NAUI Rescue

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NAUI Scuba Rescue Diver

NAUIWORLDWIDE strives to enable people to enjoy underwater activities as safely as possible by providing the highest quality practical education, and to actively promote the preservation and protection of the world's underwater environments. NAUIWorldwide is a professional association of persons believing themselves, with good reason, to be the finest diving and underwater recreation instructors and practitioners in the world. As a notfor-profit, membership organization founded on excellence, ethics and education, NAUI is unique in the world of diving, and proud of its position of leadership in recreational diving instruction. NAUI Worldwide members work hard to develop and promulgate the latest training techniques, and participate in testing and developing new equipment and diving practices in a \vide variety of diving environments and conditions. Their diligence and continuing commitment to safer diving is a sound basis for your buying this book and taking a NAUIWoridwide Scuba Rescue or Advanced Scuba Rescue Specialty Course. As you begin this text, or before your first class session, read the introduction completely. You will learn how best to use this book to help you in your course, and more importantly, in your future diving.

PREFACE The chief goal of NAUIWoridwide rescue training is tlle prevention or successful resolution of diving mishaps. This book is designed to support the following NAUI courses: Scuba Rescue Diver Advanced Scuba Rescue Diver

This text is meant to be used by certified scuba divers who wish to acquire additional diving skill practice and increase their diving knowledge under the direct supervision of a qualified NAUI Worldwide Instructor in a controlled, professionally conducted class that includes academic and practical learning experiences. While the information presented can help all levels of divers, and even interested non-divers, leam more about the significant risks and rewards of recreational diving, reading about diving activities is no substitute for detailed instruction, skill demonstration, repeated practice, critical evaluation and expert guidance. It is unwise to attempt to use reading this book as a replacement for a Vigilant instructor's coaching and critiques in confined and open water diving activities. To do so is inresponsible: it can prove dangerous to yourself and jeopardize the safety of your diving companions. Even so, this book is about becoming a safer, more aware and knowledgeable diver. Abasic tenet of all NAUIWoridwide courses is emphasis on a responsible approach to diving that includes proper self-evaluation of your readiness to participate in any given diving or snorkeling activity. The information in this book will help increase your ability to judge your readiness to make any dive. Reading about diving safety will also improve your awareness of recommended diving practices. Do plan to intelligently apply the knowledge gained to your diving activities, including underwater rescue techniques and considerations. Having the knowledge required to evaluate contraindications to diving, to apply accident prevention techniques and recognize the need for s\vift professional care in the event of a diving mishap can help make you a better dive buddy, and more confident in your own diving.

IV

Introduction

The Scuba Rescue Diver Course The Scuba Rescue Diver Course (SRD) is designed to equip certified divers with additional selfrescue skills, and to enable them to effectively intervene if their dive buddy experiences specific common diving problems. SRD graduates can perform assists and rescues in open water situations and environmental conditions similar to those in which they train. In addition, SRD participants learn the rudiments of victim care and positioning, basic principles of first aid, common remedies for diving ailments and illnesses, as well as important information on the legal ramifications and requirements that govern the use of their rescue training in actual practice. All prospective NAUI Worldwide members must obtain Rescue Diver certification prior to entering leadership courses, and should also be currently certified in cardiopulmonary resuscitation and first aid from a recognized national-level agency, such as the American Safety and Healtllinstitute.

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The Advanced Scuba Rescue Diver Course The Advanced Scuba Rescue Diver Course (ASRD) is open to NAUI Worldwide Rescue divers, or divers qualified in rescue skills by another recognized agency after individual evaluation by tlle course Instructor. It is designed as intensive training for those who wish to be able to assume more responsibility during a water rescue, and in particular to acqUire the ability to effectively manage and direct rescue efforts under conditions similar to those under which they were trained. The certification is valid for three years after completion. This is a course for individuals who may contemplate working in tlle recreational diving industry, or who may be called upon to direct a rescue effort, provide immediate [lOSt-rescue aid, direct or participate in the transportation of an accident victim or victims and oversee site and post-incident procedures. Particular emphasis is placed on effective communication witll professional rescue organizations and first responders, as well as participation in direct patient care consistent with tlle graduate's level of training.

The Challenge 01 Continuing Education AProfessional NAUI instructor can help you improve your skills throughout your diving career. Skin and scuba diving and snorkeling are lifetime sports. Given good health and reasonable fitness, anyone can enjoy them with minimal risk at any age, provided the participant is fully aware of and able to meet the physical challenges presented, knowledgeable of appropriate practices and the inherent risks of the specific event, and takes pal1 only in activities for which they have been professionally trained. Enjoyable diving is the result of good training, and confidence in your own and your buddy's ability to meet the demands of the activity. Continuing education helps one meet all the requirements necessary to continue enjoying dive recreation througbout life. ARescue Course in particular will ask you to e~1end yourself in order to meet the demands of the scenarios and skill practice included. it is physically strenuous and engaging. The infonnation you will receive will make you a more knowledgeable and aware diver, increasing your ability to assess your own a11d your diving companions' abilities, and help you make appropriate choices about the risks as.~ociated with a given dive. Ail additional diving classes increase your diving skills, and give you the chance to evaluate your strengths and improve upon any deficiencies

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you may discover. As part of its mission to promote safer enjoyment of our aquatic resources, NAUI Worldwide strongly recommends you continue your diving education tluoughout your diving lifetime.

Using tIIis Book in Your NAUI WorldWide Rescue Course Your Instructor is the best source of infol1llation on your effective use of this book in your Rescue Course. Since NAUI Worldwide gives its members the academic freedom to meet the unique needs of their students, there is no specific menu for your individual experience. There are, however, specific skills and perfomlance standards that your Instructor will ask you to meet before you may be recognized as a NAUI Worldwide Scuba Rescue or Advanced Scuba Rescue Diver. Different parts of tllis book will support different sessions 111thin your class, and the course schedule or curriculum will indicate the associated chapters. Infonnation is presented in different ways in this book. Some important points will be illustrated with drawings, graphics or photographs. Pictorial infol1nation, however, will always be accompanied by an appropriate caption to help you meld the image with tlle ideas it represents. This book is organi7a1 into 15 chapters, each covering a different area that impacts directly on underwater rescue. The first five chapters review many of the concepts presented in your initial NAUI Worldwide Scuba Diver Course. The next eight chapters include infonnation and skills review material relating to preventing diving problems, and dealing with any mishaps that may occur. The final two chapters address accident management and requisite information if you must use your skills to help another diver. Follow the advice of your Instructor regarding the order in which to read these chapters, and the emphasis to give any particular material. Under the NAUI Worldwide educational system, it is likely that your instructor lvill provide additionalmaterials as part of your class. ThiS is obVious, given a professional instructor seeking to develop your diving skills and knowledge in a specific geographical area. No text, however complete, can hope to be able to prOVide all the answers necessary for any situation, nor can a text written to cover general diVing concepts and skills substitute for an experienced persons' insights and creativity in the field. In short, this text is a resource for you and your instructor to explore as you expand your diving knowledge and skills, and focus your ability on becoming a more aware, risk-conscious diver capable of helping other divers. Good luck in your course and safe diVing always.

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VI

InlPoducUon

GETTING THE MOST OUT OF THIS BOOK Throughout tllis study book there will be sections that require your special attention. The following icons are used to mark these sections.

Indicates that you should take note of the information, because it forms the basis for the final exam.

Indicates information that will help you complete the workbook.

Indicates a warning or safety information.

Indicates responsible diving practice.

VII


TABLE OF CONTENTS

Preface The Scuba Rescue Diver Course The Advanced Scuba Rescue Diver Course The Challenge of Continuing Education Use of This Book

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Leaming Goals Incident vs Accident Rescue self-Rescue Assisting Another Diver The Right Response

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lun Emergency 10

Leaming Goals Critical Incident Stress Overcoming fear The Unkindness of Strangers Leadership Issues

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12 12 13 13 14

Readiness 18

The Assumption of Risk self-Awareness and Buddy Assessment... Fitness to Dive Absolute Contraindications Asthma 'fuberculosis (TB) Emphysema Chronic Bronchitis Diabetes Epilepsy Angina Pectoris Myocardial Infraction Coronary Artery Disease Temporary Conlraindications Pregnancy Earache, Respiratory Infections

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18 19 20 20 20 21 21 21 22 22 22 22 22 23 23

and Common Colds Medications Medications Substance-Related Contraindications Alcohol Tobacco Over-the-Counter Medications "Recreational" Drugs Food Relative Contraindications Persons With Disabilities Heart Diseale and Hypertension Chronic or Temporary Physical Problems and Pain Congenital Defects Allergies Obesity Mental Stability Physical Fitness for Diving Safety Diet Rest...

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23 24 24 24 24 25 25 25 25 25 26 27 27 27 28 28 28 28 29 30

_ing To Dive 32

Training ReqUired Equipment.. Specialized Needs Technical Diving Deep Air Exposure Altemate Breathing Gases and Mixtures Nitrox and Oxygen-Enriched Air Diving Overhead Environments ..........................•, Planning and Preparing for Successful Dives ChOOSing Ole Site EqUipment Preparation Dive Planning Depth, Duration and Air Consumption Planning Emergency Planning Your First Aid Kit Oxygen Administration Equipment

34 34 36 37 37 38 39 39 40 40 .41 42 42 42 44 .45 .45

Table 01 Contents

Buddy Briefings Dive Plan Coordination Mutual Gear Check Signals Emergency Procedures

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46 46 46 .47 47

Reducing Common Diving Risks 50

Leaming Goals Judgment Problems Evaluating Your Personal Diving Fitness Managing Your Decisions: Peer Pressure Proper Training Passing vs. Proficient Power vs. Mastery Preventing Problems Equalization Difficulties Squeezes and Blocks Avoiding Squeezes Avoiding Blocks EqUipment Difficulties Common EqUipment Problems Mask and Fin Straps Buoyancy Compensators Wetsuits Dry Suits Ballast Systems Over-weighting Weight Belts Integrated BC and Ballast Systems The DUITM Weight System.... .

.52 52 .52 .52 54 54 54 55 .55 .55 55 56 57 57 57 58 59 .59 .59 59 60 60 61

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Air Delivery Systems Environmental Hazards Weatller Related Problems Temperature Tonnents Dehydration ::Sunburn Musculoskeletal Problems Avoiding Diving Related Musculoskeletal Problems

61 62 62 63 63 64 64 64

General UndeIWater Hazards 65 Avoiding Problems From Cold 65 Temperature Problems .. 65 Density Issues 66 Effort, Fatigue and Safety. .. 66 Narcosis .. 67 Oxygen Toxicity . ..67 Water Hazards .. 67 Natural and Artificial Hazards 68 Entanglement .. 68 Ocean Diving Hazards .. 69 Tidal Current... 69 Rip and Longshore Currents .. .. 70 Surf Diving..... ...71 Surge.......................... ................................71 Freshwater Issues .. 71 Rivers........................... .. 72 Thennoclines 73 Altitude Diving 73 Boating Traffic . .. 73 Overhead Environments .. 74 Breathing-Related Problems .. 74 Improper Breathing Techniques 74 "Skip-breathing," Shallow breathing, and Breath Holding 74 Coughing, SneeZing, Choking And Gagging 75 Hyperventilation and "Shallow Water Blackout" 75 AFinal Word........ .. 75

~ II Learning Goals

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Sb!ess and Distress 78

Recognizing Excessive Stress Stress-Related Behaviors Gear-fumbling Blabbering Behavioral Extremes Obsessive Behavior Helping A"Stressed-Out" Buddy Personal Stress Management Distress Signs of Distress ..

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80 80 81 81 81 81 82 82 83 84 84

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Self-Rescue... . Observable Surface Problems Sinking, Agitation, Gear RemovallRejection, Erratic Breathing-"Bubble Mania," Terror Underwater Signs of Distress/Impending Problems Bubbles Buoyancy Problems Erratic, Jerky Movement ("Scared Stiff') Vertical OrientationlTrim Problems Gear Rejection . Rescue Is It Safe To Intervene? . Effecting ARescue

84 86 86 86 86 87 87 87 87 88 88 88

Dealing With An Out-Of-Air Emergency 90 .................. ................................ 92 Prevention is Everything 92 Self-Rescue for An Out Of Air Emergency 93 Emergency Swimming Ascent 93 Emergency Buoyant Ascent 94 Extra Air In An Emergency 94 Shared Air Ascents 95 Mutual Emergency Planning 96 Alternate second Stage Air Sharing Techniques 96 "Octopus" Second Stage..... . 96 BC-Mounted Integrated Second Stage .97 Redundant Scuba Ascent 98 Buddy Breathing 98 Buddy Breathing Method....... . 98 Problems With Sharing Air.. 98

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Underwater Rescue 100

Learning Goals Responsibility vs. Duty Risk Assessment. AResponsive Victim An Unresponsive Victim Underwater Panic Warning Signs of Impending Panic Is It Safe To Intervene

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Monitoring APanicked Diver Underwater Attack AFinal Note...

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Diving Maladies 108

Learning Goals Pulmonary Barotrauma Types of Lung Overexpansion Injuries. . Subcutaneous Emphysema Mediastinal Emphysema Pneumothorax Arterial Gas Embolus (AGE) Understanding Decompression Sickness Types of Decompression Sickness "Skin Bends" "Limb Bends" "Neurological Bends".. . "Inner Ear Bends" Chokes Signs and Symptoms of Diving Maladies The Trouble With Symptoms.... . Dealing with DeniaL Neurological Assessment .. .. Basic Principles of Neurological Assessment... Performing The Exam .

110 IIO 111 .I11 lll 111 111 112 114 114 114 114 115 115 115 116 116 .. 117 117 117

Treatment 01 ........-_OiVing Maladies 120 Learning Goals............ . Why Oxygen? Handling Oxygen 1)'pes of 0, Delivery Systems.

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Recompression Therapy: The Necessary Second Step.... . A"Typical" Multi-Lock Multi-Place Recompression Chamber

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Learning Goals Assessing Risk............... The Approach

122 . 122 123 124 127 .127

Surface Rescue .

132 132 132

Table 01 Contents

Surface Rescue Priorities Ensure Buoyancy Ensure Breathing Mouth to Mouth Rescue Breathing Mouth to Snorkel Rescue Breathing Pocket Mask Rescue Breathing Dealing With Panic at The Surface Escape.HH H HH Defense Assessing The Problem Equipment Considerations Towing Cylinder Valve, BC or Exposure Suit Tow "Wheelbarrow" Push "Oo-si-
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133 133 133 134 135 136 136 137 137 138 138 139 139 139 140 .140 140 141 141 143 144 H.I44 145 145 146 H147 147 H147 148 149 149 150 150 150 15!

Diver FirstAid 152

Learning Goals The Basis of First Aid 'nle First Responder At ADiving Accident.. General Dive First And Principles First Aid For Common Diving Injuries

154 155 155 156 156

External Wounds Internal Wounds Head Injuries Fractures Cramps . Food Poisoning............ . Burns Marine Animallnjuries Bites Stings: Urchins,Jellyfish and Rays Gas Toxicity Seasickness Life-Threatening Emergencies Heart Attacks Stroke Drowning, Near Drowning and Secondary Drowning Blanket,Stretchers and Found Objects

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164 164

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The Chain 01 Survival in Diving Accidents 188

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Accident Management 174

Learning Goals Cardiopulmonary Resuscitation Perfonning CPR Assessing the need: Problems Opening the AilWay Abdominal Thrusts Problems with Compressions Problems with CPR in General Cold Water Drowning

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156 158 158 158 159 159 160 H.HI60 161 161 162 162 163 164 164

168 168 169 169 169 172 172 I72 H.. I72

Learning Goals 178 Emergency Planning Before The Dive 178 Communications 177 EqUipment 178 Other Trained Personnel H HHH 178 Emergency Management Procedures 179 Evacuation Procedures 180 Assisting The Diver During The Evacuation 180 Victim Transport And Transfer 181 Boat to Boat Transfer. 181

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Boat to Dock Transfer Boat lb Shore Transfer Air Evacuation Helicopters Airlift From AVessel Airlift From The water

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182 182 182 182 183 183

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Learning goals liability Negligence Standard Of Care And Duty Assumption of Risk And Your Actions In Arescue Assistants .. Insurance and "The Good Samarit:m"

188 188 189 189 190 190 190

IIIB 192

XII

CHAPTER

The "Zero Accident" Goal


LEARNING GOALS In tilis chapter you will:

1. Learn what is meant by the "zero Accident" Goal 2. Learn what your rescue training is designed to do for you. 3. Learn about the value of continuing education and practice and the effect they will have on your diving ability. 4. Understand the difference between an incident and an accident. 5. Be introduced to the concept self rescue. 6. Learn the definition of a rescue. 7. Understand your responsibilities as a AU! certified Scuba Rescue Diver or an Advanced Scuba Rescue Diver.

AGURE 1·2. AS ENJOYABlf AS DIVING IS, EVERY DIVE ENCOMPASSES SIGNIFICANT RISKS.

As a group, NAUI Worldwide's altitude has always

been that even one diving accident is too many. It should be your attitude, too. Very likely it is, or you wouldn't be in this course. With luck, knowledge and commitment, "zero Accident" can be a reality for your diving - but all diving will always entail risk. Though the incidence of diving accidents is low, statistics do little to console injured victims or their loved ones. AUI Worldwide's members seek to help divers reduce risk and avoid accidents by equipping them \vith the knowledge that will foster the attitude and judgment necessary to do so (Figure I-I). This knowledge is a

FGIlE 1-1. ANY W AC1MlY CAN BE lNJlJ'rNllf f YIlJ WI YlIIl IlIIlOY All PIIlI'EIlIY 11WNIII, BIlfPIIl AMI PflIIlAIlIIJ.

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combination of academic infomlation on tile dynamics of diving and undel\vater activities covering the full range of necessary subjects like physics, physiology and geography, as well as perfonnance training in tile specialized skills and techniques integral to successful dives. Amled with knowledge, and prepared for the dive at hand, skilled divers are able to accept the remaining risks of the activity (figure 1-2). One of the most important aspects of a Rescue Course, or of any NAUI World\vide class, is that it provides divers a means to continue their diving education. SCUBA is a dynanlic activity. Most of its experts and early pioneers in the field freely admit that there is still much to learn, and that they continue to learn from every dive they make. Our knowledge of the long-ternl effects of pressure, and of the dynamics of the human nervous system continues to evolve. The resultant evolution in diving theory is complicated by developments in diving technology, like rebreathers, widespread use of breathing mixtures other tilan air, and tile expanding frontiers of recreational diving activities. Research and experimentation in these and otiler fields will continue, but perfect knowledge of all the factors affecting diving physiology will likely remain elusive, and diving will never be without significant risks.

Chapter 1· The "Zero Accident" Goal

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Your rescue training is designed to help you better understand these risks, and to help you deal witll any undesirable outcomes from your own or others' dives. Rescue training will also include the chance to practice your skills, or relearn as necessary. Good basic skills are the essential foundation upon which more advanced techniques can be learned. A$ Witll any skills, infrequent or sloppy application will freeze diving skills at a plateau. Over surprisingly little time, atrophy can develop, and the skills that were once second nature, like the ability to comfortably recover a lost mask, become problematic. A$ effective skills deteriorate, bad habits often arise to take their place. The same end may be achieved, but the poor metllod is simply an accident in the making. A$ an example, think of diving with more ballast weight tllan necessary to compensate for poor breathing techniques and the inability to relax in the water. More weight will help a diver descend, but will also more readily fatigue the person it encumbers! It will also change the diver's trim significantly, likely requiring the diver to work hard just to stay horizontal in the water. Back problems from strain and the unnatural swimming position can result. Diving becomes more a chore than effortless, weightless fun. When poor responses become routine, and activities are conducted by rote instead of in a thoughtful manner, problems can occur. This is especially true when something unexpected occurs - for instance, your mask is dislodged by a buddy's fin; you inhale water and begin choking; the situation escalates to crisis. In the water, things can "snowball" rapidly, as you may have discovered. The challenges of diving well can only be met through constantly engaged awareness, and by working to refine, develop and increase your water skills. Continuing education and practice will help you keep your skills fresh, automatic and effective.

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INCIDENT V8. ACCIDENT NAUI worldwide divides diving problems into two categories: diving incidellts and diving accidents.

Adivillg incident is an anticipated, diving-related event that may result in injury. Most diving incidents are preventable. They are usually the result of poor decisions or bad judgment. Many diving incidents occur because divers are literally "in over the heads" in tenns of training and experience. Trying out a new underwater activity before seeking additional training may seem reasonable, but can have terrible consequence (figure 1-3). Incidents will happen. When they do, your rescue training can prevent them from becoming accidents! To attempt a rescue is to assume responsibility for anotller's welfare. To do so without training and a clear concept of your own ability to help is irresponsible and endangers yourself and the victim. Dive wisely. Other diving incidents occur because participants often know better but choose to ignore their knowledge. Take the example of someone with a known medical condition that precludes diving, who chooses to dive anyway. While this person is exercising personal freedom, that liberty is placing the diver and the diver's companions in jeopardy. Other incidents may result from poor planning, rather than deliberate, albeit misguided, choice. Failure to anticipate what may occur on a dive is generally because of inexperience with the activity or a lack of understanding of the implications of conditions. Diving accidents are incidents that result in injury to anyone involved. A$sisting a tired diver back to the dive platfor.m, boat or beach is an incident, but if the person performing the assist is struck by the boat's ladder, for instance, while helping the potential victim aboard, a diving accident has occurred as certainly as if it involved a pulmonary injury. Unfortunately, accidents lvill occur because nothing in life, and certainly not diving, is ever totally free of risk. TIle range of human physiology and response, coupled with the changing nature of the underwater environment, assure us that at one point or another hazards lvillioom. It is inevitable that eventually, despite the best planning and training, someone will suffer injury as a result.

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RESCUE Rescue is a multi-faceted concept. In the view of NAUI WORLDWIDE, to rescue is to assume the

responsibility for releasing another (others) from inuninent peril, or to intervene to prevent further injury from a diving acrident. So defined, rescue is a creative process that includes

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anticipation and prediction, as well as the ability to react properly to an emergency. While tllere are protocols and accepted procedures to follow when aiding another diver or oneself, every actual sinlation is so unique that parts of any number of these may require use in an unusual way. Atrained Scuba Rescue Diver or Advanced Scuba Rescue Diver is expected to recognize potential problems that may cause a diving incident, and to employ a creative reasoning process in alleviating the difficulty before an accident occurs. With this in mind, it is easy to understand why the "best" rescues never happen!

RGURE 1·3. EXCEfDING YOUR ABIUTY OR TRAINING IS AGOOD WAY TO BECOME ADIVING STATISTIC.

Prevelltillg a divillg illcidellt is jar superior to suaessjuily cOl/eludil/g a divillg aceidellt.

Prevention begins with anticipating likely outcomes of various factors, remembering that events in the real world are usually far less easy to predict than they are to describe aftelWards. Even so, as with tlle example of over-weighting, observing certain behaviors, other apparent indicators of potential difficulties and gathering a bit of infomlation about dive buddies will often reveal a problem in the making. Attention to detail and focus on tllOse around you, as well as realistic selfassessment, will prevent many diving incidents. Despite our best efforts, however, incidents and accidents can occur, and often with no apparent reason until later analysis reveals the subtle clues of the chain of events. With this in mind, safer diving is a function of a diver's ability to anticipate, reduce and deal with the inherent risks of any dive. In some cases, there never is a clear-cut answer as to how or why an accident happened. When faced with a developing situation, a trained SRD or ASRD will progress through a hierarchy of responses designed first to stabilize, then appropriately relieve difficulties.

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fIGURE 1-4. WHEREVER AND WHENEVER YOU DIVE, YOU MUST BE COMPlfTElY COMfORTABLE WITH YOUR EQUIPMENT.

SELF·RESCUE Though most recreational divers are unlikely to participate in an actual rescue, the first step in reducing the risks of diving and preventing diving accidents is to be a competent buddy to oneself - a diver whose skills include well-rehearsed methods of dealing with possible

Chapter 1· The "Zero Accident" Goal

AGURE 1·5. CARffIJllNVENTDRY AND INSPECTION OF YOUR OMNG EQUlPMEIiT SHOULD PRECBIE ANY OMNG EXCURSION.

individual difficulties. Taking this course is an effort to me€t this goal, and will contribute to our mutual "Zero Accident" Goal, bllt divillg wisely is tbe most effective metbod available.

Self-rescue skills include practicing basic diving skills until they are as natural as any routine act you would perfom1 out of the water Clearing a mask should be the easy equivalent to brushing one's te€th in the moming. Adjusting diving eqUipment under water, whetl1er wearing a dry suit in cold water or dive skin in the tropics, should be no more a task than adjusting any other gannent (figure 1-4). Your ability to relax in the water is directly related ~ to the likelihood of a successful dive. Achieving this kind of proficiency is unlikely without regular practice. DiVing, unlike bicycle riding, is something you do forget. Any sucoessful dive is comprised of the perf0l111anCe of diving skills. Each of these is linked to others to f0l111 a chain of consequences that can seriously affect the outcome. Equipment must be checked, adjusted and donned, then re-checked by yourself and your dive buddy, and vice versa (figure 1-5). The dive excursion must be planned, and contingency plans made (figure 1-6). In a group experience, the expected organization and conduct must be understood

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AGIJRE HI. MHY DIVE WIll 11M ITS OWN UNIQUE REQ1IIRlMEIiTS. PlAN TO OfAl WITH THEM IN ADVANCE.

Knowledge + Ability + Experience

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by all partiCipants, and lines of control and supervision, if any, must be established. Yet every dive is still an individual experience, and you, your judgment, skills and experience, are your own first source of aid for most common diving incidents. Dealing with any dive problem on your own is a function of your confidence in your own ability. Competence is a direct result of confidence, itself dependent on your knowledge, ability and experience. Under most circumstances, your own ability will prevent any incident you encounter from becoming an accident. Specific remedies for events notwithstanding, all self·rescue begins with the faculty to assess the situation. To detennine what is wrong, the diver must think. Thinking can only take place when one is relaxed, not reacting haphazardly. For instance, were your gear to become snagged on some underwater feature, trying desperately to swim free \villlikely do no more than

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tum an unsettling situation into a dangerous one that includes a frightened, frustrated and rapidly tiring diver! Taking a moment to feel where you may be caught, then tilinking of how best to free yourself, or get your buddy's attention if not immediately notioOO, will solve the pmblem much more efficiently than an unthinking struggle. In any given situation, tilere are several possible options, a~ you will learn in this course, but the best option always starts Witil stabilizing the situation you are facing in order to plan a reasonable and effective solution. One key water skill essel1lial to safer diving, and at the core of self-rescue is simple buoyancy control (figure 1-7). It is absolutely essential to be able to remain relatively stationary at a specific deptil, or even on the surface, effortlessly relaxed, if one is to enjoy diving, and even more so, if presented with an "incident" situation (figure 1-8). Good buoyancy control skills give divers the ability to concentrate on problem solving when necessary, as opposed to dealing with the additional problems of potentially hazardous random depth changes. This is particularly vital in shallow water where equalization issues and discomfort can further aggravate a situation, but holds true during diving at any point in the water column.

ASSISTING ANOTHER OlVER In line with the concept that the "best accidents never happen," is the fact tilat neither do the best rescues. Good interventions to aid another diver are not obvious or overblown efforts to call attention to one's rescue skills or imagined authority, but instead, are quiet, gentle assists that enable the other diver to relax and deal with the problem. Your presence as a ready source of aid, perhaps in contact with the other diver or simply hovering alongside, will often give the individual in difficulty the moment needed to stabilize, assess and correct the difficulty without any otiler intervention (figure 1-9). If not, your help is best kept to the absolute minimum necessary to fully relieve tile problem, and hopefully, continue the dive. Probably the most common

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FIGURE 1-7,l·B, CAREFUL BUOYANCY CONTROL MAKES DIVING EFFORTlESS, CHECK YOUR OWN AND YOUR BUDDY'S BUOYANCY BEFORE EACH OESCENI

"rescue," is just supporting another diver, usually by holding the upper arm, while a piece of gear is better adjusted or some other minor incident is dealt with. The reassurance provided is generally enough to get things under control. Never exceed your training and ability. When you intervene, you assume a duty to perfonn to the best of your ability, consistent with recognized standards. After the dive, a kind word can go a long way towards helping to ensure that a similar incident doesn't recur. Privately discussing what happened with the person, perhaps sharing a similar experience you have had,

Chapter 1- The "Zero Accident" Goal

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assuming management responsibility for a rescue effort. The same response process pertains regardless of the situ- I'i'rI ation: tllinking precedes action and the amount of action ~ is dictated by the "least amount necessal)''' rule. When faced with a potentially life-threatening situation, however, tlle temptation to extend yourself beyond your level of training and ability may be strong. Pressure from bystanders, even the family of the victim, can be a factor. Regardless of the innuences on you, it is up to you to decide what to do consistent with your ability at that moment in that specific situation, and your training. As a certified SRD or ASRD, absent some professional obligation tllat may otherwise exist, you have no duty to respond to anyone's difficulties in the water.

FIGURE 1·9. ASTEADY HAND CAN OFTEN PREVENT AMINOR PROBlfM FROM BECOMING AMAJOR INCIDENT. and outlining any ways you may be able to think of to avoid the problem in tlle future is almost always appreciated. More importantly, this follow-up chat will enable you both to learn what went on in each of your minds. The exchange can help you both better understand the event, and what might be an even more effective method of assistance in the future if the possibility of the problem recurring cannot be eliminated.

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If you do decide to respond, however, you establish a duty to perfoIlll to the best of your abilities and to the limit of your training - and no further. Having heard or read about, or observed some technique gives you no right to tl)' it on a person without having been trained and certified to perform it, even if it is apparently the right response. If it doesn't work, or there are attendant negative outcomes, you may be held responsible. Your performance at any diving accident will be scrutinized by all present, and vel)' likely examined later by attoilleys and otllers. Sad to say, all your good intentions may be for naught, though your motive was only to help as best you could. In the event of a serious acciden~ and frequently even in minor incidents, if the amount of help you tried to give was greater than the amount of help you are qualified to give, your conduct will surely be questioned. You may have to answer for your actions in a legal proceeding. Just as all dives contain an element of risk, dive rescue has risks beyond the physical peril you may face in voluntarily coming to the aid of another diver.

THE RIGHT RESPONSE If all diving problems could be solved easily, there • would be no need for rescue trainingl Not all diving incidents can be solved easily or quickly. 111ere may well come a point when your rescue skills are put to the test in a real accident, and you are thrust into tlle position of providing necessary aid, and even

9

CHAPTER

Acting • In an Emergency


LEARNING GOALS In this chapter you will: I. Leam the definition of stress. 2. Be introduced to the concept of stress and distress and how they affect divers and rescuers. 3. Learn methods of reducing stress. 4. Understand the issue involved in managing bystanders and crowds at an accident scene. Dealing with any emergency entails a high degree of stress. For that reason, understanding stress and its management is a central element to rescue training. Ironically, stress itself is a neutral concept, having to do with an}1hing that disturbs the equilibrium. By that definition any stimulus that is emotionally disruptive, from falling in love to great sadness can be stressful. The stress inherent in any emergency response can cause your efforts to fail, or if understood and used properly, will enhance your likelihood of success.

Most stress comes from uncertainty and apprehension (figure 2-1). ot being able to predict the outcome of your actions when attempting to aid someone, or even being unable to feel secure about your own safety are unsettling feelings. Loss of control is a particularly stressful realization for almost everyone. Stress may interfere \vith your ability to function effectively, or even prevent you from acting at all despite training and ability. You may experience two kinds of fear from stress: fear that your actions \vill prove inadequate in resolVing the situation, and fear of undertaking the responsibility intrinsic to acting to help someone, especially someone whom you do not know. Just as negative aspects of stress can affect tile outcome of your efforts, so can the positive elements of stress, notably excitement and the anticipation of rewarding feelings of deep satisfaction when your efforts succeed. Focus your concentration on these positive elements. As noted earlier, your confidence in your ability, born of knowledge and effort, will enable you to channel the stress you will feel in dealing with an emergency into positive focus on the likelihood of your success, and the benefit your actions will have to the victim. Stress: a. Amentally or emotionally disruptive or upsetting condition occurring in response to adverse extemal influences and capable of affecting physical Ii"I""1 healtil, usually characterized by increased heart rate, ~ a rise in blood pressure, muscular tension, irritability, and depression. b. Astimulus or circumstance causing such a condition.

CRITICAL INCIDENT STRESS ..

.... ,,. I FIGURE H AN EFFECTIVE DIVE PlAN, Will HElP TO AVOID STRESS UNDERWATER."

12

Arescuer will invariably face stress when confronted with the abnonnal circumstance of haVing to decide to attempt to save someone, or provide them with crucial care until professional help is available. Merely seeing an injured or ill person is stress-producing for most people. Having to be involved in a life-threatening ordeal heightens stress immeasurably, and that stress is even far worse when, for any number of reasons, your best efforts fail or appear to be failing.

Chapter 2- Acting in an Emergency

Just as in deciding how much you are willing to risk in order to savor the pleasure of diving, you must decide to what extent you are willing to risk the possible negative outcomes of involving yourself in a major rescue. Post-event anger at oneself, at the victim, and others, as well as frustration at your own performance can lead to deep depression. You may begin blaming yourself and others for the misfortune that has befallen tile individual, even though you have no rational basis for that feeling. Others around you may reinforce those negative feelings as they seek to relieve their own anxiety and depression. You must avoid thiS, or you willunnecessarily and unreasonably suffer. Asuccessful rescue can also leave the rescuer anxious and depressed, to some extent the consequence of the honnones released by the stress one has experienced, but also from the powerful emotional load tilat the event carries. In any event, this stress must be relieved or the rescuer will no longer be effective. There are several ways to do this. Methods to reduce stress related to a critical inciIi"l""'I dent may be fonnal, such as seeking aid from a counsel~ ing professional, or infol1nal, like frank conversation with a peer. Your best approach will depend on who you are, and the circumstances. Whatever the best option for you, it is imperative to do sometiling, rather than ignore the feelings you will ineVitably experience as part of the Ii"l""'I afternlath. Unchecked critical incident stress can lead to ~ physical and emotional illness.

"We become brave by acting brave0'. " -Nalive American Saying Only you will know if you are up to performing at the level required. Only you will know if you are truly capable. Your NAUI Worldwide [nstmctor will help you hone the skills you will need to petform effectively in a rescue situation, but your commitment to practice and maintain your level of skill, and your dedication to improvement, will determine your real ability. There will be times when you realize that your level of ability is exceeded by the demands of the situation. It is at that point that your honesty and character will detemline whether or not you will endanger the victim further, ;md yourself as well, through misguided "heroics." By maintaining your focus on the goal of a successful rescue, rather than the pOSSibility of negative consequences, you will be able to act up to the level of yoUI' ability and training without being hindered by fear 'Ib some extent, the rehearsals of appropriate action you will undergo in dealing with tile emergency scenarios in your Rescue Course will help you team to focus on the outcome. Practicing proper action, focusing yoUI' attention on the hierarchy of response - from assessing a situation to stabilizing the problem and then responding appropriately to the best of your ability - will help you later to act in the same way if ever faced with a real rescue. Though there will always be fear, it need never hinder your performance if you are prepared to deal with it in advance.

The Unkindness of Strangers OVERCOMING FEAR Fear is the natural consequence of being faced with the pOSSibility of a negative result in any endeavor. Without fear, however, there would be no courage, for bravery does not hinge on the absence of fear, but rather the ability to act in spite of it. In dive rescue, overcoming fear is again a function of your knowledge and training. Having confidence in your competence comes from honest evaluation of your skills and ability relative to what you will be expected to do to achieve a successful rescue.

.

One of tile biggest problems that any rescuer can face is dealing with the bystanders at the scene of an accident or rescue. The emotional responses that you are prepared for by your training and involvement are for them unexpected, often ovelWhelming problems. They may interfere by hying to help, and must be tactfully put off or given simple tasks, such as watching for the arrival of emergency vehicles, in order to stop and direct them. They may experience rage, and you, for lack of a better target, may be its recipient. An insidious outcome of this is the amount of self-blame that can develop; worse, you may actually find yourself agreeing

13


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FIG 2.2 CONTROlliNG THE SCENE AT AN ACCIOENT, INCLUDING CDNTRDLUNG YOUR INTERACTION WITH BYSTANDERS, IS CRUCIAL TO SUCCESSFUL RESCUES.

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14

with them regarding your poor perfonnance, lack of skills or ultimate responsibility for tile victim's problems. None of this is true, but in tile moment, it may seem so. Unfortunately, like Pandora, you cannot effectively later retract things -like statements of blame - that you have reconsidered. It is, however, necessary to deal with the crowd that may be at the scene. This is best achieved by remallllllg courteous, respectful and sympathetic. By circumstance, and in the case of diving leaders, by position and design, you are in charge of the situation, and must act appropriately professional. Your COlllments, directions to others and statements should all focus on the ultimate goal of rendering aid to the victim as best you are able, until relieved of that burden by better qualified personnel (figure 2-2). Confrontation with bystanders serves no purpose but to distract you from your goal. Discussions of guilt, blame and responsibility, even of possible outcomes, leave you open to undesirable consequences. In order to best aid the victim, and preserve your own peace of mind, concentrate on the task at hand throughout the situation.

FIG 2.3 ALL DIVERS CAN BENEFIT FROM UNDERSTANDING THE FUNDAMENTALS OF RISK MANAGEMENI

LEADERSHIP ISSUES Diving leaders who organize or supervise recreational diving, or teach or assist dive classes are in an especially delicate position when aiding other divers. These issues are lllore fully explored in the NAUJ Worldwide publication, Mastering NAUJ Leadership, however it is important that all SRD and ASRD divers understand that the most qualified individual at the scene is not necessarily the person who will take charge of the incident. The concept of duty, expressed as the reasonable obligation to provide aid on the part of a diving leader and reasonable expectation of that aid on the part of a supervised diver, is an area of real debate. The easiest answer to such questions is for the lea~er to avoid any ambiguity about her role in the event, and the parameters under which he or she may act. These are best spelled out in writing in advance of the event, usually through the use of waiver and release forms contained in NAUI Worldwide's current Risk Management Handbook (figure 2-3).

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15

I

CHAPTER

Diving Readiness


LEARNING GOALS In this chapter you will: 1. Learn about the "assumption of risk" and assessing "fitness to dive." 2. Be introduced to medical contraindications to diving. 3. Understand the difference between absolute, relative and temporal)' contraindications. 4. Learn about the risks associated with specific conditions such as: as~lI113, diabetes, bronchitis, colds and flu and many others. 5. Explore the issue of the use of alcohol and other drugs and the reasons they are not recommended while diving or participating in aquatic activities. 6. Understand the value of aerobic fitness has for a diver or rescuer. For many people, recreational diving is the ultimate frontier, a chance to explore a world that few experience direc~y. Many people feel that this opportunity is, or should be, granted equally to all. Realistically, ~lis is no more the case than anyone choosing to operate a motor vehicle without being qualified and fit to do so. There is some confusion, especially in free and open societies, between the abstract idea of freedom and the practical exercise of responsible choices based on evaluation of facts and the exercise of sound judgment. The truth is that scuba diving is no more a right than the right to operate a motor vehicle in that it is an activity regulated in the interests and safety of other participants. There are usually no penalties written into the rules of scuba like there are in motor vehicle laws, though, unless one counts ~le terrible crippling effects or loss of life a serious diving injul)' can entail. Instead of laws, the recreational scuba industl)' in most countries relies on the integrity and good sense of its professionals to ensure that participants are protected as much as possible from their own and o~lers' irresponSibility or ignorance. Anyone's participation in recreational diVing is a personal choice, not an imperative. No one must be allowed to dive; not being able to participate has no

AGORE 3-1. BOODlES SHOIIlD BE INDIPEMIOOIY CAPABLE IJtVEIlS WIfO CONSENT TO BONG MIJT1W.IY INTIROEPENDENI

more real consequence than not being able to play tennis or ski. The absence of these diversions in one's life, though disappointing for an enthUSiast, detracts little from the real quality of an individual's existence. There are O~ler venues for their enjoyment, and if they are not eqUivalent, they will at least fill the desire for wholesome recreation. NAUI Worldwide endorses ~le concepts of freedom, as its members well know, but recognizes that there are individuals who should not participate in recreational diving, and others for whom participation in a particular actiVity at a specific time is an unwise choice. As an SRD or ASRD, understanding why this is so will help you prevent accidents by enabling you to recognize and better evaluate diving risks. Safer diving begins with intelligent, risk-aware participation. .'

THE ASSUMPTION OF RISK One important reason that recreational diving is not subject to stringent regulation by civil authorities is that the public's participation in diving is based on the concept of voluntary "assumption of risk." Qualified people make a free, infonned and considered choice in order to participate, and expert profesSionals judge their

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Chapter 3- Diving Readiness

ability to make the appropriate choice wisely. Good dive buddies are competent, skilled, independ~lt divers who agree to be mutually interdependent in 00 order to reduce tile risks inherent in a dive thev choose to share (figure 3-1). . Diving is a unique, shared activity, practiced by trained individuals. All participants have responsibility to and for themselves, but divers also have a responsibility to tile others with whom they choose to dive, ~U1d more importantly, who choose to dive with them. No sane person would pick a buddy or group of dive companions known to be a danger to tilemselves, and by extension, to tilOse with whom they dive. And yet, tilrough ignorance or stubbomncss, some divers do just that! NAUI Worldwide has a vety simple criterion to judge whether or not an individual should be allowed or encouraged to participate. Divers must be able to affirm that their participation in ~U1y dive does not create a direct, probable threat to other divers, and any NAUl Worldwide members conducting that dive must, based on Uleir professional expertise, agree with Ulat assertion. As a certified diver, you have the justifiable right to plan and execute any dive for which you are qualified and also possess the requisite skills and ability. Further, though, you assume the responsibility to yourself and to l:"2"Your dive buddy to apply your own best judgment, based ~ ~n your own experIence and knowledge, to every dive you plan. Prudence dictates that you use those same critical faculties and intuition to assess your diving companions, and Uleir ability to be a resource for you, or a potential hazard to you in case of difficulty. Only through frank evaluation of the known and possible risks of every dive you make, including those represented by your diving companions, can you be said to have made an informed choice.

SELF-AWARENESS AND ... BUDDY ASSESSMENT Scuba is an activity shared by qualified individuals committed to the mutual goal of enjoying the undelWater environment. Deciding whether or not to participate

RU2 &UOD DIVE BUDDIES ASSfSS THBR PIAN THROUGHOUT THBR DIVE.

begins with self-assessment. Though evaluating one's own knowledge and skills is difficult, one must be completely honest with oneself about participation in every dive. Some questions to ask yourself include: • Am I properly trained for, and do I understand the risks of this dive? • Am 1experienced in these conditions? • Have [ the appropriate, recommended eqUipment, in good working order, and am [ well-practiced in its use? • Are my skills and fitness level equal to the challenges Ulis dive is likely to present? • Am I aware of the hazards inherent in this dive , and in diving in generaJ7 • Are there any unusual hazards of which I must be particularly aware? • Am [ eager to dive with this buddy and/or group? • Is my dive plan complete, and does my buddy agree? • Am [ enthusiastic and confident about making this dive today under these conditions considering all these questions and my answers? Variations of these questions should be applied to your chosen buddy, and to the other members of the dive group, if any. This also applies to anyone whom you may be choosing to lead Ule dive. It is a mistake to assume that any individual whom you do not know, or

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CD •

with whom you have not dived before, is completely competent, despite their apparent leadership position or even their employment in a recreational diving business. Nobody is perfect all the time. Even professionals can have an off day. You are the ultimate decision maker about any dive you make. It is a responsibility you can neither relinquish nor ignore if you are committed to safer diving. Another important aspect of safer diving is your ability to be a good buddy, and your chosen buddy's ability to provide you lvith the same (figure 3-2). It is axiomatic that good divers make good buddies, but not invariably true. Some good divers are selfish about their own dive enjoyment, or impatient with others of lesser actual or perceived ability or experience. Other good divers may be inadvertently inattentive to a buddy, perhaps distracted by some other compelling activity like underwater photography. Regardless of whom you may choose as a buddy, it is important to coordinate the individual objectives and expectations of the dive before entering tlle water

FITNESS TO DIVE While dive training is open to virtually everyone who is able to enjoy and appreciate its allure, there are some people who cannot dive because of medical or other conIi'I""I ditions tllat make tlleir participation unacceptably dan~ gerous to themselves and their companions. These conditions are termed Absolute Contraindicalions. The presence of an absolute contraindication completely precludes scuba diving as a recreational choice. At other times, a situation may exist where for some reason making a particular dive, or diving at a particular time is too hazardous because of the increased likelihood of some ill effect. These situations are termed Temporary Contraindicalions. When the situation, be it an illness or some other issue, is resolved, then diving is once again an assumable, reasonable risk to take. But sometimes the issues preventing reasonable risk assumption are cloudy. These instances mayor may not prohibit diving given the spirit of freedom and notions of personal liberty that many divers cherish.

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Circumstances like these are described as Relalive Contraindimlions, questions as much of judgnlent as conscience in some instances. In any event, identifying these restrictions and understanding how they prevent or mitigate participation is a large part of preventing dive accidents. But knowing details about these conditions is less important tllan acting on the knowledge in your diving. No one is comfortable prohibiting another person from enjoying something that tlley themselves enjoy freely, but, for exanlple, few people are so callous as to encourage an alcoholic to drink, however moderately. In the same way, encouraging or even allowing a person whose condition contraindicates diving activity to participate knowingly is acting against principle. Absolute Contraindications to diving include several types of conditions, the presence of which make diving dangerous to the person who attempts to participate despite them, and to anyone with whom they dive. These are primarily medical conditions that interfere with eitller the ability to breathe, tIle ability to nonnally exchange gases across the capillary bed in the lungs or perfuse the tissues, or to maintain consciousness. They include respiratory diseases, frequently identified as Chronic Obstructive Pulmonary Disorders (COPDs), like astllma, tuberculosis, emphysema and chronic bronchitis. Other medical problems that prevent participation in underwater recreation include serious circulatory prob- IIiiiij lems like angina pectoris, a history of myocardial infarction, (heart attacks), or acute constriction or loss of elasticity in the blood vessels (arteriosclerosis/atherosclerosis), or seizure disorders like epilepsy and diabetes. Aperson known to have an Absolutl: Contraindication to diving must never be allowed to participate witllout strenuous challenge by any knowledgeable diver.

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ABSOLUTE CONTRAINDICATIONS Asthma Astluna is the general term for a complex group of effects which disrupt normal lung function. Medically

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called "reactive air-Yay disease," the causes of asthma can be as diverse as specific allergic reactions to airborne particles like pollen and animal hair, or chronic illnesses from long-teml exposure to various chemicals. Some asthma is exercise-induced, or aggravated by cold, dI)' air, conditions which prevail in SCUBA diving. Although, in many parts of the world, asthmatics are not unifomlly prohibited from diving, NAUI Worldwide regards active asthma as an Absolute Contraindication. "Getting ready for a dive by taking medications is an unacceptable risk to yourself and those Witll whom you dive." During an asthma attack the air passageways swell and make normal breathing torturous. In particular, normal exhalation is compromised. Breathlessness from an increase in carbon dioxide levels ensues, which may be rapidly followed by panic. Disastrous consequences can resul) on land, let alone under-vater! Undel\vater, the combination of inability to breathe or catch one's breath, repeated inhalation (lung distention) and uncontrollable compulsion to seek the surface invites tragedy. Many asthmatics treat their condition with bronchial dilators, generally taken orally as inhalants. Well-controlled asthmatics may mistake their symptomatic medication as a cure for their disease. This is not the case.

TuberCUlosis (T8)

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TB is a bacterial disease of the lungs that may also affect tile joints and other organs of the body. Extremely debilitating, it is unlikely that someone suffering from active "consumption," as the disease was once known, would choose to participate in scuba, however, like asthma, some forms may be more or less controlled by drug therapy. Pulmonaty tuberculosis is characterized by coughing, weakness atld sputum.. The symptoms themselves are contraindicators of acceptable levels of risk in diving. Coughing and excessive phlegm in the bronchial tracts are certainly inimical to enjoyable diving, and physiologically dangerous due to the possibility of serious lung damage and arterial gas embolus (AGE).

3- Diving Readiness

'Illberculosis is easily transmissible through inhalation. AI a result, people who believe they may have been exposed should immediately seek medical attention and a TB test. Newer strains of tuberculosis have developed in recent years that are resistant to the traditional drug therapies, making control of the disease problematic. Like those afflicted with astilIlla, TB sufferers should never dive.

Emphysema Another of the COPDs, emphysema is characterized by degradation of the alveolar sacs in the lungs, making breathing difficult. Emphysema victims are unlikely to wish to participate in scuba, but in any event, anyone afflicted should not do so. Emphysemics are treated with oxygen and respiratOlY therapy in an effOl1 to stabilize the continuing deterioration of lung function. Breathing is so complicated because of the loss of lung elasticity that the diaphragm itself may flatten as the pleural sac sags onto it. VentiiatolY muscle training seeks to literally teach the emphysema victim to breathe more easily, since the normal lung function is hampered by the chronic changes that have occurred. Portions of the lungs are weakened by emphysema. These points are more susceptible to both trapping air and rupture on ascent when the air expands. Obviously, the increased risk of such a serious event as AGE makes diving foolhardy.

Chronic 8ronchitis Chronic bronchitis is a severe inflammation of the major air-vays that results from long-term exposure to smoke (including tobacco smoke), irritating fumes and air pollution or as the result of bacterial infection of the lungs. Acute short-tenn bronchitis can be treated with antihistamines, antibiotics and bronchodilators. Unfortunately, these drugs may contraindicate diving in themselves. Chronic bronchitis is usually accompanied by chronic coughing and may include chest pains. While it would seem that someone suffering from these effects would not wish to dive, many more divers than reason would suggest are heavy smokers, or otherwise


frequently exposed to serious lung irritants. Those afflicted with chronic bronchitis cannot dive witll any reasonable safety. Their lung ti ue and breatlling function are too problematic to permit participation.

Diabetes

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Diabetes is a disorder that makes it difficult for tlle body to normally metabolize food. Some severe fomlS of diabetes require treatment with injected insulin, a hormone nomlally produced by the body, to enable the victim to function normally, based on usual activity. Witllout the appropriate insulin dosage for the unpredictable demands of diving, the diabetic's blood sugar level may fluctuate beyond nomlal limits, causing confusion, unconsciousness or even deatll. The chance of unconsciousness underwater presents unacceptable risks to tlle diabetic and to diving companions. Long teml diabetics with well-controlled disease can still suffer these same effects. Over time, other health consequences of diabetes can include nerve and kidney damage and circulatory problems like vascular disease and hypertension (high blood pressure) which tllemselves are contraindications to diving. Not knowing the amount of exercise that scuba may involve virtually precludes the appropriate timing and dosage of insulin relative to food ingestion. The possible effects of pressure on damaged organs in the body also creates unpredictable health concenlS that impact adversely on the diabetic's ability to function under water and on the safety of others. Therefore, NAUI Worldwide believes that insulin-dependent diabetics should not dive.

Epilepsy Epilep~y is the common name for a group of neurological disdrders characterized by confusion, muscular spasm, loss of motor control, unconsciousness, or periodic convulsive seizures Although treated somewhat successfully since 1936 with variations of the drug Dilantin' (phenytoin), a barbiturate also used to control heart arrhythmia, the chance of a seizure in or underwater with the attendant near certainty of drowning rule out diving lvith epilepsy.

Angina Pectoris For all its relaxing aspects, diving is physical work. From carrying dive gear, to Slvimming underwater, to hoisting oneself and gear aboard a vessel or negotiating surf or current, a diver's ability to perfonn is dependent on a relatively healthy cardiovascular system. Angina pectoris, the sudden and excruciating pain in the chest associated with a decreased blood supply to the heart, can strike a person without waming during any of the physically strenuous events associated with scuba. When angina strikes, further activity is impossible because the associated pain is literally crippling. The sudden, likely inability to function undelwater is an unacceptable risk in diving. Angina pectoris is also often a precursor to full-blown heart disease.

Myocardiallnfraetion Nobody wants to die today, particularly not suddenly and in pain. Unfortunately, this is what happens in at least one-third of common heart attacks, and almost assuredly if the event happens during diving. Ahistory of heart attacks, whatever the cause, current state or prognosis makes scuba diving a recreational form of suicide. Regardless of one's own desires to end one's life or risk its loss, there is no concomitant right to endanger those with whom you may dive. As an example country, some 15,000,000 people in the United States suffer from heart disease. Hopefully, none of them are scuba divers, but some probably were certified to dive at some point. It is tllis group, those who have been diagnosed or suffered altered health circumstances subsequent to their dive'iraining, that requires particular SRD and ASRD vigilance. That "one more dive for old time's sake," may well be a person's last, and attempting to rescue them could be tlleir buddy's or your own final dive as well.

Coronary Artery Disease The heart is a muscle and cannot function properly lvithout a normal blood supply. When coronary artery disease, arteriosclerosis, general thickening or stiffening


CD•

of the arterial walls or atherosclerosis, the deposit of lipids (fat) along tlle interior arterial walls is present, blood supply to the heart is restricted. The result is a reduction in the ability of the heart to circulate blood tlHough the body, and an increase in blood pressure (hypertension). The heart must work harder, and even at the greater work load, may still be insufficient to maintain normal perfusion. This is an especially serious problem not only because diving can include arduous physical activity, but because insufficiency in blood flow invalidates the use of all models and mathematical algoritllms used to calculate tissue nitrogen load, whether in decompression tables or dive computers. Thus, decompression illness becomes statistically impossible to predict, and the likelihood of decompression sickness (DeS) or AGE unacceptably high. Temporary or not, a contraindication means that diving is prohibited until the situation is resolved. Diving while the problem exists is not wise, and endangers you and your companions.

TEMPORARY CONTRAINDlCATlONS Fortunately, the human body is adept at healing itself, or with help from medical professionals, from many ailments that would preclude diving. Temporary contraindications to diving prevent diving solely while they are present. Like absolute contraindications, however, temporary or not, these are not conditions that are negotiable or subject to discussion. When they exist, NAUI Worldwide prohibits training and holds that certified divers should wait until the problems are resolved before going diving.

to avoid diving when pregnancy occurs or is suspected. Prenatal development studies ,vith animals do suggest that there are negative consequences to unborn offspring with repeated hyperbaric exposures. In any case, there is an intuitive case to be made for not expOSing developing organisms to the largely unknown effects of increased pressure, gas saturation and the process of offgassing that would necessarily be accomplished through the more complicated route of umbilical transfer, sinoe the baby has no respiratory functions until born. Pregnant women should not dive.

Earache, Respiratory Infections and Common Colds Earache is often tlle symptom of a more serious infection. In any even~ diving with the ears already in pain is not smart since normal actions to equalize pressure can be compromised. The pOSSibility of injury to delicate membranes within the eal; discussed more fully later in this book, is also heightened if the ears are not clear of congestion. Congestion is frequently a byproduct of low-grade infection or inflammation. In this case, easy clearing is difficult, increasing the stress and henoe, risk inherent in diving. The effects of the water environment on bacterial groWtll and infection also make diving with an ear problem foolhardy. It is entirely

Pregnancy Scuba training or diving is prohibited during pregnancy because there is no known study about the direct or • indirect short or long-teml effects of pressure on prenatal developmen~ and surely no parent is willing to sacrifioe the healtll and well-being of tlleir unborn child to fmd out. Perhaps when our species is routinely living under tlle ooeans, such studies will be done, but until then it is wiser

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possible that an existing earache will worsen significantly after diving, necessitating medical care, and possibly entailing long-tenn negative effects which could include hearing loss. Any changes in the function of the lungs particularly, and the respiratory system in general should be completely rectified before diving. Amild cold or cough is included in this proscription. The usual "runny nose" associated with a cold is the result of increased mucous production, and can interfere with normal efforts to equalize pressure. The inability to equalize efficiently and easily can result in a diVing accident. Respiratory problems like a cough or wheeZing, whether induced by infection, allergy or irritation, make safe diving unlikely. Coughing underwater is not especially hazardous if dealt with properly, but there is always the possibility of a problem, and entering the water in less than optimal condition is unwise.

Medications The modern pharmacopoeia is nothing short of miraculous, but for the most part, drug interaction and side-effect studies are done at sea level. Descending below sea level, increasing the pressure on the circulatoIY system and the other organs in the body, and adding the increased gas uptake inherent in diVing, introduces new elements with effects impossible to predict. Hyperbaric exposure can also have an unpredictable Ii"I""'I effect on any drug's efficacy and outcome, and may ~ invalidate the dosage regimen prescribed by the physician. The water environment may increase or reduce the effect of a drug that is perfectly prescribed under nomlal surface conditions. The side-effects may also change with pressure. Divers prescribed medications should discuss with their doctors their appropriateness for diving actiVity. Altematives may exist. Under most circumstances, no matter what medication one is taking, it is probably better to wait until the condition clears before diving (figure 3-3).

~ Seasickness As miserable as seasickness makes one feel, its chief

adverse effect is dehydration. In itself, this makes diving

unwise. ContralY to popular belief, one can feel seasick in and below the surface of the water. Jumping in to combat seasickness is as likely to exacerbate as a1lleliorate the problem, but at least ashore or on the boat one CailIlOt suffer any serious diving consequences like Decompression Illness (DCl) or lung-overexpansion injuries due to a bout of undelwater vomiting.

SUBSTANCE-RELATED CDNTRAINDICATIONS In colonial America, Benjamin Franklin's Poor Ricbard advised "Moderation in all things." This is still wise counsel in diving practice geared to prevent accidents. Be it applied to diving itself, or as is more common to the use of alcohol, tobacco, food, non-prescription medications or so-called "recreational drugs," any self-imposed alteration in the proper function of the body or nervous system interferes with diving safety. Participating in scuba while in an altered state, whatever its cause, is an invitation to trouble. (figure 3-3).

Alcohol Alcohol dehydrates and alters the flow of blood through tile tissues. It also affects the mental state. Whether one believes this to be a positive or negative result, it is completely inappropriate for diving, since the activity depends on mental acuity, rational thought and physical coordination. There is no acceptable amount of alcohol that can be consumed when a1lticipating diving, and most divers accept this witilOut.question. The problem may arise after diving, howeve~ when an individual may feel tilat there is no longer ~U1y reason to abstain. This is not the case, as a bit of knowledge about DCI would reveal. Since the body is not equilibrated at one atmosphere of pressure for as long as 24 hours after the last dive, alcohol consumption can be unwise in that it may interfere with the nonnal process of offgassing. When multiple days of diving are planned, this is a particular concern, as are the possible consequences of alcohol-related dehydration.


Tobacco

"Recreational" Drugs

Tobacco, b€coming one of the more controversial substances in our world, is tile source of a potent, potentially letilal combination of chemicals ranging from carbon monoxide to addictive or neuro-affective, toxic essences like nicotine and coal tar. There is no reason to re-hash the debate about the many deleterious effects of tobacco; one need only read tile label on the packet. Still many people choose, or rather, have no choice but, to continue to smoke, Unfortunately, many divers don't understand tilat tile effects of their smoking can have serious consequences for themselves and those around them. Tobacco adversely affects blood pressure, heart function, lung elasticity and circulation, and may cause heart disease, emphysema and cancer, Cigarette smokers are more than twice as likely to suffer heart attacks, and from two to four times as likely to die from sudden cardiac arrest as non-smokers, From a diver's standpoint, even occasional smoking increases the risk of DCI. "Second-hand smoke" is another form of air pollution, and like all air pollution carries with it the risk of respiratOly irritation and diseases, Depending on the severity of one's smoking addiction, and the individual reaction to respiratOly irritants in tobacco, diving may be contraindicated,

Whether one agrees or disagrees with the permissive, "live and let live" attitude, any deliberate alteration of consciousness via chemical ingestion is completely incompatible with the informed judgment necessary to diving, [n most parts of the world, possession or use of such substances is also illegal, and can result in Draconian penalties without the benefit of due process, The consequences may also impact innocent companions as well as offenders, All psychoactive substances are contraindicators to diving due to judgment impairment. Some, like cocaine derivatives, amphetamines and most narcotics, also produce ph)~ical effects on the cardiovascular system that are extremely hazardous under pressure, invalidate dive tables, and can lead to disaster for the diver/user and companions, The long-tenn effects of habitual usage of such drugs are likely to result in severely decreased physical and mental function, let alone the degrading physical, mental and emotional hazards of full-blown addiction.

Over-the-Counter Medications Like Alice in Wonderland, divers may be exhorted to "drink this," or "eat tilis," ovelcthe-counter drug - antihistamines in particular - as preparation for diving, "It will help you clear more easily," is the standard reasoning, Unfortunately, using these drugs regularly, regardless of their easy availability, is as dangerous and unhealthy as taking any other drug indiscriminately, No diver should "need" anything to equalize pressure other than proper technique, [f one does, something is wrong, and should...be rectified before more diving, The other issue is tiMt the use/abuse of these drugs can have extremely undesirable side effects, as a quick reading of the labels would reveal. If conditions exist that require these drugs, desist from diving, When once again ahle to dive Witilout them, do so,

Food Though it may seem odd to include food in a list of temporary contraindications to diving, some people experience severe eating disorders that are extremely debilitating, and otilers suffer from various types of allergic reactions, In either case, nonnal participation in diving is regulated by tile diver's eating choices, Divers who avoid food entirely during a long, active day may experience temporary weakness or disorientation, particularly as a result of pressure ch~U1ges, Othel~ who over-eat, or who eat improperly may become ill in the water, endangering themselves and tileir companions with easily avoidable problems, Any dietary or eating problem that detracts from well-being, peace of mind or concentration is another condition to resolve before diving,

RELATIVE CONTRAINDICATIONS For the sake of having a benchmark, NAUI Ii'I""t Worldwide defines a relative contraindication to diving as ~


liD ~

a condition that may require modified or adapted participation, but which definitely requires regular, specialized medical assessment. Relative contraindications are those that test one's personal judgments, and tax the professional judgment of diving ph)~icians. For some people, the presence of a condition that for oillers might prec1ude diving is an incentive to work harder to overcome the impediment, or participate despite it. That diver's usual companions may find this determination exhilarating and inspiring. Others might find it foolish, and choose not to participate with that person. In either case, there is no routine, clear-cut answer, except that the person undergo appropriate evaluation on a regular basis. Relative Contraindications are the "gray areas" of diving judgment. Regardless of what anyone proclaims, be they physician, diving professional or both, you always have the option to refuse to participate in any dive if anoiller group member's condition makes you question their fitness to dive. Qualified diving/hyperbaric doctors, usually in consultation with the individual's personal physician or specialist for the specific condition, are the most authoritative source for these evaluations. The Divers Alert Network (DAN) provides a consultation and referral service to help doctors, divers and would-be divers locate local diving physicians that can help those unfamiliar with diving make well-informed decisions about relative contraindications. For non-emergency contacts, the DAN Diving Medical Information number is

(919) 684-2948 As an SRD or ASRD, you decide whether a dive is too hazardous for you, owing to a relative contraindication in a person in the group. Though the individual has been medically "cleared," unless that physician, even a hyperbaric/diving doctor, is present at the site, their judgment is subject to yours. If you believe that the situation is extraordinary to ille extent that you feel it is unacceptably risky, you always have the personal option of refusing to participate. Whatever choice you may make, however, your obligation is to convince the divers that will still participate that the presence of these conditions at that specific time may constitute an unacceptable risk. Strategies that

FIG 3.4 PROPERlY TRAINED DlSABlfD DIVERS AND TUBR BUD· DIES CAN ENJOY DIVING UNDER STRICTlY CONTROllED CONDITIONS. SEEK THE SPECIAUIED TRAINING NECESSARY TO PARTICIPME SAFELt

might be employed to that end are discussed at length furiller on in this book. Next, we'll examine some of these gray areas.

Persons With Disabilhies There are many divers whose physical condition would seem to preclude participation, but who have the will and wherewithal to overcome these factors. Their efforts to enjoy scuba sometimes seem to border on the heroic, but in some cases, their day-to-day activities require no less arduous work. There are several organizations devoted to divers with disabilities that range from loss of single or multiple limbs to various kinds of sensOlY deprivation including blindness (figure 3-4). NAUJ Worldwide recognizes that these individuals, with the aid of other qualified, sensitive divers, participate freely in a variety of diving activities. Through groups like the Handicapped Scuba Association (HSA International), standards of training, eqUipment and certification as handicapped divers and for able-bodied divers serving as in-water escorts have been established. These efforts are completely commendable. NAill Worldwide seeks to be in compliance with the Americans With Disabilities Act (ADA). When a disabled individual applies for training, in addition to


regular screening for medical contraindications, NAUI worldwide instructors or leaders must complete a risk assessment considering the individual nature of the disability(ies) as it pertains to a probable direct threat to others. If there is none and reasonable accommodations can be made, then the disability cannot be a basis for not admitting the person for training/supervision. Only those persons who meet the NAUI Standards requirements for a particular certification shall be certified. Problems arise from the diving safety standpoint when the disabled diver's condition may interfere with the rapid assessment and treatment of a serious diving malady. DCI often presents with pain, numbness, weakness and paralysis. In some handicapped persons, the existence of these conditions prior to diving may mask an injury or illness that develops while diving. Delaying treatment may lead to tragic consequences as the situation progresses beyond initial symptoms and becomes life-threatening. Possibilities like these make some disabled persons' participation more problematic.

~ Heart Disease and Hypertension While fully developed heart disease, a history of heart attacks and seriously occluded coronary arteries are absolute contraindications, the degree of high blood pressure that disallo\\~ diving is a question impossible for a lay person to answer. Persons with these conditions, some well-controlled by medications, mayor may ~ not be allowed to dive by their physician. The point to note is how familiar that physician is with the stresses and demands of diving before accepting or rejecting any recommendations made. Consultation with a diving physician as stated above is mandatory before accepting for training or supervision anyone taking prescription medication for cardiac problems.

m

Chronic or TemporaryJlhysical Problems and Pain Like more extensive disabilities, a so-called "bad back" can be a real hindrance to safer diving. It certainly detracts from a diver's ability to render assistance

to a buddy who may need help leaVing the water, or getting back to a dive platfonn or boat. Whether or not this is a disqualifying condition will depend on the individual and physician involved. Your choosing to accompany this diver is, again, a personal decision. Some physical problems resulting from injuries are temporary. Clearly, these heal with time, and waiting until once again fit before diVing is common sense. Other injuries may leave lasting effects that need more fonnal assessment, or may require adaptation or modification of standard eqUipment to accommodate the diver's needs. Product liability issues are problematic with deviations from the intended and customary use of diving eqUipment, and manufacturers are best consulted before making any changes, however minor. With risk reduction the overarching concept, only an individual and that person's infonned physician can decide whether or not participating with the level of discomfort that a painful condition represents is a good choice. Again, it is important to evaluate to what extent the condition will make disceming a diving illness difficult. Adive' instructor or leader can make tlleir own individual decision not to be involved with a person in obvious difficulty.

CONGENITAL DEFECTS Some people bam with various defects achieve remarkable levels of skill innumerous sports. Many become fine athletes on land, and others become adept at strenuous water activities like competitive SWimming. Diving, however, is unique in that it includes expOSing the entire person to a constellation of only partially understood mechanisms for the uptake and elimination of inert gases from the tissues. Diving is also a shared activity, and beginning any dive in a position of dependency may be a problem for the diver's buddy. The key, from the standpoint of risk acceptance, is that the buddy must understand the choice being made and concur. While an imperfect heart may not prevent someone from becoming a fine skier or long distance runner, the presence of a patent foramen ovale (PFO) in a diver can

21


present significant risk. Aproblem existing from birth with the Eustachian tubes or the middle ear does not preclude competitive basketball, but clearly affects the ability to dive comfortably, and to some extent safely. Various leaming disabilities may also interfere with a person's ability to grasp the conceptual framework within which risk-acceptable diving is contained. Diminished mental capaCity may not prevent a person from living alone, working and thriving, but may well preclude making infomled diving decisions, though tlle Il€rson is completely able to meet the physical challenges. In sum, as with other relative contraindications, the decision to participate must be made on an individual basis in consultation with a knowledgeable physician.

Allergies The presence of most allergies does not necessarily preclude diving. Allergy medications may be contraindicated in a hyperbaric environment. Also, the pOSSibility of delayed allergic reactions that may occur on scuba can be dangerous to the diver and companions. Again, the type and severity of the allergy, any medication involved and the individual's ability and motivation must be appropriately evaluated.

Obesity Obesity, weighing more than 20% of recommended body weight, is a problem that affects over one third of the population of the United States. Thus there are overweight divers, and most are diving without incident. Even so, physical ability is an issue in assuming the risks inherent in diving. Moreovet; fat and fatty connective tissues are more hospitable to inert gas uptake tllan leaner, muscular tissue. An overabundance of dissolved inert gas, beyond that amount calculated in the exposure limits for relatively "average" people generally used, is a factor in the likelihood of DCI

Mental Stability The range of mental illness and the treatments used for it, whether or not including drug tllerapy, makes any

but the most general statements useless from the perspective of promoting safer diving. Regardless, diving requires concentration, focus and a complete grounding in real events and time. Prior mental illness and treatment are certainly not problems for those who would enjoy underwater activity with a physician's approval, unless ongOing drug therapy changes the situation. Current mental instability, however, which has as its component any depressive or psychotic components, violence, evidence of bi-polar thinking, grandiosity, schizophrenia or lack of rationality will increase the likelihood of diving safety problems. No one incapable of understanding tlle consequences of actions pertaining to themselves or others should be pennitted to dive, but deciding who is "incompetent" at a dive site is clearly impossible. Again, your personal comfort with the actions and behavior of your diving companions prior to the dive are your best insurance against problems that may ensue later in the water.

PHYSICAL FITNESS FOR DIVING SAFETY As a strenuous, physical activity, diving makes demands on a participant's aerobic system, strength and flexibility. Of these three areas, aerobic health is chief among equals because it is the sustained ability to continue perfonning at a reasonably relaxed pace that is the hallmark of diVing comfort. Finning against a moderate current as is sometimes reqUired demands a level of aerobic fitness that is not usually achieved without some effort apart from diving itself. Your personal training regimen sh(fiJld take the demands of diving into account. Although the most specific training for any sport is generally participation in the spon itself, a program of physical fitness with the goal of increasing aerobic capacity through controlled, moderate stimulation of the cardiovascular system according to recognized parameters has been recognized as beneficial to health and longevity. Training to the level of a marathon runner or swimmer is not required for diving safety, but developing confidence in your ability to deal with the common and

UIJ I


possible stresses of the diving you enjoy is obviously smart. Whether your chosen activity is running, slvimming, bicycling, hiking or walking, regular participation in it will payoff in an increased ability, better outlook and trimmer appearance. As effortless as being suspended in the water is, getting into and out of it wearing a heavy cylinder and other gear is an exercise is strength and balance. Carrying diving equipment on land is a chore. Lifting oneself from the bench on a boat in a rocking sea while wearing a cylinder and ballast is not easy, but there are few diving venues that provide "caddie" service, helpful divemasters notwithstanding. Building strength, particularly in your lower back, legs and arms, lvill make these efforts less likely to cause injury or contribute to later disability. Proper lifting techniques include using the large muscles of the legs, particularly the quadriceps at the front of the thighs, to lift heavy items while maintaining a relatively erect trunk. Straining your lumbar region in order to lift something with the waist bent is a sure route to lower back injury. Smaller divers would do well to remember that not all cylinders weigh the same, and that if air consumption is not an issue, using a smaller, lighter cylinder is smart. In addition, since diving is for the most part predicated on tile mutual interdependence of buddies, tilere is nothing wrong 111th asking your buddy for help witil the heavy work, so long as the individual is capable and lvilling. Teamwork divides any task into reasonable components. For most people, building strength is synonymous with some form of resistance weight training, be it using dedicated machines or so-called "free weights". Deciding to embark on such a program is itself a personal choice, but also an investment in better health and well-being. Before doing so, however, it is wise to consult a physician. Sound advice at any age, beginning an exercise program..(lfter a long period of abstinence or after the teenage years is not wise without this kind of assessment. In addition, a guided program tilat includes the feedback and coaching of a professional trainer, at least initially, will help you avoid common mistakes that may lead to injury.

Finally, although there are few maneuvers in diving that rely on the skills of a contortionist, your physical flexibility, the simple ability to move your body efficiently through as wide a range of motion as possible, lvill make the time you spend below more enjoyable. Difficulty dealing with a cramp, donning, removing gear or just easily adjusting gear owing to lack of flexibility can lead to insecurity and accidents. On the other hand, agility and confident command of your body will enhance the likelihood of problem-free diving.

Diet Inasmuch as scuba is a lifetime sport, working to reinforce your physical capacity will help ensure that your lifetime enjoyment is prolonged as much as possible. Another factor in this is your diet. The healthful benefits of sensible eating have long been established, and there are few people likely to be interested in diving today that cannot identify good and bad food choices and eating habits. But to know is different from acting on knowledge. Current thinking in diet is focused on the idea that for most people, a higher fiber, lower fat, moderate animal protein and dairy style of eating, in sensible amounts, will reap rewards later in life that include avoiding disease and living longer and healthier. Everyone can point to someone who as much as possible avoided tilese dictums and lived happily to a ripe old age. Regardless of tile exceptions, the general rule is that eating healthier foods is better for you than not doing so, and would have been better for these people as well. Maintaining nannalweight through sensible eating is ultimately more enjoyable and worthwhile for your continued health. As lvith exercise programs, dieting is an activity tilat works best when practiced under the guidance of an experienced mentor, familiar lvitil your physiology and needs. Not everyone needs to look thin or trim to be reasonably fit for their level of activity and general physical body type. At the same time, looking tilin is not the equivalent of being fit. '11le ultimate criteria are individual, and decisions are best made lvith a specific goal in mind: to maintain good health in order better to enjoy a good life.


Rest No discussion of health and fitness would be complete without addressing the necessity for rest and relaxation. N, stressful as life can be, with the attendant demands of professional obligations, family and friends, the time to simply shut down, relax and get a good night's sleep is time well-spent. This is true despite the myriad things demanding attention that may remain temporarily unfinished. Your ability to relax in your life should also extend to your recreational activities, especially diving. There is never any real need to make any dive, especially if doing so adds another level of stress to your life! Diving above all is supposed to be fun - an activity that participants eagerly anticipate for the enjoyment it lvill provide. When it is not going to be fun, to continue is completely wrong. Arriving stressed and harried at a dive site because you said you were going to go diving, rather than giving yourself the benefit of needed rest, is one way to remove the enjoyment from the experience. Diving all the time is anotller. Varying your recreational choices and activities will help you develop a substantial portfolio of enjoyable things to do, each of them uniquely appropriate for some personal reason. By choosing between them regularly, you will feel better about all of them. You will be refreshed, eager and enthusiastic to enter the water when SCUBA is the choice you freely make.

"

otes

CHAPTER

Preparing To Dive


LEARNING GOALS In this chapter you will: 1. Understand tlle importance of training as a component of diving readiness. 2. Learn the advantages of owning your own set of scuba diving eqUipment. 3. Learn the definition of "Task Loading." 4. Be introduced to "technical diving" and alternative breathing mixtures used by divers. 5. Understand the value of dive planning and emergency planning has in preventing and better responding to diving accidents. Diving accident prevention begins with careful preparation as a means of reducing the variables inherent in any dive to only those over which you have no control. You then prepare for these uncontrollable events on a contingency basis. Although the dynanlic nature of any diving experience makes accurate prediction of the dive on a moment to moment basis impossible, projecting what you are most likely to encounter can mentally prepare you to meet the challenges that are routine on any dive.

FIGURE 4·1. EVERY DIVING ACTIVITY PRESENTS UNIQUE CHAUENGES, AND RElIUIRES SPECIAC TRAINING.

34

TRAINING The risk-reduction benefits of simply paying attention to the details of any dive cannot be minimized. Diving is an activity rooted in on-going evaluation of constantly changing conditions (figure 4-1). Subject to weather, unexpected events, environmental variables and the unquantifiable interactions of unique individuals, any dive is a rich mixture of many possible outcomes. Yet despite tllese factors, the vast majority of dives end with everyone safely out of the water discussing the exciting things they saw and tlle pleasure of the activity. Good dive training, like that provided by professional NAUI Worldlvide instructors, makes tlle difference for most dives. To be most effective in preventing diving accidents, training must focus on tlle actual diving being done. Leaming to dive in the warm waters of the Caribbean is not sufficient preparation for exploring tlle wrecks of Lake Michigan. Learning to dive in Lake Michigan does not provide the necessary experience for penetrating the cenotes of the Yucatan Peninsula or going below the winter ice of a frozen pond. Most divers realize this, but as an SRD or ASRD, it becomes even more important to evaluate your experience level and that of your diving companions because you may have to render them aid in case of a mishap. Even though the myriad variables of a dive can alter quickly, the general environmental conditions, cold or warm water, day or night, current or none, fresh or

FIGURE 4·2. PRIOR PlANNING SHOULD BE FOUOWED BY ACARE· FUl ASSESSMENT AT THE SITE BEFORE ENTRI

Chapter 4- Preparing To Dive

fIGURE 4·4. NEW ACTIVITIES REPRESENT NEW CHALLENGES. PLAN YOUR DIVES SO THAT YOU CAN COMfORTABLY MEET ALL Of ITS DEMANDS. RGURE 4·3. FUNCTION, AT AND COMfORT SHOULD BE THE GUIDING fACTORS IN CHOOSING YOUR DIVING EQUIPMENI

salt water, should be well-knolVll and prepared for in advance. Environmental conditions are only part of the story, of course. The planning of an actiVity, be it anything from a reef tour to a wreck penetration, is also an important part of the preparation period in advance of the dive (figure 4-2) You will know that you are experienced in the projected activity, but only your efforts to ascertain whether or not, and to what extent your companions are, will allow you to make the informed choice essential to safer diving This is not to make this a "Catch-22" situation: where getting the experience is only open to those with prior experience, but instead to make sure that there are enough qualified, trained individuals available to make the likelihood of an enjoyable dive that much greater. The same advance preparation and research that applies to training for the dive and assessing tlle training of your companions holds true for being completely comfortable with the actual gear that will be used to make the dive, and for having "the right stuff' available. This is why having your own dive eqUipment is one of the best ways to enhance your diving ability. You will grow more and more accustomed to your equipIllent and diving dress, reducing it as a factor that must be tracked throughout the dive. Using borrowed or rented eqUipment, other than ballast weight or a dive

fIGURE 4·5. MOST DIVERS WHO OWN THEIR EQUIPMENT MEET STANDARDS AND RECOMMENDATIONS.

cylinder, takes away a portion of tlle comfort zone that you would have with complete confidence in the fit and function of your well-maintained personal gear (figure 4-3). Using brand new or unfanliliar gear on a dive that includes elements that you have not experienced before may introduce extra levels of stress through "task load- Ii"'I""1 ing," a teml used to describe a condition of literally ~ having too many things to think about at once. Avoid

35


FIGURE 4-8. APPROPRIATE OIVING EQUIPMENT IS MANOATORY FOR ASUCCESSFUL OM.

AGURE 4-B. PONY BOTTLES ARE AVAILABLE IN AVARIETY OF SIIES TO MEET ALL DIVERS' NEEDS.

REQUIRED EQUIPMENT NA IWorldwide and most diving operators have standards and make recommendations that can be used to help make diving safer (figure 4-5). The items that divers may carry vary as widell' as the number and level of divers, from those equipped with the latest (and often most expensive) eqUipment available to those equipped with the tattered remains of someone else's long forgotten diving experience. Regardless of the range of equipment choices, and despite the fashions of the moment, Certain items are universally required for safer diving (figure 4-6). These include: • An appropriate Buoyalll)' Compem¥l/ol' that includes an automatic inflation valve tlmt connects directly to tlle dive cylinder via a low pressure hose (figure 4-7). • Diving Instruments: a reliable depth gauge, underwater timel; and submersible pres~ure gauge (SI'G). • An Alternate Air Source: - Asecond, second stage and low pressure hose ("Octopus") or

."

FIGURE H. POWEJlINFLATORS MAKE BUOYANCY CONTROL EASt

putting yourself in that situation, and guard against others that may be, by planning your activities carefully, and by making sure that your training, and as best you can discover, the training of those witllwhom you are diving is appropriate to the level of challenge and the activities of the dive you intend (figure 4-4).

38


reels if penetrations have been trained for and are planned. Photographers obviously need cameras and most probably lights. In sum, you must again consider and plan for the actual dive before entering the water. Deciding on a spot where you intend to go hunting, neglecting to tell your buddy who entered the water first, and then grabbing a pole spear or speargun as you make a giant stride into the water sounds impossibly foolish, but does unfortunately occur without a proper dive plan.

FIGURE 4·9. ASPARE AIR'" IS ASElF CONTAINED RESERVE SYSTEM.

- ABC-mounted second stage 01' - ARedundant SCUBA de\1ce like an appropriately sized pony bottle that includes its own regulator and SPG 01' (figure 4-8) - ASpal'e Ail'~ 01' (figure 4-9) - Double Cylinders equipped Witll a manifold or separate regulators

TECHNICAL DIVING Technical Diving is the tenn used to describe planned decompression diving well beyond usual diving depths, as well as the use of ne\v (to traditional recreational diving) technologies like switching anlong custom-blended breathing gas during a dive and even using re-breathing systems. This type of diving requires

Specialized Needs Some kinds of diving require more than just normal diving equipment. Conditions of the dive will dictate some of the obvious ones. Most divers are aware that a dive in the dark will require a dive light, but having a back-up light beyond tlle primal)' is an even better choice. Extreme cold water requires more complete themlal protection, like a dl)' suit. River diving requires more rigging and specialized knowledge to reduce the risks of current, and the diving dress may also be modified to accommodate the hazards of murky water and possibly sharp, dangerous objects that have been discarded in the area. Otller than the items Ihat are in response to the environmental conditions named above, particular activities themselves impose specialized equipment needs. Hunters need spears, collectors carl)' bags and bottles. Wreck divers may need lights even during daylight, and probably need to consider trail lines and

AGURE 4-10. NAIll'S T££HNlCAL OMNG STANDARDS INCWO£ SPE-

eiRe TRAINING ANO BIlIIPMENT IlECOMMfNlIAJ1ONS FOR THOSE INIHlESTBJ IN 11IIS IlMNG FRONTIER.

37


to increased gas uptake. Narcosis and oxygen toxicity dangers also generally increase under dle conditions of a rescue effort. The additional considerations and requirements if assisting an injured or impaired diver at depth. when slilfacing requires long decompression stops, requires additional training beyond the scope of either of these training courses. On the other h:U1d, surface rescue and rescue management and victim/patient care of an injured Technical Diver is, apart from the likely severity of the injury incurred, the same as for other fon115 of recreational diving.

Deep Air Exposure

FIGURE 4·11. DECOMPRESSION OBLIGATIONS TYPICAL OF MOST TECHNICAL DIVES IMMEDIATELY COMPLICATE ANY NEEDED RESCUE.

specialized training and equipment, and even so, entails risks beyond that encountered in more traditional diving (figure 4-10) 1110se diving on the cutting edge of modem knowledge and ability, like those doing more usual dives, are still required to plan to reduce the controllable risks they \\111 face to the absolute minimum, and then intelligently assume those that remain. SRDs and ASRDs who are Technical Divers should be aware that rescue under the conditions of deep, planned decompression dives is extremely hazardous (figure 4-1 I). Increased workloads at depth can adversely affect planned decompression schedules due

38

Tech diving was originally focused on expanding the depth limits of air diving through the development of techniques to reduce risks of exposures to pressure and the required decompression dms engendered. A concomitant thrust was to train divers to cope with the increased effects of inert gas exposure, primarily nitrogen, at unusually high partial pressures likely to cause signifiC:U1t narcosis. While many successful deep dives are made, there is currently no credible scientific evidence that dle acclimatization process to nitrogen narcosis actually takes place. In fact, individual reactions to high partial pressures of nitrogen val)' considerably, even within the same diver, based on water temperature, fatigue, workload, other situational factors and still other as yet unknown reasons. 1X11at does change, however, is the well-trained diver's ability to cope with narcosis. While training can help a diver p~rform better in the face of nitrogen narcosis, there is little that can be done to reduce the risks of oxygen toxicity on a deep air dive. As discussed more fully later, prolonged exposure to higher concentrations of oxygen can lead to undesirable pulmonal)' and psychomotor effects, including lung irritation and damage and convulsion. Tech divers accept these risks after assessing, dll'ough graduated depth and time exposures, their individual resistance to problems. Even so, AU! Worldwide does not advocate "deep air" training when and where there is access to helium based mixtures.


Nole AI symptoms vary Wlth dilterent poopIe and occur dtlteloolty at varyrng

Surf8Cit

depths on eadl side. 15m (SOft)

lnabllity to thlilk clearly alld make accurate judgements In some dlVars.

Inability

r

30m (100ft)

to communicllie Of

per1(lf1l'1 SImple mo1Or Of .. mental tasks I A....-.ge dtvef is more Of Ies5 usel8ss and becomes a safety ' ~.

RGURE 4·12. SOME PEOPLE SAY THEY GROW ACCUSTOMED TO NARCOSIS; OTHERS SAY THEY OONl

ALTERNATE BREATHING GASES AND MIXTURES Avoiding narcosis and oxygen toxicity while reducing the necd for prolonged stage decompression times is the chief goal of using different inert gases as diluents for the essential metabolic gas, o~'Ygen (figure 4-(2). By mixing different gases, primarily helium with nitrogen and oxygen (so-called TrimLx) or with only oxygen (Heliox), and carefully monitoring tlle percentages, custom blended gases can be used for specific depth, time and decompression objectiVes. Combining custom blended gases with a multiple cylinder and manifold arrangement allows the technical diver to switch between mixtures at pre-planned depth and time poinll in the dive, flllther reducing the risks of nitrogen narcosis and oxygen toxicity. Final under.vater decompression stops may also include periods of breathing pure oxygen, either diver-carried or deployed from the surface. This is not tratlitional recreational diVing by any means. It reqUires substantial financial and time invesonents, from acqUiring sophisticated monitoring devices to analyze tlle breathing mixtures, more sophisticated gas compressors and uniquely prepared filling stations and cylinders, to learning to use the equipment

RGURE 4-13. MArCHING BIIEAIIIING MIXTURES TO DMNG REOUlREMOOS IS lIN THE FURERlONT OF RB:REAIlONAl.IIMNG, BlIT IlEOOIRES SPECIAIJlED EOUIPMENT AND AIlIJIJ1lINAI. 11lArR RlllM QlIAIJRBJ EXPIIlTS.

properly, and training and practicing techniques. All of these systems, from the multi-cylinder and primary stage regulator set-ups to the well-equipped tech diver's valved gas manifold, cylinders and fill stations are far more complex than usual recreational diVing equipment. As a dive buddy, if you are not completely familiar with your companion's gem; you are risking an accident. NAUI Worldwide recommends that divers interested in technical diving activities seek professional training to reduce the risk level as much as possible. Local diving operators can make referrals to NAUI Worldwide members adept in the techniques and skilled in the practices.

CD.

Nitrox and Oxygen·Enriched Air Diving Another aspect that started as technical diving but has become mainstream is the use of nitrox or oxygenenriched air both as a primary under.vater breathing gas, and as a "scrubbing" gas after a dive to help

39


FIGURE 4·14. ENRICHED AIR DIVING MAY HElP TO REDUCE THE RISK OF DCS ON SOME DIVES.

remove residual (dissolved) nitrogen from a diver's system more efficiently (figure 4-13). SRDs and ASRDs should be familiar with this, since the possibility of an accident caused by the misuse of an oxygen-enriched mixture does exist. Nilrox is mixed generally in two standard percentages, each of which is appropriate for a specific maximum depth. Using the gas for a prolonged time or at deeper than its usable depth can lead to severe reaction to oxygen that can include convulsions or unconsciousness underwater, almost certain precursors to drowning. NAUI Worldwide recommends additional training for those who wish to use oxygen-enriched air for their dives. Completing additional training and proper use of enriched air may help to reduce the risk of DCS in recreational diving (figure 4-14). SRDs and ASRDs who participate in dives with those utilizing these gases must Ii"l"'1 be cognizant of the mixes' limitations and possible ~ effects from mishandhng and misuse 111 order better to prevent accidents.

OVERHEAD ENVIRONMENTS Overhead environments are those with restricted access to the surface. These include diving inside underwater wrecks, caverns, caves, and under ice. Each of these environments offers challenging and interesting diving experiences for those with the desire to obtain the

40

FlGlJllf 0} 15. OVBlHfAO ENVIRONMENTS CAN IM:UlDE WRECK PENfTlWlON, CAVERNS ANII CAVES, AND MAY BE FOUNIJ IN ANY MARINE ENVIRDNMENl PlAN Tn AVOID THEM UNLESS PROPERlY T1lAINEII AND EIIU1PPEII.

extensive additional training required (figure 4-15). Without that training, entering these areas is extremely dangerous. Excellent open water divers, have died after deliberately entering overhead diving areas without appropriate training. Avoid all overhead environments unless specifically trained and equipped to enter them. ~ Overhead environments should be considered as additional hazards when tlley are in proximity to an open water dive sites. Divers need to understand these potential dangers prior to agreeing to make the dive. ASRDs and SRDs untrained for overhead environments should never attempt a rescue in which they need to enter these areas. Even with advanced training, rescue attempts in overhead environments mw be unduly dangerous to the rescuer, and are probably better left to rescue units specifically trained and equipped for the task.

m

PLANNING AND PREPARING FOR SUCCESSFUL DIVES There is no substitute for advance planning and preparation in order better to enjoy a dive. Having the confidence that this imparts, and the knowledge, skills


and equipment requisite for the dive you planned, helps make the dive itself seem effortless. Unfortunately, the reverse is also true: without the time spent before the dive, the experience can be miserable, or unacceptably dangerous. There isn't a diving saying more well known than "Plan your dive; dive your plan," but it is incredible how many divers don't. Many will rely on a buddy to plan tlle dive. Many more will depend on the person leading the dive to simply tell them what they are expected to do, preparing and planning minimally, if at all. These attitudes, whetller from laziness, complacency or ignorance, have little to do with good diving practice, other than as bad examples. Planning and preparation are the cornerstones of acci~ dent prevention.

m

Choosing the Site Agood dive begins with a good dive site, but a great dive begins with research. While any suitable location ~ underwater is "dive-able," enjoying the dive depends on what you most enjoy doing and seeing, underwater. Fortunately, there are plenty of sources of excellent information available to help you choose where you are most likely to find what it is you want to see and do underwater (figure 4-16). There is no source of infonnation as accurate as having been to a particular place yourself, but it does limit your range of choices considerably. For some, this is no drawback, and they frequently dive the same spots repeatedly, enjoying the familiarity with the terrain, and depending on wild or still life of the area to vary the mood of the dive. The fact that no two dives to the same spot are tlle same makes this reasonable. But most divers like to explore places new to tlleir experience. They will either travel to distant locales, or try out new spots closer to home (figure 4-17). Finding out about a new dive site is as easy as a qUick trip to the local dive.shops. Most operators will have extensive experience in tlleir local area, and are running dive charters for certified divers on a regular basis. These charters may include a guide or escort undel\valer if pre-arranged, and are excellent ways to leam about an area's diving. Most dive shops also now

RGURE 4·18. ON DIVING EXCURSIONS, PROFESSIONALS Wilt OFTEN GIVE DIVERS THE CHDICE OF SEVERAL SITES THEY MAY ENJOY

m

FIGURE 4·17. WHEN DIVING, SEEKING LOCAL KNOWLEDGE 8EFORE~ HAND HELPS REDUCE RISK.

include a travel section for those interested in destination diving (figure 4-18). Diving publications, from magazines to various gUide books, are another excellent source of infornlation about dive areas and specific sites. MagaZine information is usually more timely, but a good gUide book to a resort area will generally list sources of current information. Many other resources for diving information exist in cyberspace. l1lere are numerous web sites devoted to

41


FIGURE 4·18. LOCAL NAUI WORLDWIDE DIVE CENTERS OFFER MANY TYPES AND lEVELS OF DIVING EXPERIENCES FOR THEIR CUSTOMERS, AND ARE EXCEllENT SOURCES OF DIVING INFORMATION.

scuba information, travel, and many "chat rooms" where experienced dive buddies can be found. As always, filter all infollllation through your own experience and common sense!

Equipment Preparation If you properly think of your diving eqUipment as a collection "life support" devices, you will very likely begin to care for it more diligently (figure 4-19). All diving eqUipment manufacturers recommend regular care for their wares, and publish service intelvals and servicing procedures that are included with the item when purchased. The habit of being conscientious about your equipment will develop rapidly tile first time it fails due to neglect or misuse, assuming that nothing worse than an incident is the result of the problem. Regular servicing by a qualified professional is mandatory for breatlling apparatus. Good washing and appropriate storage for aU your diving eqUipment will prolong its useful life, and protect yours. Follow the manufacturer's procedures, use common sens2 and ask a professional if there is any question about your eqUipment's fit or function before it is used.

42

FIGURE 4-19. DIVING EQUIPMENT IS LIFE SUPPORT EQUIPMENT. TREAT IT ACCORDlNGL~

DIVE PLANNING Dive planning, after simply learning to use diving eqUipment and acqUiring underwater skills, is the essence of any course of diving instruction. How a specific dive unfolds is, for the most part, a direct result of how it was planned. Dive planning includes: • Deptll, Duration and Air Consumption Planning • Activity Planning and Coordination • Contingency Planning

Depth, Duration and Air Consumption Planning ~Iost recreational diving is planned as no-decompression diving based on a "square dive" profile. This means assuming that the whole dive is spent at the deepest point of the dive. and not eXceeQing the recommended exposure time for that depth. -Repetitive dives, those tllat take place within 24 hours of each other, are planned to account for the residual nitrogen that is present in the body. and so subsequent dives are for less aenlal bottom time than the published limit would allow if there had been no previous dive. DiI~ng done this way, by the appropriate dive tables, generally presents no problem for most divers, if done properly. Many divers now, howevel; have abandoned the concept of the square dive profile in favor of a dive computer that tracks the actual depth and time of the dive at


AGURE 4·20. PROPER CARE AND CONSISTENT MONITORING HElPS RmUCE THE RISK IN THE MNT OF A COMPUTER FAILURE.

regular intervals, and calculates allowable dive time remaining based on that multi-level information. The constantly updated infonnation input by the diver's movements through the water is computed according to a pre-detennined mathematical fornlllia that models inert gas uptake. Some diving computers will actually monitor alternate breathing mixtures as well, factoring in the reduction in inert gases. While these devices are truly remarkable scientific and engineering achievements, they are only as good as their pre-programmed infonnation, and can be misused and misunderstood without proper training in their use. Such devices are tools, not foolproof insurance against DCI. NAUI Worldwide recommends that divers be coml"OItable using the traditional methods of dive planning, even witil ti1eir use of computers. Having tile planned depth and time limits finnly in mind before entering the water will provide a ready and reasonable back-up against the misuse or failure of a diving computer (figure 4-20). There is a dangerous, .albeit popular, misconception that most divers, especially newer divers, lvill nm low on air before they reach sufficient depth/time exposure to worry about DCI, hence air consumption planning is unnecessary. As often as it is said, it remains inaccurate, and misses the point of air consumption planning

ReUBE 4-21. PlANNING FOR EMERGENCIES IS PAIlT OF OM PlANNING MN THDUGH THE GRW MAJOIUIY OF IJVIIlS ARE IWUKID' TD EVBI EXPERIENCE ARfAI. EMERGENCl

entirely. Air consumption planning is not about risking DCI; plaJUling your air consumption is wise to ensure tilat you will never run out of air on any dive you make, and that you will be able comfortably to complete any dive you plan. Under the best of circumstances, running out of air under water is a terrible, frightening event. It is also extremely easy to avoid: monitor your air, aJ1d know when your dive must end based on a minimum amount of air needed to make a norn1al ascent to the surface at the recommended rate. That includes sufficient air for a three minute safety stop at about 5 meters (15 feet) for any dive to a depth greater than 9 meters (30 feet), or any dive approaching the table limits for time exposure. Knowing how quickly you lvill use your air at depth on a real dive lvill increase your capacity to plan effectively, and give you more confidence in your diving ability.

43


FIGURE 4·22. IT IS USUALLY THE GROUP'S DIVING LEADER WHO IS RESPONSIBLE FOR THE OVERAlL EMERGENCY RESPONSE PLAN.

AGURf 4-23. OMNG ACTM1IES ARE AVAIlABLE IN ANY PART OF THE GLOB~ EMBIGENCY RESPONSE TEAMS MAY NOT BE. UNOBlSlANO AND PlAN FOR THE RISKS YOU MAY FACE.

This is another controllable, predictable variable you can remove from your concern, allowing you to concentrate on enjoying the dive.

Emergency Planning No dive plan is complete without a good contingency plan in place should anything go wrong. Your emergency plan is crucial to the rapid response necessa!)' in the event of a diving accident. Whether you are participating in a professionally organized and supervised event, or on a dive Witll just one buddy, taking the time in advance to make sure that things \\111 go smoothly despite initial difficulties is mandato!)' for reducing diving risk (figure 4-21). When part of a larger group, emergency planning might only include ascertaining the lines of command and control for the event, and satisfying yourself that an emergency plan exists (figure 4-22). You will be able to tell this from the kind of infonnation you receive in advance from the event's organizer. If it consists of professional-looking materials, including waivers, checklists and directions, and asks for appropriate emergency contact infonnation, it is highly likely that the organizer is risk-aware and has planned for contingencies. In addition, no responsible operator will object to a diver, especially a certified SRD or ASRD, examining the

44

AGURE 4·24. HAVING THE RIGHT TOOLS FOR AN EMERGENCY CAN MAKE AlL THE DIffERENCE TO AN INJURED VICTIM.

event's first aid and oxygen kits or inspecting any of the other safety gear at the site. Neither will a professional operator decline to discuss the arrangements necessa!)' for evacuation or seeking emergency medical care. Diving on your own, however, you will need to do the research about activating the emergency medical system in the area. In many parts of the United States, a single telephone call to "911" will put one in touch with eve!)' appropriate source of aid imaginable. But this presumes you have a telephone and are diving in an accessible, populated area.


Much diving around the world is done in remote areas, or areas with less developed emergency response systems. Short of not diving in these areas, you need to be comfortable with the additional risks that tile lack of such facilities represents, or prepare ways to circumvent the problem (figure 4-23) This can include carrying a more complete medical kit than would be usual, greater amounts of oxygen or oxygen first aid rebreather system, the primary treatment for most diving-related ailmentl and pulmonary injuries, or increased communications capability from cell phones to marine radio. It may also mean diving more conservatively to reduce the risk of having to deal with a problem. No matter what means of reducing risk you choose, the point is to do so actively by planning how you will deal with any emergency that may arise. Anotiler important point to consider is tilat someone other tilan you should be fanliliar witil the emergency response system in the dive area in case you are the victim of a mishap. Keeping important infonnation to yourself is as dangerous as not haVing it available, if you are the injured person.

rn

YOUR FIRST AID KIT The contents of a diving first aid kit depend on the kind of diving you are doing, and tile level of training you have and expect to use in case of an emergency (figure 4-24) As noted, the more remote the area, the greater likelihood that you will need an extensive kit. This is also true if you are a diVing leader who may have a duty to be able to help people to whom you are proViding services. In any case, there are some basic items that most dive first aid kits will include: • Prescription medications that you take regularly, or other medical items that you may use like contact lens flUid. • Over-the-counter medications such as analgesics, eye washes, antiseptfcs, topical antibiotic creams or lotion, iodine or Mercurochrome, disinfectant like alcohol, disinfecting soap, decongestants (pills or inhalers for use after diving, if necessary), local anaesthetic ointments and sun block.

Dil~ng specific remedies like Vinegar and meat tenderizer, and hot and cold packs for organic wounds from marine life. • The usual tools in a first aid kit, from tweezers, sharp knife, scissors and needles, to forceps and magnifying glass. • Appropriate bandages, first aid tape, elastic bandages, adhesive bandages in assorted sizes, gauze pads of various thickness and sizes. • Paper, pencil, market; slate, change for the telephone, a first aid manual, possibly juice, water, blanket, pad or mat, flares, signaling mirror, flashlight, communications devices like a cellular telephone, or handheld marine VHF radio and spare batteries. You may have to increase the amounts or types of eqUipment in your first aid kit depending not only on your diving locale, but your role in diving and qualifications as a care proVider. If you are a diving leader responsible for organizing or supervising others, you lvill undoubtedly need to have more in your kit than if you are simply a prudent diver. Another factor that will make a difference in your kit's eqUipment is your level of training. As a SRD or ASRD, you may seek more extensive training than balic first aid training, to the level of Emergency Medical Technician or beyond. As you become more qualified, you will likely cany more eqUipment and medications, and may also increase your level of duty'and responsibility.

•

Oxygen Administration Equipment If you don't already know that pure oxygen is the first aid treatment of choice for DCI and many other diving and diving related injuries, tilen it is a very good thing that you are in this course and reading this book. NAUI Worldwide recommends that oxygen administration equipment and a trained proVider be readily available whenever and wherever diving takes place. Oxygen is the first aid treatment of choice for any suspected DCI. It should be administered without hesitation at as high a partial pressure as is possible for as long as it takes for professional medical personnel to respond, or until the supply runs out.

45


What kind of oxygen equipment you will cany, if any, depends on your role in the diving in which you are involved. As an SRD or ASRD you need not cany oxygen yourself unless you wish to; however, if you are in a leadership role, it is your responsibility to comply with AUI standards, and the policies of the organization for which you work. You must know what these standards and policies are, and if as a result, you do carry oxygen, you must ensure that it is readily available, and that you or someone under your supervision is qualified to administer it. As a diver concerned with reducing the inherent risks of your chosen activity, it is good sense to ensure that oxygen is readily available to you in the event of a mishap. If this means that you need to provide it, there is little excuse for not doing so. See Chapter 10 for more infonnation on o'l'gen administration equipment and usage.

Buddy Briefings Clear communication between dive buddies is

~ another of the cornerstones upon which safe diving

rests. Making sure in advance that there is agreement on the activity choices, level of coordination expected and desired, procedures and emergency responses removes them as concems for either buddy. Knowing what to expect from your primary undel\vater companion and source of aid contributes greatly to one's peace of mind and Significantly increases diving enjoyment.

and how and where to conduct the recommended safety stop. The minimum air to retum to the surface should be agreed upon, and this along with planned depth and time, recorded on botll divers' slates. If a particular feature of the dive is its main attraction, as might be in wreck diving, then the plan for tilat portion of the dive should also be discussed in detail. On any dive, one buddy usually agrees to act as leader, and how tile divers intend to stay positioned relative to each other.

Mutual Gear Check One basic responsibility that buddies have to each ollier is to be completely familiar with each other's equipment (figure 4-25). This includes knowing the proper placement of, and how to remove, all gear wom - any ballast in particular. It also includes making sure that the equipment is appropriate for the planned activity, and that it functions as expected. Many diving leaders perform routine head-to-toe checks on their diving companions as a means of avoiding problems on supervised dives. This practice, limited to examining your buddy, and as may concern you, tlle others with whom you are diving, is a good one for SRDs and ASRDs to adopt as part of their efforts at accident prevention.

Dive Plan Coordination The initial part of a mutually conducted buddy briefing sets the parameters of the dive, and correlates expectations. Buddies must agree first on the dive they are going to make: how deep for how long and to do what? Any specific activities in which eitller diver wishes to participate, whether it is mask clearing practice or raising a lost weight belt, should be discussed and agreed upon in advance to avoid any confusion or surprises later under water. Buddies should also discuss the general procedure for entry, descent and ascent that they intend to follow,

48

FIGURE 4·25. YOU SHOULD UNDERSTAND YOUR BUDDY'S EQUIPMENT NEARLY AS WELL AS YOU 00 YQUR OWN. A CAREFUL CHECK Will HELP SOLVE EQUIPMENT PROBLEMS ON THE SURFACE.


Ok?!

Danger

Stop

Ok (surtace)

I'm out of air

Share air

Ok (surtace)

Low on air

Help! (surtace)

Pick me up (surlace)

FIG 4·28 HAND SIGNALS

Making sure that your dive buddy's and your equipment work properly prior to entering the water is standard operating procedure for all divers. Items to check include diving instruments, especially the SPG, and the function of all breathing apparatus, including alternate air sources.

SIGNALS Divers have always depended on hand signals to convey important information undeiWatet; and at the surface. Common hand si,gnals, such as those illustrated here (figure 4-26), should be reviewed by buddies prior to any dive, especially if tlle divers are new to each other. In addition to the usual signals, any personally developed signals should be gone over to ensure that they will actually work if needed.

Emergency signals relating to problems that can occur with equalization, air supply or any discomfort experienced should be clear to both divers, and the desired response detailed. In general, any air supply issues are best dealt with on the surface where air is abundant. Because of this, a signaled air-related problem of any nature is generally followed immediately by a "thumbs up." In rare instances, this may be preceded by tlle signal requesting that the buddy share air.

EMERGENCY PROCEDURES After doing evelything possible to ensure that one doesn't own; the most important part of a buddy briefing is discussing dealing with an emergency undelwater. Buddies should practice in advance of the dive the chosen method of sharing ail; how to be the donor and the

[btl 47


AGURE 4-27. MOST DIVBlS PREFBl AN OBVIOUS PlACE fUR THEIR AlIBlNATE AIR SOURC~ YOUR BUDDY AND YOU MUST BE COMPlflRY ClEAR ON ITS LOCAnON, AND ON THE TECHNIQUE YOU WILL EMPLOY IN AN EMEHGENC{

donee, and understand the limitations of their mutually preferred system. The location of the alternate air sources must be obvious to each diver, and to other divers in the group (figure 4-27). (Methods of sharing air are discussed more fully in Chapter 7.) Besides dealing with an out-of-air emergency, thankfully quite rare, divers should go over tile procedure for dealing with the much more common problem

of misplacing one's buddy. Theoretically, buddies should never lose sight of one another, or be outside touching distance. Unfortunately, a temporarily "lost" buddy is a common occurrence (figure 4-28). Here is a way to deal with it: 1. Stop immediately after you notice your buddy missing. Sweep your gaze through a full circle, looking up and down for about one minute. If on the bottom, you need only gaze qUickly down around your position to make sure your buddy is not supine, then concentrate on looking around and up. If in mid-water, look down, up and around. If visibility is poor (less than six feet), you will probably have examined the area in less than one minute, however your buddy may be on the way, haVing seen you. Maintain position for the allotted minute. 2. Surface at the recommended ascent rate, but do not make the safety stop. Establish buoyancy at the surface, and wait one minute while sweeping your gaze around. On a supervised dive, or on a professionally organized dive, you will likely be signaled by the diving supervisor when you surface without your buddy in the middle of a dive, if you are within a reasonable distance of the entry/exit point. Signal that you are okay. The next signal you receive will be the one asking where your buddy is. At this point, depending on tile deptil of the dive, you \\~II have been separated over two minutes, suf-

FIG 4·2B THE LOST BUDDY PROCEDURE SHOULO BE REVIEWED BEFORE EVERY DIVE.

48


ficient time for your buddy to have noticed you missing, and surfaced as well. If not, there may be a problem. If the dive was led, an escort or divemaster may approach you, looking for you and your buddy. Follow this person's directions. 3. Signal the diving supervisor your buddy is lost by using a standard distress signal. Arescue effort will ensue. If you and your buddy are diving alone, you will have to decide on your next best step. It 'viII generally be to seek outside aid as you will have discussed in your emergency planning prior to the dive. Under most circumstances, descending alone without notice to any outside resources to commence a search for a lost, possibly injured buddy is a bad choice, however compelling it may feel. The wisest course of action, absent some previously agreed upon or understood duty, usually is to notify professional rescuers of the predicament, and wait for their arrival. This approach may vary if you are in very remote locations. 4. If your buddy rejoins you on the surface, as occurs most frequently, discuss what went wrong and how to avoid it in the future. Depending on tlle point in the dive when the separation occurred, the circumstances of the dive, and the frame of mind of both divers, the dive may be continued to its planned conclusion.

48

CHAPTER

Reducing Common Diving Risks


LEARNING GOALS In this chapter you will: 1. Learn the difference between passing and proficient 2. Review recommended actions when experiencing squeezes or blocks. 3. Learn various methods, techniques and strategies for reducing the risk of injUry from common conditions faced by every diver 4. Understand the "why" underlying some of diving's so-called "rules". Every dive made has a certain amount of risk. Some of these risks, like the chance of DCI are statistical: given enough dives, some divers will have a problem with it There is little tllat can be done to eliminate this risk, save not diving. The risk can be reduced to an acceptable level, howevel; by foll0\\1ng recommended practices, and especially by maintaining your diving fitness and diving conservatively within the limits of accepted dive tables. Other risks of diving can be nearly eliminated or reduced to the point where the chance of a problem is negligible. Examples of these risks include equipment failure and running out of air Regularly maintaining your gear, and checking it thoroughly prior to diving, ~ and your diligence in dive planning and monitoring ~ your air supply throughout the dive, will virtually eliminate these potential problems. But some variables can never be completely controlled, like changing weather and water conditions, errors in judgment and miscalculations, or sudden unexpected illness. In these instances, knowing the right response and making the right decision can literally save your life. r=-f: Ignoring a known contraindication to diving is ~ irresponsible, and needlessly places diving companions at risk.

JUDGMENT PROBLEMS Every dive you make reqUires your informed judgment, the capacity to discern relationships and make

52

sound decisions based upon them. Yet, most diving accidents examined in hindSight reveal a pattern of poor judgment Too frequently, people who know better do not act on their knowledge.

Evaluating Your Personal Diving Fitness Making a good decision about one's fitness to participate in any given dive is crucial to accident prevention. This is especially true since most diving does not take place under supervised conditions where divers will be assessed by a keen professional eye. Instead, most dives are made by pairs of buddies, or groups of friends and acquaintances diving together as buddy teams. Under these circumstances, everyone depends on the honesty of the others as each diver evaluates personal readiness to make the proposed dive. In order to make a good decision about the actiVity, one must honestly consider whether there are any contraindications to participation. While absolute contraindications are unlikely to be present, many divers deny the effects of temporary or relative contraindications, or simply ignore them in favor of "enjoying themselves." Acting in this manner is unacceptable from the perspective of risk management, and more importantly, from the standpoint of the safety of oneself, and of the other divers in the group. Other than ignoring potential adverse health riSks, some divers may overestimate their physical ability or underestimate the strenuousness of the planned dive. Once in the water, some divers will often struggle with challenging conditions, rather than signal their buddy that they would like to surface and exit the water. Emphasize to yourself that diving is ~upposed to be fun! When it is not enjoyable, there is no point in continuing. When participation endangers your well-being, and by extension that of your companions, find something else to do. There are other challenges in life that are less dangerous and that do not also risk friends and acquaintances tacitly trusting you to act responsibly.

Managing Your Decisions: Peer Pressure Most people are susceptible to the influence of those

CJ:

Chapter 5- Reducing Common Diving Risks

CD

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FIGURE 5-1. FEEUNGS ARE AN IMPORTANT PART OF DIVING FITNESS. NEVER PARTICIPATE IN ANY DIVE ABOUT WHICH YOU ARE APPREHENSIVE REGARDLESS OF THE WISHES OF OTHERS.

around them. Groups of like-minded individuals often seek each other out, and peoples' attitudes about themselves, their likes and dislikes are shaped by those whose company they find attractive, or otherwise admire. Divers are no different. Choosing a group of regular diving companions whose interests and abilities are similar to your own is a good way to enjoy wholesome recreation. Often, the friendships formed on a diving excursion or trip extend into other parts of one's life. Sometimes, however, groups can have an unfortunate effect on an individual's judgment. The desires of the majority, or the strong opinions of a few vocal people, may cause others to follow suggestions about which they have misgivings. Psychologists term this "peer pressure," but whatever it may be labeled, if it influences you to participate in an activity about which you are personally uncomfortable, it is wrong. It is also wrong if the opinions or attitudes of diving companions are able to make you set aside what,¥ou know to be correct practice in favor of what others hold to be "okay" for the sake of expedience. Regardless of the trust you may have in another's ability or judgment, even in that of a diving leader, never make a dive about which you have misgivings for any

FIGURE 5-2. WHEN LEARNING TO DIVE, EACH SHILL IS TAUGHT AND REHEARSED INOIVIDUAUY BEFORE BECOMING PART OF THE OVERALL TECHNIQUE. PRACTICE INDIVIDUAL SKILLS THROUGHOUT YOUR DIVING CAREER.

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reasons (figure 5-1). Diving is a personal choice that you make after due consideration each time you plan to enter the water. You are obligated to yourself and to those with whom you dive make that choice Wisely. Another form of negative group behavior ensues when someone feels the need to impress the others with "daredevil" actions Attention-seeking like this often leads to injury. Such individuals often brag about close calls they have survived, and tell other tall tales, the usual moral of which is that they are lucky or channed, or unusually adept. Diving with this kind of thrill-seeking buddy is clearly not a responsible choice, let alone likely to be an enjoyable experience. In many cases, this bravado is simply a mask for the individual's own fears and anxieties, overcompensating for being afraid that they may not meet the challenges the dive represents. Whatever the source of the behavior, unless you feel completely comfortable with the person's ability and frame of mind, stay out of the water. Finally, there are those people in any group who can only thrive if they are in charge, or in conflict with those who are. Possessive about "their" dive, and selfish about their skills or expertise, these individuals disdain common buddy practices like mutual gear checks and

53


dive planning. They may also grow belligerent or aggressive in the face of questions or legitimate requests for cooperation from others in the group. Deliberately confrontational about policies or recommended practices, these divers are unreliable as buddies, primarily because they cannot admit to ever making a mistake, or see the wisdom of someone else's choices. It is safer to avoid them, than to attempt to appease their needs.

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PROPER TRAINING Diving skills are learned behaviors (figure 5-2). While this may seem obvious, everyone has different levels of physical and intellectual ability, and therefore everyone cannot attain equal levels of skill. You need not be the best, most skilled diver in the world to enjoy scuba, but you must be sufficiently skilled and able to pelfol1n to the anticipated level, and have sometlling in reserve just in case l Like planning your air consumption to include a margin of safety "in case," it is wisest to dive well within your physical ability, and certainly only within the activities for which you have been competently trained. If conditions change, as in encountering an unexpected current, having the ability to continue by comfortably increasing your level of effort can make the difference between a frightening, marginal experience and a challenging, strenuous dive. In the same vein, using skills that are ingrained through a process of "overleaming" and continuous practice is better than trying to figure out what to do when faced with a problem by watching those around you, or hoping for aid. Ii"'I""'I Self-reliance and confidence can only come from ade~ quate training and practice. To reinforce these concepts, NAUI Worldwide establishes minimum standards that students must meet in order to be certified. But it is rare tllat any NAUI Worldwide trained diver gets by through achieving at the minimum level of competence.

Passing YS. Proficient Ii"'I""'I

"Passing" is just minimal. Proficient comes from ~ extended effort and coaching. Your enrollment in this

54

SRD or ASRD class is a good example of the difference: you care enough about your diving ability to want to improve it by acquiring new skills and \vider information. This attitude is not something that can be taught. The desire to improve and to expand one's diving abilities comes from enthusiasm for the sport, and respect for the risk~ it contains. Your commitment to improvement can be translated into action on every dive you make. By taking the time to ensure that your skills are maintained and performed well on every dive, by regularly practicing the basics in a controlled setting at evelY opportunity, and by continuing your diving education and participating in diving, your diving skills will stay sharp and focused.

Power YS. Mastery Learning about anything is usually measured by some kind of test, an instrument designed to evaluate the level of achievement attained. But there are often conflicting reasons for tlle test. Some examinations are designed to rank people so that some may be eliminated. These are so-called "power" tests, like professional licensing exams that only admit the talented few to practice as a means of keeping out many would-be, but less able, practitioners. Other exams, like those within recreational diving, have the purpose of helping wouldbe divers achieve mastery of the material necessalY for them to evaluate the risks of their participation. In other words, diving tests teach tllose who take them how to avoid problems. This book and its work book m~e up an example of mastery-oriented leaming. Instead of trying to "trick" you into making errors, the work is designed to help increase your knowledge of important concepts that will bear directly on your ability to recognize, reduce and understands the risks you will take. Continuing your diving education \vitll courses like this one is probably tlle chief way tllat you can build mastery of central diving concepts, and increase your abil ity to make better infol1ned decisions about your participation.


PREVENTING PROBLEMS The more variables you can control or eliminate from your diving activities, the more likely you are to enjoy problem-free diving. Inevitably, tllere \vill be times when a problem arises. If this were never the case, dive, and especially rescue training would be unnecessary! Coping appropriately with the inevitable problems that arise \\~II prevent incidents from becoming accidents.

Equalization Oitticulties Besides needing to breathe gaseous oxygen, all problems affecting humans who enter tlle underwater environment are consequences of the pressure gradient between the surface and the much denser medium of water. Some of these are problems stemming from air spaces within and around humans that must be able to freely exchange gas at any pressure to avoid pain and injury (figure 5-3).

Squeezes and Blocks Squeezes and blocks are the temlS divers use to describe the direct effects of pressure on the air spaces

within and around the human body. Squeezes occur on descent when the pressure is increasing, causing the air within internal spaces like sinuses, or around the face enclosed by a diving mask, to compress. Blocks occur on ascent, when air that entered internal spaces at higher pressure is unable to exit easily as it expands due to the lowering ambient pressure. In either case, the consequence is pain and possible injury. In addition, the pain can be so severe that rational action is impossible, and even more serious effects can result as the diver attempts to flee the discomfort.

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Avoiding Squeezes Most common squeezes concern the middle ear and sinuses. These are easily prevented by the simple process ~ of "clearing," gently and frequently equalizing the pres- Iaii'dI sure between the internal space and the ambient environment during descent. Diving is impossible without healthy, congestion-free nasal and sinus passageways, and without developing an efficient technique at moving air through the Eustachian tube into the middle ear and sinus cavities (figure 5-4). The pain that results if one continues to descend though unable to equalize is

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FIGURE 5·3. EAR ANATOMY

55


space in a diving hood (external ear/hood squeeze) or from air being trapped in a fold of a dry suit (suit squeeze). Of this group, mask squeeze is the most common, and all are easily avoidable with proper diving technique and awareness. [f you cannot equalize on descent: 1. Stop descending; signal your buddy that you have a problem. 2. Take your hands away from your face. 3. Ascend a few feet until the pressure is relieved to the surface, if near. 4. Stabilize at the lesser depth, and again attempt to clear. 5. If it works, descend again slowly, clearing frequently before feeling pressure. If it doesn't, abort the dive.

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FIGURE 5·4. THE SINUSES MUST BE CONGESTION FREE TO AVOID SQUEEZES AND BLOCKS.

FIGURE 5·5. CLEARING YOUR MASK OF WATER ALSO EQUALIZES PRESSURE WITHIN IT.

unbearable. Worse, it will rapidly cause injury which can include a burst membrane in the middle ear that may result in permanent hearing loss or long-term infection. Other squeezes may result from forgetting to exhale some air into the diving mask upon descent (mask squeeze - figure 5-5), improper dental work (tooth squeeze/barodontalgia), not allowing water to fill the

58

Avoiding Blocks Blocks, when higher pressure air is trapped internally, are very rare in a healthy diver. Divers who routinely use decongestants while diving, however, put themselves at greater risk of a sinus or ear block since the nonna! function of the mucous membranes in the nasal passages is temporarily restored by the drugs. When the drug wears off, a rebound effect can occur, producing exacerbated symptoms that may cause air to trap. Since the block occurs on ascent, and generally at the end of a dive, breathing supply may be an issue. Forcing yourself to surface in a blocked condition will very likely lead to a severe ear or sinus injury. If experiencing a block, stop, and Signal your buddy that you have a problem. Descend a few feet, and calm down. Very slowly resume your ascent, rocking yctUr head laterally so that first one side then the other is higher. Stopping frequently may be necessary to avoid pain. Plan your air consumption to accorrunodate this kind of contingency. Never dive with pain! If diving is painful, something is wrong. Think about what it is, and then cor.rect it. Never endure pain while diving. Doing so can lead to serious injUry. Sometimes improper diet before diving can cause an intestinal or "gut" squeeze which is actually a block when internal dietary gases produced during the

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Chapter 5· Reducing Common Diving Risks

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AGURE 5·B. IT IS FAR BmER TO SPOT THE PROBLEM ON THE SUR· rACE BEFORE THE DIVER IS IN THE WiliER THAN TO HAVE TO ASSIST THE PERSON lATER. OBSEIIVf YOUR DIVING COMPANIONS CAREFUllY FOR POTENTIAL MISHAPS.

FIGURE 5·7. AVAIlABIlITY OF ITEMS LIKE THESE ON ADIVING EXCURSION IS NOT THE EQUIVALENT OF TRAINING OR COMPETENCE. DIVE WITH YOUR HEAD, NOT OVER IT.

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dive begin to expand on ascent. In time, these gases generally will exit in the usual fashion if the diver relaxes and ascends slowly. Avoiding spicy and known gasproducing foods and heavily carbonated drinks prior to diving will prevent this uncomfortable condition.

Equipment OiUiculties

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Scuba and snorkeling rely on appropriate equipment without which the activities are for the most part impossible. Unfortunately, anything mechanical, no matter how well-made or well cared for can eventually wear out or fail without warning. Knowing how to deal with these possible problems yourself, and how to recognize and resolve them for your buddy, will help you prevent accidents. Fortunately, tile most likely problem that can occur with any piece of diving eqUipment, "user error," is also the easiest to avoid. Thorough familiarity with all of the eqUipment with which you dive comes from thorough practice, as most divers understand. Problems arise when there is no time to achieve tilis level of comfort due to a sudden malfunction prior to a dive necessitating replacement with an unfamiliar piece of eqUipment, or when renting eqUipment Also, many dive operators offer unusual kinds of underwater equip-

ment, like undel\vater vehicles ("scooters" - figure 5-7) or even re-breathers for rental to certified divers. While there is nothing wrong with trying out new items, the individual diver's good judgment must prevail. AqUick run-through of the equipment's function and a breezy "you'll do fine," assurance is not a real check-out with a new piece of gear, nor does it mean that you are competent. Use common sense when renting or trying out unfamiliar items. Competence with any piece of diving eqUipment comes from repeated practice under controlled conditions. The best practice also includes time spent on how to overcome common problems that may result from misuse or from the item's failure.

COMMON EQUIPMENT PROBLEMS Mask and Fin Straps Most breaks occur when the gear is being put on prior to entering the water, but can happen under water as well (figure 5-8). When straps break, they are usually easily replaced if there is a spare available; however heavy gloves or mittens can make undel\vater

57


AGURE 5·B. ATUG ON THE SURFACE WOULD PROBABLY HAVE MEANT REPlACEMENT BEFORE THE DIVE.

replacemelll impossible (figure 5-6). Depending on the presence of any current and difficulty of the dive, continuing with one fin may be a good choice, but under most circumstances, retuming to the surface to correct the problem is better. Most divers are proficient at breathing without a mask in place should it become dislodged or fall off due to the strap or a buckle breaking. If you aren't, this is an important skill to practice in a controlled environment. If one does lose a mask, it will usually be right at the feet or beneath the diver. This is where an alert buddy can be of real sen1ce. If the strap is broken, then one hand on the mask will keep it in place during an otherwise routine ascent.

Buoyancy Compensators BCs come in many types, but all have in common a means of inflation and deflation, and a bladder that is supposed to hold air. If any of those components are not working, the eqUipment cannot be safely used. This would be revealed prior to entering the water, when tlle broken device can be exchanged for a functioning unit. It is rare for the bladder to fail under water, unless the device is over-inflated and the built-in pressure relief valve does not operate properly. This is extremely unlikely, though possible. It is more probable that the inflator or deflator mechanism will malfunction, although with good maintenance this a rare occurrence as well (figure 5-9). If the inflator mechanism does not

58

FIGURE 5·Y. SIMPLE CLEANLINESS, AND ACAREFUL INSPECTION OF ALL DIVING EQUIPMENT BEFORE AND AFTER ANY DIVE CAN HELP ELIMINATE THE CHANCE OF EQUIp· MENT RELATED PROBLEMS.

operate at all, the BC can still be inflated orally, another basic diving skill that should be maintained through regular practice. If the diver is comfortable with the process, the dive may be continued. If not, a retum to the surface is mandatory. Controlling the ascent rate will require that air be released from the BC effiCiently, either through the inflator hose as usual, or through another release valve on the device. (Virtuallv all modern BCs have alternate means of releasing ;ir quickly in an ~mergency that are controlled by pressure and/or by tlle diver. As with all functions of life support eqUipment, tllese should be periodically checked.) The most usual failure for an inflator hose, however, is not the inability to release air, but tlle slow leakage of air illlo the bladder. This problem is usually more annoying than dangerous. However, if the diver is unaware, it can lead to rapid ascent and more serious problems. If the diver is adept at oral inflation, the dive can be continued after the inflator hose is disconnected from the low pressure

Chapter 5- Reducing Common DiVing Risks

hose. If not confident in tile ability to maintain neutral buoyancy with oral inflation, or if the low pressure hose is leaking, the diver can monitor the rate of leakage, and periodically release air from the BC in tile usual way.

Wetsuits Most wetsuits are trouble-free, garments that last longer tilan most divers choose to keep them! TIle biggest problem tiley present is when zippers malfunction, an annoyance that strikes most frequently before a dive, but can also make getting out of the suit after diving a miser~ able task Keeping the zippers operating is as easy as fol~ lowing the suit manufacturer's recommendations. Though tile suit itself is virtually foolproof, problems can occur if it fits poorly. If the suit is too loose, it will not protect against cold. Achilled diver functions poorly, and is at greater risk of decompression sickness. If the suit is too tight, it \vill constrict movement and may ~ affect breathing and circulation, obviously undesirable occurrences that can contribute to a diving accident. Wetsuits should fit snugly and be comfortable. For opti~ mum perfonnance in colder waters, a custom fitted suit is recommended.

Dry Suits Dry suits depend on maintaining a water~tight seal to provide thennal protection. Atear or puncture under~ water usually means the end of the dive. This is espe~ cially true because most divers use dry suits in colder water where unprotected exposure can rapidly lead to severe hypothennia. Additionally, because of the greater inherent buoyancy of many dry suits, the diver may be wearing more ballast, and although not a recommended practice, may have not worn a BC. Thus, a failure of tile suit's integri~ ty can also result in a sudden loss of buoyancy. Dry suits also depend Oll an inflator hose and control valve similar to that of a BC. Leakage into tile suit from the valve can be dealt with in tile same way as for a BC. However, disconnecting the inflator hose can usually only take place if the diver is at a stationary depth below which no further descent is intended unless the diver is

able easily to disconnect and re~connect it. Witilout this ability, descending can lead to suit "squeeze." Dry suits require supervised training in confined water in the additional skills specific to their safe use. Without successfully completing sufficient dry suit train~ ing, NAUI Worldwide regards diving in a dry suit an unacceptable risk. Uncontrolled shifting of the air inside a dry suit is another possible hazard, the risk of which can be reduced through training and practice. Since tile whole suit is an air bladder, the trim and position of a diver under water can cause the air to migrate to one portion of the suit. If the legs are the destination, the diver rapidly can be "dragged" feet first to the surface. Fins may be lost in the process. Dry suit training courses teach how to deal with these eventualities, and other situations unique to dry suits. Finally, there have been statistical implications that dry suit divers are more likely to experience DCI. This mayor may not be the result of wearing a dry suit, though prolonged exposures to colder water tempera~ tures may increase the risk of decompression sickness in some divers. It is also possible that dry suit divers simply dive more, or adopt dive profiles tilat include stage decompression, increasing statistical risk through greater frequency of dives or activity choices.

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BALLAST SYSTEMS Over-weighting It is an unfortunate fact of diving that many divers seem to carry more ballast than required. The causes of this problem are numerous, but for the most part, can be traced to improper initial training or poor advice from more experienced divers who themselves choose to sacrifice skill to expedience. An over~weighted diver will sink easily, and \vill certainly stay down. Enjoying the dive, and returning comfortably to the surface, however, are not always the result (figure 5- 10). NAUI World\vide recommends that all divers under~ stand and perfoml the process of testing for neutral buoy-

59


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FIGURE 5-11. WHATEVER WBGIITING SYSTEM YOU AOOP~ MAKE SURE YOU AND YOUR BUDDY ARE PROACIENT IN ITS EMERGENCY RElEASE TECHNIQUE.

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ancy when tllere is any doubt about tlle anlount of ballast tllat should be worn on any dive. Recording ballast weight, water type and equipment worn in one's log book is also highly recommended to create a reference database that a diver can use in the future under similar conditions. Once neutral at the surface, the diver mal' elect to add sufficient weight, generally about one kilogram (two pounds) to ensure tllat as the tank empties, neutral buoyancy can be maintained. This is essential to perfonning the recommended safety stop at the end of the dive. If using a dive cylinder that will remain negative even when empty, this is unnecessary. Never dive overweighted, and encourage anyone who appears to be to check for proper weighting before diving. An over-weighted diver will not only be uncomfortable tllroughout the dive, but will also risk back injUry. Debilitating fatigue is another possibility and overweighted divers will probably use more air struggling to maintain a natural swimming position. Diving is an uncomfortable experience while fighting excessive ballast that is forcing the diver into an upright, or even backward leaning, position.

80

Weight Belts Most divers wear ballast on a simple weight belt that includes a means of ensuring that weights do not shift position during the dive, and that has a reliable, onehand-operable quick release buckle. Though most divers use individual weights in convenient denominations to make up the amount of ballast they need, other divers use lead shot - pellets that are more comfortable to carry, and more easily adapted to a diver's exact needs. Most divers position the weight belt so that the right hand can be used to release it in an emergency. Regardless of the ballast choice or the positioning of the release, the key to safely wearing a weight belt is the ease and speed with which it can be jettisol)ed by oneself or one's buddy. This is again, a function of training and practice (figure 5-1 I).

Integrated BC and Ballast Systems Some divers shun weight belts in favor of an integrated Be and ballast system. These systems also make provision for a qUick release of the ballast in case of an emergency. Awell-designed system will have a clear and functional one-hand release with which you must familiarize your buddy.


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The DUr Weight System M

Many divers, in particular wearers of this popular brand of dry suits, have adopted a ballast system that is worn like a harness, and transfers the drag of the weight from the lower back area to the shoulders. These systems have as efficient and practical a method for swift jettisoning as any other, but if one is unfamiliar with their usage, an accident can result Make sure that your buddy is comfortable with the procedure to release the ballast from this or any other system you choose.

Trim Trim refers to the diver's physical orientation in the

m water. Efficient trim positions the diver for least resist-

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ance in the direction of progress. Obviously, vertical, heads-up trim is best for ascent and descent, and, for the most part, the natural horizontal swimming position is best for easy underwater progress. Proper filming technique causes thrust in the opposite direction that the fins point, so deviation from the horizontal or improper finning to compensate for poor trim increase resistance, contributing to fatigue. Tiring oneself out trying to maintain position against the pull of improperly placed or excessive ballast

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FIGURE 5·13. TURNING AFREE FLOWING REGULATOR MOUTHPIECE DOWN IS USUALLY ALL THAT IS REQUIRED TO STOP AFREE FLOW.

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is frustrating at best, and can be dangerous. Energy that would be in reserve, available throughout the dive to meet unexpected challenges, is needlessly expended. Compounded by poor buoyancy control skills, improper trim and over-weighting are the diver's stronger adversaries in a no-win fight against water density. Practice maintaining an efficient, streamlined swimming position under water, and think about moving ballast around your person to accommodate this. Some divers remove weight from the belt and wear it on their ankles; others may attach small amounts of weight to their chests. While these weights may not be quickly shed, they are generally negligible compared to the major ballast worn elsewhere. But even if only a small portion of the total load, re-positioning these weights can make a big difference in comfort and effective maneuvering.

Air Delivery Systems The development of the demand regulator gave birth to modem scuba diving. Since that time, an evolutionary process of development, and large scale public

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field-testing of the devices have made them almost entirely fault-free, Almost, however, is not a satisfactory guarantee where life support equipment is concerned, Though negligible, there is some possibility of a regulator failing to give air on demand, particularly an older model in poor repair, Most modem regulators are designed specifically to "free-flow," that is, to give air without demand, if there is a failure within the first stage valves (figure 5-12), If this occurs, immediately make a direct ascent to the surface, ensuring as best you can that your ascent rate is adequate to reach the surface with air, Your alert buddy will either monitor or accompany you, ready to offer aid or share air as needed, Afree-flOWing regulator will qUickly empty a full cylinder; at the end of a dive, it may only take a moment before all remaining air is gone, If diving with an older regulator, there is tlle remote chance it will fail "closed," If it does, your skills at emergency ascent and you and your buddy's prior agreement and technique at sharing air by the chosen method can save your life, Second stage failure is almost as rare as first stage problems, however, many second stages will free-flow if handled improperly. In the desire to create a breathing apparatus that is comfortable to carry in the mouth and offers little breathing resistance, manufacturers have created regulators capable of field tuning, and others whose finely tuned response level is such tllat the merest differential in pressure will set them bubbling. It is usually easy to stop this annoying actiVity. Submerge the second stage and tum the mouthpiece downward to stop the flow (figure 5-13). If it continually recurs, have the regulator serviced before diving with it. In fact, proper servicing is the most important issue in keeping regulators operating at peak perfonnance. There are few underwater inconveniences as annoying as a hard-breathing regulator from which breath must be begged instead of freely taken. Worse, the effort of breathing can lead to excessive carbon dioxide in the circulatory system, a condition that, if ignored, can lead to underwater panic. Even \\~thout this extreme resUlt, laborious breathing will prove fatiguing and remove any pleasure you may have derived from the dive. Avoid this

AGURE 5·14. SOME AREAS ARE MORE HAlAROOUS TO DIVERS TItAN OTHERS. WHY OM TllEHE?

by checking the breathing action of the mouthpiece before using it underwater.

ENVIRONMENTAL HAZARDS The chief attraction of diving for most people is the wholesome outdoor environment in which it is usually practiced. Visions of the tropical waters of the world are usually what drive most people to seek instruction, and it is this high-viSibility, life-teeming wonderland that most divers seek as frequently as they can. But scuba diving is practiced wherever people can get underwater. Though most dives take place in the oceans of the world, and mostly in temperate or tropical areas, many dives are made in flooded mountain quarries, frozen fresh water lakes or rivers, Each environment represents its own constellation of risk variables. Wherever you may choose to dive, awareness of the unique variables represented by the environment will help you better understand and accept the risks they represent (figure 5-14),

WEATHER RELATED PROBLEMS Those beautiful, bright, sunny summer days when diving is most pleasurable can also be tile days when


weather-related hazards are most prevalent. Warm temperatures can increase your body temperature to the point of illness. The combination of heat, exposure and a cooling offshore breeze can rapidly dehydrate a diver. Sunburn is always dangerous, and likely on unprotected skill. Each of these can be prevented.

Temperature Torments The human body operates best within a very narrow thermal range. As little as a two percent deviation from normal internal temperature of 37°C (98.6°F) is a problem; five percent can be life-threatening. Working hard in hot sun, such as when carrying heavy dive equipment, can qUickly overheat. Adding in tile effect of wearing a wet suit while doing it, and rapid thermal overload is the result (figure 5-15). Most people will not feel "thir.;ty" until long after (]) they are seriously dehydrated. Don't wait! Drink plenty of water before and after diving. Ii'I"""I The fir.;t stage of severe overheating, heat exhaus~ tion, is characterized by feeling hot, flushed, dizzy and perhaps nauseous. The per.;on will likely be sweating profusely, if not already dehydrated (see below) The skin will be moist, but clammy. Headache may also be present. leaVing the exposed area for a shaded one is mandatory, as is stopping any more hard work. Exhausted per.;ons should be monitored closely to make sure that their condition doesn't wor.;en. Although not life-threatening, heat exhaustion is a contraindication to diving until the individual has recovered. Overheated per.;ons should be allowed to cool off slowly, aided by wet compresses at areas where the blood supply is close to the surface: neck and head (scalp), underarms, wrists and groin. If simple heat exhaustion is ignored, it can turn W qUickly into a life-threatening condition called heat stroke. In this condition an individual's ability to maintain life processes is ... compromised: internal organs are too stressed to function properly and begin to shut down. Sweating ceases and circulation falter.;. The skin feels hot and dry, and respiration is labored. Without immediate medical attention, this per.;on • may die.

People in this kind of severe distre&1 need qUick professional care. In the interim, they should be monitored for consciousness and vital signs, specifically breathing and heartbeat. ObViously, if it is safe to do so, they should be moved out of the sun. Not so obViously they should not be encouraged to eat or drink anything but sips of plain water. In such a weakened state, digestion of anything more could cause hl1JOvolemic (low blood volume) shock.

Dehydration Any kind of outdoor activity can cause dehydration, but the condition is particularly concerning for diver.; The body's capaCity for carrying dissolved gas is directly related to its state of hydration. If the tissues are not internally moist ,the whole gas exchange model upon which dive table exposures are predicated is invalidated. Decompression sickness is far more likely in a dehydrated diver. This is an easy risk to reduce. Drink water, lots of it. The excess will be naturally eliminated, and in fact, proVides a good indication of the your state of hydration. The more frequently and clearly you eliminate water, the more likely it is that you are well hydrated. While water is the best drink to maintain adequate hydration (figure 5-16), almost any non-sweetened, decaffeinated, non-aCidic, non-alcoholic beverage will

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do, including so-called electrol}1e replacement drinks. Avoid eating or drinking excessively salty items which will tend to pull water from the system. Unfortunately, many of the activities tllat precede diving, from long, seasickness- provoking boat rides and travel in ai~)lanes, to exercise in the hot sun and thernlal stress, can dehydrate a person. The common result of dehydration is fatigue and irritability, but Iight-headedness may also result. In any case, it is an easy enough situation to avoid. Drink water or another suitable beverage as much as possible. The medically recommended eight glasses a day should be considered a minimum.

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Sunbur Sunburn is a bum like any other. It is a condition caused by overe>,posure to solar radiation. Like any other radiation bUIll, it is a serious condition, though for most people it is a natural consequence of being exposed to direct sunlight. Even so, sunburn can be dangerous for two major reasons. Sunburn can cause major changes in the skin, some of which can lead to skin cancers. Wearing appropriate c1otlling, including a hat and ultraviolet blocking, polarized sunglasses, and using sun-blocking creams with sufficient protective ability, will prevent many of the hannful direct or indirect effects of sunlight.

MUSCULOSKELETAL PROBLEMS Unfortunately, there is a significant amount of heavy lifting involved inmost scuba diving. EqUipment is heavy, although much less so in the water. To make matters worse, since so much diving takes place from boats, lifting and walking around with heavy eqUipment is often done in an unstable, shifting environment. Slips and falls can happen. Back problems can also develop. Avoiding injuries, back pain and chronic disability that can result from mishandling heavy equipment is po ible by follOWing some simple rules, and understanding your own physical limitations.

84

AGURE 5-18. DRINKING Plf/IIY OF WATIIIlS THE EASIEST AND BEST DEHNSE AGAINST MOST HEAT RIIMIlJ PRDBlfMS, AND AlSO MAY DECREASE THE CHANCE OF ADMNG A1LMENI

Avoiding Diving Related Musculoskeletal Problems. I. Know your physical limitations: never attempt to lift objects heavier than you nonnally would. Get help from your buddy. 2. Dive with tile appropriate-sized cylinder for a person your size participating in tile activity you choose. 3. Use only tile minimum necessary ballast and distribute it wisely to avoid having to wear an excessively heavy weight belt. Weight !)elts should always be considered "last on/first off' pieces of equipment to ensure tilat it can be jettisoned witilout entanglement in otiler equipmenl 4. Lift heavy items properly: use the large muscles of your legs, and maintain an erect spine when lifting. Avoid bending to lift and the resulting lower back strain. 5. Don't lift and twist! Thrn your whole body, not just your torso, when carrying heavy objects that must be placed elsewhere. 6. Avoid walking around wearing your diving

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equipment, especially on an unstable or moving platform, or on rough terrain. Transport gear to the exit point, and don it there. This is especially true for swim fins! 7. If appropriate, consider donning gear in the water. Whenever possible, remove heavy gear prior to climbing a boarding ladder. S. Maintain your diving fitness including strength and flexibility to betlfr avoid musculoskeletal injuries.

GENERAL UNDERWATER HAZARDS Water provides us with a wonderful venue for recreation, but it is a vastly different physical environment than that to which humans are accustomed. The inability to breathe beneath its surface without life support equipment is only the most obvious difference.

Avoiding P~oblems

F~om

Cold

l. Consider all dives made to be in cold water! It

is virtually always colder than your body's temperature. 2. Always wear an appropriate environmental suit. 3. Leave the water whenever you feel chilled. 4. If you grow cold, increase your Repetitive Dive Group/Residual Nitrogen letter by a full interval. 5. End your diving day if you feel cold. Avoid making a repetitive dive if you were chilled on the initial dive. Most of humankind's physical adaptations to living on earth are unsuitable in the water. Our senses are for the most part insufficient to provide us with accurate information under water. Our bodies have difficulty maintaining thennal balance in water. Movement through the much denser medium is more difficult than on land. Ingenuity, inventiveness and determination have enabled humans to overcome many of these problems, but they still exist. Divers must be cognizant of the differences between water and our natural environment in order to understand the risks that are present during every water activity.

Tempe~atu~e P~oblems Humans chill far more rapidly when immel~ed in water than when on land. While a 22°C (72°F) day is pleasant for outdoor activities with minimal clothing, the same temperature in water is only tolerable for a brief time without a wetsuit. In diving, chilling is not just an uncomfortable situation; it can be dangerous. Achilled diver can be physically unable to perform properly. Acold diver is at greater risk of decompression sickness, and may be unable to think properly. NAUl Worldwide recommends that any diver who feels cold in the course of a dive consider immediately terminating the dive by making a normal ascent to the surface that includes the recommended safety stop. In addition, on any dive where a diver became chilled, NAlJl Worldwide recommends increasing the time value of the dive to the next greater interval (letter) group to account for the increased solubility of a gas in colder liquid (figure 5-17). Divers who elect to ignore the early signs of chilling: discomfort, feeling cold, and shivering, risk hypothermia, a life-threatening conditioning characterized by loss of muscular control, reduced ability to think, and eventual unconsciousness. This condition can easily occur over the course of repeated dives that result in chilling.

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AGURE 5-17. PlANNING EACH DIVE TO REMAIN WElL WITHIN THE RECOMMENDED DEPTH AND DURATION UMITS, AND EXECUTING YOUR DIVE PlAN CAREfUllY WIU DEANITElY REDUCE THE RISKS OF DIVING.

85


cold over a short time to freeze water within the first stage. An ice crystal can obstruct air flow, causing a dangerous, out-of-air emergency. Other than free-flow, a hardworking diver, demanding a large amount of air through the system for a time, given cold water temperature, can produce the same effect. These are not usual occurrences, but the pOSSibility of their happening should be considered when planning dives in cold water, especially under severe conditions.

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Core heat lost by chilling on an initial dive is ~ almost never regained before making a repetitive dive. Losing heat in one's core is not easily replaced by laying out in the sun for an hour or two between dives. It may take considerably longer for your nonnal core temperature to retum. Diving before regaining nonnal temperature increases your risk of hypothennia. Agree with your buddy in advance to end a dive if either diver feels cold. Dehydration contributes to chilling and hypothennia. Cold water diving can also have an effect on a diver's equipment. Ice divers will often use a multiple first stages on a cylinder as backup against the pOSSibility of a life support malfunctIon from ice forming within one first stage (figure 5-18). This can happen because of the sudden additional chilling from the rapid reduction in pressure that occurs between the high pressure within the cylinder and the intermediate pressure of the air delivery system upon breathing demand. While nannally never an issue, a free-flowing regulator in relatively temperate water can produce sufficient

88

Water is approximately 800 times denser than air. This huge difference contributes to another unique set of problems. Chief, and most obvious among these, moving through water takes a much greater amount of energy, and requires different techniques, than moving over land. Practice good water skills, including streamlining your equipmentfor efficiency underwaler, on every dive.

Enort, Fatigue and Safety. No one can be stronger than water. Even the most modest current can eventually overpower the strongest swimmer. As a result, it is incumbent upon divers to be wise about the conditions they will face under water, and serious about their ability to handle what may arise. Most divers unfortunately rely on others to make some important decisions about their diving ability, frequently asking others "Is the current strong)" or "Is the water cold)" Who can better answer those q1!estions than the individual diver? NAUI Worldwide recommends making these assessments yourself, and agreeing with your buddy prior to entering the water on how to handle conditions which may be uncomfortable - before they become dangerous. Another part of being wiser about dealing with water's density is to develop your swimming and finning techniques, as well as by increasing your level of fitness and strength. Be aware of your level of ability when facing the constantly changing conditions that are routine on every dive. Act in advance of necessity if things seem


to be getting tough to h;U1dle. This kind of thinking will help to ensure that your dives are all enjoyable. A fatigued diver will always be more prone to incidents and accidents tllan one who is physically and mentally in charge of the experience.

Narcosis Density is also apparently the culprit in another diving problem, inert gas narcosis. The nitrogen in breathing air is not metabolized during its stay in the tissues of the body. Instead, it is dissolved according to tlle ambient pressure and temperature of the environment. and other physical factors affecting the gas' solubility, such as the amount of liquid to which it is exposed. One side effect of tllis process is that the pressure driving the gas into solution, and the partial pre&sure of the gas itself, apparently have an effect on the transmission of neurological impulses. Most divers at depths greater than about 18 meters will begin to experience a wide range of effects due to tllis phenomenon. Some of these effects can be dangerous. There is no way to easily predict the effects of nitrogen narcosis on any particular diver. Effects can range from physical symptoms like tingling lips or humming in the ears to psychological effects like euphoria, dysphoria, depression or paranoia. The key is not what happens, since any unusual effects underwater, and in particular on the thought process, are undesirable. The key is that all such effects are easily prevented, and rapidly resolved by confining your diving to shallower depths, or ascending a few feet when unusual symptoms develop.

Oxygen Toxicity At depths beyond those of usual recreational diving, divers can experience ill effects from the high partial pressure of o~'Ygen. Starting at about 65 meters, the partial pressure of oxygen in compressed air begins to approach levels where it can have harmful effects on a diver. These effects include tlle possibility of convulsions ;U1d loss of consciousness. NAUI Worldwide recommends that divers avoid these life-threatening conditions by limiting their diving activities to depths shallower than 40

msw (130 fsw). There are no known oxygen toxicity problems associated 111th diving on air to that deptll. Divers involved in technical diving to greater depths or Witll non-air mixtures are encouraged to seek the additional training and skills required under the responsible supervision of qualified profesSional instructors. Divers who use other breathing mixtures than normoxic air must be wary of the effects of increased partial pressures of oxygen. By increasing the percentage of oxygen in the breathing mixture, tlle depth at which toxicity may occur is correspondingly shallower. Divers who use these mixtures are likewise encouraged to seek the additional training mandatory for their safe usage.

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WATER HAZARDS Depending on the reason for the dive, such as the desire to view a specific under.vater feature or shipwreck, divers may sometimes find themselves choosing to enter water that most people would tend to avoid because of poor visibility. In otller cases, divers may unknowingly or umvittingly choose sites where the water is contaminated. Dealing lvitll problems of visibility is relatively easy, but diving in contaminated water is unnecessarily risky. Water's density changes the way light travels, and alters the images tllat our eyes would perceive if the same thing were viewed in air. Divers know that this is the reason tllat dive masks are used: to add the crucial air space back into the perceptual mix, sha~Jening what we can see when diving. In fact, diving is primarily a visual experience. Water's density also contributes to its ability to hold particles suspended within it. These particles, be they sediment (silt and clay), disturbed bottom material (mud or sand), or algae blooms and pollution lvill affect tlle clarity of the water, and directly impact on diving enjoyment. Divers can minimize the effects of disturbed sediment and bottom material by practicing effective buoyancy control and proper filming techniques. The larger concem is that buddies address the problems of diving in reduced visibility and are completely familiar and in

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87

NAUI Scuba Rescue Dive~

NATURAL AND ARTIFICIAL HAZARDS As placid as the surface of any body of water may

be, many hazards can lie beneath it (figure 5-19). Some of these can be naturally occurring geographic problems like tunnels, caves and caverns, while others may be the result of plant or animal life, like kelp or sea urchins. Other hazards result from humans' unfortunate subscription to the concept that "out of sight is out of mind." Many lovely areas are strewn with the refuse and discards of thoughtless people, or the losses of other water users such as lines from boats or fishing tackle. FIGURE 5·19. GOOD BUOYANCY CONTROL SKILLS AND PROPER FINNING WILL HElP AVOID THE PROBLEMS ASSOCI· ATEO WITH OISTURBEO SEDIMENT AND MUD.

agreement on the procedures to follow in the event of separation. Some divers choose to employ buddy lines in low visibility conditions. However, this technique is not recommended when diving around obstructions or irregular terrain. If electing to use such lines, they should be held individually by each diver as opposed to ~ being attached anywhere on tlle person or equipment. In the event of a snag, they can easily let go without any danger of entanglement. Amore serious hazard exists in diving in areas where contamination may be present. Due to a combination of environmental conditions, some areas are subject to excessive plankton blooms or a condition commonly called "Red Tide." Whatever the cause for such phenomena, it is unwise to dive in them due to possible health risks. The same holds true for diving in areas where there may be an abundance of bacteria or other organic contamination. Generally a problem of inland diving, drainage from household effluent, augmented by heavy rain in the recent past, sometimes pollutes normally acceptable water. Until natural forces flush out tlle contaminating factors, tllen stabilize and regulate the area again, diving should be avoided. Unfortunately, coming across an inviting body of water is not a blanket invitation to good diving. Diligent investigation of the local area, through dive operators, clubs and residents should precede any adventures into unknown waters.

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88

Entanglement There are few things more frightening than feeling trapped underwater. When diving in areas where there may be this possibility, such as places where fishing is popular, extra caution is mandatory. Lost fishing tackle continues to fish long after its owner has forgotten it. A hook remains a hook, and will catch an unwary diver no matter what its original purpose or the fonner owner's intention. Watch for these dangers whenever you dive. If caught by something like a fish hook, immediately stop. Signal your buddy that you have a problem, and calm down. Struggling against the snag will only result in depleted air and energy. If your buddy is able to see the object better than you, allow the other diver to release you. If you are hooked in the flesh, do not remove the hook. Free the line attached to the hook, and return to the surface normally to treat the wound. If caught by lines, or another kil1d of debris, the procedure is the sanle. Signal your l1Uddy, assess the problem, and whoever is in a better position can deal with it. The problem is compounded when you cannot get your buddy's attention, another strong argument for good buddy briefing and dive plan coordination. Kelp diving always presents the possibility of entanglement, but undel~tanding tlle plant will eliminate any problems. Kelp is strongest along its long axis. Trying to pull yourself free from a good sized strand would probably not work. At the same time, kelp is extremely easy to cut, or even better, break. If caught, find a place near tlle


Burntcoat Head, Bay of Fundy, Nova Scotia July 1999 Atlantic Daylight Time

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FIGURE 5·20. KELP DIVING ALWAYS PRESENTS THE POSSIBILITY OF ENTANGlfMENT, BUT UNDERSTANDING THE PLANT Will ElIMINATE ANY PROBlfMS.

entangling part, and simply bend and snap the strand to free yourself. Streanllining your equipment can reduce the likelihood of snags of all types (figure 5-20). Other kinds of debris may lie on the bottom of dive sites, from the remains of rusting automobiles to construction waste, broken glass or discarded metal. Each of these carries a potential for injury. When diving in such areas, consider these possibilities, avoiding problems by looking carefully around and down before settling on the bottom, and maintaining a safe distance from any potentially hazardous objects.

Ocean Diving Hazards Whether entering the water from the shore or from a boat, ocean diving represents some of the most popular and stimulating diving to be had. Yet oceans are vast, and underwater demarcation between the dive site and the rest of the water covering the world may be unclear. Tides and wind can cause current and waves. Geography can cause water movement anomalies that make entry and exit difficult, and particular areas unusually hazardous. Each of these concerns presents challenges to divers. •

ndal Current Water flows within the ocean for various reasons, but most ocean currents near recreational dive sites are

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AGURE 5·21. TIDE TABlfS

tidal. Tidal currents are caused by the interaction of the moon's gravitational field and the rotation of the earth. These currents are for the most part predictable in intensity and direction. It is wise to consider them when choosing a dive site since they will have a direct effect on the your comfort and safety throughout the dive. Whenever possible, it is usually best to plan your dives around the time of slack water, the time between the change from ebb to flood and vice versa. This is when tidal current is least (figure 5-21). S/art your dive against/he current, and plan your turn around point a.nd air consumption /0 lake advantage oj/he wa/er's jlow Oil/he way back /0 the exil point. Other currents, however, may be more persistent or erratic than predictable tidal currents. They may be the

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change rapidly during the cout~e of your dive, and that tllere is no guarantee that change \vill be for the better

Rip and Longshore Currents

AGURE 5·22. ARIP CURRENT CAN EASILY OVERPOWER THE STRONGEST SWIMMER: SWIM PERPENDICULAR TO THE CURRENT OR GO WITH FLOW, AND THEN "EAO FOR THE BEACH WHEN CLEAR.

result of obstructions or geographic features in the undeIWater terrain, or the result of much larger forces, including the rotation of the planet. In any case, tllese can be dealt with so long as the diver is willing to use sound judgment. Whenever entering tlle water for an ocean dive, even one planned for slack water, check the current that you are experiencing, if any. Begin your dive going into the current, and plan your dive to take advantage of the current coming back to your exit point. In strong currents, those greater than about 0.5 knot, consider drift diving as a comfortable alternative to fighting against the density of moving water. Sometimes current is affected by weathel; specifically wind. in strong wind conditions, current in the direction the wind is blowing will increase dranlatically. This is a surface phenomenon. When tlle wind opposes the current at the sluface, large waves can develop. Either condition, strong current and Wind, or large waves makes for difficult, possibly excessively dangerous diving. Use your common sense when assessing tllese conditions. Postpone any diving activity in which conditions appear threatening. Consider also, that what you see now can

Sometimes the terrain \vill contribute to cutTent that is localized, and other than for its presence in the area, largely unpredictable. Currents like these can be extremely dangerous if not dealt \vitll properly. In general, tlley should be aVOided, however, tllis is sometimes impossible as they can develop rapidly when conditions are right for them to do so, perhaps in the course of your dive. Attempting to rescue anyone caught in any of these problems is a difficult job that may require additional equipment and training. Don't become an additional victim because of misplaced heroics. Rip currents, for instance, are the local effect of beach erosion or man-made structures that cause a funnel-like area through which the bac~'wash of slllf accelerates, driving anyone in it away from land. This current can cover a relatively wide area, and is generally too strong to swim against. When faced witll a rip, relax, and go \vitll it for a moment to re-group, tllen swim perpendicular to the current until the current dissipates (figure 5-22). At that point you should once again be able to swim to the beach. Other currents, known as longshore currents, may run along tlle beach, car!)'ing an unwa!)' dive team far from their ent'1' point. This is not necessarily bad, so long as it is planned for by entering tlle water significantly further up-current along the beach from where you would like to end the dive. If not, a long walk can be the result (figure 5-23). WOl~, if unplanned, the area the divers are in when their air supply'is depleted may be untenable for leaving the water due to rocks. surf or some other problem. Adangerous local geographic current can develop when, due to erosion and terrain, the beach slopes shaqJly into the water and there is significant wave action. Sometimes (incorrectly) called an undel1ow, this kind of current will sweep an unwa!)' bather or diver from their feet, dragging them into the surf. if caught in such a backwash, tumbling with dive gear on, hold on to your mask and mouthpiece. Unlike simple bathers, you


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fiGURE 5·23. ALONGSHORE CURRENT MAY TAKE YOU fAR fROM YOUR PLANNED EXIl LOCAL KNOWlEDGE Of PRE· VAIUNG CURRENTS AND SITES CAN HBP AVOID THIS PROBLEM. ASK BEfORE YOU ENTER!

have an air supply witll you. Although you may be tumbled and tossed, you need not suffer anything more than a bruised ego if you maintain control. Even in the strongest such case, tllere will be a lull when the incoming water ovel]lowers tlle effect of the water flowing from the beach. At that point you will be able to break free and regain the surface, and then crawl back up to the beach. Alternatively, you can usually easily swim down and away from the beach into deeper water, where you can surface and select another, protected exit site.

Surf Diving Many wonderful diving experiences lie just offshore, easily accessible by a short swim. Sometimes, however, that swim is preceded by haVing to negotiate a line of roiling white water. Surf is the result of waves breaking on the shallower area of a beach, and it may cause any of the currents noted above, or be a hazard in and of itself, unless one is properly prepared and trained to deal with it. Showing up to dive atJll1 unknown beach where there are breaking waves is a recipe for disaster, unless at least one member of tlle buddy team is familiar with the techniques for negotiating surf successfully. These skills are easily learned and should be practiced in more placid surf conditions before being used in a difficult

AGURE 5·24. GRAPHIC IllUSTRATING THE RIVER CURRENT

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Surge Sometimes a dive in the ocean is affected by events far from your chosen site. The water movement you experience may be the result of deep, distant waves circling the globe, or even the result of some underwater seismic activity on the other side of the world. This long, unbreaking wave, called swell, moves through tlle water, and can easily cause a local rebounding effect, called surge, where a diver will move horizontally back and forth through the water. An unwary diver in these conditions may bounce off a nearby object. When diving in surge, maintain good buoyancy control, and stay away from objects. If attempting to progress against it. treat it like any other intermittent current, waiting for the momentary lull to gain ground against it and move with it.

FRESHWATER ISSUES Though not as common or as popular as ocean diving, inland bodies of waters and rivers are wonderful

71


Dams Are "Drowning Machines" Hydraulic Backwash

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FIGURE 5·25. LIKE OTHER DAMS, LOWHEAO DAMS MAY CAUSE DISRUPTIVE, DANGEROUS CURRENT BDiLS THAT

CAN TRAP THEUNWARl diving venues, and the recreational choice of more and more divers. Although usually not subject to surf, rivers can have strong currents (figure 5-24), and large lakes may be subject to wave action that can create substantial surf.

Rivers [n rivers, the current can be substantial, sometimes even requiring special tools and rigging to reduce the risk of being swept away. TIlis current can also make retaining diving eqUipment, especially face masks, a problem. Besides the current, rivers are notorious dumping grounds for those who live along their banks. This frequently means that there is a great deal of debris built up under the surface. The combination of sharp objects, strong currents, and often reduced visibility from suspended silt and particulate matter can cause real problems. NAUI Worldwide recommends tllat divers receive specialized training in river diving from qualified professionals prior to their participation. Some rivers have obstmctions created to enable people to live near them more comfortably. Low head and other kinds of dams may be located to provide erosion and flood control. Hydroelectric dams may create large inland lakes into which rivers feed. Fishing activity along the banks can also create unusual hazards.

72

FIGURE 5·2B. ALTITUDE DIVING IS BASED ON THE CONCEPT Of ElIUIVALENT AIR DEPTH. CONSUU LOCAL NAUI DIVE CENTBlS FOR REVIEW OF THESE CONCEPTS PRIOR TO PLANNING OR EXECUTING ALTITUDE DIVES.

When certain species are spawning, some people erect weirs, a fence set across a stream to trap fish that may pass. Occasionally, weirs are erected to temporarily divert or measure the flow of a river. Regardless of the reason, these obstructions can be dangerous to divers. Low head dams in particular can be a hazard since divers can become trapped in swirling water at the base of these objects. The currents created by water flOlving over, and then circularly at the base can easily lead to drowning as one becomes pinned and unable to escape. Such areas are to be avoided at all times (figure 5-25). Out falls and gated inlet areas, often found around power plants situated on river banks, are other areas of great potential har.m. Environmental iSsues aside, the release of processed or raw sewage can cause sudden rises in bacteria content tllat may lead to illness or infection for anyone unlucky enough to be in the area. Inlets will sometimes have deteriorated metal grates and can have pumps that create a strong local current. Either can be dangerous. These areas are generally well-known to locals who usually avoid them. Checking with knowledgeable divers will help you avoid problems with tllem. In any event, rescue in swift-flOWing or turbid or obstructed waters is a job for professional teams.

Chapter 5· Reducing Common Diving Risks

U.S. International Dive Flag

International Diver Code "Alpha"

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AGURf 5-27. USING APPROPRIATE DIVING FLAGS, AND UNDER· STANDING THE LOCAL RULfS GOVERNING DIVING CAN HElP REDUCE YOUR RISK OF ABOATING ACCIDENT WHILf DIVING.

The~moclines Still bodies of inland water offer inviting diving opportunities, but the source of their water may cause an uncomfortable situation for an unwary diver. It is a mistake to confuse the water temperature at the surface of an inland body of water with the likely water temperature at depth. Many inland waters are fed by underground streams that flow directly from deep, cold water sources. Others are fed by mountain streams and snowmelt. Since these are generally still waters, not subject to the frequent natural mixing of tides except on a seasonal basis, the denser colder water sinks beneath the surface. The interface between the warmer, sun-warmed surface water and the deeper, much colder water, is called a thermocline. Crossing this boundary can have a chilling effect on divers, especially if they are unprepared. It is not impossible to succumb to hypothermia on a hot sum• mer day while making an inland dive! It is always easy to immediately ascend above the tllennocline. Bear in mind that thermoclines are also caused by natural action within a lake regardless of the temperature of input waters.

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Altitude Diving Diving Significantly above sea level, at an altitude over 1000 feet, requires a change in exposure calculations to account for the reduced anlbient air pressure as well as the slightly less dense nature of fresh water.

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Ignoring these factors increases the likelihood of decompression sickness. Calculating allowable exposures for altitude dives is based on the concept of "equivalent air depth." (figure 5-26) l1lis means that the diver must consider the dive to be deeper than it actually is to account for the altitude's lower ambient pressure.

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Boating Traffic Although not only an issue in fresh water, the likelihood for a boat and diver collision is higher in waters that provide recreation for many people in the relatively limited areas of inland waters. Also, inland waters generally provide novice boaters with their first taste of the activity. This combination of overcrowding and inexperience is potentially very dangerous. Avoiding the problems that can result requires diligence on the part of divers especially since they are much more vulnerable to injury than the careless boater. Use appropriate dive signals on tlle slllface, and remain in compliance with any local rules that dictate proximity to the float or flag that you deploy (figure 5-27). Ascend cautiously after first pausing to listen carefully for approaching traffic. Using a buoyant signaling device to notify any traffic in tlle area of your presence prior to breaking the surface is also a good idea.

73


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Divers struck by a boat are generally critically injured. If a head wound is the result, unconsciousness and death are likely. If struck by a moving propeller, loss of limb or life is also quite possible. Diving as part of a large group, using rowboats or other surface support to maintain a safe perimeter around the undetWater activity, is highly desirable and can further reduce collision risk.

4, Streamline your equipment. 5, Pelfect your l'ick. 6, Maintain neutral buoyancy. 7. Keep fit. 8. lrim pmperly. 9, See #2, to. See #1,

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OVERHEAD ENVIRONMENTS Whether in salt or fresh watel~ diving where access back to the surface is restricted is an activity with significantly greater risks than usual recreational diving. As such, it requires significantly more training. No one who is untrained in the specific techniques designed to reduce the risks of diving in shipwrecks, caves, caverns or under ice should participate in these activities (figure 5-28). Doing so is foolish and endangers yourself and those with whom you may dive. rf you inadvertently enter such an area, stop immediately. Slowly and carefully look around to determine the way you entered, and carefully reverse yourself. Without kicking too hard to avoid stirring up sediment and destroying visibility, retrace your entry until you are clear.

Breathing-Related Problems Breathing largely consumes a new diver's consciousness on the first few scuba dives. Natural breathing interruptions like coughing, sneezing or hiccups are for the most pan harmless on the sllIface, but can cause problems for a diver under water. Most divers strive to reduce the amount of air they breathe while diving, thereby extending their time below. Alow air consumption rate is a competitive point of pride in an othetWise non-competitive SpOlt Reducing your air consumption is easy if you know the secrets of experienced divers. 10 Secrets ofLower Air Consumption: 1, Dive ji'equently! 2, Rela:<', 3. Dive with minimal bat/ast,

74

IMPROPER BREATHING TECHNIQUES "Skip-breathing," Shallow breathing, and Breath Holding [n a misguided attempt at minimizing air consumption in a seemingly easy way, some divers put tllemselves at risk of severe injuly. By attempting to breathe less, they use any or all of the techniques named in the subhead above, Unfoltunately, none of them actually work, though one would intuit they would, and :Uly of them can create a major problem, Breathing less than one needs to will only momentarily lessen the amount of air consumed. Fairly rapidly, d the carbon dioxide level in the circulatory system rises. ~ Since it is primarily carbon dioxide build-up that triggers the breath reflex, that is to say that primarily the amount of carbon dioxide in the bloodstream, NOT the lack of oX'Ygen drives the need to breathe, delaying or depressing ventilation (exhalation) of carbon dioxide, triggers the need to breathe! Thus, "skip-breathing," attempting to only exhale on every other breath, or sh~llow breathing, ~ "sipping" air lightly instead of breathing normally, over ~ the course of a dive will lead to increased air consumption. Worse, they may cause a diver to panic. Since the ultimate effect of excessive carbon dioxide in the bloodstream is breathlessness, the inability to catch one's breath, a diver using these false techniques to extend air can suddenly feel trapped under water. Hypoventilation can ensue, In this state, breathing rapidly, but only in the upper portion of the lungs, great amounts of bubbles are produced, but little gas is exchanged in the lungs, Because carbon dioxide levels


continue to increase, in the diver's mind, the mouthpiece is unable to provide sufficient air. This situation is intolerable, and flight to the surface where there is obviously "enough" air, often without the "malfunctioning" regulator in place, is the only solution. Unfortunately, it may also be the diver's last solution. The same sequence of events can take place for divers who intennittently hold t1leir breath while on scuba, Witll the added danger of lung overexpansion injury being more possible. In this case, if the diver rises as few as five feet while breath-holding, air may tear through lung tissue leading to an arterial gas embolism (AGE), in itself a potentially life-threatening event. Breathe regularly throughout every dive. Your air consumption rate will lower gradually over time as you more diligently practice the "diving secrets" given previously.

Coughing, sneezing, choking and gagging It is rare for this to happen while diving, but if it ~ does, the first and most important things to do are to

IallI hold onto your mouthpiece and maintain a stationary depth until the problem is solved. If near the bottom, settle down to exclude depth change as a concern. So long as the mouthpiece is in place and you are not changing depth, no matter what you may expel, or how you may gasp, there will be no problem. This includes those rare instances when seasickness strikes while div~ ing. (A severely seasick person should not dive, especialIallIly if the illness has been extended over several hours and has included vomiting. Dehydration is almost certain, and immersion does little to end this kind of illness.) After the episode, a simple tap on the purge valve with the mouthpiece still in place and the tongue blocking the mouth will ensure an unobstructed air flow. Any vomitus will be blown out the exhaust valve. If you must sneeze, and your mask is on tightly, it may be helpful to crack the seal slightly to relieve pressure that will build up With-the sharp expulsion of breath through your nose. Otller than this, there is not much to do but get back under control and breathing as usual. If you notice a diver coughing underwater, a friendly underann assist will reassure the person, and allow them

to relax again. Monitor depth carefully to help tile victim avoid a possible lung overexpansion injury.

HYIJerventilalion and "Shallow Water Blackout" Aproblem of skin divers wishing to extend breath- ~ hold ability, shallow water blackout claims lives annually. ~ The scenario usually includes a younger person breathing deeply and repeatedly for several minutes prior to a surface dive, who then spends more time below than would be otherwise possible because the deep breathing has significantly reduced tile usual level of carbon dioxide in the body. By doing so, tile person has short-circuited the delicate relationship between tile need to breathe - based almost entirely on carbon dioxide level- and the level of oxygen in the body. By the time the carbon dioxide level rises to the point where breathing need is felt, more than the usual amount of oxygen has been metabolized. On the way back to the surface, the partial pressure of oxygen in the brain drops below that needed to maintain consciousness, and the victim blacks out before reaching the surface. Unconscious and underwater, the autonomic system is freed from the Willful restraint of breath-holding, and the person aspirates water. Drowning ensues.

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AFINAL WORD Most diving problems are preventable. Proper training, concentrated practice and awareness throughout your diving activities will reduce most diving risks to acceptable levels. Even so, underwater and in-water recreation is never risk-free. You must maintain your ability to dive, knowledge and skills, and assess your diving fitness and fitness to participate each time you intend to enter the water. As a NAUI Worldwide certified SRD or ASRD you must also assess, as appropriate to your level of training and role, the qualifications of those with whom you dive. This is not as a means of regulating or restricting the rights of others, but as part of your commitment to increasing diving safety, as well as to preventing diving accidents. Just as you have elected to increase your diving ability, preparation and knowledge by participating

15


in a rescue course, encourage others to improve their diving ability and preparedness by continuing their diving education, and by sharing yours freely. Actively discourage any diver who is unqualified either by apparent deficits in fitness or lack of training from making a specific dive. If unable to dissuade a person whom in your best judgment is unfit to participate, make the difficult choice necessary to reduce the risk you perceive by refusing to enter the water. If you do, you will almost certainly have the opportunity to dive again. Unfortunately, tile reverse may also be true.

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77

CHAPTER

Stress an~

Distress


LEARNING GOALS In this chapter you will: I. Learn practical ways to recognize excessive stress. 2. Learn about stress related behaviors. 3. Understand how to manage personal stress. 4. Learn tile defmition of distress. 5. Learn to recognize the signs of stress and distress both on the surface and underwater. Stress and life are inteffivined. Virtually every event in life is attended by stress, since everything that occurs stimulates us one way or another. Viewed as tile normal condition of living, stress is neither good nor bad. JoY and pleasure cause stress as do sadness and discomfort. Some stress can be positive, heightening awareness and shaJjJening focus. But too much stress can be overwhelming and lead to distress, an inability to cope or function. Understanding stress in diving is central to avoiding distress and reducing the chances of diving mishaps (figure 6- J). Every dive made provides a new experience, and the uncertainty inherent in any dive is stressful. Reducing that stress to a manageable level is a corollary benefit to careful planning and preparation. Ignoring recommendations on planning and preparation, will, if the diver knows better, increase the stress of making the dive. Not knowing better, as can happen witil a poorly trained diver, will not disturb the diver in advance, but can

AGURE H ASHIP AT SEA IS UNDER STRfSS. ASHIP ON THE ROCKS IS IN DISTRESS. PlAN TO REDUCE STRESS AND ACT PROMPTlY TO REUEVE IT TO AVOID DISTRESS!

80

cause deadly stress underwater if confronted by even a routine unusual situation like a flooded face mask or difficulty equalizing pressure.

RECOGNIZING EXCESSIVE STRESS Determining if you are under excessive stress is difficult since the uncomfortable feelings experienced can m' skew perception. Agood self-test is to simply ask your- ~ self if you are eager to make the dive at hand, and then, of course, to answer the question honestly. If the answer is "no," or even just a tentative, "I think so," you are most likely overly stressed about something associated with the dive. If you cannot resolve that issue, either on your own, witil your buddy or companions, or with someone in charge of the event, stay out of the water. Certain feelings are associated with excessive stress. As an aware diver, you must monitor whether these feelings are present, and whether or not they may detract from your enjoyment. These feeling include severe apprehension, feeling ill at ease, restless or anxious (malaise), and isolation. Outright fear is not included because no one truly afraid to make a dive will do so, no matter what inducements are offered! Feelings generated by excessive stress are far more subtle than simple fear. They lead to strong misgivings and the inability to act. Attention shifts from the present to anxiety about the future. Rehearsing "what-if' scenarios as part of preparing for the dive, becomes a torment of worrying about things that will go wrong and their dire consequences, ratiler than how to deal with events that might happen. Diving in-this frame of mind is not fun, and can be dangerous. Fortunately, your awareness, confidence in your skills and ability, and careful preparation and planning lvill forestall these feelings. Unfortunately, those lvith whom you may be diving may not be so favored. Recognizing when your diving companion is experiencing debilitating stress requires careful observation. Excessively stressed individuals will frequently display certain types of behavior, depending on their personalities and the situation (figure 6-2). These

Chapter G· Stress and Distress

ago," and they often ask those around them if they saw where "I put my...." Donning gear takes a long time, and is accompanied by great frustrations. Zippers stick, buckles don't clip, bands don't hold. There's no cylinder available, the regulator doesn't fit, and the weight belt is too tight or loose or light or heavy. Things are always in a state of disrepair and disorganization. Aperson in this state may simply be very uncomfortable about making the dive. Unable to focus on the task at hand because of stress, the diver is often asking for help as a means of reassuring himself that there is someone "out there" who will take care of him. In any case, dealing with the problems on the surface will help prevent far worse problems later.

Blabbering FIGURE 8·2. FEELING EXTREME ANXIETY A80UT ADIVE IS NOT FUN! DISCUSS YOUR FEELINGS WITH YOUR BUDDY, OR ADIVING LEADER, AND IF UNRESOLVED, CONSIDER NOT MAKING THE DIVE.

behaviors can help you to "see" what feelings might be present, but remember that behavior can only give hints about another's actual state of mind. Without really having had experience with that individual, judging the actual level of stress present is purely a guessing game. If, however, the way another diver is acting makes you uncomfortable before the dive, as an SRD or ASRD, it is entirely appropriate to discuss the matter with the individual to resolve your concerns. There is no harm done if you are wrong, and an accident can be prevented if you were right.

There are many people who talk a lot, and divers tend to be a friendly and gregarious bunch as groups go. But t!lere is a big difference between conversation and incessant chatter to conceal apprehension. Divers under ~ great stress will often talk constantly, whether anyone is IaiilI listening or not! They may also simply make noise, humming, singing, whistling or even making nonsense sounds, just to fill the void they feel trapped in. In general, stress-induced chatter will center on issues concerning the dive, and in particular on how to deal with problems. Adiver expressing a series of fanciful "what if's," is probably not simply preparing thoroughly, but asking for help. Worrying aloud about water conditions, temperature, depth or continually expressing dread or consternation about the dive or its possible challenges is often indicative of too much stress.

Behavioral Extremes

STRESS·RELATED BEHAVIORS Gear-fumbling There are divers who never seem to be able to get themselves together. Their equipment is scattered, things are always missing or lost, though "just there a minute

Sometimes stress is indicated by unacceptable, outrageous behavior. There is a difference between a prank and an aggressive act, between a fondness for privacy and withdrawn, distracted behavior. When divers are acting unusually aggressive or passive, inappropriately giddy or depressed and wit!ldrawn before an initial dive, their behavior can be t!le result of excessive stress. (After diving, an unusual or dramatic alteration in behavior or

81


mood may be the result of a diving illness.) At the same time there are good divers who may be surly, and others who prefer their own company to that of others whom they do not know. Most people, however, are able to tell the difference between reasonable desire for solitude and rude, aggressive, off-putting behavior. The same is true for the contrast between friendliness and cloying dependency.

Obs .ssive Behavior Thorough, careful preparation prior to getting into the water is one hallmark of a careful diver. Repetitively setting up, breaking down, and re-setting up one's cylinder and regulator, however, is not. Nor is constantly readjusting one's mask and fin straps, or continually checking air supply and second stage function necessary or desirable. Excessive stress can sometimes cause divers to continually repeat actions, or concentrate on a specific act as if it were the talisman that would keep harnl at bay. [f someone is acting this way, it is often accompanied by being completely withdrawn from the surrounding group. They are often completely out of step with those around them, either far ahead or lagging behind the group.

HELPING A"STRESSED·DUT" BUDDY If your dive buddy evidenoes any of the above prior to the dive, or if you think this is the case, you must deal with ~ it before diving or make someone in charge aware of the IaiilI fact that you need a new buddy, and that tile reason for your decision is that you believe the person you are rejecting may be unfit to make the dive. This is difficult, but far easier than dealing with the aftermath of an accident. On the positive side, you may be able to intervene in and ameliorate your buddy's difficulty prior to the dive by simply being supportive of the person's feelings. Speak with your buddy when you become aware of their apprehension, and share your confidence with them (figure 6-3). Remind your buddy of the wellplanned dive you have both prepared for and will enjoy.

82

AGl.Ilf 6-3. 1MB oor YOI.IR I8Stfll AIlI11JT AIWII1CtlIJJl DIVE WI11I YIUl BtJIJIl'( DR AlIVING lfAIIEII CAN AIIlUENTlY PUT ClL'mNS IN1D APPflIIlIMTE PIIlSPICIM. Help to focus the person's attention, and your own, on the positive aspecl.l of the dive. Bear in mind that telling the person that "there's nothing to be afraid of' is far less effective than providing them with an alternative to their misgivings. That alternative is the confidence that comes from their prior successful diving experienoes, your mutual planning and preparation, the thorough buddy briefing you have had, and from having you as their buddy. [f you share witi1 them your experience, not as a source of all knowledge, but simply as another well-prepared, enthusiastic diver, you may very well relieve the person of the feelings that are detracting from their proper enjoyment. Learn to listen to the other person without judging. Separate what is being said from what you think the person should be feeling or should know. Instead, attend to what the person is expreSSing, and appreciate that this is not an easy thing for this"person to discuss. Never invalidate the other person's feelings by expressing shock, amusement or by belittling their concerns. It is far more effective to let people slowly talk themselves free of their doubl.l, than to try to push the doubl.l aside. If the individual feels that you do not understand or do not care, there can be no resolution, and worse, the conversation lvill cease. Many people lvill simply gloss over the problem in this case, and take a bad situation underwater. Don't let this happen to you, or to anyone with whom you dive.

Chapter G- SlI'ess and Disll'ess

PERSONAL STRESS MANAGEMENT Stress management is one of the growth industries of modern times. Various "gurus" offer advice on reducing stress by employing diverse means from diet and meditation to more or less fonllal religious practices. While all of these methods probably have some value for adherents, preventing excessive stress in diving is remarkably susceptible to some very simple, far less esoteric means. There is absolutely nothing better for removing negative stress from diving than feeling competent and confident about your ability based on a frank assessment of your level of fitness, diving knowledge and well-practiced skills! Coupling this foundation to careful preparation and planning of all your diving activities and always diving well within the level and activities for which you are trained, will insure that the pleasant stress of excitement, anticipation and enthusiasm is the only one you experience while diving, If stress does start to build before a dive, however, it is importimt for you to recognize and deal with it immediately and effectively. One way is to maintain a keen sense of self-awareness about diving by giving the activity the attention it deserves. Too often people dive as an afterthought to a full schedule of other demands and bracketing commitments. If you need to rush your dive to get it in around other recreational, social or family commitments, consider leaving something out. You will enjoy whatever you decide to do far more if you do not feel that you should be doing something else, stealing time and attention from something equally or even more compelling. Basically, come to your diving with a clear head and a positive outlook. Be prepared to enjoy yourself, and wait to dive until you freely can without guilt over something else you are mi&ling or ignoring. If beginning to feel apprehensive about a dive for any reason, consider whaWipecifically is bothering you. Frequently there will be a particular part of the dive or the activity that is making you uncomfortable. Once you discover what it is, think about it consciously. Bringing the problem into the forefront lvill often resolve it. Vague anxieties often fade under sober scrutiny. If

m

AGURE B-4. BUOYANCY CONTROL IS KEY TO ARElAXING DIVE EXPERIENC[

the problem doesn't go away, then look into its causes more thoroughly. Is tllere something about this dive that is legitimately troubling, and if so, how can you resolve it beforehand? The previous chapters detailed some means to remove contl1Jllable risk variables as much as possible. However, some lisks 1I1ll always remain, and it is entirely possible tllat you may not be 1I111ing to assume tllem. If so, don't dive. It is more likely, ulough, that your concems are not focused on any specific aspect of the dive, so much as they are focused on your own ability. Review your preparation and dive planning. Discuss Ule dive with your buddy and a diving leader UUlt may be running the activity. If your qualms remain, you can always opt not to dive. One useful technique for removing vague apprehensions about a dive is to visualize the pleasure and satisfaction the dire promises to provide. Focus your attention on the desirable adventure that diving represents, and mentally rehearse all of your actions on Ule

83


upcoming dive. If you can see yourself successfully enjoying the dive, you are most likely to calm dO\~ and actually do so. Practice calming yourself before you enter the water in the same way, by seeing the dive before you experience it. If you are prepared, savor the feeling of knowing that you have done a good job in getting ready, in organizing the dive, planning the activity on your own and with your buddy. Review your plan so that it is in the forefront of your mind. When you get into the water, relax consciously. Calm your body, regulate and adjust your breathing and enjoy the sensation of floating that comes from proper weighting and buoyancy. Diving is not a race. Relax, don't rush into it! Under-vater, strive to make your movements fluid -pun intended! Adapt to being in the water, and being in control. Have confidence in your ability, and in your eqUipment and your use of it. Float, weightless in the dive (figure 6-4). Descend slowly, clearing in anticipation of any pressure, soaking up the experience of your surroundings. Breathing rhythmically, inhaling and in particular exhaling fully and slowly as you relax will help you maintain a calm and collected mental state. Keep your buddy close at hand and make eye contact from time to time. Feeling cOlmected with your buddy, and at ease in the environment you are enjoying will prevent any negative, overly stressful feeling from developing. Finally, be aware of your illler dialogue. Successful people in any endeavor from athletics to zoology, speak to themselves positively. Under-vater, where communication with others is limited for most, you are your own best conversationalist. Concentrate your attention on tile wonder that you are experiencing, while you maintain careful awareness of what is around you and the demands of the dive, and stress will not hamper your perfonnance.

AGURE &-5. ORE OFIDJ T1lAII Nin AOIVBlIN DISTRESS IS OBVIOUS!

or ASRD, your most useful diving-related skill will be your ability quickly to assess and effectively address growing stress and actual distress in your diving associates.

SIGNS OF DISTRESS Unlike stress, distress is usually obvious and easily observable (figure 6-5). There is nothing subtle about someone struggling for buoyancy or air, or having difficulty managing themselves on the surface or underwater. However, there is a phenomenon known as Passive Drowning, wherein victims passively accept their fate and slip quietly beneath the surface. This might also be identified as such, because the observer discovered the victim post-struggle, having become exhausted and giving up. SRDs and ASRDs need to develo~ their awareness of other divers as acutely as they develop their self-awareness. Keen observation and the ability to quickly and effectively intervene will often prevent an incident from becoming an accident.

DISTRESS When stress is so excessive that an individual can no longer cope, it becomes distress: acute anxiety due to uncontrollable physical and mental stress. Distress requires immediate rescue or hann will result. As an SRD

84

SELF·RESCUE You are your own best buddy on any given dive, and as a result, you are also your own best source of aid.

Chapter 8· Stress and Distress

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FIGURE 8·7. THE EASIEST WAY ENSURE YOUR SURVIVAL IF IN OISTRESS IS MAKE SURE YOU ARE POSITIVB.Y

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8UOYftNTI PRACTlCE OOOPPIMl YUill M1GIfT IlfU AMI NEVIll HESITATE IF DOING SO cmssES YOUR MIND.

This presumes that you remain observant of your own mental and physical state tllfoughout any dive you make, and that you are fully prepared to act if confronted Witll a problem, even to the point of leaving the water. At the surface, the ability to maintain buoyancy is crucial to any diver's survival. At the first hint of a problem, or at the first moment that you consider that buoyancy is an issue, DROP YOUR BALLAST I (figure 6-6) It is a sad fact that many diving accident fatalities are found wearing a weight belt. Had they only dropped tlle weight, there would have been at least a chance of their having been on the surface where their possibility of survival would have been immeasurably higher (figure 6-7). Once tlle ballast is gone and buoyancy is assured, by either the exposure suit or the exposure suit and an inflated Be, relax. Taking the time to literally catch one's breatll, tllink about what is happening and how best to proceed is often the solution that will relieve the difficulty.

RGURE 8·7. RECOMMENDATIONS ABOUT STREAMUNING EQUIPMENT CONFIGURATIONS AND PRACTICING SKillS COMES FROM EXPERIENCE.

o one can ever depend on ove~)()wering natural forces. Instead, a well-trained diver or snorkeler knows how to accommodate themselves to the forces of nature to allow the person and the forces to co-exist as comfortably as possible. One technique for this is to practice the skills of survival swimming. This simple technique of rhythmic breathing in conjunction with immersion of tlle head and face can provide a tired or stressed person in tlle water with the needed respite to regain command and control of the situation and themselves. Realizing that your head is the only weight that you are trying to keep out of the water, time your respirations so that your face is free of the water only when it is necessary to take a breatll. At other moments, relax, exhaling into tlle water, and let your natural buoyancy, aided by your exposure suit and Be, if any, do tlle work. Over tlle brief span of a few controlled breaths, you will find yourself relaxing. When calm, decide how to proceed.

85


rescuer's relationship with the individual under other circumstances, anyone or tiling standing in the way of the victim's escape from their perceived problem is in danger. Trying to help an irrational person is no proof against their hanning you. In the state they are suffering, there is no friendship, consideration or reason. Depending on the victim's common sense to help alleviate the distress is an error that can result in the wouldbe rescuer's injury, or even death. No matter what the problem is that is being experienced, so long as the victim and rescuer remain on tile surface, it \vill pass. ki a result, the first task of the rescuer is to insure a safe distance for one's self and buoyancy for the distressed person. In a commanding tone, tell the person to: Drop Ballast! Inflate the Be' You will learn several techniques for safely approaching a person in this condition, but realize that your decision to intervene puts you at risk. It is wiser to wait until tlley lire suffiCiently before making contact. fiGURE 8·8. ADIVER IN DISTRESS IS DANGEROUS TO CONTAC~ BUT WILL QUICKlY TIRE.

OBSERVABLE SURFACE PROBLEMS Sinking, AgUaDon, Gear Removal/Rejection, Erratic Breat~i g·"Bubble Mania," Terror However it manifests, a person in distress at the surface is in obvious, easily recognizable trouble. Their behavior is characterized by frenzied activity the goal of which, if any, is to get out of the water. The rescuer's job is to see that they do so without hurting themselves or anyone else in the process. Observing a diver unable to maintain herself at the surface, removing equipment in an agitated, unorganized fashion, gasping for air, rejecting the mouthpiece or fighting to get higher in the water -literally trying to walk out of it, is frightening for anyone who witnesses it (figure 6-8). The person is out of control, and at the moment, no matter who the person is othel\vise, or the

88

UNDERWATER SIGNS OF DISTRESS/IMPENDING PROBLEMS Aperson in distress undel\vater is frequently less obvious than one in a similar condition on the surface, but the situation is far more serious. Without swift and effective aid, a submerged person in distress can drown. Even with aid, the likelihood of a serious injury to the rescuer and the victim is much high~r when the incident occurs undelwater. •

BUbbles The first and clearest sign of a person in distress or difficulty wldel\Vater is usually indicated by some problem \vith their breathing, and that means bubbles (figure 6-9). If there are clouds of bubbles, or few bubbles apparent, investigate immediately. Excessive bubbling can be either the result of an eqUipment problem, or worse, a diver unable to control breathing or gasping

Chaple~

6- Sl~ess and Disl~ess

for air. Too few bubbles can be the result of breathing having been interrupted or halted due to injury or unconsciousness, equipment failure or running out of air. In any case, the diver is threatened with drowning.

Divers who have difficulty controlling tileir buoyanC)' are more likely to suffer accidents than those who can. Observing an individual "elevator diving," making large depth changes for no apparent reason, hand on the Be inflator, struggling shallower, then sinking rapidly and repealing the C)'de is to see an underwater cry for help. Even if the only help needed is to assist the individual to stabilize at a depth and relax, intervention will prevent a more serious problem from developing. Apart from the up and down diver, you may observe a diver simply sinking rapidly, finning against it, or not. No matter what the cause of this, over-weighting, poor technique, or even unconsciousness, if the diver is apparently out of control, aid is required. What is an acceptable risk to take aiding this person, however, will depend on the circumstances of the dive, your own air supply and the depths involved.

Eli, J,r yMVL n,nt CSc ned S"ff ) Fear can consume a (generally inexperienced) diver at any depth, even within the first few feet of tile surface. More experienced divers can also grow terrified from any number of reasons ranging from some psychological problem exacerbated by tile specific dive, to inert gas narcosis or seeing a particular marine animal. In any case, a person who appears unable to function well undel\vater, listless or tense, whether accompanied or not by apparent breathing or buoyancy difficulty, may be having a serious problem. Approach this indi\~dual Witil special caution since tilere is no way to tell what their mental state mal' be, nor how they will react.

lI~al

OrientationJ1 im Prot P, s

Adiver who is swimming horizontally through tile water maintaining a vertical orientation, may be trying to

FIGURE 9·9. ARElAXED DIVER IN CONTROL OF DEPTH AND TlUM USES lfSS AIR.

escape from deptil or may just be poorly trained. If tile movements are accompanied at all by signs of stmggle or breathing anomalies, react to it as a problem that requires intelvention. If no otiler signs are apparent, continue to observe the diver in case the situation deteriorates. If you are this diver's buddy, consider ending the dive, or at least, returning to the surface momentarily to discuss your observations and reassure yourself of the diver's fitness and ability. It is always preferable to sacrifice a few minutes of bottom time for the chance to dive again, rather than to let a more serious problem develop.

Any diver who discards the mouthpiece in particular, or any other piece of gear underwater in an apparent panic should be considered in grave danger, and requiring immediate assistance. Whether you approach this diver to render aid depends on your proximity, the circumstances of the dive, your level of duty, if any, the assistance you are capable of providing, and the level of risk you are Willing to assume. Even if you are in a position to help, decide to do so, and do everything right, a diver acting in this manner undel\vater is very likely to suffer severe injury or death despite the best efforts and intentions of a SRD or ASRD.

87


RESCUE Rescue begins with a complicated, but almost instantaneous mental process that includes several steps (figure 6-10). The first step is to realize that there is a problem. This is followed by simultaneously considering several crucial variables. These include:

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Is It Sale To Intervene? Ironically, the answer to this question is always NO. The real question is, "Am I willing to assume the risks that intervention represents?" Your answer to tllis question will depend on the situation, your level of duty, if any, and your honest appraisal of, and confidence in, your training and physical ability. • What can I do to relieve this person's distress? • Do I know what should be done? • Am I capable of perfonning to the needed level? • Am I close enough to make a difference? • If the answers to all of the above are positive, you may then act.

FIGURE 8·10. THOUGHT SHOULD ALWAYS PRECEDE YOUR iNTERVENTION, EVEN IF ONLY FOR ASPLIT SECOND!

mitment and creativity on the part of everyone involved to achieve success, nor is success especially likely despite good intentions and the willingness to accept extraordinary risks.

EFFECTING ARESCUE No matter what the situation, all diving rescues of an unconscious victim will follow the same scenario: I. Get the victim to the surface. 2. Establish buoyancy. 3. Stabilize breathing or begin and maintain appropriate life support. 4. Remove the victim and the rescuer(s) from the water. 5. Provide appropriate first aid in consideration of tlle victim's needs and available personnel and supplies. 6. Activate the Emergency Medical System. 7. Transport and/or maintain the victim until relieved by more qualified personnel. How a SRD or ASRD goes about achieving the goals of the standard dive rescue scenario will depend on the individual circumstances of the situation. Rest assured that in any case it will require hard work, com-

88

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89

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CHAPTER

Dealing With An Out-Of-Air Emergency


LEARNING GOALS ~

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[n this chapter you will: 1. Learn the importance and ease of preventing out-of-air emergencies. 2. Review procedures for emergency ascents. 3. Understand the advantages of a redundant air supply. 4. Understand the problems associated lvith sharing air in an emergency. Few situations are as distressing or life-threatening as running out of air while scuba diving (figure 7-1). Fortunately, given the advent of the submersible pressure gauge and ever more reliable air delivery systems, it is virtually impossible, but for human error. Indeed, running out of air is most frequently the result of poor planning or insufficient monitoring of air supply. Regardless, dealing with an out-of-air emergency is taught in every beginning certification class. There are several compelling reasons why this is true, but foremost among them is not, as might be thought, to avoid liability in case a diver does run out of air. Rather, it is to instill within new divers the confidence in their own ability to cope lvith any emergency, even the worst one imaginable!

FIGURE H YOUR BUDDY'S COMPETENCE AND PROXIMITY ARE CRUCIAL IN AN OUJ.OF·AIR EMERGENCY.

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PREVENTION IS EVERYTHING Running out of air is the Single most avoidable event in diving, yet it can occur if one is not familiar with some elementary rules of dive planning, or is careless while diving. All divers lvill use their air supply at a different rate. This rate depends on many different variables, some of which, like level of exertion, can change lvithin tile course of a dive. Even so, by monitoring one's air supply throughout the dive, and making sure never to stay past the point of a pre-planned minimum amount of air to ascend, it is virtually impossible to run out of air. NAUI Worldlvide teaches divers to record the way they use air on each dive in their log books. By creating a personal data base of air consumption, usually reduced to an easily applied unit, like liters or cubic feet per minute of air consumption a diver can estimate fairly accurately at what point to ascend from any depth with a good margin of air left in the cylinder for contingencies. TIlese calculations, however, are only predictions. Actual usage will vary according to the dive, which makes consistent monitoring of your own, and of your buddy's air supply mandatory. Careful monitoring of your own and your buddy's SPG throughout every dive is the most reliable means of aVOiding an out-of-air emergency. Buddies should also agree before the dive on what tile minimum air supply to leave the bottom is, and furthennore, agree that when either member of the teanl reaches that point, both divers lvill surface. On some organized dives led undel\vater by a qualified diving gUide, the plan often includes an ending point in the proximity of the exit point where divers can relax and enjoy the end of the dive after a tour. Sometimes the leader will have beforehand infonned divers of the recommended minimum air to leave the bottom, and lvill allow divers to change buddies for the ascent to accommodate different rates of air consumption. This is a very different situation tllan diving alone with a buddy. When diving solely with a buddy, or with a group of buddy teanlS, it is the individual divers' and buddy teams' responsibility to coordinate their air consumption planning as it is to coordinate tile rest of the diving activity. Having a buddy who has asimilar air consumption rate R.l\ will help to insure a more enjoyable dive for both buddies. ~

Chapter 7- Dealing With An OUI-Of-Air Emergency

But having vel)' different air consumplion rates may tempt the diver with the more rapid rate of usage to seek to extend the team's time underwater by ignoring the planned minimum amount of air to ascend. This is a dangerous practice that puts both divers at risk. If diving with a buddy who has a lower consumplion rate than you is the only choice, as is often the case when diving with a more or less experienced buddy, or with a member of the opposite sex, it is often better for the more air-efficient diver to use a smaller cylinder. Both divers will then reach a pre-planned minimum anlount of air to leave the bottom at about the same lime. The diver with the lower consumption rate, generally the smaller diver physically, will also benefit from haVing had to carry less raw weight around due to tlle lighter cylinder.

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SElf-RESCUE fOR AN OUT-Of-AIR EMERGENCY Though good buddies always remain within touching distance and monitor each other throughout the dive, it often happens that buddies separate beyond this recommended spacing. This is especially true in shallower, clear, warm water. The envirOlllilent feels more relaxed, and the buddy is easily visible from a good distance away. Unfortunately, even in benign environmental conditions, divers do not grow gills, and running out of air is as much an emergency under the best circumstances as under any others l In this situalion, faced with the prospect of S\vimming after a buddy who is inattentive and some distance away, or making a direct ascent, heading for the surface may be the best course of action.

EMERGENCY SWIMMING ASCENT NAU IWorldwide recommends that an emergency s\vimming ascent be used primarily from a depth of less ~ than 10 to 15 meters (30 to 45 feet) (figure 7-2). If a W diver finds himself unable to draw breathe from the reg-

FIGURE n AN EMERGENCY SWIMMING ASCENT IS INCREASINGLY MORE D1FFICUIJ mOM DEPTHS GREATER THAN 10 METERS. STAY CLOSE TO YOUR BUDDY, AND MONITOR YOUR AIR!

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ulator, and out of position to request timely assistance from a buddy, S\vim to tlle surface at the recommended rate with the mouthpiece in place, exhaling throughout the ascent. Although there may be apparently no air in the cylinder, retaining the mouthpiece in place \vill help keep tlle airway open during the ascent, and if necessal)', the diver can at least attempt to get a breath. Frequently, as ambient pressure is reduced, especially within tlle area of greatest pressure gradient, between one and two atmospheres (surface and 10 meters [33 feet] of seawater), residual air in the cylinder will become available. Divers erbibiting any sigllS or e.rperiellcing any symptoms tbat may be associated witb a diving injUlJI or illness wbo have made an emergency swimming ascent sbould be placed immediately on Q.\ygen at as bigb an inspiredpartialpressure as possible and EAtS activatedfor evacuation to a medicalfacility The Be hose should be extended overhead.

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Expanding air can be released in bursts, but should retain some air to provide buoyancy. If the ascent rate is too fast, raise the hose to dump more air. At the surface, immediately inflate the BC orally. l1le weight belt should be retained in place until reaching the surface, when it should be discarded. Note that this is a relatively simple, underwater swimming procedure that can still have dire consequences. The ascent will undoubtedly be made faster than it would be under more controlled conditions. There is a greatly increased risk of a serious diving iJIness or lung overexpansion injury as a result of the rapid out-of-air asoent. Any diver who makes an emergency out-of-air swimming asoent should be examined by a qualified diving physician before diving again.

EMERGENCY BUOYANT ASCENT From depths beyond ten meters, it is possible that an out-of-air diver will not be able to maintain consciousness long enough to reach the surface. Partial pressures of cerebral oxygen may drop below the level needed to support consciousness. It is also possible that some divers may experience this from deptlls shallower than ten meters. As a result, some divers may begin the ascent swimming, but may need to include buoyancy to complete the trip to the surface (figure 7-3).

If unable to draw breath from the cylinder at depth, immediately begin swimming to the sUlface with tlle moutllpiece in place, exhaling while ascending. Do not empty the BC. Residual air in the bladder will expand on ascent, increasing buoyancy and the ascent rate. As with an emergency swimming ascent, it is possible that reduced ambient pressure will "free" residual air in the cylinder allowing the diver in distress to draw air. In any case, the mouthpiece should be retained, and the urge to breathe satisfied at any point in tlle ascent. After leaving the bottom, the diver should drop the weight belt or jettison other easily removable ballast. Flare the body back as means of controlling the ascent rate by increasing water resistance (figure 7-3). Unconsciousness underwater at any depth is most often the precursor of death. At the same time, being found on the surface at least insures that further aid will be much more likely to do some good. Paying attention to ballast distribution and floatation characteristics of the BC being wom can help to ensure that a diver found on the surface lvill be in a face up position. It may be as simple as shifting some ballast to adjust trim so that, in a relaxed state, divers will slowly roll onto their backs, helping to open and extend the airway. Because a dil'er's buoyancy varies during a dive, it is necessary to check the relaxed surface floating position both at the beginning and end of a dive to determine tlle optimum ballast distribution. It is also necessary to consider eqUipment configuration tllat can vary from dive to dive because of changing dive objectives or reliance on rental gear. This is another good reason to own a complete set of equipment and become intimately famiJiar with its operation and idiosyncratic characteristics - buoyancy and otherwise.

EXTRA AIR IN AN EMERGENCY

fiGURE 73. FlARING OUT ON YOUR BACK CAN HELP SLOW THE ASCENT RAlf IN ABUOYANT ASCENT

94

There are other creative means of helping to insure tllat divers need never run out of air, and these are more or less effective if used properly. One such device, Spare Air~(figure 7-4), provides a small cylinder that has an integrated mouthpiece and regulator. Attached to the

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

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AGURE 74. REDUNDANT SPARE AIR" IS ASElf CONTAINED BUT MINIMAL AIR SUPPLY.

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

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

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

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

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

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

MUTUAL EMERGENCY PLANNING

ALTERNATE SECOND STAGE AIR SHARING TECHNIQUES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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CHAPTER

Underwater Rescue


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

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

102

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

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

Chapter 8- Underwater Rescue

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

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

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

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

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

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

104

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

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Chapter 8- Underwater Rescue

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

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

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

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

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

liIJ 105


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

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

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UP

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

IN

T. T

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

108

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

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

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

[I

It'

otes

107

CHAPTER

Diving Maladies


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

IiIJ

110

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

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

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

are lell,

Circulation of Air Sac Arterial

FIGURE g.1. GRAPHIC OF LUNGS

Airway

Chapter g- Diving Maladies

3

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

TYPES OF LUNG OVEREXPANSION INJURIES

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

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

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

PIl

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

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

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

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Arterial Gas Embolism

Mediastinal Emphysema

,,

, ,

I

Pneumothorax

Subcutaneous Emphysema"

fiGURE 9-2_ LUNG OVEREXPANSION INJURIES

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

112

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

Chapter g- Diving Maladies

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

vein

Nitrogen bubble blockage in capillaries

1:: •

c-

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

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

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Decompression Sickness Theory

-A

B

-

c

o

E

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

FIGURE 9-4. GRAPHIC OF DeS

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

"s in

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

114

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

lOb

."

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

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

Chapter 9- Diving Maladies

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

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

rn

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

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

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

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

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

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

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

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

118

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

[btl


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

m

2.

3.

4.

5.

6.

7.

8.

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

•

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

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

117


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

118

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


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

...

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CHAPTER

Treatment 01 Diving Maladies


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

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

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

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

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

Chapter 1O· Treatment of Diving Maladies

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

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

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

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

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

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

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

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

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

Chapter 10- Treatment of Diving Maladies

Cylinder Type

Liter Volume

Time per Cylinder

C

200

40 minutes

Portable kits, generatty carried in pairs.

0

350

70 minutes

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

Application

delivery system is included.

E

626

125 minutes

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

M

3000

App. 10 hrs.

Boat or trainin tacilit su

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TABLE 10·1.

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

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

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

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

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

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

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Chapter 10- Treatment of Diving Maladies

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

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

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

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

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Communications Sound Powered Phones

A&URE 10·8. BECOMPBESSION CHAM8E8

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

128

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

Chapter 10- Treatment 01 Diving Maladies

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

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

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I

CHAPTER

Surtace Rescue


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

ASSESSING RISK

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

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

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

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

Chapter 11- Surtace Rescue

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

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

SURFACE RESCUE PRIORITIES

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

Ensure Buoyancy

Ensure Breathing

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

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

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

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

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

34

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

Chapter 11· Surlace Rescue

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

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

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

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

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


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

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

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

DEALING WITH PANIC AT THE SURFACE

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

38

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

Chapter 11· Surface Rescue

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

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

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

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

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

m

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

131


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

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

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

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

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

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

I':""r'1 ~

Chapter 11- Surface Rescue

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

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

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

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

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

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


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

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

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

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

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

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


m

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

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

Paddlec~alt

and Dive Kayaks

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

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

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

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

141


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

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

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

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


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

MOVING AN INJURED OlVER

rn

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

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

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

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


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

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

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

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

Chaplep 11- Supface Rescue

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

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

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

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

IirI ~


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

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

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

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

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


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

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

FOUND OBJECTS

CARRIES AND LIFTS

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

m

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

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

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


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

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

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

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


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

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

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

Bank Drags

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

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


SHORE CARRIES WITH HELP

[tJ

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

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

Two-Person Carry

Three-Person Carry

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

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

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


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

CHAPTER

Diver First Ai~


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

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

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

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

Chapter 12- Diver First Aid

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

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

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

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

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155


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

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

2. 3.

4.

5.

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

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

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


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

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

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

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

151


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

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

158

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

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


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

CRAMPS

m W

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

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

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

159


m ~

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

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

180

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

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

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


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

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

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

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

Stin s. U~ChiqS,

Jell~ish

dRays

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

lbtJ 181


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

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182

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

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

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

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


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

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

m

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

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

183

I


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

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

184

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

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

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


[t]

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

185

CHAPTER

The Chain 01 Survival in Diving Accidents


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

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

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188

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

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

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

1m

Chapter 13· The Chain of Survival in Diving Accidents

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

PERFORMING CPR

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

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

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

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189


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

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

170

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

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

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

m

Chapter 13- The Chain of Survival in Diving Accidents

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

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

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

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

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

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

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

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

171


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

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

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

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

172

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

COLD WATER DROWNING

,"

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

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173

CHAPTER

Accident Management


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

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

EMERGENCY PLANNING BEFORE THE DIVE ~

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178

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

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

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

Chapter t4- Accident Management

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

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

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

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

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

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

m

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

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

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

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

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

Chapter 14- Accident Management

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

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

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

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

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

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

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

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

Chapter 14· Accident Management

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

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

Victim Transport and Transfer Ii"fI"1

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

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

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

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

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

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

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

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

Helicopters Helicopters significantly increase the ability to deliv-

Chapte~

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

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

14- Accident Management

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

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

183


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"

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

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

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

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191


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

....w

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

192

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

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

c

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

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

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

INDEX

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

Dry suits problems with

.. .

..59 56, 104

......

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

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

..

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

G Grates, river diving hazards

72

193


H

R

Hypertension Hyperventilation Hypoventilation

27 ...75 74

Ice Independent ascents Infections, temporary contraindications

..40, 66 93-95 23

J Jellyfish

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

L Lifts, surface rescue and

148

M Mask rescue loss of scuba mask partial rebreather Medications

.. ..

125, 126 5 I25 24, 25

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

..

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

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

194

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

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

INDEX

mask

56

sinus Stress Stroke

.56, 117 \2, 80-84

164

Surf surface rescue and

71

\46

Surface rescue

132

T TB

21

Telephone, cellular, emergency

44, 45, \77, 180

Tidal currents

69

Tobacco as contraindication to diving

25

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

.

6\ .21

u Undel\vater rescue, emergency ascent and

102-107

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

72 156, \58

•

195

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

headings

tab system

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

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

Clear headings on every page improve access to specific subjects.

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

• new lea~ning featu~es

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learning goals

lull color design

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Clear leaming goals are outlined for each section.

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

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

Learning goals set /foreach section.

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Each chapter is color coded to Visually organize the information.

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

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infonnalion. responsible diling ~ practices. ~ In~icates

ISBN 0-9679903-2-7

Item #15400

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NAUI Rescue

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