The Physician’s Guide to Diving Medicine

I The Diving Environment.- A. Introduction.- B. Types of Diving.- 1. General.- 2. Breath-Hold Diving.- 3. Scuba Diving.- 4. Surface-Supplied Diving.- 5. Bounce Diving.- 6. Saturation Diving.- 7. Excursion Diving.- C. Natural Diving Environments.- 1. General.- 2. Oceans.- 3. Lakes.- 4. Rivers.- 5. Harbors.- 6. Cave Diving.- 7. Diving in Kelp.- 8. Diving in Polluted Water.- 9. Diving in Wrecks.- 10. Diving in Cold Water.- 11. Diving under Ice.- References.- D. Man-Made Diving Environments.- 1. Introduction.- 2. Caissons and Tunnels.- 3. Deck Decompression Chambers.- 4. Diving Systems.- 5. System Characteristics.- 6. Hyperbaric Facilities.- 7. Rescue Chambers.- 8. Undersea Habitats and Underwater Welding Chambers.- References.- II Physics of Diving and Physical Effects on Divers.- A. Introduction.- B. Pressure.- 1. Units of Pressure.- 2. Pressure Nomenclature.- C. Pathophysiology of Gases Associated With Diving.- 1. Air.- 2. Oxygen.- a. Description.- b. Partial Pressure.- c. Toxicity.- d. Use of High Pressure Oxygen (HBO).- 3. Nitrogen.- a. Description.- b. Physiological Effects.- 4. Helium.- 5. Hydrogen.- 6. Neon.- 7. Carbon Dioxide.- a. Description.- b. Human Production.- c. Control of Breathing.- d. Transport.- e. Symptoms and Signs of Carbon Dioxide Retention.- f. Diving Implications.- g. Causes of Carbon Dioxide Excess.- h. Remedial Measures and Prevention.- 8. Carbon Monoxide.- a. Description.- b. Causes of Carbon Monoxide Poisoning in Diving.- c. Symptoms.- d. Treatment.- D. Gas Laws.- 1. Boyle’s Law.- 2. Charles’ Law.- 3. General Gas Law.- 4. Dalton’s Law.- 5. Henry’s Law.- E. Characteristics of Gas.- 1. Diffusion.- 2. Moisture.- 3. Density.- 4. Viscosity.- F. Buoyancy.- G. Energy in Diving.- 1. Light.- 2. Sound.- 3. Heat.- 4. Temperature.- 5. Specific Heat.- 6. Conduction.- 7. Convection.- 8. Radiation, Evaporation.- H. Effects of Changing Pressure on the Diver.- 1. Aural Barotrauma.- 2. Blowup.- 3. Gastrointestinal Barotrauma.- 4. Pulmonary Barotrauma.- 5. Sinus Barotrauma.- 6. Squeeze.- 7. Toothache or Aerodontalgia.- 8. Vertigo.- I. Summary.- References.- III Physiology of Diving.- A. Respiration.- 1. Lung Volumes: Effects of Gas Compression and Expansion.- a. Dynamics of Gas Flow in the Lungs.- 2. Gas Density, Ventilation Distribution, Gas Exchange.- a. Control of Ventilation and Carbon Dioxide Retention.- References.- B. Immersion Effects.- 1. Respiratory Function.- 2. Circulatory Function.- a. Significance.- 3. Renal Effects.- a. Significance.- 4. Gastrointestinal System Effects.- a. Significance.- 5. Buoyancy Effects.- References.- C. Cardiovascular Effects.- 1. Hyperbaric Bradycardia.- a. Early Studies.- b. Effects of Increased Partial Pressure of Oxygen.- c. Effects of Increased Gas Density.- d. Effects of Increased Hydrostatic Pressure.- e. Effects of Increased Gas Tensions of Helium and Nitrogen.- f. Autonomic Mediation of Hyperbaric Bradycardia.- 2. Cardiovascular Effects of Saturation Exposure.- 3. Summary.- References.- D. High Pressure Nervous Syndrome.- 1. Signs and Symptoms in Man.- 2. Strategies for Amelioration of HPNS.- a. Variation in Susceptibility and Personnel Selection.- b. Choice of Compression Rate.- c. Use of Excursions.- d. Adaptation.- e. Use of Narcotic Agents.- References.- E. Inert Gas Narcosis.- 1. Nitrogen Narcosis.- 2. Other Gases and Narcosis.- a. Argon.- b. Xenon.- c. Helium.- d. Neon.- e. Hydrogen.- 3. Quantification of Narcotic Effects.- a. Rapid Compression Effects.- b. Carbon Dioxide Effects.- c. Individual Differences in Narcotic Response.- 4. Mechanisms of Action Underlying Inert Gas Narcosis.- 5. Inert Gas Effects.- a. Model Surface Membrane Effects.- b. Inert Gas Protection against the High Pressure Nervous Syndrome.- c. Opposing Physiological Effects of Pressure and Inert Gases.- d. Clinical Use of Nitrogen Narcosis as a Benign Stress.- References.- F. Women and Diving.- 1. History.- 2. Physical Performance and Adaptability.- 3. Decompression Sickness.- a. Extra Fat Burden.- b. Oral Contraceptives.- c. Intrauterine Devices.- d. Premenstrual Fluid Retention and Menstruation.- e. Summary.- 4. Pregnancy and Diving.- 5. Questions Frequently Asked.- References.- G. Monitoring of Vital Signs; Doppler Monitoring.- 1. Voice Communication.- 2. Cardiovascular Monitors.- 3. Pulmonary Monitoring.- 4. Temperature Monitoring.- 5. Bubble Detection.- a. Ultrasound Research and Methods.- b. Clinical Significance.- References.- H. Thermal Considerations.- 1. Heat Exchanges in Air at One Atmosphere.- 2. Thermal Balance in Water at One Atmosphere Absolute.- a. Heat Transfer Coefficient of Water and Critical Water Temperature.- b. Quantity of Heat Loss.- c. Protection by Wet Suits.- d. Regional Heat Loss.- e. Effects of Exercise.- f. Symptoms of Severe and Prolonged Cold Exposure.- g. Treatment of Immersion Hypothermia.- h. Effects of Alcohol and Marijuana.- i. Cold Acclimatization.- 3. Thermal Balance in Dry Hyperbaric Environments.- a. Heat Transfer Properties.- b. Heat Exchange.- 4. Thermal Balance in Wet Hyperbaric Environments.- References.- I. Metabolism and Dietary Effects.- 1. Energy Metabolism in Divers.- a. Energy Metabolism in the Ama.- b. Energy Metabolism in Saturation Divers.- 2. Electrolyte Metabolism in Divers.- 3. Dietary Effects.- References.- J. Hyperbaric Arthralgia.- References.- K. Vestibular and Auditory Function.- 1. Auditory Function.- 2. Vestibular Function.- References.- L. Vision.- 1. Physical Factors in Underwater Seeing.- a. Vision without a Face Mask.- b. Effects of Refraction.- c. Effects of Absorption and Scatter.- 2. Physiological Factors in Underwater Vision.- a. Effect of Hyperbaric Oxygen.- b. Effects of Nitrogen.- c. Effect of Pressure.- References.- M. Breath-Hold Diving.- 1. Physiology.- a. Mammalian Dive Reflex.- b. Limits of Breath Holding.- c. Depth Limits of Breath-Hold Diving.- d. Acclimatization to Breath-Hold Diving in Man.- 2. Medical Considerations.- a. Drowning and Near-Drowning.- b. Cardiological Considerations.- c. Barotrauma.- d. Decompression Sickness.- e. Vertigo and Disorientation.- References.- IV Decompression Theory.- A. Introduction.- B. Defining the Problem.- C. The Haldane Concepts.- D. Using the Haldane Concepts.- E. Post-Haldane Difficulties.- F. U.S. Navy Initiative.- G. Diffusion vs. Perfusion.- H. Data From Tunnel Workers.- I. Bubble Generation and Growth.- J. Diving Tables Today.- K. General Observations.- References.- V Immediate Medical Evaluation of the Diving Casualty.- A. Introduction.- B. Emergency Care.- 1. General Statement.- 2. Divers Alert Network.- 3. Diving Medics.- 4. Immediate Action.- C. Diagnosis.- 1. Background.- 2. Air Embolism.- a. General Statement.- b. Signs and Symptoms.- c. Emergency Treatment.- 3. Decompression Sickness.- a. General Statement.- b. Symptoms.- c. Treatment.- 4. Determining the Cause of the Accident.- References.- VI Diagnosis and Treatment of Decompression Sickness.- A. General Survey.- 1. History.- 2. Symptoms and Signs.- a. Cutaneous and Lymphatic Symptoms.- b. Musculoskeletal Symptoms.- c. Central Neurological Symptoms.- d. Peripheral Neurological Symptoms.- e. Audiovestibular Symptoms.- f. Respiratory and Cardiovascular Symptoms.- g. Shock and Other Manifestations.- h. Aseptic Bone Necrosis.- 3. Diagnosis.- 4. Therapy.- 5. New Ideas.- References.- B. Inner Ear Decompression Sickness.- 1. Introduction.- a. Recent Human Studies.- b. Recent Animal Studies.- 2. Management of Inner Ear Decompression Sickness.- References.- C. Neurological Forms of Decompression Sickness.- 1. Overview and Introduction.- 2. Clinical Presentation.- a. Onset.- b. Signs and Symptoms.- c. Diagnosis.- 3. Mechanisms of Neurological Decompression Sickness.- 4. Prognosis.- 5. Concepts of Treatment.- a. Philosophy.- b. Initial Treatment.- c. Adjuvant Therapy.- d. Clinical Management.- References.- D. Delay After Decompression Sickness before Diving Again.- VII Diagnosis and Treatment of Gas Embolism.- A. Pulmonary Barotrauma and Arterial Gas Embolism.- B. Pulmonary Barotrauma.- 1. Introduction and Definitions.- 2. Intravascular Gaseous Emboli.- a. Effect on Pulmonary Circulation.- b. Cerebral Arterial Gas Embolism.- 3. Etiology of Pulmonary Barotrauma.- 4. Presentation and Diagnosis.- C. Arterial Gas Embolism.- 1. Presentation.- 2. Diagnosis.- 3. Therapy.- a. Pressure.- b. Oxygen.- c. Adjuvant Therapy.- 4. Relapse after Initial Response to Therapy.- 5. Other Considerations.- References.- VIII Near-Drowning.- A. Definitions.- B. Modifying Factors.- C. History.- D. Physiological Changes.- 1. Oxygenation and Acid-Base Balance.- 2. Anatomical Pulmonary Changes.- 3. Blood Volume and Electrolyte Concentrations.- 4. Cardiovascular System.- 5. Hematology.- 6. Renal Function.- 7. Central Nervous System.- 8. Infection.- E. Treatment.- 1. Immediate First Aid.- 2. Emergency Transportation.- 3. Emergency Room Care.- 4. Respiratory Care.- 5. In-Hospital Monitoring and Therapy.- 6. Brain Resuscitation.- 7. Corticosteroids and Antibiotics.- 8. Hyperbaric Oxygen Therapy.- 9. Summary.- Case Histories.- 1 Case No. 1: DD, 1972.- 2 Case No. 2: VYW, 1979.- 3 Case No. 3: CV, 1980.- References.- IX Diagnosis and Treatment of Other Diving-Related Conditions.- A. The Unconscious Diver.- 1. Factors Leading to Loss of Consciousness.- a. Relevant Physiology.- b. Predisposing Conditions.- c. Environmental Factors.- d. Physiological Factors.- 2. Recovering an Unconscious Diver.- a. Unconscious Diver in the Water.- b. Unconscious Bell or Habitat Diver.- 3. Resuscitation.- a. Check Vital Signs.- b. Insert Airway.- c. Mouth-to-Mouth Resuscitation.- d. Cardiac Resuscitation.- e. Treat Significant Bleeding.- f. Transfer Injured Diver.- g. Report the Incident.- References.- B. Osteonecrosis.- 1. Introduction.- 2. Diagnosis by Radiology.- a. Juxta-articular Lesions.- b. Head, Neck, and Shaft Lesions.- 3. Other Methods of Diagnosis.- 4. Clinical Management and Treatment.- 5. Underlying Pathological Changes.- 6. Etiology.- References.- C. Microbes and the Diver.- 1. Introduction.- 2. Cross-Infections.- 3. Diving with an Infection.- 4. Local Infections Associated with Diving.- a. Sinusitis.- b. Skin Infection.- c. Infections from Wounds, Bites, Stings.- 5. Systemic Infections.- a. Disease From Polluted Water.- b. Leptospirosis.- c. Pharyngoconjunctival Fever.- d. Near-Drowning.- References.- D. Ear and Sinuses.- 1. Otologic Barotrauma.- a. Middle Ear Barotrauma.- b. External Ear Canal Barotrauma.- c. Inner Ear Barotrauma.- 2. Otitis Externa.- 3. Inner Ear Injuries at Stable Deep Depths.- 4. Inner Ear Injuries and High Background Noise during Diving.- 5. Paranasal Sinus Barotrauma.- References.- E. Blast.- 1. Physical Aspects.- 2. Clinical Aspects and Pathology.- 3. Treatment.- 4. Prevention and Protective Measures.- References.- F. Dangerous Marine Life.- 1. Infections from Marine Microorganisms.- a. Infections Associated with Near-Drowning.- b. Tetanus.- c. Gas Gangrene.- d. Mycobacterium marinum Infections.- e. Erysipelothrix Infections.- f. Marine Vibrio Infections.- g. Coral Trauma Infections.- h. Marine Wounds.- i. Marine Fungal Infections.- j. Schistosome Cercarial Dermatitis.- k. Marine Viral Infections.- 2. Poisonous and Venomous Marine Organisms.- a. Blue-Green Algae.- b. Gymnodinium breve (Red Tide).- c. Dogger Bank Itch.- d. Green Algae (Phylum Chlorophyta).- e. Brown Algae (Phylum Phaeophyta).- f. Sponges.- g. Nematocyst Envenomizations.- h. Spine Puncture Envenomizations.- i. Venomous Octopus Bites.- j. Sea Snake Envenomizations.- 3. Human Toxic Ingestions.- a. Scombroid Poisoning.- b. Ciguatera Poisoning.- c. Puffer Poisoning.- 4. Marine Trauma.- 5. Conclusion.- References.- G. Spontaneous Pneumothorax.- References.- X Emergency Treatment While under Pressure.- A. Use of Drugs and Related Substances under Diving Conditions.- 1. Physiological Background.- a. Direct Effects of Pressure.- b. Interactions of Pressure and Gas.- c. Physical and Emotional State of Diver.- d. Known Interactions of Drugs with Environment.- 2. Clinical Applications.- a. Drugs Acting on Central Nervous System.- b. Cardiovascular Agents.- c. Respiratory Agents.- d. Otorhinolaryngeal Agents.- e. Antiallergenic Agents.- f. Antibiotics.- g. Abused Psychoactive Agents.- 3. Conclusions.- References.- B. Anesthesia for Emergency Surgery under High Pressure.- 1. Protection of the Airway.- a. Direct Visual Tracheal Intubation.- b. Blind Nasotracheal Intubation.- 2. Regional Anesthesia.- a. Toxicity of Local Anesthetics.- b. Techniques.- 3. General Anesthesia.- a. Inhalation Agents.- b. Intravenous Anesthesia.- c. Suggested Course of Action for General Anesthesia under High Pressure.- References.- XI Physical and Psychological Examination for Diving.- A. Physical Standards for Diving.- 1. Background.- a. Military Diving.- b. Commercial Diving.- c. Scientific and Technical Diving.- d. Semiprofessional Diving.- e. Recreational Diving.- 2. Physical Evaluation of Divers.- a. Age.- b. Sex.- c. Body Build.- d. Nervous System.- e. Ear, Nose, Throat.- f. Eyes.- g. Respiratory System.- h. Cardiovascular System.- i. Alimentary System.- j. Musculoskeletal System.- k. Skin.- l. Metabolic Disorders.- m. Genitourinary Disorders.- 3. Special Studies Required for Divers.- 4. Physical Fitness to Dive.- Appendix A.- Appendix B.- Appendix C.- Appendix D.- Appendix E.- References.- B. Psychological Standards for Diving.- 1. Recent Selection and Evaluation Research.- a. Mechanical and Arithmetic Aptitudes.- b. Age.- c. Demographic Factors, Medical History, Social Adjustment.- 2. Summary and Conclusions.- References.- XII Stress Physiology and Behavior Underwater.- A. Introduction.- B. Concept of Stress.- C. Stress in Diving.- 1. Training to Alleviate Stress.- a. Organized Training Programs.- b. Physician’s Role in Training.- 2. Diver Motivation—A Stress Factor?.- 3. Physical and Physiological Stress Factors.- a. Fatigue.- b. Cold.- c. Cardiovascular Disorders and Sudden Death.- 4. Cardiovascular Effects of Stress: Emotional Factors.- D. Diving Accidents.- 1. Hazards and Accidents.- 2. Diving Hazards and Accidents.- E. Diver Panic.- 1. Helplessness and Anxiety.- a. Behavioral Reactions.- 2. Physiological Events in Panic.- a. Hyperventilation.- b. Hypoventilation.- F. Concluding Remarks.- References.- XIII Safety Considerations.- A. Introduction.- B. The Diver.- 1. Selection of the Diver.- a. Physical Examination.- b. Pyschological Evaluation.- c. Diving History Evaluation.- 2. Training.- 3. Predive Condition.- a. Age.- b. Drugs.- c. Alcohol.- d. Cigarettes.- e. Diet.- f. Obesity.- g. Fatigue.- h. Physical Condition.- i. Emotional Stability.- j. Infections.- k. Previous Diving History.- C. The Dive.- 1. Organization and Planning.- 2. General Safety Precautions.- 3. Personnel: Qualified, Trained, Ready to Dive.- 4. Natural Hazards: Environmental Conditions.- 5. On-Site Hazards.- a. Traffic.- b. Sonar.- c. Radioactive Contamination.- 6. Object Hazards.- a. Fouling.- b. Pollution.- 7. Special Situations.- 8. Recompression Chamber.- 9. Equipment, Regular and Emergency.- 10. Orientation.- 11. Diving Operations.- a. Diving Platform.- b. Warning Signals.- c. Line Signals.- d. Hand Signals.- e. Descent.- f. Fouling.- g. Explosives.- h. Electric Power.- i. Shark Defense.- j. Decompression.- D. Diving at Altitudes above Sea Level.- E. Flying after Diving.- F. Fire Safety.- G. Electrical Safety.- H. Blast.- I. Drowning.- J. Hazards of Marine Life.- K.Escape and Rescue.- 1. Submarines.- a. Escape.- b. Rescue.- 2. Submersibles and Habitats.- L. Ice Diving.- References.- XIV Equipment and Procedures.- A. Treatment Chambers.- 1. Multiplace Chambers.- a. Introduction.- b. Contributions of Caisson Work.- c. Contributions of Diving.- d. Contributions of Aviation.- e. Contributions of Clinical Chambers.- f. Development of Safety Codes.- g. Principles of Safe Treatment Chamber Operations.- h. Summary.- References.- 2. Monoplace Chambers.- a. Introduction.- b. Optimal Monoplace Chamber System.- c. Application of the Monoplace Chamber.- d. Maintenance and Safety.- e. Conclusion.- References.- B. Scuba Diving.- 1. Introduction.- 2. Development of Modern Scuba.- 3. The Scuba Diving Community.- 4. Scuba Procedures.- 5. Basic Scuba Diving Equipment.- a. Cylinder Group.- b. Regulator Group.- c. Masks, Fins, Snorkels.- d. Buoyancy Control Group.- e. Protective Clothing Group.- f. Instrument Group.- 6. Conclusion.- References.- C. Surface-Supplied Diving.- 1. Air Diving.- 2. Mixed-Gas Diving.- D. Deep Diving and Saturation Systems.- 1. Diving With a Deep Diving System: Deep Bounce Diving.- 2. Saturation and Saturation-Excursion Diving.- 3. Habitat Diving.- References.- XV Diving Accident Investigation.- A. Accident Reporting.- B. Objectives of Diving Accident Investigation.- 1. Human Factors.- 2. Environmental Factors.- 3. Equipment Factors.- 4. Other Factors Bearing on the Accident.- C. Authority for Investigation and Autopsy.- D. The Autopsy in Diving Accident Investigations.- E. Medical Investigation of Fatal Diving Accidents.- 1. Identification of Victim.- 2. Examination of Equipment.- 3. Total Body Radiography of Victim.- 4. Photographic Record of Investigation.- 5. Postmortem Examination.- a. External Examination and Search for Evidence of Injury.- b. Internal Examination and Search for Evidence of Injury.- c. Microscopic Examination.- d. Chemical and Toxicological Examinations.- e. Microbiological and Serological Examinations.- F. Summary.- References.- Appendixes.- Appendix A: Glossary.- Appendix B: Abbreviations and Acronyms.- Appendix C: Pressure Conversion Table.- Author Index.