Diving medicine



Diving medicine, also called undersea and hyperbaric medicine (UHB), is the diagnosis, treatment and prevention of conditions caused by humans entering the undersea environment. It includes the effects on the body of pressure on gases, the diagnosis and treatment of conditions caused by marine hazards and how relationships of a diver's fitness to dive affect a diver's safety.

Hyperbaric medicine is a corollary field associated with diving, since recompression in a hyperbaric chamber is used as a treatment for two of the most significant diving related illnesses, decompression illness and arterial gas embolism.

Diving medicine deals with medical research on issues of diving, the prevention of diving disorders, treatment of diving accidents and diving fitness. The field includes the effect of breathing gases and their contaminants under high pressure on the human body and the relationship between the state of physical and psychological health of the diver and safety.

In diving accidents it is common for multiple disorders to occur together and interact with each other, both causatively and as complications.

Diving medicine is a branch of occupational medicine and sports medicine, and an important part of diver education.

Range and scope of diving medicine
The scope of diving medicine must necessarily include conditions that are specifically connected with the activity of diving, and not found in other contexts, but this categorization excludes almost everything, leaving only deep water blackout, isobaric counterdiffusion and high pressure nervous syndrome. A more useful grouping is conditions that are associated with exposure to variations of ambient pressure. These conditions are largely shared by aviation and space medicine. Further conditions associated with diving and other aquatic and outdoor activities are commonly included in books which are aimed at the diver, rather than the specialist medical practitioner, as they are useful background to diver first aid training.

The scope of knowledge necessary for a practitioner of diving mediciene includes the medical conditions associated with diving and their treatment, physics and physiology relating to the underwater and pressurised environment, the standard operating procedures and equipment used by divers which can influence the development and management of these conditions, and the specialised equipment used for treatment.

Scope of knowledge for diving medicine
The ECHM-EDTC Educational and Training Standards for Diving and Hyperbaric Medicine (2011) specify the following scope of knowledge for Diving Medicine:


 * Physiology and pathology of diving and hyperbaric exposure.
 * Hyperbaric physics
 * Diving related physiology
 * Hyperbaric pathophysiology of immersion
 * Pathophysiology of decompression
 * A brief introduction to acute dysbaric disorders
 * Chronic dysbaric disorders
 * Hyperbaric oxygen therapy basis - Physiology and pathology
 * Oxygen toxicity
 * Pressure and inert gas effects
 * Nitrogen narcosis
 * High pressure neurological syndrome
 * Medication under pressure
 * Non-dysbaric diving pathologies
 * Diving technology and safety
 * Basic safety planning
 * Compressed air work
 * Diving procedures
 * Wet bells and stages
 * Scuba diving on air and mixed gas
 * Surface supplied diving
 * Standard diving (copper helmet)
 * Rebreather diving (semi-closed and closed circuit)
 * Other diving procedures
 * Characteristics of various divers
 * Diving equipment as used to c.50m and Chambers
 * Diving tables and computers
 * Regulations and standards for diving
 * Saturation diving
 * Saturation mode
 * Physiology of deep exposure
 * Compression
 * At depth in a living chamber
 * Bell excursions


 * Fitness to dive
 * Fitness to dive criteria and contraindications for divers, compressed air workers and HBOT chamber personnel
 * Fitness to dive assessment
 * Fitness to dive standards (professional and recreational)
 * Diving accidents
 * Diving incidents and accidents
 * Emergency medical support with no chamber on site
 * Barotrauma: ENT; dental; cutaneous, conjunctival, etc.
 * Physical injuries
 * Decompression illness
 * Pathophysiological basis and mechanisms of DCI
 * Differential diagnosis of decompression illness
 * Management of decompression incidents at the surface
 * Immediate management, recompression tables and strategies
 * Rehabilitation of disabled divers
 * Diving accident investigation
 * Clinical HBO
 * Recompression chambers

Scope of knowledge for hyperbaric medicine
The ECHM-EDTC Educational and Training Standards for Diving and Hyperbaric Medicine (2011) specify the following scope of knowledge for Hyperbaric Medicine additional to that for Ddiving medicine:
 * Physiology and pathology of diving and hyperbaric exposure.
 * HBO-Basics - effects of hyperbaric oxygen - physiology and pathology
 * Clinical HBO
 * Chamber technique (multiplace, monoplace, transport chambers, wet recompression)
 * Mandatory indications
 * HBO Recommended indications
 * HBO Experimental and anecdotal indications
 * HBO Data collection / statistics / evaluation
 * HBO General basic treatment (nursing)
 * HBO Diagnostic, monitoring and therapeutic devices in chambers
 * Risk assessment, incidents monitoring and safety plan in HBO chambers
 * HBO Safety regulations

Diagnostics
The signs and symptoms of diving disorders may present during a dive, on surfacing, or up to several hours after a dive. Divers have to breathe a gas which is at the same pressure as their surroundings, which can be much greater than on the surface. The ambient pressure underwater increases by 1 atm for every 10 m of depth.

The principal conditions are: decompression illness (which covers decompression sickness and arterial gas embolism); nitrogen narcosis; high pressure nervous syndrome; oxygen toxicity; and pulmonary barotrauma (burst lung). Although some of these may occur in other settings, they are of particular concern during diving activities.

The disorders are caused by breathing gas at the high pressures encountered at depth, and divers will often breathe a gas mixture different from air to mitigate these effects. Nitrox, which contains more oxygen and less nitrogen is commonly used as a breathing gas to reduce the risk of decompression sickness at recreational depths (up to about 40 m). Helium may be added to reduce the amount of nitrogen and oxygen in the gas mixture when diving deeper, to reduce the effects of narcosis and to avoid the risk of oxygen toxicity. This is complicated at depths beyond about 150 m, because a helium–oxygen mixture (heliox) then causes high pressure nervous syndrome. More exotic mixtures such as hydreliox, a hydrogen–helium–oxygen mixture, are used at extreme depths to counteract this.

Decompression sickness
Decompression sickness (DCS) occurs when gas, which has been breathed under high pressure and dissolved into the body tissues, forms bubbles as the pressure is reduced on ascent from a dive. The results may range from pain in the joints where the bubbles form to blockage of an artery leading to damage to the nervous system, paralysis or death. While bubbles can form anywhere in the body, DCS is most frequently observed in the shoulders, elbows, knees, and ankles. Joint pain occurs in about 90% of DCS cases reported to the U.S. Navy, with neurological symptoms and skin manifestations each present in 10% to 15% of cases. Pulmonary DCS is very rare in divers.

Pulmonary barotrauma and arterial gas embolism
If the breathing gas in a diver's lungs cannot freely escape during an ascent, the lungs may be expanded beyond their compliance, and the lung tissues may rupture, causing pulmonary barotrauma (PBT). The gas may then enter the arterial circulation producing arterial gas embolism (AGE), with effects similar to severe decompression sickness. Gas bubbles within the arterial circulation can block the supply of blood to any part of the body, including the brain, and can therefore manifest a vast variety of symptoms.

Nitrogen narcosis
Nitrogen narcosis is caused by the pressure of dissolved gas in the body and produces impairment to the nervous system. This results in alteration to thought processes and a decrease in the diver's ability to make judgements or calculations. It can also decrease motor skills, and worsen performance in tasks requiring manual dexterity. As depth increases, so does the pressure and hence the severity of the narcosis. The effects may vary widely from individual to individual, and from day to day for the same diver. Because of the perception-altering effects of narcosis, a diver may not be aware of the symptoms, but studies have shown that impairment occurs nevertheless.

High pressure nervous syndrome
Helium is the least narcotic of all gases, and divers may use breathing mixtures containing a proportion of helium for dives exceeding about 40 m deep. In the 1960s it was expected that helium narcosis would begin to become apparent at depths of 300 m. However, it was found that different symptoms, such as tremors, occurred at shallower depths around 150 m. This became known as high pressure nervous syndrome, and its effects are found to result from both the absolute depth and the speed of descent. Although the effects vary from person to person, they are stable and reproducible for the individual.

Oxygen toxicity
Although oxygen is essential to life, in concentrations significantly greater than normal it becomes toxic, overcoming the body's natural defences (antioxidants), and causing cell death in any part of the body. The lungs and brain are particularly affected by high partial pressures of oxygen, such as are encountered in diving. The body can tolerate partial pressures of oxygen around 0.5 bar indefinitely, and up to 1.4 bar for many hours, but higher partial pressures rapidly increase the chance of the most dangerous effect of oxygen toxicity, a convulsion resembling an epileptic seizure. Susceptibility to oxygen toxicity varies dramatically from person to person, and to a smaller extent from day to day for the same diver. Prior to convulsion, several symptoms may be present – most distinctly that of an aura.

Treatments
Treatment of diving disorders depends on the specific disorder or combination of disorders, but two treatments are commonly associated with first aid and definitive treatment where diving is involved. These are first aid oxygen administration at high concentration, which is seldom contraindicated, and generally recommended as a default option in diving accidents where there is any significant probability of hypoxia, and hyperbaric oxygen therapy, which is the definitive treatment for most incidences of decompression illness. Hyperbaric treatment using other breathing gases is also used for treatment of decompression sickness if HBO is inadequate.

Oxygen therapy
The administration of oxygen as a medical intervention is common in diving medicine, both for first aid and for longer term treatment.

Recompression and hyperbaric oxygen therapy
Recompression treatment in a hyperbaric chamber was initially used as a life-saving tool to treat decompression sickness in caisson workers and divers who stayed too long at depth and developed decompression sickness. Now, it is a highly specialized treatment modality that has been found to be effective in the treatment of many conditions where the administration of oxygen under pressure has been found to be beneficial. Studies have shown it to be quite effective in some 13 indications approved by the Undersea and Hyperbaric Medical Society.

Hyperbaric oxygen treatment is generally preferred when effective, as it is usually a more efficient and lower risk method of reducing symptoms of decompression illness, but in some cases recompression to pressures where oxygen toxicity is unacceptable may be required to eliminate the bubbles in the tissues in severe cases of decompression illness.

Education and registration of practitioners
Specialist training in underwater and hyperbaric medicine is available from several institutions, and registration is possible both with professional associations and governmental registries.

Education
NOAA/UHMS Physicians Training Course in Diving Medicine: This course has been presented since 1977, and has been influenced by internationally accepted training objectives recommended by the Diving Medical Advisory Committee, the European Diving Technology Committee, and the European Committee for Hyperbaric Medicine. The course is designed for qualified medical practitioners, but may be useful to others who work in the field of diving safety and operations.

The course is to train physicians to recognize and treat diving medical emergencies. Subject matter includes:
 * Basic physics and physiology of the hyperbaric environment:
 * the laws and principles;
 * the differences between hyperbaric and hypobaric pressure;
 * hyperbaric gases and their effects under pressure;
 * links between the physiological effects of the hyperbaric environment and the pathology of the disease
 * Basic decompression theory:
 * historical development to current concepts
 * factors affecting decompression safety including acceptable risks and thermal issues
 * distinguish decompression sickness from barotrauma and arterial gas embolism;
 * Dive computer theories and types, and comparison to dive tables
 * Introduction to commercial diving and comparison to recreational and technical diving, including differences in procedures, equipment, and diver categories
 * The clinical application of hyperbaric oxygen therapy and the treatment tables used;
 * Participation in surface-supplied diving operation and hyperbaric chamber operations;
 * Components, types, operational and safety hazards associated with hyperbaric chambers;
 * Diving related conditions resulting from the effects of long term effects of diving, flying after diving, altitude, thermal conditions, age and gender
 * Neurologic assessment on a diver with signs and/or symptoms of DCI
 * Medical and fitness standards for diving, including:
 * contraindications for both commercial and recreational divers
 * differences in medical standards for recreational versus occupational diving communities
 * legal implications for approving and denying fitness to dive in an occupational setting
 * approaches for determining the safety of prescription and OTC medications used by divers

Fellowship in Undersea and Hyperbaric Medicine: The Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) offer 12 month programs in undersea and hyperbaric medicine associated with ACGME or AOA accredited programs in emergency medicine, family medicine, internal medicine, occupational medicine, preventive medicine, or anesthesiology.

ECHM-EDTC Educational and Training Standards for Physicians in Diving and Hyperbaric Medicine: The standard drawn up jointly by the European Committee for Hyperbaric Medicine and the European Diving Technical Committee defines job descriptions for several levels of diving and hyperbaric physician: Education and assessment to these standards may be provided by institutions of higher education under the leadership of a Level 3 Hyperbaric Medicine Expert as defined below. Certificates of competence may be issued by a nationally accredited institution or an internationally acknowledged agency, and periodic recertification is required.

Level 1. Medical Examiner of Divers (MED) minimum 28 teaching hours. Level 2D. Diving Medicine Physician (DMP) minimum 80 teaching hours. Level 2H. Hyperbaric Medicine Physician (HMP) minimum 120 teaching hours Level 3. Hyperbaric medicine expert or consultant (hyperbaric and diving medicine) is a physician who has been assessed as competent to:
 * The MED must be competent to perform the assessments of medical fitness to dive of occupational and recreational divers and compressed air workers, except the assessment of medical fitness to resume diving after major decompression incidents.
 * A DMP must be competent to perform the initial and all other assessments of medical fitness to dive of working and recreational divers or compressed air workers, and manage diving accidents and advise diving contractors and others on diving medicine and physiology (with the backup of a diving medical expert or consultant).
 * A DMP should have knowledge in relevant aspects of occupational health, but is not required to be a certified specialist in occupational medicine.
 * A DMP should have certified skills and basic practical experience in assessment of medical fitness to dive, management of diving accidents, safety planning for professional diving operations, advanced life support, acute trauma care and general wound care.
 * An HMP will be responsible for hyperbaric treatment sessions (with the backup of a hyperbaric medicine expert or consultant)
 * An HMP should have appropriate experience in anaesthesia and intensive care in order to manage the HBO patients, but is not required to be a certified specialist in anaesthesia and intensive care.
 * An HMP must be competent to assess and manage clinical patients for hyperbaric oxygen therapy treatment
 * manage a hyperbaric facility (HBO centre) or the medical and physiological aspects of complex diving activities.
 * manage research programs on diving medicine.
 * supervise a team of HBO doctors and personnel, health professionals and others.
 * teach relevant aspects of hyperbaric medicine and physiology to all members of staff.

Gesellschaft für Tauch- und Überdruckmedizin e. V.: Society for Diving and Hyperbaric medicine German standards for education and assessment of diving medical practitioners are similar to the ECHM-EDTC Standards and are controlled by the Gesellschaft für Tauch- und Überdruckmedizin e. V.. They include Medical Examiner of Divers, Diving Medicine Physician, Hyperbaric Medicine Physician, Chief Hyperbaric Medicine Physician and Hyperbaric Medicine Consultant.

Schweizerische Gesellschaft für Unterwasser- und Hyperbarmedizin: Swiss Society for underwater and hyperbaric medicine. Swiss standards for education and assessment of diving medical practitioners are controlled by the Schweizerische Gesellschaft für Unterwasser- und Hyperbarmedizin. They include Medical Examiner of Divers, Diving Medicine Physician and Hyperbaric Medicine Physician.

Österreichische Gesellschaft für Tauch- und Hyperbarmedizin: Austrian Society for Diving and Hyperbaric medicine. Austrian standards for education and assessment of diving medical practitioners are controlled by the Österreichische Gesellschaft für Tauch- und Hyperbarmedizin They include Medical Examiner of Divers, Diving Medicine Physician, Hyperbaric Medicine Physician, Chief Hyperbaric Medicine Physician and Hyperbaric Medicine Consultant.

Registration
The American Medical Assocition recognises the sub-speciality Undersea and Hyperbaric Medicine held by someone who is already Board Certified in some other speciality.

The South African Department of Labour registers two levels of Diving Medical Practitioner. Level 1 is qualified to conduct annual examinations and certification of medical fitness to dive, on commercial divers (equivalent to ECHM-EDTC Level 1. Medical Examiner of Divers), and Level 2 is qualified to provide medical advice to a diving contractor and hyperbaric treatment for diving injuries (equivalent to ECHM-EDTC Level 2D Diving Medicine Physician)

Australia has a four tier system: In 2007 there was no recognised equivalence with the European standard.
 * GPs completing the first tier four- to five-day course on how to examine divers for ‘fitness to dive’ can then add their names to the SPUMS Diving Doctors List
 * GPs completing the second tier two-week diving medicine courses provided by the Royal Australian Navy and the Royal Adelaide Hospital, or the two-week course in Diving and Hyperbaric Medicine provided by the ANZ Hyperbaric Medicine Group, qualify to do commercial-diving medicals.
 * The third tier is the SPUMS Diploma in Diving and Hyperbaric Medicine. The candidate must attend a two-week course, write a dissertation related to DHM and have the equivalent of six months’ full-time experience working in a hyperbaric medicine unit.
 * The fourth tier is the Certificate in Diving and Hyperbaric Medicine from the ANZ College of Anaesthetists.

Divers
A basic knowledge understanding of the causes, symptoms and first aid treatment of diving related disorders is part of the basic training for most recreational and professional divers, both to help the diver avoid the disorders, and to allow appropriate action in case of an incident resulting in injury.

Recreational divers
A recreational diver has the same duty of care to other divers as any ordinary member of the public, and therefore there is no obligation to train recreational divers in first aid or other medical skills. Nevertheless, first aid is training is recommended by most, if not all, recreational diver training agencies.

Recreational diving instructors and divemasters, on the other hand, are to a greater or lesser extent responsible for the safety of divers under their guidance, and therefore are generally required to be trained and certified to some level of rescue and first aid competence, as defined in the relevant training standards of the certifying body. In many cases this includes certification in Cardiopulmonary resuscitation and Oxygen administration for diving accidents.

Professional divers
Professional divers usually operate as members of a team with a duty of care for other members of the team. Divers are expected to act as standby divers for other members of the team and the duties of a standby diver include rescue attempts if the working diver gets into difficulties. Consequently, professional divers are generally required to be trained in fescuoe procedures appropriate to the modes of diving they are certified in, and to administer first aid in emergencies. The specific training, competence and registration for these skills varies, and may be specified by state or national legislation or by industry codes of practice.

Diving supervisors have a similar duty of care, and as they are responsible for operational planning and safety, generally are also expected to mange emergency procedures, including the first aid that may be required. The level of first ait training, competence and certification will generally take this into account.


 * In South Africa, registered commercial and scientific divers must hold current certification in first aid at the national Level 1, with additional training in oxygen administration for diving accidents, and registered diving supervisors must hold Level 2 first aid certification.
 * Offshore diving contractors frequently follow the IMCA recommendations.

Diver Medic
A diver medic is a member of a dive team who is trained in advanced first aid. A Diver Medic recognised by IMCA must be capable of administering First Aid and emergency treatment, and carrying out the directions of a doctor pending the arrival of more skilled medical aid, and therefore must be able to effectively communicate with a doctor who is not on site, and be familiar with diving procedures and compression chamber operation. The Diver Medic must also be able to assist the diving supervisor with decompression procedures provide advice as to when more specialised medical help should be requested, and must be fit to provide treatment in a hyperbaric chamber in an emergency, and must therefore hold a valid certificate of medical fitness to dive.

Training standards for Diver Medic are described in the IMCA Scheme for Recognition of Diver Medic Training.

Timeline

 * November 1992: The first examination for certification in Undersea Medicine by the American Board of Preventive Medicine.
 * November 1999: The first examination for Undersea and Hyperbaric Medicine qualification.

Notable researchers

 * Arthur J. Bachrach
 * Albert R. Behnke
 * Peter B. Bennett
 * Thomas E. Berghage
 * Paul Bert
 * George F. Bond
 * Alf O. Brubakk
 * Albert A. Bühlmann
 * Carl Edmonds
 * William Paul Fife
 * John Scott Haldane
 * Robert William Hamilton, Jr.
 * Leonard Erskine Hill


 * Brian A. Hills
 * F. J. Keays
 * Christian J. Lambertsen
 * Simon Mitchell
 * Richard E. Moon
 * František Novomeský
 * John Rawlins (Royal Navy officer)
 * Charles Wesley Shilling
 * Edward D. Thalmann
 * Richard D. Vann
 * James Vorosmarti
 * R. M. Wong
 * Robert D. Workman

Research organisations
Defence and Civil Institute of Environmental Medicine: DCIEM is a combined military and civilian research organisation to research the operational needs of the Canadian Forces in all environments.

Divers Alert Network: The Divers Alert Network (DAN) is a non-profit organization supported by donations, grants, and membership dues, for assisting divers in need. The DAN Research department conducts significant medical research on recreational scuba diving safety, and the DAN Medicine Department provides support for divers worldwide to find answers to their diving medical questions.

Diving Diseases Research Centre: The Diving Diseases Research Centre (DDRC) is a British hyperbaric medical organisation located near Derriford Hospital in Plymouth, Devon. It is a registered charity and was established in 1980 to research the effects of diving on human physiology.

The main objective of DDRC is research into diving medicine, which is partially funded through 'The Friends of DDRC'. The centre has become a world authority on hyperbaric medical treatments with many publications detailing its work.

The Centre is also an education and training base providing diving medical, clinical and hyperbaric courses.

Diving Medical Advisory Committee: DMAC is an independent committee with the purpose of providing advice about medical and safety aspects of commercial diving. They publish guidance notes about various aspects of diving and diving medical practice, and run a scheme for approval of courses in diving medicine.

European Committee for Hyperbaric Medicine: The ECHM is an organisation to study and define indications for hyperbaric therapy, research and therapy protocols, standards for therapeutic and technical procedures, equipment and personnel, and related cost-benefit and cost-effectiveness criteria. It is a representative body with the European health authorities, and works toward cooperation among scientific organizations involved in the field of Diving and Hyperbaric Medicine.

Membership of the committee includes doctors practicing diving medicine in Northern Europe, representatives of relevant health authorities, medical representatives from relevant navies, and a diving safety officer nominated by the International Marine Contractors Association.

European Underwater and Baromedical Society: The European Underwater and Baromedical Society (EUBS) is a primary source of information for diving and hyperbaric medicine physiology worldwide. The organization was initially formed as the European Underwater and Biomedical Society in 1971.

National Board of Diving and Hyperbaric Medical Technology: The National Board of Diving and Hyperbaric Medical Technology (NBDHMT), formally known as the National Association of Diving Technicians, is a non-profit organization for the education and certification of qualified personnel in the fields of diving and hyperbaric medicine.


 * The Diver Medic Technician (DMT) program is designed to meet the specific medical care needs of commercial, professional and scientific divers that often work in geographic isolation. DMT's are specifically trained for the various diving hazards found at remote work sites. The curriculum covers a wide range of topics from barotrauma to treatment of decompression sickness.


 * The Certified Hyperbaric Technologist (CHT) program is tailored to meet the specific safety and operational needs for biomedical devices within the department, and the necessary knowledge and skills to administer clinical treatment. The curriculum covers a wide range of topics including hyperbaric chamber operations to transcutaneous oxygen monitoring.


 * The Certified Hyperbaric Registered Nurse (CHRN) program is a subspecialty for registered nurses, sometimes referred to as baromedical nurses.

South African Undersea and Hyperbaric Medical Association: SAUHMA is a voluntary association recognised as a Special Interest group by the Group Council of the South African Medical Association.

South Pacific Underwater Medicine Society: The South Pacific Underwater Medicine Society (SPUMS) is a primary source of information for diving and hyperbaric medicine physiology worldwide. The organisation supports the study of all aspects of underwater and hyperbaric medicine, provides information on underwater and hyperbaric medicine, publishes a medical journal and holds an annual conference.

SPUMS offers a post graduate Diploma of Diving and Hyperbaric Medicine.

Undersea and Hyperbaric Medical Society: The Undersea and Hyperbaric Medical Society (UHMS) is the primary source of information for diving and hyperbaric medicine physiology worldwide.