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SAUNDERS An Imprint of Elsevier Science The Curtis Center Independence Square West Philadelphia, PA 19106 BOVE AND DAVIS’ DIVING MEDICINE ISBN 0-7216-9424-1 Copyright 2004, Elsevier Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, photocopying, recording, or otherwise, without prior permission of the publisher (Saunders, The Curtis Center, Independence Square West, Philadelphia, PA 19106-3399). First Edition 1976. Second Edition 1990. Third Edition 1997. Library of Congress Cataloging-in-Publication Data Bove and Davis’ diving medicine / [edited by] Alfred A. Bove—4th ed. p. ; cm. ISBN 0-7216-9424-1 (alk paper) 1. Submarine medicine. 2. Diving. I. Title: Diving medicine. II. Bove, Alfred A. III. Davis, Jefferson C. (Jefferson Carroll), 1932-1989 [DNLM: 1. Diving. 2. Naval Medicine. QT 260.5.D6 B783 2004] RC1005.K583 2004 616.9′8022—dc21 2003041520 Acquisitions Editor: Todd Hummel Senior Project Manager: Natalie Ware Designer: Steven Stave Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 NOTICE Diving medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the Publisher nor the author assume any liability for any injury and/or damage to persons or property arising from this publication. The Publisher To my Wife Sandy, who endured watching long enough and then became my partner in both diving and diving education. Memorial HUGH GREER, M.D. Hugh D. Greer was a former contributor to Diving Medicine and a recognized authority in the neurologic aspects of diving. He died suddenly while swimming on October 2, 2001. Dr. Greer was born in Madison, Wisconsin in 1932 and joined the Navy Reserve as a midshipman in 1949. After completing college at Dartmouth, he was commissioned as a Lieutenant Junior Grade in the Navy and was a member of Underwater Demolition Team 22 until his discharge in 1956. He attended Medical School at the University of Kansas and received his medical degree in 1960. He interned at the Mary Hitchcock Hospital from 1960 to 1961 and continued his training in neurology at the Mayo Clinic. Dr. Greer published several papers in clinical neurology and was board certified in neurology and psychia- try. He joined the Santa Barbara Clinic as a clinical neurologist in 1964, where he remained until his death. Over his many years at the Clinic, he developed expertise in the neurologic aspects of diving and became recognized as an international expert. Dr. Greer was formally trained in diving medicine through the National Oceanic and Atmospheric Administration program in 1978. He served as an adjunct sci- entist to the USC Institute of Marine and Coastal Studies and was a diving medicine consultant to the Catalina Hyperbaric Chamber, Santa Barbara City College, and a number of commercial diving companies. He was a fellow of the Explorers Club of New York. Along with Dr. Paul Linaweaver, he directed the southwestern division of the Divers Alert Network. Throughout his career, he continually published in the literature of diving medicine and contributed the chapter on the neurologic aspects of diving in the second and third editions of this text. Dr. Greer contributed to the governance of the Santa Barbara Clinic by serving at various times as the President of the Board of Trustees and as President of the Board of Directors. Dr. Greer was a fellow of the American Academy of Neurology, a fellow of the American Academy of Electromyography and Electrodiagnosis, and a member of the Undersea and Hyperbaric Medical Society. He is survived by his wife, son, two daugh- ters, and six grandchildren. Paul G. Linaweaver, M.D. SUK-KI HONG, M.D., Ph.D. Suk-Ki Hong, author of the chapter on breath-hold diving in the second and third editions of Diving Medicine, died on October 4, 1999. Dr. Hong’s studies in diving physiology encompassed both human breath-hold diving and saturation diving and were performed in collaboration with colleagues in Korea, Japan, Europe, and the United States. His publications concerning breath- hold diving covered 35 years and constitute the most thorough record in the literature on all aspects of breath-hold diving. Throughout his career, Dr. Hong received numerous awards for his work in diving medicine. His scientific legacy is not only the impressive volume and quality of his research publications but also the many students and fellows who now follow in his path and have gone on to productive scientific careers in many parts of the world. Dr. Hong’s generosity with his ideas, his comprehensive knowledge, and his unselfish good nature earned him the enduring respect and genuine affection of all who had the good fortune to know him. Even though he was a famously hard worker, setting high standards for himself and his associates, he was always constructive and truly interested in bringing out the best in people. His desire to excel was always tempered by his humanity, sense of fairness, and lively sense of humor. His family, friends, and colleagues sorely miss him. Charles V. Paganelli Arthur J. Bachrach, B.S., M.A., Ph.D. Taos, New Mexico Former Director, Environmental Stress Department Naval Medical Research Institute Bethesda, Maryland Human Performance Underwater Peter B. Bennett, Ph.D., D.Sc. Professor of Anesthesiology Duke University Medical Center Durham, North Carolina Inert Gas Narcosis and High-Pressure Nervous Syndrome Alfred A. Bove, M.D., Ph.D. Emeritus Professor of Medicine Temple University School of Medicine Philadelphia, Pennsylvania Marine Poisoning and Intoxication Diving in the Elderly and the Young Cardiovascular Disorders and Diving Medical Evaluation for Sport Diving Frank K. Butler, Jr., M.D. Associate Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Attending Ophthalmologist Naval Hospital Pensacola, Florida U.S. Navy Diving Equipment and Techniques James M. Clark, M.D., Ph.D. Clinical Associate Professor of Environmental Medicine in Pharmacology Institute for Environmental Medicine University of Pennsylvania Medical Center Philadelphia, Pennsylvania Toxicity of Oxygen, Carbon Dioxide, and Carbon Monoxide Carl Edmonds, M.B., B.S., D.P.M., M.R.C.Psych, F.R.A.N.Z.C.P., M.R.C.P.(Lond), Dip. D.H.M., F.R.A.C.P., F.A.F.O.M. Director, Diving Medical Centre Ocean Royale Manly, N.S.W., Australia Marine Animal Injuries Glen H. Egstrom, Ph.D. Emeritus Professor, Department of Physiological Sciences University of California at Los Angeles Westwood, California Diving Equipment Human Performance Underwater David H. Elliott, D.Phil.(Oxon), F.R.C.P., F.F.O.M. Robens Institute of Health and Safety University of Surrey Guildford, Surrey England Aseptic Necrosis of Bone Medical Evaluation of Working Divers Joseph C. Farmer, Jr., M.D. Professor and Chief, Division of Otolaryngology/Head and Neck Surgery Duke University Medical Center Durham, North Carolina Ear and Sinus Problems in Diving Massimo Ferrigno, M.D., F.C.C.M. Assistant Professor of Anesthesia Harvard Medical School Staff Anesthesiologist Brigham and Women’s Hospital Boston, Massachusetts Breath-Hold Diving Edward T. Flynn, Jr., M.D. Naval Sea Systems Command Washington Naval Yard Washington, District of Columbia Medical Supervision of Diving Operations Contributors T. James Francis, Ph.D., M.F.O.M., Dip D.H.M. Consultant Diving Diseases Research Center Plymouth, Devon England Pathophysiology of Decompression Sickness Frank St. C. Golden, M.B., Ph.D. Consultant in Environmental Medicine and Honorary Lecturer University of Portsmouth Portsmouth, Hampshire England Hypothermia Hugh D. Greer, M.D. Deceased Santa Barbara, California Neurologic Consequences of Diving R.W. Bill Hamilton, Ph.D. President Hamilton Research, Ltd. Tarrytown, New York Mixed-Gas Diving Shannon E. Hunter, M.D. Chief Resident, Otolaryngology/Head and Neck Surgery Duke University Medical Center Durham, North Carolina Ear and Sinus Problems in Diving Eric P. Kindwall, M.D. Associate Professor Emeritus, Department of Plastic and Reconstructive Surgery Medical College of Wisconsin Milwaukee, Wisconsin Former Director of Hyperbaric Medicine Froedtert Memorial Lutheran Hospital Brookfield, Wisconsin A Short History of Diving and Diving Medicine Peter R. Lynch, B.S., M.S., Ph.D. Emeritus Professor of Physiology Temple University School of Medicine Philadelphia, Pennsylvania Marine Poisoning and Intoxication Allan D. Marks, M.D. Emeritus Professor of Medicine, Endocrinology Section Temple University School of Medicine Philadelphia, Pennsylvania Diabetes and Diving E.Wayne Massey, M.D. Clinical Professor, Neurology Division, Department of Medicine Duke University Medical Center Durham, North Carolina Neurologic Consequences of Diving Igor B. Mekjavic, B.Sc(Hos), M.Sc., Ph.D. Institute of Biomedical and Biomolecular Sciences University of Portsmouth Portsmouth, Hampshire England Senior Scientific Consultant Department of Automation, Biocybernetics, and Robotics Institut Jozef Stefan Ljubljana Slovenia Hypothermia Simon J. Mitchell, M.B., Ch.B., Dip D.H.M., Dip Occ. Med., Ph.D. Diving and Hyperbaric Physician Department of Diving and Hyperbaric Medicine Prince of Wales Hospital Randwick, N.S.W. Australia Pathophysiology of Decompression Sickness Richard E. Moon, M.D., C.M. Professor of Anesthesiology and Associate Professor of Medicine Duke University Medical Director Center for Hyperbaric Medicine and Environmental Physiology Duke University Medical Center Durham, North Carolina Treatment of Decompression Illness Tom S. Neuman, M.D. Professor of Medicine and Surgery University of California at San Diego Associate Director, EMS Director, Hyperbaric Medicine Center UCSD Medical Center San Diego, California Pulmonary Barotrauma Near Drowning Pulmonary Disorders Duke H. Scott, M.D. Medical Advisor YMCA Scuba Program Chicago, Illinois Diabetes and Diving x Contributors David J. Smith, M.D., M.S. Formerly Commanding Officer U.S. Naval Hospital, Rota, Spain Chief of Staff Tricare Management Activity Falls Church, Virginia U.S. Navy Diving Techniques and Equipment Larry “Harris” Taylor, Ph.D. Senior Research Associate Diving Safety Coordinator University of Michigan Ann Arbor, Michigan Diving Physics Maida Beth Taylor, M.D., M.P.H. Associate Clinical Professor, Department of Obstetrics, Gynecology, and Reproductive Medicine University of California San Francisco, California Senior Clinical Research Physician Women’s Health and Reproductive Medicine Eli Lilly & Company Indianapolis, Indiana Women in Diving Stephen R.Thom, M.D., Ph.D. Associate Professor of Emergency Medicine Institute for Environmental Medicine University of Pennsylvania Medical Center Philadelphia, Pennsylvania Toxicity of Oxygen, Carbon Dioxide, and Carbon Monoxide Michael J.Tipton, M.Sc., Ph.D. Professor of Human and Applied Physiology University of Portsmouth Portsmouth, Hampshire Head of Environmental Medicine Division Institute of Naval Medicine Alverstoke, Hampshire England Hypothermia Richard D.Vann, Ph.D. Assistant Research Professor Department of Anesthesiology Duke University Medical Center Vice President, Research Divers Alert Network Durham, North Carolina Inert Gas Exchange and Bubbles Mechanisms and Risks of Decompression Dennis N.Walder, M.D., F.R.C.S. Emeritus Professor of Surgical Science University of Newcastle upon Tyne Consulting Surgeon Royal Victoria Infirmary Newcastle upon Tyne England Aseptic Necrosis of Bone Contributors xi Advances in diving medicine have intermit- tently followed and led the past 100 years of astounding engineering developments in practical operational diving. Two milestones in treating the triad of decompression sickness, nitrogen narcosis, and oxygen poisoning were Haldane’s increase in helmet ventilation to avoid the effect of CO2 compounding nitrogen narcosis and the permanently sensible concept of multiple exponential uptake and elimination of inert gas in albeit indefinable body microtissues during compression and decompression. In the 1920s and 1930s, dedicated diving medical giants related to the U.S. and British Navies laboriously established improved tables for limited air diving, derived in part from Haldane’s concepts of staged decompression to “avoid formation of gas bubbles.” These groups then responded to the sugges- tions of Hildebrand in 1924 and to civilian open-water diving trials concerning the use of helium to avoid the narcosis induced by nitrogen in deep air diving. These groups developed equipment and procedures to facilitate decompression by using helium with high levels of inspired oxygen in both working and decompression phases (the tables were baptized in the severe challenges of the salvage of the U.S.S. Squalus). In laboratory experiments on human divers, these groups explored the degrees of hyperoxic exposure that would avoid the drastic diving hazard of oxygen convulsions. These early advances in suited hardhat diving and in the prevention and therapy of decompression sickness were refined in Navy laboratories by trial and error in large numbers of practical tests. These allowed empirical adjustment around a theoretical base. The rules were established and the equipment designed to encase the diver, provide security and stability at the work site, and provide for safe passive extraction back to the surface when necessary. Before 1940, diving that required backup and developments by diving medicine was essentially limited to naval services. The extensive damage resulting from World War II turned Navy salvage diving methods development back to shallow air diving for clearing harbors alongside Army Engineer diving. However, before and during that war, a new form of diving evolved in Italy, the United States, and the United Kingdom: pure oxygen diving with rebreathing and carbon dioxide absorption in closed-system “pendu- lum” and “circuit rebreathing” designs. The resulting Self-Contained Underwater Breath- ing Apparatus—-scuba—-provided complete independence from the surface. The require- ment now was to closely match detailed engineering design with the human physiologic demands of covert, long-duration sub- mergence astride an underwater “chariot” or, for neutral-buoyancy underwater swimming, with “fins” over long distances at variable depths. The specific stresses were temperature, the toxicity of oxygen, and carbon dioxide accumulation, none of which was solvable by medical guidance alone. These military operational advances were generally not well known because of their initial highly secret status, but the neutral- buoyancy shallow diving method using pure oxygen opened wide new areas of basic physiologic research interest important to oxygen therapy, respiratory and circulatory regula- tion, blood gas transport, the concept of damage by free radicals, improved therapy of all decompression sickness, and expanded recognition of the usefulness of oxygen in diving gas mixtures to limit inert gas uptake and accelerate its elimination. After World War II, wide civilian use of a demand valve for self-contained, open- system air breathing underwater swung the cycle of diving medical interest back to the classic naval guidelines for air diving. The relative safety of the open-system method for shallow air diving allowed many millions of individuals to begin diving for Foreword sport. The result was a parallel expansion of interest by civilian physicians in diving and diving medicine while military interest was low. This book on diving medicine has provided a window on the continually expanding scope of operational and scientific accom- plishment related to all forms of diving, from their beginnings to the extreme range of present activity. The book is generally con- cerned with the effects of self-imposed expo- sures to stresses by otherwise healthy persons rather than with spontaneous disease occurring in working divers. Stresses may be small or severe. Today, most sport diving involves the relaxed, harmless, and pleasurable activity of air breathing and seeing during submerged swimming in con- ditions of neutral buoyancy in clean, warm, shallow water. This hardly requires the atten- tion of diving medicine. In the usual properly controlled circumstances of current open- circuit diving, stress and its effects are incon- sequential; problems relate to the potential for accident rather than to intolerance of stress. However, diving is not just breathing underwater, and all divers are not normal. With increased degree and durations of exposure to hydrostatic pressure, respira- tion of inert and chemically active gases, and severe thermal environments, the varied forms of physiologic stresses inherent to all types of diving may be intrinsically harmless but can lead to personal hazard or death in the unnatural underwater situation. The commercial working diver or the military combat diver continues to encounter the most severe combination of stresses and physiologic trauma of any form of human activity. At the extremes of practical forms of working diving, the individual is exposed to resistance to breathing, toxic effects of increased oxygen pressures, mental dulling by nitrogen, neurologic derangement due to the effects of physical ambient pressure, incapacitating loss or excess of body heat, and damage due to failure to avoid free gas phase development in body tissues. Because each of these stresses is a consequence of exposure to the pressure or temperature of water, or both, disease is always possible. The composite result of multiple added stresses is unpredictable and conducive to accident or failure. From my vantage point as an equipment designer, operational diver, investigator, and diving physician, I am impressed by the col- lective breadth of scientific competence rep- resented by the many contributors to this text. Such detailed expertise was hard to come by. How did it develop? The evolution of clinical or technical close communion has played a special large role in accelerating research and development in diving and diving medicine. The present state of instantaneous voice or graphic communication should be contrasted with the previous limitations of worldwide direct personal communication by mail and ship prior to World War II. The expansion of interest and activity fol- lowing World War II was directly aided by the U.S. Office of Naval Research’s interest in sustaining international medical research in aviation and diving and other forms of physiologic environmental stress. This effort stimulated development of a National Science Foundation and the National Institutes of Health, with each new agency actively supporting undersea biomedicine for several decades. All of this individual and agency initiative, communication, and national support gave rise to spontaneous and wide activity in university laboratories, including development of new laboratory systems for pressure and thermal environmental research. The composite of university, industry, and naval interest investment and work was worldwide. Two large steps were responsible for the special worldwide influence on the course of international communication and the advance of undersea activity and medicine. One was the 30-year triennial series of International Underwater Physiology Symposia. The other was establishment of an Undersea Medical Society, which in turn spawned a European Underwater Biomedical Society and satellites. All participants enjoyed the new practicality of international travel and continuous direct scientific communication. Interest in diving medical research expanded concurrently with the initiation and gigantic growth of an offshore petroleum industry, diving for rec- reation, and military clandestine diving - equipment. Inevitably, hyperoxygenation therapy research and application became important for clinical disorders beyond the scope of diving decompression incidents. With all of the varied forms and purposes of human underwater activity and the expanding ranges of interacting stresses, modern diving medicine must continue to xiv Foreword