Emergency pressure treatment when bent?

[Wayan]

simple answer to all of this is;
Most places / people do not have the equipment, training / experience to do IWR

It is difficult to get the basic first aid for DCS to the majority divers as it is i.e. provision of O2 And denial reigns supreme.

Carls IWR does have applications but needs the experience to decide who and what equipment is available this becomes a medical decision not a laymans decision. (remember this person should be attended at all times therefore you are potentially putting others at risk

We are all taught from our open water course the S+S of DCS / DCI and yet a number still go into denial (regardless of experience)

There is enough anecdotal evidence to support that the provision of surface 100% O2 by and fluids soon after onset of DCS/ DCI is very beneficial and some cases may even negate re-compression (the person still needs to be evaluated).

Placing someone in one of those sausages and transporting IMHO is not of any advantage but rather could be detrimental to the persons health, if they have a problem then just how quickly can you get to them....? remembering that divers do suffer from non diving medical emergencies as well, stroke/heart attacks.....etc all of which need immediate primary first aid.

Note that when divers are transported in TUP device (transferred under pressure - HYTEC DART / DUOCOM) there is an attendant with them.

 

[graywhale]

We are changing the circumstances:

"......the consensus being to reduce DCS risk in the first place by making dive profiles less agressive, gas mixes more benign and then if you have problems... use Option 1."

So let's correct the direction back to where it started. The thread question as to IWR revolves around the issue when option 1 is not an readily available (what if there's a storm and the plane can't get in for days?). That is transport to a chamber would take too long or is otherwise not available. Under these circumstances, does IWR make sense - that was how I began this thread.

We're slowly amending the circumstance in the beginning of this thread to evaluate IWR when a chamber is not far away, rather when it is very far away. My conclusion is that when a chamber is too far away and IWR is otherwise possible (knowledge, competence, equipment, weather...) that there are clearly situations where it is a very good option and very beneficial.

 

[Thalassamania]

We are changing the circumstances:

"......the consensus being to reduce DCS risk in the first place by making dive profiles less agressive, gas mixes more benign and then if you have problems... use Option 1."

So let's correct the direction back to where it started. The thread question as to IWR revolves around the issue when option 1 is not an readily available (what if there's a storm and the plane can't get in for days?). That is transport to a chamber would take too long or is otherwise not available. Under these circumstances, does IWR make sense - that was how I began this thread.

We're slowly amending the circumstance in the beginning of this thread to evaluate IWR when a chamber is not far away, rather when it is very far away. My conclusion is that when a chamber is too far away and IWR is otherwise possible (knowledge, competence, equipment, weather...) that there are clearly situations where it is a very good option and very beneficial.

The consensus of the medical, hyperbaric and professional diving worlds is that, despite interesting anecdotal tales, unless you are unusually well prepared IWR should not be attempted. What is favored is 100 percent oxygen and Option 1.

 

[DevonDiver]

Agreed.

Instead of contemplating IWR, people who conduct aggressive diving in remote locations would be far better served from conducting the appropriate training on providing a more complete surface solution.

The Dive Medic Technician and Remote Area Medical Technician courses would provide the ability to more accurately assess and monitor the casualty, as well as providing more efficient emergency care...such as intraveneous hydration, rather than oral hydration and appropriate medicinal provision (anti-clotting drugs, immune system medication etc).

 

[graywhale]

DevonDiver,

"such as intraveneous hydration, rather than oral hydration and appropriate medicinal provision (anti-clotting drugs, immune system medication etc)."

That sounds more complicated than IWR to me. Not only is it easier to make a mistake with the above, but a mistake is more costly than IWR. The use of the above also requires more exacting training as well, IMHO. Unless properly licensed, think of the liability. It also requires other medical history knowledge and drug use of the victim. Not to speak of the fact that the drugs need to be on hand. And to keep this on an apples to apples basis, assumed is that option 1 is not available. Option 1 fixation is not going to make it appear in this hypothetical case.

In preparing for my next diving trip, most of them certainly do not have option 1 available. Cocos, Malpelo, Cuibo, etc....Same for the Tubbataha reef live aboards in the philippines, etc....You'd need a seaplane and calm seas for it to land for it to be even remotely possible and even then it would take at least 6-10 hours at a bare minimum everything going perfectly and quickly, to get to a chamber. And we know how quickly things go in these countries.

A helicopter is out as the distances are too long, even for twin turbine ones. No helicopter in common use has 600+ miles of unrefueled range.

Granted, most divers do dive not too far from a chamber or where option 1 is available. But this thread assumes option 1 is off the table. (Option 1 is evacuation to a chamber).

 

[Thalassamania]

To do IWR you should have on board two surface supplied full face masks with coms and a surface pannel with PTT coms that also permits gas switches. The last time I put a system like that together I spent about $6K.

 

[graywhale]

I suggest studies be done using Nitrox EAN 50 to say 60 feet for IWR treatment. or different combinations, Perhaps EAN 40 to 80 feet (or whatever PP02 of 2 equals). I am not Nitrox certified and thus can not calculate the max PP02, but it should be right around 2.

Most studies are with pure air only or with 02 only. Seems we have room for more studies. If Nitrox at PP02 of 2 is shown to be much more effective than pure air, that would be a great standby treatment as this is easily available and cheap. This could be the minimum equipment available for any remote dive operation where option 1 is unavailable.

A step up would be the availability of a FFM with 100% 02, as would be ideal and perhaps carried by live all aboards etc...

Even simple recompressing on air to finish missed decompression stops should be taught to all. This is not common knowledge, as the example with the Seattle diver shows. He died due to blown deco stops (faulty buoyancy bottle) and quick ascent, but was kept at the surface rather than being brought right back down to do his deco.

 

[Thalassamania]

It is already know that the best thing to do in the way of breathing media is use pure oxygen at the deepest possible commensurate with the degree of safety required. Using any mix with nitrogen in it just takes away from the efficacy of the treatment and only makes sense when you have to go deeper to relieve symptoms. Work on using Heliox as a treatment gas however is of significant interest, though some recent work suggests that, "the only important independent variable is the clinical severity at presentation" (Gempp & Blatteau, 2009).

 

[Wayan]

I suggest studies be done using Nitrox EAN 50 to say 60 feet for IWR treatment. or different combinations, Perhaps EAN 40 to 80 feet (or whatever PP02 of 2 equals). I am not Nitrox certified and thus can not calculate the max PP02, but it should be right around 2.

Most studies are with pure air only or with 02 only. Seems we have room for more studies. If Nitrox at PP02 of 2 is shown to be much more effective than pure air, that would be a great standby treatment as this is easily available and cheap. This could be the minimum equipment available for any remote dive operation where option 1 is unavailable.

A step up would be the availability of a FFM with 100% 02, as would be ideal and perhaps carried by live all aboards etc...

Even simple recompressing on air to finish missed decompression stops should be taught to all. This is not common knowledge, as the example with the Seattle diver shows. He died due to blown deco stops (faulty buoyancy bottle) and quick ascent, but was kept at the surface rather than being brought right back down to do his deco.

OMG!!! what for.

Remember the problem is Nitrogen. Nitrogen to be eliminated out of the system not have more introduced more into the system.

In some severe cases Hyperbaric Units may use USNTT6A (COMEX 30 preferred but expensive and not available at most units). Theory here was to reduce bubble size. Today USNTT6A is rarely used, Rather USNTT6 (RN62) are used with extensions as necessary. (USN TT6a takes you 165 feet / 50 metres)

If the suggestion was as for deeper depths using Heliox (or other inert gases) that could be understood. However here in lies the problem. Who decides, based on what information, what is the creditability of the information being provided.
There in brings all sorts of other problems (loss of body heat happens quicker....etc)

As with all things that can go wrong they will and so there is nothing like the KISS principle.

It all comes down to training and expertise. As said before most people out there can not still after all the years and training get the first aid right for DCS/DCI as it is today. Basic lay them down breathe 100% O2 by demand if avail, if not then free flow 15 litres / min on NRB or Hudson masks or resuscitator masks, and of course fluids (FIO2 reduces substantially depending on the delivery method).

We prefer people not to have IV infusions if at all possible, in some cases it can be a management problem in the unit. The less invasive medicine that is used the better.

With all the diving that is done from Live-aboards and here there are over 40 running around by far the greatest percentage of divers we see at the unit are from land based operations. Why that is .........probably good for a study.....

Dehydration is a problem and it is important that the person is re-hydrated quickly, so now we need to train our divers how to drink underwater as well. Then we not monitor if there is any urinary output (a major complication if there is not).

There are too many what ifs.

So as stated previously Carls Edmonds IWR certainly does have applications in some cases, but certainly not all. However it would require there to be expertise in administrating IWR, this should be a medical decision and needs to have all sorts of requirements to be met.

In some places which are regular visited and dived simple things like O2 is scarce and hard to obtain.

 

[Wayan]

I suggest studies be done using Nitrox EAN 50 to say 60 feet for IWR treatment. or different combinations, Perhaps EAN 40 to 80 feet (or whatever PP02 of 2 equals). I am not Nitrox certified and thus can not calculate the max PP02, but it should be right around 2.

.

Nope not quite. Note easier to do calculations in metres (mulitples of 10)

Formulae
EAD = (1-O2%) x (Depth+10) -10 / 0.79

PPO2 = (Depth+10)/10 xO2%


EAN 50 18 metres ppO2 1.4
EAN 50 30 Metres ppO2 2.0
EAN 40 24 Metres ppO2 1.36
EAN 40 40 Metres ppO2 2.0 EAD here is 27.974 Metres

Also note patients are taken to a ppO2 of 2.8 in the hyperbaric chamber.