Medic FA being replaced

[MikeFerrara]

Thanks, That's what I thought. I talked a firemen freind who is a First responder or emt (not sure which) and he has not been trained on the procedure.

It sounds to me as if it would only be required in the case of a collapsed lung which is not always the case with lung overexpansion injuries. At the leymen level (MFA or comparable training) I wonder if a reliable diagnosis can even be made.

We generally don't concern ourselve with differentiating between dcs and lung injuries let alone between different lung injuries.

As to the question of wether or not a dive medic is present on most dives, All the divers I dive with have this training.

However, I do not know if the training is adequate to maintain a patient until als can be provided because we haven't yet had a serious injury.

Dr Thomas, are you suggesting that we shouldn't bother learning bls or are you telling us that dead people usually stay dead.

 

[jbd]

is the problem. Few recreational divers could afford the time and the expense of getting this level of training. When I got my training it was my sole job to get that training and it was provided by Uncle Sam at no cost to me.

My opinion of the material presented in these CPR/First Aid courses is that the layman can take the proper steps to give the victim the best chance of surviving under the circumstances until more advanced aid and treatment is available. I think the point that Dr. Paul is making is that at best even with this laymans level of care the chances of survival are not good. I think he also makes the point that the really serious dive injuries need more care than can be given by the typical rescue diver.

Another thing all involved in responding to a dving emergency need to keep in mind is that sometimes no matter what level of care is available at the time some victims just won't make it.

 

[The Iceni]

MikeFerrara once bubbled...
It sounds to me as if it would only be required in the case of a collapsed lung which is not always the case with lung overexpansion injuries.

I am not sure that this is true.

At the laymen level (MFA or comparable training) I wonder if a reliable diagnosis can even be made.

We generally don't concern ourselves with differentiating between dcs and lung injuries let alone between different lung injuries. . . . . a dive medic is present on most dives . . . However, I do not know if the training is adequate to maintain a patient until ALS can be provided because we haven't yet had a serious injury.

Dr Thomas, are you suggesting that we shouldn't bother learning bls or are you telling us that dead people usually stay dead.

I did say I was acting as Devil's Advocate Mike! What I am saying is,

1) Most diver medic courses are variations of the Public First Aid courses, taught by public first aider teachers with an emphasis on BLS and the treatment of cardiac arrest; early BLS, early defibrillation and ACLS - with some mention of diving related injuries.

2) Since most divers are fit young men the incidence of cardiac arrest secondary to ischaemic heart disease is relatively rare. When present cardiac arrest is likely to be due to near drowning or pulmonary barotrauma and defibrillation may not be appropriate or indeed safe to perform.

3) There is rightly emphasis on the use of oxygen but it is quite wrong to state "dead people usually stay dead" as many apparently dead victims of immersion, especially when hypothermic, can be resuscitated.

The point I was making, in an effort to provoke some debate, was that tension pneumothorax CAN be successfully treated by battlefield medics and I really see no reason why this lifesaving procedure should not be taught to diver medics. OK diagnosis is not easy for the untrained but when PB is present a failure to treat will inevitably lead to death in an individual who might otherwise be rescued.

For example, diver surfaces after a rapid ascent and is fully concious but then complains of difficulty in breathing, rapidly deteriotates stops breathing complely then loses conciousness and collapses. He does not improve with oxygen and CPR and appears to be dead, right not much more you can do and "dead peoples do stay dead"?

CPR and oxygen will be of no help to this victim of pulmonary barotrauma without needle thoracostomy, or another way of releasing the high pressure gas from the chest cavity. Once the pressure is released spontaneous respiration returns as does normal cardiac function and the casualty could survive unimpaired. Without it death is certain and rapid.

Sadly, I doubt that this procedure can be successfully incorporated into the courses taught to diver medics but I believe it is a technique they should be made aware of.

 

[jbd]

you incorporate this into diver rescue courses? I think you make an excellent point about the current training and that needle thoracostomy could be quite useful. I think that people taking the course would need more than to be made aware of the technique. It would seem to be safer to teach them the procedure and its proper application based on diagnosis. I wonder what legal ramifications would be involved?

 

[MikeFerrara]

OK. You convinced me. Certainly, I don't know enough to argue. I can certainly believe that in a case like this there might be little to lose and everything to gain. What are the downsides to trying to teach such a procedure to laypeople? Are emt's and paramedics taught this technique? Many of the locations we dive have EMS response times measured in minutes. However, there are the dives which take place thirty or fourty miles out into Lake Superior. The only treatment we can provide is CPR and O2.

The only point I might disagree on is that many new divers are middle aged. About the time one has the money and the time to dive they are just getting ready to have their first hart attack.

Question - Is the issue with AED that if cardiac arrest is secondary to pb that the hart is not in fib, therefor the defib is of no use?

Does the safety issue stem from the fact that everything is wet?

Pardon my laymen's grasp of the issue but I'm an engineer turned dive instructor and bls is the extent of my medical training.

 

[jbd]

the procedure itself is simple enough to do. Its the knowing to do it that presents the problem IMHO. It is something that would have legal issues also, again IMHO.

To my knowledge most EMT's are not taught this technique. Paramedics might well receive this training although I'm not really knowledgeable about the training for civilian paramedics. My knowledge of combat medic training is dated.

The repsonse time in minutes is what most CPR/First Aid is geared to. In the long response time scenarios then certainly the higher level of care that can be provided the better.

I also disagree somewhat with most divers being fit young men. When I look at people at the local quarries I see many in the age range and in the right condition to be headed for a "heart attack".

As for the AED, there was some concerns over mixing electricity and water, but it is my vague understanding that those issues have been overcome.

The AED will respond to fibrillation and I think although I'm not positive about this it will respond to ventricular tachycardia that is above a certain level. Some please correct me if I'm wrong about that.

 

[The Iceni]

MikeFerrara once bubbled...
The only point I might disagree on is that many new divers are middle aged. About the time one has the money and the time to dive they are just getting ready to have their first hart attack.

Question - Is the issue with AED that if cardiac arrest is secondary to pb that the hart is not in fib, therefor the defib is of no use?

Does the safety issue stem from the fact that everything is wet?

Yes Mike, I agree being middle aged myself (well past it) I have recently returned to diving and have noticed a few others of similar vintage and there exists an epidemic of obesity and ischaemic heart disease in the West. So EAD would be effective in VF secondary to acute MI. Have AEDs on hard boats by all means but on a RIB?

However, in PB there are at least two features that would make defibrillation ineffective.

The first is that the cardiac arrest (whether asystole VT or VF) is secondary to impaired venous return to the heart due to the raised intrathoracic pressure. So even if the electrical rhythm of the heart is restored from VF it does not have anything to pump.

Secondly, ventilation is ineffective and thus the blood will not be oxygenated. Without oxygenation even BLS is ineffective and the biochemical changes of hypoxia will not be reversed.

This is known as electromechanical dissociation which is seen in hypovolaemia, poisoning, cardiac tamponade, hypothermia, electrolyte disturbance, hypoxia and tension pneumothorax. The last four being very likely in PB.

Note, particularly hypothermia, which can easily mislead rescuers.

The principles of needle thoracostomy are simple and can easliy be demonstated using a sheep or pig's carcass (That's how I was taught about it). Since the pressure in the chest compresses the lungs against the mediastinum the simple insertion of a needle in a target area above the nipple is unlikely to damage any vital organ and would be lifesaving, releasing that pressure.

As I have already said. It is unlikely to be the sort of procedure taught to diver medics because of the risks of litigation but it is routinely taught to combat medical technicians.

I do not believe it is taught to EMTs and paramedics because normal surface response times are pretty good and tension pneumothorax is seldom seen, PB never.

Not so in diving incidents and that's the point.

:doctor:

 

[cmay]

Guys,

I respect your views, and I understand where you are coming from but I think we are getting a little ahead of ourselves. Let's remember the purpose of the MFA (or whatever) course is to teach basic first aid. I feel that it is extreme to teach such advanced techniques such as thoractostomy to recreational divers. Quite frankly, it scares me to think about it.

Where I do start to agree with you is providing this training to people in more dive leadership roles. As an instructor, I have always felt that with my "basic" first aid training I would not be able to handle a severe diving medical emergency in a more remote location. I have looked into EMT training, but the time and money committments have kept me from it. I don't know if you all are aware of it, but there is a Diver Medic program out there that focuses more on diving related medicine. I think it is geared more towards commercial and scientific diving communities, but I think it would serve instructors and divemasters very well. I do know that the minimum requirements are an EMT-Basic certification. Here is the link to the site telling more about it.



Just my $.02,

Chris

 

[The Iceni]

Hi cmay,

I think you will find that almost all such recognised diver medic (technician) courses are geared to assisting chamber operators deal with a stabilised patient or, as you say, providing a basic level of competence.

I admit to being an enthusiast. There are not many doctors out there who would even attempt ACLS let alone the specialised technigues I discussed above.

I think there is a role for the diver paramedic but suggest he/she would need perhaps to be a doctor, EMT or accredited paramedic before being taught such advanced techniques. I agree instructors do have a certain responsibilies and perhaps should also have additional skills.

 

[Ronmedic]

Just as an FYI. The local Paramedics are well trained in the performance of needle Thoracostomy in the cases of tension pneumothorax that is hemodynamically unstable. The use of it related to diving medicine has been proven to be effective with lung overexpansion injuries. The only problem being is that many severe hyperbaric cases not only involves lung overexpansion injuries. If Type 1 DCS is involved in a significant manner the circulation throughout the body becomes restricted by the expansion of nitrogen bubbles in the bloodstream and the heart. I have seen many cases during recompression therapy that literally the heart will develop something similar to vapor lock in the ventricles from expansion and accumulation of nitrogen bubbles, effectively making recompression nearly impossible in a local chamber. It also makes the heart literally unable to pump blood through the systemic circulation due to large nitrogen bubbles negating the effectiveness of the heart as a pump. The PADI MFA course is an effective way for non medically trained people to learn how to help in an emergency when medical help is not delayed for any length of time. Although I do not know much about the new program I am sure it is very similar to MFA and also may have more hands on skills to go along with the book and video work. The intent is not to make people professional medical rescuers, or diver medics. It is intended to educate the non medically trained in just the basic life support techniques until they can receive more difinitive care. PADI is not the only SCUBA agency in the first aid game. SSI has used National Safety Council's first aid and CPR for years, and now I hear they are going to be creating their own program as well. $$$$$$$. Well, I have been rambling enough


Ron
Firefighter-paramedic
SSI,TDI,PADI Instructor
former US Navy Corpsman:doctor: