Mobilization and Deployment Vol. 1, Chapter 26, Military Diving Medicine
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Military Diving Medicine Chapter 26 MILITARY DIVING MEDICINE RICHARD S. BROADHURST, MD, MPH; LELAND JED MORRISON, MD; CHARLES R. HOWSARE, MD; AND ANDREW F. ROCCA, MD INTRODUCTION MILITARY DIVING OPERATIONS HISTORY OF DIVING Early Diving Endeavors Evolution of Diving Equipment DIVING PHYSICS AND DECOMPRESSION THEORY Application of Gas Laws to Diving History and Development of Decompression Procedures Current Decompression Procedures and Tables GASES AND DIVING Oxygen Disorders Carbon Dioxide Toxicity Carbon Monoxide Poisoning Nitrogen Narcosis Helium Diving ENVIRONMENTAL HAZARDS Thermal Dangers Acoustic Hazards Blast Injuries Electrical Hazards Radiation Hazards Dangerous Marine Life DYSBARIC ILLNESS Decompression Sickness Pulmonary Over-Inflation Syndrome Barotrauma Dysbaric Osteonecrosis EPIDEMIOLOGY OF DIVING CASUALTIES AND DECOMPRESSION ILLNESS Civilian Experiences Military Data PREVENTION OF DIVING-RELATED ILLNESSES AND INJURIES The Fit Diver Personnel and Their Roles in Prevention Diver Training Research INJURED DIVER ASSESSMENT The Evaluation Monitoring the Dive Summary DIVING ACCIDENT MANAGEMENT Recompression Chambers Diving Accident Investigation SUMMARY 575 Military Preventive Medicine: Mobilization and Deployment, Volume 1 R. S. Broadhurst; Colonel, Medical Corps, North Carolina Army National Guard; Commander, Company C, 161st Area Support Medical Battalion; formerly, Lieutenant Colonel, Medical Corps, US Army, Senior Diving Medical Officer, US Army Special Opera- tions Command, Fort Bragg, NC 28307 L. J. Morrison; Captain, Medical Corps, US Navy (Retired); Chief Physician Naval Forces, United Arab Emirates; formerly, Senior Medical Officer, Naval Diving and Salvage Training Center, 350 S. Crag Road, Panama City, FL 32407 C. R. Howsare; Medical Director, Healthforce; 210 W. Holmes Avenue, Altoona, PA 16602; formerly, Lieutenant Commander, Medi- cal Corps, US Navy, Training Medical Officer, DMO Course Coordinator, Naval Diving and Salvage Training Center, 350 S. Crag Road, Panama City, FL 32407 A. F. Rocca; Lieutenant Commander, Medical Corps, US Navy; Senior Resident, Department of Orthopedics, National Naval Medi- cal Center, Bethesda, MD 20889-5600; formerly, Director of Clinical and Hyperbaric Medicine, Naval Diving and Salvage Training Center, 350 S. Crag Road, Panama City, FL 32407 576 Military Diving Medicine INTRODUCTION All services in the Department of Defense have a specialized type of occupational medicine, con- elements actively involved in diving operations. siders the medical issues involved in working in Historically the US military, particularly the US the unique conditions of the undersea environ- Navy, has been a world leader in the development ment, much as aviation medicine is concerned of diving and undersea technology, including div- with similar issues in the hypobaric realm of ing medicine.1 Diving Medical Officers (DMOs), flight. This chapter will address the issues that both physicians and physician assistants, and military preventive medicine specialists should Diving Medical Technicians (DMTs) are specifi- understand about military diving, including rel- cally trained in military diving medicine and per- evant physics and physiology associated with form fitness-to-dive evaluations, prevent and diving, approaches to the prevention of diving ill- treat diving-related injuries, and monitor ongo- nesses and injuries, and the epidemiology and ing diving operations for safety. Diving medicine, management of diving medicine problems. MILITARY DIVING OPERATIONS Military diving is divided into two general Land (SEAL) forces conduct all aspects of SOF missions, fleet diving (eg, underwater ship’s diving, including maritime direct-action opera- husbandry, salvage, underwater construction) tions (eg, ship attacks, ship boardings, harbor and specialized diving (eg, special operations, penetrations, hydrographic reconnaissance, explosive ordnance disposal [EOD], saturation). clearance of beaches for amphibious assaults, Military diving is generally performed at depths shallow-water mine countermeasures). Divers in of less than 60 ft, except for some salvage, EOD, the Marine Corps Force Reconnaissance Units and saturation (prolonged duration) diving op- survey landing beaches and conduct covert un- erations. Fleet diving is conducted throughout derwater insertions. The Coast Guard, a Naval the US Navy and by US Army Engineer Corps augmentee in time of war, uses divers for ship’s divers, while specialized diving is performed by husbandry, navigational buoy maintenance, and all four services in the Department of Defense. ocean search and rescue. As part of what is the Special Operations Forces (SOF) in the Army in- most extensive diving program in the US mili- clude Rangers and Special Forces (“Green Be- tary, the Navy operates the Naval Experimental rets”). Combat divers in the Special Forces per- Diving Unit, the Naval Submarine Medical Re- form inland search and rescue and combat search search Laboratory, and the Naval Medical Re- and rescue, as well as coastal infiltration and search Center. These organizations conduct exfiltration, reconnaissance, and demolitions. manned and unmanned testing of military div- Army Ranger combat divers are currently used ing equipment, decompression algorithms, and only to perform reconnaissance. The SOF ele- hyperbaric physiology. The Naval Safety Center ments in the Air Force—Pararescue Teams and supports all diving in the Department of Defense Combat Controllers—also must be capable of by managing diving data, issuing safety mes- conducting downed-aircraft recovery and infil- sages, inspecting diving lockers, and investigat- tration into denied territory. Navy Sea/Air/ ing accidents.2,3 HISTORY OF DIVING Early Diving Endeavors evolved to include reconnaissance, covert infil- tration, ordnance disposal, obstacle removal, and The first recorded example of military diving demolitions, in addition to underwater sabotage. was in the 5th century BC when a Greek diver US divers disposed of ordnance during the Civil cut the anchor lines of Persian warships to create War, investigated the sinking of the USS Maine in confusion between vessels and cover his escape.4 1898, and performed submarine rescue and sal- Salvage diving is nearly as old, traceable to the vage in the early part of the 20th century. It was 1st century BC in the eastern Mediterranean. Over the period during and after the second World War, time, the use of divers in combat operations has however, that saw rapid growth in military div- 577 Military Preventive Medicine: Mobilization and Deployment, Volume 1 ing, including the development of all types of spe- cialized diving and significant improvements in fleet diving.5 All of these advances were made possible by revolutionary improvements in div- ing technology. Evolution of Diving Equipment Humanity’s success underwater has always de- pended on the ability to procure air or oxygen and to survive in the environment. Although the an- cients initially relied on simple breath-hold div- ing, they soon recognized the need to spend greater time working at depth. One solution was the diving bell, an inverted container lowered by rope to provide air at depth and increase bottom time. Alexander the Great is reported to have used one in the 4th century BC.4 Diving bells were im- proved and came into widespread use from the Fig. 26-1. Siebe’s Diving Dress and Helmet. Augustus 16th to the 19th centuries to support the growing Siebe developed the first practical diving suit. He im- business of salvage diving. Then in 1840, Augustus proved on earlier attempts by attaching the helmet to the Siebe improved on existing diving suits, designed rest of the suit and adding an exhaust valve. to protect divers from temperature and pressure Source: US Department of the Navy. US Navy Diving extremes and other hazards, with new technology Manual. Rev 4. Washington, DC: Naval Sea Systems Com- that allowed air to be pumped from the surface to mand; 1999: 1-5. divers at depth (Figure 26-1). This surface-supplied diving apparatus was the prototype for deep sea diving rigs, which are still used today in situations and increased diving time, while the use of air as a requiring prolonged bottom time, stationary work, breathing gas was a safer and cheaper alternative or other specific circumstances.5 to oxygen. The Aqua-Lung not only provided more The next significant technological breakthrough opportunities in military diving, it set the scene for was the development of scuba (self-contained un- the development of diving for sport and recreation.4 derwater breathing apparatus). In 1878, Fleuss After World War II, researchers became inter- demonstrated the first practical scuba, which was ested in testing human endurance under the a closed-circuit (no expired gas released into the waves. Saturation diving grew out of experiments water), 100% oxygen rebreather rig. This technol- designed to test whether or not divers could sur- ogy was used to develop oxygen rebreather sys- vive at depth for days and weeks with their tis- tems for submarine escape and rescue in the early sues “saturated” with the gases they breathed. 20th century. The first scuba used to a significant Neither air nor pure oxygen could be used at these degree in the US was invented in 1940 by Dr. Chris- extreme depths because they caused nitrogen nar- tian Lambertsen and was a semi-rebreather rig cosis and oxygen toxicity, respectively, which are with steady-flow oxygen. This physician was also explained later in this