CI{APTERTEN Diver - someconsiderations and uncertainties

JohnLippmann

Aboutthe Author JohnLippmann has beendiving for more than 20 yearsand has held scubainstructor clualifications rvithseveral agencies. He has specialisedin teachingdiver rescue,cleep diving and orygcrtadminjs- tlationcourses. He has been an instructor and examincr in with the Royal Life- SavingSocieiy of Australia (RLSSA)for the past 10 years,and is the ImmediatePast Chairman of the QxygenResuscitation Panel of the Victorian Branch of thc Society..Tohn currentl.y rept'esents RLSS (Vic)on the Australian ResuscitationCouncil. He is also cerlihed to-teachoxvgen courses untlerthe sanction of the , and is a cert.ifiedfirst aid instluctor". Johnis 1hema-ior author of Thc DESIDAN Em.ergenclHond,booh. and is the aulhor of DeeiterInto Diuing,Tlrc Essent.ia/sof Deepe,rSport Diuirtg and Or;gen Fi.rst Aid t'r;rDir:ers. all of wh ich havc gained 1'or.ldrvideacclaim. ,Iohn's numerous articies on diving safetvate publishedthroughoul, the rvorld.

At some tjme, a ciiver rnay find himself jn a support or refirte the r"ationales behind certain sihration where it is necessary to tescue an suggested techniques. ln addition. unconsciousdiver, either submerged or on the i-snot a black and whil,e situation q'hcrr: one set surface.Fortunately, such situations are rat'e.' of specific actions trnivcrsallv applies. I)ivers shoulcl be madc ar,vareof gerrei'alpt'ini:ipals of Sometlaining :rgenciesinclude a protocol for the rescue,so t,heyare bettcr equipped t,oadapt to a les(rueo{'an unconscious diver during their basic palticular situation, should it arise. ropenwater)divc course. Other agencies don't is 1,opreselnl, issLres teachthe shiils until the level. The purpr.rseolthis chapter not have consider^ed.ancl Rescue and resuscitation skills are very that some divers mav discussion on this valuable tools that all divers should to encourage thought and acquire as soon as possitrle. Once learned, important toprc. theseskills need to be practiced reasonably One point 10 sen-sidcl is thc deglereof tirgencv often (ie at least twice annually) to main- of the s:il.uation.Whether'1.he outcome rvill bc a tain the required level of performance. possihlc rescLrcor a body le{to\r€rfv.-le:pettrds on a valiet.S'of factors, rvhich includel:{l I w'hel.hcl or The :rctrral plotocols currentlv taught vary not tlre divcr is still bleathilrg Ir'ont his rergrr- bttl,een agcncies, ancl from instructol to in- lator: (2ihor'r'much t.rnrelras r-'l:tpstttlsince tlte stluctor'.One common problem is that many dive: diver stopped brcathing; and 13) llrr: tempcra- $udents leave the colrrse rvith the berlief that tr.u'eof the rvatr:r and in.qulation of tl're clivc'r', lhcreis only one correct method to perfirrm such among other l'actors. afescue.Although within the time consl.raintsof The paltial pres-qlu'eof ox\igctl {pO I in ar'1,r:r'ial a commerciallvorientecl dive course it is olten thc brairt is norntallv 80-90 onlvpractical to train the students in one partic- hloocl suppJving When a pelson stops breatl'ring, Lrlalprotocol, the divers should be made awarre mmHg. pO- falls rapidl.y and ltv thc timer it reachcs that unconscious diver are nol neces- the 40 mrnI{g, consciousrte,qsis selior,r-qlvin-rpailcd. salilv so straight fort'ard. There is still a lot ol uncertaintysurrourrding rrarious aspects of' diver Dr George IJalpur', a Canadian h-ype:rb:'rlic recovcrysince there is a paucitv of data tr-r phvsician, ha-qargued that it nornlallY talics I)lvER RItS(lLrli - Solv-lECONSIDtrRATIONS AND UNCIIRTAINTIES

apllroximately 90 seconds from Lhe tirne con- diver is breathingand mav, or may not becon' sciousness is seriously impaired (40nmHgr, scious.The absenceof bubblesfol morethan fbr thc pO, to drop to ler.els lvhcre pernlanenl about 5-10 secondsindicates that a divel isnoi dam:lgc to the cenlral nervous system occurs . A slumped position,eyes closed oL {trpproxin'ratelv 20rnrnIlg).' Consequentlv, Dr blankly staring mav indicate impailed con' I{arpul has sugecsted that, r,,l'rere po-*sible. sciousness.Gently shaking the djvel should lcscucr'-cshoulc[ aim to have lhe r-ron-brcathing, elicit a resporlsei{'he is ful[y conscious.A divcr inlured diver brought to tho surfilce ancl vcntj- u'ho cloesn'treact at all, or onlv reactsterr Iated rviihin .c)0seconds of losing conscjousness. u'eak1v,should be broughtto the surfat:e. Ilou,ever', altlrough this time fiame appears to bc re:rsonablt: on land, the situation m:rv be ver-yciiffcrent lvith a diver underwater'. Non-diving-casualLir:s have at tirnes made dra- matic and successf'rrltcco.,'eries atter rcsuscitir- tion tbllr.rwing long periods (up to about 60 minutes) of immersion rvithotrt bleathing in 'Ilre vcrv colcl waterr. lower oxygen Lrsage lesulting from the reducccl bloocl flow to thc rron-vital organs tcliving reflc'x) trnd slorvercl rnctabolic rate fi ()m hypotl-relnria.together' witl.r the higher oxygen partial pre-ssuresassociated rvith de.pth,have bcen used to explain thi-s plte' n0rnen0n. In scriesof 50 caseso['indivic[ials rvho ]rad onc Nrrrrnollr'. the lirst slrlt is to dclcrntine ttltalht'r or nattlr bet:n subnto'gccl in colcl n,atei' lbr periods o{' 'fhe betwcen six to sixlv minr,rtes.45 had sLrflciecl rescue.i' should get a firm grip on thr: no cletcr:tablencurojogical impairnrent atlrr iniured cliver',ancl tzrke a couple of secondstl being resLr,sr:itiltctland rervarrned.' Clonsc- compose himself and assess the best coul'.se0f clucr-rtly.it, is recommendcd that lesuscitatirtn action to takc. rvtiile quickly locating thrr ancl rcrvai'nring be :rtternpted on anv ca-cua]t]' cliver's rveightbelt :rnd BC int'late/dcflatemedi- n,ho has bc'en subnielgecl fil' up to 60 mrnutes anisms. Although it is important not to in rviLt,erof'21 C oi cooler. waste time, the few seconds taken trr Llnfoytunatelv, there is a lack of daltr to inclicatc' assess the situation may save unnecessarl' hor'vlhe rveaiing of'an cxposrlrr-'sr.rit arrcl chving complications down the track. ma-qk cf'fcct the sui'r'ivabilitv o1'a clivc'r rvho rs Whether the cliver i,s bleathing or not. thl unconscious.subnrergecl artd not,bre irthing. It is lescuer should suppor"t the regulatol in thr pr-rssibleth:rt strch cquipmc'nt could reduce 1.1-rc diver's moubh to ensure that it doesu't become 1.tre chance-qol sulvival bv delaying or reLlucing clislodged.Positioning tl-reinjr-rred diver''s head prtlcctive e{T'ectso{ hypothei'rnia and the cliving' with bacl

Somerescue protocols suggest that the rescuer The expanding air ivill water through the shouldsupport the victim's head in a neutral victim's nose and into the throat, possibly position(i.e. not tilted back or forward).'n causing , if is not fully Whetheror not a neutral head position will unconscious. providean adequateairway in this situation is If the mask is full of rvater. it can either be debatabie.It has been suggestedthat because rernoved underwater, or on reaching the sur- theunconscious victim underu'ater should nor- face.It probably won't make much difference. maliybe brought to the surface in an upright position,airway obstruction from the tongue is If the diver is breathing ancl the mask is lesslikely, and, therefore, a neutral head posi- removed, the rescuer can pinch the injured tionshould be adequateto allow air to enter the dir,er's nose to prevent water entering during lungsof an unconscious,breathing diver (with the ascent. anair supply), or to vent from the of a Certain protocols suggest that the victim's breathingor non-breathing diver. One argu- weightbelt be removed.rj'qeThe injured diver is mentput forward against using backward head often heavy (many being substantialll,- over- tilt is that any water that has coiiectedin the weighted"')and it may be necessaryto remove diver'smouth could be encouragedto enter the his lveightbelt to increasethe diver's buoyancl,. throatif the head was tilted back. If the diver is If the victim'sbelt is removed.the rescuermust notfully unconscious,this water could cause a have a firm grip on the diver prior to removing reflexspasm of the larynx, known as laryn- the belt, as mentionedearlier. It is also a good gospasm.Laryngospasm may last for minutes. idea to locate the injured diver's BC inflate/ It usually abates as the diver becomes vert/ deflate mechanism, since it may save time shortof oxygen(deeply hypoxic).The likellhood finding it later. The weightbelt may then be oflaryngospasmdecreases as the injured diver removedand pulled well clearto preventit lan- lapsesfrrrthcr into unconsciousness. gling with other gear, and dropped. Iflaryngospasmis occurring during the ascent, However.not all lrescuersfind it necessalv.or- expandingair in the lungs may not escape desire, to remo\/e the victim's weightbelt effectivelv,increasing the possibility of'a pu1- undelwater. The main reason put forwald is monary barotrarima. Aithough it has been the difficultv in controlling the subsequent assertedthat air can still escape from an ascent.''Some suggest to add air to the victim's unconsciousperson's lungs dg.spite iaryn- BC, via the dii"ectfeed, to providetlre necessarv gospasm',this assertionhas not always been positive .'' Unfortunately, this will supportedby anaestheticexperience. In anaes- thesia,in fullv developedlaryngospasm. both inhalationand exhalation ma.vbe impossible.- Hou'ever.this situation onll' occlrrsin a pai- tially consciousperson and not in the fuliv uncOnscrt)uijpel'son. Some rescue plotocols urge the rescuer to lnspectthe victim's mask. If there is no water in it. it is r.isuallyrecommended to leave the maskin 1:1ace,altl.rough a possibleexception tci this is discussedlater. Horvever,if there is waterin tlre mask. it has been arguedthat the maskshould be removed.'The rationale is as follows: If the mask contains air and water-, Certain. prolocals srrggesl that the t'icl.int's the air rvill expand on the u'ay to the sut'face. u'eighthclI bt' rentrn'ed. Pholo Lnurtest rtf \\'arnc R,I/t:, 99 I]iVEIt 1TI'SC]LJE_ SONII' CONSIDERATIONS AND UN(]F]R'I]AINTIES

not be possible if there is no air in the victim's crealing an uncontrolled and rapid ascent,a t:rnk. It may not be practicable even if the arr rescuer who ditched his own weightbelt, would suppl.y is not depleted, especialiy in deep be unable to interrupt the ascent if it became watel'. Varit,us tests have demonstrated that it necessary, possibly due to his dlopping the can take up to a minute ot' molc to inflate victim, to entanglement or to sonie other certain BCs at depth, and at low suppl-v pres- unforeseen circumstance. L'r sules. This delay could be detrinerrtal to the 'I'he, " next decision is a somewhat controversial outcome of the lescuc. one. The rescuer has to decide whether io Altelnativerly, the lequired buoyancv may be maintain contact with tire victim throughout achieved bv the lescuel inflating hls own BC."-- the ascent, which is the usuai teaching, or to The advantage of this is that it is usuaily ensure the victim is positively buoyant, let hirn easier' lbr: a l'escuer to control buoyancy using go and follolv him up. The decision rnay be his own familiat devirre. However, this n-ray influenced by the depth of the w'ater, and the mean that the injuled diver remains neBativel)/ resuucrs orvnsitutt iun. buoyant, at least fol sorne ofthc ascent. Again, The most commonly taught technique is to a film grip on the vicrint is esseritial. maintain contact with the victirn throughout \\rht'r'e pt-issible,the in;uled diver should be pos- the ascent. In this procedure, the rescuer itivel.y buoyant thrttughout the ascent in case ensules positivr buoyanc; by inirialll rr. contact is lost. If the dlvers sepalate fol any moving the victim's weightbelt and/or adding reason during the ascent, the victim's positive air to either the victim's or his olvn BC, buo.yancy shouid enstlt'e that the victim wiil con- Contact is maintained, and both divers ascend tinue to ascend towards the sulf'ace, r,vhere he towards the surf'ace, driven by positive buoy- can be more easily locattd. If the victim is nega- ancy. If' the diver is breathing. it is possible tiveiy buoyant and corlt.iet is lost. he will sink that he could regain consciousness during the and ma.y ber difTicult to relocare. This is one c.rf ascent. Ii'this occurs, the diver wjll be very drs' the polential pioltlcms li'ith leaving the vicLim's oriented and may . Therelbre, the rescuer' rveighrbelt on and using the rescuerrs BC to should have a firm hold of the injr-rred diver, plovidu sufTicient bucil,ancy fbr ascent. it is also possibly better from behind, to enable the ()ne ]'eitson rvhv the removal o1' the rescuer's rescuer to restrain the injui'ed diver if neces rveightbelt is not recommended. sary and to ensui'e his own sa1-etl.

Positive buoyanc-\' nlay not be appropriate if The rescuer can control the ascent rate t0 s0ile direct iiccess to the surfiice is hindered, such as extent by releasing ait' from his or,vnBC and/or irL a . In such situations, it ma1' be neces- lhe victim's. This is a time u,hen skill acquired safv to leave the injurecl diver's rveig-htbeltrn bv priol practice, ancl an extra pail o1'hands place. trv to achierve neutt-al buol.ancy lbr both rvould be vely help{'ull lescruerand l'ictin.r,and srvim the divei out. The rate of ascent can valy considerably. lf Altho'ugh it is taught by sttme instructors, both divels are wealing filll 7mm and thele trppears to be little justification fol t,he the victim's iveightbeit has been ditched, very rescLrelto lelease both the victim's and his own fast rates can occur near the surlace, especially rveightirelts, even in shallow rvtrter." Some if expanding air hasn't been dumpeci lrom the divei'; fi rlget that the lisk of a overexpan- BCs cur tire way up. The rescuer should ensurc sion is greaLest during tire last metres that he breathes in and out, possibl-v exhaling before the sulface. The rescuer shouid nc.rr- rnole than nomraliy (although not continu- mally retain his orvrr rvcightbelt, at least until ouslyr 1y[66 uppluuching tht. sullat'c. Angling alter reachir)g the surf'aere arrd aftel rnaking the fins and arching the body to create extfa the victint positiveil' buttyant. In addition to drag can also help r:educe the ascent late. DI\-FIR RriSCUbl - SOME CIONSIIIERATIONS r\Ntl UN(IFIRTAINIfIItS

rescuer follow at a saf'e r:ate of ascent, retrieve the victim on the surface and comntence expired air resuscitation. The ploceclrtre u'as recommcnded as an option of last resort in cir- cumstances where the victim is not breathing. the sr,rrface is clear of obstructions, calm and thele is concern that tire t'escuei" cannot make a -qafe.re asonably rapid ascent. It rvas argrred that, by positioning the divet' verticali,v rviih the head up, the pressule on the lower chest will be greater than tha.t on the upper chest. This ptessure diffelcntial should force exces-s aii' out flom the mouth and prel'ent further lvater fi'om erntetring the 1ar1'nx. As the diver: ascends, expanding ail should vent fi:om the lungs and out fiom the mouth, so preventirrg ir pulmonan' baro- tirauma- Some prelirrrinarl- tests u'ere con- to inve-qtigate the erfTr:ctof posititrning a Therescuercan utn.trol th.e(tscent rate. to som.eertenl.. by ducted releasingoir front tlte BCs. Pltrtr.tc:ourlesr of GeoffStt,6birg. person verticallv with thc head up in the did appear tcr In 1974,Dr George Harput suggesteda i"acli- water. The feu, tests conducted that the upright position callvdifferent protocoiwhich iras been adopted. support the clalm from ti.re 1ungs. Harpur to varying degrees,by some rescuers. despite encoulages airflow on arrjr,al at the theabsence ofsubstantial supporting data. frirthel ireasoned that, surface. lhe diver rvould shoot fi"om the u'atcr Whena non-breathingdiver is brought to the and then fall back into a hoi'izontal ftrcr: up surface.the partial of oxygen in the position. plor,ided he n'a-* rvearing a BC that diver'sbody rapidly falis due to the reduction will float him on his back (rvhich manv cuLi'ent lr arxbientpressure and the body'soxygen con- BCs will not do). sumption.Dr Harpur al"$.tedthat. as the gases The vision of an unconscious cliver rocketing to in the che-.t expand and esc:rpe during the the surface, probablv rvith his chin dorvn ascent.oxvgen will bc quickly drarvn alvav the chest. raises the obviou-qconcci'n of' from the bodv tissues and transported to the against pulmonary ;rnd associated compli- lungs.This u'ouldrapidly depletethe oxygenin cations. Horver.cr, w'irereas a conscions. pan- theblood and tissuesand could lead to oxygen icking diver can init,iate a r.ariety ot rcspon-ses stan'ation(anoxia) and death. The deeperthe prevcnt h'om ventir-rg adcclualelv victim is found. the greater the potential for that can air fi'om his lungs during ascent, Har"pur theorised oxygendrair-r due to therlarger pressure differ- unconscious victim ma;- be in less ential and incr"easeddistance and time of that the fi om n lung ,'r'ot'pt'essttrein.itrt'r. or on ascent.Harpur argued that the injured diver dnngel at the exce.qsivc ascent rates thal could be must be bror-rghtto the surface as rapidly as r.i-ith hls suggestcd rescuerpr"ocedule possihlerto minimise the oxygen drajn fi'om the acirieved tis-ques.Consequently, he suggestedthat if a Air cannot entel tire iung-. n'hen an uncon-qcious diveris found unconscious(eg. at 18m)u,ith his person has the head slumped foru'ard. Horvevct', regulator"out, the rescuer should remove the Ffslnrn' asserts t.hrt even if the unconscious injureddiver's weightbelt and mask, raise him diver"s head has siumped lbru'ald, expanding tothe vertical position,inflatc the victim's BC air from the lungs can pas-sivelyopen the airu'aY and let him go. It rvas suggestedthat the from helorv and escape -.afelv. In supporl, of this ]]IVEIT ITESCUE - SON{E (]ONSIDERATIONS AND UNCERTAINTIES

idea, it has been pointed out that a conscious as soon as possible so that more effective person who takes a deep breath and then tucks assessment and resuscitation procedures his head down so that his chin is firn:rly against can be implemented. his chest can still exhale easily. In addition, Various protocolsdiffer on holv these aims are medical experience has shown that people with to be achieved. laryngeal cancers biocking the vocal cords who protocol have great diff,rculty breathing in, can vent air One recommends that the rescueL or oxygen introduced into the trachea quite suc- should attempt to ventilate the victim as soon cessfully. However, the beiief that air can as they reach the surface and prior to making always escape from an unconscious person's any buoyancy adjustments. Buoyancy is ad- justed iungs has nol been veri{ied by anaesthetic expe- after the first breaths of expired air' rience, which is normally conducted with the resuscitation have been given.' Another plo. -.-+i ^.-+ 1..:- ^. +-l-+ tocol suggeststhat after checking for breathing Pa Lrsrrr r-)rlri< rrd L. and draining water from the victim's mouth, So, the rescuer must decide holv to get the ventilations are initiated, if required, prior t0 victim and himself to the surface as quickly adjusting buoyancy.' Other protocols recon. and as saf'eiy as possible. The best rvay to mend that buoyancy be increasedbefore ventr- achievetliis must be assessedaccording to the lation is attempted.5'j!)'': prevailingcircumstances. Tire victim's face must be supported abovethe The rescuer who was trained to leave the surface.This can usually be achievedeffectively victim's weightbelt on may in fact need to by the rescueradopting the do-si-doposition, b1 remove it to raise the victim. A rescuer whcr placing a hand under and cradling the victims had planned to maintain contact lvith the and various other rrreans. victim throughout the ascent may be forced to The amount of buoyancy required to enable releasethe victim in order lo prevent himself the rescuer to deliver "dry breaths" to the rockcting to the sui'face. victim depends on a number of {'actorswhich The rescuer should be able to quickly adapt if include the skili of the rescuer and the surface circumstances become different to what was conditions. expected.If the rescuerhad planned to bring the victim to the surfacein a conti'olledman-ner and linds that he is fbrcedto allow the victim to lapidly ascendalone, he should not abort the rescuejn the beiief'thathe has prejudiceda suc- cessfuloutcome. Upon reachingthe surface,the rcscuerrshould locatethe victim irnd continue lhe lescueas appropliate.If Di' Harpur is cor- rt'ct, the rapid ascentma,y have in fact increased the injureddiver's chances ofsurvival. Once troth divers are on the surface, it is important to establish a clear and open (patent) airway and ventilate a non- breathing victim as soon as possible. To achieve this eff'ectively in the rvater, the rescuel sirould ensure that both he and the victim are su{licientiy tluoyant plior to at- tempting ventilations. It is also essential to remove the injured diver from the water The uittint's face mttst be supported abot:e the surfau. DiVER RESCUE - SONTE(]ONSIDERATIONS AND LINCER,TAINTII'S

Thevictim's u'eightbelt should have been during the ascent, it is unlikel1, he r,vill he ditchedunderwater or on reaching the surface breathing on surfacing. Thereis normally no advantage in leaving on If the injrired diver lvas breathing during the thevictim's weightbelt at this stage.Many res- ascent and if surf'aceconditions are choppv. .it cuers,especially those carrying a lot of lead, may be better to leave the regulator in the maybe better off ditching their own weightbelt diver'smouth, as long as there is enoughairin aithe surface, ensuring it is puiled clear and the victim's tank. Holding the regulator in heldawa;, from themselves and the victim. place (and ieaving on the mask, if present) beforedropping it. Horn'ever,some divers find it should help prevc+ntthe victim from inhaling diffrcultto maintain the desired orientation irr water. The diver's hcad should be tilted bacl< the water without a weightbelt. This may- and chin supported. if possible.to open the sometimesoccur with a diver wearing a full airwav. If the dir,er is breathing effectivelr- andvery buol'ant exposllresuit. Occasionally, from the regu)ator,the rescuershould hear the therescuer might be reiuctant to remove his demandvalve being triggered. weightbeltin case he may need to resubmerge iorsome reason. If the diver' 'nvasnot breathing underrvater it i-s Partialinflation of the victim's BC usuallv pro- highly unlikelv that,spontaneous l.rrealhing r,idessufhcient support for the victim. Fullv would have begun on reaching the surface. Ar mentioned pt'er.iouslv, inflatingthe BC mav restrict the victim's chest it is also \rcry difficult to movementand may aiso make it more difficult detect bleathing in this situation. Con- toget close to the victim's head foi. ventilation. sequentl,v. some protocols don't include a Aslong as the rescuer has ditched his rveight- breathing cheek prior to commencir-rgexpired air resuscitation. belt,it is usually unnecessar)rto inflate his ou'n BC,although it ma-vsometimes be useful,espe- If the diver can be landed vely quicklv. it ma.v ciallyif little buoyancy is provided b5, the be better-not to lose time trving to ventilate rvetsuit.If both BCs are substantiallyinflated, him in the water. it canbe more difficult to get close enough to Over the vear"sthere has been debate about thevictim to vetrtilate him rvithout pushing his rvhether or not the rcsclrel"should tr\' 1,, ,1rut-, headundern'ater. This dependsLo some extent lhe airlvay before beginning resu"ccitation. onthe tvpes of BCs q,orn and is more of a Although on land it i.qlelativel)r easv to roll the problenrwith iachet-r.vpeBCs. Some people victim onto the side to clear the airrval'. thc haveused the analogv of two very obesepeople situationis a lot more complicatedin tlrc n,ater. triringto make love - it's important to approach atthe right anglel The victjm ma}, have r-omiteclol legtn'qitated, or Therescuer should position himself appropri- there may be frothv sputum comingfr.om hjs mouth. The atelynhen a-qses-singbreathing. establishing a rescuer can attempt to scoopout q'ith patentairwav and/or"attempting ventilations. anv obviousmaterial hi-qfingers, although this will Itis usuallybetter to approachthe victim from be difficult to do effectiveiv in the r.rrater. behindthe , rather than from beside thechest. This reducesthe chancesof pushing Although it has been suggested that tbe ther,jctim under r.vhileattempting ventilations. rescuer pull dorvn the corner of thc victint'-c Therescuer cernoften turn the victim's head mouth to allorv natel to dr':rinout'. this ma,v $ightly tor,vardshim to get a little closer, if often be unsr-rccessl'uland can allor.vrvater: in surfaceconditions permit. from a passingwave. 0n the surface it may be very difficult to deter- Most protocois don't require the rescuer rcr mine whether or not the iniured diver is attempt to clear foreign matter from the airr",-a-r'. breathing.Llniess the diver was breathing When resuscitation is commenced,anv foreign I]IVF]R RESCUE _ SO}VIECONSIDERATIONS AND UNCERTAINTIES

matber blorvn into the larynx lvill not cause Laryngospasrn,unless the victim is not fuiiy unconscious.Complications caused by inhala- tion of foreign matter will be addressed,if neces- sary, when the victim arrives at the hospital. It is important to try to open the victim's airway as lvidely as possible lvhen delivering the breaths.The first step in achievingthis is to tilt the victinr'shead back maximally. In additiorr, the injured diver's chin should be supported,if .\r possible.If performing mouth-to-mouth ventila- ls tiorrs,chin support may be rnore easily provided ifthe rescuercan use a cheekseal (rathel than his fingels) The injured tliuers'chirt should besupportetl to seal the victim's llose, so freeing tL,lrc re possibl e, du r i try ue n tilalians one hand fbr chin support. Jaw support can also be provided relatively easily if mouth-to-nose r,entilationsare used. It may also be easierto obtain a goodcontact seal tvith mouth-to-nose, rather than mouth-to-mouth ventllation. Mouth-to-nose ventilation may be the only altelnative if' the victim's jaw. ls clenched and the mouth cannotbe opened. A pocket-styleresuscitation mask can be very useful in this situation. Working from behind the victim'sheacl, the rescuercan use jaw thmst to lilt the Jaw and tilt the head back. In this lva.y,easier and more e{Tectiveventilations can

be achieved.Only masks thart float should be Apu, Arr-sr.vl'//rdsft(o/r lr' urcd r,Lsed. Some lescuers are taught to usera snorkei as an aid to ventilation.Nlouth-to-snolkel i'esusci- Lationcan reducererscuer latigue bv enabling lhe rescuer to sta.ylower in the water'. The fcscuel' can sometimesprovide chin support with thersame hand that is sealingthe ir-rtl-re injured diver's mouth. However'.the lechniquc can be curnbersomeand dilficult to perli.rrm,r'equires legtrlar practice, and cannot be clonee1l'ectively rvith celtain snorkels. Ther Australian Resuscitation (ARCr, Sollie l?--caels o re tau.ght to ttse a snornrcl Council as un attl. to t'ettliktttons. rvhich is the guiding body fol resuscitation plc;tt-ict.riin Austrrilia, r'ecomrnendsthat expired Un{brtunately, it is often very clifficult and air lesuscitation be commencedlvith five full impractical to maintain thc recommended brealhs dolil.ei'ed over appruximately ten seqlrencewhen rescuing an injured scubadiver soconds,fbllowed b.v a checkfor a calotid pulse. rn the lvater'. lf a pulse is detected,ventiltrtions are deliveled Nlost rescue protocols don't require a pnlse at the rate o1'oneeverrv 4 scconds.'' check in the rvater becauseof' the cliilicultyof DIVER RESCUE- SOMECONSIDERATIONS AND UNCERTAINTIF]S

detectinga puise when hindered by cold hands In addition. the procedure requires a speciallv anddiving gear, and becausein-water CPR js modified regulator if performed by a single near impossible. The majoritl, of procedures rescuer. Not surprisingly, the technique never makethe assumption that a pulse is present caughton. andcall for ventilations to be maintained until If ventiiations are continuedrvhile towing the thediver is landedand further assessed. diver to a boat or shore, the rescuer should If a pulse is in fact present, effective ventila- endeavour to maintain a regular rate of venti- tions should provide the necessary oxygen to lation and prevent r,vater from entering the preser\relife. However, if the victim's heart is injured diver's upper airway. notbeating effectively (cardiac arrest), the ven- It is difficult, physically tiring and time con- tilations will serve no useful purpose and are suming to try to maintain the sequenceof one likely to delay transport of the victim to the breath e\rery4 secondsas recommendedbv the boat or shoreline where CPR can be imple- ARC. No sooner has the rescuer begun to get mented. underway when he has to stop to ventilate the If the victim is pulseless, it is very impor- Consequentlv,it may be a reasonable "'ictim. tant to begin CPR as soon as possible and compromise to provide a sequenceof 2 slow to ensure that an ambulance is called breaths every 10-15 seconds.The rescuercan without delay. Data from the United States tow for about 5 secondsbefore stopping to inter- haveindicated that the highest hospital dis- pose the 2 slow breaths. If sr,rrfaceconditions chargerate has been achievedin those patients are chopplt, the rescucr can often cover the forwhom CPR rvasinitiated u,ithin 4 nrinutes victim's mouth and nosewater while towing, lo of the time the heart stopped beating effec- prevent more water from entering the airway. tively. and who. in 'Ihe addition, were provided rescuer should pace the ph-u-sicalexertion with advanced cardiac life support within 8 to avoid exhaustion.Unnecessarv equipment minutesof cardiac arrest.'o can be removed to reduce and drag. 0bviously,time is cruciaito the non-breathing, What gear to ditch and when to do so clepends and especiallvto the pulselessvictim. If the on the particular circumstances.Any assi-s- rescuersuspects that the victim's heart has tance that is availabie -qhouldbe utiiised to an'e.qted.which is likely if he rvas submerged hasten the rescueand reducerescuer . rvithout breathing for more than about 3-5 Technique-sfor remor.al of a vjctim from the minufes.it ma.vlte better not to attempt venti- lvater are important and demandregular prac- lationsif thershore or the boat can be reached tice beibrehand. fairl-vqtricklv. Once the iniured diver is ianded on a solid Severalvears ago. a studv was conducted to surface, the normal resuscitaticrn plotocol assessr,i'hether it was possibleto pcrfrrrm effec- shouidbe follorved.The injui'eddivel shouldbe tive CPR in the rvatei'. The technioue was rolled into the recovcrv (lateralt position,the demonstratedon an instrumentecl aquatic airway cleared and the breathing and pulse manikin.which wa-qr,entilated with a speciallv checked.Resuscitation should be continued, as modified,pressure iimited secondstage regu- appropriate,until medical aid arrive-"and takes lator.The trials were performedin full scuba over the management of the victim. Oxvgen. at gearbv trairredrescuers. The results achieved the highe-st possible inspired concentr:rtion. on the manikin met the minimum limits for shouldbe administered.if availaltle. CPR.'-Howcver, the technique requires that The attending medical personnel should be thevictim be positionedhead up in the w.ater ur:ged to contact DES/DAN Australia ancVor andit is dou].rtfulu'hether adequatecirculation the local hyperbaric facilit-v-if sufficient per- rvouldrcach the rrictim'sbrain in this posilion. sonnelare present. ]]IVER RE SC]LTI] SOIIE C]ONSII]ERATIONS AND UNCF]RTAINTIES

It is stressedagain that there is no one colreci way to peribrm all rescues.There arc so rnany variablesthat can influence the nanagement of the ernergency and aifect the eventual outcome. Each rescue and resuscitation is likely to be unique. The potential rescuer' should have an overview of various possible rescue protocois and an undelstancling of the basic underiying principles. Somekey points to remember are: r Unlessthe victim reachesthe sulface he will certainlydie. a The rescuershould get the non-bleathing

lanJcJ, th, nurtttol resus,iluliutt diver to the surfaceas c1uicklvas possibie protor:ttlslnuLd belbLLowetL without endangeringhimself.

n s4trrx '- a Once on the surface,sufficienl buoyancy if r*"" should tle obtained to plovide drv ventilations, iI' required. o The diver shouldbe landedas quickly as possibleto enableproper assessment and management. o The rescuershould enlist help as soon as possibleand ensurean ambulance is contactedrvith rninimal delay. o The rescueshould be pacedto avoid exhaustionof the rescuel. r The introduction of I}Aq( oxygenfbr the victim is desirableif the necessar'.yskills

O.n'gen, al tltc highL:st possible itt.spied conL:nntratiort, and equipmentare available. slrr'ultl be cLdnttnistered as stttrt os ptts;i.bLc. r The diver shouldbe kept in If'thc injured diver regains consciirusness he a horizontalposition. should not be prompted to sit up, in case he has r The victim nrust be rnedicallyassessed, an a]'telial gas embolisut" and to minimise the er,enifhe appearsto have recovered. effects o1'sl'rock. Tl.re divel must go to hospital fol observation ancVor treatment, even if he appeafs to have reco\rerecl.This is because a pioportjon of victirns 01'neal drou,ning develop lung problems some hours trftel apparent recove|y. DIVERRESCUE - SOMECONSIDERATIONS AND UNCERTAINTIF]S

References 1 Fead1,. Buddies speah out! In: BooneC. ed. 10 EdmondsC and Walker D. Scubadiving Proceedingsof the 1lth Intern.a.ti.onal fatalities in Australia and New Zealand: Conferenceon Un.derutaterEdu.cation. Colton" Part 1 The human factor. California:National Associationof Underwater SPUMS Journal 1989:19 (3i: 94-104. Instructors,7979:3i-45 11 GatesVL. A New Frameworkfbr Rescuel)iver 2 Harpur GD. Ninety secondsdeep scuba rescue. Tlaining. In: Wilks ,i, Knight J and Lippmann NAUI Neu's,1974; Januar_v:4-8. J. eds.Scu6o Safety irt Att.stra.li.a.Melbourne: 3 GoodenBA. Why somepeople do not drow.. J L Publications' 1993 versus the diving response. 12 The Brltish Sub-Aqua Club. Safel1,and Resute Medicol,Journal. of Australia 1992;157 (9): for Di,r,e.rs.London: Stanley Paul. 1987. 629-632' 13 Wong TM. Buovancy and unnecessarydiving 4 Millar I. (1990),Cold and the diver. SPLTMS related deaths.SPUrl/S JounnL 1989'. Journal 1990:20(1): 33-39. 19(1): 12-17. 5 BrylskeA and RichardsonD (eds).Rescue L4 EdmondsC et ai. Deepdiving Di.ter Man.unL Santa Ana: PADI, 1991. and someequipment limitations. (7):20-24' 6 Telford HW. Diui,tg RescueTc,chniques and SPUMS 'Iournal 1992:22 Diuer First Aid Manual. Brisbane: National 15 Austrol.irLnResusci.tctt.i.otz Cou.ncil Pol.rtl Associatior-rof Underwater Instructors Statent,en.tX[an.uaL. Melbourne: Australian tAustralia).1990. ResuscitationCouncrl. 1991 7 PierceA. Scu6o Life Sat'ing.Champaign: 16 Guidelines for Cardiopulmonary Re-suscitation Leisule Press. 1985. and Emergency Cardiac Care. In: .Iourn.alot' Thc AntcricanHeart Association;1992:268 8 MorrisonH anciSinclair S. Scuba DiuerLife ('16't" Sa.r.ri.gCo*rse - StudentWorle Sheel.s. Tuart 2L72-2299' Iliil: Fedelation of Austlalian Llnderrvater 17. March NF and Matthervs RC. Feasibilit-"-studv Instructors. 1984. of CPR l-r rl'ater. UnderseaBionted.i.col Researclt1980: 2 141-148' 9 clark l,K (ed).lllrrer sfressond Rescrze.scuba t2): SchooisInternational. Fort Coilins.Concept Systemsinc., 1990.