DIVING

MEDICINE

by

dr. Merlin Avongsa,

MKes
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CURRICULUM VITAE

Merlin Avongsa
Semarang, 20 Oktober 1971
Mayor Laut (K/W) Nrp. 13688/P
* Medical Faculty, Diponegoro
University Smg
* Underwater & Hyperbaric Medicine,
Post Graduate Program, Airlangga
University, Sby
* Underwater Medicine Course, HMAS
Penguin, Sydney

 * Medical Service, Eastern Fleet of

Indonesia Navy Sby
* Naval Health Institute of Indonesia
Navy Sby
* Medical Check-up, Naval Health
Department, dr. Mintohardjo, Navy
Hospital Jkt

DEFINITION
Diving is going underwater with or
without breathing equipment.
History :
1. Breath-hold diving
2. Breathing equipment

PHYSICS

Pressure :

* Boyles Law :
P1xV1 = P2xV2
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* Daltons Law :
P total = P1 + P2 + P3 + P..
100% O2 may be
breathed here, but
may become toxic

* Henrys Law :
Gases : O2, N2, CO2, inert
Buoyancy : density, specific
gravity
Environment :
* Temperature
* Light & colour
* Sound
* Altitude
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PHYSIOLOGY
Respiratory system

Cardiovascular system

Compressed air diving :

resistance to breathing
air consumption
Gas pressures narcosis
Breath Hold Diving

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DIVING STRESSOR
1.

AMBIENT PRESSURE

2.

GAS DENSITY

3.

GAS PARTIAL PRESSURE

4.

GAS DISSOLVED

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DIVING STRAIN
1. RESPIRATORY SYSTEM
2. CARDIOVASCULAR SYSTEM
3. CEREBRONEURAL SYSTEM
4. OTHERS (EYE, EAR, GIT etc)

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BAROTRAUMA
Ear Barotrauma

Middle Ear Equalisation (ME=) Clients Problem Check

List
I descend a bit slower than my buddies.
If there is any pressure, I halt my descent and wait a
bit. Or,
I may ascend until the ear clears. (Yo-Yo)

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WHY DO THESE PROCEDURES?

These procedures merely allow the ME to
fill with blood or tissue fluids, and thus
allow further descent with less pain or
discomfort. It results in middle ear
congestion, Eustachian tube
obstruction and other pathology which
may be temporary or permanent.

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SINUS BAROTRAUMA

PULMONARY BAROTRAUMA

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FACIAL OR MASK BAROTRAUMA

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DECOMPRESSION
SICKNESS
ETIOLOGY AND PATHOPHYSIOLOGY
Decompression sickness is a disease of some
clinical manifestations which is produced by
excessively rapid lowering ambient pressure.
This reduction causes inert gas dissolved in
tissue to come out of physical solution and
enter the gas phase.
The result is the formation of gas bubbles in
the tissue, and in arterial and the venous
blood
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PENYAKIT DEKOMPRESI
MENYELAM TEKANAN
MENINGKAT
KE PERMUKAAN TEKANAN
MENURUN
PROSEDUR DEKOMPRESI SALAH

GELEMBUNG GAS NITROGEN

PENYAKIT DEKOMPRESI

REKOMPRESI (OHB)RESOLUSI
GELEMBUNG
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CLINICAL MANIFESTATIONS
A. TYPE I (PAIN ONLY)
LIMB PAIN
LYMPHATIC MANIFESTATIONS
CUTANEOUS MANIFESTATIONS
B. TYPE II (SERIOUS)
CARDIOPULMONARY
CEREBRAL
SPINAL
VESTIBULAR

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PRINCIPLES OF FIRST AID MANAGEMENT

The principles of first aid management of
decompression sickness (DCS) are:
Basic life support (BLS).
100% oxygen (O2).
Positioning and rest
Fluid replacement
Hyperbaric Oxygen Therapy : table 5, table 6 or
table 6A

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O2 TREATMENT TABLE 5
O2 TREATMENT TABLE

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O2 TREATMENT TABLE
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IN WATER TREATMENT USING O2

Duration of O2 breathing periods
DEPTH (m)

9
8
7
6
5
4
3
2
1
0

depending on sysmtoms

Mild

More
serious

Most serious

30
12
12
12
12
12
12
12
12
12

60
12
12
12
12
12
12
12
12
12

90
12
12
12
12
12
12
12
12
12
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HBO FACILITIES IN INDONESIA

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DYSBARIC
OSTEONECROSIS
An area
of localized bone death, predominantly
occurring in the long bones of the arms and thighs.
Pain and symptoms of arthritis, along with a reduction
in mobility of the joint is a common consequence
often occurring in mid or later life.
A delayed effect of damage caused by gas bubbles
produced during a dive. In this sense it is a delayed
form of decompression sickness.

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OTHER PRESSURE RELATED

DISEASES
1. Nitrogen Narcosis
2. High Pressure Neurological
Syndrome
3. Hypoxia
4. Oxygen Toxicity
5. Carbon Dioxide Toxicity
6. Carbon Monoxide Toxicity
7. Breathing Gas Contamination
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DANGEROUS MARINE
ANIMALS

1. Shark

2. Box Jellyfish
3. Venomous Cone Shells

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4. Blue Ringed Octopus

5.Sea Snake

6. Stone Fish

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PRESSURE BANDAGE & IMMOBILISATION TECHNIQUE

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WHY DIVERS DIE

Diving Fatality Data
90% died with their weight belt on.
86% were alone when they died.
50% did not inflate their buoyancy vest.
25% encountered their difficulty first on the
surface,
50% actually died on the surface.
10% were under training when they died.
10% were advised that they were medically
unfit to dive.
5% were cave diving.
1% of rescuers became a victim
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Contributing factors :
1. Diving Techniques (Inadequate
air supply, buoyancy, buddy
system)
2. Human Factors (medical,
physiological, psychological)
3. Equipment Factors (misuse,
faults)
4. Environmental Factors
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ERSIAPAN SEORANG PENYELAM :

1. PERSIAPAN FISIK
2. PERSIAPAN
MENTAL
3. PERSIAPAN
PERTIMBANGKAN
:
KETRAMPILAN
1.APAKAH MENYELAM MEMPERBURUK
KONDISI ?
2.APAKAH KONDISI TSB AMAN BAGI
PENYELAM & BUDDY DIVER SELAMA
MENYELAM ?
3.APAKAH MENJADI PREDISPOSISI

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MEDICAL EXAMS FOR

DIVING

Diving medical format comprises of 3

sections
:
(1) Medical
history
(2) Diving [and diving medical]
history
(3) Clinical examination and
investigations.

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Riwayat Ganguan
Kesehatan
Kategori
Diskualifikasi
Asthma (except chilhood)
Mutlakor restrictive pulmonary
Chronic cystic, obstructive
disease
Chronic bronchitis
Spontaneous pneumothorax
Seizure disorders or frequent syncope
Diabetes requiring insulin, hypoglicemic episode central
nervous system disease of any kind, including vascular
insufficiency
Closed head or spinal cord injury with sequelae,
craniotomy, depressed skull fracture
Chronic perforation of tympanic membrane
Middle ear surgery with placement of protheses chronic
serous otitic media or otitis media
Chronic sinusitis

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Severe speech impediment

Sickle cell trait anaemia
Angina pectoris or myocardial infarction
Cardiac arrhythmia except occasional premature
ventricular contraction
Wolff-Parkinson-White Syndrome
Valvular heart disease
Congestive heart failure, cardiomyopathy, intracardial
shunt
Aseptic bone necrosis
Colour blindness
Claustrophobia,
suicidal
tendency
Occlusive peripheral
vascular
disease
Myasthenia
gravis, periodic paralysis
Chronic arthritis
Disk disease with neurologic deficit
Menieres disease, death labrynthi, episodic vertigo
Narcolepsy
Decompression sickness or gas embolism with persistant
neurologic deficit
Chronic renal disease
Active peptic ulceration
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Riwayat Ganguan
Kesehatan
Kategori Diskualifikasi
Dentures, difficulty
may be experience in holding a
Relatif
mouthpiece and denture may interferre with
resuscitation following a seizure or loss of consciousness
Heavy smoking, secretions and brochospasm may lead to
air trapping and air embolism
Migraine headache, prodomate may be confused with
decompression sickness or air embolism
Hernia, these may become strangulated or incarcerated
rupturing the bowel on ascent or requiring surgery at
depth if the diver is saturated

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Riwayat Gangguan Kesehatan

Kategori Disqualification
Temporarily
URI, sinusitis, seasonal allergic rhinitis or other
conditions that would interferre with proper
equalization
Acute bronchitis
Acute gastroenteritis
Recent orthopedic injury
Alcoholic or other drugs intoxication
Pregnancy

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MEDICAL CHECK LIST FOR

SNORKELLERS
Have you ever had any of the following medical
conditions :
1. Any cardiovascular disease?
(Heart, blood pressure, blood, etc).
YES NO
2. Any lung disease?
(Asthma, wheezing, pneumothorax, TB, etc.) YES NO
3. Any fits, epilepsy, convulsions or blackouts? YES NO
4. Any serious disease? (Such as diabetes)
YES NO
5. Serious ear, sinus or eye disease?
YES NO
6. Any neurological or psychiatric disease?
YES NO
7. Any family history of heart disease?
YES NO

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Over the last month have you had any of the following
:
8. Operations, illnesses, treatment?
YES NO
9. Drugs or medications? YES NO
10. If female, are you pregnant? YES NO
11. Can you swim 500 metres without aids?
NO YES
12. Can you swim 200 metres in 5 minutes or less? NO YES
NAME :
DoB :
ADDRESS :
(If under 16 years, guardian to sign.)
Note : If the candidate indicates an answer in the left
hand column, then further investigation or action is
required before snorkelling is considered as safe.
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THANK YOU
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