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Treatment of Decompression Illness in Remote Locations

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When treating Decompression Illness in remote locations, patient selection is critical. Due to limited resources, it may not always be practical to treat every patient with signs and symptoms of decompression sickness (DCS) with definitive therapy such as portable hyperbaric oxygen (PHBO) chambers or in-water recompression (IWR.)  A three-tiered triage system is effective when deciding which patients would most benefit from recompression versus conservative management. Tier 1 patients have mild disease, Tier 2 patients have more moderate symptoms, and Tier 3 patients have life-threatening DCI.
Patients with mild symptoms, including mild joint pain or rash consistent with “skin bends,” are very common. Because of the benign nature of Tier 1 patients, it is reasonable to manage these cases conservatively by administering 100 percent surface oxygen, intravenous fluids and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. More definitive therapy may not be required as the natural progression in these cases is typically benign and self-limiting, but patients must be carefully monitored for progressive signs or symptoms with serial neurologic exams.

Tier 3 patients are those with life-threatening DCI, either severe Type II spinal cord DCS, cardiovascular DCS or arterial gas embolism (AGE) with altered mental status or cardiac arrest. When patients are this sick, advanced cardiac life support takes precedence over hyperbaric therapy. It is unsafe to go back in the water for a trial of IWR and patients are typically too sick to be put in a small portable hyperbaric chamber where team members would be unable to intervene without decompressing the chamber.

Tier 2 patients are the best candidates for either IWR or PHBO therapy. Typically, these patients have moderate to severe Type I DCS including significant joint pain and rash. In contrast to Tier 3 patients, Tier 2 patients are generally able to actively participate in their own care: They’re awake, oriented, able to maintain their own airways and spontaneously breathing. Most important, they must be willing and able to either get back into the water with the appropriate IWR staff and equipment or complete a modified treatment table in a portable chamber.

Portable Hyperbaric oxygen therapy, or PHBO, is the use of a hyperbaric chamber able to deliver at least 2.0 ATA of 100% oxygen in an easily transportable package.   This is in contrast to the majority of portable mild hyperbaric chambers available on the internet, as most of these are soft sided and can only achieve approximately 1.3 ATA and frequently employ compressed air instead of oxygen.  There are several options on the market, the best known being the Hyperlite chamber from SOS/Hyperlite company in the UK.  Their design is essentially a hyperbaric stretcher that has been extensively used by various militaries for transporting DCI patients under pressure from the site to a more stable location.  It has also been used in civilian applications for programs that require some form of safety net while diving in remote locations.  While rather small and claustrophobic, the chamber has an excellent safety record, collapses down into two hard plastic transport cases and can be shipped anywhere in the world along with the rest of the dive gear.  Some training is required to learn how to set up and use the chamber, and its use should only be done by those who are very familiar with hyperbaric chamber operations.  Another drawback is its cost, somewhere north of $50,000 USD with options.

The second option is the use of in-water recompression or IWR.  This method has been rather controversial over the years, and its detractors feel the risks of treatment outweigh the benefits.  But, done with proper training, IWR has been used successfully in the past to treat DCI in remote locations.  The concept involves breathing compressed oxygen at varying depths, basically going back in the water and attempting what some would consider a completion of a blown deco stop.   The equipment required includes facemasks with comm equipment, surface supply oxygen, and a deco stage or trapeze.  Depths underwater vary, but to achieve maximum benefit while minimizing risk depths greater than 9 meters but under 15 meters should be employed.  The availability of 100% surface supplied oxygen is important, but 100% oxygen in an open circuit tank with the ability to gas-switch underwater to a mixed gas (air or nitrox) will do in a pinch.  Treatment time is typically less than a standard U.S. Navy Treatment Table Six, which is 240 minutes.  Instead of exposing the diver to the risk of seizure at depth or hypothermia, it is better to do more frequent but shorter treatments, typically three to five treatments in a 24-hour period, perhaps about 90 to 120 minutes each.  While the patient is on the surface, IV fluids and 100% oxygen should be continued.  It becomes clear that IWR is not to be undertaken lightly and requires significant training, but in the right hands can be used as a supplement to definitive hyperbaric therapy and the equipment is significantly less expensive than PHBO chambers and is much more easily transported.

Regardless of patient selection, treatment of DCS in remote locations with either IWR or PHBO chambers requires significant training, equipment and experience. All patients should receive 100 percent oxygen, intravenous fluids and possibly NSAID therapy. Those who have more significant disease should be considered for recompression therapy. The logistical and financial difficulties associated with both IWR and PHBO can be challenging but are not insurmountable.

Matthew S. Partrick, M.D.

Medical Director, Institute for Diving Medicine

Southern Ocean Medical Center

Manahawkin, NJ USA

drpartrick@scubadivingmedicine.com

www.scubadivingmedicine.com

Photo: Wayne Brown

Matthew S, Partrick, M.D. is medical director of the Institute for Diving Medicine at Southern Ocean Medical Center in New Jersey. He is also an attending physician in emergency medicine. Since finishing fellowship in undersea and hyperbaric medicine at the University of Pennsylvania, he has been active in the diving medicine community as well as serving as the dive medical officer on several expeditions with the Institute of Nautical Archaeology. He is a fellow in The Explorers Club.

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Dive into Adventure: Limited Space Available for January Socorro Liveaboard Trip with Oyster Diving

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Socorro Giant Mantas, Sharks and Dolphins – 8-16th January 2025

Oyster Diving is offering an unforgettable opportunity to experience one of the world’s most extraordinary dive destinations – Socorro Island. With only one male space left for this January’s liveaboard adventure, divers are invited to join an exclusive trip to explore the waters of Socorro, renowned for its remarkable marine life and incredible dive experiences.

Unmatched Diving in Socorro

Socorro is home to a unique population of giant oceanic mantas that actively seek interaction with divers and snorkelers, making it one of the best places in the world to encounter these majestic creatures. But the adventure doesn’t stop there – the waters surrounding Socorro are also teeming with marine life, including schooling hammerheads and silky sharks, over 10 other species of sharks, playful bottlenose dolphins that love to interact with divers, large schools of pelagic fish, and, during the season, humpback whales.

Luxury Aboard the Nautilus Belle Amie

Diving in such an extraordinary location is made even more special by the Nautilus Belle Amie. Launched in 2015, this modern, spacious liveaboard yacht is designed with divers in mind, ensuring comfort and luxury throughout the trip. The boat offers various suite options, including twin rooms and superior double suites, all with the ambiance of a boutique hotel. Divers will spend 8 days aboard the Belle Amie, with all meals, guided dives, and soft drinks included.

Pricing and Availability

This exclusive Socorro liveaboard trip is available for the following prices:

  • Twin Room (2 people sharing a Stateroom): £3360 per person
  • Superior Double Suite (2 people sharing): £3860 per person

Both prices include Socorro Island fees. A port fee of $35 is payable upon arrival.

Additional Costs:

  • Return economy flights: Approx. £1,000 – £1,300 per person (prices confirmed prior to booking)
  • One night hotel B&B accommodation before the liveaboard: Approx. £100 per person

Book Now

With only one spot left, this opportunity to explore Socorro’s spectacular underwater world is sure to fill up fast. Interested divers are encouraged to get in touch with Oyster Diving Holidays to secure their place today.

For more information and bookings, please contact:

Oyster Diving Holidays
Phone: 0800 699 0243
Email: info@oysterdiving.com

Don’t miss your chance to dive with mantas, sharks, dolphins, and humpbacks in one of the world’s most pristine marine environments!

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Marine Life & Conservation

12 Days of Zero-Waste Fish-mas

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This holiday period, the Marine Conservation Society, the UK’s leading ocean membership charity, invites you to make some simple changes to eating fish this Christmas to help our seas.

Dr Kenneth Bodles, Head of Fisheries and Aquaculture at the Marine Conservation Society, said, “During the festive season, our consumption increases, but so does waste. Sustainability isn’t just about where food comes from – it’s also about how you use it. By reducing waste and making the most out of your seafood, you’re not only taking steps to be more ocean-friendly, but can also help to cut costs during what is often one of the most expensive times of the year”.

The Marine Conservation Society has compiled twelve tips on how to consume seafood sustainably with zero-waste this Christmas:

Buy whole fish instead of fillets

Instead of fillets, consider buying whole fish such as salmon, hake, or lemon sole. By adopting a “nose to tail” approach with cooking, whole-baked fish not only feeds a crowd, but also helps to minimise waste and maximise sustainability by using up every part of the animal, including bones, skin, and fat.

Make fish stock

Leftover fish bones or shells can be put to good use by boiling them to make a nourishing fish stock or bisque. This can be frozen and preserved for later use and makes for a flavourful base in a soup.

Make your own fish pâté

Avoid waste by turning leftover fish, such as smoked mackerel or salmon, into a delicious pâté by blending with cream cheese and lemon. Perfect when paired with crackers.

The sustainability of salmon and mackerel varies depending on where and how it is caught or farmed. For more information on green-rated options, check the charity’s Good Fish Guide.

Buy frozen

By purchasing seafood that is frozen or vacuum-packed, this helps to reduce waste by extending the shelf life of your food.

Fish pie

If you’re wondering what to do with leftover cooked fish, why not opt for a classic fish pie with mashed potatoes, leeks, and a cheesy sauce? A sure crowd pleaser on Boxing Day.

Use the head

Don’t forget the fish head! The meat is incredibly tender and flavourful. The charity recommends a cod’s head curry or recreating Fallow’s renowned cod’s head in siracha butter.

By stretching your ingredients further, not only is this a more sustainable way to enjoy seafood, but also cost-effective by repurposing leftovers and cooking creatively.

Boxing Day brunch

Mix leftover kippers or smoked salmon with scrambled eggs for a tasty, zero-waste, Boxing Day brunch.

For best choice, make sure you buy kippers, or herring, from the North Sea and the North Irish Sea.

Zero-waste storage

A top tip from the Marine Conservation Society to avoid waste is freezing fish offcuts to save for future use.

Crisp up the skin

Even leftover fish skin can be turned into a quick savoury snack by crisping it up in an air fryer with a little olive oil and salt.

Anchovies two ways

Leftover anchovies can either be blended with butter to make a delicious anchovy butter or tossed into pasta for a hit of umami flavour.

The charity recommends opting for anchovies caught in the Bay of Biscay for best choice.

Fishcakes

For an easy, zero-waste meal, leftover seafood trimmings can be mixed with mash and fried in breadcrumbs to make fishcakes.

Pickled mussels

Try pickling mussels in 1:1 vinegar and water, with a dash of sugar for a sustainable, zero-waste snack that can be enjoyed well beyond the festive season.

Mussels farmed in the UK are a seafood superhero. Grown using low-impact methods and harvested by hand, they get all the food they need from the sea around them. This makes them one of the most sustainable, ocean-friendly, and cost-effective seafood options.

Players of People’s Postcode Lottery have raised £6.6M towards the Marine Conservation Society’s vital work in making seafood more sustainable.

Laura Chow, Head of Charities at People’s Postcode Lottery, said: “Fish is a festive favourite for many, but making sustainable choices when it comes to how we buy and eat seafood makes all the difference for our ocean. Support from players of People’s Postcode Lottery has helped the Marine Conservation Society further its sustainable seafood work, so that we can all enjoy healthier, better protected seas.”

The Marine Conservation Society encourages you to make sustainable seafood choices a year-round habit, not just for Christmas. To check how sustainable the seafood on your plate is, you can visit the charity’s Good Fish Guide. The Guide helps consumers and businesses identify the most sustainable seafood using a simple traffic light system, based on where and how species are caught or farmed. Green is the best choice, amber means improvements are needed, and red indicates fish to avoid buying.

Zero-waste gift idea

Why not embrace a zero-waste Christmas by gifting a membership to support marine conservation? It’s a meaningful, low-waste gift that helps protect our ocean for generations to come. Memberships start from as little as £5 a month – the price of a sandwich and drink from your local coffee shop.

Find the latest sustainable seafood advice for wild-caught and farmed seafood on the Good Fish Guide, downloadable to your phone from www.mcsuk.org/goodfishguide.

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