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.

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


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