Des Gorman, Drew Richardson,

Mike Davis, Richard Moon

and James Francis

Accidents, decompression illness, first aid, injuries, policies, rescue, transport, treatment

A SPUMS policy is intended to be a statement of best practice. While such policies are based on the concept of practicability, they are not intended to be drafts for subsequent codes or regulations. The concept of practicability deserves some explanation. In the context of Society policy, this refers to something being achievable. Practicability is not synonymous with convenient. For example, in an ideal world, all injured and ill divers would be rescued from the sea in an horizontal position and all would undergo intravenous fluid resuscitation. Are these responses practicable ? An horizontal rescue is achievable already in the majority of diving situations, given some forethought and practice, and achievable for most others given minor modification. Consequently, an horizontal rescue is considered to be practicable and is cited in the Society policy. Conversely, it is almost impossible to maintain intravenous infusion skills for existing para-medics, let alone recreational dive instructors, dive masters and charter boat operators. Consequently, with the exception of diver medical technicians, a requirement for anyone supporting diving to be able to undertake intravenous fluid resuscitation is considered impracticable and is not cited in the Society policy.

There is a plethora of diving first aid protocols and procedures available to the diving and medical communities. Some of these are in conflict and the Society has been asked to clarify its position in this context. In addition, there are data that now support an increasing role for some drugs in the treatment of decompression illness (DCI). The potential for the latter to be widely recommended as first aid measures needs to be determined and included in any policy on the initial management of injured and ill divers.

Because of the differing interpretations of the term "first aid", this policy is deliberately titled, The initial management of diving injuries and illnesses. This policy describes a generic approach to the initial management of an unwell diver, regardless of the nature of the injury or illness. This is in recognition of the difficulties that most medical practitioners and essentially all divers have with specific diagnoses. The policy aims to describe initial management that does not require an accurate diagnosis and is divided into the following sections:

1 training requirements;

2 resuscitation equipment and supplies;

3 rescue and resuscitation;

4 posture;

5 oxygen administration;

6 fluid resuscitation;

7 drug therapy and pain relief;

8 communications systems and retrieval;

9 management of specific conditions.

The term occupational diver here is used in the modern context of any diver who dives for pay or reward. The term commercial diver is used to distinguish all other occupational divers from recreational dive instructors.

All occupational divers should be trained in basic life-support techniques. There is a need for occupational divers to be able to demonstrate an ongoing (annual) competence in airway management, expired air resuscitation (EAR), external cardiac compression and administration of oxygen, at as close as is possible to 100% oxygen, to both conscious and unconscious people. Recreational divers should be encouraged to acquire and maintain these skills by undertaking advanced diver training modules and/or by attending first aid courses run by organisations such as St John Ambulance. These recommendations are consistent with the policy goals of the Australian and New Zealand Resuscitation Councils.

While the ability to administer intravenous fluids is highly desirable, access to training in this is limited. Only diver medical technicians should be expected to demonstrate an ongoing competence in intravenous line insertion and fluid administration.

Resuscitation equipment and supplies

All dive platforms should have a proven and exercised system to rescue an unconscious diver from the water horizontally. Similarly, shore based operations should have a proven and exercised procedure for removing a diver from the water horizontally.

All commercial dive and dive-training platforms should comply with local regulations and codes with respect to the provision of an on-site diver medical technician and should also have equipment and supplies immediately available to enable:

10 oxygen administration (see Note 1);

11 intravenous fluid administration;

Note 1.

With respect to oxygen administration, the following comments apply:

Recovery of a free-swimming diver from underwater should follow the techniques currently taught by the recreational dive instructor agencies and the licensed occupational diver training schools. The recovery to and resuscitation of a diver on or in a stage, open or closed bell will be determined by the specific diving system in use.

Expired air resuscitation in the water should never delay the recovery of a diver to a diving platform or ashore. There are sufficient doubts about the safety and efficacy of EAR in the water at present (April 1997) to prevent the general recommendation of this technique.

Resuscitation of a diver should be conducted in accordance with the current guidelines of the Australian Resuscitation Council or equivalent national organisation.

The re-warming of a cold diver should be based on the following.

Divers with vertigo should be encouraged to keep still and not to do anything which could cause additional stress to the inner ear, such as a Valsalva manoeuvre or straining.

Sitting or standing up a diver to perform tests of balance and gait, or to undertake investigations such as a chest X-ray, should only be undertaken by a physician and then only after specific contraindications are excluded (such as a significant risk of cerebral arterial gas embolism, postural hypotension and severe vertigo). Preferably, this should be delayed until the patient arrives at a definitive treatment facility, one which has a recompression chamber (RCC).

Oxygen should be stored and used in accordance with local standards, codes or regulations.

Oxygen should be administered to all injured and ill divers at as close as is possible to 100% oxygen. With the specific exception of instructions from a physician at a facility which has agreed to accept an injured or ill diver for hyperbaric treatment, this administration of oxygen should not be interrupted.

There are sufficient doubts about the safety and efficacy of oxygen therapy in the water to currently prevent the general recommendation of this technique.

An accurate record of fluid administered and urinary output should be kept for any injured or ill diver. Bladder catheterisation by or on the order of a physician may be necessary.

There are at present (April 1997) no drugs that can be recommended for the initial management of diving injuries and illnesses. Inhalation of nitrous oxide (such as Entonox) for pain relief should never be used for analgesia in anyone suspected of decompression illness (DCI). Parenteral administration of analgesics should only ever be undertaken on the instructions of a physician.

All dive operations should have systems in place to provide immediate contact with the local diving emergency services and the local emergency services to obtain advice about initial management, regional retrieval systems and treatment facilities. An accurate record of events should be kept.

An acutely injured or ill diver should be retrieved to the nearest suitable treatment facility by the most appropriate method possible, providing that the following conditions are recognised or apply:

An altitude of 300 m is considered the maximum that should be allowed during the retrieval of a diver suspected of suffering from DCI. However, situations do arise where a commercial aircraft with a cabin pressure equivalent to an altitude of 2,400 m is the only option available. Clearly, this option is not ideal and should be accompanied by continuous oxygen administration.