Diving and Subaquatic Medicine

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Diving and
Subaquatic
Medicine
fifth edition
Diving and
Subaquatic
Medicine
fifth edition

Carl Edmonds was the OIC of the Royal Australian Navy Diving Medical Unit,
Foundation President of the South Pacific Underwater Medical Society and Director
of the Australian Diving Medical Centre, Sydney, Australia
Michael Bennett is Academic Head, Wales Anaesthesia and Senior Staff Specialist,
Diving and Hyperbaric Medicine, Prince of Wales Hospital and University of New
South Wales, Sydney, Australia
John Lippmann is Founder and Chairman of Divers Alert Network Asia-Pacific,
Ashburton, Australia
Simon J. Mitchell is a Consultant Anaesthesiologist and Diving Physician, and Head,
Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Authors

Carl Edmonds, OAM, MB, BS (Sydney), MRCP Simon Mitchell, MB ChB, PhD, Dip DHM, Dip
(Lond.) FRACP, FAFOM, DPM, MRC Psych, Occ Med, Cert DHM (ANZCA), FUHM,
MANZCP, Dip DHM FANZCA
Director, Diving Medical Centre, Sydney, Head of Department, Department of
Australia (1970–2000) Anaesthesiology, University of Auckland,
Formerly, Officer in Charge Royal Australian Navy Auckland, New Zealand (2011–present)
School of Underwater Medicine (1967–1975) Consultant in Diving and Hyperbaric Medicine,
Formerly, President, South Pacific Underwater Slark Hyperbaric Unit, North Shore Hospital,
Medicine Society (1970–1975) Auckland, New Zealand (2012–present)
Consultant in Underwater Medicine to the Royal Formerly, Medical Director, Wesley Centre for
Australian Navy (1975–1991) Hyperbaric Medicine, Brisbane, Australia
Consultant in Diving Medicine (1967 until retired (1998–2002)
in 2015) Formerly, Director, Slark Hyperbaric Unit, Royal
New Zealand Navy Hospital, Auckland,
Michael Bennett, MB, BS (UNSW), DA (Lond.), New Zealand (1995–1998)
FFARCSI, FANZCA, MM (Clin Epi) (Syd.),
MD (UNSW), Dip DHM, FUHM John Lippmann, OAM, BSc, Dip Ed, MAppSc
Director, Department of Diving and Hyperbaric Founder, Chairman and Director of Research,
Medicine, Prince of Wales Hospital, Sydney, DAN (Divers Alert Network) Asia-Pacific
Australia (1993–2008) (1994–present)
Academic Head, Wales Anaesthesia, Sydney, Author or co-author of: The DAN Emergency
Australia (2012–present) Handbook, Deeper Into Diving, The Essentials
Formerly, President, South Pacific Underwater of Deeper Sport Diving, Scuba Safety in
Medicine Society (2008–2014) Australia, Oxygen First Aid, First Aid and
Formerly, Vice-President, Undersea and Hyperbaric Emergency Care, Automated External
Medical Society (2006–2007 and 2011–2012) Defibrillators, Advanced Oxygen First
Conjoint Associate Professor in Anaesthesia and Aid, Basic Life Support, Cardiopulmonary
Diving and Hyperbaric Medicine, University Resuscitation, Decompression Illness, Am I
of New South Wales, Sydney, Australia Fit to Dive? and various incarnations of these
(2010–present) books.

v
Contents

Authors v
List of abbreviations xi
Preface and excerpts from earlier editions xiii
Dedication xv
Acknowledgements xvii

Part 1 DIVING 1

1 History of diving 3
2 Physics and physiology 15
3 Free diving 27
4 Diving equipment 37
5 Undersea environments 53

Part 2 DYSBARIC DISEASES: Barotraumas 63

6 Pulmonary barotrauma 65
7 Ear barotrauma 81
8 Sinus barotrauma 103
9 Other barotraumas 115

Part 3 DECOMPRESSION SICKNESS 123

10 Decompression sickness: pathophysiology 125

11 Decompression sickness: manifestations 141
12 Decompression sickness: prevention 153
13 Decompression sickness: treatment 167
14 Dysbaric osteonecrosis 185

Part 4 ABNORMAL GAS PRESSURES 203

15 Inert gas narcosis 205

16 Hypoxia 217
17 Oxygen toxicity 229

vii
viii Contents

18 Carbon dioxide toxicity 245

19 Breathing gas preparation and contamination 255
20 High-pressure neurological syndrome 267

Part 5 AQUATIC DISORDERS: The drowning syndromes 273

21 Drowning 275
22 Pathophysiological and clinical features of drowning 285
23 The management of drowning 291
24 Salt water aspiration syndrome 303
25 Why divers drown 309

Part 6 OTHER AQUATIC DISORDERS 319

26 Seasickness (motion sickness) 321

27 Thermal problems and solutions 325
28 Cold and hypothermia 329
29 Infections 339
30 Scuba divers’ pulmonary oedema 357
31 Trauma from marine creatures 367
32 Venomous marine animals 377
33 Fish poisoning 397
34 Underwater explosions 405

Part 7 SPECIFIC DIVING DISEASES 411

35 The ear and diving: anatomy and physiology 413

36 The ear and diving: investigations 421
37 The ear and diving: hearing loss 429
38 The ear and diving: vertigo and disorientation 435
39 Cardiac problems and sudden death 449
40 Neurological disorders of diving 459
41 Psychological and neuropsychological disorders 467
42 Miscellaneous disorders 487
Carotid sinus syndrome 487
Caustic cocktail 488
Cold urticaria 488
Dental disorders 488
Hyperthermia 489
Musculoskeletal problems 489
Compression (hyperbaric) arthralgia 489
Cramp 489
Decompression 490
Lumbosacral lesions 490
Temporo-mandibular joint dysfunction 490
Tank carrier’s elbow 491
Ocular disorders 492
‘Bubble eyes’ 492
 Contents ix

Ocular problems from corneal lenses 492

Ocular fundus lesions 492
‘Swimmer’s eyes’ (blurred vision) 493
Trauma 493
Other disorders 493
Pulmonary oedema and dyspnoea 493
Diving diseases 493
Asthma provocation 493
Cold urticaria 494
Deep diving dyspnoea 494
Skin reactions to equipment 494
Contact dermatitis (mask, mouthpiece and fin burn) 494
Angioneurotic oedema (dermatographia) 494
Allergic reactions 495
Burns 495
Diaper Rash (nappy rash) 495
Fin ulcers 495
Trauma 495
43 Drugs and diving 497
44 Long-term effects of diving 509

Part 8 THE DIVING ACCIDENT 517

45 Stress responses, panic and fatigue 519

46 Why divers die: the facts and figures 527
47 Unconsciousness 551
48 First aid and emergency treatment 557
49 Oxygen therapy 567
50 Investigation of diving accidents 575
51 Investigation of diving fatalities 583

Part 9 MEDICAL STANDARDS FOR DIVING 601

52 Medical standards for snorkel divers 603

53 Medical standards for recreational divers 607
54 Medical standards for commercial divers 623
55 Asthma 629
56 Cardiac and peripheral vascular disease 649
57 Insulin-dependent diabetes mellitus 657
58 Age and diving 673
59 Diver selection 681

Part 10 SPECIALIZED DIVING AND ITS PROBLEMS 685

60 Female divers 687

61 Breath-hold diving 697
62 Technical diving 703
63 Divers with disabilities 719
x Contents

64 Submarine medicine 725

65 Occupational groups 731
66 Diving in contaminated water 737
67 Deep and saturation diving 739

Part 11 RELATED SUBJECTS 745

68 Hyperbaric equipment 747

69 Hyperbaric medicine 755

Appendix A: Decompression tables 767

Appendix B: US Navy recompression therapy tables 785

Appendix C: Recompression therapy options 793

Appendix D: Diving medical library 797

Appendix E: Diving medical training 801

Appendix F: Diving medical organizations and contacts 803

List of abbreviations

ADS atmospheric diving suit FEV1 forced expiratory volume in 1 second

ADV automatic diluent valve FIO2 fraction of inspired oxygen
AGE arterial gas embolism FVC forced vital capacity
ALS advanced life support HBOT hyperbaric oxygen therapy
ARDS acute respiratory distress syndrome HPNA high-pressure neurological syndrome
ATA atmosphere absolute IBCD isobaric counterdiffusion
ATG atmosphere gauge ICP intracranial pressure
BCD buoyancy compensator device IDDM insulin-dependent diabetes mellitus
BLS basic life support ILCOR International Liaison Committee on
BOV bail-out valve Resuscitation
BSAC British Sub-Aqua Club IPE immersion pulmonary oedema
CAD coronary artery disease IPPV intermittent positive pressure
CAGE cerebral arterial gas embolism ventilation
CCR closed-circuit rebreather ISO International Organization for
CMF constant mass flow Standardization
CPAP continuous positive airway pressure lpm litres per minute
CPR cardiopulmonary resuscitation MOD maximum operating depth
CSF cerebrospinal fluid msw metres of sea water
CSL Commonwealth Serum Laboratories NEDU Navy Experimental Diving Unit
DAN Divers Alert Network NOAA National Oceanic and Atmospheric
dB decibel Administration
DCI decompression illness NUADC National Underwater Accident Data
DCIEM (Canadian) Defence and Civil Centre
Institute of Environmental Medicine OPV over-pressure valve
DCS decompression sickness PaCO2 alveolar pressure of carbon dioxide
DDC deck decompression chamber PaCO2 arterial pressure of carbon dioxide
DPV diver propulsion vehicle PADI Professional Association of Diving
EAD equivalent air depth Instructors
ECC external cardiac compression PaO2 alveolar partial pressure of oxygen
ECG electrocardiogram PaO2 arterial partial pressure of oxygen
ECMO extracorporeal membrane oxygenation PCO2 partial pressure of carbon dioxide
ECoG electrocochleography PEEP positive end-expiratory pressure
EEG electroencephalogram PEF peak expiratory flow
ENG electronystagmography PFO patent foramen ovale
EPIRB electronic position-indicating radio PICO2 inspired partial pressure of carbon
beacon dioxide

xi
xii List of abbreviations

PIO2 inspired partial pressure of oxygen SDPE scuba divers’ pulmonary oedema
PMCT post-mortem computed tomography SMB surface marker buoy
PMDA post-mortem decompression artefact SPUM South Pacific Underwater Medicine
PMV pressure maintaining valve Society
PN2 partial pressure of nitrogen SSBA surface-supply breathing apparatus
PO2 partial pressure of oxygen SWAS salt water aspiration syndrome
PPV positive pressure ventilation UHMS Undersea and Hyperbaric Medical
RAN Royal Australian Navy Society
RCC recompression chamber UPTD unit of pulmonary toxic dose
RGBM reduced gradient bubble model USN United States Navy
RMV residual minute volume (also VC vital capacity
respiratory minute volume) VER visual evoked response
SCR semi-closed-circuit rebreather VGE venous gas emboli
scuba self-contained underwater breathing VPM varying permeability model
apparatus V/Q ventilation-perfusion
Preface and excerpts from
earlier editions

This book is written for doctors and paramedics a comprehensive clinical text. We tried to remedy
who are called on to minister to the medical needs this. Our primary focus remains on the diving cli-
of those divers who venture on or under the sea. nician, the physician responsible for scuba divers,
It was based on our experience in dealing with a the diving paramedic and the exceptional diving
vast number of diving accidents and with trouble- instructor who needs some guidance from a prac-
shooting many diving problems, and it is also an tical reference text.
attempt to integrate the experience and more eru- Diving accidents are much better defined,
dite research of others. investigated and treated than when we com-
The very generous praise bestowed by review- menced writing on this subject, many years ago.
ers on the first edition of Diving and Subaquatic It was our intent to present, as completely as
Medicine, and its surprising acceptance outside the ­possible, an advanced and informative book on
Australasian region, inspired us to prepare further clinical diving medicine. We have avoided the
editions of this text. ­temptation to write either a simplistic text or a
In the later editions, we attempted to be less research-­oriented tome.
insular. Instead of an Australian book about This text encompasses the range of diving dis-
Australian experiences, we sought the advice and orders experienced by divers. It presents all aspects
guidance of respected friends and colleagues from of diving medicine from ancient history to the
other countries, and from other disciplines, espe- latest trends, in a concise and informative man-
cially in the United Kingdom, the United States, ner. Each disorder is dealt with from a historical,
Canada, Japan and mainland Europe. This has not aetiological, clinical, pathological, preventive and
prevented us from being judgemental and selective ­t herapeutic perspective. Summaries, case histories
when we deemed it fit. This is still a very special- and revision aids are interspersed throughout. For
ized field where evidence-based medicine is in its the doctor who is not familiar with the world of
infancy. Truth is not always achieved by voting, diving, introductory chapters on physics and phys-
and consensus is often a transitory state. We have iology, equipment and the diving environments
documented what we believe to be current best have been included.
practice. The future will judge this. The inclusion of anecdotes and occasional
The extension of diving as a recreational and humour may lessen the load on the reader, as
commercial activity has led to the bewildered it does on the authors. As in previous editions,
medical practitioner’s being confronted with div- each chapter is edited by one of the authors, with
ing problems about which he or she has received overview and peer review available from the oth-
little or no formal training. Doctors interested in ers. This means that not always will there be exact
diving had previously found themselves without agreement among authors, and there may be some

xiii
xiv Preface and excerpts from earlier editions

variation among chapters. This is inevitable when will experience as much excitement, fascination,
evidence and consensus are not always complete. achievement, ­camaraderie and fun from diving as
It is also healthy for the future. we have.
Three of the four previous authors have
departed from this scene, and the fourth is about Carl Edmonds, 2015
to leave. The baton needs to be passed. Our leg- on behalf of all previous
acy and intent are that our younger colleagues and new authors of this text.
Dedication

This book is dedicated to the memory of Pluto, who study when the original three authors were postu-
died, even though he never left dry land. lating about an appropriate dedicatee for their text.
I have often been asked who Pluto was. He was We could not decide between Paul Bert, Al Behnke,
a much loved basset hound who strolled into our Jr., and J.B.S. Haldane. Pluto solved our dilemma.

xv
Acknowledgements

Carl Edmonds, John Lippmann, Michael Bennett Peter Bennett Eric Kindwall
and Simon Mitchell would like to thank Chris­ Ralph Brauer Clarrie Lawler
topher Lowry, John Pennefather and Robyn Walker Greg Briggs Christopher Lawrence
for their invaluable contributions to previous edi- Ian Calder Dale Mole
tions, upon which material in this latest fifth edition Jim Caruso Owen O’Neill
is based. Richard Chole John Pearn
We wish to acknowledge the assistance given David Dennison Peter Sullivan
by the Royal Australian Navy, the Royal Navy and Chris Edge Ed Thalmann
the United States Navy for permission to repro- Glen Egstrom John Tonkin
duce excerpts from their diving manuals, and to David Elliott John Williamson
the many pioneers on whose work we have so heav- Des Gorman David Yount
ily drawn, our families who have suffered unfairly, John Hayman
and our clinical tutors – the divers.
Numerous experts have been consulted to Originally published in 1976 by the Diving Medical
review and advise on specific chapters of this or Centre (Australia) ISBN 09597191-0-5.
previous editions. Our gratitude is extended to
these valued colleagues, but they are not to blame
for the final text. They include the following:

xvii
 1
Part    

Diving

1 History of diving 3
2 Physics and physiology 15
3 Free diving 27
4 Diving equipment 37
5 Undersea environments 53
 1
History of diving

Breath-hold diving 3 Modern military diving 8

Early equipment 4 Deep diving 9
Modern diving equipment 6 Recreational diving 12
Self-contained equipment 7 Further reading 12

BREATH-HOLD DIVING In other parts of the world, industries involving

breath-hold diving persist, to some extent, to this
The origins of breath-hold diving are lost in time. Notable examples include the Ama, or diving
time. Archaeologists claim that the Neanderthal women of Japan and Korea, and the pearl divers of
human, an extinct primitive human, dived for the Tuamoto Archipelago.
food, likely in the first instance gathering shell- The Ama has existed as a group for more than
fish by wading at low tide before diving from 2000 years. Originally the male divers were fisher-
canoes. By 4500 BC, underwater exploration had men, and the women collected shells and plants.
advanced from the first timid dive to an indus- The shells and seaweed are a prized part of Korean
try that supplied the community with shells, food and Japanese cuisine. In more recent times, diving
and pearls. has been restricted to the women, with the men
From the ancient Greek civilization until today, serving as tenders. Some attribute the change in
fishers have dived for sponges, which, in earlier pattern to better endurance of the women in cold
days, were used by soldiers as water canteens and water. Others pay homage to the folklore that div-
wound dressings, as well as for washing. ing reduces the virility of men, a point many divers
Breath-hold diving for sponges continued seem keen to disprove.
until the nineteenth century when helmet diving There is a long history of the use of divers
equipment was introduced, allowing the intrepid for strategic purposes. Divers were involved in
to gamble their lives in order to reach the deeper operations during the Trojan Wars from 1194
sponge beds. Greek divers still search the waters to 1184 BC. They sabotaged enemy ships by bor-
of the Mediterranean Sea as far afield as northern ing holes in the hull or cutting the anchor ropes.
Africa for sponges. Divers were also used to construct underwater
The ancient Greeks laid down the first rules defences designed to protect ports from the attack-
on the legal rights of divers in relation to salvaged ing fleets. The attackers in their turn used divers to
goods. The diver’s share of the cargo was increased remove the obstructions.
with depth. Many divers would prefer this arrange- By Roman times, precautions were being taken
ment to that offered by modern ­governments and against divers. Anchor cables were made of iron
diving companies. chain to make them difficult to cut, and special

3
4 History of diving

guards with diving experience were used to protect not permitted to pull on this line to assist movement.
the fleet against underwater attackers. No weights can be removed during the dive. Mono-
An interesting early report indicated that some fins or bi-fins can be used.
Roman divers were also involved in Mark Anthony’s ‘Constant weight without fins’ is the same as
attempt to capture the heart of Cleopatra. Mark constant weight apnoea but without the use of fins.
Antony participated in a fishing contest held in With ‘variable weights’, the diver again descends
Cleopatra’s presence and attempted to improve his with the aid of a weighted sled, but this weight is
standing by having his divers ensure a constant sup- limited. Ascent is achieved by finning or pulling up
ply of fish on his line. The Queen showed her dis- the cable, or both.
pleasure by having one of her divers fasten a salted ‘Free immersion’, which emerged in places
fish to his hook. where equipment was difficult to obtain, involves
Marco Polo and other travellers to India and a finless diver (with optional suit, mask or weights)
Sri Lanka observed pearl diving on the Coromandel who pulls himself or herself down and then up a
Coast. They reported that the most diving was to weighted line.
depths of 10 to 15 metres, but that the divers could ‘Static apnoea’ involves resting breath-holding
reach 27 metres by using a weight on a rope to assist (usually lying in a pool) with the face submerged.
descent. They carried a net to put the oysters in Officially recorded times in excess of 11 minutes
and, when they wished to surface, were assisted by have been achieved using this method.
an attendant who hauled on a rope attached to the ‘Dynamic apnoea’ measures the distance cov-
net. The divers were noted to hold their nose during ered in a pool during a single breath-hold.
descent.
The most skilled of the American native div- EARLY EQUIPMENT
ers came from Margarita Island. Travellers who
observed them during the sixteenth, seventeenth The history of diving with equipment is long and
and eighteenth centuries reported that these divers complex, and in the early stages it is mixed with
could descend to 30 metres and remain submerged legend. The exploits of Jonah are described with
for 15 minutes. They could dive from sunrise to conviction in one text, but there is a shortage of
sunset, 7 days a week and attributed their endur- supporting evidence. Further reference is made to
ance to tobacco! They also claimed to possess a him later, on the technicality that he was more a
secret chemical that they rubbed over their bod- submariner than a diver. Because his descent was
ies to repel sharks. The Spaniards exploited these involuntary, Jonah was at best a reluctant pioneer
native divers for pearling, salvage and smuggling diver. The history of submarine escape, when the
goods past customs. The demand for divers was submariner may become a diver, is discussed in
indicated by their value on the slave market, fetch- Chapter 64.
ing prices up to 150 gold pieces. Some claim that Alexander the Great descended
Free diving appears to have evolved as a modern in a diving bell during the third century BC.
sport in the mid-1940s, initially as a competition Details of the event are vague, and some of the fish
among Italian spearfishers. Currently the sport, stories attributed to him were spectacular. One fish
which is steadily gaining popularity, encompasses was said to have taken 3 days to swim past him! It
a variety of disciplines. These include the following: is most unlikely that the artisans of the time could
In ‘no limits’, a diver can use any means to travel make glass as depicted in most of the illustra-
down and up the line, as long as the line is used to tions of the ‘event’. This may have been a product
measure the distance. Most divers descend down a of artistic licence or evidence that the incident is
line using a weighted sled and return to the surface based more in fable than in fact.
aided by an inflatable balloon. Officially recorded Snorkels, breathing tubes made from reeds and
depths in excess of 210 metres have been achieved bamboo (now plastic, rubber or silicone), were
using this method. developed in many parts of the world. They allow a
‘Constant weight apnoea’ diving is where descent diver to breathe with the head underwater. Aristotle
and ascent occur along a line, although the diver is inferred that the Greeks used them. Columbus