Tuesday, November 30, 2004

Scubadoc's Ten Foot Stop Newsletter, 11/30/04

---NOTE FROM SCUBADOC---

We thought that we had made it clear last year that our newsletter is a free service, and that any emails that you might get from Paypal are actually holdovers from the days when we were charging for the publication. Paypal is still used by us to allow many of you to donate money to support the continuance of the newsletter. Other than completely discontinuing the service, we have no way of stopping them from sending you the requests for subscription money. So - there are still three ways that you can support our effort: use Paypal, use amazon.com or send us a small check by snail mail. See http://scuba-doc.com/sbscrb.html . We always appreciate thoughtful donations to our educational web site.

Please note that we are now placing changes to our web site on our Diving Medicine blog at http://scubadoc.blogspot.com/ . In addition, we will also continue publishing this newsletter on the Ten Foot Stop blog at http://tenfootstop.blogstop.com/ . All of our prior newsletters are stored in pdf at http://scuba-doc.com/archives.html .

We would like to hear from you regarding interesting diving medical problems, links and humor that would be fit to print. We test all the links on three different browsers before sending out the material - but sometimes your personal computer will require a cookie or will block the access until you register at the remote site.

Best regards:

scubadoc
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---QUESTION OF THE WEEK---

Here is a question from Prof. Dr. Schipke:

Dear Ern,

It is fun to receive your news and to realize that you are doing well. My question today: would you know articles (studies or reviews) on diving with pacemakers? I don't find much.

Kind regards from wintery Germany

Jochen

Dear Dr. Schipke:

Very nice to hear from you and hope that you are well!

I have discussed this from time to time in my newsletter, the last in November 2003.

"Cardiac pacemakers are used to regulate a person's pulse rate (both too slow and too fast). It is implanted in the person's subcutaneous tissue and will be exposed to the same ambient pressures as the diver. For most recreational diving, an adequate pacemaker must be rated to perform at least a maximum depth of 130 feet / 40 meters and must operate satisfactorily during conditions of wide pressure changes - as during ascent and descent.

What if most of your diving is deeper than this? The St. Jude Medical pacemaker is said to be rated to a depth of 230 feet. (70.104 meters). See pacemakers and arrhythmias on our web page at http://www.scuba-doc.com/pace.htm

Other links
UKSDMC Standards
http://snipurl.com/asls

Kratz JM, Blackburn JG, Leman RB, Crawford FA. Cardiac pacing under hyperbaric conditions. Ann Thorac Surg. 1983 Jul;36(1):66-8.
http://snipurl.com/aslv

A good review by my friend, Jim Caruso, written for DAN. http://diversalertnetwork.org/medical/faq/faq.asp?faqid=143

Interesting cautionary http://e-nekton.com/archive/edition3/feature-1.html

Dr. Simon Mitchell, mentioned in the above article as having developed a list of pacemakers and specifications can be contacted at the following :
Simon Mitchell, MB.ChB.,
DipDHM, Ph.D.
Wesley Centre for Hyperbaric Medicine
Medical Director
Sandford Jackson Bldg., 30
Chasely Street
Auchenflower, QLD 4066
Australia
smithchell@wesley.com.au

Basic information about pacemakers
http://circ.ahajournals.org/cgi/content/full/105/18/2136

Scuba Diving and the Heart. Cardiac Aspects of Sport Scuba Diving,
Claus-Martin Muth1 und Kay Tetzlaff2
http://www.bnk.de/herz/en/3805_3811.htm

This should get you started.

Warm regards:

Ernie Campbell

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---COOL SITE OF THE WEEK---

DAN's web site regarding diving medicine has continued to improve and add more and more material that answers many questions for divers and instructors. This is located at http://diversalertnetwork.org/medical/index.asp .

In addition, there is a medical research section located at http://diversalertnetwork.org/research/index.asp and a training and education page at http://diversalertnetwork.org/training/ .

++++++++++++++++++++++++++++++++++++++++++++++++

---MAILBOX POTPOURRI---


Wound Healing Society

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Telephone: (763) 765-2377 • Facsimile: (763) 765-2329 • Visit www.woundheal.org for the latest information on the program.

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15th Annual Meeting & Exhibition

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Keynote Address - Developing a Regenerative Medicine:

The Amphibian Limb as an Experimental System

David Stocum, PhD, Indiana University

Clinical Trials in Wound Healing Workshop

Dual Track Plenary Sessions

Angiogenesis:Paul Bornstein, PhD, University of Washington

Hynda Kleinman, PhD, NIOCR, NIHBioengineering:

Howard Greisler, MD, Loyola University

Phillip Messersmith, PhD, Northwestern University

Brenda Russell, PhD, University of Illinois at ChicagoClinical Trials:

David Margolis, MD, University of Pennsylvania

Martin Robson, MDStem Cells:

Darwin Prockop, MD, PhD, Tulane University

Shahin Rafii, MD, Cornell University

The 2005 Program Committee has organized a strong program of plenary speakers and sessions featuring:Translational Research:

Mark Ferguson, PhD, University of Manchester

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Blue Ribbon Industrial R & D Award

Presentations

Young Investigator Award Competition

Concurrent Abstract Podium Sessions

Poster Sessions

3M Award Presentation

Exhibition

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WHS 2004 Annual Meeting Attendee
********************************************************

Stracener Joins DAN Board of Directors


Douglas N. Stracener, a DAN Member, NAUI Instructor and longtime attorney based in Baton Rouge, La., has joined the DAN Board of Directors effective immediately.

Stracener, 55, joins William Anlyan, Dennis H. Liberson, Dr. E. Wayne Massey, Lee Selisky and Kathy Weydig as new members on the 11-member board for 2004-2005. He replaces Dick Long, whose term on the board has expired.

Prior to Stracener joining the board, at a meeting last week, board members chose Anlyan as its new chairman. He is a partner with Anlyan and Hively Wealth Management and certified scuba and nitrox diver.

“I welcome Mr. Stracener’s addition to the board,” said DAN President and CEO Michael D. Curley, Ph.D. “As he has been a DAN Member since 2000, he is familiar with our organization and its vision and mission. I look forward to his helping guide DAN toward fulfilling its goal of being the leading dive health and safety research organization.”

Stracener was admitted to practice law in Louisiana in 1977. From that year, he was a member of the Stracener, Stracener and Stracener firm engaged in general criminal and civil law before starting his own similar practice from 1999 through the present. He also is a notary public, a licensed commercial pilot and a communications officer with the state of Louisiana Office of Emergency Preparedness. As the latter, Stracener coordinates statewide amateur “ham” radio operators to serve as active communication support specialists to state and local government agencies during emergency operations, usually weather-related.

As a NAUI Instructor, Stracener has trained students from basic open-water through master diver courses, as well as nitrox, drysuit specialty checkout and rescue diver training and checkout. He teaches at Underwater Adventures Inc., a DAN Business Member operation in Baton Rouge.

In his application to be on the DAN Board of Directors, Stracener wrote: “I am excited about its ongoing research on dive medical, safety and associated research areas, and would love to work on behalf of the leading edge organization in this field.”

For more information on this press release, contact Wesley Hyatt, DAN Communications, at 1-800-446-2671 ext. 282 or email whyatt@dan.duke.edu .

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Question: Problems equalizing

A year ago I had problems diving and couldn't equalise properly in one ear. That night my ear was very painful and leaked a yellowy puss and traces of blood. I took antibiotics and it cleared up fairly quickly. Last month I noticed a very faint fluttering noise in my ear (tinnitus). Could this be as a result of the diving accident. I understand that if I were to develop tinnitus because of this that the onset would be fairly immediate, not a year later. I have been going through a bit of stress recently which I understand can also result in ringing noises.

Answer from Dr. Allen Dekelboum

Your request was referred to me for comment.

You are correct in assuming that tinnitus from a diving injury should
occur close to the time of the incident. Your original injury appears
to be a perforation of the ear drum. I hope you consulted an ear, nose
and throat doctor at the time. It is important that the ear drum has
healed completely.

You describe the tinnitus as a "flutter". That might be attributed to
spasms of one of the small muscles in the middle ear, the stapedius
muscle, which attaches to the stapes (stirrup) bone. This is not a
serious problem, often associated with stress, and is usually relieved
when the stress is controlled. True tinnitus is a ringing or buzzing
sound in the ear, usually continuous, but sometimes pulsing. If the
problem persists, I would consult an ear, nose and throat doctor.

Good luck.

Allen Dekelboum, M.D.

Links
http://www.scuba-doc.com/entprobs.html

http://www.scuba-doc.com/entprobs.html#Tinnitus

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Diving after surgery for splenic artery aneurysm?

Question:
If an anneurysm in the spenic artery was removed a year ago, can I dive and not worry or how deep? I feel fine. thanks.

Answer:
Given that you have made a complete recovery from your surgery with good wound healing and physical rehabilitation from the operation- then you would have no problems diving. If the spleen was removed during the operation - then you will need to be aware that you might be more subject to marine infections and have appropriate immunizations as determined by your doctor.

There would be no adverse effects of the surgery on depth/pressure or vice versa.

You should be able to physically don and doff your gear, perform entries and exits gracefully and without excess strain and should be able to perform self rescue and buddy rescue.

See also:
http://www.scuba-doc.com/surgdiv.html

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Question: Gas, abdominal distention, vomiting after diving
I have a friend who, after going to depths of about 20m or more has a problem with gas/air in his stomach upon surfacing. He feels fine under the water but on surfacing is sick, vomiting and needing to burb up the air. He thinks he is taking in too much air under water and while ascending it is expanding and causing this problem. It means he can't do a second dive that day. Do you have any suggestions on fixing this?

Answer:
Your friend's problem is from excessive air swallowing during the process of
equalizing his ears. He also may be an 'air swallower' due to excessive
nasopharyngeal mucous between dives and probably starts out with a gas load
in the stomach.

Remedies for the problem would be for him to avoid eating gas forming foods
and soda pop prior to the dive and to change his technique for clearing his
ears.

More about this on my web site at http://www.scuba-doc.com/hrtbrn.htm .

Here is a list of equalizing techniques by Allen Dekelboum, MD
http://www.scuba-doc.com/Equalizing_Techniques.pdf .

**************************************************

Save yourself a heap of trouble!
Here is some very good information from my friend, Glen Egstrom:

We pass along jokes on the Internet; we pass along just about everything. Pass this information along. It could really help someone you care about.

1. The next time you order checks have only your initials (instead of first name) and last name put on them. If someone takes your checkbook they will not know if you sign your checks with just your initials or your first name but your bank will know how you sign your checks.

2. When you are writing checks to pay on your credit card accounts, DO NOT put the complete account number on the "For" line. Instead, just put the last four numbers. The credit card company knows the rest of the number and anyone who might be handling your check as it passes through all the check processing channels won't have access to it.

3. Put your work phone # on your checks instead of your home phone. If you have a PO Box use that instead of your home address. If you do not have a PO Box, use your work address. Never have your SS# printed on your checks. (DUH!) You can add it if it is necessary. But if you have it printed, anyone can get it.

4. Place the contents of your wallet on a photocopy machine, do both sides of each license, credit card, etc. You will know what you had in your wallet and all of the account numbers and phone numbers to call and cancel. Keep the photocopy in a safe place. I also carry a photocopy of my passport when I travel either here or abroad. We've all heard horror stories about fraud that's committed on us in stealing a name, address, Social Security number, credit cards, etc.

Unfortunately I, an attorney, have firsthand knowledge because my wallet was stolen last month. Within a week, the thieve(s) ordered an expensive monthly cell phone package, applied for a VISA credit card, had a credit line approved to buy a Gateway computer, received a PIN number from DMV to change my driving record information online, and more.

But here's some critical information to limit the damage in case this happens to you or someone you know:
1. We have been told we should cancel our credit cards immediately. But the key is having the toll free numbers and your card numbers handy so you know whom to call. Keep those where you can find them

2. File a police report immediately in the jurisdiction where it was stolen, this proves to credit providers you were diligent, and is a first step toward an investigation (if there ever is one).

But here's what is perhaps most important: (I never even thought to do this).

3. Call the three national credit reporting organizations immediately to place a fraud alert on your name and Social Security number. I had never heard of doing that until advised by a bank that called to tell me an application for credit was made over the Internet in my name. The alert means any company that checks your credit knows your information was stolen and they have to contact you by phone to authorize new credit.

By the time I was advised to do this, almost two weeks after the theft, all the damage had been done.

There are records of all the credit checks initiated by the thieves' purchases, none of which I knew about before placing the alert. Since then, no additional damage has been done, and the thieves threw my wallet away this weekend (someone turned it in). It seems to have stopped them in their tracks.

The numbers are:

Equifax: 1-800-525-6285

Experian (formerly TRW): 1-888-397-3742

TransUnion: 1-800-680-7289

Social Security Administration (fraud line):
1-800-269-0271
**************************************************************

Reporting email about illegal drugs to the FDA
Here is a note from Dr. Jolie Bookspan regarding reporting receipt of email touting what you consider illegal sales of drugs.

"I offered my friend at the FDA to send the following FDA request to those with medical bulletin boards for posting, where appropriate.

Good Things,
Jolie"

**********************************

If you ever run across anything on counterfeit or black market pharmaceuticals, significant trafficking in controlled substance pharmaceuticals, or adulteration/tampering/off-label marketing of food, drugs or cosmetics please keep us in mind.

Special Agent Marc Hess
FDA/Office of Criminal Investigations
US Attorneys Office
615 Chestnut Street, #1250
Philadelphia, PA 19106
215/861-8253
marc.hess@fda.gov
**********************************************

DAN Sets Holiday Shipping Dates

For more information on this press release, contact Wesley Hyatt, DAN Communications, at 1-800-446-2671 ext. 282 or email whyatt@dan.duke.edu.

Know what to get for divers on your holiday list? Maybe a DAN backpack, jacket, board shorts or mock turtleneck? Or a first aid kit or oxygen unit?

To ensure that its customers’ gifts arrive in time for a happy holiday season, Divers Alert Network announces these shipping deadlines for ordering from the organization.

Please note the following dates:

• The last day to place an order before 3:30 p.m. EST via ground shipping (Federal Express Ground or U.S. Post Office First Class / Priority Mail) is Wednesday, Dec. 15.

• The last day to place an order before 3:30 p.m. EST via Fedex 2Day is Wednesday, Dec. 22.

• The last day to place an order before 3:30 p.m. EST via Fedex NEXTDAY is Thursday, Dec. 23.

For those wishing to do business on other days this season, the DAN offices will be closed on Nov. 25 and 26 in observation of the Thanksgiving holiday, Dec. 24 for Christmas and Dec. 31 for New Year’s Eve.

Customers may place orders to DAN by calling toll-free 1-800-446-2671 or +1-919-684-2948 or by using its product catalog on the website, www.DiversAlertNetwork.org. For regions outside the United States, Canada or U.S. Territories, please call DAN at +1-919-684-2948 ext. 614 for additional shipping information.

You can also purchase DAN products, including several exclusive items, without shipping deadlines at your area DAN Business Member stores. To locate the one nearest you, visit the Dive Business Directory at www.DiversAlertNetwork.org.

++++++++++++++++++++++++++++++++++++++++++++++++

---INTERESTING LINKS---

Hypothermia is not always bad:
Near-drowning treated with therapeutic hypothermia - The Medical Journal of Australia -1 November 2004 - Full text: http://www.mja.com.au/public/issues/181_09_011104/wil10138_fm.html

From Buenos Aires, Omar Sanchez, MD, Wetdoc.

******************************************************
Medical Seminars has added material on their web page at http://www.medsem.com/destination_information.html . Outstanding destinations, outstanding diving medicine courses.

******************************************************
This link from Jolie Bookspan:
Dolphins 'protect' lifeguards from great white
http://www.abc.net.au/news/newsitems/200411/s1249440.htm
*****************************************************
Doctors worried people are diving without training
http://snipurl.com/atpi
*****************************************************
Bends cases prompt warning for recreational divers.
22/11/2004. ABC News Online
http://snipurl.com/atpe

****************************************************
Scientific Scuba Diver Manual
http://www.sbg.ac.at/ipk/avstudio/pierofun/transcript/ssd.pdf

*****************************************************
Headache and Facial Pain in Scuba Divers
http://tinyurl.com/6gw79

****************************************************
Scuba Diving Hand Signal - Talking Below the Waves - Underwater Hand Signals
http://snipurl.com/aqgl

*****************************************************

---HUMOR---
[ Warning! Some may find this material offensive! ]

The best of the lot!

A guy walks into a bar with a pet alligator by his side. He puts the alligator up on the bar. He turns to the astonished patrons. "I'll make you a deal. I'll open this alligator's mouth and place my genitals inside. Then the gator will close his mouth for one minute. He'll then open his mouth and I'll remove my apparatus unscathed. In return for witnessing this spectacle, each of you will buy me a drink."

The crowd murmured their approval. The man stood up on the bar, dropped his trousers, and placed his privates in the alligator's open mouth. The gator closed his mouth as the crowd gasped. After a minute, the man grabbed a beer bottle and rapped the alligator hard on the top of its head. The gator opened his mouth and the man removed his genitals unscathed, as promised.

The crowd cheered and the first of his free drinks were delivered. The man stood up again and made another offer.

"I'll pay anyone $200 who's willing to give it a try!" A hush fell over the crowd. After a while, a hand went up in the back of the bar. A Blonde woman timidly spoke up. "I'll try, but don't hit me so hard on the head with the beer bottle!"

*****************************************************

A man's walking late at night when he sees a woman in the shadows.

"Fifty bucks," she says.

He's never been with a hooker before, so he decides what the hell.

They're going at it for a minute when all of a sudden a light flashes on them---it's a police officer.

"What's going on here, people?" asks the officer.

"I'm making love to my wife," he answers indignantly.

Oh, I'm sorry, I didn't know," says the cop.

"Well, neither did I until you shined that light in her face.

**********************************************************************

Conversation overheard at the gas station between two blondes....

First blonde: "I expect they'll be raising the gas prices again soon."

Second blonde: "Won't affect me. I always put in just $20 worth."
************************************************************************
1. Two vultures board an airplane, each carrying two dead raccoons. The stewardess looks at them and says, "I'm sorry, gentlemen, only one carrion per passenger."

2. Two fish swim into a concrete wall. One turns to the other and says "Dam!".

3. Two Eskimos sitting in a kayak were chilly, so they lit a fire in the craft. Unsurprisingly it sank, proving once again that you can't have your kayak and heat it too.

4. Two hydrogen atoms meet. One says "I've lost my electron." The other says "Are you sure?" The first replies "Yes, I'm positive."

5. Did you hear about the Buddhist who refused Novocain during a root canal? His goal: transcend dental medication.

6. A group of chess enthusiasts checked into a hotel and were standing in the lobby discussing their recent tournament victories. After about an hour, the manager came out of the office and asked them to disperse. "But why?" they asked, as they moved off. "Because," he said, "I can't stand chess nuts boasting in an open foyer."

7. A woman has twins and gives them up for adoption. One of them goes to a family in
Egypt and is named "Ahmal." The other goes to a family in Spain; they name him "Juan." Years later, Juan sends a picture of himself to his birth mother. Upon receiving the picture, she tells her husband that she wishes she also had a picture of Ahmal. Her husband responds, "They're twins! If you've seen Juan, you've seen Ahmal."

8. Two friars were behind on their belfry payments, so they opened up a small florist shop to raise funds. Since everyone liked to buy flowers from the men of God, a rival florist across town thought the competition was unfair. He asked the good fathers to close down, but they would not. He went back and begged the friars to close. They ignored him. So the rival florist hired Hugh MacTaggart, the roughest and most vicious thug in town, to "persuade" them to close. Hugh beat up the friars and trashed their store,saying he'd be back if they didn't close up shop. Terrified, they did so, thereby proving that only Hugh can prevent florist friars.

9. Mahatma Gandhi, as you know, walked barefoot most of the time,which produced an impressive set of calluses on his feet. He also ate very little, which made him rather frail, and, with his odd diet, he suffered from bad breath. This made him...[Oh, man, how bad is this one?!!]...a super callused fragile mystic hexed by halitosis.

10. And finally, there was the person who sent ten different puns to his friends, with the hope that at least one of the puns would make them laugh.

No pun in ten did!


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Scubadoc's Ten Foot Stop Newsletter is a free service of Diving Medicine Online, one of the Top Most Visited Diving Medicine Websites in the world!
Visit us on the Internet at: http://scuba-doc.com/
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

Tuesday, November 16, 2004

Scubadoc's 'Ten Foot Stop Newsletter'

Scubadoc's 'Ten Foot Stop Newsletter'

Now located in our Ten Foot Stop Blogspot at http://tenfootstop.blogspot.com/
(Prevoius newsletters still located at http://scuba-doc.com/archives.html )
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

NEED TO KNOW MORE ABOUT A CONDITION THAT YOU HAVE - OR A MEDICINE THAT YOU ARE TAKING? Then go to our web site and use the easy to follow links that are intuitive for your personal situation. http://scuba-doc.com/

Or, go to the faqs page and see if the condition has been discussed. http://scuba-doc.com/Q&A.html

Or, go to the 'Scuba Clinic' forum and place your own question or comment. http://scuba-doc.com/scubaclinic .

--> Ten Foot Stop Subscribers get first response treatment for queries and problems!
[ALL THIS IS FREE!]

++++++++++++++++++++++++++++++++++++++++++++++++

--> LEARN SOMETHING NEW EVERYDAY ON OUR WEB SITE!
The home page has two search facilities [Google and Free Find] that will bring up any references to keywords that you need information about - on our web site or on the web. You'll be surprised at the extensive coverage of diving medicine on our site.

++++++++++++++++++++++++++++++++++++++++++++++++

-NOTE FROM SCUBADOC-
***How many of you would be interested in owning a book that would give you immediate access to information about whether or not you or one of your students or divers should dive with a condition or medication? What if the book was written by several individuals with extensive knowledge and credentials for teaching diving medicine? What if the book was inexpensive and written expressly for the diving instructor and divemaster? Well, it seems that such a book is well along the path to being published by several individuals expert in the area of 'fitness to dive'. I'll keep you posted on this venture as it progresses so that you can get your order in for book early on. In the meantime, let me know if you're interested. Write me for more information at scubadoc@scuba-doc.com

***********************************************************************
We had a recent newsletter that had several comments about 'In Water Resuscitation'. [ http://scuba-doc.com/nl043004.pdf ]

Dr. Omar Sanchez sends the following:
In-water resuscitation—is it worthwhile?

David SzpilmanCorresponding Author Contact Information, E-mail The Corresponding Author, E-mail The Corresponding Author, a, b and Márcio Soaresb, c
a Fire Department of Rio de Janeiro—Drowning Resuscitation Center (DRC) of Barra da Tijuca (CBMERJ-GMAR-GSE), Av. das Américas 3555, Bloco 2, sala 302, Rio de Janeiro RJ 22793-004, Brazil
b Intensive Care Unit, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
c Intensive Care Unit, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
Received 16 February 2004; Revised 14 March 2004; accepted 14 March 2004. Available online 15 September 2004.

Abstract
Objectives: At present, there is no reliable information indicating the best option of rescuing a non-breathing drowning victim in the water. Our objectives were to compare the outcomes of performing immediate in-water resuscitation (IWR) or delaying resuscitation until the victim is brought to shore. Material and methods: A retrospective data analysis was conducted of non-breathing drowning victims rescued by lifeguards in the coastal area of Rio de Janeiro, Brazil. Patients were coded as IWR and no-IWR (NIWR) cases based on the lifeguard’s decision whether to perform IWR. Death and development of severe neurological damage (SND) were considered poor outcome. Results: Forty-six patients were studied. Their median age was 17 (9–31) years. Nineteen (41.3%) patients received IWR and 27 (58.7%) did not. The mortality rate was lower for IWR cases (15.8% versus 85.2%, P<0.001). p="0.038]" or="0.05" ci="0.01–0.50)," p="0.011]" or="1.77" ci="1.13–2.79)," p="0.013]." style="font-weight: bold;">

-QUESTION OF THE DAY-

Here is a query that was posted on our 'scuba clinic' forum:
Arteriovenous malformation, brain
"Through a non-related accident and ct scan, I was recently diagnosed with a 3cm avm on my occipital lobe of my brain which was treated through Novalis radiation in August, 2004. I am 49 years old and have had no previous symptoms due to the avm. I have in the recent past (prior to finding out about the avm) participated in "resort" diving and had given serious consideration to pursuing diving certification to participate in recreational scuba as a hobby. In investigating the avm condition and how it relates to scuba, I get conflicting information. From a health standpoint, what should I anticipate my capability for future participation in scuba to be."
Our answer:
Problem -- AVM post irradiation.
Novalis "shaped beam" fractionated radiation is thought to leave little in the way of scarring. You don't mention any post irradiation symptoms or residuals.
Diving Concerns
---Condition Related
Recurrence of AVM is about 2 % in adults. Seizure activity would be a major concern, as drowning would surely ensue if this occurred underwater. Oxygen toxicity would increase this risk.
---Treatment Related
Scarring from the treatment is said to produce an increased risk for the development of bubbles in areas of altered vasculature, either decreased or increased, an unproven suspicion. Also, we don't know exactly how the Novalis system works over a period of months to decrease blood flow.
---Diver Related
Residual weakness would be of some concern in hindering the diver's ability to gear up and perform tasks required for safe diving. It might also diminish his ability to self rescue and to rescue his buddy, thereby endangering the entire dive operation. [The degree of disability is of some importance]. Enhanced reaction to nitrogen is a possibility but this is not known.
Symptoms require carefully recorded delineation in order to be able to differentiate between this entity and possible decompression symptoms - should this untoward event occur.
Risk Assessment
---Risk from the Condition
Depth and pressure should have no effect on the condition. Recurrence of the condition has to be accounted for with the realization that should a hemorrhage occur underwater, the risks are very high for death from drowning.
---Risks from the Treatment
Scarring from the irradiation treatment would need to be determined by various studies. Foci of altered vascularity could possibly lead to DCS in the area with further diminution in neuronal coverage of the penumbra of injury. Side effects and risks of stereotactic radiosurgery may include seizures, infection, hemorrhage, nausea, vomiting, dizziness, headaches and temporary hair loss. These side effects are generally only temporary.
---Risks to the Diver
Chance of a bleed or rebleed underwater, minimal but present. Vigorous exercise, lifting heavy weights and using the Valsalva method for ear-clearing when diving all increase arterial pressure in the head and may increase the likelihood of a recurrent hemorrhage. Chance of convulsions, both from the scarring and from the increased propensity for seizures from borderline high oxygen partial pressures at depth. [O2 pp greater than 1.4 ata can lead to oxygen toxicity and seizures].
Advising the Diver
---Potential for injury from future diving
A long time, previously certified sport diver might possibly return to diving with the full knowledge of the potential for injury after an appropriate period to allow for full radiation effect [three years]. A commercial diver should not return to diving for various reasons, namely the depths, strenuous activity and likelihood of decompression diving and liability potentials. However, a new diver or partially trained diver could participate in the sport depending on the degree of disability and appropriate wait for full effect of the focused radiation as determined by MRI studies and angiography.
---Modifiers
Degree of disability
Age
Findings on studies and degree of benefit as determined by studies.
History of convulsions or anticonvulsant therapy.
---Dive or not dive
There are several unsubstantiated reports that recommend for cerebral hemorrhage that if there are no convulsions and the person is not taking anticonvulsant medication - then diving may be considered after a wait of three seizure free years. [Parker, The Sport Diving Medical].
If there is a highly motivated individual who is well informed of the risks and is willing to accept these risks - then one might consider allowing low stress diving [shallow diving [60 fsw or above], warm water with little in the way of current, surges or wave action] sooner if the AVM is shown to be stable and asymptomatic. Again, as the effect of the focused radiation on the AVM is realized over many months; blood flow through the AVM should be monitored and retreatment performed if necessary.

It would be wise to avoid all factors that would increase the risks of O2 toxicity (deep diving, Nitrox, rebreathers) because of the possibility of initiating seizures.

***The patient should be given enough time to demonstrate that the AVM has fully responded to the focused irradiation.
***Close observation of changes over a several month period are required. Whether or not the full three year wait is necessary should be determined by clinical experience in combination with the MRI, angiograms and the material provided above.

This seems to be pretty straighforward and should help you decide that you should wait for the effects of the irradiation to become manifest.

Links to other neurological problems and diving
http://www.scuba-doc.com/nbjprb.htm

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-COOL DIVING MEDICINE WEB SITE-

Doc's Diving Medicine
http://faculty.washington.edu/ekay/
Dr. Ed Kay's Excellent Site

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-MAILBAG-

From UHMS concerning Wound Healing. org Meeting

See Meeting Promo Flyer at http://scuba-doc.com/woundhealorg.pdf

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From DAN:
For more information on this press release, contact Wesley Hyatt, DAN Communications, at 1-800-446-2671 ext. 282 or email whyatt@dan.duke.edu.

2004 DEMA Show Productive for DAN

The recently completed 2004 DEMA Show in Houston was a considerable success for Divers Alert Network (DAN). Final sales and attendance figures from the show regarding DAN’s participation are not available at present, but preliminary indications are that they were in line with expectations for the show.

“DAN goes to DEMA to support diving, to inform and educate all areas of the diving industry about DAN’s mission in helping divers, keeping them safe and learning about what happens to divers when they dive,” said Tony Bacci, Vice President, DAN Marketing and Business Development and DEMA Show attendee. “DEMA provides a forum for the Medical, Training, Research and Development departments of DAN to showcase their latest findings and developments on diving.”

“Although it is believed fewer conventioneers attended than last year, those who did visit the DAN booth were ready to do business and learn about the latest news and products related to dive safety and health,” said Steve Barnett, DAN Director ofMarketing and DEMA Show attendee.

Here are some show highlights reported by DAN departments:

• Business Membership: The DAN Business Membership Team had a very strong DEMA, as they met with more than 200 DAN Business Members. Two new programs were released at the show, the DAN Trip Insurance that can now be sold through dive centers and the DAN On-Site Neurological Assessment for Divers course. Plus, DAN rolled out new products and an improved restocking program for the very popular Point-of-Purchase display.

• Training: The DAN Training team remained extremely busy during the 2004 DEMA Show, as more than 250 DAN Trainers, Instructors and those wishing to learn more about DAN Training programs participated in 24 training courses, seminars and orientations – more than 57 hours of training – conducted in Houston throughout the show. Two new programs released at the show, the DAN On-Site Neurological Assessment for Divers course and the DAN Diving Emergency Specialist recognition program, were among the most popular with participants.

• Research: DAN Research met with 11 computer manufacturers. Most now incorporate the Dive Log-7 (DL-7) data format from DAN in their software to use as part of Project Dive Exploration (PDE), and many are working to make their computers PDE compatible. Several dive operators expressed interest in getting involved in PDE too. Some operations indicated they would like to be new data collection sites and / or new host sites for the DAN Research Internship Program. And Research staff presented three lectures on current research projects and some key issues in diving. Research made many

*****************************************************
From Don Chandler, UHMS
All UHMS Members:
There is still time to sign on for our next two Medical Assessment for Fitness to Dive courses. Courses will be held in Honolulu Hawaii on January 21-24, 2005 and in New Orleans, Louisiana on February 10-13, 2005. Please use the attached to apply. Remember we now have a legal section of the course taught by lawyers who handle maritime cases (they, too, attended our course)...this alone is worth the cost of the course.
Diving trips are available at a significant discount for those who attend the course in Hawaii. If you are interested in diving note such on your application and we will "connect" you to the dive company who is offering the discount.
Don

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TO: All UHMS MEMBERS
CAWC Conference Details Available: Don't Miss this One!
The Canadian Association of Wound Care's Tenth Annual Conference will be held in Calgary, ALBERTA, CANADA November 11-14, 2004. "Celebrating the Advancement of Wound Care" is the title of this year's conference and it will showcase 10 years of experience and learning. Download the flyer (PDF) or visit the Conference section of this Web site for details http://www.cawc.net/

Hyperbaric Medicine is also well represented in the field of Wound Care Field at this Convention, as per the stated objectives of the UHMS Wound Care Liazon Commiittee.
Dr. Wayne Evans, UHMS Wound Care Liazon Commiittee International Member, will be manning the UHMS booth -- come by and show your support.
Also at the conferance Dr. Evans:
will assist in leading the Nov.12 Clinical Practice Forum
as well as providing 2 clnical study presentions Nov.13 demonstrating the value of HBO in the management of radiotherapy late efects injury,
plus a Nov.13 presentation on the introduction of advanced electronic educational tools featuing transcutaneous oximetry.

******************************************************
From Tom Workman, UHMS
We are pleased to announce that the Society's Clinical Hyperbaric Facility Accreditation Program has achieved a major milestone. On November 10th, the Accreditation Council conferred accreditation for three years to our 38th facility. According CMS data on the number of hospitals billing for hyperbaric services, this represents 10% of the hospitals in the country with hyperbaric medicine programs! The Society wishes to extend our sincere gratitude to the hyperbaric community for supporting this voluntary program allowing this level to be attained in just over 25 months.
Please join us in congratulating the Center for Wound Care and Hyperbaric Medicine at Virginia Baptist Hospital, Lynchburg, VA for being our newest accredited facility and for helping the hyperbaric community achieve this mark.

W.T. Workman, MS, CAsP, CHT
Director, Quality Assurance & Regulatory Affairs
Undersea and Hyperbaric Medical Society Satellite Office
18111 Copper Ridge Drive

San Antonio, Texas 78259-3612
Tel: +1(210) 404-1553
Fax: +1(210) 404-1535

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-LINKS-

The treatment of cochleovestibular incidents after diving.
http://snipurl.com/ais6

Other links
http://www.scuba-doc.com/entprobs.html
http://scuba-doc.com/inearprobs.htm

*****************************************************
Facial baroparesis secondary to middle-ear over-pressure: a rare complication of scuba diving.
http://snipurl.com/ais9

Other links
http://www.scuba-doc.com/nbjprb.htm
*****************************************************
Venous Air Embolism During Supine Craniotomy For Aneurysm: Role of Hyperbaric Oxygen Therapy
http://snipurl.com/ajtx

*****************************************************
Venous air embolism following orogenital sex during pregnancy.
http://tinyurl.com/5bkf7

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eMedicine - Venous Air Embolism : Article by Steven A Conrad, MD, PhD
http://www.emedicine.com/EMERG/topic787.htm

*****************************************************
Dive charge wrong, says appeal court
http://snipurl.com/aoal

*****************************************************
Trailer Delivers Rare Treatment
http://tinyurl.com/4zyw3

*****************************************************
Vancouver hospital gets hyperbaric chamber to treat divers
http://tinyurl.com/57s7b

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SCUBA Oxygen Enriched and Oxygen Service FAQ
http://snipurl.com/ajk6

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-HUMOR-

The best of the lot! We get many jokes and humorous stories sent to us via email. Space does not allow me to use all of the material. Here is a joke that is well told and gave me a good laugh!

Subject: Boudreaux and Thibodeaux
Boudreaux staggered home late after another evening with his drinking buddy, Thibodeaux. He took off his shoes to avoid waking his wife, Clotile. He tiptoed as quietly as he could toward the stairs leading to their upstairs bedroom, but misjudged the bottom step. As he caught himself by grabbing the banister, his body swung around and he landed heavily on his rump. A whiskey bottle in each back pocket broke and made the landing especially painful.

Managing not to yell, Boudreaux sprung up, pulled down his pants, and looked in the mirror to see that his butt cheeks were cut and bleeding. He managed to find a full box of Band-Aids and began putting a band-aid as best he could on each place he saw blood. He then hid the now almost empty box and shuffled and stumbled his way to bed.

In the morning, Boudreaux woke up with searing pain in his head and butt and Clotile staring at him from across the room. She said, "You were drunk again last night weren't you Boudreaux?"
Boudreaux said, "Mer chais, why you say such a mean ting?"

"Well," Clotile said, "it could be the open front door, it could be the broken glass at the bottom of the stairs, it could be the drops of blood trailing through the house, it could be your bloodshot eyes, but, mostly....it's all those Band-Aids stuck on the downstairs mirror!"

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Unsubscribe by writing "unsubscribe" in the subject field and emailing scubadoc@scuba-doc.com .

This newsletter will be posted on our blog at http://tenfootstop.blogspot.com/ . It will also be stored in pdf at http://scuba-doc.com/archives.html .

Warm regards:

Ernie Campbell, MD
Webmaster and author, Diving Medicine Online and Ten Foot Stop Newsletter
http://scuba-doc.com/

Ono Island, Alabama
Redneck Riviera, USA
Tuesday, November 16, 2004


Monday, November 08, 2004

Ten Foot Stop Newsletter, Oct. 31, 2004

Ten Foot Stop Newsletter
October 31, 2004 Newsletter

-Note from scubadoc-
Thanks! To all of you who have written asking about our experiences with the Hurricane Ivan visit. As some of you know, we live in Orange Beach, Alabama on the coast of the Gulf of Mexico. Ivan came ashore about 7 miles west of us and of course we lay right in the path of the worst wind and surge action which is usually on the eastern edge of the storm. We were somewhat protected, living on a barrier island about 500 yards inland of the sea. However, extensive damage was done to our house, pier, boat house and boats. We won't be fishing or sailing anytime soon - as the boats are heavily damaged.

The devastation to our trees and plants is remarkable - seventeen trees down with all the leaves having turned brown from the blown seawater and plantings dead from 4 feet of salt water surge. The undersides of the house have washed through and there is extensive damage to the roofing from a large tree limb and wind damage. We are thankful that we have a house to live in - others on the beach are not so lucky, having been completely washed away. It will take us a while to clean up and get back to normal - but it always happens eventually [this is our sixth hurricane since we've been here the past twelve years].
Again - we appreciate your thoughtfulness and concern!

Ernie Campbell

DAN Press Releases

For more information on this press release, contact Wesley Hyatt, DAN Communications, at 1-800-446-2671 ext. 282 or email whyatt@dan.duke.edu.

Third Annual Auction Coming on DAN Website in November

Ski trips, dive vacations, liveaboard excursions – Divers Alert Network (DAN) has them all up for bid in the 2004 DAN On-Line Auction.

Visit the DAN website at www.DiversAlertNetwork.org/ to bid on items for the third annual auction. (There also will be an emblem linking to this section located at the top of the right-hand column of the DAN home page.) The auction starts on Nov. 1 at noon Eastern Time and closes Dec. 1 at noon ET. A preview of select items will be on the DAN website from Oct. 28-31 prior to the bidding.

More than 250 items will be up for sale – a greater amount than there were in last year’s auction, which generated more than $125,000 in support for DAN. DAN Members and non-members alike can bid on scuba equipment and accessories, merchandise, artwork and much more donated by artists, dive operations and others. DAN also will have its own oxygen first aid units, calendars and other products in the auction.

The name and contact information of the donor will appear with each item up for auction, as well as a description and picture of the item, its suggested retail price, its current bid price and whether the reserve has been met. There also will be a live link to the donor’s website during the auction, for those wanting more details.

Winning bidders will be notified in early December. Many items will be delivered to winning bidders through their local dive shops and are slated to arrive no later than Dec. 15.

All dollars raised from winning bids will support The DAN Endowment, as well as DAN Research and DAN outreach programs.

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DAN Launches Portuguese Version of Website

Divers Alert Network (DAN) announces the launching of its Portuguese website that will let the organization interact with the Portuguese-speaking diving community in real time.

The DAN Portuguese website, at www.DiversAlertNetwork.org/p, will build new relationships for DAN and strengthen existing ones, especially in Brazil, the only Portuguese-speaking country in the DAN America region. Its translated text, features and layout mimic that of the DAN English-language version, and it includes:

• Headlines on the home page;

• A Membership section with info on member benefits, forms to join, renew or request a change of address, and access to Portuguese versions of the DAN Member Handbook, the DAN Business Member Brochure, and the DAN Business Member Information Pack;

• Registration information for the Student Membership Program;

• A Diving Medicine page with phone and email contacts for dive-related medical queries;

• An Insurance section with descriptions of each DAN insurance plan and comparisons between their coverage areas;

• A Training & Education page with a description of each DAN course in Portuguese and links to each individual course’s details in the English website; and

• A Contact DAN page including vital email addresses and phone numbers.

This website is the second foreign-language version for DAN America. The organization launched a Spanish website last December, at www.DiversAlertNetwork.org/s.

To contribute material to this website in Portuguese, write to brasil@DiversAlertNetwork.org, or contact Claudio Nascimento at cnascimento@dan.duke.edu or at +1-919-684-2948 ext. 478.


Pulmonary Artery Obstruction from Multiple Thromboemboli

While doing my non-diving medical reading I ran across a summary of a case that's being presented at the Annual Scientific Assembly of the Southern Medical Association. The case was an oral presentation abstract, "Recurrent Pulmonary Thromboemboli Diagnosed at Autopsy", by Shuler, CM and Gililand, M.G.F of East Carolina University, Greenville N.C.

This report describes the pathology involved when multiple small thromboemboli gradually obstruct the pulmonary arterial tree over months to years. The thromboemboli are clinically silent, as they are too small to cause right ventricular failure or pulmonary infarcts. The patient was a young woman who died of a large pulmonary embolus; the subsequent autopsy findings showed that she had recanalized organized emboli in the arteries to the lungs forming fibrous septae with multiple vascular channels. Extensive collagen and elastic tissue were seen surrounding the recanalized vascular channels. Pulmonary hypertensive changes were evident with heart enlargement and thickening of the right ventricle [hypertrophy].

I couldn't help but wonder at the possible similarities of a diver who has repeated bouts of venous gas emboli and whether or not there would be similar changes in the pulmonary arteries with pulmonary hypertension. Certainly, there would not be the clots requiring recanalization - but it has been repeatedly shown that he presence of bubbles arouses all of the defenses that one ordinarily sees with a foreign body in the circulation, including changes in the vessel walls. I have been unable to find any studies or reports concerning any pathological changes to be found in the pulmonary arteries of divers who have been subjected to many years of repeated floods of venous gas emboli. Maybe one of our pathologists can shed some light on this question.

In regard to physiological changes, it has been generally thought that divers had larger vital capacities than nondivers, but this theory was rebuked in a study by Thorsem and coworkers. They observed 152 saturation divers and compared them with 106 matched controls, and found differences in lung function variables between the two groups. These changes were consistent with small airways dysfunction and with the transient changes in lung function seen immediately after a single saturation dive. The association found in this study between reduced pulmonary function and previous diving exposure suggests that there are cumulative long-term effects of diving on pulmonary function. Though this change of vital capacity probably has little effect upon the diver's general health, recent studies, including one by Lehnigk and colleagues, have indicated that divers develop some degree of air flow obstruction due to airway narrowing.

Pulmonary diffusion capacity deteriorates with age and this process may be accelerated in divers. Early research has been limited to deep diving, where a diminution of pulmonary diffusion post-dive may not be clinically significant and improves in a few weeks. A change in pulmonary diffusion capacity is also associated with diminution of exercise tolerance but this has functional rather than clinical significance.

The clinical entity, 'chokes', is used to describe the pulmonary effects of decompression sickness due to large quantities of venous gas emboli causing substernal chest pain, shortness of breath and cough. The breathing pattern becomes rapid and shallow, and cyanosis may develop as the disorder rapidly progresses to right-side heart failure and cardiovascular collapse.

As I stated above, my search failed to turn up any pathologic studies showing any parallel with chronic venous thronboemboli. Possibly the rapid absorption of the gases does not allow for the chronic pathologic changes to occur - but just the acute physiologic changes that require urgent recompression treatment.

Here are some pertinent links that I found that are interesting.

Pulmonary Decompression Sickness [Chokes]
http://www.scuba-doc.com/puldcs.htm

Pulmonary decompression sickness at altitude: early symptoms and circulating gas emboli.
http://tinyurl.com/566fa

Radionuclide lung imaging in respiratory decompression sickness: potential role in the diagnosis and evaluation of hyperbaric therapy.
http://snipurl.com/a4i6

Effect of ventilation with soluble and diffusible gases on the size of air emboli.
http://snipurl.com/a3hb

A 32-year-old man with acute bilateral leg weakness following recreational diving.
http://tinyurl.com/5tajb

Full Report at
http://www.cmaj.ca/cgi/content/full/170/12/1792

Exercise effects during diving and decompression on postdive venous gas emboli.
http://tinyurl.com/65wr4


-Hyperbaric Oxygenation-

Request for Hyperbaric Chamber Photographs
Subject: Hyperbaric Chamber Photographs

Hello:

I am working with Dr. Michael Coughlin on a new edition of "Surgery of the Foot and Ankle". In the chapter on infection we discuss the use of hyperbarics to treat osteomylitis. My google searches keep turning up your web site. I would like to include photographs of both a monoplace and multiplace hyperbaric chamber. Do you have any recommendations for a source that would be willing to allow us to publish their photos?

J. Speight Grimes, MD
Surgery of the Foot and Ankle
901 N Curtis, Suite 503
Boise,ID 83706
208-377-1000

Contact me at scubadoc@scuba-doc.com if you have any good chamber photos.


Ulster to get £250,000 chamber to treat bends

By Nigel Gould
20 October 2004

Northern Ireland is to get a new £250,000 divers' recompression unit for the treatment of the life-threatening bends, it can be revealed today.
Question from Arun Madisetti, Consultant for the Ministry of Health on the Commonwealth of Dominica, West Indies

Request for information on European hyperbaric chamber manufacturers, we are wishing to purchase one (EU funded) for the Ministry of Health on the Commonwealth of Dominica, West Indies.

Arun Madisetti
Marine Manager
Soufriere Scotts Head Marine Reserve
The Dominica Marine Reserve Service
Commonwealth Of Dominica
00109-8000, West Indies

http://www.avirtualdominica.com/ssmr/
http://www.dominicamarinereserves.com

ssmrdominica@hotmail.com

Send replies to address above.


New Chamber in Scottsdale Arizona.
Scottsdale Healthcare Osborn Hospital installs new hyperbaric chamber. To open December 7, 2004.
Large multiplace chamber installed - the first hospital based chamber in Scottsdale.

Scottsdale Hyperbaric Medicine, a private clinic in the Scottsdale Airpark, has offered clients a similar multiperson hyperbaric chamber for four years


-Mailbox Potpourri-

Guidelines for Return to Diving After Coronary Angioplasty [Answer by Dr. Omar Sanchez, Cardiologist, Argentina]

Question:
I have just gotten home from having Angioplasty. My doctors told me that my heart muscle was in good shape. I am wonder what the parameters for a stress test that would indicate that I would be ready to go diving again. I would like to have this information so that I can start setting my goals for recovery and diving. Please understand, I have been fairly athletic most of my life and until this have been diving since I was 14. I am currently a 45 year old male 5'11" 210 lbs.

I know you can not give me direct medical advise with out a consultation but if you can point me in the right direction that would be appreciated.

Answer:
Scubadoc forwarded your mail to me.

I assume that the Angioplasty was for Angina Pectoris ( myocardial ischemia ) or equivalent ( failed stress test, etc. ) , without Heart Failure, and wasn´t one revascularization in Acute Myocardial Infarction.

Restenosis is one of the principal limitations to the long-term Angioplasty or Stent success. The incidence of restenosis has declined significantly with the use of drug-eluting Stents (DES) , but still exists . With only Angioplasty ~ 20% . Usually one exercise stress test ~ 1- 2 months after the intervention is recommended ( Bruce Stage 4, 13 METS ).

But the high restenosis risk may delay some months. One new re-evaluation after ~ six month gives additional safety. Maybe later if you have predictor factors: angiographic factors, stenting of multiple lesions, clinical factors, contact allergy, mechanical problems, lesion morphology.

If you have antecedent of Arrhythmias, one Holter ECG may help. There are another causes of Arrhythmias, different than exercise.
If this is OK, annual exercise stress test is recommended.

The other key: the Cardiac Risk Management. Tobacco, Hypertension, Hypercholesterolemia, Obesity, Sedentary lifestyle, etc.
Low Aspirin dose is dive compatible. Anticoagulants like Coumadin (warfarin) aren´t compatible with dive. If you take calcium blocker, beta blocker or diuretics may have aditional care.

Summary: Meanwhile one good exercise program to be fit.
Off the record: the exercise stress test (treadmill) is "only" an effort simulator, but we haven´t one "cold simulator" or "psychologic stress simulator". One good treadmill isn´t a Superman credential.

I believe that an angioplasty not only may improve the coronary flow, but may ( also) improve the "idea flow": Avoiding unnecessarry current, cold waters, complex dives, bad weather, unexperienced partner, exhausting travel, etc.
Enjoy the dive, all the live.

This message is for informational purposes only, always consult your physicians with your questions and concerns.

From Buenos Aires, Omar Sanchez, MD, Wetdoc.

Some Unusual Questions we have answered
[I'd be interested in hearing your thoughts on these queries]

Question about Piranha bites in scuba divers

We have many dammed up rivers in Brazil that are full of piranha. Are there any reports of divers being attacked by these fish?

Answer:
We have had no questions or reports of scuba divers being attacked or bitten by piranha. However, we have found a report in Wilderness and Environmental medicine that deals with piranha bites. The abstract of this article can be seen here.
A piranha bite is unlike the bite of any other animal in that it results in a 100% loss of flesh. They are equipped with powerful jaws and razor sharp triangular teeth that neatly fit together in such a way that there are no gaps. The resulting wound from a piranha bite has a smooth surgical look to it. There are no abrasions or puncture marks but rather a complete tissue loss. If you are bitten while diving, get out of the water immediately and initiate the following steps:

# Stop bleeding
# Clean well with a brush, soap and water
# Scrub and debride foreign particles
# Bed rest, elevation, antibiotics for severe cuts
# Be aware of danger of anaerobic infection and clostridial infection
# Topical antibiotics
# Tetanus prevention


Bleomycin and Diving?

Question:
I am an oncologist in Switzerland and I am treating a lot of young patients
with testicular cancer or lymphoma with bleomycin containing chemotherapy
regimen.

There is always some uncertainty about diving in this population (after
finishing chemotherapy) since bleomycin has some lung toxicity and in the
anaesthesic literature there is evidence that high oxygen presssure in these
patients can be a problem. Since they are luckily mostly treated in curative
intend we would like to know what you experiences are.
What would you recommend? May they dive normally or just in a certain
deepness or with a certain equipment.
Unfortunately I am an absolute ignorant when diving is concerned, so I would
hope you have some help for us!

Answer:
Hello Dr. :

I have had no experience with divers after treatment with bleomycin - but have dealt with patients (surgical) who required very careful monitoring of the FlO2 during anesthesia. As you are familiar with the sensitivity to elevated O2 levels in these patients, you know that in patients who have received bleomycin lung damage can occur at lower concentrations that are usually considered safe.

I am not aware of any studies about scuba diving while on or after taking bleomycin. There is one report in the Netherlands Journal of Medicine that describes advice given a scuba diver after treatment. ‘Bleomycin and scuba diving: to dive or not to dive?’, by G. Huls and D. ten Bokkel Huinink in the Netherlands Journal of Medicine, 2003, November 2003 , Vol . 6 1 , No. 11, 388
There are several problems that come to mind about the patient diving after bleomycin.

First, diving may be particularly hazardous for post-bleomycin patients because of increased risk of oxygen toxicity in their lungs due to high oxygen partial pressure. The partial pressure of inspired oxygen is a function of the depth of the dive. When a scuba diver breathes compressed air (21% oxygen at the surface) at a depth of 29.7 meters (approx. 90 ft depth) of seawater, the partial pressure is 0.84 atmosphere or the equivalent to breathing 84% oxygen on the surface.

Secondly, the treatment of most scuba diving accidents (decompression sickness, barotrauma with gas embolism or drowning entails the use of 100% oxygen, initially by the first-responder at sea level pressure and then by the hyperbaricist. We would have a dilemma as this necessary recompression with the use of periods of 100% oxygen might be harmful to the bleomycin treated diver.

Thirdly, we have the pulmonary changes that have taken place from the drug (fibrosis, 30%), increasing the risk of pulmonary barotrauma and possible gas embolism. (No reports, to my knowledge).

I would recommend that divers who have been treated with bleomycin not dive at all and if they choose to dive with full knowledge of the risks involved that they not use 'nitrox' in any of it's configurations as the percentage of O2 is 32, 36 and as much as 40 percent of the breathing mixture.

I hope that this has answered your questions!

Response to our article on Bleomycin and diving from Richard Hodgson, MD
See http://scuba-doc.com/nl021504.pdf

Unfortunately there is no solid scientific data on Bleomycin lung injury and the safety of oxygen exposure after treatment for germ cell tumors. Experience and multiple animal experiments have been performed and some of the abstracts are attached. Unfortunately we have experienced bleomycin toxicity induced by oxygen exposures that have been fatal. Since all SCUBA involves elevated concentrations of oxygen and any treatments for post diving symptoms will involve high levels of oxygen then return to diving can not be done safely. As a diving medical examiner I would have to disqualify any diver from returning after receiving bleomycin.

POTS and Diving

We have a question from a cardiologist about one of her associates. "She carries a diagnosis of "postural hypotensive tachycardia syndrome" or POTS, short for Postural Orthostatic Tachycardia Syndrome. She is on beta-blockers and has not had syncope since 1996. She has not had any pre-syncope either. Her exercise capacity/tolerance is good and she states that she is in good physical condition.

My concern would be that although at depth, the pressure would increase the central blood volume, when she gets out of the water and the fluid shifts back to the periphery, she would be at risk for hypotension and thus be at risk for pre-syncope/syncope. Additionally, she would have to remain well hydrated as the diuretic effect of diving would cause volume depletion and increase her risk for hypotension.

Can you help further? "

Our answer:

Hello Dr.:

My good friend Dr. ---- has requested an opinion on whether or not you can scuba dive with your condition, "postural hypotensive tachycardia syndrome." (POTS). Her advice about the physiological changes that occur in normal individuals while diving are correct and it would be impossible to predict what effect it would have on you with your condition. From my perusal of the literature about the condition, it would appear that it has all sorts of protean manifestations in addition to the tachycardia and postural hypotension. See http://tinyurl.com/yvyx9
.
The obvious reasons why a person should not be allowed to dive are as follows:

1. Disorders that lead to altered consciousness
2. Disorders that inhibit the "natural evolution of Boyle's Law"
3. Disorders that may lead to erratic and irresponsible behavior.

Syncope underwater would lead to immediate drowning. (See item #1 above).
Your condition has apparently responded well to the beta blocker - with no episodes of syncope in eight years. This is good but there is a caveat. Beta
blockade prevents the heart from performing maximally in the event of a stressful situation possibly leading to pump failure underwater, a disastrous situation. In addition, beta blockers can cause bronchial constriction in some individuals, a condition inimical to divers due to the possibility of pulmonary barotrauma and gas embolism. See item #2 above. The bronchial aspects of the beta blocker do not occur in every one and a good listen with the stethoscope after exertion or cold air might give you a clue.

If you have never dived and require certification from one of the agencies - I'm afraid I could not certify you as fit to dive

However, if you are certified and are fully aware of the risks involved - it might be worth a trial dive in a pool or simply a headout immersion to check and see what your cardiac parameters would be upon exit from the water. If these are OK, and you plan shallow, warm water diving with little exertion and an aware buddy - then I would say go for it.

Several questions about diving with 'Thalassemia'.
This inherited blood disease, in which the red blood cells are deformed by abnormal hemoglobin, has varying levels of severity and careful attention must be paid to each individual and the degree that the person is affected by the condition.

As with most blood diseases the level of illness, response to treatment and many other factors have to be considered before allowing a person to dive. Many with the condition can dive without risk - if not severely anemic or if there are no other intercurrent complications related top the breakdown of
hemoglobin with resultant iron storage problems.

Obviously, one should not dive with a low hemoglobin level or if weakened or debilitated from the illness or the treatment of the illness (which sometimes can be quite severe). The patient needs to have a medical exam to check for anemia, liver/spleen enlargement, or any of the complicating factors that are associated with the condition.

Whether or one can dive would be a difficult call without some hands on examination and laboratory information.
Question from a physician about malignant hyperthermia and diving

Answer:
Hello Dr.:

As you know, MH requires a triggering mechanism of some anesthetic, usually one of the fluranes or succinylcholine. I am not aware of any situation in scuba diving that would cause this mechanism to occur at depth with increased ppN2. Nitrous oxide specifically is excluded as a cause.

None of the diving medicine text books address this entity and I would certify your diver as "fit to dive".

Accutane and Diving

I was recently on your website and was wondering if you could answer a question for me. I am going to be getting certified to Scuba Dive in the upcoming weeks and am also contemplating taking accutane for acne. I was wondering if you could tell me any associated risks with the combination of the two, or any advise on this matter. Would it be best to hold out until I after I get certified to start this treatment?
Thank you for your time.
Answer:
Depression with suicidal tendencies is the most serious side effect of accutane. If you have not had any depressive problems prior to taking the medication - the risk would be small and apparently dose related. This would not be brought on or affected by diving. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD) says you should carefully consider the disadvantages of Accutane. In addition to being linked to birth defects, it can cause other side effects, such as:

---Inflammation of the lip and mucous membrane of the eye [diving relationship with regulator]
---Dry mouth, nose or skin [diving relationship]
---Itching [confusion with symptoms of DCS]
---Nosebleeds [diving relationship, possibly worsened by barotrauma]
---Muscle aches [be aware of confusing this with DCS]
---Photosensitivity, and rarely, decreased night vision [diving is a sun related sport activity - use adequate sun block]

Other more serious side effects include increased blood cholesterol, lipid and triglyceride levels and abnormal liver enzymes, according to the NIAMSD. Because of those side effects, doctors usually do periodic blood tests as a way of monitoring a patient.

Finally, evaluation of the risk[s] would show this to be quite small and there should be little in the way of alteration of your diving habits except for the caveats noted above. To be completely free of risks however, you might wait until you finish your certification so that there won't be any question about the drug.


Magnets and Diving?
Question:
I have a bad back, L4 & L5 are bulging. I have found unbelievable results with magnets. A company called Nikken makes them for all parts of the body. My question is, are they safe to dive with? Will nitrogen be attracted to the spot of the magnet? How will magnets affect off gassing?

Answer:
Interesting query! I cannot find any good answers to your question. The abstract below in the Russian literature is the only one that addresses magnets and gases, and this probably would include nitrogen.

The physical mechanism of the effect of low-intensity electromagnetic radiation on biological cells
Biofizika. 1999 May-Jun;44(3):555-8.
[Article in Russian]
Emets BG.
Kharkov State University, Ukraine.

The presence of dissolved air and air in the free form (bubbles) was taken into account in the study of electromagnetic radiation on biological cells. It is shown that, upon movement in a temperature gradient field, some bubbles increase in size due to the dissolving of others and the coalescence of bubbles during collisions. As a result, the concentration of dissolved air decreases, which leads to cell responses. It is shown that the temperature gradient needed for substantial degassing can be generated by electromagnetic fields of low intensities.

Here is an interesting web page that I found concerning magnetic fields.
http://snipurl.com/5zza

Without more information, I cannot advise you any further about your use of the magnets in the peri-diving period. Obviously, you can wear the magnets up to the time of your dive, removing them during and for a period of time after the dive while you off gas. [See bubble coalescence reported above].

Utilize other back preserving methods, such as in water gearing up and off; asking for help during exits and avoidance of lifting, climbing and other activities that exacerbate your back pain. I have personally found that the antigravity effects of the water benefit my back problems immensely. [HNP L4, 5, S1; compression fractures T12, L1, 2, 3]

Carefully record all of your symptoms and neurological deficits so that you and a doctor can differentiate between the effects of your discs and possible DCS.

More on back problems on our web site at
No More Back Pain, Part I
Back Pain, Parts II and III
Herniated Disc
How to treat your own bad back


-Question of the Week-

Subject: Free diving fatalities

Morning Ern

Occasionally I get a question I do not know what to do with. Have you ever heard fatality stats for free diving. I know many different styles of
diving without a tank. Sport ab diving to 30-40 fsw, 60-90 fsw pearl diving and then there are those sled divers.

Any ideas?

Hi:

There's not very much information about this - the best that I could find is this paper by Edmonds and Walker in the Australian Medical Journal - the full article reprinted at this site: http://snipurl.com/4079 .

Basically, the deaths are due to drowning from loss of consciousness due to hypoxia, hypercapnia, cardiac induced and large predator attack (one recently reported).

In Edmonds book, 4th Edition, Chapter 61 he reports two groups of fatalities, 60 recent and a previous group of 132 - but gives no denominators. He describes a change in the demography in that the divers are older, more female and the three major causes of death are drowning [45%], cardiac [30%] and hypoxia from hyperventilation and/or ascent producing loss of consciousness with drowning [20%].

Dr. Frank Butler, in Alert Diver for Sept/Oct 2004 says that there is no one who is keeping track of free diving fatalities, but that DAN will start tracking these deaths in their 2005 report on Diving Fatalities. He states that Edmonds reported 12 fatalities in snorkelers in Australia between 1987 -1996. Butler anecdotally reports on seven deaths. This is probably a very small portion of the approximately 4600 drownings in this country each year.

Here is a quote from the web site: " Free Diver"

"Free diving is dangerous, and in some cases a deadly sport. There are about 5,000 free divers around the world, and an estimated 100 die each year."

Other interesting data about relative risks on this same site at
http://www.arthurhu.com/index/health/death.htm

Hope this is helpful and finds you well!

Ernie

Forum discussion on the subject
http://forums.deeperblue.net/archive/topic/52005-1.html

-Interesting Links-

From Larry "Harris" Taylor:
This month I added 2 articles to my site:

A preliminary (more coming next year) evaluation of the SeaDoo Extended version DPV

http://www-personal.umich.edu/~lpt/seadoo.htm


A three sentence (with 2 images) comment on My Dive Patches

http://www.mindspring.com/~divegeek/patches.htm

New sites and corrected re-directs added this month to my list of ~8000 links at

http://www-personal.umich.edu/~lpt/links.htm


Diving

Scuba Spot: http://www.scuba-spot.com/
UK Diving: http://www.ukdiving.co.uk/
Diving Art: http://www.divingheritage.com/artmainkern.htm

Amazing Caves: http://www.amazingcaves.com/
Cave Diving Rocks: http://awooten.1afm.com/mysite/
Overhead Times: http://www.overheadtimes.com/


Insurance-R.D.I.: http://www.rdi-diving.com/
NBRF Diving Safety Manual: http://spacecraft.ssl.umd.edu/old_site/SSL/NBRF_DSM_v0.3/DSM1.intro.html


Historical Diver: http://www.hds.org/hds_magazine.html
Wet Gazette: http://www.thewetgazette.com/
Xray: http://www.xray-mag.com/


Medicine (Scottish): http://www.sdm.scot.nhs.uk/scuba_diving/
Panic Underwater (Morgan): http://whyfiles.org/sports/scuba/qlist.html
Plonger les Diabétiques: http://www.diabeteplongee.com/
Quickie Scuba Medicine: http://www.utahdiving.com/medicine.htm


Nitrox Scuba Diving: http://www.online.uillinois.edu/oakley/nitrox.html

Great New England Sea Serpent: http://www.pibburns.com/tgness.htm

Euro-Divers: http://www.euro-divers.com/e1000.asp
San Diego Oceans Foundations: http://www.sdoceans.org/programs/artificial_reefs/ships_reefs.php
Ships to Reefs: http://s2r.affiniscape.com/displayemailforms.cfm?emailformnbr=31416


Coral Kingdom (NOAA): http://www.photolib.noaa.gov/reef/
NOAA Photo Library: http://www.photolib.noaa.gov/index.html


DiveCalc (4 Sharp Zarus): http://divecalc.narced.com/

Good Format Dive Tables (PDF): http://www.gooddiving.com/Doc/AirDiveTables.pdf

Interesting Occupation! - Farming killer cone snails for research is a risky affair
http://snipurl.com/a6w1

Other links
Clarkson University: http://www.clarkson.edu
Elan Corp: http://www.elan.com
American Society for Clinical Pharmacology and Therapeutics: http://www.ascpt.org/
Cone shells http://www.scuba-doc.com/conshl.htm & http://www.scuba-doc.com/inject.htm

Dysbaric osteonecrosis screening in submarine escape instructors.
http://tinyurl.com/6sq2c

Link on our web site
http://www.scuba-doc.com/Dysost.htm
http://www.scuba-doc.com/dysostref.htm

Neoprene wet-suit hood affects low-frequency underwater hearing thresholds.
http://tinyurl.com/456o3

Seizure as the manifestation of relapse of multiple sclerosis in a military pilot.
http://snipurl.com/a3it

Seizure is apparently not an infrequent occurrence in multiple sclerosis - and occasionally is the first manifestation of relapse in the disease - which is characterized by remissions and relapses. Certifying a person with multiple sclerosis in remission as 'fit to dive' would seem to carry some risk of seizure underwater with subsequent drowning.

Links on our web site
MS and Diving
http://www.scuba-doc.com/msdiv.htm

Epilepsy and Diving
http://www.scuba-doc.com/epildv.htm

Decompression sickness in Miskito Indian lobster divers: review of 229 cases.
http://tinyurl.com/68yha

More about the Miskito Indian Divers
http://tinyurl.com/4f9we

Google Search
http://tinyurl.com/5tnls

Treatment of decompression sickness in swine with intravenous perfluorocarbon emulsion.
http://tinyurl.com/4l5a2

Related articles
http://snipurl.com/71ba

Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale.
http://snipurl.com/9dbz

More PFO information
http://www.scuba-doc.com/pfo.htm
http://tinyurl.com/6vc2n [Bove]

Undersea Diving Found Safe For Older Divers
http://tinyurl.com/3zwbz

Related links on our site
http://www.scuba-doc.com/agedvn.htm

New 'Bumpy' Jellyfish Found In Deep Sea
http://snipurl.com/a1wy


-Meetings, Courses and Conferences-

The latest news in this area can best be obtained by going to the respective web sites of the agencies involved. These are listed on our web page at http://scuba-doc.com/meetcrse.html .
SEADO Meerting on Dauphin Island

Mike Dardeau with the Dauphin Island Sea Lab writes that the meeting of the South East Association of Dive Officers still has plenty of spaces left for their meeting on November 12. Write him at mdardeau@disl.org .

2005 Winter Symposium
Hyperbaric Medicine and Wound Management
January 29, 2005 - February 2, 2005
Beaver Run Resort, Breckenridge, Colorado
Directors: James Holm, MD, FACEP and Takkin Lo, MD, MPH, CHT


Topics Include:• HBO Research Design• Carbon Monoxide Poisoning• Radiation Injury and HBO• Advances in Wound Care• Dangerous Marine Life• Altitude Induced Decompression Sickness• Barotrauma in HBO• Myringotomy Lab• Complications of HBO Therapy• HBO Facility Credentialing

CME Credit: 19 HoursFor more information, call (719) 365-6850or email Brandy.Swennes@memhospcs.org or Dr. Holm at hbodoctor@yahoo.com. For more information, access the web page at www.hbodoctor.com .


Program Planning Committee
James R. Holm, MD, FACEP
Medical Director, Hyperbaric Medicine Department
Department of Emergency Medicine
Memorial Hospital, Colorado Springs, Colorado

Takkin Lo, MD, MPH, CHT
Director, Hyperbaric and Wound Medicine
Director, Medical Intensive Care Unit
Loma Linda University Medical Center, Loma Linda, California

Laurie Beth Gesell, MD, FACEP
Director, Division of Hyperbaric Medicine
Assistant Professor of Emergency Medicine
University of Cincinnati Medical Center, Cincinnati, Ohio

Dick Sample, RCP, CHT
Supervisor, Hyperbaric Medicine
Loma Linda University Medical Center, Loma Linda, California

Lon W. Keim, MD
Medical Director, Baromedical Unit
Nebraska Health System
Clarkson Hospital, University Hospital, Omaha, Nebraska

Brandy Swennes
Continuing Medical Education, Manager
Memorial Hospital, Colorado Springs, Colorado

Memorial Hospital is accredited by the Colorado Medical Society to provide continuing medical education for physicians. Memorial Hospital designates this continuing medical education activity for a maximum of 19.0 Category 1 credits towards the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit actually spent in the educational activity.


-Cool Scuba Tip Of The Day!-


Sopite syndrome: a sometimes sole manifestation of motion sickness.
http://tinyurl.com/5jct9

Sopite Syndrome is a sleepiness or drowsiness that is associated with motion sickness - above and beyond the vertigo, nausea and vomiting that more or less is associated with sea sickness. This article asserts that this drowsiness can sometimes be the only outward effect of motion sickness and the risks that this can cause to unsuspecting divers is obvious.

See also:
Acta Astronaut. 1998 Aug-Sep;43(3-6):181-92.

The sopite syndrome revisited: drowsiness and mood changes during real or apparent motion.

Lawson BD, Mead AM.

Naval Aerospace Medical Research Laboratory, Pensacola, FL 32508-1048, USA. blawson@namrl.navy.mil

The sopite syndrome is a poorly understood response to motion. Drowsiness and mood changes are the primary characteristics of the syndrome. The sopite syndrome can exist in isolation from more apparent symptoms such as nausea, can last long after nausea has subsided, and can debilitate some individuals. It is most likely a distinct syndrome from "regular" motion sickness or common fatigue, and is of potential concern in a variety of situations. The syndrome may be particularly hazardous in transportation settings where other performance challenges (e.g., sleep deprivation) are already present. It is also a potential concern in cases where illnesses such as sleep disorders or depression may interact with the syndrome and confuse diagnosis.


-Humor-

ACTUAL WRITINGS ON CHARTS IN HOSPITALS

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. Patient's medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.

5. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

6. Patient has chest pain if she lies on her left side for over a year.

7. On the second day the knee was better and on the third day it disappeared.

8. The patient is tearful and crying constantly. She also appears to be depressed.

9.The patient has been depressed since she began seeing me in 1993.

10. Discharge status: Alive, but without my permission.

11. Healthy appearing decrepit 69-year old male, mentally alert, but forgetful

12. Patient had waffles for breakfast and anorexia for lunch.

13. She is numb from her toes down.

14. While in ER, she was examined, x-rated and sent home.

15. The skin was moist and dry.

16. Occasional, constant infrequent headaches.

17. Patient was alert and unresponsive.

18. Rectal examination revealed a normal size thyroid.

19. She stated that she had been constipated for most of her life until she got a divorce.

20. I saw your patient today, who is still under our car for physical therapy.

21. Both breasts are equal and reactive to light and accommodation.

22. Examination of genitalia reveals that he is circus sized

23. The lab test indicated abnormal lover function.

24. Skin: somewhat pale. but present.

25. The pelvic exam will be done later on the floor.

26. Large brown stool ambulating in the hall.

27. Patient has two teenage children, but no other abnormalities

Ethics Out the window?

A lady walks into a drug store and tells the pharmacist she needs some cyanide.

The pharmacist said, "Why in the world do you need cyanide?"

The lady then explained she needed it to poison her husband.

The pharmacist's eyes got big and he said, "Lord have mercy, I can't give you cyanide to kill your husband! That's against the law! I'll lose my license, they'll throw both of us in jail and all kinds of bad things will happen! Absolutely not, you can NOT have any cyanide!"

Then the lady reached into her purse and pulled out a picture of her husband in bed with the pharmacist's wife.
What's That Again?

A man is lying in bed in the hospital with an oxygen mask over his mouth. A young nurse appears to sponge his hands and feet. "Nurse," he mumbles from behind the mask, "Are my testicles black?" Embarrassed, the young nurse replies, "I don't know, I'm only here to wash your hands and feet." He struggles again to ask, "Nurse, are my testicles black?" Finally she pulls back the covers, raises his gown, holds his penis in one hand and his testicles in her other hand and takes a close look, and says, "There's nothing wrong with them!" Finally, the man pulls off his oxygen mask and replies,

"That was very nice but, are... my... test...results...back ?"

FUNERAL PROCESSION:

A woman was leaving a convenience store with her morning coffee when she noticed a most unusual funeral procession approaching the nearby cemetery.

A long black hearse was followed by a second long black hearse about 50 feet behind the first one. Behind the second hearse was a solitary woman walking a pit bull on a leash. Behind her, a short distance back, were about 200 women walking single file.

The woman couldn't stand her curiosity. She respectfully approached the woman walking the dog and said, "I am so sorry for your loss, and I know now is a bad time to disturb you, but I've never seen a funeral like this.

Whose funeral is it?"

My husband's."

What happened to him?"

The woman replied, "My dog attacked and killed him"

She inquired further, "Well, who is in the second hearse?"

The woman answered, "My mother-in-law. She was trying to help my husband when the dog turned on her."

A poignant and thoughtful moment of silence passed between the two women.

"Can I borrow the dog?"

"Get in line." His name was Harvey [Wallbanger]

In Jerusalem, a female journalist heard about a very old Jewish man who had been going to the Western Wall to pray, twice a day, everyday, for a long, long time.

So she went to check it out. She went to the Western Wall and there he was!

She watched him pray and after about 45 minutes, when he turned to leave, she approached him for an interview.

"I'm Rebecca Smith from CNN. Sir, how long have you been coming to the Western Wall and praying?"

"For about 60 years."

"60 years! That's amazing! What do you pray for?"

"I pray for peace between the Christians, Jews and the Muslims. I pray for all the hatred to stop and I pray for all our children to grow up in safety and friendship."

"How do you feel after doing this for 60 years?"

"Like I'm talking to a f------- wall!"
A woman went to a pet shop and immediately spotted a large, beautiful parrot. There was a sign on the cage that said $50.00.
"Why so little?," she asked the pet store owner.

The owner looked at her and said, "Look, I should tell you first that this bird used to live in a house of Prostitution, and sometimes it says some pretty vulgar stuff."

The woman thought about this, but decided she had to have the bird anyway. She took it home and hung the bird's cage up in her living room and waited for it to say something.

The bird looked around the room, then at her, and said, "New house, new madam."

The woman was a bit shocked at the implication, but then thought "that's really not so bad."

When her two teenage daughters returned from school the bird saw and said, New house, new madam, new girls."

The girls and the woman were a bit offended but then began to laugh about the situation considering how and where the parrot had been raised.

Moments later, the woman's husband, Keith, came home from work. The bird looked at him and said, "Hi, Keith."

-Poetry from DrSnakebelly-

haiku 1

motionless herons in the wetlands..
wait patiently
pelicans dive ...

haiku 2

little pink seahorse
dances on a fan
swaying with the wave rhythm

haiku 3

down some ancient steps
divers swim in single file
throughout the morning


Let me know if you have any announcements, tips, links, articles or responses to any of the material in our newsletter.

Best regards for safe diving!

Ernie Campbell, MD, FACS
Diving Medicine Online
http://scuba-doc.com
scubadoc@scuba-doc.com
DAN Physician Consultant


* To unsubscribe or change your address - email scubadoc@scuba-doc.com .