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At 09:15 22-11-99 -0500, you wrote: >David, you obviously have never done it with a scuba reg You are absolutely right! And unless anyone can provide me with information to refute the issues I raised in my last post I never will. The idea of using a scuba reg for resuscitation is not new, I remember discussing this issue with a fellow diver more than twenty years ago and we came to the conclusion back then that it was not a viable option. - I have - it >works. > >Now you tell me what to do on the surface with a victim that you just >brougt up - should I call for a pocket mask hooked to a bag and a >lawyer? Aah, on the surface, eh? This is a tough one! My previous post was really considering a victim who had been landed. Obviously the use of a pocket mask or bag and mask will not be possible in this situation. This basically leaves you with EAR (mouth to nose being preferred by most in this situation to prevent water entry into a wide open mouth). Hopefully the majority of divers on this list will have had rescue training and know how difficult this can be, and will recognize the need for frequent practice. One of the major problems with a patient still in the water is the difficulty of assessing the presence or absence of breathing/heart beat. Even on land it can sometimes be more difficult than you would think (even for trained medical personnel) to establish if someone is breathing or not. In water, with a partially submerged patient, it will be even more difficult. It can therefore be difficult to know if the patient requires ventilation or not. However it is probably better to ventilate someone who is still breathing (although undesirable) than to not ventilate someone who has stopped breathing (ie the lesser of the two evils). The major problem however is that it is virtually impossible to check for a pulse on a diver due to wetsuit/drysuit, not to mention cold fingers (on the rescuer), and being thrown around by wave action etc. So the problem with doing in-water EAR is that they may not have a pulse (quite likely if they have been submerged for some time with no reg in their mouth) and thus EAR serves no purpose, since it must be combined with chest compression in a pulseless patient. In fact in these circumstances doing EAR in water may just delay getting the patient to the boat/shore where more appropriate treatment can be commenced. There is no easy answer to this problem, and each individual will have to consider the circumstances at the time to decide whether to do EAR in-water or to concentrate all efforts on getting them as quickly as possible onto the boat for better assessment and treatment. > >You make me sick with this attitude and this long winded effort to >discredit real life and then offer nothing viable as an alterrnative. I have actually discussed a number of alternatives both in this post and my previous post. It is important to realize that no two rescue/resuscitation situations are ever the same so absolute definitive answers to all possible problems that may be encountered simply don't exist. Proper training, along with adaptability, is the key. George, I hope that you do not see my comments on this issue as any form of personal dispute with you. The only issue that is important here is that those reading this list are able to make a well informed choice in this matter. If you, or anyone else, can provide logical arguments to refute what I have said I am quite happy to "eat humble pie". I would certainly be interested in detailed accounts of "how it was done" from anyone who has actually used a reg in this fashion. In the hope of clarifying this issue further I will see if I can get someone with expertise in this area to comment further, and will post any info that I can glean. Cheers, David > > >David Reinhard wrote: >> >> Dear List, >> sorry to have come in rather late on this discussion but I have been away >> from my computer for a few days. I am sure there are many people on this >> list who are better able to discuss legal issues than me, so i will stick >> to the medical side of this debate. There are a number of points that need >> to be considered. >> >> Firstly, any resuscitation system requires an interface between that >> system and the patient. With resuscitators of any type this generally >> invoves a face mask, which encloses both mouth and nose, and has a soft >> rubber/silicone cushion designed to seal against the face. The ability to >> achieve a good seal with this mask is probably the most important skill in >> using a resuscitator. Without a good seal it will not be possible to >> ventilate the lungs. Air/O2 will obviously follow the path of least >> resistance so if the seal is not perfect (or near to perfect) then gas will >> simply escape via that leak to the atmosphere and not into the patients lungs. >> If using a scuba regulator as a resuscitation device this principle >> obviously still applies. It would be necessary to place the mouthpiece into >> the mouth in such a way that a perfect seal is obtained. Not having done >> this on an unconscious person I cannot comment on whether or not this would >> be easy to achieve. When pressing the purge button with the aim of >> inflating the chest the gas will still of course follow the path of least >> resistance. This means that the gas will predominantly vent out the exhaust >> ports since the resistance in the airways and the need to expand the chest >> will be much greater than the passage of gas out of the ports. It would >> then be necessary to block both ports in order to achieve lung inflation. >> If this was done manually it would obviously require two hands. Since the >> nose also provides a path of lower resistance than the airways in the lungs >> the nose must be pinched closed. To achieve this (ie blocking both vents, >> pinching the nose) while pushing the purge button will require at least two >> operators. >> "Positive pressure ventilators" that work on a similar principle to a >> "purge button" also require a pressure relief valve (typically set at >> around 50-70cm H2O) to avoid overpressure injury to the lungs. This of >> course is not present on a scuba regulator. The air flow from many >> regulators (the Oceanic showerheads are a good example) is quite remarkable >> and would pose a significant risk to the lungs. It would also be difficult >> at these extraordinary flow rates to judge when to stop pressing the >> button, since chest inflation would be very rapid. Another path of least >> resistance, especially if the airway is not fully opened (a very common >> fault with unskilled operators), is via the oesophagus to the stomach. >> Inflation of the stomach would, I believe, be highly likely using a scuba >> regulator in this fashion. Inflation of the stomach has two adverse effects >> 1) increased likelihood of regurgitation with possible inhalation of >> stomach contents (potentially fatal) and 2) an inflated stomach puts >> pressure on the diaphragm and thus limits the excursion of the lungs >> reducing the ability to ventilate the lungs effectively. >> The use of positive pressure ventilators has been gradually phased out >> over the last ten years or so (in Australia anyway) in favour of bag and >> mask systems. Bag and mask systems are capable of delivering close to 100% >> O2 with greater contol over ventilation volumes and at generally lower >> pressures than positive pressure ventilators. >> Options for divers when treating a non-breathing patient are probably >> primarily 1) bag and mask with or without O2, 2) EAR via a "pocket mask >> with or without O2, 3) straight EAR (eg mouth to mouth. (EAR = Expired Air >> Resucitation) >> While I have been involved in probably several hundred resuscitation >> attempts I have never done mouth to mouth. I would personally find it very >> difficult to place my mouth over someone elses especially when covered with >> vomit. Many of the people i have resuscitated have been heroin ODs and >> quite frankly I would not take the risk of acquiring the diseases that >> these people often carry. I have utilised a "pocket mask" for EAR when I >> have not had equipment immediately available and found this to be a >> relatively easy technique which would be well suited to a "lay person" with >> minimal training. However, normally I use a bag and mask system which I >> feel is the best alternative for a trained operator. However if you have >> not been well trained, and maintained your skills with regular practice, >> the bag and mask may not be appropriate. >> While it is desirable to deliver high O2 concentrations to a non-breathing >> patient do not disregard the value of EAR just because it delivers only >> around 17% O2. Many lives have been saved by EAR. It is far better to >> effectively ventilate the lungs with 17% O2 than to improperly utilize >> equipment (whether a properly designed ventilator or an improvisation with >> a scuba regulator) and achieve little if any ventilation, or put the >> patient at risk of further harm by lack of training/experience. >> It is my opinion that from a medical viewpoint a scuba regulator has many >> disadvantages that would exclude its use as a resuscitation device. I would >> not personally use it. In fact you are probably taking a legal risk using >> any device that you have not been properly trained for. So unless you have >> received traning in the use of a scuba regulator for resuscitation (which >> is highly unlikely!!) leave it alone. >> >> For those of you who think credentials are important I have been an >> instructor in CPR and O2 use for over twenty years (accredited by the >> National Heart Foundation and the Royal Lifesaving Society of Australia), I >> have worked as a professional ambulance paramedic for 16 years, the last >> five of which have been on Mobile Intensive Care Ambulances. Despite that I >> do however recognize that my opinions are potentially fallible and I remain >> open to anyones viewpoint if they can demonstrate any flaws in what I have >> written above. >> >> Regards, David Reinhard. >> >> -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- >> Ocean Internet - "The Quality ISP" >> http://www.ocean.com.au/info.html >> >> -- >> Send mail for the `techdiver' mailing list to `techdiver@aquanaut.com'. >> Send subscribe/unsubscribe requests to `techdiver-request@aquanaut.com'. > > -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Ocean Internet - "The Quality ISP" http://www.ocean.com.au/info.html -- Send mail for the `techdiver' mailing list to `techdiver@aquanaut.com'. Send subscribe/unsubscribe requests to `techdiver-request@aquanaut.com'.
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