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SDI Rescue Diving Manual
A Guide to Techniques, Stress, Injury and Accident Management
SCUBA DIVING INTERNATIONAL

tdisdi.com
Scuba Diving International
4
Publisher: Scuba Diving International
Phone: 888-778-9073 Fax: 877-436-7096
tdisdi.com | email: worldhq@tdisdi.com
© 2001, 2011, 2013 International Training v.0918
Notice of Rights: All rights reserved. No part of this book may be reproduced
or transmitted in any form by any means, electronic, mechanical, photocopy-
ing, recording, or otherwise without the prior written permission of the pub-
lisher. For information on getting permission for reprints and excerpts, please
contact TDI.
Author: Joe Mokry
Photography: Bret Gilliam, Steven M. Barsky, Joe Mokry, Wayne Hasson,

Sean Harrison, Joe Coulas
Illustrations: Steven M. Barsky
ISBN Number: 1-931451-02-8 Product ID #: 210002-01
5
6
Table of Contents
Chapter 1: Safe Diving and the Diver 15
The Self-Reliant Diver 15
Awareness 17
Preparing for the dive 18
Physical Preparation 18
Mental Preparation 19
Equipment Preparation 20
Diving Hand Signals 21
Dive Planning 22
Buddy Check 22
Special Emergency Skills 24
Out-of-Air Emergencies 24
Buddy Dependent Options 25
Procedure for using an octopus regulator 25
Procedure for buddy breathing 26
Redundant air supplies 27
Direct ascent 28
Limited Visibility 29
Lost buddy search 30
Navigation 31
Scuba I.Q. Review 33
Chapter 2: How Stress Leads to Diving Emergencies 35

Stress in Diving 35
Recognizing Stress in Others 36
Withdrawal 37
Gear Problems 38
Hyperactivity or talking 38
Recognizing Stress in Yourself 39
Dealing with stress 40
Separate Fact from Fiction 40
Conduct a Good Dive Briefing 40
Conduct a Good Buddy Check 40
Talk to the Dive Leaders 41
Visualize the Dive 41
Stress and Panic in the Water 42
Panicky Diver on the Surface 42
Panicky Diver Underwater 43
Assisting Panicky Divers 44
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Table of Contents
Chapter 3: The Causes of Diving Accidents 49
How Diving Accidents Happen 49
Exceeding prior experience and training 49
Cold or tired diver 51
Muscle cramps 52
Overweighted diver 53
Currents 53
Freshwater diving 58
Gear problems 61
Injuries 65
Hyperthermia 67
Hypothermia 67
Case histories 69
Case 1 69
Case 2 70
Chapter 4: Responding to Emergencies on the Surface 75

Staying alert to trouble 75
Response options 77
Reach or throw 77
Swimming rescues 81
Panicky diver on the surface 81
Tired diver assist 85
Diver in distress on the surface 87
Conscious Diver 88
Unconscious Diver on the Surface 90
Rescue breathing 92
Rescue breathing techniques 94
“Do-si-do” technique (pronounced Doe-see-Doe) 95
Chin-carry technique 96
Removing a diver from the water 97
Backpack carry 97
Two-person carry 101
Recovering a person to a boat 103
Unconscious person lift 103
Roll-up net 105
Boarding ladder 106
Spine boards and flotation litters 107
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Table of Contents
Useful rescue equipment 108
Swimmer devices 109
Personal considerations 110
Chapter 5: Responding to Emergencies Underwater 113

Responding to Emergencies Underwater 113
Recognizing underwater hazards 113
Accident prevention 113
Signs of trouble underwater 114
Underwater emergencies 115
Entangled diver 115
Carotid sinus reflex 117
Carbon monoxide (CO) gas poisoning 118
Nitrogen narcosis 120
Squeezes 123
Ear squeeze 123
Reverse squeeze 125
Sinus squeezes 127
Equipment squeezes 128
Mask squeeze 128
Dry suit squeeze 129
Hood squeeze 130
Vor barotraumas- Decompression illness 130
Decompression sickness 131
DCS recognition 133
Lung over-expansion injuries 136
Mediastinal and subcutaneous emphysema 137
Pneumothorax 138
Arterial gas embolism 139
Marine life injuries: 141
Punctures- Includes bites and spine wounds 142
Stings- Includes jellyfish and corals 146
Cuts and Scrapes 147
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Table of Contents
Chapter 6: Dive Accident Management 151
Dive Site Organization 151
Personnel 151
The Emergency Plan 153
Recognize 153
Respond 154
Rescue 156
Record 157
Assessing the diver’s injuries 157
The scene survey 158
The primary survey 158
Rescue Breathing 158
The secondary survey 162
Neurological examination 163
Orientation 164
Muscle strength 164
Balance and coordination 164
Eyes 164
Sensory 164
Swallowing reflex 164
Shock 165
On-scene oxygen therapy 166
Hypothermia Treatment 168
Hyperthermia Treatment 170
Chapter 7: Lost Diver Search and Recovery 175

Searching for a diver on the bottom 175
Organizing the search 176
Last Known Point 176
Available personnel 177
Search Plans 179
Circular search 180
Sweep search 182
Random searches 184
Abandoning the search 185
Assisting a diver up to the surface 186
Conscious diver 186
Unconscious Diver 189
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Table of Contents
Chapter 8: Recompression Chambers and Therapy 195
Why recompression? 195
Recompression and decompression chambers 196
Recompression therapy 199
Divers, do you know where your chambers are? 200
Appendix 203
A Diver’s First Aid Kit 203
Useful contact information: 204
Blood-Borne Pathogens 204
About the Author- Joe Mokry 205
Glossary 208
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Forward
It’s often said that the best lifeguards
don’t have to make any rescues. A true pro-
fessional can recognize an accident or stress
scenario before it happens and intervene with
positive results.
While diving is generally con-
ducted in a fairly benign setting, the marine
environment can be a hostile, unforgiving
place. Inevitably, what can go wrong, will
go wrong for some people. How you deal
with these situations can mean the difference
between a learned response to stress that neu-
tralizes the situation or allows it to escalate
into a lesson in survival.
There’s not much mystery about sport diving and the scenarios
for accidents are predictable and manageable for the most part. This
book is dedicated to providing information to help you learn confident
independent diver skills as well as giving you the tools to help others. A
large part of preventing stressful problems and accidents is developing
an awareness as a diver to potential scenarios and taking early action to
eliminate rescue situations.
Joe Mokry, a top rescue professional, is our author for this text
because of his pioneering work in diving and boat rescue. Joe has trained
police, fire, and U.S. Coast Guard teams in all phases of water rescue,
as well as working with divers of all levels. His no nonsense approach
to the subject brings a career perspective of unequalled experience and
application under varying conditions. He is well respected in his field.
This book will help you “dive defensively” and provide the
educational basis for skills for self-rescue and the rescue of others. Stu-
dy the information contained in this valuable resource and practice both
the mental and physical skills to proficiency. Some day, maybe sooner
than you think, you’ll need them.
Brian Carney, President
13
Safe Diving
and the Diver
The Self-Reliant Diver

Your view of scuba diving has probably changed somewhat from the
time of your initial training program to the time when you’re ready to
undertake rescue diver training. You’ve broadened your range of expe-
rience through repeated diving activities in increasingly wider types of
diving environments. You’ve learned new skills, “tricks of the trade”,
amassed more knowledge, and dived with several, if not many, buddies.
You’ve gained experience and judgment—the two indispensable keys
to safer, more enjoyable diving. Most of your beginner’s jitters and
reservations have been conquered and you feel that you’re becoming the
kind of diver you always wanted to be; reliable, capable and self-reliant.
Self-reliant?
An important attribute for a diver to posses is self-reliance. If you
haven’t given this much thought before, this would be a good time to
do so. Admittedly, the ability to look after all your problems underwater
without assistance from a buddy may not be the first thing that would
occur to you when you consider what you need to dive properly. After
all, the point was made time and time again in your training programs
that you always dive with a buddy. This is a good rule that helps increa-
se your enjoyment of diving, brings people together in a shared social
setting, and gives you the confidence to explore new areas. So, where
does self-reliance come in?
Imagine for a moment that you and your buddy are nearing the end
of what has been a truly memorable dive: the walls were vertical and
15
Chapter 1: Safe Diving and the Diver
blanketed in the kinds of marine life seen only in the magazines, the
warm water was clear enough to see from here to next week, and the
prospect of relating the dive to envious friends back home beckons.
Then you realize that your buddy is gone. Which of you is responsible
for this: you, because you were daydreaming, or your buddy, because
he stopped to take just one more photograph? Your own air supply
is dwindling and you suspect that your buddy may have even less. It
dawns on you that you’re not even sure where you are; you weren’t
paying that much attention on the way back, and your buddy was doing
the navigating anyway. What to do?
Looking around more carefully, you see bubbles in the distance and
swim to your buddy who’s trying hard to tighten a loose weight belt
while balancing the camera and the demands of buoyancy control at the
same time. With a little help from you the crisis is quickly resolved and
you’re both soon back on the boat again and reliving the highpoints of
the dive. Some new lessons have been learned, too. Never again will you
leave the navigation entirely in someone else’s hands, and you wish to
seek out a buddy who is independently capable of looking after typical
underwater problems without causing you moments of anxious concern.
TDI/SDI believes that all divers should be trained to be self-suf-
ficient. This means that each diver accepts the responsibility for his
or her own planning, equipment, and performance underwater. We are
all ultimately responsible for our own safety and conduct on a dive.
Any time our problems require assistance from our buddy on a dive, we
disrupt the flow of the dive at the least and possibly endanger them at
the worst. In fact what we strive to be is the ideal buddy; able to plan
Self-Reliance
• Understand your equipment
• Take personal responsibility
• Develop self-awareness skills
• Become more aware of your surroundings
• Plan for contingencies
• Learn to handle your own emergencies
16
and lead the dive, capable of looking after most underwater problems,
attentive and responsible. We can become better than we are by practi-
cing and refining the basic skills of diving and by developing new skills
and knowledge. Many of the new assessment and problem solving skills
that will make you an independently capable diver will be learned in
this Rescue Diver course. Along with this will come the knowledge that
you’ll also become a more valuable dive buddy.
Relaxed confidence is a characteristic of the self-reliant diver.
Awareness
Self-awareness to a diver means keeping in touch with the personal
factors affecting our survival underwater. These include how cold or
tired we are, how we and our equipment, as a system, are working to-
gether, and knowing what our remaining air and actual depth are at any
given moment without having to look at the gauges. While this may all
seem obvious, it’s common enough for divers to withdraw from their
surroundings and forget to pay attention to what’s happening to them.
This is not a diver in the comfort zone. This is also a diver more likely
to blunder into an accident simply from carelessness.
17
Dives are always more enjoyable when each diver is independently competent.
“Global awareness” is defined as attentiveness to our surroundings,
and is equally important in staying out of trouble underwater. In practice
it gives us the ability to “feel” in a 3-dimensional sense. An alert diver
knows his orientation underwater, maintains his sense of direction at all
times and in his mind’s eye “sees” himself in the middle of a changing
seascape as he fins through the water. Global-awareness helps you regi-
ster approaching entanglements and evade them, judge distances from
the bottom and avoid kicking up the silt, stay in synchronous motion
with a buddy without getting in the way and almost instinctively pick
the best natural navigation clues. It’s no coincidence that both self-awa-
reness and global-awareness are the hallmarks of the self-reliant diver.
Preparing for the dive

Most of us view diving as a liberating experience that frees us from our
every-day “topside” worries. Still, preparation in advance of the dive
will help ensure that we make the most our time underwater, and do so
enjoyably. These activities fall into several categories.
Physical Preparation
Scuba diving is a relaxing activity, one that allows the neutrally buoyant
diver to swim with little effort and to stop and rest underwater whenever
18
the diver feels the need. Nevertheless, the presence of currents and surge
underwater can significantly increase the diver’s workload. Gearing up
on the boat or on shore and entering the water wearing 60 to 100 lbs. of
equipment can be physically demanding. Exiting the water after a long
swim to shore or the dive boat can exhaust an already tired diver. In
short, despite our view that diving is effortless, we can expend a great
deal of energy on almost any dive. Add to this the caloric requirements
to stay warm in anything but the most tropical waters and it’s evident
that even “easy” dives are work.
With this in mind, divers should strive to maintain a level of fitness
appropriate to their typical kinds of diving. For all of us, we should
attempt at the least to undertake sufficient regular exercise to keep us
in condition for diving. This should include regular swimming sessi-
ons, especially with mask, snorkel, and fins. Any other exercises that
emphasize cardiovascular fitness such as, running, tennis, and most
competitive sports will also provide benefit for divers.
Keep in mind that many of the rescue skills and techniques you
will be performing in TDI/SDI’s Rescue Diver program will require
sustained physical effort. Real life rescues may involve a long towing
assist of a tired buddy. Even minimal swims on the surface while towing
a helpless person can be exhausting. Are you ready?
Mental Preparation
A sure way to avoid pre-dive jitters is good mental preparation for the
dive. If it’s a site that’s new to you, this starts with having done adequate
research in advance of the dive. Talk to divers who have done the dive
before, study the charts for the area, learn where all the entry and exit
points are, and understand the effects of weather on the dive site. If the
dive is challenging, such as boat diving on a relatively deep wreck, this
might be a good time to review your present experience and training to
make an honest determination as to whether you’re really ready for this
type of dive.
If you think you’re up to the challenge and are diving in solid,
experienced company, then you might benefit from mentally walking
through the proposed dive with your dive buddy. Examine each step
19
of the dive process to familiarize yourself with the way it should all
unfold. Then mentally create some of the possible obstructions to the
smooth progress of your dive. This kind of preparation will help prepare
you for the many unforeseen events that so often arise in even the most
straightforward dives.
Equipment Preparation
Scuba diving is an equipment-intensive activity. Without properly func-
tioning dive gear, we run the risk of equipment malfunction while un-
derwater, particularly during deep or high-exertion activities. However,
equipment preparation extends even to our exposure suit. Improperly
cared for suits may get stiff and uncomfortable with age. The same may
happen to improperly cared for bodies. If it’s been a while since you last
had the suit on, good advanced preparation would call for a pre-dive
fitting to ensure that the suit is still serviceable.
Regular annual inspection and maintenance of all scuba equipment,
including regulator, buoyancy compensator, and air cylinders will help
prevent avoidable gear breakdowns that may cut a dive short, or cause
an underwater emergency. Make sure that all your underwater gauges
are in good working order. Check electrical contacts on bottom timers
and computers. These need to be kept clean and without corrosion to
function reliably during the dive. TDI/SDI believe that dive computers
are an essential component to good diving. A computer that fails during
a dive calls for an immediate end to the dive. You should not be near
decompression limits on any average dive; however, always remember
to make a safety stop at 15 ft (5 m) for at least three minutes on ascent.
The use of a marked ascent line and alternate timer will allow a proper
stop in the event of computer failure.
Specialized equipment required for the upcoming dive should be
inspected well in advance. This might include line reels, lift bags, bot-
tom grid lines for plotting debris or artifact distribution, marking buoys
and flags, inflatable personal markers and the batteries in underwater
cameras, strobes and dive lights. The last thing you should have to
worry about is whether your dive gear is going to be able to perform as
well as you will on the dive.
20
Diving Hand Signals
Stop Something is OK?,OK OK?,OK (gloved)

wrong
Go up, going up Go down, going Which direction? Get with your buddy
down
You lead, I’ll follow Level off, Take it easy,

this depth slow down
Distress, help! OK? OK OK?OK

(on surface at distance) (one hand occupied)
Come here Me, or watch me Out of air Buddy breathe or

share air
Danger Ears not clearing I am cold Go that way
21
Dive Planning
Few pre-dive activities are more important than setting up a good
agreed-on dive plan. All divers in the group or both divers in a buddy
pair should participate. The dive intentions and nature should be cle-
arly stated to avoid confusion later on. The dive plan should include
the maximum depth and time of the dive and be calculated to keep all
divers out of mandatory decompression. Or, if decompression stops are
planned, that sufficient cylinders are in place. Most experienced divers
will already have a good working number for their air consumption rate,
and this should be compared to the proposed maximum depth and time
of the dive. Be sure to allow adequate reserve air for the safety stop at
15 ft (5 m) for three minutes, as well as sufficient air for emergency use.
The dive plan should also include a proposed route to follow under-
water. This provides for a much better sense of orientation during the
dive, as the divers should be able to visualize their relative position on
the route at any time. Deviations from the route are always acceptable
as long as both divers understand and agree to the changes. The route
should be designed to bring the divers back to their entry point, or ano-
ther selected alternative.
All divers and surface support personnel should review the range
of hand signals that might be used on the dive. This is best done before
the divers are fully geared up for the dive and are impatient to get into
the water. This review should include the support personnel as well, as
hand signals may be used for communication to them from divers on
the surface.
Buddy Check
One of the most important ways to ensure a successful dive and to avert
accidents is to get in the habit of conducting a thorough buddy check
before every dive. Most divers start with checking the scuba unit and
air supply. Ensure that straps on the harness or buoyancy compensator
are not twisted and are properly buckled. Typically the second stage of
the regulator will come over the diver’s right shoulder, though this is
not always the case with some models. This is a good time to make note
of this fact, as it will change your mutual orientation if buddy breathing
22
should become necessary. Note also the arrangement of your buddy’s
octopus or other backup air supply. Be sure you know precisely where
to find it in an out-of-air situation. Ideally the octopus will be distinctly
colored and attached in such a way that it can be quickly released.
Complete your check of the scuba unit by noting your buddy’s
starting air pressure and that any gauge and dive computer are in good
condition and functional. A quick test to determine whether the air
supply has been fully turned on is to hold the pressure gauge in one
hand while pressing the purge button on the second stage. The needle
on the gauge should not move. Continue the buddy check by examining
the mask and snorkel, ensuring that the hood does not lift the mask
and that all straps are in place. Pay particular attention to the weight
belt or other integrated weighting system. The buckle on the belt must
be unobstructed by any other straps or belts and readily accessible.
Buddy Check
• Is air on? Alternate air source?
• Are all hoses properly placed?
• Is mask sealed? Are straps secure?
• Weight system release accessible?
• Dive knife or tool in place?
• Signal review?
• Dive plan review?
• Contingencies review?
Pull-toggles or any other mechanism used to release integrated weights

must be both properly functioning and completely understood by both
divers. There should be no doubt about how to drop the weight in an
emergency situation. Take this opportunity as well to check that the belt,
if used, is snug around your buddy. One frequent cause of inability to
release a belt when necessary is that the belt loosens in the water and
swings around so that the buckle is behind the diver. It may be almost
impossible to reach the release mechanism without removing the diver’s
buoyancy compensator and scuba unit first in these cases. Remember
that it is almost always a mistake to remove a diver’s buoyancy source
before dropping his ballast.
23
Note where your buddy’s straps are on the dive knife or other tool.
Most frequently this will be on the lower leg. The general recommenda-
tion is that the tool be strapped inside the calf so that a dropped weight
belt doesn’t get snagged while falling. Many divers, especially those
frequently involved in rescue operations, will wear a second knife, often
placed within easy reach on the buoyancy compensator. In some cir-
cumstances, such as walk-in entries on rocky beaches, dive fins will not
be put on until the divers are in the water. In any case offer assistance to
your buddy in donning fins. Make sure straps are straight and properly
placed.
It should go without saying that all these steps of checking your
buddy before entering the water apply to you as well. Take the time
needed to familiarize your buddy with the configuration of your own
gear. You may be the one to require assistance on the dive, and your
buddy may be the one who will have to handle the emergency, including
your equipment.
Special Emergency Skills

Beyond the specialized rescue skills you will learn in the Rescue Diver
course, there are particular diving skills that will both increase your sa-
fety and improve your effectiveness during emergency situations. While
these are skills that any competent diver should possess, the nature of
distress on or under the water calls for refined abilities to deal with
emergencies.
Out-of-Air Emergencies
Most divers will gratefully spend their diving careers without ever ha-
ving to face the prospect of an out-of-air emergency underwater. Proper
dive planning, prudent air rationing, and staying within bottom time
limits will diminish that possibility even more. Nevertheless, circum-
stances will sometimes conspire against us and result in air shortage
situations. This can happen by not leaving enough air for a full safety
stop, deviating from the planned route that results in extended swims
back to the exit point, “lost buddy” searches, unanticipated currents on
the way back, stopping to relieve cramps, and delays due to entangle-
24
ments. Fighting for breath as the pressure gauge shows very low air
pressure can be panic inducing. Reviewing your options before this
happens is good emergency preparation. There may be more choices
available than you think.
Buddy Dependent Options

The most widely employed option for the diver in a low air situation is to
“borrow” air from his buddy. Always remember that if you are out of air,
or nearly so, that your buddy is likely in the same or similar situation. At
worst this makes the buddy dependent option one that exposes both of
you to the risk of an out-of-air problem. At best it’s a solution that calls
for an immediate ascent together to the surface.
The preferred method of sharing air is through the use of an octopus
regulator or other additional second stage (sometimes referred to as a
“safe second”). There are several variations of second stage regulators
directly incorporated into the low-pressure inflator hose. In both cases,
the mouthpiece/second stage must be cleared or purged before inhaling
a full breath. Whatever the arrangement, the out-of-air diver should
know exactly where to find and how to use the device. This is a critical
part of the buddy check and should never be left until the time of need.
Procedure for using an octopus regulator

1. The out-of-air diver signals “out of air” and “share air”.
2. The air donor passes over the octopus regulator or allows receiving
diver to take it from him.
3. Both divers grasp each other’s buoyancy compensator or harness
straps with their right hands.
4. Maintaining constant eye contact, the divers ascend together, using
their left hands to vent air from their buoyancy devices as required.
5. Keep breathing as regular and normal as possible during this ascent.
6. On the surface both divers make themselves buoyant.
25
Buddy breathing, or sharing a single second stage, has been used

successfully many times to assist an out-of-air diver. This method has
been largely replaced by required training in the use of an octopus regu-
lator. All TDI/SDI training requires an octopus, though buddy breathing
remains an effective alternative, but only if practiced on a regular basis.
Any out-of-air emergency is a stressful event and to employ buddy
breathing as the alternative of choice will necessitate that the divers
exercise excellent self control, thus the need for frequent practice.
Procedure for buddy breathing

1. The out-of-diver signals “out
of air” and “share air”.
2. The air donor takes a breath be-
fore passing the second stage to
the receiver.
3. The receiving diver guides the
regulator to his mouth and takes
two breaths.
4. The donor replaces the regula-
tor and takes two breaths in turn
before passing it back to the
receiver.
5. Throughout this exchange the
An octopus regulator is the preferred divers hold on to each other, the
buddy-dependent option. receiver using his right hand to
grasp the donor’s BC, while the
donor uses his left hand to grasp the receiver’s BC. The donor uses his
right hand to pass the regulator while the receiver uses his left hand to
guide the regulator to his mouth.
6. Be sure that both divers exhale slightly whenever the regulator is not
in their mouth.
7. Both divers ascend carefully together, venting air from their buoyancy
compensators as required.
26
Buddy Independent Options

Both buddy breathing and using a buddy’s octopus share the drawback
of requiring that your buddy be nearby, be practiced in the proper tech-
niques and that the urgency of the situation does not cause mistakes. The
best options are those that allow the out-of-air diver to act independently
to help himself. These fall into two categories: redundant air supplies
and direct ascents.
Redundant air supplies

Probably the most useful and
easiest method of solving an
out-of-air problem is to have a
true alternate air source. A com-
pletely redundant system would
include tank and regulator. This
has the further advantage of
a replacement regulator if in
fact the out-of-air emergency is
actually caused by a faulty regu-
lator, rather than an empty scuba
cylinder. Typically called “pony
bottles,” these small tank setups
range in size from as little as 6
cubic feet to 40 cubic feet capa-
city. The most commonly used
sizes are the 13 and 19 cubic foot A true alternate air source is
usually the best option in an
bottles. Depending on the depth, out-of-air emergency.
pony bottles will allow a diver
several to many minutes of bottom time, usually more than enough to
ascend safely to the surface.
Increasingly popular among serious sport divers are self-contained
bottle and integrated regulator devices, such as Spare Air® and its
smaller relative HEEDS. The latter is essentially an escape air supply
for pilots or others who may be temporarily entrapped underwater.
Spare Air also provides a short-term air supply, though with its larger
27
size (up to almost 2 ft3), it gives the diver a little more ascent time. Both
units have a built-in regulator with mouthpiece and are refillable from
scuba cylinders.
Whether having a pony bottle or small, integrated bottle/regulator
system available in emergencies, the diver is still in need of refresher
practice from time to time. You need to be completely certain of where to
find the second stage of the pony bottle regulator or the holster holding
the Spare Air without thinking about it. Bear in mind that if you were
wearing certain types of full-face masks when you run out of air, then
you will also be maskless when you ditch your regulator for an alternate
air source. It might be advisable to carry a spare mask in a side pocket
for this possibility.
Direct ascent
Often times it may be quicker and easier to ascend directly to the surface
without pausing to change air supplies, signal your buddy to share air or
otherwise delay. Certainly in depths of less than 30 ft. (9 m), the surface
is only seconds away. Considering the time it might take to employ
another option, a direct ascent might make more sense with less risk
to either diver. However, t here are several important points to keep in
mind to make this a successful procedure.
First, even though you may not be able to get a breath from the regu-
lator at 40’, it’s unlikely that the cylinder is completely empty, even if the
regulator had been free flowing. Most likely there is simply insufficient
pressure left to overcome the ambient pressure due to the depth. This
means that as you rise in the water and the ambient pressure falls, there
should be some residue of air in the tank available to you. The shallower
you ascend, the more air is available. Clearly, to take advantage of this
air, you must have your regulator in place. The procedure is to attempt
to inhale on ascent, to exhale normally, and to attempt to inhale. As long
as you continue to attempt to inhale and exhale normally, your airway
will stay open and any expanding air will automatically vent from your
lungs on its own. This will happen even as you attempt to inhale.
As you get to shallower water, you’ll find that you’ll get as much
air as you need (when you really need it). Remember, never hold your
28
breath on ascent. Methods that limit your exhalation such as humming,
blowing a fine stream of bubbles, etc., will likely cause some lung ex-
pansion. The surest way to avoid a lung over-expansion problem is to
keep the airway open by attempting to breathe normally throughout the
ascent.
Limited Visibility
Diving in conditions of visibility less than 5 ft. (1.5 m) will often lead
the buddy pair into problems of separation and navigation. Separation
of buddies during a dive is not an unusual event, but may become more
than a nuisance if conditions are unfavorable to rapidly finding the other.
Prevention is the best cure in this case. Agree beforehand that you and
your buddy will stay within arm’s length throughout the dive and will
frequently check with each other. Determine who will lead the dive so
that the other is not jostling to be in front. In severely limited conditions
a buddy line, i.e., a 6 ft. (2 m) length of line held between the divers, will
be necessary to maintain constant contact.
In low visibility conditions, divers might consider using a buddy line

between them.
29
Despite your best efforts, however, buddies will inevitably drift apart
on occasion. This is not in itself an emergency, but the stress level in
both divers is sure to rise if they cannot readily find each other. As long
as both divers understand and apply the same “lost buddy search”, then
the separation will last only a minute or two. This may be an anxious
time in some circumstances, but rarely will divers fail to be reunited
shortly if they follow the same plan.
Lost buddy search

1. As soon as you realize that your buddy is gone, stop and take a good
look around you, looking up and down, as well as from side to side.
2. It helps to rise a few feet when you survey the area around you. If
your buddy has stayed at the same depth, you may see the reflection of
light off the tops of his bubbles.
3. Spend no more than about a minute looking for your buddy. It may
help to backtrack a bit to determine if he stopped for some reason, rather
than wandered off on his own.
4. Ascend to the surface, always observing the correct ascent rates and
procedures.
Every diver should be accomplished in the art of accurate underwater navigation.
30
5. If not already there looking for you, your buddy should arrive shortly.
6. If your buddy has not returned to the surface after 5 minutes, there
may indeed be a problem and you should consider calling for assistance.
Most experienced divers go to some lengths to prevent this kind
of situation from happening at all. Surfacing and returning to depth is
not only a waste of time and air, but also makes divers more prone to
precipitate decompression sickness. It also causes “wear and tear” on
the ears and sinuses due to repeated, and unnecessary, pressure changes.
Navigation
Limited visibility diving is essentially a test of a diver’s self control
and ability. There will always be a certain amount of stress associated
with diving in poor visibility conditions. Divers prefer to have readily
available visual reference points to help them plot their course across an
otherwise featureless bottom. In the case of visibility of less than about
5 ft. (1.5 m), divers are forced to conduct all their wayfinding through
the use of their instruments, particularly the compass.
Underwater Navigation
• Visualize your dive plan.
• Visualize your environment.
• Superimpose both images.
• Calculate your progress so far.
• Plot your position on the dive plan.
• Use all available natural and instrument
aids to complete route.
Good navigational skills are essential to any kind of diving activity,
but are often neglected by divers. Diving in clear visibility waters, ha-
ving readily apparent underwater landmarks or being routinely guided
by other divers, it is easy to become lazy in wayfinding skills. Planning
a search for a missing diver and actually conducting such a search will
usually require that we possess fairly refined navigational skills. Most
search patterns that we might undertake will necessitate that we can
cover the bottom in an organized and systematic fashion. This demands
skills that will guarantee our being able to conduct the search and not
get lost ourselves. As with any other diving skill, we lose proficiency
31
when we fail to practice. Get into the habit of using a compass on every
dive. Set up your dive plans so that they require some facility with na-
vigational ability to complete them. Challenge yourself by making the
compass critical to completing underwater routes successfully. Certain
standard search patterns, as discussed later, will depend on these skills.
Even more importantly, the rescue diver should become adept at
the skills of global awareness. Place yourself in your environment and
know where you are at all times. There is a multitude of clues available
on almost every dive. Learn to visualize your plan and route, and you’ll
begin to feel orientated throughout the dive.
32
Scuba I.Q. Review
1. What does the term “self-reliant” diver mean?
2. A diver’s sense of awareness underwater is made up of what two
components?
3. List three essential parts of a good dive plan.
4. What two broad categories of options describe responses to out-of-air
emergencies?
5. When might a diver favor a buddy-independent response to a
buddy-dependent response in an out-of-air emergency?
6. Describe two self-rescue options for an out-of-air diver at a depth of
20’ (6 m).
33
How Stress
Leads to Diving
Emergencies
Stress in Diving
Most of us became involved in scuba diving because we were at-
tracted by the ideas of exploring the hidden underwater world with its
shipwrecks and marine life, traveling to warm, clear water tropical dive
sites, and enjoying the weightless sensation and extended bottom time
that breath-hold diving doesn’t offer. For most of us scuba diving both
promised and delivered on all this. The heart of the attraction to diving
is adventure, the never knowing exactly what you’ll see or precisely
where you’ll go or how your dive plan will play itself out. It’s also
fair to say that adventure is some combination of uncertainty, moderate
thrills and the unexpected. All this, to a large extent, is the reason we
learned to dive and why we continue to dive.
Scuba diving is an adventure, but may

also produce anxiety and apprehension.
The same components of adventure are also sources of stress in

divers. Divers in training and newly-certified divers are particularly
prone to stress before open water dives. Hollywood depiction of under-
water terrors, wildly-exaggerated stories from veteran divers and the
35
Chapter 2: How Stress Leads to Diving Emergencies
sure knowledge that spending any amount of time underwater without
coming up for air is just unnatural, all conspire to raise the stress level
of the novice. A large part of the diving instructor’s role is in creating a
comfort level that induces eagerness rather than anxiety and confidence
rather than bravado in the student. Still, many novice divers will enter
the water with the thought that they will always be waging a life-or-de-
ath battle with hypothermia, malicious currents and insatiable predators.
Stress is a predictable consequence of this train of thought.
While experience soon teaches us that our fears are a poor reflection
of reality, any diver can be overtaken by gnawing concerns in the right
circumstances. A veteran freshwater diver may be intimidated by the
seemingly endless expanse of ocean. An ocean diver may be unprepared
for the extra care required not to stir up the bottom in most lakes and
thus be caught unaware by the sudden limited visibility. Certainly any
diver not specifically trained for overhead environments such as penet-
ration wreck diving or ice diving will quail at the prospect, and probably
should, if the diver’s buddy attempts or proposes this kind of activity.
The diving environment itself, which may include cold water, chop-
py surface conditions and, perhaps, the diver’s first night dive, can men-
tally and psychologically tax any diver not used to these circumstances.
Again, stress will be a natural consequence of this train of thought.
Adventure now becomes a mix rather heavier on the uncertainty and
unexpected side, and lighter on the moderate thrill side. Furthermore,
left to its own devices, the mind’s eye has little difficulty in conjuring
up escalating levels of potential drama that may ultimately result in its
owner’s inability to make rational choices. In short a stressed diver may
be in trouble before even entering the water.
Recognizing Stress in Others

A certain amount of stress will almost always accompany a diver in
preparation for a dive. The mental state that sets this ball rolling will
also be unlikely to improve by itself as time goes on. The truth is that
stressed divers tend to become more anxious as time passes and the
prospect of the dive comes nearer.
We need to be able to recognize undue anxiety when we see it
36
in others and take corrective action sooner rather than later. A few
appropriate words early on may prevent a very difficult situation later.
Stressed divers may show their true feelings about a diving situation in
several ways.
Withdrawal
Preyed upon by fears of the im-
pending dive, some divers will
‘freeze up” and withdraw from
the flow of conversation around
them. They may be unable to
communicate and seek a more
private place away from others
who may be chatting excitedly
about the dive plan. When asked
to offer an opinion on the plan
such as where to enter or what
route to follow, the diver may
reply with an unconvincing, “I
don’t care.” This reply is probably
a long way from the truth, but the
Apprehension about an upcoming
fact is that the diver simply can’t dive may cause some divers to with-
or doesn’t want to deal with the draw from the activity around them.
realities of the proposed dive.
Perhaps intimidated by the enthusiasm around him and not wanting to
be the one to “spoil” everyone else’s adventure, the diver increasingly
withdraws from the group.
The dive scene, whether on board a boat or beach, can be a busy
place with several buddy pairs, a dive recorder, a Divemaster, friends
and family and others in attendance. Amid all this activity, it takes a
perceptive buddy to pick up the suddenly quiet mood of the stressed
diver and to recognize it for what it means.
37
Gear Problems
A diver uncertain about his ability to undertake a particular dive,
distracted by personal concerns unrelated to the dive, or just not “up” to
it today will find many excuses to delay entry into the water. Among the
most common are gear-related “problems”. A broken fin strap, a leaky
“O” ring, a minute hole in a glove all become reasons to abort the day’s
activities and go home. Often, too, a stressed diver will improperly
assemble the scuba unit or appear confused about the correct assembly
procedure. It helps to know the diver well enough to tell whether or
not he is stalling or simply a confused, poorly trained diver. Bear in
mind, however, that any diver making so many mistakes or having so
many excuses will probably not make the safest of buddies anyway. A
little pre-dive counseling may allow the diver the way out he needs or
straighten out the concerns he has before things go wrong underwater.
Hyperactivity or talking
Sometimes an apprehensive diver will mask fear or deep concerns in
a false enthusiasm at odds with their usual calm, deliberate manner.
Non-stop talking about nothing in particular or frequently repeating
or re-phrasing the same topic will also alert the attentive buddy to an
underlying problem. Early recognition of nervousness as the cause of
this unusual behavior and gentle intervention to ease the diver’s mind
will often resolve problems before they become emergencies later.
Recognizing the Signs of Stress

• Withdrawal
• Hyperactivity
• Constant talking
• Gear fumbling
• Inappropriate or “black” humor
• Moodiness
38
Recognizing Stress in Yourself
All divers have experienced the sensation of apprehension prior to a
dive. A dive in a new area, an unfamiliar wreck site, or a more complex
than usual dive plan may all cause us anxiety before the dive. Even
a dive in familiar surroundings may take on more significance if sea
state or other weather conditions are threatening or unusual. Often these
feelings are just common-sense cautionary indications that call for extra
vigilance to avoid complications. After all, experience will have show
us that compensating for the unexpected or unusual is only prudent.
Still, fear that you may have over-looked something in your planning
is not the same as that nagging reluctance to perform the activity at all.
The lure that pulls us to go ahead with the dive may be counteracted by
the apprehension that pushes us away. This push-pull results in a stress
level that may make us a threat to our own safety and a burden to our
buddy.
Stress may be caused by diving

new and unfamiliar sites, by
new activities such as night
diving, or when diving with
new dive buddies. Recognize
stress in yourself and others
before it becomes panic.
In this kind of situation, there is no substitute for an honest self-ex-

amination. Ask yourself some questions that may help you define the
specific causes of your anxiety and face up to them. Is this an “expe-
rience expanding” activity, or am I significantly exceeding my training
and prior experience? Do I have the skills to perform this dive safely?
If things start going wrong underwater, am I really briefed and prepared
for the contingencies? Am I capable of looking after myself and my
buddy in an emergency under these conditions? If the answer is “No” to
these questions, then maybe your fears are well grounded and this may
not be the best time or circumstances to undertake the planned dive.
39
Very often, however, pre-dive concerns are more of a psychological
nature than real. Fear of the unknown and fear of failure, especially in
front of others, can shake our confidence even when the proposed dive
is within our capabilities. Understanding this for what it is will help us
achieve a mental state to deal with our concerns realistically.
Dealing with stress

Separate Fact from Fiction
This starts with a good dive plan. What exactly are the intentions of this
dive? Have we decided on a firm route, air portioning, and turn-around
times? Are we clear on how to make changes to the plan underwater?
Have we developed plans for contingencies such as unusual air con-
sumption rates, earlier than planned surfacing or emergency decompres-
sion obligations? A good dive plan ensures that you and everyone else
involved understands exactly what is about to take place.
Conduct a Good Dive Briefing

A good dive briefing will not only cover the dive plan, but will also set
up an organized response to emergencies. Knowing that everyone on
scene has a pre-planned and designated role in emergency response can
be a great comfort to any diver uncertain of their own ability to deal
with complex problems single-handedly. Ensuring that this is carried
out to our own satisfaction will also alleviate concerns that we might
have. Be sure that the goals of the dive are well-understood. If you’re
unclear about something, don’t hesitate to ask.
Conduct a Good Buddy Check

One of the best ways of catching accidents before they happen is to see
to it that thorough buddy checks are always conducted before a dive.
Loose gear, improperly secured weight belts, and twisted straps are just
a few of the many problems that can be avoided by ensuring that all
divers, including yourself, are “checked out” before entering the water.
To be responsive in an emergency underwater, your buddy needs to
40
be fully familiar with your equipment, as you need to be familiar with
theirs. This awareness of the location and configuration of each other’s
equipment, as well as the familiarity of the buddy check routine, also
has the result of reducing stress both in ourselves and in our buddy.
Remember to include a review of signals, dive plan and out-of-air emer-
gency procedures as part of the buddy check.
Talk to the Dive Leaders

Withdrawing from the activity around you isolates you from the input
and clarifications you may need to feel comfortable with the dive. Con-
fiding openly with the more experienced members of the group and the
dive leaders is a good way of getting involved on a more personal level
with the performance expectations required for the dive. Often you’ll
discover that most of your concerns are both highly exaggerated and
very typical. A good, experienced buddy or dive leader will likely relate
their own first dive under these circumstances and give you the tips you
need to overcome your apprehension.
Visualize the Dive

Visualization is the act of mentally creating a possible progression of
events in an activity. It’s likely that you already use another kind of
visualization technique in your diving. Most of us mentally file a sketch
of the dive plan and superimpose it over the observed dive site. As we
progress through the dive, we mentally plot our position on the plan to
arrive at an approximation of where we are underwater at any given
time. Carrying a slate with the dive plan parameters on it is really just
a visualization aid. This is not a simple process, but most of us become
very good at it over time.
Visualization can also be used to forecast possible events. Visuali-
zing a dive means to step through it, bit by bit, from beginning to end.
The more detailed the image, the more comfortable we’ll be when we
pass these “way points” along the way. All normal events of the dive
will then progress as expected and add to our comfort level. This is
also an excellent way to prepare for the unexpected events of the dive.
Walking through several scenarios where things do not unfold the way
41
they were planned is not meant to be recipe for inducing terror, but
rather a method of preparing for these unlikely events. Having an idea
of what might go wrong at critical moments will help you consider an
appropriate response before the problem arises.
This technique is widely used by emergency response personnel.
Working on difficult rescue cases in less than ideal conditions often puts
rescue personnel in high risk situations. Mentally rehearsing for these
situations, and their variations, prepares rescuers for the unexpected.
In fact, most training scenarios are deliberately constructed to be yet
another variation on a basic theme so as to lower the likelihood of the
unexpected. If you’re mentally prepared, then it’s not a surprise.
Stress and Panic in the Water

Stress is not only a pre-dive occurrence, but may often develop during
a dive. Poor underwater visibility conditions, cold temperatures, an
exhausting surface swim or losing track of one’s buddy may all produce
severe stress in a diver. Even such a simple event as a partially flooded
mask may cause a diver to abandon a dive and bolt for the surface,
especially if the person was not completely comfortable with the dive to
begin with. Stress can rapidly lead to panic in the water.
Small incidents lead to other incidents and the situation can quickly
snowball out of the control. For example, a diver making a loose weight
belt a little more secure may lose track of his buoyancy and begin sin-
king. Pressure in the ears alerts him to his unplanned descent whereupon
he adds air to the buoyancy compensator. Looking for an immediate
response to his descent, he may add too much air and thus find himself
ascending more rapidly than is prudent. Any other complication added
to this scenario, such as a mask leak, could be the trigger that drives this
diver from frustrated and stressed to panic, and a too rapid ascent to the
surface. Sometimes the line between stress and panic is a fine one.
Panicky Diver on the Surface

Panic on the surface is frequently caused by conditions that make it
difficult for the diver to stay comfortably afloat, such as over-weighting.
Inability to breathe easily will almost certainly induce a feeling of great
42
stress and panic. This may be caused by a constricting wet or dry suit, a
poorly maintained regulator, choppy sea state or alterations in breathing
patterns from a general anxiety. A diver in this state wants desperately
to be clear of the water, so will demonstrate some of the classic signs of
water-induced panic; rapidly flailing arms and body as high as possible
above the water, mask and regulator removed to ease breathing, gasping
for breath and eyes wide open in fright.
The panicky diver is, by definition, not rational and may pose a
significant threat to any other diver within reach. In responding to a
panicky diver, the buddy’s first obligation is always to himself. Keeping
out of reach until you’ve assessed the situation and decided on a course
of action will keep you part of the solution and not part of the problem.
Once you’ve chosen to approach a panicked diver too closely, you’ve
exposed yourself to the possibility of loss of regulator and mask, drop-
ped weight belt, and an exhausting struggle. Your approach to such a
person needs to be reasoned and practiced.
Stay clear of a panicked person in the water until you’re certain that
you can either calm them down, or get control without undue risk to
yourself. A panicky person in the water is seeking to get as high out of
the water as possible and you may be just the stepping stone they need.
Remember this person may be a friend and long-time buddy, they are
not rational. Their actions may place you in great danger as a result.
Panicky Diver Underwater

Panic underwater is most often triggered by breathing difficulties. The
causes may range from over-exertion to actual out-of-air emergencies.
Especially when working at depths, regulators may not always provide
the diver with sufficient air for the activity level. Divers taking part in
salvage operations, game collection, heavy exertion, or else simply
over-weighted will sometimes work too hard, causing an apparent
shortage of air. As inadequate ventilations continue, the diver’s level
of CO in the blood stream rises, driving the diver to breathe faster.
2
The sensation of air starvation can easily cause the diver to abandon all
efforts to remain below and to bolt to the surface.
Divers unable to keep their buoyancy under control will also be-
43
come increasingly frustrated and stressed. This might be caused by
either over-weighting or under-weighting. Struggling to stay down or
to stay off the bottom may cause anxiety and exertion in an improperly
weighted diver. Novice divers in particular may frequently bounce up
and down until they finally master the skill of good buoyancy control.
This kind of activity could lead to ear and sinus pain, and an abrupt
termination of the dive. A diver carrying a heavy bag of scallops or
old bottles will struggle to near exhaustion without ever considering
abandoning his booty. Frequently this diver gets into serious difficulty
trying to remain on the surface. If on the surface, ask the diver to hand
you the bag. Since you probably will be no better at keeping this load
afloat, your best course of action will most likely be to drop the bag and
mark it for later recovery.
Though a diver panicking underwater will most often try to escape
to the surface as quickly as possible, sometimes he will act almost
frozen with fear or behave erratically with rapid breathing and darting
movements. This diver may reach unexpectedly for your regulator or
his actions might dislodge your mask. Passive panic is not uncommon in
aquatic emergencies, especially in those persons who have only limited
watermanship skills to begin with. The feeling of general discomfort in
the water combined with a sense of inability to help themselves in an
aquatic crisis can cause some people to yield to their “fate” without a
struggle. Their reaction can quickly shift, however, so exercise caution
as you approach a breathing, but immobile person underwater.
Assisting Panicky Divers

Dive instruction trains our bodies and minds to deal effectively with the
challenges associated with using dive equipment and dealing with the
underwater environment. A diver in panic loses self-control and forgets
the training that made him safe. This is why panic is so dangerous to the
diver and to his buddy. A diver in this state makes no rational choices,
only reacts to his fear, usually complicating the original situation that
caused the panic in the first place.
44
Diver in Distress on the Surface
Assisting a panicky diver will hinge on our remaining part of the soluti-
on and not becoming part of the problem. This will mean that we remain
out of reach of the diver until we have decided on a course of action. On
the surface a panicky diver reacts to anything within close proximity.
The prudent course for the rescuer to follow is to keep at least 15 ft.
(5m) away to avoid becoming a target of the diver’s intentions. At this
distance, the diver in distress may not even acknowledge the approach
of the rescuer. Attempt to establish contact with the diver by shouting
or waving. If the diver responds, instruct him to inflate his buoyancy
compensator and/or drop his weight belt. Watching the diver’s response
will give you a good clue to his mental state.
Often just establishing positive buoyancy will cause a diver to calm
down. If the diver fails to respond to regain control, you may have to
inflate the buoyancy compensator for him. This is best done from behind
the diver, out of range of his grasp. You may be able to swim around him
to do this, or you may need to submerge and then surface behind him.
Most any person in distress in the water will experience an alteration
in breathing pattern. Typically this will be rapid, shallow breathing or
panting. This is very inefficient as full ventilations are required to exch-
ange gases effectively. As a result the diver will increase the feeling of
suffocation and panic. This condition will rapidly result in exhaustion
due to hypoxia (lowered blood level of oxygen) and the increasing sen-
sation of air starvation due to the elevated level of the “breath trigger”
gas, carbon dioxide.
To return the diver’s blood gases to normal, many water rescue
experts suggest that you should instruct the diver to lie back and take
several deep breaths. This will very often transform a diver in distress
into just a tired diver who could use some help in getting back to the
boat or shore. During this tired diver tow, it is important to keep talking
to the victim. Reassure him that you are helping and that you’ll soon
be back to safety. Encourage him to replace his mask and regulator if
surface conditions are choppy. A wave in the face at this stage might
start the panic syndrome all over again.
45
Panic is the greatest single cause

of diving accidents. Unrelieved
stress and accumulating problems
produce panic. Be alert to the
signs of stress and panic. Deal
with apprehensions and anxiety
before they become worse.
46
Scuba I.Q. Review
1. What are some common sources of pre-dive stress?
2. How might you recognize stress in your dive buddy?
3. Describe some ways you might help reduce pre-dive stress in yourself
and a buddy.
4. How can visualization be helpful to a scuba diver?
5. What factors may cause stress and panic in a diver while underwater?
6. What dangers does the rescuer face when attempting to help a panicky
diver?
7. Why do alterations in breathing patterns affect a struggling or panicky
diver?
47
Chapter 3: The Causes of Diving Accidents
48
The Causes of
Diving Accidents
How Diving Accidents Happen

In any recreation pursued as actively as scuba diving is, an occasional
accident is inevitable. It is a tribute to recreational diver training stan-
dards, and instructors, that interested persons can usually be trained to
adapt and operate so safely in an unforgiving environment. There is a
persistent perception that scuba diving is highly dangerous, but it is less
so than downhill skiing or even bicycling, both of which have higher
accident rates. Most years more people in the US are killed by lightning
strikes than by scuba diving accidents. In fact, scuba diving ranks below
bowling in accident incident rating.
Exceeding prior experience and training

Ideally every dive will expand your underwater skills and knowledge so
that you continue to pile up new techniques and solutions to problems.
One way to provide yourself with growth opportunities is to find more
experienced divers as potential dive buddies. Dive shops are a great
place to find others who are looking for buddies. The shop itself may
sponsor diving events that allow you to participate at your own level
and still learn as you go. By participating in additional training with
your instructor through your local dive store, you will get to know many
other divers in your area.
Without participation from better trained and experienced divers,
novices may find themselves in difficulty if they undertake dives that
surpass their ability. The first deep water dive, the first boat dive, the first
49
night dive and many others may pose significant risks if proper planning
and preparation doesn’t precede these activities. Certain classes of di-
ves, such as those deeper than 100 ft. (30 m), penetration wreck diving,
cave diving and ice diving require specialized training before divers can
engage in them properly. Ask your TDI/SDI instructor about advanced
training available. You’ll not only be safer, but find that diving is also a
lot more enjoyable, too.
Accidents are often caused by divers exceeding their level of training.

Operating in overhead environments calls for special preparation.
Without participation from better trained and experienced divers,

novices may find themselves in difficulaty if they undertake dives that
surpass their ability. The first deep water dive, the first boat dive, the first
night dive and many others may pose significant risks if proper planning
and preparation doesn’t precede these activities. Certain classes of di-
ves, such as those deeper than 100 ft. (30 m), penetration wreck diving,
cave diving and ice diving require specialized training before divers can
engage in them properly. Ask your TDI/SDI instructor about advanced
training available. You’ll not only be safer, but find that diving is also a
lot more enjoyable, too.
50
Cold or tired diver
A person in the water loses heat to the water many times faster than to
air of the same temperature. Even in water at 80°F (26°C) a diver will
eventually start to feel chilly after enough exposure. In fact the American
Red Cross defines cold water as less than 70°F (21°C), a temperature
that suggests that many of us dive in cold water year round. Wet suits
are selected by thickness from 1 mm to 7 mm for the thermal protecti-
on they provide to divers in relatively warm to relatively cold waters.
Below temperatures of about 55°F (13°C), however, many divers will
choose to wear a dry suit, especially if they will be performing multiple
dives. Nevertheless, any time we lose heat faster than we can produce
it, we will eventually be affected by the cold. Apart from the effects
of deep hypothermia which will
be discussed later, the cold diver
will experience a loss of energy
and stamina.
Diving requires an output of
energy, despite the peacefulness
of the surroundings and the ease
with which we glide through the
water. Using the large muscles
of the legs to propel ourselves
through a thicker than normal
medium, carrying and wearing
heavy equipment, and some-
times having to swim against
currents, we often expend more
calories than we realize. Add
to this an entry through surf or Hypothermia is a factor in many
diving accidents. Wear an expo-
over rocks, climbing out of the sure suit appropriate for the
water up a vertical ladder or conditions and know your limits.
hauling a camera and strobe or
loaded game bag and the limits of our endurance may be reached before
the dive is finished. A good level of physical fitness is a prerequisite to
enjoyable diving; without it we may find ourselves unable to get to the
exit point without assistance.
51
Muscle cramps
Long swims may cause muscle cramps. Contributing factors include cold water,
dehydration, fins or fin straps too tight, or lack of physical conditioning.
The physical fitness component may also make itself known during pro-
longed exercise when a diver develops muscle cramps. These are typi-
cally in the legs and most often in the calves and feet, though hamstring
cramps are frequent as well. Prevention is always the best cure, so divers
should strive to stay in good diving condition even in the “off season.”
A cramp, or forceful, continuous and involuntary muscle contraction,
is caused by a muscle outworking its available blood supply. It may be
brought on by sustained effort, poorly fitted fins, cold water, dehydration
and inadequate nutrition. Cramps may be prevented by regular exercise,
drinking plenty of clear fluids during the diving day, and wearing boots
and fins that fit properly and keep you warm. Foods high in potassium,
such as bananas, help the body maintain a good sodium to potassium
ratio during exercise and will reduce the problem.
52
Overweighted diver
Many divers tend to forget that the reason they wear a weight belt or
use an integrated weighting system is not to sink more easily, but to
neutralize the buoyancy of their exposure suit. These divers, who may
carry 5-10 lbs. more than they need, will rationalize their bad habit by
stating that their BC will keep them afloat. The fact is, however, that
we should never carry so much weight that we sink from the surface
even with no air in the BC. Over-weighting is a dangerous practice and
may lead to a diver’s inability to remain on the surface in the event
of unconsciousness or exhaustion. Over-weighting may be a significant
contributing factor why the diver is in trouble to start with.
Good diving practice dictates that a diver should be neutrally buoyant
at all times on a dive. On the surface we may choose to make ourselves
more buoyant by adding air to the BC so that we’ll stay higher above the
surface. This can help keep our faces out of the waves and make it easier
to talk to our buddy. Over-weighting makes it all the more difficult to do
this and may even require that we fill the BC to capacity to stay afloat.
This in turn will result in some difficulty swimming or reaching and
handling other equipment. Ideally we are properly weighted when we
exhale and sink slightly in the water. When we take a breath from the
regulator, we should rise until our face is just above water level.
Over-weighting can sometimes be inadvertent as when a neutral-
ly-buoyant salt water diver dives in freshwater or when new equipment
is used for the first time or even if a different size tank is used. We need
to remember that different circumstances may call for adjustments to
our ballasting system.
Currents
Surface currents may pose a significant problem for divers in some
areas. On the ocean we are affected by tides and wind-generated surface
currents. While surge is mainly considered an underwater feature, its
effect is still evident on the surface and may sweep a diver away from
an exit point on the boat or shore.
Tides are predictable and generally well understood in local areas.
A common misconception, however, is that tides simply come in and
53
go out. After all, if we stand at the shore and watch the ocean, we see
that the water level rises and falls over a period of time. We can easily
believe that the water simply runs out and then comes back. The reality
is that tides always have direction and close to shore that direction is
almost always parallel to the shoreline. Divers planning their entries
and exits need to take this into account to avoid a long, exhausting swim
back against the current. Note current direction and speed by observing
the way buoys or visible kelp lean with current and plan your route
accordingly.
Avoid accidents by:

• Staying within the limits of your
training and experience.
• Keeping in good physical condi-
tion.
• Maintaining your equipment in
good working order.
• Practicing neutral buoyancy.
• Getting sufficient rest before
diving.
• Staying hydrated and nourished.
Surface currents where boat diving operations are planned may
present an even greater problem for divers in the water. Currents may be
too strong to swim against and sweep divers away from descent lines or
from the boarding platform. The direction of any currents present can be
easily determined by the direction in which the boat streams in the cur-
rent when on anchor. Bear in mind, that small, flat-bottomed boats such
as inflatables may be affected as much by the wind as by the current. A
careful boat captain will trail a long, floating drift line aft of the boat to
ensure that divers who are swept past the boat can haul themselves back
against the current. Another prudent idea is to run a water-level line
from the entry point to the descent line. Very often the descent line is the
boat’s anchor line off the front of the boat, and the entry point into the
water is off the stern or side of the boat. A line between these two points
(typically against the current) will allow divers to reach the descent line
without a difficult swim before the dive starts.
54
Pounding surf and rocky shorelines are a dangerous combination for divers.
Even on rough days there may be calmer water behind breakwaters and
jetties.
55
Rips are another surface current that can cause difficulty to the diver.
By definition they are relatively high speed currents that move out to sea
from the shore. Rips may be produced by high tide waters accumulating
behind barrier reefs and then flowing seaward with great force as the
tide changes. Many coral atolls are famous for their high water induced
rips and present the diver with a localized, but powerful, out-bound
current. In addition high tide waters may collect in small coves that also
serve as the outlet of rivers. The combination of the falling tide outflow
from the accumulated high tide water and the river flow may produce
very significant currents that can easily overpower the diver.
In the marine environment, tides may set up longshore currents and rips. Rips can
be identified by streams of foam set perpendicular to shore, while longshore cur-
rents show themselves as irregular lines of foam running parallel to shore.
Rips may also be produced by currents that move parallel to the
shoreline. Tides are the most frequent causes of “longshore currents,”
though they may also be caused by persistent wind and wave action
moving together in the same direction. When these longshores meet an
underwater obstruction, a portion of the water is diverted directly out to
sea, producing a rip. Almost any beach will demonstrate such rips that
come and go with tidal flow.
56
A good guide to the presence and location of rips and longshores
is the presence of foam or discolored water moving in straggly lines
across the surface of the water. Rips will run into and be collected by
longshores. A diver’s pre-dive scene survey should include looking for
and noting the location of these currents. In particular the diver’s route
should consider planning an exit away from rips, though the entry may
be in a rip to speed the diver outbound, especially when entering in surf.
A rescue diver might also use the power of a rip to speed him to the
scene.
Escaping from rips and longshore currents usually requires the
same method, i.e., swimming perpendicular to the current. Both rips
and longshores are normally narrow flows and are soon left behind. The
important thing is not to panic, to swim at a comfortable pace and plan
exactly where the ideal escape point should be. Though often locally
powerful, rips tend to dissipate quickly as they move away from their
source. Be patient, keep control, stay positively buoyant and you’ll
likely soon be clear of its effects.
In any case vigilance on the part of divers in the water and observers
onboard dive vessels or on shore is essential to notice early stages of a
diver having difficulties. Currents are relentless and unforgiving while
the diver’s stamina is limited. Rapid and appropriate intervention will
save a situation from evolving into an exhausted-diver rescue.
Ocean Currents
• Tides, rips, and longshore cur-
rents can be overpowering if you
try to swim against them.
• Start your dive against the
current when you’re fresh, warm,
and have plenty of air. Use the
current to help you back.
• Learn to pick out evidence of
surface currents before you dive
so that you can accommodate
them into your dive plan.
57
Freshwater diving
Freshwater is also often characterized by the presence of currents. In
general, the current velocities in moving freshwater far exceed those in
the ocean. Diving activities in rivers and streams must take into account
the forces that act on the diver’s body due to drag, and these forces
may be considerable. An ocean rip or tidal flow may move faster than
a diver can swim, but river speeds may push and tumble a diver out of
control. In addition an ocean diver will probably not encounter the kinds
of underwater obstructions that the river diver will face.
In areas of strong surface currents, the dive boat should have a drift line
floating down current for divers to hold onto while waiting their turn to
board the boat.
Fallen trees, numerous abandoned monofilament fishing lines,
and bridge pilings are just a few of the underwater hazards in rivers.
A diver snagged in the branches of a submerged tree faces a life-thre-
atening emergency. Current velocities of only 5 knots (1 knot = about
100ft./min. or about 6 miles per hour) will exert a force of more than
575 lbs. on an upright diver and nearly 100 lbs. on a horizontal diver.
River flow can easily exceed 2 or 3 times this speed, making a diver
tangled in an underwater obstruction in dire circumstances, indeed.
With a force a thousand pounds or more pressing the diver farther into
the entanglement, his chances of self-rescue are remote. Divers should
58
never enter water moving at speeds greater than just a few knots unless
they have been specially trained for such environments.
Other currents operate in rivers, as well. Whenever an obstruction
emerges from moving water, a predictable eddy or current reversal will
form downstream of the object. This eddy moves exactly in the opposite
direction of the main flow of the stream. Current reversals are typically
found below (downstream) bridge pilings, emerged rocks and outcrops
that protrude into the current. Since these reversals are predictable from
the observable topography, divers and boaters can take advantage of
them to exit from the main current either in mid-stream or along the
shoreline. Divers in distress on the surface will frequently be carried
into eddies where they can be reached and assisted.
Freshwater diving is often characterized by strong currents. Directly down-

stream of an emerged object there will always be a current reversal, an eddy
that moves upstream.
Objects that do not emerge above the surface of the water may
produce treacherous reversals called hydraulics. Hydraulics are actually
vertical eddies that constantly recirculate below (downstream) the sub-
merged object. The danger is that a diver may be carried to and pinned
on the bottom by the relentless current. In strong currents escape may
be very difficult, though the diver has a much better chance of escape
than a pinned swimmer or boater. Most persons who are drowned in
59
hydraulics are pinned long enough to run out of breath. A diver has the
advantage of an air supply, exposure suit and buoyancy compensator.
The recommended method of escape is to swim on the bottom as deep
as possible to emerge downstream. If the obstruction causing the hy-
draulic is only a rock or small shelf, it may be best to swim out to the
side to escape the direct effects of the hydraulic. Surfacing too soon may
result in being carried back upstream by the reversing current and pulled
underwater again, a cycle that may be repeated several times.
Diving in fast moving rivers is

extremely hazardous.
• Flowing water is enormously
powerful and can easily sweep a
diver away.
• Underwater entanglements may
pose greater safety risks in rivers
than in still water.
• Be especially wary of eddies,
hydraulics, and strainers.
• Anything that interrupts the
main direction of a river current
will result in current reversals that
can trap a diver underwater. Learn
to read the river.
Standing wave
Backwash Boil line
Reversal
Submerged rock
or dam wall
Anatomy of a standing wave and hydraulic.
60
A special example of a hydraulic is a low-head dam. This is a
truly dangerous aspect of river diving. In a low-head dam flood waters
are held back by a low wall that simply allows high water to over-flow
and be carried downstream. Typically these passive water control dams
have no release gates that can be closed to remove a trapped person. A
person trapped, therefore, is caught in a hydraulic that extends across
the entire river, making escape to the sides more difficult. An underwa-
ter swim on the bottom is probably the only realistic method of escaping
these killer currents.
Gear problems
Well maintained diving equipment rarely fails during a dive. Since this
equipment is manufactured for life-support and the diver’s life and
well-being depend on it, it is only reasonable that a thinking diver will
look after it. Annual service for regulators and buoyancy compensators,
as well as certified inspection for scuba cylinders, is one good way to
guarantee that the equipment will perform as required when it’s really
needed.
Regulators will usually malfunction in one of two ways. Most likely
is that a regulator will “free-flow,” i.e., deliver air flow continuously
even though the diver is not attempting to inhale. Sometimes this caused
by a deviation in the intermediate pressure being released by the first
stage, which in turn forces the second stage to open and allow the air
out. In other instances we associate a free-flow with the growth of ice
in either the first or second stage valve mechanisms. The water does not
need to be cold for this to happen; a deep dive with its associated high
air demands and thus cooling effect of air passing through valve stems,
may be sufficient to cause ice to form. Water temperatures of less than
50°F (10°C) will be cool enough to bring about this effect.
In either case a free-flowing regulator is not necessarily an immediate
crisis. It’s certainly possible to breathe from a free-flowing regulator,
though the diver must be careful not to seal the lips completely around
the mouthpiece. The trick is to permit sufficient air to escape so that the
lungs do not over-inflate. This is not at all difficult, though the diver
would be wise to practice this technique by simulating a free-flow by
gently pushing the purge button on the second stage. A note of caution; a
61
© 2001 S. Barsky. All rights reserved.

Backwash to face
of dam
Boil Line
Outwash
Water flow over a low-head dam.
Powerful hydraulics are formed in moving water. The circular motion when
water drops even a few feet can pin a person to the bottom.
62
full-blown free-flow may well propel the second stage out of the diver’s
mouth. Also, a slow free-flow often progresses into a full free-flow with
a resulting rapid loss of air. With this in mind it would be sensible to
terminate the dive when a free-flow begins.
Another type of regulator malfunction is a “freeze up.” Again a phe-
nomenon generally associated with cold water, a freeze up occurs when
water in the air supply forms a chip of ice in the air passage of the first
stage and thus blocks further air flow. The source of this water may be
from the scuba cylinder itself, if filled from an inadequately maintained
compressor. TDI/SDI recommends that divers take their tanks for fills
only to certified fill stations. This is the best way to ensure that the air is
dry and contaminant free.
Water may also enter the first stage if the dust cap is not replaced
after every dive, or during the post-dive washing/rinsing process.
This serves to highlight the importance of drying the dust cap before
replacing it after a dive. No water should ever be permitted to enter
the exposed portion of the air intake on the regulator’s first stage. For
the same reason, the purge button of the second stage should never be
pressed while it is underwater and not pressurized from the tank. Water
may seep into the second stage and find its way up the hose to the first
stage. This may result in a freeze up or free-flow, due to icing, when the
regulator is next used.
Given enough time and use, nearly every device will fail. This also
holds true for regulator hoses. Hose protectors are the best way to ensure
that constant flexing and handling will not prematurely deteriorate the
hoses, but eventually any hose can fail and rupture. On the surface a
hose may fail with an explosive bang and hiss of escaping air that will
startle anyone standing nearby. Though no real damage to other parts
or injuries to persons are likely to result from this, the dive obviously
cannot go ahead until the hose is replaced.
Hose failure underwater also occurs. The sound is dampened, of
course, but still obvious, and the constant hiss of bubbles confirms what
has just happened. High pressure hose breaks are usually quite loud,
even underwater, but the amount of air lost is both constant and rela-
tively small. A low pressure hose break will dump air much faster due
to larger hose diameter and the fact that the first stage will deliver air
63
at a higher rate in deeper water. Several hundred pounds of air pressure
may be lost before the diver reaches the surface. For this reason any
hose break spells the immediate end to the dive. This is also part of the
reason that the 500 p.s.i. end pressure rule was originally developed.
The practice of “running on empty” or completely depleting the tank
contents puts the diver at risk of catastrophic air loss if a hose breaks or
a free-flow occurs.
Other gear problems may occur during a dive. A broken mask strap
or fin strap may cause the loss of these items. Most often, however, the
diver will complete the entire dive without even knowing that a strap is
broken. Water pressure often keeps the mask in place and suction in the
foot pocket of the fin keeps it on without benefit of straps. Still, these
items may be lost or dislodged underwater, and the prepared diver will
know how to adapt.
Our eyes can only see clearly when there is an air space in front of
them. This is the reason we need the mask in the first place, to preserve
the air space. Looking for a dropped or dislodged mask on the bottom
can be difficult since our eyes will not be able to distinguish the mask
from the background clearly. We can simulate a mask by creating a
temporary air space that may give us enough time to locate our mask.
Cup your hands around your eyes and collect bubbles of exhaled breath
in these pockets. Air will leak from the pockets you’ve created, but
you may have time to see where the dropped mask is and retrieve it.
Remember to keep your head down to help hold in the trapped air.
If a fin is lost underwater, you may be able to find it if you know
where to look. The older style black rubber fins will always sink to
the bottom, while thermoplastic fins will normally rise to the surface.
It’s a good idea to test your fins to find out how they will act both in
freshwater, where they may be in mid-water, and in salt water, where
they float at the surface. If the fin cannot be found, consider using the
dolphin kick while swimming. The foot without the fin can be locked
behind the foot with the fin and both legs can be used to propel you. You
can get a surprisingly powerful kick using both legs and only one fin. To
ease the recovery of a lost fin, some divers attach brightly colored tabs
to the straps. The tabs are used to help pull the straps on and off the boot,
but also serve as great visual aids in locating a lost fin.
64
Injuries
Divers may be injured on the surface by means that really have nothing
to do with diving. For example, we typically dive around boats and are
therefore always at some risk of being threatened or even struck by a
passing boat. In fact, it’s not a rare occurrence for a diver to be run over
by his own tending boat. From the point of view of our own safety we
seek to minimize this danger through the use of dive flags.
The most widely recognized flag is the red and white Diver Down
flag. Ideally this should be flown directly over the submerged divers. To
provide an even greater level of safety divers should seriously consider
towing a buoy with the Diver Down flag displayed.
A second flag that indicates the presence of divers is flag “Alpha.”
This flag gets its name from the fact that it is the letter “A” in the flag
alphabet. Technically, this flag should be flown on the dive boat as it
specifically indicates a vessel which is unable to maneuver due to the
presence of divers below. As such it is commonly seen being flown
from a vessel that has divers below who may actually be working on an
underwater job, either on the bottom or perhaps even making repairs to
the vessel itself. For this reason it is often referred to as the “commercial
diver’s flag,” though this is misleading. If the dive boat is at anchor and
there are divers in the water, it would be appropriate to warn other boa-
ters to the fact of divers in the water. The divers themselves should tow
the Diver Down flag to indicate
their exact position.
The Alpha flag is a warning
to boat operators that means, “I
have a diver down. Keep well
clear and at slow speed.” Con-
versely, regulations regarding
the sport diving flag vary from
state to state, and sometimes
from county to county. Be sure
to check local regulations in
your area. The use of the Alpha flag bestows spe-
cific rights of location to the dive scene.
65
Keep in mind that diving in marked or accustomed ship channels
will call for special permission from local authorities. In addition, other
local “off limits” areas may be closed to divers.
Despite these precautions, accidents do
happen. Divers on the surface may be very
seriously injured, even killed, by boats.
Head injuries are a typical result though
broken arms, collar bones and neck injuries
are frequent, as well. Head wounds may
bleed profusely and neck injuries may re-
The Alpha flag is used to indi-
sult in severe compromise to motor skills,
cate that a vessel is restricted in feeling and even the ability to breathe.
its ability to maneuver because Handling a head or neck injured person re-
it has divers in the water. quires great skill and practice. Always call
for professional assistance in these cases.
A propeller injury from a boat that passes completely over a diver on
the surface may be a horrific sight. Prevention of blood loss and subse-
quent shock, treating open wounds, and dealing with the expected head
and neck injuries make the first responder a potential life saver. Training
in first aid and the presence of a good first aid kit will be necessary to
keep the patient alive long enough to reach definitive emergency care.
Are you ready?
Other non-diving hazards that the diver will face is the sometimes
rocky shoreline from which so many of our best dives start. Wearing or
carrying nearly a hundred pounds of equipment over jagged or slippery
rocks is an invitation to leg and ankle injuries. Most of these accidents
will take place before the diver even enters the water. Still, they are dive
site injuries and we need to be prepared for the eventuality. First aid
training that includes on-scene treatment for sprains, bruises, scrapes
and cuts will make the dive rescue specialist an invaluable part of the
dive team. Have a first aid kit that includes cold packs for bumps and
sprains, heat packs for cold fingers and toes, small to large Band-Aids,
absorbent dressings and tape for larger cuts and scrapes, elastic wraps,
sterile water, tweezers, shears or scissors, seasickness pills, sunblock
and burn cream, and a first aid manual. For a complete inventory of a
rescue diver’s first aid kit, see the Appendix.
66
Most dive site injuries are minor

and have little to do with actual
diving. Be prepared to deal with
strains, sprains, cuts, and scrapes.
Hyperthermia
A somewhat unexpected environmental injury is hyperthermia or ele-
vated body core temperature. We may probably be more used to the idea
of a drop in the body core temperature while diving, so that over-heating
tends to get over-looked. Divers in full wet suits or in dry suits, however,
may be at risk in warm conditions if there is delay in getting into the
water or if they exert themselves carrying gear to the dive site.
Normally, our bodies produce more heat than we actually need, so
we have several mechanisms for getting rid of excess heat. Perspiring
and losing heat through evaporation is a familiar method for dumping
heat. We may even douse ourselves with water to hasten the process. We
also lose heat by warming the air in contact with the skin. This process
is called “conduction” and is the same method we use to warm the water
in our wet suits. Fanning ourselves or standing in a breeze removes
the warmed air from around our skin and from inside our clothes by a
process called “convection.” Lastly, we emit infrared “radiation” which
also results in a heat loss. Note that all these methods take place on the
skin. Once we put on a wet or dry suit, we are effectively cut off from
the outside and can no longer transmit surplus heat to the environment.
That is, of course, the whole point of the exposure suit.
Hypothermia
The effects of cold-water immersion are insidious, creeping up on us,
sometimes unnoticed until the diver suddenly feels cold. The diver’s
exposure suit traps heat for varying lengths of time depending on the
water temperature, and type and thickness of the suit. As our body core
67
temperature drops with prolonged exposure, we begin to undergo phy-
siological changes that diminish our senses of awareness and survival
skills. We fight the effects of heat loss in two ways, by increasing heat
production and by decreasing heat loss.
We produce heat through normal metabolic processes and
through direct muscular activity. If our present level of activity is insuf-
ficient to maintain a body core temperature of at least 97°F (36°C), we
start to shiver. Shivering is actually an exceptionally effective method
of producing heat and, from the point of view of the rescuers, always a
good sign since it indicates a body that is still fighting heat loss. As the
body continues to cool, shivering may become much more vigorous,
even violent, as the body becomes desperate to keep the core and brain
warm. The brain also directs the body to take action to conserve heat as
much as possible. The vast majority of heat is lost through the skin via
the mechanisms outlined earlier. This heat is transported to the skin by
the circulation which carries it up from the core. To prevent this heat
loss, the brain constricts the blood vessels under the skin and instead
directs the circulation to shunt the blood between itself, the lungs and
the major organs only. The skin and extremities are allowed to cool as
the brain attempts to conserve heat and, thus, life.
Divers facing uncontrolled heat loss will eventually lose their ab-
ility to think rationally and to function normally. This is an exceedingly
dangerous situation for a diver who may need to make a number of
survival choices, most of which will require good motor skills. Fingers
become so numbed that weight belts cannot be dropped, masks remain
uncleared and all thoughts of the buddy system disappear.
All divers must remain alert to the challenges imposed by tem-
perature considerations. Frequent buddy checks need to be completed
to ensure that all divers are comfortable during the dive. Knowing that
a typical agreement between divers is that when one diver is cold and
wants to go back that all will go back puts the cold diver in the position
of “ruining” everyone’s dive. We all need to be sensitive to the exposure
that each of us faces, and conduct the dive accordingly. Never expose
your buddy or any other member of the dive group to hazards or circum-
stances for which they are unprepared.
68
Case histories
Understanding the most frequent causes of diving accidents, and reading
first-hand accounts and reconstruction of investigated accidents, often
leaves the rescue diver breathless with the degree of misfortune (and,
sometimes, stupidity) that befalls their fellow divers. Below is a brief
selection of accident descriptions, chosen from many, that highlight
how and why things go wrong underwater.
Case 1
A group of people in two boats traveled out onto the lake amid storm
warnings, and two divers entered the water for the purpose of inspec-
ting a submerged fishing net on the bottom of the lake. Visibility was
approximately 10 ft. (3 m) and the divers quickly became separated.
The first diver surfaced, waited a couple of minutes and dived again
to look for his buddy. The buddy surfaced looking for the first diver,
waited a couple of minutes and then dived to look for him. The first
diver surfaced again, looked around and immediately dived again.
The first diver found his buddy tangled in the fishing net on the
bottom, snagged by the tank valve and struggling to get free. The first
diver tried to cut his buddy out of the net, but ran out of air. He swam to
the boat through 7 ft. (2 m) seas and had the remaining people on board
call the Coast Guard. The Coast Guard responded, but had no diver. A
Sheriff’s department diver later recovered the buddy, still tangled in the
net.
Almost all dive accidents are

preventable. Decide what you’re
going to do before you do it. Pay
attention to what you’re doing and
stay alert.
69
Analysis:
1. A severe weather warning was in effect.
2. The first diver had about 100 logged dives; the second
diver was uncertified and had done only one prior dive.
3. The victim was using borrowed equipment and had no knife.
4. As determined in the autopsy, the victim’s blood alcohol level
was twice the legal limit.
5. No dive plan, emergency procedures or contingency plans
were discussed.
Case 2
Three divers arrived at a frozen lake to try their hands at ice diving.
None of the three had any experience at ice diving, but the “senior”
diver present was a certified Divemaster and had talked to other ice
divers about the techniques involved. A hole was cut in the ice just large
enough for a single diver to enter at a time. This meant that the first
diver in had to submerge to allow the second diver to enter. The first
diver in had a tending line attached to her BC with a locking carabiner
and was connected to the second diver by a buddy line which they held
between them. The Divemaster tended the divers and also was to serve
as the rescue diver in the event of a problem.
After about three minutes into the dive, the tending line went
slack and the Divemaster realized that the divers were off the line. He
donned his equipment and, holding a line 50% longer than used by the
women and tied off on a stake driven into the ice, started a search for
the missing divers. He swam a complete circle around the hole, hoping
to snag the divers, but without success. He then did a bottom search
at the extent of his line, again without success. During this search he
discovered that part of the area they were diving had depths in excess of
90 ft. (27 m), though they believed the maximum depth in the area to be
30 ft. (9 m). He also made numerous ascents to the underside of the ice
and back down again from the deepest part of the dive. He reasoned that
he might still have missed the divers if they were just under the ice and
so tried to look everywhere at once.
70
The Divemaster eventually returned to the hole out of air and
frantic. He summoned help, but local police divers were unable to locate
the missing divers. Their bodies were recovered in the spring nearly
a quarter of a mile away from the hole. When found, both tanks were
empty and both women still had their weight belts on. The Divemaster
showed signs and symptoms of DCS and was recompressed at a local
facility.
Ice diving is a specialized activity requiring careful planning, plenty of top-

side support, and trained divers.
Analysis
1. Divers all exceeded their prior training and experience in a
very high risk situation. Diving under overhead environments
requires specialized, certified training. It is not sufficient to read
about it in a book. The dive group made many unforgivable
errors in procedure.
2. By definition, a dive tender cannot be the rescue diver. Rescue
divers must be fully-geared up and ready to enter the water in
seconds.
3. The rescue divers must be specially trained for these kinds of
high-risk diving applications.
71
4. The critical line signals used to communicate between the

tender and divers were made up on the spot. After the fact, the
Divemaster could not even remember what they were.
5. We will never know exactly why the divers became lost, but
speculation must account for the tethered diver deliberately
disconnecting herself from the line. Possibly they dropped the
handheld line and the second diver separated from the first. The
first diver may have swum after her buddy and felt she had to
release herself from the line to catch her. Once the connection
back to the hole is broken, it is virtually impossible to find the
hole again. The fact that the divers were found so far from the
entry point suggests that they, indeed, swam a long way looking
for a way out.
72
Scuba I.Q. Review
1. List four common problems that may lead to diving accidents.
2. Relative to the observer on the shore, in which direction do the tides
run?
3. What is one way of solving the problem of divers being unable to
swim back to the dive boat against the current?
4. What are rip currents? How are they formed?
5. Describe the danger of strainers to river divers.
6. Why are low-head dams and other hydraulics so dangerous to divers?
7. The water need not be freezing cold for a free-flow or freeze up to
occur. Why is this so?
8. What kinds of injuries might you expect to find on a diver struck by
a boat?
9. List four ways in which our bodies lose heat to the environment.
10. Describe the two main methods the body uses to manage heat loss
in cold water.
11. Discuss the dangers of diving in overhead environments without
specialized training.
73
Chapter 4: Responding to Emergencies on the Surface
74
Responding to
Emergencies on
the Surface
Recognition
Ultimately all scuba diving rescues and assists become surface rescues.
Indeed, most accidents happen at or near the surface, even if the situati-
on began to develop underwater. Our principle role as a rescuer in a true
underwater emergency will likely be to get the victim to the surface as
quickly as possible. It’s only on the surface that we can really give the
kind of assistance required for most serious diving injuries. There are
exceptions to this, as will be discussed in Chapter 5.
The kind of help we can provide to a buddy may take a large variety
of forms, depending on the nature of the problem. In this chapter we will
look at surface assists, towing of unconscious divers, in-water rescue
breathing and methods to remove a helpless person from the water to
the shore or dive boat. First, however, we have to able to recognize a
diver in trouble.
Staying alert to trouble

Despite the relaxing nature of scuba diving, we will always be better
prepared for an in-water or underwater emergency if we anticipate
problems. Not only do we need to have ready skills, but we also need
to pay attention to our buddy and to what’s going on around us. Divers
frequently become so inwardly focused as they cruise through their
surroundings that they miss important clues to trouble elsewhere. Keep
your ears open for the sound of approaching watercraft overhead, ban-
ging on a tank, a whistle or shout in the distance. Keep your eyes open
75
for the signs of a diver in distress or showing discomfort.
1. Encountering or observing a diver alone, whether on the surface or
underwater, could suggest that buddies are separated or that one surfa-
ced in haste.
2. Divers observed in unlikely areas such as breaking surf zone, amid
fishing or lobster trap buoys, in ship channels or over deep water without
obvious surface support may be divers in trouble.
3. Watch a diver’s bubbles. Prolonged intervals between breaths may
indicate skip-breathing or a continuous stream may indicate a free-flo-
wing regulator. Learn the difference between the appearance of bubbles
when a diver is surfacing from when he is swimming or stationary. A
diver surfacing produces a nearly continuous stream of bubbles that
appear to “spread” over the surface. Note that these bubbles are not truly
continuous as in a free-flow, but actually arrive at the surface in bursts.
A diver that appears to be surfacing, then swimming horizontally, then
surfacing again and again may be experiencing buoyancy or equalizati-
on problems.
4. Look closely at a diver who is very high in the water or very low in
the water. The first may have dropped the weight belt due to some emer-
gency and the second may be seriously over-weighted. The “heavy”
diver may disappear off the surface just by raising the arm to wave for
help.
Whenever possible, stay out of the

water when performing a rescue.
Only enter the water if the victim
is too far away to reach or for you
to throw a rescue aid. Throw bags
and life rings with attached lines
can save a victim.
76
Response options
Reach or throw
In any rescue situation we need
always to remember that our own
safety comes first. Though highly
motivated and perhaps even per-
sonally involved with the diver
in distress, we may accomplish
nothing if we ignore the risk to
ourselves in our response. In a
few incautious moments the situ-
ation may end up with one more
victim and one less rescuer. If
the person is within reach of the
shore or boat, you may be able to
Having or throwing a flotation device
stretch your arm out to help the in the water gives an exhausted diver
person to the boat or wharf. a place to rest on the surface.
To avoid being pulled in
Stay low and keep your center of gravity away from the edge when reaching
out to a person in the water.
77
Poor lifting technique! Keep your

legs bent and weight low when lifting
someone onto a wharf or into a boat.
Use a throwable device with a line attached to

it to pull a struggling person back to safety.
78
yourself, stay as low as possible and keep as much of your weight away
from the edge as you can. Not only is this safer, but it also allows you
a longer reach. Use an oar, boat hook, branch or even jumper cables to
extend your reach. If the victim is out of reach, the best action is often
simply to throw a rescue device to the person needing help. Examples of
throwable devices include life rings, throw bags and a personal flotation
device (PFD). Once the person in distress grasps the device, it is a sim-
ple matter of pulling him back to the boat or shore. This keeps us from
having to enter the water and is actually a speedier response.
Swimming rescues
In situations where we cannot reach victims from shore or the boat,
we may have to enter the water to assist them. Do not undertake long
swims unless you are certain of your ability to cover the distance and
return towing a helpless person. This may well be much more difficult
than you think unless these are practiced skills. The SDI Rescue Diver
course will help develop the skills you’ll need to do this effectively. The
rescue can be made easier and safer if you remember to take a flotation
device with you. Hand the victim the rescue device while you retain
your grip on it. Use it to tow the victim back. This provides the victim
A panicky diver is a significant danger to himself and everyone around him.
79
A swimmer who is dispatched to assist a diver on the surface can be pulled

back, together with the victim, by using an attached tether line.
The rescuer must possess good self-control and swimming skills to attempt a
rescue in surf and near emerged rocks.
80
with additional flotation and keeps him at least arm’s length away. This
may be important if the victim is panicky or might become so.
The best swimming approach to a person on the surface is the he-
ad-up front crawl. This allows us to observe the victim continually as
we come closer in the event they disappear off the surface. Stop and
observe the behavior of the victim from about 15 ft. (5 m) away before
coming any closer. If the victim seems under control, then close the
distance and extend the buoyancy device to him. Instruct the victim to
roll over on his back and to take several deep breaths. Most people in
trouble in the water will become short of breath and start to feel as if
they are suffocating.
Make it a point to talk to the victim as you continue the tow. Panicky
or distressed persons in the water are usually their own worst enemies.
Talking to them continually and reassuring them that you’ll soon be
back to safety will greatly assist their ability to regain self-control. Take
care not to exert yourself unduly; we may finish up with two victims and
no rescuers. It will be a major asset to you if you have attached a tether
line to yourself before beginning the swim. This way both of you can be
pulled to safety without the effort of towing a passive person. This also
leaves your hands free to deal with the victim more effectively.
Panicky diver on the surface

A panicky diver represents a considerable threat to himself and to all
others around him. The unreasoning fear that grips an out-of-control
person is self-perpetuating and may even be contagious. Being dragged
down by being over-weighted or over-burdened, not being able to bre-
athe due to a too tight wet suit, a too tight dry suit neck seal, a poorly
maintained regulator, feeling defenseless in slapping waves or strong
currents all can produce the surging fear that results in panic. Panic is
the loss of self-control. A diver in panic forgets the things he needs to
know and do to take care of himself.
Dive training is essentially constructed so as to condition our minds
and bodies to the fact that we are perfectly capable of breathing and
staying underwater for long periods of time. After all, this is not a na-
tural act, and we must learn to be comfortable while scuba diving. It is
81
our self-control and understanding through experience that allows us to
relax underwater. The diver, stressed by circumstance and vulnerable to
the environment, may panic.
Whenever possible, stay out of the

water when performing a rescue.
Only enter the water if the victim
is too far away to reach or for you
to throw a rescue aid. Throw bags
and life rings with attached lines
can save a victim.
A diver on the surface who is clearly in distress and struggling needs

assistance immediately. The longer the diver is overpowered by panic,
the greater the danger of exhaustion and possible drowning becomes.
Still, the responding rescuer must exercise caution in an approach to
a panicky diver. You should stop while you are still out of reach and
try to communicate with the victim. Sometimes the nearby presence of
another diver, calm and in control, will be reassurance enough to relieve
his sense of isolation. However, the panicky diver is so withdrawn and
A panicky diver needs assistance, but the rescuer must be mindful of his
own safety. Keep your distance until you can get control.
82
detached from rationality that he won’t respond to you at a distance.
If you decide that you must physically help the diver, inflate your
BC slightly first before approaching too closely. In case the diver
grasps you, you need to have enough buoyancy to prevent being pulled
underwater by a sinking victim. The possibility of having to retrieve
a sinking victim is very real, and a good argument for keeping your
weight belt on unless there is a compelling reason to drop it. The most
important immediate assistance you can provide, is to make the diver
fully buoyant. If your shouted instructions to inflate his BC are ignored
or the diver is unable to do this himself, you’ll need to do it for him.
Carefully circle around behind him and reach over his shoulder for the
inflator hose. Keep your other hand on his tank valve so that he can’t
easily turn around and intercept you. A panicky diver will likely see you
as a “stepping stone” to get himself higher out of the water. Keep him at
arm’s length until you’ve inflated the BC.
In many instances this will be enough in itself to calm a panicky
diver. In choppy conditions, and where the diver has discarded his mask
and regulator, he is still at considerable risk of inhaling water and being
blinded by spray. Assist the diver in recovering his regulator and turning
him away from the waves. If the diver remains out of control, you may
need to tow him directly back to the dive boat or shore. Talk to the diver
continually and reassure him that you both soon be in a safe place. He’ll
calm down eventually as he realizes that he’s no longer in danger of
sinking and that help is at hand.
You may not be able to approach too closely to a panicked diver
without making yourself a target of his attentions. If he reaches for you
and you’re within range, you will likely be in for a struggle and end up
losing your own mask and regulator. Your best course of action is to
fall back into the defensive position. Swim away on your back while
keeping your eyes on the victim. Underwater and out of sight of the
victim, bring one knee close to surface and extend your fin toward him.
If the diver gets too close, plant your foot on his chest and gently push
yourself away from him. In your haste to keep your distance, don’t
become alarmed yourself and kick the victim. This could easily cause
a serious chest trauma. Also, be very careful of the position of your
fin tips. They may be close to the victim’s throat and can cause him
83
considerable injury. Thermoplastic fins, in particular, can be worn down
to rough, sharp edges. Swim in the direction of safety; the diver may
follow you there!
If you’re within range of the victim’s reach and too close to adopt
the defensive posture, you may have to get immediate control of a pa-
nicky diver. You may choose to do this anyway if delaying assistance
leaves the victim in imminent danger such as being swept away in a
current or thrown against rocks in rough seas. As the diver reaches out
to you, you’ll respond by grasping his wrist with your opposite hand.
Pull the victim toward you hard. This will cause both of you to spin and
leave you directly behind the diver. Immediately reach over his shoulder
for the inflator, make him buoyant and begin the tow to safety.
To establish control immediately, or if you can’t get out of the way quickly enough,
grasp the victim’s hand or wrist as they reach for you to gain control.
Panic may overtake a diver without warning. In the same way you
may be surprised by the panicky diver in close proximity who suddenly
has you in a death grip. Even a relatively small person can exert in-
credible force when driven by panic, and can overpower the unwary
buddy. This is a very dangerous position for the rescuer who will likely
lose mask, regulator and buoyancy as the panicked diver tries to climb
up higher out of the water. At this stage you are both victims. Your
best avenue of escape will usually be to sink underwater. The last place
84
the panicked diver wants to go is down, so pursuit there is unlikely.
Dragging the victim down with you will usually result in your rapid
release. If you are unable to let air out of your BC and sink, you’ll need
to break free of the victim’s grip first.
As the diver’s arm encircles your head or neck, turn your face away
from the crook of his arm and toward his hand. Grasp his elbow with the
hand nearest the crook of his arm while grasping his hand or wrist with
your other hand. Push up on his elbow and pull out on his hand. This
results in your sinking and his arm twisting away from you. Immediately
get clear of the victim and prepare to get control of the situation. This
escape will work on both front and back assaults from panicky divers
and swimmers.
These defenses, escapes, and control moves are valuable assets for
any diver to possess. They are especially important for rescue divers to
master. In common with all specialized skills, practice and repetition are
essential to make them second nature. Always remember, that your own
safety is your primary responsibility. Be cautious and stay within your
level of training and capability when responding to panicky persons in
the water. You’ll always be safer and usually more effective if you take
a flotation aid with you.
Tired diver assist

The physical demands of scuba diving rarely manifest more than when a
fully equipped diver has to swim on the surface. The weight belt seems
to sag down around your ankles, the BC always seems to be in your face
and you can’t use your snorkel as easily. If it’s choppy, you’ll switch to
your regulator, but that doesn’t work as effectively in the air as it does
underwater. Especially swimming back after a dive, the diver is likely
to be tired and possibly chilled to start with; a long swim to shore may
just be too much. It’s no wonder that the most common rescue is the
tired diver assist.
It’s worth pointing out that a long surface swim is usually the result
of poor planning. A good plan will lay out a route that returns the divers
as close as possible to the exit point. A poor plan will not take into
account any existing currents and their direction, surface conditions
and prevailing winds. An additional common feature of the swim, be-
85
Pull hard to spin the victim around and then quickly inflate their BC.
Once they are fully buoyant, most people will calm down.
86
sides environmental conditions, is that divers tend to become inwardly
focused as they labor toward their goal. The consequence is that the
divers often become separated on the surface. It becomes less apparent,
then, when one begins to lag behind due to tiredness or muscle cramps.
Frequent buddy checks will prevent separation at the surface, as well as
save a search and the anxious moments that go along with it.
When you notice your buddy or another diver lagging well behind
the rest of the group, you should make an effort to establish contact.
It can be frightening for a less fit diver to be left behind, especially
if already tired. Early intervention can be crucial in preventing a tired
diver from becoming a panicky diver. Talk calmly to the tired diver
while you determine whether there are any other associated or potential
problems such as muscle cramps, overweighting, low air supply, too
much or too little buoyancy, cold, etc. It may be necessary to assist
the diver in the swim back by towing him. To do this, ask the diver to
stay on his back while you hold him by the tank valve. Make yourself
suitably buoyant and pull him with you. Most often the tired diver will
be able to contribute some finning to the effort after a few moments
rest. In any case, take the tow in good time so as to avoid over-exerting
yourself. If the diver is not your buddy, be sure to let your buddy know
when you go to assist someone else. He may be organizing a search to
look for you!
Diver in distress on the surface

Most diving accidents happen at or near the surface. A solo diver on the
surface may be simply orienting himself, resting or may have been the
victim of a diving accident. Until you get closer to the diver, you may
have no idea whether the diver is having an actual problem. Certainly,
it’s always appropriate to give the “OK” signal to a diver on the surface
to assure yourself that the diver does not need assistance. Lack of a
reply can be taken as an indication that the diver does have a problem.
He may, in fact, be unable to answer.
87
The most likely rescue you’ll ever

perform is a tired diver assist. Plan
your dive so that you have enough
reserve of energy in case of a diffi-
cult swim back to shore or boat.
Conscious Diver
A conscious diver will acknowledge your approach, which, as always,
should be slow and guarded. Visual clues will help you sort through
possibilities to assess the situation. What drew your attention in the first
place? Was the diver struggling? Listless? Floating on his back? As you
approach, note whether the mask is on, the regulator in his mouth and
air is in the BC. This might indicate that he ditched them in panic or a
struggle underwater. Is he exceptionally high in the water? This might
indicate a dropped weight belt and fully inflated BC which might in turn
suggest a too rapid ascent from depth.
Ask the diver to tell you his air pressure. The amount of air left
may also imply an out-of-air emergency and his actions may hint at
lung injuries or decompression sickness. Even if there are no obvious
indicators, keep your distance while you continue to talk, question and
gather information. Some barotraumas can cause confusion and a fee-
ling of exhaustion. Remain on alert for changes in the diver’s manner
and actions. The progression of some diving injuries rapidly accelerates
and things may change from moment to moment.
If the diver requires your direct assistance, you’ll need to be sure
that both of you remain buoyant throughout the assist. Adjust both BCs
so that you are both comfortable. The diver’s state of mind and changes
over the next couple of minutes will give you a good idea of the urgency
of the situation. If you feel that his condition is deteriorating, then you
could be justified in dropping his weight belt to reduce the drag. Always
drop the victim’s belt before you drop your own belt. Other clues may
88
A common rescue is the tired diver assist. Reassure your buddy that you can
help him, have him become positively buoyant and tow him from the tank
valve or BC. If conditions are choppy, ask him to keep his mask on.
It is easier and safer to tow your buddy if he can hold onto a flotation aid.
89
develop that indicate serious internal injuries such as excessive blood
from the nose and mouth (though a small amount of blood from the nose
may indicate a minor sinus squeeze), coughing, and the diver complai-
ning of chest or abdominal pains.
This injured diver may become truly helpless in seconds. Protect
his airway from spray and waves by cupping your hand over his nose
and mouth. Don’t pinch his nose and seal his mouth unless a wave is
about to break over him. Always tell him what you’re about to do this
and advise him to hold his breath. You should start signaling for help as
soon as you see signs that indicate more than just a tired or cold diver.
You’ll no doubt need help to remove the diver from the water, and could
probably benefit from assistance during the tow. Look for help early on
in the rescue which will not end until the diver is removed to safety and
has been thoroughly evaluated.
Unconscious Diver on the Surface

A diver on the surface who fails to respond is presumably in extreme
danger. While your initial approach will be cautious, the victim’s
non-responsiveness even to touch, signals immediate assessment and
life-saving action. Unconsciousness can be brought about by many me-
ans, drowning, barotraumas, hypothermia, and contaminated air supply.
Breathing alterations may also lead to blackout. Whatever the cause,
this is doubtless a life-threatening emergency, even if the victim is still
breathing. Immediate action is required by the rescuer. Unconsciousness
is always a medical emergency and will require attention from medical
professionals.
A diver face down in the water and without a regulator or snorkel
in his mouth is clearly not breathing. The first priority is to turn the
diver face up. If you approach the diver from the side or legs, simply
grab the BC and rotate him. His legs may be hanging below the surface
if he’s wearing a fabric or shell-type dry suit, making his body an “L”
shape. You may need to push him for a stroke or two to get his legs to
rise before he will roll. If you approach from the front, simply grasp his
hand with your opposite hand (right to right or left to left) and pull him
toward you. He’ll rotate naturally into the face up position.
90
Assess the circumstances as you

approach the distressed diver.
• Does he respond to your ques-
tions? Can he tell you what’s
wrong?
• Does his equipment appear to
be intact? Is he floating high in
the water because he dropped
his weight belt? Is his BC over-in-
flated?
• Have the mask and regulator
been discarded? Is he in danger of
inhaling water?
• Is his breathing pattern abnor-
mal? Coughing or choking?
Bleeding from the nose or mouth?
Rescue breathing should be started immediately with two initiating

breaths. Shout for assistance between breaths. Drop the victim’s weight
belt and add air as required to the BC. Fully inflating the BC will not be
necessary without the weight belt and will just get in your way as you
administer breaths. In an out-of-air situation, you may need to inflate the
BC orally to a workable buoyancy level.
A diver face up in the water who remains unresponsive to direct
contact may or may not be breathing when you arrive on scene. Deter-
mining breath signs may be very difficult in open water situations, even
if the diver is not wearing a hood. Regardless, you should take a moment
to look, listen and feel. The victim’s skin color may be a good guide to
respiration efficiency. A non-breathing or inadequately breathing person
will be cyanotic (blue tinge to the skin), though this skin color will be
evident in a hypothermic victim, even with (barely) adequate respira-
tions. Whether the victim is not breathing at all or just barely, rescue
breathing is called for. Persons with inadequate ventilations (that do not
sufficiently oxygenate the brain and body tissues, thus the cyanosis),
will benefit from rescue breathing. You are unlikely to harm a breathing
person by administering rescue breathing during an in-water rescue.
91
Rescue breathing
A number of scuba diving accidents can lead to life-threatening emer-
gencies. A non-breathing person in the water, whatever the cause, is
an emergency where every second counts. Rapid and skillful rescue
breathing may be the person’s best chance for survival, and the most
important talent a rescuer can bring to an in-water rescue. There’s little
doubt that the earlier that resuscitation efforts are begun, the more likely
the victim will benefit. For this reason we will always try to commence
rescue breathing as soon as we determine that the victim is not breathing.
Except in circumstances where conditions are too rough or otherwise
unsafe, or the transport to shore or the boat will take only a few seconds,
waiting until we remove the victim from the water may be too long and
the opportunity lost.
Look, listen, and feel to determine

if a person is breathing. Skin color
is a good clue to whether a person
is breathing. A non-breathing vic-
tim will show cyanosis (blue tinge
to the skin).
The earlier rescue breathing is
started, the more likely the person
will be resuscitated.
Find the rescue breathing tech-
nique that works best for you.
What we are attempting to do with in-water resuscitation is to
ventilate the lungs of the non-breathing person by inflating their lungs
with our exhaled breath. Despite the fact that we’ve already “used” this
breath, there is still sufficient oxygen left in it to make this of value to
a non-breathing person. Mouth-to-mouth resuscitation involves sealing
the mouth of the victim with the rescuer’s mouth, pinching the nose
closed to prevent air escape, and exhaling a full breath into the (adult)
victim. On the first exchange we deliver two breaths, back to back,
called initiating breaths. The victim’s lungs will expel the air naturally
after we deliver the breaths. On land we attempt to maintain a rhythm
of one breath every 5 seconds (12 breaths/minute). In the water, this is
92
much more difficult and, during a tow of the victim to safety, extremely
demanding. A better rhythm for use in the water is two breaths every 10-
12 seconds. This gives us more time to tow the victim, but still allows
for adequate ventilations.
There are a couple of aspects of in-water resuscitation that the re-
scuer needs to keep in mind. First, to be effective the breaths must be
clean and full exhalations. This means that we must make every effort
to ensure that we do not blow any water into the victim’s lungs and that
they fully inflate. This can be difficult in poor surface water conditions,
and will take considerable practice. Second, the breath exchanges early
on in the resuscitation effort are probably the most important. It’s worth
the time to set up, relax and administer the breaths properly.
Improperly sealed mouth and nose, missed breaths, or blowing wa-
ter into the lungs are an exercise in futility and waste valuable time. In
some circumstances it may even make more sense to delay the tow until
you have successfully completed several exchanges of breath. During
a long tow you may become far too tired to breathe for anyone but
yourself. The victim’s ultimate survival in this case may well depend on
how effectively you delivered those initial inflations. Third, delivering
relatively fresh air to the victim’s lungs does not automatically oxyge-
nate the tissues.
In order to transport gases through the body, there must be a beating
heart. Determining the presence or absence of a pulse in open water,
not to mention the effect of the rescuer’s own racing heart and mental
state, is problematic at best. Therefore, we simply assume a beating
heart until there is evidence to to demonstrate otherwise. While cardiac
compressions can be performed in the water, these will most probably
be ineffectual. In any case CPR is exceptionally difficult for one person
to perform in the water
A final point for the rescuer to consider is the wisdom of performing
actual mouth-to-mouth contact during rescue breathing. The recom-
mendation of most professional life-saving agencies and emergency
medical services is to employ a barrier or mask between the rescuer’s
mouth and the victim’s mouth. This is a matter of prevention of disease
transmission through orally-borne or blood-borne pathogens, as well as
simple preference to avoid direct contact.
93
Pocket-type masks can be used in the water, though their application
takes practice to use correctly. The principle problems are those of lack
of obtaining a good seal around the mouth, and not enough hands to
hold the victim, position his head, and hold the mask simultaneously.
The best position for the rescuer is to stay at the head end and place the
mask over the victim’s face. Maintaining the mask in place throughout
the rescue operation has the advantage of helping to keep water out of
the victim’s airway. Hold a finger over the air intake port to prevent the
entry of water in rough or choppy sea conditions. Other barrier designs,
particularly flat or strip types, are all useful, though not all are adaptable
for in-water use.
Rescue breathing techniques
It's best to tow the victim to a stable platform before performing rescue breathing.
In-water rescue breathing is a task, and may do more harm than good.
There is a large number of diver tow positions that a rescuer can use to
bring a victim to safety. Only a couple, however, are really well suited to
both towing and performing rescue breathing. Though the Do-Si-Do and
“chin carry” are the most popular and, perhaps, the easiest to do, there
are other techniques that may work equally well for you. Choose the
one the gives you the best result in the greatest range of circumstances.
94
“Do-si-do” technique (pronounced Doe-see-Doe)
The Do-Si-Do technique (so-called because the divers link arms in a
manner reminiscent of square dancing partners) can be performed from
either the left or right side of the victim. Most right-handed people, ho-
wever, find it easier to use the hand positions described below. Simply
reverse the hands to use the Do-Si-Do from the other side.
1. Position the victim on his back in the water.

2. From the victim’s left side, slide your left hand and arm between
his left arm and his body.
3. Reach under the victim with your left hand to grasp the tank valve
or collar of the exposure suit.
4. Rest your right hand on the victim’s forehead to extend the neck
and keep the airway open.
5. Use your left hand and arm to roll the victim toward you suffi-
ciently to begin mouth-to-mouth resuscitation. Use your right hand to
pinch his nose closed as you exhale into the victim.
6. It is recommended that you stop swimming when delivering
breaths to the victim. Position yourself to rise slightly in the water by
bringing your fins back under you. This will give you better control.
7. If surface conditions are poor, use the right hand to cover the
victim’s nose and mouth to prevent aspiration of water.
Towing and manipulating the victim over anything but the shortest
distance will always be much easier if the victim’s scuba gear is first re-
moved. Ensure that the unconscious, non-breathing victim is positively
buoyant by dropping their weight belt. Use only enough air to maintain
buoyancy and keep the victim’s airway clear of water and spray. Note
that putting too much air in the BC may make it difficult to get close
enough to reach the victim to perform rescue breathing. This is true of
your own BC as well. Once the victim’s weight belt has been dropped,
you may choose to release your own belt. As the tow progresses, you
will probably want to ditch the victim’s BC and tank, unless you cannot
maintain sufficient buoyancy without them. Your own scuba unit will
also impede your swim and should be ditched, especially on a long tow.
95
An exception to this might be if surface conditions are so rough that you
need to breathe regularly from your own scuba unit. In this case you
wouldn’t likely be performing rescue breathing anyway.
Note that many divers find the Do-Si-Do towing method quickly
tiring and somewhat difficult to perform on a victim larger than them-
selves. The tow position is not very streamlined as the victim and rescuer
are side by side. The Do-Si-Do does give the rescuer good control and
allows for close monitoring of the victim. This is particularly import-
ant if the victim vomits during the tow or resuscitation effort. If this
happens, roll the victim to keep his airway clear and be sure there is no
residue left in the mouth.
Chin carry technique

The principle advantages of the “chin carry” method for towing and
resuscitation is the increased speed the rescuer can swim with the victim
and the ease with which almost any rescuer can deliver effective rescue
breathing. The rescuer and victim are in alignment and the rescuer is
swimming on his back, allowing a very powerful fin stroke.
1. The rescuer makes the victim buoyant as described earlier.

2. The rescuer positions himself at the victim’s head and uses the
left hand, placed between the shoulder blades or center of the back, to
provide enough lift to keep the victim clear of the water.
3. Grasping the victim’s chin in his right hand, the rescuer cradles the
victim’s head on his right shoulder. Be careful with the hand placement
so that it does not put pressure on the airway or carotid arteries.
4. To start rescue breathing, the rescue will slide the right hand up
to the forehead to pinch the victim’s nose closed during the breaths. The
left hand must stay where it is to maintain sufficient lift.
5. When swimming, the rescuer slings his body under and in
front of the victim. This permits rapid swimming and protects the
helpless person from wave break. The right hand can easily be used
to seal the nose and mouth to help keep water off the victim’s face.
96
Removing a diver from the water
Sometimes the most difficult part of a water rescue is removing a helpless
person from the water. Even with a person’s scuba equipment removed,
the act of lifting and manipulating him can be an almost impossible task
without adequate forethought and preparation. In some cases speciali-
zed equipment may be required to assist a diver with certain injuries. In
all cases, the rescuer will benefit from the ready hands of other qualified
divers and support personnel. It’s worth remembering, too, that the re-
scuer has possibly just performed a huge amount of work. Don’t forget
that the rescuer, maybe yourself, will need assistance to avoid becoming
an exhausted/injured diver.
When in doubt, call for

professional assistance.
Backpack carry
When the rescuer reaches shore with the victim, he still faces the task
of bringing him up onto the beach and away from the water. If all else
fails, the rescuer could simply grasp the victim under the arms and walk
backwards, dragging the victim behind him. In circumstances of a flat
sloping beach and breaking surf, this may, in fact, be the only safe way
to do this.
In almost all other situations, including rocky shores, it may be
better to use the “backpack carry.” Even a relatively small person can
lift a large helpless person without much difficulty and perform a good
“carry-out.”
1. The rescuer stops the tow in water about mid-torso deep, takes off
his fins and stands up.
2. Position the victim on his back with his head toward the shore or
exit point.
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3. For a right-handed rescuer it’s best to stand on the victim’s right
side at about the victim’s waist.
4. The rescuer reaches across to grasp the victim’s his left wrist in
his left hand, and holds the victim’s right wrist in his right hand. If the
victim is so large that the rescuer’s hands cannot hold the wrists tightly
enough, grab the thumbs or sleeves instead.
5. To be most effective, the rescuer will lift up on the victim’s left
arm while pushing down on the right. This will cause the victim to rotate
around his own axis. Before the victim becomes face down in the water,
however, the rescuer sinks his own body underwater and the victim will
roll up on the rescuer’s back.
6. The rescuer stays underwater while he adjusts the victim’s posi-
tion on his back. The key is to maneuver the victim to rest as high as
possible with his arms over the rescuer’s shoulders and crossed on the
rescuer’s chest. Done quickly and properly, the victim’s face will not
even get wet.
7. When the rescuer rises from the water, the victim will ride easily
on his back and can be carried out of the water. In fact the rescuer will
need only one hand to hold the victim and thus has a hand free to grab
handholds there might be available.
8. The rescuer will gently lower the victim to the ground well above
water level and remove the hood, if present, and check a carotid artery
for the presence of a pulse.
A backpack carry
is a surprisingly
easy way to lift
and remove a
person from the
water.
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Turning the victim for the backpack carry.
Duck down into the water to position the victim.
99
The backpack carry

may be the only
way to move an
unconscious or
helpless person
over a rocky shore.
Once on shore, look, listen, and feel for breath sounds.
100
If there are following seas or incoming waves during this lift, the
rescuer should use the waves to help raise the victim onto his back. In
circumstances where the waves are dangerously high, however, it would
be wiser to wait for a lull between the breakers to do this, or any, lift. As
always qualified assistants are a plus on any rescue scene.
Two-person carry
The presence of a second rescuer
can greatly help in removing a per-
son from the water. The two-person
carry is an ideal way to use a second
person to share the load and is quick
to execute. The rescuers remove
their fins and position themselves
on either side of the victim. All
three should be facing toward the
shore. The rescuers will each drape
one of the victim’s arms over their
own shoulders and wrap their vic-
tim-side arm around the victim’s
waist or back. The rescuers will
then slide their free arms under the
victim’s legs and grasp each other’s
wrist. The victim will now be in
a sitting position on the rescuers’ If you have assistance on
shore, a two-person carry
arms with his back supported by makes the load easier to carry
their other arms. The rescuers will and gives the rescuers more
then simply walk out of the water stability.
to safety. When clear of the water,
they will set the victim down gently and check for breathing and a pulse.
In conditions of breaking waves and surf, it’s entirely possible for
a diver to be injured just getting in or out of the water. The same may
also happen to rescuers attempting to remove a person from the water.
Learn to use the waves as an aid to getting out of the water. Time your
movements so that you’re not constantly fighting the flow of water in
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Call for medical

help anytime a
diver becomes or
has been uncon-
scious.
For a diver with a head, neck, or other serious injury, use a backboard or
litter for transport to shore. Start by sinking the litter under the victim while
a rescuer maintains control of the victim’s airway and spine.
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Always buckle the top

strap first and ensure
that it passes under
the victim’s arms. This
helps prevent the vic-
tim from sliding down
the board in case it
has to be raised on an
angle to get clear of
the water.
and the backwash out. Plant your feet firmly as you feel the approach of
the wave and brace yourself for the impact. Since both rescuers should
move and stop together, it helps to have one of the rescuers call the stops
and starts for both. If there is a third rescuer handy, it would be most
advantageous for this person to keep the victim’s head upright and to
stabilize the neck. This gives more protection to a helpless person.
Recovering a person to a boat

Removing a helpless or unconscious person from the water and on to a
boat can be a daunting task. Most dive boats are relatively high-sided,
and you may not be able to reach the victim from the deck. Even infla-
table boats can pose problems. Although they are low in the water, their
“rail” is much wider than a standard boat, causing the rescuer to have to
reach far out to pull the victim on board.
Unconscious person lift

To lift an unconscious person out of the water by hand calls more for
good technique than strength. Position the victim as close as possible
to the side of the inflatable to limit how far you have to reach. Most
importantly, be sure to keep your center of gravity well within the boat
to avoid falling overboard. Keep low and position the victim with his
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Even with an inflatable boat, removing an unconscious or helpless person

from the water can be difficult. Keep your arms between the victim and the
boat, and use your legs to lift the person clear of the rail of the boat.
back to the boat. Reach under the victim’s arms so the your arms are
between the victim and the boat. This is important to limit the amount
of friction generated between the two. Grasp the victim tightly and lift
with your legs, not your back. It helps to wiggle the victim from side
to side slightly, thereby lifting each side in increments. When you can
brace your elbows on the top of the inflatable’s side, use your legs to lift
the victim until his waist is at the rail.
At this stage you can gently lower the victim to the deck, or even
better, take a step back into the boat and the victim will trail along with
you. As with all rescue techniques, this one will greatly improve with
practice under experienced supervision. With a very heavy person two
rescuers may be required. It will probably help to use a short length of
rope to give the rescuers something easier to hold on to. Again start with
the victim’s back to the boat.
Pass the rope under one arm, around the chest and under the other
arm. Cross the two ends of the rope behind the victim. Each rescuer will
haul up on the end of rope nearest him until the victim is in the boat. The
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From a high-sided boat, or if the victim is particularly heavy, a roll-up net

or some variation makes the lift a lot easier. In a pinch a tarp or a blanket
can be used.
rescuers should pull away from each other during this lift to keep the
rope tightly wrapped around the victim.
Roll-up net
Sometimes the victim is simply too heavy or the freeboard (height
above waterline) is just too high to reach the victim. In these cases the
rescuers might consider using some variation of a roll-up net. A tarp or
blanket will also work well. Attach the inboard edge of the net to the rail
or deck of the boat and drape the rest of the net in the water. Position the
victim on his back in the water and pull him across the net. Reach to the
outboard edge of the net and pull it back up to the boat. As the rescuers
haul the net aboard, the victim will roll up in the net and up to the rail.
At this stage remove the person from the net and gently lower him by
hand to the deck.
If there is no net, tarp, or suitable blanket on board, you might use
a length of rope (about 20-25 ft. 6-8 m) in a pinch. Attach the two ends
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Never lift a person with a suspect-

ed neck injury into the boat or on
shore without stabilizing the head
and neck.
Professional water rescue teams

are available in many areas and
have considerable expertise in
handling persons injured in boat-
ing and diving accidents. Your dive
plan should include local contacts.
to the rail or deck, or stand on them, about 8 ft. (2.5 m) apart. Find
the midpoint of the rope and attach it in a similar fashion. Now spread
out the two “V”s on the water. Position the victim as described above
across the Vs. Reach out to grab the points of the Vs and haul back as
before. Be careful that the ropes do not cross the victim’s neck during
the lift. With a thick rope this technique is surprisingly comfortable for
the victim.
The roll-up technique is generally fairly benign and will cause no
further injury to an exhausted or near-drowning victim, though it should
not be used if you suspect that the victim has a head or neck injury, or
broken bones.
Boarding ladder
A high-sided dive boat will usually have a ladder to aid divers in the
boarding after a dive. Obviously, an unconscious or seriously injured
diver cannot climb the ladder unaided. Two well-known techniques for
assisting an injured diver up a ladder are the “ladder carry,” and the “BC
carry.” Just a quick word of caution, both of these techniques require
considerable rescuer strength and practice.
The ladder carry starts with both rescuer and victim face to face at
the foot of the ladder in the water, the rescuer stripped of all gear, the
victim stripped of weight belt and scuba unit. The rescuer positions the
victim’s arms around his shoulders and wraps the victim’s legs around
106
his waist. The rescuer puts a foot on a rung of the ladder and uses that
knee to support the victim. It helps if the victim can hold on. The rescuer
climbs the ladder, one leg at a time, using arm strength.
The BC carry takes a minute to set up, but is a little more secure. The
rescuer removes the tank and regulator attachments from the BC, but
leaves the BC in place on the victim. Unbuckling any snaps or Velcro
closures on the front of the BC, the rescuer essentially puts the BC on
while the victim is still wearing it. If the BC can accommodate them
both, the victim will be held snugly on the rescuer’s back as he climbs
the ladder. Again, arm and leg strength are important to accomplish this
without injuring the rescuer or causing further harm to the victim.
Another method that may work if the rescuers cannot carry the
victim up the ladder is to lower the ladder into the water and have the
rescuer(s) tie the injured person the ladder. This is best done simply by
positioning the injured person on his back on the ladder and running a
single line from one side rail under the person’s arms to the other side
rail. Tie the line tightly to prevent the victim from sliding down during a
vertical lift. Helpers on board the boat can then pull the ladder on board.
This technique lends itself well where several people are available to
assist, as ladders offer numerous handholds for multiple rescuers. It’s
also a good idea to test the flotation characteristics of the ladder as it’s
put in the water. A ladder that sinks quickly will need to be carefully
tended while the victim is being secured to it.
Spine boards and flotation litters

Although we don’t often think about head or neck injuries as being part
of the water world that we inhabit as divers, there are plenty of oppor-
tunities for these kinds of accidents. From the strictly diving point of
view, surfacing divers have frequently been struck by the tending vessel
or dive boat during pickups. Head, neck, collar bone and shoulder inju-
ries are almost inevitable in these accidents. Head injuries also happen
when boats bounce and roll in rough water, or when people on board
lose their footing and fall to the deck. Any person falling off a large boat
may also easily be seriously injured when striking the water. Whenever
we suspect that there has been sufficient impact to cause a head, neck
107
or “long bone” (e.g., thigh or upper arm) injury we should stabilize the
patient within a litter or on a spineboard. Since this kind of equipment
is not often carried on a dive boat, you will need to seek professional
assistance from Coast Guard or local rescue teams. Remember that any
time someone has had a period of unconsciousness for any reason you
will need to summon medical assistance.
A diver whom you suspect might have a head, neck, or other serious injury should
always be stabilized on a backboard or litter,before lifting out of the water. If possi-
ble, you should get rescue professionals to assist with these operations.
Useful rescue equipment
Throwable devices
Several items that can help to reach a diver some distance away from
the boat, or to assist a rescuer towing a victim back to the boat are
line-throwing devices. The most basic of these is the throw bag. This is
a simple nylon bag containing from 50-75 ft (15-22 m) of floating po-
lypropylene line. The rescuer opens the bag and holds the end of the line
in the non-throwing hand. Using an underarm throw, the rescuer tosses
the bag out to the person in the water. With surprisingly little practice,
108
most people can send the bag out to the full extent of the line.
Any boat should have a life ring on board with from 75-125 ft. (22-
38 m) of line attached. Though most people will have some difficulty
tossing the ring more than 50 ft. (15 m), its greater flotation than a throw
bag makes it strong contender for the most useful throwable device.
Most life ring lines are hand-coiled or bound and will need to be “sta-
cked or faked” before throwing the ring. Lay the ring on the ground or
deck and unbind or uncoil the line. Starting at the free end, which is put
to one side, feed the line into a small pile until you reach the ring. Before
throwing the ring, hold or stand on the free end to prevent its loss. The
ring itself is thrown with a side-arm motion with your throwing hand
ending up pointing directly at the target.
A recent addition to the throwing-aid arsenal is the Rescue Disc®.
Built along the lines of a double-thickness Frisbee®, the disc has 75 ft.
(22 m) of polypropylene line wrapped around it. The device is thrown
exactly like a Frisbee and can easily reach a considerable distance. The
Rescue Disc® is affected by wind direction and strength, so practice is
recommended.
For greater distances, some rescue teams use line-throwing guns of
one kind or another. Increasingly popular because it does not use rifle
shells or explosive device is the Rescue Rocket®. This device is charged
with compressed air from, for example, a scuba cylinder and can carry a
line out to several hundred feet. A special attachment allows the rocket
on the end to be replaced by a self-inflating life ring.
Swimmer devices
Seeing a diver in distress on the surface, a swimmer could deploy from
shore or boat to assist. There would be great advantage in carrying a
small flotation device in these cases to give to a panicky diver for additi-
onal buoyancy or a device for towing. A common example of a portable
flotation device is a rescue can, sometimes called a “torpedo.” Shaped
like a flattened cone with handles, these devices are easily towed by a
swimmer who wears a tether line connected to the device. The rescue
can is designed to be grasped by a struggling victim, but in skilled hands
can also be used as a flotation device. Positioning the can under the vic-
tim’s upper back will give considerable buoyancy to a helpless person
109
and make them much easier to tow.
A “rescue tube” is also a valuable aid in water rescue. Made of soft
foam under a tough vinyl skin, the tube is looped around the victim to
provide immediate flotation assistance. Also connected by a tether to the
swimmer, it greatly reduces anxiety on the part of a conscious person
and can fully float an unconscious person. It has the added advantage
of being a useful in-water tool for immobilizing a cervical spine (neck)
injury.
Consider taking a personal flotation device (PFD) with you if you
swim out to a diver in distress. Handing the PFD to the victim will allow
you to keep clear of flailing arms and legs, and give the victim enough
additional flotation that the panic may quickly pass on its own. You can
then hold the far side of the PFD and use it to tow the diver back to
safety.
Personal considerations
The ability to perform these rescue techniques is not something that
is easily accomplished the first time out. Though not complicated in
themselves, all techniques for handling another person in situations
that are both physically challenging and stressful require practice and
refinement. The basic requirement for the rescuer is to be fully com-
fortable himself in the water. The physical fitness component necessary
to perform a rescue should be obvious. Even in a pool it is tiring to
tow another person 100 yd. (90 m). Once these techniques have been
mastered, improvement will come from practicing them in increasingly
difficult conditions, the very conditions most likely to produce a diving
accident. With increased skill comes greater confidence, a combination
that makes the dive rescue specialist an invaluable asset in any dive
party.
110
Scuba I.Q. Review
1. What signs might signal to an observer that a diver on the surface
may be in distress?
2. Why is a reaching or throwing response the preferred way of assisting
a diver to shore or to the boat?
3. Why is it prudent to stop at least 15 ft. (5 m) away from a diver whom
you think might be having problems?
4. Why is panic the leading cause of diver accidents?
5. What are the best steps to follow in assisting a panic or struggling
diver?
6. The most likely rescue scenario in aiding a fellow diver is...?
7. An unconscious, breathing diver on the surface is in extreme danger
of…?
8. How do we determine if a person is breathing?
111
Chapter 5: Responding to Emergencies Underwater
112
Responding to
Emergencies
Underwater
Responding to Emergencies Underwater

By its very nature scuba diving exposes us to risks associated with being
underwater. The hyperbaric (high pressure) environment in which we
function has hazards of its own combined with temperature considera-
tions, physical hazards such as currents, entangling dangers, and even
hostile marine life, we understand that there is always the possibility of
an underwater accident. Despite all this, the most common factor in an
accident remains poor judgment on the part of the diver(s). Learning to
recognize and respond to these diving incidents is the objective of this
chapter.
Recognizing underwater hazards
Accident prevention
We already know that pre-dive preparation is our best hedge against
being overtaken by the unexpected while underwater. We plan the
dive according to what we expect the underwater environment to be
and what we intend to accomplish on the dive. We figure the route, air
consumption factors, maximum depth and time and so on. On the dive
itself we superimpose the image of the route over our actual course, so
we have a good idea of exactly where we are at any given time. Still, the
dive doesn’t often keep strictly to plan.
113
We constantly fine-tune the plan as we go along because of the rea-
lities of the dive. Such things as changing currents, thermoclines, surge,
and encountering areas of particular interest that require more than a
cursory glance, all may conspire to make a shambles of the original
plan. This is not a problem in itself. After all, spontaneity is a virtue,
not a vice. Awareness of the effect that such alterations may produce on
important dive parameters such as depth limitations, air rationing and
bottom times, however, is critical to good diving. Awareness is, in fact,
the key ingredient to accident avoidance, which is why the self-reliant
diver is usually a better diver.
Having adequately prepared for the dive, accident prevention under-
water will ultimately depend on our ability to pay attention to ourselves,
our buddies and our environment. In the end, mishaps will almost always
come from our actions, inactions or reactions.
Signs of trouble underwater

A good diver learns to recognize those things that indicate a diver at
ease in the environment and in their personal comfort zone. A diver
may unintentionally signal a growing sense of unease to the alert bud-
dy. Common indicators of stress are erratic movement and breathing
patterns.
A diver who experiences apparent difficulty with buoyancy control,
orientation or maintaining buddy contact may not be concentrating on
the dive. This could be caused by several factors such as cold, fear,
weighting problems or confusion. At depth we might add nitrogen
narcosis and poor equipment performance to this list. Breathing pat-
tern alterations produce or indicate problems, too. Exceptionally slow
breathing or rapid breathing may be the result of other problems or,
conversely, can cause physiological changes in the diver that may lead
to panic or unconsciousness.
Buoyancy control is of particular importance in “blue water” diving,
that is, when diving over deep, open water. Boat diving near a reef or
wall with a deep drop-off is such an example. Poor buoyancy control
may result in rapid changes in depth which in turn can cause ear and
mask squeezes, too rapid descents resulting in excessive depths and too
rapid ascents resulting in over-exertion to stay down and endangers the
114
Watch carefully for the signs of a

diver in trouble underwater.
Look for:
• Poor buoyancy control. Slower
or faster than normal ascent or
descent.
• Irregular breathing pattern.
Slower or faster than normal. Skip
breathing or other breath holding.
• Erratic or jerky movements. Con-
stantly looking around.
lungs due to expanding air. A diver “bouncing” up and down should
be watched carefully and assisted to achieve neutral buoyancy. More
serious problems may be imminent unless the diver regains control, or
his buddy intervenes.
Underwater emergencies
Diver emergencies can happen at any depth and at any stage of the
dive. They can happen to novices and to experienced divers, in calm
conditions or in turbulent waters. A timely response will depend on our
recognition that something is wrong and a working knowledge of the
signs these emergencies present.
Entangled diver
Diver-entanglement incidents are neither that unusual nor as life-threa-
tening as the novice diver might believe. It takes only a moment’s inat-
tention for a diver to swim into an anchor line, buoy line or long, thick
strands of kelp. Any of these and more may cause a diver to become
hung up. The chief culprits here are the tank valve and dangling gauges
and hoses. Interestingly, most divers get snagged and spend several
seconds or more finning, never suspecting that they’re making little or
no progress, since lines and kelp have enough “give” in them to create
the illusion of forward movement. Divers who belatedly realize that
they’re caught often react with impatience, rolling from side to side or
115
else swimming up. Both of these reactions typically result in further
entangling the victim.
The watchwords in this and any other underwater predicament are
always Stop your activity, keep your Self-Control and consider your
Options. Kelp strands, for example, seems to have the remarkable and
irritating ability to wrap more tightly as the diver struggles against them.
Instead of thrashing at inanimate objects, the diver would do much bet-
ter to stop and back out or relax completely and float out of the kelp bed.
This lesson in self-rescue holds true for almost any other circumstance a
diver might encounter. The only real exception might be a monofilament
fishing net (gill net). Though these are not very common anymore, they
are still used in some areas. Constructed to be invisible underwater, an
unwary diver could blunder into one and not realize it until well tangled.
Absolute buoyancy control is required to prevent further tangling while
you retrieve and use the dive knife to free yourself. You may even have
to remove the scuba unit as you do this as the tank valve and first stage
of the regulator are the most likely objects to snag.
Prevention is always
preferable to rescue. Seeing
your buddy about to swim
unawares into a line or other
snag, you would save him
frustration and anxiety by
warning him. If your buddy
does get caught, your first
task is to keep him calm.
With the advantage of being
Lack of adequate hydration is
a contributing factor to hypo- able to see what exactly is
thermia, hyperthermia, and holding the diver in place,
decompression sickness. it will probably only take
you a moment to disentangle
him. Rarely will it be necessary to cut anything if you can get the diver
simply to back up and out of the kelp or line. In lakes and large ponds,
however, it’s not at all unusual to accidentally drag along nylon fishing
lines which have the peculiar habit of snagging on fin straps and wrap-
ping around your feet. A good, line-cutting knife is usually the quickest
116
solution and, leaving the line in small pieces, prevents another diver
from making the same mistake.
Carotid sinus reflex

Humans are terrestrial, rather than naturally aquatic animals. One of the
consequences of this has been that our bodies have adapted to changes
in the way gravity affects our circulation depending on whether we’re
standing upright or lying down. To function properly we need to have
nearly constant blood pressure to all parts of our body.
The brain, in particular, is very sensitive to changes in blood flow as
this determines the amount of oxygen the brain receives. The “measu-
ring gauges” for blood flow to the brain are in the carotid arteries. These
large arteries are found on either side of the windpipe and are the source
of the pulse we feel in the front of the neck. Specifically, the pulse is the
carotid artery sinus, an enlarged space in the arteries themselves. This
measuring device determines the correct pressure of blood to deliver to
the brain, depending on the body’s position.
These sinuses can be tricked, however, if external pressure is applied
to the carotid arteries or to the sinuses themselves. If this happens, then
the sinuses will react by signaling for a reduction in the blood pressure
and, thus, the oxygen to the brain. In the diving environment this can
come about if the wet suit hood or jacket collar is too tight, or if the neck
seal of a dry suit is constrictive. Even if normal wear of these items is
not all that uncomfortable, we can sometimes bring the condition on by
craning our head back to look straight up in the water. This may cause
increased pressure in the carotid arteries which in turn will lead to a
drop in blood pressure.
The diminished flow of oxygen to the brain has an immediate effect.
The diver will feel sudden bouts of dizziness and vertigo. Since this
seems to come out of nowhere, completely without warning and evident
cause, it can be a frightening experience. The sensation will pass quick-
ly, however, when the diver looks down, restoring normal blood flow to
the brain. Sudden blackout can occur in extreme cases, one of the very
few ways this may happen to a scuba diver on the bottom.
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Unconsciousness underwater may

be due to several factors:
• Carbon monoxide poisoning
• Hypothermia
• Drowning
• Lung over-expansion injuries
• Nitrogen narcosis
• Carotid sinus reflex
• Out-of-air emergency
• Marine life injury
• Traumatic injury
Our single most important objective
is to return an unconscious diver to
the surface as rapidly as possible.
Carbon monoxide (CO) gas poisoning

As scuba divers we’re completely dependent on our breathing mixture
while underwater. We depend on the fact that the air meets the stringent
standards necessary for us to stay healthy and functional under pressure.
One of the most critical measures of impurities in breathing air is the
amount of CO, carbon monoxide, present in the air we breathe. Because
we will always have more air in our lungs while underwater than we’d
have if we were on the surface, trace gases that would be acceptable in
normal breathing air will be unacceptable on scuba. For scuba air a level
of only 0.001% CO is permitted.
CO is odorless, colorless, and tasteless, thus impossible to detect
in the air. Since it is produced by incomplete combustion, however, the
air may have an associated taste that could alert the diver. Typically,
CO gets into the scuba cylinder when the intake to the compressor used
to fill the tank is too close to exhaust from vehicles or smoke sources.
In some cases it may be produced in the compressor itself if the high
pressure stage of the compressor is “burning” oil. In all these cases there
is the possibility that the diver may detect an oily or smoky taste, but
there is no guarantee of this.
CO is dangerous because it binds so readily to the hemoglobin mo-
118
lecule in red blood cells. In fact it has a much greater affinity for hemo-
globin than oxygen has. This means that CO will attach to hemoglobin
more quickly than O will. To make matters worse, CO stays attached
2
to the red blood cells far longer than oxygen does. Oxygen exchanges
readily throughout the body in those tissues that require it. CO stays
attached for up 5-6 hours before releasing itself from hemoglobin. For
this period of time, the hemoglobin of the affected red blood cells is
effectively out of action.
For the diver the effects of CO poisoning underwater are insidious.
The gradual accumulation of CO-bound red blood cells causes a gradual
diminishing of O transport throughout the body. Still this drop in O
2 2
level in the red blood cells is compensated for to some extent by the
increased partial pressure of O the diver receives in the air he breathes.
2
Even though the hemoglobin is increasingly bound by CO the elevated

PO in the lungs allows the plasma and other fluids to absorb more O
2 2
than usual. This O is transported throughout the body as easily as if

2
were attached in the red blood cells and mitigates the effects of CO
poisoning to some extent, as long as the diver stays on the bottom. As
the diver ascends, probably assailed by headache, tightness across the
forehead, and feeling a little “dopey”, the PO drops to more normal
2
levels. Suddenly the diver is starved of oxygen on the way up. At the
surface or shortly afterward, the diver may face a real crisis as the red
blood cells cannot provide sufficient oxygen to keep the brain and vital
organs supplied. Collapse may be sudden and catastrophic. Recall that
CO may stay attached to hemoglobin for 5-6 hours, and the peril to the
victim is clear.
The on-scene treatment of choice is pure oxygen, delivered through
a non-rebreather mask at the highest possible flow rates. There are two
benefits to this treatment. First, breathing pure oxygen raises the PO of
2
the circulating blood by the same process as took place while the diver
was underwater. This allows oxygenation of tissues that the red blood
cells are no longer able to supply in the normal way. We can literally
keep the brain and body alive in this way, even without a large number
of CO-bound red blood cells participating. A second important benefit
is that a high level of O helps to flush CO from the body much more
2
quickly than would normally occur. Instead of a 5-6 hour turn-over time
119
for CO, this can be reduced to as little as one to one and a half hours.
The definitive treatment is hyperbaric oxygen as can be administered in
a recompression chamber. In this case the CO binding time can be cut
back to 30 minutes.
On scene we must be prepared to support both ventilations and
circulation by CPR, if necessary. Rapid transport to medical facilities
is essential, even if the patient seems to have recovered. There may be
serious long-term consequences of CO poisoning that must be treated
by medical professionals. Also, be sure to secure the diver’s equipment
for later examination. The air must be tested for purity. Note that it’s
certainly possible for several divers on scene to have had air fills from
the same suspect compressor. No one who had a fill from the same sta-
tion as the victim can be permitted to use those tanks until the air has
been tested.
Nitrogen narcosis
One of the most fascinating, and fabled, aspects of scuba diving is the
phenomenon known as nitrogen narcosis. Layered with doubtful stories
of buddy-breathing with fish and accounts of mermaid sightings, and of
its incompletely understood cause, the truth behind narcosis is consi-
derably less dramatic.
Narcosis is certainly related to the depth of the dive and to the gases
we breathe. Dives deeper than 100 ft. (30 m) will induce many recrea-
tional divers not accustomed to this depth to begin to demonstrate the
effects of narcosis. At this depth, the effects are subtle and may not even
be evident to the diver or buddy. Tests of fine motor skills or problem
solving may show some deficits, but on a normal dive with normal
activities, these deficits will likely be missed.
Narcosis passes quickly, as the diver rises to shallower depths, and
disappears completely on ascent. That narcosis is caused by the nitrogen
in the breathing air is also beyond dispute. This is surprising since we
understand nitrogen to be an inert gas; that is, it doesn’t combine or
react with other compounds easily. The most widely accepted theory for
nitrogen’s effect is that it is readily soluble in fat tissue at high pressures.
Some of the tissue absorbing nitrogen, then, would be parts of nerve
120
cells’ natural wiring that connects nerve cells together. It is theorized
that this absorption interferes with nerve signal transmission, resulting
in delays and misfiring between cells in the nervous system.
Interestingly, nitrogen is not the only gas that causes narcosis, and
not even the worst. Argon and other inert gases have more severe effects
than nitrogen, while others such as helium have far less effect. It’s for
this reason that divers who use mixed gases for the more extreme dives
will substitute much of the nitrogen with helium. Even though any inert
gas can cause decompression sickness (including helium), narcosis
poses a greater risk to the prepared deep diver than does decompression
sickness. It’s worth noting that experienced deep water divers concur
that a certain amount of adaptation to narcosis occurs with frequent deep
dives. This is another strong argument for advanced training and greater
than normal experience before undertaking the more extreme dives.
Unconsciousness underwater may be caused by several problems. Approach

a non-moving diver carefully and attempt to rouse them by gently shaking
them.
121
Nitrogen narcosis can be an in-

capacitating event for a diver at
depths greater than 100 feet (30m).
Develop your deep diving skills
slowly to help get adapted to the
demands of depth.
The effects of narcosis are proportional to depth, but, generally

within sport diving ranges, the most commonly reported are:
• Euphoria.
• Decreased manual dexterity.
• Light headedness.
• Diminished problem solving ability.
• Fixation.
• Hallucinations.
To make this list even more interesting, many divers experience
a certain amount of amnesia after the dive, thus do not remember or
else deny their odd behavior. Factors that seem to predispose divers to
narcosis include:
• Rapid descent.
• Heavy exertion at depth (resulting in CO retention).
2
• Cold water.
• Alcohol or other drugs.
• Apprehension (may be brought on by low visibility or other cir-
cumstances).
• Pre-existing fatigue (late nights, hard work).
Our role as a rescuer in these situations has to be, first and foremost,
one of remaining vigilant to the signs of narcosis in ourselves or our
buddy. We must recognize that this is not an amusing situation. A diver
suffering the effects of narcosis is a danger to himself and any others
on the dive. Bear in mind that divers may find themselves at depth
unintentionally. Diving along steep walls that fall off to great depth,
cruising with whales or dolphins in blue water or being moved off reefs
122
by currents may all result in much deeper than intended dive profiles.
The utter tranquillity and beauty of many dive sites may capture the
diver’s attention when in fact he should be looking at his depth gauge. It
can and does happen to the best of divers.
Ascent is the only real solution to narcosis. Signal your buddy to go
up until you see that the effects of narcosis have passed. Be insistent,
if necessary, but attempting to take control of your buddy’s equipment
by inflating his BC or dropping his weight belt are not good responses.
Your buddy might resist your interference with dire consequences for
you both, or if successful, you may send your buddy uncontrolled to the
surface from great depth.
Squeezes
The most common direct effects of pressure for scuba divers are
squeezes, or the compression of discrete air spaces in the body. This
is a consequence of the simple pressure/volume relationships that acts
upon almost all aspects of diving. Numerous such air spaces exist in the
body, the middle and outer ears, the sinuses, and the lungs. External to
the body, but in contact with the skin, are other air spaces. Examples of
these are between the mask and face, under the diver’s hood, and within
a dry suit.
Ear squeeze
By far the most likely
injury a diver will ever
experience is a middle
ear squeeze. The middle
ear is an air space
between the ear drum
on the outside and the
eustachian tube on the
inside. The eustachian
tube leads directly to the If you fail to equalize the
pressure inside your mask
back of the throat, ano- you can suffer a “squeeze.”
ther air space. At normal
123
Early and often are the key words

for clearing your ears on descent.
Learn several methods of equaliz-
ing pressures to ensure complete
clearing, while sparing excess work
on your ear drums.
atmospheric pressure on the surface, the air pressure in the middle ear is
the same as the ambient or surrounding pressure.
As we descend underwater, the pressure builds up around us faster
than it can be equalized in the middle ear. This results in an imbalance of
pressure outside pressing on the ear drum and causing it to flex inward.
The diver experiences this first as discomfort and then as outright pain.
Unless the diver undertakes corrective action to equalize these pressures
as the descent continues, the external pressure may bring about a rupture
or perforation of the drum. Water will then flood into the middle ear,
drawn by the relative vacuum inside.
The pain of this squeeze cannot be ignored by the diver, who will
always react to restore the equilibrium. In most cases it becomes increa-
singly difficult to correct the problem the longer the diver waits to take
action. For this reason we should always suggest to the diver having
apparent difficulties with equalizing pressures to ascend a few feet. The
drop in external pressure as the diver rises will make it easier to clear
his ears by reducing the pressure differential. Relaxation also helps. A
diver who is tense and in a hurry will have a harder time equalizing than
one who is deliberate and calm. In any case slower descents are always
better than rapid ones.
Early, frequent and continuous efforts to minimize the imbalance
will prevent most incidents of middle ear squeeze, but a diver who is
over-weighted or who has poor buoyancy control may descend too
quickly to equalize properly. If a perforation or rupture takes place and
water enters the middle ear, it will come into contact with the inner
ear “windows.” These membranes cover openings to the hearing and
124
balance mechanisms of the inner ear. This may have a drastic effect
on the diver’s ability to orientate himself underwater. The colder the
water, the greater the effect. The diver may, in fact, be trying to swim
to the surface, but because of his lack of balance and orientation, he
may not be able to swim in the correct direction, even if he can see his
destination.
Clearly our role as a rescuer is to prevent the diver from panicking
and swimming off in the wrong direction. The best course of action is to
calm the victim and assist him to get back to the surface at the recom-
mended ascent rate. On the surface he may still require help to swim
back to shore or the dive boat. Much of the effect will wear off over the
next few minutes, however, as the water warms to body temperature; it’s
the temperature shock that disorients the diver.
On the surface there may be some blood evident in the diver’s outer
ear from the ear drum. Cover the ear canal with a clean dressing to
help limit the chances of infection. The diver will need to seek medical
attention for definitive care which will probably include staying out of
the water for at least a month or two. Beyond this, there is rarely a more
serious outcome to this accident. The drum normally heals well and will
not often result in any compromise to hearing in the long run.
Reverse squeeze
Once at depth and fully equalized, a diver’s ears will have air in the
middle ear at the same pressure as the water around him. On ascent the
water pressure surrounding the diver begins to drop, making the air in
the middle ear at a higher pressure than the surroundings. Fortunately,
the diver rarely has to pay much attention to this imbalance as the excess
pressure in the middle ear seeps naturally down the eustachian tube and
into the back of the throat. In fact many divers often wonder why the air
exhausts so easily from the middle ear, but requires direct intervention
on the part of the diver to get into the middle ear. The reason is that
the end of the eustachian tube at the back of the throat is covered by a
one-way valve which naturally opens outward. Air easily pushes out
of the eustachian tuba and middle ear, but must work past the one-way
valve to get in.
125
Most experienced divers know that using the Valsalva method of
equalizing pressures during multiple ascents and descents on a dive will
eventually cause pain in the ears. This is because artificially increasing
the internal air pressure in the throat forces the valve inwards, not its
natural direction. While this does push the high pressure into the middle
ear, it comes at a price. Over frequent episodes of ear clearing by this
method, the valve and surrounding tissues become irritated and swollen.
This in turn may precipitate problems later in the dive. There are much
better and gentler ways of ear clearing with which divers should be
accustomed.
On ascent anything that prevents or slows the escape of the rela-
tively high pressure air from the middle ear will cause discomfort and
pain. The culprit here is the high pressure air pushing outward on the
ear drum in an effort to escape. Failure to drain this air back through
the eustachian tube may well result in a perforated or torn ear drum
on ascent. This failure of air to escape in the normal fashion results
from several possibilities. The most common circumstance is when a
diver is diving with a head cold. Mucous, blown into the eustachian
tube, may plug the outlet and trap the air inside the middle ear. Also,
too forceful and frequent Valsalvas may produce so much irritation and
inflammation that the end of the eustachian tube swells shut.
Typically, the reverse block or squeeze comes at an unfortunate
time for the diver. He’s probably at the end of the dive and low on air,
a bit chilly, and ready to get out of the water. Ascending higher only
exacerbates the problem since it results in a greater differential between
the ambient and internal pressures. In fact there is no simple, foolproof
way of dealing with this problem. The best advice to give the diver is
to descend again until the pain disappears or at least lessens. From this
depth the diver should ascend slowly, allowing sufficient time for the
growing pressure in the middle ear to force the blockage out. This may
have to be repeated several times. Swallowing may be helpful, too, as
the pressure fluctuations this produces in the throat can aid the plug in
moving. Even if the diver is successful in surfacing without causing an
ear drum injury, he may complain of muffled hearing or “water in the
ear” or stuffiness in the ear after the dive. This is the residue of high
pressure air that did not escape and remains trapped in the middle ear.
126
While this will pass over time, anywhere from a few minutes to days
after the dive, it does likely indicate that the diver should not undertake
any further diving until the underlying issue, that head cold and runny
nose, has been completely eradicated. Decongestants and antihistamines
will help clear away these effects sooner. Never take these drugs prior
to a dive.
Sinus squeezes
The sinuses are four sets of hollow areas in the skull bones. As they are
all air-containing spaces, they are subject to the same changes in pres-
sure as the ear passages. The sinuses themselves are lined with mucous
membranes which are themselves well supplied with blood vessels.
Each sinus is connected to the nasal passages or throat by its own air
passage through the bone. Normally these air spaces are equalized at the
same time the diver equalizes his ears, and rarely present themselves as
a problem. Diving with a cold or when suffering from an allergy or other
infection, however, may block these passages and not permit one or
more sinus to equalize properly. If this happens on descent, the relative
vacuum in the sinus may rupture small blood vessels and fill the sinus
with fluid. Depending on which sinus is affected, the diver will feel
discomfort and pain in different places in the skull.
Most commonly, the maxillary sinuses are blocked. These are
located just above the teeth and on either side of the nose. Divers so-
metimes confuse this pain with a ‘tooth’ squeeze which is a rare and a
different condition altogether. A tooth squeeze results from the effects of
pressure on a pocket of air under a filling in a tooth. The filling should
have been packed tightly so that no air was left, but air will sometimes
seep between it and the tooth. Pressurized air left remaining in this tiny
space on ascent has been known to actually crack the tooth or even
cause it to explode.
Often a sinus squeeze occurs and the diver felt no significant sensa-
tion at all. The only evidence that it occurred is the presence of blood
in the mask after the dive. In some cases the diver may complain of
a headache, depending on which sinus or sinuses were affected and
whether any high pressure remains trapped after the dive. A common
127
dive site remedy for this condition and for reverse ear squeezes is to
take antihistamines or decongestants before the dive to clear, dry and
open the air passages. This is not a safe practice. These drugs have side
effects that can effect the diver’s performance underwater and increase
the risk of other injuries. In addition these drugs may wear off while the
diver is still underwater, putting him in a very difficult position for the
ascent. TDI/SDI policy does not recommend taking these or any other
drugs prior to diving.
Equipment squeezes
Our diving equipment encloses air spaces against our body from the
outside. These air spaces are subject to compression, or squeezes, as the
diver descends in the water column, just as the internal air spaces are.
The resulting partial vacuum effects the body part directly underneath
the piece of equipment and may result in injury.
Mask squeeze
The increase in ambient pressure on descent may cause a diving mask to
squeeze ever more tightly to the diver’s face. The effect of this suction
on the diver’s face is clear to see after the dive. Often the diver has
blood-shot eyes from burst blood vessels, perhaps a nosebleed and in
extreme cases the diver’s face may look bruised. There may not be any
pain associated with this, but the results are often unsightly.
This whole syndrome is an unexpected offshoot of a mask that fits
too well. Most of us have to clear some water out of our masks from
time to time and thus introduce ambient pressure into the mask. Divers
who feel the pressure building on the mask will thus deliberately exhale
air into the mask to prevent the squeeze. This is of particular importance
to breath-hold divers who have limited time to descend and may pay
less attention to mask equalizing. Any diver, however, is subject to mask
squeezes.
128
Dry suit squeeze
Dry suits trap an insulating layer
of air within the special dry suit
undergarments worn by the diver,
creating a warmer environment
for its wearer. This also allows the
diver to vary his insulation in colder
or warmer water. This in turn traps
more air and increases the insulating
quality of the suit. This air space is
also subject to compression as the
diver descends in the water. Unless
the diver acts to add air to the suit,
the fabric of the suit and even the
clothing may be pressed tightly
to the diver’s skin, much like a
vacuum-packed food item. Divers
who use their BC to control their
buoyancy, rather than add air to
If you are not properly
the suit for buoyancy, may suffer a trained, you can experience
suit squeeze that leaves bruises on a “squeeze” when using a
the skin. The bruising is the result dry suit.
of blood vessels under the skin that
burst due to suction directly on the skin.
Most authorities recommend using the dry suit for buoyancy control
underwater, and the BC for surface flotation and back-up for beginning
divers. Adding air to the suit for buoyancy purposes has the advantage
of also maintaining the insulating layer at the original thickness, keeping
the diver warmer. In addition, on ascent the diver need vent only suit air
to control the ascent rate.
Experienced dry suit divers who choose to add air to the BC un-
derwater must also remember to add some air to the suit to prevent a
squeeze and to retain at least some of the insulating properties of the
undergarments. They must also remember to vent both the BC and the
excess air in the suit on ascent. Managing two buoyancy compartments
129
underwater is considered an advanced
skill.
Adding air to both the dry suit and
BC underwater has lead to numerous
rapid ascent situations among already
task-loaded divers. A growing number
of professional divers have concluded,
therefore, that the BC should be used
for additional surface flotation only,
except in those cases where additional
buoyancy may be required in an un-
derwater situation.
Hood squeeze
In order for the diver to equalize
external ear pressures correctly, water
A snug fitting hood can must enter the diver’s hood. If this
cause a squeeze, too. does not happen, the hood will be
forced into the outer ear by external
pressure, but will never be able to effectively transfer the exact or full
ambient pressure since there is still air trapped in the outer ear. This is
typically a greater problem with dry suit divers who tend to use hoods
which have tight-fitting “skin-seals” around the face and similar seals
to mate more intimately with the dry suit neck seal. Divers who wear
latex hoods and employ full-face masks run the same risk. To be able to
effectively equalize external ear pressure, the diver must force air past
the face seal into the hood.
Vor barotraumas- Decompression illness

Technically, the term “barotrauma” refers to any pressure related injury.
Thus, though the squeezes just discussed are really barotraumas, the term
is equally used for those most serious and potentially life-threatening
diving injuries; i.e., lung over-expansion injuries, and decompression
sickness. Prevention, early recognition and appropriate on-scene treat-
ment will greatly aid in averting long-term consequences.
130
The term “DCS” - decompression sickness - is more properly used to
describe the “bends.” The term “DCI”- decompression illness - is used
to describe cases that have features of both DCS and “AGE” - arterial
gas embolism - caused by a lung over-expansion injury.
Decompression sickness
Popularly known as the “bends,” decompression sickness or DCS is
caused by the rapid release of nitrogen held in solution by higher than
normal ambient pressure. This nitrogen is that portion of the air that the
diver breathed at depth and which dissolved in the tissues and blood.
Basic gas laws tell us that the greater the ambient pressure, the greater
the amount of gas will dissolve in liquid. As long as the diver remains
under pressure, the absorbed gas will stay in solution, even as more is
absorbed. This applies to all divers regardless of their depth and how
long they stay. On ascent the nitrogen will leave its dissolved state and
be exhaled. It’s literally true that a diver exhales less air than he breathes
in while at depth, and breathes out more than he inhales on ascent.
The problem arises when the diver ascends faster than his body can
recover and exhale nitrogen from his system. In this case, the nitrogen
will form bubbles in the tissues and blood. Since these bubbles are
collected on the return portion of the circulation, DCS is a condition
of venous gas embolism. Where the bubbles travel and how many of
them form will determine the severity of the decompression sickness
“hit.” It should be emphasized that rate of ascent is one of the most
important factors in precipitating DCS. Most dive computers currently
recommend an ascent rate of approximately 30 ft./minute, although
some may be faster or slower. A slow ascent rate really just gives the
diver’s physiology time to catch up with the physics.
All divers understand that we operate under no-decompression rules
which limit the time we may spend at any particular depth and still allow
us to ascend at a normal ascent rate. Exceeding those limits, as may
happen on repetitive dives or especially deep dives, requires a stop for
decompression at pre-set depths and duration. What these stops actually
do is slow our ascent rate so that in fact our physiology can catch up
with the physics. Always ascend at a slow, controlled rate and make a
safety stop at 15ft. (5 m) for three minutes.
131
On-going research into the exact mechanisms of bubble formation
and transport in the body have revealed decompression sickness to be a
highly complex condition. What has become clear, however, is that there
are several positively pre-disposing factors to its incidence, and that
this susceptibility is variable between individuals. In general it’s agreed
that dehydration makes a diver more susceptible to DCS, as it does to
hypothermia and heat-related injuries. Breathing very dry scuba air,
especially if working hard underwater, will dehydrate a diver quickly.
Working hard will itself increase the chances of DCS by mainta-
ining high concentrations of nitrogen-rich air in the lungs and increasing
the circulation rate. In fact, anything that affects the physical health of
the diver underwater, such as poor physical condition, habitual heavy
smoker, abuse of alcohol or other drugs, and tiredness before the dive
can increase the risk of decompression sickness, as well as other risks.
Generally, older divers are more at risk due to the gradual deterioration
of respiratory and circulatory systems. Since adipose (fat) tissue has
a special affinity for dissolved nitrogen, obese individuals are also at
increased risk of DCS.
Conditions of the dive will bear on the likelihood of DCS, as well.
In particular, cold-water diving results in the absorption and retention
of more nitrogen. Again, the gas laws tell us that cold liquids will hold
more dissolved gas than will warm liquids. As the diver chills, and this
is especially true of the blood circulating just under the skin, more N2
can be held in solution, thus increasing the body’s total nitrogen load.
Divers operating in cold water are advised to decrease their projected
no-decompression limits accordingly. This applies, too, to those divers
exerting themselves during the dive. The presence of currents, extra
distances to swim and carrying loaded game bags or photo equipment
will cause divers to fall into this category and call for more conservative
bottom times. If facing both cold water and heavy work load, divers
need to compensate for both.
Most divers are careful enough to plan their dives taking into ac-
count the effect of bottom time and decompression sickness. Though
many divers use dive tables which give guidelines for maximum bottom
times at any given depth, increasingly divers are trained in the use of
132
dive computers, and a majority of divers own one. Whether using dive
tables or computers, divers are cautioned not to extend their dive times
to the limit displayed. Individual variability, which may change even
from one day to the next, means that no dive is ever completely without
some risk.
DCS recognition
Aside from preventing DCS through cautious and considered diving
practice, our principle concern as rescue-trained divers is the recognition
and on-scene treatment of decompression sickness. In part, knowing the
history or witnessing the event will give us much important information
to help us determine the likelihood that any set of signs and symptoms
indicates DCS. For example, knowing that rapid ascents often precipi-
tate DCS, a diver arriving at the surface from depth without a weight
belt or without air, both suggesting a very rapid ascent, would be looked
at as a very high risk candidate for DCS. Likewise, an examination of
the diver’s recent dive profile(s) may suggest no-decompression limits
violations.
Decompression sickness may strike a diver in two forms categorized
according to their severity and what parts of the body are affected. Type
I may produce a rash-like reddening of the skin, usually on the upper
body and arms. The affected areas are itchy and irritated, and may be
accompanied by mild, transient joint pains (niggles). Taken together,
skin itch and joint pains are a fairly accurate sign of DCS, especially if
the history supports the possibility. Typically symptoms appear shortly
after the dive, usually about 30 minutes, but onset may be delayed by
24 hours or more.
Joint pain is more common and often exists in the absence of skin
involvement. Pressure from growing bubbles of nitrogen is thought to
stimulate nerve transmission near affected joints, resulting in these fair-
ly localized pains. Since these sensations are not related to strained or
bruised muscles, or any other actual palpable injury, they are not readily
affected by the application of hot or cold packs or even direct massage.
The victim himself will describe these pains as deep and boring, rather
than sharp.
133
If DCS is suspected, the rescuer
should insist that the victim be ta-
ken to a diving physician at once. In
this respect, the rescuer needs to be
aware that a high proportion of DCS
victims will refuse to admit that
their symptoms reflect a bends hit.
Denial is a well-recognized aspect
of early DCS onset. The victim may
need to be coaxed with reason and
calm persuasion to seek medical
attention. Though Type I bends will
likely pass on its own over time,
there is no real method to predict
that this will happen. Much more
serious Type II bends could appear
In the event a diver suffers from shortly and with it the risk of grave
decompression sickness, a VHF radio long-term injury. On-scene the re-
is the fastest way to call for help.The
Coast Guard monitors Channel 16 as scuer should keep the victim calm,
do most boaters and harbormasters. cool and relaxed. Energetic activity
In addition, local fishermen have on the part of the victim will make
their favorite working channels. It the condition worse by hastening
may be a significant help to contact
them if you’re far from shore. the release of nitrogen from soluti-
on, adding to the size and number of
bubbles already in the tissues. Hot
baths or showers serve the same purpose and should be avoided.
The rescuer should deliver high-flow O to the victim for as long as
2
possible during transport to a diving physician. Use of oxygen for tre-

atment will often produce almost immediate relief for the victim. This
merely confirms that the problem is DCS, but does not cure the patient.
The definitive cure for DCS is recompression in a chamber. TDI/SDI
does not support in-water recompression as a safe practice for the field
treatment of DCS.
The more serious form of DCS, Type II bends, can be life-threatening
to the victim and frightening to onlookers. Symptoms may cascade
upon the victim in rapid succession, all of them debilitating and some
134
of them bizarre. The source of the problem is growing nitrogen bubbles
pressed hard against the spinal cord and even the brain. As such, any
sign that demonstrates impairment of motor skills, thought processes,
or behavior may strongly indicate Type II bends.
Signs and symptoms include staggering, transient or continuous
numbness or paralysis of any part of the body, respiratory distress or
choking, visual disturbances and pains. The senses are also affected, in-
cluding touch, taste and hearing. Blotches of discolored skin may appear
and disappear over the victim’s body. There may be apparent weakness
in limbs on one or both sides of the body. This bilateral appearance of
weakness is distinctly different from the one-side only weakness often
evident in a stroke victim or arterial gas embolism as discussed below.
Arrange for the immediate transport of a Type II bends victim to a
diving physician. Follow the procedure outlined above for the field tre-
atment of Type I bends during transport, but do not delay for any reason.
Be prepared to administer CPR, if necessary, as respiratory paralysis is a
real possibility in severe cases. Call for professional assistance as early
as possible to meet with you and the victim en route to medical aid. Air
transport via helicopter may be available in your area. Know how to
contact the help you need.
Carefully observe any diver who

made a rapid ascent from depth.
A diver who arrived at the surface
out of air, without a weight belt or
with a full BC may have ascended
too rapidly. Decompression sickness
may develop within 30 minutes
of surfacing or may not become
evident for 24-48 hours. Remember
that the effects of DCS may prog-
ress from mild to severe over a very
short period of time.
135
© S. Barsky. All rights reserved.

Lung over-expansion injuries
The golden rule of scuba diving is never hold your breath while under-
water. While the regulator sees to it that the air we breathe at any given
depth is equal to the ambient pressure, changes in our depth will cause
the air to expand or contract if we fail to exhale during this depth change.
Holding our breath on ascent clearly holds more serious consequences
as our lungs can only withstand a small amount of expansion beyond
normal. The weakest links in the respiratory system are the alveoli, the
tiny air sacs at the very end of the bronchiole tubes. Though elastic and
flexible, the alveoli are delicate and have strict limits to expansion. It
takes a rise of only a few feet in the water while holding your breath on
compressed air for the alveoli to burst. Bubbles of air, escaping from
the lung tissue, may travel to all parts of the body, with potentially
life-threatening outcomes.
In reality it is not always necessary to breath-hold to cause this
over-expansion to occur. Individuals with compromised respiratory
systems and medical conditions, such bronchitis, emphysema, tuber-
culosis, or those suffering from chest infections or colds, all possess
lungs which have some existing blockage. In some cases this is tempo-
136
rary, but in others is a permanent feature. In either case, scuba diving
is extremely hazardous to those persons as air may be trapped within
partially obstructed alveoli and may not be able to escape before dama-
ging expansion takes place.
Inadvertent breath-holding is another potential source of trouble.
This happens every time we attempt to equalize pressures in our ears, or
when an underwater photographer holds his breath to steady the camera,
or when we use breathholding to stabilize our buoyancy. It also happens
in an unexpected way when we stop for decompression in shallow water
and the trough between swells passes overhead. There may be a drop of
4-5 ft. (1-1.5 m) in an instant when this occurs. What was a full breath
as the swell passed over is now over-full when under the trough. For
this reason it is frequently safer to hang from a line attached to a surface
buoy or the boat, rather than one fixed and marked from the bottom.
Once air escapes from the alveoli and lung tissue, several outcomes
are possible. Though we are not expected to make a specific diagnosis
of which type of illness has resulted from the lung rupture, we need to
be familiar with the range of signs we see and symptoms the victim tells
us about to recognize that a lung rupture has taken place.
Mediastinal and subcutaneous emphysema

Emphysema describes a condition where air has gathered in and
inflated some part of the body or an organ. Mediastinal refers to the
center mid-point of the chest and includes the area containing the heart.
Air escaping from the lung tissue may collect in this area and expand
around the heart. This expansion may actually move the heart out of
place and puts increased external pressure on it. The result may be a
reduction in cardiac output and strain on the heart. As air continues to
move freely around the thoracic cavity, it can rise along the trachea to
come to rest under the skin, especially around the neck. This results in
a bizarre condition, “subcutaneous emphysema,” where the skin may
crackle like cellophane paper, but has the more serious outcome of pres-
sing on the victim’s trachea. Breathing may become difficult as a result.
While not grave emergencies in themselves, these conditions are, more
importantly, indicators of a lung over-expansion and rupture.
137
What to look for:
1. Shortness of breath
2. Pain in the center of chest
3. Rapid, erratic pulse
4. Signs and symptoms of shock
5. Swelling around neck
6. Possible voice changes
What to do:
1. Recognize that a lung injury has occurred.
2. Support breathing efforts through O therapy.
2
3. Be aware that you may be witnessing only the early stages of a

progressively more serious sequence of events. Alert emergency medi-
cal personnel and transport as soon as possible.
Pneumothorax
The term pneumothorax describes a condition where air has escaped
from the lungs and has crept between the pleural membranes that cover
the lungs and the chest wall. These membranes serve as protective coa-
tings on each, and also trap a lubricant between them to allow the lungs
to slide along the chest wall with each inhalation and exhalation. As air
flows between these membranes, and especially as it expands during
the diver’s continued ascent, the pleural membranes begin to strip away
from each other. The expanding air also puts pressure on the lung and
may cause it to collapse. At this point the lung, or the portion of it that
has collapsed, is non-functional.
What to look for:

The diver will complain of pain, almost always on one side only, and
may lean his body toward the injured side. Breaths will be labored and
possibly painful. Other signs of respiratory distress such as coughing,
wheezing, and cyanosis (blue tinge to the skin) may be evident. Notable
in such cases is “tracheal shift.” This is a condition where the lack of
pressure in one lung versus normal pressure in the other forces organs
and the trachea toward the effected side.
138
Injured persons survive pneumothoraces every day, as there are many
and varied causes for this injury. In the diving circumstance, however,
the injured person is probably in the water, may have been unconscious,
and possibly was without air for some period. The accident probably
happened a long way from definitive medical care and the cause is a
ruptured lung from expanding air.
What to do:
1. Recognize that a lung injury has occurred.
2. Respiratory dysfunction as indicated by breathing effort and
cyanosis always requires that we support ventilations. Start the victim
on O as soon as possible.
2
3. Keep the patient comfortable and covered during transport to

medical facilities.
4. Be aware that his condition may change for the worse. Be prepa-
red to administer CPR.
Arterial gas embolism

The alveoli are the site of gas exchange in the body. This exchange
takes place across the membrane of the alveoli and the walls of the
capillaries which cover the surface of the alveoli. The capillaries carry
blood loaded with CO from the heart to the surface of the alveoli for the
2
exchange to take place, and then carry the blood, now loaded with O , 2
back to the heart for distribution throughout the body. When a lung rup-
ture occurs, it’s the alveoli that burst. When this happens, it’s inevitable
that capillaries surrounding the alveoli are torn as well.
In the most extreme case of a lung over-expansion injury, blood
trickles into the alveoli and, even more ominous, air begins to enter
the circulation through the open ends of these tiny blood vessels. The
bubbles return to the heart and may then be pumped to all parts of the
body. It happens, however, that the first major blood vessels that these
bubbles encounter are the carotid arteries, the large vessels that feed
directly into the brain.
As blood vessels enter an organ, whether the brain or muscles, they
divide in two. Each of these will divide in two, a process repeated many,
139
many times. Eventually the smallest of blood vessels, capillaries, reach
the point where they deliver their load of oxygen and begin to join
together again.
Bubbles traveling this route will therefore enter progressively
smaller vessels until they can no longer pass through the capillary.
Blood flow in that vessel stops due to this blockage (embolism). Most
critical is the fact that no tissue “down stream” of this point will receive
oxygen, and the tissue begins to die. Since this embolism is caused by
air and takes place on the arterial side of the circulation (as opposed to
DCS-nitrogen bubbles on the venous side), this condition is referred to
as arterial gas embolism or “AGE.” Significantly, bubbles may not have
to travel to the smallest vessels to become jammed. The bubbles may
in fact be growing in size as the diver ascends, allowing for continued
bubble growth after the air escapes into the circulation. Larger bubbles
get trapped in larger vessels, meaning that greater areas of tissue become
deprived of oxygen (ischemic). Note that the capillaries in the lungs will
clot and seal themselves off very quickly after rupture. The damage is
done early in the accident, though the consequences may follow up to
15 minutes later.
Thus, AGE is an immediately life-threatening condition where
every second counts in recognition and taking the victim to definitive
care. Even the chance that what you observe in a diver might be an
air embolism necessitates activating the emergency medical system
and arranging a hasty transport. All the lung-over-expansion injuries
described above may appear in succession or even simultaneously.
This makes for a stunning and frightening presentation to the observer.
Keeping your own head and taking the correct steps may save a life, or
a life-time of disability.
What to look for:

The onset of signs and symptoms of an arterial gas embolism may be
sudden. The diver may collapse without warning after returning to the
boat or may even arrive at the surface unconscious. The diver will show
signs identical to a stroke, the cause in both cases is an embolism in the
brain, bubbles in AGE or blood clot in stroke. Weakness on one side
may be observed, the diver staggering and complaining of dizziness and
140
severe head pain. Visual disturbances are common. Note that all other
symptoms previously mentioned for lung over-expansion injuries may
also be present.
What to do:
1. Recognize the likelihood of a lung over-expansion injury.
2. Recognize the possibility of AGE.
3. Lay the patient down on ground or deck of boat. He should not be
made to walk anywhere.
4. Loosen tight clothing/exposure suit and treat for shock.
5. Deliver high-flow oxygen for as long as possible.
6. Transport as quickly as possible.
7. Be prepared to support life with CPR, until arriving at definitive
medical care.
Marine life injuries:

It has often been said that the most dangerous and destructive animal
in the ocean is a diver. Certainly it is generally true that we cause far
more injury and upset to the wildlife through accident and harassment
than it ever causes us. Still, opportunities exist for divers to come in
contact with animals that are far from defenseless. Typically the victim
is a novice diver who has yet to master good buoyancy control, or even
an experienced diver new to the area. Local knowledge, good diving
skills and a respect for the underwater environment will greatly lessen
the chances of close encounters of the wrong kind.
Unconsciousness for any reason re-

quires an eventual call for medical
assistance. Don’t hesitate to contact
professional help.
141
Marine life injuries are classified according to the kind of wound
caused rather than by the specific kind of animal involved.
Punctures- Includes bites and spine wounds

Sea urchin spines are hard, very brittle and often very sharp. Depending
on the species, they vary in length from 1/4 to 8 inches (0.5-20 cm).
They may easily break off under the skin on contact, and will certainly
penetrate the average wet suit. Significant irritation and itching may
result. A few tropical species inject a mild toxin.
Lionfish are docile,

spectacular fish, but
beware of their sharp,
venomous spines.
Sculpins and related fish possess long, very sharp spines. The spines
to beware of are typically the dorsal fin spines, though some species
have an inconspicuous pectoral fin spine, as well. Most are quite sharp
and strong, but breakage under the skin is fairly rare. Though usually
quite painful if the puncture is deep, the major danger is infection rather
than poison.
Other fish such as, lionfish, scorpionfish and stonefish possess
highly toxic spines and are a distinct danger to divers. Lionfish spines
are long (5-10”), thin and radiate from the dorsal and pectoral fins. From
the front the fish seems to be surrounded by a halo of spines and is very
striking in appearance. Stonefish spines are shorter and far less obvious.
The fish itself is not very conspicuous and is very much like the northern
sea raven in appearance, that is, squat, drab and well-camouflaged. Its
spines, however, are no less poisonous than those of the lionfish.
142
Punctures from these spines produce an immediate intense pain
that persists for many hours. The victim may show signs of weakness,
nausea and vomiting. Cardiac arrest is possible.
Sting rays carry a sharp, barbed spine on their tails that is capable
of inflicting a very painful wound. If molested, sting rays will defend
themselves with this spine. Divers often encounter rays inadvertently
while wading into the water. Shuffling your feet alerts the rays to the
diver’s approach and allows the rays time to move away. This is an
outstanding example of the best first aid being prevention.
There are many sharp

spined fish like this east
coast “sea raven.” Most
are drab, inconspicuous
bottom dwellers that
become more active at
night.
Bites from marine animals are rare and almost always result from
provoking the animal first. Any animal that is large enough to bite should
be treated with caution. Be aware that some fish such as wolf fish and
moray eels are highly territorial and have a very different view from
humans as to what constitutes provocation. Larger predators (sharks and
barracuda) may be dangerous in some circumstances and must always
be treated with respect. Remember that although unprovoked attacks on
divers underwater are vanishingly small, provocation is a relative term.
Feeding sharks by hand may provide a diver with the thrill of a lifetime,
but wild animals do not confine themselves to our rules. If it’s capable
of swimming away with your hand, maybe you shouldn’t put your hand
in its mouth.
What to do:
1. Clean wound thoroughly with fresh water and soap.
2. If spine particles are observed under the skin, these should be
removed if possible. Left unattended and in place, these will become
143
increasingly uncomfortable and result in infections over the next few
weeks.
3. Non-poisonous bites may require control of bleeding as a priority.
After bleeding is controlled and the wound cleaned, it should be covered
with clean, dry bandages. Medical attention should be sought as the
greatest danger remains infection.
4. Poisonous spine puncture
may present a life-threatening
emergency. The victim will
be anxious and apprehensive,
so calm and reassure him.
As most wounds will be on
the hands, feet and knees, the
victim may need assistance in
walking. The best on-scene
treatment is immersion in hot
water, basically as hot as the
victim can tolerate. The spine
toxin is heat-sensitive and can
be denatured (broken down) by
high heat. Be prepared to deal
Wolf fish have extremely powerful jaws
with airway obstructions due and sharp teeth. Usually secretive and
to vomiting and to give CPR, solitary, they are territorial and don’t
if necessary. Medical attention welcome close encounters.
should be obtained as soon as
possible.
Sea snake bites are fortunately rare, mainly because these reptiles
are placid and not easily provoked. Even if bitten, there is an excellent
chance that the diver will not be envenomated as many sea snakes are
back-fanged. Fang punctures are, therefore, by no means assured. Ne-
vertheless, seas snake venom is deadly and specific antivenin must be
sought as soon as possible. Be sure to remember what the snake looked
like so that the proper anti-venin can be selected. These reptiles do not
occur in Atlantic or in Caribbean waters.
Symptoms of sea snake envenomation may not be obvious at first.
The bite itself is not always painful and the effects start mildly. The
144
victim becomes drowsy as the level of consciousness decreases. Swallo-
wing and speaking become difficult. Complete paralysis with respiratory
and cardiac arrest may follow.
What to do:
1.Poisonous sea snake bites are also life-threatening emergencies.
The neurotoxic venom is powerful, but somewhat slow acting, so the
first order of business is for everyone to stay calm. Increased activity on
the part of the victim only speeds the circulation of the venom and the
onset of more severe symptoms.
2. Clean the wound site thoroughly.
3. Apply a 2 inch (5 cm) wide constricting band, for example, a
handkerchief, above and below the bite. These must not be too tight
(you should be able to force your finger under the band). Loosen the
bands for 1-2 minutes every hour.
4. Suctioning snake bit wounds is controversial and of dubious value
in any case. You will probably better use the time to transport the victim
to medical attention.
5. Splint the extremity to limit movement. Keep it below heart level.
6. Be prepared to assist ventilations, as necessary.
Many jellyfish have

very long, nearly
invisible tentacles
and are capable of
delivering potent
stings.
145
Stings- Includes jellyfish and corals
Most jellyfish are graceful, harmless animals that are a delight to
watch ”swimming” underwater. A few species, however, are capable
of delivering powerful, venomous stings to the bare skin of a diver.
Specialized cells in the tentacles, called nematocysts, are really no more
than spring-loaded harpoons that will fire their dart at any object that
approaches too closely or touches the tentacle. Basically a food-ga-
thering method, the impaled harpoon is reeled in complete with prey
which is then raised into the body of the jellyfish. Even tentacles that
have broken off from the main body of the jellyfish are still capable of
stinging.
Symptoms of jellyfish envenomation may be severe and include:

• sharp, burning sensation.
• inflammation.
• nausea and fainting.
• mental confusion and unconsciousness.
Fire coral is the best known of the stinging corals. Soft, sponge-like,
and an innocuous tan or brown color, fire coral contact on bare skin
can produce an impressive reaction in a diver. The burning sensation
is immediate and may progress to muscle and joint soreness. A few
sensitive people may show more severe reactions. Fire coral is probably
not highly dangerous (except in certain individuals), but accidentally
kneeling on it can ruin your day.
Jellyfish tentacles can sting even

after they’ve broken off the main
part of the body. The nematocysts
can sting as long as they are wet.
146
What to do:
1. Wash skin carefully with warm water and soap to remove any
clinging tentacles. Wear gloves to avoid contacting the tentacles directly.
2. Rinse skin with a dilute paste of baking soda or very dilute am-
monia to help neutralize the acid-based venom. Some claim that vinegar
works as well, but this is doubtful.
3. If the burning and itching persists, apply an antihistamine cream.
4. There may be severe generalized reactions that call for immediate
medical attention. The patient may require respiratory and cardiac sup-
port during transport.
Note: There is considerable debate on the best way to prevent un-
fired nematocysts from discharging, if tentacles are still clinging to the
skin. Some claim that vinegar poured over the tentacles will prevent
this. Others claim that alcohol will “fix” the nematocysts and prevent
their discharge. Finally, lab results have suggested that neither of these
methods is effective on all species. Warm water, soap, gloves and quick
response will probably serve you as well as anything else and with much
less fuss.
Cuts and Scrapes

By far the most common injuries to divers while diving will be cuts and
scrapes from bumping into or rubbing against abrasive objects. Typical
examples are knee or elbow scrapes from coral outcrops, and hand and
knee cuts from barnacles. Poor buoyancy control and simple inattention
are the usual culprits here, though experience with these mishaps serves
as a notable memory prod to be careful where you put your hands in
the future. With the exception of fire coral already discussed, coral and
barnacles are neither poisonous nor menacing. They can, however, be as
sharp as a razor and effortlessly lacerate water-softened skin. These cuts
often run deep and can be quite painful. Even worse, left attended, they
will often become infected and cause intense irritation for many days.
The infection risk comes from the fact that the edges of the coral
or barnacle are far from clean, and the deep cuts introduce all manner
of infectious agents under the skin. Unless the wound site is carefully
cleaned and disinfected, some discomfort down the road is a sure bet.
147
What to do:
1. Wash the cuts and abrasions carefully with warm water and soap.
2. Rinse thoroughly with fresh water, making sure that the cuts
themselves are flushed out.
3. Paint the area with a Betadine-type (iodine) solution or spread on
an antibiotic cream.
4. Small wounds dry and heal better if left open, but larger scrapes
may ooze and will need to be covered with an absorbent bandage.
148
Scuba I.Q. Review
1. What indicators of problems that your buddy may be experiencing
might be apparent to you?
2. What are the watchwords to keep in mind in any underwater problem?
3. Describe the carotid sinus reflex.
4. What is the danger of carbon monoxide contamination in a diver’s air
supply?
5. What is the best way to deal with nitrogen narcosis problems?
6. Describe the physics of an ear squeeze.
7. Why is the BC a factor in dry suit squeezes?
8. What is a barotrauma?
9. Why is recommended ascent rate only 30 ft. (9 m) per minute?
10. List some contributing factors to the occurrence of decompression
sickness.
11. What is the difference between Type I and Type II bends?
12. What is the on-scene treatment of choice in the event of decom-
pression sickness?
13. How does a lung over-expansion injury happen?
14. List the most common signs and symptoms of a lung over-expansion
injury.
15. Why is a lung over-expansion injury immediately life threatening?
16. Why is decompression sickness a venous gas embolism and bubbles
in the blood from a lung over-expansion injury an arterial gas embolism?
17. Describe the signs and symptoms of a venomous puncture wound
from a lionfish or stonefish.
18. Describe how you would handle the tentacles of a stinging jellyfish.
149
Chapter 6: Dive Accident Management
150
Dive Accident
Management
Dive Site Organization

Whether diving from a luxurious live-aboard dive boat or from a specta-
cular rocky shoreline, all divers will obviously benefit from a well-run
operation. One advantage of organization is the security of knowing
that all support persons are practiced and rehearsed in their roles. The
other benefit is not always obvious... until there is an accident on the
dive scene.
Personnel
A busy, well-run dive site will be under the supervision of personnel who
take their roles seriously. There may be instructors present, but for the
most part non-training dives are conducted by the divemasters. Even on
training dives, a divemaster on scene often functions as a foreman, kee-
ping things on schedule, ensuring divers are briefed on the underwater
features and hazards, and serving as the point person in a trouble-shoo-
ting role. Depending on the kinds of diving being undertaken, there may
be safety divers available, extra hands to assist divers in and out of the
water, and the dive recorder. Dive accidents on a well-planned, well-run
dive site are especially rare, but can happen anywhere. This is where the
great “silent” benefit of a good organizational plan becomes clear.
A dive crew should be able to fall instantly into their new roles in
managing the accident with the view to mitigating a potential injurious
situation, and helping keep it from getting worse. Having an accustomed
151
station in the event of a diving emergency gives the crew, which might
well include certified rescue divers, a blueprint for action.
Among those who will be
called to respond to the scene
will be highly trained professio-
nals who may be able to assist or
even take the lead in managing
the incident. Such teams, often
associated with Public Safety
departments have very speciali-
zed skills and abilities, as well as
specific local knowledge. They
will likely also have the kinds of
equipment that even a well-or-
ganized dive center might not
have. Never hesitate to call for
assistance if you think it could
A well-run dive boat will be helpful. Emergency response
have someone assigned to teams do this kind of thing for
assist divers from the water, a living, and can be formidable
helping avoid over-exertion
assets in a crisis.
and possible injury.
A planned response to a
diving incident is similar to fire
drill rehearsals in schools; it prepares us for the unthinkable, and helps
to avoid time wasted in wondering what to do next (or first!). The dive
leader may send out the recall signal to bring all divers back, task rescue
divers to assist a victim in the water, assign someone to begin recording
the events and times of occurrence and someone else to summon more
help to the scene.
Rescue divers understand their role, as well, having been trained
in dealing with the desperate injuries that can occur in a hyperbaric
environment. Others on board or on the shore know how to contact and
activate emergency medical services (EMS). A planned and practiced
response, as well as appointed roles and the relevant contact informati-
on may be as important to the survival of a victim as the skills and speed
of response of professional assistance.
152
Accident scene behavior

• Be gentle with people.
• Preserve the victim’s dignity
• Stay calm yourself
• Be reassuring in a crisis situation
The Emergency Plan

Tending an injured diver is not always a straightforward procedure.
The injured person may be a friend of yours, maybe even your buddy.
Often there are family members present on the site. There are complex
emotional issues in these cases. There will be fear, confusion and much
anxiety. Professionals try to remove distractions from the scene, as
much to help them keep a clear head as to “give the victim room to
breathe”. Here are a few rules professional rescuers use:
• Never forget the dignity of the person you’re assisting.
• Avoid making a fuss of minor incidents, i.e., don’t cause him undue
embarrassment.
• Do not talk about him in the third person in front of others. Use
his name.
• Do not shriek in alarm at the sight of the victim’s blood or other
injuries. Even an unconscious person often hears every word that is said.
• Reassure the victim. Mental state is very important to survival.
•The rescuer’s attitude is solicitous, never condescending.
Recognize
The first step in assisting a diver in distress is recognition of an emergen-
cy. The principle features and signs of a diver in trouble have been re-
viewed in Chapters 3 & 4. One common cause for delay on any accident
scene, however, is a persistent reluctance to commit to action. This is
frequently observed in persons who have no prior training in accident
recognition and conditioned response. Bystanders watch passively while
someone is injured or attacked. The mind simply refuses to believe what
153
Breaking waves are just one way divers may receive injuries through inat-
tention.
it is witnessing. Even trained lifeguards will sometimes hesitate before

responding to a swimmer in trouble. The possibility of embarrassment
to the rescuer caused by an all-out response to a situation that has been
misinterpreted or where the rescuer may fail in front of onlookers can
root the rescuer to the spot. Remember that for every second you debate
the pros and cons of action, a second is lost. Don’t fail through inaction.
Respond
Response options depend in great measure on the type of incident in
progress. On an organized scene, a dive leader may take charge and
direct others to the best advantage of the victim. If you are rescue qua-
lified, you may become an invaluable and integral part of any response.
In a small group you may well be the most highly qualified person on
scene. Your assessment and judgment will become paramount in any
response taken. Specific response options for many categories of diver
distress have already been detailed in earlier chapters, however, there
may be much more to do as well. Other participants should be assigned
to provide specific assistance.
154
Preparation before the dive
will have included contact tele-
phone numbers for EMS and
rescue personnel. These may
be provided by local police,
fire or ambulance services. At
sea or in navigable waters, the
Coast Guard or harbor patrols
will always be a first option
for aid. Although most often
the first communications with
Coast Guard stations will be
via marine VHF radio, further
communications are often
easier and more secure via cell
phone. The U.S. Coast Guard
monitors channel 16, but once
contact is established you will
likely be requested to switch Whenever possible, assign other per-
to another working frequency. sons on scene to assist in the recov-
When on the radio, keep your ery of the injured diver. This may be
especially important during the
communications short and removal of the diver from the water.
concise. Be able to tell other
boaters or responding rescue
vessels exactly where you are. Learn the local landmarks and always
note the position (latitude and longitude) of the dive vessel.
Any rescue equipment on board the vessel should be readied. This
might include throwing devices, extra PFDs, a backboard, first aid kit
and oxygen kit. You may be the only person on the dive scene who can
give the correct first aid and administer oxygen, but it helps if others can
ready this essential equipment. Recall any other divers from the water.
In a real emergency, it becomes extremely difficult to keep track of peo-
ple. Use other divers to assist you if this is within their capability, but
don’t endanger anyone else. Their most effective role may be to assist in
the removal of the victim from the water after you have recovered and
towed him back to the boat/shore.
155
Rescue
Circumstances that require you to
enter the water to assist another
diver will always put you at some
risk. Do not overlook the hazards
to you in choosing to respond.
Water rescue can be a dangerous
business; you must be certain of
your abilities and level of fitness
before you commit to an in-water
rescue.
Whenever possible, enlist the
assistance of other qualified in-
dividuals to make the job easier.
This may include help in towing
a person to the boat/shore,
someone holding a paddleboard
or other flotation device, help
A diver using a signal device to
in removing the victim from the
get attention may be calling for water, a bystander sent to alert
immediate assistance. the nearest Emergency Medical
Services station, or even to fetch
appropriate equipment for on-scene treatment. Be careful not to press
persons without good water skills or presence of mind into stressful
situations. Nearby lifeguards, harbor patrol officers and harbormasters
are often good sources of hands-on help. Despite all this, never forget
The 4Rs Emergency Plan

• Recognize that a person is in danger.
• Respond in a practiced, appropriate
manner.
• Rescue and return the victim to
safety.
• Record all events, victim information
and treatment delivered.
156
the golden rule of rescue; you are the most important person on the
rescue scene. When rescuers forget that, we too often end up with one
more victim and one less rescuer. Your own safety is always your most
important responsibility.
Record
In the aftermath of the flurry of activity that accompanies an actual
in-water rescue, especially of an injured scuba diver, participants
typically experience only vague memories of the sequence of events.
Stories are confused and contradictory, and it seems that no one paid
any attention to the time. It’s important to delegate the responsibility
of record keeping early to someone on scene. There are several reasons
for this. In the event of a missing diver, it may be critical to know just
how long the victim may have been submerged. A diver last seen on the
surface will likely have drifted. Knowing the set and drift of the current
will aid searchers who will be looking for the victim, if they know when
he was last seen. Also, a good working record of the rescuer/dive lea-
ders’ responses will aid in the reconstruction of the incident.
Finally, it’s important to log all of your efforts in reviving, treating,
and transporting the victim to safety. These records are an invaluable part
of the patient records that should accompany the victim to the medical
authorities. This will help medical personnel evaluate the effectiveness
of on-scene treatment and give them a good clue as to the patient’s pro-
gress. Your data are the baseline from which all further examinations
are measured. Do not underestimate the value of your initial surveys of
respiratory rate, heart rate and the other features of importance in these
early surveys.
Assessing the diver’s injuries

Most diver injuries are minor. Events that result in sprained ankles and
cut fingers are easy to see and diagnose. Occasions when a diver may
complain of vague headaches or dizziness, or inexplicable tiredness, or
any changes in his level of consciousness should raise a red flag for the
rescue diver. Certainly, any diver who experienced even a brief period
of unconsciousness will be a cause for concern and further investigation.
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The best approach to assessing injuries is a systematic one that falls into
the “primary survey” and the “secondary survey.”
The scene survey

This quick review of the scene is safety-oriented with the identification
of dangers to the victim and rescuer the principle object. Is there con-
tinuing danger to the victim if left in place? Would it be best to move
the victim to another place? Are there any dangers to the rescuers in
operating here? Is time a factor?
The primary survey

This consists of the A, B, C’s, for airway, breathing and circulation.
Airway- Check to determine if the victim’s airway is clear.
Can the victim speak?
Is there any danger of obstruction such as bitten-off pieces
of mouthpieces or vomitus?
Breathing- Check to determine if the victim is breathing.
Look for rise and fall of the chest.
Listen for breath sounds.
Feel exhaled breath on your cheek.
Circulation- Check to determine that the victim has a pulse.
Feel for a pulse at the carotid artery in the neck. Victim’s hood
must be removed.
If no breath sounds can be determined, then rescue breathing

must begin before checking for circulation.
Rescue Breathing
• Begin by tilting the victim’s head back by lifting the chin and
opening the mouth. Ensure that no blockage is evident. If any is
observed, use a finger sweep to retrieve and clear the articles.
• Seal your mouth over the victim’s mouth, pinch his nose closed
and exhale two full breaths into the victim. Use of a pocket mask
will provide you with protection from the transmission of diseases
158
Remove the diver’s hood to check for the carotid artery pulse.
possible with direct mouth-to-mouth resuscitation.
• If the chest does not rise with your attempted exhalations into the
victim’s lungs, or if you feel total resistance to these breaths, the
airway may be blocked farther down. Try repositioning the head and
inflating the lungs again.
• Failure to inflate the lungs after repositioning the head, implies

a blockage.
For a victim laying down on the deck or ground, straddle the victim’s
legs and place one hand on top of the other on the victim’s abdomen.
Thrust hard with your hands into the abdomen and towards the victim’s
chest along the midline of the body. The effect should be to push the
diaphragm upward as in a hard exhalation to clear the obstruction in the
airway. Repeat this several times and check the mouth for the obstruc-
tion. Attempt another breath. If the airway is still blocked, repeat the
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Dive site treatment includes a thorough primary and secondary survey,
procedure. Until the airway can be cleared, there may be little else we
can do to help the victim.
Once breaths can be successfully delivered to the non-breathing
victim, the next step is to check for a pulse. If the diver is wearing a
hood, this must be carefully removed to find the carotid artery. Most
often it is quicker and easier on the victim if you simply cut the hood
off. This is best done using blunt-point shears. Start the cut at an edge
nearest the victim’s mouth or chin, and continue toward the neck and
collar. The hood will loosen as you cut and get easier. Take no more than
5 seconds to do this.
Feel for the pulse for about 5-10 seconds using your fingers (not
your thumb which has a measurable pulse of its own). Failure to find a
pulse indicates that the victim’s heart has stopped. We can aid the victim
by external cardiac compressions which simulate a beating heart. To be
effective, we need to open the zipper of any wet suit jacket the victim
may be wearing. It will not be necessary at this stage to remove the
jacket.
160
• Position yourself alongside the supine victim at about mid-chest
level.
• Trace the edge of the rib cage back to the “V” of the sternum
(breastbone).
• Measure a 3-finger-width distance mark toward the neck from the
“V.”
• At this mark place the heel of one hand, then stack your other
hand on top.
• Lean your upper body over your hands and push sharply in to the
victim’s chest. Compress the chest about 2” and release.
CPR requires both cardiac compression and rescue breathing. As a

solo rescuer we need to keep a regular rhythm that alternates between
compressions and breaths.
One Person CPR-

• Start with two full initiating breaths.
• Immediately find your mark and do 15 full compressions at the rate
of about 80-100 per minute.
• Immediately give another two breaths and return to compressions.
• After about a minute of compressions and breaths, or 4 full cycles,
stop and look again for a pulse. Take ten seconds for this as before. The
first minute cycle of breaths and compressions may have restarted the
heart and breathing cycles. If not, begin CPR again. Stop and check for
a pulse and natural breathing every few minutes.
TDI/SDI recommends that all divers learn and be certified to

perform effective CPR and be trained to deliver oxygen at the scene of a
diving accident. First Response Training International, TDI/SDI‘s sister
company, offers programs that are a good example of this essential trai-
ning. Your diving instructor will be able to give you specific information
on these valuable courses.
161
The secondary survey
If the patient is breathing and has a pulse, the rescuer will conduct the
secondary survey. This is a head to toe examination with the intention of
finding any other injuries to the victim.
Check and record vital signs and level of conscious for changes
every 15 minutes. These changes are the best indicators that a patient is
improving or deteriorating.
Vital Signs
• Respirations- Check and record.
Normal is between 10-20 per minute and effortless.
• Heart rate- Check and record.
Normal is 50-90 beats per minute and steady.
• Check and record skin color, temperature and moisture.
Skin- check characteristics
Color- skin, nail beds, eyelids should be pink.
Temperature- warm
Moisture- dry, but is obviously an uncertain indicator
in divers.
Level of Consciousness
• Alert and oriented- fully conscious and aware of surroundings.
• Responds to verbal stimuli- Answers questions, though may
be confused.
Responds to painful stimuli- Cannot speak, but responds to pin-
ching.
Unresponsive- Will not respond to any stimuli, fully unconscious.
Patient Examination
• Start at the head. Gently slide your hands under the back of the
victim’s head to feel for blood, bumps or deformities. Slide hands under
back of neck to ensure proper alignment, absence of blood and deformi-
ties. Check for blood or other fluids in ears, nose and mouth.
•Slide hands over chest and gently press. Check for bruising or blood
and any unevenness. Run hands over abdomen. Stomach muscles should
be relaxed and normal. Stomach muscles held rigid may indicate internal
injury to organs, and possible internal bleeding.
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• Continue examination over legs and arms. If conscious, have the
patient confirm sensation in extremities.
Does the patient react to any of these contacts? Is there pain associ-
ated with any area? Is the dive suit torn or scuffed anywhere? Can the
victim relate the history of the accident? Were there witnesses? Can you
deduce what may have happened from the circumstances and examina-
tion of the diver’s equipment?
Diving accidents include several circumstances that may lead to
injuries to the brain or other parts of the nervous system. These include
any temporary period without oxygen such as near-drowning, other
non-breathing unconsciousness situations, bubbles of air or nitrogen in
the brain or nervous system, or being struck in the head by a boat. It
is imperative that we conduct an examination on any diver we suspect
might be suffering from such an injury as soon as possible. This exami-
nation is directed specifically to those functions that are under the con-
trol of the brain or central nervous system. We’re testing neurological
function in this case, so this process is called a “neurological exam,” or
“neuro exam.”
The neurological exam and sec-

ondary survey should be repeated
every 15 minutes in the first hour.
Neurological examination
The examination should be conducted with the patient “in from the we-
ather” if the patient shows signs of distress. The first examination should
be conducted as soon as possible after the onset of the first symptoms,
and repeated every 15 minutes afterwards for at least the first hour.
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Orientation
Does the diver know his name and age? Does he know where he is? Is
he oriented to time? These simple questions are important as they may
reveal confusion in an impaired diver.
Muscle strength
Bear down on the diver’s shoulders while he shrugs. Is strength appro-
ximately equal on both sides? Check arm strength by having diver resist
your effort to raise or lower his arms.
Balance and coordination

Ask the diver to stand with eyes closed and raise arms out to the sides.
From this position, then have the diver bring hands together, palm to
palm, in front of body.
Eyes
Are the diver’s pupils equal and reactive? Can the patient identify distant
objects? Can the patient correctly count the number of fingers you hold
in front of his face equally well with both eyes?
Sensory
With the patient’s eyes closed, gently touch the patient’s skin and scalp
(ask first!) with your finger tips to ensure equal detection of sensations
on both sides of the body.
Swallowing reflex
Instruct the patient to swallow while you watch the movement of the
“Adam’s apple.” Look for a regular up and down motion, as well as that
it has not been displaced to one side.
164
Shock may be immediately life

threatening.
Shock
One of the more serious consequences of injury may be shock. Because
of the urgency it imparts to the accident scene, it’s important to under-
stand just what it is and how it works. Shock is normally brought about
because of a radical drop in the body’s fluid level. For this reason it is
referred to most often as “hypovolemic shock.”
Whenever an injury results in considerable bleeding, whether inter-
nal or external, or loss of fluid through profuse sweating and vomiting,
then the circulatory system is unable to transport sufficient blood, and
thus oxygen, to all parts of the body. The brain then switches circulation
away from the other tissues and directs it only to itself, the heart and the
lungs. This cannot continue indefinitely, however, without irreversible
harm being done to the body and eventually the brain itself. Therefore,
shock is a life-threatening emergency and must receive immediate at-
tention.
What to look for:
• Victim appears restless and apprehensive.
• Breathing is light and rapid.
• Pulse is rapid and may feel “thin.”
• Patient’s skin is pale, cool, and clammy.
• May be unsteady and staggering.
• May vomit.
• Diminishing level of consciousness.
• May collapse suddenly.
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A good or even suggestive history can help. Since we are assuming

that shock is the result of a diving injury, we will likely see shock as a
consequence of those accidents that may produce a hypovolemic state.
Examples of shock-producing dive injuries include, external blood loss
from arterial bleeding from cuts or large fish bite, internal blood loss
from lung over-expansion injuries or blunt trauma to the body, e.g.,
being struck in the torso by a tending boat, or dehydration from profuse
sweating or vomiting.
What to do:
1. Calm and reassure the patient.
2. Determine and treat the cause of the shock reaction.
3. Victim should be placed on his back with the feet slightly
elevated.
4. Remove wet suit hood and loosen suit.
5. Monitor vitals closely.
6. Maintain an open airway and watch for vomiting.
7. Give oxygen and get help.
On-scene oxygen therapy

It is clear that one of the most significant first aid remedies that rescuers
can apply in a diving emergency is supplying oxygen to the victim.
Oxygen may diminish the size of nitrogen bubbles in DCS, easing pains
and limiting long-term tissue damage. It can also reduce the size of air
bubbles in AGE, as well as help preserve tissue cut off from direct blood
flow. In fact, any time we have reason to believe that either the respi-
ratory or circulatory systems may be compromised, we should deliver
oxygen to the patient. First Response Training International‘s Oxygen
Administration course will help you to determine what type of kit, size
of cylinders, and what array of masks you might use, given the nature
of your typical diving activities. Consideration of how far you might
have to transport a diving accident victim to a medical facility will also
dictate how much oxygen you should have on scene.
In general, you should have as much oxygen on hand as you can
166
Oxygen therapy may be the most important treatment you can deliver at the acci-
dent scene. A non-rebreather mask delivers upwards of 90% oxygen to the victim.
reasonably carry. Oxygen cylinders are sized by the number of liters of

gas they contain. As with scuba cylinders, they are available both in steel
and aluminum construction. For our purposes, we will probably want to
provide oxygen for at least 30 minutes during the initial assessment and
transport. We will almost certainly want to deliver oxygen at as high a
rate (in liters per minute or LPM) as possible. Flow rates below 10 LPM
would be selected in cases where the patient is conscious, resting and
breathing comfortably. The typical setting on a O regulator in this case
2
would be 6 LPM. For a patient experiencing greater respiratory or circu-

latory distress, we would select a higher setting, typically around 10-15
LPM. The cylinder size, and therefore the amount of oxygen required,
will determine how long we will be able to continue to provide oxygen
to the patient.
To be effective in providing the most satisfactory supply of oxygen
to the patient at the flow rates discussed above, we should use a cylinder
or cylinders with at least 300-450 liters capacity. Cylinders designated
“D” or “E” ,and the so-called jumbo “D,” contain between 350 and 625
liters and would be appropriate for a dive scene. For oxygen delivery
in the lower ranges the patient may be fitted with a nasal cannula. This
167
arrangement uses tubes to de-
livery oxygen to the patient’s
nostrils and has the advantage
of not blocking the mouth or
face. The victim can talk and
is easy to monitor. It also
does not interfere with airway
control in the event the victim
vomits. The downside is that
the patient only receives about
30-40% oxygen, and much
oxygen is wasted through
spillage between breaths.
For more serious cases
A demand valve oxygen regulator deliv- where high percentages of
ers the highest percentage of pure gas
and has the added advantage of wast- O are required, a standard
2
ing the least amount of oxygen through non-rebreather mask with

spillage. This is not only more efficient, reservoir bag is essential. This
giving longer delivery times, but is should be used with a high
safer as it reduces the chance of oxy-
gen-induced combustion. flow setting (10-15 LPM).
Oxygen concentrations of
90% can be provided to the patient in this configuration. Oxygen de-
livery systems that employ a demand-type regulator, similar in many
respects to a scuba regulator, also deliver very high concentrations of
oxygen to the patient. There is an added advantage in that O flows only
2
on demand, thus decreases the amount spilled through the free-flow

style of mask. Rarely will we provide O to a diving accident victim at
2
anything but the highest percentages we can achieve.
Hypothermia Treatment
Prolonged exposure to environmental conditions that result in a net heat
loss will eventually lead to hypothermia. While the exposure time varies
with temperature and amount of environmental protection the diver has,
until we remove the diver from the environment, we cannot fight the
effects of cold injury. In warm climates, it may be enough to simply
remove the diver from the water for them to rewarm naturally, though it
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will probably be helpful to keep the effect of wind-chill to a minimum
by covering them with a blanket. In cooler conditions we may need to
move chilled divers to a more sheltered area. This may be below decks
on a larger boat or in a vehicle for shore-based dives. Depending on the
extent of compromise due to hypothermia and how remote the dive site
is from an actual, indoor warm area, we may have to take more action
than that.
A diver suffering from moderate hypothermia will be shivering
violently, be somewhat cyanotic, may slur his speech, have difficulty
walking and will appear weak. Even out of the water the diver may con-
tinue to cool due to wind exposure and evaporative heat loss, unless we
can bring him in from the weather. Lacking immediate access to a warm
shelter, stabilize the victim by using some version of a “hypothermia
wrap.” Essentially, a hypothermia wrap is a windproof, waterproof co-
vering within which we’ll enfold the diver. Though commercial models,
such as the “Brr…ito” are available, homemade versions consist of a
tarp, a wool blanket and a reflective metal-film blanket.
In practice, the tarp is spread on the ground, the reflective blanket
laid on the tarp, and the wool blanket laid on top of that. In northern
areas, many divers and water rescuers carry the whole thing rolled up
like a sleeping bag and stored in a plastic garbage bag in case of emer-
gency. It’s a good addition on board a dive boat, as well.
Removing the patient’s exposure suit outdoors in extreme weather
may be a mistake. If the air temperature is very cold, it’s perfectly ac-
ceptable to wrap the victim, suit and all, in the hypothermia wrap. If
conscious, give the patient warm, sweetened fluids to drink. These need
not be hot as the warmth these drinks impart is more psychological than
of any real physiological value. Ideally, rewarming should be gradual
and by heat generated from within the victim’s body. We can aid this by
permitting the cold diver some mild activity such as walking, after which
we’ll wrap the victim again to prevent heat loss. Oxygen is indicated if
the diver remains cyanotic or shows respiratory distress.
Never immerse a hypothermic victim in hot water. This may induce
a condition known as “after-drop” which may cause a person to go into
cardiac arrest.
169
Hyperthermia Treatment
Unless cooled through immersion
in cool water, a diver can rapidly
and dangerously over-heat in an
exposure suit. Muscle cramps may
be the first sign of over-heating,
though dizziness and an overwhel-
ming tiredness may weaken the
diver as he demonstrates the early
stages of heat exhaustion. The
diver will be pale and sweating
profusely in an desperate attempt
to cool himself and will be begin-
ning to suffer from fluid loss as a
result. Do not ignore the diver who
complains of the heat and who is
showing its effects. Cool the diver
by stripping off the exposure suit
or allowing him in the water to
cool. Give him plenty of cool,
A diver suffering from moderate
hypothermia will be shivering vio-
clear fluids to drink to prevent
lently dehydration. Sport drinks are also
useful for electrolyte replacement.
Left unattended, heat exhaustion may rapidly progress to heat stroke,
a true life-threatening emergency. Heat stroke is, in fact, the second lea-
ding cause of athletic death after head injury. Speed of recognition and
response is critical to preventing permanent brain injury or death of the
victim. The victim will be listless, possibly unresponsive, with a rapid,
stronger than normal pulse (bounding), rapid breathing and the skin will
be hot, red and dry.
Immediately cool the diver as rapidly as possible by dousing with
cold water, ice (if available), and loosen all clothing. The brain can easily
be damaged by the body’s internal temperature (upwards of 105° F or
40° C by this stage ), so pay particular attention to cooling the head. If
conscious, the patient should be given as much fluid to drink as possible.
170
Be alert to the possibility of vo-
miting, however, and be prepa-
red to keep the victim’s airway
unobstructed. Among other
things, he will be suffering from
hypovolemic (low fluid level)
shock. If oxygen is available, it
should be provided to the diver
at high flow rates. Advanced
medical treatment will likely be
required. Do not delay in getting
help.
A simple precaution such as a sus-

pended tank with regulator in place
can help divers in low-air situations,
and allow decompressing divers full,
required stop time before surfacing.
• Temperature extremes in any

direction will affect a diver’s perfor-
mance.
• Stay alert to the effects of hypo-
thermia and hyperthermia.
• Fluids and oxygen are appropriate
in both cases.
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Scuba I.Q. Review
1. Why is good, general dive site organization a benefit in the event of
a diving accident?
2. List and explain the four R’s of the emergency plan.
3. Who is the most important person on the accident scene?
4. What is meant by the A, B, C’s of the primary survey?
5. What are the indications that CPR should be begun on a diving ac-
cident victim?
6. What will we measure and record on the Secondary Survey?
7. Describe the steps in a field neurological examination.
8. How often should the secondary survey and neuro exam be repeated?
9. What is shock and how do we treat it?
10. Why is oxygen therapy so valuable in treating diving injuries?
11. List and describe the main methods of delivering oxygen to the
patient.
12. How do we recognize hypothermia?
13. What are the signs and symptoms of heat exhaustion and heat stroke?
172
173
Chapter 7: Lost Diver Search and Recovery
174
Lost Diver Search

and Recovery
Searching for a diver on the bottom

Despite our best efforts, it sometimes happens that divers become
separated underwater. Differences in interests cause some divers to
slow down to look at tiny, attached
marine life, while others swim on
ahead looking for that elusive wreck.
Photographers frequently stop to get
a close up of some item of interest, or
to wander off, practices well-known
to drive dive buddies to distraction.
Failure to keep good buddy con-
tact over long swims also accounts for
separation of divers. The best buddy
pairs or groups allow for the slower
swimmers to set the pace. Whatever
Pay particular attention to a diver
the reason, it happens frequently who surfaces alone. It may indicate an
enough that divers perform the “lost uncontrolled ascent alone, an out-of-
buddy search” numerous times in air emergency, a dropped weight belt,
their diving careers (see Chapter 1). or the result of a lost buddy search.
Though a frustrating inconvenience,
if all divers follow the same procedure, then they are always reunited on
the surface within the next couple of minutes.
Still, it can, and does, happen that the divers are separated because
one of them has had a serious problem, or develops such a problem
175
after separation. The lost diver has become a missing diver. In previous
chapters we’ve seen many ways in which divers can get into trouble
on the surface and underwater. In the event that a diver is missing and
unaccounted for 10 minutes, we have to assume that there has been a
problem that is keeping him from surfacing. At this point we will likely
make the decision that we have to find him.
Organizing the search

Relying on blind luck is rarely
the most successful means of fin-
ding a lost person underwater. A
thought-out and planned search
will, over the long run, almost
invariably produce more consi-
stent results and should always
be our first response to a missing
diver emergency. Nevertheless,
there are some occasions when a
random search may be the better
choice. These situations will be
discussed later.
Interviewing the missing diver’s
buddy should provide us with
information on the circumstances
of the dive, how deep they were Last Known Point
diving, how long they had been in
the water and how much air the The most important piece of
lost diver had left. early information we can acquire
is a good sense of the missing
diver’s last known point. This information may come from the diver’s
buddy who might have a very good idea of where the separation oc-
curred. The diver should at least know where the separation was first
noticed which is as good a starting point as any.
Shore or boat observers may be the source of last known point in-
formation as well. Alert observers tend to watch the divers’ bubbles as
a matter of course and generally can determine an approximate area to
search. Also, the point where the buddy surfaced is a valuable clue. If the
176
surfacing buddy followed the general rules for a lost buddy search, then
he’ll likely not be far from the last known point. Finally, the missing
diver may have surfaced at some time and gone back down again. This
may have been a deliberate attempt to locate his buddy or may have
been to an overweighting problem or other factors. Observers, seeing a
lone diver on the surface, would have noticed this event and mentally
recorded it.
We might have a choice of last known points or we may have none.
If there are candidates for possible search locations, these should be
marked with buoys for immediate investigation. Otherwise, we will
need to try to reconstruct the activities of the divers from the buddy’s
narrative, and devise a defined
search area with a suitable search
plan.
Available personnel
The worst of all possibilities is
that you are the only diver on
scene and that the missing diver is
your buddy. Under these circum-
stances, you may be the worst
of all choices to be the search
diver. You are probably tired,
low on air, maybe getting cold,
and probably carrying a burden
of great apprehension and guilt.
In terms of diving preparedness
and mental preparation, you are
not the ideal candidate for the
solo diving required to conduct
a safe and thorough search. After Once contact with professional
assistance is established by radio,
determining some landmarks use of cell phones may be prefera-
and being assured that you can ble. Phones are more private, more
located this exact spot again, secure, and make it easier to com-
leave the water, if necessary, and municate complicated plans.
get help.
177
If there are other people on the dive site, shout to get their attenti-
on and let them know what the nature of the emergency is. Divers on
neighboring boats or farther down the beach can be recruited to assist in
the search. In addition many public safety departments have dive teams
who may be able to respond to the area quickly. Although persons who
have drowned have been resuscitated after as much as an hour of sub-
mergence, these are very rare cases. The more divers we can mobilize
to the scene, the more likely we
can recover the lost person in the
shortest time.
Any dive scene with multiple
divers underwater simultane-
ously requires organization, and
the search scene more than most.
It’s critical to everyone’s safety
that someone has an overview of
the situation and is not actively
diving. This person, who may
be a divemaster or rescue diver,
will determine specific areas and
Be sure of your own navigational search patterns for the divers to
abilities before you undertake any cover. Any divers participating in
underwater searches. the search must first be cleared
for diving in this endeavor. While
we may not be able to prohibit unqualified divers from participating, we
need to exercise some control over who dives where. In terms of search
coverage, this is important. More importantly, however, is not allowing
persons to dive beyond their training and experience.
Depth of water, currents, visibility and many other factors may pose
significant challenges to less experienced divers. These challenges will
become hazards in the high stress conditions of search. Moreover, divers
responding from other dive sites, for example, other boats or shore sites,
will probably be carrying their own burden of nitrogen from previous
dives. They may have limited air and be tired. Like you, as the missing
diver’s buddy, they may be poor choices to search an unknown bottom
under stress. Still, someone must dive. Choose carefully to avoid placing
others in danger.
178
With all this in mind, the arrival on scene of an independent, fresh
group of divers in a Public Safety team can be a real blessing. They will
have their own organization, practiced techniques and available back-
up. It is best to allow them to take the lead in the search, though most
groups will welcome your information and continued diving activities.
Referring to the marker buoys you’ve placed that indicate areas already
searched, and providing them with all the information you have, will
help greatly in narrowing the search parameters to find the missing diver
sooner.
Search Plans
There are many good search plans available for divers to employ when
looking for a lost diver underwater. Most of them, however, require
practice to conduct effectively. Besides, these practice sessions will have
best been conducted under controlled conditions, not under the crisis of
a real rescue. For a complete review of search techniques, the reader
should refer to texts that deal in this topic as a specialization. For the
rescue diver, there are still a couple of good, simple search patterns that
are both effective and straightforward. All search and rescue techniques,
however, should be practiced to be effective.
Search areas need to be made manageable in size so that divers are
not sent out to inspect seemingly endless expanses of bottom. Each
specific area needs to have clearly defined boundaries, a designated start
Search Planning
• Gather as much information as
possible.
• Define the major search area.
• Divide the major area into easily
searched portions.
• Designate a well-marked starting
point.
• Determine a stop point in advance.
• All search divers/dive teams must be
tended or observed.
179
point and a designated stop point. Usually it’s best if these points are
pre-set and marked in advance. This way the divers know when they’ve
finished an area and can rest, move to the next area, or search the same
area again. Markers should be left for future reference to indicate areas
that have been searched.
Circular search
Marker Float
Buoy Line
Searchline
Center Weight
Diver-directed circular search pattern
180
The circular search is very simple to perform, can be done by a single
diver, and is still amongst the most effective of all searches in open
water. In principle, the diver swims around a fixed point, attached to the
point by a tether line. After com-
pleting one revolution, the diver
may move away from the point
by a measured distance of line,
determined by underwater visi-
bility and other factors, and will
then swim another revolution. In
this way, the diver can cover a
great deal of area in a fairly short
time. Another plus is that he has
a good idea of where he is at any
given time due to the tether line.
If two divers are available
for this search, it is probably
best that one remain at the center
point and control the amount of
line deployed for each revolution,
rather than both swimming and
controlling the line length at the
same time. Also, after a couple Search and rescue diver prepar-
of revolutions, one diver can ing for night operations. Note
pony bottle and spare mask tucked
spell the other for a rest break. in BC pocket.
In order to be truly effective, it is
necessary for the search diver to exert some force against the tether line
and center point. This is to ensure that all revolutions are fully circular,
thus covering all the ground in a uniform manner. The maximum di-
stance out from the center that a diver should search in a circular search
pattern is about 100 ft. (30 m). A circle of this radius starts to become
a long distance to swim, especially if several circles have already been
completed by the same diver. Avoid over-exertion in these and any other
diving circumstance.
If this search is unsuccessful, then the center point buoy is left in
place and the dive team moves to another adjoining area. These areas
181
should share some overlap to guarantee complete coverage. This process
is continued until the entire “high probability” area has been searched.
Failure to locate the lost diver will hinge on how well the searches were
done and how accurate the original information was. A decision may
then be made as to the advisability of moving locations or re-searching
the entire area again.
Sweep search
This is an effective and easily run search technique that can be con-
ducted from a boat or from shore. Usually it is the method of choice in
shore-based search situations. The technique requires a tender on shore
to direct the diver and deploy search line as required. The diver holds
the tending line as he swims in an arc from one side to the other, usually
from shallow area to shallow area. Again the diver needs to exert some
pull on the line to ensure that all search tracks are parallel and even. As
the diver finishes one complete track from shallow to shallow, the tender
Carefully review the parameters for your part of the search effort before
you and your buddy submerge.
182
Dive Tender
Track Spacing
Search Line
Search Diver
Semi-circular or sweep search pattern.
pays out more line depending on the underwater visibility. Though

professionals advise to begin the search at the maximum extent of line
and work inwards, most relatively untrained persons find it easier to
work out to deeper water. There can be an inherent problem in doing
this, since the diver finishes at the farthest distance from shore and in
the deepest water. The tender must not let the diver get too far out from
shore. Again, the usually-advised maximum distance out will be about
100 ft. (30 m).
183
The diver and tender
both must pay particular
attention to underwater
features that may snag
the search line during
the sweeps. Swim high
enough above the bottom
to avert entanglements,
consistent with being
able to observe the
bottom clearly. Paired
divers on the same line
Individual divers may be assigned
free-swimming roles to run searches in
works well and permits a
areas not easily examined by standard greater amount of bottom
patterns. to be covered in the same
time. There is also some
comfort in having a second diver along during the tension and stress of
a search for a missing fellow diver.
Random searches
There are some circumstances when random searches may have better
success than more organized patterns. Along shorelines where there are
many rocky outcrops and coves, or where underwater there are crevices
and overhangs, or anywhere the kelp is long and subject to swaying
from the surge, the rescue diver may need extra time and the freedom
to conduct a more thorough inspection. Regular search patterns rely on
the diver running consistent and unvarying search tracks to maximize
success by ensuring the best coverage. In these difficult search areas,
standard patterns will often miss the search object.
Competent free-swimming divers should be deployed to check
these features carefully. Surge can have very unpredictable effects on
motionless objects and can tuck things in the most unlikely of places.
Take the time it takes to do the job fully.
Untended divers need to be watched at all times in these kinds of
searches. In a full-blown operation there may be boat traffic overhead,
184
other divers conducting searches in adjacent areas and other auxiliary
persons on the scene. The person in charge needs to be fully aware of
the location of all search divers in the water at all times.
Abandoning the search
Good dive site organization will show itself in rapid assignment of roles for
a search and rescue operation.
At some stage the search and rescue operation will pass from rescue
to a recovery. A rule of thumb is that when an hour and a half has
passed after the diver would have run out of air, then survival is unli-
kely. This takes into account the diver rationing air carefully, but finally
succumbing to hypoxia. The period during which we might have hoped
for a resuscitation after rescue would be included in this period. Do
not endanger other divers by continuing a futile effort. Public safety
departments are in a much better position to effect the recovery than
most individuals.
185
Assisting a diver up to the surface
Finding the missing diver on the bottom or encountering a distressed
diver underwater, we need first to determine what the problem is. Be
careful not to rush into a situation that you do not fully understand. Your
first reaction to solving a problem for another diver may prove to be a
solution for a problem that doesn’t exist. The correct response to a diver
with difficulties underwater will vary depending whether the diver is
conscious or unconscious, but always take a second to determine what’s
really going on.
Bring a non-breathing diver off the bottom by first removing the weight belt. On a
deep dive, it may be necessary to add a little air to the BC to overcome suit com-
pression.
Conscious diver
Establish contact with the diver while you’re still out of arm’s reach. Si-
gnaling “OK” should provoke some response and will give you an idea
of the diver’s state of mind. Often the diver will indicate the problem
and request some assistance. This might be as simple as a loose weight
belt or cramp to more complicated problems like entanglement in fishing
line. Before you attempt to lend assistance, however, you should signal
186
Position the victim so you

can hold the regulator in
their mouth. If the regulator
was out of the mouth, do not
attempt to replace it.
Bring the diver to the surface

as rapidly as possible, but
keep in mind your own safety.
Depth and/or bottom time may
not permit you to ascend
quickly. In this case, you may
need to let the victim go and
recover him again on the sur-
face.
187
the diver your intentions. Sudden movements, helpful, might disrupt the
diver’s own attempts to help himself or cause a startle reaction that may
not improve the diver’s state of mind.
Failure of the diver to
respond appropriately to the
OK signal probably indi-
cates that the diver requires
immediate assistance. We’ve
reviewed many of the pro-
blems that divers may expe-
rience underwater in Chapter
5. Pay particular attention to
the signs of a diver in pain or
confusion. Serious hyperba-
ric issues may be developing
and staying on the bottom
is probably not an option.
The cascade of problems
that snowball from little
incidents may overwhelm a
diver’s ability to deal with
them. There is probably only
one place to solve all these
problems in safety, and that
is on the surface.
When dropping your own or a bud- Signal the diver to slow
dy’s weight belt, be sure to hold it
down and take a couple of
away from the body as you let go of
it. Falling belts can snag on buckles breaths to relax. This may be
or tools as they fall. only partly successful, but
your intention is to escort the
diver to the surface and calming him first will aid this. Moving so that
the diver can see your approach, gently and firmly grasp him under the
arm while signaling to ascend with your other hand. Judge your actions
based on what you can see of the diver’s reactions. If he fails to vent
his BC, you’ll have to do this for him as well as for yourself. The diver
may try to bolt for the surface or act erratically. Maintain control and
188
continue to signal the diver to relax and breathe normally. Monitor the
diver constantly and communicate with him frequently. Just the contact
alone sometimes helps a diver keep himself under control.
Ascend at as normal a rate as possible by using good buoyancy
control. Weight belts should remain in place unless there is good reason
to drop them. A diver may have too little air to spare for inflation or
may be seriously overweighted at depth. If your own BC is inadequate
to start you both toward the surface, then it may be appropriate to drop
the victim’s belt. Understand that this may make control of the ascent in
shallow water a problem. Anticipate this by staying ahead of your own
buoyancy changes.
Once on the surface, establish positive buoyancy for the victim and
yourself. If you determine that his problems are medical rather than ge-
ar-related, then drop his weight belt. Signal for help or, if alone, start the
swim or tow back to safety. Maintain contact and conversation throug-
hout this time. It’s important to talk to the diver. There have been many
instances where apparently unconscious or otherwise unresponsive
divers have been able to recall every word spoken by the rescuer. The
effect of human contact on an injured person cannot be overemphasized.
On the shore or boat continue the assessment of the diver’s pro-
blems. Was there a time when the diver was fully unresponsive? not
breathing? out of air underwater? Try to get a history of events from the
diver to arrive at cause of the distress. Conduct a neurological exam as
outlined in Chapter 6. If there are any signs of neurological impairment
or any time that the victim was truly unconscious, immediate medical
assistance is necessary.
Unconscious Diver
An unconscious diver on the bottom is in the greatest of peril. If the di-
ver is breathing but unresponsive to our attempts to arouse him, we must
escort him to the surface as quickly as we can. Our main concern will
be to ascertain that the victim’s regulator stays in place on the ascent to
safety. There is no uniform position in which a breathing, unconscious
scuba diver will rest. Whatever the position, hold the regulator in the
victim’s mouth while you manipulate him into a posture that will allow
189
you to hold him upright and maintain control of his regulator. The victim
is probably negatively buoyant at this stage, so drop his weight belt. If in
deep water, dropping the weight belt by itself may have little effect on
the victim’s buoyancy, so add a small amount of air to the BC to make
him easier to handle.
As you start the ascent, you need to anticipate buoyancy changes in
the shallower depths. Venting both BCs will be difficult while sparing a
hand for the victim’s regulator. If only one BC can be vented, it should
be yours. This way you can serve as a brake on the ascent rate, and if
you lose the victim, he will continue to ascend. An effort should be
made, however, to dump air as you’re able from his BC. Without his
weight belt and with a BC continually filling due to expansion, he may
become very difficult to hold down. A complication may be added by a
dry suit diver.
Though most dry suit divers also wear a BC, very many, if not most,
use the dry suit for buoyancy control. They reserve the BC for emer-
gency use, not for buoyancy control. This means that in order to control
the rate of ascent, you will need to purge their suit on ascent. Even if
you’re familiar with dry suits, this may be difficult to do with one hand.
A solution may be to hold the victim from behind so that you can hold
the regulator with your right hand and purge the exhaust valve (usually
on the diver’s left upper arm) with your left.
If the victim is not breathing, waste no time in getting him to the
surface. Drop the weight belt, inflate the BC if there is air in the tank
and pull him upright. If the regulator is not in his mouth, do not put it
back in, you’ll only force more water into the lungs. Even in a drowned
diver there is still some air in the lungs. Even if there is no appreciable
amount of water in the lungs, as may be the case in the early “dry” pe-
riod of drowning, there is little danger of a lung over-expansion injury.
An unconscious person is not holding his breath, thus the expanding air
will vent by simple physics on ascent. This may even have the effect of
clearing water from the lungs.
The only caution on ascent with either a breathing or non-breathing
victim is your own safety. If ascending from a deep water dive, your
nitrogen limits may dictate a slower ascent rate. Remain aware of the
dangers of a too rapid ascent to your safety. This may result in having to
190
release the victim in shallow water while you stop for decompression or
just complete the last 20 ft. (6 m) at a slow rate. Surface conditions may
make this last choice a poor option if it’s choppy or dark. Finding the
victim again may require an agonizing few minutes of searching.
Once at the surface with the victim, drop your own weight belt and
add air to the BCs as necessary. This may call for oral inflation of his BC
if the victim was out of air. Shout for help and prepare to start in-water
rescue breathing, as described in Chapter 4.
191
Scuba I.Q. Review
1. What kinds of information do we need to gather to plan an underwater
search?
2. List the three major components in any underwater search pattern.
3. When might we use free-swimming divers to conduct random sear-
ches?
4. How would you bring a conscious, but confused diver to the surface?
5. If the diver is breathing, but unresponsive on the bottom, what would
our main concern be as we bring him to the surface?
6. Why is a lung over-expansion injury not a serious consideration when
bringing an unconscious, non-breathing victim to the surface?
192
193
Chapter 8: Recompression Chambers and Therapy
194
Recompression
Chambers and
Therapy
Why recompression?
Dive accidents that involve the formation of bubbles in the blood and
body tissues are usually caused by decompression incidents. Specifical-
ly, the injuries occur because of a drop in ambient pressure as the diver
ascends toward the surface. As we have seen already, these barotraumas
fall into two major groups, decompression sickness and lung over-ex-
pansion injuries.
We also know that good, on-scene first aid will include the delive-
ry to the patient of as high a concentration of pure oxygen as we can
manage. The O may help to reduce bubble size and get some oxygen
2
through diffusion to tissues cut off from direct circulation by bubbles.

Still, bubbles will persist, and even continue to grow over time, which
accounts for the progressive nature of decompression sickness. Left on
their own, little bubbles often get bigger, causing greater and greater
damage.
In the case of DCS, nitrogen dissolved in the blood and tissues pops
out of solution to form micro-bubbles. This happens when the diver
ascends too quickly (decompresses) and the excess nitrogen is not given
sufficient time to be safely exhaled. In the case of “free” air in the body
and circulation from a lung rupture, the diver ascended while holding his
breath. This air expands as the ascent continues and the diver continues
to decompress until reaching the surface.
In both cases, gases were released from pressure and allowed to ex-
pand in the body. Clearly, the smaller the bubbles can be made after the
195
fact, the less pain and damage will result. It makes sense to subject the
diver to pressure again to shrink the bubbles to the smallest size possi-
ble. If we could shrink the bubbles sufficiently, we could drive them into
solution and resolve these illnesses. This is why we use recompression
chambers in the event of major barotraumas.
Decompression stops and safety stops are the best way to avoid decompression
sickness. These planned stops allow our bodies to unload excess nitrogen and to
minimize the formation of bubbles in the circulation and body tissues.
Recompression and decompression chambers

Chambers used to pressurize divers come in a variety of sizes and types,
but divers are not the only group treated in a hyperbaric environment.
Many large hospitals now use chambers to treat a spectrum of illnesses
and diseases including burns, carbon monoxide poisoning, and even
migraines. These are large walk-in facilities resembling ward rooms.
The benefits of hyperbaric oxygen have long been recognized and are
increasingly studied for application in other treatment regimes including
multiple sclerosis. For the diver, the benefits include both hyperbaric
oxygen and the direct effects of pressure.
There is no physical difference between a “recompression chamber”
and a “decompression chamber.” They are built to the same specifica-
196
tions, the American Society of Mechanical Engineers (ASME) code
known as “PVHO,” i.e., Pressure Vessel for Human Occupancy. The
only distinction between a recompression chamber and decompression
chamber is the application or use of the chamber. The more appropriate
term would be “hyperbaric chamber.”
Decompression chambers are the staple of the working deep water
diver. Spending a working day in depths of 300-500 ft. (90-150 m),
these divers would require very long decompression obligations to
surface safely. Entering double-lock chambers at or near their working
depths, the chambers are lifted on board support vessels where the
divers can complete their decompression schedules in a warm and dry
environment. In fact, there are live-in, on-board chambers where divers
can spend their non-working hours in comfort and then be lowered in
similar chambers to the working depth again for the next day’s work.
In this way the divers remain “saturated” with the inert gases of their
breathing mixtures and may incur no more decompression time than if
they’d spent only a day on the bottom. This is far more efficient and sa-
fer for the diver than fully decompressing and then fully recompressing
the next day.
Some decompression chambers are large enough for several divers

and dive medics.
197
Recompression chambers are most often used to repressurize a di-
ver, in other words to return him to equivalent depth without putting him
back in the water. Most chambers are similar in form, large cylinders on
their side with hatch doors for entry. They range in size from one-man
units with as little as a 36 inch (about 1 m) entry port, to multi-person
chambers with room for 4 divers and a dive medic attendant. Many small
models are designed and equipped for field use and are fully portable.
These units are manufactured by several companies around the world
and are frequently used for remote commercial and serious technical
diving activities where other facilities are scarce or non-existent.
Diving is simulated by pumping pressurized air into the chamber
and, thereby, increasing the ambient pressure. Pressure increases simu-
late diving deeper until the desired “depth” is reached. Throughout this
“descent,” the diver experiences the same pressure changes as descen-
ding underwater, i. e., ears must be cleared, and any sinus problems
the diver might have underwater will be evident in the chamber. The
chamber becomes increasingly heated, too, from the compressing air,
and ventilation becomes an issue with the deeper dives. Interestingly,
voice sounds change as the compressed, denser air transmits sounds
much faster, raising the pitch of the voice. This can be a very disconcer-
ting phenomenon to those who haven’t experienced this before!
The chamber operator monitors the internal pressure, temperature
and air purity on gauges on the outside of the chamber. An intercom or
telephone is used to communicate from the outside, where a hyperbaric
physician may direct the treatment, to the inside. The dive medic moni-
tors the patient carefully for pressure-related problems, as well as taking
and recording frequent vital sign checks. In addition to being returned
to a hyperbaric environment whose purpose is to shrink the offending
bubbles, the diver will also be put on a pure oxygen breathing medium.
This hastens bubble removal and reoxygenates ischemic tissue.
To avoid building up an oxygen-rich environment inside the cham-
ber, however, with its associated fire hazards, the diver breathes the
O through a mask. Oxygen is supplied by the operator only when the
2
patient uses the mask. Hyperbaric oxygen has the side-effect of causing
nervous system reactions such as convulsions and paralysis. As such,
patients are monitored closely for the signs and symptoms of oxygen
198
toxicity during the chamber episode. The dive medic will typically
cycle the patient on and off oxygen for periods of time to avoid serious
complications while still promoting its benefits.
Recompression therapy
Divers are recompressed according to preset tables which guide the
treatment period. Though depths and times vary in some instances, the
general rule has become that serious DCS events are immediately retur-
ned to the equivalent of 60 ft.
(18 m) where oxygen therapy
is begun in an “on- off again”
cycle. In some extreme
instances of DCI, injured
divers may even be brought
down as deep as 165 ft. (50
m) or 6 ATA (atmospheres
absolute). Many patients
experience immediate relief
from symptoms as this the-
rapy is begun. This is in fact
the only true verification that
the signs and symptoms thus
far exhibited by the patient
are actual DCS. Helicopter evacuation from remote
There are numerous sto- dive areas to definitive medical care
ries of remarkable recoveries may be an option. Part of your dive
planning should include determining
of critically injured divers in the level of emergency resources avail-
recompression chambers. In able.
some instances, divers in full
cardiac arrest have spontaneously re-established a heart rhythm. The
treatment continues through progressively shallower depths until the
patient is returned to the “surface,” a process that may take 4 hours or
more. If the patient is lucky, the hyperbaric accident has now run its
course and pains will not recur. Note, however, that some cases are not
199
easily cleared up and may require several chamber dives to resolve.
Some of these dives may be much longer than the original recompressi-
on and become very burdensome. This is especially true in cases where
the time after the initial diving incident that precipitated the bends sym-
ptoms and when the patient presents himself for treatment is lengthy.
There is no doubt that the earlier treatment is begun, the easier
symptoms are to resolve. This argues strongly that all divers should
be familiar with the field signs and symptoms of DCI so that on-scene
treatment can be begun and transport arranged for the afflicted diver
as soon as possible. A final sobering note: many divers redevelop
symptoms that may persist for months afterwards, even after several
treatments. The rescue diver needs to know what to look for and how to
respond appropriately.
Divers, do you know where your chambers are?

Few divers give much thought to the processes of rescue and emergency
response to a dive accident until it happens. We’ve learned that prepa-
ration is always the best hedge against the unforeseen, and so we seek
to become qualified rescue divers. The rescue doesn’t end on the beach,
however, and we may well need to know exactly where to transport
the victim for definitive care. This will vary from one place to another.
In some instances help will come directly to you and relieve you of
lifesaving responsibilities. In other areas you may need to transport to a
recompression chamber yourself.
Bear in mind that even if you are certain that the victim will require
recompression because you determined beyond a doubt that a lung
over-expansion injury has occurred or that decompression sickness is
the culprit, you may not be permitted to transport the victim directly to
the chamber facility. Local protocol may insist that any diving patient
first be transported to a medical facility for evaluation. The attending
physician may then recommend recompression therapy. Part of our
preparation, then, is to obtain the sure knowledge of the appropriate
manner of action to minimize confusion and delay in the event of an
accident.
200
Traveling to and diving in an unfamiliar area means, among other
things, finding out in advance what services are available and how to
access them. There will likely be some noteworthy differences between
what you’re used to and how things are done here. You may decide as a
precaution to minimize the exposure of your dives if the lack of ready
assistance warrants it. To find out how the local system is activated, in-
quire at a local dive shop, talk to other divers in the area and call an area
hospital before you finish planning for the dive trip. There are online
sources available, too. For example, a list of recompression chambers
and associated diving physicians worldwide can be found at the web site
www.hyperbariclink.com. Some diving agencies also offer information
on area chambers through their web sites, or can be contacted directly
for further guidance.
It’s clear that recompression may be the one procedure that can
save a diver’s life in some instances. Even if a chamber is nearby and
accessible, however, this treatment, along with the expenses associated
with an evacuation, is not inexpensive. Insurance developed specifically
for scuba divers is available and very worthwhile.
201
Scuba I.Q. Review
1. What is the value of recompression in decompression sickness ac-
cidents?
2. What is the difference between decompression chambers and recom-
pression chambers?
3. How does a chamber simulate descending to depth?
4. Do you know where the nearest chamber is to your frequent dive
sites?
202
Appendix
A Diver’s First Aid Kit

TDI/SDI recommends that all divers obtain training in first aid and
oxygen therapy. For rescue divers this is particularly important as they
may be the most qualified lifesavers on the accident scene. Below is a
suggested list of contents for a diver’s first aid kit:
First aid manual

Oxygen kit with selection of appropriate masks
Disposable latex or vinyl surgical gloves
Barrier mask for CPR
2 liters of fluid; 1 liter of a sport drink for electrolyte replacement,
I liter of water
Topical disinfectant such as Betadine for barnacle and coral scrapes
Topical antibiotic cream for cuts and scrapes
Topical anesthetic or anti-itch cream
50% hydrogen peroxide, an effective external ear wash
Eye drops to wash out foreign objects
Decongestant tablets such as Sudafed to drain blocked sinuses or
ears after diving
Antihistamine tablets such as Chlor-Trimeton to reduce swelling
and irritation in ears and sinuses
Eye dropper
Gauze squares, 4”x 4”, for use as pressure bandages to stop bleeding
Absorbent pads for bleeding
Assortment of ‘bandaids’
Self-adhesive surgical dressing to cover large wounds
Tweezers, scissors, sharp knife or scalpel
Air-activated heat pads
Cold packs to reduce swelling of sprains
Reflective ‘Space Blanket’ for wrapping cold persons
203
Plastic bag for the disposal of soiled or blood-contaminated items
Notebook and pen to record information
Useful contact information:

DAN (Divers Alert Network) (919) 684-2948
This is a 24-hour hot line for information and advice on the treatment
of diving injuries.
US Coast Guard Monitors VHF Channel 16 continuously.
Also can be reached locally via telephone or cellular phone. Obtain the
phone number for your area.
Blood-Borne Pathogens
The possibility of transmission of disease organisms from one person to
another is heightened by contact with body fluids. While that possibility
is greatest through contact with another person’s blood, mucus and other
fluids may also carry viruses and bacteria. Of greatest concern is the
accidental transmission of HIV and hepatitis viruses. Despite the fear
of contracting these disease agents, transmission in the aquatic environ-
ment during rescue operations is very remote. The sharing of regulators,
for example, has never been shown to transmit HIV or hepatitis. The
marine environment is patently hostile to HIV, although hepatitis A
will survive in both salt and fresh water. Although transmission during
in-water resuscitation efforts would be unlikely, caution is advised.
Dry land rescue procedures, especially first aid, however, does
carry a greater risk of accidental infection. The first aid provider should
avoid contacting the body fluids of another person by using disposable
surgical gloves during treatment of actively bleeding wounds. Wash off
any contaminating body fluids as soon as possible after exposure to your
skin or clothing. One-way valve barrier masks are recommended for
CPR on land.
“Universal precautions” as a means of reducing the transmission of
causative agents of disease is included in many modern first aid courses
and should be a matter of standard practice for all responders.
204
About the
Author
Joe Mokry
Joe’s interest and involvement in water rescue, particularly scuba res-

cue, has been direct and long-standing. As a diving instructor for more
than 15 years, Joe has been instrumental in developing new techniques
and strategies for rescue, and delivered these to hundreds of students
in training classes. This resulted in his being awarded NAUI’s annual
Outstanding Service Award. Now as an Instructor Trainer for TDI/SDI,
he is passing along this knowledge to new instructor-candidates.
Joe’s background includes a Master of Biology, Wilderness EMT,
First Aid and CPR instructor, and oxygen-therapy instructor. A licensed
Able Bodied Seaman and Coast Guard certified Ship’s Master, Joe
is most at home on, in or under the ocean. His long association with
marine rescue led to his developing a Fast Rescue Boats program that
has been certified by the US Coast Guard and recognized by the In-
ternational Maritime Organization, one of only a half-dozen such pro-
grams world-wide that has reached this level of distinction. A working,
professional diver himself, his work with Public Safety departments
in all aspects of water rescue, including Dive Rescue Team training
and Search and Recovery Team training routinely takes him across the
205
country as a trainer and speaker. Two of his more esoteric specialties
are training “high exposure” Rescue Swimmers and Fast Rescue Craft
crews for the extremes of rescue situations.
A Maine resident, Joe spends much of his time as a Visiting Pro-
fessor at the Massachusetts Maritime Academy on Cape Cod where he
trains both cadets and maritime professionals in international-standard
courses. As a long-serving member and officer of the Cape Elizabeth
Water Extrication Team (WETeam), he has received several commen-
dations for rescue operations, including the prestigious Public Service
Commendation for his actions in the rescue of a downed Air-Med heli-
copter pilot in horrendous sea conditions.
Joe can be reached through Ocean Rescue Systems at www.ocean-
rescue.com.
206
OW Scuba Diver
• Snorkeler • Advanced Adventure

Advanced Diver Rescue Diver
• Scuba Discovery • Advanced Buoyancy
Control
• Future Buddies
• Altitude
• Shallow Water Diver
Master Diver SDI Divemaster • Boat
• Supervised Diver
• Computer
• Computer Nitrox
Inactive Diver / SDI Assistant • CPROX 1st AED

SDI Instructor
Refresher Instructor • Deep
• Diver Propulsion
Vehicle
SDI Scubility • Drift
Scubility SDI IT Staff Instructor
Instructor
• Dry Suit
• Equipment Specialist
• Full Face Mask
SDI Instructor Trainer
• Ice
• Marine Ecosystems
Awareness
• Night/Limited Visibility
• Research
• Search & Recovery
• Shore/Beach
• Sidemount
• Solo
• U/W Hunter &
Collector
• U/W Navigation
• U/W Photographer
• U/W Videographer
• Visual Inspection
Procedures
• Wreck
207
Glossary
After-drop: Continued cooling of the body core of a hypothermic victim
after rewarming. Too rapid external rewarming can cause a catastrophic
core temperature drop and cardiac arrest.
AGE: See arterial gas embolism
Alveolus: Air sac at the very end of lung passages. Plural is alveoli.
Amnesia: Loss of memory.
Arterial gas embolism: Bubble of air trapped in the arterial side of the
circulation causing a blockage of blood flow. Possible result of a lung
over-expansion injury.
Artery: Blood vessel that carries blood away from the heart.
Aspiration: Inhaling foreign matter into the lungs, such as vomit
Barnacle: Marine animal which attaches to a firm substrate such as

rock and is characterized by a hard, sharp volcano-shaped shell.
Barotrauma: Injury caused by changes in pressure.
Bends: Popular term for decompression sickness.
Breath trigger: Elevated level of carbon dioxide in the circulating

blood that stimulates the breathing response.
Bronchitis: Excessive mucus or other fluid production in the lungs

resulting in chronic cough.
208
Capillary: Tiny blood vessels through which oxygen and carbon dio-
xide are exchanged across the lung tissue and other organs.
Carabiner: Spring-loaded clip for connecting lines, harnesses or hard-

ware.
Carbon dioxide: Gas produced in the body from the combustion of

oxygen and organic materials. Odorless, colorless and tasteless.
Carbon monoxide: Toxic gas produced from the incomplete combusti-

on of oxygen and organic materials. Odorless, colorless and tasteless.
Cardiac arrest: Sudden stopping of cardiac output resulting in loss of

a pulse.
Cardiovascular fitness: A measure of overall capacity to perform at a

sustained level of exercise; a measure of endurance.
Carotid artery: Artery that supplies the head and brain with blood.
Pulse from these two arteries can be felt on either side of the Adam’s
apple.
Carotid sinus reflex: Reaction of the circulation to disproportionate

pressure being applied to the carotid artery, resulting in drop in blood
pressure and flow to the brain. Usually leads to blackout.
Conduction: Transfer of heat from one source to another by direct

contact.
Convection: Loss of heat from a body caused by air or water flow

across its surface.
Current reversal (eddy): Change in direction of water flow caused by

an obstruction in the water course.
Cyanosis: Blue tinge to skin and nail beds resulting from poor or no
oxygen supply.
209
DCI: See decompression illness.
DCS: See decompression sickness.
Decompression chamber: A pressurized air chamber used to permit

deep water divers to return to normal atmospheric pressure while out
of the water. Mechanically identical to a recompression chamber. More
properly referred to as a “hyperbaric chamber.”
Decompression illness: Term used to describe the major barotraumas

in diving and includes decompression sickness and lung over-expansion
injuries.
Decompression sickness: Condition caused by the expansion of nitro-

gen bubbles in the body tissues during or following an ascent, especially
in the connective tissues of the joints.
Dorsal fin: Prominent fin on the back of a fish.
Drowning: Suffocation caused by the inhalation of water.
Dysfunction: Inability to function properly.
Embolism: Blockage in circulation caused by bubbles, blood clots or

other matter.
Free flow: An event where the regulator delivers air constantly. May be
caused by ice formation within the moving parts, or because of inade-
quate servicing.
Freeze up: An event where the regulator stops supplying air due to an
ice blockage in the first stage.
Global awareness: Consciousness and perception of one’s surroun-

dings.
210
Hemoglobin: Protein in blood cells which is responsible for carrying
oxygen and carbon dioxide.
Hydraulic: Term used to describe the circulating water flow that forms
downstream of a submerged object in a current.
Hyperthermia: Elevated core temperature due to the body’s inability

to cool properly.
Hypothermia: Lowered core temperature due to the body’s inability

produce and conserve heat as quickly as it is lost.
Hypovolemic shock: Failure of circulation to supply oxygen to the

body tissues due to lack of sufficient fluids.
Hypoxia: Lack of sufficient oxygen
Ischemia: Lack of blood supply to body tissues resulting in a lack of

oxygen.
Knots: Measure of speed, one nautical mile (6076 ft.) per hour or about
1.1 statute (land) mile per hour or about 1.8 kilometers per hour.
Longshore current: Ocean current running parallel to shore , usually

set up by tides or persistent winds and surf.
Lowhead dam: Manmade structure across a river which holds back

flow at low water levels, but permits overflow at times of high water.
Mediastinal emphysema: Gathering of air into the space between the

two lungs surrounding the heart, major blood vessels, and trachea. A
possible consequence of a lung over-expansion injury and rupture.
Nasal cannula: An oxygen-delivery device consisting of plastic tubes

that drape around the patient’s head and end in short tabs that release
oxygen directly into the nostrils.
211
Nematocyst: Specialized cells possessed by jellyfish and other stinging
invertebrates which contain tiny harpoon-like devices used for defense
and food gathering.
Neurotoxic venom: Poisonous fluid injected by sea snakes and other

animals having its principle effect on the nervous system.
Nitrogen narcosis: Stuporous or elated state induced by the narcotic

effect of nitrogen on the body. Associated with relatively deep diving.
Oxygen toxicity: A possibly life-threatening condition characterized by

convulsions, caused by breathing oxygen at elevated partial pressures.
Panic: Overwhelming fear and loss of self-control in the face of real or

imagined danger.
Panting: Abnormal breathing pattern characterized by rapid, shallow

breaths, resulting in elevated carbon dioxide levels, hypoxia and the
feeling of suffocation.
Pectoral fin: Fin located just below and behind the gills on a fish.
Plasma: The portion of blood that is liquid and non-cellular.
Pleural membranes: Membranes covering the lungs and inside of the

chest wall.
Pneumothorax: Free air between pleural membranes. A possible con-

sequence of a ruptured lung, and may lead to a collapsed lung.
Primary survey: Initial assessment conducted to detect and correct

life-threatening medical conditions.
212
Recompression chamber: A pressurized air chamber used to simula-
te returning a diver to depth for the treatment of major barotraumas.
Mechanically identical to a decompression chamber. More properly
referred to as a “hyperbaric chamber.”
Red blood cells: The major cellular component of blood that carries
oxygen.
Rescue: The removal of a person from danger.
Respiratory arrest: Cessation of breathing.
Resuscitation: Act of reviving an unconscious or apparently dead

person.
Reverse block (or squeeze): A condition where high pressure air is

trapped in the middle ear or sinus, causing discomfort or pain on ascent.
Rip: Relatively high velocity stream of water moving directly away

from shore, usually set up by deflected longshore currents or dammed
tidal waters.
Secondary survey: Assessment of the patient undertaken to detect pro-

blems that are not immediately life-threatening, but which may become
more serious if left untreated.
Self-awareness: Consciousness of one’s own feelings and perceptions;

being alert.
Sign: An observable indication of the patient’s condition, such as shi-

vering or cyanosis.
Skip-breathing: An abnormal and deliberate breathing pattern alte-

ration characterized by brief breath-holding followed by a prolonged
exhalation and then repeated. The intent is to obtain more bottom time
from a scuba cylinder, but often results in hypoxia and severe headache.
213
Sprain: Injury involving tearing or stretching of ligaments.
Squeeze: A direct effect of pressure on air spaces in the body or beneath

equipment next to the body in response to increased pressure on descent.
Stress: A physical and emotional challenge to an individual requiring

some effort to maintain control and mental balance.
Stroke: Sudden loss of neurological function due to interruption of

blood flow to some part of the brain.
Subcutaneous emphysema: The presence of air directly under the

skin which may have migrated from other parts of the body. A possible
consequence of a lung over-expansion injury.
Supine: Lying flat on one’s back.
Surge: Back and forth motion of water associated with the passage of
a swell.
Symptom: An indication of the patient’s condition that he feels and

describes.
Thoracic cavity: The space in the chest occupied by the lungs, trachea
and esophagus.
Trachea: Windpipe
Tuberculosis: Bacterial disease affecting the lungs and other body parts.
Spread by coughing and sneezing (droplet dispersal).
Type I bends: Symptoms of decompression sickness principally cha-

racterized by joint pains and skin rash or itch.
214
Type II bends: Very serious form of decompression sickness caused by
growth of nitrogen bubbles in the spinal cord and elsewhere. Symptoms
include ‘pins and needles’ in the legs, radiating back and abdominal
pain, weakness in legs and paralysis.
Vein: Blood vessel that carries blood back towards the heart.
Venous gas embolism: Nitrogen bubbles collected in the veins as the

gas comes out of solution and the tissues on ascent.
Visualization: Act of producing a set of mental images related to an

impending activity or event for the purpose of preparing emotionally
and mentally for the activity.
215
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SCUBA DIVING INTERNATIONAL

© 2001, 2011, 2013 International Training v.0918

Author: Joe Mokry

Photography: Bret Gilliam, Steven M. Barsky, Joe Mokry, Wayne Hasson,

Illustrations: Steven M. Barsky

ISBN Number: 1-931451-02-8 Product ID #: 210002-01

Chapter 2: How Stress Leads to Diving Emergencies 35

Chapter 4: Responding to Emergencies on the Surface 75

Chapter 5: Responding to Emergencies Underwater 113

Chapter 7: Lost Diver Search and Recovery 175

The Self-Reliant Diver

Relaxed confidence is a characteristic of the self-reliant diver.

Preparing for the dive

Stop Something is OK?,OK OK?,OK (gloved)

You lead, I’ll follow Level off, Take it easy,

Distress, help! OK? OK OK?OK

Come here Me, or watch me Out of air Buddy breathe or

Danger Ears not clearing I am cold Go that way

Pull-toggles or any other mechanism used to release integrated weights

Special Emergency Skills

Buddy Dependent Options

Procedure for using an octopus regulator

Buddy breathing, or sharing a single second stage, has been used

Procedure for buddy breathing

Buddy Independent Options

Redundant air supplies

In low visibility conditions, divers might consider using a buddy line

Lost buddy search

Every diver should be accomplished in the art of accurate underwater navigation.

Scuba diving is an adventure, but may

The same components of adventure are also sources of stress in

Recognizing Stress in Others

Recognizing the Signs of Stress

Stress may be caused by diving

In this kind of situation, there is no substitute for an honest self-ex-

Dealing with stress

Conduct a Good Dive Briefing

Conduct a Good Buddy Check

Talk to the Dive Leaders

Visualize the Dive

Stress and Panic in the Water

Panicky Diver on the Surface

Panicky Diver Underwater

Assisting Panicky Divers

Panic is the greatest single cause

How Diving Accidents Happen

Exceeding prior experience and training

Accidents are often caused by divers exceeding their level of training.

Without participation from better trained and experienced divers,

Avoid accidents by:

Freshwater diving is often characterized by strong currents. Directly down-

Diving in fast moving rivers is

Backwash Boil line

Anatomy of a standing wave and hydraulic.

© 2001 S. Barsky. All rights reserved.

Most dive site injuries are minor