Diving and

Subaquatic
Medicine
fifth edition
Diving and
Subaquatic
Medicine
fifth edition

Carl Edmonds was the OIC of the Royal Australian Navy Diving Medical Unit,
Foundation President of the South Pacific Underwater Medical Society and Director
of the Australian Diving Medical Centre, Sydney, Australia
Michael Bennett is Academic Head, Wales Anaesthesia and Senior Staff Specialist,
Diving and Hyperbaric Medicine, Prince of Wales Hospital and University of New
South Wales, Sydney, Australia
John Lippmann is Founder and Chairman of Divers Alert Network Asia-Pacific,
Ashburton, Australia
Simon J. Mitchell is a Consultant Anaesthesiologist and Diving Physician, and Head,
Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Authors

Carl Edmonds, OAM, MB, BS (Sydney), MRCP Simon Mitchell, MB ChB, PhD, Dip DHM, Dip
(Lond.) FRACP, FAFOM, DPM, MRC Psych, Occ Med, Cert DHM (ANZCA), FUHM,
MANZCP, Dip DHM FANZCA
Director, Diving Medical Centre, Sydney, Head of Department, Department of
Australia (1970–2000) Anaesthesiology, University of Auckland,
Formerly, Officer in Charge Royal Australian Navy Auckland, New Zealand (2011–present)
School of Underwater Medicine (1967–1975) Consultant in Diving and Hyperbaric Medicine,
Formerly, President, South Pacific Underwater Slark Hyperbaric Unit, North Shore Hospital,
Medicine Society (1970–1975) Auckland, New Zealand (2012–present)
Consultant in Underwater Medicine to the Royal Formerly, Medical Director, Wesley Centre for
Australian Navy (1975–1991) Hyperbaric Medicine, Brisbane, Australia
Consultant in Diving Medicine (1967 until retired (1998–2002)
in 2015) Formerly, Director, Slark Hyperbaric Unit, Royal
New Zealand Navy Hospital, Auckland,
Michael Bennett, MB, BS (UNSW), DA (Lond.), New Zealand (1995–1998)
FFARCSI, FANZCA, MM (Clin Epi) (Syd.),
MD (UNSW), Dip DHM, FUHM John Lippmann, OAM, BSc, Dip Ed, MAppSc
Director, Department of Diving and Hyperbaric Founder, Chairman and Director of Research,
Medicine, Prince of Wales Hospital, Sydney, DAN (Divers Alert Network) Asia-Pacific
Australia (1993–2008) (1994–present)
Academic Head, Wales Anaesthesia, Sydney, Author or co-author of: The DAN Emergency
Australia (2012–present) Handbook, Deeper Into Diving, The Essentials
Formerly, President, South Pacific Underwater of Deeper Sport Diving, Scuba Safety in
Medicine Society (2008–2014) Australia, Oxygen First Aid, First Aid and
Formerly, Vice-President, Undersea and Hyperbaric Emergency Care, Automated External
Medical Society (2006–2007 and 2011–2012) Defibrillators, Advanced Oxygen First
Conjoint Associate Professor in Anaesthesia and Aid, Basic Life Support, Cardiopulmonary
Diving and Hyperbaric Medicine, University Resuscitation, Decompression Illness, Am I
of New South Wales, Sydney, Australia Fit to Dive? and various incarnations of these
(2010–present) books.

v
Contents

Authors v
List of abbreviations xi
Preface and excerpts from earlier editions xiii
Dedication xv
Acknowledgements xvii

Part 1 DIVING 1

1 History of diving 3
2 Physics and physiology 15
3 Free diving 27
4 Diving equipment 37
5 Undersea environments 53

Part 2  DYSBARIC DISEASES: Barotraumas 63

6 Pulmonary barotrauma 65
7 Ear barotrauma 81
8 Sinus barotrauma 103
9 Other barotraumas 115

Part 3  DECOMPRESSION SICKNESS 123

10 Decompression sickness: pathophysiology 125

11 Decompression sickness: manifestations 141
12 Decompression sickness: prevention 153
13 Decompression sickness: treatment 167
14 Dysbaric osteonecrosis 185

Part 4  ABNORMAL GAS PRESSURES 203

15 Inert gas narcosis 205

16 Hypoxia 217
17 Oxygen toxicity 229

vii
viii Contents

18 Carbon dioxide toxicity 245

19 Breathing gas preparation and contamination 255
20 High-pressure neurological syndrome 267

Part 5  AQUATIC DISORDERS: The drowning syndromes 273

21 Drowning 275
22 Pathophysiological and clinical features of drowning 285
23 The management of drowning 291
24 Salt water aspiration syndrome 303
25 Why divers drown 309

Part 6  OTHER AQUATIC DISORDERS 319

26 Seasickness (motion sickness) 321

27 Thermal problems and solutions 325
28 Cold and hypothermia 329
29 Infections 339
30 Scuba divers’ pulmonary oedema 357
31 Trauma from marine creatures 367
32 Venomous marine animals 377
33 Fish poisoning 397
34 Underwater explosions 405

Part 7  SPECIFIC DIVING DISEASES 411

35 The ear and diving: anatomy and physiology 413

36 The ear and diving: investigations 421
37 The ear and diving: hearing loss 429
38 The ear and diving: vertigo and disorientation 435
39 Cardiac problems and sudden death 449
40 Neurological disorders of diving 459
41 Psychological and neuropsychological disorders 467
42 Miscellaneous disorders 487
Carotid sinus syndrome 487
Caustic cocktail 488
Cold urticaria 488
Dental disorders 488
Hyperthermia 489
Musculoskeletal problems 489
Compression (hyperbaric) arthralgia 489
Cramp 489
Decompression 490
Lumbosacral lesions 490
Temporo-mandibular joint dysfunction 490
Tank carrier’s elbow 491
Ocular disorders 492
‘Bubble eyes’ 492
 Contents ix

Ocular problems from corneal lenses 492

Ocular fundus lesions 492
‘Swimmer’s eyes’ (blurred vision) 493
Trauma 493
Other disorders 493
Pulmonary oedema and dyspnoea 493
Diving diseases 493
Asthma provocation 493
Cold urticaria 494
Deep diving dyspnoea 494
Skin reactions to equipment 494
Contact dermatitis (mask, mouthpiece and fin burn) 494
Angioneurotic oedema (dermatographia) 494
Allergic reactions 495
Burns 495
Diaper Rash (nappy rash) 495
Fin ulcers 495
Trauma 495
43 Drugs and diving 497
44 Long-term effects of diving 509

Part 8 THE DIVING ACCIDENT 517

45 Stress responses, panic and fatigue 519

46 Why divers die: the facts and figures 527
47 Unconsciousness 551
48 First aid and emergency treatment 557
49 Oxygen therapy 567
50 Investigation of diving accidents 575
51 Investigation of diving fatalities 583

Part 9  MEDICAL STANDARDS FOR DIVING 601

52 Medical standards for snorkel divers 603

53 Medical standards for recreational divers 607
54 Medical standards for commercial divers 623
55 Asthma 629
56 Cardiac and peripheral vascular disease 649
57 Insulin-dependent diabetes mellitus 657
58 Age and diving 673
59 Diver selection 681

Part 10  SPECIALIZED DIVING AND ITS PROBLEMS 685

60 Female divers 687

61 Breath-hold diving 697
62 Technical diving 703
63 Divers with disabilities 719
x Contents

64 Submarine medicine 725

65 Occupational groups 731
66 Diving in contaminated water 737
67 Deep and saturation diving 739

Part 11 RELATED SUBJECTS 745

68 Hyperbaric equipment 747

69 Hyperbaric medicine 755

Appendix A: Decompression tables 767

Appendix B: US Navy recompression therapy tables 785

Appendix C: Recompression therapy options 793

Appendix D: Diving medical library 797

Appendix E: Diving medical training 801

Appendix F: Diving medical organizations and contacts 803

List of abbreviations

ADS atmospheric diving suit FEV1 forced expiratory volume in 1 second

ADV automatic diluent valve FIO2 fraction of inspired oxygen
AGE arterial gas embolism FVC forced vital capacity
ALS advanced life support HBOT hyperbaric oxygen therapy
ARDS acute respiratory distress syndrome HPNA high-pressure neurological syndrome
ATA atmosphere absolute IBCD isobaric counterdiffusion
ATG atmosphere gauge ICP intracranial pressure
BCD buoyancy compensator device IDDM insulin-dependent diabetes mellitus
BLS basic life support ILCOR International Liaison Committee on
BOV bail-out valve Resuscitation
BSAC British Sub-Aqua Club IPE immersion pulmonary oedema
CAD coronary artery disease IPPV intermittent positive pressure
CAGE cerebral arterial gas embolism ventilation
CCR closed-circuit rebreather ISO International Organization for
CMF constant mass flow Standardization
CPAP continuous positive airway pressure lpm litres per minute
CPR cardiopulmonary resuscitation MOD maximum operating depth
CSF cerebrospinal fluid msw metres of sea water
CSL Commonwealth Serum Laboratories NEDU Navy Experimental Diving Unit
DAN Divers Alert Network NOAA National Oceanic and Atmospheric
dB decibel Administration
DCI decompression illness NUADC National Underwater Accident Data
DCIEM (Canadian) Defence and Civil Centre
Institute of Environmental Medicine OPV over-pressure valve
DCS decompression sickness PaCO2 alveolar pressure of carbon dioxide
DDC deck decompression chamber PaCO2 arterial pressure of carbon dioxide
DPV diver propulsion vehicle PADI Professional Association of Diving
EAD equivalent air depth Instructors
ECC external cardiac compression PaO2 alveolar partial pressure of oxygen
ECG electrocardiogram PaO2 arterial partial pressure of oxygen
ECMO extracorporeal membrane oxygenation PCO2 partial pressure of carbon dioxide
ECoG electrocochleography PEEP positive end-expiratory pressure
EEG electroencephalogram PEF peak expiratory flow
ENG electronystagmography PFO patent foramen ovale
EPIRB electronic position-indicating radio PICO2 inspired partial pressure of carbon
beacon dioxide

xi
xii  List of abbreviations

PIO2 inspired partial pressure of oxygen SDPE scuba divers’ pulmonary oedema
PMCT post-mortem computed tomography SMB surface marker buoy
PMDA post-mortem decompression artefact SPUM South Pacific Underwater Medicine
PMV pressure maintaining valve Society
PN2 partial pressure of nitrogen SSBA surface-supply breathing apparatus
PO2 partial pressure of oxygen SWAS salt water aspiration syndrome
PPV positive pressure ventilation UHMS Undersea and Hyperbaric Medical
RAN Royal Australian Navy Society
RCC recompression chamber UPTD unit of pulmonary toxic dose
RGBM reduced gradient bubble model USN United States Navy
RMV residual minute volume (also VC vital capacity
respiratory minute volume) VER visual evoked response
SCR semi-closed-circuit rebreather VGE venous gas emboli
scuba self-contained underwater breathing VPM varying permeability model
apparatus V/Q ventilation-perfusion
Preface and excerpts from
earlier editions

This book is written for doctors and paramedics a comprehensive clinical text. We tried to remedy
who are called on to minister to the medical needs this. Our primary focus remains on the diving cli-
of those divers who venture on or under the sea. nician, the physician responsible for scuba divers,
It was based on our experience in dealing with a the diving paramedic and the exceptional diving
vast number of diving accidents and with trouble- instructor who needs some guidance from a prac-
shooting many diving problems, and it is also an tical reference text.
attempt to integrate the experience and more eru- Diving accidents are much better defined,
dite research of others. investigated and treated than when we com-
The very generous praise bestowed by review- menced writing on this subject, many years ago.
ers on the first edition of Diving and Subaquatic It  was our intent to present, as completely as
Medicine, and its surprising acceptance outside the ­possible, an advanced and informative book on
Australasian region, inspired us to prepare further clinical diving medicine. We have avoided the
editions of this text. ­temptation to write either a simplistic text or a
In the later editions, we attempted to be less research-­oriented tome.
insular. Instead of an Australian book about This text encompasses the range of diving dis-
Australian experiences, we sought the advice and orders experienced by divers. It presents all aspects
guidance of respected friends and colleagues from of diving medicine from ancient history to the
other countries, and from other disciplines, espe- latest trends, in a concise and informative man-
cially in the United Kingdom, the United States, ner. Each disorder is dealt with from a historical,
Canada, Japan and mainland Europe. This has not aetiological, clinical, pathological, preventive and
prevented us from being judgemental and selective ­t herapeutic perspective. Summaries, case histories
when we deemed it fit. This is still a very special- and revision aids are interspersed throughout. For
ized field where evidence-based medicine is in its the doctor who is not familiar with the world of
infancy. Truth is not always achieved by voting, diving, introductory chapters on physics and phys-
and consensus is often a transitory state. We have iology, equipment and the diving environments
documented what we believe to be current best have been included.
practice. The future will judge this. The inclusion of anecdotes and occasional
The extension of diving as a recreational and humour may lessen the load on the reader, as
commercial activity has led to the bewildered it does on the authors. As in previous editions,
medical practitioner’s being confronted with div- each chapter is edited by one of the authors, with
ing problems about which he or she has received overview and peer review available from the oth-
little or no formal training. Doctors interested in ers. This means that not always will there be exact
diving had previously found themselves without agreement among authors, and there may be some

xiii
xiv  Preface and excerpts from earlier editions

variation among chapters. This is inevitable when will experience as much excitement, fascination,
evidence and consensus are not always complete. achievement, ­camaraderie and fun from diving as
It is also healthy for the future. we have.
Three of the four previous authors have
departed from this scene, and the fourth is about Carl Edmonds, 2015
to leave. The baton needs to be passed. Our leg- on behalf of all previous
acy and intent are that our younger colleagues and new authors of this text.
Dedication

This book is dedicated to the memory of Pluto, who study when the original three authors were postu-
died, even though he never left dry land. lating about an appropriate dedicatee for their text.
I have often been asked who Pluto was. He was We could not decide between Paul Bert, Al Behnke,
a much loved basset hound who strolled into our Jr., and J.B.S. Haldane. Pluto solved our dilemma.

xv
Acknowledgements

Carl Edmonds, John Lippmann, Michael Bennett Peter Bennett Eric Kindwall
and Simon Mitchell would like to thank Chris­ Ralph Brauer Clarrie Lawler
topher Lowry, John Pennefather and Robyn Walker Greg Briggs Christopher Lawrence
for their invaluable contributions to previous edi- Ian Calder Dale Mole
tions, upon which material in this latest fifth edition Jim Caruso Owen O’Neill
is based. Richard Chole John Pearn
We wish to acknowledge the assistance given David Dennison Peter Sullivan
by the Royal Australian Navy, the Royal Navy and Chris Edge Ed Thalmann
the United States Navy for permission to repro- Glen Egstrom John Tonkin
duce excerpts from their diving manuals, and to David Elliott John Williamson
the many pioneers on whose work we have so heav- Des Gorman David Yount
ily drawn, our families who have suffered unfairly, John Hayman
and our clinical tutors – the divers.
Numerous experts have been consulted to Originally published in 1976 by the Diving Medical
review and advise on specific chapters of this or Centre (Australia) ISBN 09597191-0-5.
previous editions. Our gratitude is extended to
these valued colleagues, but they are not to blame
for the final text. They include the following:

xvii
 5
Undersea environments

Introduction 53 Night diving 59

Altitude diving 53 Water movements 59
Cave and wreck diving 55 White water 59
Cave diving 55 Surge 59
Wreck diving 56 Inlets and outlets 59
Cold/ice diving 56 Tidal currents 59
Deep diving 57 Surf 61
Fresh water diving 58 Further reading 62
Kelp diving 58

INTRODUCTION the effects of cold (see Chapters 27 and 28), ­a ltitude

and fresh water diving (see Chapter  2),  explo-
For the diver who is adequately trained and physi- sives (see Chapter 34), depth (see Chapters 2, 15,
cally fit, who is aware of the limitations of the 20, 46  and 68) and marine animal injuries (see
­equipment and who appreciates the specific require- Chapters 31 and 32). Other environmental topics
ments of different environmental diving conditions, that are covered more comprehensively in diving
the sea is rarely dangerous. Nevertheless, it can be texts are summarized in this chapter.
hazardous and unforgiving if attention is not paid Being kept underwater and exceeding the lim-
to all these factors. ited air supply will result in drowning. This is a
Diver training is specific to the environment in situation common to many of the hazardous envi-
which the diver is trained. Specialized techniques ronments, including caves and wrecks and under
are recommended to cope with different environ- ice, overhangs, water flows and so forth. A variety
ments. They cannot be automatically extrapolated of materials can trap the diver, including kelp, lines
to other diving environments. The induction of fear (even ‘safety’ lines), fishing nets and fishing lines.
in the inexperienced diver and of physical stress in If the diver does not have a compromised air sup-
the more skilled diver is appreciated only when one ply, then knowledge of the environment, a buddy,
examines each specific environmental threat. These a communication facility, a calm state of mind and
environmental stresses are mentioned in this and a diving knife or scissors will cope with most of
other chapters. The reason for including them in a these circumstances.
medical text is that unless the physician compre-
hends the problems and dangers, the medical exami- ALTITUDE DIVING
nations for diving fitness and the assessments of
diving accidents will be less than adequate. The term altitude diving refers to diving at an alti-
Some aspects of the environments have physi- tude of 300 metres or more above sea level. Non-
ological and pathological sequelae and therefore diving disorders should be considered, such as the
have specific chapters devoted to them. They include dyspnoea and hypoxia induced by high altitude
53
54  Undersea environments

and the altitude sickness that frequently develops decompression stops, the nitrogen load in tissues
above 3000 metres. Diving at altitudes higher than afterward, the safe durations before flying or repet-
this is strongly discouraged. itive diving, the ascent rates recommended during
The following numerical examples do not rep- diving and so forth. Formulae are available to con-
resent actual diving conditions and are used to vert the equivalent altitude decompressions to sea
explain the problems as simply as possible, thus level decompressions.
avoiding complicated mathematics. The conven- Another problem of diving in a high-altitude
tional idea of diving is that a diver descends with lake is the rate at which a diver may have to exhale
the sea surface (1 ATA) as the reference point and during ascent. A diver who ascends from 10 metres
returns there when he or she has finished the dive. (2 ATA) to the ocean surface (1 ATA) would find that
A diver may have to dive at altitude, in a mountain the volume of gas in the lungs has doubled. Most
lake or dam, where the pressure on the surface is divers realize this and exhale at a controlled rate
less than 1 ATA. Problems stem from the physics during ascent. They may not realize that an equiva-
at this altitude. lent doubling in gas volume occurs in only 5 metres
For simplicity’s sake, the following descrip- of ascent to the surface, if the dive was carried out at
tion is based on the useful, but not strictly cor- an altitude (pressure) of 0.5 ATA. Equivalent effects
rect, traditional theory that the ratio between the are encountered with buoyancy, which can more
pressure reached during the dive and the final rapidly get out of control at altitude.
pressure determines the decompression required. The diver’s equipment can also be affected or
If this ratio is less than 2:1, then a diver can ascend damaged by high-altitude exposure. Some pres-
safely without pausing during ascent. This means sure gauges start to register only when the pressure
that a diver from the sea surface (1 ATA) can dive is greater than 1 ATA. These gauges (oil-filled, ana-
to 10 metres (2 ATA) and ascend safely, as regards logue and mechanical types) may try to indicate a
decompression requirements. A diver operating negative depth, perhaps bending the needle, until
in a high mountain lake, with a surface pressure the diver reaches 1 ATA pressure. Thus, the dive
of 0.5 ATA, could dive only to 5 metres (1 ATA) depth would have to reach more than 5 metres
before he or she had to worry about decompres- before it even started measuring, if the dive had
sion. This statement ignores the minor correction commenced at an altitude of 0.5 ATA.
required with fresh water. Fresh water is less dense The other common depth gauge, a capillary
than salt water. tube, indicates the depth by an air-water boundary.
Another pressure problem occurs when a diver, It automatically adjusts to the extent that it always
who dives at sea level, then flies or ascends into the reads zero depth on the surface. The volume of
mountains after the dive. For example, a 5-metre gas trapped in the capillary decreases with depth
dive (1.5 ATA) from sea level could be followed (Boyle’s Law). For a diver starting from 0.5 ATA
by an immediate ascent to a pressure (altitude) of altitude, this gauge would read zero, but it would
0.75 ATA, with little theoretical risk. Deeper dives show that the diver had reached 10 metres when
or greater ascents may require the diver to pause at he or she was only at 5 metres depth. Theoretically,
sea level if the diver is to avoid decompression sick- the diver could plan the dive and decompression
ness. If the diver ascends, in a motor vehicle or an according to this ‘gauge’ depth, but only if he or she
airplane, the reduced pressure will expand ‘silent’ was very courageous.
bubbles or increase the gas gradient to produce Many electronic dive computers do permit cor-
larger bubbles, thereby aggravating the diseases rection for altitude, and some need to be ‘re-zoned’
of pulmonary barotrauma and decompression at the dive site. Other decompression meters are
sickness. damaged by exposure to altitude (e.g. as in aircraft
Thus, exposure to altitude after diving, or div- travel), and the applicability of other dive comput-
ing at altitude, increases the danger of decompres- ers to altitude diving or saturation excursions is
sion sickness, compared with identical dives and questionable.
exposures at sea level. It influences the decom- Divers who fly from sea level to dive at altitude,
pression obligations, the depths and durations of as in high mountain lakes, may commence the dive
 Cave and wreck diving  55

with an already existing nitrogen load in excess of The diver descends, often through a small
that of the local divers, who have equilibrated at access, passes down a shaft, goes around a few
the lower pressures. Thus, the ‘sea level’ divers are bends and is faced with multiple passages, in total
in effect doing a repetitive dive, and ‘residual nitro- darkness. Under these conditions, and to make
gen’ tables must be employed. this particular type of diving safe, it is necessary
Decompression tables that supply accept- to be accompanied by a diver who has consider-
able modifications for altitude exposure include able cave experience – in that cave – and whose
the Buhlmann and Canadian Defence and Civil judgement is trustworthy. It is equally important
Institute of Environmental Medicine (DCIEM) that the equipment is both suited to cave diving
tables (see Appendix A). and totally replaceable with spares during the
Altitude exposure and altitude diving are more dive. Apart from the obvious environmental dif-
hazardous extensions of conventional diving. ficulties inherent in diving through a labyrinth of
They are not as well researched, and the greater passageways, there are added specific problems.
the altitude, the more applicable is this statement. Safety in cave diving is not usually achievable
It  includes not only the problems already men- by immediate surfacing. Thus, all necessary equip-
tioned, but also the complication of diving in fresh, ment must be duplicated for a long return swim,
often very cold, water. This water may contain at depth, and possibly while rescuing a disabled
debris that has not decomposed as it would in the companion.
ocean and may therefore threaten entrapment. The Air pockets found in the top of caves are
sites are often distant from diving medical facili- sometimes non-respirable because of low oxy-
ties. Undertaking a specialized course in altitude gen and high carbon dioxide levels (especially in
diving is a basic prerequisite. limestone caves), so when entering this pocket,
breathing should be continued from the scuba
CAVE AND WRECK DIVING equipment. Sometimes the roof of the cave is
supported by the water, and when this water is
These enclosed environments are hazardous to replaced by air from the diver’s tanks, the roof
open water divers. Cave diving and wreck diving are can collapse. The common claim that ‘the diver
more complex than they first appear. Completion of was so unlucky for the roof to collapse while
the open water scuba training course is inadequate he was there’ is incorrect. It collapsed because he
preparation for cave and wreck diving. Planning was there.
involves not only the setting of goal-oriented The minimum extra safety equipment includes
objectives, but the delineation of maximum lim- a compass, powerful lights and a safety reel and
its (depths, distances). The main problems are as line. It is a diving axiom that entry into a cave is
follows: based on the presumption that the return will have
to be carried out in zero visibility.
●● No direct ascent to the surface (i.e. safety). For visibility, each diver takes at least two
●● Disorientation and entrapment. lights; however, other factors can interfere with
●● Loss of visibility. the function of these lights. A great danger is
●● Enclosed spaces and panic. the silt that can be stirred up if the diver swims
along the lower part of the cave or in a head-up
Cave diving position (as when negatively buoyant). If there is
little natural water movement, clay silts can be
The techniques of cave diving are very rigidly delin- very fine and easily stirred up. It is for this reason
eated. Specialized training includes dive planning, that fins should be small, and the diver should be
the use of reels and lines and the lost diver proto- neutrally buoyant and should swim more than a
cols. Most people who have difficulties with cave metre above the bottom of the cave. Visibility can
diving have not followed the recommended rules, be totally lost in a few seconds as the silt curtain
and unfortunately cave diving problems tend to ascends, and it may remain that way for weeks.
cause multiple fatalities. Sometimes it is inevitable, as exhaled bubbles
56  Undersea environments

dislodge silt from the ceiling. Layering of salt penetrations, not vertical. Otherwise, entangle-
and fresh waters also causes visual distortion and ment is likely with rapid ascents, especially if
blurring. divers precede the lead diver. Thin, non-floating
The usual equipment includes double tanks man- lines especially cause entanglement if they are
ifolded together, making a common air supply, but allowed to slacken.
offering two regulator outlets. With the failure of Specialized cave diving training is a ­prerequisite
one regulator, the second one may be used for the air for this diving environment.
supply – or as an octopus rig. The second regulator
must have a long hose, given that often divers cannot Wreck diving
swim alongside each other. Because of space limita-
tions, buddy breathing is often impractical under Wreck diving has potentially similar problems
cave conditions. An extra air supply (‘pony’ bottle) to some cave and ice diving. In addition, it has
is advisable. the hazards of instability of the structure and the
For recreational divers to explore caves, the dangers of unexploded ordnance, sharp objects,
ideal equipment is a reliable compressed air sur- toxic cargo and fuel. Exhausted gas from scuba
face supply, with a complete scuba back-up rig. may cause air pockets and disrupt the wreck’s
All the instruments should be standardized; e.g. stability.
the watch goes on the left wrist, the depth gauge Silt in wrecks is usually heavier than that in still
above it, the compass on the right wrist and the water caves. Thus, the sudden loss of visibility that
dive computer (this can include a contents gauge, can occur when silt is stirred up may be less persis-
decompression meter, dive profile display, com- tent. The diver should ascend as far as is safe and
pass) attached to the harness under the left arm. wait until the silt cloud settles down.
The gauges and decompression must be modified
for fresh water and altitude, if these are applicable. COLD/ICE DIVING
The knife is strapped to the inside of the left leg, to
prevent entanglement on any safety lines. The obvious problems are those of cold and hypo-
The buoyancy compensator is often bound thermia. They are so obvious that most people will
down at the top, to move the buoyancy centre more avoid them by the use of heating systems, drysuits
toward the centre of gravity (cave divers do not need or efficient wetsuits. See Chapters 27 and 28 for
to be vertical with the head out of water). There is the effects of a cold environment on physiological
no requirement for excess buoyancy because safety performance.
in cave diving is not usually equated with a direct A major difficulty with cold and ice diving is the
ascent; thus, any carbon dioxide cylinders should tendency of many single hose regulators to freeze,
be removed and replaced with exhausted ones to usually in the free-flow position, after about 20 to
prevent accidental inflation of vests. A principle of 30 minutes of exposure to very cold water (less
cave diving is that safety lies in retracing the entry than 5°C). This situation is aggravated if there is
path by the use of lines and not by ascent, as in the water vapour (potential ice crystals) in the com-
normal open ocean diving. pressed air and if there is a rapid expansion of air,
Preferably no more than three divers should which produces further cooling in both first and
undertake a single dive, and on completion of the second stages. The first stage or the second stage
dive each should have a minimum of one third of may then freeze internally.
the initial air supply. If there is water flow within Expansion of air as it passes from the high tank
the cave, and the penetration is with the flow, this pressure to the lower pressure demand valve and
reserve air supply may not be adequate because the then to environmental pressures (adiabatic expan-
air consumption is greater when returning against sion) results in a drop in temperature. It is therefore
the current. not advisable to purge regulators if exposed to very
Vertical penetrations need a heavy shot line cold temperatures. The freezing from increased air
moored or buoyed at the surface and weighted or flow follows exertion, hyperventilation or panic.
fixed at the bottom. The reel is used for horizontal Octopus rigs become more problematic to use
 Deep diving  57

under these conditions, or at great depth, because insulating ability. In that case, non-­ compressible
of this increased air flow. An emergency air source wetsuits, inflatable drysuits or heated suits are
(pony bottle) has replaced buddy breathing and required. In Antarctic diving, to gain greater dura-
octopus rigs. tion, we had to employ a wetsuit or other thick cloth-
‘External’ ice is formed in and around the ing under a drysuit.
first (depth compensated) stage of the regulator, Ice diving is in many ways similar to cave div-
thus blocking the orifice and interfering with the ing. It is essential that direct contact must always
spring. Moisture from the diver’s breath or water be maintained with the entry-exit area. This should
in the exhalation chamber of the second stage may be by a heavy-duty line attached to the diver via a
also freeze the demand mechanism, causing free bowline knot. The line must also be securely fas-
flow of gas or ‘internal’ freezing with no flow. tened at the surface, as well as on the diver. The
Modifications designed to reduce freezing of dive should be terminated as soon as there is a
the water in the first stage include the use of very reduced gas supply or any suggestion of cold expo-
dry air and the replacement of first-stage water-­ sure with shivering, diminished manual dexterity
containing areas with silicone, oils or alcohols and so forth.
(which require lower temperatures to freeze) or The entry hole through the ice should be at least
with an air flow from the regulator. The newer, two divers wide. Allowing room for only one diver
non-metallic second stages are less susceptible to enter ignores two facts. First, the hole tends to
to freezing. Despite all this, regulator freezing is close over by freezing. Second, in an emergency
common in polar and ice diving. Surface supply two divers may need to exit simultaneously. There
with an emergency scuba, or twin tank–twin regu- should be a surface tender with at least one standby
lator diving, as with cave diving, is probably safer. diver. A  bright light, hanging below the surface at
It must be presumed in under-ice diving that the the entry-exit hole, is also of value in identifying the
regulator will freeze and induce an out-of-air situ- opening. If large diving mammals contest the open-
ation, and this must be planned for. ing in the ice, they should be given right of way.
Under ice there is little use for snorkels, and If the penetration under the ice is in excess of
so these should be removed to reduce the likeli- a distance equated with a breath-hold swim, then
hood of snagging. Rubber suits can become sharp a back-up scuba system is a requirement, as with
and brittle. Zippers are best avoided because they cave diving.
freeze and may also allow water and heat exchange.
Buoyancy compensators should be small and with DEEP DIVING
an independent air supply.
As a general rule, and if well-fitting drysuits ‘Divers do it deeper’ represents a problem with
are unavailable, the minimum thickness of the ego trippers and a challenge to adventure seekers.
Neoprene should increase with decreased water Unfortunately, the competitive element sometimes
temperatures, as in the following examples: overrides logic, and divers become enraptured,
literally, with the desire to dive deeper. They then
<5°C – 9-mm-thick wetsuit move into a dark, eerie world where colours do not
<10°C – 7-mm-thick wetsuit penetrate, where small difficulties expand, where
<20°C – 5-mm-thick wetsuit safety is farther away and where the leisure of rec-
<30°C – 3-mm-thick wetsuit reational diving is replaced with an intense time
urgency.
Hood, gloves and booties should be of a con- Beyond the 30-metre limit the effect of narco-
siderable thickness, or heat pads can be used. Heat sis becomes obvious, at least to observers. The gas
pads must not be in contact with high-oxygen supply is more rapidly exhausted and the regulator
gases because overheating can result. is less efficient. Buoyancy, resulting from wetsuit
Unheated wetsuits do not give sufficient insula- compression, has become negative, with an inevi-
tion at depth (beyond 18 metres) when the Neoprene table reliance on problematic equipment, such as
becomes too compressed and loses much of its the buoyancy compensator. The reserve air ­supply
58  Undersea environments

does not last as long, and the buoyancy compen- as an anchor chain for people to use when they
sator inflation takes longer and uses more air. are equalizing their ears, as well as to attach other
Emergency procedures, especially free and ­buoyant objects such as floats, diver’s flags, surf mats, speci-
ascents, are more difficult. The decompression men bags and so forth.
tables are less reliable, and ascent rates become Giant members of this large brown algae or
more critical. seaweed may grow in clear water to depths of
Overcoming some problems leads to unintended 30 metres. The growth is less in turbid or unclear
consequences. Heliox (helium-oxygen mixtures) water. Kelp usually grows on hard surfaces, e.g. a
reduces the narcosis of nitrogen, but at the expense rocky bottom, a reef or, for more romantic divers,
of thermal stress, communication and altered a Spanish galleon. It is of interest commercially
decompression obligations. Inadequate gas supplies because it is harvested to produce alginates, which
can be compensated by larger and heavier cylinders, are useful as thickening, suspending and emulsify-
or even by rebreathing equipment, but with many ing agents, as well as in stabilizing the froth on the
adverse sequelae (see Chapter 62). diver’s glass of beer (après dive, of course).
Many of the older, independent instructors Kelp has caused many diving accidents, often
would qualify recreational divers only to 30 metres. with the diver totally bound up into a ‘kelp ball’
Now, with instructor organizations seeking other that becomes a coffin. The danger of entanglement
ways of separating divers from their dollars, spe- is related to panic actions and/or increased speed
cialty courses may be devised to entice divers to and activity of the diver while in the kelp bed.
‘go deep’ before they have adequately mastered the Twisting and turning produce entanglement.
shallows. Divers who are accustomed to kelp diving
usually take precautions to ensure that there is
FRESH WATER DIVING no equipment that can snag the strands of kelp;
i.e. they tend to wear knives on the inside of the
The main problem with fresh water is that it is not the leg, tape the buckles on the fin straps, have snug
medium in which most divers were trained. Thus, quick-release buckles and not use lines. Divers
their buoyancy appreciation is distorted. Acceptable descend vertically feet first to where the stems are
weights in sea water may be excessive in fresh water. thicker and there is less foliage to cause entangle-
Depth gauges are calibrated for sea water, and so ment. The epitome of bad practice in kelp diving
they need to be corrected for diving in dams, lakes, is to perform a head first roll or back roll because
quarries and so forth. Because these waters are often it tends to result in a ‘kelp sandwich with a diver
stationary, there may be dramatic thermoclines, filling’.
requiring adjustments for thermal protection and The kelp is pushed away by divers as they slowly
buoyancy, as one descends. descend and ascend; i.e. they produce a clear area
There are also many organisms that are destroyed within the kelp, into which they then move. They
by sea water but that thrive in warm fresh water. ensure that they do not run out of air because this
Some of these, such as Naegleria, are fatal. situation will produce more rapid activity. If they
do become snagged, divers should avoid unneces-
KELP DIVING sary hand and fin movements. Kelp can be sepa-
rated either by the use of a knife or by bending
Kelp beds are the equivalent of underwater for- it to 180 degrees, when it will often snap (this is
ests. Kelp can be useful in many ways to the diver. more difficult to achieve while wearing gloves). It is
It allows a good estimate of clarity of the water by unwise to cut kelp from the regulator with a knife
assessing the length of plant seen from the surface. without first clearly differentiating it from the reg-
The kelp blades indicate the direction of the pre- ulator hose. Some divers have suggested biting the
vailing current. In kelp beds there is usually an strands with one’s teeth. This may be excellent as
abundance of marine life, and the kelp offers other regards dietary supplementation, kelp being high
benefits such as dampening wave action both in in both B vitamins and iodine, but it does seem
the area and the adjacent beach. Kelp can be used overly dramatic.
 Water movements  59

Kelp does float, and it can often be traversed on WATER MOVEMENTS

the surface by a very slow form of dog paddling
or ‘kelp crawl’, in which one actually crawls along Because of the force of water movement, a diver
the surface of the water, over the kelp. This can be can become a hostage to the sea.
done only if the body and legs are kept flat on the
surface, thus using the buoyancy of both the body White water
and the kelp, and by using the palms of the hands
to push the kelp below and behind as one proceeds This water is white because of the foaming effect of
forward. Any kicking that is performed must be air bubbles. This dramatically interferes with both
very shallow and slow. visibility and buoyancy, as well as implying strong
currents or turbulent surface conditions. A diver in
NIGHT DIVING white water is a diver in trouble. Under these condi-
tions, the recommendation is usually to dive deeper.
Because of the impaired visibility, extra care is
needed for night diving. Emergency procedures Surge
are not as easy to perform without vision. There is
a greater fear at night. For inexperienced divers it The to-and-fro movement of water produces dis-
is advisable to remain close to the surface, the bot- orientation and panic in inexperienced divers, who
tom or some object (e.g. anchor, lines). Free swim- often try to swim against it. Other divers use the
ming mid-water and without objects to focus on surge by swimming with it, then hold onto rocks
causes apprehension to many divers. or corals when the surge moves in the opposite
Preferably the site should be familiar, at least direction. This approach may be detrimental to the
in daylight, without excessive currents or water ­ecology, but good for survival.
movements and with easy beach access – diving
between the boat and the shore. On entry the diver Inlets and outlets
sometimes encounters surface debris that was not
obvious from the surface. Occasionally, there is a continuous water flow,
Any navigational aid needs to be independently because of a pressure gradient through a restricted
lighted. This includes the boat, the exit, buoys, opening, which can siphon and hold (or even
buddies and so forth. A chemoluminescent glow extrude) the diver. It is encountered in some caves,
stick (Cyalume light) should be attached firmly blue holes or rock areas near surf (an underwater
to the tank valve, and at least two reliable torches ‘blow hole’), in human-made structures such as the
should be carried. The snorkel should have a fluo- water inlets in ships’ hulls and in outlets in dams
rescent tip. A compass is usually required. A whis- and water cocks (taps). The pressure gradient may
tle and a day-night distress flare are sometimes of slowly draw the diver into its source and then seal
great value in summoning the boat operator, who him or her in, like a bath plug. Protection is by not
has not the same capabilities of detecting divers at occluding these inlets and by avoiding the area or
night. covering it with a large grating.
Marine creatures are sometimes more difficult
to see. Accidents involving submerged stingrays Tidal currents
and needle spine sea urchins are more likely.
Signals include a circular torch motion (‘I am These currents are very important to the diver. If
OK, how about you?’) or rapid up and down move- used correctly, they take the diver where he or she
ments (‘something is wrong’). The light should wants to go. Otherwise, they are likely to take the
never be shone at a diver’s face because it blinds diver where he or she does not want to go. The lat-
him or her momentarily. Traditional signals can be ter event can be both embarrassing and terrifying,
given by shining the light onto the signaling hand. and it can also be very physically demanding.
Waving a light in an arc, on the surface, is a sign Frequently, divers are lost at sea because of cur-
requesting pickup. rents. Sometimes these currents can be vertical and
60  Undersea environments

cannot be combated by swimming or buoyancy. underwater and return with ease if desired or to
Certain popular diving areas, such as at Palau (espe- rescue a companion.
cially Pelalu), Ras Muhammad, the Great Barrier The lines attached to the boat are of extreme
Reef and Cozumel, are famous for their currents, importance when there are currents. First, there is
and multiple fatalities are not uncommon. the anchor line, and this is the recommended way
Divers sometimes relate their successful swims to reach the sea bed upstream from the boat. The
against 4- to 5-knot currents. In fact, the aver- anchor chain should not be followed right down
age fast swim approximates 1.2 knots. For brief to the anchor because this may occasionally move
periods, it may be possible to reach up to 1.5 if the boat moves, and it can cause damage to the
knots. The average swimmer can make very slow adjacent divers. More than one diver has lost an
progress or none at all against a 1-knot current. eye from this ‘freak accident’. How may the diver
A half-knot current is tolerable, but most div- reach the anchor line? A line may be attached to
ers experience this as a significant problem, and the top of the anchor line, with the other end to the
so it is. They tend to exaggerate the speed of the stern of the boat. It should have enough play in it
current as the hours go by, and especially during to allow divers to sit on the side of the boat and to
the après-dive euphoria (1  knot = approximately hold it with one hand – the hand nearest the bow
2 km/hour). of the boat – while using the other hand to keep the
Tidal currents are usually much faster on the face mask and demand valve in place. On entry, the
surface than they are on the sea bed because of diver ensures that he or she does not let go the line.
friction effects. A helpful observation is that the The diver then pulls himself or herself forward to
boat will usually face the current with its anchor the anchor line and descends.
upstream and the stern of the boat downstream. Perhaps the most important line, if there is a
Any diver worth his or her salt knows that it is current, is a float line or ‘Jesus’ line. This line drags
safer to swim against the current for the first half 100 metres or more behind the boat, in the direc-
of the usable air and allow the current to bring the tion of the current, and it has some floats to ensure
diver back to the boat for the second half of the that it is always visible to divers on the surface. It is
dive. The ‘half-tank rule’ is worked out by tak- often of value to have one diver on this line while
ing the initial pressure, say 200 ATA, subtract the the others are entering the water. The diver on the
‘reserve’ pressure (the pressure needed to charge line virtually acts as a backstop to catch the odd
the regulator), say 40 ATA, i.e. 160 ATA, and divide stray diver who has not followed instructions and
this by 2, i.e. 80 ATA. Thus, for this example, 80 is now floating away with the current. The Jesus
ATA is used on the outward trip, and then the line is also of immense value at the end of the dive
return is made with ample air to allow for misad- when divers have, incorrectly, exhausted their air
venture (e.g. navigational error). supply or when they come to the surface for some
Untrained divers tend to make unplanned other reason and find themselves behind the boat.
dives. They submerge and ‘just have a look around’. This would not have happened had a dive plan been
While they are having their look around they are constructed and followed correctly. Occasionally,
being transported by the current, away from the however, it does happen to the best divers, and it is
boat, at a rate of 30 metres every minute in a 1-knot of great solace to realize that the Jesus line is there
current. When they consider terminating the dive, and ready to save the sinner – irrespective of reli-
after they have used most of their air, they have a gious persuasion.
very hard return swim against the current. They Even divers who surface only a short way behind
surface, because of their diminished air supply, the boat in a strong surface current may find that
well downstream from the boat and have to cope it is impossible to make headway without a Jesus
with a faster, surface current. This is a very diffi- line. If this is not available, they can descend and
cult situation and far more hazardous, than that of use their compass to navigate back to the anchor
the experienced diver who used the half-tank rule, line or inflate the buoyancy compensator, attract
who surfaced upstream from the boat and floated the attention of the boat lookout and hope to be
back to it, but who also had enough air to descend rescued.
 Water movements  61

Buddy breathing while swimming against a off Florida and the Torres Strait, but tidal currents
strong current is often impossible. Even the octo- are likely to give an hour or more of slack water
pus (spare) regulator is problematic at depth or with the change of tide. At these times diving is
when two people are simultaneously demand- usually safer and more pleasant because the sedi-
ing large volumes of air, typical of divers swim- ment settles and enhances visibility. To ascertain
ming against a current. An alternative air supply the correct time for slack water, reference has to be
(a reserve or pony bottle) is of value, if it has an made to the tidal charts for that area. The speed
adequate capacity. of the current can be predicted by the tidal height.
In dive planning, there should be at least one
accessible fixed diving exit, easily identifiable, that Surf
serves as a safe haven. This may be an anchored
boat, in areas with tidal currents. The safety boat Entry of a diver through the surf is loads of fun
is a second craft – not anchored – and this, like any to an experienced surf diver. Otherwise, it can be
boat that is driven among divers, needs a guard on a tumultuous moving experience and is a salutary
its propeller. To attract the safety boat, various res- reminder of the adage ‘he who hesitates is lost’. The
cue options include the following: major problem is that people tend to delay their
entry at about the line of the breaking surf. The
●● A towed buoy. diver, with all his or her equipment, is a far more
●● An inflatable 2-metre-long bag, called the vulnerable target for the wave’s momentum than is
‘safety sausage’, to attract attention. any swimmer.
●● Pressure tested distress flare (smoke/light). The warning given to surfers, referring to water
●● Personal floatation devices. colour, is that ‘White is right but green is mean and
●● Personal electronic, sonic or luminous location blue is too’. This ensures that the surfer enters the
devices. surf and avoids rips. For the diver, it is the oppo-
site. The diver may use the apparently calmer water
Divers can now carry a personal location bea- to ride the rip into the ocean.
con or emergency position-indicating radio bea- When the surf is unavoidable, the recommen-
con (EPIRB), especially of value if diving in fast dation is that the diver should be fully equipped
currents. These devices need to be pressure pro- before entry and not re-adjust face masks and fins
tected and are of value only once on the surface. until he or she is well through the surf line. The fins
There are other problems with currents, and and face mask must be firmly attached beforehand
these are especially related to general boat safety because it is very easy to lose equipment in the surf.
and ensuring that there is a stable anchorage. The diver walks backward into the surf while look-
When the current is too strong or the depth or ing over his or her shoulder at the breakers and
sea bed is not suited to an anchored boat, a float or also toward a buddy. The face mask and snorkel
drift dive may be planned. This requires extreme have to be held on during the exposure to breaking
care in boat handling. Divers remain together and waves. The regulator must be attached firmly to the
carry a float to inform the safety boat of their posi- jacket, with a clip, so that it is easily recoverable at
tion. It allows the surface craft to maintain its posi- all times.
tion behind the divers as they drift. When a wave does break, the standing diver
The concept of ‘hanging’ an anchor, with divers presents the smallest possible surface area to it;
drifting in the water near it and the boat being at i.e.  he or she braces against the wave, sideways,
the mercy of the elements, has little to commend it. with feet well separated, and he or she crouches
The raising of the diver’s flag under such ­conditions, and leans, shoulder forward, into the wave. As
although it may appease some local authorities, is soon as possible, the diver submerges and swims
often not recognized by the elements, reefs or other (in preference to walking) through the wave area.
navigational hazards, including moored boats. If the diver has a float, then this is towed behind.
Some currents are continuous, e.g. the standing It should never be placed between the diver and
currents of the Gulf of Mexico, the Gulf Stream the wave.
 27
Thermal problems and solutions

Basic temperature physiology 325 Diving in hot environments 327

Diver in shallow water 326 Diver in a recompression chamber 328
Deep diver 327 Further reading 328

BASIC TEMPERATURE PHYSIOLOGY losing heat is in warming material that enters

the body. Warming and humidifying air before
For a diver in the water or a pressure chamber, it reaches the lungs are continuous heat drains.
the heat transfers are often greater than normally Ingestion of cool food and drinks plays only a
experienced on land. Most readers will not need small part.
a more detailed discussion of basic temperature A constant temperature is maintained if the
physiology. Any who do are advised to read any of production and loss of heat remain equal. The body
the basic or, if preferred, more advanced texts on can achieve this in a variety of ways. In a warm
the subject. environment, the amount of heat produced is set
With the exception of the animals that hiber- by the activity of the metabolic processes and the
nate, mammals require a relatively stable body tem- exercise undertaken. So, the production side of
perature to operate. For a person to be comfortable, the equation is fixed. Heat loss to the environment
the deep body temperature must remain at about can be adjusted. It is influenced by skin tempera-
37 ± 1°C. Temperatures above this initially cause ture, which is monitored by, and to some extent
sweating, and higher temperatures may lead to heat under the control of, the nervous system. If more
exhaustion, heat stroke and the potential for subse- heat needs to be lost, nervous stimuli will initiate
quent death from hyperthermia. Below the comfort peripheral vasodilatation, causing increased blood
range, shivering can progress to the various stages flow to the skin and more heat to be transferred.
of hypothermia, potentially leading to coma and If  still greater heat loss is needed, the body can
death. Hypothermia is covered in Chapter 28. sweat. The consequent evaporation cools the skin
Humans maintain their body temperature by and enables more heat to be lost.
balancing heat production and loss. Heat is pro- In a cold environment, if peripheral vasocon-
duced by the biochemical processes that convert striction and the subsequent reduction of blood
food to energy and waste products. Heat can also flow to the skin are insufficient to conserve heat,
be gained from the external surroundings. This more heat can be produced by muscular ­activity,
occurs in a hot climate or by touching, or being such as shivering. The main other methods of
exposed to, something that is warmer than the maintaining body temperature are behavioural
person; including the ingestion of food and drink. and include, for example, putting on or taking off
Most heat is lost from a warm body by trans- clothes and moving to a warmer or cooler place.
fer to a cooler environment. The other avenue of

325
326  Thermal problems and solutions

DIVER IN SHALLOW WATER previous exposure to cold, which generates a degree

of tolerance.
The temperature of the oceans range from −2°C Wetsuits are the most common protective
(28.4°F), which is the freezing point of sea water of ­clothing used in temperate water. They are made
normal salinity, to a surface temperature in some from sheets of rubber that has gas bubbles injected
places of almost 38°C (100°F). In most regions, the into it as it solidifies. A surface layer of fabric gives
annual range of temperature in open ocean is less the rubber strength and protection. The fabric
than 10°C. This narrow range is caused by the high adds little to the insulation, which mainly comes
heat capacity of water that dampens the seasonal from the trapped gas bubbles. Some heat is also
change in temperature. The thermal environment conserved, especially with a well-fitting wetsuit,
is usually predictable enough to allow precautions because the layer of water between the wetsuit
to be taken when diving. and the skin is trapped and warms up, thus help-
In most circumstances, the diver’s problem is to ing to reduce heat loss. Because the bubbles in the
maintain body heat. Cooling occurs because water rubber obey Boyle’s Law, their volume decreases
is a good conductor and has a high specific heat. with depth, so the insulation diminishes as depth
For most dives in shallow water, an increase in increases (Figure 27.1).
insulation reduces heat loss to an acceptable level. Drysuits are made from a fabric-rubber com-
Increased insulation is also required for survival posite sheet. They derive their name from the
during prolonged exposure to cold water. The intention that the wearer of the suit should remain
temperature at which extra insulation is required dry under the watertight barrier of the fabric.
depends on the duration of the dive, the heat pro- Because  of this, a warm layer of clothing can be
duction the diver can maintain and the diver’s worn, and a layer of air is trapped in the suit. As a
internal insulation. This internal insulation is gas space, the undersuit layer follows Boyle’s Law,
related to the amount of body fat carried and to the so gas must be added to the suit during descent

(a) (b)

Figure 27.1  Compression of a wetsuit under pressure. A piece of 7-mm (1/4-inch) Neoprene, initially at
1 ATA (a) and then at 4 ATA (30 metres/100 feet) (b). Note how much the Neoprene has compressed.
 Diving in hot environments  327

and vented during ascent to preserve the insulat- boiler on the surface remains the most common
ing layer and control buoyancy. commercial diving ­system. This water is pumped
A wetsuit or drysuit provides adequate thermal down to the diver and circulates through the
comfort in relatively shallow water. The drysuit is space between diver and wetsuit.
the preferred option for colder, deeper and longer If the breathing gas is not heated, a deep diver
dives. A common problem with both suits is the can suffer from dyspnoea induced by the cold gas.
loss of dexterity caused by cooling of the hands in This can manifest as substernal discomfort and
cold water. chest tightness that may spread to cover the whole
The insulating efficiency of these suits is demon- substernal area. The more important response for its
strated by a comparison of the likelihood of survival effect on safety is the production of large amounts
of subjects immersed in water at 5°C. Without pro- of thick mucus that can plug the airways and equip-
tection, most would die within 3  hours. However, ment. With high heat loss, shivering may be uncon-
a thin man in a thick wetsuit would be expected trollable, and the diver may be unable to hold the
to  survive for up to 20 hours (see Figure  28.1 in mouthpiece. Rest and breathing warm gas cure the
Chapter 28). condition. Warming the inhaled gas prevents it.
Heat loss during immersion is much greater Dehydration is a hazard of diving with a heated
from some body surfaces than from others. Areas suit. One study showed that the level of dehydra-
of high heat loss include skin over-active muscles tion could be as high as 4 to 5 per cent of the body
and areas of the body with little subcutaneous weight of the diver. This is a level that can cause
fat. In cold water, a diver in a wetsuit will lose a decreased mental and physical performance.
substantial amount of heat from the head unless
it is appropriately insulated. The effective insula- DIVING IN HOT ENVIRONMENTS
tion of hands presents a problem for long dives in
cold water, which cause loss of dexterity. Despite Hot water is a less common problem than cold,
the use of commonly available gloves, this can be a but cases of divers overheating have occurred. This
factor limiting performance unless active warming may happen when diving in water that is artificially
is provided. heated, as in a power station. It can also occur if a
diver needs the protection of a drysuit when diving
DEEP DIVER in warm water because of a risk of disease. Some
divers, including police and maintenance or repair
A diver at substantial depth is generally breath- contractors, occasionally have to dive in sewerage
ing an oxygen-helium mixture from a supply of processing plants and other places with a high risk
dry gas. Because of the higher specific heat of the of infection. These divers can be at risk of overheat-
helium, extra heat is required to warm the gas. This ing caused by the thermal protection of the drysuit.
can cool the diver to an extent that requires the In some circumstances, a wetsuit with cooler
use of external heat to warm the gas. Norwegian water pumped down to it provides a satisfactory
commercial diving guidelines recommend that, method of maintaining body temperature. If  a
for dives deeper than 150 metres, the breathing drysuit is needed for protection, a cooling vest con-
gas must be warmed. Failure to warm the gas can taining ice pouches can be used to help prevent the
cause dyspnoea (see later). diver from overheating. It may also be feasible to
Various techniques of diver warming have circulate cold water through the vest to provide a
been investigated and/or used. They include the longer period of tolerance.
use of electrical and chemical energy and even There is also a risk of hyperthermia on the sur-
nuclear energy. Heat from the decomposition of face while waiting to dive, particularly if the diver
concentrated hydrogen peroxide or from other is in the sun, or if the diver exerts himself or
hydrogen catalytic reactions has been tested. ­herself. In this situation, a bucket of cold water
Drysuits with inner garments using aerogel poured over the diver, or a quick immersion to cool
materials have been shown to extend dive dura- off, is generally an adequate method of cooling the
tion greatly. However, hot water supplied from a diver. Deaths from heat stroke have occasionally
328  Thermal problems and solutions

occurred during military training when divers, to monitor temperature control with a helium-rich
wearing an insulating suit, were required to exer- atmosphere in the RCC closely. In any RCC, dehu-
cise. This is an entirely preventable condition if the midification is required if the RCC temperature is
supervisors are aware of the problem. warm.
The problems of humidity and overheating
DIVER IN A RECOMPRESSION are least with an RCC in which carbon dioxide is
CHAMBER removed by flushing the chamber with compressed
air. This also removes water vapour, and the diver
Problems with the heat balance of divers in recom- can keep cool by sweating.
pression chambers (RCCs) have caused deaths from
hyperthermia and difficulties from hypothermia. FURTHER READING
In any RCC with a carbon dioxide absorbing
system, overheating may be a problem in a warm Crawshore LI, Wallace HL, Dasgupta S.
climate, and a method of cooling and dehumidifi- Thermoregulation. In: Auerbach PS, editor.
cation is needed. If the carbon dioxide is removed Wilderness Medicine. 5th ed. Philadelphia:
by reaction with soda lime, water is produced, and Mosby Elsevier; 2007.
this is added to the water produced by the diver as Flynn ET. Temperature effects. In: Lundgren
sweat, thereby humidifying the air in the RCC. The CEG, Miller JN, editors. The Lung at Depth.
atmosphere becomes saturated with water vapour, New York: Marcel Dekker; 1999.
and the diver can no longer rely on sweating as a Larsson A, Gennder M, Ornhagen H. Evaluation
method of cooling the body. This situation leads to of a Heater for Surface Independent Divers.
an increase in body temperature. The problem is FOA Report C50094-5. Stockholm: National
compounded because, as temperature rises above Defense Research Establishment; 1992.
normal, the body produces more heat as the chem- Mekjavic IB, Tipton MJ, Eiken O. Thermal consid-
ical reactions in the body accelerate. erations in diving. In: Brubakk AO, Neuman
Because helium is a good conductor of heat, a TS, editors. Bennett and Elliot’s Physiology
diver in a helium atmosphere heats or cools more and Medicine of Diving. 5th ed. Philadelphia:
rapidly than in an air-filled space. In an air-filled Saunders; 2004:115-152.
RCC, a person in light clothes is comfortable in a Nuckols ML. Analytical modeling of a diver
temperature range from about 20°C to 30°C. For a dry suit with enhanced micro-encapsulated
diver in an oxygen-helium atmosphere, the thermal phase change materials. Ocean Engineering
comfort range is narrower and warmer than for a 1999;26:547-564.
diver in air. The acceptable temperature increases United States Navy. Report TA 04-16, NEDU
with depth because there is more helium in the TR 05-02. Panama City, Florida: Navy
atmosphere as the pressure is increased. A diver Experimental Diving Unit; 2005.
is comfortable at about 29°C at shallow depths, United States Navy. Report TA 04-04, NEDU
and this increases to about 34°C as the pressure is TR 05-08. Panama City, Florida: Navy
increased. There is an associated narrowing of the Experimental Diving Unit; 2005.
temperature range in which a diver is comfortable, US Navy Diving Manual Revision 6 SS521-AG-
to less than 1°C. PRO-010 (2008). Washington, DC: Naval Sea
With this narrowing of the comfort range, Systems Command; 2008.
there is also an increase in the rate at which cool-
ing and overheating occur if the temperature goes This chapter was reviewed for this fifth edition by
beyond the comfort zone. Therefore, it is necessary John Lippmann.
 28
Cold and hypothermia

Introduction 329 Gastrointestinal system 334

Initial reactions to immersion in cold water 330 Renal system 334
Cardiovascular responses 330 Liver 334
Respiratory responses 330 Locomotor system 334
Musculoskeletal responses 331 Cutaneous reactions 334
Signs and symptoms of hypothermia 331 Prevention of hypothermia 334
Mild hypothermia 331 Treatment of hypothermia 335
Moderate hypothermia 332 First aid 336
Severe hypothermia 333 Hospital care 336
System review 333 Methods of rewarming 336
Cardiovascular system 333 Prolonged immersion 337
Central nervous system 333 References 337

INTRODUCTION the drysuit and possibly the breathing gas may be

necessary.
Immersion in cold water may result in a variety of Failure to maintain heat balance results in a fall
adverse events. In some cases, the exposure may be in body temperature. If this is mild (1°C to 2°C),
rapidly fatal as a result of cold shock. Victims who the diver feels cold and may shiver. This shivering,
survive this period may not be able to rescue them- and a loss of dexterity, may affect delicate manual
selves because of a loss of motor power. Prolonged tasks. A continued loss of heat may cause the body
exposure raises the possibility of progressive hypo- temperature to fall to a level where the diver is
thermia, which can be exacerbated during time incapable of self-care and is liable to drown. At still
spent above water in exposed environments. lower body temperatures, death occurs even if
If heat loss from the body is greater than heat drowning is prevented.
production, then body temperature falls and hypo- Hypothermia is a common cause of death in
thermia is likely. In all except the warmest seas, marine disasters. None of the 1498 passengers who
divers must wear some form of thermal protection entered the water after the sinking of the Titanic
to maintain a favourable balance between heat pro- survived. Although many could swim and had life
duction and heat loss to the water. As discussed in jackets, few lived longer than 40 minutes. Almost all
Chapter 27, a wetsuit generally provides adequate passengers in the life boats were saved. Figure 28.1
insulation for short exposures in tropical and tem- shows the relationship of expected survival time
perate water. In colder climates (and e­ specially for with water temperatures. Curves of this type should
long exposures), a drysuit, which provides more be used with caution. For example, most would pre-
insulation, may be required. In prolonged expo- dict that people could not swim the English Channel,
sures in extreme conditions, active heating of but the swimmers do not take much notice.

329
330  Cold and hypothermia

40

Estimated maximum survival time (hrs)

Fat man
Thick wet suit
30

Thin man
Thick wet suit
20
Thin man
Thin wet suit

10
Naked man

0 5 10 15 20
Water temperature (°C)

Figure 28.1  Survival expectancy related to water temperature.

The realization that hypothermia was one of the Cardiovascular responses

most common causes of death of sailors during the
Second World War led to the development of cov- There is an immediate increase in heart rate of
ered inflatable life rafts and exposure suits that give about 20 beats/minute and an increase in cardiac
better protection in cold water. Information on all output. There is a fall in peripheral perfusion as a
aspects of hypothermia, including some not con- consequence of vasoconstriction. Not surprisingly,
sidered in this discussion, is available in several these changes are accompanied by an increase in
reviews. Keatinge’s text is famous1. Other reviews blood pressure.
should be consulted by readers likely to deal with These responses may explain some of the ­sudden
hypothermia in a clinical setting2–4. deaths. Swimmers with coronary disease are at risk
In this chapter the emphasis is on the clinical because of the simultaneous increase in cardiac work
features, prevention and treatment of hypothermia (tachycardia, increased preload and afterload sec-
as encountered by the diving physician. ondary to peripheral vasoconstriction) and decrease
in coronary perfusion (because of the tachycardia).
The second group at risk comprises those with cere-
INITIAL REACTIONS TO IMMERSION brovascular disease. The sudden hypertension may
IN COLD WATER trigger a cerebrovascular incident.
In many cases, good swimmers have died within a
few metres of safety after short periods of cold immer- Respiratory responses
sion. Some workers postulated that these deaths were
caused by inhaling water, whereas others suggested The initial gasp on entering cold water may be
a cardiac aetiology. The Royal Navy studies in this ­followed by uncontrollable hyperventilation. There
area were reviewed by Tipton5. He provided a range may be a 10-fold increase in ventilation; three- to
of rational potential explanations for these fatalities fourfold increases are common. This response can
based around a complex series of early physiological lead to water inhalation and drowning, which is
responses. Tipton divided them into several groups, more likely to occur in rough water or where there
which are summarized here. is a period when the head is immersed. The ­v ictim
 Signs and symptoms of hypothermia  331

simply cannot hold his or her breath, so even a SIGNS AND SYMPTOMS OF
good swimmer may aspirate water. HYPOTHERMIA
A less obvious problem is that the hyperventi-
lation causes hypocapnia. Tipton5 cited a study in The degree of hypothermia that ensues after
which the arterial carbon dioxide fell 12 mm Hg immersion depends on environmental and physi-
after an iced water shower for 1 minute. He sug- ological factors.2,3,7 Environmental factors include
gested that this fall could cause enough reduction the water temperature and flow, the duration
in cerebral blood flow to explain the disorienta- of exposure, the insulating materials (e.g. fab-
tion and clouding of consciousness that has been rics, fat, grease) and the gas mixture employed.
noted. Physiological factors include somatotype, activity
Cold and hyperventilation can trigger broncho- during exposure, the degree of cold adaptation and
constriction in persons with asthma. In ­addition, the use of drugs that induce vasodilation or pre-
in physiologically normal subjects there is a shift vent heat-saving vasoconstriction.
in end-expiratory volume so that the subject is With rare exceptions, the lethal lower limit
breathing close to total lung capacity. This is an for humans has been 23°C and 25°C (rectal). The
inefficient form of respiration because the lung vol- effects of hypothermia are set out in the following
ume is on an unfavourable part of its compliance paragraphs.
curve, and this will rapidly induce fatigue.
Figure  28.2 presents a more complete version Mild hypothermia
of possible cold shock responses.
The core temperature is in the range of 33°C to
Musculoskeletal responses 35°C. The victim is handicapped by the cold but is
breathing and fully conscious. The victim is prob-
Another crucial response to immersion in cold ably shivering and experiencing local reactions
water is a decrease in swimming performance. including the sensation of coldness in the extremi-
Tipton and colleagues6 had subjects swim at a ties. Numbness occurs as the peripheral sensory
range of temperatures. Only half could complete nerves are affected. Vasoconstriction, particularly
a 90-minute swim in 10°C water. A decrease in in combination with immersion, leads to a cen-
stroke length and a reduction in distance travelled tralization of blood volume and a diuresis that can
for a given energy expenditure were observed in the cause dehydration.
subjects who did not complete the cold water swim. Difficulty in performing co-ordinated fine move-
People with more fat over the arms fared better, a ments, in response to motor nerve involvement, may
finding suggesting that part of the decrease in per- result in a dangerous situation in which a diver can-
formance may have been caused by local cooling not effectively manage a task or the equipment. This
rather than generalized hypothermia. In sudden loss of control because of cold hands may also be a
immersion in even colder water, a rapid deteriora- problem even in divers with normal body tempera-
tion of physical performance (before the onset of ture. Indeed, maintenance of hand function despite
significant hypothermia) has emerged as a crucial adequate ‘whole body’ thermal protection is one of
contributor to death by drowning because there the most challenging aspects of prolonged dives in
is a very limited time beyond which the victim is very cold water. In water near freezing, it is possible
physically unable to effect self-rescue. to encounter situations where, despite the use of dry
gloves with insulating ‘under-gloves’, the diver is
warm but the hands are useless.
Immersion in cold water usually causes A major danger with mild hypothermia is that
●● Tachycardia. lethargy and sluggish reactions may lead to an
●● Hypertension. accident or drowning. Other local reactions, such
●● Hyperventilation. as immersion foot and frostbite, are more applica-
●● Rapidly decreasing muscle performance. ble to general and military medicine than to diving
medicine.
332  Cold and hypothermia

Rapid skin cooling

Stimulation of
peripheral receptors

Gasp reflex and Peripheral Tachycardia

hyperventilation vasoconstriction
Filling
Inability pressure
Hypertension
Hypocapnia to hold
( arterial and
breath
venous pressure)
Cardiac
Respiratory
output
alkalosis Inspiratory
shift
Ventricular Work of
fibrillation Vessel heart
Serum and rupture
body fluid
Ca2+ Coronary
Cerebral
Dyspnoea blood flow
blood flow

Cerebrovascular
Tetanic spasms accident
convulsions
Panic
Myocardial
Cerebral ischaemia
hypoxia Swim
failure

Ventricular
Inhalation irritability
of water
Disorientation
loss of Stimulation of
consciousness nasal and glottal
Arrhythmias/
receptors
ventricular
fibrillation

Drowning Vagal arrest

Figure 28.2  A more complete version of possible cold shock responses. ↑ increase, ↓ decrease.
(Adapted from Tipton MJ. The initial responses to cold-water immersion in man. Clinical Science
1989;77:581–588.)

Moderate hypothermia The electrocardiogram (ECG) may show prolonged

Q-T intervals, and a J wave may be present. Nodal
With a core temperature between 30°C and 33°C, a rhythm, atrio-ventricular block, atrial fibrillation
diver is slow to respond or unconscious. Shivering and ventricular ­fibrillation can develop. Respiratory
is a variable response; if present, it often ceases in frequency falls with the reduction in tissue oxygen
this temperature range and is replaced by mus- needs. Many of  the victims of maritime accident
cle rigidity. Heart rate and cardiac output fall. cases of h
­ ypothermia succumb at this stage because
 System review  333

they are no longer able to contribute to their rescue, SYSTEM REVIEW

to keep swimming or even keep to their head above
water. A review of systems is performed3.7.

Severe hypothermia Cardiovascular system

The victim has a core temperature below 30°C. The initial stimulatory response to immersion
He or she is unconscious or semi-conscious, and in cold water is discussed earlier. Later, as tem-
muscle rigidity can be confused with rigor mor- perature falls, both chronotropy and inotropy are
tis. Respiration and pulse may be depressed or not reduced, leading to a reduction in cardiac output
detectable; indeed, respiration may be reduced to and blood pressure. Ultimately, cardiac arrest may
one to two gasps per minute. There is a high risk occur at about 20°C (rectal) or earlier. Various
of ventricular fibrillation. Any electrical activity arrhythmias are common: atrial fibrillation occurs
on the ECG or electroencephalogram (EEG) is at about 30°C, and ventricular fibrillation usually
evidence of continued life. Bizarre ECGs should occurs below 25°C. The blood becomes more vis-
not be considered artefacts. In a field situation, the cous, and because hypothermia reduces the effec-
pupillary light reflexes may be helpful, but their tive release of oxygen from haemoglobin, tissue
absence is not evidence of death. hypoxia may develop.
Recognition that severe hypothermia can ‘imi- In the past, it was emphasized that movement of
tate death’ has given rise to ‘The Alaskan dictum’, the throat, limbs or chest during rescue or resus-
which states: ‘do not assume a patient is dead until citation could trigger ventricular fibrillation in a
he is warm and dead’. This may lead to unsuc- hypothermic heart. However, Larach9 presented
cessful attempts at revival, but this is preferable to data showing this to be a rare complication.
unnecessary deaths. The chilled brain has a greatly Effects of hypothermia on inert gas exchange in
increased tolerance to ­hypoperfusion, and remark- divers are sometimes raised as an issue, but it is
able recoveries have been recorded. For example, not clear that ‘hypothermia’ per se is required for
the paper by Gilbert and colleagues8 provided water temperature to influence gas exchange. This
dramatic anecdotal support for the Alaskan dic- is largely a semantic argument, however. There is
tum. These workers reported the resuscitation of convincing evidence that becoming ‘cooler’ during
a victim with a core temperature of 13.7°C. A skier decompression is disadvantageous from a decom-
became trapped in an ice gully and was continu- pression sickness risk perspective when compared
ously flooded by freezing water. She struggled with remaining ‘warm’ during decompression
for about 40 minutes and was trapped for a fur- (see Chapter 12). This is probably because being
ther 40 minutes before she  was extracted and cooler results in reduced perfusion of peripheral
basic first aid was started. This was replaced by tissues, with correspondingly impaired washout
­cardiopulmonary resuscitation (CPR) and positive of inert gas. Temperature may also influence the
pressure ­ventilation with oxygen during a 1-hour solubility of inert gas in tissue, and a reduction
flight to hospital. Given advanced hospital care, in gas solubility in peripheral tissues during a hot
she has made a good recovery. Similarly, in her post-dive shower has been invoked as an explana-
review, Larach9 ­mentioned cases where survivors tion for contemporaneous onset of decompression
were ­neurologically intact after more than 4 hours sickness symptoms in a small number of cases
of cardiac arrest associated with hypothermia. (see  Chapter  12). It is not certain whether these
symptoms were coincidental with the shower or
whether the t­ emperature effect was ‘causative’.
Clinical phases of progressive hypothermia:

1. Mild – 35°C to 33°C Central nervous system

2. Moderate – 33°C to 30°C
3. Severe – less than 30°C With a core temperature below 35°C, impairment
of speech, fixation of ideas, sluggish reactions and
334  Cold and hypothermia

mental impairment occur. Depersonalization, Liver

amnesia, confusion and delirium are possible.
Unconsciousness may develop at about 30°C, and There is a decrease in liver function that is prob-
by 27°C most reflexes are lost. Exposure to cold ably a direct temperature effect on enzyme activity.
initially causes reflex hyperventilation, but with As a consequence, metabolites such as lactate may
increasing hypothermia the respiratory centre is accumulate. Drugs accumulate because their clear-
depressed, and this contributes to hypoxia and ance is slowed or stopped.
acidosis.
As alluded to previously, hypothermia is neu- Locomotor system
roprotective and may be beneficial in cold water
drowning (assuming it did not cause the drown- Shivering is a heat-producing response to cold. It
ing in the first place!). Indeed, an extensive exper- mainly affects the large proximal muscles, but it
imental literature demonstrates hypothermia to also causes a loss of co-ordination and difficulty
be neuroprotective in most carefully conducted in the performance of fine tasks. There is a loss
in vitro and in vivo experiments. Harnessing this of muscle power. Swimming ability is decreased,
protective effect for clinical benefit in humans has with increasing discomfort and fatigue. Apathy
been more problematic, although there are con- and euphoria may combine with fatigue to stop the
spicuous examples in which it is usually success- diver from taking appropriate action for rescue. As
ful. One is the use of deep hypothermic circulatory previously mentioned, the cooling of peripheral
arrest for certain thoracic vascular procedures muscles in very cold water can impair the ability
where simple cardiopulmonary bypass with or to self-rescue before the onset of significant core
without selective cerebral perfusion is not pos- hypothermia, which may lead to drowning.
sible. The mechanism of this protection is not
certain. Although it is widely assumed that it Cutaneous reactions
accrues from a reduction in the cerebral meta-
bolic rate for oxygen, hypothermia confers extra Any prolonged immersion results in softening and
protection in experiments where cerebral electri- swelling of the skin, rendering it susceptible to
cal activity is already ablated by pharmacological injury and infection. This ‘washerwoman’s skin’ is
means. Other mechanisms have been proposed characterized by soft ridges, especially over the tips
to explain such observations. For example, it is of fingers and toes.
thought that hypothermia may independently In cold water, there may be a sudden release of
suppress the release of harmful excitotoxins by histamine in susceptible persons that causes cold
hypoxic neurons. or allergic urticaria. In some cases the skin rapidly
becomes hot, red and oedematous. Symptoms may
Gastrointestinal system occur during or after exposure. Occasional deaths
have been reported (see Chapter 42).
Some slowing of intestinal activity and retarda-
tion  of the rate of destruction of bacteria occur. PREVENTION OF HYPOTHERMIA
Paralytic ileus may develop in cases of severe
hypothermia. The most important and effective means of prevent-
ing hypothermia during diving is wearing expo-
Renal system sure protection that is appropriate to the expected
water temperature and duration of the dive. Broadly
Cold and immersion initially cause an increase in speaking, exposure protection can be divided into
central blood volume and a diuresis. Hyponatraemia three categories: stinger suits, wetsuits and drysuits.
and hypovolaemia may follow. As  the temperature Stinger suits are usually made of Lycra or a
falls further, cardiac output and hence glomerular similar material and are intended mainly to pre-
filtration are reduced, resulting in decreased urinary vent skin contact with marine stingers. Although
output. some of the heavier materials have some insulating
 Treatment of hypothermia  335

properties, stinger suits provide minimal ther- between breaths, is not advocated because of
mal protection, and their use is best restricted to the increased heat loss from the head.
warmer tropical waters. ●● Do not swim unless very close to safety; groups
Wetsuits come in a variety of styles and thick- of survivors should remain huddled tightly
nesses. They work on the principle that water enters together to conserve heat (and to give the res-
the suit but then is trapped and warmed, and heat cuers a larger target to find). For completeness,
loss to the environment is subsequently prevented it should be mentioned that the literature is not
by the insulating properties of the Neoprene foam unanimous on this point, and the question of
of which the suits are made. This action relies sub- whether or not exercise causes an improvement
stantially on a snug fit, which prevents circulation in the balance between heat production and
of water through the suit. The insulating proper- heat loss is highly nuanced. It is probably true
ties of the suit are determined by fit, thickness to say that for an exposure where the eventual
and degree of body coverage; and various designs duration is uncertain (but potentially long), the
are made to be suited to conditions. Thin suits safest option is to avoid exercise.
(e.g. 3-mm Neoprene) with short legs and arms are ●● Wear clothing to reduce heat loss. In particu-
designed for tropical use. Thick suits (e.g. 7-mm lar, a hood or some other head protection is
thick, often with overlapping layers) that cover the important in conserving heat.
entire body, including head, feet and hands, can be ●● Avoid or delay immersion if any other options
used in cold temperate water, especially for short- are feasible.
duration dives.
Long-duration dives in temperate waters usually TREATMENT OF HYPOTHERMIA
require a drysuit. These also come in various styles.
Some of these suits effectively provide a waterproof It is desirable to obtain a measurement of the vic-
‘shell’ with little inherent heat insulation capa- tim’s temperature if this is possible. A rectal tem-
bility, whereas others are constructed of material perature should be obtained, and a low-reading
that provides some insulation. Nevertheless, in thermometer may be required. This is the best
both cases, it is the ‘undergarments’ chosen that measurement of those commonly used. Where it
largely determine the insulating properties of the is not possible to obtain a rectal temperature, the
combination. Heavier insulating undergarments tympanic membrane temperature is a useful mea-
that trap more still air between the diver and the sure that can be obtained with minimal distur-
drysuit shell are generally warmer. Some divers use bance to the patient or protective insulation, but
argon to inflate their drysuits (gas must be added it requires a special digital thermometer. Others
during descent) because of its low thermal capac- choose oesophageal temperature as their preferred
ity. However, several studies of this strategy have measure of deep body temperature2, but this is
failed to show a clear advantage over air. unlikely to be available in the field.
In non-diving immersions (e.g. after maritime In mild cases of hypothermia, removal from
accidents), hypothermia can be delayed or pre- the cold environment, protection from wind, the
vented by use of a variety of strategies: use of blankets and the use of hot water bottles in a
sleeping bag are all remedies that have worked and
●● Wear a wetsuit or a survival suit to reduce heat may be all that is required.
loss. Shivering slowly restores body heat if further
●● If wearing a life jacket, try to adopt a spheroi- heat loss is prevented. Heat loss from the head
dal position (foetal position), with the head should be minimized, as should evaporative heat
out of the water and the legs pulled up to the loss from wet clothing. In an exposed situation,
chest and the arms wrapped around the legs. two large plastic bags, one over the victim’s body
This has been referred to as the Heat Escape and one over an insulating layer such as a sleep-
Lessing Posture (HELP). It may increase the ing bag, have been recommended. This prevents
survival time by 50 per cent. ‘Drown-proofing’, evaporative cooling as well as avoiding the need
where the victim rests with head under water to strip the wet clothes from the survivor. In an
336  Cold and hypothermia

unexposed environment, wet clothes should be Correction of ventricular fibrillation by elec-

replaced with dry clothes or an alternative (e.g. trical defibrillation may not be effective when
a blanket or sleeping bag), and the victim should the core temperature is below 30°C (or even
be protected from air movement as much as pos- until higher temperatures), but expert consen-
sible. When removing the clothes in patients with sus holds that defibrillation should be tried up
moderate to severe cases of hypothermia, the gar- to three times no matter what the temperature,
ments should be cut to avoid excessive movement after which (if unsuccessful) CPR should be
of these patients. maintained while rewarming continues11. When
The specific treatment of serious hypother- 30°C is reached, further attempts at defibrillation
mia includes measures discussed in the following should be made.
sub-sections. Although there are few relevant human data, it
is usually recommended that resuscitation drugs
are not administered until the victim is warmer
First aid
than 30°C. This is because these drugs are not
It is important to keep the patient horizontal thought to be particularly effective in a very cold
during and following removal from the water, patient, and the drugs may accumulate with repeat
especially after prolonged immersions. A ­rescue dosing (from delayed distribution and metabo-
basket, a stretcher or a double-strop system, with lism), resulting in a toxic picture once the patient
one loop lifting the patient under the arms and is rewarmed11.
another under the knees, can be used. This pre-
vents a sudden fall in blood pressure that can Hospital care
occur with the loss of hydrostatic pressure on the
legs10. There have been cases where the patient was The victim with severe hypothermia needs hos-
alive and responsive in the water but apparently pital care during and after rewarming. Most
dead by the time he or she reached a rescue heli- patients should be kept immobile, handled gently
copter after being lifted in a vertical position. This and given supplemental oxygen. Intravenous flu-
shock reaction is thought to be caused by blood ids should be warmed to at least body tempera-
pooling in the legs. ture. Although one animal study suggested that
centrally administered intravenous fluid can be
as hot as 65°C12 , expert consensus suggests that
The pulse may be difficult to detect in a 42°C is a sensible maximum11. Intravenous fluid
­hypothermia casualty, and blood pressure infusion is not an effective means of rewarm-
may be unrecordable despite the presence ing (the required volumes would be too high),
of tissue perfusion. but the goal of warmed fluids is to avoid further
cooling with cold fluid. A balanced electrolyte
solution (not normal saline), with supplemen-
If drowning has occurred, then CPR takes tal glucose if the patient is hypoglycaemic, is
­ recedence over the management of hypothermia,
p suggested. Administration of 500 ml at once
although any practicable steps should be taken to then 100  ml/hour is a simple guide to ­overcome
try to prevent further heat loss. Remember that haemoconcentration and possible shock as the
signs of life can be very difficult to detect in a peripheral vessels expand, but experienced clini-
hypothermic victim. A normal life support algo- cians will tailor fluid administration to the needs
rithm and resuscitation algorithm should be fol- of individual patients.
lowed, but with some modification. Concern is
sometimes expressed over the potential for airway Methods of rewarming
manipulation to precipitate ventricular fibrillation
in a cold patient, but maintaining an airway and Rewarming should begin as soon as possible.
ensuring ventilation take precedence over such A  review of therapy stressed the shortage of trials
concerns11. comparing methods of rewarming patients with
 References 337

moderate or severe hypothermia13. The choice of survivors were dehydration and mental issues. It is
rewarming method often depends on the skills and not clear whether these mental problems stemmed
equipment available rather than on best evidence. from lack of sleep, anxiety related to the delayed
Some of the options are outlined here. rescue or severe dehydration16.
Most victims of mild hypothermia will recover Beckman and Reeves17 stressed that, in such
if they are allowed to rewarm passively with good patients, hypoglycemia, dehydration, haemocon-
thermal protection including blankets and caps. centration and adrenocortical stress response are
To speed the process, they can lie under a forced factors to be considered along with hypothermia.
air warmer and be disturbed as little as possible. This would suggest that fluids with glucose may be
This seems to be the best rewarming treatment in needed, as well as heating, but how the warming
a small hospital. It is non-invasive, safe, easy to use should be administered in these patients is open to
and readily available14. There has been previous question. Probably the best advice is to be prepared
advocacy for the use of graded temperature baths15. for complications.
An initial water temperature of 36°C, to reduce
the pain response and risk of atrial fibrillation, and REFERENCES
then an increase over 5 to 10 minutes to 40°C to
42°C, until the rectal temperature is above 33°C, 1. Keatinge WR. Survival in Cold Water.
has been recommended, but this approach has Edinburgh: Blackwell Scientific Publications;
been omitted from more recent definitive reviews11. 1977.
It is logistically difficult, and it is probably unnec- 2. Giesbrecht GG. Cold stress, near drown-
essary with the present wide availability of forced ing and accidental hypothermia: a review.
air warmers in hospitals. Aviation, Space, and Environmental
A forced air warmer is also a valid option for Medicine 2000;71:733–753.
active rewarming in patients with more serious 3. Short BH. Cold induced thermoregulatory
cases who are spontaneously breathing and have failure. 1. Physiology and clinical features.
a perfusing rhythm. For patients requiring resus- Australian Military Medicine 2000;9:29–33.
citation (circulatory and/or ventilator support), 4. Short BH. Cold induced thermoregulatory
the gold standard for active rewarming is cardio- failure. 1. Management and outcomes.
pulmonary bypass or extracorporeal membrane Australian Military Medicine 2000;9:88–90.
oxygenation. These have the advantage of support- 5. Tipton MJ. The initial responses to cold-
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