Friday, February 25, 2005

Ten Foot Stop Newsletter, FEBRUARY 28, 2005

TEN FOOT STOP, FEBRUARY 28, 2005

See previous newsletters in the Archives
http://scuba-doc.com/archives.html
This newsletter can also be seen at http://tenfootstop.blogspot.com/


<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< ==>NOTE FROM SCUBADOC <==
"Water, water everywhere and my bod did shrink?"
One of the more interesting letters that we received recently asked the question, "When I go on a scuba diving vacation, (diving at least twice a day whether permitting), I find that when I get back home, I've lost weight, can you tell me why?, also is there a scientific equation that can explain this phenomenon, example: if your diving in 68 degree water, your body has to exert X amount of energy to maintain your body temperature.?"
This is a phenomenon that I have noted personally and always looked forward to returning home to brag about my slim figure. I'm sure there are all sorts of equations that could be set up for calorie loss but that really doesn't have very much to do with your weight loss. Well, there are many possible answers but the most important is that associated with the 'pee factor'. Most of us have some extra onboard water, some more than others from various causes of peripheral edema. When a person is immersed in water, there occurs an obligatory diuresis of this fluid, causing an increase in urine formation and the consequent increase in urination. This will result in the direct loss of weight from this loss of fluid, amounting to as much as 10 to 12 pounds of weight over a period of time. In addition, you also lose a certain amount of fluid by breathing the very dry compressed air in your tanks.
Somehow, I never could get the figures quoted for 'calories burned' to add up to the amount of weight that I lost, 12# in one week of live aboard diving with great food.
So, there must be other factors in play.
Depending upon who you read, calories burned in an hour of scuba diving (general) is variable with the weight going in. For example, a 100# person burns 336 calories, 125# burns 420 cal., 150# burns 504 cals., 175# burns 586 calories and a 200 pounder burns 672. Another source states that a 150 pounder person burns 1050 calories in an hour. (Dr. Bookspan doubts that even military divers could burn this much energy.)
So, I added in other factors:
---Surface temperature
---air (oxygen) uptake. Gulpers or sippers? Gulpers burn more O2 (not necessarily more calories).
---water temperature. Just a few degrees will make a big difference.
---amount and kind of hypothermia protection. Hood? Thickness of Neoprene. Type of wet suit. Shivering burns a lot of energy.
---what kind of diver, very active with lots of arm and leg motion or a 'slug' (as I am), using very little energy with as little motion as possible.
---repet diving.
---currents and surges. Obvious reason to burn more calories.
---food and alcohol intake on the trip. Some people really decrease their ethanol intake and drink more water. This will cause weight loss. Alcohol has large amounts of calories.
---body fluid composition prior to diving (such as chronic peripheral edema). Immersion causes diuresis. If a person has excess on board water - this will be lost as weight.
Dr. Jolie Bookspan states: "Remember that weight loss over a one or two week period does not reflect calories as much as food and drink weight, and that the caloric burning normalizes over much longer periods (anyone losing pounds in a day or week is not losing fat)." The answer is 'water weight' - plus, those calorie expenditures are on the too high side. Most recreational divers do not run exertion levels that high. Also note that other people eat the boat food and often come back heavier.
Dr. Omar Sanchez states: "In my experience the diuresis by the hydrostatic pressure and the cold, and the dry air is most important in weight loss. Loss of water in fact. I would like to control John´s weight after the first dive, to evaluate the liquid loss. And three days after the last dive!
Some years ago I proved to control the basal weight and after the first immersion, and the difference was significant. In order to calculate the exact replacement, avoiding the dehydration. The basal weight was controlled pre breakfast and post pee. "
Dr. Jim Chimiak has the following remarks:
"Just as you listed, there are a host of factors that could come into play.
weight change is going to be difference between intake and calorie expenditure.
so intake, what is being consumed on a vessel, what is the true caloric intake, actual number of calories, is it being absorbed (diarrhea, sea sickness)
caloric expenditure is very difficult in elevation in BMR , shivering, mental activity, stress, active human contact (the usual TV/video game vs energy expenditure in active interaction, energy burned on pitching deck while at "rest" vs sitting in easy boy all add expenditures that are not usually tallied. Shivering or activation of involuntary muscle contraction increases energy expenditure enormously.
Your citing a dehydrating effect is probably on target and would be relatively easy to rule out in the diver in question by asking how quickly he gains the weight back, if fluid mobilization that it would be quickly. Dehydration from immersion diuresis, breathing dry gas, sunburn, sweating, and GI loss(diarrhea, vomiting) can occur."
From Glen Egstrom, PhD
You are on track as usual. The many variables that affect metabolic activity as well as fluid balance will affect both short and longer term weight issues.
John is seeing primarily a loss of fluids.
Negative pressure breathing, breathing a dry gas in and a saturated gas out, increased urine production, are a few of the active mechanisms that shift the fluid balance. We even sweat when we dive. These mechanisms have been held responsible for losses of fluid on the order of 1-1.5 liters per hour. At 2.2 lbs/liter this adds up. Fluid replacement is frequently inadequate.
Inadequate replacement of fluids is a big factor. In our experimental studies years ago we recognized the need for regular replacement regimens.
Body temperature - We burn more calories as the core cools and temperature regulation mechanisms go to work to maintain adequate blood temperature.
During dive trips and extended dive operations the energy costs may not be met with intake and thus the increased activity level will result in burning reserves i.e. fat. which is easily replaced when we become more sedentary again. Aw shucks.
The use of diuretics doesn't help the fluid balance issue.
Remember "I have never encountered a problem, however complicated, which when viewed in the proper perspective did not become more complicated"
There is a large literature in this area mostly in the 70's and 80's.
See excellent article about fluids and divers by Glen Egstrom, PhD at http://scuba-doc.com/FLUIDS.html

From Jim Caruso: Way too many variables to even give an estimate. I hardly move a muscle while drift diving. I used to have a workout equivalent to a marathon with mine clearing exercises with my EOD team. I think Dr Campbell gave at least the main variables and highlighted the scope of the problem.
Losing weight on a liveaboard? I think it depends not only on the diving but on the chow. I was on one once that offered 3 meals and two snacks each day plus hot cookies out of the oven after every dive. And the dinners were along the lines of steak and lobster. Hard to work those kind of calories off! They also babied us, assisting with equipment and even with getting back into the boat.

Capt. Richard Carson, USN (ret.) PADI Instructor:
I believe you covered the whole picture. Breathing very dry air and diuresis lead to the recommendation to hydrate hydrate hydrate.
Water and decompression sickness
There is another, more ominous effect of dehydration besides weight loss - decompression sickness. Becoming dehydrated is an insidious cascade that usually starts as you leave home for the airport. Slugging down a large dose of caffeine (a diuretic) upon leaving home, possibly having one or two alcoholic drinks (diuretic) on the plane, which is pressurized (dry air with loss of fluid via lungs), welcome alcoholic drink on arrival (diuretic), more tea or coffee (diuretics). The next day, diving with pressurized air (dry with loss of fluid via lungs) and immersion diuresis during diving can almost guarantee an increased risk of bubbles on ascent from diving unless a conscious effort to rehydrate is accomplished.

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==> CHANGING YOUR E-MAIL ADDRESS?<==

Don't miss a single issue. Update your subscription e-mail address: Send both you old and new email addresses and we'll make the change immediately.
scubadoc@scuba-doc.com
Lost your copy of the newsletter? See the latest at
http://tenfootstop.blogspot.com or at http://scuba-doc.com/archives.html .

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==> QUIZ OF THE WEEK <==

Prevention of Decompression Accidents
http://www.scuba-doc.com/prvndcs.htm

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

==> COOL WEB PAGE ON DIVING MEDICINE ONLINE <==
Disease Transmission from Gear
There are many transmissible diseases that have the capability of being passed on to another through the use of unclean equipment. These conditions are caused by viruses, bacteria and fungi - some short-lived on inanimate objects, and some lurking and living in the moist confines of the crevices and tubes of unwashed scuba gear.....
http://www.scuba-doc.com/AIDSrsk.htm

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==> INTERESTING LINKS <==

Auckland: A diver who got into difficulty while diving on the Rainbow Warrior had popped both lungs, an expert says.

Latest Scuba Diving Industry News


CPSC, Head USA Inc. Announce Recall of SCUBA Diving Computers
http://biz.yahoo.com/prnews/050222/dctu027_1.html


Systematic review of hyperbaric oxygen in the management of chronic wounds.
Roeckl-Wiedmann I, Bennett M, Kranke P.
http://snipurl.com/d26k

Wound Healing Institute opens HBO therapy center
Dover Community News - Dover,NH,USA

Visual loss as a late complication of carbon monoxide poisoning and its successful treatment with hyperbaric oxygen therapy.
Ersanli D, Yildiz S, Togrol E, Ay H, Qyrdedi T.
http://snipurl.com/d26n

URGENT RECALL: Scubapro Uwatec Aladin Air X Nitrox Dive Computer - Date: 2003-02-05
http://snipurl.com/d26x


=>QUESTIONS AND ANSWERS FROM SCUBA CLINIC FORUM <=

Visit, register and participate in our diving medicine bulletin board.
http://scuba-doc.com/scubaclinic/

Question: Nasal Operation
I've just been diagnosed with a deviation in the nasal passages. Its in the upper part of my nose. I've seen it on a monitor and it looks like a 'spur' in the right nasal passage, growing from right to left, just touching the left side.

It causes me pressure/equalising problems when I dive, especially when returning to surface. (And when I land (come down) in a plane). Ear pain, reverse block under my eye, eye pain (feels like eye strain) sinus type problems, headaches etc. I also have milder 'sinus type' symptoms with headache and eye 'strain' pain, 'squish' sounds in my ears etc, most of the time.

The surgeon has suggested an operation to remove the spur and some bone, which he says is specifically done on divers, but has mixed results. I'm at the start of my career and need to dive like I need to breathe!

I see him again soon. I would like to find out more about it. Has anyone heard of this problem or operation? I got him to write it down, but can't read the writing! It looks something like Vouie?r?n?s/o - E?F?thmidal su?section?
Many thanks for any input.

Question: Fluid in ear again
I received my open water in October of 2004. I had fluid in my ear after the dives went to ENT prescribed medrol 21's (a steroid) & antibotic cleared up the problem. After talking to a pharmacist I tried suitafed & afrin nose spray before the dive. Went to Mexico in mid January did a 20 meter dive for 43min & my ears were great for my 30min surface interval. Next dive a 13meter 58min dive after ascent ears plugged & this time I went to my family doc. He gave me the same thing to try to clear up the problem. I think it will work but the real question is. What am I doing wrong? Am I trying to hard to clear? When I feel anything I ascend a few feet clear till I don't feel a problem & go back down Pain free. Am I really not clearing? I don't feel any pain. I also take Allegra-D/flonase & a saline spray on a regular basis. Sad

Thanks

Dermatologist consultant disagrees with scubadoc
I dive in the Pacific Northwest with a friend who for the past ten years has suffered from "chilblains" (sp?) in her feet. Her toes become cold, and deep purple in color and there is sometimes a lack of sensation in them after a dive.

Occasionally this is accompanied by fine raised bumps that radiate down the sides of her toes. When this occurs she says it "feels as if I've burned myself there". Diving in a dry suit with plenty of socks has pretty much cured this problem until last week when the same symptoms started occurring on her hands.

I dove with her yesterday and after the dive ( one hour at a max depth of 35 feet, water temperature around 45 degrees F)her finger tips looked a blotchy deep purple color more so at the tips than towards the palms. There was again a fine line of raised bumps (each the size of a pencil tip) on sides of her middle two fingers. Once again she said that it was beginning to feel as if she had "put those fingers into a fire".

Do you have any suggestions about the cause and possible relief for this phenomenon? By the way, she currently is wearing dry gloves.


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==> MAILBOX POTPOURRI <==
Question:Coumadin Rx for Heart Valve Replacement

My patient is a middle aged, white, male, diver for many years. Very fit. Is now on coumadin therapy after a heart valve replacement. He wanted to know if there were any contraindications to his diving - my concern is for possible bleeding, but I just don't know. Any information you have would be helpful.

Answer:
You got this one right! Coumadin is an extremely dangerous and fickle medication that can cause dangerous bleeding in divers from barotrauma.
The ears, sinuses and lungs are subject to the changes in volume from Boyle's law, decreased volume with descent, increased volume with ascent. Minor barotrauma that ordinarily would not be risky can turn into hemorrhage with coumadin.
See my web page about this at http://www.scuba-doc.com/antcoag.htm .


Thank you! I read with interest the coumadin info. I will have a VERY disappointed patient, who probably won't listen to this advice. His major dive site is near Thailand, so if (when) anything goes wrong, I may never know.
Thanks again -


Question:How long after blepharoplasty (eyelid surgery) should one wait before diving again?

Answer
Hello Diver:

Of course, the big risk for diving too soon after this surgery is a mask squeeze, which would disrupt suture lines and damage the repair of the operation. Two to three weeks would be a reasonable wait before diving. (See below).

The waiting period would vary from patient to patient, depending upon the healing process and the extent of the surgery. Sutures come out anywhere from two days to a week after the operation. The swelling and discoloration around your eyes will gradually subside, and you should be able to read or watch television after two or three days. However, you won't be able to wear contact lenses for about two weeks, and even then they may feel uncomfortable for a while. You will need to avoid strenuous activities for about three weeks. It's especially important to avoid activities that raise your blood pressure, including bending, lifting, and rigorous sports. Healing is a gradual process, and your scars may remain slightly pink for six months or more after surgery. Eventually, though, they'll fade to a thin, nearly invisible white line.

See more about the eye and diving at http://snipurl.com/curj . We will also send your question to one of our plastic surgery consultants for his
opinion.

From Dr. Edward Golembe, MD
Medical Director
The Hyperbaric & Wound Healing Center
Brookdale University Hospital

Basically, I agree with your reply. There is a little more detail in the Alert Diver issues on plastic surgery and diving. I'd only add that the diver with a blepharoplasty should know him/herself with regard to the ease of equalizing mask pressure and act accordingly.


Subject: scoliosis (curvature of spine)
I present a twenty year male with a hx of scoliosis surgically 'corrected' at a Boston hospital. Insertion of metal rods was done to maintain correct posture. It is now two years post op and he is in college leading a cautious but normal life. Do you feel there are any contraindications to learning scuba diving at this point. I am planning to ask a local NAUI instructor who is also a doctor (dentist) as instructor if that makes any difference. Please advise your suggestions.

Answer:

There should be no reason for this person not to dive - given the information that he has been released by his surgeon to resume full activities without restrictions.

The metal rods are incompressible and therefore will not be affected by depth or pressure. If he has fully rehabilitated and is neurologically
normal then there would be no reason not to certify him as 'fit to dive'.


Subject: inner ear fluid

I have a medical problem and I'm wondering if you might have an answer? I was recently diving in the BVIslands and on one dive I had some trouble clearing my left ear. I tried and tried but it felt clogged so I finally surfaced. Later that night I had extreme pain in the ear and the next day felt as if my inner ear were full of fluid. The pain has gone away but my ear still feels 'full' and I have tinnitus. I am assuming that I somehow forced fluid or mucus into the inner ear and I am wondering how and when it will go away? It has been four days since this happened.

I would appreciate any advice.

Answer:

What you seem to have experienced is middle ear barotrauma, not inner ear fluid. This is a frequent occurrence in divers who have difficulty in equalizing their middle ears (clearing) and continue descending with the Eustachian tubes "locked". Boyle's Law causes the air in the middle ears to decrease in size on descent and increase in size on ascent. Unless this pressure is equalized properly the middle ear responds by either rupturing the ear drum or swelling, bleeding and seeping body serum. This can also become infected.
Treatment once this has happened is to stop diving, take decongestants (Sudafed), antibiotics and mild pain relievers. It usually responds in 5-7 days of treatment - occasionally longer. It might be wise to see an ENT doctor to make sure that you don't have some anatomical reason that this happened. Most often however, the cause is poor technique for equalizing. Attached are suggestions and guidelines for performing the process of clearing and you should practice these until you are competent to descend without difficulty.
If you haven't already visited our web page - there is a lot of information about this on my web site at http://www.scuba-doc.com/entprobs.html . There is also a section in our FAQ web page about preventing ear infections at http://scuba-doc.com/Q&A.html .

Carbon monoxide misconceptions
Question:
I have a couple of questions I was wondering if you could answer for me?
1. Can you explain how the atoms work in you blood as I am a little muddled.
Is it true that normally 2 atoms are carried on your blood somehow? then if you have CO poisoning in the blood, you have one of the two atoms carrying oxygen and the other carrying CO which makes it difficult to what?
2. As carbon monoxide is carried in the blood which goes to the nerves in our teeth can carbon monoxide poison effect our teeth?
3. Our bones, can carbon monoxide get to our bones and cartilage by any blood supply or any other way, also can this effect children?
I was talking to a diver today who said they had to know about poisons and he thought that the poison gets into the cartilage and then the bone is this correct.
Answer:
Carbon monoxide poisons by entering the lungs via the normal breathing mechanism and displacing oxygen from the bloodstream. Interruption of the normal supply of oxygen puts at risk the functions of the heart, brain and other vital functions of the body.
CO is not a poison that lasts in our bodies as does mercury or other heavy metals. It performs it's damage by selectively blocking sites on the Hgb molecule thereby depriving the body of oxygen. It does this by replacing O2 in the hemoglobin molecule as it has a much greater affinity than oxygen. A second effect is to block several of the critical enzymes which convert oxygen and fuel to energy in the mitochondria of cells. Both effects combine to cause a severe lack of energy to individual cells, and the cells often die.
It causes neurological damage by decreasing oxygen to the brain and spinal cord. It would not selectively affect the nerves to the teeth, nor is it deposited in the bones and cartilage. As it attaches to the hemoglobin molecule very tightly it is difficult to treat; 100% oxygen and hyperbaric oxygenation in a chamber are both used to force the CO molecule away from the hemoglobin.
There is a good link about CO poisoning at http://www.scuba-doc.com/carbonmon.html .


==> 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 .

Here are some organizations giving courses linked to the above site:
DAN --
http://www.diversalertnetwork.org
SPUMS Courses -- http://www.spums.org.au/courses.htm
Medical Seminars -- http://www.medsem.com/destination_information.html
UHMS -- http://www.uhms.org/Courses/Courses.htm
Temple University Underwater Medicine -- http://www.scubamed.com/educ.htm
EUBS -- http://www.eubs.org/
ISAM -- http://www.divingdocs.org/
NOAA -- http://www.uhms.org/Courses/NOAA01/noaa.asp
DCIEM -- http://www.dciem.dnd.ca/publications/factsheets/t22_e.html
DDRC -- http://www.ddrc.org/docs/ddrcpage.asp?pageid=10


Workshops from Dr. Jolie Bookspan

Here is some info on two great workshops in one day.
Hope we'll get a chance to see some of you here in Philadelphia.
This is a great way to learn many top modalities that will work for yourself and your patients.

If you have questions, please feel free to e-mail me.
Good Things,
Dr. Jolie Bookspan
Director, Neck and Back Pain Sports Medicine


1. No More Back Pain!
Four hour workshop. Taught by Dr. Jolie Bookspan, Sports medicine specialist named "St. Jude of the Joints" by Harvard Medical School clinicians.

Temple U Center City. 1515 Market Street
Saturday March 5th 2005 in a fun, one day seminar 9am-1pm. $65.

In this fun, active class, learn to get rid of your back pain and keep it from coming back. Fix stiffness, aches, sciatica, bad discs, and back pain. Identify common problems, learn easy and fun solutions, and how to not get stiff and sore in the first place. Combination lecture and non-strenuous practice. Suitable for the out-of-shape as well as the athlete. Wear comfortable loose clothing.
To register call Temple Center City (215) 204 6946.
or e-mail kwood@temple.edu

Take it with our seminar Stretches That Help/ Stretches That Harm
also Saturday March 5, from 2-4:30pm. just $45.


Did you know that many stretches are bad for you and other don't do what you think? Learn which help and which harm in this fun active workshop. You won't just sit there and stretch, you'll learn how your body needs to move for real life. Dr. Bookspan will teach you how to reduce stiffness, muscle soreness, stress, and back pain, and how to not get tight and sore in the first place. Fun, rejuvenating class for body and mind, suitable for the out-of-shape as well as the athlete. Combination lecture and non-strenuous practice


For more class info see Dr. Bookspan's web site www.drbookspan.com
To register call Temple Center City (215) 204 6946.
or e-mail kwood@temple.edu

If you want Philadelphia lodging info, let me know. Come visit!



DAN CME Announces 54th and 55th Diving and Hyperbaric Medicine Courses

For those who have missed its just-sold-out April course, DAN will host its 54th and 55th Diving and Hyperbaric Medicine Courses in August and October of this year.

The 54th Diving and Hyperbaric Medicine Course will be held Aug. 4-6 at the Searle Center at Duke University Medical Center in Durham, N.C. The 55th course will be held Oct. 22-29 at the Plaza Resort in Bonaire.

These courses are designed as continuing medical education (CME) primarily for physicians, emergency medical personnel, paramedics and nurses, but instructors, divemasters and other non-medical dive related personnel might also find them of value. Faculty and CME credit are to be announced later.

The diving and hyperbaric medicine courses continue to be the only ones in America hosted by an internationally recognized organization – DAN – and which present topics with the latest diving medical and research data discussed by practicing clinicians from the field.

DAN jointly sponsors its educational activities with the Undersea and Hyperbaric Medical Society (UHMS) for CME credit. Even though the 53rd course is already sold out, those interested in attending a similar course this year can plan for the 54th or 55th events.

For further information on these courses, contact the DAN CME office at +1-919-684-2948 or 1-800-446-2671 ext. 609 or 610, fax +1-919-493-3456 or email cduryea@dan.duke.edu or ceasterling@dan.duke.edu.

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==>HUMOR<==

Why Men Are Just Happier People -

What do you expect from such simple creatures?
Your last name stays put..
The garage is all yours.
Wedding plans take care of themselves.
Chocolate is just another snack.
You can be president.
You can never be pregnant.
You can wear a white T-shirt to a water park.
You can wear NO T-shirt to a water park.
Car mechanics tell you the truth.
The world is your urinal.
You never have to drive to another gas station restroom because this one is just too icky.
You don't have to stop and think of which way to turn a nut on a bolt.
Same work, more pay.
Wrinkles add character.
Wedding dress $5000. Tux rental - $100.
People never stare at your chest when you're talking to them.
The occasional well rendered belch is practically expected.
New shoes don't cut, blister, or mangle your feet.
One mood-all the time.
Phone conversations are over in 30 seconds flat.
You know stuff about tanks.
A five-day vacation requires only one suitcase.
You can open all your own jars.
You get extra credit for the slightest act of thoughtfulness.
If someone forgets to invite you, he or she can still be your friend.
Your underwear is $8.95 for three-pack..
Three pairs of shoes are more than enough.
You almost never have strap problems in public..
You are unable to see wrinkles in your clothes.
Everything on your face stays its original color.
The same hairstyle lasts for years, maybe decades.
You only have to shave your face and neck.
You can play with toys all your life.
Your belly usually hides your big hips.
One wallet and one pair of shoes one color for all seasons.
You can wear shorts no matter how your legs look.
You can "do" your nails with a pocketknife.
You have freedom of choice concerning growing a mustache.
You can do Christmas shopping for 25 relatives on December 24 in 25 minutes.
No wonder men are happier!


These have been around a while - but are still good!

A man comes into the ER and yells, "My wife's going to have her baby in the cab!"
I grabbed my stuff, rushed out to the cab, lifted the lady's dress, and began to take off her underwear. Suddenly I noticed that there were several cabs, and I was in the wrong one.

At the beginning of my shift I placed a stethoscope on an elderly and slightly deaf female patient's anterior chest wall. Big breaths," I instructed.
"Yes, they used to be," remorsefully replied the patient.

One day I had to be the bearer of bad news when I told a wife that her husband had died of a massive myocardial infarct (heart attack). Not more than five minutes later, I heard her reporting to the rest of the family that he had died of a "massive internal fart."

I was performing a complete physical, including the visual acuity test. I placed the patient twenty feet from the chart and began, "Cover your right eye with your hand." He read the 20/20 line perfectly.
"Now your left." Again, a flawless read. "Now both," I requested. There was silence. He couldn't even read the large E on the top line. I turned and discovered that he had done exactly what I had asked; he was standing there with both his eyes covered. I was laughing too hard to finish the exam.

During a patient's two week follow-up appointment with his cardiologist, he informed me, his doctor, that he was having trouble with one of his medications. "Which one?" I asked. "The patch. The nurse told me to put on a new one every six hours and now I'm running out of places to put it!" I had him quickly undress and discovered what I hoped I wouldn't see.
Yes, the man had over fifty patches on his body!
Now the instructions include removal of the old patch before applying a new one.

While acquainting myself with a new elderly patient, I asked, "How long have you been bed-ridden?"
After a look of complete confusion she answered .
"Why, not for about twenty years -- when my husband was alive."

I was caring for a woman from Kentucky and asked, "So, how's your breakfast this morning?"
"It's very good, except for the Kentucky Jelly. I can't seem to get used to the taste," the patient replied.
I then asked to see the jelly and the woman produced a foil packet labeled "KY Jelly."

A new, young MD doing his residency in OB was quite embarrassed performing female pelvic exams.
To cover his embarrassment he had unconsciously formed a habit of whistling softly.
The middle aged lady upon whom he was performing this exam suddenly burst out laughing and further embarrassed him. He looked up from his work and sheepishly said, "I'm sorry. Was I tickling you?"
She replied, "No doctor, but the song you were whistling was "I wish I was an Oscar Meyer Wiener."


Unsubscribe (if you must!) by sending me an email with your email address and the word unsubscribe as the subject. scubadoc@scuba-doc.com


Enjoy!

Ernie Campbell, MD
scubadoc
Diving Medicine Online

Tuesday, February 15, 2005

TEN FOOT STOP, FEBRUARY 15, 2005

See previous newsletters in the Archives
http://scuba-doc.com/archives.html

<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

==>NOTE FROM SCUBADOC <==

In the Winter 2004 Issue of the Journal of Undersea & Hyperbaric Medicine we noted in our last newsletter a study on chamber attendants showing that there is a significant decompression stress with venous gas embilism found in most hyperbaric chamber attendants. The study was done after one of the attendants developed neurological DCI. There is a discussion of measures that can be taken to reduce the incidence of this side effect of HBO treatment. Venous gas embolism in chamber attendants after hyperbaric exposure. http://snipurl.com/cstt
Risberg J, Englund M, Aanderud L, Eftedal O, Flook V, Thorsen E.
Haukeland University Hospital, Bergen.

Dr. Ben Zwart has written us about his experiences with this problem during
his five years at the Brooks AFB chambers. His note with some excellent
links is printed below:

For some unknown reason, chamber attendants seem to dislike breathing oxygen
during treatment dives, and for some weird reason believe that the
physiology of dry diving is the same as the physiology of wet diving (which
I do NOT believe). They therefore base their decompression requirements on
the US Navy Standard Air Decompression Tables - - which, to my way of
thinking, significantly underestimates the actual safe IO decompression
requirements. After a year of following the standard protocols, I found that
a little added caution paid big dividends during my 5 years at the Brooks
AFB chambers. During my tenure there, I required all inside tenders to
increase their oxygen intake during our wound care dives, as well as all of
the US Navy treatment tables. As a frequent inside observer myself, I noted
a significant decrease in post-dive fatigue when using the increased oxygen
breathing times.

These recommendations are all based on (surprise) Nobendem calculations
using Safety Enhancements of 55 and 65 as described in the Nobendem
Download. Generalized tables, including recommendations for swapping inside
observers in mid-treatment can also be found at the Brooks AFB website. They
have been standardized and used successfully at Brooks since 1998.

Oxygen Decompression Tables for Inside Observers: Dry diving is
physiologically different than wet diving, as tissue bed perfusion, among
other things, is different when buoyed up in water than when under the
differential effects of 1G in the dry chamber. This fact was noted in 1963
when Dr. Bruce Bassett developed the USAF Diving Tables in an attempt to
decrease the DCS hit rate in dry dive IOs. The attached tables were derived
from Nobendem at depths of 30, 45, 60, 165 FSW with Safety Enhancements of
55 and 65. Repetitive Group Indicators have been calculated which are
compatible with the USN table 7-4. (in Acrobat format).

http://www.brooks.af.mil/web/hyper/files/Deco_O2.PDF

Oxygen Deco Tables for IOs during Fire Suppression Equipment Tests:

Every 6 months, multiplace chamber units should check their water deluge
fire extinguisher system. This involves a descent to 165 for 2-3 min at
depth, an ascent to 60 FSW where the test is repeated, followed by final
ascent and Oxygen decompression. The attached tables specify Nobendem
derived Deco Tables based on Time At Depth for each segment, and include the
Repet Group for the dive. (in Acrobat format).

http://www.brooks.af.mil/web/hyper/files/Deco_FST.PDF

http://www.brooks.af.mil/web/hyper/files/Nobendem.ZIP

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

DAN Executive VP and COO Dan Orr Elected to DEMA Board

DAN Executive Vice President and Chief Operating Officer Dan Orr has been
elected to serve on the 2005 Diving Equipment and Manufacturing Association
(DEMA) Board of Directors.

"I am honored to join this board," Orr said upon learning of his victory in
mid-January. "I always have been a strong supporter of DEMA, and believe we
as a board have an opportunity to be a leading voice to promote positive
change in the scuba diving industry. DEMA must be a strong and responsive
trade association for all industry stakeholders if we are to grow our sport
and our industry."


In promoting his candidacy, Orr noted that his long experience in the dive
industry, coupled with his contributions at Divers Alert Network, made him
well suited to serve on the DEMA Board. His stated goals in his position are
as follows:

. Identifying, developing and implementing effective and creative efforts to
improve acquisition and retention of divers;

. Continuing to find ways to improve the DEMA Show so that exhibitors,
attendees and the association reap the maximum benefit;

. Finding ways to develop and use effective metrics, using the latest
applied market research, to collect and disseminate important demographic
data for use by our association and stakeholders;

. Promoting a positive conservation ethic that fosters responsible use of
our natural resources through the promotion of global educational outreach
programs; and

. Being ready and prepared to respond quickly and decisively to legislative
issues that affect the diving industry.

A scuba diver for more than 40 years, Orr has held membership and leadership
positions in many notable diving organizations such as NAUI, PADI, ACUC,
YMCA, NASE, IANTD, UHMS, NACD, AUAS, the Institute of Diving, the Our
World-Underwater Scholarship Society and the Explorers Club. He is the
recipient of numerous awards such as the NOGI Award for Sports/Education,
the Leonard Greenstone Award for Diving Safety, the Our World-Underwater
Award, Beneath the Sea's Diver of the Year. He was named Chairman of the
Board of the Historical Diving Society in 2004. He was one of the first DAN
members and DAN volunteers. He became a DAN employee in 1991 as Director of
Training responsible for the development and implementation of the DAN
Oxygen Program.

Orr attended his first DEMA Board meeting on Feb. 1, 2005.

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

==> CHANGING YOUR E-MAIL ADDRESS?<==

Don't miss a single issue. Update your subscription e-mail address: Send both you old and new email addresses and we'll make the change immediately. scubadoc@scuba-doc.com
Lost your copy of the newsletter? See the latest at
http://tenfootstop.blogspot.com or at http://scuba-doc.com/archives.html .

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

==> QUIZ OF THE WEEK <==

Bone & Joint Self-Grading Quiz http://www.scuba-doc.com/bonequiz.htm
Check your answers at http://www.scuba-doc.com/bone.htm


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

==> COOL WEB PAGE ON DIVING MEDICINE ONLINE <==

Medications, Drugs and Substance Abuse Guidelines, databases, Substance abuse, drug chart http://www.scuba-doc.com/drugsdiv.htm


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

==> INTERESTING LINKS <==

Dive Industry Mourns The Loss Of Shawn Beaty of Dive Training Magazine http://snipurl.com/cspj

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

>From Larry "Harris" Taylor, PhD

Underwater Hockey Tourist: http://www.pucku.org/uwht/

Seahorse & Sea Dragon: http://www.isidore-of-seville.com/seahorse/

Sharks-Hammerhead: http://www.isidore-of-seville.com/hammerhead/

Rec.Scuba: http://www.news2mail.com/rec/scuba.html

USAA: http://usaa.freedivers.com/

Mermaids on the Web: http://www.isidore-of-seville.com/mermaids/

Tsunami! Info Resource: http://www.geophys.washington.edu/tsunami/intro.html

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

Huskies' top scorer gets hyperbaric treatment

http://sports.espn.go.com/ncb/news/story?id=1988511

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

Trouble with bubbles in your body
http://snipurl.com/crzk
http://www.stuff.co.nz/stuff/0,2106,3187326a1861,00.html

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

Find nearest AED, learn how to use it

Devices are simple and successful, but seconds count

http://www.al.com/news/huntsvilletimes/index.ssf?/base/news/1108376123261630.xml

++++++++++++++++++++++++++++++++
EDTC Fitness to Dive Standards
http://www.edtc.org/EDTC-Fitnesstodivestandard-2003.pdf


+++++++++++++++++++++++++++++++++
Evaluation of glucose monitoring devices in the hyperbaric chamber.
http://snipurl.com/cqwc

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

Hyperbaric Oxygen Therapy in the Pediatric Patient: The Experience of
the Israel Naval Medical Institute -- Waisman et al. 102 (5): 53 --
Pediatrics
http://snipurl.com/cqw8

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

NATO Challenged by International Coalition to Reduce Sonar Harm to Whales
and Other Marine Species
http://www.commondreams.org/news2005/0210-11.htm
+++++++++++++++++++++++++++++++++++++++++++++++++

HYPERBARIC TREATMENT HELPED
TERRELL OWENS PLAY IN SUPER BOWL
http://snipurl.com/cpi6

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

Performance Freediving Runs 5th Freediving Research Study at Simon
Fraser University
http://snipurl.com/cngb

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

Systematic review of hyperbaric oxygen in the management of chronic wounds.
http://snipurl.com/ckhe

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

MayoClinic.com - First-Aid Guide
http://snipurl.com/841u

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

Health aspects of diving in ENT medicine. Part I: Diving associated
diseases]
http://tinyurl.com/4tndg

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

Tinnitus -- Hannan et al. 330 (7485): 237 -- BMJ
http://tinyurl.com/69he7

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


=>QUESTIONS AND ANSWERS FROM SCUBA CLINIC FORUM <=

Visit, register and participate in our diving medicine bulletin board. http://scuba-doc.com/scubaclinic/

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

Ruptured TM and Doc's ProPlugs

I have a hx of barotrauma with elevation changes and had a t-tube placed in
my left TM in aug. I started to take a scuba class and was released by my
ENT and he removed the tube in his office 2 weeks ago. I had problems with
the descent and equalizing and tried the docs proplugs which I thought
helped on Sunday. I had a f/u appt. with my ENT for a tympanogram on Monday
and found out that I had ruptured my right TM. He has no hx with scuba
diving medicine and told me that I will not be able to do my open water
dives. I went back to the dive shop and was fitted at 2 sizes smaller for
the docs proplugs and they are on special order. Do they really help? Any
suggestions? I really don't want to give up at this yet!!!

See discussion at this address:

http://scuba-doc.com/scubaclinic/viewtopic.php?t=93&highlight

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

Dive Medical Training In Canada?

http://scuba-doc.com/scubaclinic/viewtopic.php?t=94

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

Nasal Operation?

http://scuba-doc.com/scubaclinic/viewtopic.php?t=95

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

Gingko biloba and diving?

http://scuba-doc.com/scubaclinic/viewtopic.php?t=92


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

==> MAILBOX POTPOURRI <==

From Jolie Bookspan, PhD re 'The Ab Revolution'


A study on the training method that I developed called "The Ab Revolution"
shows that it helps low back pain more than conventional core training and
Pilates.

This study will be published in "Medicine and Science in Sports and
Exercise," and I will present it at the national conference of the American
College of Sports Medicine (ACSM) this May.

There is info on my web site about how the Ab Revolution works:
www.drbookspan.com/AbRevolutionSyllabus.html
This month, Ab Revolution  classes run at Temple University center city.
Other workshops will run at other locations later this year. After this
semester, we are changing the Temple classes to a single-session workshop
format to accommodate the number of requests from "out-of-towners" who want
the information, but can't make the six week session to learn the method.
Hope to see you at a workshop some day.
Good Things,
Jolie

Study abstract:
Functional Core Retraining Superior To Conventional And Pilates Core
Training In Remediating Low Back Pain
Jolie Bookspan. Temple University, Neck and Back Pain Sports Medicine,
Philadelphia, PA.

Core training is postulated to increase back support, lessening strain and
pain syndromes, yet chronic pain persists in many patients with strong core
musculature. Moreover, posture and ergonomics, known related to low back
pain, remain unchanged after standard core training.

PURPOSE: To compare a functional core training method, The Ab Revolution,
with two common core strengthening methods on participants with low back
pain.
METHODS: Ninety-six participants (40 M 56 F age 22 - 77) with chronic low
back pain (pain > six months, free of non-orthopedic origin) participated in
either a functional core training class (Ab Revolution, N=26, M10 F16),
Pilates (N=23, M5 F18), or standard core strengthening exercise (N=25, M14
F11). Participants enrolled in university and community exercise classes. A
control group (N=22, M11 F11) attended no classes. Classes met 1h/wk for six
weeks. Ab Revolution training consisted of specific core positioning
exercises for life activity. Pilates and conventional core training was
standard flexion-based floor exercise. Outcome measures were self-assessment
of low back pain at conclusion of the six-week exercise program, and at
three, six and 12 months post. Data were analyzed using Chi-Square, with
non-parametric sign test to examine difference between groups.
RESULTS: Significant reduction of low back pain in Ab Revolution over
Pilates, conventional core training, and control groups (P<.0001) with no gender difference. At the end of the six-week exercise, 14 increased low back pain (Ab Revolution 0, control 1, conventional 6, Pilates 7). Three months post, the number with increased pain was twelve: (Ab Revolution 0, control 1, conventional 6, Pilates 5). A category was added for participants from Pilates and conventional core training who developed new neck pain following the flexion-centered exercise programs. CONCLUSIONS: Ab Revolution training reduces chronic low back pain in male and female participants. The mechanism seems to lie in functional muscle retraining to actively reduce lordosis with crossover to daily activity. In this study, Pilates and conventional core exercise had little effect on pain indices, with added result of increasing cervical spine flexion strain. Increasing repositioning of core musculature through functional exercise, not increasing strength through exercise, seems to be key in resolving low back pain. Publication: Bookspan, J. Functional Core Retraining Superior To Conventional And Pilates Core Training In Remediating Low Back Pain. Medicine and Science in Sports and Exercise, Volume 37:5 Supplement. May, 2005.

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

Question from Dive Operator: Hi guys, *I have a diver who is a dive master in his late 50's been diving for 20 years who tells me he has an enlarged heart. reduced function, A fib without side effects and he takes high blood pressure medication and is well controlled. Can he dive??? he is on attenolol 100 mg lisonopril 10 mg triempterent 35mg warfarin 10 mg Captain Dave Answer by Martin Quigley, MD Dear Captain Dave, I have a number of concerns about your diver. First of all, is his capacity to perform physical exercise, An individual with an enlarged heart and reduced heart function very often has a significant reduction in his exercise capacity. While this may not be an issue in a warm, calm, tropical sea, an unexpected current or other problem may be beyond his ability to cope. Secondly, his high blood pressure must be pretty severe at it appears that he is taking three separate medications to control it. (I am guessing that triempterent is Triamterene, a diuretic that can be used as part of a drug regimen for high blood pressure.) One of the drugs he is taking, Atenelol, is a "beta-blocker", a class of drugs that limits the body's ability to react in a stressful situation or emergency. I generally try to avoid beta-blockers in divers. See https://www.diversalertnetwork.org/medical/articles/article.asp?articleid=11
for further information about cardiovascular issues and diving.

Finally, warfarin (Coumadin) is a "blood-thinner" and is being given to him
to prevent stroke complications from his atrial fibrillation. However
warfarin can increase his tendency to bleed and might increase the damage
from middle-ear or pulmonary barotrauma. See
http://www.scuba-doc.com/antcoag.htm for further information.

What do I suggest? First, that he have clearance from his cardiologist to
dive. Second, that he have a cardiac exercise stress test (treadmill). As
Dr. Caruso's article referenced above states, he needs to be able to reach
"13 METS" level of exercise to indicate sufficient cardiovascular reserve to
consider diving safely, obviously without any sign of abnormal EKG.

You didn't indicate whether this diver was functioning as a "dive master"
for you, or whether that is his highest level of training. Based on the
above concerns, I would not consider that this individual is suitable to
assume responsibility for others in the water.

Other than that, if his cardiologist OKs it and he passes his stress test, I
would permit him to continue to dive.

Martin M. Quigley, MD

Writer's Credentials: Board Certified in Obstetrics and Gynecology and
Reproductive Endocrinology. Trained in Diving and Hyperbaric Medicine by
NOAA and UHMS. Current PADI Instructor. Certified Cave and Trimix Diver.
Faculty Member at DAN's 2001 and 2005 Dive Medicine Courses.

See also our web pages at http://www.scuba-doc.com/hrtprb.html .

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

Question:

Flying between dive sites

I have been asked to organise a week long SCUBA diving expedition to Fiji,
with the aim of using seaplanes to access the remote dive sites in the
archipelago. I was hoping you could let me know of any safety concerns and
what the current guidelines are on flying after diving.

Logistically all flights can be kept to within 100mts of the surface, back
up boats will be used as top cover and safety equipment will be on board,
but it is more the physiological concern I have to address to know what the
safe operating parameters would be?

Thanking you in advance,

Answer:

It would appear from the information in the attached file that your divers
would have no problem if the altitude is maintained as you state.

See http://www.scuba-doc.com/fad.pdf

http://scuba-doc.com/fad_web.pdf

Best regards:

Ernie Campbell, MD
Diving Medicine Online

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

Subject: pool instruction while pregnant

Hello, I'm a PADI instructor that is anticipating a busy summer of teaching
in confined water that is no deeper than 15 feet. I am currently 16 weeks
pregnant and have decided to refrain from open water diving during this
pregnancy. However, I wonder if frequent pool dives can pose any threats to
a fetus.

Answers:

I feel that you are wise to not do any open water teaching while pregnant.
We don't really know, but shallow diving after the first trimester (three
months) would impose very little in the way of decompression stress on the
fetus. There are few reports and no good studies, one way or the other.

Most diving medical sources feel that pregnant females should refrain from
diving, because the fetus is not protected from decompression problems and
is at risk of malformation and gas embolism after decompression disease. My
gut feeling is that frequent shallow dives would not impose very much risk
on the fetus, but in the final analysis - I would not certify you as 'fit to
dive' from a medico-legal point of view. In addition, from a liability point
of view, would you, as a diving instructor, give lessons to someone 16 weeks
pregnant? I doubt it.

I want you to read my web page about this and study carefully what is said
( and left unsaid). Also, note the material on DAN's web page at
http://snipurl.com/cpiv .

In addition, I am sending your question to one of our consultants, Dr.
Martin Quigley, a Gynecologist who is also a Diving Instructor.

See also our web pages at http://www.scuba-doc.com/womdiv.html .

Best regards:

Ernie Campbell, MD

>From Dr. Martin Quigley

Dr. Campbell asked me to add to his usual excellent insights. I think his
bottom line 'if you wouldn't accept a pregnant student as "fit-to-dive",
then you certainly shouldn't consider yourself as "fit-to-dive"' pretty much
says it all.

There is very little published science on pregnant women diving. Since the
RSTC and all the major training agencies (plus NOAA and the US Navy)
prohibit diving while pregnant, the data that exists dates from the late 70s
and early 80s. While the data is somewhat contradictory, there is certainly
no absolute proof that diving is either safe or harmful for the fetus. There
are some data on pregnant women treated with hyperbaric oxygen for Carbon
Monoxide poisoning that did not show any increase in fetal abnormalities,

There is a fair bit of animal data on hyperbaric exposures while pregnant.
While much of this data is rather extreme (like surfacing without
decompression), it does appear that the fetus may be more susceptible to DCI
than the mother.

Even diving to 15 fsw in confined water produces some profound physiologic
changes. For example, your blood levels of oxygen are 50% higher than on the
surface and we know that a premature infant's eyes can be damaged by
prolonged exposures to elevated oxygen. In addition, there is the
theoretical concern that a fetal "bubble" might obstruct the blood supply to
a developing organ or limb and produce profound abnormalities.

In short, there are theoretical risks of diving while pregnant, but no firm
data establishing safety (or risk) to the fetus.

But most importantly, do you want to take any risk of damage? Most pregnant
women don't smoke, don't drink alcohol, increase their vitamin intake, and
otherwise practice a healthy lifestyle. Why take any avoidable risk?

Finally, an instructor is supposed to be a role model and an example. I
would hope that you don't smoke and drink alcohol between dives even though
you could "get away" with it without significantly increasing your risks.
Since you should be telling your women students not to dive while pregnant,
you should be setting the same example.

Sincerely,

Martin M. Quigley, MD, FACOG

Writer's Credentials: Board Certified in Obstetrics and Gynecology and
Reproductive Endocrinology. Trained in Diving and Hyperbaric Medicine by
NOAA and UHMS. Current PADI Instructor. Certified Cave and Trimix Diver.
Faculty Member at DAN's 2001 and 2005 Dive Medicine Courses.

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

Fracture, neck of the femur, diving?

Hello I have recently suffered a break to the neck of my femur during a
skiing accident and am in need of advice as to the long term affects such an
injury could means in respect to my diving future. I have been to theatre
twice now to correct the fracture and currently have a pin and plate in
place to align the two pieces of bone. So far it has been two weeks since
the last surgery and I have been advised by the surgeon to keep the leg
(left) non weight bearing for up to 12 weeks with a reassessment at the 6
week mark. The primary concern however is the supply of blood to the head of
the femur as the break is quite close to the head and therefore limited by
the amount of tissue available to provide this supply whilst the bone is
healing. If the supply of blood is limited and the head of the femur suffers
damage bacause of this then what are the long term consequences of diving.
Will any nitrogen in bubble formation be able to force it's way to the head
and cause further damage even with a limited or non existent blood
supply..... the questions are endless and my knowledge in the matter is
limited so any info would be appreciated.

Kind Regards


Hello Diver:

Although the specter of nitrogen bubbles increasing the risk of damage to a
fracture site is often brought up in answering questions about diving after
a broken bone - there is little to no evidence that this actually occurs.

However, on the other hand, you have had two surgeries to try and maintain
proper alignment of the fracture, the last with the use of hardware. This
has got to have caused at least some disruption in the blood supply to the
surrounding area from which the femoral head receives it's blood flow. In
the condition, dysbaric osteonecrosis (DON), which usually occurs in deep
divers over a prolonged diving career - the femoral head is involved in
about 15% of the cases. One of the conjectures is that the cause of this
condition is from nitrogen bubbles blocking the blood supply. There are no
reports of DON occurring in divers who have had fractures of the femoral
head - on the contrary, just the opposite occurs - there are reports of
fractures of the femoral head in divers with DON.

I would have to say without further data to prove or disprove my
point, that you would be at greater risk from diving with a poorly
rehabilitated leg or
from unrecognized DCI than from nitrogen bubbles focusing at the healed
fracture site. Anecdotal and individual case reports are just not adequate
in advising you as to the possible long term outcome should you resume
diving.

Obviously, the leg will require complete healing in order to allow full
weight bearing for water entry and exit with heavy gear. It should
have been rehabilitated to the point that you will be capable of
satisfactory self and
buddy rescue and perform all the thousands of physical tasks required of a
dive instructor. A recorded neurological exam on a dive is a necessity, so
that by careful comparison any symptoms that could be confused with DCI
would be known about prior to diving.

I plan to send your query to other physicians who might have had some
experience dealing with similar situations. Thank you for your interesting
question!

See also our web pages at http://www.scuba-doc.com/bone.htm

Best regards:

Ernie Campbell, MD
Diving Medicine Online
http://scuba-doc.com/

>From Prof. David Elliott

This is a difficult problem because, besides diving, one of the many causes
of femoral head necrosis is trauma and this was obviously a bad break.

Dysbaric femoral head necrosis is rare in recreational diving and the few
that I have met

- have been diving relatively deep on air (regularly to >40 m or 130 fsw),

- have stretched safe decompression procedures or

- have been mixed-gas tekkies.

But, even in this group, it still seems rare (though, as there is no regular
surveillance, this could be an underestimate).

So my opinion is that diving within the PADI envelope (or its equivalent)
would be relatively safe for instructors after a simple fractured femoral
neck. If instructing entirely within the PADI range, consider breathing
Nitrox but using it as though it is air and stick to the air tables. Safe
diving would be unlikely to contribute significantly to whether or not a
simple fracture will progress to necrosis. There is a possibility that
necrosis will follow even without diving, but the orthopaedic surgeon is the
expert for assessing that risk. Diving beyond these ill-defined limits
deserves greater caution, because these are unchartered waters.

>From Martin Quigley, MD

Agree completely with your assessment. This poor chap might end up with a
partial hip replacement, which, I guess, makes DON of the femoral head
impossible. In any case, your answers still apply. Here's a DAN comment
about diving after hip replacement:
http://www.diversalertnetwork.org/medical/faq/faq.asp?faqid=52

>From Jim Chimiak, MD

As to your question, I was concerned in the actual description by the diver
in that he has been given the information that he has a poorly perfused
femoral head. Is this conjecture or does he have studies. I believe your
advice addresses this. Based on what the diver is telling you, I believe he
should refrain from diving.
If nitrogen can not be transported in the "normal " fashion than there is a
very good theoretical reason that decompression tables may not describe his
physiology as well as to others (And this assumes our decompression models
even comes close to describing the physiology). And lastly understanding
the complexities of bone decompression and DCS/DON that would occur if
decompression is performed suboptimally is not well defined. I do not know
of studies looking specifically at dive profiles that yield lower
decompression stress on bone, ie longer shallower vs deeep bounce, that may
help make the dive safer.
Lacking the information, the diver makes the choice and dives without overt
findings that are only seen incidentally at autopsy if at all or he becomes
a "defining" case report.


>From Jim Caruso, MD

I agree with Dr Campbell

We believe that altered anatomy due to an injury increases the risk of DCI
in that area because of poor blood perfusion. But much of that is based on
theoretical or anecdotal evidence.

Even though you are an instructor, your risk of DON is small. I would make
sure you are absolutely healed and rehabbed before returning to diving and I
might not push the envelope as much as I would with a good hip, but I do not
think there is a significant risk in your case. I advise divers with
artificial hips to dive after the same recovery period.

Jim Caruso, M.D.

U.S. Navy Diving Medical Officer/Flight Surgeon

DAN Consulting Physician

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

Subject: Hernia repair and diving?

Good Day Doc,

To start with:Thank you very much for a wonderfull dive-site!!!

I am a social scuba diver...and LOVE it!!! But only one problem,or is it? I
had a hernia/hiatus repair 3 months ago, and everything is going fine since
the operation. Is it save for me to dive,and if so, say up to a max depth of
25meters?

I will also contact the Doc who did the op, but he dont know much about
diving, thats the reason I need your opinion.

Thank you very much for your time.

Diver,

Pretoria,South Africa

Subject: Re: Hernia repair and diving?


Hello diver:

Thanks very much for your kind words about our web site!

Diving with a repaired hiatal hernia is certainly safer than diving with one
that has not been fixed. The problem with both situations is the air that
can be trapped in the upper part of the stomach. Air is swallowed during the
process of diving with ear clearing and this air can enlarge on ascent and
if there is no egress - then there is the possibility of rupture. Barring
wound complications, three months should be a sufficient time to heal before
diving - again depending upon whether or not you had an open operation or a
laparoscopic fundoplication.

Depending upon the type of repair that you have had and whether or not you
have had an actual hernia repair or a 'fundus wrap' - you should be able to
dive to your training depth. If either of these situations have caused you
to have any trapped air - then you should not dive at all. (The inability to
belch is an indication that you might have trapped air). A barium swallow
can often detect this situation. Also, it is the last four to six feet
before surfacing that is dangerous - not how deep you go.

My suggestion would be for you to contact or have your surgeon contact one
of the South African experts in diving medicine and get a local opinion
according to your particular surgical situation. Information about local
facilities can be obtained on my web site at
http://www.scuba-doc.com/divSA.htm .

See also our web pages at http://www.scuba-doc.com/giprbs.html

I hope this is helpful!

Ern Campbell, MD



Hi Dr. Campbell,

Thank you very much for all the info, it is indeed very helpful! Sorry, I
forgot to tell you that I had a laparoscopic fundoplication (the 5 small
cuts on belly) but like I said, everthing is going well.

I'm so glad that I can still enjoy the ocean without going to IMAX or a
videostore. You made my day!!! I will also contact the local facilities on
the website you gave me for a check-up.

Thanks again,

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

Questions:

1. The diver is under the water. How the diver know which direction to swim
to rich the surface_
2. Why the divers feel the headache only when they dive down or swim up

3. Why the divers do not feel any preasure when diving when they wear the
scuffanders

Please, please could you answer my questions
Thanks very much

Answer:

Hello Student:

A diver knows which way is "up" by looking at the bubbles move. Bubbles will
always enlarge as they go up.

The headaches that you describe are due to the same principle of air getting
smaller on descent and larger on ascent - Boyle's Law. This is due to the
pressure change in the sinuses and is called barotrauma. See our web pages
at http://www.scuba-doc.com/gasesprbs.html

I don't know what you mean by 'skuffander'.


Best regards:

scubadoc
++++++++++++++++++++++++++++++++++++++

Question re oxybutin and diving

Hi Dr. Campbell,
I have a young person (22 years old) put on oxybutnin by her family doctor
for ?overactive bladder. She wants to learn to scuba dive and I was trying
to find information on your website wrt this drugs effects with diving. I
have advised her on hte anticholinergic effects of this drug, and would
appreciate your comments. Thank you kindly.

British Physician

Hello Doctor:

Nice to hear from you again! Oxybutynin (or Ditropan) can have adverse
effects on divers early in the course of treatment, but these effects
usually wear off. The anticholinergic effects are used to ameliorate
frequency of urination due to urethrotrigonitis and bladder spasms.

Side effects include drowsiness, dizziness or blurred vision. A diver has
to have enough visual acuity to read the gauges properly. One should not
drive, use machinery, or do anything that needs mental alertness until the
effect is manifest - one would suppose that this includes diving. The
dizziness is postural and to reduce the risk of dizzy or fainting spells, do
not sit or stand up quickly, especially if you are an older patient. I don't
know how the weightlessness of the underwater milieu would affect this diver
but suspect that the immersion effects of central migration of blood and
fluids would counteract any postural changes of blood volume.

Alcohol can potentate the drowsiness - and again one would suppose that the
sedative effects of nitrogen at depth would be additive to the effects of
the drug.

One should avoid extreme heat (e.g., hot tubs, saunas) as Oxybutynin can
cause one to sweat less than normal. This would not be a problem with scuba
diving - unless lessons are to be given in a heated pool. Dry mouth and
thirst are usually described, but this would be a good thing as hydration is
a definite benefit to prevent decompression illness.

Although the risks seem to be few, the diver and her instructor should be
aware of the possibilities and take action should she decide to proceed with
diving. It most likely will not be enough danger to withhold her
certification as 'fit to dive'.

Warm regards:

Ernie Campbell, MD
Diving Medicine online
http://scuba-doc.com

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

Subject: referral from scuba diving magazine - Diving over age 65 in
Australia?

I was referred to you by the magazine regarding diving in Australia after
age 65.Diver Alert periodical had some info last year re:needing medical
clearance.I want to dive there but will not travel there unless I can find
out prior to going.

Can you shed any light on this subject for me?

Thank you in advance for any assistance

Answer:

Hello Daryl:

I'm not aware of any Australian rules against diving after age 65. However,
the Australian rules are a good bit more stringent and something may have
changed since I last investigated.

Here is a web page that describes pretty well all of the things that you
will need to do in order to dive in Oz (with all the forms, etc.).

http://www.diversden.com.au/medical.htm . There is a 90 day limit on the
exams.

Let me know if this doesn't fit your case properly. Our web page on older
divers might be of some interest. http://www.scuba-doc.com/agedvn.htm

Best regards:

Ern Campbell, MD

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

TO ALL UHMS MEMBERS
BETWEEN 1/26/05 AND 2/2/05 WE WERE EXPERIENCING TECHNICAL DIFFICULTIES WITH
OUR ONLINE FORMS, IF ANYONE HAS SUBMITTED ANY OF THE FOLLOWING ONLINE
FORMS...PLEASE RESUBMIT AND ACCEPT OUR SINCERELY APOLOGIZE FOR ANY
INCONVENIENCE THIS MAY HAVE CAUSED.
* MEMBERS ONLINE DUES
* MEMBERSHIP ONLINE APPLICATION
* PUBLICATIONS ONLINE ORDER
* 2005 ANNUAL SCIENTIFIC MEETING ONLINE REGISTRATION
* 2005 ANNUAL SCIENTIFIC MEETING EXHIBITOR REGISTRATION
* FITNESS TO DIVE COURSE ONLINE REGISTRATION

THANK YOU!
LISA Wasdin

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

==> 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 .

Here are some organizations giving courses linked to the above site:
DAN -- http://www.diversalertnetwork.org/cme/events.asp
SPUMS Courses -- http://www.spums.org.au/courses.htm
Medical Seminars -- http://www.medsem.com/destination_information.html
UHMS -- http://www.uhms.org/Courses/Courses.htm
Temple University Underwater Medicine -- http://www.scubamed.com/educ.htm
EUBS -- http://www.eubs.org/
ISAM -- http://www.divingdocs.org/
NOAA -- http://www.uhms.org/Courses/NOAA01/noaa.asp
DCIEM -- http://www.dciem.dnd.ca/publications/factsheets/t22_e.html
DDRC -- http://www.ddrc.org/docs/ddrcpage.asp?pageid=10


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

==>HUMOR<==

Annual Neologism Contest Once again, The Washington Post published its yearly contest in which readers are asked to supply alternate word meanings. 1. Coffee (n.), a person who is coughed upon. 2. Flabbergasted (adj.), appalled over how much weight you have gained. 3. Abdicate (v.), to give up all hope of ever having a flat stomach. 4. Esplanade (v.), to attempt an explanation while drunk. 5. Willy-nilly (adj.), impotent. 6. Negligent (adj.), describes a condition in which you absentmindedly answer the door in your nightgown. 7. Lymph (v.), to walk with a lisp. 8. Gargoyle (n.), an olive-flavored mouthwash. 9. Flatulence (n.) the emergency vehicle that picks you up after you are run over by a steamroller. 10. Balderdash (n.), a rapidly receding hairline. 11. Testicle (n.), a humorous question on an exam. 12. Rectitude (n.), the formal, dignified demeanor assumed by a proctologist immediately before he examines you. 13. Oyster (n.), a person who sprinkles his conversation with Yiddish expressions. 14. Pokemon (n), A Jamaican proctologist. 15. Frisbeetarianism (n.), The belief that, when you die, your soul goes up on the roof and gets stuck there. 16. Circumvent (n.), the opening in the front of boxer shorts" ********************************* Things my Mother taught me! 1. My mother taught me TO APPRECIATE A JOB WELL DONE "If you're going to kill each other, do it outside. I just finished cleaning." 2. My mother taught me RELIGION "You better pray that will come out of the carpet." 3. My mother taught me about TIME TRAVEL "If you don't straighten up, I'm going to knock you into the middle of next week!" 4. My mother taught me LOGIC " Because I said so, that's why." 5. My mother taught me MORE LOGIC. "If you fall out of that swing and break your neck, you're not going to the store with me." 6. My mother taught me FORESIGHT. "Make sure you wear clean underwear, in case you're in an accident." 7. My mother taught me IRONY. "Keep crying, and I'll give you something to cry about." 8. My mother taught me about the science of OSMOSIS "Shut your mouth and eat your supper." 9. My mother taught me about CONTORTIONISM "Will you look at that dirt on the back of your neck!" 10. My mother taught me about STAMINA "You'll sit there until all that spinach is gone." 11. My mother taught me about WEATHER . "This room of yours looks as if a tornado went through it." 12 My mother taught me about HYPOCRISY . "If I told you once, I've told you a million times. Don't exaggerate!" 13. My mother taught me the CIRCLE OF LIFE "I brought you into this world, and I can take you out." 14. My mother taught me about BEHAVIOR MODIFICATION "Stop acting like your father!" 15. My mother taught me about ENVY "There are millions of less fortunate children in this world who don't have wonderful parents like you do." 16. My mother taught me about ANTICIPATION "Just wait until we get home." 17. My mother taught me about RECEIVING "You are going to get it when you get home!" 18. My mother taught me MEDICAL SCIENCE "If you don't stop crossing your eyes, they are going to freeze that way." 19. My mother taught me ESP "Put your sweater on; don't you think I know when you are cold?" 20. My mother taught me HUMOR "When that lawn mower cuts off your toes, don't come running to me." 21. My mother taught me HOW TO BECOME AN ADULT "If you don't eat your vegetables, you'll never grow up." 22. My mother taught me GENETICS "You're just like your father." 23. My mother taught me about my ROOTS "Shut that door behind you. Do you think you were born in a barn?" 24. My mother taught me WISDOM "When you get to be my age, you'll understand." 25. And my favorite: My mother taught me about JUSTICE "One day you'll have kids, and I hope they turn out just like you!" +++++++++++++++++++++++++++++++++++++++++++++++++++++++ DICTIONARY FOR WOMEN'S PERSONAL ADS: 40-ish.............................................49 Adventurous.................Slept with everyone Athletic......................................No tits Average looking....................Ugly Beautiful.........................Pathological liar Contagious Smile..................Does a lot of pills Emotionally Secure.......................On medication Feminist...........................................Fat Free spirit.....................................Junkie Friendship first..........................Former slut Fun...........................................Annoying New-Age..............Body hair in the wrong places Old-fashioned! ............................No BJs Open-minded.................................Desperate Outgoing........................Loud and Embarrassing Passionate...............................Sloppy drunk Professional....................................Bitch Voluptuous....................................Very Fat Large frame..................................Hugely Fat Wants Soul mate................................Stalker WOMEN'S ENGLISH: 1. Yes = No 2. No = Yes 3. Maybe = No 4. We need = I want. 5. I am sorry = you'll be sorry 6. We need to talk = You're in trouble 7. Sure, go ahead = You better not 8. Do what you want = You will pay for this later 9. I am not upset = Of course I am upset, you moron! 10. You're certainly attentive tonight = Is sex all you ever think about? MEN'S ENGLISH: 1. I am hungry = I am hungry 2. I am sleepy = I am sleepy 3. I am tired = I am tired 4. Nice dress = Nice cleavage! 5. I love you = Let's have sex now 6. I am bored = Do you want to have sex? 7. May I have this dance? = I'd like to have sex with you 8. Can I call you sometime? = I'd like to have sex with you 9. Do you want to go to a movie? = I'd like to have sex with you 10. Can I take you out to dinner? = I'd like to have sex with you 11. I don't think those shoes go with that outfit = I'm gay Wisdom: DANGEROUS: What's for dinner? SAFER: Can I help you with dinner? SAFEST: Where would you like to go for dinner? ULTRASAFE: Have some chocolate. DANGEROUS: Are you wearing that? SAFER: Wow, you look good in brown. SAFEST: WOW! Look at you! ULTRASAFE: Have some chocolate. DANGEROUS: What are you so worked up about? SAFER: Could we be overreacting? SAFEST: Here's my pay check. ULTRASAFE: Have some chocolate. DANGEROUS: Should you be eating that? SAFER: You know, there are a lot of apples left. SAFEST: Can I get you a glass of wine with that? ULTRASAFE: Have some chocolate. ++++++++++++++++++++++++++++++++++++++ Four guys from Lake Aasgaard went up to Northern Minnesota to go fishing. To save a little money, they rented a small cabin that had only two bedrooms. Well, Arne sleeps with Ole the first night and he comes to breakfast the next morning with his hair a mess, and his eyes all bloodshot. They say, "Vat happen to you?" Arne says, "That Ole, he snores so loud, I was kept avake vatching him all night. I can't do that 'nother night so vun of you's got to do it." Since Ole snores so loudly, no one else wanted to room with him, but they finally agree to take turns. The next night is Oscar's turn. In the morning, same thing - hair all standing up, eyes all blood shot. Oscar declares, "Fer sure, dat Ole shakes the roof. And he sleeps so hard, I couldn't vake him. I vatch him all night." The third night was Sven's turn. Next morning Sven came to breakfast bright eyed and bushy tailed. They can't believe it! They say, "Vat happened?" Sven say, "Vell, ve get ready for bed. I go und tuck Ole into bed and kiss him good night. Den he vatches me all night!" +++++++++++++++++++++++++++++++++++++++++++++++++++++++++ How Blonde Was She??? She was Soooooooo Blonde . * She thought a quarterback was a refund. * She thought General Motors was in the army. * She thought Meow Mix was a CD for cats. * She thought Boyz II Men was a day care center. * At the bottom of an application where it says "Sign here:" she wrote "Sagittarius." She Was Soooooooooooooo Blonde... * She took the ruler to bed to see how long she slept. * She sent a fax with a stamp on it. * Under "education" on her job application, she put "Hooked On Phonics." She was Sooooooooooooooooo Blonde... * She tripped over a cordless phone. * She spent 20 minutes looking at the orange juice can because it said "Concentrate." * She told me to meet her at the corner of "WALK" and "DON'T WALK." * She tried to put M&M's in alphabetical order. She was Soooooooooooooooooooo Blonde... * She studied for a blood test. * She sold the car for gas money. * When she missed bus #44 she took bus #22 twice instead. * When she went to the airport and saw a sign that said, "Airport Left," she turned around and went home. She Was Sooooooooooooooooooooo Blonde... * When she heard that 90% of all crimes occur around the home, she moved. * She thought if she spoke her mind, she'd be speechless. * She thought that she could not use her AM radio in the evening. * She had a shirt that said "TGIF," which she thought stood for "This Goes In Front." AND MY PERSONAL FAVORITE: She is sooooooooooooooooo Blonde... She thinks Taco Bell is the Mexican phone company. **************************************************************** Unsubscribe (if you must!) by sending me an email with your email address and the word unsubscribe as the subject. scubadoc@scuba-doc.com


Enjoy!

Ernie Campbell, MD
scubadoc