Rescue breathing/EAR/CPR/etc

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DrSteve

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I'm just about to take my SSI Rescuse Skills course. I have completed 5 CPR courses (ran by American Heart Association, American Red Cross and St Johns) including a 1 week course in "Public First Aid" (St Johns Ambulance, UK) and also been well trained by BSAC. I'd welcome any comments from qualified individuals about whether I was taught incorrectly or just maybe the texst (and course?) is written very badly. In balance I will add I think I will get something from the course as I know the instructor and his style and he goes above and beyond.

So on page 97 of the book it makes the following statements:
"rescue breathing is very difficult in water...and it may also force water into the lungs."

Excuse me? 6 courses so far have told me that if in doubt perform EAR (expired air resuscitation/artificial respiration). If water is in the lungs, it does need to be drained. But the air you push in will be the difference between a realistic recovery after return of consiousness and a vegetable. BSAC teaches a very effective method of performing mouth-to-nose EAR which is comparatively easy to perform in water.

It also claims that in-water CPR should not be attempted as it can "pose the risk of forcing gastric stomach contents into the victim's lungs."

OK once again I am left wondering. First, who could perform chest compressions in water anyway? You can't even perform them on a bed. How would chest compressions cause stomach contents to go up the aesophogus and into the lungs (unless the victim just regained consciousness and threw up)?

Finally the book states that if you have to "intensify" your rescue breathing due to proximity of help/shore/boat etc., that you should breath for the non-breathing casualty every 5s. OK once again...every 5s? I am conscious and I breath once every 5s. Are they trying to tell me that an unconscious diver needs as much air as I do? (Let's face it the rate for CPR/EAR is 12-15 compressions per 2 breaths, that's slower than one every 5s) If you are attempting to tow and breath I think every 5s is near impossible. If you are stationary maybe. I seem to recall 1 breath every 10 fin strokes, meaning 1 breath every 10 s.

The final corker on page 89 says:
"If you are familiar with your buddy's equipment, such as how the power-inflator operates, a buddy assist will run smoother."

I cannot believe I am reading this drivel. If you are diving with someone you should know how their equipment operates! It's called a pre-dive buddy check.

*wanders away muttering to himself*

Thanks guys!
 
I am also taking the SSI Stress/Rescue course. My instructor, who I respect, repeated the injunction mentioned on p. 97. Apparently, SSI deems this concept so important, it is one of the end-of-chapter review questions.

It has been a number of years since my last CPR/First Aid course, and I've spoken to others about recent changes in theory and practice. I've been warned to expect some new concepts. Can't wait.

Finally, I believe this course is not intended to put you on a Fire Department rescue unit. It is simply to make you a better diver.
 
DrSteve:
6 courses so far have told me that if in doubt perform EAR (expired air resuscitation/artificial respiration). If water is in the lungs, it does need to be drained. But the air you push in will be the difference between a realistic recovery after return of consiousness and a vegetable.
This is what I was taught. It will be difficult, if not impossible, to drain aspirated water while you and the patient are in the water. Do the artificial ventilation, rescue breaths, EAR, or whatever you want to call them anyway.
DrSteve:
It also claims that in-water CPR should not be attempted as it can "pose the risk of forcing gastric stomach contents into the victim's lungs."

OK once again I am left wondering. First, who could perform chest compressions in water anyway? You can't even perform them on a bed. How would chest compressions cause stomach contents to go up the aesophogus and into the lungs (unless the victim just regained consciousness and threw up)?
As you noted, without a hard surface, chest compressions are dang near impossible. Even when done properly, chest compressions can cause gastric contents to be expelled and aspirated (I've seen it happen, so I know it can). This usually occurs when air has been forced into the stomach from artificial ventilations. It can be mostly prevented with properly applied crichoid pressure to seal off the esophagus.
DrSteve:
t you should breath for the non-breathing casualty every 5s. OK once again...every 5s? I am conscious and I breath once every 5s. Are they trying to tell me that an unconscious diver needs as much air as I do? (Let's face it the rate for CPR/EAR is 12-15 compressions per 2 breaths, that's slower than one every 5s) If you are attempting to tow and breath I think every 5s is near impossible.
1 breath ever 5 seconds is 12 per minute. That's the minimum recommended. During CPR, the rate of compressions should be such that the 15:2 ratio of compressions:breaths should result in ~ 12 breaths per minute (it comes out to a rate of ~120/minute, but actual # of compressions is more like 90/min due to pausing for breaths.)
DrSteve:
The final corker on page 89 says:
"If you are familiar with your buddy's equipment, such as how the power-inflator operates, a buddy assist will run smoother."
Of course you should be familiar with your buddy's equipment :wink:
 
Snowbear:
As you noted, without a hard surface, chest compressions are dang near impossible. Even when done properly, chest compressions can cause gastric contents to be expelled and aspirated (I've seen it happen, so I know it can). This usually occurs when air has been forced into the stomach from artificial ventilations. It can be mostly prevented with properly applied crichoid pressure to seal off the esophagus.

So if you are doing the breathing correctly ie. head tipped beack all the way so you don't inflate the stomach you should be relatively OK then?

Snowbear:
1 breath ever 5 seconds is 12 per minute. That's the minimum recommended.
I rechecked my manual last night and you are correct. But I also remember that if you are doing CPR and EAR *solo* the breathing frequency has to be slowed down so you can do both.

It's good to know that others don't like some of the book's content as well. I for one will be throwing that "manual" out as soon as I am done with the course and sticking to my holy grail manual "BSAC Safety and Rescue for Divers."

Incidentaly if you are truly interested in developing your rescue skills, you can order it through the BSAC web site for about 22.50 USD + shipping:
http://www.bsac.org/shop/manuals.htm
 
DrSteve:
So if you are doing the breathing correctly ie. head tipped beack all the way so you don't inflate the stomach you should be relatively OK then?

No, tipping the head back opens the airway, but does not prevent stomach inflation. Short bursts of exhaled air (high pressure) are more likely to cause gastric distension than longer exhalations at lower pressure. Same goes for when using bag/mask ventilation.

Jim
 
No matter what you do, unless the patient is properly intubated, you are going to force some air into the stomach. There will be vomiting.

Do not delay getting a person who is in the water onto boat/shore in order to perform respirations, if getting tham onto a dry surface is a short distance away. In water AR is difficult at best, with a large chance of complications. CPR is almost impossible. Prognosis is poor for any diver who goes into resp arrest, even with the best care.
 
There is a large body of opinion gathering that in water resuscitation may not be appropriate, and that it may be best simply to get the patient out of the water where proper treatment can be implemeted. Firstly, it is difficult to achieve, even for well trained operators. Secondly, it is impossible to check for a pulse in the water, hence if the patient is in cardiac arrest all your efforts are futile and your energy would be better directed at getting them out of the water fast. If help is a long way away then maybe EAR may be worthwhile in the hope that the patient isn't in cardiac arrest.

This is a difficult area...it is difficult to set hard and fast guidelines, especially for the layman. Basically if the patient is in respiratory arrest only then EAR in the water may be of significant benefit (only if it is performed to a high standard), but if they are in cardiac arrest it is a complete waste of time and effort (and may significantly decrease any chance of survival that they had). Statistically it would be near impossible to document whether the majority of "stricken" divers are in respiratory arrest or in cardiac arrest at the surface. I wouldn't be surprised if the emphasis on resuscitation in the water fades out over the next 5 years or so, to be replaced by a "get them out of the water fast" approach.
 
Well guys I finished the course and I actually got a lot out of it. The emphasis with the SSI course is dealing with stressed out divers before they get to the panic stage, but also dealing with them at the panic stage if necessary. It is ironic that my instructor told me there were some scenarios he would love to "teach" but unfortunately "keeping within the standards of learning" restricts what he can and cannot do during course time for liability reasons. Such a shame!
 
BlueDevil:
There is a large body of opinion gathering that in water resuscitation may not be appropriate, and that it may be best simply to get the patient out of the water where proper treatment can be implemeted. Firstly, it is difficult to achieve, even for well trained operators. Secondly, it is impossible to check for a pulse in the water, hence if the patient is in cardiac arrest all your efforts are futile and your energy would be better directed at getting them out of the water fast. If help is a long way away then maybe EAR may be worthwhile in the hope that the patient isn't in cardiac arrest.

This is a difficult area...it is difficult to set hard and fast guidelines, especially for the layman. Basically if the patient is in respiratory arrest only then EAR in the water may be of significant benefit (only if it is performed to a high standard), but if they are in cardiac arrest it is a complete waste of time and effort (and may significantly decrease any chance of survival that they had). Statistically it would be near impossible to document whether the majority of "stricken" divers are in respiratory arrest or in cardiac arrest at the surface. I wouldn't be surprised if the emphasis on resuscitation in the water fades out over the next 5 years or so, to be replaced by a "get them out of the water fast" approach.

I agree with you Blue. I've seen first aid instructors and professional rescuers (in the "old days") being inadequate performing AR on land. I can't imagine a diver having taken a rescue class one time being anywhere near efficient in the water. I'd say the energy is better directed at finning the patient to shore/boat asap.
I'm curious as to why you think that taking a pulse in the water is impossible? There's nothing you can do for an absent pulse in the water as you said so theres probably no need to even check
 
As I was taught if the victim is breathing it does not matter if you give them "rescue breaths." So we were advised through the SSI method to do them anyway. If the victims heart has stopped rescue breathing won't do any harm, and at worst you are 10s delayed.
 
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