CAMTS Representative
Thomas J. Cahill, RCP, RRT, EMT-P
3229 Burnet Ave.
Cincinnati, OH 45229-3095
tcahill@shrinenet.org

The section has seen a lot of progress since the first of the year. Membership is still growing, and our section web site has been totally revised. The new site, which went online the last week in February, includes a photo gallergy and other resources. To access most of the information on the site, you will need to enter your AARC membership number.

We are always on the lookout for additional photos for the site, especially those of teams in action, vehicles, aircraft, or team photos. Plans are also in the works for a “swap shop” where we can share resources such as shorts for training, competencies, and protocols. Please contact Kris Williams at the AARC or Steve Sittig with other ideas and/or photos for the site. Remember: this is our web site, so we all need to consider how we can help make it the best that it can be.

As you probably know by now, 2004 marks the 50 th anniversary of the AARC International Respiratory Congress. The meeting, slated for December 4-7 in New Orleans, promises to be one of the best on record, as the Program Committee is going all out to make this landmark 50 th anniversary an affair to remember. As a section, we were able to submit a record 18 transport-related lecture proposals for the Congress. The Program Committee, which met earlier this year, had its work cut out for it, as the “book” with all the lecture proposals was reportedly three inches thick!

I want to thank everyone who submitted lectures for consideration. It will be awhile before we know how many of our proposals will be approved, but every submission was outstanding. So, whichever presentations make it into the final program, you can be sure the meeting will be well worth attending. And if a proposal isn't utilized this year there is always the chance it will be accepted for the 51 st Congress in San Antonio in 2005.

I am hoping that our section will have a record turnout for the 50 th Congress as well. I am planning to repeat the Transport Uniform Day, which was a big hit in Las Vegas. We are also working on a special raffle for active Transport Section members, with a prize of free conference registration to the New Orleans Congress! More details will follow, but I have a tentative commitment from a corporate sponsor for this exciting raffle.

[Top]

The activity over the last quarter has definitely kept your section leadership busy. In addition to working on the Bulletin, e-mailing section members for input and working with the AARC office to discuss the revised web page, the quarterly AARC Board Report was due, and I used the occasion to recommend that the section name be changed to “Surface and Air Transport Section. “Since the Board recently changed the name of the Subacute Care Section to Long Term Care to better represent what the section embodies, I felt this would also be a good time for us to have a section title more reflective of our specialty.

Other issues have also come to the forefront; such as helping a group of transport RTs address safety issues with their vendor's choice of a new aircraft. I was able to put them in touch with a resource to help them address the issues involved.

I was also asked to conduct a telephone interview with a reporter for the Baltimore Sun newspaper. Kris Williams, communications manager at the AARC, noted an inquiry on a public relations e-mail list to which the AARC subscribes requesting someone to discuss private verses state supported trauma flight services. In the state of Maryland, the state police operate a fleet of 12 helicopters for trauma scene flights, search and rescue flights, and other law enforcement duties. A state trooper/medic and a pilot staff these aircraft. The ongoing discussion centers around whether the public would be better served by having private or hospital-based programs take over the medical transports. I was able to get in a plug for the transport RT when the discussion started to address the needs of children and newborns, and was also able to mention both the AARC and the Transport Section. You can read more about the article online.

[Top]

One of the projects I would like to move on this year is to seek approval for RRTs to take the accelerated, 24-hour EMT-B course and to sit for the national certification exam. As you may recall, I brought this issue up last year, but it was tabled as we strove to increase section membership.

Currently, physicians, physician assistants and registered nurses are allowed to take this shortened course and sit for the national certification exam. As registered respiratory therapists, we are allowed to take the shortened, 24-hour course, but we are not allowed to take the national exam for certification. To qualify as a candidate for this exam, RRTs must take the full, 120-hour course, the same as any non-medical person off the street. I am sure you feel as I do that this regulation needs to be changed. I do not think we need to take a class on oxygen devices or spend hours in the emergency room observing or learning how to take a set of vitals. We need only concentrate on such things as backboards, C-collars and the like.

[Top]

On June 8, 2003, LIFE STAR and Stonington Fire were dispatched to Stonington Harbor for a 53 year-old male who was unresponsive and in severe respiratory difficulty after an early morning scuba dive. Upon arrival, the fire department found an unresponsive diver on the pier with fellow divers providing artificial ventilations. According to the patient's dive partner, this experienced commercial diver was performing a routine saltwater dive at a depth of no greater than ten feet. Immediately following ascent, fellow divers found him apneic, cyanotic and unconscious. Advanced life support was initiated, and the patient began to awaken prior to the arrival of the LIFE STAR flight crew.

A detailed exam found an acutely distressed but conscious male with a Glasgow coma scale of 15. Auscultation of lung sounds revealed severe expiratory wheezes throughout all lung fields, which were treated with albuterol updrafts. The patient denied any chest pain or aches in his joints, ears or back. Upon palpation, there was no subcutaneous air to chest or neck, and he moved all extremities equally with no evidence of facial asymmetry. As the patient was being prepared for flight, he became acutely anxious, combative, air hungry, cyanotic and dyspneic. Due to the acute changes in the patient's status, he was medicated and intubated for airway management during flight.

In flight, the patient was continuously assessed and monitored for any adverse changes in his condition. A 12 lead EKG was performed, which showed no acute ischemic changes. Lung sounds were reexamined and improved from the previous exam prior to intubation. A radio report was given to the William W. Backus Hospital, and complete transfer of care was made to the staff.

After further examination and stabilization, the patient was diagnosed with an acute gas embolism (AGE) by pulmonary angiography. Backus Hospital referred the patient to Norwalk Hospital's Center for Diving and Hyperbaric Medicine for further treatment. LIFE STAR was again utilized in the transportation of the diver to definitive care at Norwalk Hospital. The patient's course of treatment included three dives in the hyperbaric chamber. He was discharged later in the week. The diver was able to make a complete recovery from his injuries.

Discussion

Commercial and recreational divers are made aware of potential life threatening injuries that could occur during a venture underwater. Due to the effects of breathing compressed gases at above atmospheric pressure, the potential exists for serious injury. The common pathway by which diving injuries occur can best be described by the gas laws of physicists Boyle and Henry. Boyle's law states that at constant temperature the relationship between pressure and volume are inversely related and expressed by the formula P1V1=P2V2. Normal atmospheric pressure acting on the body at sea level is expressed as one atmosphere, or 760 mm of Hg (mercury). When a diver descends, atmospheric pressure against the body increases one atmosphere for every 33 feet of seawater.(2) For example, a balloon is filled with 1 liter of gas at 2 atmospheres of pressure (or at 33 feet of sea water). As the balloon rises to the surface, the volume of this gas-containing structure will increase to 2 liters. Anatomically, the human body contains air in the sinuses, ears, and lungs, and the potential exists for trapped gases in these cavities to expand similarly to those in the balloon.

Injuries associated with the physics of Boyle's law include pneumothorax, pneumomediatinum, sinus squeeze, Eustachian tube dysfunction, and arterial gas embolism (AGE). Though sinus squeeze and Eustachian tube dysfunction are related to Boyle's law, these injuries are not life threatening and can be easily overcome while diving. The true life threatening emergencies, and the primary focus of this discussion, are the formation of a pneumothorax and AGE. Similarly to the balloon in the previous example, the volume of gas within the lungs will expand as a diver makes an ascent to the surface. But unlike the balloon, the diver can vent this gas by naturally exhaling throughout ascent. The problem arises when ascent is rapid or a breath hold is performed. This maneuver causes gas to expand against a closed glottis and will eventually tear the alveolar membrane. Gas could accumulate within the thoracic cavity, causing a pneumothorax, or enter the pulmonic vascular bed, from which it will eventually enter arterial circulation. Typical signs and symptoms of acute pneumothorax and AGE are sudden loss of consciousness, cardiovascular collapse, and severe respiratory compromise immediately after arising to the surface.

Henry's law describes the ability of a gas to dissolve into a solution when increased atmospheric pressure is exerted on the gas and liquid.(2) An example of Henry's Law can be witnessed during the opening of a carbonated beverage. During the manufacturing and bottling process, carbon dioxide gas is added to the solution by bottling the solution and gas at a pressure of 3-4 atmospheres. At this pressure, carbon dioxide is forced into solution and is released when a consumer opens the bottle, thus restoring normal atmospheric pressure.

Similarly, a diver's breath compresses gas at above atmospheric pressure, which forces nitrogen into solution. If ascent is completed rapidly, dissolved nitrogen will come out of solution and form gas bubbles, typically in fatty tissue, synovial joints and blood vessels. Since the formation of gas bubbles is related to the time spent underwater and the depth of the dive, onset of signs and symptoms can occur from minutes to greater than 24 hours after a dive. Typical signs of decompression sickness (DCS) include pruritis, rash, lumps, subcutaneous emphysema, joint or muscle discomfort, limited limb movement, crunching sound in joint, nausea, vomiting, abdominal cramps, coughing, chest pain, tachypnea, headache, confusion, memory loss, tremors, visual disturbances, nystagmus, ataxia, paresthia, urinary retention, tinnitus, vertigo, paraplegia and unconsciousness.(3)

Decompression sickness can be subdivided by the severity of symptoms into type I and type II DCS. Usually, DCS type I presents hours after a diver ascends with mild symptoms and no immediate life threat. Typically, cases of DCS type I are associated with air travel after diving or more than one dive per day. Signs and symptoms include a slowly progressing pain or numbness in the limbs. Pain in the joints, muscles or back usually worsens over time and is most acute when moving. If symptoms worsen, the patient can progress into DCS type II, which is a life-threatening emergency. DCS type II becomes an emergent condition when the symptoms affect the central nervous system and cardio-respiratory systems. Dyspnea, chest pain, severe headache, altered mental status and shock are the usual symptoms, with the most severe cases developing complete unresponsiveness and coma.(2)

When treating a patient with a suspected diving-related injury, a broad range of differential diagnoses should be suspected as well. Eliminating differentials begins with a good history about the dive and the relationship to the onset of symptoms. Typically, important information to obtain includes the depth of the dive, bottom time, decompression stops, dive category, past diving accidents and past medical history. Since DCS type II and AGE present with similar neurologic and cardio-respiratory compromise, field diagnosis between the two pathologies is difficult, though treatment is very similar. Initial assessment and the physical exam will reveal the need for immediate management of life threatening injuries like tension pneumothorax, respiratory arrest and cardiac arrest. Detailed examination of the patient may reveal the presence of subcutaneous emphysema, decreased motor or sensory function of extremities, joint pain, difficulty breathing, altered mental status, abdominal pain or paralysis. As in the case of the diver from Stonington, the patient's mental status may acutely deteriorate after initial assessment and may require immediate intubation, even though the remainder of the exam is benign.

Ultimately, the appropriate treatment for a patient diagnosed with DCS type II or AGE will be recompression therapy in a hyperbaric chamber. Hyperbaric therapy creates above-atmospheric pressure similar to the pressures placed on the body during a dive. Through the creation of increased atmospheric pressure, the body can reabsorb gas bubbles that have formed within blood vessels or tissues. Once the atmospheric pressure forces the gas bubbles into solution, ascent in the chamber can begin at a slow and controlled rate. During the slow rate of ascent, the body is given ample time to naturally allow the gases in solution to be released, thus resolving previous symptoms. Though both diseases are initially treated in the same manner, hyperbaric therapy varies among the two disease processes. As a guideline, most hyperbaric chambers utilize the U.S. Navy dive table to determine the course of action for proper therapy.(1)

Today, hyperbaric medicine is used to treat many different diseases, including AGE, DCS, carbon monoxide poisoning, gas gangrene, crush injuries, wounds resistant to healing, blood loss anemia, intracranial abscess, necrotizing soft tissue infections, osteomyletis, delayed radiation injury, compromised skin grafts and thermal burns.(4) Few hospitals in the Northeast offer hyperbaric therapy for the acute management of the previously mentioned diseases. Within the state of Connecticut, two hyperbaric chambers are open to the public for management of acute diseases. Norwalk Hospital has been treating critically ill patients in their monoplace (one person) chamber for many years. On August 18, 2003, Hartford Hospital opened the Center for Wound Healing and Hyperbaric Medicine with a large, ten-patient multiplace chamber. Operating one of the largest hyperbaric chambers in New England, the Center for Wound Healing and Hyperbaric Medicine will continue to manage critically ill patients and provide valuable research to the medical community about the value of hyperbaric medicine.

References

1. Campbell, Ernest S. Decompression Illness in Sports Divers: Part I. Medscape Orthopaedics & Sports Medicine eJournal. 1997.
2. Kaplan, Joseph. Emedicine. July 23, 2003. About Sept 20, 2003 .
3. Walker, Stuart. Hyperbaric Medicine Unit. September 02, 2003. About December 26, 2003.
4. Indications for Hyperbaric Oxygen Therapy. Undersea and Hyperbaric Medical Society.

[Top]

Specialty Practitioner of the Year: Submit your 2004 nominations now.

Recruit a new member: Know an AARC member who could benefit from section membership? Direct them to section sign-up. It's the easiest way to add section membership to their overall membership package.

[Top]