Do not ever say you are a rescue diver

[John C. Ratliff]

In the Facebook discussion on this situation in Malta I raised what I think was a misdiagnosis by the medical examiner. This to me, as a former USAF Pararescueman and EMT Paramedic (long ago for both) was a case of air embolism, not drowning. With extreme air embolism, unless treatment is immediately available, the patient will most probably die. The treatment we used to use was getting the victim in the Trendelenburg position, administer 100% oxygen, and get to a chamber ASAP. The Facebook discussion raised questions about the Trendelenburg position, as apparently it is no longer taught. But I found a medical paper saying to use this position, dated 2017. Here’s what I said there:

Okay, I have read through the article, and the pathologist report is apparently not accurate:

“The Autopsy Pathologists stated in their report that Christine died due to “natural causes, namely seawater drowning and coronary artery atheroma””

“Atheroma,” is not the same as a air embolism, which from my reading sounds like what happened (look up the term). After she surfaced, if she had in fact embolized, there is not much a buddy could do. Air within the circulatory system would be fatal no matter the buddy’s actions unless immediate treatment was available, and that appears unlikely from the description of this dive. (Putting the diver in the Trenbelenburg position (sp?) from my memory and immediate use of 100% oxygen is the treatment, along with recompression in a chamber.). I feel that if there is an appeal, a discussion with the court about the particularities of an air embolism on the diver should be pursued.

Trendelenburg position - Wikipedia

en.wikipedia.org

Now, I have a policy that “no one dies in the water while I’m around.” So I don’t agree with those that say they would not help in an emergency that did not involve their own loved ones. But then again, I have a much different background than almost all of you (USAF Pararescue 1967-77). “These Things We Do, That Others May Live.”

SeaRat

PS, two other posts from me on that Facebook page.

One thing about Wikipedia is that it is not a definitive source. I linked it above because I needed to ensure that my memory from a long, long time ago was correct, and corrected the spelling of the Trendelenburg position. You will note that this entry also references the number [18]. Here is that abstract:

A STUDY IN PRECHAMBER TREATMENT OF CEREBRAL AIR EMBOLISM PATIENTS BY A FIRST PROVIDER AT SANTA CATALINA ISLAND.
Authors: Stonier, JC
Keywords: Hyperbaric Oxygenation
Cerebral Air embolism
treatment table
case reports
human
neuropsychological sequelae
Neurological
Issue Date: 1985
Publisher: Undersea and Hyperbaric Medical Society, Inc.
Citation: Undersea Biomedical Research, Vol. 12, No. 1 Supplement, March 1985
Abstract: Since 1975 the Los Angeles County Lifeguard rescue boats at Catalina Island, "Baywatch Avalon and Isthmus", have responded and treated 58 Cerebral Air embolism victims. All patients were using SCUBA except 1 that was using Hooka. 40 patients were sport diving, 15 were on their training check out dive, and 3 were commercial abalony or sea urchin divers. These patients presented a wide range of signs and symptoms, from alert and oriented with pain and nuero-deficits, to coma and full arrest. All signs and symptoms were reported as happening upon surfacing or immediately afterward. The average mean response time to the stricken diver from onset of symptoms to arrival of the Baywatch was 18 minutes (2min-55min spread).The average delay from onset of symptoms. to arrival time in the chamber with Baywatch Isthmus was 31 minutes. Because of the longer distance from the chamber, the Baywatch Avalon delay was an average of 1 hour and 7min. All breathing patients were transported in the Left lateral Trendelenburg position with high flow Oxygen form either a demand valve with a mask (conscious patient) or inhalation mask (altered LOC). 31 patients were also started on an IV with Lactated Ringers solution. With this treatment, 34 patients condition improved, 20 patients condition remained the same, and 4 patients deteriorated during transport. Out of the 21 patients picked up unconscious, 12 regained consciousness before arrival at the chamber. Also, 13 patients were in full arrest and were given full ACLS protocol. 9 of these regained vital signs before arrival in the chamber and 4 patients remained in full arrest. (UHMS Spon: K.K. Macdonald)

I tried searching the DAN website, and they have no articles that I can see about the Trendelenburg position. I am not trying to say what you said is incorrect, but rather to update myself in this matter. I did find this paper: https://www.futuremedicine.com/doi/full/10.2217/fca-2017-0015

These are from the Facebook page, “Scuba Accidents and Risk Management Techniques for Divers.”

For more about Pararescue, see this link:

Pararescue

Air Force Pararescuemen, also known as PJs, are the only DoD elite combat forces specifically organized, trained, equipped, and postured to conduct full spectrum Personnel Recovery (PR) to include

www.af.mil

 

[Cthippo]

In the Facebook discussion on this situation in Malta I raised what I think was a misdiagnosis by the medical examiner. This to me, as a former USAF Pararescueman and EMT Paramedic (long ago for both) was a case of air embolism, not drowning. With extreme air embolism, unless treatment is immediately available, the patient will most probably die. The treatment we used to use was getting the victim in the Trendelenburg position, administer 100% oxygen, and get to a chamber ASAP. The Facebook discussion raised questions about the Trendelenburg position, as apparently it is no longer taught. But I found a medical paper saying to use this position, dated 2017. Here’s what I said there:

Now, I have a policy that “no one dies in the water while I’m around.” So I don’t agree with those that say they would not help in an emergency that did not involve their own loved ones. But then again, I have a much different background than almost all of you (USAF Pararescue 1967-77). “These Things We Do, That Others May Live.”

SeaRat

PS, two other posts from me on that Facebook page.



These are from the Facebook page, “Scuba Accidents and Risk Management for Divers.”

Trendelenburg went out of our protocols a couple of years ago as a general treatment for hypotension because the research just wasn't there to back it up. That said, it might work for certain specific conditions.

That said, I am kind of scratching my head about why you would go Trendelenburg for an air embolism. Are you trying to get the bubble to "float" towards the feet? It seems like if it is the venous system it should not get past the valves. Curious what the rationale for this treatment is.

 

[John C. Ratliff]

Trendelenburg went out of our protocols a couple of years ago as a general treatment for hypotension because the research just wasn't there to back it up. That said, it might work for certain specific conditions.

Be aware that hypotension (low blood pressure) and air embolism are very different medical conditions. Take a look at the two studies that I referenced above. While it may not be in the protocols now, there are still research papers that as of 2017 say it works for air embolism caused by barotrauma.

SeaRat

 

[Cthippo]

Be aware that hypotension and air embolism are very different medical conditions. Take a look at the two studies that I referenced above. While it may not be in the protocols now, there are still research papers that as of 2017 say it works.

SeaRat

I edited my post while you were replying to it. Can you explain why that should work for air embolism?

 

[John C. Ratliff]

I edited my post while you were replying to it. Can you explain why that should work for air embolism?

Yes, the theory is that in the Trendelenburg position, laying on the left side, head below foot level, the air in the circulatory system would mostly go toward the extremities instead of the brain. This would be due to the buoyancy of the air bubbles within the liquid circulatory system. In the brain, the air bubbles can do extreme damage; in the extremities, not so much. Read the report I quoted above about the 1980s report on treatment of air embolism.

SeaRat

 

[SlugLife]

Now, I have a policy that “no one dies in the water while I’m around.” So I don’t agree with those that say they would not help in an emergency that did not involve their own loved ones.

I cannot speak for anyone else, but I suspect you may be misinterpreting comments.

The standard concept is "to not endanger yourself, to rescue another diver." In this particular scenario, what does one do when their dive-buddy blows through deco to the surface, and is out of reach? Presumably, if your buddy would be injured by that, and you followed, you would be injured in the same way.

 

[BlueTrin]

As a side note, I think I’d skip two minutes deco on the last stop if I had a worry that my buddy wouldn’t make it.

But I don’t have a good feeling about how much deci we can skip and have good chances to not have permanent damage.

Anyone aware of studies on this topic?

 

[Searcaigh]

As a side note, I think I’d skip two minutes deco on the last stop if I had a worry that my buddy wouldn’t make it.

But I don’t have a good feeling about how much deci we can skip and have good chances to not have permanent damage.

Well you could be lucky but I would continue breathing the deco gas on the surface to mitigate any adverse effects from surfacing early, and I guess if you had 100% as your deco gas that would be an advantage.

Personally, unless it was my daughter, I would still fulfil my deco obligation.

 

[Wibble]

As a side note, I think I’d skip two minutes deco on the last stop if I had a worry that my buddy wouldn’t make it.

But I don’t have a good feeling about how much deci we can skip and have good chances to not have permanent damage.

Anyone aware of studies on this topic?

Would look at the SurfGF and make the decision based on that.

Normal dive gradient factors (for me) are 50:80. If at the final stop there was some emergency and I had a SurfGF under 100, I'd surface but then continue the deco on 100% for some time.

100 is basically the M-value, i.e. normal Buhlmann. Statistically it should be fine, unless today's the day to collect my £€$200 for passing Go.


In other words, the response depends upon the circumstances and events happening there and then. I wouldn't consider some toss-bag legal knobhead pontificating where it doesn't harm him.

 

[BlueTrin]

Would look at the SurfGF and make the decision based on that.

Normal dive gradient factors (for me) are 50:80. If at the final stop there was some emergency and I had a SurfGF under 100, I'd surface but then continue the deco on 100% for some time.

100 is basically the M-value, i.e. normal Buhlmann. Statistically it should be fine, unless today's the day to collect my £€$200 for passing Go.


In other words, the response depends upon the circumstances and events happening there and then. I wouldn't consider some toss-bag legal knobhead pontificating where it doesn't harm him.

Yea I assumed that 2mins would be 100% because I use 80 for GFHi too.

2 mins of skipped deco is actually more skipped for me since I would normally do the 1m per meter after the last stop.