Wednesday, November 30, 2005

UHMS News from Don Chandler - Four Important Matters

To all--

So those of you who are interested in the following issues can do some advance planning the following announcements are important:

1. UHMS/NOAA Physician Course date change. Due to a heavy workload during the fall at the NOAA Diver Training Center, the date for the next UHMS/NOAA Physician's Course had to be changed to 10-21 July 2006. This will require those of you who want to attend the course to get your applications in much earlier than in previous years. Because of this three month change, the only way we at the UHMS home office can support it for 2006 is to accept the applications on a first-come, first-serve basis. That is to say we will accept the first 30 applications we receive rather than waiting to receive all the applications and sending them off to Dr. Morgan Wells for his review and selection. We are not sure at this time about course dates for years beyond 2006 but will let you know as we learn about future schedules.

2. Next Fitness to Dive Course is in Charleston, SC 16-19 March 2006. The next very popular Fitness to Dive Course will be held in beautiful and historic Charleston, South Carolina on the dates listed herein. Lisa is currently arranging for a venue and we will let you know all the details as soon as we have a contract. You can apply be going to our website www.uhms.org scrolling down to the box about the course, click where indicated and it will take you to where you can get an application...either for on-line registration or by fax or by regular mail. March is a great time of year to visit Charleston, SC, what with the great spring weather there and with the azaleas in bloom. Please sign on for this course soon.

3. Plan to attend our annual scientific meeting in Orlando. As I write this, our Scientific Meeting Planning Committee is meeting with Lisa and the convention managers of the Hilton Hotel at Disney World in Orlando, Florida to look at our meeting spaces and to make final arrangements for our annual meeting there in June. We are planning a joint effort with Divers Alert Network and SUNY Buffalo for a two-day pre-course on Breath Hold Diving that will be held on 20-21 June. We will also be offering a hyperbaric medicine pre-course entitled "How to Get Paid and Stay Out of Jail" which will be held on 21 June. Our Associates will be planning a pre-course so far as we know at the moment (will let you know more about this later). Following our annual scientific meeting June 22-24, we will be offering a post-course "Medico-Legal Aspects of Fitness to Dive" (morning session) and "Medico-Legal Aspects of Practicing Hyperbaric Medicine" (afternoon session) which is scheduled for Sunday, 25 June. We will also be partnering with ATMO for a 25 June post-course entitled "Inspection, Maintenance, and Documentation of Chamber Acrylics." We will also be conducting our annual "How to Prepare for Facility Accreditation" that Tom Workman teaches (more details later on this). As you can see, we will have lots to offer this June. Plan to be there...you will not be disappointed.

4. The UHMS 40th Anniversary Meeting in Maui, Hawaii, 14-16 June 2007. The Ritz-Carlton Hotel and Resort at Kapalua, rated as one of the two best in the world, is the location for our 2007 annual scientific meeting. We will celebrate the 40th anniversary of our Society with several special events, none of which you will want to miss. And the cost to our members? Better than we could have possibly imagined when we started looking for a place to have our 40th anniversary meeting. Lisa has negotiated garden/golf/mountain view rooms at this 5-star resort for $215 per night, partial ocean view at $240 and ocean view at $265. She has also arranged for 20 rooms at the 2007 government per diem rate ($160 this year) for military, government employees and our Associates. Usual rates for these rooms range from $265 to $415 per day. The room rates as negotiated will be honored by the Ritz Carlton three days prior and three days after the peak nights of 13-15 June. Lisa has negotiated a bargain for you here and you can take advantage of it...our estimated savings from just the complimentary suites and no resort fees currently stands at $41,300 and will be more when the cost for the per diem rooms is set. Plans are still in the works for pre- and post-courses but we will be offering a pre-course entitled "Are Asthmatics Fit to Dive?" and will be updating our own publication of the same title from the proceedings. We are looking for someone to take the lead in arranging another ever popular Dive Expedition as we did in San Diego and Australia...if you are interested, please let me know.

Don

2005 International Consensus on CPR, from Omar Sanchez, MD

Dr. Omar Sanchez, a cardiologist diver in Buenos Aires posts this very valuable information concerning recent updates in CPR guidelines.

Available at: http://circ.ahajournals.org/content/vol112/22_suppl/
http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-5
And: http://circ.ahajournals.org/rapidaccess.shtml

From Buenos Aires, Omar Sanchez, Wetdoc.

Scholarship Deadlines Extended by Women Divers Hall of Fame



The Women Divers Hall of Fame (WDHOF), the international non-profit organization that is dedicated to the women who shape the world of diving, has announced that they have extended the deadline for their 2006 scholarship applications to January 31, 2006. WDHOF provides educational and financial support for individuals of all ages who wish to pursue higher education & training, further career goals, and seek out opportunities in the aquatic and diving-related industries.

The scholarships involved are:

Cecelia Connelly Memorial Scholarship - awarded to a woman diver who is enrolled in an accredited course of study in the field of Underwater Archeology.

Hugh Fletcher Memorial Scholarship - awarded to a disabled individual who wishes to begin or further their dive education. Candidates can be male or female.

Ocean Pals Scholarship - awarded to a female (age 13-18) to be used towards an entry level or advanced diving related educational program.

Reimers Systems Scholarships (2) – awarded to a diver to be used towards a Certified Hyperbaric Technician course. Candidates can be male or female.

Scuba Made Easy Scholarship - awarded to a woman diver working in the areas of marine sciences, oceanography or ocean engineering.

Undergraduate Marine Research Internship Scholarship - awarded to a female student who is participating in a marine biology internship.

Hillary Viders, Ph.D. Scholarship - awarded to a woman who is enrolled in an accredited course of study in the field of marine science and conservation.

Women Divers Hall Of Fame Scholarship - awarded to a woman of any age who wishes to begin or further her dive education.

Women’s Scuba Association Scholarship - awarded to a participant in the Navy’s NJROTC or NROTC program. Candidates can be male or female.

Women Underwater Scholarship - awarded to a woman diver to continue her education/training in the area of technical diving.

To learn more about the WDHOF organization visit: www.wdhof.org For additional scholarship information, criteria and applications visit: www.wdhof.org/scholarship.html

DAN Board of Directors Name Dan Orr to Post of DAN President and CEO

Divers Alert Network has named Dan Orr as President and CEO of the dive
safety organization. The appointment follows the announcement at DAN of the
resignation of Dr. Michael D. Curley.

William Anlyan, chairman of the DAN Board of Directors, made the
announcement to the DAN staff on Wednesday, Nov. 23.

Anlyan praised Orr for his long and distinguished career at DAN and in the
dive industry. 'DAN is fortunate to have a man of his experience and service
to lead this organization forward,' he said. 'The Board is excited to have
Dan Orr at the helm.'

Orr said it is both an honor and privilege to be asked to lead DAN. 'I
pledge to continue DAN¹s vital mission of providing the very best emergency
medical and educational services available to the diving public, as well as
finding new and innovative ways of serving our members and stakeholders,' he
said.

'This fulfills a dream of merging my love of diving with my desire to
continue to improve diving safety. I hope to live up to the high standards
set by the exceptionally qualified and dedicated professionals who work here
at DAN.'

Orr, a veteran diver of 40-plus years, has served DAN in various positions,
most recently, Executive Vice President and Chief Operating Officer, Vice
President for Training and Training Director. He joined DAN in 1991 and
immediately established the DAN Training department and the Oxygen for Scuba
Diving course, a standard in the dive industry.

Orr has held membership and leadership positions in many notable diving
organizations such as NAUI, PADI, ACUC, YMCA, NASE, IAND, UHMS, NACD, the
Historical Diving Society, Academy of Underwater Arts and Sciences,
Institute of Diving and the Explorers Club. He is Chairman of the Board of
the Historical Diving Society and Secretary of the DEMA Board of Directors.

At Wright State University, in Dayton, Ohio, Orr created comprehensive diver
education program offered for academic credit from 1973-1988. This program
consisted of all levels of certification from entry-level through
instructor-trainer.

At Florida State University from 1988-1991, as Instructional Coordinator and
Associate Diving Safety Officer, he revamped the existing diver education
program, offering academic credit through the marine sciences department.
This program expanded emphasis on diver safety and skill development. He was
Diving Safety Officer for the first Mixed Gas Workshop conducted by Florida
State University and conducted at the FSU Marine Lab and Wakulla Springs
State Park.

In a statement to the DAN staff, Anlyan expressed appreciation to Curley for
his service to DAN and acknowledged the fine accomplishments during Curley¹s
21-month tenure. Curley¹s resignation was effective Nov. 22, 2005.

'Both the Board and Dr. Curley agree that as this holiday season approaches,
the time is opportune for the transition, in anticipation of the challenges
the new year will bring,' he said. 'Dr. Curley plans to resume his
independent consultancy career with his firm in Connecticut.'

Dr. Curley¹s statement to the staff read, 'I am most grateful for having the
opportunity to lead this fine organization and to meet many of our DAN
family. It has been my great privilege to support the terrific assistance
provided by DAN¹s staff to divers in need.'

For more information, contact DAN Communications at +1-919-684-2948.

Monday, November 28, 2005

New Corporate Member Designation, UHMS

The UHMS Board of Directors met in Durham, NC on Friday, October 28, 2005. One of the Board’s actions was to create a separate Accredited Corporate Member category for accredited facilities. Prior to this action, accredited facilities received a complimentary one-year general corporate membership as a benefit of accreditation. Accredited facilities will now receive the following benefits:

---Accredited Corporate Membership for the duration of their accreditation period (three-years)
---A plaque suitable for display in a prominent location of the healthcare facility
---A quarterly report from the Board of Directors highlighting Society activities related to regulatory issues, reimbursement, Fiscal Intermediary communication, etc.
Note: Communication will be directed to the healthcare facility senior management, not the Medical Director of the hyperbaric facility to keep the leadership of the organization current with issues related to the practice of hyperbaric medicine
---An electronic copy of Pressure
---Expanded facility information on the UHMS website to include contact information, category of accreditation (Level One, Two, Three), etc., thus making the listing more beneficial to patients and referring physicians
---Authorization to use the UHMS logo on stationery, marketing brochures, etc., indicating that the facility is accredited by the UHMS
To accommodate these new benefits, the accreditation survey fee will be $4500 for all applications for survey received after January 1, 2006. Other accreditation fees remain unchanged.

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Hyperbaric Chambers on Scubadoc's Diving Medicine Online

(Free)

Question about Meniere's surgery and Diving

I have Meniere's Desease. I am having surgery for it that will hopefully work. The surgery involves going through the skull behind the ear, putting a shunt in the inner ear sac and also injecting a fluid toxic to the balance nerve.

I also have a PE tube in my eardrum to help with my abnormally small eustachion tube and trouble equalizing (under water, in airplanes, etc.).

Can I dive after the surgery and/or with the tube in my ear?
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Answer:
All divers require functioning eustachian tubes because of the need for equalizing pressure in the middle ears as they descend and ascend in the water. Inability to 'clear' or equalize allows a high risk of damage to your good ear, with the risk of deafness or other nerve damage from barotrauma.

The tube in your ear would also allow water (and bacteria) to enter the middle ear, causing you to be at major risk for infection and caloric vertigo underwater - a major risk for drowning.

Even if your surgery is totally successful, you would be at risk for vertigo underwater from the imbalance of your killed nerve (alternobaric vertigo), again a major risk for drowning.

A last consideration would be the risk of occurrence of inner ear decompression sickness or barotrauma. It would extremely difficult to differentiate symptoms of these injuries from the effects of your surgery. These two conditions might possibly severely disrupt or damage your surgical results.

I m not aware of any studies on problems such as yours but would hesitate to certify you as 'fit to dive', considering all of the caveats listed above - any one of which would be cause to disallow diving. More information on our web site at http://www.scuba-doc.com/entprobs.html .

I am sending your query to one of our ENT scuba diving consultants for another opinion.

I hope this is helpful!

Ern Campbell, MD
Scubadoc's Diving Medicine
http://scuba-doc.com
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Answer from ENT Consultant, Dr. Allen Dekelboum:

Your request was referred to me for comment. I am very familiar with the procedure you are having, but have more concerns about your difficulty in equalizing while flying and in the water. How long have you been diving with the PE tube in place and how do you protect your middle ear from water getting into it through the tube? If you have a tube in place, I would not recommend any scuba diving. Also, an episode of Meniere's with vertigo while you are underwater can be very hazardous to your life.

Allen Dekelboum, M.D.



References to Meniere's disease and Diving in Scubadoc's Diving Medicine Online

Blast Injuries: A Review in Medscape

Introduction
Terrorism
Explosions and Explosive Devices
Mechanisms of Injury and Injury Patterns in Explosions
General Management
Pulmonary Injuries
Gastrointestinal (GI) Injuries
Neurologic Injuries
Auditory Injuries
Orthopedic Injuries
Ocular Injuries
Miscellaneous Injuries
Summary
Additional Resources
References

http://www.medscape.com/viewprogram/4714?src=mp


References to Underwater Blast Injuries in Scubadoc's Diving Medicine Online

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Malaria Vaccine Effective in Clinical Trial

http://snipurl.com/jy0h

Malaria References in Scubadoc's Diving Medicine Online

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U.S.S. Safeguard concludes SALVEX exercises

http://snipurl.com/i1lh
http://www.military.com/NewsContent/0,13319,77862,00.html

Nitrogen Narcosis reference in Scubadoc's Diving Medicine Online


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The Hyperbaric Healing Institute has Risks of HBOT on it's web page

Hyperbaric Healing Institute
http://www.hhi-kc.com/sideeffects.htm


Side Effects
As with any treatment, side effects are possible. However, with hyperbaric oxygen therapy they are minimal. The most common is barotrauma to the ears and sinuses caused by pressure changes.

Patients are taught autoinflationary techniques to promote adequate clearing of the ears during treatment. Decongestants may be helpful. This problem is temporary and resolves when HBO treatment is completed.

If the patient has ear pain or is unable to clear his or her ears, the insertion of myringotomy tubes may be necessary before the treatment continues.

Taken from a 10-year study of 1,505 patients who received 52,758 2-hour HBO treatments at 2.4 ata once or twice daily (The maximum treatment protocol used for problem wounds around the world).

Inability to equalize middle ear pressure 0.37%
Paranasal sinus blocks 0.09%
Confinement anxiety 0.05%
Oxygen convulsions 0.009% (all ceased after removing hood/masks)
Pulmonary oxygen toxicity 0.00%
Permanent ocular refractive changes 0.00%

Other side effects are more rare.

Oxygen toxicity can cause CNS and pulmonary effects. Seizures occur rarely during treatment and are self limiting.
Seizures will cease when the patient is removed from breathing the pure oxygen.
Factors such as history of seizures, high temperature, acidosis and low blood sugar are taken into account before treatment is begun.
Pulmonary oxygen toxicity may occur in patients who require supplemental oxygen between treatments. This is very rarely seen with the limited number of treatments currently used.
Some patients may suffer claustrophobia. This is managed by maintaining communication, use of relaxation techniques and mild sedation, if necessary. Incidents of claustrophobia, however, are decreased by HHI's large diameter multiplace chamber.
Rarely, patients develop temporary changes in eyesight; these are minor and occur only in those individuals who have large numbers of treatments. Vision usually returns to normal within eight weeks following the end of treatments.
Patients with cataracts may experience accelerated maturation of the cataract, but the treatments do not cause cataract formation.

Contraindications
Anyone with any of the following conditions may not be a suitable candidate for HBOT:

1. Asthma - Small airway hyper-reactivity may result in air trapping and pulmonary barotrauma on ascent. A decision to treat such patients should not be undertaken lightly, particularly in light of evidence that the administration of some bronchodilators may increase the incidence of cerebral arterial gas embolism through pulmonary vasodilation.

2. Congenital spherocytosis - Such patients have fragile red cells and treatment may result in massive haemolysis

3. Cisplatinum - There is some evidence that this drug retards wound healing when combined with HBO.

4. Disulphiram (Antabuse) - There is evidence to suggest that this drug blocks the production of suproxide dismutase and this may severely effect the body's defenses against oxygen free radicals. Experimental evidence suggest that a single exposure to HBO is safe but that subsequent treatments may be unwise.

5. Doxorubicin - (Adriamycin). This chemotherapeutic agent becomes increasingly toxic under pressure and animal studies suggest at least a one week break between last dose and first treatment in the chamber.

6. Emphysema with CO2 retention - Caution should be exercised in giving high pressures + concentrations of oxygen to patients who may be existing on the hypoxic drive to ventilation. Such patients may become apnoeic in the chamber and require IPPV. In addition, gas trapping and subsequent lung rupture are associated with bullous disease.

7. High Fevers - High fevers (>38.5degC) tend to lower the seizure threshold due to O2 toxicity and may result in delaying of relatively routine therapy. If patients are to be treated then attempt should be made to lower their core temperature with antipyretics and physical measures

8. History of middle ear surgery or disorders - These patients may be unable to clear their ears, or risk further injury with vigorous attempts to do so. An ENT consult for possible placement of grommets is usually wise

9. History of seizures - HBO therapy may lower the seizure threshold and some workers advocate increasing the baseline medication for such patients

10. Optic Neuritis - There have been reports in patients with a history of optic neuritis of failing sight and even blindness after HBO therapy. This complaint would seem to be extremely rare but of tragic consequence.

11. Pneumothorax - A pocket of trapped gas in the pleura will decrease in volume on compression and re-expand on surfacing during a cycle of HBO therapy. During oxygen breathing at depth nitrogen will be absorbed from the space and replaced with oxygen. These fluxes of gases and absolute changes in volume may result in further lung damage and or arterial gas embolization. If there is a communication between lung and pneumothorax with a tension component, then a potentially dangerous situation exists as the patient is brought to the surface. As Boyle's Law predicts, a 1.8 litre pneumothorax at 20 msw is potentially a 6 litre pneumothorax at sea level - certainly a life threatening situation. For this reason it is mandatory to place a chest tube to relieve a pneumothorax before contemplating HBO therapy. Particular care must be taken with patients who give a history of chest trauma or thoracic surgery.

12. Pregnancy - The fears that either retrolental fibroplasia or closure of the ductuc arteriosus may result in the fetus whose mother undergoes HBO appear to be groundless from considerable Russian experience. However, HHI continues to exercise caution in limiting treatment of pregnant women to emergency situations.

13. Upper Respiratory Tract Infections - These are relative contra-indications due to the difficulty such patients may have in clearing their ears and sinuses. Elective treatment may be best postponed for a few days in such cases.

14. Viral Infections - Many workers in the past have expressed concern that viral infections may be considerably worsened after HBO. There have been no studies to give convincing evidence of this and no reported activation of herpetic lesions associated with HBO.


References to Risks of HBOT on Scubadoc's Diving Medicine Online

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Bubble study to add fizz to champagne

Article by Anna Salleh for ABC Science Online

Champagne bubbles rise to the top of the glass in a mathematical pattern that changes over time, French and Brazilian researchers say.

Associate Professor Gerard Liger-Belair, of the University of Reims, and his team report their unexpected findings in the current issue of the journal Physical Review E.

http://www.abc.net.au/news/newsitems/200510/s1473454.htm


References to 'bubbles' in Scubadoc's Diving Medicine Online


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Diagnosis and Management of Injuries From Dangerous Marine Life


From Medscape General Medicine™

Diagnosis and Management of Injuries From Dangerous Marine Life CME
Posted 09/28/2005

Thomas P. Brown, DO

Abstract
Injuries from marine life encompass a wide spectrum, from mild stings to severe bites. Fortunately most of the injuries are mild, although some may be significant, resulting in death. Most of these injuries can be treated by family physicians with a knowledge of the cause of the pathology. Over the years, there have been many treatment options. Some have actually caused an increase in severity. An important rule in treating these injuries is to inactivate the venom, treat the local reaction or injury, and treat the systemic sequelae. Jellyfish stings are the most common type of marine injury. The tentacles possess nematocysts, which are stinging units that are inactivated by the application of vinegar. Sea urchin and stingray injuries require the removal of the imbedded spines after the wound is soaked in hot water. Coral, sea bathers eruption, and swimmer's itch require thorough scrubbing and irrigation. Sea snakes, cone shells, and venomous fish possess a neurotoxin that requires close monitoring in the event of cardiopulmonary collapse. All of these injuries require tetanus status monitoring and consideration of coverage for infectious sequelae.

http://www.medscape.com/viewarticle/512590


References to 'Dangerous Marine Life' in Scubadoc's Diving Medicine Online


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Questions we answered for Scuba Diving Magazine

I'm planning a trip to the Dominican Republic in a few months. My doctor told me I need to take a prescription antimalarial drug. I've done some research, but I don't know which drug to use. What do you suggest?

Orlando, Fla.

There is no risk for malaria if you're staying in a resort area in the Dominican Republic, but if you'll be visiting rural areas (or taking a side trip to Haiti), you'll need to take an antimalarial drug. Chloroquine (brand name Aralen) or hydroxychloroquine sulfate (brand name Plaquenil) are the drugs of choice for visitors to the D.R.

Malaria symptoms occur at least seven to nine days after a victim is bitten by an infected mosquito. Fever during the first week of travel in a malaria-risk area is unlikely to be malaria; however, any fever should be promptly evaluated.

Travelers who become ill with a fever or flu-like illness while traveling in a malaria-risk area and up to one year after returning home should seek prompt medical attention and should tell the physician their travel history.

Antimalarial Drugs: Know When To Take Them

Drugs to prevent malaria are available only by prescription through a health care provider. Your health care provider should prescribe your antimalarial based on your travel itinerary and medical history. Here's why: Some antimalarial drugs are more effective in some parts of the world than others. In addition, a medical condition may prevent you from taking certain drugs.

Drug - Mefloquine (brand name Lariam)

Dosage - 250 mg (one tablet) once a week—take the first dose one week before arrival, then once a week on the same day while in the malaria-risk area and once a week for four weeks after leaving. Take after eating.

Side Effects - Nausea, dizziness, difficulty sleeping and vivid dreams. Rarely reported to cause serious side effects, such as seizures, hallucinations and severe anxiety.

Recommended For Travel To - South America; Darien and San Blas provinces, including the San Blas Islands, in Panama; Africa; the Indian subcontinent; Asia and the South Pacific.

Drug - Doxycycline

Dosage - 100 mg once a day—take the first dose one or two days before arrival, then once a day at the same time each day while in the malaria-risk area and once a day for four weeks after leaving.

Side Effects - Increased risk of sunburn, vaginal yeast infection and nausea. Can cause permanent teeth staining in children under the age of eight. Do not take if pregnant.

Recommended For Travel To - South America; Darien and San Blas provinces, including the San Blas Islands, in Panama; Africa; the Indian subcontinent; Asia and the South Pacific.

Antimalarial Drugs: Know When To Take Them (cont.)

Drug - Malarone (combination of atovaquone and proguanil)

Dosage - One tablet (250 mg atovaquone/100 mg proguanil) once a day—take the first dose one to two days before arrival, then once a day while in the malaria-risk area and once a day for seven days after leaving. Take at the same time each day with food or milk.

Side Effects - Side effects are rare, but abdominal pain, nausea, vomiting and headache can occur. Women who are pregnant or breastfeeding should not take Malarone.

Recommended For Travel To - South America; Darien and San Blas provinces, including the San Blas Islands, in Panama; Africa; the Indian subcontinent; Asia and the South Pacific.

Drug - Chloroquine (brand name Aralen)

Dosage - 500 mg chloroquine phosphate—take the first dose one week before arriving, then once a week on the same day while in the malaria-risk area and once a week for four weeks after leaving. Take after eating.

Side Effects - Side effects are rare, but nausea, vomiting, headache, dizziness, blurred vision and itching can occur.

Recommended For Travel To - Haiti; Dominican Republic; certain countries in Central America (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama's Bocas del Toro province); the Middle East and Eastern Europe.

Drug - Hydroxychloroquine sulfate (brand name Plaquenil)

Dosage - 400 mg—take the first dose one week before arrival, then once a week on the same day while in the malaria-risk area and once a week for four weeks after leaving. Take after eating.

Side Effects - Side effects are rare, but nausea, vomiting, headache, dizziness, blurred vision and itching can occur.

Recommended For Travel To - Mexico, Haiti, Dominican Republic, certain countries in Central America, the Middle East and Eastern Europe.

Dive Med Essentials: The Mefloquine Controversy

The most commonly prescribed prophylactic for malaria is mefloquine, or Lariam. While all antimalarial drugs have some side effects, Mefloquine has been linked to disturbing side effects, including anxiety, dizziness, nausea and hallucinations. There have also been a few reports of seizures, frank psychosis and depression resulting in suicide attempts in people taking this medication. That this drug has effects on the central nervous system is not disputed; in fact, the manufacturer recommends that it not be used by anyone with a history of psychiatric illness or seizures.

While these severe side effects are seen almost exclusively in patients taking doses of 1,500 mg, the incidence of side effects such as dizziness, anxiety and nausea seen in patients taking the 250 mg weekly prophylactic dose is also of concern, particularly to divers. Divers should also be aware that some of these side effects mimic the symptoms of decompression illness.

With documented side effects such as confusion, anxiety and seizures, the dangers of diving while on this medication are obvious. Any effects felt on the surface might be exacerbated by the effects of increased nitrogen and oxygen partial pressures.

It should be noted that certain forms of malaria—particularly P. falciparum—have developed resistance to various antimalarial drugs. Because of this, if you are traveling to an area with this type of malaria, you'll have to take mefloquine—the disease is far worse than the side effects.

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Loss of Hearing and Diving

I have read that hearing loss is very common among divers. Is this a sacrifice that I should be prepared to make to enjoy my new addiction?

Paso Robles, Calif.

This depends to a certain degree on how much difficulty you have in clearing your eustachian tubes as you descend and ascend. Difficulty in clearing can cause middle and inner ear damage and hearing loss. This does not always occur, however, and most hearing loss is in commercial divers who are subjected to noise and the changes that take place with clearing difficulties.

Learning to clear is a must for any kind of diving due to the effects of Boyle's Law on the ear. Clearing techniques must be learned or the diver is headed for deafness, ringing in the ear (tinnitus) or dizziness.


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After diving, I often get minor to severe headaches. What's causing this?

Mt. Pleasant, S.C.

There are many different types of headaches, and you'll need to visit a doctor familiar with diving for a thorough examination to determine whether yours are related to diving.

Most diving headaches are caused by either carbon dioxide retention or sinus barotrauma. Here are the most common headaches resulting from diving and what you can do to prevent them.

Carbon Dioxide Headaches

Symptoms: Post-dive localized throbbing pain

The carbon dioxide headache, one of the most common for divers, is caused by an increase in the body's carbon dioxide level, which stimulates receptors in the brain's blood vessels. An increase in the brain's blood flow to these receptors leads to headaches. Typically, they are caused by a diver taking shallow sips of air, which allows carbon dioxide to accumulate. This buildup can also occur when a diver "skip breathes" by pausing after each inhalation and holding the throat closed. Taking measured, slow, complete breaths under water is the best way to avoid carbon dioxide headaches, which don't respond to analgesics or migraine medications.

Tension Headaches

Symptoms: Post-dive neck and head pain

New divers often experience tension headaches resulting from the stress of their first experiences in the underwater world. Clenched jaws and muscular stress in the neck and back of the head lead to these types of headaches, which usually disappear once the diver gains experience and becomes more relaxed under water.

Migraine Headaches

Symptoms: Severe headaches with nausea

Post-dive vomiting can be caused by a migraine headache, but, if coupled with other symptoms, could indicate a DCS headache. If the diver has a history of migraine headaches, then there could be a direct correlation between diving and the onset of the cranial pressure. Unless they are able to take measures to prevent a migraine attack, people with migraines should not dive. If the diver has migraines accompanied by visual anomalies, he should be checked for patent foramen ovale, which may be a factor in undeserved DCS hits.

DCS Headaches

Symptoms: Post-dive headache with neurological deficit

A headache that comes on strong after a dive, coupled with other symptoms like nausea, vomiting, joint pain, dizziness, ringing in the ears, muscle aches, localized swelling, itching or skin rash, could indicate the onset of Type II decompression illness or an arterial gas embolism. This, the most severe dive-related headache, requires a quick response from onboard personnel and a call to the Divers Alert Network to coordinate hyperbaric treatment.

Sinus Headaches

Symptoms: Forehead, face and eye pain during ascent or descent

A diver without a history of migraines could be suffering from a sinus headache, especially if he has a history of problems equalizing. Shifting pressure based on changes in depth without proper equalization can lead to sinus barotrauma. This pain usually spreads across the forehead and eyes. Thus, inflammation of the sinuses, caused by colds or allergies, can further complicate diving.

Post-dive Fatigue

Why am I always tired after diving? My divemaster mentioned something called post-dive fatigue. Can you help?

Crown Point, Ind.

Fatigue in divers often accompanies more acute signs and symptoms of decompression sickness. For other divers, fatigue is the only complaint. Some experts consider post-dive fatigue to be a subclinical form of DCS, possibly caused by tiny bubbles that form in the veins and then filtered out by the lungs.

Fatigue lessens when divers are recompressed, indicating that it may be caused by gas bubbles. On the other hand, anyone who spends the better part of a day out in the tropical sun and breathing compressed air under water is likely to get worn out. If you don't usually lead a fit, active lifestyle, you may just be tired.

Diving After Back Surgery

I had surgery on one of the discs in my lower back to relieve chronic sciatica. Although my back has responded well to the treatment, I am unsure when it would be wise to think about diving again. I have heard that surgery could increase my chances of getting DCS.

London, England

Post-surgical and healed vertebral fusions generally do not prevent divers from pursuing their favorite sport. There is a theoretical increased risk of bubble formation in regions of bone and adjacent spinal cord where there has been some disruption of blood supply. There have been no studies to prove or disprove this possibility, however.

Conventional recommendations about diving after any injury to the spinal cord are that there might be an increased risk of bubble formation at the site of the disturbed blood supply. To my knowledge, there is no evidence to this effect. However, you should consider the risk of an increased incidence of spinal decompression illness and that this risk may be reduced by limiting depth and frequency of dives, using slow ascents and making a safety stop before surfacing.

If you dive, you may have to make adjustments because of the weight-bearing, climbing and hyperextended neck position that is required with scuba diving. You might want to don and doff your gear in the water to avoid excessive weight-bearing, for instance.

There should, however, be no ill effects caused by depth and pressure on the disc herniation. Once your surgeon has cleared you for diving, after you've healed and rehabilitation has occurred, you should be able to dive again (usually six to eight weeks post-op).

It's wise to have a neurological examination carefully recorded to take with you on your dives for comparison reference in case of a decompression accident.

Old and Wiser Diver

I am 68-year-old diver in good physical health. I run 20 miles a week and am presently training for a half-marathon. I got certified in 1995 and have 125 dives in total. Is there a strategy that will allow me to reduce my DCS risk while diving?

Ontario, Canada

You are to be congratulated on keeping yourself in good physical condition. Some people believe that you should gradually reduce the depth and times of dives as you grow older; others feel that you should lengthen safety stops and surface intervals. The only proven ways to reduce your risk of DCS are using nitrox on air tables and not diving at all.

Aging imposes some added risks to divers, but most older divers alter their activities to take these factors into consideration. These include arthritis, heart problems, diabetes and obesity, hardening of the blood vessels in the brain, visual problems and the ever-present specter of cancer. The risk of DCS is thought to increase with age and Carl Edmonds in Diving and Subaquatic Medicine suggests that bottom times should be reduced by 10 percent for each decade of life after 30. Heart problems are by far the most serious of the age-related changes, and probably accounts for the largest number of diving deaths. For this reason, it is recommended that divers over the age of 40 undergo regular cardiac exams.

PSDiver Monthly and The Wet Gazette WILL be delayed

Mark Phillips, Publisher of the PSDiver Monthly and 'The Wet Gazette' magazine, has the following on his web page.

"We have been severly affected by hurricane Rita. We may be down for a month. The next issue of PSDiver Monthly and The Wet Gazette WILL be delayed. We will send the next issues out as soon as we can.

Mark was forced to miss the International Police Divers Symposium and was unable to present his paper on Auto Recover and Related Underwater Crime Scenes. He will also miss DEMA. These two events are crucial to the existance of PSDiver Monthly and is where we gain new sponsors.

If you know of a company who is actively working or promoting safety in equipment, training or otherwise relative to Public Safety Diving, Police diving or Water Rescue, please send us a referral and we will contact them directly. We need sponsors to keep going. We can use your help with this. Email us at psdivermonthly@aol.com.

'Pressure', UHMS Publication

Here is the UHMS publication, 'Pressure', for 2005 JULY/AUGUST/SEPTEMBER/OCTOBER VOL. 34 #4 & #5

http://snipurl.com/kaoi

Sunday, November 20, 2005

Diving Risk

When asked about "risk" in scuba diving, one almost automatically thinks of ratios, percentages and comparisons with other activities. Various estimates are published, varying from a risk of 3% (3% of what?) estimate of causing death during a lifetime to one dive equaling certain known dangerous activities; such as 1.4 cigarettes, or 1 hour in a coal mine or eating 40 tablespoons of peanut butter. You can see the absurdity in trying to place numbers on any activity that could cause death or injury - but the insurance planners have to do this in order to apply a monetary value to their protection.

Scuba diving does not allow for accurate accounting of risk because we have only vague ideas of what numbers we should fit into any equation that we might want to use. We have incomplete figures for deaths and injuries (numerator)and absolutely no true values for how many dives are made over a period of time(denominator). This is all guesswork. Divers Alert Network makes a valiant (and intelligent) effort to do this every year in their publication, 'Report on Decompression Illness, Diving Fatalities and Project Dive Exploration: 2002 Edition', but it should be apparent that their figures are incomplete for the general diving population.

I have long thought that a more sensible approach to assessing risk to the individual would be to identify factors that increase risks and to offer some guidelines to the diver for reduction of these risks. DAN's follow-up and assessments of individual diving deaths comes the closest to offering this solution to the problem. Undercurrent Newsletter (www.undercurrent.org/) has long had a section on why divers die and other books and agencies use this method effectively,;e.g., Carl Edmonds book, Diving and Subaquatic Medicine.

An injured or dead diver represents a 100% statistic for that individual, and a study of "who, what, where when and why" often provides an insight into scuba risks that will not be found in any actuarial compendium. Risks arise from some identifiable hazard. A hazard is a source of danger, whether this is derived from the diver (host factors) or from external (environmental) factors. It seems to me that this can also be simplified into knowledge (training) and fitness (both physical and medical). Knowledge comes from training and experience. Types of fitness come from directed physical activity and from medical awareness of conditions dangerous to a diver under pressure.

On the positive side of the ledger (factors that decrease risk), knowledge of and sensible motivation to carry out activities that decrease risk include:
---Training and certification for the diving activity that is to be undertaken. (E.g., technical diving done by a diver who has only basic or advanced skills). In 10 years of DAN's collection of diver fatalities, uncertified divers accounted for 7.7% (70) of the fatalities and students for 5.2% (47).
---Experience. This is a factor that cannot be quantified but which obviously decreases risk. (unless it leads to repeating the same mistake over and again).
---Being physically fit requires conscious effort and motivation from the knowledge that this will be beneficial.
---Good health or the absence of conditions that are adverse to diving. The diver should have knowledge that the diver does not have disorders that lead to altered consciousness, disorders that inhibit the "natural evolution of Boyle's Law" or disorders that may lead to erratic and irresponsible behavior.
---Knowledge about the appropriate age of safe diving. Debatable, but there are many reasons why divers below 14 and above 70 should not dive.
---Knowledge of the positive effects of not smoking, using drugs and drinking alcohol
---Knowledge of the benefits of excellent, well-maintained equipment.

Negative factors increasing risks of diving include some or many of the following:
---Lack of proper (or no) certification for the dives undertaken. This includes clearing technique, ascent and deco technique. Poorly planned dives.
---Technical Diving (Inadequate knowledge for the dives undertaken) DAN's collection of diver fatalities show recreationally certified divers making a technical dive accounted for 10.4% (95) of the fatalities.
---Commercial diving (a catch 22 of having to dive for a living but knowledge that prolonged work at depth can be detrimental, a whole 'nother subject!)
---Hazards.
--Water --currents, surges, wave action, boat traffic, overhead diving (wrecks, caves)
--Weather
--Marine Life
---Buddy factor. A stranger or poorly trained buddy; buddy inadequate to rescue due age, strength or maturity. (Buddy separation occurred in 39.7% (362) of deaths and 14.4% (132) of divers were diving without a buddy).
---Equipment Malfunction. For whatever reason. This is rare.
---Air. Bad air, out of air, air never there. Happens more often than it should.
---Medical problems as outlined above (natural disease). Australian figures show that 9% of divers who die have been specifically advised by a diving medical expert or their dive instructor that they were unfit to dive. At least 25% of those who died while diving were medically unfit to dive and should not have been doing so.
---Cognizant/psychiatric problems. Diminished mentation from whatever cause. Mental illness, drugs, buccaneers.
---Age factors (see above) Knowledge and mentality to apply that information. See my web page at http://www.scuba-doc.com/agedvn.htm

Interesting information is gleaned from ten years of diving fatality epidemiology: Divers Alert Network database, 1989-1998. Figures indicate that for the 912 diving fatalities a thorough investigation usually reveals a critical error in judgment or a violation of recommended safe diving procedures. (James Caruso, MD, in Journal of the Marine Medical Society, India,)

Dr. Caruso has also noted that in the 1995 review of this data, there are several recurring themes associated with fatal recreational diving accidents. He states, "Divers with little or no experience in more challenging types of diving are disproportionately represented in the DAN diving fatality database. Common causal and contributing factors include running out of air, cardiovascular disease, and buddy separation. Emphasizing increased training and experience, identifying significant pre-existing natural disease processes, and adhering to the recommended diving safety guidelines should reduce the annual number of diving fatalities."

So it seems to boil down to knowledge and the application of that knowledge as the prime factors in risk management of diving injuries and fatalities. Of course, one cannot teach intelligence or common sense - but it would appear that our teaching agencies are all generally doing a good job in the training sphere, with the possible exception of training children.

What do you think?


References to "Risks" in Scubadoc's Diving Medicine Online


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Friday, November 18, 2005

NAUI and GAP Team Up On Diving Software

From Alp Maritimes Sports Newsletter V5N9-A

"It is with great pleasure we inform you that a strategic alliance has been struck between NAUI and GAP. Now the world’s best decompression software has a version that is NAUI specific. GAP uses the RGBM fully-fledged decompression program for both technical and recreational dive planning. This revolutionary Reduced Gradient Bubble Model (RGBM) decompression algorithm model was developed by Dr. Bruce R. Wienke. NAUI-GAP with RGBM can be used for recreational, nitrox and mixed gas decompression dive planning; any dive, any gas, and depths up to 153 m/500 feet.

NAUI-GAP RGBM's graphical user interface (GUI) is both user friendly and efficient. For speedy input of a data, a spreadsheet-like input is also available. The new improved GUI supports on-the-fly deco gas selection (including PPO2 setpoint settings for CCR), a quick review of the dive plan and a tissue compartment information review.

NAUI-GAP RGBM Dive Planning software:

• features the classic, complete version of the RGBM program.

• supports dives with open circuit and constant PO2 rebreather.

• supports custom Nitrox, Trimix and Heliair mixes and suggests optimal mixes for a given dive.

• supports metric and imperial units.

• supports multiple gas switches during the dive and decompression.

• utilizes templates for personalized settings.

• generates extensive reports about the dive, including decompression, oxygen tracking, END and gas consumption.

• easily generates bailout tables.

• profile editor provides either graphical or textual output

• has a Table Expert tool which allows you quickly to generate square profiles for many dive depths/durations at the same time.

• has a Gas Mixer tool that uses partial pressure blending.

• can output the information to paper or in HTML or CSV files.

With NAUI-GAP RGBM, you can change the dive parameters, e.g. ascent rates, available deco gases or altitude settings and make a series of dives with any profile.

Clique on www.technicaldivingops.com and scroll down the front-page to the GAP link.'

Thursday, November 17, 2005

Article in Mobile Press Register features CO Poisoning and Generators

Julio Garcia, CHT, Director of the Hyperbaric Center at Springhill Hospital in Mobile Alabama writes and sends an article that was published in the Mobile Press Register today:

"CDC reviews poisonings related to use of generators
Thursday, November 17, 2005
By PENELOPE McCLENNY
Staff Reporter

The high number of carbon monoxide poisonings treated at a local hospital after Hurricane Katrina has captured the attention of two scientists at the Centers for Disease Control and Prevention.

And they've interviewed local victims to develop more effective ways of educating the public about the dangers associated with improper use of portable generators.

Renee Funk, an epidemiologist with the Atlanta-based CDC, and Deidre Crocker, an epidemiological intelligence officer with the agency, spent two weeks in Mobile earlier this month interviewing several of the more than 20 patients who were treated at Springhill Medical Center for carbon monoxide poisoning following the Aug. 29 storm.

A colorless, odorless gas, carbon monoxide can be lethal when it accumulates in small enclosed areas. Such situations are more likely to arise when storms such as Katrina trigger widespread power outages, causing people to turn to portable generators.

In the days after Katrina, the hyperbaric medicine department at Springhill became packed with carbon monoxide victims, said Julio Garcia, a registered nurse and director of the department. The hospital uses its hyperbaric chamber to treat those poisoned from carbon monoxide with pressurized oxygen.

While some of the ill people had operated generators inside their homes, Funk and Crocker discovered that other victims thought they had placed generators in safe areas.

"So many poisonings had occurred, even though people knew not to keep them indoors. That's one of our concerns," Funk said. "Most people had them in carports or porches."

Garcia, who worked with the CDC scientists and local health department officials during their review of the situation, said he was surprised by some of the information that they uncovered.

"What we found to be the biggest contributing (factor) is that it is not well-defined what is a well-ventilated area," Garcia said. "It not as simple as you think. Really ... they thought they were doing the right thing."

In a number of cases, people put generators in covered areas close to their homes to protect them from rain, or placed them in nearby outdoor areas to guard against theft, Garcia said.

A generator that's too close to a house-- especially near an open window or vent -- poses dangers because of the high concentrations of gas that it emits.

"They actually produce more carbon monoxide than a car," Funk said.

Funk and Crocker said they will use the information they gathered in Mobile to encourage more public awareness campaigns about generator safety. For instance, out of all the Mobile-area victims they interviewed, few said they used carbon monoxide detectors while their generators were operating. Those that did have detectors had dead batteries, Funk said.

Funk and Crocker are planning on working with the Consumer Product Safety Commission to ensure that instructions on generators clearly explain where to keep them in proximity to a home. The epidemiologists also plan to talk to retailers, urging them to group generator-related supplies together in their stores.

"If they see the CO detector and the extra long extension cord, they are more likely to pick them all up at once," Funk said.

The Mobile County Health Department is considering holding news conferences on generator safety at the start of next year's hurricane season, according to Melissa Tucker, the department epidemiologist who worked with the CDC scientists.

"I don't know what it's going to take to make people understand that people can get hurt or killed from carbon monoxide poisoning," Tucker said."

Garcia can be contacted at these sources:

Julio R. Garcia CHT, RN
Center Director
Springhill Medical Center
The Center for Wound Care & Hyperbaric Medicine
(251) 461-1300/460-5461 Office
(251) 345-1556 Fax
email:jgarcia@springhill.org


Carbon monoxide in Scubadoc's Diving Medicine Online

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Wednesday, November 16, 2005

U N D E R C U R R E N T S U B S C R I B E R O N L I N E U P D A T E



Undercurrent -- Consumer Reporting for
The Serious Scuba Diver since 1975
www.undercurrent.org

November 15, 2005

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Diver Death in Belize: In our April issue, we gave a big thumbs down to Advance Divers in Placencia, because of their safety practices, which included their motors conking out far from land. Unfortunately in October, a motor conked out again, so the four tourist divers aboard decided to swim for land. Failing to make it, they drifted for three days, and eventually one succumbed to the exposure. It's a tragic story and in our January issue, we will have an exclusive interview with one of the divers and look at the incident in greater depth.

The Devils Teeth: a true story of Obsession and Survival among America's Great White Sharks: Perhaps the greatest gathering in numbers of great white sharks in the world is at the Farallon islands, 26 miles from downtown San Francisco. Researchers have been tracking and studying them for years and at least one diver still collects sea urchins for the foreign market in the midst of their gatherings. Journalist Susan Casey lived on these barren islands to write a fascinating, awe-struck account of the sharks, their amazing behavior, their killing strategies, their travels, and life with the researchers on these barren islands. Purchase at www.Undercurrent.org and our profits will go directly to coral reef research. (This year we will give away $4250; details in the January issue).

Emily Hurricane Damage: Cozumel was hit hard, but nearly all dive operators are operating and many hotels are open. As for the reefs, we have reports of plenty of shallow damage here and there _ we read emails from people who found splendid toadfish on the street _ but the deeper Cozumel diving is out of hurricane range. If you have pending reservations, contact both the hotel and dive operator for information, but here's a website that can help you with the status. And, here's a link to an interesting piece written November 1 by Dave Dillehay, owner of Aldora Divers, a favorite with Undercurrent readers. Or, see a few photos at www.imagestation.com/album/pictures.html?id=2118380855&mode=guest

Have Problems Clearing and Equalizing? Then you may wish to participate in this study of a simple nonprescription FDA-approved sinus rinse, conducted by several physicians, David Covard MD, included. They are soliciting divers to receive a product sample and then participate in an online survey to discover the validity of the rinse, which in a small survey has showed some effect in helping clear and equalize ears when diving and in reducing the need for pre-dive decongestants. If you choose to participate, go to the Diver "Before" Survey and follow the instructions.

Insurance Company Refuses to Cover Bent Diver Who Went Beyond Policy Limits. In August, a British scuba diver got seriously bent in the Red Sea, and as he recovered in an Egyptian Hospital his Insurance Company refused to cover the nearly $70,000 in treatment costs. The firm said 68 year old Anthony Allen went deeper than the 30-meter limit stipulated in its small print. Allen's sons said doctors had told them their fathers illness was caused by dehydration, and not the depth to which he dived. Lloyds TSB insurance said the terms of Allen's policy exclude coverage for diving beyond 30 meters. The tour company that Allen was diving with confirmed that he reached a depth of 49.5 meters before seeking medical assistance. Egypt threatened to keep the diver, but eventually allowed him to travel home, after he paid much of the bill.

So, We Have a Question. Have ever been refused reimbursement for a diving-related incident? Have you been refused coverage for an injury on a trip that is not diving related? Do you have a policy with limits? If so, we'd appreciate hearing from you as we research this story. Write me at editor@undercurrent.org.

The 464 page Travelin' Diver's Chapbook will be sent to all print subscribers about December 10. It's chock full of reviews of hundreds of dive resorts and live-aboards, each carefully edited by our editors. Any written by people with an agenda _ either unfairly critical or shamelessly gushing _ don't make the cut. You can count on what you read. If you are not a subscriber, there is a special one time introductory offer at www.Undercurrent.org that will get you the 2006 Chapbook.

The Easy Holiday Gift for your Dive Buddy: Give your dive buddy the 2006 Travelin' Diver's Chapbook and nine issues of Undercurrent for $33. We'll send a diver's holiday card from you announcing the subscription. (And, if your diving buddy is already a subscriber, we'll let you know). Sign up at www.undercurrent.org/UCnow/join.shtml.

Coming Up: New proven remedies to stop no-see-ums . . . A great Galapagos trip . . . Wrecks at Midway Island . . . How gear gets stolen at airports and how to prevent it . . . a British Virgin Islands getaway . . . Why divers die . . . Guaranteed diving with Mexico's great whites . . . PADI loses lawsuit to shut down critical website . . . Another inexpensive Sea of Cortez venture . . . Why not a live-aboard in Australia . . . Those secret limits on injury and travel insurance . . . Nicaragua's undeveloped Caribbean islands, on the cheap . . .

Subscribe to Undercurrent today. www.undercurrent.org

Note: Our travel writers never announce their purpose, are unknown to the destination, and receive no complimentary services or compensation from the dive operators or resort.

Ben Davison, editor/publisher
editor@undercurrent.org

NOT AN ONLINE SUBSCRIBER? If you're a subscriber to the print newseltter, you can become an online subscriber at a reduced, one time rate. While the newseltter itself isn't online, you can access all current chapbook reports submitted for the 2006 chapbook, past reports and past articles. www.undercurrent.org/UCnow/join.shtml

Recent Queries and Answers



Question re idiopathic cardiomyopathy
Do you have any thoughts on an experienced diver returning to diving after a diagnosis of idiopathic cardiomyopathy (2001). The followings meds are taken daily: Coreg & Lisinopril. The EF is 40% on a MUGA test.

Answer:
Hello:
Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with advice from your personal physician. Thank you for your interest and for taking the time to write. You will be placed on our mailing list for updates unless we hear from you otherwise.
That having been said - there are all sorts of flashing caution lights concerning this person diving.
Here is my short list of reasons why he/she should not dive:
---In idiopathic cardiomyopathy, arrhythmias are highly likely with the increased preload of immersion. This is not a good diagnosis to have and be underwater. People with this condition are prone to severe heart irregularities (dysrrhythmias) and can lose consciousness due to the irregular heart rhythm. This is exceedingly dangerous underwater and would lead to drowning in most cases. Another problem is the possibility of heart failure due to the effects of immersion. An immersed person shifts fluid centrally to the heart and lungs - leading to congestive failure in the heart that is unable to respond.
---A common cause of sudden death in athletes in cardiomyopathy is due to the severe hypertrophy of the left ventricle. This hypertrophy causes a bulge into the ventricular outflow, acting like aortic stenosis. These patients are prone to sudden ventricular fibrillation.
---Any loss of consciousness or decreased attention underwater can lead to drowning, with endangerment of the diving buddy and can cause a hazard for others on the diving trip.
---It would be good to know whether or not there has been an exercise treadmill test with results. It may be that the person has a good exercise tolerance and would not be affected by the effects of hydrostatic pressure - but this would be chancy.
I would personally be reluctant to certify this individual as 'fit to dive'.
Hope this is helpful! Let us know if there are extenuating factors. We have a son who has had a heart transplant for this condition.
Best regards:
Ernie Campbell, MD
Scubadoc's Diving Medicine Online
http://scuba-doc.com/

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Question re gastric bypass
Is there any contraindication to diving after having a gastric bypass 8 months ago? There have been no complications and I am working out without difficulty

Answer:
Hello:
Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with advice from your personal physician. Thank you for your interest and for taking the time to write. You will be placed on our mailing list for updates unless we hear from you otherwise.
There is no simple yes or no answer since there are many different kind of procedures that are performed for weight loss. Here is just a list of some of the procedures that are now being done - some with more risks than others and some with little to say for their success:

Adjustable Gastric Banding (AGB)
Vertical Banded Gastroplasty (VBG)
Roux-en-Y-Gastric Bypass (RGB)
Biliopancreatic Diversion (BPD)
Duodenal Switch (BPD/DS)
Fat Reduction - Liposuction Surgery
Jaw Wiring Surgery
Lap Band Surgery
Stomach Balloon Surgery

The type of procedure you have had performed will dictate to some degree whether or not you will be able to scuba dive. The main limiting factor would be the trapping of air in the segments of the stomach or bypassed bowel, a risk for rupture from the effects of ascent and Boyle's Law.

Diving can usually be done after operative procedures on the stomach, given complete recovery and rehab from the operation and given the ability to belch - a clue that air has not been trapped.

Liposuction would not be adverse to diving, nor would the balloon procedure (assuming that the balloon is filled with liquid).

Jaw wiring would be a distinct absolute contraindication to diving, due to the inability to manage the regulator, manage secretions and perform the clearing maneuvers required of a diver.

Hope this is helpful!
Best regards:
Ernie Campbell, MD
Scubadoc's Diving Medicine Online
http://scuba-doc.com/

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Mechanical Heart Valve
My mother has a mechanical heart valve and she was told not do dive below 60 ft. Do you have any information on this? They said it was pressure related.
Thanks

Answer:

Hello:
Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with advice from your personal physician. Thank you for your interest and for taking the time to write. You will be placed on our mailing list for updates unless we hear from you otherwise.
I am not aware of any depth effect on a person with a mechanical valve. However, there are two other big problems: the valve may not function well in high output states related to exercise; and the second consideration relates to diving while taking anti-coagulants. Diving often is associated with minor trauma (barotrauma of the ears, sinuses and lungs) and anti-coagulation can produce excessive bleeding. In addition, anticoagulation is thought to possibly worsen the damage done by a spinal decompression accident.
Patients with mechanical valves probably should not dive as both of the caveats above generally apply. An exercise stress test would be a good way to see if the valve can keep up with the increased cardiac output.
See our web site at http://www.scuba-doc.com/hrtprb.html
See Bove's web site at http://www.scubamed.com/divmed.htm
You might register and ask your question on our forum, 'Scuba Clinic' at http://scuba-doc.com/scubaclinic/ . Possibly someone else might have a different answer.

Best regards:
Ern Campbell, MD
Scubadoc's Diving Medicine
http://scuba-doc.com/


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Post pneumothorax air travel

Dear Dr Campbell
I had a bad auto accident Monday 8-29 that may have ended my almost 30 year orthopedic surgery career and 33 year scuba hobby. Grade 1=2 spleen injury, both bone forearm fracture, almost all of the left ribs fractured, along with pneumothorax. I found you on the internet several weeks ago and was impressed with your article on diving post pneumo, but have not been able to document restrictions on flying with FAA or the literature or texts on hand although my recollection is of restrictions.
So, based on that, my guess is that hurricane Katrina had less lasting memories for you than for me. I imagine that there was plenty of rain and wind, but none of the major trauma of New Orleans or the MS gulf coast. Friends and I had skirted down to the Caymans just before Katrina arrived on the eastern side of Florida. We had great diving Aug 24-26, and it was only Saturday 8-27 that the winds there whipped up the water and decreased visibility (we planned on not diving that day anyway because of flying that private-less pressurized plane back on Sunday). Florida and especially Tampa were rainy and a bit bumpy, but were a good example of how a hurricane can be avoided in an airplane.
I landed in Albuquerque that day and was driving east toward Lubbock, TX on monday when my previously undiagnosed sleep apnea got me into this abominable situation. I am still a while from deciding even if a work up for diving will be indicated if I can regain adequate strength), but with all of the holidays approaching it would be nice to travel by air again if it can be done safely. If you are able to either endorse or discredit my recollections of the warnings against air travel, it would be appreciated.

Thank you.
Sincerely,

MD

Amswer:
Hello Dr.:
Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with advice from your personal physician. Thank you for your interest and for taking the time to write. You will be placed on our mailing list for updates unless we hear from you otherwise.
I found several references to situations such as yours. Here is a section taken from The Physician and Sports Medicine:
"Air travel. Because many athletes travel great distances to compete, it is important to note some precautions concerning air travel and pneumothorax. There has been much research in the aviation literature that addresses pneumothorax and pilots, particularly in the military. However, there are no clear recommendations for airline passengers and pneumothorax, except that a patient with an acute, unresolved pneumothorax should not travel by air, if at all possible, because of the risk of enlargement of the pneumothorax that could compromise circulatory and ventilatory functions.
The issue as to how soon a pilot should return to flight after resolution of a pneumothorax remains controversial, with recommendations ranging from several months to 9 years (9,26). The authors cited suggest reasons for their recommendations that include the dramatic changes in intrathoracic pressure associated with aggressive military flying and the tremendous responsibility for in-flight safety that a pilot bears. Without these conditions, it seems reasonable that routine commercial airline passengers can return to air travel sooner. Both the athletes we describe (below) returned to air travel within 1 to 2 months without complications. Team physicians and other healthcare providers must be aware of, and appropriately counsel their patients on, the concerns of air travel and pneumothorax. "
Pneumothorax in Sports (in The Physician and Sports Medicine)http://www.physsportsmed.com/issues/2000/08_00/curtin.htm
In another article from a British travel organization, I found the following:
"You may be able to fly six weeks after surgical intervention and confirmation that the pneumothorax has resolved. If there was no surgical intervention a chest x-ray must confirm it has resolved before you can safely do so. Although recurrence is unlikely during flight, consequences can be serious and it might be better to arrange alternatives to flying up to a year after pneumothorax occurring. "(chss.org factsheet) http://snipurl.com/jn39
Finally, I found this abstract in Medline:

Am Surg. 1999 Dec;65(12):1160-4.

Air travel following traumatic pneumothorax: when is it safe?

Cheatham ML, Safcsak K.

Department of Surgical Education, Orlando Regional Healthcare System, Florida 32806, USA.

The safety of air travel for patients sustaining a recent traumatic pneumothorax has long been a subject of debate. The Aerospace Medicine Association has suggested that patients should be able to fly 2 to 3 weeks after radiographic resolution of their pneumothorax. To validate these recommendations, a prospective study was performed. Twelve consecutive patients with recent traumatic pneumothorax expressing a desire to travel by commercial airline were evaluated. Ten patients waited at least 14 days after radiographic resolution of their pneumothorax before air travel (mean, 17.5+/-4.9 days), and all were asymptomatic in-flight. One of two patients who flew earlier than 14 days developed respiratory distress in-flight, with symptoms suggestive of a recurrent pneumothorax. We conclude that commercial air travel appears to be safe 14 days following radiographic resolution of a traumatic pneumothorax.
As you can see, the wait varies from two weeks to two months to as long as one year. Sensibly, one should have proof that there is no longer a pneumothorax and that there is no air trapping - as determined by a spiral CT scan and/or helium dilution studies.
Hope this is helpful! You can also register and post your question on our forum, 'Scuba Clinic' - possibly gleaning other answers from our moderators. http://scuba-doc.com/scubaclinic/
Best regards:
Ern Campbell, MD
Scubadoc's Diving Medicine Online
http://scuba-doc.com/

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Hypertension and diving

A friend of mine has been prescribed for high blood pressure. The medication's name is LOBIVON, the chemical name is NEBIVOLOL HYDROCHLORIDE.
As is written on the information leaflet the medication is an eclectic b-blocker. According to the doctor, this medication is of a new category. Please advise us if it's safe for my friend to dive using this medication or not? Thanks in advance.

Hello :
Thanks for your query - which brings up two aspects of diving: hypertension and beta blockers. Nebivolol is one of the newer cardioselective blood pressure reducers with a second action - it increases nitric oxide in the endothelial lining of the arteries, thereby causing vasodilation. I'm unable to find any specific studies that relate to the drug and scuba diving so I'll extrapolate from my remarks on my web page.
If a patient has mild, well-controlled hypertension with none of it's complications, there is nothing to worry about if diving or planning to dive. Well-controlled hypertension means a pressure of less than 145/90 (160/95, BSAC) and complications of hypertension include renal failure, eye problems, coronary disease.
Because divers with a clear diagnosis of hypertension may have exaggerated responses to exertion, immersion and cold stresses they should not dive until their high blood pressure has been investigated and appropriately treated.
The diver who is under treatment and is controlled on medication should be allowed to dive, if there is no target organ damage (eye, kidney or heart). Of course, consideration should be given to the interaction of diving and the medication used to treat the diver. Caveats are given for the use of beta blockers and diuretics.
If one is on B-blockers--a treadmill test should be done and if one can exercise without chest pain, BP elevation, EKG changes or arrhythmias (and without fainting), then it's probable that one would be OK for sensible diving. This should be cleared with the personal physician. Beta blockers blunt the response of the body to the effects of exercise and can cause syncope in the maximally challenged diver. In healthy volunteers Nebivolol has no significant effect on maximal exercise or endurance.
Syncope (fainting) underwater could, of course, lead to drowning and would definitely not be good for the diver or his buddy. Divers who are in excellent physical condition should have few problems.
Beta blockers can also be associated with bronchial constriction, an increased risk factor with diving. This is a stated side effect of Nebivolol.
I hope this is helpful!

Best regards:
Ern Campbell, MD
Scubadoc's Diving Medicine
http://scuba-doc.com/
Thanks for your donations!
http://scuba-doc.com/donate.html
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Eustachian Dysfunction

About four years ago I under went an operation for purulent otitis media, conductive hearing loss, canal stenosis, foreign body in the middle ear and protympanum; all of which was done on the right ear. The actual operation was a tympanomastoidectomy with ossicular chain reconstruction using temporalis fascial athroplasty of incudomalleolar joint, canal plasty, removal of foreigh body in protympanum. My final audiogram and impedence test showed normal ear canal volum for both ears, negative middle ear pressure l., c/w eustachian tube dysfunction. The left ear was normal.
I am interested in taking a commercial underwaater welding course. However, I am not sure if the above procedure will keep me from doing this. Can you please tell me if this will keep me from diving? I there any kind of equipment
Answer from Allen Dekelboum, MD
Your request was referred to me for comment.

Thank you for your very complete history of your disease and surgery. If you have negative middle ear pressure in that ear with Eustachian tube obstruction, you will not be able to equalize adequately and would be a candidate for further damage to the operated ear. Without examining you, I cannot give you any advice about your entering a diving course. I would discuss this carefully with your surgeon, but from what you tell me, I think you should try a profession that would not require you to be under water, under pressure. The only suit that would keep you out of pressure would be a one atmosphere suit (JIM suit), not available except for very sophisticated research (very expensive).

Allen Dekelboum, M.D.

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Tuesday, November 15, 2005

Recruiting Scuba Divers to test a product that may help clear/equalize ears when diving

Here is a note from Dr. David Colvard:

Announcement: Recruiting Scuba Divers to test a product that may help clear and equalize ears when diving and reduce the use of pre-dive decongestants and rebound congestion

The 2004 diver safety survey revealed that 42% of the divers had difficulty clearing their ears occasionally and 6% had difficulty half or more of the time (publication pending).

I have been asked by another physician to help test his simple non-prescription FDA-approved product (NeilMed’s Sinus Rinse System) in divers over the next six months. In a small pilot test it showed some effect in helping clear and equalize ears when diving and in reducing the use of pre-dive decongestants and minimizing rebound congestion. At this time we are recruiting divers to participate in a larger scale test. If you choose to participate, then you will receive the product with instructions for free during the test. You will be asked to complete “Before” and “After” web-based surveys, which will take 3 to 5 minutes each.

Some amount of mucus production from the nasal and sinus lining is normal. Allergies and infections will cause excessive mucus production. This will create nasal and sinus symptoms such as runny and stuffy nose and post nasal drip. When the nasal rinse is performed, you wash away mucus, allergy causing particles and irritants such as pollens, dust particles, pollutants and bacteria, thus reducing the inflammation of the mucus membrane. Normal mucosa will fight infections and allergies better and symptoms will be reduced and allow the Eustachian tube to function more normally.


· 1 Custom Designed Cap

· 1 Rinse Bottle 8 oz. (240 mL)

· 1 Tube

· Regular Premixed Packets of pH Balanced Sodium Chloride & Sodium Bicarbonate Mixture (USP Grade, Natural Ingredients, Isotonic, Preservative Free & Iodine Free)

· Educational Brochure

· Instructions in English, Spanish or French

If you or any other divers you know are interested, then please go to the Scuba Diver “Before” Survey (http://www.unimedprod.com/diver_survey_before.shtml) to take the survey and to request your free samples. The manufacturer is paying the shipping costs, but not import duties or taxes that may be required in your country or state or province. After you have used the product and made several dives, you will be asked to complete the Scuba Diver “After” Survey using the identification number included with the samples you received.

There is no guarantee that this product will work as well for you as it has for me or others. But, we want to find out how effective the product is before recommending it to other divers.

Financial Disclosure: At this time I do not have a financial interest in this product or the companies that manufacture or distribute or sell this product.

David F Colvard, MD

http:/www.divepsych.com

Raleigh NC USA

(919) 781-3141

Diving With Disabilities in the Maldives

ATTENTION DIVER'S!!!

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TEL: (+960) 3340622

FAX: (+960) 3340621

EMAIL: HOPETRAVEL@DHIVEHINET.NET.MV

WEBSITE: WWW.HOPETOURS.COM

November Humor

The Washington Post's Mensa Invitational once again asked readers to take any word from the dictionary, alter it by adding, subtracting or changing one letter, and then supply a new definition. These are this year's winners:

1. Cashtration (n): The act of buying a house, which renders the subject financially impotent for an indefinite period of time.

2. Ignoranus: A person who's both stupid and an asshole.

3. Intaxication: Euphoria at getting a tax refund, which lasts until you realize it was your money to start with.

4. Reintarnation: Coming back to life as a hillbilly.

5. Bozone (n): The substance surrounding stupid people that stops bright ideas from penetrating. The bozone layer, unfortunately, shows little sign of breaking down in the near future.

6. Foreploy: Any misrepresentation about yourself for the purpose of getting laid.

7. Giraffiti: Vandalism spray painted very, very high.

8. Sarchasm: The gulf between the author of sarcastic wit and the person who doesn't get it.

9. Inoculatte: To take coffee intravenously when you are running late.

10 Hipatitis: Terminal coolness.

11 Osteopornosis: A degenerate disease. (This one got extra credit)

12 Karmageddon: It's like, when everybody is sending off all these really bad vibes, right?? And then, like, the Earth explodes and it's like, a serious bummer.

13 Decafalon (n): The grueling event of getting through the day consuming only things that are good for you.

14 Glibido: All talk and no action.

15 Dopeler effect: The tendency of stupid ideas to seem smarter when they come at you rapidly.

16 Arachnoleptic fit (n): The frantic dance performed just after you've accidentally walked through a spider web.

17 Beelzebug (n): Satan in the form of a mosquito that gets into your bedroom at three in the morning and cannot be cast out.

18 Caterpallor (n): The color you turn after finding half a worm in the fruit you're eating.

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LAWS


These are the laws of the natural universe

Law of Mechanical Repair: After your hands become
coated with grease, your nose will begin to itch.

Law of the Workshop: Any tool, when dropped, will roll
to the least accessible corner.

Law of the Telephone: When you dial a wrong number,
you never get a busy signal.

Law of the Alibi: If you tell the boss you were late
for work because you had a flat tire, the very next
morning you will have a flat tire.

Variation Law: If you change lines (or traffic lanes),
the one you were in will start to move faster than the
one you are in now (works every time).

Bath Theorem: When the body is fully immersed in
water, the telephone rings.

Law of Close Encounters: The probability of meeting
someone you know increases when you are with someone
you don't want to be seen with.

Law of the Result: When you try to prove to someone
that a machine won't work, it will.

Law of Biomechanics: The severity of the itch is
inversely proportional to the reach.

Theatre Rule: At any event, the people whose seats are
furthest from the aisle arrive last

Law of Coffee: As soon as you sit down to a cup of hot
coffee, your boss will ask you to do something which
will last until the coffee is cold.

Murphy's Law of Lockers: If there are only two people
in a locker room, they will have adjacent lockers.

Law of Dirty Rugs/Carpets: The chances of an
open-faced jelly sandwich landing face down on a floor
covering are directly correlated to the newness and
cost of the carpet/rug.

Law of Location: No matter where you go, there you
are.

Law of Logical Argument: Anything is possible if you
don't know what you are talking about.

Brown's Law: If the shoe fits, it's ugly.

Oliver's Law: A closed mouth gathers no feet.


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Respect

A man and his friend were hunting deer in rural Missouri near a blacktop highway. A huge buck walked by and the hunter carefully drew his bow and took careful aim.
Before he could release his arrow, his friend alerted him to a funeral
procession passing on the road below their stand.

The hunter slowly let off the pressure on his bow, took off his hat, bowed his head and closed his eyes in prayer.

His friend was amazed. "Wow, that is the most thoughtful and touching thing I have ever seen. You are the kindest man I have ever known."

The hunter shrugged. "Yeah, well, we were married for 35 years."

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Wisdom from Grandpa


Whether a man winds up with a nest egg, or a goose egg,
depends a lot on the kind of chick he marries.

Trouble in marriage often starts when a man gets so busy earnin' his salt,
that he forgets his sugar.

Too many couples marry for better, or for worse,
but not for good.

When a man marries a woman, they become one;
but the trouble starts when they try to decide which one.

When a man has enough horse sense to treat his wife like a thoroughbred,
she will never turn into an old nag.

On anniversaries, the wise husband always forgets the past -
but never the present.

A foolish husband says to his wife, "Honey, you stick to the washin' ironin', cookin', and scrubbin'.
No wife of mine is gonna work."

The bonds of matrimony are a good investment,
only when the interest is kept up.

Many girls like to marry a military man - he can cook, sew, and make beds, and is in good health,
and he's already used to taking orders.

Eventually you will reach a point when you stop lying about your age,
and start bragging about it.

The older we get, the fewer things seem worth waiting in line for.

Some people try to turn back their odometers. Not me, I want people to know "why" I look this way. I've traveled a long way and some of the roads weren't paved.

How old would you be if you didn't know how old you are?

When you are dissatisfied and would like to go back to your youth.... Remember about Algebra.

You know you are getting old, when everything either dries up, or leaks..

I don't know how I got over the hill without getting to the top.

One of the many things no one tells you about aging
is that it is such a nice change from being young.

Ah, being young is beautiful, but being old is comfortable.

Old age is when former classmates are so gray and wrinkled and bald, they don't recognize you.

If you don't learn to laugh at trouble, you won't have anything to laugh at when you are old.

First you forget names, then you forget faces. Then you forget to pull up your zipper,
but it's really worse when you forget to pull it down.

Long ago when men cursed and beat the ground with sticks , it was called witchcraft........
Today, it's called Golf.

He who laughs, lasts.

I've gotten to the age where I need my false teeth and hearing aid before I can ask where I left my glasses.

I am sitting here thinking how nice it is that wrinkles don't hurt.

If I knew I was going to get this old, I would have taken better care of myself when I was young.

If you laugh a lot, when you get older your wrinkles will be in the right places.

Middle age is when you burn the midnight oil around 9:00 PM.

My grandson asked me if I still look at young women -
I said yes, but I can't remember why.

My mind not only wanders, sometimes it leaves completely.

Old age and treachery will overcome youth and skill.

The big thing today is computer dating. If you don't know how to run a computer it really dates you.

The golden years: When actions creak louder than words.

There's nothing wrong with the younger generation that twenty years or so won't cure.

When did my wild oats turn to prunes and all-bran?

The older you get, the better you get, (unless you're a banana).

Of all the things I've lost . . . . I miss my mind the most.

Wednesday, November 09, 2005

"Hyperbaric Oxygen Treatment" Googled

Hyperbaric Oxygen Therapy: Does It Work?
WJXX - Jacksonville,FL,USA
... a growing number of athletes, celebrities, and just plain folks swear by the benefits of hyperbaric oxygen therapy - a trendy new treatment promising relief ...


Physical therapy for a horse? Of course!
Knoxville News Sentinel (subscription) - Knoxville,TN,USA
... be monitored in a hyperbaric oxygen chamber ... Kentucky inventor modified the oxygen chamber from ... Performance Equine Program provides treatment and rehabilitation ...


Curative Health Services Renews National Services Agreement With VHA...
Market Wire (press release) - USA
... care services to provide ongoing prevention and treatment for people ... inpatient, post-acute (skilled nursing facilities) and hyperbaric oxygen therapy components ...

Sunday, November 06, 2005

Tourism Minister says Maldives a safe diving destination

Minister of Tourism and Civil Aviation, Mahmood Shaugee says that Maldives is a safe diving destination and that the government is endeavouring to minimize regretful diving accidents.

He made the statement while addressing held in Bandos Island Resort today, to mark the 8th dive-safety medicine course graduation and Maldives Dive-Safety Day 2005. In his speech, he noted that hazardous diving incidents in the Maldives were greatly reduced over the past 5 years. He said that this resulted from hard work and collaboration from those serving in the diving field and tourist resorts.

The Tourism Minister also said that consultation to amend the diving regulations in the Maldives will be taken from professional and expert divers and those providing the service. The 8th dive-safety medicine course was a joint venture run by Divers Alert Network, DAN and Bandos Island Resort.

The course was facilitated by European experts, and was taken part by doctors of Maldives and Scandinavia. The ceremony was attended by senior officials of the Ministry of Tourism and Civil Aviation, Ministry of Health and Bandos Island Resort. The ceremony was followed by three information sessions on diving.

Friday, November 04, 2005

2006 Winter Symposium on Hyperbaric Medicine and Wound Management

More info about the 2006 Winter Symposium on Hyperbaric Medicine and Wound Management, which will be at Copper Mtn, CO in Jan 29-31, 2006. This conference is sponsored by Memorial Hospital (a city owned not for profit hospital) and UHMS. We have some good speakers on HBO, WC and diving medicine. With respect to diving... there will be lectures on PFO, the bubble reseach at DAN, diving in Anartica and more. Should be fun.

More info is at www.hbodoctor.com. I will send a pdf as soon as I can get the speakers "inked" in!

Jim

James R Holm, MD, FACEP
Colorado Springs, CO

Thursday, November 03, 2005

Deadline for Application for Executive Director, UHMS - from Don Chandler

To all--

During our most recent Board of Directors meeting in Durham, North Carolina, Dr. Bret Stolp announced that the deadline for accepting applications for the UHMS Executive Director position is 01 June 2006. The Executive Director position will be vacated at the end of 2007 when Don Chandler plans to retire. The first formal meeting of the Search Committee will be during the UHMS Annual Scientific Meeting in Orlando, Florida, in June, 2006. Applications should be sent via email to Don Chandler at donchandler@uhms.org The Search Committee is chaired by Bret Stolp, MD, with membership made up of: Ron Bangasser, MD: Simon Mitchell, MD; Neil Hampson, MD; Dick Clarke, CHT; Laurie Gesell, MD, Enrico Camporesi, MD, and Don Chandler, MA. As announced earlier, an undergraduate degree is required whereas an advanced degree is desired and a terminal degree by an applicant will weigh heavily in his/her favor. Also, experience in managing a non-profit organization will be a big plus in the selection process.

As you know, the location of the UHMS office is in transition since selling our property in Kensington, Maryland, and our Board of Directors are currently considering management and location options. A decision on the location and management of the UHMS office is expected by the time of our annual meeting in June, 2006. Currently, the corporate office is temporarily located in Dunkirk, Maryland in leased office space.

The salary of the position is negotiable commensurate with the applicant's experience and education.

Please let me know if you have questions.

Don