Compiled and
edited by Jeffrey Bozanic
There can be
no doubt that in a serious diving accident, such as decompression sickness
(DCS) or arterial gas embolism (AGE), the immediate administration of
oxygen has significant benefits for the victim. Another unarguable axiom
is that as dive instructors we are committed to providing the best care
and supervision we reasonably can for the students and clients we lead
on dives. The point of contention, in the question of whether all instructors
should be required to have oxygen administration capability, is what
defines the word "reasonable" in the context of today's diving
environment.
Ten individuals
responded to this month's query. The respondents were equally divided
on the matter, with two individuals suggesting an intermediate approach.
Surprisingly, many of the same arguments were advanced by members opposed
in their views to support their opinion.
The legal ramifications,
as was only to be expected, was a major point of concern by all members.
Those opposed to the suggestion of mandatory oxygen capability stated
that since oxygen is considered to be a drug, that it could only be
prescribed by a physician, or other trained individual. However, another
argument advanced was that since the delivery of oxygen is universally
accepted as the primary immediate first aid treatment for DCS and AGE,
that the instructor involved would be negligent not to supply oxygen
in such circumstances.
Cost was cited
as another variable used by both sides to support their beliefs. Both
the "high" and "low" costs of obtaining the needed
equipment and training were declared, although no actual prices were
stated.
Training was
another issue with which both groups sought to bolster their concepts.
It was felt that CPR and First Aid training on a regular basis should
be required by all active instructors before training in oxygen administration.
Some respondents expressed their concern that the only means of being
trained in oxygen administration would be to enroll in a full Emergency
Medical Technician (EMT) or paramedic course, however NAUI, the American
Red Cross, and the National Association for Search and Rescue working
cooperatively have developed a two day program expressly for the purpose
of training non-medical personnel in the use of oxygen.
A compromise
solution was advanced by some members. They argued that since most diving
and dive training occurs at sites to which an ambulance or other type
of emergency medical system responder could arrive at within minutes,
that oxygen delivery equipment and training should only be required
of instructors who are at remote locations. Thus, oxygen and the associated
equipment necessary for its use only need be carried by dive boats,
instructors leading foreign tours, and by those teaching at remote sites.
However, rapid and efficient communication, as well as the definition
of a "remote" site, then become important points of consideration,
and raise their own contentious questions.
The legal environment
in which we all work as instructors is continually shifting. It is this
parameter which, in the United States at least, which will ultimately
guide this decision. Sources outside this column have advised that the
key issue is most likely training, as the cost is negligible when compared
to the expense of the other equipment needed to safely teach scuba,
and that there are no medical arguments against the use of oxygen in
the situations under consideration. It may be that as the training in
oxygen administration becomes more readily available, that we may have
no choice but to require this training and support equipment as part
of our regular requirements for NAUI instructor members.
QUESTION: "SHOULD
INSTRUCTORS BE REQUIRED TO HAVE OXYGEN ADMINISTRATION EQUIPMENT AND
TRAINING TO REMAIN IN TEACHING STATUS?
A. Aside from
CPR if it is required, there is no question that the administration
of oxygen is the single most important thing that a diving leader can
do for a diver suffering from air embolism, decompression sickness,
or drowning. One only needs read the volume of material written on the
subject over the years in such publications as the PRO Manual, NDA News,
Sources, and Underwater USA as well as information published by DAN,
UHMS, and the other nine recreational certification agencies to understand
the issues. No leader would ever be able to claim that he or she did
not know this. DAN has even negotiated a deal with a manufacturer to
provide appropriate equipment at a price significantly lower than the
local ambulance company can buy it. Given that NAUI has co-sponsored
an oxygen administration training course with the National Association
for Search and Rescue (NASAR) for the past several years, the same diving
leaders(s) would find it impossible to claim no access to such training.
The British Sub-Aqua Club made a serious commitment to oxygen training
for its membership several years ago. In the past three years, they
have trained over 1500 of their members with a course virtually identical
to that of NAUI/NASAR in eleven different countries.
Many years ago, the late Dr. Jefferson Davis told me that the moral
responsibility of a diving leader to administer oxygen to a diving accident
victim far outweighs the falsely perceived legal liability. Most attorneys,
I suppose, care little for moral responsibilities, but they will go
after a legal responsibility with the enthusiasm of a junk yard dog.
NAUI does not need to require oxygen equipment and training for its
members ... the attorneys and the courts will see to that. From NAUI's
own legal perspective, they really have no choice in the matter. Some
of the first questions attorneys are now asking during the aftermath
of a diving accident are, "Was there oxygen available, and was
it administered?" Shame on the instructor or divemaster who cannot
answer "yes" to both questions, and shame on NAUI if they
do not have a policy requiring the proper equipment and training.
It is a sophisticated society in which we live. What we require of our
diving leaders today is far different from the requirements we placed
on them ten years ago. Today, we have required paperwork, BCDs, and
alternate air sources, just to name a few. Face the fact that it is
becoming more expensive and our responsibilities are only increasing
to teach or supervise divers. We have entered an era in which we have
no choice as dive leaders but to see that demand-style oxygen equipment,
an adequate supply of oxygen, and appropriately trained personnel are
available at all locations where we conduct dive training. I carry two
jumbo "D" cylinders with two demand valves in a waterproof
case on all dive outings. I cannot even imagine not having the system
with me. If you genuinely cannot afford the equipment or the training,
write to me. I will help you work something out. Do yourself a favor
... GET THE EQUIPMENT, GET THE TRAINING, and educate yourself to the
point that you can prevent the accident before it happens.
--Jim
Corry, NAUI 7184L; Washington, D.C.(Has taught all levels to ITCs both
privately and at UCLA. Currently serves as Chairman of the Diving and
Water Rescue Committee of the National Association for Search and Rescue.
Has written many articles about diving safety. 1989 Recipient of the
Greenstone Award.)
A. NAUI Instructors
should have annual CPR and First Aid training as a priority. Then we
can discuss a requirement for oxygen equipment and use. Dive boat operators
and diving bases must have oxygen equipment. However, it would be too
much to expect individual instructors to invest in expensive oxygen
delivery equipment. I would agree that the standard in question is worthy,
but you cannot climb a mountain in one step. I would recommend that
CPR and First Aid training be required annually, with oxygen use training
considered at a later date.
--Norbert
Zanker, NAUI 9657; Geissen, West Germany (Registered
emergency medicine and anaesthesia nurse. Has taught all levels of diving
up to and including ITC staff experience. NAUI Chapter Leader for Germany.)
A. Speaking as
a research diving officer, it has long been our policy to have oxygen
at each of our dive sites with individuals trained in its use. It is
well known that the use of oxygen is the most effective "first
aid" for pressure related maladies such as decompression sickness
or air embolism.
In addition, as Jon Hardy pointed out in an article some time ago, it
is tough to sit in a court of law and have a plaintiff's attorney shake
his finger in your face and demand to know why if you knew oxygen was
recommended as a safety measure for diving injuries you did not have
it available.
--James
R. Stewart, NAUI A-88; La Jolla, CA(Diving Officer for Scripps Institution
of Oceanography, and the National Science Foundation. Has extensive
research diving and instruction experience worldwide. Member, NAUI Board
of Advisors, Recipient of the Leonard Greenstone Award, NOGI Award,
and other awards. Has written diving safety guidelines for a wide variety
of governmental and private institutions.)
A. Dive leadership
personnel are not only responsible for supervision of the safest possible
conduct during diving activities, but they are also entrusted with a
duty to respond effectively should a scuba diving related emergency
occur. Every textbook published by every agency involved in the field
of scuba diving clearly dictates an undisputed protocol proscribing
oxygen administration as a mandatory segment of emergency first aid
to an diver injured as a result of breathing compressed air. An instructor
who is not trained and is not able to administer oxygen in such an event
would not be much different from a First Responder or a Paramedic who
is unable to perform chest compressions during basic CPR life support.
With the widespread availability of emergency oxygen administration
courses within our industry, there is no longer any excuse for having
such training. I hope that oxygen equipment and trained individuals
on the site of diving activities will soon become a mandatory standard
for a dive leader to maintain teaching status.
--George
Safirowski, NAUI 8921L; Hackensack, NJ(Contract Instructor for Lifeguard
Systems, teaching all levels of diving to ITCs, as well as Underwater
Photography, Video, and Diver Rescue specialties. Has done videography
for many underwater projects.)
A. Oxygen administration
equipment and training is useful, but should not be mandatory to maintain
ones teaching status. Being able to administer oxygen until medically
qualified help can arrive would increase a victims chance of survival.
However, once a person is qualified to administer oxygen would they
also be required to maintain their qualification, like for CPR and first
aide? And what about the logistics of purchasing and maintaining the
equipment. Would NAUI be willing to carry oxygen equipment as a product?
If so, what make and model of equipment and for what price? Diving safety
is a very important question, but there are practical matters to also
consider.
--James
Weston, NAUI ????; Santa Cruz?, CA(Private Professional Instructor,
had taught for Fort Ord, dive stores and universities.)
A. In a word,
yes. All instructors doing any water work with students in pools and
in open water should have mandatory oxygen equipment. The same holds
true for instructors who run local dive trips, especially on boats.
Simply put, this is a standard of care in the industry. In the event
of a diving accident, an instructor could be found negligent if he did
not carry oxygen administration equipment.
Certification training in the use of oxygen administration equipment
should also be mandatory. This would seem to be obvious, but it is apparently
not based on the number of instructors who have access to oxygen equipment,
but who do not know how to use it properly. Training can be obtained
through an Emergency Medical Technician course or an Oxygen Administration
and Field Management of SCUBA Accidents course.
Jeff Stone,
NAUI 8156; San Antonio, TX(An Emergency Medical Technician who has taught
all levels of diving through leadership levels, including specialties.
Has instructed as a private professional, Caribbean divemaster, and
dive store manager.)
A. I am taking
a strong position against this requirement. I believe a cost benefit
analysis of such a requirement would suggest that there would be a very
high investment in training and equipment procurement, a potential increase
in the cost of liability insurance, to gain a very small benefit.
There are many factors to support this view: (1) Oxygen is a drug, and
must be administered only under the direction of a physician. (2) Bends,
air embolism, and myocardial infarction are extremely rare occurrences,
and if oxygen is needed, it is probable that simple air inhalation equipment
would be insufficient. Airway management equipment (oral airways, etc.),
positive pressure or bag-valve devices, and suction equipment would
also be required. (3) Most diving areas are served by well-trained police,
fire, and emergency medical service organizations which are able to
respond quickly, usually within minutes, with oxygen and delivery equipment.
(4) A new training program in oxygen administration for non-medical
personnel would need to be developed, as presently existing courses
are not provided to average citizens, and the skills are not a part
of a typical first aid course. (5) Dive instructors frequently work
in groups, making any requirement that each instructor have oxygen delivery
equipment redundant.
Instead, I would make the following suggestions: (1) The dive instructor
or leader should have knowledge of the proper way to activate the local
emergency medical system (EMS). Quarters for phone calls in the first
aid kit are important, but it would be reasonable for a group of instructors
to pool their funds and purchase one or more cellular mobile telephones.
This would allow prompt EMS activation, and can be obtained for about
the price of three proper oxygen ventilation rigs. (2) Oxygen and personnel
trained to administer it should be available to diving groups in truly
remote areas and on boats, or where for any other reason the EMS cannot
be readily accessed. (3) If the industry truly perceives a need, then
the requirement should indicate that oxygen administration equipment
and personnel trained to use it should be available at each dive site--each
individual instructor should not bear the burden.
--Howard
A. Kirkwood, Jr, M.H.A., NREMT-P, NAUI 6524; Mount Laurel, NJ(Free lance
diving instructor, has taught all levels from resort scuba to ITC staff.
B.S. in Biomedical Sciences/Physiology, M.H.A. in Health Services Administration
(Emergency Medical Services). Director of the Emergency Medical Technician
Program for Registered Nurses in New Jersey, 1985-88.)
A. First of all,
as a part of the answer to this question, I cannot believe that a teaching
NAUI Instructor does not have to be current in CPR and First Aid. How
can you expect someone to conduct a reasonable and competent rescue
if the instructor has not had CPR training for years? I believe that
this requirement would be a reasonable first step.
In our particular training area advanced care is only a matter of minutes
away. I do not believe that it would be productive for all NAUI instructors
to be trained and required to have oxygen equipment. It would obviously
be prudent in certain remote areas to be more self-contained, but an
across the board requirement is not called for.
--John
Heine, NAUI 5924; Moss Landing, CA(Diving Safety Officer at the Moss
Landing Marine Laboratories of the California State University. Course-director
for 3 ITC's. Past Mid-Pacific Branch manager. Serves as Secretary of
the American Academy of Underwater Sciences, and is a contributing editor
of Sources. Holds a masters degree in marine biology.)
A. I am AGAINST
this requirement because NAUI already has enough requirements for teaching
status. I thought NAUI was a democratic organization, yet I have never
been asked to vote on CEUs, recertification, or oxygen administration
equipment.
Who is going to define what is "adequate equipment," where
is the training on oxygen management for diving accidents going to be
given, and how often do you have to be recertified in this? There is
no place locally that the training is available, and I have NO desire
to become an EMT.
Some states consider oxygen a drug and the public is not allowed to
administer oxygen. You must be an Emergency Medical Technician (EMT)
in many states to give oxygen. Liability is the biggest issue against
this requirement!
--Edward
E. Harper, NAUI 6112; North Canton, Ohio(Primarily teaches specialty
courses for National Charter Service.)
A. If teaching
in remote areas where emergency services are not readily available instructors
should be required to have oxygen respirators and training. Otherwise,
it is just another cost, affordable only by full time and institutional
instructors. In most areas this equipment is redundant to local emergency
medical services. Is the next step that all instructors be required
to have recompression chambers and medical doctors on site like the
commercial diving industry?
--Don
Canestro, NAUI 5877; Santa Barbara, CA(Research diver at the University
of California, Santa Barbara. Has taught extensively in university settings.)
A. Instructors
should definitely be required to have training in oxygen therapy to
maintain a current status. This must include the theoretical rationale
for oxygen delivery, familiarization with the types and patterns of
oxygen systems available, and hands-on administration practice. In addition,
oxygen therapy equipment should be immediately available during all
phases of diving training. Whether the actual units are owned by the
swimming pool, charter vessel, resort, or the instructor is unimportant.
It is critical that oxygen therapy equipment be available, properly
maintained, and tested prior to the start of any diving.
--Neal
Pollock, NAUI 7068; Vancouver, British Columbia, Canada
A. No. To require
the diving instructor to pay for 100% oxygen gear is premature in 1990,
but asking dive stores and universities to foot the bill for this investment
in safety is reasonable. Good quality oxygen equipment can usually be
purchased for about $500. There is basic first aid training available
at a token cost that teaches management of 100% oxygen and positive
pressure systems. It is called the EMT-1 rating. Advantages of this
entry level emergency care training can include increased physical self-awareness
and a broader ability to deal with diving related accidents. This is
due partly to the moderate but effective study of human physiology and
anatomy. Most colleges periodically offer this training for a few dollars.
NAUI's intention to get involved with oxygen/medicine/CPR is met with
mixed emotions among our circle of instructors. We can teach scuba and
get our specialized training from the medical community if we seek it.
Let's also keep NAUI at the progressive edge of adventure/travel sports
and research professions. We should also endeavor to establish broad
new ethical and legal standards of safety for our future.
--Jim
Larson, NAUI 10346; Berkeley, CA (Co-owner of the NAUI Pro Facility
Cal School of Diving. NAUI Instructor Trainer, regularly participates
in ITCs and rescue workshops. Holds a current EMT rating.)
A. Absolutely!
The facts speak for themselves: for decades oxygen has been used throughout
the U.S., to treat military as well as sport diving accidents with impressive
documented success. Oxygen, administered acutely at the dive site, can
make the difference between a clean bill of health and a lifetime of
unresolved medical problems. In some cases, oxygen can literally make
the difference between life and death!
It is unfortunate that the medical community has not as yet sanctioned
the administration of oxygen by scuba instructors. Oxygen, which is
classified as a drug in some states, can only be administered by medical
professionals. I feel it is erroneous for the AMA to group dive instructors,
who have undergone many hours of rescue training, together with the
general "lay public."
Hopefully, by expanding that training to include a mandatory accredited
oxygen administration program, such as the NAUI oxygen course, (which
has been approved by the Undersea Hyperbaric and Medical Society (UHMS)
and the EMT National Registry) will convince the medical community otherwise.
In the meantime, instructors still have a moral as well as a legal commitment
to fulfill. When we take the NAUI oath of leadership we are undertaking
an awesome responsibility. We are placing in our hands the safety of
many divers in a potentially dangerous environment. We owe it to our
students and to ourselves to possess the lifesaving skills and tools,
such as oxygen, which can best secure that safety.
--Hillary
Viders, NAUI 10107L; Tenafly, NJ(Director of Operations for Scuba Connections,
Inc. Teaches entry level courses to ITCs, and wreck, photography, modeling,
oxygen administration, and rescue specialties. Member of the UHMS, National
Association of Diving Medical Technicians, and crew member of the Milford,
NJ Recompression Chamber.)
A. A resounding
yes, yes, yes to this very basic question. I cannot possibly think of
any instructor that would have any objection to make this a standard
to obtain teaching status. Ever since I learned to dive, in 1985, I
was taught that oxygen was the very best treatment you could give a
diver with either DCS or AGE. While I am sure some members will object
to the cost factor, including training and that of the equipment, I
doubt that they would ever disagree with this statement: It is better
to have oxygen and not need it, than to need it and not have it. I truly
think that if this policy is adopted it will keep NAUI at the forefront
of agencies in regards to safety for our students.
--Charles
Capps, NAUI 11430; Knightdale, NC
A. I have studied
this question and in researching this answer I have found the following:
some fifteen training manuals, handbooks, and handouts on the subject
are being used by twenty-two scuba agencies, associations, societies,
and government agencies all recommending the use of oxygen in at least
seventeen types of diving related accidents.
I recently attended a meeting of the Undersea and Hyperbaric Medical
Society and the Lifeguard Systems oxygen administration and accident
management workshop. As a result, I have come to appreciate the importance
of having the correct equipment and the knowledge required to administer
oxygen. Both of these workshops dealt, in part, with cases in which
a diver could have been saved had the equipment and the knowledge been
immediately available.
Although I am not a NAUI leadership member, I feel that all instructors
should take the time to gain the knowledge required and acquire the
equipment. Further, I feel NAUI should actively encourage all Divemasters
and Assistant Instructors gain training as well.
--Fred
Brown, NDA 38 cdn; Mississauga, Ontario, Canada
A. Yes, instructors
should have to carry oxygen administration equipment. How can an instructor
stand before his/her students and tell them how important 100% oxygen
is in the management of a diving accident and then not have it at the
dive site? By doing this the instructor is not showing professionalism,
nor concern for his/her students if a diving accident should happen.
The biggest complaint is going to be the cost, but this should not be
an issue because it is part of the price you pay for being a professional
instructor.
--Mike
McKay, NAUI 11273; Walled Lake, MI(Private Professional teaching Openwater
I through Advanced, and the Ice Diving specialty.)
[NOTE: The views
expressed in this column are opinions held by the individual members
referenced, and are not those of NAUI or the editors of Sources.]
