Comhairle Fó-Thuinn DIVER MEDIC. Student Handouts

Comhairle Fó-Thuinn DIVER MEDIC Student Handouts Irish Underwater Council 1999

Diver Medic Training Programme STUDENT HANDOUT Course Introduction Introduction This course, CFT Diver Medic, is designed to educate CFT members to recognise dive related injuries and to provide emergency first-aid to injured divers. These skills should be performed while activating the Emergency Medical Services (EMS), and arranging for transportation to the nearest hospital/chamber if required. The objective of this course is to teach the practical skills required to deal with a diving accident. These practical skills are a very important part of the treatment and recovery process for the victim of a diving emergency. From the moment an injured diver surfaces to the time advanced medical care becomes available is a critical period of time. During this critical period the care provided by the Diver Medic is essential. Assessment of the ABC, 100% oxygen, and correct recovery techniques greatly improve the probability of recovery of the injured diver. Basically the role of the Diver Medics is to recognise a problem exists, to identify the problem, and to deal with it within the limits of their training and expertise prior to the arrival of the EMS. Course Content The course covers three areas which, combined provide the first-aid support for an injured diver. CPR - As the primary concern of any first-aider is to ensure the victim is breathing, this course teaches the practical application of CPR including recovery techniques. Oxygen - This is the main section of the course, dealing with the use of oxygen in diving emergencies. Any time a diver has a pressurerelated accident or a near drowning is suspected, 100% oxygen should be administered following assessment of the victim s vital signs (ABC). This course will teach students to recognise the signs and symptoms of a diving injury and the treatment of it using oxygen. As oxygen is the primary firstaid treatment for injured divers it is essential that CFT Diver Medics also understand the safe handling procedures for the use of oxygen equipment. First-Aid Awareness - This section only covers the very basic theory of first-aid to help the CFT Diver Medic recognise some common non-diving related injuries, and to provide basic first-aid support. This section will not make the Diver Medic proficient at first-aid skills as it is not comprehensive or detailed enough to do so. Diver Medics requiring these skills should do a recognised first-aid course. Emergency Medical Services (EMS) When at sea the Emergency Medical Services are activated by the Coast Guard and are contactable through the local coast radio stations on VHF Channel 16 (calling, answering and distress channel), or by dialling 999/112 on a telephone/mobile phone and asking for Marine Rescue. The Coast Guard can arrange for helicopter transportation (if required), or ambulance transportation from the nearest landing point. They are trained to deal with diving incidents and can offer advice to the Diver Medic. Coast Guard radio operators can also relay expert advice from the recompression chamber to the Diver Medic, thus assisting them when dealing with a diving incident. If a diving incident occurs the Coast Guard should be contacted, regardless of how minor it may seem. Even if the incident is considered to be minor with no signs and symptoms of a diving injury, and oxygen is only being used as a precautionary measure, the Coast Guard should still be informed and given the details. If the Coast Guard are aware of a diving incident which may initially not require any assistance, they can monitor the situation and provide expert advice if requested. Also, if the injured diver s condition

deteriorates the Coast Guard will be in a better position to provide assistance if they have prior knowledge of the incident details. The information the Coast Guard will require when contacted is as follows: 1. The incident location. 2. The number of injured divers. 3. The incident history (e.g. rapid ascent) 4. Signs and symptoms. 5. The treatment being given. 6. The assistance required. This information will assist the Coast Guard to provide the best and most appropriate response to the Diver Medic s call for help. Remember, every diving incident does not require helicopter transportation. If the injured diver displays only very minor signs and symptoms of decompression illness (skin rash/itch), then transportation by road (ambulance or car) to a recompression chamber may be more appropriate. The Coast Guard will give every assistance to the Diver Medic with the resources they have available to them, thus giving the injured diver the best chance of making a complete recovery. If a diving incident occurs while shore diving and the injured diver is recovered to dry land, the Diver Medic may require the Emergency Medical Services to attend. If the injured diver shows signs and symptoms of decompression illness then the Coast Guard should still be contacted as they are the emergency service best trained and equipped to deal with diving incidents. If the injured diver shows signs and symptoms of a near drowning or any other illness, then the Coast Guard or the ambulance service (999/112) should be contacted for assistance. Diver Medics should always prepare an emergency plan before they go diving. Then, in the unlikely event of a diving incident, the Diver Medic will have all the emergency contact details to hand. The Emergency Plan should consist of the contact phone numbers and the location details of : 1. Coast Guard 2. Ambulance 3. Recompression Chamber 4. Emergency Hospital 5. Doctor 6. Gardaí.

Diver Medic Training Programme STUDENT HANDOUT Cardiopulmonary Resuscitation Introduction Cardiopulmonary Resuscitation, known as CPR, is a simple and effective method of introducing oxygen into the lungs of a person who has stopped breathing, and maintaining the circulation of blood when the heart has stopped. This lecture will explain and demonstrate the techniques to be applied to the victim of a drowning or divingrelated incident that has caused the heart and lungs to stop functioning. There will be an emphasis on the practical methods to be used rather than the theoretical. Advantages of CPR CPR is a technique that requires little training and can be carried out by single or dual operators. It is relatively easy to learn and even children can be taught the basic principles. Requiring no special apparatus CPR can be commenced at an early stage after an incident, with ventilations beginning while the victim is still in the water. It is possible to administer CPR to a victim over a long period, particularly if there are two operators. Prior to demonstrating the CPR technique it is important to revise the fundamental respiratory and circulatory systems of the body. As described in other lessons, air enters the body through the mouth or nose proceeding past the tongue and epiglottis into the bronchus, and from there into the lungs. Gas exchange takes place in the lungs, where the oxygen from the air in the lungs is exchanged for the carbon dioxide (CO 2 ) dissolved in the bloodstream. In order for adequate gas exchange to occur it is essential that the circulatory system is functioning. The heart is the organ responsible for blood circulation. It is located in the chest beneath the lower third of the sternum, just above the diaphragm muscle, and between the spine and sternum. CPR Technique for Adults Once a problem has been identified by the rescuer a speedy response is vital. Check safety of subject and self. Gently shake the victims shoulders. If there is a response (movement or answer) leave the victim in the position, check condition and get help if needed. If there are others to help send someone else, or if you are on your own leave the victim and go for help. Lungs Airway Sternum Are you O.K.? Heart Diaphragm

If there is no response shout for help and initiate the sequence of CPR easily remembered by using ABC. AIf you cannot assess the victim in the position you find him/her turn the victim on their back and open the airway. First tilt the head back by putting one hand on the forehead and the first twofingers of the other hand under the chin. Then by simultaneously pushing the forehead and lifting the chin, the head tilt/chin lift method opens the airway. The rescuer should look into the mouth to ensure it is clear of any foreign bodies. These tests will determine if the victim is breathing. Look listen and feel for no more than 10 seconds. Once the airway has been established, breathing may then begin spontaneously. If so, reassure the victim. If the victim is unconscious place in the recovery position until medical help arrives. If the victim does not breathe, begin resuscitation immediately. Close the nostrils with the thumb and index finger of the hand on the forehead, this will stop air escaping through the nose when inflating the victim. Give 2 full inflations taking about 2 seconds each time to make the chest rise. If the air enters freely, the chest will rise, thereby confirming a clear airway. Remember to maintain an open airway throughout using the head tilt / chin lift method. If you have difficulty achieving an effective breath recheck the mouth for obstruction and there is adequate head tilt and chin lift. Make up to 5 attempts to achieve 2 effective breaths. We will see later how to deal with an unconscious victim when rescue breathing is not effective. Even if unsuccessful move onto C B The rescuer now checks to see if the victim is breathing by: Looking for the rise and fall of the chest as the victim breathes. Listening and feeling for the exhalation of breath by keeping his ear close to the victim s mouth. C Look for signs of circulation. (a) With your ear near the victim s mouth, look, listen, and feel for normal breathing or coughing. (b) Scan the victim for any signs of movement. Take no more than 10 seconds to do this. Only if you have been trained to do so should you check the carotid pulse. - If you are confident there are signs of circulation: - Continue rescue breathing (giving breaths to victim) - Recheck every 10 breaths (approximately 1 minute) for signs of circulation If victim starts breathing on his/her own but remains unconscious place in recovery position. Be ready to turn onto back to re-commence rescue breathing If there are no signs of circulation or you are unsure begin chest compressions.

Chest compressions should be commenced immediately by: (a) Using your index and middle fingers locate the lower rib edge closest to you. Slide your fingers keeping them together upwards to where the rib joins the sternum (breastbone). Keeping your middle finger in place put your index finger on the sternum. Slide the heel of your other hand down the sternum to meet your index finger. Place the heel of your other hand on top of this hand interlocking the fingers, ensuring pressure is not applied over the ribs. 4-5 cms 1½ -2 Resuscitation should continue until: (i) There is a spontaneous return of circulation; or (ii) Victim is handed over to qualified medical personnel e.g. ambulance/paramedics, doctor, nurse; or (iii) You are physically unable to continue. (b) Keep arms straight. Keep the shoulders directly over the point of compression. The rescuer should establish a consistent rate and depth of compression, avoiding "jerky" movements. (c) Compress the heart by pushing the chest down 4 5 cms. For a Single and Dual Operator The correct ratio of compressions to breaths is 15:2 delivered at a rate of 100 compressions per minute (This rate is a little less than two compressions a second). Aim for four cycles per minute. Only stop to recheck for signs of circulation if the victim makes a movement or takes a spontaneous breath. Resuscitation should not otherwise be interrupted. Two person CPR This is less tiring and is more effective when performed by well-trained teams. To change from a single operator to dual operators the second rescuer should commence chest compressions after the first rescuer has given two breaths. After each series of 15 compressions the "breathing" rescuer must be ready to give 2 ventilations during which time the compressions must cease. Compressions should recommence immediately after the second inflation of the chest, waiting only for the rescuer to remove his/her lips from the victim s mouth. If the two operators wish to change places the rescuer administering the chest compressions announces the change, moving quickly to give 2 breaths at the end of the 15 compressions. Meanwhile the second rescuer can be positioning his/her hands ready to recommence compressions.

Complications Blocked airway If, during resuscitation, the chest does not rise then air is not getting into the lungs. The most common cause of airway obstruction is the tongue. To remove this obstruction correctly apply the head tilt/chin lift. Other foreign bodies (dentures, vomit etc.) may also cause an airway obstruction and can be removed if visible by a simple finger sweep of the victim s mouth. As described earlier the rescuer should make up to 5 attempts to effectively inflate the lungs. If, in an unconscious victim, effective breaths cannot be achieved the rescuer should proceed immediately with chest compressions without the need to check for signs of circulation. The action of chest compression will dislodge any blockage. After 15 compressions check the mouth for any obstruction. The rescuer can now re-apply the head tilt/chin lift and attempt to ventilate the victim to confirm the airway is clear. If the airway is still blocked then the rescuer should continue with 15 compressions followed by attempts at rescue breaths. Once the airway is clear the rescuer should then check for signs of circulation and continue rescue breaths/chest compressions as appropriate. In a conscious victim a blocked airway, causing choking, can be treated by encouraging coughing. If the victim becomes weak or ceases to cough carry out 5 back slaps. If this fails abdominal thrusts should be administered. If the obstruction is still not relieved continue alternating between 5 back slaps and 5 abdominal thrusts. If the victim becomes unconscious commence with ABC resuscitation as described. Mouth to Nose During the mouth to nose technique, the rescuer keeps the victim s head tilted back with one hand on the crown of the head and uses the other hand to lift the victim s lower jaw. This seals the victim s lips. The rescuer then seals his lips around the victim s nose and inflates, watching for the chest to rise. The rescuer then removes his mouth and can see the chest fall. When mouth to nose resuscitation is used, it may be necessary to open the victim s mouth or separate his lips to allow the air to escape during exhalation. Mouth to nose should be used in preference to mouth to mouth if (i) Victim is in the water (ii) Mouth is contaminated with blood or vomit (iii) Mouth is damaged due to injury. Blow through the nose Close the mouth Air in the stomach During resuscitation the victim s stomach may swell. This is caused by the rescuer s excessive ventilations. This should be recognised and corrected by reducing the strength and volume of the ventilations. Each rescue breath should take about 2 seconds. Vomiting The victim may vomit at any stage during CPR. If this happens the rescuer should quickly turn the victim onto his side, keeping the head, neck and back in line and clean out the mouth to ensure the airway is kept clear. The rescuer should then look, listen and feel for signs of breathing. If absent resuscitation should be restarted. Children and Infants When performing CPR on children/infants the technique should be less forceful due to their smaller physique. The objective is to achieve a RATE of 100 compression per minute, but with children (approximately 1-8 years) and infants (< 1 year) the compression to breath ratio is 5:1 for both single and dual operators. In an infant the area for compression is midsternum, one finger width below a line between the nipples. One finger is used for compression. For a child use the technique described for an adult, but use only two or three fingers. The depth of the compression should be no more than one third the depth of the chest. If the child is too large for adequate compressions using fingers then the heel of one hand can be used.

If rescue breathing is not effective the obstruction must be removed by using back slaps, chest compressions or abdominal thrusts. It must be noted that abdominal thrusts are not recommended in infants due to the potential danger of organ damage. O 2 Therapy O 2 enriched CPR: - Give O 2 at 15 litres per minute through a Pocket Mask. Recovery: - Give O 2 using a demand valve; - Give O 2 at 15 + litres per minute through a non-rebreather mask, or - give O 2 at 15 litres per minute through a pocket mask. Recovery Monitor rate of the ventilations and supplement if less than 10 breaths per minute. Give 100% O 2 if available. Treat for shock - Reassure and keep warm. Recovery position - The recovery position will be demonstrated in the practical. - It must be stressed that a conscious volunteer should not be left in the recovery position for more than a few minutes. One person operation - If a victim has to be kept in the recovery position for more than 30 minutes he/she should be turned to the other side. Peripheral circulation of the lower arm must be monitored throughout. - The recovery position should be used for unconscious victims only. - Despite the possible problems, placing the unconscious, breathing victim into the recovery position can be life saving. Two person operation Note: It is not recommended to give O 2 to non-divers Watch victim at all times. Ensure early transportation to hospital.

Diver Medic Training Programme STUDENT HANDOUT Oxygen Theory Introduction This lecture will begin with a review of the respiratory and circulatory systems. The focus will then be on the diagnosis and treatment of diving injuries, namely drowning or near drowning, and the decompression illnesses caused by air embolism and decompression sickness (DCS). The lecture will then finish on the benefits of oxygen in the treatment of an injured diver. Respiration and Circulation The respiratory system deals with the exchange of oxygen and carbon dioxide in the lungs. Air is made up of approximately 78% nitrogen and 21% oxygen. The oxygen from the air we breathe into our lungs is exchanged for the carbon dioxide in our blood stream through the walls of our lungs (alveoli). A constant supply of oxygen through our lungs to the bloodstream is vital for our body s metabolism to function normally. Carbon dioxide is a waste product of this metabolism. The process of breathing is so constant that we are seldom aware of it. However, if breathing is interrupted for even a few minutes, we pass through stages of discomfort, unconsciousness, permanent brain damage and death, if it is not restored. Lungs Diaphragm Airway Sternum Heart The circulatory system consists of the heart and the blood vessels. The heart pumps the deoxygenated blood to the lungs where the exchange of gas takes place (oxygen and carbon dioxide). From there the oxygenated blood returns to the heart and is pumped throughout the body, eventually returning to the heart again as deoxygenated blood. The importance of oxygen to our living existence is now obvious. Oxygen first-aid provided to the injured diver following assessment of the divers ABC, is one of the most important measures to be taken at the scene of a diving accident prior to the arrival of the Emergency Medical Services.

Drowning Drowning, or near-drowning, occurs when water enters the lungs. This impairs the lungs ability to transfer oxygen into the blood stream resulting in oxygen deficiency or hypoxia. The signs and symptoms of drowning include unconsciousness, cyanosis (bluish colouration), shortness of breath, coughing, frothy sputum, and death. Signs are observed by the rescuer while symptoms are experienced by the injured diver. The injured diver experiencing drowning symptoms requires prompt first-aid treatment and hospitalisation. This treatment should include CPR if required, 100% Oxygen to overcome the damaging effects of hypoxia, correct recovery techniques, and early transportation to hospital. It is vitally important that the victim of a drowning or near-drowning incident is assessed in a hospital as soon as possible because water in the lungs can cause further serious complications which may not be immediately obvious to the Diver Medic or the injured diver. Decompression Illness (DCI) Decompression illness is caused by a pressure related accident while scuba diving. It can also occur for no apparent reason, even if diving within the limits of the dive tables/computer. There are two such illnesses, Air Embolism, and Decompression Sickness (DCS) which is commonly referred to as the bends. Because the symptoms of both disorders are similar it is often very difficult for the Diver Medic to differentiate between them. Also, as the first-aid treatment for both is essentially the same, it is unimportant for the Diver Medic to distinguish between either. What is vitally important though, is for the Diver Medic to recognise the signs and symptoms of Decompression Illness and to immediately provide 100% Oxygen to the victim while contacting IMES for advice and to arrange for transportation to the nearest chamber (if required). Air Embolism - Air Embolism may occur as a result of a burst lung while breathing compressed air and ascending from a dive. Bubbles in Carotid artery Ruptured Alveoli Air Embolism

Common contributing factors are rapid ascent, breath holding on ascent, lung disease (asthma), lung scar tissue or PFO (hole in the heart). Air introduced into the bloodstream may seriously disrupt the blood supply to the heart and/or the brain causing rapid and dramatic symptoms. The signs and symptoms of air embolism include unconsciousness, convulsions, paralysis, weakness, confusion, numbness/tingling, chest pain and headache. The onset of symptoms is usually immediate. If the injured diver is unresponsive the Diver Medic should immediately request assistance from IMES and check for ABC. A diver suffering from an air embolism will urgently require recompression treatment and therefore rapid transportation to a recompression chamber is essential. Assuming the injured diver is breathing, immediately provide 100% Oxygen and ensure correct recovery techniques. Decompression Sickness (DCS) is a result of bubbles which form or grow in our tissues during or after the ascent of a dive. The bubbles are a result of excess nitrogen absorbed by the tissues during a dive. These bubbles can disrupt the blood circulation and cause tissue damage. Contributing factors such as physical exertion, dehydration and altitude exposure may accelerate the development of DCS symptoms. The signs and symptoms of DCS can range from minor to severe, depending on the location of the bubbles. These signs and symptoms include skin rash/skin itch, joint pain/discomfort, numbness/tingling, headache, extreme fatigue, weakness, general ill feeling and paralysis. On average the majority of the signs and symptoms of DCS will present themselves within 20 minutes to 2 hours after surfacing. If the injured diver is suffering severe signs and symptoms of DCS, urgent recompression treatment is required and rapid transportation to a recompression chamber is essential. If the injured diver has only minor signs and symptoms of DCS (skin rash/itch), then recompression treatment may not be necessary, but expert advice should be sought from IMES/ Recompression Chamber. A diver experiencing DCS symptoms, or a diver who is deemed at risk of DCS as a result of rapid ascent, omitted decompression or for any other reason, must be provided with 100% Oxygen as soon as possible after surfacing while contacting IMES for assistance. Providing 100% Oxygen to an injured diver may result in no symptoms of DCS appearing, or may reduce or reverse the onset of symptoms. If this occurs oxygen therapy must still be continued by providing 100% Oxygen to the injured diver until the oxygen supply is depleted, while also requesting expert advice from IMES/Recompression Chamber. If the injured diver is alert, oriented, has no breathing difficulties and is not feeling sick or vomiting, drinking water is recommended. Water is rapidly absorbed by the body, rehydrating it. No other drinking fluids should be considered. Benefits of Oxygen As a Diver Medic your highest priority is preventing death or supporting an injured diver until advanced medical care becomes available. Any time a diving injury or a near-drowning incident is suspected, 100% Oxygen should be given to the injured diver by the Diver Medic following assessment of the ABC. Oxygen may reduce, reverse, or eliminate the onset of symptoms of a diving injury. Oxygen should never be withheld from a suspected injured diver as it costs little and is widely available. Oxygen should be used as a precautionary measure even if no signs and symptoms are present in the injured diver. From the moment an injured diver surfaces to the time advanced medical care becomes available is a critical period of time. During this critical period the care provided by the Diver Medic is essential. Assessment of the ABC, 100% oxygen, and correct recovery techniques greatly improve the probability of complete recovery by the injured diver. Basically, the role of the Diver Medic is to recognise a problem exists, to identify the problem, and to deal with it within the limits of his training and expertise prior to the arrival of the Emergency Medical Services. Oxygen benefits the injured diver in a number of ways. A diver suffering from decompression illness has nitrogen bubbles in his bloodstream and tissues. Breathing high concentrations of oxygen increases the elimination of nitrogen from the bloodstream/tissues and reduces the bubble sizes. As a result of these bubbles, blood circulation can be affected causing tissue swelling and hypoxia. Breathing high concentrations of oxygen reduces tissue swelling and increases oxygen levels in hypoxic tissues. A diver who has had a neardrowning incident will have difficulty breathing and be suffering from hypoxia as a result of water in the lungs. Breathing high concentrations of oxygen should help ease breathing and reduce levels of hypoxia.

Remember, once high concentrations of oxygen are provided to the injured diver, symptoms may disappear or the injured diver s condition may dramatically improve. Do not discontinue oxygen treatment. High concentrations of oxygen must be continued until arrival at the chamber/hospital, until the oxygen supply is depleted, or until advised otherwise by the recompression chamber (minor signs and symptoms). Note: Oxygen must never be rationed to prolong the duration of the available oxygen supply. A higher concentration of oxygen for as long as possible is much more beneficial to an injured diver than a lower concentration for an extended duration.

Diver Medic Training Programme STUDENT HANDOUT Oxygen Equipment Introduction This section covers the oxygen equipment a CFT Diver Medic should have when dealing with a diving emergency. An oxygen delivery system should consist of : 1. Oxygen Cylinder filled with medical grade oxygen, 2. Oxygen Regulator, - Oxygen Demand Valve, - Constant Flow Meter 3. Oxygen Masks Non-Rebreather Mask Pocket Mask 4. Oxygen Hoses and Tubing 5. Waterproof Casings Oxygen cylinders Oxygen cylinders are easily identifiable by their colouring. The main body of the cylinder is black with the shoulder coloured white. They are subject to visual and hydrostatic testing and are available in various cylinder sizes and filling pressures. Only medical grade oxygen should be used in diving emergency oxygen units as industrial grade oxygen has an allowance for a small percentage of impurities. However, in the event of a diving emergency, using industrial grade oxygen would certainly be better than not using any oxygen at all. Adapters can be purchased which will adapt larger oxygen cylinders or industrial oxygen cylinders for use with diving oxygen kits (Bull-Nose to Pin Index). O 2 cylinder In Ireland it is preferable to rent oxygen cylinders due to difficulties in refilling privately owned cylinders. Oxygen cylinders are available for rental from various outlets, some of which are listed later. CFT recommends that an oxygen kit should have a minimum of 600 litres of oxygen. However, if divers are operating further offshore, then sufficient oxygen Pin index valve should be available so that 100% oxygen can be maintained until the injured diver reaches a hospital/chamber, or the EMS arrive on scene. Oxygen Regulators The oxygen regulator has a very similar function to the first stage of a scuba regulator. It reduces the cylinder pressure to a safe working pressure for use with a demand valve or constant flow system. O 2 regulator Regulators used on portable oxygen cylinders have a pin index system. This is where two pins on the clamp of the regulator specifically engage on the pillar valve of the oxygen cylinder. This pin indexing is unique to portable oxygen delivery systems and ensures that the regulator and cylinder are only compatible with each other, and will therefore not be used with any other breathing gas system.

Demand Valve The optimum method of providing an injured diver with oxygen is via a demand valve in conjunction with oro-nasal mask. The demand valve supplies 100% oxygen on demand and is therefore providing the most economical use and the highest concentration of oxygen possible. The demand valve of an oxygen unit works on the same principles as the second stage of a scuba regulator. When the injured diver inhales, the oxygen regulator supplies 100% oxygen through the demand valve. The demand valve is connected to an oro-nasal mask which is clear-coloured and covers both the mouth and nose of the injured diver. It is important to achieve a proper seal between the mask and the injured diver s face if 100% oxygen is to be inhaled. The oro-nasal mask is clear-coloured to allow the Diver Medic to monitor the injured diver s airway in case of vomiting or breathing difficulties. The demand valve is connected to the oxygen regulator using an intermediate pressure hose with threaded fittings on either end. This design would also be similar to that of a scuba regulator. Constant Flow Meter The constant flow meter is an integral part of the oxygen regulator and can be either a fixed flow or variable flow system. Oxygen flow is measured in litres per minute (l/min) and the fixed flow system is less effective as it does not allow the Constant flow meter Demand valve Diver Medic any flexibility in adjusting the flow of oxygen to suit the injured diver s needs. Regulators with fixed flow systems are usually available for purchase with pre-settings of 10 l/min, 12 l/min, or 15 l/min. Only regulators with the 15 l/min fixed flow setting should be considered, as anything less would be insufficient to supply an injured diver, using a non-rebreather mask, with a high concentration of oxygen. A regulator with a variable flow system is more efficient as the Diver Medic can increase the flow of oxygen to suit the diver s increased needs if necessary. A regulator with a suitable variable flow system should be capable of providing at least 15 l/min of oxygen. This is the recommended amount of oxygen required to supply a non-rebreather mask. Oxygen Masks Non-Rebreather Mask The Diver Medic should consider using the nonrebreather mask if the injured diver will not tolerate the demand valve, or if there is a second injured diver. The non-rebreather mask consists of a clear-coloured mask with exhalation ports and Non-rebreather mask valves, and a reservoir bag positioned below the mask with a one-way valve connecting the two together. Oxygen tubing is connected to the side of the valve connecting the mask and the reservoir bag. The other end of the oxygen tubing is connected to the constant flow meter on the oxygen regulator. A non-rebreather mask requires 15 l/min of oxygen to supply an injured diver with up to 90% concentration of oxygen, providing the mask is a good fit. The disadvantages of this mask are that it requires a large supply of oxygen because of the constant flow. Also, it is almost impossible to achieve high concentrations of oxygen of up to 90%; up to 65%

is considered common. If the oxygen regulator being used has a maximum constant flow (fixed or variable) of 10 or 12 l/min then the concentration of oxygen will be lower. If the oxygen regulator has a constant flow of less than 10 l/min then a non-rebreather mask should not be used. This is very important because, if the supply of oxygen to the non-rebreather mask is insufficient or interrupted, the injured diver may suffocate. Therefore, it is extremely important to monitor his breathing while providing oxygen using this mask. However, to achieve the high concentrations of oxygen required for the maximum benefit to the injured diver, a diving oxygen unit should consist of an oxygen regulator with a constant flow system capable of supplying 15 l/min of oxygen. Pocket Mask The pocket mask is a clear-coloured mask so the Diver Medic can observe the injured diver s airway in case of breathing difficulties or Waterproof Casings Different types of protective casings are available for oxygen units, but regardless of which unit is purchased, the features of the protective casings should be the same. The oxygen regulator, demand valve, and masks should be stored in a waterproof durable casing which may, or may not, accommodate an oxygen cylinder. If the oxygen cylinder is stored in the waterproof casing, the unit should be stored assembled and ready for use, with the oxygen cylinder valve turned off. Pocket mask vomiting. It is used mostly on non-breathing divers. It has an oxygen inlet port, and if used with 15 l/min of oxygen on a non-breathing diver during resuscitation, it will provide up to 50% concentration of oxygen to the injured diver. It can also be used on an injured breathing diver. At 15 l/min of oxygen it will also provide the injured breathing diver with up to 50% concentration of oxygen. Oxygen Hoses and Tubing The hose connecting the demand valve to the regulator is an intermediate pressure hose with threaded fittings on either end. The oxygen tubing used with the non-rebreather mask and the pocket mask is oxygen-safe, clear plastic tubing, and is often supplied with the non-rebreather mask. Two different types of waterproof casing for O 2 sets Oxygen Safety While oxygen itself does not burn, it strongly supports combustion. The following safety precautions must be observed when using oxygen. 1. Do not use oxygen near a naked flame or allow smoking near oxygen equipment. 2. NEVER use oil or grease (carbon based lubricants) on any oxygen equipment. Exposure to high concentrations of oxygen may result in spontaneous combustion or explosion of the lubricant. 3. Use oxygen in well ventilated areas only. 4. Do not expose oxygen cylinders to extreme temperatures. N.B. Oxygen units should be checked and tested prior to diving activities.

Diver Medic Training Programme STUDENT HANDOUT First-Aid Awareness Introduction This lesson, First-Aid Awareness, covers only the very basics of first-aid. The objective of this lesson is to make the Diver Medic aware of the basic treatment of some common non-diving related injuries. This awareness may assist the Diver Medic when dealing with these injuries. Diver Medics should not, however, consider themselves to be competent First- Aiders as this lesson is neither detailed nor comprehensive enough to cover all aspects of firstaid. Comprehensive first-aid courses are available through the voluntary first-aid organisations. First-aid is the immediate and skilled treatment given to the victim of sudden illness or injury. This treatment is applied using any available materials, and improvisation is often required. It is also the injured or ill person s first step on the road to recovery. The role of the first-aider is to preserve life, to prevent the victim s condition from deteriorating, and to promote his recovery. This is done by providing the best care that the first-aider s training and expertise allows. First-aid can be applied by anybody with basic to advanced first-aid skills. A good first-aider will know the limits of his expertise, but yet be willing and confident enough to help in an emergency situation. Remember, the role of the first-aider is to preserve life, to prevent deterioration, and to promote recovery. Even a first-aider with only basic knowledge and skills will still have an important and positive contribution to make towards the recovery of an injured or ill person. Responsibilities of the First-Aider In any accident or emergency situation where people are ill or injured, first-aid should immediately be provided while awaiting the arrival of the Emergency Medical Services (if required). The responsibilities of the first-aider are as follows: 1. Assess - The first-aider must firstly assess the overall situation. and get a general grasp of everything that is happening i.e. personal safety, number of victims, and extent of injuries. 2. Identify - Secondly, the first-aider must be able to identify which victims require treatment before others (the most seriously injured first), and which injuries require treatment before others (the most life-threatening injuries first). 3. Treat - Thirdly, the first-aider must treat the injured victim to promote their recovery and to prevent his condition from deteriorating. The level of treatment applied will obviously depend on the training and expertise of the first-aider. Yet, the first-aider with only basic skills should not underestimate the importance of the contribution he can make. Even simple things like comforting and reassuring the victim can greatly help their situation. 4. Transport - Finally, if transport to a doctor or hospital is required, the first-aider should be able to arrange this through either the Emergency Medical Services (if serious injury/illness) or by car/taxi. If the injuries are obviously only very minor (cuts or bruises) then further treatment may not be necessary. However, if in doubt err on the side of caution and send the victim to a doctor/hospital for expert medical assessment. Bleeding Bleeding is caused by damage to blood vessels. There are three types of bleeding: capillary, venous, and arterial, each referring to the blood vessel damaged. Capillary bleeding - This is the least serious type of bleeding as capillaries are the smallest blood vessels. The blood flow from capillaries is usually quite slow, often described as oozing. Venous bleeding - This can be quite serious as some of the larger veins can carry large quantities of blood. Venous bleeding is usually a steady flow of blood and can be quite heavy. Venous blood is usually dark red in colour.

Arterial bleeding - This is the most serious type of bleeding. Arteries carry blood under high pressure and therefore the bleeding from an artery is often rapid and profuse, spurting with each heartbeat. Bleeding can be external or internal. External bleeding is easier to treat as the wound is exposed and obvious to the first-aider. Internal bleeding is more difficult to treat as it is often difficult to locate or identify. Treatment (External): Initially the first-aider must ensure his own safety by avoiding personal contact with blood. This is usually done by wearing disposable latex gloves. The treatment for each type of bleeding is basically the same as the objective is to stop the flow of blood. Firstly, expose the wound and apply direct pressure by pressing a sterile pad or dressing (if available) over the wound. otherwise a clean cloth can be used. If possible, elevate the wound to assist in stopping the blood flow. Apply further dressings (if necessary) until the bleeding is stopped. If further treatment is necessary, or if in doubt, arrange for the victim to be transported to a doctor or a hospital. Treatment (Internal): Internal bleeding can sometimes be very difficult to detect as there may not be any outwardly visible signs of bleeding. It can be very minor (small bruise) or it can be severe and life-threatening. It is usually caused by impact with a blunt object and results in tenderness, swelling, and bruising around the area of impact, indicating internal bleeding. The treatment of internal bleeding is to firstly maintain the victim s ABC, then keep him lying down and treat for shock. If further treatment is necessary, or if in doubt, arrange for the victim to be transported to a doctor or hospital. Foreign Body - If a foreign body is protruding from a wound (i.e. glass), do not remove it. Instead, pad around the object using sterile pads or dressings (or clean cloths), then apply direct pressure to the pad to stop the bleeding. Once the bleeding has stopped, apply dressings around the pad making sure not to touch the foreign body, as this will only aggravate the wound. If possible, elevate the wound, and apply further dressings if necessary. Arrange for the victim to see a doctor or go to hospital as further treatment will be necessary to remove the foreign body from the wound. Fractures A fracture is quite simply a broken bone and can be either open or closed. An open fracture is when there is an open wound over the broken bone, possibly with pieces of bone protruding. A closed fracture is when there is a broken bone with no penetration of the skin, this being the most common type. The signs and symptoms of a fracture are as follows: severe pain, tenderness and swelling in the injured area which may also be deformed and have lost function. Treatment (Closed fracture): Firstly, and most importantly, avoid any movement of the injured area. Make the victim comfortable, treat for shock and alert the emergency medical services. If the victim has to be moved, then immobilise the injured area before any movement takes place, using splints or improvising if necessary. Anyone who has a fracture, or a suspected fracture, must go to hospital for further assessment and treatment. Treatment (Open fracture): Firstly ensure personal safety, pad around the wound, as previously described (foreign body), to stop bleeding, and then treat as for a closed fracture. Burns A burn is most commonly caused by heat even though there are many other elements that can cause burning (e.g. cold, chemicals, electricity, etc.). Burns cause damage to the skin, thus exposing the body to infection and dehydration. A person with burns (other than very minor) will require assessment and treatment by a doctor/hospital. Treatment: Remove the source of the burn and cool the area with water. Cover with a sterile dressing if available, or a clean cloth and treat the victim for shock. Ensure the victim is assessed by a doctor/hospital (except very minor burns) to avoid further possible complications. Head and Spinal Injuries Head and spinal injuries are usually caused by a sudden and violent impact such as falling from a height or a road traffic accident. As with other types of injuries they can range from minor to severe and life-threatening. Regardless of how minor the injuries may seem to the first-aider, if there are any signs or symptoms of head or spinal injuries, or if the nature of the accident suggests

that head or spinal injuries may be present, then full and proper first-aid treatment must be administered to the victim. Firstly look at the nature of the accident when assessing for head or spinal injuries. There may have been loss of consciousness following the accident, and the victim will have pain, swelling and tenderness around the injured area, with possible tingling or loss of sensation in the limbs. Treatment: The treatment of head and spinal injuries are to firstly ensure the victim s ABC. The first-aider must then stabilise the victim s head and spine by kneeling down behind his head, gently placing one hand either side of the head and holding it steady, thus eliminating any movement of the victim s head. Treat for shock and ensure the victim is not moved until the EMS arrive on the scene. Anyone with suspected head or spinal injuries will need to be assessed and treated in a hospital. Hypothermia This is a condition caused by the lowering of the body core temperature. As divers are often exposed to cold water they are prone to suffering from this condition. The signs and symptoms of hypothermia can range from shivering (mild), to co-ordination difficulties (severe), to unresponsiveness (extreme). Treatment: The first-aid treatment is basically to stop the cooling process and slowly begin to rewarm the victim. Firstly remove the victim from the cold environment, then remove wet clothes and replace with dry clothes and/or blankets and protect from windchill. Move the victim to a warmer environment where they can slowly rewarm. If the victim is alert and oriented a warm drink (nonalcoholic) may be given to them slowly, and treat for shock as with all other injuries/sudden illnesses. A person suffering from hypothermia must NOT drink alcohol, exercise, or have their limbs rubbed as to do so would worsen their condition. They should also be assessed by a doctor/hospital (other than very mild hypothermia) to ensure their recovery. If in any doubt seek professional advice. Shock This is a potentially life-threatening condition which can affect anyone who has suddenly become ill or injured. It is vitally important for the first-aider to treat every victim for shock to help prevent their condition from deteriorating and to promote their recovery. Treatment: Sit or lay the victim down and ensure their ABC. Treat the illness or injuries and calm and reassure while also keeping him warm. Further assessment by a doctor/hospital may be necessary depending on the extent of the illness/injuries. Note: Know the limits of your expertise, but yet be willing and confident enough to help in an emergency situation. Always err on the side of caution and seek professional advice if in doubt. Remember, CPR takes precedence over the treatment of other injuries as respiration and circulation must always be maintained.