol and Drug Abuse (More later) but know if company wants further action. Is patient danger to self and worksite urine tests, reports to base? Criminal Injury Must be reported to O.I.M. And own Co. Ops. Manager make out report. Doctor Code of conduct guard confidence of patient no info to friends or relatives without permission (nor employer) discretion Nurse Patient entering hospital retains all rights nurse must obtain signed permission for operations may be held negligent or incompetent.

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First Aider/Medic Skilled application of accepted principles of treatment using facilities or materials available approved care until placed in care of Dr. or hospital TO PRESERVE LIFE TO PREVENT DETERIORATION TO PROMOTE RECOVERY Medical Aid Treatment by a doctor at a hospital or surgery. First Aider Trained person attended both theory and practical course pass examination valid three years Only because: HIGHLY TRAINED REGULARLY EXAMINED KEPT UP TO DATE IN KNOWLEDGE AND SKILL Property List checked by 2 persons and put in safe keeping if searching habe witness same for deceased. (List items gold as yellow metal silver as white metal). Death Drowning may be 1 hour for resuscitation. Dr. must say deceased. (May be obvious decapitation cremated). DO NOT REMOVE until a full enquiry has been carried out. DETAILS OF INCIDENT LEADING UP TO DEATH LIST OF EQUIPMENT RETAIN EQUIPMENT IN EXACT STATE (I.E. DO NOT TURN MASK VALVES/BAILOUTS ON/OFF ETC.) IF HAS TO BE CUT RETAIN FITTINGS RETAIN PROPERTY (SEE ABOVE) FULL REPORT OF ACTIONS TAKEN PLUS STATEMENTS FROM WITNESSES NO NEED TO DECOMPRESS DECEASED RETAIN COOL LAYOUT (RIGOR MORTIS) INFORM BASE / OIM ETC COMPLETE COMPANY REPORTS

Diver Medic Course SECTION TWO DIVING (General) PERSONAL AND SATURARION HYGIENE
Basic rules of personal hygiene On the surface: Follow the common rules of hygiene based on strict personal cleanliness. Do not however carry out vigorous cleaning of the outer canal with cotton tips. Before going into saturation: Shower, cut fingernails short, do not take cotton-tipped sticks into the chamber. During saturation: Observe strict personal cleanliness (wash with Septivon type bacterial wash). Do not clean ears Maintain for PERSONAL USE only: Your bunk; Stereo Headset; Towel and wash mitt or flannel. For working in the water: Whenever possible the diver should wear a dry helmet (help to keep the ears dry). Otherwise wear a cap and dry the ears when out of the water.

THE USE OF TREATMENT EAR DROPS

Treatment drops contain the following antibiotics: Polymyxin B Sulphate 0.5% + Gentamicin Sulphate 0.3% If the laboratory services are available it will be possible to distinguish between ear infection due to Pseudomonas Aeruhinosa (Pyo) and those due to other Gram negative bacilli (Gram negative, not Pyo). Divers suffering from psuedomona infections shlukd always be removed from saturation as soon as possible. Divers suffering from other ear infectoins due to other bacteria may continue in saturation under treatment, although this is not desirable. DETAILS OF TREATMENT: 1- Treatment drops must not be used prophylactically. They must only be used when there is positive indication, significant ear pain and/or the results of bacteriological studies. 2- The use of prophylactic drops (e.g. Otic Domeboro) must stop before treatment drops are used. 3- Each individual diver should be issued with two bottles of drops. Both should be clearly labelled with his name, and one marked left and one marked right for use in each respective ear.

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4- DOSE: 3 drops into each ear, four times a day (every 6 hours). Do not exceed this dose as toxic side effects may occur. 5- DURATION OF TREATMENT: Divers should be treated for seven full days. Any remaining drops should be discarded at the at the end of this time. 6- TECHNIQUE OF TREATMENT: Always treat both ears. Objects should not be stuck into the ear canal. One diver should apply the drops to another divers ear canal and vice versa. 7- SIDE EFFECTS: If divers develop any other symptoms beside ear whilst under treatment, ask for medical advice. 8- EAR SWABS AND TREATMENT: Ear swabs must not be taken during treatment results during this time are misleading. At the end of a course of treatment, drops should not be used for a further 2 days, then ear swabs taken on the 3rd day. If these swabs are clear, a cure can be assumed. If the infection persist, seek medical advice. 9- Divers should not undergo repeated courses of treatment in any one saturation. 10- STORAGE OF TREATMENT DROP: Not more than 5 months at +4C (domestic fridge). Not more than 3 weeks at 30C (saturatione environment). N.B The proper use of treatment drops, whilst simple, is not a trivial matter. Treatment must be supervised and carried out with close attention to detail.

Diver Medic Course DECOMPRESSION ILLNESS NEW TERMINOLOGY

The following unit is kindly reproduced with permission of Surgeon Commander TJR Francis (RN) of Institute of Naval Medicine. Interdive Services was the first commercial diver training centre, outside the services, to implement this new terminology and diagnosis procedure. This unit will hopefully give the Diver, Supervisor, LST or DMT, a better understanding of the limitations of previous thinking on Decompression Illnesses. There has previously been a gross over-simplification of the divisions between Type II DCS (associated with gas burden) and AGE (associated with over expansion of the lungs) + lungs swamped with bubbles, PFO & ductus: -Gas entertin Arterial Circulation by wathever means. This is why the new terminology was introduced. ACUTE DECOMPRESSION ILLNESS Background. Acute decompression illness (DCI) is a syndrome of numerous possible manifestations, which may develop following decompression. It is althought, to be initiated by the presence of bubbles of gas in body tissues including the blood stream. Althought the means where by these bubbles cause tissue dysfunction have yet to be fully elucidated, the manifestations have been recognised for may years and are described below. Disease Mechanisms. There are a number of sources of these gas bubbles: a. Dissolved gas. The concentration of inert gas in arterial blood is approximately the same as in the gas mixture, wich is being breathed. For example, at sea level, both air and arterial blood contain approximately 0.8 atmospheres of nitrogen. During most dives or hyperbaric exposures, the partial pressure of inert gas, wich is breathed , increases with depth and the concentration of that gas in arterial blood increases accordingly. Under these circumstances, the partial pressure of inert gas in tissues will gradually increase until it equals the ambient partial pressure. The dynamics of tissue gas exchange are beyond the scope of this text, but can be summarised by the statement that it is, at present, incompletely understood. b. During decompression,inert gas moves in the opposite direction, from the tissues into the blood, where it is carried to the lungs and exhaled. If this process occurs in a controled manner, so that the inert tension gas does not reach a sufficient level of super saturating for bubbles to form, the decompression will progress uneventfully. However, if the rate of decompression is such that the capacity of the tissues, cardiovascular system and lungs to remove inert gas is exceeded, bubbles of that gas may start to form in tissues or blood. c. The human body is capable of tolerating a certain bubble burden. Bubbles in venous blood, for example, are efficiently removed from the circulation by the lungs and numerous studies have demonstrated the presence of such bubbles in asymptomatic divers. Furthermore, bubbles may form in some tissues (such as adipose tissue) without causing overt disease. However, other tissues, particularly nervous tissue, are much more sensitive and the presence of even a small numbers of gas bubbles may result in abnormal tissue function. How these bubbles provoke decompressoin illness has yet to be completely clarified. Hypotheses for the means whereby ther exert their

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deleterious effects on tissue function include: the physical disruption of tissue architecture; interruption of tissue microcirculation and derangement of tissue biochemical activity at the tissuebubble interface. d. Arterial gas bubbles. The lungs are excellent filters of gas bubbles, however, this capacity is finite; if the bubble burden is such that this is exceeded, they till transit the lungs and enter the arterial circulation. e. The transit of venous bubbles to arterial blood may occur before the pulmonary filter is overwhelmed. In approximately 25-30% of the normal, adult population, the septum that separates the upper chambers of the heart contains a potential or actual defect, which is known as Patent Foramen Ovale or PFO. This is a relic of the foetal circulation and normally results in no ill effects. However, it does offer a possible route for bubbles to bypass the pulmonary filter and consequently, along with other right-to-left shunts, has the potential to promote the arterialization of otherwise relatively harmless venous bubbles: coughing and forced Valsalva manoeuvres may expedite the bubbles through the PFO. f. Another source of arterial gas bubbles is discussed in the Decompression Pulmonary Barotrauma section. g. How bubbles in arterial blood interfere with tissue function is another subject, which is incompletely understood. One ovbious mechanism is that they physically obstruct small blood vessels and thereby cause tissue ischaemia. The behaviour of bubbles in the cerebral circulation has been studied extensively and, although the obstruction of blood vessels occurs as soon as bubbles arrive in the brain, this effect appears to be short-lived. Cerebral blood vessels respond to the presence of bubbles by dilating and thus allowing the bubbles to move on. It is now thought that much of the illnes which results from bubble embolism of the brain is due to the consequences of traumatic injury to the dellicate endothelial lining of cerebral blood vessels, which, in places may be stripped away from the vessel wall. This results not only in a breakdown of the blood-brain-barrier and the consequential leaking of potentially harmfull blood constituents into the brain, but also, by exposing blood components such as white blood cells and platelets to the damaged blood vessel wall, a tissue reaction to injury is promoted. Ironically, it is the physical and biochemical consequences of this reaction, that may actually result in a further deterioration of cerebral blood flow and function. Although it is recognised that tissue bubbles may arise from two fundamentally different process it is often difficult, in individual cases, to be certain of the origins of the disease-provoking gas. Indeed, with respect to some organ systems, such as the ear and lungs, it may occasionally be difficult to distinguish between a bubble-induced condition and the results of barotrauma. Consequently, it is now recognised that, for practical purposes, the distinction between the conditions that used to be known as decompression sickness and arterial gas embolism was artificial. As a result, the term decompression illness, which encompasses the two, is increasingly being used to reflect this. Symptoms and Signs. Since decompression illness can interfere with the function of a wide range of body tissues, the number of potential signs and symptoms is truly enormous. In the past, these have been lumped together into syndromes according to the anatomical site and presumed mechanism of disease. One of these syndromes has been further classified into types according to perceived severity: Mild (Type 1) and Serious (Type 2) decompression sickness. These terms are still used, but it is

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increasingly recognised that they are of very limited value. Descriptive Protocol. Rather than imposing this somewhat artificial classification on the decompression disorders, a better understanding of the natural syndromes is likely to result if a descriptive system is used. To simplify what could otherwise end up as a bewildering collection of terms, the symptoms and signs of decompression illness will be discussed using evolution and manifestation terms. a. Evolution. The evolution term is used to describe the development of the condition PRIOR TO RECOMPRESSION. DCI is frequently a highly dynamic condition, the term used may change from one observation to the next, e.g. A condition will probably present initially as being progressive as the patient becomes increasingly aware that something is wrong. However, the situation frequently stabilises so that it may then be described as static. Tha patient may then undergo a substantial improvement, occasionally to complete resolution of the symptoms, and at that stage be described as spontaneously improving. Occasionally, the symptoms may then return or new symptoms appear, in wich case the condition would be described as relapsing. (i) Progressive. A condition may be described as progressive if the number or severity of symptoms or signs is increasing. Examples would include an increasing severity of limb pain or the involvement of additional joints or a neurological presentation in which the loss of motor or sensory functions is becoming more profound or where the extent of any loss of function is increasing. The development of a new manifestation, such as a neurological symptom or sign in addition to limb pain also represents progression of the condition. Terms such as rapidly or slowly may be used to enhance the description of this evolution where this is appropriate. Rapidly and slowly would refer to the progression of symptoms over a period of minutes or hours respectively. (ii) Static. This is self-explanatory. Neither the severity nor number of manifestations is changing substantially. (iii) Spontaneously Improving. It is common for a number of presentations of decopression illness to improve, albeit transiently in certain instances, without recompression. Substantially improvement must occur for this term to be applied. As with other evolution terms, improving should only be used to describe events prior to decompression. (iv) Relapsing. Occasionally, cases that have improved spontaneously undergo a secondary deterioration. This is particularly true of some neurological manifestations. This term is used to describe such cases. When a condition gets worse in the absence of any spontaneous improvement it should be described as progressive. Relapsing should be reserved for cases, which have, at some stage in their evolution, undergone substantial, spontaneous improvement. b. Manifestations. There are a number of manifestations of decompression illness, which occur commonly, and these are outlined below. They may occur alone or in combination. Occasionally, unusual cases occur and in such instances, the use of additional descriptive terms may be required. (i) Pain. Limb pain. This is probably the most frequent manifestation of decompression illness. It is used to describe the deep aching pain in or around one or more plus joints that may begin during decompression or after completion of a dive. Following bounce dives, the upper limbs tend to be involved more often than the lower limbs and the shoulder is involved particularly frequently. Conversely, in saturarion divers, aviators and compressed-air (caissons) workers, it is the lower limbs and particularly the kness, which are involved most commonly. The pain usually begins

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gradually and is poorly localised; it may resolve spontaneously and is then known as a niggle. Niggle may flit from joint to joint. If the pain gets worse, it becomes more readily localised and is described as a dull, boring ache, similar in character to tooth ache. Sometimes the joint is held in a particular position that is least painful, but pain is seldom made worse by movement. If the pain is in a lower limb, weight bearing may be poorly tolerated on that limb. On examination, there are often no objective signs. Occasionally, there is a skin rash over or adjacent to the affected joint. Notably, the clasicalsigns of inflammation: redness, swelling, warmth to the touch and tenderness are missing. Even cases of apparently straightforward limb pain must be FULLY EXAMINED. A patient in pain may not notice mild paraesthesiae or a small area of numbness. Ensure that no neurological symptoms can de detected before the choice of a therapeutic table is made. Limb pain decompression illness usually resolves completely, even without treatment over a period of 12-72 hours. However, deliberate withholding of recompression is difficult to justify. Not only is rapid relief of pain usually obtained but, particularly in cases where there are has been a rapid onset of pain after surfacing, the onset of subsequent neurological symptoms may be prevented. Girdle Pain. This is a poorly localised, aching or constricting sensation which is generally in the abdomen, pelvis, or occasionally, in the chest. Girdle pain in the context of DCI is generally considered ominious since it frequently portends neurological deterioration. (ii) Neurological. Involvement of the nervous system may be subtle, multi-focal and consequently of bewildering variety and very difficult to localise. Both the central and peripheral nervous systems may be involved and the manifestations can be broken down into the loss of certain functions: Higher functions, wich would include aberration of thought processes or affect, loss of memory, dysarthria etc.; Alteration to the level of consciousness, including seizures; loss of co-ordination; loss of strength or sensation with almost any distribution; dysfunction of special senses and loss of sphincter control, especially of the bladder. It is likely that many of these disorders involve the brain. In these cases, some loss of consciousness to the point of disorientation is a frequent finding and coma may occasionally ensue. Visual symptomps are common, as are motor and other sensory deficits. Because this disease may be subtle, it is most important that a diving supervisor knows his divers. Otherwise signs such as a change of mood, dulling of intellect and loss of short-term memory may go unrecognised. It is also apparent that the spinal cord is also involved in neurological decompression illness with some frequenciy. It may appear to be involved alone or with other parts of the nervous system. Dives that readily appear to provoke disease with a predominantly spinal cord distribution are short, deep dives with a rapid ascent to the surface. The onset of symptoms commonly occurs shortly after reaching the surface, with about half of serious cases becoming symptomatic within 10 minutes. Less than 10% of serious cases presents more than 4 hours after completing the dive. In severe cases, the condition is often heralded by the onset of girdle pain. Shortly afterwards, the patient may notice pins and needles, numbness and muscular weakness in the legs wich rapidly progresses to paraplegia. It is possible for all four limbs to be involved and, in severe cases, shock may complicate the clinical picture. In less severe cases, the onset is not so dramatic and progress to paraplegia may be delayed and incomplete. There may be little in the way of girdle pain in such cases. On examination, it is often possible to determine a level above which spinal cord function is apparently normal. This level is often in the lower thoracic or upper lumbar segments. It is occasionally possible to determine different levels for motor innervation and the various sensory modalities. The bladder is frequently involved. Tha patient may report difficulty-initiating urination, but more often, this will be detected by de absence of urinary output and the presence of a distended bladder on examination of the abdomen.

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Unless the fulminant condition is rapidly treated with recompression, a complete recovery is unlikely. The prognosis for cases with a less dramatic onset is better. Even without recompression some spontaneous improvement generally occurs. Nonetheless, improvement will be more complete and rapid with recompression. Audio-Vestibular. This is a unique subclass of neurological decompression illness. It is thought that there are two mechanisms whereby the audio vestibular system may be involved: barotrauma and tissue injury resulting from the formation of bubbles from dissolved gas. Possible targets of this second mechanism include the cochlea, the eight nerve nuclei and cerebellar or cortical pathways. In individual cases it may be very difficult to distinguish between these mechanisms or sites of injury by clinical examination alone. As a consequence this term may be used to describe the syndrome which includes: vertigo (a sense of rotation), tinnitus, nystagmus or loss of hearing after a dive. Nausea and vomiting may accompany these symptoms, but of themselves are insignificant to imply audio-vestibular involvement in decompression illness. Experimental and anecdotal evidence now exists to show that recompression does not appear to have an adverse affect on pathology due to round or oval window rupture. Therefore, if the mechanism of disease is uncertain, appropiate recompression therapy should be undertaken. All such cases should then be referred for specialist investigation to stablish the need for further treatment for a perilymph fistula. (iii) Pulmonary. Involvement of the lungs in decompression illness may be because of two quite distinct processes: decompression pulmonary barotrauma and the cardio-pulmonary consequences of massive venous gas embolism. Although the mechanisms involved are distinctly different, it may be difficult to distinguish between them immediately in a clinical setting, because many of the symptoms and some of the signs are shared. Those which imly pulmonary (or, rarely, cardiac) involvement in decompression illness are: chest pain, cough, haemoptysis, shortness of breath, cyanosis and, rarely, shock. In the rare instances that the condition is progressive, it may prove fatal unless the patient is managed correctly. Progressive disease may be due either to a tension pneumothorax or massive gas embolism of the lungs. Where there has been a dive, which has induced a low gas burden, it is most likely that a pneumothorax is the cause of the problem. This mey be diagnosed clinically from the classic signs described in de Decompression Pulmonary barotrauma lecture. An x-ray, if available, may confirm the diagnosis. The presentation of patients with massive, overwhelming venous gas embolism of the pulmonary circulation has been described, although it is very rare and generally associated with missed decompression. These patients usually become symptomatic within about half an hour of reaching the surface. The condition commences with central chest pain and a cough, which may be aggravated by taking deep breaths or inhaling cigarette smoke. Breathlessness and central cyanosis follow and, shortly thereafter, signs of shock. The condition is progressive, the patient may deteriorate rapidly and cardiovascular collapse, loss of consciousness and death may follow, unless the patient is recompressed. Apart from cyanosis and respiratory distress, there are no signs of a Pneumothorax. (iv) Cutaneous. The skin may be affected by diving in a number of ways. Two very common manifestations of decompression, but wich are not generally regarded as illness, are suit squeeze and itching in the absence of a rash. The term cutaneous decompression illness should be used to describe the condition, wich generally presents with severe itching around the shoulders or over the trunk. After a time, this developes into an erythematous rash, which may progress to cyanotic mottling or marbling of the skin. When further describing the condition, it is desirable to identify the location of the disorder.

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(v) Lymphatic. Occasionally, lymph nodes may become enlarged and tender and this may be associated with oedema. The skin feels thickened and may have the pitted appearance of orange peel. If pressure is applied to the skin, for example, by the thumb and released after about a minute or so, a visible indentation remains. (vi) Constitutional. There are a number of non-specific symptoms that occur after diving and which, if severe or if accompanied by other manifestations, may be considerated part of the decompression illness syndrome. These include headache, fatigue, malaise (wich may include nausea and, possibly, vomiting) and anorexia. Terminology. By including the evolution and manifestation terms in the phrase decompression illness, a highly flexible diagnostic label can be applied to any case. This label imparts a great deal of information and because it does not require the observer to guess at either a mechanism of the disease or location of the lesion, it should be possible for these terms to be applied consestently. The term acute is used to distinguish these conditions from possible chronic consequences of diving such as dysbaric osteonecrosis. Examples of how the terminology is used include: ACUTE, RELAPSING, NEUROLOGICAL, DECOMPRESSION ILLNESS or: ACUTE, PROGRESSIVE, LIMB PAIN AND CUTANEOUS DECOMPRESSION ILLNESS In rare, highly complex cases, rather than enumerate a long list of manifestations, it may be appropiate to use the term Multi-system. Additional Information. While the descriptive diagnostic terminology imparts a considerable amount of information, it is inadequate, of itself, to summarise a case of decompression illness. As was mentioned avobe, this a poorly understood syndrome and if a better understanding is to evolve, it is important that additional information is collected: a. The time of onset. Decompression illness usually presents within a short period of time following a dive. Symptoms may become apparent before surfacing in saturation and occasionally in bounce dives, particularly where decompression has been omitted. However, most symptoms occur after surfacing and the majority of serious neurological or pulmonary symptoms are usually manifested within about 30 minutes. The onset of limb pain also occurs in this time period but this may be delayed for many hours after a dive. It should be remembered that decompression illness might be provoked or made worse many hours after a dive if the diver takes a flight. If a diver has been asyptomatic for 48 or more hours after a dive and has not flown, then symptoms, which develope subsequently, are problably not dive-related. It is important to record the time of onset of each manifestation of decompression illness. If a flight was taken after the last dive, this should be recorded as well. b. Gas burden. When considering possible mechanism for decompression illness, it is a desirable to have an idea of the amount of gas that is likely to be present in the various tissues. At present there is no convenient means of summarising this. Consequently it is important that the dive profile is recorded as accurately as possible. Where a dive computer or depth-time recorded was born, the information should be retrieved from this source. c. Evidence of barotrauma. This is particularly important in the case of pulmonary and audio

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vestibular decompression illness as discussed above. However, any evidence of any barotrauma, such as middle ear should be recorded. d. Response to recompression. Quite often, the only means of confirming a diagnosis of decompression illness is if there is some measure of improvement following recompression. Consequently, it is important to record the response to recompression. e. Results of investigations. There are an icreasing number of investigations, which are performed on cases of decompression illness, such as tests for a PFO, electrophysiological tests and perfusion scans of the brain. The results of all investigations form an important part of any case notes and may influence the eventual diagnosis.

Diver Medic Course FLYING AFTER DIVING

DMAC Memo 07. For the purposes of these guideliness, it was considered that diving could be divided into two categories, viz: 1. Air and Nitrox diving 2. Mixed gas diving Two maxima of cabin altitude were considered, viz: a. A maximum cabin altitude of 2000' (600m), provided the predicted flight plan has been checked. b. A maximum cabin altitude of 8000' (2600m), all other flights. CAUTION The times given below are minimum times; longer time intervals are recommended, in particular if the planned journey involves a number of take-offs. Shorter times may be considered but only after the advice of a qualified medical doctor. Flying in the presence of even minor symptoms or residua of a decompression illness carries a considerable risk of provoking serious neurological illness. 1. Diving without DCI problems Minimum times before flying at cabin altitude 2000' (600m) 1.1 No stop dives. Total time under pressure less than 60 minutes within previous 12 hours. All other Air and Nitrox diving, heliox and mixed gas bounce diving. (Less than 4 hours under pressure). Heliox Saturation (More than 4 hours under pressure) Air, Nitrox or Trimix Saturation (More than 4 hours under pressure) 24 hours 48 hours 2 hours All other flights 8 hours (24 hours)* 24 hours

1.2

12 hours

1.3 1.4

* 8 hours applies to short flights. For longer flights, i.e. Intercontinental, the time is extended to 24 hours.

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2. Following therapy for DCI, advice should be sought from a diving medical specialist The times given below are minimum times.

Minimum time from completion of therapy 2000' (600m) 2.1 Inmediate & complete resolution of symptoms 24 hours on first recompression All other flights 48 hours

2.2 A diving medical specialist must decide cases without immediate response or with residual Diving Medical Specialist symptoms on an individual basis. Generally wait as long as possible.

3. DCI in flight Where the diver's symptoms consist only of pain in a limb, he should be treated with analgesics, oral fluids, oxygen if available, and the plane can continue to its destination without diversion or adjustement in altitude. When the diver has any other symptoms, immediate advice should be sought from a diving medical specialist. It may be necessary to reduce the cabin altitude or divert to the nearest airport. In the meantime, the patient should be given oxygen and oral fluids if available.

Diver Medic Course INTERDIVE RULES FOR RECOMPRESSION TREATMENT

NEVER 1. Permit any shortening or other alteration of the tables, except under the direction of a Diving Medical Officer. 2. Wait for a bag resuscitator. Use mouth-to-mouth resuscitation immediately if breathing ceases. 3. Break rhythm during resuscitation. 4. Permit the use of 100-percent oxygen below 18 msw. 5. Fail to treat doubtful cases. 6. Allow personnel in the chamber to assume cramped position that might interfere with complete blood circulation.

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ALWAYS Follow the treatment tables accurately, unless modified by a Diving Medical Officer with concurrence of the Supervisor. Have qualified tender in chamber at all times during treatment. Maintain the normal descent and ascent rates as much as possible. Examine patient thoroughly at depth of relief or treatment depth. Use air treatment tables only if oxygen is unavailable. Be alert for warning signs of oxygen toxicity if oxygen is used. In the event of oxygen convulsion, remove the oxygen mask and kee the patient from selfharm. Do not use mouth gags or force mouth open during convulsion. Maintain oxygen usage within the time and depth limitations prescribed by the treatment table. Check the patent's condition and vital signs periodically. Check frequently if the patient's condition is changing rapidly or the vital signs are unstable. Observe patient after treatment for recurrence of symptoms. Observe two hours for painonly symptoms, six hours for serious symptoms. Maintain accurate time keeping and recording. Maintain a well-stocked medical kit at hand.

Diver Medic Course ABORT SCHEDULES

In the event that a saturation dive has to be terminated early, and within ten hours, the diving contractor lays down abort schedules. If it is necessary to abort a planned saturation during pressurisation, the LST on duty will have alternative tables with which to decompress the occupants i.e. He will probably switch to a bounce dive table for the depth duration of the dive at the time of aborting, but it may be necessary to use a deeper and or/longer table since the partial pressure of He during the saturation pressurisation will have been higher than for a bounce dive to the same depth. The same procedure may be be followed when locking a Doctor or DMT into the chamber (during saturation) for a short period.

EMERGENCY SCHEDULES
When conducting shor duration dives, emergency schedules must be available for the dive that runs over time. These schedules may include Oxy/Helium Partial Pressure Tables, Abort Tables, or transfer to saturation.

Diver Medic Course The Diving Medical Advisory Committee Medical Equipment to be Held at the Site of an Offshore Diving Operation
DMAC 15 Rev. 2 May 2009
Supersedes DMAC 15 and DMAC 15 Rev. 1, which are now withdrawn

Commercial diving operations include both surface and saturation diving operations and cover a wide range of work activities. Appropiate medical equipment to be held at any particular site is best determinated by an occupational health service with special knowledge of commercial diving operations. This list is designed to provide guidance on equipment to be held at the site where such advice is not available. It is recognised that in certain circumstances similar or greater facilities may be available from other sources which are sufficiently close and reliable. The list covers equipment suitable for the treatment of diving related disorders on the surface or in a recompression chamber and for other potential problems eg. Trauma which may occur during diving operations. The list takes account of situations where the diving operation may be remote from a vessel or installation sickbay and medical services. It includes equipment for use in an immediate first aid situation, equipment and drugs which may be used by personnel with advanced first aid training as well as equipment which would almost certainly only be used by medical staff. Medical staff who attend a casualty at a dive site may not necessarily be able to bring the appropiate equipment. Some of the drugs mentioned in this note may not be available in some geographical areas and in such cases alternative drugs to those identified should be considered. It is anticipated that except in emergency situations, equipment other than in the bell or chamber first aid kits would be for use by or on the direction of medical staff. There should be an appropriate system for the control and maintenance of the equipment and responsibility for the equipment should be vested in the Diving Superintendent or vessel medic. Equipment should be stored in a locked container and appropriately labelled. The diving supervisor must have access to the equipment at all times. Scheduled drugs should be held in a secure double locked container (with vessel medical supplies or installation sickbay). A logbook should be maintained with the equipment in which all use of equipment and drugs is recorded. The equipment should be inspected regularly (at least every three months) to ensure that all items are in working order (e.g. Batteries) and to exchange drugs and other equipment which is nearing the end of its shelf life. These regular inspections shold be recorded in the logbook. Consideration shold be given to the need for pressure testing mechanical or electrical equipment.
The views expressed in any guidance given are of a general nature and are volunteered without recourse or responsibility upon the part of the DMAC, its members or officers. Any person who considers that such opinions are relevant to his circumstances should immediately consult his own advisers.

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Equipment to be Held in a Diving Bell 1 Torniquet 3 Polythene bags 1 Pocket resuscitator (pocket mask) 1 Airway size 4 (e.g. Guedel type) 1 Tuf cut scissors 1 Medium dressing 1 Large dressing 2 Triangular bandage 1 Role of 1 inch adhesive tape 2 Crepe bandage 3 in 1 Hand operated suction pump (e.g. Vitalograph) 1 Water tight bag 1 Suction catheters sizes 12 and 14 20 Hyoscine dermal patches for Hyperbaric evacuation chamber (e.g. Scopoderm plasters) The same equipment should be held in each living chamber of a saturation system, in air diving chambers and in hyperbaric lifeboats. In living chambers a foot or gas powered suction pump may be preferred. Equipment to be Held at the Dive Site Diagnostic Equipment Pencil torch Stethoscope Reflex hammer Tuning fork (256 Hz) Tongue depressors Otoscope (with spare bulb and batteries) Thoracocentesis Intercostal drain/trocar and drainage kit (Foley type) Heimlich valve Urinary Catheterisation 2 Urinary catheters sizes 16 and 18 (Foley type) 2 Catheter spigots 2 Urethral anaesthetic gel Dressings 10 pkts Gauze squares 10x10cm 10 pkts Cotton wool balls 2 Adhesive bandage 75mm x 3m 2 Adhesive bandage 25mm x 3m 2 Large dressings 2 Medium dressings 2 Small dressings 2 Ambulance dressings Intravenous Access 3 Giving sets 4 Butterfly infusion sets 19g 4 Infusion bottle holders Thermometer (electronic) inc low range Anaeroid sphygmomanometer Tape measure Pins for testing sensation (Neurotips) Urine testing strips

2 Intravenous cannulae 14g 1 wide bore needle 2 Urine collection bags 2x20ml sterile water

6 Triangular bandages 12 Safety pins 40 Adhesive bandages 2 Crepe bandages 3in 2 Crepe bandages 6in 2 Dressing bowls 4 Eye pads

4 iv cannulae 16g 4 iv cannulae 18 g 2 long needles (for venting infussion bottles)

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Sterile Supplies General 4 Universal containers 10 Alcohol swabs 5 Gloves (selection of sizes) 2 Resorbable sutures (2/0 3/0) 5 x 10 ml Syringes 10 x 18g Needles 38mm 2 x 18g Needles 90mm Sterile Instruments 2 Spencer Wells forceps 5 inch 1 Spencer Wells forceps 7 inch 1 Scissors fine pointed 1 Forceps fine toothed 6 Sachets skin desinfectant (cetrimide) 2 Drapes 6 Sutures nylon (2/0 3/0) 5 x 20 ml Syringes 5 x 2ml Syringes 10 x 21g Needles

1 pr Mosquito forceps 1 Dressing forceps 2 Disposable scalpels 1 Dressing scissors

Resuscitation Resuscitator to include reservoir and connection for BIBS gas (e.g. Laerdal type)* 3 resuscitation masks (varied sizes) Pocket resuscitator with one way valve (e.g. Laerdal pocket mask) Laryngoscope and batteries and spare bulb Endotracheal tubes (e.g. Sizes 7,8,9). 2 Laryngeal masks or oesofago-laryngeal tubes may replace endotracheal tubes.** 1 ET tube coupling and mount 2 Airways sizes 3+4 (e.g. Guedel type) Foot operated suction device Torniquet 2 Endotracheal suction catheters 2 wide bore suckers Semi-automatic defibrillator *Resuscitators may require modification to gas inlet to ensure adequate filling at pressure. **Endotracheal tubes should be provided for use by doctors only. Drugs Anaesthesia/Analgesia 5 x 10ml Lignoocaine 10mg/ml amps 25 x 500mg Paracetamol tabs 20 x 30mg Dihydrocodeine tabs 20 x 300mg Soluble aspirin tabs 5 x 10mg Morphine sulphate amps (or 100mg pethidine) 2 x 1ml Naloxone 0.4mg/ml amps Various 2 x 10 mg Cholorpheniramine amps 2 x 50mg Chlorpromazine amps 5 x 10mg Diazepam amps 10 x 5mg Diazepam amps 1 Tube Silver Sulphadiazine cream 1% 6 x 500ml Saline 9mg/ml 20 x 250 mg Erythromycin tabs 2 x 10mg Diazepam (rectal) Resuscitation 2 x 40mg Furosemide amps 10 x 1ml Adrenaline 1mg/ml amps 2 x 1.2mg Atropine amps 5 x 100mg Hydrocortisone amps 2 x 25 Prochlorperazine amps 3 x 20ml Glucose 50mg/ml 6 x 150mg Amidarone amps

20 x 250mg Amoxycillin tabs 2 bottles antibiotic ear drops

Diver Medic Course SECTION THREE DIVING (Medical) NON-RECOMPRESSION TREATMENT DIVER INJURIES
The following diagnosis and treatment procedures apply to the most common types of diver injuries, that do not require recompression treatment. Management of traumatic injuries should be accomplished using standard first aid procedures. SQUEEZE Squeeze occurs whenever fixed volume gas spaces within the body or diving gear are not pressure counterbalanced to surrounding depth. Pain is caused by compression and contraction of tissues and, if the pressure difference is allowed to increase, by the haemorrhage and rupture of blood vessels. TYPES AND SYMPTOMS Ear Squeeze Caused by the inability to equalise sinus spaces in the skull as a result of obstruction of passages, wich connect with the nasal cavity. Severe pain in sinus areas around nose and eyes. Swelling of lining tissues and (if the pressure difference is high enough) haemorrhage into the sinus spaces can cause blood and mucus to discharge from nose. Face or Body Squeeze Caused by sudden non-equalisation of facemask, suit, or hardhat resulting from failure of surface gas supply and non-functioning on non-return valve, or rapid increase in depth without compensating gas pressure. Pain caused by local tissue compression and possible haemorrhage of blood vessels in affected tissue. Bleeding into skin, around eyes, or from nose may occur. Thoracic (Lung) Squeeze Caused by compression of lungs to less than their residual volume resulting from an extremely deep skin dive (breath holding) or pronounced body squeeze. May produce significant lung damage due to blood and tissue fluids being forced into the alveoli and uncompensated air passages. Breathing difficult and blood, frothy sputum may be noted. TREATMENT: re-establish pressure balance as quickly as possible. Stop descent and attempt to equalise. If unable to compensate pressure, ascend to the surface do not continue deeper.

BAROTRAUMA
Definition Pressure injury because of differential pressures between body air cavities and the external environment. Classification Barotrauma of descent (squeeze) Barotrauma of ascent Body Spaces Affected Thorax lungs, ears, sinuses, tooth cavities, gut, spaces between body and suit and between mask and face.

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Barotraumas will occur where there is a non-vented fixed mass of gas. BAROTRAUMA OF DESCENT Nips (suit squeeze) Definition Skin trapped in folds of diving suit Cause Failure to equalise suit at depth S&S Painful pinching of skin by suit. Wheals on skin. Prevention Use adequate suit inflation during descent. Treatment Mild none. Severe Lasonil ointment to disperse bruising. FACIAL SQUEEZE Definition Volume drops inside mask, due to increased pressure on descent. Cause Rapid descent, without equalising pressure inside mask. Failure of one way valve, in helmet or bandmask supply line. Prevention Blow into mask via nose or open free-flow. Check function of one-way valve before diving. Maintain adequate gas volume from surface panel. S&S Pain around eyes, blood-shot eyes, puffed-swollen cheeks. Treatment Mild none. Severe stop diving until clear. Sinus Squeeze Definition Inability to equalise pressure in sinusses. Cause Blockage of sinus opening, due to catarrh or mucus. Prevention Do not dive with head colds Tooth Cavities Squeeze Definition Pain or injury between a tooth and a filling.

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Cause Increasing pressure on faulty fillings. Bad teeth. (Air space below filling may cause implosion, venting tooth cavity may fail on ascent; leading to explosion of filling form tooth or in extreme cases the tooth). S&S Pain in affected tooth. Tooth may implode. Prevention Regular dental check-ups. Treatment Stop descent return to surface. Analgesics for pain if required. See dentist. Thoracic Squeeze Definition Injury to lung due to air spaces not equalising to ambient pressure. Cause Too deep descents on breath hold dives. S&S Pain in the chest. Bleeding in severe cases. Diver can drown in his own blood. Prevention Limit depths of breath hold dives. Breathe normally on SCUBA. Treatment Stop descent return to surface. Seek medical aid. Aural/Otic Barotraumas External Squeeze Definition Injury to the outer ear canal due to blockage. Cause Tight hoods, ear plugs, and most commonly WAX. S&S Pain in ear, bleeding, rupture ear drum (reversed ear). Prevention Avoid tight hoods and regular plugs. Have ears checked for wax and removed if present. Treatment Halt descent return to surface. Seek medical aid if required. Middle Squeeze Definition Damage between the eardrum and Eustachian tube.

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Cause Inability to clear the ears (equalise) due to blockage of the Eustachian tubes, with catarrh or mucus. S&S Pain in ears, injection of eardrum, blood in middle ear, perforated eardrum. Treatment Halt descent return to surface. Stop diving until condition clears. If severe seek medical aid.

MIDDLE EAR BAROTRAUMA

The most common transient problem associated with diving is middle ear barotrauma, caused by inadequate pressure equalisation between the middle ear and the external environment. Symptoms and Signs Symptoms of middle ear barotrauma consists initially of the sensation of ear blockage. With further descent and greater pressure differential, pain occurs. A conductive hearing loss is always present, but may not be a primary complaint because of ear pain. Mild tinnitus and vertigo may occur. With eardrum rupture, pain usually is severe and vertigo occurs, especially if cold water enters the ear. If hearing loss, tinnitus and vertigo and frequently vomiting occur in association with a nodecompression dive, barotrauma with round window rupture and inner ear damage should be suspected. Such divers should be referred immediately to an ear specialist. Recompression therapy should not be attemped if inner ear barotrauma of compression is suspected since therapy exposes a diver to the same pressure differentials that resulted in the initial injury and thus could cause further round window and inner ear damage. Round Window Rupture The round window in the middle ear is though to rupture due to an increase in C.S.F. Pressure during forceful Valsalva in susceptible individuals. Symptoms: 1 Vertigo +/- vomiting 2 Disorientation 3 Tinnitus 4 Ataxia (Failure of muscle co-ordination) 5 Sensation of blockage in affected ear 6 High frequency hearing loss N.B. Unless there is surgical repair of the window, there may be permanent damage and hearing loss. Marine mammals have very tough round windows.

Diver Medic Course EAR AND SINUS DYSFUNCTION

The common symptoms of otologic (ear) dysfunction are a sensation of ear fullness, pain, hearing loss, noise in the ear (tinnitus), or vertigo. EAR FULLNESS or the sensation of a blocked ear is usually caused by a difference between the pressure in the middle ear and the ambient pressure. This condition causes a decrease in sound transmission to the inner ear. Ear fullness also can occur when the external auditory canal is completely blocked with wax or other debris. HEARING LOSS is classified in three categories: Conductive hearing loss, which is caused by dysfunction of any component of the sound conduction system, such as complete occlusion of the external auditory canal by wax, inflammation, swelling of the ear drum or lining of the middle ear, fluids in the middle ear, changes in middle ear gas densities, pressure gradients across the ear drum, fixation of the ear bones, or loss of elasticity of the ear drum caused by scaring, large perforations, or interruption of the ear bones. Neurosensory or nerve hearing loss, caused by occlusion of the blood supply to the inner ear, head injury, stroke, bubbles, leakage of inner ear fluids from a round or oval window rupture, excessive noise exposure, or various other inner ear disease or conditions. Mixed or combined conductive and neurosensory hearing loss caused by sumultaneous dysfunction of the middle and inner ear.

TINNITUS or spontaneous noise or ringing in the ear can occur with middle ear disease that causes a conductive hearing loss, but it is usually associated with inner ear or brain disease. TRUE VERTIGO is a disorder of spatial orientation characterised by a sense that either the individual or the surrounding are rotating. Injury to the vestibular system accompanied by vertigo frequently is associated with nausea, vomiting, visual disturbance (frequently nystagmus), fainting, and generalised sweating. Vertigo is the most hazardous ear symptom to occur in diving. When it is caused by inner ear dysfunction, it may be accompanied by ear pain, hearing loss, or tinnitus. Vertigo can result from cold water entering the external ear canal, unequal ear clearing during ascent, inner ear barotrauma, eardrum rupture with cold water entering the middle ear, or injury to the central nervous system. Once dizziness is experienced during diving examination by a specialist is necessary before any further diving is attempted. COMPLICATIONS OF AURAL/OTIC BAROTRAUMA If the eardrum ruptures, cold water may enter the middle ear causing unequal thermal stimulation giving rise to dizziness, nausea, ringing in ears and causes acute or chronic infection with resultant temporary or permanent deafness. Excessive Valsalva manoeuvre may cause damage to the oval window connected to the stapes.

Diver Medic Course BAROTRAUMA OF ASCENT

Stomach and Bowel Definition Discomfort due to distension with expanding gas. Cause Trapped gas expanding on ascent. S&S Abdominal discomfort, pain sharp in nature. Prevention Avoid fizzy drinks, chewing gum and heavy meals before diving. Treatment Usually self-curing by belching or passing wind. If severe, slow down rate of ascent and give carminatives if occurring in chamber, e.g. Peppermints.

Dental Barotrauma (Barodontalgia or Aerodontalgia in some text)

Definition As in squeeze, pain in affected tooth. Cause Badly fitted teeth, inlay or dental cap, gas fills spaces and expands on ascent. S&S Pain, slight bleeding, feeling blown out. Prevention Regular dental care. Treatment Depends on severity, if severe, analgesics may be used. All cases should be referred to dentist. Open tooth cavities use oil of cloves as analgesia or choice. Sinus Definition Blockage of sinusses with catarrh or mucus. S&S Pain over affected sinus. Bleeding from nose. Prevention Do not dive with colds. Treatment Lay off diving until clear, analgesics and decongestants to alleviate discomfort. If severe seek medical advice.

Diver Medic Course Ears

Definition Inability to clear ears during ascent. Cause Blockage of Eustachian tube with blood, mucus or catarrh. Prevention Do not dive with colds. Treatment Ascend slowly; roll jaw from side to side to assist clearing. Seek medical advice if reversed ear. Stop diving until condition clears.

DECOMPRESSION PULMONARY BAROTRAUMA

Decompression pulmonary barotrauma is a syndrome, which results in gas, which is normally retained within the airways, leaving its natural confines and entering either the interstitial space within the lung, the pleural cavity or the blood stream. Cause the mechanisms whereby this happens are incompletely understood. At the simplest level, if gas that has been breathed while at depth is trapped within the lung during ascent, then the resulting expansion in volume of that gas, in accordance with Boyle's Law, may be sufficient to cause the architecturally delicate pulmonary tissue to rupture. The gas may be trapped as a result of voluntary or involuntary breath holding, or as a result of pulmonary pathology. However, numerous cases of decompression pulmonary barotrauma have occurred in which no evidence of pulmonary pathology has been found and independent observers have witnessed exhalation during ascent. Consequently, there probably remain other causes of the condition that have yet to be identified (a cange of 70 cm has caused an AGE). Prevention A number preventive measures are taken: a) Divers and those undergoing training for escape from submarines are trained to exhale during ascent. b) Both divers and submarines are carefully screened for evidence of obstructive lung disease, which may result in the trapping of pulmonary gas. This applies both at entry into the military diving and submarines branches and during employment. Those suffering from short-term respiratory illness are taught not to dive or undertake submarine escape training while they remain symptomati. c) Other prevention measures include: the careful planning of dives: and adherence to that plan and the avoidance of emergencies, such as running out of air, which helps to promoe safe ascents. Symptoms and signs Decompression pulmonary barotrauma is often associated with the following symptoms and signs: a) A sharp chest pain, usually behind the breastbone.

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b) Shortness of breath. c) Difficult or painful breathing. d) Coughs that may be productive of slightly bloodstained sputum. Depending on the route that the gas takes after lung rupture, additional symptoms and signs may be observed: Mediastinal and Subcutaneous Emphysema If gas escapes into the interstitial tissue space, it may track along the outside of the airways and blood vessels to the hila of the lungs and from there into the mediastinum. This is the space between the lungs, which contains the heart, great vessels, and major airways. The presence of a little gas in the mediastinum is often symptom less. However, if tissues are stretched by a substantial amount of gas, mild to moderate retosternal pain may be felt. Oher possible symptoms include a sensation of fullness in the chest or throat and a change in the tone of the voice or hoarseness. Gas in the mediastinum may migrate up into the subcutaneous tissues of the neck and, occasionally, the head. It is not usually painful and may only be detected by noticing sweelling or crepitation (the skin crackles) in the neck when doing up a collar. Occasionally, considerable quantities of gas scape from the lung and this may track down into to abdomen and, rarely, the pelvis. The gas is retroperitoneal and may outline the liver and kidneys. It is unusual for such gas to generate symptoms. Pneumothorax A pneumothorax occurs when alveolar gas escapes into the pleural space. This is often painless but may cause a sharp pain, which is made worse by taking a deep breath. Commonly the Pneumothorax is small and there are few physical signs. With a more substantial Pneumothorax the classical signs of: shortness of breath, slight bluing of the lips and finger nail beds (cyanosis); reduced movement of the chest wall on the affected side; tracheal shift towards the affected side; hyperresonant percussion note and reduced breath sounds may be detected. This is not a lifethreatening condition because it is possible to survive with one intact lung and it is most unusual for both lungs to be involved simultaneously. Occasionally, however, the leak is such thas gas escapes into the pleural space with each breath, but is unable to return to the lung. Under these circumstances the volume of the Pneumothorax gradually increases. This is known as a Tension Pneumothorax. Tension Pneumothorax This condition is dangerous because if gas continues to escape from the perforated lung, the pressure generated within the chest may eventually cause both lungs to collapse. In such circumstances the tracheal shift will be away from the affected side. Cyanosis will become pronounced and shock, unconsciousness and death mey ensue unless the patient is treated appropriately. Tension pneumothorax is a rare condition under normal conditions at the surface. However, a simple pneumothorax, that occurs at depth, for example in a recompression chamber, will increase in size during decompression and effectively become a tension pneumothorax. If a diver's condition deteriorates during ascent, especially if the symptoms are respiratory, a pneumothorax should always be suspected. Treatment a) Asymptomatic mediastinal emphysema and subcutaneous emphysema usually resolves gradually without specific treatment. If there are troublesome symptoms, resolution will be accelerated by breathing 100% O2 on the surface. In the very rare instances where there are serious symptoms, recompression may be necessary. If there is no associated Pneumothorax,

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it is safe to compress to 10m for an hour breathing 100% O2. b) A small pneumothorax can be treated by breathing 100% O 2 on the surface. Large pneumothoraces and all tension pneumothoraces require draining. A chest drain, large bore IV cannula, or some other device with a one-way valve (such as a Heimlich valve), should be inserted into the chest by an appropiately trained individual. Arterial Gas Embolism If gas from a ruptured lung enters the pulmonary microcirculation, it will migrate to the left side of the heart and from there be distributed to the body as arterial gas emboli. Two organs that are particularly susceptible to functional disturbance as a result of such emboli are the brain and heart. Consequently, divers who have sustained decompression pulmonary barotrauma should be carefully examined for evidence of cardiac or cerebral disorders. In the past, it was considered possible to make a diagnosis of arterial gas embolism in patients who experienced the onset of neurological symptoms during decompression or shortly after surfacing from a dive. This diagnosis was made even in the absence of any other evidence of decompression pulmonary barotrauma. It is now recognised that such a diagnosis may be inaccurate since other conditions may present in a similar manner. Consequently, neurological symptoms or signs presenting after a hyperbaric exposure should be termed acute neurological decompression illness.

THE EXTERNAL EAR

The blind pit leading down to the eardrum serves a useful purpose in protecting the ear mechanism, while allowing access of sound waves to the eardrum. Hairs near the outside of the canal and wax secreted at its entrance reduce the entry of foreing particles. The skin, as elsewhere, sheds its scales continously, but a mechanism of migration prevents accumulating of these scales within the canal. It is never desirable to push wax or dead skin back into the ear canal. Disorders of the External Ear 1. Excess of wax formation may block the canal and give rise to deafnexx and occasionally cause differential caloric effects and vertigo. Wax accumulation is less common in divers due to the constant irrigation of the ears. 2. Local infection of the hair follicle may form a boil, which is called a furuncle in this situation. 3. Generalised inflammation of the skin with the external auditory channel often with infection is a localised form of dermatitis, called diffuse otitis externa. 4. Small growths of bone in the dephts of the canal, called exostoses, sometimes cause partial blockage of the deep canal. They are commoner in people whose ears have been exposed to cold water in early life, such as keen swimmers, and the treatment is surgical. Predisposing factors to otitis externa are excessive humidity, the presence of infecting organisms (either bacterial or fungal), and skin damage through cracks in the skin or wetting of the skin. Care of the skin of the external ear can often prevent infections. The skin should be kept dry as far as possible, and water drained from the ear by gravity, not application of towels etc. The ear should not be rubbed or scratched, and probes should never be used. Use of cotton buds is especially discouraged.

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Treatment of External Ear Conditions Wax may be syringed or picked out, but this should be done only by doctors or nurses, or directly under medical supervision. Systemic antibiotics may treat furuncles. Gentle warmth is helpful and dressings of glycerine and ichthyol may be applied locally. In diffuse otitis externa it is important to exclude any aggravating agents. Aluminium acetate drops or dressings are applied for their astringent affect, or ointments sometimes containing antibiotics and hydrocortisone may be applied under medical direction.

MIDDLE EAR DISORDERS

An intact eardrum, continuous and freely moving chain of ossicles, and a middle ear containing air, are all necessary for conduction of sounds through the middle ear normally. Ventilation of the ear through the eustachian tube is vital for normal ear function uder diving conditions. The eustachian tube is the key to middle ear in divers, and failure to equalise pressures between the middle ear and external environment is a common cause for unfitness to dive. The tube is normally closed and opens only when the muscles of the palate contract during yawning or swallowing movements. The structure of the nasal end of the eustachian tube is of a triangular sheet of cartilage in the shape of an inverted J with the remainder of the wall closed by soft fibrous tissue to which the muscles are attached. The muscles can contract with the palate on yawning or swallowing. Positive pressure in the air of the back of the nose tends to close the tube and act against the muscles. If sufficiently great this air pressure can be stronger than the power of the muscles themselves so that excessive force in inflating the ears by blowing with the nose pinched, and excessive pressure though descent during diving without opening the tube sufficiently frequently, may prevent equalisation altogether. Gentler inflation or ascent again by even a few feet can allow the muscles to act again. Failure of the tube to open results in distortion of the ear drum inwards during descent. The drum progressively becomes more inflamed and painful until blood and fluid are forced into the middle ear space and ultimately the eardrum ruptures. During ascent air can bubble out of the middle ear along the eustachian tube more readily and it is less usual to have problems of barotrauma in this phase. Flying shortly after diving may accentuate difficulties in clearing the eustachian tubes and may also show up decompression problems. Again barotrauma is more manifest during descent. Reversed Ear Consider what happens if a diver descends when the outer part of the ear canal is blocked by wax or by a tight plugh for noise protection, or by tightly fitting hood. In this case, if the eustachian tube is functioning normally, the pressure in the external ear canal is negative relative to the outside atmosphere, the air in the nose and in the middle ear. The ear drum bulges outwards, blood and tissue fluids is forced under the skin of the external ear canal forming blood blisters ans ultimately the ear drum may rupture. This is the syndrome of reversed ear, and is avoided by ensuring that the outer ear is clear of obstruction during diving. Otitis Media Acute infections of the middle ear called otitis media, and its occasional complications such as mastoiditis, may occur in divers as in others. The need to clear the ears frequently gives increased opportunity for infections to spread from the back of the nose to the ear. For this reason and because of the increased incidence of barotrauma with inflammations around the eustachian tube it is of

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fundamental importance never to allow a dive in the presence of a head cold.

INNER EAR
The inner ear consists of the delicate end organs where the physical stimuli of sound and position changes are converted into nervous impulses for transmission to the brain along the auditory nerve. The cochlea is a coiled tube having a similarity to a snail's shell, wich is adapted to the reception of sound impulses that reach it through the other small bones of the middle ear. The round window, covered by a thin membrane which also opens into the middle ear, allows compensating movements of the perilymph wich is thin fluid bathing the inner ear contents. Hair cells placed on the basement membrane in the organ of Corti excite auditory nerve endings. The mechanism is delicate and excessive sound can cause selective damage at certain frequences, usually centred round 4000 Hz. Other membranes exist at junction zones in the inner ear, notably those separating perilymph from cerebrospinal fluid. All these membranes are subject to rupture under conditions of strain through pressure differentials and sudden hearing loss sometimes occurs, with or without vertigo, as a result of such rupture. Surgical exploration to seek a possible leak in the region of the oval or round windows is sometimes necessary in such cases, and needs to be conducted within a week of injury for best results. Other Causes of Damage in the Inner Ear are: Excessive noise (water is a good conductor of damaging sound waves). Drugs Aspirin and Quinine are examples of simple drugs, which can cause deafness in sufficient amounts and susceptible individuals. Some of the lesser-used antibiotics also have such an ototoxic effect. Injury either by shock waves from underwater explosion, direct blow on the ear forcing incompressible water into the canal and which often also ruptures the eardrum, and skull injury causing fracture of the temporal bone, all may cause irreversible damage. Fractures often injure the facial nerve also, which passes in close relation to the ear to supply the muscles of the face that may be paralysed by injury to that nerve. Decompression sickness may damage the inner ear structures either by direct distortion, or causing labyrinthine window ruptures and perilymph leakage as described earlier. It is possible that when mixed gases are breathed under pressure, differential diffusion rates cause such injuries even when total pressure remain constant (due to changing partial pressures of the various components).

VERTIGO
Whereas the occurrence of deafness in a diver underwater may cause disability even resulting in loss of fitness to continue diving, the occurrence of vertigo underwater is dangerous, being a potential cause of fatal underwater accidents. Normal balance under physiological conditions on dry land is maintained by the inter-action of gravity and a series of sensory organs. Joints and muscles, vision, and the vestibular organs all give complementary information to the brain about position in space, movements etc. Under water a profound change takes place. Buoyancy reduces the value of clues from joints and muscles. Darkness precludes visual clues and a great deal more reliance is placed upon sensations from the semi-circular canals and the vestibular apparatus generally.

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Under calm conditions an experienced diver gains extra clues from incidental observations such as bubble streaming, and buoyancy of objects with known behaviour at the depth involved, but under emergency or panic conditions this information too may not be available and sensation from the ear organs becomes a vital matter for survival. Symptoms of failure of the vestibular organs are false sensations of movement of the subject or of his surroundings, known as vertigo. This is often spinning sensation, such as is felt after getting off a soundabout, but may be of swaying or falling. Accompanying it, and useful objective sign for the observer, is often nystagmus (a flickering movement of the eye, very like that seen when a passenger watches passing telegraph poles from a train window). Side effects of vertigo may be profound. There is often pallor, sweating and vomiting to an extent that confuses this condition with a heart attack or serious food poisoning. The dangers of vomiting underwater when breathing through a mask cannot be over-emphasised, and it may be that underwater accidents involving this symptom have gone unrecognised in the past. Some causes of vestibular failure underwater are now discussed. Decompression sickness can clearly cause gas release in the semi-circular canals or vestibule, causing physical disruption of the hair cells, which detect the relative movement of the labyrinthine fluids, and also the labyrinthine membrane ruptures noted in the previous section. Caloric effects are the influence of temperature change upon the fluids within the inner ear structure. There are three semi-circular canals in each ear arranged at right angles to one another. The horizontal one placed in a plane parallel to the brim of an imaginary hat placed on the back of the head at 30 degrees to the horizontal is the closest to the surface of the middle ear and most susceptible to induction of convection currents within, when there is temperature change in the external auditory canal. This is most marked when the plane of tha canal is vertical. Physiology of the internal ears by the streaming impulses, which are acceleratec or decelerated by change, means that only changing conditions, especially if they are unilateral, will promote vertigo. Occlusion of one ear by wax while the other remains free can thus promote caloric vertigo and nystagmus when cold water enters the unobstructed ear, but not the obstructed one. Pressure effects by barotrauma can cause vertigo, especially when unilateral, and such is the mechanism of alternobaric vertigo, when a diver has difficulty in clearing both eustachian tubes simultaneously. When one side lags significantly sensations from the two sides get out of step and vertigo results. Haemorrhage and embolism may occur in the end organs of the ear, and be postulated as causes for ohterwise unexplained sudden vertigo. The nature of nervous tissue is such that damage when once established is rarely repaired by healing, although compensation can often occur as the condition settles. This menas that often there is permanent damage after an incident which causes vertigo, and this may render the diver unfit for further underwater service with safety, althought he may appear superficially fit for a normal and an athletic life ashore. Prevention of underwater accidents through unexpected vertigo can exist only by careful selection

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of personnel, with high standards of fitness. Compromises are not permitted, for more than the health or life of the diver himself is at stake -colleagues and rescue workers also being involved. Treatment of an episode of vertigo related to diving would consist of rest ashore; followed by full investigation; use of labyrinthine sedatives such as the anti-motion sickness drugs -Avomine, Stemeti, Marzine, Dramamine and Fentazin; recompression where there is any question of decompression sickness; and admission to hospital with surgical exploration, when labyrinthine window rupture is suspected. This should, if possible, take place within a week of injury, taking precedence over other considerations with the single exception of re-compression if required. Mr R J Sellic, R.R.C.S. East Anglian Regional Audiology Centre Norwich

DECOMPRESSION ILLNESS IN FLIGHT

In addition, a workshop considered the problem of decompression illness occurring during a scheduled flight. They recommended the following procedures: 1) Where the diver's symptoms consist only of pain in a limb, he should be treated with analgesics, oxygen if available and the plane can continue to its destination without diversion or adjustement in altitude. 2) When the diver has any other symptoms, immediate advice should be sought from a diving medical specialist. It may be necessary to reduce cabin altitude or divert to the nearest airport. In the meantime, the patient should be given oxygen if available.

FIRST AID MANAGEMENT OF DIVING ACCIDENTS

1) Effective first aid will greatly increase the chances of subsequent recovery, especially if there is a likely to be any delay in recompression therapy. 2) In addition to standard life saving measures, the following action should be taken: a) Ventilation with 100% O2 is the most effective form of first aid. This should be administered by a tight-fitting mask with a demand valve regulator or other apparatus designed to deliver as close to 100% O2 as possible. Note. Most forms of hospital mask and nasal cannula, wich employ a continous flow of oxygen, deliver much less than 100% O 2, and rapidly empty oxygen cylinders. Consequently, such equipment should only be used when no alternative exists. b) Dehydration invariably complicates decompression sickness and arterial gas embolism. Re-hydration should commence at the earliest opportunity: i. Give conscious patients who can protect their airway oral fluids. At least a litre of still water or fruit squash should be drunk initially. Additional fluid should be

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consumed until a substantial urinary output is provoked. In the absence of a urinary output the abdomen should be examined for the presence of an enlarged bladder. If the bladder is enlarged and the patient has difficulty initiating urination, urinary catheterisation should be undertaken by appropiately trained personnel. ii. Semiconscious and comatose patients should be given intravenous fluids by appropiately trained personnel. Start re-hydration by infusing one litre of normal saline or Hartmann's solution over 30 minutes and then a further litre over the next hour. The use of Dextran is discouraged since it may provoke idiosyncratic adverse reactions and an increased tendency to bleed. Equally, solutions containing glucose should be avoided since these appear to compromise the recovery of ischaemic nervous tissue. Urinary catheterisation may be required if the level of consciousness does not improve or if the spinal cord is involved. iii. Steroids have been employed in the treatment of serious decompression illness. Although there is no compelling evidence that they improve the outcome, they may reduce incidence of secondary deterioration. 12-20 mg dexamethasone may be given by SLOWLY intravenous or intramuscular injection as an initial loading dose and 48 mg doses repeated 6 hourly up to 48 hours thereafter. 1) a 2) a 3) Symptoms of pain may be asked by the administration of analgesics and this may complicate monitoring of the progress of the patient. Analgesia should only be given where there is little likelihood of recompression within 2 hours and, where possible, after consultation with a diving medicine specialist. The drug of choice is Paracetamol. Nitrous oxide (ENTONOX) should NOT be used. It is highly soluble in other gases and consequently it tends to make inert gas bubbles grow which aggravates decompression illness. The use of aspirin and other non-steroidal anti-inflammatory agents may also be detrimental, since they may provoke or sustain haemorrhage into central nervous system lesions. 4) Patients will often show some improvement with first aid treatment, occasionally to the point of apparent recovery. Nonetheless, recompression appropiate for the worse symptoms should be performed at the earliest practical opportunity to reduce the risk of relapse or secondary deterioration. 5) In the past, it has been considered appropiate to manage cases of neurological decompression illness in a head-down position. It has been shown that this is detrimental and consequently all patients should be managed in a horizontal attitude. If the patient is conscious, he or she may lie recumbent. If the patient has a reduced level of consciousness, the recovery position should be used.

ADIABATIC COMPRESSION
Adiabatic compression is the term used to explain how temperature increases in a vessel (decompression chamber or bell), due to the compression of gas into it, as in the bell blow down or chamber pressurisation. It is thus of prime importance that you do not exceed the pressurisation speeds set down by your diving company, for the type of dive being performed. During a pressurisation, you may feel you could go faster (no ear clearing problems etc) but

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Interdive recommend you should guard against this desire. Oxy/Helium is about 6 times more conductive of heat than air, and if the humidity is high (over about 85%), then the body cannot sweat to loose heat. The body will become hyperthermic, this is more difficult to correct than hypothermia, and fat people are more at risk than thin. Normally, we maintain the chamber environment between about 28C to 32C. Should the termperature rese to 35C or above, we must take corrective action to reduce it. 2C above body temperature will be very serious. 41C is classed as an emergency, which can result in brain damage or death. Preventative measures are: a) Do not exceed pressurisation speeds. b) Monitor chamber temp during compression (check temp reader is calibrated). c) Do not overheat chamber prior to compression. d) Keep chambers in hot climates shaded. e) Check correct gauges on-line to complex. Corrective action may be: 1) Cool occupants with cold water (shower, ice, sponge), and give cool fluids (weak salt water). 2) Douse chamber exterior with cold water (cover with blankets and soak). 3) Divers remove excess clothing. 4) Flush chamber with correct mixture 5) Decompress if emergency (chamber atmosphere will cool down). 6) Use chamber heating system (if appropiate) on cold cycle to act as heat sink. 7) Seek medical aid.

ASEPTIC BONE NECROSIS

Definition Strictly speaking, aseptic bone necrosis is dead bone tissue in the absence of infection. What is usually understood by the term is: death of bone tissue in the absence of infection or other disease process, occurring in part of a bone, which is otherwise normal. Because death of bone tissue occurring in otherwise healthy bone is thought to be due to an absence of a blood supply to part of the bone, aseptic bone necrosis is often referred to as Avascular Necrosis.

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Towards the end of the las century, aseptic bone necrosis was found to occur in men who worked in caissons. These are closed chambers used underwater in the construction of firm bases for the support of bridges across rivers. The chamber is filled with air at pressure to keep the water out. As the chamber is called a caisson, this condition was originally known as Caissons Disease of Bone. Causes of Aseptic Bone Necrosis 1) Trauma. Following damage to bone resulting from fracture or dislocation. 2) Latrogenic. Literally = physician produced Side effects of treatment with Steroids and Radiation. 3) Some Blood Disorders. 4) Alcoholism. 5) Idiopathic Literally own disease. Occurring in certain well-recognised sites. 6) Hyperbaric Exposure. Aseptic bone necrosis occurring in divers and compressed air workers. This is now called DYSBARIC OSTEONECROSIS. The other conditions in which Aseptic Bone Necrosis occurs are mentioned in order to illustrate the points that: a) Aspetic bone necrosis is not confined to divers and compressed air workers. b) Whenever a diagnosis of aseptic bone necrosis is made, the above conditions have to be considered as a possible cause. c) A medical examination of fitness to dive should, among other things, rule out any of the above relevant predisposing causes of aseptic bone necrosis.

DYSBARIC OSTEONECROSIS (DON)

History Earliest description 1888. X-ray findings first described in compressed air workers in 1911. First described in divers in 1941. Cause Not known for certain. ? Occlusion of bone blood vessels by bubbles. ? Other mechanisms related to accumulation of gas in the tissues.

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Incidence Compressed air workers 17% have definite lesions. Divers (professional divers in Britain) approximately 3% have definite lesions. These figures may be underestimated. In a proportion of these men the lesions occur on both sides. In groups of unsupervised divers (e.g. Japan) the incidence is much higher sometimes approaching 100%. Pathology Confined to certain areas of humerus, femur and tibia. May occur on both sides simultaneously. Typical microscopic appearance shows an area of dead bone adjacent to bone undergoing a repair process. X-ray findings Two groups of lesions: 1) A Lesions. Situated close to the articular surface of hip and shoulder joints. These are termed juxta-articular lesions. 2) B Lesions. Situated in the head, neck and shaft of the bone i.e. Away from joint surface. Natural History As yet not well understood, but is known that severe symptoms may develop from the A lesions many years after the last exposure to compressed air or diving. Clinical Presentation A Lesions May be symptoms less? May give rise to sudden and persistent pain in a joint, indicating sudden structural failure. May give rise to gradually increasing pain, stiffness and loss of movement of a joint, indicating the development of degenerative arthritis. The above symptoms are considerably more disabling when there is multiple joint involvement. B Lesions Symptom less do not appear to cause trouble. Diagnosis X-rays - the mainstay of diagnosis. Bone scaning not yet widely available. Interpretation remains controversial. Management

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Early asymptomatic lesions advice about advisability of continuing exposure to compressed air or diving. Treatment of lesions producing mild symptoms - conservative initially. Treatment of lesions producing severe symptoms especially if there is bilateral joint involvement; surgery considered. Current Research Aimed at: 1) Searching for the cause. 2) Developing methods of early detection. 3) Finding curative treatment.

HIGH PRESSURE NERVOUS SYNDROME (HPNS)

This is a condition, which may be experienced in dives to an excess of 200m of seawater. The effects are mainly upon the Central Nervous System, and the symptoms are manifested as neuromuscular disturbances in the form of coarse tremor, incoordination, and jerky movements. It is also manifested throug the higher cerebral function in the form of disorientation. (Loss of ability to place oneself in conjunction with space and time). In animal experiments convulsions have also been recorded. In 1965 the Royal Navy Physiological Laboratory was conducting a series of deep dives in a compression chamber to depths of 600 800 fsw. The subjects of these experimental dives were observed to be developing coarse tremors of the extremities, and even involving the whole body. These symptoms were also accompanied by nausea, occasional vomiting, dizzness and vertigo. This condition lowered their ability to carry out task involving fine manual dexterity. The condition appeared to improve after 90 minutes at depth, and the subjects gradually returned to normal. There have been many reports from various sources, describing these basic characteristics of the syndrome. EXAMPLE: In a series of dives, the following symptoms were reported. Using a compression rete of 2.5m/min without rest stops. At 200m: At 240m: At 320m: At 330m: Tremors appeared. Changes in the brain activity was recorded by ElectroEncephalogram. Development of muscular incoordination. Subjects beginning to experience loss of alertness.

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At 350m: comprehension. Subjects develop extreme indifference, and decreased

Some reports have recorded bouts of sleep occurring from which the subject is readily awakened. Difficulty in right left orientation has also been reported. The develpment and severity of High Pressure Nervous Syndrome appears to be related to the rate of compression at great depths being particularly more noticeable at faster rates. Investigations into other possible contributory causes, such as the effects of Oxygen, Carbon Dioxide, Temperature, and fluid shift within the tissues due to gas pressure, have been found to have little, or no part in the incidence of HPNS. It has been found that the inclusion of Nitrogen, or other heavier narcotic gases has significantly reduced the cost of the mixture, alleviated the effects of voice distortion, and reduced the dangers of excess heat loss. For this reason it is common to use a TRI-MIX of Oxygen, Nitrogen and Helium when diving deeper than 200m. The main cause of HPNS would at this stage of investigation, appear to be directly attributable to speed of compression, so prevention can be best served by following the general rule, the deeper the dive, the slower the rate of compression. There has also been report's of a reduction in the HPNS symptoms when incorporating rest stops into the compression schedule. A further method of prevention of HPNS symptoms has been in the use of excursions. This technique involves a slow compression to the saturation depth, deeper levels of 50m, or so may be carried out with fairly rapid compression rates, which would not be tolerable if carried out from the surface. Again, the deeper the excursion from the saturation depth, the slower the rate of compression must be. Various commercial diving companies employing saturarion techniques employ the above-mentioned principles although the particular regime will vary according to the policies, and the particular preferences of each individual company.

HYDROSTATIC NERVOUS SYNDROME

A similar condition to HPNS may occur when the subject has been exposed to extreme depths for long periods. This is known as the Hydrostatic Nervous Syndrome, and is not dependendt on rate of compression. Although the symptoms of this condition are similar to those of HPNS, the exact mechanism of this action is not fully understood. The main difference is in its occurrence after the depth as been stable for some time. The main form of treatment in both cases when symptoms are severe is to gradually decompress the individuals involved until the symptoms disappear.

COMPRESSION ARTHRALGIA
Hyperbaric arthralgia is pain in the joints due to raised ambient pressure. A diver suffering from hyperbaric arthralgia sometimes hears a creacking and cracking from his joints and feels as if his joints surfaces are dry (no joint fluid). Joints hurt especially on movement. The condition is aggravated by too rapid compression. A compression rate of not more than 1m/min (3.2ft/min) often avoids the painful effects of this condition although the cracking of the joints continues.

Diver Medic Course SECTION FOUR GAS TOXICITY OXYGEN TOXICITY

Occasionally, pulmonary and cerebral oxygen toxicity may occur during chamber treatments. a) Pulmonary Oxygen Toxicity. Pulmonary Oxygen toxicity is unlikely to develop on USN Table 5 or 6, or RN Tables 61, 62 or 63, even if they are fully extended. However, if RN Table 62 is repeated, or used following a Table 63 then toxicity may occur. On long air tables the large amounts oxygen that may have to be administered may result in end-inspiratory discomfort, progressing to substernal burning and severe pain on inspiration. Substernal burning should normally be cause for discontinuing oxygen breathing in patients who are responding well to treatment. However, if significant neurological deficit remains and improvement is continuing (or if deterioration occurs when oxygen breathing is interrupted), oxygen breathing should be continued as long as considered benefical or until pain limits inspiration. If Oxygen breathing must be continued beyond the period of substernal burning, or if the 4 hour air breaks on long air tables cannot be used because of deterioration upon the discontinuance of oxygen, the oxygen breathing periods should be changed to 20 min on oxygen, followed by 10 min breathing chamber air. The Diving Medical Specialist may tailor the above guidelines to suit individual patient response to treatment. b) Cerebral Oxygen Toxicity. At the first sign of cerebral oxygen toxicity, the patient should be taken off oxygen and be allowed to breathe chamber air. Fifteen minutes after all symptoms have subsided, oxygen breathing may be restarted and the interrupted O2 period completed. If symptoms of cerebral toxicity develop again, interrupt oxygen breathing for another 15 mins. If cerebral oxygen toxicity develops a third time, discontinue oxygen for 1 hour and then resume the treatment table. If the depth dercreases by 3 m during the hour, try to restart O2 at the shallower depth at once. If cerebral oxygen toxicity develops again, do not attempt oxygen breathing again until depth has been decreased at least another 3 m on the appropiate treatment table. If symptoms of decompression illness are still present and the patient continues to show symptoms of oxygen toxicity, the Diving Medicine Specialist will have to decide whether oxygen should be continued and whether or not decompression should be attempted or continued, or whether deeper recompression is needed. The onset of cerebral oxygen toxicity is unlikely in resting individuals at depths of 15 m or shallower, and very unlikely at 10 m or shallower no matter what the level of activity. However, patients with severe cerebral decompression illness may be abnormally sensitive to oxygen. Convulsions unrelated to oxygen may also occur. If an oxygen convulsion occurs, the only thing that need be done is to remove the patient from oxygen and keep him from hurting himself. The patient's head should be kept gently back and his jaw prevented from falling backward and obstructing the airway. It is not neccesary to pry the patient's mouth open to insert any airway or bite block while the patient is convulsing. ATTENDANTS TO TREATMENTS Attending Frequency Normally, Attendants should allow a surface interval of at least 12 hours between consecutive treatments on RN tables 61, 62 and 63 and USN Tables 5, 6 and 6A. If a

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treatment has to be undertaken sooner than this, the attendant will require additional O2 breathing periods at 9 metres. a) Attendants' Return to Diving. Attendants for RN Tables 61, 62 and 63 and USN Tables 5, 6 and 6A should allow a surface interval of 12 hours from completing the table and undertaking no-stop diving. A surface interval of 24 hours should elapse before conducting dives, which require decompression stops. Attendants for RN Tables 64 and 65 should allow a surface interval of at least 48 hours before returning to diving. b) Oxygen Toxicity. If O2 is breathed at a high partial pressure for long periods it becomes toxic, particurlarly to the lungs. If a very high partial pressure of O2 is breathed, even for short periods of time, it may rapidly become toxic to the brain. PULMONARY OXYGEN TOXICITY a) Causes. For practical purposes, pulmonary oxygen toxicity will not arise from normal air bounce diving to less than 50 metres. This is because decompression considerations will limit exposure to O2 to within safe limits. Diving near the time/depth limits, particularly when such dives are performed repetitively, may provoke pulmonary O2 toxicity in sensitive individuals. Patients being treated with fully extended recompression Tables 62 and 63 or Tables 64 and 65 may also experience pulmonary O2 toxicity, particurlarly where repeated treatments are applied. b) Symptoms and signs. These often start with a tickling sensation in the throat which is worse on inspiration and wich may provoke coughing. After a few hours of continued O2 exposure, the tickle is gradually replaced by a sensation of substernal burning and coughing becomes uncontrollable. Shortness of breath eventually prevents even mild exertion. In sensitive individuals, the first symptoms of toxicity may be provoked by breathing 100% O2 at 2 BA for three hours, There are often no physical signs associated with pulmonary oxygen toxicity; however, progress of the condition can be monitored by measurement of the vital capacity, which decreases with O2 exposure. A 10% decrease in vital capacity occurs after about 10 hours breathing 100% O2 at BA. c) Unit Pulmonary Toxic Dose Where prolonged exposure to hyperbaric oxygen is necessary, such as during recompression therapy, an estimate of the reduction in vital capacity can be calculated from the following equation:

UPTD = kp x t
Where kp is a factor derived from the PPO2 using the table below, and t the duration of exposure (in minutes).

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The kp table for UPDT calculation is provided below:

PO2 (BA) 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2

kp 0.00 0.26 0.47 0.65 0.83 1.00 1.16 1.32

PO2 (BA) 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0

kp 1.48 1.63 1.78 1.93 2.07 2.22 2.36 2.50

PO2 (BA) 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

kp 2.64 2.77 2.91 3.04 3.17 3.31 3.44 3.57

The appropiate kp value is multiplied by the period of time (in minutes) spent at each oxygen partial pressure. These values are then summed to generate the total UPDT value for the exposure. Standard USN Table 6 or RN 62 Treatment Table without extensions are equivalent to 625 UPDT's. Below is a table, which presents approximate values for expected decrement in vital capacity as a result of various UPDT exposures. It should be recognised that individuals may vary considerably in their response to high partial pressures of oxygen and the UPDT value is useful only as a guide. Generrally, dose of 1425 UPDT is considered to be the upper limit of acceptable exposure.

UPDT UNITS % DECREMENT IN VC 615 825 1035 1230 1425 1815 2190 2 4 6 8 10 15 20

Normally, a complete recovery from the effect of pulmonary O2 toxicity can be expected. The time taken for recovery depends largely on the extent of the exposures and where there is a substantial decrement of vital capacity, this may take days or weeks. d) Treatment. Reduce the concentration of O2 in the breathing mixture, preferably to 0.2 BA/PO2

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CEREBRAL OXYGEN TOXICITY a) Symptoms and Signs. These are highly variable. Furthermore, there is no fixed O2 exposure at which toxicity becomes apparent. Instead, susceptibility varies both between individuals and within the same person from day to day. As a consequence, there is no cerebral equivalent of the UPTD. It is not unusual for the first sign of cerebral O2 toxicity to be a grand mal convulsion. This generally occurs in two phases: First, there is a period of body rigidity -the tonic phase- which may last for up to a minute. It is dangerous to attempt to surface the casualty at this stage because spasms of the glottis and respiratory muscles will result in inadequate exhalation and may therefore provoke pulmonary barotrauma. The tonic phase is followed by the clonic phase during which the casualty undergoes true convulsions. This can last for widely varying periods of time. Symptoms wich may precede the onset of a grand mal convulsion include: lip twiching; dizziness; nausea; ringing or roaring in the ears; tunner vision; a chocking sensation; difficulty breathing and tremor. Consciousness is usually regained 1 3 minutes following cessation of the seizure if the PO2 is reduced to near normal levels. A post-ical period follows which lasts for 5 30 minutes. b) Treatment. If a convulsion occurs underwater, the diver's depth should be kept as constant as possible until at least the tonic phase of the convulsion subsides. He should then be returned to the surface. If a diver surfaces because of an oxygen convulsion or must be surfaces to prevent drowning, there is a risk of pulmonary barotrauma and the possibility of decompression illness should be considered in the event of subsequent neurological abnormalities. A neurological examination should be completed to exclude decompression illness. On reaching safety, remove the breathing apparatus and place the casualty in fresh air to recover. If there are any further convulsions, use sufficient restraint to prevent self-injury. Do not force the mouth open but, if necessary, keep the airway open once the convulsion has subsided. The casualty must be kept under observation by his fellow divers or in a medical unit for at least 12 hours; loss of memory almost invariably occurs, but this is normally limited to short-term memory and resolves quickly. Note. Paradoxically, the symptoms of cerebral O2 toxicity may be made transiently worse when the inspired PO2 falls. This is the so-called off phenomenon. Consequently the onset of symptoms or signs may be delayed by up to 5 minutes after leaving the water, coming off O2, or during a decompression stop where the partial pressure of O2 is reduced. 0 bar A N O X I A 160mb H Y P O X I A 210mb N O R M A L 500mb 1.5 bar HYPEROXIA IN THE WATER 2.8 bar HYPEROXIA IN THE CHAMBER CNS (ACUTE)

PULMONARY HYPEROXIA (CHRONIC)

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ANOXIA A complete lack of oxygen (0 bar abs) HYPEROXIA CNS (Acute or Rapid) Cause: Breathing oxygen above 1.5 bar abs in water or 2.8 bar abs in RCC. Symptoms: V E N T I D Vision (tunnel vision) Ears (ringing/tinnitus) Nausea Twiching Irritability Dizziness

Treatment: Remove from cause (stop decompression, check for injury, protect airway). PULMONARY (chronic or slow) Cause: Breathing oxygen for long periods with PPO2 > 0.5 bar (500mbar). Symptoms: Dry irritated throat Tight feeling in chest (behind sternum) Dry cough, painful, non-productive Painful fingertips Shortness of breath Treatment: Remove from cause, observ patient, check for neurological symptoms. HYPOXIA When O2 is less than 0.16 bar (160mbar) or 16% SEP (16% on surface). Symptoms: Cyanosis (Blueing of fingers, earlobes) Breathing Increased heart rate Poor co-ordination Note: most symptoms pass unnoticed leading straight to collapse!!! HYPERCAPNIA (CO2 POISONING) 1) Onset 20.000 ppm = 2 SEP = 0.02 BA = 20 mbar Unconscious 150.000 ppm = 15 SEP = 0.15 BA = 150 mbar 2) Should not exceed 5.000 ppm in chamber (0.5 SEP) = 0.005 BA = 5 mbar

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Cause: Inadequate ventilation of mask. Over exertion. Soda lime not changed regularly. Symptoms: Increase in respiration & pulse rate Headache Sweating Dizziness Nausea Anxiety Unconsciousness Treatment: Stop work and flush through CARBON MONOXIDE POISONING 1) EN 12021 CO shold not exceed 15ppm in air from a compressor or 0.02 mbar abs in DDC. 2) Sudden in onset lose consciousness rapidly. 3) CO has affinity to Haemoglobin 200 times greater than O2. Cause: Impure air (e.g. From a badly sited compressor intake or from oil breakdown in an overheating compressor). Exposure: < 8 hrs. 2.38 ppm per 1% O2 > 8 hrs. 1 ppm per 1% O2 Emergency 47.6 ppm per 1% O2 Cherry red complexion (unreliable) Breathlessness on exertion Lassitude Dizziness Tinnitus Confusion Loss of consciousness | } Approx. |

Symptoms:

Treatment: change gas supply, jump standby to assit divers ascent, recompression, administrating pure O2 by BIBS (Flushes out CO). NITROGEN NARCOSIS Cause: Increased PP of Nitrogen (nitrogen in air becomes narcotic beyond 30msw) Symptoms: Feeling of euphoria. Treatment: Decrease depth or change mix.

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CARBON DIOXIDE RETENTION The relevance of carbon dioxide retention in the conventional SCUBA diving practices, is not well clarified. It is known that the different commercial regulators will produce varying degrees of resistance to ventilation, with consequent carbon dioxide retention. The degree of carbon dioxide retention will also rise with the increased breathing resistance due to inadequate maintenance of the regulator, or the deposit of foreing bodies and salt particles. Maintaning regulator perfomance to an acceptable physiological level can be extremely difficult. The level of carbon dioxide retention is usually minor and not of certain clinical significance. It does increase with exposure to depth, and with a low SCUBA cylinder pressure driving the gas through the regulator. Perhaps more important than the consistent but mild carbon dioxide retention with SCUBA diving, is the occasional atypical subject who responds inadequately, either under pressure or on the surface, to raised carbon dioxide levels. It may be that these divers progressively elevate their carbon dioxide levels, as an alternative to increasing their ventilation, with the increased resistance to breathing. Under these conditions it is theoretically possible that carbon dioxide toxicity, to the stage of unconsciousness, may eventuate. Isolated case reports suggesting such a mechanism have recurred throughout the diving medical literature, but have yet to be sufficiently investigated to be acceptable as a definite clinical entity. There is marked variation in the ventilatory response to inspired carbon dioxide, but the hypothesis of trained divers retaining carbon dioxide requires verification. One hypotesis divides divers in two groups those who tolerate an increased pCO2 rather than increase their ventilation, and those who increase their ventilation in an effort to maintain a normal arterial pCO2. Clinical Features These depend of the rate of development and degree of carbon dioxide retention. They vary from mild compensated respiratory acidosis, detected only by blood gas and electrolyte estimations, to rapid unconsciousness with exposure to high-inspired pCO2. Although carbon dioxide is a respiratory stimulant, most of its effects are related to the acidosis it produces and are neurological depressant. At 1 BA a typical subject breathing air to which 3% carbon dioxide has been added doubles his respiratory minute volume. A 5-6% carbon dioxide supplement may cause distress and dyspnoea accompanied by an increase, mainly in tidal volume but also in respiratory rate. There is a concomitant rise in blood pressure and unconsciousness. A 12-14% level will cause death by central respiratory and cardiac depression if continued for a sufficient time (arterial pCO2 greater than 150mm Hg). A 20-40% inspired carbon dioxide level rapidly causes mid brain convulsions, extensor spasm and death. If the inspired carbon dioxide is allowed to increase gradually (as might occur with a re-breathing set with failing absorbent), the following sequence is observed on land. The subject notices hyperpnoea, throbbing frontal or bi-temporal headaches, dizziness, unsteadiness, disorientation and restlessness. There is sweating of the forehead and hands, and his face feels flushed, bloated and warm. Respiration is increased in both depth and rate. Muscular fasciculation, incoordination and ataxia that is demonstrable. Jerking movements may occur in the limbs. The subject becomes confused, ignores instructions, and pursues his task doggedly. Gross tremor and convulsions may appear. Depression of the central nervous system leads to respiratory paralysis and eventually death.

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Underwater, the diver may not notice sweating and hot feeling, due to the cool environment. Incoordination and ataxia are much less obvious because movements are slowed through the dense medium and the effect of gravity is almost eliminated. Hyperpnoea may not be noted by the diver performing hard work of engrossed in a task. With the rapid development of hypercapnia, there may be no warning symptoms preceding unconsciousness. During the recovery period, the diver may remember an episode fo light-headedness or tansitory amblyopia, but these occupy only a few seconds and there is therefore insufficient time to take appropiate action. An exercising diver in the water may have little warning of carbon dioxide toxicity prior to becoming unconscious. If the diver is removed from the toxic environment prior to the onset of apnoea, recovery from an episode of acute carbon dioxide toxicity is rapid and he appears normal within a few minutes. He may complain of nausea, malaise or severe headache for several hours. The headache does not respond to the usual analgesics or Ergotamine preparations. The role of carbon dioxide retention in enhacing nitrogen narcosis and rendering the diver more susceptible to oxygen toxicity is discussed in the appropiate chapters. It is also believed that carbon dioxide increases the possibility of decompression illness by increasing tissue perfusion and by increasing red blood cell agglutination.

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SECTION FIVE. INTRAVENOUS CANNULATION & INFUSION SIZES OF E.T. TUBES IN RELATION TO AGE 4.5mm 6mm 8mm 9mm Young Child (3 years). Uncut red oxford tube. Average Child (8 years). Cut to 19 cm. Average Female. Cut to 22 cm. Average Male. Cut to 24 cm.

IV CATHETER (VENFLON) RANGE COLOUR IV SIZES & FLOW RATES *Denotes the types that should be in the medical kit. The grey Venflon is mainly used for the rapid transfusions of whole blood or blood components, whereas the green is used for surgical and other patients receiving blood components or large volumes of fluid. Smallest Large COLOUR Purple Yellow Blue Pink * * Green White Grey Brown/Orange GAUGE 26 24 22 20 18 17 16 14 CATHETER DIAMETER Ext. mm INT mm 0.5 0.6 0.8 1.0 1.2 1.4 1.7 2.0 0.4 0.6 0.7 0.8 1.0 1.2 1.4 1.7 25 32 45 45 45 45 31 54 80 125 180 270 Length in mm Flow ml/min

INTRAVENOUS INFUSION This section covers: The decision to use intravenous infusion. Techniques. Issues and complications.

Introduction To maintain circulation you must minimise blood loss. If there has been significant loss of blood you must replace it by intravenous infusion. If you do not, the drop in blood pressure and tissue

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perfusion can cause severe damage to the vital organs. Key decision Should you use intravenous infusion? YES IF There are signs of hypovolaemic shock (controlled blood loss only) There is a serious external blood loss. There is significant loss of body fluid from other causes, e.g. Burns.

IF NOT Minimise blood loss using basic techniques, i.e. Controlling external bleeding by local pressure on the wound and elevation of the part. Raising patient's leg above the level of the heart (controlled blood loss only). Immobilising fractures.

HYPOVOLAEMIC SHOCK This is the most important factor in deciding to use intravenous infusion. Shock is diagnosed by combination of: Pallor Sweating Anxiety Rapid shallow respiration Cold skin Rapid and weak pulse. Low blood pressure

INTERNAL BLEEDING Extreme care must be taken when infusing a patient with suspected internal bleeding. This is due to the very real risk of increasing the blood loss by the mechanism of increased blood pressure leading to clot bursting. Likewise raising the blood pressure by auto-infusion (leg raising, pneumatic anti shock garment PASG) may also be detrimental. HEAVY EXTERNAL BLOOD LOSS You should assess the quantity of blood lost at the scene of the accident, e.g. The degree of

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saturation of the patient's clothing or dresssings (wich has proved too difficult at times). INFUSION EQUIPMENT The giving set The most commonly used giving set is a twin-chambered type. It has a sharp plastic needle, which is sheathed, at the chamber end of the set. This is inserted into the bag or bottle of fluid. Ah the end of the set to be attached to the cannula there is a Luer connector attached to the resealing injection port. There is a variable compression clip fitted to the tubing between the chamber and the injection port to regulate the flow of the fluid. CHOOSING THE FLUID The fluids available are: Crystalloids electrolyte solutions. Colloids plasma substitutes.

CRYSTALLOIDS Normal saline, Hartmans solution (Ringer's lactate) are normally used. You can also use them for fluid replacement until fully grouped and cross-matched blood is available, provided the blood pressure remains at a satisfactory level. But you must remember that these fluids diffuse out of the circulation within an hour. COLLOIDS Haemanccel and Gelofusine are commonly used. They are better then simple electrolyte solution for patients with a low blood volume because they are retained in the circulation for longer. They do not cause problems with blood cross matching. However, 2% of the population will have an allergy reaction to Haemanccel and it may also cause haemorrhage. Infusion fluids come in three type of container: a soft plastic bag with a port for insertion of the giving-set needle. A semi-stiff plastic container with a snap-off port or ring; when removed this allows for the insertion of the giving-set needle. A glass container, which also needs an air vent.

CHECKING THE INFUSION Before you connect the giving-set to the fluid container you must check: the fluid is of the correct type. it is not beyond its expiry date. the fluid is clear. the container is undamage.

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PREPARING THE GIVING-SET 1. Remove the giving-set from its package. Check expiry date & packaging In date & sterile. Move the flow regulator to the closed position. Check that the tubing is not defective. 2. Remove the protective sheath from the needle at the chamber end of the giving-set. Push it firmly through the entry port of the fluid container without touching it. 3. Half-fill the chambers of the giving-set by gently pumping their walls. 4. Open the flow regulator slowly. Let the fluid flow until it reaches the Luer lock at the far end of the giving-set. Make sure there are no air bubbles in the tube. 5. Close the flow regulator. The giving-set is now ready to use. CHOOSING A SITE FOR VENEPUNCTURE It can be difficult to set up an infusion at the scene of an accident. It is much easier to introduce an intravenous cannula while the circulation is being maintained. Ideal sites are in the: antecubial fossa. radial side of the forearm. dorsum of the hand. external jugular vein in the neck.

Avoid the legs if you possibly can. INDICATION FOR INFUSION a) Hypovolaemic Shock (established shock from fluid loss). b) Potential Hypovolaemic Shock (possible shock from fluid loss). c) Neurogenic and Cardiogenic Shock (electric shock, cardiac arrest, cares with Cardiogenic). Refer to your training notes and note all the conditions whereby fluid can be lost from the circulation i.e. Burns, vomiting, coughing up blood, etc. DANGERS a) Air Embolus. 20 ml of air is considered large enough to create an air embolus capable of causing problems. Can be caused by the incorrect assembly of the drip, or by air being drawn into the circulation throug the junction of the terminal end of the giving set and the inserted cannula. b) Localised infection at the cannula site of insertion. Could precipitate septicaemia. c) Straight throug puncturing of the venous wall.

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d) Sub-cutaneous oedema (infusing into the tissues). e) Venous spasm; preventing drip from flowing. f) The breaking off of part of the terminal end of cannula (due to repeated attempts at infusion using the same cannula). g) Infection transmitted through the drip (caused by using un-sterile equipment or by mishandling the sterile points of the fluid bottle and giving set). h) Blood clot forming at site of insertion (mainly due to inserting the cannula in the vein then not flushing it). i) Fluid overload leading to pulmonary oedema. ADVANTAGES 1. Maintains blood volume/pressure. 2. Prevents Hypovolaemic Shock. 3. Prevents venous collapse. 4. Replaces lost body fluids. 5. Assists in the restoration of acid/alkali balance in the blood. 6. Prevents general deterioration of patient's condition. 7. May provide immediate resuscitative measures at the scene. HAZARDS AND COMPLICATIONS OF INTRA-VENOUS INFUSION HAZARD Infection OVERCOME BY Maintain sterility of equipment Use of the no-touch technique Adequate cleansing of the infusion site with sterile swabs Air Embolism Purge the giving-set of air Care in the connection of the giving-set to the cannula and fluid container. Avoid allowing the giving-set to become empty of fluid.

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Hypothermia Allergic Reaction Fluid should be warmed to normal body tempereture before administration. Determine whether the patient is allergic to Bovine Gelatine prior to an infusion of Haemenccel (most usually known in farmers). If an allergic reaction manifests stop the Haemaccel infusion and change to Saline. Inform the A&E Dept. Immediately Vein Damage Careful venu-puncture. Correct size of cannula. Wrong choice of site. Sub-cutaneous Infusion (cannula not in the vein or vein leaking) Cannula Embolism (caused by the plastic tip of the cannula breaking off) Indadequate Infusion Rate Re-site the cannula on the heart side of the original site. Dispose of a cannula after three unsuccesful attempts at venu-puncture. Change cannula for one of a larger bore. Ease back cannula if tip occluded against the side of the vein or the cusps of a valve. Removal of the tourniquet if still in place. Increase the height of the fluid container. Squeezing of the drip/pump chamber of the giving-set to completely fill the filter chamber between each action. Open the roller tap fully. Excessive Infusion Rate Reduce by closing the roller tap.

Cardiac Overload/Hypertension Stop infusion. Inform A&E Dept. Immediately (wrong fluid could have been administered) Infusion of wrong fluid Delay in the cross -matching of the patient's blood (can be caused by the administration of Dextran solutions). Accidental arterial puncture Stop infusion. Inform A&E Dept. Immediately Obtain a blood sample prior to infusion essential if Dextran solutions are to be given. Withdraw the cannula and apply direct pressure.

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Reduced blood viscosity Infusion failing to run satisfactorily Not more than 1000ml of fluid administered prior to arrival of the Supervisor. Refer to Interdive training notes.

IMPORTANT Review IV at least daily (maximun review duration NOT to exceed 72 hours) Victims of heart attacks must not be given fluid resuscitation due to the chances of fluid overload on a weakened heart. CATHETERISATION This is the introduction of sterile rubber tubing into the bladder in order to release retained urine. Urinary retention is caused either by physical blockage, e.g. Enlarged prostate in older men, e.g. Blood clot in the bladder after trauma (D.C.S.). In the former cause retention is painful; in the latter it may cause localised pain, but can contribute to serious distress and should be looked for. Signs of Retention Has not passed water. Lower abdominal swelling and tenderness. Dullness to percussion. Anatomy See cross section diagram (resistance may be felt as prostate is reached). Equipment Sterile catheter, e.g. Foley (gauges 10-24 French). Choose 12 or 14. 2 concentric tubes: a) to drain urine b) to inflate 20-40ml retaining balloon near tip throug non-return valve. Sterile gloves Sterile forceps (2 pairs) Sterile lubricating anaesthetic jelly, e.g. Lignocaine gel Sterile urethrl adapter Sterile drapes Collecting bowl Antiseptic lotion, dish and sterile swabs Spigot or draining bag Sterile water 20ml

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Sterile needles CATHETERISATION 1. Avoid if possible (due to infection not possible to do completely sterile). 2. Give sedative (Diazepam) Valium 2 to 5mg by mouth or 100mg pethidine by injection (NOT IF DCI SUSPECTED) but lignojel is usually more than enoug. 3. Try smallest catheter first (Gibbon type 1.5mm 0 x 150cm). If pulled out by patient use Foley type (has latex balloon). 4. Wear mask use sterile packed catheter only. 5. Wash penis with soap and water, then dab with 1:2000 Hibitane solution. Isolate area with clean towels (1 with hole in for penis). 6. Wash hands and put on sterile gloves. 7. Inject into urethra with urethral syringe up to 10ml of sterile jelly containing 1g/dl lognocaine and 0.1g/dl Hibitane. Retain it for 4 to 5 minutes by penile clamp. Massage some into posterior via perineum. 8. Lubricate catheter with same jelly. 9. Hold penis between finger and thumb of left hand. 10. With right hand hold catheter by sterile Haemostat or catheter forceps and pass tip into urethra, andvance catheter (making sure any part held by fingers does not enter) if it sticks, withdraw, twist and try aganin. 11. Having entered the bladder, connect catheter to closed sterile draining bag. Dibujillo con las siguientes partes 1. Urinary bladder 2. Epididymus 3. Vas deferens 4. Prostate 5. Seminal vesicle 6. Penis with erectile body 7. Glands penis with erectile body 8. prepuce 9. pubic bone 10. rectum 11. urethra 12. testical

Diver Medic Course SECTION SIX CHARTS

RN TREATMENT TABLES RN Table 61 = USN Table 5 RN Table 62 = USN Table 6 RN Table 63 = USN Table 6A
Diagnosis acute Decompression Illness

Compress to 18m on O2

Assess the Patient after 20 minutes

Yes

Are there any Neurological Symptoms Or signs?

No

Are the Symptoms Relieved after 10 minutes @ 18m?

Yes

Compress to 50m on air or EAN 32.5 If available

Yes

Is the Patient Deteriorating?

No

USE TABLE RN 62 OR USN TABLE 6

Compress to 18m on O 2

Decompress on Table RN 61

Consult a Diving medical specialist

Consult a Diving medical specialist

No

Have symptoms And signs Resolved After 3 O2 periods?

Consult a Diving medical specialist

Yes

Have any Symptoms returned?

Yes No Yes

Yes

Is the patient Free Of symptoms After 25min At 50m?

Extend Table RN 62 or USN Table 6

Have any Symptoms And signs resolved?

No
Is the patient Continuing to Deteriorate?

No

Remain at 50m For a total of 2 hours

Yes

Are there Any significant signs?

No

Decompress With Table RN 62 Or USN Table 6

Yes
Consult a Diving medical specialist Consult a Diving medical specialist

Yes

Have Any Symptoms worsened Or returned ?

Decompress Using Table RN 63 Or USN Table 6A

Compress to depth Of relief (max 70m) And use table 65

Decompress Using RN 64

Consider Recompression To 18m and Transfer to Table RN 64 Or extending RN 62

No
Complete table RN 62 or USN Table 6 Complete Table RN 61 or USN Table 5

Diver Medic Course DR ABC CHART

D
CHECK FOR DANGERS

Note 1 R
SPEAK TO CASUALTY (SUPPORT HEAD) SHAKE THE SHOULDERS ENSURE CLEAR AIRWAY LOOSEN TIGHT CLOTHING CHECK CERVICAL SPINE HEAD TILT & CHIN LIFT

USED CAROTID ARTERY FOR ADULTS & OVER ONES. BRACHIAL ARTERY IF UNDER ONES

USE EYES NOT FINGER DO NOT HYPEREXTEND

CHECK BREATHING FOR 10' LOOK, LISTEN AND FEEL UNCONSCIOUSNESS

NOT BREATHING = CHILD DROWNING, CHOCKING

NOT BREATHING NORMALLY

IS BREATHING?

2 GOOD BREATH, 5 IF DROWNING OR CHOCKING

HELP, RETURN

CHECK PULSE USUALLY PRESENT

CHECK PULSE

30 GOOD COMPRESSIONS

PRIMARY SURVEY HEAD TO TOE

NO PULSE

PULSE 2 BREATHS

TURN PATIENT IN RECOVERY POSITION TO PROTECT AIRWAY

1 MIN CPR 30-2

10 GOOD BREATHS IN 1 MINUTE CHECK ABC COVER CASUALTY

HELP RETURN

HELP RETURN

30 COMPRESSIONS 2 BREATHS UNTIL HELP ARRIVES

CHECK ABC

CHECK ABC IF PULSE

HELP RETURN

CONTINUE CPR 30-2

10 GOOD BREATHES PER MINUTE

CHECK ABC

IF STARTED PULSE

STARTED

SECONDARY SURVEY & MONITOR ABC'S

IF BOTH

Diver Medic Course INTUBATION

ASSESS NEED ASSESS LEVEL OF CONSCIOUSNESS PLACE PATIENT IN THE SNIFFING THE MORNING AIR POSITION PRE-OXYGENATE PT FOR A MIN OF 2 MINS (WITH CPR IF NEC.)
S H O U L D L A S T O N L Y 3 0 S E C O N D S

SWITCH ON LARYNGOSCOPE (CHECK LIGHT) INSERT LARYNG. INTO RIGHT SIDE OF MOUTH USING LEFT HAND DISPLACE TONGUE TO THE LEFT, CHECKING OBSTRUCTIONS LOCATE EPIGLOTTIS EXPOSE VOCAL CORDS - ASPIRATE IF NECESSARY INTRODUCE SELECTED E.T. TUBE (PRE-JELLIED) IF FAILED FOLLOW ARROW CONNECT SWIVEL CONNECTOR CATHETER MOUNT INFLATE CUFF OF E.T. TUBE INFLATE LUNGS 4 INFLATIONS

CHECK E.T. TUBE IN CORRECT POSITION, STETHOSCOPE AND VISUAL CHECKS INFLATE LUNGS TWICE INSERT ORAL PHARYNGEAL AIRWAY SECURE E.T. TUBE WITH ONE INCH TAPE INFLATE LUNGS TWICE CHECK BALLON SECURITY OF E.T. TUBE CONTINUE EAR/ECM AND MONITOR VITAL SIGNS SUPPLEMENT RESPIRATIONS WITH 02 WHEN POSSIBLE

Diver Medic Course EXTUBATION

REMOVE SECURING TAPE

REMOVE ORO-PHARYNGEAL AIRWAY

INSERT LARYNGISCOPE

ASPIRATE ORO-PHARYNX (YANKEUR)

TURN PATIENT ON SIDE

DEFLATE CUFF

INSERT TRACHEAL CATHETER (FLEXIBLE)

SWITCH ON ASPIRATOR

REMOVE TUBE/CATHETER ON INSPIRATION

GIVE 02 @ 6 8 l/min REDUCING CHECK MASK (REDUCING 02 FLOW ON SOME MASKS CAN LEAD TO CO2 RETENTION) MONITOR ALL VITAL SIGNS & LOOK OUT FOR LUCID INTERVALS

Diver Medic Course IV INSERTION

EXPOSE AREA OF I.V. SITE, PUT ON GLOVES

APPLY TOURNIQUET TO RAISE VEINS (SHOW METHOD)

TELL PATIENT WHAT YOU ARE GOING TO DO

CLEANSE I.V. SITE (ALLOW TO DRY, IF TIME ALLOWS)

SELECT APPROPRIATE CANNULA (MAKE AND SIZE)

OPEN AND CHECK CANNULA FOR SERVICEABILITY

TELL PATIENT ONCE AGAIN WHAT YOU ARE GOING TO DO

INSERT CANNULA INTO VEIN (JUST LIKE THAT)

REMOVE TOURNIQUET

REMOVE AND DISPOSE OF STILLETTE INTO SHARPS BIN

FLUSH WITH NaCl 0.9% 5ml SECURE CANNULA TO SKIN

Diver Medic Course INFUSION SETUP PROTOCOL FOR SETTING UP ADMINISTRATION

OPEN ADMINISTRATION SET (CHECK INDATE & STRILITY) TURN OFF GIVING SET SELECT/CHECK FLUID DATE, CLARITY, PARTICLES, RIGHT FLUID BREAK FLUID BOTTLE SEALS BREAK GIVING SET SEALS INSERT GIVING SET INTO BOTTLE HALF FILL CHAMBERS SLOWLY RUN FLUID THROUGH TO END OF GIVING SET CHECK FOR AIR BUBBLES RUN DRIP VERY SLOWLY REMOVE CAP PLUG CONNECT GIVING SET TO CANNULA HEAD SET DRIP TO CORRECT RATE FORM LOOP WITH GIVING SET SECURE WITH TAPE SECURE ARM TO SPLINT CHECK TIGHTNESS INTEGRITY OF DRIP MONITOR PATIENTS OVERALL CONDITION

Diver Medic Course INTERDIVE OBSERVATION & RECORD CHART

Name____________________Age Occupation__________Company_________Worksite_______ Brief details of how injury caused, or illness started:______________________________________

FALTAN 2 HOJAS CON TABLAS

DIVING INCIDENT (SUPPLEMENTARY) RECORD SHEET Time incident began__________________________ gmt Depth at which incident began__________________ Did the incident begin: In the water? In the bell? In the deck chamber? Ohter? Descending? At workin depth? At living depth? Ascending? On the surface?

At the time of accident or onset of symptoms was the patient

Type of dive (Sat, bounce, etc)___________________ Was excursion involved? If so state range______________________ Medical treatment given?___________________________________________________________ Treatment table followed?___________________________________________________________

Diver Medic Course

SECTION SEVEN FIRST AID (SUPPLEMENT) UNDERWATER BLAST INJURIES

Introduction In any explosion with the same energy and at the same distance the underwater blast is the more deadly. A man who would be unharmed by an air explosion of a hand grenade at 5 meters (assuming he is not hit by shrapnel) would undoubtedly be killed by a similar charge exploding at the same distance underwater. The nature of the underwater explosion is complex, but some understanding is needed. An explosion produces rapidly expanding spherical gas bubble, which is responsible for the first, or primary, pressure wave, called the short pulse. This is because of the rapid gas expansion in a noncompressible environment. There is a sequence of bubble contractions and re-expansion resulting in an oscillation of pressure waves. These move through the water at different volocities. The nearer the diver is to an explosion the greater the velocity. Eventually, at some distance, the velocity of the pressure waves is slowed to approximately that of sound, from this point on the pressure waves follow the laws of sound underwater. A PRESSURE WAVE IS TRANSMITTED OVER GREATER RANGE IN WATER THAN IN

Diver Medic Course

AIR In an explosion most of the damage is achieved by the initial pressure wave: Initial pressure wave Subsequent waves Heat and turbulence energy energy energy

If an explosion is near the seabed and the seabed is of a hard material, there is very little absorption and much reflection. This causes pressure waves to inflict increased damage. Pressure waves are reflected from the surface and also thermal layers, corals, walls, shore and large ships. Damage will be influenced by size of charge, depth, and distance of the diver form the explosion. Injuries With air explosions much of the pressure wave is reflected by the body surface, since this represents an interface between mediums of different densities. The density of the body and water are similar. Underwater the pressure wave passes throught the body except at areas capable of compression, i.e. Gas spaces. Therefore damage will be found at these interfaces, e.g. Lungs, sinuses, ear cavities and the abdomen. A SHREDDING EFFECT will take place in the lungs, the tissue will literally be torn apart. INJURY UNDERWATER OCCURS MAINLY AT GAS/TISSUE INTERFACES AS IN BAROTRAUMA Management of injuries The patient must be admited for observation to a hospital or similar medical centre, even thought he may not appear seriously affected, there are often no external signs of injury. Exposure to altitude may aggravate the damage. Until fully assessed, the patient should be maintained on intravenous fluids and gastric suction. MANAGEMENT IS SIMILAR TO THAT OF SEVERE BODY TRAUMA FROM OHTER CAUSES. Care must be taken in the administration of positive pressure ventilation although the administration of 100% oxygen is required whenever there is a degree of hyperaemia. By placing the patient in a hyperbaric environment you could probably de delaying and complicating the cardio-pulmonary support and gastro-intestinal surgery. Dry suits could reduce the damage caused, since they would be the first water-air interface struck. Summary Exposure to an underwater blast will result in damage far in excess of that caused by a simmilar air blast. This is because water is an incompressible substance and transmits the pressure waves with

Diver Medic Course

the velocity of sound underwater. The surface and/or the seabed or obstacles may also reflect the pressure wave. When the pressure wave hits the diver, it is transmitted through his body and will damage tissues adjacent to gas spaces. ANY DIVER who experiences an underwater blast is likely to have suffered some injury. No external injuries may show, but he may develop serious clinical symptoms and signs over the next couple of days, as a result of internal bleeding, etc. MEDICAL ATTENTION MUST BE SOUGHT

MOTION SICKNESS
Seasickness can be a distinct hazard to a diver using small craft such as a surface-support platform. Diving should not be attempted when a diver is seasick. Vomiting while submerged can cause suffocation and death. Symptoms and Signs Nausea Dizziness Feelings or withdrawal Pallid or sickly green complexion Sturred speech Vomiting

Prevention There is no effective treatment for seasickness except to return the stricken diver to a stable platform. All efforts are therefore directed at prevention. Some people are more susceptible than others, but repeated exposures tend to decrease sensitivity. Suggestion therapy by a trained mental health specialist has been helpful in some cases. The susceptible person should eat lightly just before exposure and avoid an alcoholic hangover. Seasick individuals should be isolated to avoid affecting others on board adversely. Drug therapy is of questionable value and must be used with caution because most preparations contain antihistamines that make the diver drowsy and could affect judgement. Drugs should be used only under the direction of a physician who understands diving, and the only after a test dose on nondiving days has been shown not to effect the individual adversely.

Classification of Recovered Immersion Patient

Hospital treatment below: What can remote medic do? 1. Adequate ventilation no apparent sequelae.

Diver Medic Course

2. Inadequate ventilation. 3. No ventilation: no cardiac output. Treatment for class 1 a) Immediately encourage coughing and deep breathing. b) Hospitalise 24 hours or may be more. c) Clinical signs in ches may require intensive care. d) Laboratory test: chest x-ray blood gases core temperature sputum sampling. e) Chest physiotherapy. f) Oxygen and intravenous access. Treatment for class 2 a) As for (1) but with more urgency. b) Monitor arterial oxygen pressure CO2 Electrolytes. c) Careful ventilation with 02 100%- +/- PEEP/CPAP/BIPA/IPPV d) Careful administration of I.V. Fluids e.g. Bicarbonate, Mannitol (after ABGs). Treatment for class 3 a) As for (1) and (2), but with even more urgency. b) Removal of debris and false teeth etc, from mouth watch out for passive vomiting. c) Intubate and maintain positive end expiratory pressure, ventilate with 02 (IPPV) (PEEP) d) Monitor laboratory tests frequently. e) Consider appropriate method of re-warming and wheteher or not to defibrillate etc. f) Drugs Steroids? Diuretics Sedatives Antibiotics? OIL CONTAMINATION Divers have three problems here: 1. Swallowed encourage vomiting. This will reduce inflammation in the stomach and guts by oil removal. In the absence of other problems, milk is a good sooting agent. 2. Inhaled this irritates the lung and causes a chemical pneumonia. Prevent further inhalation

Diver Medic Course

and encourage coughing. Drugs, which include antibiotics and steroids, will be needed. Also oxygen. 3. The eyes oil in the eyes causes chemical conjunctivitis. They should be cleaned should the mouth and nose with liquid parafin. Sooting drops or ointment may be applied later. Cleansing of the rest of the body can wait until other problems have been resolved.

Diver Medic Course

SECTION EIGHT GENERAL INFORMATION DRUGS THE STATUTORY DRUGS HELD OFFSHORE UNDER THE OFFSHORE INSTALLATIONS ACT 1976. These notes have been produced to assist the first aider or medic when administering the drugs and medicinesa available offshore. Certain drugs and medicines must only be used on the advice of a doctor; these are listed separately (Head 2) in the official list, and are asterisked in these notes. The directions given in the notes for this restricted group of drugs and medicines are intended to familiarise the first aider or medic, and should never be regarded as instruction in lieu of medical advice. SECTION A ANALGESICS Oral preparations: a) Soluble Aspirin & Codeine tablets b) Paracetamol tablets (Panadol) c) *Pethidine tablets Injections: a) *Morphine injection b) *Pethidine injection SECTION B ANTIBIOTICS AND ANTIMICROBIAL AGENTS Oral preparations: a) *Ampicillin capsules (Penbritin) b) Co-trimoxazole tablets (Septrin or Bactrim) c) *Penicillin V tablets d) *Tetracycline tablets Injections: a) *Fortified Procaine Penicillin injection

Diver Medic Course

SECTION C DRUGS AFFECTING THE GASTRO-INTESTINAL TRACT Antacids: a) Aluminium Hydroxide tablets b) Magnesium Trisilicate compound powder Anti-diarrhoea's: a) Diphenoxylate Hydrochloride with Atropine tablets (Lomotil) b) Kaolin and Morphine mixture Laxatives: a) Senna tablets (Senokot) Local applications: a) Benzocaine compound ointment SECTION D DRUGS AFFECTING THE RESPIRATORY TRACT Cough mixtures: a) Ipecacuanha and Morphine mixture b) Opiate Squill linctus (Gee's linctus) Inhalations: a) Benzoin compound tincture (Friar's Balsam) SECTION E DRUGS AND PREPARATION AFFECTING THE SKIN Applications to the surface: a) Benzoic Acid compound ointment (Whitfield's ointment) b) Benzyl Benzoate solution c) Calamine lotion d) Hydrocortisone cream 1% e) Methyl Salicylate liniment

Diver Medic Course

f) Sodium Bicarbonate g) Surgical spirit h) White soft Paraffin (Vaseline) i) Zinc ointment j) Zinc Starch and Talc dusting powder k) Zinc Undecenoate dusting powder (Mycota powder etc) Tablets: a) *Promethazine tablets (Phenergan) Antiseptic: a) Cetrimide Cream (Savlon) b) Cetrimide Solution (strong) (Savlon) SECTION F SEDATIVES AND SLEEPING TABLETS Oral preparations: a) Nitrazepam tablets (Mogadon) b) *Diazepam tablets (Valium) c) *Promethazine tablets Injection: a) *Diazepam injection (Valium injection) SECTION G AGENTS AND DRUGS AFFECTING THE EYE a) Chloramphenicol eye ointment b) Sulphacetamide eye drops 10% c) *Amethocaine eye drops SECTION H DRUGS AFFECTING THE EAR a) Neomycin, Polymyxin and Hydro-cortisone ear drops (Otosporin) (See also antibiotics and anti-microbial agents section B above)

Diver Medic Course

SECTION I MISCELLANEOUS Oral preparations: a) *Glyceryl Trinitrate tablets b) Hyoscine Hydrobromide tablets c) Mouth Wash tablets d) Vitamin C tablets Injections: a) *Hydrocortisone injections b) Water for injections Applications: a) Clove oil b) Kaolin poultice SECTION A ANALGESICS Oral preparations Soluble Aspirin and Codeine BP 300mg General analgesic for mild and moderate severe pain. Also effective in lowering temperature in a feverish patient, e.g. Influenza. Soluble form and advantage over tablets. USE: Adult dose, 2 tablets dissolved in water every 4-6 hours as required. Precautions: i. Dyspepsia may occur, and in a few particularly susceptible individuals bleeding may occur. ii. Very occasionally true allergy may occur, usually present as a skin rash or wheeze in the chest. Always ask if aspirin has ever upset patient in the past. Paracetamol tablets BP 500mg (Panadol) Alternative analgesic and temperature lowering agent to aspirin for mild and moderately severe pain. USE: 2 tablets every 4-6 hours as required.

Diver Medic Course

* Pethidine tablets BP 25mg Analgesic for relief of severe pain where an injection is not required. See pethidine injection below. USE: 2-4 tablets (occasionally up to eight tablets) as required to control pain every 4 6 hours as directed by a doctor. Precautios: See Pethidine injection following. Injections *Morphine Sulphate Injection One of the most powerful analgesics for relief of severe pain. Reserved for the most severe cases. Also has a sedative effect, which may be desirable in certain circumstances. USE: Where possible Morphine should always be given IV and titrated against the pain for effect. Precautions: i. Is a powerful sedative and also causes pupil constriction, therefore should never be used where a head injury has occurred or is suspected, as important signs or worsening head injury may be masked. ii. Often procedures nausea and vomiting, therefore patient should be kept as quiet as possible. The administrator should be prepared for this eventually. iii. The danger of addiction is not relevant where this preparation is given over a short period of time. iv. Because of the danger of masking worsening symptoms morphine should be used with extreme caution in cases of undiagnosed abdominal pain. Extreme care must be taken with chest injuries because of the respiratory depressant effect of Morphine. A bag and mask for artificial ventilation must always be present when administering large doses of Morphine. *Pethidine Injections Powerful analgesics for the relief of severe pain, although not quite as powerful as morphine. Has very little sedative effect, and also does not constrict pupils, therefore may be used where head injury has occurred, or is suspected. Less likely to cause nausea and vomiting than morphine. USE: Usually 100mg given by intramuscular injection every 4 6 hours as directed by a doctor. Precautions: i. May produce nausea and vomiting. ii. Rarely a patient may be allergic to Pethidine; usually evident as a skin rash or wheeze.

Diver Medic Course

iii. Because of the danger of masking worsening symptoms should be used with extreme caution in cases of undiagnosed abdominal pain. SECTION B ANTIBIOTICS AND ANTIMICROBIAL AGENTS Oral preparations *Ampicillin capsules BP 250mg (Penbritin) An antibiotic belonging to the Penicillin group that acts against a fairly wide range of bacteria. May be indicated where there is a chest infection or an infection involving the kidneys or bladder. Less effective than Penicillin in certain circumstances (see below). USE: Dose 250 or 500mg four times a day as directed by a doctor. Precautions: i. Always check with the patient that he has never had an adverse reaction or rash to Penicillin in the past. ii. Should not be used for throat infections as this may result in a skin rash where the infection is due to certain organisms. Co-trimoxazole tablets BP (Bactrim, Septrim) This agent acts against a fairly wide range of bacteria and is particularly useful in infections of the kidneys and bladder, and for patients known to be sensitive to the penicillin group. This preparation may also be used for chest infections, throat infections, middle ear infections, and for infections of the soft tissues and skin. USE: 2 tablets to be taken twice a day. The regulations allow this drug to be used without the direction of a doctor where the condition is one of infection of the kidneys or bladder, otherwise medical advice should be sought. Precautions: i. Always ask the patient if he has ever had a reaction or skin rash following the administration of this preparation, Sulphonamides or Sulpha containing drugs. ii. A iii. Ensure that any patient receiving this preparation has a good intake of fluids. *Tectracyline tablets BP 250mg Not usually considered an antibiotic of first choice, although it does act against a fairly wide range of bacteria. Useful where the patient is allergic to other antibiotics. Used as first choice drug in some venereal disease. USE: 250mg four times a day as directed by doctor.

Diver Medic Course

Precautions: i. Out of date stock should not be used. ii. A iii. Not recommended during pregnancy, or for children uder 7. Injections *Fortified Procaine Penicillin BP Long acting form of simple Penicillin (see penicillin V above). Useful where there is severe infection and rapid effective treatment required, especially where the patient is vomiting and the retention of oral preparations cannot be guaranteed. Also in the treatment of some venereal diseases. USE: Usually one or two ampoules (300,000 or 600,000 units) daily as directed by a doctor. The preparation consists of a powder to which water for injection BP must be added. Precautions: i. As for all Penicillin's (see Penicillin V above). ii. A iii. Partially important to ensure that the patient is not allergic to Penicillin as the preparation is long acting and adverse effects will be correspondingly severe and prolonged. SECTION C DRUGS AFFECTING THE GASTRO INTESTINAL TRACT Antacids: a) Aluminium Hydroxide tablets BP 250mg b) Magnesium Trisilicate compound powder BPC c) Sodium Bicarbonate BP All three of these agents help relieve pain and discomfort of hyperacidity, i.e. indigestion or dyspepsia by neutralising excess stomach acid. Selection of any one of the agents may simple be a matter of personal preference. However, differences do exist. Sodium bicarbonate acts very fast and is useful where rapid pain relief is required. However, this preparation is not recommended for regular, repeated doses. Aluminium hydroxide and magnesium trisilicate take longer to act, but have a more prolonged action. They may also be used regularly, long term. Aluminium hydroxide will tend to constipate whilst magnesium trisilicate will tend to loosen bowels. Tablets are often more convenient for the patient to carry and use than powders. USE: One or two aluminium hydroxide tablets should be chewed before swallowing. One teaspoonful of sodium bicarbonate or magnesium trisilicate should be mixed with water. All preparations may be taken for relief of symptoms or regularly four times a day before meals.

Diver Medic Course

Anti-diarrhoea's: a) Diphenoxylate Hydrochloride with Atropine tablets (Lomotil) b) Kaolin and Morphine mixture BPC Choice between these two preparations usually depends upon personal preference. Tablets are often more easy to carry and use, and may be retained more easily by a patient who feel sick. USE: Diphenoxylate and Atropine tablets One or two tablets as required to control symptoms, three or four times a day. Kaolin and Morphine mixture Ten or fifteen ml required to control symptoms, three or four times a day. Laxatives: Senna tablets BP (Senokot) Simple laxative. USE: Two or Four tablets at night. Precautions: laxatives should not be given in cases of undiagnosed severe abdominal pain. Local applications: Benzocaine compound ointment BPC A combination of local anaesthetic, astringent and soothing agent. Apply to haemorrhoids (piles) twice daily. SECTION D DRUGS AFFECTING THE RESPIRATORY TRACT Cough mixtures: a) Ipecacuanha and Morphine mixture BPC b) Opiate Squill Linctus (Gee's Linctus) Both these preparations contain a cough suppresant and an agent thought to act as an expectorant. Little to choose between the two preparations. Choice depending upon personal preference or taste. USE: 5 or 10ml to be taken as required, three or four times a day. Inhalations: Benzoin compound tincture BPC (Friars Balsam)

Diver Medic Course

Simple remedy for catarrh. USE: 5ml to be added to one pint of hot water. Vapour is inhaled. Precautions: NOT to be taken by mouth. SECTION E DRUGS AND PREPARATIONS AFFECTING THE SKIN Local applications: Benzoic Acid compound ointment BPC (Whitfield's Ointment) Preparation used in the treatment of fungal infections of the skin, in particular athletes foot. USE: Apply twice per day to the affected area. Precautions: NOT to be taken by mouth. Benzyl Benzoate solution BPC An application for specific use in the treatment of scabies infection. USE: Apply on day 1 to all areas of the skin below the neck following a bath. Do not wash off. Apply second application on day 2. Do not wash off. On day 2 wash off applications by bathing. Change underclothes and bedding which can then be laundered as usual. Precautions: Do Not continue using application after full course even if skin irritation persists. Calamine lotion BPC Simple soothing lotion which, may be applied to any unbroken area of skin affected by irritant rash. Apply liberally as often as required. Precautions: NOT to be taken by mouth. Hydrocortisone cream BP 1% Cream for use of irritating rashes and dermatitis where skin infection is not suspected. USE: apply sparingly twice a day. Precautions: should be used for a limited period of time only if used without medical advice. Should not be applied to the skin where infection is present. Methy Salicylate liniment BPC For relief of pain in muscles and other soft tissue structures. Acts as a counter irritant producing local warmth in skin adjacent to the affected area.

Diver Medic Course

USE: apply once or twice a day. Precautions: DO NOT apply to area of broken skin. NOT to be taken by mouth. Sodium Bicarbonate BP May be used as a solution to irrigate acid burns. USE: makes up a solution of one part in a 100. Surgical Sprit Disinfectant for use on unbroken skin, e.g. Prior to administering an injection. Can also be applied to cold sores with good effect. Precautions: NOT to be taken by mouth. Contains Methyl alcohol which is poison. Surgical spirit is inflammable White Soft Paraffin BP (Vaseline) Useful, protective ointment. Particularly for protection of lips from chapping. Zinc Ointment BP Useful soothing ointment that may be applied to abraded areas of the skin. Zinc starch and talc dusting powder BPC For use as talcum powder. Zinc Undecenoate Dusting Powder BPC (Mycota Powder) For use as foot powder in subjects prone to athletes foot and to prevent recurrence of this condition. Oral Preparations: Promethazine Hydrochloride tablets BP 10mg (Phenergan) May be used to relieve skin itch and particularly useful where a rash is due to an allergy. May also be indicated when an allergic patient develops soft tissue swelling due to an allergy. USE: usually one or two tablets three or four times a day as directed by a doctor. Precautions: these tablets may cause drowsiness and care should be taken if the patient operates machinery or drives a vehicle whilst taking his preparation.

Diver Medic Course

Antiseptics: Centimide Cream BPC (Savlon) Antiseptic cream which may be applied to small open wounds prior to dressing. Larger wounds, especially those that may require suturing, are better cleaned with Centrimide solution (see below). The cream may also be applied to the surface of small burns where the skin is broken. Centrimide Solution (Strong) BPC (Savlon) When diluted may be used to cleanse open wounds. USE: make up solution of one part in 40 using freshly boiled water. Precautions: the diluted solution must not be used later than one week after preparation. SECTION F SEDATIVES AND SLEEPING TABLETS Oral Preparations: Nitrazepam tablets BP 5mg (Mogadon) Effective sleeping tablets. If pain is preventing patient from falling asleep, then an analgesics should be given rather than a sedative. USE: one tablet is often sufficient in patients not normally taking this preparation, otherwise two may be taken. Precautions: may cause a hangover effect the following morning especially in the larger dose. *Diazepam tablets BP (Valium) Useful sedative for treating agitated and excitable patients. USE: usually one or two tablets as required every four to six hours as directed by doctor. Precautions: sedatives should not be administered where a head injury is suspected. Large doses may cause the patient to become completely unconscious. Care should be taken to protect the patient if this occurs. *Promethazine tablets BP 10mg (Phenergan) Alternative sedative, which can be used as night sedation. USE: usually 2 or 3 tablets as directed by a doctor. Injections: Diazepam injection BP (Valium injection)

Diver Medic Course

Sedative given by injection where rapid onset of action required. Can be used with good effect where recurrent convulsions is occurring due to epilepsy. May also be used in extreme circumstances where sedation is required and patient is unable to take oral preparation. USE: usually 10mg by deep intramuscular injection as directed by a doctor. In extreme circumstances a doctor may advise an intravenous injection. However, extreme care should be taken as response to dosage is less predictable and deep unconsciousness may occur. Precautions: as above and as for Diazepam tablets. SECTION G AGENTS AND DRUGS AFFECTING THE EYE Chloramphenicol eye ointment BPC 1% Antibiotic eye ointment used to treat infections of the surface of the eye and to prevent infection where a foreign body has entered the eye and scratched the surface. USE: ointment should be squeezed into the eye with the lower lid drawn back and the patient looking upwards. May be used every four hours. Precautions: the tube should be discarded one month after opening. The date of opening should be marked on the label. As other serious conditions of the eye may produce a red painful eye, mimicking an eye infection, it is unwise to persist treating with this agent if there is no response without seeking medical advice. Sulphacetamide eye drops BPC 10% Alternative anti-bacterial eye drops for use in eye infections. It is sometimes easier to administer eye drops than eye ointment. USE: instil drops in the eye every four hours taking care not to touch the eye with the end of the dropper in order to avoid contamination of the remaining solution. Precautions: Sulphacetamide is a sulphonamide and therefore should not be used in patients that have a history of rash or allergy to sulphonamides, septrim or bactrim. Other precautions as for Chloramphenicol eye ointments. *Amethocaine eye drops BPC 0.5% Local anaesthetic eye drops for relief arising from the surface of the eye, e.g. Foreign bodies on the cornea and abrasions due to direct injury. USE: one or two drops should be instilled into the eye and repeated as necessary to control pain as directed by a doctor. Precautions: extreme care should be taken to protect the eyes from further injury once these drops have been applied, as the patient will no longer be aware of any foreign material scratching the surface of the eye. An eye pad and bandage must be applied immediately and kept in place.

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SECTION H DRUGS AFFECTING THE EAR Neomycin, Polymyxin and Hydrocortisone ear drops (Otosporin) Ear drops for use in treatment of infection of the ear canal. USE: 3 or 4 drops to be instilled in the ear four times per day. Precautions: if ear drops cause sudden giddiness, then a perforation should be suspected and the treatment stopped. In this case it would be wise to administer an antibiotic by mouth. The advice of a doctor should therefore be sought. SECTION I MISCELLANEOUS Oral preparations *Glyceryl trinitrate spray These sprays may be used to relieve heart pain in patients suffering from angina. USE: dose 400mg. The dose may be repeated if the pain reoccurs, as directed by a doctor. Precautions: the spray often produces headache and may produce faintness, which is sometimes severe. If side effects occur, treat by lying down. Hyoscine Hydrobromide tablets BP 0.3mg For the prevention and treatment of sea illness. USE: 1 or 2 tablets every 6 hours. Precautions: may cause drowsiness. Mouth wash solution tablets BPC For use as mouthwash or to gargle to relieve local irritation. USE: dissolve one tablet in 250ml of water. Repeat as necessary. Note: a solution of soluble aspirin and codeine tablets may also be used as a gargle with good effect. Vitamin C tablets BP 25mg Presumably included to avoid the statutory requirement to carry limes whilst at sea! Injections *Hydrocortisone Sodium Phosphate injection BPC 100mg/ml Used in the treatment of severe shock, i.e. Where the patient is severely ill with a low blood

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pressure, the result of haemorraghe, burn, acute abdominal emergency, heart attack or an overwhelming infection. Also used in patients who have suffered a severe reaction as the result of an allergy. Also used in the treatment of asthma. USE: often given in extremely large doses of several hundred mg in life threatening situations. May be given either by intramuscular or intravenous route depending on severity of conditions. Should only be given on the direction of a doctor. Water for injection BP Used to make up solution for injection where main agent is stored in the form of a powder within an ampoule. Amount of water to be used will be marked on the container of the agent concerned. Required for Fortified Procaine Penicillin injection BP and for some preparations of Hydrocortisone injection. Applications Clove oil BP May be used for the relief of toothache where a cavity is present. USE: taking care that the oil is not brought into contact with the gums. This treatment should not be applied repeatedly over short periods. Analgesic tablets should also be used. Precautions: see above Best avoided unless experienced in its use or unless analgesic tablets infeffective. Kaolin poultic BP Has been used in the past to provide local warmth over areas of deep tissue inflammation and to assist the discharge of pus from skin infections. However, unless one is well practised in its use, it is best avoided. USE; the tin is opened and stood in a saucepan of boiling water for ten minutes. The poultice is well stirred and then applied in a layer approximately '' thick to a piece of lint. The kaolin is covered with a layer of gauze and after the temperature of poultice has been checked to ensure that heat is not excessive the sandwich with the kaolin poultice as the filing is applied to the area, the gauze being in contact with the skin. Precautions: never apply a hot poultice direct to the skin. Care should be taken not to burn the patient. MEDICAL PRODUCT CODING AND EXPIRY DATING There seems a lot of out of date medical items such as: sutures, iv cannulas, iv giving sets, sterile surgical packs, sterile dressings and other items around in industry in general and particularly the oil and gas industry. A lot of people medical and lay, do not realise that everything has a shelf life. The shelf life of the majority of sterile products is 5 years from date of sterilising dependant on the type of packaging. If

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it is a simple paper wrapping it may only be a couple of years at most. Invasive items such as cannulas, hypodermic needles, syringes and other surgical instruments, etc, is particularly important. Plastic degrades and can become brittle with age, which may then break off into the patient the same with needles bonded to plastic connectors. Also pathogens can lurk unseen within old packaging and be a source of infection that can be avoided. Any old, tatty or damaged wrappers should indicate poor storage and warrant the item to be discarged and not used. Sterile dressings and swabs must also come into this category. Because an item looks in good condition if it is out of date is should not be used on a patient. Before 1998 it was not mandatory to display an expiry date, even the batch numbers did not have to give you a clue. Some companies were putting manufacture/sterilising dates and expiry dates on their products. This was not a legal requirement then. Now all products should display an expiry date. As s rule of thumb any product that cannot be dated must be considered no longer usable and out of date. To quote from the European Directive 93/42 EEC. A surgical dressings and bandage's for human use manufactured, imported of sold within the EU are medical devices and must comply with the European Directive 93/42 EEC. The regulations for medical devices became valid as from January 1995 and have been fully implemented as of June 1998. The minimal requirements under the directive are as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9. Content of packaging. Size of dressing. Storage conditions. Where appropriate the handling conditions. Trade or brand name and address of manufacturer. Use of symbols for the batch code (LOT) and expiry date. Some additional information (Where necessary). Brief description. The CE Symbol.

This information is for guidance only if there is any doubt as to it's accuracy please obtain a copy of Bulletin 19 from the Medical Devices Agency, Hannibal House, Elephant and Castle, London, SE1 6QT. Copies of the European Directive 93/42 EEC are obtainable from HM Stationery Office. This information is intended to help anyone who needs to replace out of date dressings etc, to justify why they are ordering new when they have still got stock which may not even show a date on it. There is a duty of care to the workforce that the companies nedd to address and this area often gets neglected. Author: Rod Urwin RN. REMT (P), DMT, Senior Offshore Medic.

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ORDERING, STORING & ADMINISTRATION OF ANTIVENOM Administering the Serum (Sea Snake) Inject subcutaneously 0.2ml of a 1/10th dilution. If there is no reaction: the serum should be injected again immediately intravenously. If there is a reaction: the serum should be administered intravenously with adrenaline, antihistamine and corticotheapy within half an hour to an hour. If there is a reaction during the injection, inject: either adrenaline subcutaneously and antihistmine intravenously, or antihistamines intravenously. Ordering the Serum Sea Snake anti-venom 1000 units (35.8ml) code seasn. Available from: Commonwealth Serum Laboratories 45 Poplar Road, Parkville Victoria Australia 3052

Storing the Serum It should be stored in a refrigerator. It has a validity of one year. It should be transported in an isothermal box. Note: Early ventilatory support has the greatest influence on outcome. The mimimal initial dose of sea snake antivenin is 1-3 vials; as many as 10 vials may be required. Responsibility: each worksite should keep enough antivenin to cover this purpose on board and replenish them from base as necessary. SEA URCHINS Most divers in marine waters are familiar with the sea urchin. The spines, being very brittle, break off at the slightest touch. Symptoms and signs: Immediate sharp burning pain. Redness and swelling. Spines sticking out of skin or black dots where they have been broken off. Purpling of skin around place spines entered.

Diver Medic Course

Redness and swelling in affected area.

Treatment: Remove those spines that can be grasped with tweezers. Spines that have broken off flush with the skin are nearly impossible to remove, and probing around with a needle will only break the spines into little pieces. The body will dissolve most of the spines within a week. Others may fester and can then be popped out to the point, where they can be then removed with tweezers. Some forms have small venomous pincers that should be removed, and the wound should then be treated as a poisonous sting. Coral Cuts Coral frequently causes lacerations, and abrasions to inexperienced divers. These injuries may initially appear minor in natyre, but because of foreign material, such as pieces of coral, nematocysts, infected slime, etc, they frequently become inflamed and infected. Clinical Features The laceration, usually on the hand or foot, causes little trouble at the time of injury. Some hours later there may be a smarting sensation, and a mild inflammatory reaction around the cut. This may be due to the presence of discharging nematocyst. In the ensuing 1 to 2 days, local swelling, erythema, and tenderness develop around the site. Usually this abates in 3 to 7 days. Occasionally an abscess, or ulcer will form and discharge pus. This may become chronic, and osteomyelitis of the underlying bone has been reported. Celluitis, and/or lymphadenitis may accompany the accute stage. Fever, chills, arthralgia, malaise, and prostation occur in some cases, probably reflecting the systemic effects of a severe bacterial infection. Healing may take months to years if complications ensue. Treatment This involves early antisepsis, and total removal of foreing material (e.g. With soft brush). The wound should then be dressed with antibiotic powder, or ointment several times daily. Tetanus prophylaxis may be advisable. Cellutitus, lymphangitis, etc, indicates the need for a broad-spectrum systemic antibiotic (e.g. Ampicillin, tetracycline) after a swab is taken for culture, and sensitivity. In such cases, bed rest, elevation of the affected limb, and other general supportive measures will also be required. Prevention Coral cuts can be avoided by the use of protective clothing, gloves, and swim fins with heal cover and active treatment of minor abrasions. VACCINATIONS Certain vaccinations are required by the World Health Organisation (WHO) or by the public health services of some countries. This is the case for: YELLOW FEVER CHOLERA* Cholera vaccinations are indispensable because of the risk of infection on-site in certain countries. TETANUS TYPHOID* Medical treatment however is generally effective for this disease.

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IT IS THEREFORE COMPULSORY THAT ALL OPERATIONAL PERSONNEL BE VACCINATED AGAINST: YELLOW FEVER TETANUS* Usually given in conjuction with poliomyelitis vaccination. The following are the rules to be followed for each type of vaccination: Tetanus Initial course of injections, then 10 yearly unless a skin wound requires treatment, if no tetanus vaccination received within las 5 years a booster vaccination is given. Polio Initial course, then a booster 10 yearly. Typhoid Initial course then a booster given 3 yearly. Diphtheria Initial course then a booster given 10 yearly. Yellow fever Initial course then a booster given 10 yearly (international certificate required). Hepatitis A Initial course then a booster given 10 yearly. Hepatitis B Initial course then a booster given 5 yearly (blood test after last injection to confirm sero-conversion). Tuberculosis Immunity should be confirmed or vaccination carried out. Booster given 10 yearly. Menigococcal meningitis A and C: primary injection then booster 3 yearly.

Other vaccination may also be required additionally, dependent on the bounty being visited. When several vaccinations are to be made, they should be given according to the following schedules: 1) Yellow fever. 2) A 3) Tetanus/polio 2 weeks later. MALARIA There is no vaccine against malaria, but there is an effective means of prevention, which is IMPERATIVE TO USE before, during and after a visit to an endemic malarial zone. The treatment consists of taking 0.1g of NIVAQUINE every day, starting just prior to departure for the area and continuing for three weeks following departure from the area. A registered doctor must prescribe all malaria chemoprophylaxis. In some countries malaria is resistant to Chloroquine/Nivaquine and should not be used. Recommended anti malaria prophylaxis: Malarone 250mg tablet Dosage i. One tablet 2 days prior to going into a malaria area. ii. One tablet daily whilst in the area. iii. One tablet daily for seven days on leaving that area.

Diver Medic Course

Mefloquine 250mg tablet Dosage i. One tablet two weeks prior to going to a malaria area. ii. One tablet weekly whilst in the area. iii. One tablet for 4 weeks on leaving the area. Doxycycline 100mg capsule Dosage i. One capsule daily for one week prior to entering a malaria area. ii. One capsule taken daily whilst in the area. iii. One capsule to be taken daily for 3 weeks on leaving the area. The above anti malaria tablets are given as a guide only, and should be prescribed by a registered doctor, as the above medications taken long term may make some people unwell with the side effects of these drugs. EMERGENCY RADIO FREQUENCIES Maritime Emergency Frequencies Ships with radiotelegraphy station, while at sea, keep a 24 hours listening watch of 500kHz and on 2182kHz. Coastal radio stations keep a 24 hours listening watch on 500kHz, 2182kHz and some also on 8364kHz. Ships with radiotelephone station, while at sea, keep a 24 hours listening watch on 2182kHz. Coastal radio stations and ships with VHF radio keep listening on VHF frequency 156.8MHz (channel 16). 2182kHz 500kHz 8364kHz 156.8MHz telephony telegraphy telegraphy telephony alarm/speech alarm/Morse alarm/Morse speech

Aeronautical Emergency Frequencies Commercial air traffic keep a listening watch of 121.5MHz. Military air traffic keep a listening watch on 243MHz. SEA KING rescue helicopters can home on all maritime and aeronautical emergency frequencies except of 156.8MHz (channel 16).

Diver Medic Course

Rescue helicopters may keep communication on all maritime and aeronautical emergency frequencies. Commercial helicopters can home on 500kHz and 2182kHz. 121.5MHz 243MHz 121.5MHz/123.1MHz SILENCE PERIODS 00-03 Civil aeronautical emergency frequency Military aeronautical emergency frequency Communication frequency

48 Telegraphy to 45 Telephony

Telephony 15 to Telegraphy 18

33-30 DISTRESS CALLING Telegraphy: Alarm signal: Distress message: Telephony: Alarm: Distress message: VHF telephony: Alarm: Distress message: 500kHz-8364kHz May-Day 12 x 4 sec. Points + S.O.S. S.O.S. + message. 2182kHz Two-tone alarm signal. May-Day + message. 156.8MHz (channel 16) None. May-Day + message.

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DISTRESS MESSAGE PROCEDURE May-Day, May-Day, May-Day 3 times. This is ........................ 3 times. Position. Type of distress or emergency situation. Type of assistance requested. Weather condition (wind-wave-visibility etc) Other information: Number or person(s) missing. Injured person(s) medical assistance. Emergency radio beacon/communication. Ship and rig to shore communications should be on 2182kHz supplemented in the case of rigs or platforms by any other established links. It is important that all marine units involved in the emergency should maintain radio communication with the same Coastal Radio Station that is controlling the emergency traffic. Air to ship communication is to be on 2182kHz R/T. However, the rescue helicopters are equipped with, and will communicate with vessels on channel 16, VHF emergency radio, operating on 121.5MHz or 123.1MHz may be used as back-up if a total loss of communications is experienced. Aircraft and helicopters participating in an emergency or rescue operation will keep a listening watch on 121.5MHz. Emergency Position Indicating Radio Beacons Air traffic keeps a listening watch on the International Aeronautical Distress Frequencies 121.5MHz VHF. Emergency position indicating reporting beacons may therefore be used to indicate that an emergency or distress situation exists. Rescue helicopters and aircraft can home on the emergency beacons, thus saving valuable search time.

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PHONETIC ALPHABET Misunderstanding verbal communication causes may accidents. Divers using heliox are even more vulnerable (dependant upon the quality of voice unscrambler). Common practice is to keep conversation to a minimun, and to use words easily understood. The phonetic alphabet is a worldwide standard used to prevent, mis-understanding when communication quality is poor, or interference great. A B C D E F G H I J K L M N O P Q R S T U V W X Y Z ALPHA BRAVO CHARLIE DELTA ECHO FOXTROT GOLF HOTEL INDIA JULIET KILO LIMA MIKE NOVEMBER OSCAR PAPA QUEBEC ROMEO SIERRA TANGO UNIFORM VICTOR WHISKEY X-RAY YANKEE ZULU