Friday, February 25, 2005

Ten Foot Stop Newsletter, FEBRUARY 28, 2005


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<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< ==>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

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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Prevention of Decompression Accidents


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.....



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

Systematic review of hyperbaric oxygen in the management of chronic wounds.
Roeckl-Wiedmann I, Bennett M, Kranke P.

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.

URGENT RECALL: Scubapro Uwatec Aladin Air X Nitrox Dive Computer - Date: 2003-02-05


Visit, register and participate in our diving medicine bulletin board.

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


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.


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.

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 .

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?

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 . We will also send your question to one of our plastic surgery consultants for his

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.


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.


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 . There is also a section in our FAQ web page about preventing ear infections at .

Carbon monoxide misconceptions
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.
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 .


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 .

Here are some organizations giving courses linked to the above site:
DAN --
SPUMS Courses --
Medical Seminars --
Temple University Underwater Medicine --

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

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
To register call Temple Center City (215) 204 6946.
or e-mail

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 or



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."

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Ernie Campbell, MD
Diving Medicine Online