Do not ever say you are a rescue diver

[Dody]

I

I really don't think it matters what you present. My (limited) experience in buddy selection was people would chat and choose. Most boat diving I have done has been group diving in which everyone is solo as no one has accepted the role to be a specific person's buddy. However, that role has limited responsibility. If in the situation described a buddy just drops like a rock into the abyss, no one should risk their own health in that scenario. Let the staff handle that.

I think dive guides watch people during the dive and adjust accordingly. Who can they safely monitor very little to whom do they need to monitor more. Unless they are brand new, dive guides see a lot of people fairly quickly.

As far as the side conversation going involving @Dody and his wife, I doubt he has shared all details necessary for a clear picture, and people have a tendency to interpret statements through their own lens. I'm sure we've seen the overbearing husband on a boat, and a number of folks here may be interepreting @Dody as such. As I have never seen him and his wife dive, I won't say this is similar to what I've seen, but I won't say it isn't either. I just won't throw stones here.

Stress is a significant issue for some people (one of my most nervous students for diving in the Puget Sound was a 6'5" 280 lb firefighter) that needs to be addressed in training. It happens and not addressing stress but ramming through combined with "you'll be fine" is counterproductive for learning. @Dody has agreed that more training for his wife is a good idea, so he definitely isn't being hardheaded/stubborn. Everyone knows I'll recommend fundies here, but since that's a given, I'll keep my mouth shut .

 

[Dody]

In fact, I have lined up my wife for a fundie in a couple of months. And when she asked why I was not coming along, instead of replying that it was darn expensive, I told her that I wanted her to be a better diver than me .

 

[doctormike]

Mike,
ABC has been changed CAB on the newest guidelines.
Your operating room example is not analagous and thus transferable for this scenario. Most of your patients in OR do not have cardiovascular collapse. Whereas, most of the adult CPR is due to circulatory problem (even if it started as respiratory issue). Thus, if you close to shore or boat, it is of utmost importance to get the victim to initiation of compressions and/or AED.
Two rescue breaths every 6 seconds while you are trying to tow a disabled victim in the water is very exhausting (it was the most physically challenging part of the rescue course for me), so the delay is not simply due to administered ventilations but also due to ensuing fatigue.
To avoid confusion, I would follow PADI advice and get diver on the hard surface ASAP if you are within 5 min.

OK, a few things…

1) My comments upthread have nothing to do with the standards for adult CPR, which is what it sounds like you are referring to. Yes, I agree, if you find someone unresponsive/pulseless/apneic in a shopping mall, an AED is the way to go, plus compressions and ventilation while transporting to the ER. Those protocols are simply not directly transferrable to the situation where you surface with an unconscious diver.

2) Irreversible brain death begins within a few minutes of significant desaturation. We all have heard the stories of people surviving cold water drownings, and “you aren’t dead until you are warm and dead”. But we are talking about simplifying action in a crisis situation when the victim - whatever else is going on - has been in respiratory arrest for an unknown amount of time. That’s because of the whole “being underwater” thing.

So the first thing to do would be to open the airway and give a breath. That at least gives some chance of survival, assuming there is still a pulse. If there is no pulse and no respirations when someone surfaces, do what you like, an AED is not likely to make any difference, no matter how quickly you get the victim to one.

3) Shockable rhythms (VF and pulseless VT) can indeed be addressed by an AED. But the idea of a cardiac event being the primary issue doesn’t transfer from the shopping mall to the surface of the ocean. I suppose it’s possible that someone was breathing fine, developed a malignant arrhythmia, and then popped to the surface with well oxygenated blood, but I wouldn’t design protocols based on that remote possibility.

4) I didn’t imply that you had to deliver rescue breaths the entire time you are swimming the victim to the boat or the shore. Yes, that would be difficult. But taking 3 seconds to open the airway and give a breath or two may be the difference between life and death, especially if the victim has been apneic for more than a few minutes. Two rescue breaths every six seconds is not necessary - that would seriously impede rescue. But if you are going to be swimming for more than a minute, maybe rest for another 3 seconds and give another few breaths.

5) Restarting circulation (by AED or chest compressions) doesn’t do anything if you are circulating anoxic blood.

6) The idea that you have five minutes of grace time with an apneic victim, who has most likely been already apneic for some time, is simply not true. If I ever surface unresponsive, I want my airway opened and some of that EAN 16 right away, not in five minutes.

 

[Dody]

She

I really don't think it matters what you present. My (limited) experience in buddy selection was people would chat and choose. Most boat diving I have done has been group diving in which everyone is solo as no one has accepted the role to be a specific person's buddy. However, that role has limited responsibility. If in the situation described a buddy just drops like a rock into the abyss, no one should risk their own health in that scenario. Let the staff handle that.

I think dive guides watch people during the dive and adjust accordingly. Who can they safely monitor very little to whom do they need to monitor more. Unless they are brand new, dive guides see a lot of people fairly quickly.

As far as the side conversation going involving @Dody and his wife, I doubt he has shared all details necessary for a clear picture, and people have a tendency to interpret statements through their own lens. I'm sure we've seen the overbearing husband on a boat, and a number of folks here may be interepreting @Dody as such. As I have never seen him and his wife dive, I won't say this is similar to what I've seen, but I won't say it isn't either. I just won't throw stones here.

Stress is a significant issue for some people (one of my most nervous students for diving in the Puget Sound was a 6'5" 280 lb firefighter) that needs to be addressed in training. It happens and not addressing stress but ramming through combined with "you'll be fine" is counterproductive for learning. @Dody has agreed that more training for his wife is a good idea, so he definitely isn't being hardheaded/stubborn. Everyone knows I'll recommend fundies here, but since that's a given, I'll keep my mouth shut

She just said. You are arrogant but absolutely not a macho.

 

[tursiops]

If I ever surface unresponsive, I want my airway opened and some of that EAN 16 right away, not in five minutes.

Exactly. Me too. That is why an open airway and two rescue breaths, immediately, are the protocol in Rescue. The protocol does NOT say to wait 5 minutes. That is a red herring.

 

[doctormike]

Exactly. Me too. That is why an open airway and two rescue breaths, immediately, are the protocol in Rescue. The protocol does NOT say to wait 5 minutes. That is a red herring.

No, I was responding to @Ukmc ... maybe I misunderstood his last sentence?

 

[Ukmc]

OK, a few things…

1) My comments upthread have nothing to do with the standards for adult CPR, which is what it sounds like you are referring to. Yes, I agree, if you find someone unresponsive/pulseless/apneic in a shopping mall, an AED is the way to go, plus compressions and ventilation while transporting to the ER. Those protocols are simply not directly transferrable to the situation where you surface with an unconscious diver.

2) Irreversible brain death begins within a few minutes of significant desaturation. We all have heard the stories of people surviving cold water drownings, and “you aren’t dead until you are warm and dead”. But we are talking about simplifying action in a crisis situation when the victim - whatever else is going on - has been in respiratory arrest for an unknown amount of time. That’s because of the whole “being underwater” thing.

So the first thing to do would be to open the airway and give a breath. That at least gives some chance of survival, assuming there is still a pulse. If there is no pulse and no respirations when someone surfaces, do what you like, an AED is not likely to make any difference, no matter how quickly you get the victim to one.

3) Shockable rhythms (VF and pulseless VT) can indeed be addressed by an AED. But the idea of a cardiac event being the primary issue doesn’t transfer from the shopping mall to the surface of the ocean. I suppose it’s possible that someone was breathing fine, developed a malignant arrhythmia, and then popped to the surface with well oxygenated blood, but I wouldn’t design protocols based on that remote possibility.

4) I didn’t imply that you had to deliver rescue breaths the entire time you are swimming the victim to the boat or the shore. Yes, that would be difficult. But taking 3 seconds to open the airway and give a breath or two may be the difference between life and death, especially if the victim has been apneic for more than a few minutes. Two rescue breaths every six seconds is not necessary - that would seriously impede rescue. But if you are going to be swimming for more than a minute, maybe rest for another 3 seconds and give another few breaths.

5) Restarting circulation (by AED or chest compressions) doesn’t do anything if you are circulating anoxic blood.

6) The idea that you have five minutes of grace time with an apneic victim, who has most likely been already apneic for some time, is simply not true. If I ever surface unresponsive, I want my airway opened and some of that EAN 16 right away, not in five minutes.Mike,

while it sounds great in theory, I would have to strongly disagree with you on this one. You have seen people desaturate and become hupoxic. How long does it take to get their oxygenation back up using full bag mask ventilation, 100% O2 and that is while hyperventilating? Now think of 18% O2 of one or two breaths . Let’s add no circulation to this scenario. I think you would be better off on the boat/shore as soon as you can.
I suspect above is the reason for PADI recommendations.
Sure, two breaths at the beginning to see if you can ”wake“ them up. However, if it did not work, you better haul your victim to the boat/shore as soon as you can If you are within 5 min.

 

[doctormike]

while it sounds great in theory, I would have to strongly disagree with you on this one. You have seen people desaturate and become hupoxic. How long does it take to get their oxygenation back up using full bag mask ventilation, 100% O2 and that is while hyperventilating?

Less time that it takes with no ventilation at all.

Let’s add no circulation to this scenario.

Yes. Now you don't know they are pulseless, so you are giving them the benefit of the doubt and doing your best to salvage a bad situation. Surfacing diver who is actually pulseless and apneic is what is commonly called a "recovery"

I think you would be better off on the boat/shore as soon as you can.
I suspect above is the reason for PADI recommendations.
Sure, two breaths at the beginning to see if you can ”wake“ them up. However, if it did not work, you better haul your victim to the boat/shore as soon as you can If you are within 5 min.

They aren't going to "wake up" with two breaths. That's not the point. The point is to minimize irreversible brain damage. If they survive this, it may be a long road to recovery, even assuming that they ever wake up, months from the rescue.

There are two possilbities when surfacing and apneic - they have a pulse or they don't. If they don't, do what you like, it probably doesn't matter. But if they do, oxygenating that blood may literally be the difference between life and death. Since you don't know, assume a pulse and get some O2 in that system, it really shouldn't cause a big delay in overall egress.

 

[scubadada]

Please see the attached https://www.nejm.org/doi/full/10.1056/NEJMra1013317 especially the sections on Rescue and In-Water Resuscitation and Initial Resuscitation on Land. It's ABC, perhaps with some extra breaths up front.

 

[Ukmc]

Less time that it takes with no ventilation at all.



Yes. Now you don't know they are pulseless, so you are giving them the benefit of the doubt and doing your best to salvage a bad situation. Surfacing diver who is actually pulseless and apneic is what is commonly called a "recovery"



They aren't going to "wake up" with two breaths. That's not the point. The point is to minimize irreversible brain damage. If they survive this, it may be a long road to recovery, even assuming that they ever wake up, months from the rescue.

There are two possilbities when surfacing and apneic - they have a pulse or they don't. If they don't, do what you like, it probably doesn't matter. But if they do, oxygenating that blood may literally be the difference between life and death. Since you don't know, assume a pulse and get some O2 in that system, it really shouldn't cause a big delay in overall egress.

Well AHA will disagree with you. Drawing parallels to above the water CPR - what do you do if you find someone in the cardiopulmonary arrest? According to your line of thinking it is to give rescue breaths because of possibility of anoxic injury. That was recommendation 10 years ago. Now you go notify EMS first, then Compressions, and then rescue breaths. Why? because it has been shown to be more successful.
Furthermore, the newest guidelines say if you are not comfortable or incapable to give rescue breaths, continue with compressions along.
With that, I would rather get victim to 100% O2 and potential compressions sooner than delay by performing multiple rescue breaths.