EAV in water and the rationale behind it [Archive]

Chris Edge

22-10-2003, 22:32

As I understand it, at present the BSAC is still teaching the practice of
expired air ventilation in an unconscious diver in the water.

Now, apparently the idea is that this EAV is continued in the water until
the diver is either able to be picked up by the boat, or until the diver is
swum to the shore. Once on "dry land" the full business of CPR and EAV can
then be commenced.

I have no problem with CPR and basic life support on the shore or on "dry land" (whether that be on shore or in the boat) at all. What
I do have a problem with is the business of EAV in the water. The reasons
for this are:

1. I hope that I'm not wrong in making the assumption that most of the BSAC
divers are not children i.e. they are mostly above the age of 18. Given this age profile,
what is the most likely cause of unconsciousness in the diver? Well, it
could be drowning (the end product of a multitude of pathological causes
e.g. out of air, hyperoxic fit, etc.) or it could be due to cardiac causes,
especially in the age group of persons over the age of 40. It is extremely
unlikely that the diver has a purely respiratory cause for the
unconsciousness.
2. If an unconscious diver is to stand a chance of being rescued, then
he/she should be got onto "dry land" (definition as above) as quickly as possible. This is
particularly true if the diver has suffered a cardiac arrest, where it is
now felt that the best hope of survival is to defibrillate the heart if it
is in VF, or to give adrenaline and CPR if in asystole or in a pulseless
rhythm. Even if the diver has drowned through other causes, then it is
still a requirement to get the diver onto a firm surface asap and then
commence appropriate action.
3. The business of EAV in the water slows the process of getting the
afflicted diver onto "dry land" very considerably, as well as contributing
markedly to the rescuing diver's exhaustion.
4. EAV is not being taught well in the pool, and becomes even less
well-taught out in open water. Most trainers do not understand the need for
good neck extension and most do not teach the cantilever approach to neck
extension, with the result that the drowning diver is most unlikely to
receive sufficient air into the lungs to maintain good respiration. The
wet- or dry-suit hood makes this neck extension even less likely, as does
the presence of the other equipment in the diver. Besides, from 1. and 2.,
AV is not the main concern; it is probably access to a defibrillator and
other equipment that is.

Could it be, therefore, that there are grounds for ceasing the teaching of
EAV in the water? It would be enough to ensure that the diver does not have
an obstructed airway (vomit or seaweed in the mouth) and then ensuring good
neck extension. The emphasis then becomes more on getting the diver to a
safe place as swiftly as possible, with the rescue diver being in better
shape to call for help, assist with CPR, coordinating the rescue etc.

I would be interested to know whether any diver has truly been saved by EAV
in the water (as opposed to just having the airway cleared and therefore
being allowed to breathe, which is the process related by most of the anecdotal tales that I've heard).

I think that it would be helpful to have a rational discussion of the scenario, as opposed to just "personal feelings". Any evidence for or against would be good.

matt

22-10-2003, 23:11

Steve Walker

23-10-2003, 14:22

As I understand it, at present the BSAC is still teaching the practice of expired air ventilation in an unconscious diver in the water.
1. I hope that I'm not wrong in making the assumption that most of the BSAC divers are not children i.e. they are mostly above the age of 18.

So from that do I take it you're _not_ a BSAC diver? Because I'd reckon that most BSAC divers would know the answer to those questions already.

or it could be due to cardiac causes,especially in the age group of persons over the age of 40.

Whoa there! I'm sure there's plenty of 40+ y.o BSAC divers that might want to take you to task on that, not least of all myself.
And I'm basing that on a recent HSE medical.

It is extremely unlikely that the diver has a purely respiratory cause for the unconsciousness.

Because...

2. If an unconscious diver is to stand a chance of being rescued, then he/she should be got onto "dry land" (definition as above) as quickly as possible.

If their heart is still beating (normally) then there is a good argument for keeping them in the water and maintaining EAV, as cold british waters will delay hypoxia-induced neuronal degradation, ask Dr Paul Thomas who has first hand experience of this.

This is particularly true if the diver has suffered a cardiac arrest, where it is now felt that the best hope of survival is to defibrillate the heart if it is in VF, or to give adrenaline and CPR if in asystole or in a pulseless rhythm

Good point, but I've yet to see divers carrying defibrillators or adrenaline aspart of their surface cover kit, perhaps this will become more prevalent in the future.

3. The business of EAV in the water slows the process of getting the afflicted diver onto "dry land" very considerably, as well as contributing markedly to the rescuing diver's exhaustion.

Yes and yes, but if I were unconcious I'd want my buddy to be giving me EAV

4. EAV is not being taught well in the pool, and becomes even less well-taught out in open water.

Whoa, ah say whoa there boy! Do you live under a bridge waiting for the three Billy goats gruff to pass by ? (ie are you Trolling?) Who says it's not being taught well in the pool or open water? Having recently instructed several ODs going onto SD training, I don't recall seeing you there at the time, nor any of the times teaching this in some muddy hole in the middle of winter. Perhaps you've seen some folk not teaching it well but there's no grounds for this kind of sweeping generalisation

Most trainers do not understand the need for good neck extension

Actually, this is something that is strongly emphasised during instructor training (at least it was when I did my Club Instructor I some years ago) so again, what are you basing this on? Perhpas not every instructor will be able to give a detailed description of the interplay between oesophagus, trachea and epiglottis, but I think most have the gist of it.

The wet- or dry-suit hood makes this neck extension even less likely, as does the presence of the other equipment in the diver.

Funny, I've demonstrated (and been demonstrated upon) neck extensions in full kit and it's not hard to get the proper extension nor to test the efficacy of such by asking the casualty to attempt to swallow

Besides, from 1. and 2., AV is not the main concern; it is probably access to a defibrillator and other equipment that is.

Again assuming heartbeat irregularities , MI, VF etc

Could it be, therefore, that there are grounds for ceasing the teaching of EAV in the water?

I Can't see that happening ever.

OK, seriously, the statistical probability of AV + towing and all the associated part we teach in diver rescue being necessary is quite small: most casualties we "rescue" are going to be conscious and breathing (we are taught). Perhaps once in a branch's lifetime (my conjecture) the skills we all learn from SD upwards "might" be needed to save someone's life, and that once is in my opinion enough justification, especially if the casualty was me! ;-)

IIRC I've seen your name (or a similar name) posting on medical issues before so I'm assuming you're in some sort of medical professional, especialy using terminology such as "asystole", but it wasn't all that long ago that someone posted on here in the style of "The trouble with BSAC instructors is..." so keep your asbestos suit handy :))

I'm all in favour of receiving extra training such as defibrillator useage and even adrenaline injection, (hey! we've all seen Pulp Fiction ;-) but I'm personally not in favour of removing any of the skills currently taught.
Regards

John Williams

23-10-2003, 19:50

Just to keep things in perspective:

Chris is a senior member of the UK Sports Diving Medical Committee and has considerable medical experience with divers. He is also a longtime supporter of the BSAC and has addressed DOC on several occasions & provided medical advice to Council and is extremely well respected in this field.

So his medical credentials should not be questioned - unless you are a similarly respected expert in diving medicine.

It is also my understanding that he is not a senior BSAC diver, nor is he a BSAC instructor - which may explain his aparent lack of knowledge of what is contained in the current DTP.

However - I too take issue with his observations that certain skills are not taught well.

Perhaps - if Chris's anecdotal evidence is to be beleived - we should concentrate on solving this perceived problem instead of admitting defeat and binning a skill because a few people demonstrate poor skills.

I can confirm categorically that Rescue/first aid skills are a key area of input during instructor training courses (at all levels). Indeed I am teaching on an IFC this weeeknd and we will be ensuring that AV is performed properly - we DO see many divers presenting at this level of course who do not seem to be following the advice that *ALL* BSAC instructors are trained to emphasise.

Chris himself should be aware that any anecdotes or personal experiences related are rarely of any use when considering "evidence based medicine". For doctors to alter accepted medical opinion today a large randomised and double-blind prospective clinical study must be conducted over a number of years. I suspect that there was an element of "troll" in his post...but maybe this was to assess the need to conduct a properly set up clinical study.

I'd urge everyone to give him the benefit of the doubt and contribute...if they have any personal experience of AV working (or not) - especially if the casualty was later examined by a doctor and the underlying cause of their "incident" was formally identified.

Yours

John

Steve Walker

23-10-2003, 22:13

Just to keep things in perspective:

Chris is a senior member of the UK Sports Diving Medical Committee and has considerable medical experience with divers. He is also a longtime supporter of the BSAC and has addressed DOC on several occasions & provided medical advice to Council and is extremely well respected in this field.

Given that he then has some influence within our "sport", is that not all the more reason to take issue with his unsupported statements of alleged instructor incompetence?

So his medical credentials should not be questioned - unless you are a similarly respected expert in diving medicine.

I disagree, anyone who wants to make such bold and (seemingly deliberate) controversial statements, will, AFAIAC, get taken to task in the same manner as would someone presenting a controversial piece of research at a conference, it doesn't matter a jot to me whether they're medical Doctors, or academic Fellows, Readers, Professors, Ph.D., D.Sc. etc. In my line of work (academic research) it's a case of "put up or shut up".

Many thanks to my three fellow BSAC divers who took the time to mail me directly in respect of Chris's position on the UKSDMC. However "status" is less important to this diver than "content" and in all honesty I'm greatly surprised and disappointed at the content of Chris's original post.

However, we can correct that with the greatest of ease via a simple experiment.

Chris, Please accept this as an open invitation to accompany me at any time (and there'll be plenty of opportunities now we're into the "training season") to observe first hand how a BSAC Instructor teaches EAV and associated rescue skills in open water (ie the proverbial muddy holes so beloved of winter divers). Real data is so much more acceptable than anecdotes.

If, afterwards, you think my rescue skills are below par then you can make me eat my words publicly on the forum, if you find they're in order then you can teach me (FOC) how to use a defibrillator and to perform adrenaline injections.

John, seeing as you're my DO you can come too, and do my AD Rescue Assessment while we're at it ;-)

Regards

iainmsmith

24-10-2003, 01:21

However - I too take issue with his observations that certain skills are not taught well.

What I would be interested in, given his interest in diving medicine, is why he believes this to be the case and particularly, what his evidence for it is. I would not be surprised if he has some - certainly the quality of land-based resuscitation that I have seen demonstrated by divers on courses is not hugely reassuring. I suspect it's a result of skill fade - CPR and AV are _not_ skills that wait around to be used, and I'd put money on the fact that most BSAC divers do _not_ do a six monthly (or even yearly) resus practice.

Remember also that those who teach resus within BSAC have not been assessed to anything like the extent that the voluntary first aid societies assess their instructors.

Perhaps - if Chris's anecdotal evidence is to be beleived - we should concentrate on solving this perceived problem instead of admitting defeat and binning a skill because a few people demonstrate poor skills.

IF there is a good reason to do so. If there is solid evidence that in-water AV is of significant benefit (or that its absence
would lead to a serious reduction in survival) then there is a reason for it. If it delays things, then it should be abandoned.

An analogy could be drawn with pre-hospital intravenous access in trauma victims. There are a number of reported cases where individuals with otherwise survivable injuries died because people got too focused on trying to get a line in (to provide fluid replacement in transit) and lost site of the bigger picture.

Another comparison could be made with pre-hospital CPR, where it was shown that non-expert resuscitators performing chest compressions alone have similar outcomes to when they do AV also.

I can confirm categorically that Rescue/first aid skills are a key area of input during instructor training courses (at all levels).

Is this a local policy or a BSAC policy? If the latter, did it change recently? I ask because practical resuscitation formed no part of my ITC, CIE or OWIC. And it still suffers from the same "dilutional" problem mentioned above.

Chris himself should be aware that any anecdotes or personal experiences related are rarely of any use when considering "evidence based medicine". For doctors to alter accepted medical opinion today a large randomised and double-blind prospective clinical study must be conducted over a number of years.

Not true. Doctors make decisions based on the available evidence. The weakest form of evidence is "opinion" (eg BSAC members argue for the retention of in-water EAV because it appears to make sense). On this basis, Dr. Edge's "expert opinion" rates more highly. There are various types of trial which can be conducted, but there are very, very few situations in clinical medicine where it is possible to conduct the massive double-blind randomised controlled trials needed for gold-standard evidence.

I suspect that there was an element of "troll" in his post...but maybe this was to assess the need to conduct a properly set up clinical study.

And this case is a perfect example of where a blinded controlled trial would be impossible. How do you prevent the rescuer knowing whether he is giving in-water AV or not? Are there sufficient non-breathing casualties that enough data could be generated to provide statistically meaningful results. How do you arrange such a trial?

Medicine is rarely as simple or as absolute as the public believe!

Iain

Philip Smith

24-10-2003, 09:21

Just to keep things in perspective:

Chris is a senior member of the UK Sports Diving Medical Committee and has considerable medical experience with divers. He is also a longtime supporter of the BSAC and has addressed DOC on several occasions & provided medical advice to Council and is extremely well respected in this field.

Agreed.

It is also my understanding that he is not a senior BSAC diver, nor is he a BSAC instructor - which may explain his aparent lack of knowledge of what is contained in the current DTP.

Perhaps Dr Edge will confirm, but I have a recollection of seeing written somewhere that, in addition to his medical and research credentials, he is a BSAC FCD and AI, as well as being nitrox, trimix and rebreather qualified.

The question about whether to ventilate or make a rapid return to safety often arises during rescue courses. I suppose it is a judgement that has to be made by the rescuer, but at present they have little to go on. It would be useful to be informed by a likelihood analysis of causes of unconsciousness in divers and their consequences for the onset of respiratory and cardiac arrest. What proportion of rescued unconscious divers can be expected to have an effective heartbeat when they are surfaced? What factors affect this (e.g. type of disorder, time between onset of condition and surfacing, depth, environmental conditions)? Is in-water AV effective even if there is a circulation? By how much does AV slow down a tow?

The second last question relates to Dr Edge's observation that in-water AV is generally poorly taught. I too would therefore be interested in the basis for that comment.

Philip Smith

tony dwyer

24-10-2003, 10:46

Hi Chris

Interesting reason even if much of it is over my head.

Just one point though.

You mention that EAV contributes to the rescuer becoming exhausted. Now I have stood over a manikin and spent a good 30 mins doing EAV wihtout much in the way of fatigue. By comparison a 50m tow in the sea is pretty draining particularly if you outpace yourself.

I have always thought the rationale for inwater EAV had as much to do with the rescuers well being as attempting to revive the casualty. That is; it is always faster for the boat to come to you. It is always faster for a surface swimmer to come to you. Towing is a last resort and is only going to succeed over any sort of distance if you take things slowly (stopping to give breaths is a method of pacing), otherwise you exhaust yourself and fail. So you are going to be in the water for some minutes before assistance arrives, hence you do what you can, inwater EAV.

Just a thought

Matt

You must be pretty fit. Was it just EV or were you doing full CPR?

I have only performed full CPR for real once, for about 10 minutes at an RTA. When I was relieved by the Paramedics I was totally shattered, physically and mentally. At the time I was in my 20s and razor fit!
I extend my experince to what would happen to me if I had to perform a rescue of an unconscious casualty while diving. I have no doubt that I would perform pretty well. However, my real priority would be to get the casualty onto a firm surface so that full CPR can commence.
Current First Aid teaching advises that most of us make mistakes when testing for a pulse. I would maintain that it's practically impossible in the water. We don't teach it anyway.
The assumption (IMHO) must be that the casualty has arrested (the worst case) and must be provided with assisted circulation rapidly if there is any chance of survival.

EAV on a casualty with no pulse is a waste of effort and time.

In the situation you describe, AV while waiting for pickup is sensible. If you are conducting a shore dive, a boat my not be available. How much faster can you tow if you ditch the kit and simply go for it? Considerably quicker than if you are performing in water EAV.

I know this is heresy for many!

It is always faster for a surface swimmer to come to you.

Not necessarily. By the time a surface swimmer has made it to you through waves and such, after having prepared to swim in the first place, you could be well on your way to the shore. Thereby reducing the rescue time.

dave woodward

24-10-2003, 14:27

As you say John, and in my little experience, there is usually quite a bit of input during ITS events with regard to in water AV, as I have seen because poor technique is highlighted and is corrected at this point. An ITS event may well be the first point at which they encounter what would be generally accepted as the better techniques for neck extensions and so on. I know that the technique I was taught when learning to dive was c**p and difficult to carry out compared to the proper/better technique I was shown on my first ITS event. So maybe it is emphasised because a number of people arrive at the ITC/IFC point without good skills in this.

With most all training now being carried out by/with NQI's, I think there are more people doing it much better than they were a while ago, when it was just divers (experienced) teaching, who may not have been exposed to having their techniques scrutinised and corrected.

Also there are probably still many divers who trained long ago and how have not "refreshed" their thinking/techniques on in water AV and so on. Not supposed to, but these guys coul be passing along the skills to new divers where there is a lack of NQI's and /or supervision.

Just my thoughts

Dave

Just to keep things in perspective:

Chris is a senior member of the UK Sports Diving Medical Committee and has considerable medical experience with divers. He is also a longtime supporter of the BSAC and has addressed DOC on several occasions & provided medical advice to Council and is extremely well respected in this field.

So his medical credentials should not be questioned - unless you are a similarly respected expert in diving medicine.

It is also my understanding that he is not a senior BSAC diver, nor is he a BSAC instructor - which may explain his aparent lack of knowledge of what is contained in the current DTP.

However - I too take issue with his observations that certain skills are not taught well.

Perhaps - if Chris's anecdotal evidence is to be beleived - we should concentrate on solving this perceived problem instead of admitting defeat and binning a skill because a few people demonstrate poor skills.

I can confirm categorically that Rescue/first aid skills are a key area of input during instructor training courses (at all levels). Indeed I am teaching on an IFC this weeeknd and we will be ensuring that AV is performed properly - we DO see many divers presenting at this level of course who do not seem to be following the advice that *ALL* BSAC instructors are trained to emphasise.

Chris himself should be aware that any anecdotes or personal experiences related are rarely of any use when considering "evidence based medicine". For doctors to alter accepted medical opinion today a large randomised and double-blind prospective clinical study must be conducted over a number of years. I suspect that there was an element of "troll" in his post...but maybe this was to assess the need to conduct a properly set up clinical study.

I'd urge everyone to give him the benefit of the doubt and contribute...if they have any personal experience of AV working (or not) - especially if the casualty was later examined by a doctor and the underlying cause of their "incident" was formally identified.

Yours

John

matt

24-10-2003, 15:02

Hi Tony

You must be pretty fit. Was it just EV or were you doing full CPR?

Just EAV, I am fully aware that CPR is a completely different story but it is not possible in the water so somewhat moot to my point.

I have only performed full CPR for real once, for about 10 minutes at an RTA. When I was relieved by the Paramedics I was totally shattered, physically and mentally. At the time I was in my 20s and razor fit!

You have my respect. I have fortunately never had to do it for real. I have had some fairly realistic training and experienced the exhaustion that comes after stress induced adrenalin. I don't know how qualified that makes me but the effect of physical and mental exhaustion on the rescuer has much to do with my point. It should not be underestimated.

I extend my experince to what would happen to me if I had to perform a rescue of an unconscious casualty while diving. I have no doubt that I would perform pretty well. However, my real priority would be to get the casualty onto a firm surface so that full CPR can commence.

My first priority will always be ensuring that we don't end up with two casualties. A rescuer who strikes out on a tow with over enthusiasm is very likely to find themselves exhausted before they make the beach. AFAIC the only tow that can be considered too slow is the one which ends with the casualty still in the water.

Current First Aid teaching advises that most of us make mistakes when testing for a pulse. I would maintain that it's practically impossible in the water. We don't teach it anyway.
The assumption (IMHO) must be that the casualty has arrested (the worst case) and must be provided with assisted circulation rapidly if there is any chance of survival.

I am sure that is the case. In these circumstances it is unfortunate that there is a casualty, it is unfortunate that they may well die. It would be an absolute tragedy if the rescuer also became a victim by putting the priorities of the casualty above theirs as the rescuer. But that is what happens far too frequently.

EAV on a casualty with no pulse is a waste of effort and time.

My point is that the optimum towing speed is limited by the phyisical capability of the rescuer. The rescuer must pace themselves. If you attempt a non stop tow at the fastest speed you can attain you become exhausted very quickly. A slower speed and regular "recovery" pauses is likely to put you on the beach quicker over any sort of distance or in any sort of sea. Inject the sort of adrenalin levels involved in a real situation and I can see an argument for retaining EAV simply as a way to enforce the rescuer to manage the stress involved.

Now given the choice of a rescuer involved in towing with regular pauses or becoming exhausted, should they do EAV during the pauses?

In the situation you describe, AV while waiting for pickup is sensible. If you are conducting a shore dive, a boat my not be available. How much faster can you tow if you ditch the kit and simply go for it? Considerably quicker than if you are performing in water EAV.

Ditching the kit is obviously a good idea. But it will take time. Even then the speed of the tow is limited by the speed the rescuer can sustain. Anyone that has only ever towed in a lake really should have a go in the sea, a bit of wave and tide make it a very different undertaking. Bit like comparing EAV with CPR possibly.

The question as I see it is given the unavoidable delays and the difficulties in divers attempting an accurate diagnosis, does EAV have any benefit whatsoever?

I know this is heresy for many!

:=It is always faster for a surface swimmer to come to you.

Not necessarily. By the time a surface swimmer has made it to you through waves and such, after having prepared to swim in the first place, you could be well on your way to the shore. Thereby reducing the rescue time.

Not disagreeing. There will always be the need to make judegements on what will be effective. I think you need a simple and clear priority scheme when it comes to these things though, like the lifesavers "reach, throw, row/wade, tow" which incidently, is provided to protect the rescuer, not to effect the fastest possible rescue or provide the casualty with the best chance of survival.

I know some people find this way of thinking objectionable but a fireman once put it "Super human efforts are great if your super human, most of us aren't!"

tony dwyer

24-10-2003, 16:29

Hi Tony

:=You must be pretty fit. Was it just EV or were you doing full CPR?

Just EAV, I am fully aware that CPR is a completely different story but it is not possible in the water so somewhat moot to my point.

:=I have only performed full CPR for real once, for about 10 minutes at an RTA. When I was relieved by the Paramedics I was totally shattered, physically and mentally. At the time I was in my 20s and razor fit!

You have my respect. I have fortunately never had to do it for real. I have had some fairly realistic training and experienced the exhaustion that comes after stress induced adrenalin. I don't know how qualified that makes me but the effect of physical and mental exhaustion on the rescuer has much to do with my point. It should not be underestimated.

:=I extend my experince to what would happen to me if I had to perform a rescue of an unconscious casualty while diving. I have no doubt that I would perform pretty well. However, my real priority would be to get the casualty onto a firm surface so that full CPR can commence.

My first priority will always be ensuring that we don't end up with two casualties. A rescuer who strikes out on a tow with over enthusiasm is very likely to find themselves exhausted before they make the beach. AFAIC the only tow that can be considered too slow is the one which ends with the casualty still in the water.

:=Current First Aid teaching advises that most of us make mistakes when testing for a pulse. I would maintain that it's practically impossible in the water. We don't teach it anyway.
:=The assumption (IMHO) must be that the casualty has arrested (the worst case) and must be provided with assisted circulation rapidly if there is any chance of survival.

I am sure that is the case. In these circumstances it is unfortunate that there is a casualty, it is unfortunate that they may well die. It would be an absolute tragedy if the rescuer also became a victim by putting the priorities of the casualty above theirs as the rescuer. But that is what happens far too frequently.

:=EAV on a casualty with no pulse is a waste of effort and time.

My point is that the optimum towing speed is limited by the phyisical capability of the rescuer. The rescuer must pace themselves. If you attempt a non stop tow at the fastest speed you can attain you become exhausted very quickly. A slower speed and regular "recovery" pauses is likely to put you on the beach quicker over any sort of distance or in any sort of sea. Inject the sort of adrenalin levels involved in a real situation and I can see an argument for retaining EAV simply as a way to enforce the rescuer to manage the stress involved.

Now given the choice of a rescuer involved in towing with regular pauses or becoming exhausted, should they do EAV during the pauses?

:=In the situation you describe, AV while waiting for pickup is sensible. If you are conducting a shore dive, a boat my not be available. How much faster can you tow if you ditch the kit and simply go for it? Considerably quicker than if you are performing in water EAV.

Ditching the kit is obviously a good idea. But it will take time. Even then the speed of the tow is limited by the speed the rescuer can sustain. Anyone that has only ever towed in a lake really should have a go in the sea, a bit of wave and tide make it a very different undertaking. Bit like comparing EAV with CPR possibly.

The question as I see it is given the unavoidable delays and the difficulties in divers attempting an accurate diagnosis, does EAV have any benefit whatsoever?

:=I know this is heresy for many!
:=
:=:=It is always faster for a surface swimmer to come to you.
:=
:=Not necessarily. By the time a surface swimmer has made it to you through waves and such, after having prepared to swim in the first place, you could be well on your way to the shore. Thereby reducing the rescue time.

Not disagreeing. There will always be the need to make judegements on what will be effective. I think you need a simple and clear priority scheme when it comes to these things though, like the lifesavers "reach, throw, row/wade, tow" which incidently, is provided to protect the rescuer, not to effect the fastest possible rescue or provide the casualty with the best chance of survival.

I know some people find this way of thinking objectionable but a fireman once put it "Super human efforts are great if your super human, most of us aren't!"

Matt

an excellent post. Very constructive, I have no disagreement.

regards

Tony

tony dwyer

24-10-2003, 16:46

I have been concerned regarding some of the approaches to performing AV in water. Neck extension is of particular interest to me. Many years ago I had fusion surgery in my neck. As a result of this I am particularly aware of any attempt to over extend my neck.

I have been hurt by others attempting over enthusiastic neck extension during AV practice.

I have also seen people attempting to force an extension on a conscious person while practising AV in water, levering the head back so hard that pain has been felt. This is far too hard and presents a very real danger to the fake casualty. Add the slight possibility of a rotation of the spine, with the neck hyper-extended, while the casualty is rolled and you have the potential for a serious spinal injury. Especially if there is a large size difference in the two people.
In open water the risk is even greater. The moving water may apply an unintended rotation.

It is important to ensure that the trunk and head are moved as a complete unit while the neck is extended to any degree.

It is also important to remember that an unconscious casualty will not resist the attempt to extend the neck. With modern BCs there is little to resist the head falling back. A hood will of course add resistance.

I am under the impression that the hard levering of the head stems from when ABLJ's were the norm and provided a cushion behind the head on the surface. This had to be overcome in order to achieve any extension at all. ABLJ's are not common today.

Try a simple test - tilt your head back as far as you can then try to move it to the left or right. Most of you will experience discomfort. An unconscious persons head will go evene further back as there will be little muscular resistance.

Mark R Sims

24-10-2003, 20:56

Perhaps Dr Edge will confirm, but I have a recollection of seeing written somewhere that, in addition to his medical and research credentials, he is a BSAC FCD and AI, as well as being nitrox, trimix and rebreather qualified.

Chris taught at a Bristol ITC a few (cough) years back, when both my wife and I attended.

John Bantin

25-10-2003, 19:10

tony dwyer

26-10-2003, 00:43

I think all training-agency rescue-scenarios may be flawed in that they have borrowed techniques from other accreditted first-aid agencies which assume that professional help (with a defrillator for example) will arrive imminently.
The experience I had (well covered in the national press) revealed to me the harsh truth that what one is attempting to do is keep the body in best condition until the experts can attempt to revive the casualty. If you are a long way out to sea, this might not be for some time and, alas, may have little hope of success.
I am with the Doc on this one, and I can tell you he has never been coy about saying what he thinks!

John

I am also in agreement. I have long held the suspicion that the practice of in water AV is usually of little true value. I am however prepared to be convinced otherwise by sound data. Regretably I have never seen such data.

What I have often heard has been emotive argument for AV based on 'This is what we have always done!'.

What I do believe is that in most attempts at AV or CPR by a non-paramedic without defibrillation fail. A first aider providing such care is merely supporting life until the professionals take over.
For a diving casualty, it is likely to be a long time before such professional care is available. It surely must be most important to get the casualty to a location where primary care (Av or full CPR) can be conducted effectively.

regards

Tony

John Bantin

26-10-2003, 07:58

Did you know that there has never been any incident recorded where using a life-jacket while on a civil airliner has saved a life?
Why do they still insist on carrying life-jackets?
Because it is politically expedient.
Would you want to travel on an airliner without a life-jacket under the seat? Probably not.
I think agencies continue to train people to do AV in the water because no-one wants to be pilloried for dropping the idea! (Just my honest opinion - for what it is worth!)

tony dwyer

26-10-2003, 08:05

iainmsmith

26-10-2003, 08:30

Could it be, therefore, that there are grounds for ceasing
the teaching of EAV in the water?

A further thought:

BLS teaches that:

"It is vital for rescuers to get help as quickly as possible...
A single rescuer will have to decide whether to start resuscitation or to go for help first. If the victim is an adult, the single rescuer should normally assume that he has a heart problem and go for help immediately it has been established that he is not breathing...However, if the likely cause of unconsciousness is a breathing problem, as in:
- trauma
- drowning
- choking
...
the rescuer should perform resuscitation for about 1 minute before going for help."

I have also been told that the rationale for the above is that if a casualty's problem is as a result of such a condition then then, fundamentally, they have a healthy heart and restoration of air exchange in the lungs may be all that is required for them to recover. (Indeed, it may well be that the heart is still beating. This latter point is supported by my experiences on elective in a trauma unit, where frequently gunshot head casualties would have detectable cardiac output in the absence of respiratory effort for some considerable time after they were declared unrecoverable and left without ventilation). Certainly, near-drowning casuaties have a far better prognosis (70%) than cardiac arrest casualties.

Near-drowning casualties with respiratory arrest but no circulatory interuption (who received rapid resuscitation) do far better than those who have progressed to cardiac arrest (89% survival vs 11% survival)

If the above is correct, then does abandoning in-water EAV significantly reduce the survival chances for a casualty with such a respiratory arrest, in comparison with the _increase_ in survival of a cardiac arrest casualty (whose 28-day survival in the pre-hospital setting is is variously reported as between 4 and 12%) who receives more rapid transport to the boat/shore?

Unfortunately, I have not managed to identify data comparing survival in near-drowning casualties who received in-water AV.

Interestingly, (and probably relevant to most diving situations) a study published this year suggested that one-month survival in cardiac arrest victims who had a delay in excess of four minutes between collapse and call for the ambulance was 2.8% (compared to 6.9% for those with a shorter delay in calling) As suggested elsewhere in this thread it is likely that response times (from time of arrest) will be increased in diving situations, thus placing most casualties very firmly in the longer-delay group (and, indeed, by the time the casualty is recovered to the surface and the nature of the problem communicated to the surface cover, times are probably well in excess of the four minute cut off). Add in the delay in EMS access due to the location of diving casualties and prognosis for victims of cardiac arrest is rather bleak.

Iain

Refs:
-----
"Basic Life Support" in "Resuscitation Guidelines 2000", United Kingdom Resuscitation Council, 2001

Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest. 1997 Sep;112(3):660-5.

Heller RF, Steele PL, Fisher JD, Alexander HM, Dobson AJ, Success of cardiopulmonary resuscitation after heart attack in
hospital and outside hospital, BMJ. 1995 Nov 18;311(7016):1332-6

Lindholm DJ, Campbell JP: Predicting survival from out-of-hospital cardiac arrest. Prehospital and Disaster Medicine 13(2):126-129.

Herlitz J, Engdahl J, Svensson L, Young M, Angquist KA, Holmberg S. A short delay from out of hospital cardiac arrest to call for ambulance increases survival. Eur Heart J. 2003 Oct;24(19):1750-5.

Keith L

26-10-2003, 15:09

BLS teaches that:

"It is vital for rescuers to get help as quickly as possible...

A very interesting post Iain, a good analysis and some excellent references.

[Personal Opinion]

I?ve been following this thread with interest, not being a medical person but being very concerned about diver safety I must admit to having a certain unease at Chris?s initial premise and justification for the abandonment of in-water AV. If the problem is one of poor training then it is that which should be addressed rather than the abandonment of the practice.

But I also have a certain unease about the current practice of continual AV whilst towing, this would certainly delay the eventual recovery onto a hard surface where full CPR could be carried out. Given Ian?s analysis of the statistics for near-drowning vs heart conditions it would seem that the abandonment of in-water AV may simply transfer any improved survival rate from one category of casualties to another.

Considering the BSL recommendations of one minutes worth of resuscitation before seeking assistance and the recovery chances of near-drowning vs heart casualties then that would seem to add weight to the old wives (or old instructors) tale that I have always considered to be pretty close to the truth ?

If an alive but non-breathing diver with a chance of survival is brought to the surface?
+ 9 out of 10 will start breathing when the neck is correctly extended.
+ Of those that don?t? 9 out of 10 will start breathing after the first two good breaths of AV.
+ Of those that don?t? 9 out of 10 won?t make it anyway.

My personal view is that there is a case for the teaching of and the practice of an initial neck extension and a couple of breaths of AV immediately upon surfacing, but if that doesn?t work then there?s not a lot of point delaying the tow by continuing AV whilst towing ? just go for it! This approach would seem to be in line with the current BSL practice and would not simply transfer any improved chances of survival from one casualty group to another as I feel that the complete abandonment of the practice would.

Discuss.

Regards

Keith L

John Williams

26-10-2003, 22:16

:=Perhaps Dr Edge will confirm, but I have a recollection of seeing written somewhere that, in addition to his medical and research credentials, he is a BSAC FCD and AI, as well as being nitrox, trimix and rebreather qualified.
:=

Chris taught at a Bristol ITC a few (cough) years back, when both my wife and I attended.

If this is the case then I apologise unreservedly to Chris for my earlier comments...but would still like to know the size of the "study" he has made to come to his conclusions about EAV being taught badly.

John

TerryH

27-10-2003, 00:27

If this is the case then I apologise unreservedly to Chris for my earlier comments...but would still like to know the size of the "study" he has made to come to his conclusions about EAV being taught badly.

Ask anyone who has attended an ITC/IFC as to the quality of the
candidates and you will have at least one/two horror stories of
somebody who cannot perform a rudementry skill.

On average amongst a group of say 20 candidates again one/two may be given AV as part of there practical skills.

As most clubs experience of other divers teaching skills are on
such courses, doesnt the law of averages make it pretty likely
that those attending might get exposed to some dubious AV
skills?

Take it further and isnt it likely that those running the
courses would have even more experience of same?

My own experience on my OWIC at Horsea was of a Club Instructor
(remember that made him an NQI/DL) who was unable to perform
AV tow & ditch as a student let alone an Instructor. We ended
up having to run through the whole process prior to him attempting to teach it.

So ask yourself this question. If this was part of
your 'exposure' to other clubs AV, wouldnt you come to the
conclusion that EAV was being taught badly.

Isolated case?

Maybe, but I no longer take as read, the rescue skills of
existing divers when they join. Sport and above all have to do
a full rescue.

TerryH

John Williams

27-10-2003, 08:34

:=
:=If this is the case then I apologise unreservedly to Chris for my earlier comments...but would still like to know the size of the "study" he has made to come to his conclusions about EAV being taught badly.
:=

Ask anyone who has attended an ITC/IFC as to the quality of the
candidates and you will have at least one/two horror stories of
somebody who cannot perform a rudementry skill.

On average amongst a group of say 20 candidates again one/two may be given AV as part of there practical skills.

As most clubs experience of other divers teaching skills are on
such courses, doesnt the law of averages make it pretty likely
that those attending might get exposed to some dubious AV
skills?

Take it further and isnt it likely that those running the
courses would have even more experience of same?

My own experience on my OWIC at Horsea was of a Club Instructor
(remember that made him an NQI/DL) who was unable to perform
AV tow & ditch as a student let alone an Instructor. We ended
up having to run through the whole process prior to him attempting to teach it.

So ask yourself this question. If this was part of
your 'exposure' to other clubs AV, wouldnt you come to the
conclusion that EAV was being taught badly.

Isolated case?

Maybe, but I no longer take as read, the rescue skills of
existing divers when they join. Sport and above all have to do
a full rescue.

TerryH

Still anecdotal evidence...and therefore not powerful enough to suggest a requirement for such widespread change of existing practice.

Also ... you too have concluded that the problem of "poor skills" is one that should be checked for in all transferring members (a strategy I agree with and indeed put into place myself). I need to reassure myself that these new divers can keep the divers I'm responsible for safe (including themselves).

How often do you find poor skills?

How difficult is it to fix them when you find them?

Do you fix them?

Chris was suggesting that people are so bad at these skills - and so untrainable (because instructors are so bad at training them) that we should simply give up and stop teaching it/fixing it!!!

I think we're on the same side here Terry.

We both recognise that these skills need checking. We both accept that (even if taught well) these skills diminish with time and need practice. We both teach them regularly - to keep our own skills and those of our trainees crisp and fresh. We both feel the skill important enough to check and to fix if necessary.

Dare I suggest that we agree that Chris needs to provide a great deal more conclusive evidence to convince us (and the BSAC) to change our views?

As previously mentioned...perhaps this is just his early attempt to assess the need to gather a body of that more convincing evidence. I don't agree with his idea that we should ditch the skill of AV from the DTP...but I try to keep an open mind.

So...Chris,

Convince me that I'm wrong and I'll support your cause.

John

John Williams

27-10-2003, 08:40

:=Did you know that there has never been any incident recorded where using a life-jacket while on a civil airliner has saved a life?
:=Why do they still insist on carrying life-jackets?
:=Because it is politically expedient.
:=Would you want to travel on an airliner without a life-jacket under the seat? Probably not.
:=I think agencies continue to train people to do AV in the water because no-one wants to be pilloried for dropping the idea! (Just my honest opinion - for what it is worth!)

Be careful, as I have said before, we're getting very close to heresy! We could be burned at the stake.

I'm sure you are being over-cynical.

Show the powers that be the evidence - and if it's convincing enough then change will follow.

As to John's lifejacket scenario. If my airliner were to crash into the sea....I'd rather have an airbag under the seat in front to save me from the impact. If it was detachable and able to be lown up outside of the fuselage (if I got that far out) I'd be MUCH happier than with a lifejacket.

For me it's not he floating about at sea bit that is scary (help is on the way). The scary bit is the impact.

So John...please present your evidence on that one to the CAA.

John

Chris Edge

27-10-2003, 11:28

Gentlemen (and any ladies who wish to contribute)

Dear me, I appear to have generated a lot of controversy here. I think that, as some of you have questioned my street cred., I had better give my credentials. They are:

MA, PhD, MB, BS, AFOM, FRCA, MRCS, CChem, FRGS

So, basically, I have qualifications in anaesthesia and intensive care, occupational medicine, chemistry and I happen to have been on many diving archaeological expeds. (the last with Prof. George Bass in Turkey), most of them as medical officer and/or diving officer (so was elected a Fellow of the Royal Geographical Society). I'm also First Class Diver no. 410, AI no. 935 and have taught on the Instructor Training Courses and examined divers. I taught the Wilkinson Sword winner and runner-up in (I think) 1989. I have been diving for 30 years and am a medical referee and member of UKSDMC. I have instructor qualifications in nitrox, trimix and rebreathers. I dive with a KISS.

BUT, none of these qualifications are relevant to the question that I posed. The reason that I put them on record is that I am irked by the fact that I dare to question some dogma (with an open mind) and then folks query my right to question in terms of my qualifications. Diving doesn't advance unless we question the rules e.g. diabetes and diving. Anyone is entitled to question, provided that they've done at least one dive and they do so with an open mind as to the answer.

Do I have any data to support my original thesis? Well, yes. Observational data: I have dived with a fair few dive clubs, and very few instructors really teach good neck extension. Does this matter? Yes. In hospital, I am resuscitating people on average about twice a week (no, that's not my poor care; I get called in when people collapse in the hospital beds...). Now, many of the SHOs and other junior staff are taught to be able to open an airway and administer oxygen. Even in this rather more ideal environment, they seldom give oxygen effectively, using a sealed mask that can deliver 100% oxygen. That's why junior doctors are now strongly encouraged to go on resus. courses annually and why I am called in as an anaesthetist to protect the airway. If you don't get good neck extension, gas goes down the oesophagus, blowing up the stomach, making it more difficult to ventilate the patient and increasing the risk of vomiting with subsequent inhalation of vomit. I do accept the point made by one respondent about overextension of the neck, but in practice in the unconscious patient, this does not appear to happen sufficiently to cause detriment to the patient.

In open water, the situation is far from ideal. First, in cold waters, the divers are wearing quite a thick neoprene hood, which hinders neck extension. Secondly, there is the hinderance of the breathing apparatus on the back (either aqualung or rebreather). Thirdly, I have seen the stab jacket be blown up too far, thus hindering neck extension further.

All these considerations, plus the lack of practice of EAV by many (not all) divers, led me to question the validity of the whole exercise. I do NOT question (as many of you imply) the teaching abilities of the BSAC instructor as a whole.

I thank all of you who have raised valid points, and have discussed them rationally without querying my right to raise the question. They will make me think further on the topic. If this makes you think further about the topic, then that's good.

Chris Edge

27-10-2003, 11:44

I agree with the comments made by Iain Smith and the excellent references. Certainly some divers will breathe once good neck extension is obtained. Whether some will breathe after 2 breaths of EAV is rather more controversial. I certainly think (but am willing to change my mind) that continuous intermittent EAV in the water is potentially dangerous for the rescuer and time-wasting for the rescued.

I know that there was a congress on drowning last year. I will ask David Elliott who went to it, what the conclusions were as regards rescue of the diver, and whether there are any stats. on divers drowning as opposed to retaining their regulators in the mouth.

John Bantin

27-10-2003, 13:12

The CAA/FAA already know about this and have the evidence. As I said, it is more about consumer-confidence than efficacy.

tony dwyer

27-10-2003, 18:23

I do accept the point made by one respondent about overextension of the neck, but in practice in the unconscious patient, this does not appear to happen sufficiently to cause detriment to the patient.

Thank you.
I accept that injury to an unconscious person on land through extending the neck is probably very unlikely. In water it is a different matter. I have seen and been shown VERY severe levering of the head back, attempting to over extend the neck. As I said earlier, it hurt (a lot). It is virtually impossible to do this to a casualty lying on a table or on the ground. It is however very easy to do it in the water. Add adrenaline to the equation and you have the potential for serious injury. Rotation of the head while the neck is fully extended is dangerous. A conscious person will resist if you do it to them, an unconscious one does not have that luxury.

In open water, the situation is far from ideal. First, in cold waters, the divers are wearing quite a thick neoprene hood, which hinders neck extension.

In terms of resistance to leverage, it's very little indeed. Any normal adult should barely notice it. Even less so when hyped up in an emergency.
If the casualty is face up, the head will fall back to its natural position allowed by the hood and bouyancy. It does not require great force to achieve an open airway in such circumstances. It requires skill and care as I am sure that you will agree.

Secondly, there is the hinderance of the breathing apparatus on the back (either aqualung or rebreather).

Most modern rigs should provide little obstruction behind the head. Indeed we teach students to rig their sets so they don't easily bang their heads on them. Of course there are many rigs out there that are not setup this way. If the aqualung set is in the way, it will be very hard to use the head to push it out of the way and will probably cause additional injury (grin!)

Thirdly, I have seen the stab jacket be blown up too far, thus hindering neck extension further.

Most BC's in use today have little immediately behind the head and allow the head to fall back with the casualty face up on the surface. This is not so true for many wing based designs. Many of those present other problems of control of an unconscious casualty on the surface.

terryh

28-10-2003, 11:07

Still anecdotal evidence...and therefore not powerful enough to suggest a requirement for such widespread change of existing practice.

I thought by expressing concern he was doing what we are now
and getting it discussed in the public domain.

I'm not sure if you can totally dismiss anecdotal evidence
if the only exposure a club has to other clubs AV skills, gives
the impression of poor peformance, then isnt that relevant?

Isnt the shear number of SDC's & IFC's etc. where AV skills
are asessed likely to create enough combined evidence?

Trouble is that it's all relative. Would another club see my
clubs AV skills as better or worse than it's own? What is the
benchmark?

Happily all the current NQI's in our club were trained by the
3x 1st class/AI/Lifesaver examiners in our club, so that's
about the highest standard you can get.

IMO we need to clarify wether it's AV vs no-AV and NOT wether
AV is effective.

So I would say lets forget about the side issue of AV skills
(if they are bad then we need to retrain) and concentrate on a
level playing field.

Basic Rescue Scenario ....
2x Divers surface 500m out from shore (One unconcious
apre-CBL). Whats better? AV tow? or Just Tow?

TerryH

John Williams

28-10-2003, 14:59

2 separate questions then?

1) Good AV or no AV?

2) Do we need to raise our performance and give refresher/remedial AV training to everyone periodically?

Both are valid questions...so let's see if we get sufficient interest/evidence to warrant asking them!

I have no problem with posting a question to trawl the ether to discover the need.

John

tony dwyer

28-10-2003, 15:38

Good comments, thinking hat is on. Hopefully other will employ theirs.

Basic Rescue Scenario ....
2x Divers surface 500m out from shore (One unconcious
apre-CBL). Whats better? AV tow? or Just Tow?

TerryH

Bloody hard that one. 500m is a hell of a way to tow while giving AV. Either option will almost certainly result in a corpse if the casualty has no pulse, as the two would take too long. Even if the casualty has a pulse, I would doubt whether many people could successfully tow a fully kitted diver that far, while providing AV.
If no shore or boat cover was available to help, I'd ditch the kit (mine as well) and go for it, after firing a flare!. The casualty would get what air I could spare. My first priority would be my own survival.

terryh

28-10-2003, 15:56

:=
Good comments, thinking hat is on. Hopefully other will employ theirs.

:=Basic Rescue Scenario ....
:=2x Divers surface 500m out from shore (One unconcious
:=apre-CBL). Whats better? AV tow? or Just Tow?
:=
:=TerryH
:=
Bloody hard that one. 500m is a hell of a way to tow while giving AV. Either option will almost certainly result in a corpse if the casualty has no pulse, as the two would take too long. Even if the casualty has a pulse, I would doubt whether many people could successfully tow a fully kitted diver that far, while providing AV.
If no shore or boat cover was available to help, I'd ditch the kit (mine as well) and go for it, after firing a flare!. The casualty would get what air I could spare. My first priority would be my own survival.

I deliberatly made it a long swim as it seems to me that the
criteria to all this is the accessability (or lack of) access
to shore/boat.

If there is a possiblity of getting the casualty to shore and
quick, then might Chris's assertion that to go straight for
that without messing with AV the best option?

But .......

If the distance is such that the propesctive tow is a severe
one, then not only can (IMO) AV + tow be preferable, but it
allows a respite for the now very tired rescuser.

I can see where Chris is coming from, but isnt this really
down to distance?

What is an acceptable distance/time to NOT give AV in these
circumstances and would a half-way house approach be an
advantage?

TerryH

tony dwyer

28-10-2003, 16:27

I deliberatly made it a long swim as it seems to me that the
criteria to all this is the accessability (or lack of) access
to shore/boat.

If there is a possiblity of getting the casualty to shore and
quick, then might Chris's assertion that to go straight for
that without messing with AV the best option?

But .......

If the distance is such that the propesctive tow is a severe
one, then not only can (IMO) AV + tow be preferable, but it
allows a respite for the now very tired rescuser.

I think that you may well have a point. In such circumstances the would be rescuer is probably going to be very demoralised too.
It would be interesting to see an analysis of rescues and attempted rescues, in order to better understand the probabilities.

I can see where Chris is coming from, but isnt this really
down to distance?

What is an acceptable distance/time to NOT give AV in these
circumstances and would a half-way house approach be an
advantage?

TerryH

Perhaps a max distance of say 50 mtrs without AV, which most people could probably manage in under 2 mins (including a kit ditch). Thus hopefully getting the casualty to shore before irretrievable brain damage occurs. Of course it requires that someone (perhaps the rescuer)will perform effective CPR.

It might be sensible to perform AV if the tow is longer.

Perform AV if a boat is available.

regards

Tony

terryh

29-10-2003, 14:10

Ok next problem ....

If we accept that there is a grey area between, getting a
casualty to shore (its close enough) without botering with AV.

and

AV + tow because it's too far to do it quickly or without
tiring/endangering the rescuer.

Then in such a stressful situation, how do you make that call?

At present it's cut and dried. You give AV and tow to shore,
no question. If we are saying that you now can in some
circumstances tow straight to shore, then maybe this varaint
needs to be taught when both diving experince and rescue
skills are a more accomplished. More likely to make an
objective (and hopefully correct) assessment of the situation.

TerryH

tony dwyer

29-10-2003, 16:43

Keith Lawrence(BSAC)

29-10-2003, 22:09

I would be inclined to say that we instruct the less experienced to conduct the tow only. As it's a less demanding skill.

Then we introduce the idea of applying AV when the diver is more experienced and at ease with scuba gear...

What a brilliant idea Tony! Now I'm sure I've seen something like that somewhere fairly recently, I just can't think where at the moment ;-)

Keith L

terryh

30-10-2003, 00:39

I would be inclined to say that we instruct the less experienced to conduct the tow only. As it's a less demanding skill.

Then we introduce the idea of applying AV when the diver is more experienced and at ease with scuba gear. Perhaps as an add-in at Sports Diver level. They will also be less stressed (probably marginally) in the event of an emergency. Armed with a greater range of skills and experience they can then make the judgement of whether or not to perform AV.

Oops! I appear to have suggested something similar to the PADI schedule, where CBL's and AV aren't introduced until the Rescue Diver Course!

I believe that CBL is a valid skill to learn from the beginning, as currently.

Hmm not so sure you have anything different to what we do now.

Ocean has CBL + tow.
Sport has CBL + AV/tow.

So that fits in with your less experienced + introducing AV/tow
at Sport level.

I'd like to take it further and say
Ocean = CBL + tow.
Sport = CBL + tow or CBL + Static AV.
DL = CBL + tow/AV.

So as an Ocean Diver you tow to the shore.
As a Sport Diver you do AV static (waiting for a boat) or
tow for the shore.

But as a DL you have enough dives and have done 2x rescue
assessments + 1st Aid and PRM sections. Your Tow + AV should be
pretty good and you could make an objective decison whether
to head for shore without giving AV.

As there is NO pool time in DL there is even a case for
bringing in Lifesaver or Advanced Lifesaver to make those AV/Tow skills A1.

TerryH

tony dwyer

30-10-2003, 08:30

Hmm not so sure you have anything different to what we do now.

You noticed! rather than a major change in training, I was suggesting more an addition, that we introduce the idea of deciding whether or not to perform AV while towing.

Ocean has CBL + tow.
Sport has CBL + AV/tow.

So that fits in with your less experienced + introducing AV/tow

Yes

at Sport level.

I'd like to take it further and say
Ocean = CBL + tow.
Sport = CBL + tow or CBL + Static AV.

Yes - rather what I had in mind.

DL = CBL + tow/AV.

So as an Ocean Diver you tow to the shore.
As a Sport Diver you do AV static (waiting for a boat) or
tow for the shore.

But as a DL you have enough dives and have done 2x rescue
assessments + 1st Aid and PRM sections. Your Tow + AV should be
pretty good and you could make an objective decison whether
to head for shore without giving AV.

As there is NO pool time in DL there is even a case for
bringing in Lifesaver or Advanced Lifesaver to make those AV/Tow skills A1.

TerryH

Yup, we are in agreement. What does happen is that the Sports Diver pool and open water sessions get simpler.

I agree that by Dive Leader, our trainee should have acquired the in water confidence and judgement to make the call whether to tow/AV or not.

regards

Tony

tony dwyer

30-10-2003, 08:37

:=I would be inclined to say that we instruct the less experienced to conduct the tow only. As it's a less demanding skill.
:=
:=Then we introduce the idea of applying AV when the diver is more experienced and at ease with scuba gear...

What a brilliant idea Tony! Now I'm sure I've seen something like that somewhere fairly recently, I just can't think where at the moment ;-)

Keith L

Aw shucks, you noticed! :-)
See Ocean Diver / Sports Diver training programme.

However, my point on including making the judgement on whether or not to perform AV while towing stands. That is the NEW element we should include in the training.

At present the sacred cow says that 'Thou shalt perform AV while towing, regardless of whether it is pointless or detrimental to the rescue!'

regards

Tony

vice-chairman

30-10-2003, 10:42

John Williams

30-10-2003, 17:42

Hi Chris, et al,

I?ve been following this thread with interest over the last week or so and some very good points have been made. However, lets not forget just what we are teaching and in what conditions.

? The majority of dives in the UK are carried out from boats of one description or another

? The golden rule of rescue is for the rescuer not to endanger themselves. If taught correctly, the rescuer would single the boat and wait for the boat to come to them rather than towing the casualty to the boat

? By providing buoyancy to the casualty as well as to themselves the rescuer can provide a neck extension (in itself, a very positive action) and EAV without too much effort whilst waiting for the boat to pick them up. This in no way delays getting the casualty to ?dry land? and commencing CPR if this is in fact required. I trust that you will all agree that even the slowest boat is considerably faster than any swimming diver whether towing or not.

? So what about shore dives and inland dive sites? The vast majority of inland dive sites have rescue facilities and some even have high speed RIB?s that can get to a casualty in seconds. Again, there is no need to tow or reduce the time taken to get to ?dry land? so really, what is the point in not giving EAV?

? Yes, I accept that situations will occur where a group of divers are diving in the middle of nowhere on a shore dive or inland dive site but what are they to do? Tow the casualty to shore without EAV? Will this really give such a significant time advantage?

? Given the choice, I?d much rather dive with a buddy that is capable of providing EVA than one that is not.

Cheers??..Allan

Allan,

Whilst I agree entirley with your comments ...they still rest upon opinion.

In my opinion you are correct. I too would rather have a buddy capable of effective AV.

Chris wishes to challenge our opinion. This is because his opinion differs from ours.

I have absolutely NO problem with him doing that. I welcome challenges to my opinion at every opportunity - because if I can be shown a better way then I am costantly improving and my opinion becomes strengthened by that challenge (either by support or alteration). The day I hold my opinion to be unchallegeable is a day I hope never comes.

So...bring it on Chris - do your challenging. I await some results backed up with evidence rather than opinion.

I know Allan welcomes your challenge too...but we'd both like you to know that we are very sceptical of the idea you put forward and will need much convincing to alter our opinion (and we are not in the minority).

All the best

John

terryh

30-10-2003, 18:41

I know Allan welcomes your challenge too...but we'd both like you to know that we are very sceptical of the idea you put forward and will need much convincing to alter our opinion (and we are not in the minority).

All the best

John

So if you are not in the minority you must be in the majority.
Would that be your "opinion" as to a majority, or is it backed
up by real (not anecdotal) evidence of a majority?

I also await your evidence to prove that you are indeed part of
the supposed majority.

TerryH

John Williams

30-10-2003, 21:19

:=
:=I know Allan welcomes your challenge too...but we'd both like you to know that we are very sceptical of the idea you put forward and will need much convincing to alter our opinion (and we are not in the minority).
:=
:=All the best
:=
:=
:=John

So if you are not in the minority you must be in the majority.
Would that be your "opinion" as to a majority, or is it backed
up by real (not anecdotal) evidence of a majority?

I also await your evidence to prove that you are indeed part of
the supposed majority.

TerryH

Get a life!

I'm trying to help Chris to gain his evidence to challenge my views.

You are just being pedantic!

Keith Lawrence(BSAC)

30-10-2003, 21:54

Get a life!

Please state where I can download one of those from.

Keith Lawrence
BSAC IT Team Leader

terryh

30-10-2003, 21:57

I'm trying to help Chris to gain his evidence to challenge my views.

You are just being pedantic!

Absolutley, it was intentional.
The words kettle & black come to mind.

Asking for evidence to back up his opinion is fine, but do you
really need to bolster your own views by claiming to be in the
majority.

Doesnt that just invite the question: Can you prove it?
You cant have it both ways.

TerryH

Vic

31-10-2003, 01:31

>> Get a life!
>
> Please state where I can download one of those from.

<a href="http://www.beer.org.uk/life.html" >http://www.beer.org.uk/life.html</a>

HTH

Vic.

[Sheer brilliance Vic, I REALLY liked that one! K]

PeteM

31-10-2003, 08:56

>> Get a life!
>
> Please state where I can download one of those from.

http://www.beer.org.uk/life.html

HTH

Vic.

[Sheer brilliance Vic, I REALLY liked that one! K]

Must be a techy thing - so did I!

Andy Wade

31-10-2003, 16:36

:=>> Get a life!
:=>
:=> Please state where I can download one of those from.
:=
:= http://www.beer.org.uk/life.html
:=
:=HTH
:=
:=Vic.
:=
:=[Sheer brilliance Vic, I REALLY liked that one! K]

Must be a techy thing - so did I!

No, it's just bloomin' funny, I refreshed the page 3 times before I twigged....
LMAO
;-)
Nice one Vic

Steve Walker

31-10-2003, 18:49

I'm trying to help Chris to gain his evidence to challenge my views.

I don't think Chris has any intention of gathering "evidence", he made no response to my direct challenge to show this instructor (and yourself) what might/might not be wrong "techniques-wise", and for all his many post-monicker letters, he's behaved no better than the common-or-garden "troll" in my opinion.

Anyway, I'm off to the Red Sea tomorrow so what do I care :p
Cheers

Richie771

03-11-2003, 20:26

Dont forget to make sure you have a Life Preserver under your seat!!!

Enjoy your trip.

Andy Nye

03-11-2003, 21:23

Dont forget to make sure you have a Life Preserver under your seat!!!

Enjoy your trip.

And no nicking the O2 masks.....

Have a good hol, Steve

Andy

david lisk

04-11-2003, 15:16

In reply to John Bantin's earlier post 'Did you know that there has never been any incident recorded where using a life-jacket while on a civil airliner has saved a life? '

Johh, Stick to answering diving questions, as you clearly do not know much about aviation accidents. You are posting mis-information

Details:

Date: November 23, 1996
Type: B767-200ER
Registration: - ET-AIZ
Operator: Ethiopian Airways
Where: Comoros Islands, Madagascar
125 fatalities of 175 on board

Two British girls lives were clearly saved by the use of their underseat lifejackets (well documented in their book). Indeed they put on their lifejackets before the plane crashed and contary to procedures inflated them inside the aircraft (as did all the other passengers) which actually contributed to their lives being saved.

"I was free of whatever trapped me. I urgently needed to breathe and above me I could see the surface of the water and the brightness of the sunshine. Without doing anything myself, I was pulled towards the moving light. I burst throught, back into the real world, back into air...My life jacket had dragged me to the surface and held me there, allowing me to bob up and down as I tried to take in what was happening, one thing at a time. " Lissie Anders from Hijack: Our story of survival (1998).

A powerful description of what a life jacket can do for you.

David Lisk (Webmaster)

airdisasters.co.uk

David Humm

05-11-2003, 15:24

Hope you guys don't mind if I post a reply, (SAA member - Ex BSAC)

I've followed this thread with interest and decided to pose the same question to instructors within my club.

The consensus of opinion was (all things considered through this thread), that AV should still remain a part of (our) diver training. These are essential live saving skills and, any diver not knowing those skills *might* hinder the first aid process.

Now, following on from that opinion we also agreed that "experience counts" and making an 'in water? assessment whether to tow with or without AV, to administer AV while waiting for boat recovery, or in fact any other situation that presented it's self on the day, was the more important issue. Naturally, if a diver lacked AV skills they wouldn't be in a position to make that decision thus limiting the options available.

Personally, I feel making a choice depending upon circumstance is by far the better option. Naturally we have to ensure those skills (like all other diver related skills) are up to scratch. I do not however agree that AV skills are being taught poorly (not in our club anyway) whether those skills are kept honed is perhaps another question but, From our perspective (and again I hope you guys don't mind a non member's input) we thought AV should continue to be taught in conjunction with the use of both common sense and an assessment of the 'need vs other considerations' should the situation ever happen.

Kind regards

Dave Humm