First Aid for Diving Emergencies - Does the Diagnosis Matter?

Dr Michael Davis, MD, FRCA, FANZCA, Dip DHM

Diving emergencies develop out of the blue according to Murphy's Law - when least expected and at the Figure 1. FIRST AID ALGORITHM
worst possible moment. They are invariably the result of a chain reaction of circumstance that breaks This decision flow chart has been used in several versions by the author since 1978 for teaching diving
through the loose-knit but nevertheless effective safeguards built into scuba diving, and are rarely caused first aid management. It was first published in the South Pacific Underwater Medicine Society Journal
by any one factor alone. 1981; 11 (Suppl): 63-67.
This is a harrowing moment for a group of divers faced with sudden chaos and a motley of non-specific
symptoms and signs in the victim (Table 1).
The circumstances may provide sufficient clues to what is happening (eg. oxygen toxicity is hardly likely
in someone in difficulties on the surface prior to an air dive, but near drowning is a strong bet).

Table 1 START HERE

Common DCI Pneumo- Ear baro Marine Near Hypo- Myocard- Trauma
signs/ thorax - trauma Sting Drowning thermia Infarct
symptoms
CONTROL MASSIVE
EXTERNAL BLEEDING
Pain Limb + - - + - + + + SPEED IS VITAL
Pain Chest + + - + + - + +
Headache + + + + + + + +
Fatigue + + + + + + + +
Shivers + + + + + +/- + +
UNCONSCIOUS?
Nausea &
Vomitting + + + + + + + +
Short of
Breath + + - + + + + +
Cyanosis + + - + + + + +
Tinnitus + - + - - - - + CLEAR AIRWAY YES NO OBSERVE
Motor
Loss + - - + - - + +
Sensory
Loss + - - + - - + + BREATHING? INJURY?
Convulse + + - + + - + +
Loss of
Consc. + + + + + + + +
Signs of YES NO
shock + + - + + + + + NO YES
Cardio-
Respir.
Arrest + + - + + + + +

The author's contention is that precise disease diagnosis is largely irrelevant to the institution of appropriate BASIC LIFE LOOK FOR:
First Aid. SUPPORT MAINTAIN AIRWAY STOP BLEEDING
PAIN: Chest or Joint
Thus, the approach to First Aid teaching must either be based on an in-depth study of each medical (CPR) RECOVERY POSITION IMMOBILISE SHORT OF BREATH
condition, or be a pragmatic one that presents a sequence of simple decisions and actions - a treatment HORIZ. or 10o FRACTURES PARALYSIS
algorithm - that provides immediate care for all potentially life-threatening conditions, whilst medical aid HEAD DOWN & STINGS NUMBNESS
is sought.
VISION or BALANCE
This approach is clearly illustrated in the modern teaching of Basic Life Support. What must also be ADVANCED PROBLEMS
emphasised is that the actions of those at the accident scene largely determine the outcome for the injured LIFE SUPPORT
diver.
This is not to say that the triad of Resuscitation, Disease Diagnosis and Treatment do not go hand-in-hand
in dealing with medical emergencies. The author simply contends that it is unproductive to teach this
process to most amateur sport divers. Indeed evidence from case referrals to the Christchurch hyperbaric
unit suggests that the wet-suited mini-doctor sometimes does his fellow diving victim a disservice. The
old adage that a little knowledge is a dangerous thing should not be forgotten!
What replaces disease-orientated diagnosis in the immediate First Aid management of diving accidents
is condition recognition. That is, the establishment of priorities in immediate care. For instance, there is
little point treating shock only with intravenous fluids if the real cause of the shock is severe hypoxia from OBSERVE
upper airway obstruction due to head trauma from an outboard prop blade, and not the haemorrhage from REST & PROTECTION
the scalp wound!
Therefore, the question is rhetorical. Of course diagnosis is important, but first identify and prioritise OXYGEN
immediately life-threatening problems like the airway obstruction example above, rather than disease RE-ENTER
processes.
Thus principals 1-6 inTable 2 do not require disease recognition, and it is only for 8, often combined with
7, that this becomes necessary.
An algorithm used by the author for many years for teaching diving accident management is shown in
Figure 1. DISTRESS / URGENCY SIGNAL
Table 2
TEN COMMANDMENTS of FIRST AID for DIVERS
1 Do NOT place yourself in DANGER, and KEEP CALM
2 BASIC LIFE SUPPORT - Airway, Breathing, Circulation
3 POSTURE - recovery position/control bleeding/immobilisation
MEDICAL ATTENTION URGENT
4 OXYGEN - in every case
5 REST & PROTECT (from the elements, further injury, spread of toxins, etc) DIVER EMERGENCY SERVICE 0800 4DES 111
6 OBSERVE & RECORD the diver repeatedly & without bias Christchurch Hospital (03) 364 0640, Hyperbaric Unit Doctor
(Describe only what you hear and see + ABC review)
7 CONSULT - Emergency Services/ Medical Advice (eg. DES/DAN) RETAIN EQUIPMENT FOR INSPECTION + INCIDENT REPORT
8 SPECIFIC CARE - Fluids / Marine Stings & Bites /Advanced Life Support / Disease Diagnosis (NZ Underwater, P.O. Box 875, AUCKLAND)
9 EVACUATE - Hospital / Hyperbaric Centre, etc
10 SECURE EQUIPMENT & DOCUMENT ACCIDENT fully