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Diving safety & emergency management guidelines
SPECIFIC CONDITIONS and PROCEDURES for the U-1105 SITE
The U-1105 site has been designated an Historic Shipwreck Preserve and marked
with a buoy to facilitate the preservation of the vessel. Although diving at the site is
difficult and can be dangerous, it was reasoned that active, experienced divers would
attempt to locate and dive on the site regardless of what policy the State of Maryland or
the United States Navy might implement. Divers searching for the site would be likely to
damage the submarine by dragging anchors into it and without government monitoring,
artifact looting was certainly possible. By marking the site with a buoy and publicizing
the Preserve to the dive and local community it is expected that preservation of the site
will be greatly enhanced. Also, experienced divers who choose to dive on the site will be
afforded direct access to the submarine which will increase safety considerations at the
site. Diving is a demanding and exciting activity. When performed properly, applying
correct techniques it is a safe sport. When established safety procedures are not followed,
however there can be dangers. Despite modern equipment and up to date training pro-
grams sport diving, when conducted improperly, can be considered hazardous and like
any other active sport, accidents can occur. Statistics show that the majority of diving
accidents can be prevented if safe diving standards are followed. Diving accident reports
reveal that many diving fatalities can also be prevented if proper rescue and resuscitation
Therefore the following safety procedures manual is a summary of accepted safe
diving practices and guidelines as well as emergency management procedures. It is in-
tended to be used as a reference; for suggestions or recommendations only. (Federal or
State agencies cannot require dives to be conducted in a specific manner). To minimize
the potential for mishap, a list of possible accident scenarios, and how to prevent them,
are outlined in the emergency management section. If an accident does occur, following
the emergency procedures guide could possibly prevent a more serious situation.
Each dive and the conditions encountered are specific unto themselves, particularly
on the U-1105 site. The decision to dive this site and the technique(s), used to conduct the
dive should be made by each diver based on his/her level of experience, training,, physi-
cal ability, and proper equipment. The weather and sea conditions should also be taken
into consideration and constantly monitored as wind and waves at the site can change
The diving conditions at U-1105 site can be dangerous and diving should only be
undertaken by advanced divers experienced in low visibility environments, deep depths,
strong currents and wreck diving environments. All divers should understand that any
diving conducted at the U-1105 site is done at your own risk.
I. GENERAL ACCEPTED SAFE DIVING PROCEDURES
When diving, you will be expected to abide by current standard diving practices.
These practices have been compiled to reinforce what you have learned and are intended
to increase your comfort and safety in diving. As a certified diver, you should:
Maintain good mental and physical fitness for diving. Avoid being under
the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills,
striving to increase them through continuing education and reviewing them in controlled
Be familiar with your dive sites, if not, obtain a formal diving orientation
from a knowledgeable, local source. If diving conditions are worse than those in which
you are experienced, postpone diving or select an alternate site with better conditions,
Engage only in diving activities which are consistent with your training and experience.
Use complete, well maintained, reliable equipment with which you are fa-
miliar; and inspect it for correct fit and function prior to each dive. Deny use of your
equipment to uncertified divers. Always have a buoyancy control device and submers-
ible pressure gauge when scuba diving. Recognize the desirability of an alternate source
of air and a low pressure buoyancy-control inflation system.
Listen carefully to dive briefings and directions, and respect the advice of
those supervising your diving activities.
Adhere to the buddy system throughout every dive. Plan dives, including
communications, procedures for reuniting in case of separation, and emergency proce-
Be proficient in dive table usage. Make all dives no-decompression dives
and allow a margin of safety. Have a means to monitor depth and time under water.
Limit maximum depth to your level of training and experience. Ascend at a rate of 60 feet
Maintain proper buoyancy. Adjust weighting at the surface for neutral buoy-
ancy with no air in the buoyancy control device. Maintain neutral buoyancy while under
water. Be buoyant for surface swimming and resting. Have weights clear for easy re-
moval, and establish buoyancy when in distress while diving.
Breathe properly for diving. Never breath hold or skip breathe when breath-
ing compressed air. Avoid overexertion while in and under the water and dive within
Know and obey local diving laws and regulations, including fish and game,
dive flag laws, and submerged historic properties guidelines and regulations. If in doubt
check first with the appropriate agencies.
II. SPECIFIC CONDITIONS AND PROCEDURES for the U-1105 SITE
It should be stressed that the waters surrounding the German submarine U-1105
can be considered a hazardous diving environment, typified by strong currents, high
turbidity, and considerable depth. In addition, from the late fall through spring the bot-
tom temperatures on the site can be very cold. The sediments on and around the subma-
rine consist of a black-brown very fine river bottom silt that is quite fluid. If these sedi-
ments are disturbed, a black cloud forms instantly around the diver suddenly creating a
zero visibility environment. However if the diver remains calm , the strong currents on
the site will usually remove the cloud in a few moments. Currents can be difficult to
predict on the site even with tide tables, there are usually counter flowing top and bottom
currents of different intensities. All of these environmental conditions combined make it
a challenging dive site for even the most experienced of divers. Yet it is undoubtedly one
of the most unique shipwreck sites of its kind found to date in American waters.
Scuba diving, by its very nature, can be a hazardous sport, with incumbent dangers
increased or decreased as bottom conditions vary. Recommendations in this report do
not suggest that this site will ever be a safe dive site. The environment cannot be altered,
although hazardous features of the wreck itself have been corrected. It should be noted,
however, that site conditions are not unlike those of thousands of other Atlantic Coast
and Chesapeake Tidewater wrecks which are dived on by sport divers every day, each
with their own set of inherent hazards.
Safety Guidelines for Diving at the U-1105 Site
In addition to normal safe diving rules there are some aspects of the U-1105 site that
call for closer attention to specific safety considerations. The site is marked with 2 buoys,
a large blue and white (can type) buoy and a smaller orange buoy, the smaller buoy is
connected directly to the bridge on the submarines conning tower.
There is daily commercial boat traffic on the river in the area of the site,
therefore be sure the dive vessel displays both the alpha (blue & white) as well as the
standard (red & white) dive flag. This is also called for under Maryland law.
Because of the strong currents on the site, dive vessels should deploy a long
buoyed safety line to assist divers surfacing away from the dive vessel. Boat captains
and/or dive masters should also have a prearranged plan for recovering divers surfacing
too far from the dive vessel. Drifting surfaced divers may not be able to reach the dive
boat and the vessel may need to leave the mooring to recover them while other divers are
still down. The plan for this contingency should be discussed and understood by all
Because of the strong currents on the site, surface lookouts should be posted
to watch bubbles and to spot divers surfacing away from the site. Once a surfaced diver
is spotted the lookout should confirm that the diver is OK and maintain visual contact
with the diver until recovery is completed.
A buddy pre-plan is especially important, be sure to plan for contingencies
Divers should descend and ascend on the down line of the smaller buoy
which connects directly to the bridge/ conning tower area and stay on the site.
The U-1105 is a unique and valuable resource. Most submarines off the American
coast have been stripped bare by relic hunters leaving little purpose or pleasure in visit-
ing these sites. The submarine Black Panther is interesting because it has remained rela-
tively undisturbed. The U-1105 Historic Shipwreck Preserve was created to protect the
vessel and to ensure divers access to enjoy this significant historical site. To this end a
number of rules have been instituted to minimize the chances of damage to the subma-
rine. The site is marked by 2 buoys, a large blue and white can buoy identifies the site and
acts as a mooring for vessels waiting to access the site and a smaller orange buoy which is
connected directly to the bridge on the submarine.
The submarine is over 67 meters (220 ft.) long, therefore anchoring within a
300 meters (600 ft.) radius of the buoys is prohibited.
Only one vessel at a time may occupy the small buoy attached directly to
the site. All other vessels must utilize the larger mooring buoy or stand clear while wait-
ing to dive on the site. Vessels larger than 30 feet should moor only on the larger buoy
and rig a diver safety line to the smaller buoy. Because of depth/time limitations, dive
vessels are unlikely to occupy the site for more than one hour including time to don and
Minimize sediment disturbance when on the site. Adjust for neutral buoy-
ancy and try not to crawl around on the site, this will maintain a better level of visibility
and lessen the possibility of damage to the site in areas where the metal has graphitized
Look dont touch, the features and artifacts on the U-1105 are there for ev-
eryone to see and experience. Some features are fragile and all objects are US Navy prop-
erty,, nothing may be removed from the site. Artifact recovery is strictly prohibited,
offenders will be prosecuted under Federal Law. This can result in the confiscation of
The preserve will be monitored in an ongoing manner with formal assess-
ments twice a year, however, any damage or vandalism on the site or to the buoy should
be reported to the State Underwater Archaeologist (410-514-7662) or to St. Clements Is-
land Museum (301-769-2222). Report any theft or vandalism observed to DNR police
(301-888-1601) or Maryland State Police (301-475-8955). Failure to report criminal activity
In order to ensure adequate upkeep and management of the preserve, the
Maryland Historical Trust needs to assess use statistics for the preserve. In addition,
comments and suggestions for improving the preserve are welcome and encouraged.
Please complete site use forms available at either Piney Point or St. Clements Island
Museums or from the Maryland Historical Trust, Office of Archaeology, 100 Community
Place, Crownsville, MD 21032-2023. Comments may also be submitted by telephone (410-
514-7661), fax (410-987-4071), or e-mail (firstname.lastname@example.org). Please include your name,
IV. EMERGENCY MANAGEMENT at the U-1105 SITEPotential Accident Scenarios on the U-1105 Site
Lost Diver - A diver or divers could become disoriented in the low visibility
and lose contact with the wreck itself and/or their buddy. The diver may ascend slowly
and surface safely down current away from the site but may not able to return to the dive
vessel because of strong currents. If the surfacing diver is not seen or heard by a lookout
aboard the dive vessel, the diver will continue to drift farther away, by the time he is
discovered as missing, he may not be visible to those on board the dive boat.
PREVENTION - Pre dive plans / orient divers to the site
Post a lookout to watch for bubbles and surfacing divers
Deploy a long current line and float from the dive vessel
Have a plan for recovery of drifting down current divers
Make sure all divers know and understand the plan
Air Embolism - A lost or disorientated diver may become panicked and surface
too rapidly which could result in an air embolism injury. This problem could be com-
pounded if the injured diver surfaces too far down current to be easily seen or reached by
PREVENTION - Pre dive plans / Orient divers to the site
Post a lookout to watch for bubbles and surfacing divers
Deploy a long current line and float from the dive vessel
Have a plan for recovery of drifting down current divers
Have a prearranged plan for the treatment of air embolisms
Have a prearranged plan for evacuation if necessary.
3. Exhaustion /Heat Stroke/ Heart Attack - The strenuous conditions at the U-1105 site
require that divers be in good physical shape. It is possible that divers may overestimate
their physical abilities and return from the dive exhausted and unable to properly exit
from the water. While this is not in itself a serious problem it could become more compli-
cated in the strong currents at the waters surface or manifest itself once the diver is aboard
PREVENTION - Screen divers before they enter the water
Post stand by surface rescue divers to assist tired divers
Decompression Sickness - The U-1105 is considered a deep dive and as such pre-
sents the potential for decompression sickness. In spring and late fall the water tempera-
tures on the site are very cold, in addition the current flow can be as strong as one knot or
better depending on the tide. A deep dive involving cold water and strenuous exertion
on the part of the diver can result in a case of decompression sickness, even if the diver
PREVENTION - Compensate dive tables to allow for cold deep strenuous Dive
Have a prearranged plan for the treatment of decompression
Have a prearranged plan for evacuation if necessary
How to Recognize a Diving Accident Victim
A diving accident victim could be any person who has been breathing air underwa-
ter regardless of depth. Gas embolism can occur in as little as 2-4 feet of water if one
ascends holding his breath. Even a well-trained diver may encounter problems because
of respiratory medical problems. Asthma, broncholithiasis, congenital or acquired cysts,
emphysema, fibrosis, tuberculosis and infection, especially fungal, obstructive lung dis-
eases may result in air trapping during ascent, this expansion of trapped air may be suf-
ficient to rupture air spaces. The escaping air may cause emphysema of the lungs, medi-
astinum, or neck. Alternatively, it may cause pneumothorax. Finally, arterial air embo-
Decompression sickness (usually the least serious of the barotrauma illnesses) can
occur in any individual who violates the decompression tables either willingly or unin-
tentionally when surfacing from depths greater than 30 feet.
Bubble trouble can happen to anyone, anywhere, at anytime, far out at sea, in home
swimming pools -lakes - harbors - canals and from submerged cars.
To insure a successful treatment, instructors, divemasters, EMTS, rescue personnel,
physicians, and emergency room personnel must be able to recognize the problem, begin
diving accident treatment procedures and move the victim into the hyperbaric trauma
In the presence of a medical emergency exhibiting any signs resembling those of a
diving accident, there is one primary question. Did the subject breath air underwater?
If the answer is Yes, you must regard the subject as a diving accident victim, especially
in the case of unconsciousness. The diving accident treatment procedure must be initi-
ated immediately. This includes restoration of vital signs, administering oxygen,
Trendelenberg Position, and immediate evacuation to the recompression chamber com-
A major problem with divers is that they tend to ignore the mild symptoms of bubble
trouble in the early stages. By doing so, they eventually have more serious symptoms.
Immediate diving accident identification can be broken down and handled in two cat-
egories mild and severe symptoms. (See DAN Flow Chart p. 20) To simplify identifica-
tion all symptoms of gas embolism and decompression sickness will be considered to-
Mild symptoms are those that can be treated at the dive site by the diver using surface
oxygen. Indifference, fatigue, skin rash, and weakness are considered mild symptoms.
Although joint pain is also considered a mild symptom, it will be treated as a severe
symptom according to the DAN Flow Chart because recompression is required.
If a diver comes up from a dive and acts indifferent, appears not to know what is going
on, or ignores people trying to communicate with him, this may be an early warning of
bubble trouble. The same applies to extreme fatigue, weakness, or skin rash.
Do not hesitate, place this person on surface oxygen, head downward (Trendelenberg
Position). Also follow the DAN Flow Chart through to the final stage. Doing this often
relieves the symptoms or prevents them from getting worse. Surface oxygen, and assum-
ing the Trendelenberg Position have been successful in being the complete treatment.
The biggest problem in the early stages is the divers ego. Divers do not want to admit
there is anything wrong with them and refuse to be put on oxygen because they feel
others will think less of their diving ability. Do not let your ego or the patients ego overrule
common sense. Use surface oxygen and place the patient in the Trendelenberg Position
immediately. If the symptoms appear to be relieved after the patient has been on oxygen
for a short period of time do not remove the oxygen immediately, as bubbles will reload
from gases in the surrounding tissue, and the symptoms will reoccur. If symptoms are
relieved in 10 minutes, keep the patient on oxygen for 30 minutes total. If symptoms get
worse, find new symptom on Flow Chart and follow chart recommendations.
Severe symptoms are those that require immediate treatment and evacuation into the
hyperbaric trauma system (See DAN Flow Chart p. 20), if the victims vital signs cease to
function, CPR will be required This is first and foremost in diving accident treatment. If
a patient comes up from a dive, or anytime within 24 hours after a dive, and shows any of
the severe symptoms indicated on the Flow Chart, immediately place the Patient on sur-
face oxygen and in the Trendelenberg Position after insuring vital signs are functioning
properly, and follow the Flow Chart to eventual evacuation to a recompression chamber.
it is important to remember that because these signs/symptoms can develop hours
after diving, the patient may show up in a hospital emergency room or other medical
facilities in the community. For this reason, it is important for paramedics and physicians
to recognize the symptoms and to understand this hyperbaric problem so that the diving
accident procedure can be initiated. It is also extremely important that any person deliv-
ering a diving accident patient to professional medical personnel explain this procedure
to them, so that the patient will receive proper recompression if needed.
If you have a radio on board, contact the Coast Guard Directly, on channel 16 VHF
marine band. Declare an emergency and state the type of emergency, e.g., This is a
diving accident victim needing treatment in a recompression chamber. Give your exact
location by direction and distance from prominent land marks. Give all symptoms of the
victim and dive history if applicable. State the condition of victim, i.e., can he walk, sit
up, or is he unconscious. Describe any unusual circumstances, and the number of vic-
tims. Give detailed description of your boat, including any outstanding features for iden-
tification. Give weather, sea condition, wind direction and speed.
If you should change your location, keep all concerned advised of your new location
The Coast Guard does monitor CB, Channel 16. This is a very unreliable means of
communications for many reasons. If you are unable to raise the Coast Guard via CB,
contact someone else to relay your messages.
If you have a cellular phone on board your vessel, call 911, ask the 911 operator for
Maryland Emergency Assistance. In this area the 911 call will go to Virginia however
If you have no radio on your boat, if practical, hail a boat with a marine band radio and
give them the information to relay to the Coast Guard. Keep them with you for further
contacts. The International Convention for safety of life at sea requires the providing of
If no other boats are immediately available proceed immediately to the nearest inhab-
ited dockage and telephone local paramedical or USCG services. Advise them of a diving
accident, state your need for transportation and your EXACT location. Have someone
remain at the telephone for further assistance. Insure that they are aware at this time that
a recompression chamber will be needed.
If symptoms occur on land after diving, contact local paramedics or USCG. They should
be able to assist or advise location of nearest recompression chamber.
When the rescue aircraft arrives in your area, wave, fire flares or smokes. LET THEM
KNOW YOU ARE THE ONES WHO WANT ASSISTANCE. Do not assume the pilot will
recognize you. He may waste valuable time searching for you unnecessarily.
Hospitals and Recompression Chamber Information
Shock Trauma / Hyperbaric Med. Dept.
George Washington University Medical Center
The following medical evacuation information should be forwarded with the patient.
If possible, take time to explain the following steps to the physician or paramedic. Dont
assume they understand the reasons why oxygen should be administered to a diving
accident victim. If a person is breathing normally, the physician may take him off oxygen
not realizing the patient must be kept on to continue to off-load the bubbles. When this
has been explained the following steps should be followed:
1. Maintain breathing and heart functions, insure airway is open and remains
2. Keep patient on oxygen and incline head downward, left side down, during
transportation (Trendelenberg Position).
3. Insure para-medic/physicians understand why head downward, left side, on
oxygen is required until patient arrives at chamber.
4. Insure paramedics /physicians understand why patient needs to be taken to a
recompression chamber instead of a hospital.
5. Do not remove oxygen from diving accident patient unless you need to reopen
airway, or he shows signs of oxygen convulsions, even if patient is breathing
normally. Without oxygen, bubbles will reload with nitrogen and cause increas-
6. Keep patient out of hot sun, watch for possibility of shock.
7. Do not give any pain killing drugs, 1. IV.s can be given to prevent vascular
collapse or dehydration, (D5LR, Plain LR or D1/2N. S.). 2. Two aspirins orally.
9. Provided the aircraft can handle extra weight, diving buddy should be trans-
ported with patient, as he may also need recompression and can be useful with
information, comfort and contact with patients parents /relatives.
10. A complete history of all events leading up to the accident and until evacuation
11. Depth gauges, tanks, regulators, and other diving equipment should be for-
warded with patient if weight limitations allow, especially if the accident is fatal.
Once it has been established that the patient is a diving accident victim, and someone is
caring for his immediate medical needs (vital signs, surface oxygen, and Trendelenberg
Position), someone must also be initiating the evacuation protocol into the hyperbaric
Because many divers and/or boaters fail to plan emergency evacuation procedures
in advance, a great amount of critical time is often lost, causing needless suffering and
possible loss of life. The most important part of any dive and/or boat trip is to know
your procedure for emergency evacuation.
If it is necessary to evacuate an accident victim by helicopter it would be advisable
to take the victim ashore to the nearest landfall and prepare for a land based evacua-
tion. To select a landing zone and prepare for a helicopter evacuation the following
1. The landing area should be at least 3600 square feet (perimeter 60 ft. per side).
2. All persons should be kept well back from the landing zone.
3. The area must be free from obstacles such as trees or power lines.
4. Any non secured items that could be blown away by the wind of the rotor blades
should be removed from the landing zone.
5. A guide should stand at the windward corner of the landing zone to direct the
pilot to the appropriate site. During the actual landing the guide should turn
away from the aircraft to avoid flying particles of sand or dirt.
6. Never approach the aircraft unless motioned to do so by the pilot. When ap-
proaching maintain a low, crouched position and eye contact with the pilot.
7. Be aware of the relative position of the rotor blades, because as the aircraft slows
the blades will drop lower, especially in strong winds. Special care should be
taken ff the landing is on uneven ground.
8. Never approach the aircraft from the rear as the rear rotors are almost invisible
When a victim is to be flown to a hyperbaric treatment facility, instruct the flight
crew to fly at the lowest possible safe altitude. The reduced pressure at high altitudes
during the flight could further expand air bubbles and complicate the victims condition.
1. Determine where and when the diver was last seen.
b. Determine the direction of current flow on the site, both bottom
a. Look for bubbles around the boat.
b. Scan the horizon especially in the direction of the surface current
4. Dispatch a scuba team with equipment to initiate underwater search:
Establish a recall system to avoid delay once a diver is found.
Never subject searchers to undue danger from decompression sick-
ness, by allowing single handed searching or from using inexperi-
If only inexperienced or unqualified divers are present call for
5. Terminate the search in 30 minutes if the victim is not found. Turn the
situation over to emergency professionals.
When oxygen is breathed, the oxygen partial pressure (PO2) of the blood is increased.
This establishes a steeper gradient across the bubble-tissue interface and aids in the elimi-
nation of inert gases (from the bubble), reducing the bubble size to some extent. Addi-
tionally, the elevated (PO2) allows better oxygenation of tissues where the blood supply is
marginal, because the initial bubble has impaired that flow. Although this discussion
relates to the use of oxygen at sea level as a first aid measure, the same principles apply to
the use of oxygen under hyperbaric conditions.
Tissue integrity depends essentially upon two factors: (1) adequate PO2 and (2) ad-
equate flow to deliver the oxygen. Even though there is some vasoconstriction, the flow
should be adequate with the improved PO2 to help reduce bubble size and to supply
The Trendelenberg Position means head down, but with legs bent at the knees. The
Scoltetus Position means head down with the legs straight. Either position would be
satisfactory to accomplish the goals mentioned.
A patient is put into the head-down position for several reasons. In the case of embo-
lism, it prevents further intravascular bubbles from reaching the cerebral circulation. This
is explainable simply as counteracting gravity, for as the lighter bubbles rise, they will,
hopefully, pass to the lower extremities rather than to the head.
In the case of decompression sickness, the position should be used particularly if the
patient is in shock, because it will allow a better flow of blood back to the core organs
(heart, lungs, brain. and kidneys). If there are bubbles in the systemic circulation (left
side of the heart), the position also prevents their migration into the circulatory system in
the same manner as described for embolism cases.
Knowing the causes, signs and symptoms is necessary to insure the proper treatment of a
diving accident victim. You should be able to recognize the following:
As a diver surfaces, the gas trapped in the lungs expands, rupturing the alveoli. Bubbles
of gas are forced into the circulatory system, to the heart, and distributed to the body
tissues. As the ascending diver is normally in a vertical position, these bubbles tend to
travel upward toward the brain. As the bubbles enlarge and pass into smaller arteries,
they reach a point where they can move no further, and cut off circulation. The effects of
halting circulation, especially to the brain, are serious and require immediate treatment.
Symptoms of embolism occur within 3-5 minutes of surfacing. One, a few, or all of the
Feeling of blow on chest, progressively worsening
Sudden unconsciousness (usually immediately after surfacing, possibly before sur-
Confusion or difficulty in seeing (i.e., moving in a wrong direction, bumping into
Paralysis or weakness in extremities or face
Immediate first aid is to place the victim with head and chest inclined downward and
lying on his left side. This position lessens the chances of bubbles being carried to the
brain. Also, breathing 100 percent pure oxygen,, if available, is indicated. Begin oxygen
treatment for air embolism in route to a recompression chamber. Treatment for air embo-
lism is immediate recompression in a recompression chamber. This may reduce the size
of the bubbles to the point where the circulation of blood may resume. The victim should
be recompressed to 165 feet as soon as possible, and treated on the appropriate treatment
table. Under no circumstances should the victim be taken back into the water to depth for
This condition occurs when the intake of water and salts are inadequate to compen-
sate for losses due to perspiration. It is commonly characterized by cool and clammy skin
and a grayish look to the face. A person may also complain of feeling dizzy, weak or
faint, with accompanying nausea or headache. The body temperature of a heat exhaus-
tion victim may be near normal and a rapid pulse may be present.
Emergency care for heat exhaustion begins with a primary assessment - arouse pa-
tient, check for open airway, breathing, circulation, bleeding, and shock. Next move the
patient to a cool location and if he is wearing an exposure suit remove it immediately.
The patient should be urged to lie down. If fully alert, the patient should be encouraged
to drink up to a liter of water or a diluted, commercially available balanced salt solution.
Patients will typically respond favorably to these emergency care measures within
30 minutes. If the symptoms do not clear promptly, the level of consciousness decreases,
or the body temperature remains elevated, the patient should be transported to the hospi-
tal. Heatstroke occurs when the body is subjected to more heat than it can handle. The
normal mechanisms for getting rid of excess heat are disrupted. When these mechanisms
fail, the body temperature rises rapidly to a level that destroys tissues and may result in
death. Heatstroke is rare, but it is a life-threatening emergency requiring immediate first
aid. In advanced stages, heatstroke victims have hot, dry, flushed skin because they do
not sweat. The absence of perspiration, however, may be an unreliable sign since heat
exhaustion often precedes heatstroke and some moisture may remain on the skin. The
skin color will be red and body temperature may rise to 103 degrees F or higher. The
pulse is usually rapid and strong at first, but as the victim becomes unresponsive, the
pulse will fade. Sudden unconsciousness often results, and convulsions may occur.
A heatstroke victims body temperature must be quickly and immediately lowered.
First remove the patient from the hot environment, also remove or cut away the patients
exposure suit. To effectively cool the patient, either cover Mm with wet towels or place
him in cold water. When his body temperature begins to lower, continue the circle of care
Heart Attack and CPR (Cardiopulmonary Resuscitation)
If an unconscious accident victim stops breathing and has no pulse someone
trained in the use of CPR should begin resuscitation immediately. The following out-
line could serve as a guide for the procedure.
1. Kneel at the victims side. With one hand, lift under the neck and tilt the head
2. Lean down to listen - feel - watch for signs of respiration.
3. If there is no breathing, seal the nose with your free hand, seal your lips around
victims (or use a mouth mask) and give 2 full slow breaths.
4. If breathing doesnt start spontaneously, check for a pulse on either side of the
5. If there is no pulse, begin chest compressions (1-5 to 2 inches of depression) at a
rate of about 60 to 80 beats per minute.
6. Give 2 breaths between every 15 compressions (if you are alone) or intersperse
one breath every five compressions if working with another rescuer. Do not interrupt
compressions for longer than five seconds at a time.
7. As color returns to the victim, recheck for pulse. When breathing starts, keep
victim lying down, turn head to the side if vomiting occurs. Avoid aspiration of vomitus
into the victims lungs as this can cause acidosis and decrease the bloods ability to trans-
8. Resuscitation attempts should be continued until:
a. Competent medical authorities take over.
b. You are no longer physically able to continue.
Decompression sickness (bends) is the result of inadequate decompression following
exposure to increased pressures. While immediate recompression is not a matter of life
and death as with air embolism, the quicker recompression is initiated the better the rate
of recovery. While under pressure, the inert portion of the breathing gas (nitrogen, he-
lium, etc.) is passed, into solution in the blood and absorbed by the body tissues. As long
as the diver remains under pressure this gas presents no problems. Should the pressure
be quickly removed (as in rapid surfacing) the inert gas can come out of solution and
form bubbles in the tissues and blood stream. The controlled ascent permits the body to
rid itself of excess inert gas at a rate which will enable it to remain in solution.
Symptoms of decompression sickness are extremely varied, and are in many cases
similar to air embolism. The effects of air embolism will be noticeable prior to or immedi-
ately after the diver surfaces. Any occurrence of symptoms more than 1/4 hour after the
diver reaches the surface can generally be assumed not to be air embolism. The most
frequent symptoms of decompression sickness and frequency with which they occur are
Evidence of local pain (rubbing arm, limp, favoring one side)
Staggering, clumsiness, lack of response as if drunk
The treatment for decompression sickness is recompression as quickly as possible ac-
cording to the symptoms. Any symptom except a rash and local pain is considered a
serious symptom and should be treated as such. Administer 100 percent pure oxygen in
While decompression sickness may, in some rare cases, occur up to 24 hours after the
exposure to pressure, the vast majority of cases (95 percent) will be evident within 3 hours.
Fifty percent will occur within 30 minutes and 85 percent within an hour. Only 1 percent
DAN (Diving Accident Network) INFORMATION
The National Diving Accident Network (DAN) was formed in 1981 to assist in
treatment of underwater diving accidents by providing a 24 hour telephone emergency
number (919-684-8111). This number, which may be called collect in emergencies, is re-
ceived at the national DAN headquarters located at Duke University Medical Center. For
medical problems, the caller is connected with a physician experienced in diving medi-
cine. These physicians assist with diagnosis and initial treatment of the accident and
supervise referral to appropriate recompression chambers while working with regional
DAN does not maintain any treatment facility and does not directly provide any
form of treatment, but is a service which complements existing medical systems. The
most important function of DAN is to facilitate the entry of the injured diver into the
hyperbaric trauma care system by coordinating the efforts of everyone involved in the
The nation is divided into regions, each headed by a regional coordinator who is a
physician experienced in diving medicine. Each regional coordinator maintains up-to-
date information on chamber status,, transportation facilities and other diving medical
services within his area. The DAN physician and the regional coordinator work together
in transferring the patient to the appropriate chamber.
An other important function of the Network is collecting and analyzing data on
diving accidents to improve the understanding of the causes of diving accidents and to
IX. DAN DIVING ACCIDENT MANAGEMENT FLOW CHART
In a suspected diving accident the first question is Did the victim take a breath under-
water? from a SCUBA tank, hose, bucket, submerged car, or any compressed air source,
If the answer is no, give CPR and oxygen if needed and evaluate as a medical problem
If the injured diver did breathe underwater and only mild symptoms are present (fa-
tigue and itching only), place the patient in left-side-down-head-low position
(Trendelenburg position) and administer two aspirin, oxygen and oral fluids while main-
If these mild symptoms clear totally within thirty minutes have the person contact a
diving physician at his earliest convenience.
If the symptoms do not clear, seek medical advice and treat as a serious injury.
If the injured diver did breathe underwater and has serious symptoms, do the fol-
2. Keep airway open and prevent aspiration of vomitus. Intubate unconscious injured
3. Keep injured diver in left-side-down-head-low position (trendelenburg position).
4. Administer oxygen by tight-fitting double-seal mask at the highest possible oxygen
concentration. Do not remove oxygen except to reopen the airway or if the victim
5. Protect the injured diver from excessive heat or cold.
Give conscious patients non-alcoholic liquids such as fruit juices or oral balanced salt
7. Intravenous fluid replacement with electrolyte solutions is preferred for unconscious
or seriously injured victims. Ringers lactate, normal saline, or 5% dextrose in saline
may be used. Do not use 5% dextrose in water.
8. Give two aspirin, as an anti-platelet agent, as a one time dose to a conscious diver
9. If there is evidence of involvement of the central nervous system, give steroids, hy-
drocortisone hemisuccinate, 1.0 gm. i.v. or dexamethasone, 20-30 mgm. i.v.
10. Evaluate and stabilize patient at the nearest hospital emergency room prior to trans-
fer to recompression chamber if needed.
11. Contact a physician experienced in diving medicine.
12. If air evacuation is used, it is critical that the patient not be exposed to decreased
barometric pressure at altitude. Flight crews must maintain cabin pressure at sea
13. Contact Hyperbaric Trauma Center before transporting the injured diver.
14. Send this manual and recorded history with the patient.
15. Send all diving equipment with the patient for examination. If that is not possible,
arrange for local examination and gas analysis.
DAN - DIVING ACCIDENT NETWORK (919) 684-8111
(Call collect if necessary in an emergency) Ask for diving physician
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ALGEMEEN KADER VAN DE LIJST 2012 De lijst van de geneesmiddelen die niet door het RIZIV worden terugbetaald maar ten laste worden genomen door de OCMW’s van de Conferentie van de 19 OCMW’s van het Brussels Gewest, wordt opgemaakt volgens dit algemeen kader opgesteld door de Commissie voor Geneesmiddelen. Opgelet: Wijzigingen van CNK, van verpakkingsgrootte , van naam, nieuwe dosering