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 )
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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!]

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--> 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.

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-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

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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

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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.

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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

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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
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Venous Air Embolism During Supine Craniotomy For Aneurysm: Role of Hyperbaric Oxygen Therapy
http://snipurl.com/ajtx

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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

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

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

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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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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