Diving and Subaquatic Medicine This page intentionally left blank Diving and Subaquatic Medicine Fourth edition Carl Edmonds M.B., B.S. (Sydney), M.R.C.P. (Lond.) F.R.A.C.P., F.A.F.O.M., D.P.M., M.R.C Psych., F.R.A.N.Z.C.P., Dip. D.H.M. Director, Diving Medical Centre, Sydney, 1970-2001. Formerly Officer in Charge Royal Australian Navy School of Underwater Medicine, 1967-75. Formerly President of South Pacific Underwater Medicine Society, 1970-75. Consultant in Underwater Medicine to the Royal Australian Navy, 1975-1991 Christopher Lowry M.B., B.S., (Sydney), Dip D.H.M, F.F.A.R.A.C.S. Director, Diving Medical Centre, Sydney, 1973-1991. Formerly Deputy Medical Officer in Charge, Royal Australian Navy School of Underwater Medicine, 1973-74. Visiting Anaesthetist, Royal North Shore Hospital, Sydney, 1980-1991. Visiting Anaesthetist, Lismore Base Hospital, 1991-present. Consultant in Diving Medicine, Far North Coast, NSW. John Pennefather B.SC. (Hons.) Scientific Officer at the Royal Australian Navy Submarine and Underwater Medicine Unit 1972-2001 Robyn Walker M.B., B.S., Dip. D.H.M. Formerly Officer in Charge, Royal Australian Navy Submarine and Underwater Medicine Unit 1995-2001. President, South Pacific Underwater Medicine Society, 2000-01 A member of the Hodder Headline Group LONDON • NEW YORK • NEW DELHI First published in Great Britain in 2002 by Arnold, a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.arnoldpublishers.com Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2002 Arnold All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1P 9HE. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies' printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 0 340 80630 3 1 2345678910 Publisher: Joanna Koster Development Editor: Tim Wale Production Editor: James Rabson Production Controller: Bryan Eccleshall Cover design: Terry Griffiths Typeset in 10/12pt Minion and Ocean Sans MT by J&L Composition Ltd, Filey, North Yorkshire Printed and bound in Italy by Giunti Contents Preface ix Preface (Excerpts from earlier Editions) x Acknowledgments xi DIVING 1 History of diving 1 J. Pennefather 2 Physics and physiology 11 J. Pennefather 3 Free diving 23 C. Lowry 4 Diving equipment 33 J. Pennefather 5 Undersea environments 47 C. Edmonds DYSBARIC DISEASES BAROTRAUMAS 6 Pulmonary barotrauma 55 R. Walker 7 Ear barotrauma 73 C. Edmonds 8 Sinus barotrauma 93 C. Edmonds 9 Other barotrauma 103 C. Edmonds DECOMPRESSION SICKNESS 10 Decompression sickness: history and physiology 111 R. Walker 11 Decompression sickness: pathophysiology 131 R. Walker 12 Decompression sickness: clinical 137 R. Walker vi Contents 13 Decompression sickness: treatment 151 R. Walker 14 Dysbaric osteonecrosis 167 C. Lowry ABNORMAL GAS PRESSURES 15 Inert gas narcosis 183 C. Lowry 16 Hypoxia 195 C. Edmonds 17 Oxygen toxicity 207 C. Lowry 18 Carbon dioxide toxicity 223 C. Edmonds 19 Breathing gas contamination 233 J. Pennefather 20 High-pressure neurological syndrome 243 C. Lowry AQUATIC DISORDERS THE DROWNING SYNDROMES 21 Drowning syndromes: drowning 249 C. Edmonds 22 Drowning syndromes: near-drowning 257 C. Edmonds 23 Drowning syndromes: the management of near-drowning 263 C. Lowry 24 Drowning syndromes: saltwater aspiration syndrome 273 C. Edmonds 25 Drowning syndromes: why divers drown 277 C. Edmonds 26 Seasickness (motion sickness) 285 J. Pennefather 27 Thermal problems and solutions 289 J. Pennefather 28 Cold and hypothermia 293 J. Pennefather 29 Local infections 305 C. Lowry 30 General infections 317 C. Lowry 31 Trauma from marine creatures 325 C. Edmonds 32 Venomous marine animals 335 C. Edmonds 33 Fish poisoning 353 C. Edmonds 34 Underwater explosions 359 J. Pennefather Contents vii SPECIFIC DIVING DISEASES THE EAR AND DIVING 35 The ear and diving: anatomy and physiology 365 C. Edmonds 36 The ear and diving: investigations 371 C. Edmonds 37 The ear and diving: hearing loss 379 C. Edmonds 38 The ear and diving: vertigo and disorientation 385 C. Edmonds 39 Cardiac problems and sudden death 399 C. Lowry 40 Neurological disorders of diving 409 R. Walker 41 Psychological and neuropsychological disorders 417 C. Edmonds 42 Miscellaneous Disorders 433 C. Edmonds Carotid sinus syndrome Caustic cocktail Cold urticaria Dental disorders Hyperthermia Musculoskeletal problems Ocular disorders Pulmonary oedema and dyspnoea Skin reactions to equipment Trauma 43 Drugs and diving 445 C. Lowry 44 Long-term effects of diving 457 R. Walker and C. Edmonds THE DIVING ACCIDENT 45 Stress responses, panic and fatigue 465 C. Edmonds 46 Why divers die: the facts and figures 473 C. Edmonds 47 Unconsciousness 491 C. Edmonds 48 First aid and emergency treatment 497 R. Walker 49 Oxygen therapy 503 C. Edmonds 50 Investigation of diving accidents: equipment 511 J. Pennefather 51 Investigation of diving fatalities 517 C. Edmonds viii Contents MEDICAL STANDARDS FOR DIVING 52 Medical standards for snorkel divers 531 C. Edmonds 53 Medical standards for recreational divers 533 R. Walker 54 Medical standards for commercial divers 553 R. Walker 55 Asthma 559 C. Edmonds 56 Cardiac disease 575 R. Walker 57 Insulin-dependent diabetes mellitus 581 The pros - C. Edge and P. Bryson The cons - C. Edmonds, C. Lowry and R. Walker 58 Age and diving 597 C. Edmonds 59 Diver selection 603 R. Walker SPECIALIZED DIVING AND ITS PROBLEMS 60 Female divers 607 R. Walker 61 Breath-hold diving 615 C. Edmonds 62 Technical diving 619 J. Pennefather 63 Technical diving problems 625 C. Edmonds 64 Handicapped divers 635 R. Walker 65 Occupational groups 639 C. Edmonds and J. Pennefather 66 Diving in contaminated water 645 J. Pennefather 67 Deep and saturation diving 647 J. Pennefather 68 Deep and saturation diving problems 653 J. Pennefather 69 Hyperbaric equipment 657 J. Pennefather 70 Submarine medicine 665 R. Walker APPENDICES A Decompression Tables. BSAC (UK), US Navy, NOAA, DCIEM (Canadian) 671 B Recompression Therapy Tables, US Navy 687 C Recompression Therapy Options, COMEX, Australian, Duke 695 D Diving Medical Library 699 E Diving Medical Training 701 F Diving Medical Organizations, Contacts and Internet 702 INDEX 703 Preface I take full responsibility for the decision to produce a the problems of free divers, divers with disabilities, fourth edition of this text. There have been many and technical divers. changes in diving medicine over the past decade, and I no longer promise that this will be the last edi- some of these have been worthy of inclusion. tion. What I do promise is that it will be the last edi- The problems of diver safety, and the causes of tion for the original three authors. Already we have deaths while diving, have not altered appreciably had to enlist the assistance of a younger, but very over the past thirty-five years. The lessons from the experienced and skilled co-author, Dr Robyn Walker. past have not been well learnt. Hopefully, and because of the enthusiasm, expert- Nevertheless, the scope of diving medicine has ise and skills of our younger colleagues, we can with increased, partly due to the wider range of divers - confidence pass the baton to them. Our legacy and both psychologically and medically. It is also due to intent is that they will experience as much excite- the extension of the diving envelope, including the ment, achievement, camaraderie and fun from div- diving exposures and equipment available. ing as we have. The final reason for producing a new edition is the admission that the previous texts were incom- Carl Edmonds plete in that they did not pay adequate attention to