Taking care of injured diver: what do the experts say ?

Taking care of injured diver

What could be better than to take advantage of a rainy Saturday to focus on the medical aspects of taking care of injured diver

It is with these words that this day of studies and discoveries began, organized by the Belgian Society of Hyperbaric and Underwater Medicine at the Never-Over-Hembeek Military Hospital in Belgium.

I was looking forward to attending this event. Especially since I had already had the opportunity to meet Pierre Lafère a few times in the past. As a diving instructor and an exciting teacher on all medical issues related to hyperbaric medicine, I was happy to have the opportunity to talk to him. 

Pierre Lafère et Hélène Adam à l'hôpital militaire de Bruxelles
Avec Pierre Lafère | © Different Dive

It would be difficult to relay the three quality presentations I have attended. As well as the many exchanges that preceded or followed them.

I will therefore present to you the points that have caught my attention the most without making a precise distinction between what the speakers have said:

Frédéric Vanderschueren: physiotherapist, BLS and industrial safety trainer and diving instructor.

Frederic Verschueren lors du colloque sur la prise en charge du plongeur accidenté
Frédéric Verschueren | © Different Dive

Pierre Lafère: MD, PhD in physiology, anaesthetist specialized in hyperbaric medicine working at the ORPHY in Brest after 10 years spent at the Hyperbaric Centre of the military hospital in Brussels.

Pierre Lafère lors du colloque sur la prise en charge du plongeur accidenté
Pierre Lafère | © Different Dive

Peter Germonpré: Head of the Hyperbaric Oxygen Therapy Centre at the Brussels Military Hospital and specialist on Patent Foramen Oval issues. 

Peter Germonpré lors du colloque sur la prise en charge du plongeur accidenté
Peter Germonpré | © Different Dive
Here are the recommendations of the three specialists regarding the management of the injured diver:

Note prior to any treatment of an injured diver: the more effective the intervention by the rescuers, the more effective the doctor’s intervention will be.

Management of the unconscious diver underwater

  • Keep in mind that most of us are not professionals. Of course, you have to bring the unconscious diver to the surface. But first of all, it is important not to risk an overaccident.
  • Ideally, two people are needed to provide effective aid. Also, we can wonder about the minimum number of divers that must compose a team.
  • Weight release: no need to waste time underwater with this point. Current BCD allow a victim to be lifted up effortlessly. Therefore, it is much more interesting to teach learners to use the correct weight tending towards neutral buoyancy. Similarly, the use of a BCD with an adequate volume for the person’s morphology should be taught.
  • Convulsions: If the person no longer has his regulator in his mouth, he must be brought back to the surface without delay. If he still has her regulator in his mouth, it might be better to wait until the seizures are over so as not to risk being embarrassed in the ascent.
  • Placing the regulator back in the mouth: Except in the case of cave diving, the regulator should not be replaced in the mouth of an unconscious person who has lost his regulator. Indeed, during the ascent, the gas still present in the lungs will expand. Handling the regulator and wanting to put it back in the mouth at all costs is not a good idea and wastes our time.

During the ascent:

  • Head position: It is regularly heard that the head must be placed in hyper-extension to clear the airways. In fact, if this is true on the surface with a victim lying horizontally, it should not be done with an unconscious person held in a vertical position (during the ascent) at the risk of having the lingual mass obstruct the pharynx. 
  • Ascent rate: the literature gives no indication other than to keep a controlled rate.
  • Deco-stops: Here, the information seemed to me to be unclear. On one hand, it was recommended to let go the victim the last few meters alone and to make stops if there is an unreasonable risk of an accident. The unreasonable risk is not defined here other than by a significant amount of time of mandatory stops left to the diver’s judgment. On the other hand, it was mentioned that when choosing a decompression tool it must be relied upon. However, we know that interrupting a stop for less than 3 minutes might penalize us but should not, according to the algorithms of our computers, put us in a situation considered dangerous by our decompression tool. These 3 minutes then gives us time to go up, call for help and put the victim’s head above the water before going down again to make our deco-stops. So what can we do? Sometimes I think that divers are definitely guinea pig.

In any case, let us remember that it is essential to have surface security and to keep in mind that…

… « Never put yourself in danger and risk an extra accident". 

Management of the unconscious diver when getting out of the water

  • Make sure the victim is kept horizontal. That, in short, to leave the blood in the head.
  • If there is any doubt that the person is breathing, perform at least 5 breaths directly
  • Ideally: disassemble while blowing and start towing.
  • If the shore is more than 5 minutes away, blow 1 minute before starting the ventilated tow.
 "The success of ventilated towing will depend very much on the training received by the rescuer"

Handling of the injured diver when out of the water

There are many recommendations, but most of them are based on animal studies. Or on studies with humans but with very questionable reliability. Pierre Lafère and his colleagues conducted a major study on the management of injured divers. The results have just been published in June 2019 and some of them are shared with us here.

Reminder of how the care will be provided in case of DCS:

  • Activation of the emergency chain
  • Arrival at the deco-chamber within 6 hours after the first symptoms appear
  • Contact with hyperbaric doctor and deco-chamber sessions
  • Rehydration
In any case, if specific care is required (hyperbaric chamber recompression), under no circumstances can a delay be accepted in the emergency chain.

It is therefore necessary to reduce the delay at all costs when taking care of injured diver and call for help immediately even in case of doubt. VHF rescue channel or 112/911 depending on whether you are at sea or on land and DAN if you have this insurance. Indeed, DAN will ensure the coordination of rescue efforts and sometimes speed up the whole care. 

Some interesting figures:

  • In 45 to 50% of the time, the patient (or his or her immediate environment) is responsible for the delay.
  • 50% of injured divers show symptoms within 10 minutes of leaving the water. This figure rises to 70% within 30 minutes
  • However, only 10% will have medical care within… 6 hours
  • Keep in mind that a treatment within 10 minutes (well OK, we don’t have a recompression chamber with us, I admit), allows us to have no sequelae. But let’s remember that the faster the recompression, the better the results will be.
  • Similarly, if the diver waits 6 hours before going to the hyperbaric chamber, he is twice as likely to have sequelae after a DCS.
  • 100% of injured divers are dehydrated 
  • 30% of divers do not go to the doctor in case of DCS
  • In this 30%, one in 10 divers will have DCS sequelae
  • It should also be noted that if the diver is over 42 years old or has dived to a depth of more than -40 m, he or she is also twice as likely to have sequelae after a DCS.
  • Specialists note that divers who have had a DCS dive deeper and longer, going against the recommendations of hyperbaric doctors…. Incredible, isn’t it?
  • In the same context, hyperbaric medical experts note that among people who have had several DCS, most of the divers who have had a third DCS are mostly people who dive deeper, longer and are older. Therefore, they are doing the opposite of what they should be doing.

What is the reason for delays in the rescue chain?

  • The injured diver first addresses his buddy, an instructor, a dive centre director… instead of calling a medical service.
  • Very often, the one who takes the injured diver in charge relativizes and makes, even in spite of himself, a kind of filtering by preferring to wait, giving oxygen, etc…If the injured diver is conscious, let him talk directly to the doctor.
Do not filter and activate the emergency services as soon as possible, even if you hesitate

While waiting for help:

  • Giving oxygen is a good first intention. Not because it will prevent sequelae (no significant studies) but because, in case of disappearance of symptoms, the diagnosis of ADD will be signed. And also because studies have shown that oxygen intake reduces the number of decompression chamber sessions. And therefore shortens treatment in the event of a decompression sickness.
  • Using a mask with two valves when administering oxygen gives the best results.
  • Hydration: the more dehydrated you are, the more likely you are to suffer after-effects. When diving you have to drink without thirst: before and after your dive.
    However, glucose-containing solutions should be avoided. Also ban sodas, alcohol and caffeine.
    Drink water and make an injured diver drink if he is conscious.
    In case of management after a DCS, it is sometimes necessary to give up to 8 litres of liquid before the person urinates. So much dehydration is strong!
  • Medication: While some people still like to think that aspirin is useful for DCS, studies do not attribute any efficacy to it in this case… But no disadvantages either. Everyone will do what they want/can do. Only anti-inflammatory drugs combined with hyperbaric chamber sessions have been shown to be effective.

Other points of attention 

  • Therapeutic recompression in water is generally not accepted in Europe and the USA. However, it is sometimes offered in Australia but within a well-defined framework and requiring appropriate training and heavy logistics.
  • The rule saying that you have to wait 24 hours before you fly. However, we notice that even if this deadline is respected, some people make bubbles after 30 minutes of flights. Making bubbles does not mean having a de facto DCS. This may in the future call into question this 24-hour rule.
  • Think carefully about the desirability of having a complete diving insurance that covers hyperbaric treatment everywhere. For example, an hyperbaric chamber session in Zanzibar can cost $45,000
  • With the advent of computers and TEK equipment, diving profiles are moving further and further away from what hyperbaric doctors recommend in terms of safety. A dive that looks well done is not necessarily well done. For the body, diving 25 minutes at 40m or 50 minutes at 20m will not have the same consequences on the body. This is even if the deco-stops are respected.
I can only reiterate the importance of compliance with safety recommendations. The one of planning, prevention, hydration, and acting fast in case of accident....
Une ancienne ambulance exposée à l'hôpital militaire de Bruxelles
L’entrée de l’hôpital militaire donne le ton | © Different Dive

Finally, after this conference on taking care of injured diver, I have a question: 

Where is the limit of recreational diving... with pleasure and in complete safety?

One of the speakers pointed out to me the limited participation in this symposium concerning an important point of our diving practice even though essential and unpublished information on the care of the injured diver was shared. He also encouraged me to disseminate this information as widely as possible to as many people as possible.

Therefore, if you also want to be active in accident prevention and diver safety issues in general, spread this article widely in all your sharing communities, clubs, associations and/or friends. For a safer dive.

What is your opinion on this subject ? Tell me in a comment directly below on the blog

And above all,… don’t forget to be happy 🤗

Hélène

[More articles on diving accident prevention here]

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