Diver Medic and Aquatic Safety Issue 1 by Diver Medic and Aquatic Safety

DIVER ISSUE 1

RED CROSS

in action

THE ITALIAN

MEDIC

&nd AQUATIC SAFETY

WATER OF LIFE STAYING HYDRATED

DEPTHERAPY HOW IT CAN SAVE LIVES

POLICE SURVIVAL IN NEW YORK CITY

DIVER MEDIC & AQUATIC SAFETY

A note from the Editor There are two passions in my life, Medicine and Diving. At the age of thirteen I began diving, starting off with a NAUI scuba course in Cape Town, South Africa with my Mother, Father and Brother, Sean. I remember closing my eyes as I flipped back off the Rib into the sea, making sure not to see any creatures that could possibly eat me. Now a Divemaster with a new understanding of the sea, I can not wait to open my eyes to new discoveries under the water. My love for medicine came at an early age of five, my parents asked; ‘what would you like for Christmas?’ to which I replied, ‘a box of plasters’. At the age of Nineteen I joined the Ambulance Service in East London, South Africa. From then on I continued my passion for medicine and soon left for the United Kingdom. Three years ago I combined my love for Diving and Medicine creating, The Diver Medic Facebook group. The group is a closed group, containing almost 7,000 active members. While building The Diver Medic group, I applied for the IMCA (International Marine Contractors Association) Diver Medical Technician Training Centre accreditation and was awarded the approval in February 2012. Since then I have been teaching with DAN Europe and Code Blue Education Ltd as the DMT course director. Why another Diver magazine? What makes this magazine unique is that it is the ONLY magazine completely devoted to the health, safety and effectiveness of divers of all kinds and of all water rescue/recovery personnel. It is the only truly encompassing magazines for all divers (recreational, working dive leaders, public safety, diver medics, technical, commercial, and military) and for all members of the water rescue and recovery community. We know you will love it! Editor in Chief and creator of “The Diver Medic” Chantelle Newman (London, UK)

ISSUE 01 | AUGUST 2014

Deptherapy How it can save lives

The Italian Red Cross In Action

Water of Life Staying hydrated

Managing Director Chantelle Newman

Editor Andrea Zaferes, Edmund Brown, Kelly Anne Moon

DESIGN Allie Crawford, Sarah Crawford

Advertising and Subscriptions Chrissie Taylor

Medical Advisor George Schroeder MD www.Oceanicrenaissance.vpweb.com

WRITER John Bantin

PHOTOGRAPHERS Chloé Maréchal, Wade Imaging, The Red Cross, Gergely Zsolnai, Shane Gross, Maridav, Tina Sotis, Stephan Kerhofs, Kristina Vackova, Gareth Lock, Rich Carey, Polly Dawson, Team LGS, Ethan Daniels, Cigdem Sean Cooper, Stephen Kerkhofs, Yiorgos GR, Kant Komalasnankoon, Little Sam

Magazine address The Diver Medic Ltd Great West House, Great West Road, Brentford, TW8 9DF

Telephone +44 020 8326 5685 EMAIL info@thedivermedic.com

White Rock turns poisonous

Improving Safety Evolution or Revolution

Police Survival In New York City

Dive Accidents happen to others... not me

A Prickly Situation With the Crown of Thorns

Near Misses With rebreathers & CO2

Women Divers Hall of Fame

DIVER MEDIC & AQUATIC SAFETY

DEPTHERAPY SAVED MY LIFE By Dr Richard Cullen

ISSUE 01 | AUGUST 2014

In his younger days Dr Cullen was an elite sportsman before careers as a senior police officer and senior civil servant followed. He learnt to dive in 2007 at 56 years old. As a sport he loved it and as such he then became involved with injured troops to rehabilitate through scuba diving. He is now responsible for Operations worldwide and is an Instructor Trainer for Deptherapy and Deptherapy Education. Dr Cullen spoke to us here at Diver Medic Magazine on how Deptherapy can save lives. Richard Cullen is the Director of Operations and Media for Deptherapy Education where he has worked as a volunteer for the Deptherapy Foundation since 2010. He explains, through Chris Middleton’s story, the process and therapeutic results of Deptherapy. "Chris was blown up nine days before his 21st birthday when he stepped on an IED in Afghanistan. Chris lost both of his legs, one below and one above the knee as well as suffering damage to one of his arms.” The above comments were posted by Chris on Facebook in March 2014. I first met Chris at Headley Court British Armed Forces’ rehabilitation centre in Surrey. He had been referred to me by a mutual friend. Chris typifies how Deptherapy, a UK based charity (www.deptherapy.co.uk), helps injured UK and US armed service personnel to rehabilitate from life changing injuries. Deptherapy was founded by Fraser Bathgate who was

"In my eyes Deptherapy will always be in my heart. If it wasn’t for Richard Cullen and Deptherapy I wouldn’t be the man I am now. You have my full support." Chris Middleton, 23 year old, Royal Scots Regiment

Photo by Chloé Maréchal

DIVER MEDIC & AQUATIC SAFETY

paraplegic as a result of a climbing wall accident when he was 23. Fraser became a PADI Instructor and a pioneer in the world of ‘disabled’ diving. Within Deptherapy and the newly formed Deptherapy Education, the training wing of the charity, we dislike the word ‘disabled’ and prefer to refer to the mental and physical challenges our programme members and students face. Since 2008, Deptherapy has been taking UK troops to the warm waters of the Florida Quays to experience scuba diving. When they arrive, the British troops meet similarly injured US Marines, who are being cared for at the Walter Reed/Bethesda Military Hospital in Washington. Chris and I met in 2011 not long after he had been injured. He wheeled himself down to the gatehouse at Headley and I was struck immediately by this young, personable young man. It is important for anyone who works on the Deptherapy programme to look beyond the injuries an individual has suffered and see the real person inside an injured body. So for us it is very important to experience the person behind the injury. It is easy with a charismatic, lively individual like Chris to be overwhelmed by sorrow and sympathy for his injuries and his altered life. The last thing you need to do is become emotional about the injuries. I have never known Chris with legs and his lack of lower mobility only concerns me so far as it influences his diving and me teaching him on his PADI courses. So whether he is in his wheelchair or on his prosthetic limbs, to me he is just Chris. Chris was enthused by the thought of diving in Florida as I guess many would be but the Deptherapy experience is not a holiday. It is a programme with a purpose to get the participants in the pool and then to the ocean for three dives. They do the complete PADI DSD experience in the pool and then in OW water. So the months of planning were done and Chris met me at Heathrow Airport with Richard Ward, a bi-lateral amputee from the Household Cavalry, and Carlos Buckley, a paraplegic after being shot through the spine during a Taliban ambush. The first task once in Florida was to kit the guys out in their scuba gear and set off to the pool

for a couple of hours. Chris’ face was a picture; he smiled continually before hopping out of his wheelchair and ‘bum shuffling’ to the pool’s edge. His kit was placed upon him and then he was lifted into the pool. One of the first things we do to ensure that the injured guys are properly weighted is to use weighting maps. They often require more weight on one side than the other and more in the front of the bcds. So it is important to have bcds with integrated weight systems. Weighting systems such as Bright Weights are essential to ensure the student doesn’t topple forward, back or sideways. Chris, Richard and Carlos beamed with delight when doing his skills. Each student, depending on their injuries, has at least an instructor but in the case of these guys a DM as well as a Support Diver were with them. All the guys completed their skills easily before having some fun in the deep end of the pool with various underwater toys. But the best was yet to come. Chris and Richard were to dive with my team of instructors and dive masters. They did a backward roll off the boat and when they surfaced they both had huge smiles across their faces. Dan Dawson, the owner of Horizon Divers who we dive with, always selects excellent dives where there is lots of aquatic life. Staff need to be aware that some students, such as Chris, have thermal issues and we needed to seal off the legs of the wetsuit with cable ties so water would not flush through. Now he has a tailored wetsuit with small drain holes where it seals around his stumps. Chris and Richard, after doing these dives, both asked to take their diving further. So they were the first troops to complete their PADI OW courses post the Deptherapy programme. They did their confined dives with me at Diving Leisure London and then came to my place in Sahl Hasheesh, Egypt, to complete their OW dives and AOW dives. Both will complete their PADI Rescue courses this summer. Since their courses I have been diving, first with Richard in Mexico and then Chris in Florida again, this time on the Duane with a vicious current flowing.

Photo by Wade Imaging

ISSUE 01 | AUGUST 2014

DIVER MEDIC & AQUATIC SAFETY

Deptherapy has allowed Chris to realise his potential that he could dive just as well as if would have done had he had two legs. Research in the US has shown that programmes like Deptherapy can reduce the symptoms of Post-Traumatic Stress Disorder by as much as 80%. It is also beneficial to amputees as when underwater they feel no pain and in some cases it will have been the first time they have been pain free since being injured. Johns Hopkins University have commissioned research by the worldâ&#x20AC;&#x2122;s leading expert on Traumatic Brain Injury to look at why we are so successful in addressing the symptoms of those with PTSD and TBI. Participants form unbreakable links with their instructors and in many cases they will disclose details of how they were injured and about their life in general that they had never previously revealed. These disclosures are spontaneous and seem to be connected to the level of trust that develops between the instructor and student. On my first Deptherapy trip I was responsible for a young American marine called Ed. He had lost the lower part of one arm and had massive internal injuries. I was in the pool one afternoon when Ed walked over with his carer (the US Marines are always accompanied by a Staff Sergeant from Bethesda) and asked if I wanted a beer. I joined them at a table and Ed straight away told me how he had been injured and how in the immediate aftermath he had tried to carry on even though his guts were hanging out and his arm was missing. The staff sergeant almost fell off his seat as, in the previous year, Ed had refused to talk to

doctors, psychologists, family and friends about the day he stepped on the IED. Such disclosures are a fairly common experience. All staff on the programme have had to undergo an induction programme, read and accept our Introductory Guide that explains how we work with the troops. This raises particular issues of how close instructors and students can become and how to manage what can be a difficult relationship. Many of the students will have serious physical injuries and at the same time chronic PTSD and or TBI. As an example, at the extreme end of the scale, two students, one American and one British, have both stated that had it not been for the Deptherapy programme they would have taken their own lives. www.deptherapy.co.uk

"I know I have said thank you a million times, but I will say it a million times more; thank you for what you have done for me." The words of one 23 year old American Marine

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SUUNTO D4i A GREAT ALL ROUNDER Terms and Conditions Answer can be found on the Suunto website. www.suunto.com •The prize is provided by Suunto. • The closing date for the competition is midnight 15 September 2014, after which the winner’s name will be drawn at random and notified within 5 days after the competition closing date. The Winner will be announced in the October issue. • Entries will only be accepted from the Magazine competition and entries will need to have the competition answer included on the entry, employees of Suunto and The Diver Medic will not be allowed to enter the competition. • The prize is non-transferable and there is no cash alternative. In the unlikely event of prize being unavailable, a substitute will be supplied. • Multiple entries will be disqualified and the winner’s name will be drawn at random. • The publisher’s decision is final.

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DIVER MEDIC & AQUATIC SAFETY

THE SPECIAL RESCUE TEAM OF THE ITALIAN RED CROSS SPECIALIST VOLUNTEERS Photo by The Red Cross

It isn’t easy to say what the Italian Red Cross’s Special Rescue Team does or what they are specialized in. The reason is easy… they do a lot and their members are trained in many different aspects of rescue and first aid. Italy has a rather big coast line and weather conditions are great, especially in the summer. These conditions make the country an excellent destination for tourists, especially for those with a love of the sea. Italy’s popularity grew very quickly in the nineteen eighties and the number of people using the sea for recreation increased as a result. This was great for the local coastal economy, however there was a serious downside - the risk and number of emergencies that were happening at sea. At this point in time in Italy, the responsibility for at-sea rescue was limited to the normal EMS services, who for the most part were only able to operate on land. In 1991, one group in particular, a branch of the Italian Red Cross in a small town called Giulianova, realised the need for a specialised emergency team able to operate at sea. They

very soon developed the OPSA – Operatore Polivalente Salvataggio in Acqua, an aquatic rescue team. The OPSA is made up of various individuals, the majority of whom are volunteers. Many are Emergency Medical Technicians (EMTs) that work at the local Italian Red Cross branch of the Emergency Ambulance Service. Despite working for the Red Cross, the trained volunteers are at the complete disposal of the Coastguard both day and night, 365 days of the year. The training received by the volunteers is very challenging but rewarding. They are taught how to deal with any at sea emergency they may be faced with. This includes dealing with swimmers in need, persons lost at sea (or in rivers

ISSUE 01 | AUGUST 2014

or lakes), collisions between boats, capsized ships and diving accidents. The good thing is that OPSA is not only about dealing with emergencies. They especially like to provide regular assistance at aquatic locations and events involving water. This helps to prevent emergencies happening in the first place. These activities include standard life guarding services at the beach, assistance during air shows (with demonstrations or acrobatics above the sea), beach parties (day and night), swimming events such as during the Iron Man (Triathlon) competition, and at sailing and fishing competitions. In order to provide these services, the team is

equipped with a 7m RIB with 2x 150 HP engines, 2 rescue jet-skis, a transportable hyperbaric chamber, and many special rescue and first aid materials. The team has an array of experienced skippers and an expert dive team. These divers are not only used in cases of emergency, but are also used for SAR (Search and Rescue) activities under water, including body recovery when required. The area in which the team operates is rather large and includes the Tremiti Islands, a popular dive destination in front of the Adriatic coast. As such, the team members receive specialist draining to enable them to deal with diving related emergencies. They are trained using the DAN (Divers Alert Network) Europe First Aid

DIVER MEDIC & AQUATIC SAFETY

Training Programme. Some members have been trained as hyperbaric chamber operators and 5 members have been trained as Diver Medic Technicians (DMT’s). Their training makes them a very unique group throughout Italy. They are skilled in oxygen provision, neurological assessment, and advanced life support, giving them the ability to cope with emergencies that are some distance from emergency medical care.

rescuer will be winched down onto the ship or they will jump directly into the water. The good thing is that the rescue swimmer is skilled and specially trained for these rescues. Thanks to their abilities as EMTs they can also provide first aid onboard or whilst the helicopter flies to the hospital, assisting the rescued person to the highest level possible.”

Helicopter Rescue, SAR and Rescue Swimmers

Originally the team started as a Water Rescue Team, however the Red Cross realised that there were other rescue groups with expert skills throughout the country. The Red Cross has since combined all of these groups to create the SMTS (Soccorsi con Mezzi e Tecniche Special - Rescues with Special Means and Techniques). This means that the team can, depending on their training, offer a variety of rescue services. Some rescue teams will be specialised in mountain climbing, some will be experts in skiing, while those at the coast will have a profound understanding of how to deal with water rescues.

The RIB and jet-skis make it possible for the rescue teams to provide a good service close to shore. However, when dealing with an emergency far away from the coastline, whether it is a severely injured or sick person on a boat or oil platform, an intervention on a cruise liner, or even when dealing with a lost person or man overboard, time is a critical factor. In these cases the specialist rescue team have the use of the SAR helicopter of the XI flight department of the Italian State Police, operating from the airport of Pescara.

Does the team only operate at sea?

This change has enhanced the basic training of the The use of a helicopter makes it possible to intervene Giulianova team. This group now receives training fast and far away. Eight members of the team are in rope handling and in the use of special materials rescue swimmers, regularly trained for several and machines which enable them to operate in less different helicopter rescue missions, both on land and than ideal conditions. These conditions include SAR at sea. activities on land, evacuation of buildings, operations in dark and narrow places, working at heights and Claudio Lamolinara, the person in charge of the Special working in natural disaster zones. Rescue Team says, “Depending on the situation, the

Photo by The Red Cross

ISSUE 01 | AUGUST 2014

DIVER MEDIC & AQUATIC SAFETY

Who are the members of the team and are the team different than others? All team members are first and foremost Red Cross volunteers who regularly undertake EMT ambulance service duties. They are of a variety of backgrounds ranging from company executives to those who are unemployed. They all, however have one thing in common, they want to use their spare time to help others in need. Claudio states â&#x20AC;&#x153;Becoming a member is not easy. The training alone is very time consuming and the dedication required is often underestimated. Every year we have a basic course, which includes life guarding and is open to Red Cross volunteers with a certain level of experience as an EMT. At the end of the course the volunteers are used as life guards and can provide assistance at events under the guidance of an experienced team member. Those who only join because it looks good or sounds cool will stop after a while because they have not considered that before you get to do certain things, one needs experience.â&#x20AC;? What kind of rescues are the team involved in? The team has in the past been involved in a variety of emergencies and SAR activities both on land and at sea. This includes having had to deal with a capsized sailing boat, a sunken fishing boat, a stranded container ship, providing assistance after natural disasters such as earthquakes, floods and heavy snowfall, and providing assistance at several drownings. They have had to deal with missing persons, where divers have had to search in low visibility conditions, looking for bodies. They have

Photo by The Red Cross

recovered some sailing boats without crew on and have had to help boats get back into the harbour after sudden weather changes. Once, they had to recover a body of a freediver from a depth of 65m. An ROV was used to locate the body and then a diver was sent down to recover it. How does the team get operational? During events the team is fully operational and although rescues can happen the team normally is there to avoid accidents in the first place. During real emergencies team members are called and have to get to the rescue base within 15-20 minutes. In order to guarantee such a service, the team are asked to provide a monthly schedule on their availability. A minimum of 4 people will be on standby and operational at all times. Where does the finance come from? The special rescue team of Giulianova is an integral part of the Italian Red Cross. In the past, the Italian government has donated money to make sure that the Red cross can stay operational, but since then it has become a private operation. This means that they no longer get subsidies from the government but need to secure the needed funding for them to keep operational. In order to achieve this, the Italian healthcare system pays a fee to the Red Cross. Additional funding is received from donations or paid for the services and assistance they offer. It is thanks to the money received from the assistance provided by the ambulance services during events, that this team is able to continue operating.

ISSUE 01 | AUGUST 2014

DIVER MEDIC & AQUATIC SAFETY

Water rescue of a non-spinal injured patient Photo by The Red Cross

DIVER MEDIC & AQUATIC SAFETY

E F I L F O WATER By Anke Fabian MD

olnai Photo by Gergely Zs

ydration h e R s s e n k ic S mpression o c e D n io t a r d id - Dehy u q li y a t s s y a lw A d it attracts millions an e tim n tio ca va is Summer time ray of warm diving ar st va a to s st ri u of diving to while surrounded en ev , ly al ic on Ir s. n destinatio at er, a diver is always at w of n ea oc e ol h by a w literally ‘run out to d an y’ dr d de n risk to ‘be stra your body does not s n ea m n tio ra yd eh of water’. D ould. It can sh it as s id flu d an have as much water id, not drinking flu ch u m o to g n si be caused by lo can cause major It . th bo en ev or s enough liquid r the functioning of fo al ci u cr is er at w problems as ical processes. em h oc bi d an s em our biophysical syst hydration?

What exactly is de

s even rit’. Some definition oc at em ‘h d se ea cr range would see an in ncentration (normal co um di so d oo bl usually require a rise in loss of body water a ity al re in t bu , 135-147 mmol/l) of solutes as well. accompanies a loss ood plasma. ease in volume of bl cr de a lly ca ifi ec sp ly in terms Hypovolemia is water deficiency on es fin de ia m le vo po rit would be Furthermore, hy water. The hematoc lly ca ifi ec sp an th . of volume rather pear simultaneously ap lly ua us s on iti nd s, the co normal. Nevertheles than adults tible to dehydration ep sc su e or m e ar body Children divers dy surface area to bo er gh hi a ve ha n s that of because childre tage of BSA exceed en rc pe r ei th e us ca weight in weight ratio, be n to the higher body tio la re in ed er id ns ren. adults when co body weight of child er w lo e th to d re adults as compa

of ed as excessive loss fin de is n) tio ra yd ficiency Dehydration (hypoh entails a relative de it s, rm te l ca gi lo io (blood body water. In phys r dissolved solutes he ot to n tio la re in erally of water molecules e blood is getting lit th d se ea cr in is ristics cells). The viscosity amic flow characte yn od em ha e th s ct t we ‘thicker’ which affe the blood cell coun In y. el tiv ga ne n io of the blood circulat

ation Causes of dehydr

peratures, t means high air tem yp Eg in er m m Su Perspiration: nsequently intensified co d an re su po ex ner. warm water, su and beneath the wat e ov ab g tin ea sw d perspiration an

ISSUE 01 | AUGUST 2014

oss Photo by Shane Gr

ble ti p e c s u s re o m re a "Children divers of e s u a c e b s lt u d a n a to dehydration th eights and higher their smaller body w d electrolytes." turnover of water an

disease’ idespread ‘tourist w e Th : is it er er nt en vomiting. If wat uipment Gastroe ev eq or y d/ av an he a g oe lin rh nd ar di e case whilst ha normally leads to nisms an n. su This is especially th ht ig br e abnormal mecha e os th th h to ug re ro su th po st ex lo g rin is being very quickly into a p lo ve in a black suit or du de n ca es yt e of electrol most of imbalanc se lo rs ve di a ub emergency. h breathing: Sc s such as (or any medical r ai Fluid loss throug d se es pr n medical condition m ai rt co Ce e th s: g on in iti th nd ea co ation by br Medical s to s leading to dehydr id nd te flu their fluids simply e of ur ss st lo oi M re . ve nk se ). t of the scuba ta diabetes can cause is due to glucosuria contain es s ur other gas mix) ou nk di ta ic a ar ol ub sc sm e (o th ia y areas. Since or even hypovolem d pressure. e on on flow from wet to dr e th an th e.g. due to high bloo r n ie io dr at ic is ed ch m hi ic w et ), ur ixes Else: di air (or other gas m contains a lot of er at rw de un r ai not d hale take: Drinking does up the surface, our ex id flu te ua eq ad ks Insufficient or in e body. Diuretic drin th moisture. r fo s id flu gh ou ple, naturally provide en coca cola, for exam d d se an ea a cr te in k ac an bl ns e, ea ffe is: Diuresis m such as alcohol, co enhanced obably pr Immersion diures r ve di id balance caused by y er flu e Ev tiv s. ga ey ne dn a ki in e lt at th e by can resu e into consideration th t th production of urin pu on to re ve su ha es pr so al er e e effect of wat kidney function. W is the hottest month ith the ch w hi has experienced th s w ey st dn gu ki Au e th in ts of er-functioning) Ramadan 2009 star lim dive-guides, who us sion M er l functioning (or ov m ca lo ‘im e d th lle at ca th so ns der water. The of the year. It mea off fluids of any kind e ater and w ar urge to urinate un , in et ns dy su bo e to th ise of fluid by absorption might fast from sunr sure. or less 2.5 litres of e es or diuresis’ is caused pr m s by ed d ne an re on rs tu er, lower tempera The average adult pe l exercise. Hot weath ica ctors ys fa mainly triggered by ph th of bo n io er at ev er w id ho s for t of the depth per day without cons raise the daily need ation es ul iti This is independen rc ci tiv d ac g oo in bl ny n ai pa m m six lisation of the diving and the acco needing as much as rently le ffe can cause a centra di op pe in e re m co so e ith th w of the limps to liquids considerably in the from the periphery se ea cr in an s ct the body dete litres a day. n ai mechanisms. Thus rt ce a of e as le d inhibits the re blood pressure an in the using an increase ca ) in ss re op as (v hormone e. production of urin

DIVER MEDIC & AQUATIC SAFETY

Photo by Maridav

n needs o rs e p lt u d a e g ra e "The av ay d r e p id u fl f o s e tr li more or less 2.5 hysical p f o n o ti ra e id s n o c without exercise."

% are usually fatal. 15 , ild m as ed n is classifi dration: Dehydratio hy de ecompression of s om pt m Sy h of the body's fluid ease the risk of D uc cr m in w on ho ti on ra g yd in eh nd depe Does D moderate, or severe h the electrolyte uc m w ho d an ed ss? lenish reatening Sickne th eis lost or goes un-rep lif a is n io at dr When severe dehy g the risk balance is affected. ar yes. to divers by increasin rd za ha n ow kn The answer is a cle a is emergency. It ation illness. kness due to dehydr sic n for decompression sio es pr m co de eased risk of and sed urine The incr explored. In swine d ea cr an d de , ie he ud st ac ad lly ca he , ifi antly Thirst, dry mouth is thoroughly scient dehydration signific itability at irr , th ss d Mild dehydration: te ne en ed m tir cu d do ne ai be cally, it dark urine, unexpl rat models it could ion. S and death. Specifi ns DC te volume, abnormally re po ve hy se tic of ta k os ris th l bolie) standing due to or increases the overal DCS (arterial gas em y ar and dizziness when on lm pu io rd ca ous increased the risk of output at d CNS (central nerv e se in ea ur cr no in d ly ib ar w ss to Po s). re dehydration: and showed a trend neurological symptom creased ith in w g, Moderate to seve II tin S in DC fa S s, re DC izu in y DCS me sleepiness, se system) symptoms sted cardiopulmonar ck of ife la d an all, lethargy or extre m an ts re ec su bj es su pr d ed n rate, drop of bloo In addition dehydrat d death. heart and respiratio nd toward more rapi tre a ed ow sh d an sooner tears when crying. crease. d respiration rates in rdiac an ca t , ar re he tu e ra th pe ed m at te eases n: Rise of body If a diver is dehydr the the body tissues incr to of e Severe dehydratio du ke h ta at up de n d ge an tro duced ciousness, delirium Consequently the ni sues will receive a re tis e ss one may arrhythmia, uncons th lo , er nd at ha w r he 6% ot to ilure. Around 5% accordingly. On the is affects the ea and us na effects of kidney fa or s he ac creased viscosity. Th ad in e he th e nc to e rie du pe w ex the flo y, ep blood to 15% n negatively during % ge 10 tro become groggy or sle ni ith e W as ). le ia re es to th oneâ&#x20AC;&#x2122;s limbs (pares ability of the tissues and el riv may feel tingling in sh ay m in sk , ay become spastic decompression time. d an d ce du fluid loss muscles m re greatly dim, urination will be an wrinkle, vision may n. Losses greater th gi be ay m m iu lir de l and may become painfu

ISSUE 01 | AUGUST 2014 tis Photo by Tina So

er w o sl a t a d n e sc a r, te under wa d te ra d y h e d l e fe u o y "If ) and te u in m r e p s e tr e m e in n an rate than normal (less th up" y a w e th n o s p o st l a n also make additio We the best case of DCS. an th le ab ur vo fa e mor (or even dry) suit is you carry one tank of n if io – at ’ dr le hy cip in al pr or nk ve ta di eebl nd. rats showed that pr recommend the ‘dou nk of water in your ha sy ta ea e y on el Scientific studies in tiv rry la ca , re ck a g ba ur et suit bubbles thus offerin compressed air on yo lly, if ady dressed in the w na re al tio n di decreases circulatory he Ad w k. lly ris cia s pe es bright sun es decompression sickn . is more Avoid the d an y means of reducing dl pi p to cover your head ra ca e a or r m ea w ue or tig t fa r ha a ffe r will su and put on dehydrated, the dive . ps cram slower rate likely to suffer muscle r water, ascend at a de un ed at dr hy de ake el If you fe minute) and also m r during pe k s or re tw et Ne m t er ne ni Al rs an gen. anaged by the Dive than normal (less th l desaturation of nitro vious ca ob iti cr an Half of the cases m to to d up te ay la w re e th a years have not been additional stops on rwater you may use en de be un ve the past number of ty ha irs th ey th ng t tti bu ge g the ession procedures If you are regularly bstitute fluids durin ly su al to re violation of decompr g) en ba be ng ey ki th in dr ndeserved’. But have SCUDA (underwater kness sic etic divers). n ‘unpredictable’ or ‘u sio es pr m co de commended for diab dicted’ re re y np hl ‘u ig (h of s ve se di ca In undeserved? t cause. ne lly the most frequen ua us is n io at wly which is best do dr slo hy te de ra yd -h re d ce Once you have surfa . The latest er op pr e th e ev reduced sport-drinks hi r ac ga to su lt or cu er ffi at di t w n n no : It is with plai al rehydration solutio tting or se re an Recommendations fo of Be . ke ta ve di in a e th ub fore and during a sc research shows that ith reduced ntain co t level of hydration be no es do ns or Oralpaedon) w ch ra hi ot w El k , in an dr dr ts hy or sp Re s on a er or (such as u will more positive effect s yo s ha ) ve off just drink lots wat di /L ol er m ng lo 0m r -5 fo 40 dy armer weather and osmolarity (sodium you are will remain in the bo If s id ty. too much sugar. In w flu irs e th t Th ge . er u at yo w as ids. Drink BEFORE the body than plain h the kidneys as fast to avoid ug r ro be need to drink more flu th t’ em m ou d Re he s. id as flu ‘w iting in ady has a lack of longer and are not alcoholic l frequency and vom y oo an st thirsty, your body alre e or th ks in ce dr du re ed at so have e coffee and carbon plain water. They al nd, it is advisable to will lead ha re on fo e caffeinated drinks lik be ar t gh RS ni O e If th l is. ercise in e dive. Excess alcoho case of gastroenterit renuous physical ex e dive st th of re beverages before th e fo be tim e on th iti g nd rin co cent pre-hydration them once a day du ses diving ea cr to dehydration. A de balance. de t bu er at rw to restore the fluid pee unde er to th y ea nc w t ge ur ho e th se e in the wet might increa laemia. The worst, pe vo po hy d an n io at dr induced dehy

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Discover the DAN Europe Safety Stop events throughout Europe. Check out the event near you and join us! www.daneurope.org/news

World renown guest speakers , Drowning investigators and qualified Instructors Walt “Butch” Hendrick and Andrea Zaferes from the USA will be flying to the UK in October, November and December 2014 to train specialist courses to Dive teams, EMS personal, Police and Law enforces. If you would like to find out more about Butch and Andrea go to their website : www.teamlgs.com All UK and Europe bookings will be dealt with by The Diver Medic Ltd on 0208579 3388

Homicidal Drowning Investigations and Underwater forensics “Drowning is a diagnosis of exclusion”, This course is designed to help First Responders, EMS, Police, Medical Examiners, Dive Teams and Prosecutors how to investigate and understand all types of Deaths in Water.

Field Neurological Evaluation & Oxygen Administration These two programs are designed for Divers, police and EMS who respond to water-related emergencies. The training most rescuers are given on the recognition and management of drowning and dive related accidents is far from sufficient and often includes misconceptions.

Drownproofing Turnout Gear—Firefighters Turnout equipment does not necessarily cause you to immediately drown, and in fact, if used correctly, may allow you to remain at the surface for a prolonged period of time. This course teaches you just how to use your turnout gear to your advantage in water.

Rapid Deployment Search and Rescue / Recovery A course that teaches search and rescue operations, prevention of diver immersion hypothermia and drowning, scene management, finding a lost diver or body, rapid dressing , blackwater rescue, out of air entanglement, accident management and more.

Swiftwater Surface Rescue Operations Before we can begin teaching a team how to set up and plan for a moving water rescue, they need to understand what moving water is and how it relates to the overall rescue and the victim.

Larger Area Rapid Deployment Search and Rescue / Recovery What can you do in the first 60-90 minutes to make this a rescue operation? And if the victims are not found in that golden hour, what should you do to make this a safe and efficient recovery operation? This course will train you to plan and execute large area search rescue and recovery operations.

Subsurface Technical Anti-Terrorist Training STAT is a recognition program to train law enforcement, fire, and other dive teams how to search their districts’ subsurface areas for possible sabotage, explosive ordnance, and other items that do not belong. Contact Chantelle for more information on the above courses—02085793388 or info@thedivermedic.com

DIVER MEDIC & AQUATIC SAFETY

WHITE ROCK TURNS POISONOUS

The risks of diving in open waters is clear for all to see and Jace Green, videographer, recounts his time on 12 December 2009 in Koh Tao, Thailand. I was filming a group of six students going on dive three of the PADI OWC at the open waters of White Rock. The group, along with their instructor Rich, descended down the buoy line within minutes of entering the water before a short swim over to our selected ‘sandy’ patch of the site away from corals and anything else that could possibly be damaged by our new divers. Rich arranged his students in a semi-circle and asked them all to kneel in the sand. The water was around 12 metres deep to complete the skills needed for Dive three. Whilst Rich was concentrating on one individual’s skills I began to film some fish swimming around

Scorpaenidae, the scorpionfish are a family of Walkman fish and are one of the most venomous species.

the backs of the students fins. My footage caught some fantastic species such as wrasse and it was whilst filming I noticed, out of the corner of my non-viewfinder eye, one of the girls becoming a little agitated. She was signaling to her buddy that something was wrong and she was pointing at her knee. As I got closer to the girl, and to provide some reassurance, I saw the Indian Ocean Walkman crawling along the sand, away from the divers. She pointed frantically at the Walkman and then at her knee and I realised she had knelt on the poisonous fish whilst it was hidden in the silty substrate.

ISSUE 01 | AUGUST 2014

Photo by Stephan Kerkhofs

DIVER MEDIC & AQUATIC SAFETY

These fish are nocturnal and spend 95% of their days buried in the sand with only the eyes peeping out. I let Rich finish the skills with the student he was with before signaling him over to the now crying female student. We both agreed that the girl and I would return to the boat to arrange first aid proceedings whilst he continued to finish the skills as briefed for the dive. We both felt that it was unnecessary for everyone to return to the boat or cause any more alarm for the victim and the rest of the group. The poor girl was in quite a bit of pain now as she made her way to the surface. I took my time on ascent so as to control her BCD, my BCD and my camera. There were two other Instructors on the boat and one jumped in immediately to help me while the other put the kettle on. Being English, I wish it was for a nice cup of tea, however it was not. The two instructors egress the injured diver from the water and hauled her up the ladder. I located the bubbles on the surface that belonged to my group below and I therefore rejoined my group to complete the dive. Whilst down there I got some great shots of the offending Indian Walkman for the movie to be shown later that evening. Back on the boat the very hot water was transferred to a rubber hot water bottle to treat the injuries. The recommended first aid treatment for treating poison from Indian Walkman includes immersing the affected area in hot water of at least 45 degrees Celsius. This can partially denature the proteolytic enzymes in the venom, effectively cooking the proteins in the venom to prevent it spreading further through the blood stream and local tissues. The hot water began to take affect and despite being very painful the victim was comfortable on the boat with one dedicated instructor constantly monitoring her condition. Once we returned to land she was carried off the boat to the local Diving Medical Centre very close to the pier. She was handed over to the resident Dive Medic who cared and monitored her for five hours in the afternoon. We managed to get a few pictures of the wound in the clinic after the hot water treatment and despite looking like a hideous and very painful injury she was in a lot less pain and discomfort than she was in the water. Once the Dive Medic had cleared her to leave the clinic she of course made it to the bar that night to have a few beers and watch the movie that she starred in ever so briefly with the rest of her dive buddies. A big loud cheer emanated from the bar when the Indian Walkman made his appearance on the screen and a good amount of expletives were shouted in good humour.

ISSUE 01 | AUGUST 2014

“The recommended first aid treatment for treating poison from Indian Walkman includes immersing the affected area in hot water of at least 45º Celsius” Inimicus didactylus, also known as Devil Stinger, is a member of the Inimicus genus of venomous fishes, closely related to the true stonefishes.

Photo by Kristina Vackova

DIVER MEDIC & AQUATIC SAFETY

IMPROVING

SAFETY

EVOLUTION OR REVOLUTION By Gareth Lock The safety of personnel during recreational sports is a necessity to ensure all taking part enjoys the activities they are pursuing. When it comes to diving, the official fatality figures are relatively low however there are many incidents that never see the light of day according to The Diving Incident and Management System. Health and Safety in recreational situations dates back to the end of the Second World War when there was interest in how pilots interact with their aircraft with a view to improving safety. This followed a number of accidents where pilots made the wrong selection due to similarity in feel and look of both the landing gear and flying control surface levers. This research moved on from just physical interaction with the aircraft controls to include crew behaviours and how crews dealt with their tasking authorities and the commercial or operational pressures to undertake a task. Over time this work was developed further into other sectors such as nuclear power plants and other high reliability industries where organisational issues were having an influence on operational outputs and safety at the individual level. One of the best known outcomes to be established was the ‘Swiss Cheese Model’ developed by Professor James Reason in 1990. This was a very simplistic model to show that it required a number of contributory factors to align before an incident or accident would occur. It was developed further by Shappell and Wiegmann to provide more

granularities which would help identify specific areas of failure in the form of the Human Factors Analysis and Classification System (HFACS). These outputs showed that the oft-used term ‘pilot error’ was not particularly useful. The reason the history of aviation is important when discussing the safety of Scuba Diving is it is a recreational activity with limited oversight and supervision whereas aviation, nuclear power plants and trains all have the HSE to ensure they are undertaken safely and to the rule book. Whilst the previous statements are partially correct, the Human Factors covers all activities when people are involved and it does not require a formal organisational hierarchy to show where things can go wrong when dealing with individuals or groups. If environments such as aviation, surgical theatres, explosive ordnance disposal, gas and oil platforms can all improve safety by understanding how people go about their job surely the basic principles can be applied to recreational diving. Photo by Gareth Lock

ISSUE 01 | AUGUST 2014

"There are a number of reporting systems in place across the industry but they nearly all focus on the ‘what happened’ not the ‘why the incident developed and the incident occurred’"

DIVER MEDIC & AQUATIC SAFETY

"Safety has been defined by Reason as: â&#x20AC;&#x153;the ability of individuals or orginisations to deal with risks and hazards so as to avoid damage or losses and yet still achieve their goalsâ&#x20AC;?"

ISSUE 01 | AUGUST 2014

There are a number of reporting systems in place across the industry but they nearly all focus on the ‘what happened’ not the ‘why the incident developed and the incident occurred’ side of health and Safety. Only by recognising, understanding and modifying behaviours will safety be improved. There are enough rules and processes in place to ensure that diving should be conducted safely however it is ultimately down to personal responsibility for the action taken. The good news is that the fatality risk for recreational Scuba Diving is relatively low. In the UK it is around 1:100 000 to 1:250 000 per diver per year with 10-24 fatalities per year (over the last 15 years) actually occurring. However, the incidence or rate of fatality is not necessarily a good measure of safety because there is evidence that a significant number of non-fatal incidents occur in diving which never see the light of day. The reasons could include: • The Diver did not believe the event was serious enough to report • The Diver did not realise anything had actually gone wrong • The Diver did not know there was a way of reporting the incident • The Diver was embarrassed about making a simple mistake The community should be focusing on reporting and discussing near-miss incidents and non-fatal incidents for a number of reasons: • Fatal incidents are normally emotive and relatives/friends get very protective of their loved ones making mistakes • Whilst fatal incidents are investigated the investigation is normally to find out the cause of death and not cause of cause of death • Many fatalities are likely to be due to poor decision making or psychological factors and the only person who really knows the answer to those questions is dead • Those involved in non-fatal accidents are normally able to explain what happened and why, although there are significant cultural issues which need to

be overcome to maximise this Therefore, to create the environment by which divers, instructors and instructor trainers can discuss the incidents in detail without fear of criticism is necessary. Only by creating this ‘Just Culture’ can reporting be improved even if it is anonymous reporting. This is made all the more complicated by the risk of litigation especially in the USA. This has been demonstrated in the American courts by examples of negligence cases showing the situation and the pressures involved have been ignored. Consequently, operational outputs have suffered as medical staff are now undertaking additional checks to make sure they are covered with the potential reduction in time to treat the patient. It could be said the same is happening within diving with safety a mere tick box exercise rather than teaching true skills and knowledge to problem solve in a diving environment. Some refer to a Safety Culture as if it were a single entity that resides in individuals. A culture has been defined as ‘a complex framework of national, organisational and professional attitudes and values within which groups and individuals function’ or more simply ‘it is how things are done around here’. Safety has been defined by Reason as: “the ability of individuals or organisations to deal with risks and hazards so as to avoid damage or losses and yet still achieve their goals”. So Safety Culture changes from ‘way things are done around here’ to ‘still achieve goals without losses irrespective of the risks present’. It also means that the environment or context needs to be taken into account and this introduces variance and ‘grey areas’. Many of the reasons for diving incidents are anecdotally known. Fortunately, research is currently underway to determine the major reasons why incidents occur, examining both the individual level (e.g. slips, mistakes, lapses or violations) and the organisational or supervisory level which includes instructors, dive centres and training agencies.

Photo by Gareth Lock

DIVER MEDIC SAFETY DIVER MEDIC&&AQUATIC FIRST RESPONDER

The outputs from this research will be published in the hyperbaric and safety literature, but where possible, it will also be made publicly available through media such as this magazine. As the subject of safety, culture, incident reporting and improvements to behaviours is vast, over the coming editions of The Diver Medic and First Responder there will be specific sub-cultures along with a discussion of specific incidents so that Divers can learn from them and improve their own behaviours. The incidents will

have a common theme regarding causality but will cover different environments or scenarios. In the meantime, if you are interested in learning about diving incidents, what happened and potentially how to prevent them from happening to you, there are two UK-based resources which will help you. These are the Diving Incident and Safety Management System (DISMS - www.divingincidents.org) which has been running since April 2012 and is primarily an online resource and the BSAC Annual Incident Reporting (www.bsac.com).

"Divers can learn from them and improve their own behaviours. The incidents will have a common theme regarding causality but will cover different environments or scenarios.â&#x20AC;&#x2122;"

ISSUE 01 | AUGUST 2014

Photo by Gareth Lock

DIVER MEDIC & AQUATIC SAFETY

Police Survival - There’s Only One Job We Need To Do Every Time - Go Home

By Deputy Walt ‘Butch’ Hendrick and Andrea Zaferes

ISSUE 01 | AUGUST 2014

Andrea Zafares and Butch Hendrick run TeamLGS in New York, USA. Both Andrea and Butch have been professional diving instructors for over 25 years and have both been awarded DAN and Beneath the Sea/Underwater Society of American Diver of the Year award in Education and Diving Safety. Butch has also been awarded the BSAC Outstanding Contribution to Diving Safety Award. Not only that, they are also water related incident experts and Homicidal Drowning Investigators assisting Law Enforcement agencies and Diving Teams across the World. Drowning is a common problem in today’s world. Anyone, even lifeguards, can drown. Oddly, we seem as a society to not truly understand the ‘anyone-can-drown’ concept. In fact, we burden many of our public safety personnel with the misconstrued concept of what a hero is and does. The hero concept is dangerously based on whether or not a person was foolish enough to attempt, in this case, a water related rescue, recklessly endangering his or her own life and possibly the lives of others. Would be heroes all too often drown themselves trying to perform a rescue beyond their personal or team capabilities. A person drowns while trying to save someone else is someone dying trying to be a foolish hero. Remember dead is forever but the media and eulogy will both remember them as a great person, a hero. Heroes do not recklessly endanger their own lives or the lives of others. Even with the minimum necessary training, equipment and personnel resources, an in-water rescue can still go wrong and a rescuer can still be killed. Without these three necessities, the probability of disaster is very high, and not only is the life of the would-be rescuer endangered, but so are the lives of the victim(s) and other rescuers who now must also save the would-be rescuer. There are several lawsuits taking place around the world today against public safety personnel that truly try the concept of rescuer and hero. Perhaps there are times when we ask, expect, too much from our local public safety agencies, police, fire, EMS, and Coast Guard. These lawsuits are taken against personnel who made the safe decision not to go in the water because they did not have the minimum necessary training, equipment, or personnel resources and because doing so would recklessly endanger their own lives. Photo by Kant Komalasnankoon

DIVER MEDIC & AQUATIC SAFETY

Let us review a past case history that took place in New York to better understand similar situations elsewhere in the United States and elsewhere in the world. A male individual physically resists arrest and flees. He finds himself at the water’s edge of the Hudson River. Police request him to stop however the individual proceeds and enters the water. Upon suddenly finding himself in water where he can no longer stand up he yells “I can’t swim, please help!” A question that needs to be asked is: Does the non-water rescue trained, non-lifeguard, police officer without any training in restraining a perpetrator in the water, have a responsibility to endanger his own life by entering the water and potentially finding himself suddenly in a full in-water attack situation? The answer is a resounding ‘No’. In fact, do any police officers, fire fighters, or even lifeguards have a responsibility to endanger their personal safety in this situation? Again, the answer is a definite ‘No’. Any lifeguard will tell you that even a six year-old panicking child can drown an adult would-be rescuer. Even the best, award winning lifeguards are not trained to approach or rescue a possible alert and aggressive attacker. They are trained to save weak, non-alert or aggressive, panicked drowning victims whose only goal is to save themselves and not escape prosecution or purposefully injure anyone who approaches. In the New York case the perpetrator did lure the police to one area and then proceeded to swim to another point, climb out of the water and escape. He also nearly drowned a police dog that was also not trained or prepared for a water operation. When a woman who claimed to witness the event from her porch over 300 metres from the incident was interviewed she was very hostile towards the police stating that they tried to drown the man by chasing him into the water. She then stated that they did not attempt to rescue him when he was supposedly drowning and calling for help. She had absolutely no concern for the officers who did not have personal flotation devices, cold water exposure suits, any water rescue training, or any rescue equipment, let alone self-defense training for handling a violent criminal in the water. As one of our lead trainers (ret), patrolman Ken Balfrey (ret), pointed out during a Lifeguard Systems staff discussion of this problem, "Suppose the perpetrator had Navy Seal or Ranger training," as once happened in his district. Such a person is trained to drown people and even a well-trained lifeguard would stand little chance against such a person. Such a perpetrator may even have training in pulling personnel out of an inflatable boat to drown them. Another hypothetical could be that the perpetrator had a knife or a gun, both of which will work in the water. How is the law enforcement, fire, EMS or other rescue personnel to know whether or not the perpetrator is faking to drown or is actually drowning?

ISSUE 01 | AUGUST 2014

"A six year-old panicking child can drown an adult would-be rescuer"

Photo by Team LGS

If a perpetrator ends up drowning a would-be rescuer during a rescue attempt, will the perpetrator be charged with first degree murder or will the defence lawyers get him off by saying it was an accident and the officer should not have gone in without the minimum necessary equipment or training? Perhaps the police department would even be sued for endangering the life of the perpetrator for chasing him into the water. This sounds like an atrocity but it has happened and is happening. Every law enforcement, fire, EMS and other public safety agency should have clearly written standard operation procedures or guidelines for these types of incidents stating that such personnel will not go in the water, or on the ice, after a conscious perpetrator under any circumstances unless the personnel have the proper rescue and in-water defence and restraint training, equipment and personnel resources. There is only one job public service personnel must do every time - go home when the job is done. 37

DIVER MEDIC & AQUATIC SAFETY

n e p p a H s t n e d i c c A e v i ‘D ’

! e M t No

Sakr d e m r. Ah D d n aher a T l e d A By Dr.

Dr Adel Taher M.D and Dr Ahmed Sakr are Directors of the Hyperbaric Medical Centre (HMC) of Sharm el Sheikh and Dahab, Egypt. Dr Adel Taher, Consultant in diving medicine, implemented the opening of the chamber in March 1993. He is the Director of both the chamber and DAN-Egypt/ME and a member of UHMS and EUBS. Dr Ahmed Sakr has been working as Assistant Director and specialises in the management of diving accidents, working closely with the surrounding Dive Centre’s in Sharm and Dahab. The chamber works closely together with the new Search and Rescue Center (SAR), which is located just over the road from the chamber. Dr Taher has been a Scuba diving Instructor since the 80s and is considered one of the top world experts in Hyperbaric Medicine. Preconceptions, Experience and the Effects of Denial Acceptance is based on knowledge, which in turn, is based on learning and experience. Many divers tend to view themselves as a breed apart from the rest of humanity, a breed of their own. The fact that they are able to breath and frolic under water renders others, in their own imagination, as something above the average human.

‘We easily succumb to visions of ourselves as a super breed, as elevated at least one step above others.’ This conceptualisation of one's self is often accompanied by feelings of adventurousness and macho superiority, permitting no space for weakness or the actual fact of augmented vulnerability for spending long periods of time at certain depths below the surface of the sea whilst relying completely on equipment that is never 100% shielded from the possibility

ISSUE 01 | AUGUST 2014

o T n

… s r e h t O

of failure. Exposing oneself to the forces of nature that are beyond their control, taking into account the complexities of the human factor and one’s dependence of the functioning of a buddy system that has various interpretations depending on who you are talking to, a sense of augmented vulnerability is actually no more than a simple statement of fact. Diving accidents occur on a regular basis and have locally and regionally registered incidence rates. They are a firm reality that cannot be thought out of existence. In treating them and surveying their occurrence and management however, an important question arises: How do divers deal with accidents and to what extent do they accept or deny their occurrence? Dealing with grief you usually pass through five stages: denial, anger followed by bargaining, succumbing to depression and then finally reaching acceptance. In theory, divers learn all the basic information to identify a diving accident during their training. They are assumed to possess the ability to realise when something wrong is happening to their bodies and that particular symptoms are most likely diving-related. In practice, however, many divers refuse to acknowledge clear symptoms due to a certain fear of the possible consequences. Peers are often an important factor in supporting and encouraging this denial that a diving accident may have taken place. They do not want to accept that one of them had a diving accident or that they might have had something to do with it; they simply do not want to get involved. Denial has a positive side and a catastrophic one. On the positive side, the process that takes place within the patient’s psyche once denial is ‘activated’ takes some time. This time is needed by a lot of people to help process what has taken place and synthesize the relevant events. It can thus help a patient arrive at the conclusion that yes, it has hit me; I am the victim of a diving accident. Thus, the process can lead to a conclusion in which the patient accepts the fact of the accident and proceeds to seek treatment. The potentially catastrophic side in this process however concerns the delay in identifying the accident, reporting the symptoms and beginning treatment. This delay will inevitably affect the prognosis.

Contrary to a widespread assumption, the level of experience of a diver involved in an accident is not likely to shield them from a reaction based in denial. On the contrary, longstanding experience may even be the trigger for denial. Such a diver may assume that, with all my experience and number of logged dives, it is highly unlikely that I could be involved in an accident. Symptoms may be relegated to bear witness to any number of psychological excuses such as a lack of sleep, bad weather conditions or an exhausting session of finning against the current, among others. Resting tends to be assumed as the best treatment for whatever psychological excuse has been selected. Sometimes these divers lie down only to wake up a half hour later, paralysed and suffering from urinary incontinence. 39

DIVER MEDIC & AQUATIC SAFETY

One of the accidents treated several years ago involved a very experienced male Trimix diver with over 300 logged Trimix dives. He had planned a Blue Hole dive for the following day with his buddy until - you may have guessed it - the next day his buddy did not show up. That morning everything that can go wrong, did go wrong. Although his buddy has not appeared he decided to proceed nonetheless with the planned dive. He had a fin strap problem during descent and, trying to fix it en route, he overshot his planned depth by 13 metres. Then, trying to ascend to his first deep stop, one of his wings started filling up with gas and he could not stop himself before reaching the surface. He thought his situation over briefly and then started descending to a suitable depth to decompress. During this descent he found himself in a strong current which he started to fight. With all of his equipment and the drag and resistance it caused under the water he ended his dive 500 metres further than his original planned exit point. He then carried the five tanks to where his car was parked instead of ditching them and driving back to pick them up. He had ample Oxygen at his disposal but did not think of breathing any because he felt â&#x20AC;&#x2DC;alrightâ&#x20AC;&#x2122;. Forty-five minutes after arriving at his hotel he started developing clear neurological symptoms including decreased sensation in the lower limbs, girdle-like pain in the lower back and generalised weakness in both lower limbs. However, he did not call the chamber and he did not breathe normobaric Oxygen. He did not inform any of his friends; instead he convinced himself that it is just tiredness and that he will feel better after getting some sleep. The following day he was brought to into hospital wrapped in a blanket in the back of a small truck, portraying a full blown case of neurological decompression sickness and unfortunately, a severely neglected one. Both lower limbs were paralysed and he could not control his sphincters. He also had a progressively rising level of sensory loss and some other grave symptoms as well. Photo by Little Sam

ISSUE 01 | AUGUST 2014

by Photo

He was debating whether these symptoms could be due to other causes and if we were sure it was really decompression. Amongst these cases of denial of decompression we have encountered on a regular basis involve a patient, dive buddy, guide or even a group member consistently suggesting and confirming that these skin discoloration patches are allergies to plankton or the material of the wet suit, overlooking associated symptoms of fatigue, dizziness or impaired sensations. The psychological process and effects of denial can brainwash the victim (or others around them) and make one adamantly refuse to see, recognise, synthesize and accept the obvious. In the above case the diver was extremely lucky; he was treated over a period of three weeks with daily recompression sessions to near full recovery. Taking denial into account as a serious factor into the scene that the dive buddy or the divemaster or instructor are the ones to report their doubts and ask for assistance and not the effected diver. Divers and especially dive professionals should be aware of what to look for when identifying a diving accident. Early recognition is the key to proper and effective management and the best possible prognosis. Denial is a normal reaction to the unexpected new situation the person is forced to face. The problems and adverse effects related to denial occur when the victim refuses to move on to the next stage and appears to be stuck in limbo. Divers involved in accidents need psychological support. Do not lie to the victim or make promises you cannot deliver. Rather, take the time to explain your concerns, go over the possible etiologies leading to the accident and reassure the person by calmly explaining how their case is going to be managed and that the physicians involved are experienced in treating these specific types of accidents. Our conclusive advice will always be to try, think and react positively to any situation. In other words, if there is ever any query or suspicious situation, consulting an expert or diving physician in person or at least by phone while providing oxygen will go a long way towards addressing even the least possibility of a potential disorder.

s Yiorgo

DIVER MEDIC & AQUATIC SAFETY

A Prickly Situation By Yvonne

Yvonne qualified as a Marine Biologist in 2004 where her final year modules included, fisheries management, environmental impact assessment, primary and secondary productivity and tropical and polar ecology. During her time studying at university she worked at a Scuba Diving Centre in Malaysia teaching her students about marine biology, today Yvonne is a qualified Diving Instructor and Diver Medical Technician Instructor specialising in Marine Life Injuries.

I vividly recall the first time I encountered a Crown of Thorns Starfish injury. I was enjoying the peace and quiet of the late South East Asian afternoon when a man came running into the dive centre screaming, holding his bloodied, swelling and reddening hand. A quick glance around me confirmed my worst fears that I was alone and that I would have to provide the necessary help. His garbled and pained account of what had happened provided me with sufficient information to establish that he had punctured his hand on the spines of a Crown of Thorns Starfish, which he had been breaking up to attract fish in order to spearfish them. Aside from being astounded by what I had just heard, I was desperately trying to recall what I should do to help him. I was 19 years of age, a Divemaster in Training and had just received my Medic First Aid Training in the UK. From what I recalled there was not much focus on envenomation from tropical marine creatures in that training. So what should I have known and what should I have done?

What is it and where does it live? The Crown of Thorns Starfish, Acanthaster planci, belongs to a large complex group of organisms of varying venomosity called echinoderms. This group includes not only starfish but sea urchins, brittle stars and sea cucumbers. Once you have seen the Crown of Thorns it is not easily forgotten and it is clear to see how its colloquial name came about. It is a large starfish (sometimes over 60cm in diameter) with a sizeable central disc and up to 21 arms. The flexibility and prehensile ability (an ability to grasp or hold like a monkeyâ&#x20AC;&#x2122;s tail) of the arms of the starfish are as a result of two rows of tube like appendages, called tube feet, at the tip of each arm. The entire surface of the organism is covered in large numbers of thick venomous slime covered spines of up to 6cm in length. The spines on the top (aboral side) are sharp and pierce soft surfaces, including skin, with ease. They do have spines on their underside (oral side) however these tend to be much more blunt and will not

ISSUE 01 | AUGUST 2014

"The entire surface of the organism is covered in large numbers of thick venomous slime covered spines of up to 6cm in length" Photo by Ethan Daniels

pierce skin as easily. They also vary in colour from dull browns and greys to bright purple and blue. The reason I did not know too much about the Crown of Thorns at 19 is that it is not found in the Atlantic Ocean which surrounds the UK. The Crown of Thorns inhabits shallow, protected coral reefs in the indo-pacific regions, where it feeds voraciously on the living coral around it. Ordinarily there should only be three to four of these organisms on a reef, but since the 1960â&#x20AC;&#x2122;s there have been numerous population explosions where entire reefs have been decimated in short periods of time. Theories surrounding the reason for their sudden increase in numbers are varied but what this has meant is that divers come into contact with them much more frequently. Luckily most divers know the inherent dangers that contact with the Crown Thorns starfish can present and consequently are very unlikely to try and break one up to

attract fish. However, some accidents have occurred as a result of divers unintentionally placing a hand or foot in the wrong place causing injury to that limb. How does it cause injury? When the spines of the Crown of Thorns starfish puncture the skin, significant bleeding occurs at the wound site and also subcutaneously (under the skin) in the surrounding area. The spines are themselves not capable of injecting venom and no mechanism to enable them to do this has been found. It is believed that venom is contained in the tissue of the starfish which enters the wound of the affected person when the spine punctures the skin. The venom of the Crown of Thorns starfish and its effects on the human body are not fully understood and much research continues into it. What is known is that the venom contains 43

DIVER MEDIC & AQUATIC SAFETY

a compound called Saponin, a toxin more commonly found in aquatic plants which acts as a repellent to prevent them being eaten by fish. Saponin is haemotoxic (toxic to blood) in so far that it has strong haemolytic properties. This means it can cause red blood cells to rupture and leak their contents into the surrounding blood plasma. It is this toxin that causes the significant bleeding and causes the affected person to feel nauseous and vomit. A second toxin discovered in the starfish venom is Plancitoxin I. Studies have indicated that this may have potential heptotoxicity (toxicity to liver cells). Studies into the effects of this venom are at a fairly early stage and at this time long term problems with the liver have not however been reported in individuals affected by the Crown of Thorns venom. The thorns of the starfish are brittle and can break very easily. As a result it is not uncommon to find fragments of them remaining in the wound site. Both the presence of this foreign object in the human body and the puncture itself will cause a localised inflammatory response to take place. Fluid containing inflammatory cells and proteins will accumulate in the affected area which is why it becomes swollen. A process called debridement (removal of debris) takes place whereby some of the inflammatory cells (neutrophils) attempt to break down the foreign body and or bacteria into smaller pieces which can then be ejected more easily. If the initial inflammatory response is insufficient to eject the foreign body further inflammatory cells (macrophages and lymphocytes) aggregate to form a mass called a granuloma. The remaining spine and granulomatous inflammatory reaction will potentially cause a condition called synovitis, whereby the membrane that lines any joints (synovial membrane) in the affected area will become inflamed. Fluid will accumulate causing swelling and pain making it difficult to move any affected joint. This will present as similar to individuals suffering with arthritis. Whilst the particles of thorn remain in the wound, this condition and its signs and symptoms will persist. This has been reported weeks after the initial injury has taken place.

"The thorns of the starfish are brittle and can break very easily. As a result it is not uncommon to find fragments of them remaining in the wound site" Photo by Cigdem Sean Cooper

Signs and Symptoms The spear fisherman that I dealt with that day classically showed many of the early signs and symptoms of being affected by the venom of the Crown of Thorns starfish. He was in an immense amount of pain. This occurs immediately after the injury takes place in the locality of the wound. There were between four and five bleeding puncture sites on his hand of which some still had thorns in place. His hand was quickly reddening and swelling as the inflammatory response kicked in. In my case I was lucky as the spear fisherman did not exhibit any signs of severe allergic reaction (anaphylaxis) and I did not

ISSUE 01 | AUGUST 2014

Photo by Stephen Kerkhofs

deal with him long term after the incident. However if I had, I may have seen him experience numbness, tingling, weakness, nausea, vomiting, joint aches, headaches and potentially in some very severe cases paralysis. Had I taken his blood pressure I may have seen that he was experiencing hypotension (low blood pressure) which would have resolved itself within about 60 minutes. In a number of cases, pain and localised paralysis have been reported in the weeks after the incident and possibly for the months following. In every case of this, follow up radiographs have shown debris or small remnants of the spine in the wound site. Subsequent surgical removal of the spine particles tends to resolve the issue. First Aid Treatment So, what did I do to help my injured spear fisherman? I got him to sit down and tried to keep him calm as I put the kettle on. For those of you that are not in the know, this was not to make him a cup of tea but I vaguely remembered something about hot water reducing pain in marine life envenomation. If I am honest, I was very lucky because my boss came back and assisted me, confirming that I was doing the right thing. Current guidelines on how to treat someone subject to a Crown of Thorns starfish injury are as follows: • Have the person sit down and try not to move the affected area too much. Do not raise it as you would with normal bleeding control, as this may cause the venom to move on from the injured site more easily to other parts of the body. • Immerse the affected area in water as hot as the person

can stand it (about 50oC) for at least 30-90 minutes. What you may find is that removal of hot water may cause the pain to re-commence and it may need to be reapplied. Studies have shown that the haemolytic activity of the starfish venom is affected by application of hot water. • Tweezers should be used to remove the spines from the affected area. Remember the spines are very brittle and can break easily. Therefore remove them in a straight line and do not hold the tweezers too tight. Scrub the area with soap and water and rinse with clean fresh water. • Topical anaesthetic may be applied or injected to reduce pain. • Monitor for severe allergic reaction. • Hydrocortisone cream may assist to treat any signs of minor localised allergic response such as itching. • Loosely cover the affected site and keep clean. • Call for medical advice if: • Severe allergic reaction occurs • Paralysis presents • Symptoms persist as surgical removal of spines may be required • There are any signs of infection, as oral antibiotics may be required As previously mentioned there is still a lot to learn about the Crown of Thorns starfish, its venom and how to treat any associated injuries. Research is currently underway which may assist in providing future, more effective medical treatment. Luckily at the moment the injury is rarely serious enough to warrant assistance from the emergency medical services. Current first aid provision provides an adequate level of care, capable of being provided by the majority of informed lay people, even a 19 year old Divemaster in training, who was struggling to remember her training. 45

DIVER MEDIC & AQUATIC SAFETY

NEAR MISSES WITH REBREATHERS AND C02 John Bantin was a pioneer diver with prototypes of the latest range of closed-circuit rebreathers and has been Technical Editor of Diver Magazine for 21 years. He's travelled to some of the best dive locations in the world. We finally caught up with him to

It was back in 1993 that rebreather evangalist Peter Readey first introduced me to the pleasures of rebreather diving. I was meant to do his pioneering course with Martha Holmes, a producer/presenter for the BBC, but her employer decided it was too hazardous and after the first day she went off to do other things. It was dangerous but in those days I was totally unaware of exactly how dangerous it was.

perform faultlessly. Many of them appeared to suffer heart attacks while in or underwater. While out in Egypt a few years earlier with Peter Readey, we’d made it a habit to dry out our scrubber material by unloading it and spreading it out in the sun to dry between dives. I can almost hear the gasps of horror coming from knowledgeable rebreather divers on reading this.

I learned first on the prototype Prism SCR, later the Draeger Atlantis SCR (even becoming briefly a consultant to Draeger) and then the prototype Inspiration, the first fully closed-circuit rebreather. By the time the Inspiration was available in a full production version, you could say that I was one of the most experienced rebreather divers around. Of course, today there are many rebreather divers who know a lot more about it than me.

It was the loss of sufficient oxygen from the breathing loop that continually obsessed me. In fact I even sat up in bed one night in my hotel room, breathing off my unit with the oxygen supply turned off in order to experience and be able to recognise the first symptoms of hypoxia. There were no symptoms. It was as dramatic as a bullet in the brain save that the mouthpiece fell from my lips and my unconconcious body was revived with air from the room. I awoke some hours later with the worst hangover imaginable but unbeknown to me, it had been a close-runthing and I had become a ‘flaker’ in relative safety. We were also concerned with the effects of two much oxygen. We’d scrutinise our ppO2 gauges as we decended because if you increased the depth too quickly, the level could spike. Equally, if we ascended too quickly it could drop. (It’s sometimes strange to consider you need less ppO2 at depth than you do in the shallows.)

I was away in the Maldives with two of the first commercially produced Inspirations and Martin Parker, CEO of the company that made them, when we heard of the first ‘flaker’. An early adopter, he’d passed out but luckily his life was saved by his friends. He’d switched his unit off while waiting to dive, presumably to save battery power, and forgotten to switch it back on again. Not looking at his display and with dropping oxygen levels since the solenoid was unable to open to replenish the breathing loop, he’d been the victim of hypoxia. There then followed some inexplicably tragic deaths of some high-profile divers using this newly available item of kit. Some divers even passed away whilst swimming and breathing from their units at the surface. What was happening? The equipment had appeared to

We were so absorbed with the dangers of hypoxia and hyperoxia (that’s caused by too much or too little oxygen in the breathing mix) we completely overlooked the dangers of carbon-dioxide poisoning. It was only during a later trip with Peter Readey down in Baja Clifornia that I grew to understand the dramatic and usually fatal consequences of failing to remove the CO2 from what we breathed.

ISSUE 01 | AUGUST 2014

Photo by Rich Carey

DIVER MEDIC & AQUATIC SAFETY

Using a later prototype Prism closed-circuit rebreather, I proved that, assembling the unit in the darkness of the early hours, you could insert the scrubber cannister into the scrubber bucket of the Prism the wrong way up. (It was immediately redesigned after the sequence of events I’m going to tell you about.) The scrubber cannister is filled with Sofnolime (a typical and commercially available absorbent) that chemically removes the poisonous bi-product of breathing and turns to calcium carbonate in the process. In putting it in inverted I had effectively bypassed the scrubber from the breathing loop. I started to breathe unscrubbed breathing mix as soon as I commenced breathing from the rebreather. You are probably aware that it is the raised level of carbon-dioxide in our lungs that is the trigger that makes us breathe. It is the urge to jettison this poisonous gas. I was always under the illusion that the onset of CO2 poisoning would be preluded by heavy breathing. This may be the case but the onset of breathlessness is also accompanied by confusion and reduced brain function. How do I know this? Wearing the rebreather and prebreathing it on the deck of the diveboat, I became short of breath. I started to breathe very heavily and assumed it was caused by the air-side weight of my equipment. It got worse and I became focused that all would be well once I was in the water and weightless. Wrong! I jumped into the sea and descended to ten-metres deep before things got so bad I realised I was fighting for my life. Somehow I managed to fight my way back to the surface where I was dragged back on board the boat. My heart by this time was beating so fast it was nearly climbing out of my chest. The doctor who annually conducts my HSE Medical Examination for Divers always reports that I have a very low heart-rate, the blood pressure readings of a teenager and a Harvard step-test result to be envied. It seems I was very fit. That’s lucky because I came the nearest I’ve been to having a heart attack. I was so exhausted from that briefest of experiences that I was unable to move for a couple of hours and could only lie on the deck of the boat. If I had been any less fit or had to swim further to the surface I might certainly have been fatality from another of those mysterious heart-attacks underwater.

ISSUE 01 | AUGUST 2014

Photo by stephan kerkhofs

DIVER MEDIC & AQUATIC SAFETY

Why should you never empty out a half-used cannister of scrubber material and repack it as we did when we dried out ours, all those years ago? Water is a by-product of the chemical reaction that occurs between the scrubber chemicals and the CO2. In fact it is said to speed up the reaction so firstly, be aware that it will get damp in use. Imagine that you have line after line of soldiers in a stack defending the monarch (that’s you) from an attacking force. As each molecule of poisonous CO2 comes into contact with a molecule of scrubber material, they both die and inactive carbonate is produced. As each grain of scrubber dies the following molecules of CO2 can pass and are killed by the next active grain of scrubber. In this way the defensive line of scrubber material passes through the stack with inactive or ‘dead’ granules of carbonate left before it. The heat generated by the exothermic chemical reaction can be monitored by a temperature-sensing stick nowadays available with some rebreather units. However, it is a guide and should not be regarded as an indication of duration as you might the pressure gauge of a tank. If you were to empty out the scrubber material mid-use, you would never be able to refill the cannister with the same granules in such a way that the original position of each of the granules was retained. You would almost be sure to end up with a route of ‘dead’ granules passing through the stack and this would allow the poisonous CO2 to channel its way through the scrubber with disastrous consequences. How we got away without serious CO2 poisoning all those years ago I’ll never know! If you use a rebreather, filling the scrubber cannister with Softnolime (or similar) is of serious consequence. Follow the manufacturers instructions and do not use a filled cannister for a longer duration that recommended in the manual, regardless of whatever else you may believe. With the growing popularity of rebreathers among divers, all divers, whether they use a rebreather themselves or not, should be aware of the hazards of both hypoxia and carbondioxide poisoing.

ISSUE 01 | AUGUST 2014

Photo by Rich Carey

DIVER MEDIC & FIRST RESPONDER

Women Divers

Hall of Fame What is the Women Divers Hall of Fame? Dedicated to recognizing and honoring the contributions of women divers, the Women Divers Hall of Fame™ (WDHOF) is an international, non-profit, professional honor society whose member contributions span a wide variety of fields including: The Arts, Science, Medicine, Exploration & Technology, Marine Archeology, Business, Media, Training & Education, Safety, Commercial & Military Diving, Free Diving, and Underwater Sports. WDHOF was created in 1999 and incorporated in 2001 by six founding sponsors: Beneath the Sea, Inc.; the Underwater

Society of America; the Women’s Scuba Association; Women Underwater; Hillary Viders, Ph.D.; and Capt. Kathy A. Weydig. WDHOF, Inc. was granted its 501(c)(3) status in 2002. WDHOF’s two-part mission is to: 1. Recognize women divers who have made outstanding contributions to the exploration, understanding, safety and enjoyment of our underwater world and 2. Support the underwater world and its associated careers by promoting opportunities for women and men in diving through scholarships, internships and mentorship opportunities and a worldwide network of industry contacts.

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The members of WDHOF form an elite group that includes the most notable women leaders and innovators in the diving community. The goal of the Founders was to recognize and honor these accomplishments, while raising public awareness of these women’s exceptional contributions. There are over two hundred members in the Hall, hailing from thirty U.S. states and Territories and twelve countries worldwide. WDHOF Members are selected on an annual basis. For profiles of WDHOF members and nomination criteria, visit the website: www.wdhof.org Where Is WDHOF? Each year, the members of WDHOF attend various consumer diving expositions, the DEMA show (for diving professionals only) as well as symposia, conferences, seminars and special events throughout the United States. These venues allow for our members to give presentations and seminars about their areas of expertise and allow our members to meet and speak directly with the public. What is the Criteria for Nomination? The Women Divers Hall of Fame seeks to recognize the outstanding contributions that women divers have made in the exploration, understanding, safety, enjoyment, and preservation of our underwater world. There are many deserving women not yet among our honorees and we are often asked about the criteria for membership. A woman nominated to the Hall must meet two specific criteria for membership: She must actually be a diver (for example free, SCUBA or surface-supplied, for scientific, commercial, military or other purposes); and her contribution must be recognized as significant. Recognition might include: • a significant contribution to the diving community’s knowledge, safety, enjoyment and/or protection of the underwater environment, • a world record in the field of diving, • being a “first” or a pioneer in a diving-related field that is recognized on the national or international level, • a Founder or CEO of a major diving organization or program, • endorsement by major leaders and/or experts in her diving-related field, or • one who is a proven leader within her diving community and/or has demonstrated outstanding leadership in her profession. (Example: one of our members is a world renowned ambassador for ocean science and stewardship, often representing ocean environmental perspectives in preeminent international meetings and panels. Additional information, as well as representative achievements which have qualified nominees for selection in the past, can be found on our website.

DIVER MEDIC & FIRST RESPONDER

Scholarships & Training Grants The Women Divers Hall of Fameâ&#x201E;˘ (WDHOF) is a 501(c) (3) nonprofit organization dedicated to honoring and raising awareness of the contributions of outstanding women divers. WDHOF provides educational, mentorship, financial, and career opportunities to the diving community throughout the world. WDHOF awards multiple scholarships and training grants that offer financial and/or educational assistance to women and men of all ages, particularly those who are preparing for professional careers that involve scuba diving. Scholarships and training grants are awarded yearly. Scholarship and training grant applications are available online in September, must be submitted by mid-November, and are awarded at the Beneath the Sea Exposition and International Film Festival in March of the following year. Scholarships topics range from underwater archaeology; journalism, graphic arts, or photography; and marine conservation to undergraduate marine research internships in marine biology. Training grants include junior dive training; certification as a hyperbaric technician; assisting the disabled to dive; marine science, oceanography, or ocean engineering; and other dive training. For more information on and applications for scholarships and training grants, as well as a complete list of previous recipients, please visit our website at www.wdhof.org.

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Sponsorships The Women Divers Hall of Fame is a volunteer organization. As such, we rely on the collective resources from WDHOF Members and Sponsor donations to help us continue our mission. Sponsors are listed on the website and in printed literature, receive invitations to special events, and may have their businesses linked to the WDHOF website. Associate Memberships Associate membership is an opportunity for anyone to support, and participate in, WDHOF programs and initiatives. Annual membership dues of $40 entitles you to: • a special WDHOF Associate Member lapel pin • a WDHOF Associate Member membership card • listing in the WDHOF newsletter • listing on the WDHOF website • an electronic version of the WDHOF newsletter • invitations to socialize one-on-one with WDHOF Officers, Trustees and WDHOF Members at dive shows, seminars, and special events. A special Student Membership rate of $20 a year is available for those individuals 13 and older still enrolled in school, through completion of a post graduate degree. And, the biggest benefit: actively supporting WDHOF and its scholarship programs! Please make your gift payable to Women Divers Hall of Fame and mail to: WDHOF, Inc., 43 Mackey Ave., Port Washington, NY 11050. Donations may also be made through the website at: www.wdhof.org Thank you for supporting WDHOF The Women Divers Hall of Fame is a 501(c) (3) non-profit organization, so your charitable donation is tax-deductible to the fullest extent of the law. By becoming a Sponsor or Associate Member of WDHOF, your generous gift provides additional funding for the WDHOF scholarship programs and provides deserving women and men with the additional education and training they need to continue in a career in the diving industry, marine sciences and arts. 55

Photo by Polly Dawson

ISSUE 2 OUT NOVEMBER 2014

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