Check what your skipper will do? [Archive]

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terryh

15-07-2004, 13:49

Following on from the Coastguard thread.

We often have the odd "incident" in the mid-dive break
usually involving the O2 kit. Part of the scenario is to tell
the skipper what's happening etc.

We dont just do the usual "go tell the skipper and come back
and tell me you've done it" routine, but actually stand by
the skipper and go through a checklist.

What I have found is that there are two very different
approaches. The most obvious (and what you would expect)
is to tell the Coastguard and inform them that diver A, has
been on O2 etc. and keep them advised. They can then allocate
resources etc. and if it warants it, send out the helo.

However on two occasions now I have been told by the skipper
that they dont call the coastguard just because a diver is on
O2 and assess the severity of the situation. The excuse being
that it costs a lot of dosh for the helo etc.

So how on earth does the skipper know how severe it is?

We now check on booking that the skipper will ALWAYS call the
coastguard if a diver is put on O2, no matter what the
circumstances. If they say it's there perogative then we dont
book.

I'm not sure if it's a historical thing, but might not be
a bad idea to ask next time you book that boat.

TerryH

Keith L

15-07-2004, 14:40

Personally I could not agree more with you, it's a pity that more people don't take the stand that you do.

If there is even the slightest doubt, the merest suspicion - then the diver should be put on O2. Once the decision to use O2 has been made then the CG =MUST= be informed. There is no such thing as "a bit of a bend" that migt just "go away" with O2, only a suitably qualified medical person can make decisions, not the divers and certainly not the skipper of the boat!

Also consider this scenario... diver shows mild symptoms, you use O2 but don't really want to "bother" the CG. It worsens, eventually to the stage where you have no choice so you call. It takes time to locate medical people, the helo is just off on excercise (just left), it takes TIME to organise an evacuation. The diver dies in the helo, just 5 minutes from medical help - "if you had got him here alive, just 15 minutes earlier" says the doctor "we may have been able to help".

Enter the laywers. The delay in getting things moving with the CG cost a diver his life. Now who is responsible for that? The DM? the skipper? the whole boat for not excercising 'duty of care'? Would you like to be involved in that? I certainly wouldn't.

I'm certainly no expert Terry, I know very little about such things - but I'm with you on this : TELL SOMEBODY WHO WILL KNOW, the CG are there to help us, we owe it to them to give them the chance to do so. We also owe it to our fellow divers IMHO.

Keith L

Andy Nye

15-07-2004, 16:10

Hi Terry.

Yet another VERY GOOD SAFETY issue raised,and one of which is worth well all skippers knowing , they can lose money from this ;-)

((( YOU QUOTE ))) We dont just do the usual "go tell the skipper and come back and tell me you've done it" routine, but actually stand by the skipper and go through a checklist.

This is a good idea when using / diving from a NON DIVE CHARTER boat i.e using fishing boat , where the skipper has no experience with o2. At least if the CG were contacted , he will have some sort of idea in answering the questions,,, without using AIR TIME with " Wait 1 or standby ".

I would and have done the following in the event of any accident onboat my vessel while i'm in COMMAND.

1) If a diver goes on o2, wether it's thier clubs kit or MY BOATS, I will inform the CG straight away with all details, This is wether the vessel is at sea or alongside. For this reason, it has many benefits.

a) All voice messages are TAPED at Dover CG.
b) It will be logged in thier log.
c) They have a direct land line to the choppers / ambo's.
d) Will be logged on my onboard laptop log.
e) Entered in my ships log.

So, from the above , if the situ goes belly up for any reason, there are 4 points where all details are record for any court / insurance case.
o2 ADMIN and any major accident that i feel needs to be reported to the CG, then i will not hesitate to tell.

Please make note , that i do this for ANY onboard incident, i.e shot dropped on foot, fingers caught in door..... but minor things like this the CG are NOT informed.

What i do admire is that during our 4 -5 Surface break bewteen dives , some club D/O's & T/O's and help from myself if needed , go though little scenarios to help with diver training or even if it's showing new coming divers the kit that charter boats carry......
((( The common one for July is ,,, THUNDER FLASHES as diver recalls ))). I even have a used flare, so people can hold / touch / take apart and pretend to fire.

Just ONE point that i would like to say ..... If my boats o2 is used and lets say 40 bar is sucked from it .... within 20 minutes of being back on my berth a FULL cylinder is replaced, i'm lucky really , where i can do a swap for swap as and when ;-)

((( YOU QUOTE )))We now check on booking that the skipper will ALWAYS call the coastguard if a diver is put on O2, no matter what the circumstances. If they say it's there perogative then we dont book.

I'm not sure if it's a historical thing, but might not be a bad idea to ask next time you book that boat. )))

Nice idea to ask if they carry o2 onboard the vessel as well. if the answer is no, then HANG UP

ATB

Steve Walker

15-07-2004, 16:13

Adrian Kelland

15-07-2004, 16:53

if the pain goes away then it is DCI & then you call the CG, if the pain is still there it's unlikely to be DCI and more likely to be a simple strain.

I think you have been lucky Steve. I assure you, a painfull DCI can still exist after 30mins of O2.

I can understand where you are coming from, but I wonder how many times this kind of analysis has worsened the final outcome. This is getting on for a justification for denial in my opinion.

Please don't delay for me if it ever comes to it.

Adrian

iainmsmith

15-07-2004, 17:06

I disagree completely.

Here's a different scenario for you: diver feels a mild twinge, no reason to suspect DCI, a reasonable suspicion it might be due to the effort of lugging a twinset onto and off their back.
so to test for possible DCI you put him on O2 for 10-15mins, if the pain goes away then it is DCI & then you call the CG, if the pain is still there it's unlikely to be DCI and more likely to be a simple strain.

Note those words: "unlikely" and "more likely". Do you think it will be of any comfort to someone who ends up with a permanent disability to be told, "Well, it was _unlikely_ that you had DCI...so I didn't call the CG."

I've been on a charter boat where the skipper has stated "If you go on O2 I'm calling the chopper - no arguments". So now instead of using the O2 sensibly to test for potential DCI you may end up with a diver who will keep quiet about a mild twinge because they don't want what they see as minor issue to become a big drama.

O2 is just a tool to be used sensibly, it's not some Holy Grail that requires major action every time it comes into play.
And yes, I have successfully used acute O2 treatments to delineate a possible DCI from a glorified case of a "dead arm" due to small boat bunks.

Steve,

1. Are you a doctor? (If so, please go to question 7.)
2. Is oxygen a drug?
3. Are you qualified to identify signs and symptoms that should receive oxygen therapy?
4. Are you qualified to determine when such signs and symptoms do _not_ require oxygen therapy?
5. Are you qualified to determine when signs and symptoms consistent with a diagnosis of DCI can be ignored and when they absolutely require evacuation?
6. Are your medical defence organisation subscriptions up to date in case you get 4. wrong?
7. If you are a doctor (and, to be honest, even if you're not), do you think it's appropriate for members of the general public, with the minimal diving first aid training and experience from the O2 Admin course (delivered by non-medical instructors within the BSAC) to be excluding decompression illness and therefore denying treatment? If so, who will bear the responsibility for the consequences if/when one of them disregards the stipulation in the O2 course that "Oxygen is a drug. When you start it, the casualty MUST be evacuated to medical attention"?

I have successfully used acute O2 treatments to delineate a
possible DCI from a glorified case of a "dead arm" due to
small boat bunks.

"Dead arms" may well resolve spontaneously and fairly rapidly on restoration of circulation. Or it may take a bit longer. A numb arm, due to DCI, may also resolve on O2 administration. Or it may not. How exactly did oxygen administration help you determine which of these four cases applied?

For what it's worth, my own answers to the above questions are:
1) Yes
2) Yes
3) Yes
4)&5) Possibly not - I'm a surgical trainee, not a hyperbaric physician.
6) Yes
7) No, and I don't intend to find out.

Regards,

Iain

PeteM

15-07-2004, 17:11

However on two occasions now I have been told by the skipper
that they dont call the coastguard just because a diver is on
O2 and assess the severity of the situation. The excuse being
that it costs a lot of dosh for the helo etc.

Having been involved with a rescue last weekend (not involving one of our branch members) I think this is a daft idea. Last weekend a diver on our boat had a hit, my wife (ex-nurse) was rescue manager. She got the skipper to call the CG then hand over the hand set to her, she was then patched through to the doctor at HMS Vernon and they then had a three way conversation. The Doctor made the call to call the helicopter; not the skipper, not the rescue manager.

Why would anyone not want to speak to an expert in these circumstances? Let the pro's make the call

Pete

Philip Smith

15-07-2004, 19:01

Steve,

so to test for possible DCI you put him on O2 for 10-15mins,

Oxygen is not a "test" for DCI, as Iain has explained.

I've been on a charter boat where the skipper has stated "If you go on O2 I'm calling the chopper - no arguments".

The skipper does not "call the chopper". The CG would usually consult with a hyperbaric doctor before deciding what type of evacuation, if any, is needed. Informing the CG of a problem does not inevitably result in a helicopter mission.

Philip Smith

Mike Halligan

15-07-2004, 19:10

We now check on booking that the skipper will ALWAYS call the
coastguard if a diver is put on O2, no matter what the
circumstances. If they say it's there perogative then we dont
book.
Absolutely agree. Oxygen is First Aid (BSAC O2 Training).
In the absence of someone qualified (and equipped, and willing) to establish that the First Aid was inappropriate and that no treatment is needed then the initial suspicion must be carried to its logical conclusion (BSAC O2 Training).
It is the hyperbaric doctor who says when the casualty is no longer at risk and we contact that person via the Coastguard.

In addition, we are increasing our risk by consuming our First Aid resources before the second dive. Is it not wise to advise HMCG that we are (a) exposed to heightened risk and (b) unable to render back-up to others.

Helicopters and cost are red herrings, IMHO. The Coastguard and doctor will decide about that - given the opportunity.

I'm not sure if it's a historical thing, but might not be
a bad idea to ask next time you book that boat.
Maybe so, and therefore a boat that has once said "I'll be the judge" may change its tune in later years.
There was a time when one of our first choice charter boats carried no oxygen of its own - so we took our sets. That ceased to be the case a while ago as others did likewise and the truth of the matter became apparent to the skipper.

Mike

matt

15-07-2004, 19:49

1) If a diver goes on o2, wether it's thier clubs kit or MY BOATS, I will inform the CG straight away with all details, This is wether the vessel is at sea or alongside. For this reason, it has many benefits.

Hi Andy

Just wondering what your attitude is to techies doing surface soaks? How would you distinguish between the guy who thinks he has a bend and the guy down his O2 stage to prevent a bend?

matt

15-07-2004, 20:24

Steve nice to see a less PC response!

so to test for possible DCI you put him on O2 for 10-15mins, if the pain goes away then it is DCI & then you call the CG, if the pain is still there it's unlikely to be DCI and more likely to be a simple strain.

Just a technicality but if you put someone on O2 and the pain gets worse they may have a bend. If O2 changes the symptoms then suspect a bend.

O2 is just a tool to be used sensibly, it's not some Holy Grail that requires major action every time it comes into play.

Countrys where evacuation and recompression has to be paid for tend to have a very different attitude to potting people. In the UK the lawyers appear to wield the influence. If you ask a skipper for the O2 he will call the CG, the CG will send a chopper and the chamber will recompress you - any other response and they are food for the landsharks. If you are a real cynic you might want to consider how health authority cross charging muddys the waters.

And yes, I have successfully used acute O2 treatments to delineate a possible DCI from a glorified case of a "dead arm" due to small boat bunks.

It is a fact that the majority of people I know who have been recompressed most likely were not bent. Whilst evacuation and recompression are free of charge in the UK there is little reason to avoid being cautious and precautionary. I just wonder if the health authorities will stomache the costs indefinately.

terryh

15-07-2004, 20:44

Why would anyone not want to speak to an expert in these circumstances? Let the pro's make the call

That's what gets me about all this. It's been the case for a
few years now that skippers say they are NOT marshals, just
taxi drivers. I've got no problems with that, after all we pay them to drive the boat, not take details. It does get a bit,
when suddenly they become experts on hyperbaric medicine.

As for carrying O2, we have the usual 3lt etc. and take it
onboard as an addition to whatever the boat carries, but i've just ordered a reconditioned ex-fire brigade 6lt. Two or more
stressed heavy breathing divers, 90 minutes out.
You do the maths.

TerryH

matt

15-07-2004, 20:57

Also consider this scenario... diver shows mild symptoms, you use O2 but don't really want to "bother" the CG. It worsens, eventually to the stage where you have no choice so you call. It takes time to locate medical people, the helo is just off on excercise (just left), it takes TIME to organise an evacuation. The diver dies in the helo, just 5 minutes from medical help - "if you had got him here alive, just 15 minutes earlier" says the doctor "we may have been able to help".

Keith I don't particularly disagree with your stance. However here is the 'Ying' to your 'Yang'

Several weeks ago we monitored a CG operation where a helo was sent to evacuate a buddy pair who had surfaced after missing 3 mins of stops after a 27m dive as indicated on their Vypers (rather more conservative than a set of 88s). The divers informed the skipper who put the pair on O2 and informed CG who dispatched a chopper. The helo had the winchman on the wire when a second dive boat called in 'diver unconcious face down on the surface'. From the location we quickly worked out that the 2nd boat was on the Moldavia (55m) and the divers would have been in the water about 40mins - so the casualty has missed around 30 mins of stops. The CG diverted the helo off the first evac seconds before the winchman was comitted. The unconcious diver was evacuated to the chamber, recompressed and got away with it lightly.

Now what if the call had come 30 seconds later? The helo would have been committed to evacuating divers who were not showing symptoms, whilst another diver in mortal danger has to wait.

Enter the laywers. The delay in getting things moving with the CG cost a diver his life. Now who is responsible for that? The DM? the skipper? the whole boat for not excercising 'duty of care'? Would you like to be involved in that? I certainly wouldn't.

Neither would I personally want to be tie up a helo and chamber simply because everyone is following their 'don't get sued plan' The rescue services are a finite resource which we should not take for granted. Possibly something to keep in mind when matching our dive plans to our abilities.

Regards
MattS

John Williams

15-07-2004, 21:16

Keith L

15-07-2004, 22:34

I hear what you're saying Matt, but would you consider YOURSELF, without knowledge of other situations, without appropriate medical qualifications, able to make the decision as to the "best" use of rescue service resources? I know that I wouldn't!

I will agree, there may be some unneccessary use or recompression facilities. I am certainly not qualified to judge that. I believe that many recompression facilities are privately owned, there may even be some incentive to "use" the facilities (and thus recharge) at some times. But again - are YOU qualified and in full possession of all of the facts to make the decision when that is the case? I know that I'm not.

Then of course enter the land sharks (laywers), I wish you (or anybody else) the very best of luck in explaining why you DIDN'T make the call to the CG. That is not a position that I would wish to find myself in.

So I do hear what you're saying, but I am not prepared to take the risk that I may make the wrong decision, I would ALWAYS pass it on to somebody (i.e. the CG) who is in a damn sight better position than me to make that decision. I do not give a damn if I "waste" resources, if I'm made to look stupid because I called in a minor incident and get laughed at down the pub afterwards. I can live with that. What I don't think that I could live with was if I made the WRONG decision and saw a friend, buddy or fellow diver in a wheelchair (or worse). That's my bottom line really Matt, that's why I would ALWAYS make the call to the CG.

Regards

Keith L

Philip Smith

16-07-2004, 11:30

If you ask a skipper for the O2 he will call the CG, the CG will send a chopper and the chamber will recompress you - any other response and they are food for the landsharks.

That chain of events is not a certainty. The CG will decide how best to use their rescue services with advice from a hyperbaric doctor. If the patient is asymptomatic after omitting a small amount of in-water decompression, simply monitoring them on O2 may be all that the doctor will advise. Patients who are taken to a chamber are assessed by a doctor and not all of them are recompressed (although recompression is diagnostic as well as a treatment, so in doubtful cases it may be used to check whether symptoms are due to DCI). As your argument in another message indicated, inappropriate deployment of limited rescue services and treatment facilities could increase the CG's or doctor's liability, rather than reduce it.

Philip Smith

terryh

16-07-2004, 12:24

The CG are a point of reference. It's there job to colate and
deseminate the information to whoever is appropriate. That means hyperbaric/medical/logistical information, none of which,
you have available on the boat. True you might have a doc on
the boat, but he/she doesnt know the availabilty of
chambers/helos/RNLI etc.

Can we use your scenario as a reason to hold back on calling
the CG? Well no. Again even if the original decision to go on
O2 is a bit premature or lets say enthusiastic, that can ONLY be confirmed later with hindsight. At the time whoever put the diver on O2, did so because to them there was a risk (even if
it was a perceived one). Who but the CG can be objective enough
to decide what to do?

We can all play the "what if" game, but it works both ways.
What if that diver who was 3 mins over on a Vyper, DID go on
to develop DCI?

TerryH

Mike Halligan

16-07-2004, 19:00

Now what if the call had come 30 seconds later? The helo would have been committed to evacuating divers who were not showing symptoms, whilst another diver in mortal danger has to wait.
In that case, I should expect HMCG to abort the exercise. The helo might be laden with two role-players and heading in the wrong direction, but they can turn the thing about and most carry more than 2 passengers. (If desperate, pass low over original boat and let them jump for it! Only joking)

Neither would I personally want to be tie up a helo and chamber simply because everyone is following their 'don't get sued plan' The rescue services are a finite resource which we should not take for granted. Possibly something to keep in mind when matching our dive plans to our abilities.
I'm very much in agreement, especially with your final sentence. Our risk assessment must also take account of the likely availability of assistance.

Regards

Mike

Steve Walker

16-07-2004, 19:35

Well I've been on this forum more than long enough to know what the typical reactions are like, this thread is no different...

Note those words: "unlikely" and "more likely". Do you think it will be of any comfort to someone who ends up with a permanent disability to be told, "Well, it was _unlikely_ that you had DCI...so I didn't call the CG."

If it was someone other than myself I've no qualms giving the CG a shout, but I reserve the right to make my own judgements about my own safety.

1. Are you a doctor? (If so, please go to question 7.)

That's what it says on my driving licence...
though to save a pointless argument I'm one of those PhD people who medics usually class as "not a proper doctor", even though I do supply some of their lectures ;)

2. Is oxygen a drug?

Absolutely not, it's one of the 110 officially named elements of the periodic table, No. 8 to be precise. It was, and still is, central to my working life in research. A quick poll of my fellow researchers is unanimous on this.

3. Are you qualified to identify signs and symptoms that should receive oxygen therapy?

O2 Admin instructor, is that sufficient?

4. Are you qualified to determine when such signs and symptoms do _not_ require oxygen therapy?

Something of a moot question, as for divers, O2 can't do any harm, and I wouldn't give it to members of the public

5. Are you qualified to determine when signs and symptoms consistent with a diagnosis of DCI can be ignored and when they absolutely require evacuation?

I think you (and some others) are mistaking my lack of a knee-jerk reaction for a lack of safe practice, which is absolutely not the case. If I'm giving O2 to another diver who's diving under the BSAC regime than I'll give them the BSAC proscribed treatment, I'm just highlighting that people needn't treat oxygen like some kind of Sacred Cow, or perhaps I shouldn't be bringing non-BSAC ideas into the BSAC forum? (no doubt there's many resounding "aye"s to that)

6. Are your medical defence organisation subscriptions up to date in case you get 4. wrong?

N/A, See #1 above

7. If you are a doctor (and, to be honest, even if you're not), do you think it's appropriate for members of the general public, with the minimal diving first aid training and experience from the O2 Admin course (delivered by non-medical instructors within the BSAC) to be excluding decompression illness and therefore denying treatment? If so, who will bear the responsibility for the consequences if/when one of them disregards the stipulation in the O2 course that "Oxygen is a drug. When you start it, the casualty MUST be evacuated to medical attention"?

See answer #5 above

:=I have successfully used acute O2 treatments to delineate a
:=possible DCI from a glorified case of a "dead arm" due to
:=small boat bunks.

"Dead arms" may well resolve spontaneously and fairly rapidly on restoration of circulation. Or it may take a bit longer. A numb arm, due to DCI, may also resolve on O2 administration. Or it may not. How exactly did oxygen administration help you determine which of these four cases applied?

Considering the "dead arm" was in the morning, the bunks were a bit compact, and I'd done an extremely cautious deco shedule the day before - using very high O2 percentages - I, and my buddies, were more than satisfied that this was not a case of DCI, and following a further dive that day and the fact that I'm still perfectly healthy, I'd say my judgement has been more than vindicated

Incidentally, this concept I posted on before was given to me by an extremely professional and accomplished TDI Instructor, (who is also a BSAC AI) he's done many thousands of dives and like me is still perfectly healthy, I just thought I'd supply a different perspective as I don't really like the clonal thinking which sometimes typifies threads here.

Cheers
Steve W

Keith L

16-07-2004, 21:36

Incidentally, this concept I posted on before was given to me by an extremely professional and accomplished TDI Instructor, (who is also a BSAC AI) he's done many thousands of dives and like me is still perfectly healthy, I just thought I'd supply a different perspective as I don't really like the clonal thinking which sometimes typifies threads here.

Thanks for the different perspective Steve. What would you suggest that us mere mortals, without a doctorate, who aren't technical instructors, who haven't done many thousands of dives - do in the situation where a diver is placed on O2?

Regards

Keith L

17-07-2004, 07:09

Guys
bit off the wall most of this, Phillip touched on the nearest, which is you do not call a "CHOPPER" when you have a prob, you call the CG, they will nearly always , in the case of a suspected DCI, patch you through to a Doc, who will make the final decision on what action to take.
not too sure about clear cut rules, best one for me is if in doubt do it, the Doc will give advice on the radio, so it is not your decision, and that is how it should be
as for the guy who is going to diagnose his own condition, perhaps he can't remember the advice we give to our students when running an o2 course, "it goes something like a diver with a possible problem will probably not be a willing patient for a variety of reasons including fright or disbelief" so mister if your on my team you absolutely do not diagnose yourself
Be safe
JP

:=We now check on booking that the skipper will ALWAYS call the
:=coastguard if a diver is put on O2, no matter what the
:=circumstances. If they say it's there perogative then we dont
:=book.
Absolutely agree. Oxygen is First Aid (BSAC O2 Training).
In the absence of someone qualified (and equipped, and willing) to establish that the First Aid was inappropriate and that no treatment is needed then the initial suspicion must be carried to its logical conclusion (BSAC O2 Training).
It is the hyperbaric doctor who says when the casualty is no longer at risk and we contact that person via the Coastguard.

In addition, we are increasing our risk by consuming our First Aid resources before the second dive. Is it not wise to advise HMCG that we are (a) exposed to heightened risk and (b) unable to render back-up to others.

Helicopters and cost are red herrings, IMHO. The Coastguard and doctor will decide about that - given the opportunity.
:=
:=I'm not sure if it's a historical thing, but might not be
:=a bad idea to ask next time you book that boat.
Maybe so, and therefore a boat that has once said "I'll be the judge" may change its tune in later years.
There was a time when one of our first choice charter boats carried no oxygen of its own - so we took our sets. That ceased to be the case a while ago as others did likewise and the truth of the matter became apparent to the skipper.

Mike

Steve Walker

17-07-2004, 11:51

Thanks for the different perspective Steve. What would you suggest that us mere mortals, without a doctorate, who aren't technical instructors, who haven't done many thousands of dives - do in the situation where a diver is placed on O2?

Regards

Keith L

Simple: how about before putting to sea you add to your kit list a mobile phone or preferably a handheld VHF radio so that if you or Terry should find yourself at the mercy of one of these recalcitrant scallywag skippers who refuses to call the CG, you can circumvent his hindrance and do it yourself?

Cheers

Keith L

17-07-2004, 12:34

:=Thanks for the different perspective Steve. What would you suggest that us mere mortals, without a doctorate, who aren't technical instructors, who haven't done many thousands of dives - do in the situation where a diver is placed on O2?
:=
:=Regards
:=
:=Keith L

Simple: how about before putting to sea you add to your kit list a mobile phone or preferably a handheld VHF radio so that if you or Terry should find yourself at the mercy of one of these recalcitrant scallywag skippers who refuses to call the CG, you can circumvent his hindrance and do it yourself?

Ah - So we should call the CG! Thanks Steve, I think that's roughly where we started IIRC :-)

Cheers

Keith L

terryh

17-07-2004, 12:45

Simple: how about before putting to sea you add to your kit list a mobile phone or preferably a handheld VHF radio so that if you or Terry should find yourself at the mercy of one of these recalcitrant scallywag skippers who refuses to call the CG, you can circumvent his hindrance and do it yourself?

Well firstly Steve it's not that they wont call the CG, it's
because they are unqualified to make a hyperbaric medical
decison and in doing so might delay calling the CG.

As for the VHF radio, never going to happen.
You are the skipper of a boat that has an I'll decide mentality
when calling the CG. We are trying to book your boat and ask
the CG question.
You now have a choice. Odds of calling out the CG are pretty
slim. Odds of calling out the CG on this booking even more so.

Money talks. if this group want to book my boat and have a CG
rule then I'll take the dosh and leave it to them.

TerryH

alunharford

18-07-2004, 01:07

:=2. Is oxygen a drug?

Absolutely not, it's one of the 110 officially named elements of the periodic table,
Whose periodic table?
Most people either leave out the ones that havn't been discovered or go up to 118.

And the reference was to oxygen molecules - not atoms.

No. 8 to be precise. It was, and still is, central to my working life in research.

Then I'm very concerned!

Alun Harford

Steve Walker

18-07-2004, 14:31

Whose periodic table?
one favoured by the American research establishment

<a href="http://pearl1.lanl.gov/periodic/default.htm" >http://pearl1.lanl.gov/periodic/default.htm</a>

:= No. 8 to be precise. It was, and still is, central to my working life in research.

Then I'm very concerned!

Alun Harford

So...?

iainmsmith

18-07-2004, 16:33

:=Note those words: "unlikely" and "more likely". Do you think it will be of any comfort to someone who ends up with a permanent disability to be told, "Well, it was _unlikely_ that you had DCI...so I didn't call the CG."

If it was someone other than myself I've no qualms giving the CG a shout, but I reserve the right to make my own judgements about my own safety.

Your original posting referred to "diver feels a mild twinge", not specific to you. OTOH, you will remember that one of the key issues with DCI is "denial". No-one can make you tell anyone...equally, anyone you do tell should be putting the call out. You're also putting a lot of faith in the use of O2 as a diagnostic tool...which it's not.

There is a saying of the medical profession: "The doctor who treats himself has a fool for a patient."

I submit that the same concept is probably true of divers deciding that the signs and symptoms they notice in themselves don't require proper evaluation by someone more objective.

:=1. Are you a doctor? (If so, please go to question 7.)

That's what it says on my driving licence...
though to save a pointless argument I'm one of those PhD people who medics usually class as "not a proper doctor", even though I do supply some of their lectures ;)

Interestingly, I've always found that the "not a proper doctor" comments come from those who are Phinally Done! Something to do with me not having a "doctorate" in anything. :-)

:=2. Is oxygen a drug?

Absolutely not, it's one of the 110 officially named elements of the periodic table, No. 8 to be precise. It was, and still is, central to my working life in research. A quick poll of my fellow researchers is unanimous on this.

And in the context of which you were discussing it, ie as a diagnostic and theraputic tool? (I didn't think it was necessary to spell that out...and I'm sure you knew what I meant)

:=3. Are you qualified to identify signs and symptoms that should receive oxygen therapy?

O2 Admin instructor, is that sufficient?

Indeed...

:=4. Are you qualified to determine when such signs and symptoms do _not_ require oxygen therapy?

Something of a moot question, as for divers, O2 can't do any harm, and I wouldn't give it to members of the public

Absolutely. But if you're not in a position to decide that signs and symptoms don't merit oxygen, how can you decide that evacuation is not required and therefore not make a call to the CG?

:=5. Are you qualified to determine when signs and symptoms consistent with a diagnosis of DCI can be ignored and when they absolutely require evacuation?

I think you (and some others) are mistaking my lack of a knee-jerk reaction for a lack of safe practice, which is absolutely not the case. If I'm giving O2 to another diver who's diving under the BSAC regime than I'll give them the BSAC proscribed treatment, I'm just highlighting that people needn't treat oxygen like some kind of Sacred Cow, or perhaps I shouldn't be bringing non-BSAC ideas into the BSAC forum?

It's not a "knee-jerk reaction". It's what you (and every other BSAC Oxygen Administrator and, probably the equivalents from every other agency) were trained to do. There's a reason you were trained to do it. That reason is that you do not have the training and experience to decide that medical treatment is not needed.

My concern is about the suggestion that someone who is not qualified in hyperbaric medicine and not trained to exclude DCI as a possible diagnosis should be using oxygen as a diagnostic tool, rather than a theraputic treatment. What is the specificity and, more importantly, sensitivity of such use? (For the non-scientists: how likely is it that you will misdiagnose DCI in a normal casualty on this basis and how likely is it that you will rule out DCI on the basis of the test in a casualty who actually has it).

To me, the real thought processes which need changing are not that use of oxygen in suspected DCI requires a medical review (which, IMO, it does) but those you outlined when you said:

"So now instead of using the O2 sensibly to test for potential DCI you may end up with a diver who will keep quiet about a mild twinge because they don't want what they see as minor issue to become a big drama."

Firstly, I question how sensible it is for a non-physician to assume that if the problem does not go away, it's not DCI.

Secondly, regarding what the diver sees as "a minor issue," see my point above re: doctors and self-treatment. Possible DCI is _not_ a minor issue and should never be considered to be one.

The problem is that people are conditioned to think that DCI means that they did something wrong, that it's their fault. It may be...but it may well be an entirely "undeserved" hit. It doesn't matter. They should be treated according to their symptoms and managed in a supportive, non-critical manner until someone comptent to exclude DCI is able to exclude it.

You may be confident in your ability to discriminate between DCI and other causes of similar symptoms. In all honesty, I'm pretty confident of my own and would probably have managed the "dead arm" scenario by observation. Given that this, as you point out, was most likely due to vascular compromise, the arm is going to get better when the circulation was restored. Oxygen is likely to accelerate that process. However, had it been a DCI case, then the oxygen is likely to improve matters as well. So what was the point in "testing" with oxygen? How did it allow you to make a valid management decision?

Whatever you or I might do individually, I don't believe for a moment that the average BSAC diver or oxygen administrator (or oxygen administration instructor) is competent to use oxygen as a diagnostic tool and I have issues with the suggestion that it should be used as such, particularly in the absence of any discussion as to the required comptencies of someone administering such a test and especially when illustrated with an example where the use of an "oxygen test" should have lead to a diagnosis of "possible bend"...but apparently didn't! That does not inspire confidence in the your understanding of the pathophysiology and response to treatment.

Incidentally, this concept I posted on before was given to me by an extremely professional and accomplished TDI Instructor, (who is also a BSAC AI) he's done many thousands of dives and like me is still perfectly healthy, I just thought I'd supply a different perspective as I don't really like the clonal thinking which sometimes typifies threads here.

I'm familiar with the concept you outline. You and he may have done many thousands of dives. So what? How often have you (or he) had a suspected bend? How often have you (or he) had to deal with a suspected bend? How often have you excluded a bend in such marginal cases? How often have you diagnosed one? How often did you get it right and wrong?

"O2 is just a tool to be used sensibly, it's not some Holy Grail that requires major action every time it comes into play."

Unless the individual using oxygen as a tool has considerable experience in the diagnosis and exclusion of DCI, I cannot agree with the above. There are very few lay people who should be ruling out DCI as a diagnosis.

Iain

iainmsmith

18-07-2004, 16:37

The rescue services are a finite resource which we should not take for granted. Possibly something to keep in mind when matching our dive plans to our abilities.

I'm very much in agreement, especially with your final sentence. Our risk assessment must also take account of the likely availability of assistance.

Indeed...how many boats actually carry sufficient O2 to support two potentially bent casualties all the way back to shore (and during the time waiting for the ambulance...and possibly on the ambulance itself - I can't remember what size of cylinders ambulances carry, but few, if any, can provide pure O2...and if they've got larger cylinders, they may well not be pin-index compatible. Anyone know for certain?)

Iain

Steve Walker

18-07-2004, 21:33

A lot of fair points there Iain. In retrospect perhaps I'm assuming too much in thinking what's good for me is ok for others too, and should therefore have written my post in the first person: I take my diving and safety with the utmost seriousness and caution, hence no hesitation in using oxygen in a somewhat prophylactic sense. You and I are both in the science business, which at it's most fundamental level is a business based on observations, measurements, and ideas. I'm sufficienty well aquainted with medics and medicine to know that in a lot of places it is no more (and very often far less) exact a science than the science carried out in labs - how often have you used the "crash cart"? And how many of those times, and other situations, are you thinking "Let's see if this will do the trick?" How often have you later changed the initial prescription given to a patient in light of further developments? A fair degree of trial and error goes on.

Incidentally, for me, in this n=1 occurence, the vascular/neuronal compromise did not resolve after 30 minutes breathing pure O2, I felt that had this been a type 1 DCI then some amelioration would be evident, and went ahead with the planned dive (NB it was my caution over the planned dive which prompted the O2 use).

In short: I had the idea (hypothesis), made measurements (over time), and based my actions on my observations, and my conclusion that this was not a DCI occurence was substantiated.

Some may think this risky, maybe it would be for folk who aren't keen analysts of their own situations. Personally I'm far more concerned about the risk of being killed or injured on our roads than I am making informed and careful decisions about my own safety such as the one I have described.

Cheers
Steve W