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Home , Sport diving (sport)

AND EMERGENCY MANAGEMENT GUIDELINES

for the

U-1105 BLACK PANTHER HISTORIC SHIPWRECK PRESERVE 18ST636

in the

POTOMAC RIVER, MARYLAND

APRIL 1995 TABLE OF CONTENTS Introduction ...... 3

I. GENERAL ACCEPTED SAFE DIVING STANDARDS PADI Standard Safe Diving Rules...... 4 II. SPECIFIC CONDITIONS and PROCEDURES for the U-1105 SITE Site Conditions ...... 5 Safety Guidelines for Diving the U-1105 Site ...... 5 III. SITE PRESERVATION GUIDELINES Damage Prevention ...... 6 Site Monitoring ...... 6 IV. EMERGENCY MANAGEMENT at the U-1105 SITE Potential Accident Scenario’s ...... 7 How to Recognize a Diving Accident Victim ...... 8 Situation Management ...... 9

V. GENERAL EMERGENCY MANAGEMENT Communications ...... 10 Hospitals and Recompression Chamber Information ...... 11 Medical Evacuation Procedures ...... 12 Helicopter Evacuation ...... 13 VI. LOST/MISSING DIVER SEARCH PROCEDURES...... 13 VII. MEDICAL PROCEDURES Why is Administered ...... 14 The Trendelenberg Position ...... 14 Signs and Symptoms ...... 15 Gas/ ...... 15 Heat Stroke ...... 16 Heart Attack and CPR...... 17 Sickness ...... 18 VIII. DAN (Diving Accident Network) INFORMATION...... 19 IX. DAN ACCIDENT MANAGEMENT FLOW CHART...... 20

2 Introduction

The U-1105 site has been designated an Historic Shipwreck Preserve and marked with a buoy to facilitate the preservation of the vessel. Although diving at the site is difficult and can be dangerous, it was reasoned that active, experienced divers would attempt to locate and dive on the site regardless of what policy the State of Maryland or the United States Navy might implement. Divers searching for the site would be likely to damage the submarine by dragging anchors into it and without government monitoring, artifact looting was certainly possible. By marking the site with a buoy and publicizing the Preserve to the dive and local community it is expected that preservation of the site will be greatly enhanced. Also, experienced divers who choose to dive on the site will be afforded direct access to the submarine which will increase safety considerations at the site. Diving is a demanding and exciting activity. When performed properly, applying correct techniques it is a safe sport. When established safety procedures are not followed, however there can be dangers. Despite modern equipment and up to date training pro- grams sport diving, when conducted improperly, can be considered hazardous and like any other active sport, accidents can occur. Statistics show that the majority of diving accidents can be prevented if safe diving standards are followed. Diving accident reports reveal that many diving fatalities can also be prevented if proper rescue and resuscitation techniques are followed. Therefore the following safety procedures manual is a summary of accepted safe diving practices and guidelines as well as emergency management procedures. It is in- tended to be used as a reference; for suggestions or recommendations only. (Federal or State agencies cannot require dives to be conducted in a specific manner). To minimize the potential for mishap, a list of possible accident scenarios, and how to prevent them, are outlined in the emergency management section. If an accident does occur, following the emergency procedures guide could possibly prevent a more serious situation. Each dive and the conditions encountered are specific unto themselves, particularly on the U-1105 site. The decision to dive this site and the technique(s), used to conduct the dive should be made by each diver based on his/her level of experience, training,, physi- cal ability, and proper equipment. The weather and sea conditions should also be taken into consideration and constantly monitored as wind and waves at the site can change very rapidly. The diving conditions at U-1105 site can be dangerous and diving should only be undertaken by advanced divers experienced in low visibility environments, deep depths, strong currents and environments. All divers should understand that any diving conducted at the U-1105 site is done “at your own risk”.

3 I. GENERAL ACCEPTED SAFE Standard Safe Diving Practices When diving, you will be expected to abide by standard diving practices. These practices have been compiled to reinforce what you have learned and are intended to increase your comfort and safety in diving. As a certified diver, you should: 1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after inactivity. 2. Be familiar with your dive sites, if not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which you are experienced, postpone diving or select an alternate site with better conditions, Engage only in diving activities which are consistent with your training and experience. 3. Use complete, well maintained, reliable equipment with which you are fa- miliar; and inspect it for correct fit and function prior to each dive. Deny use of your equipment to uncertified divers. Always have a control device and submers- ible gauge when . Recognize the desirability of an alternate source of air and a low pressure buoyancy-control inflation system. 4. Listen carefully to dive briefings and directions, and respect the advice of those supervising your diving activities. 5. Adhere to the buddy system throughout every dive. Plan dives, including communications, procedures for reuniting in case of separation, and emergency proce- dures, with your buddy. 6. Be proficient in dive table usage. Make all dives no-decompression dives and allow a margin of safety. Have a means to monitor depth and time under water. Limit maximum depth to your level of training and experience. Ascend at a rate of 60 feet per minute. 7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoy- ancy with no air in the buoyancy control device. Maintain while under water. Be buoyant for surface swimming and resting. Have clear for easy re- moval, and establish buoyancy when in distress while diving. 8. Breathe properly for diving. Never breath hold or skip breathe when breath- ing compressed air. Avoid overexertion while in and under the water and dive within your limitations 9. Know and obey local diving laws and regulations, including fish and game, dive flag laws, and submerged historic properties guidelines and regulations. If in doubt check first with the appropriate agencies.

4 II. SPECIFIC CONDITIONS AND PROCEDURES for the U-1105 SITE Site Conditions It should be stressed that the waters surrounding the German submarine U-1105 can be considered a hazardous diving environment, typified by strong currents, high , and considerable depth. In addition, from the late fall through spring the bot- tom on the site can be very cold. The sediments on and around the subma- rine consist of a black-brown very fine river bottom silt that is quite fluid. If these sedi- ments are disturbed, a black cloud forms instantly around suddenly creating a zero visibility environment. However if the diver remains calm , the strong currents on the site will usually remove the cloud in a few moments. Currents can be difficult to predict on the site even with tables, there are usually counter flowing top and bottom currents of different intensities. All of these environmental conditions combined make it a challenging dive site for even the most experienced of divers. Yet it is undoubtedly one of the most unique shipwreck sites of its kind found to date in American waters. Scuba diving, by its very nature, can be a hazardous sport, with incumbent dangers increased or decreased as bottom conditions vary. Recommendations in this report do not suggest that this site will ever be a safe dive site. The environment cannot be altered, although hazardous features of the wreck itself have been corrected. It should be noted, however, that site conditions are not unlike those of thousands of other Atlantic Coast and Chesapeake Tidewater wrecks which are dived on by sport divers every day, each with their own set of inherent . Safety Guidelines for Diving at the U-1105 Site In addition to normal safe diving rules there are some aspects of the U-1105 site that call for closer attention to specific safety considerations. The site is marked with 2 buoys, a large blue and white (can type) buoy and a smaller orange buoy, the smaller buoy is connected directly to the bridge on the submarine’s conning tower. 1. There is daily commercial boat traffic on the river in the area of the site, therefore be sure the dive vessel displays both the alpha (blue & white) as well as the standard (red & white) dive flag. This is also called for under Maryland law. 2. Because of the strong currents on the site, dive vessels should deploy a long buoyed safety line to assist divers surfacing away from the dive vessel. Boat captains and/or dive masters should also have a prearranged plan for recovering divers surfacing too far from the dive vessel. Drifting surfaced divers may not be able to reach the and the vessel may need to leave the mooring to recover them while other divers are still down. The plan for this contingency should be discussed and understood by all divers. 3. Because of the strong currents on the site, surface lookouts should be posted to watch bubbles and to spot divers surfacing away from the site. Once a surfaced diver is spotted the lookout should confirm that the diver is OK and maintain visual contact with the diver until recovery is completed. 4. A buddy pre-plan is especially important, be sure to plan for contingencies and stick to your dive plan. 5. Divers should descend and ascend on the down line of the smaller buoy which connects directly to the bridge/ conning tower area and stay on the site.

5 III. SITE PRESERVATION GUIDELINES

The U-1105 is a unique and valuable resource. Most submarines off the American coast have been stripped bare by relic hunters leaving little purpose or pleasure in visit- ing these sites. The submarine Black Panther is interesting because it has remained rela- tively undisturbed. The U-1105 Historic Shipwreck Preserve was created to protect the vessel and to ensure divers access to enjoy this significant historical site. To this end a number of rules have been instituted to minimize the chances of damage to the subma- rine. The site is marked by 2 buoys, a large blue and white can buoy identifies the site and acts as a mooring for vessels waiting to access the site and a smaller orange buoy which is connected directly to the bridge on the submarine. 1. The submarine is over 67 meters (220 ft.) long, therefore anchoring within a 300 meters (600 ft.) radius of the buoys is prohibited. 2. Only one vessel at a time may occupy the small buoy attached directly to the site. All other vessels must utilize the larger mooring buoy or stand clear while wait- ing to dive on the site. Vessels larger than 30 feet should moor only on the larger buoy and rig a diver safety line to the smaller buoy. Because of depth/time limitations, dive vessels are unlikely to occupy the site for more than one hour including time to don and doff equipment. 3. Minimize sediment disturbance when on the site. Adjust for neutral buoy- ancy and try not to crawl around on the site, this will maintain a better level of visibility and lessen the possibility of damage to the site in areas where the metal has graphitized and weakened. 4. Look don’t touch, the features and artifacts on the U-1105 are there for ev- eryone to see and experience. Some features are fragile and all objects are US Navy prop- erty,, nothing may be removed from the site. Artifact recovery is strictly prohibited, offenders will be prosecuted under Federal Law. This can result in the confiscation of vessels, vehicles and equipment. 5. The preserve will be monitored in an ongoing manner with formal assess- ments twice a year, however, any damage or vandalism on the site or to the buoy should be reported to the State Underwater Archaeologist (410-514-7662) or to St. Clement’s Is- land Museum (301-769-2222). Report any theft or vandalism observed to DNR police (301-888-1601) or Maryland State Police (301-475-8955). Failure to report criminal activity may be punishable by law. 6. In order to ensure adequate upkeep and management of the preserve, the Maryland Historical Trust needs to assess use statistics for the preserve. In addition, comments and suggestions for improving the preserve are welcome and encouraged. Please complete site use forms available at either Piney Point or St. Clement’s Island Museums or from the Maryland Historical Trust, Office of Archaeology, 100 Community Place, Crownsville, MD 21032-2023. Comments may also be submitted by telephone (410- 514-7661), fax (410-987-4071), or e-mail ([email protected]). Please include your name, address and telephone number.

6 IV. EMERGENCY MANAGEMENT at the U-1105 SITE Potential Accident Scenarios on the U-1105 Site 1. Lost Diver - A diver or divers could become disoriented in the low visibility and lose contact with the wreck itself and/or their buddy. The diver may ascend slowly and surface safely down current away from the site but may not able to return to the dive vessel because of strong currents. If the surfacing diver is not seen or heard by a lookout aboard the dive vessel, the diver will continue to drift farther away, by the time he is discovered as missing, he may not be visible to those on board the dive boat. PREVENTION - Pre dive plans / orient divers to the site Post a lookout to watch for bubbles and surfacing divers Deploy a long current line and float from the dive vessel Have a plan for recovery of drifting down current divers Make sure all divers know and understand the plan 2. Air Embolism - A lost or disorientated diver may become panicked and surface too rapidly which could result in an air embolism injury. This problem could be com- pounded if the injured diver surfaces too far down current to be easily seen or reached by those on board the dive vessel. PREVENTION - Pre dive plans / Orient divers to the site Post a lookout to watch for bubbles and surfacing divers Deploy a long current line and float from the dive vessel Have a plan for recovery of drifting down current divers Post a stand by surface Have a prearranged plan for the treatment of air embolisms Have oxygen on board the dive vessel Have a prearranged plan for evacuation if necessary. 3. Exhaustion /Heat Stroke/ Heart Attack - The strenuous conditions at the U-1105 site require that divers be in good physical shape. It is possible that divers may overestimate their physical abilities and return from the dive exhausted and unable to properly exit from the water. While this is not in itself a serious problem it could become more compli- cated in the strong currents at the waters surface or manifest itself once the diver is aboard the dive vessel. PREVENTION - Screen divers before they enter the water Post stand by surface rescue divers to assist tired divers Be prepared to administer CPR Be aware of signs of Heat Stroke

4. - The U-1105 is considered a deep dive and as such pre- sents the potential for decompression sickness. In spring and late fall the water tempera- tures on the site are very cold, in addition the current flow can be as strong as one knot or better depending on the tide. A deep dive involving cold water and strenuous exertion on the part of the diver can result in a case of decompression sickness, even if the diver stays within the dive tables.

7 PREVENTION - Compensate dive tables to allow for cold deep strenuous Dive Have oxygen on board the dive vessel Have a prearranged plan for the treatment of decompression sickness Have a prearranged plan for evacuation if necessary

How to Recognize a Diving Accident Victim

A diving accident victim could be any person who has been air underwa- ter regardless of depth. Gas embolism can occur in as little as 2-4 feet of water if one ascends holding his breath. Even a well-trained diver may encounter problems because of respiratory medical problems. Asthma, broncholithiasis, congenital or acquired cysts, emphysema, fibrosis, tuberculosis and infection, especially fungal, obstructive lung dis- eases may result in air trapping during ascent, this expansion of trapped air may be suf- ficient to rupture air spaces. The escaping air may cause emphysema of the lungs, medi- astinum, or neck. Alternatively, it may cause pneumothorax. Finally, arterial air embo- lism may result. Decompression sickness (usually the least serious of the illnesses) can occur in any individual who violates the decompression tables either willingly or unin- tentionally when surfacing from depths greater than 30 feet. Bubble trouble can happen to anyone, anywhere, at anytime, far out at sea, in home swimming pools -lakes - harbors - canals and from submerged cars. To insure a successful treatment, instructors, , EMT’S, rescue personnel, physicians, and emergency room personnel must be able to recognize the problem, begin diving accident treatment procedures and move the victim into the hyperbaric trauma system as soon as possible. In the presence of a medical emergency exhibiting any signs resembling those of a diving accident, there is one primary question. “Did the subject breath air underwater?” If the answer is “Yes”, you must regard the subject as a diving accident victim, especially in the case of unconsciousness. The diving accident treatment procedure must be initi- ated immediately. This includes restoration of vital signs, administering oxygen, Trendelenberg Position, and immediate evacuation to the recompression chamber com- plex. (Follow DAN flow chart p. 20)

8 Situation Management

A major problem with divers is that they tend to ignore the mild symptoms of bubble trouble in the early stages. By doing so, they eventually have more serious symptoms. Immediate diving accident identification can be broken down and handled in two cat- egories mild and severe symptoms. (See DAN Flow Chart p. 20) To simplify identifica- tion all symptoms of gas embolism and decompression sickness will be considered to- gether. Mild symptoms are those that can be treated at the dive site by the diver using surface oxygen. Indifference, fatigue, skin rash, and weakness are considered mild symptoms. Although joint pain is also considered a mild symptom, it will be treated as a severe symptom according to the DAN Flow Chart because recompression is required. If a diver comes up from a dive and acts indifferent, appears not to know what is going on, or ignores people trying to communicate with him, this may be an early warning of bubble trouble. The same applies to extreme fatigue, weakness, or skin rash. Do not hesitate, place this person on surface oxygen, head downward (Trendelenberg Position). Also follow the DAN Flow Chart through to the final stage. Doing this often relieves the symptoms or prevents them from getting worse. Surface oxygen, and assum- ing the Trendelenberg Position have been successful in being the complete treatment. The biggest problem in the early stages is the diver’s ego. Divers do not want to admit there is anything wrong with them and refuse to be put on oxygen because they feel others will think less of their diving ability. Do not let your ego or the patient’s ego overrule common sense. Use surface oxygen and place the patient in the Trendelenberg Position immediately. If the symptoms appear to be relieved after the patient has been on oxygen for a short period of time do not remove the oxygen immediately, as bubbles will reload from gases in the surrounding tissue, and the symptoms will reoccur. If symptoms are relieved in 10 minutes, keep the patient on oxygen for 30 minutes total. If symptoms get worse, find new symptom on Flow Chart and follow chart recommendations. Severe symptoms are those that require immediate treatment and evacuation into the hyperbaric trauma system (See DAN Flow Chart p. 20), if the victim’s vital signs cease to function, CPR will be required This is first and foremost in diving accident treatment. If a patient comes up from a dive, or anytime within 24 hours after a dive, and shows any of the severe symptoms indicated on the Flow Chart, immediately place the Patient on sur- face oxygen and in the Trendelenberg Position after insuring vital signs are functioning properly, and follow the Flow Chart to eventual evacuation to a recompression chamber. it is important to remember that because these signs/symptoms can develop hours after diving, the patient may show up in a hospital emergency room or other medical facilities in the community. For this reason, it is important for paramedics and physicians to recognize the symptoms and to understand this hyperbaric problem so that the diving accident procedure can be initiated. It is also extremely important that any person deliv- ering a diving accident patient to professional medical personnel explain this procedure to them, so that the patient will receive proper recompression if needed.

9 V. GENERAL EMERGENCY MANAGEMENT Communications

If you have a radio on board, contact the Coast Guard Directly, on channel 16 VHF marine band. Declare an emergency and state the type of emergency, e.g., “This is a diving accident victim needing treatment in a recompression chamber”. Give your exact location by direction and distance from prominent land marks. Give all symptoms of the victim and dive history if applicable. State the condition of victim, i.e., can he walk, sit up, or is he unconscious. Describe any unusual circumstances, and the number of vic- tims. Give detailed description of your boat, including any outstanding features for iden- tification. Give weather, sea condition, wind direction and speed. If you should change your location, keep all concerned advised of your new location and your intentions. The Coast Guard does monitor CB, Channel 16. This is a very unreliable means of communications for many reasons. If you are unable to raise the Coast Guard via CB, contact someone else to relay your messages. If you have a cellular phone on board your vessel, call 911, ask the 911 operator for “Maryland” Emergency Assistance. In this area the 911 call will go to Virginia however the Maryland shore is closer. If you have no radio on your boat, if practical, hail a boat with a marine band radio and give them the information to relay to the Coast Guard. Keep them with you for further contacts. The International Convention for safety of life at sea requires the providing of assistance to vessels in distress.

If no other boats are immediately available proceed immediately to the nearest inhab- ited dockage and telephone local paramedical or USCG services. Advise them of a diving accident, state your need for transportation and your EXACT location. Have someone remain at the telephone for further assistance. Insure that they are aware at this time that a recompression chamber will be needed. If symptoms occur on land after diving, contact local paramedics or USCG. They should be able to assist or advise location of nearest recompression chamber. When the rescue aircraft arrives in your area, wave, fire flares or smokes. LET THEM KNOW YOU ARE THE ONES WHO WANT ASSISTANCE. Do not assume the pilot will recognize you. He may waste valuable time searching for you unnecessarily.

10 Hospitals and Recompression Chamber Information Hospital: St. Mary’s Hospital 234 Jefferson Street Leonardtown, Maryland 20650 301 475-8981 Interlock 6 Atmosphere Chamber:

University of Maryland Hospital Shock Trauma / Hyperbaric Med. Dept. 22 South Greene Street Baltimore, Maryland 21202 24 hours 410 328-7814 Non interlock 3 Atmosphere Chamber:

Mount Vernon Hospital Alexandria, Virginia Monday through Friday 9AM -5PM 703 664-7218 At other times 703 664-7000 Non interlock 3 Atmosphere Chamber:

George Washington University Medical Center Washington, D.C. 202 994-9371

11 Medical Evacuation Procedures

The following medical evacuation information should be forwarded with the patient. If possible, take time to explain the following steps to the physician or paramedic. Don’t assume they understand the reasons why oxygen should be administered to a diving accident victim. If a person is breathing normally, the physician may take him off oxygen not realizing the patient must be kept on to continue to off-load the bubbles. When this has been explained the following steps should be followed: 1. Maintain breathing and heart functions, insure airway is open and remains open. 2. Keep patient on oxygen and incline head downward, left side down, during transportation (Trendelenberg Position). 3. Insure para-medic/physicians understand why head downward, left side, on oxygen is required until patient arrives at chamber. 4. Insure paramedics /physicians understand why patient needs to be taken to a recompression chamber instead of a hospital. 5. Do not remove oxygen from diving accident patient unless you need to reopen airway, or he shows signs of oxygen convulsions, even if patient is breathing normally. Without oxygen, bubbles will reload with nitrogen and cause increas- ing symptoms. 6. Keep patient out of hot sun, watch for possibility of shock. 7. Do not give any pain killing drugs, 1. IV.’s can be given to prevent vascular collapse or dehydration, (D5LR, Plain LR or D1/2N. S.). 2. Two aspirins orally. 9. Provided the aircraft can handle extra , diving buddy should be trans- ported with patient, as he may also need recompression and can be useful with information, comfort and contact with patient’s parents /relatives. 10. A complete history of all events leading up to the accident and until evacuation must be forwarded with the patient. 11. Depth gauges, tanks, regulators, and other should be for- warded with patient if weight limitations allow, especially if the accident is fatal.

Emergency Evacuation

Once it has been established that the patient is a diving accident victim, and someone is caring for his immediate medical needs (vital signs, surface oxygen, and Trendelenberg Position), someone must also be initiating the evacuation protocol into the hyperbaric trauma system. Because many divers and/or boaters fail to plan procedures in advance, a great amount of critical time is often lost, causing needless suffering and possible loss of life. The most important part of any dive and/or boat trip is to know your procedure for emergency evacuation.

12 Helicopter Evacuation

If it is necessary to evacuate an accident victim by helicopter it would be advisable to take the victim ashore to the nearest landfall and prepare for a land based evacua- tion. To select a landing zone and prepare for a helicopter evacuation the following guidelines should be considered: 1. The landing area should be at least 3600 square feet (perimeter 60 ft. per side). 2. All persons should be kept well back from the landing zone. 3. The area must be free from obstacles such as trees or power lines. 4. Any non secured items that could be blown away by the wind of the rotor blades should be removed from the landing zone. 5. A guide should stand at the windward corner of the landing zone to direct the pilot to the appropriate site. During the actual landing the guide should turn away from the aircraft to avoid flying particles of sand or dirt. 6. Never approach the aircraft unless motioned to do so by the pilot. When ap- proaching maintain a low, crouched position and eye contact with the pilot. 7. Be aware of the relative position of the rotor blades, because as the aircraft slows the blades will drop lower, especially in strong winds. Special care should be taken ff the landing is on uneven ground. 8. Never approach the aircraft from the rear as the rear rotors are almost invisible when turning. When a victim is to be flown to a hyperbaric treatment facility, instruct the flight crew to fly at the lowest possible safe altitude. The reduced pressure at high altitudes during the flight could further expand air bubbles and complicate the victims condition.

VI. LOST/ MISSING DIVER SEARCH PROCEDURES

1. Determine where and when the diver was last seen. 2. Immediately: a. Note the time. b. Determine the direction of current flow on the site, both bottom current and surface current. 3. Post spotters to: a. Look for bubbles around the boat. b. Scan the horizon especially in the direction of the surface current flowing away from the boat. 4. Dispatch a scuba team with equipment to initiate underwater search: a. Establish a recall system to avoid delay once a diver is found. b. Never subject searchers to undue danger from decompression sick- ness, by allowing single handed searching or from using inexperi- enced divers. c. If only inexperienced or unqualified divers are present call for emergency assistance. 5. Terminate the search in 30 minutes if the victim is not found. Turn the situation over to emergency professionals.

13 VII, MEDICAL PROCEDURES Why Oxygen is Administered

When oxygen is breathed, the oxygen (PO2) of the blood is increased. This establishes a steeper gradient across the bubble-tissue interface and aids in the elimi- nation of inert gases (from the bubble), reducing the bubble size to some extent. Addi- tionally, the elevated (PO2) allows better oxygenation of tissues where the blood supply is marginal, because the initial bubble has impaired that flow. Although this discussion relates to the use of oxygen at sea level as a measure, the same principles apply to the use of oxygen under hyperbaric conditions. Tissue integrity depends essentially upon two factors: (1) adequate PO2 and (2) ad- equate flow to deliver the oxygen. Even though there is some vasoconstriction, the flow should be adequate with the improved PO2 to help reduce bubble size and to supply oxygen-poor tissues. The Trendelenberg Position

The Trendelenberg Position means head down, but with legs bent at the knees. The Scoltetus Position means head down with the legs straight. Either position would be satisfactory to accomplish the goals mentioned. A patient is put into the head-down position for several reasons. In the case of embo- lism, it prevents further intravascular bubbles from reaching the cerebral circulation. This is explainable simply as counteracting gravity, for as the lighter bubbles rise, they will, hopefully, pass to the lower extremities rather than to the head. In the case of decompression sickness, the position should be used particularly if the patient is in shock, because it will allow a better flow of blood back to the “core organs” (heart, lungs, brain. and kidneys). If there are bubbles in the systemic circulation (left side of the heart), the position also prevents their migration into the in the same manner as described for embolism cases.

14 Signs and Symptoms

Knowing the causes, signs and symptoms is necessary to insure the proper treatment of a diving accident victim. You should be able to recognize the following: Gas (Air) Embolism

As a diver surfaces, the gas trapped in the lungs expands, rupturing the alveoli. Bubbles of gas are forced into the circulatory system, to the heart, and distributed to the body tissues. As the ascending diver is normally in a vertical position, these bubbles tend to travel upward toward the brain. As the bubbles enlarge and pass into smaller arteries, they reach a point where they can move no further, and cut off circulation. The effects of halting circulation, especially to the brain, are serious and require immediate treatment. Symptoms of embolism occur within 3-5 minutes of surfacing. One, a few, or all of the symptoms may be present. Symptoms: Fatigue Weakness Dizziness Paralysis of extremities or face Visual disturbances such as blurring Feeling of blow on chest, progressively worsening Cough or shortness of breath Signs: Sudden unconsciousness (usually immediately after surfacing, possibly before sur- facing) Bloody, frothy sputum Staggering Confusion or difficulty in seeing (i.e., moving in a wrong direction, bumping into objects) Paralysis or weakness in extremities or face Collapse or unconsciousness Convulsions Cessation of breathing

Treatment: Immediate first aid is to place the victim with head and chest inclined downward and lying on his left side. This position lessens the chances of bubbles being carried to the brain. Also, breathing 100 percent pure oxygen,, if available, is indicated. Begin oxygen treatment for air embolism in route to a recompression chamber. Treatment for air embo- lism is immediate recompression in a recompression chamber. This may reduce the size of the bubbles to the point where the circulation of blood may resume. The victim should be recompressed to 165 feet as soon as possible, and treated on the appropriate treatment table. Under no circumstances should the victim be taken back into the water to depth for treatment.

15 Heat Exhaustion/ Heat Stroke This condition occurs when the intake of water and salts are inadequate to compen- sate for losses due to perspiration. It is commonly characterized by cool and clammy skin and a grayish look to the face. A person may also complain of feeling dizzy, weak or faint, with accompanying nausea or headache. The body of a heat exhaus- tion victim may be near normal and a rapid pulse may be present. Emergency care for heat exhaustion begins with a primary assessment - arouse pa- tient, check for open airway, breathing, circulation, bleeding, and shock. Next move the patient to a cool location and if he is wearing an exposure suit remove it immediately. The patient should be urged to lie down. If fully alert, the patient should be encouraged to drink up to a liter of water or a diluted, commercially available balanced salt . Patients will typically respond favorably to these emergency care measures within 30 minutes. If the symptoms do not clear promptly, the level of consciousness decreases, or the body temperature remains elevated, the patient should be transported to the hospi- tal. Heatstroke occurs when the body is subjected to more heat than it can handle. The normal mechanisms for getting rid of excess heat are disrupted. When these mechanisms fail, the body temperature rises rapidly to a level that destroys tissues and may result in death. Heatstroke is rare, but it is a life-threatening emergency requiring immediate first aid. In advanced stages, heatstroke victims have hot, dry, flushed skin because they do not sweat. The absence of perspiration, however, may be an unreliable sign since heat exhaustion often precedes heatstroke and some moisture may remain on the skin. The skin color will be red and body temperature may rise to 103 degrees F or higher. The pulse is usually rapid and strong at first, but as the victim becomes unresponsive, the pulse will fade. Sudden unconsciousness often results, and convulsions may occur. A heatstroke victim’s body temperature must be quickly and immediately lowered. First remove the patient from the hot environment, also remove or cut away the patient’s exposure suit. To effectively cool the patient, either cover Mm with wet towels or place him in cold water. When his body temperature begins to lower, continue the circle of care and seek medical attention.

16 Heart Attack and CPR (Cardiopulmonary Resuscitation)

If an unconscious accident victim stops breathing and has no pulse someone trained in the use of CPR should begin resuscitation immediately. The following out- line could serve as a guide for the procedure. 1. Kneel at the victim’s side. With one hand, lift under the neck and tilt the head back to establish a clear airway. 2. Lean down to listen - feel - watch for signs of . 3. If there is no breathing, seal the nose with your free hand, seal your lips around the victim’s (or use a mouth mask) and give 2 full slow breaths. 4. If breathing doesn’t start spontaneously, check for a pulse on either side of the neck. 5. If there is no pulse, begin chest compressions (1-5 to 2 inches of depression) at a rate of about 60 to 80 beats per minute. 6. Give 2 breaths between every 15 compressions (if you are alone) or intersperse one breath every five compressions if working with another rescuer. Do not interrupt compressions for longer than five seconds at a time. 7. As color returns to the victim, recheck for pulse. When breathing starts, keep victim lying down, turn head to the side if vomiting occurs. Avoid aspiration of vomitus into the victim’s lungs as this can cause acidosis and decrease the blood’s ability to trans- port oxygen. 8. Resuscitation attempts should be continued until: a. Competent medical authorities take over. b. You are no longer physically able to continue. c. The victim revives.

17 Decompression Sickness

Decompression sickness (bends) is the result of inadequate decompression following exposure to increased . While immediate recompression is not a matter of life and death as with air embolism, the quicker recompression is initiated the better the rate of recovery. While under pressure, the inert portion of the (nitrogen, he- lium, etc.) is passed, into solution in the blood and absorbed by the body tissues. As long as the diver remains under pressure this gas presents no problems. Should the pressure be quickly removed (as in rapid surfacing) the inert gas can come out of solution and form bubbles in the tissues and blood stream. The controlled ascent permits the body to rid itself of excess inert gas at a rate which will enable it to remain in solution. Symptoms of decompression sickness are extremely varied, and are in many cases similar to air embolism. The effects of air embolism will be noticeable prior to or immedi- ately after the diver surfaces. Any occurrence of symptoms more than 1/4 hour after the diver reaches the surface can generally be assumed not to be air embolism. The most frequent symptoms of decompression sickness and frequency with which they occur are listed below. Symptoms: Frequency of occurrence Local pain: (described as deep-boring) ...... 89.% Leg ...... 30.% Arm ...... 70.% Dizziness (staggering) ...... 5.3% Paralysis...... 2.3% Shortness of breath...... 1.6% Extreme fatigue and pain...... 1.3% Collapse and unconsciousness ...... 5% Signs: Evidence of local pain (rubbing arm, limp, favoring one side) Staggering, clumsiness, lack of response as if drunk Paralysis or partial paralysis Blotchy or noted rash on skin Shortness of breath Collapse and unconsciousness

Treatment: The treatment for decompression sickness is recompression as quickly as possible ac- cording to the symptoms. Any symptom except a rash and local pain is considered a serious symptom and should be treated as such. Administer 100 percent pure oxygen in route to a recompression chamber. While decompression sickness may, in some rare cases, occur up to 24 hours after the exposure to pressure, the vast majority of cases (95 percent) will be evident within 3 hours. Fifty percent will occur within 30 minutes and 85 percent within an hour. Only 1 percent will be delayed over 6 hours.

18 VIII. DAN (Diving Accident Network) INFORMATION

The National Diving Accident Network (DAN) was formed in 1981 to assist in the treatment of accidents by providing a 24 hour telephone emergency number (919-684-8111). This number, which may be called collect in emergencies, is re- ceived at the national DAN headquarters located at Duke University Medical Center. For medical problems, the caller is connected with a physician experienced in diving medi- cine. These physicians assist with diagnosis and initial treatment of the accident and supervise referral to appropriate recompression chambers while working with regional coordinators throughout the nation. DAN does not maintain any treatment facility and does not directly provide any form of treatment, but is a service which complements existing medical systems. The most important function of DAN is to facilitate the entry of the injured diver into the hyperbaric trauma care system by coordinating the efforts of everyone involved in the victim’s care. The nation is divided into regions, each headed by a regional coordinator who is a physician experienced in . Each regional coordinator maintains up-to- date information on chamber status,, transportation facilities and other diving medical services within his area. The DAN physician and the regional coordinator work together in transferring the patient to the appropriate chamber. An other important function of the Network is collecting and analyzing data on diving accidents to improve the understanding of the causes of diving accidents and to develop better treatment methods.

19 IX. DAN DIVING ACCIDENT MANAGEMENT FLOW CHART

In a suspected diving accident the first question is “Did the victim take a breath under- water?” from a SCUBA tank, hose, bucket, submerged car, or any compressed air source, regardless of depth. If the answer is no, give CPR and oxygen if needed and evaluate as a medical problem not related to diving. If the injured diver did breathe underwater and only mild symptoms are present (fa- tigue and itching only), place the patient in left-side-down-head-low position (Trendelenburg position) and administer two aspirin, oxygen and oral fluids while main- taining close observation. If these mild symptoms clear totally within thirty minutes have the person contact a diving physician at his earliest convenience. If the symptoms do not clear, seek medical advice and treat as a serious injury. If the injured diver did breathe underwater and has serious symptoms, do the fol- lowing: 1. Administer CPR if required. 2. Keep airway open and prevent aspiration of vomitus. Intubate unconscious injured diver if possible. 3. Keep injured diver in left-side-down-head-low position (trendelenburg position). 4. Administer oxygen by tight-fitting double-seal mask at the highest possible oxygen . Do not remove oxygen except to reopen the airway or if the victim shows signs of oxygen convulsions. 5. Protect the injured diver from excessive heat or cold. 6 Give conscious patients non-alcoholic liquids such as fruit juices or oral balanced salt , e.g. Gatorade 7. Intravenous fluid replacement with electrolyte solutions is preferred for unconscious or seriously injured victims. Ringer’s lactate, normal saline, or 5% dextrose in saline may be used. Do not use 5% dextrose in water. 8. Give two aspirin, as an anti-platelet agent, as a one time dose to a conscious diver only. 9. If there is evidence of involvement of the central nervous system, give steroids, hy- drocortisone hemisuccinate, 1.0 gm. i.v. or dexamethasone, 20-30 mgm. i.v. 10. Evaluate and stabilize patient at the nearest hospital emergency room prior to trans- fer to recompression chamber if needed. 11. Contact a physician experienced in diving medicine. 12. If air evacuation is used, it is critical that the patient not be exposed to decreased barometric pressure at altitude. Flight crews must maintain cabin pressure at sea level. 13. Contact Hyperbaric Trauma Center before transporting the injured diver. 14. Send this manual and recorded history with the patient. 15. Send all diving equipment with the patient for examination. If that is not possible, arrange for local examination and gas analysis. DAN - DIVING ACCIDENT NETWORK (919) 684-8111 (Call collect if necessary in an emergency) Ask for diving physician

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