Compiled
and edited by Jeffrey Bozanic, NAUI 5334L
Acquired
Immune Deficiency Syndrome, or AIDS, is a topic which has permeated
our media for many years now. Because of the severe consequences (eventual
death), and the lack of effective treatment or vaccination procedures,
concern about the transmission of the disease is high. It is obviously
in the best interests of society in general, including the diving community,
to limit the spread of AIDS.
The
question of whether mouth to mouth resuscitation should be taught to
openwater diving students was posed by Roy Damron, NAUI 207. In addition
to this question, he voiced several corollary concerns: After completing
a scuba course, should a student in the future contract the virus due
to body liquid exchange while trying to revive a drowned victim, can
the instructor who encouraged mouth to mouth be held liable? And would
NAUI insurance protect that instructor? Would the same be true of a
student who contracted AIDS controlling severe bleeding in a diving
related accident, for example shark attack?
The
overwhelming majority of the respondents emphatically stated that instruction
in mouth to mouth resuscitation techniques should be continued. However,
while compiling the responses, it was evident that the question of contracting
AIDS as a result of scuba instruction could be differentiated into several
parts: (1) During mouth to mouth training on land, (2) During rescue
practice sessions in the water, and (3) During actual mouth to mouth
resuscitation efforts on a real victim during an emergency situation.
I would like to summarize and address these scenarios separately.
Instruction
in mouth to mouth resuscitation on land is routinely conducted using
mannequins ("Resusci-Annies") as a training aid. While the
AIDS virus has been found in saliva, the transmission of AIDS by saliva
has not been demonstrated. AIDS transmission has only been confirmed
as a result of interchange of blood, semen, urine, or fecal material
with an infected individual. The exchange of any of these materials
is highly unlikely as a result of using a mannequin. However, other
viral infections can be transmitted as a result of improper mannequin
use. Properly cleaning the mannequin is an essential part of preventing
disease transmission, including possible AIDS transmission.
In-water
rescue practice sessions entail the simulated rescue of an unconscious
diver. In the past, some instructors have had their students practice
actual mouth to mouth contact. This practice is clearly non-hygienic,
and should be discontinued. Other instructors utilize mouth to cheek
breathing as a simulation of mouth to mouth. This prevents the exchange
of saliva in the foregoing method, and usually has no possibility of
disease transmission. However, I have seen instances where a large wave
has jostled a pair of students while one was simulating mouth to mouth
using this technique, resulting in both students experiencing minor
bleeding from small cuts in their lips, This was caused by violent tooth
contact as one student was leaning over the other preparing to contact
the cheek. Obviously, this potential exchange of blood creates a possible
vector for disease transmission.
In
actual rescues, the exchange of body fluids other than saliva is a very
real possibility during mouth to mouth resuscitation efforts. Vomitus
is often present, as is blood from lung over-expansion injuries. Any
small cut or sore on or in the rescuer's mouth would provide a transmission
path for possible infection. So what options were raised to minimize
these problems?
Many
respondents recommended teaching the use of a pocket mask for resuscitation
activities. They further went on to suggest that every diver carry a
mask with them while diving, either in a BC pocket or other convenient
location. Some members pointed out that the risk of contracting AIDS
from another diver is very small, because the diving population is not
one of the demographic groups which is at high risk, and the incidence
level of AIDS infected people in the general populace is very low. This,
however, is no guarantee that the person you might find yourself dealing
with is a healthy individual. And it must be kept in mind that one of
the basic precepts of rescue is that the rescuer not place him/herself
at undue risk.
While
responses covered the initial question of mouth to mouth resuscitation
training, they left unanswered other questions of liability and risk
in post-training scenarios. Damron raised some very real and significant
questions, worthy of thought. In my mind, students must be informed
of the risk of AIDS and other transmittable diseases concurrently with
their rescue training. They, then, must determine what their personal
response will be to an emergency situation.
Ultimately,
rescue, rescue instruction, and AIDS becomes a moral question. It is
relatively easy to provide safe training in mouth to mouth resuscitation.
However, in the real world, faced with a life threatening situation,
it will be the option of the person at hand to determine what is acceptable
to them as to how to proceed given the resources at hand. And that may
well include either performing mouth to mouth without a protective or
isolating device, or standing by and watching someone die because such
equipment is unavailable.
QUESTION:
"GIVEN THE WORLDWIDE AIDS EPIDEMIC, SHOULD SCUBA COURSE CURRICULUMS
CONTINUE TO INCLUDE THE TEACHING OF MOUTH TO MOUTH RESUSCITATION? WHY/WHY
NOT?"
A.
"Divers traditionally try to get as far away from civilization
as possible to do their thing. They will carry heavy equipment for long
distances and down steep trails that only brave mountain goats use to
reach their favorite dive sites. Due to the isolation such areas offer
better diving than well known, crowded dive sites. But there is a price
to pay. There are no telephones. Time and distance to help is considerable.
Therefore, every diver must have the ability to manage emergencies,
such as massive bleeding and drowning, on their own for long periods
of time until professional help arrives."
The
foregoing is my "attention getter" for my first aid lecture.
The visions of secret dive sites cause them to lean forward in anticipation.
The challenge of attending to life taking injuries offers a "need
to know." I have no problem stirring up my enthusiasm because the
three times I have had to administer mouth to mouth I have been successful,
as I have been giving temporary first aid for several cases of serious
bleeding. To be honest with my students I point out that they can expect
the presence of body fluids such as blood and stomach contents, but
with adrenalin pumping we do not notice it at the moment.
Following
the usual demonstrations I wrap it up by pointing out that all humans
are responsible for one another. If we are ever in a situation where
someone's life is at stake it is our duty to take charge and do whatever
we can to save a life.
I
always encourage my students to ask questions at any time, so it came
as no surprise during a class last fall when someone raised their hand
when I was discussing body fluids. The question was, "What if they
have AIDS?" I have heard people say they felt like they were hit
by a bucket of ice water. Now I know what they mean. Having spent many
years in the dance business I have first hand knowledge of how devastating
this epidemic has become. Yet, I never recognized that it could have
a direct bearing on our wonderful world beneath the sea.
I
thought about it for a few days, and then wrote to NAUI HQ with the
following questions: Should we continue to encourage our students to
engage in mouth to mouth and bleeding control? If a student of mine
contracts AIDS and sues me will my NAUI insurance defend me? Should
not our Board of Directors set a policy for us to follow? I am still
waiting for an answer. In the meantime I have been honest with my students.
Are we responsible to our fellow man to the point of risking our lives
to save theirs? I can no longer tell them that it is their duty to do
so, since I do not know how I will react if I ever again see a stranger
lying on the beach turning purple due to lack of oxygen.
--Roy
Damron, NAUI 207; Kona, Hawaii (Diving
Instructor, current NAUI Board of Advisors member. Past NAUI Director,
Chapter Leader, West Pacific Branch Manager, and ITC Director. Recipient
of NAUI Outstanding Service Award.)
A.
It seems the standard of practice in the emergency response world is
the "mouth to mask" system, the use of "shields,"
and the use of "gloves." I vote to go with those in the know
and follow established procedures.
--Peter
Meyer, NAUI 4264; Vancouver, British Columbia, Canada (Insurance
Broker handling diving instructional liability insurance. Member NAUI
Canada Board of Directors. Has lectured extensively on risk management
in scuba instruction.)
A.
I feel that we must continue this very valuable and important skill.
We must, however, take whatever precautions that are called for such
as use of disinfectants and barriers on CPR mannequins. The American
Red Cross and American Heart Association have not stopped teaching CPR
but have upgraded their sanitary precautions. We should simply follow
their lead in this matter.
--Keith
J. Sliman, NAUI 3417L; Baton Rouge, LA (Director
of Training for SEVEN SEAS, a NAUI Pro Facility and winner of 1987 Affiliate
Award. Received the Outstanding Service Award and Continuing Service
Award. Member of NAUI Dive Table Review Committee, reviewer of Advanced
Diving Techniques, contributor to upcoming Leadership Manual and frequent
contributor to Sources. Has taught all levels from entry level to ITC.)
A.
Of course. It has never been substantiated that AIDS can be passed via
saliva (although I realize that a victim may very well have blood and
other fluids in their mouth at the time of need). There is generally
more danger in contracting Herpes or a common cold than AIDS from an
activity such as mouth to mouth resuscitation. The issue of health is
a real one however, and students should be made aware of it. Every class
should be introduced to the use of pocket masks for resuscitation, both
in the water and on land. There are compact, effective, and inexpensive
units available which could easily fit into a B.C. pocket or first aid
kit. Those concerned about disease and germs can easily obtain one.
Personally, I keep one on hand.
--Nicole
Crane, NAUI 10435; Pacific Grave, CA (Diving
Safety Officer for Stanford University. Has taught all levels of diving
to Divemaster, including specialties such as Research Diving. Has Taught
for the military at Fort Ord and at the Catalina Island Marine Institute.)
A.
It is OK to continue teaching mouth to mouth resuscitation. There is
no evidence or indications that mouth to mouth resuscitation is a vehicle
for the transmission of AIDS.
--Ian
Koblick, NAUI ????; Key Largo, FL (Director,
Marine Resources Development Foundation. Has been heavily involved in
underwater habitats and laboratories for almost thirty years.)
A.
Yes. While this maybe another argument for teaching mouth-to-snorkel
technique, there is no data to support the contention that the HIV virus
can be transmitted even by kissing. It is blood to blood contact and
sexual contact that are the major concerns.
--Phil
Sharkey, NAUI 4505L; Narragansett, RI (Diving
Officer for the University of Rhode Island Graduate School of Oceanography.
Has taught all levels and served as an ITC Director. Recipient of the
NAUI Outstanding Service Award.)
A.
Upon reading this question, I realized that I did not know that much
about AIDS. I then researched the subject and learned that the virus
that causes AIDS is named Human Immunodeficiency Virus or HIV. HIV is
difficult to transmit. The spread of HIV is limited to sexual contacts,
sharing of hypodermic needles and receiving contaminated blood or blood
products. The virus has been found in saliva and tears, but the transmission
by these body fluids has never been demonstrated and is extremely unlikely.
No family member of an HIV carrier has ever been infected by hugging,
kissing, or sharing tableware or bathroom with the infected person.
HIV cannot be spread in swimming pools or bodies of water because chlorine
kills the virus, or the infectious secretions would be so diluted as
to be harmless.
When
using CPR mannequins the same precautions as those to prevent the spread
of other infectious diseases is sufficient. Surfaces which come in contact
with the mouth should be cleansed between students with a 1:10 solution
of household bleach to water and wiped dry after 30 seconds.
In
conclusion scuba course curriculums should continue to teach mouth to
mouth resuscitation. For more information about AIDS the National AIDS
Hotline is 1 (800) 342 AIDS.
--Jerry
R. Nuss, Jr., NAUI 12585; Rossville, IL (Independent
Instructor conducting courses primarily for law enforcement officers.)
A.
Yes, absolutely, there should be no question about teaching mouth to
mouth resuscitation. It would be up to the individual to choose to use
this skill or not. Of course the individual should be able to make an
INFORMED decision. A responsible scuba course curriculum, therefore,
should include at least the minimal facts concerning AIDS epidemiology
as related to scuba. First, the number of HIV positive people is a very
small percentage of the population. Second, and most important, the
virus is not easily transferred (if at all) by oral secretions unless
visible blood is present. Current CDC guidelines does not include oral
secretions (including saliva and vomitus) as requiring universal precautions
unless visible blood is present.
There
is always the choice of using a type of resuscitation mask, but realistically,
these masks are not easy to use and seldom readily available in the
"real world". In the final analysis, when faced with the choice
of preforming mouth to mouth or watching a human being dying before
your eyes, I prefer to believe in man's humanity.
--Jeff
Lynam, NAUI 12195; Acworth, GA (Independent
Instructor and Manufacturer's Representative. Has worked in resorts,
attended I.T. Workshops, and staffed IQ '91.)
A.
Given the hysteria surrounding AIDS, this is an unfair question. Furthermore,
in all probability, at least 95% of us are not fully conversant in such
areas as the epidemiology of AIDS, the fragility or other characteristics
and virulence of HIV, its vectors, modes of transmittal, titers in saliva,
probabilities of transmission, etc. Thus the answers could be predicated
on feelings not data.
Still,
evidence appears to indicate that the probability of transmittal of
HIV through mouth to mouth contact is negligible, particularly in the
absence of oral lesions. Thus neither NAUI or any other training organization
should take it upon themselves to deprive the divers they train of the
ability and training to execute any life saving maneuvers because an
infinitesimal probability of infection lurks in the backs of our minds.
How the trained diver, equipped with the proper tools, will use that
training is between the diver and his/her conscience.
--E.
Esat Atikkan, PhD, NAUI 6274; Rockville, MD
A.
In teaching rescue skills to my students, they practice SIMULATED mouth
to mouth resuscitation. Mouth to mouth is simulated by blowing on the
cheeks of the victim rather than actual breaths in the mouth (couples
are excepted). The simulation is practiced regardless of the AIDS epidemic
for many obvious reasons.
--Burhaneddin
Z. Muntasser, NAUI 9650; Peekskill, NY (Taught
all levels, OW I through ITCs. Teaches primarily at colleges. Recipient
of the NAUI Outstanding Service Award.)
A.
I believe that scuba courses should still contain instruction on mouth
to mouth resuscitation. It may save your own life one day. There are
risks in everything we do but do not forget that AIDS is a minority
disease per capita to the number of people diving. In fact, I would
go so far as to say that divers, simply by the type of people that are
attracted to the sport, at least in this part of the world, are least
likely to be involved in activities that would contract the disease.
I know, there are always exceptions like blood transfusions and one
night stands but again these situations are a very small minority.
I
always carry a Laerdal pocket mask with me in my wetsuit pocket so that
if I ever need to I can support an accident victim using it and do not
have to check their medical record first! The pocket mask is excellent
in that it not only avoids direct contact but helps keep water from
the victim's nose and mouth and enhances towing by allowing the rescuer
to tow the victim from behind the head rather than using the 'do-si-do'
which can be quite difficult if there is any material difference in
size between the rescuer and victim.
--John
Baird, NAUI 10149; Northcote, Auckland, New Zealand (Regional
Manager, NAUI New Zealand, and Member of the NAUI Australia Board of
Directors. Teaches entry level diving, and some specialties.)
A.
As long as the major players in the Basic Life Support field (i.e. the
American Red Cross and American Heart Association) continue to require
mouth to mouth resuscitation be taught as a prerequisite skill for learning
how to use a pocket mask or other "rescue" mask we have no
choice. But the training should not stop there! CPR at the professional
rescuer level should be taught to every SCUBA student. SCUBA classes
cannot be everything for everybody; however, if the SCUBA instructor
is not qualified to teach Basic Life Support (BLS) CPR then he should
find someone who can, or insure that each student has received the training
elsewhere prior to certification. Yes, only NAUI leaders are now required
to have this level of training, but it should be required for all SCUBA
divers. Once a student is out of the TLC of his initial instructor,
we must assume that no additional training will ever be pursued.
Appropriate
first response to a diving casualty in the field, before pre-hospital
care arrives, can make a life or death difference to that victim. Recognition
of the problem, appropriate positioning, good CPR, and effective administration
of oxygen are a few things that any diver should be capable of doing
should the unusual occur. Rapid evacuation to an appropriate treatment
facility would be next on the list.
--Ronald
J. Ryan, NAUI 7205L; Two Harbors, Catalina Island, CA (Supervisor,
Catalina Hyperbaric Chamber. Past employee in the commercial diving
industry, where his duties included mixing special gasses for diving.)
A.
To date, according to the New York City Police and Fire Departments,
if a mannequin is cleaned properly, no transferred contamination is
possible, or at least none has been found in 10,000 uses. The biggest
problem in teaching mouth to mouth to scuba students is the realistic
format of what it is like to actually give mouth to-mouth to an individual
in the water during transport.
The
biggest problem in doing mouth to mouth with a mannequin is that the
student did not allow the alcohol (cleaning fluids) time to dry, before
performing mouth to mouth and making a pressure seal. Absorbing alcohol
into the lips will create an effect that is similar to herpes sores
around the mouth.
Should
we be teaching mouth to mouth? Yes.
Should
individuals be performing mouth to mouth on one another? No. More than
the AIDS issue, simply creating a good seal and experiencing the correct
back pressure in mouth to mouth is not a safe suggested teaching format.
Today,
a multitude of companies offer mannequins that are capable of being
used in the sand and water. Lifeguard Systems has been teaching mouth
to mouth via the use of a water capable mannequin for the past seven
years. These mannequins are not expensive. We have found that for $350
initial cost, and an additional $40 50 in repair, the units have survived
in sun, sand and water a minimum of three to four years with hundreds
of uses.
The
new Lifeguard Systems mannequin (water active) actually has a removable
face, and each student can be issued a personal mouth and nose for the
program. The most positive benefit is the ability to have the student
truly experience what it is like to fill a lung and transport a torso
through the water, all at the same time. Nothing beats hands on realistic
training remember Dynamic Learning Concepts.
If
any reader knows of a documented incident where an individual has received
AIDS or any other communicable disease from doing mouth to mouth on
a mannequin, please copy me with same.
--Walt
"Butch" Hendrick, NAUI ????; Hurley, NY (President
of Lifeguard Systems, Inc. Actively teaches all levels of diving to
ITCs. Past North Atlantic Branch Manager and Member of the NAUI Board
of Directors. Recipient of the NAUI Outstanding Service Award and Leonard
Greenstone Diving Safety Award.)
A.
Good God, Yes! That might be me that needs mouth to mouth! Bear in mind
that: (1) most rescue breathing is done for family members and friends,
for whom there should be no question of AIDS (or hepatitis or other
communicable disease); (2) there has never been a documented case of
AIDS communicated through rescue breathing; (3) AIDS requires body fluid
transfer--it is not communicated through the air--and there are effective
barriers to fluid transfer that still permit good ventilation; and (4)
no one is obliged to administer mouth to mouth, even if they know how.
I recommend going beyond rescue breathing, and encouraging every SCUBA
diver to take CPR training. The number of lives (not just divers') that
could be saved every year if this training were more widespread is estimated
in the hundreds of thousands, and more often than not the individual
saved would be no stranger to the rescuer.
--Dr.
Robert Clemons, NAUI 10551; Garland, TX (Teaches
privately and at Divers World in Richardson, TX. In addition to open
water instruction teaches Diving Rescue, Marine Geology, and Archeological
Diving specialties and leadership courses. Instructor Trainer in Basic
Cardiac Life Support for the American Heart Association. Also teaches
First Aid, Field Neurological Assessment and Emergency Oxygen Administration.)
A.
I do not believe we should base our decisions for such things on fear
but on solid medical evidence. So far no medical evidence links mouth
to mouth resuscitation to the transmission of aids. The value and in
fact necessity of this procedure in an emergency is not debatable, therefore,
we should maintain teaching this technique. If in the future evidence
appears that mouth to mouth resuscitation does transmit the virus then
we should switch to concentrating on mouth to snorkel etc. We still
teach mouth to mouth resuscitation in CPR courses where, the American
Heart Association and Red Cross have gone to great pains to show that
no evidence shows a link between mouth to mouth resuscitation and the
transmission of aids. Why should NAUI contradict these organizations
who base their policies on current medical evidence?
--Frank
J. Toal Jr., NAUI 10185; St. Georges, Bermuda (Diving
Safety Officer for the Bermuda Biological Station for Research, Inc.
Certified DMT and EMT. Teaches all levels of diving to Divemaster and
scientific diving techniques.)
A.
As a Red Cross Instructor of CPR, I find it somewhat surprising that
it should even be considered that rescue breathing techniques not be
taught in scuba course curriculums. When we teach Red Cross CPR courses
we do not ignore the very real concerns over the AIDS issue, but rather
teach our course safely. We do not practice on our students nor allow
them to do so on each other. That is what Annie is for. Naturally, we
disinfect with a bleach based solution between students.
This
should be even less of a concern for scuba instructors. Unless qualified,
their course curricula should not be intended as anything other than
a study in specialized application of a skill already taught through
a proper certifying agency. This skill may be learned without any possible
exchange of saliva. I think that a scuba instructor would be more concerned
about sharing a regulator with a student than teaching in-water rescue
breathing.
--Lawrence
Coyne, NAUI 11185; Fort Lauderdale, FL (Teaches
Openwater I thru Divemaster courses with the Florida Ocean Science Institute.
Has also taught in the resort environment. CPR and First Aid Instructor.)
A. The alarming
rate at which the AIDS virus has propagated throughout the international
general population has caused such a drastic transformation of worldwide
attitudes in so many areas of daily life, that the very question of
whether or not to even give the "breathe of life" is indeed
a very real concern to many.
I, personally,
do not teach artificial resuscitation to my students; at any non leadership
level. I do, however, discuss the dynamics, styles, and choices available
to the potential rescuer; and enthusiastically condone the continued
learning and recertification of the skill. I will often demonstrate
a "full blown" rescue to a basic and/or advanced class, though
the person who plays the part of the victim is well known to and selected
by me. I do not, thereafter, encourage the students to practice with
each other during the course; though they will often "inflate"
by blowing into the air while practicing the scuba rescue/tow.
I know of several
instructors/stores who have had students purchase their own regulator
mouthpieces, for a course, since the onset of the AIDS awareness. While
this may be a bit drastic (pool water will likely kill almost anything!),
I cannot and will not censure such a practice.
--Struther Macfarlane,
NAUI 6676; Toronto, Ontario, Canada
A. Please, please,
please can we, at NAUI, help control some of the rampant paranoia about
AIDS? There has never been a documented case of AIDS being transferred
by mouth to mouth contact. AIDS is a very weak (albeit fatal) virus
that is not easily transmitted.
Approximately
500 health care workers die each year from hepatitis contracted through
patient contact, and it is much more contagious than AIDS. The herpes
virus is endemic in our society, and the consequences of genital herpes
on childbirth is very serious, with complications ranging from blindness
to severe retardation to death. Herpes is also very contagious, and
can easily be transmitted from mouth to mouth contact if both parties
have open lesions.
The SCUBA industry
may have reason for concern about the continuing use of mouth to mouth
resuscitation, but AIDS is very definitely not one of the reasons for
that concern!
--Kenneth W. Bowers,
PhD, NAUI 6138; Oxnard, CA (Clinical
Psychologist specializing in conducting training in sexually transmitted
disease prevention and AIDS follow-up care.)
A. Being a dive
instructor as well as a health care professional, I feel dive instructors
should continue to teach mouth to mouth resuscitation. The lifesaving
potential of mouth to mouth resuscitation is invaluable. If one is not
properly trained in mouth to mouth resuscitation, how is one going to
administer it in an emergency? Using pocket masks could be taught in
addition; however, even though this device may reassure the rescuer
that a risk is minimized, maintaining an open airway and a good seal
would be virtually impossible during an in-water dive rescue.
As dive professionals,
it is important to remember that infection control policies and procedures
have been designed to limit and control the transmission of communicable
diseases. These precautions are recommended by the Center for Disease
Control (CDC) for health care professionals as well as other professionals
involved in various types of emergencies. The CDC has shown that the
risk of contracting HIV is extremely low as a result of workplace exposure.
The key to reducing
the risk of an accidental exposure to AIDS is the awareness and education
of dive professionals, not the omission of mouth to mouth resuscitation
from the scuba diving curriculum. Mouth to mouth resuscitation gives
the victim the best chance of survival in an emergency.
--Regina Bennett,
NAUI 8544; Beaverton, OR (Registered
Nurse, CPR Instructor)
A. I personally
do not feel that AIDS is of much consequence when discussing transmission
through oral exchange during SCUBA exercises. The first circumstance
I would evaluate is the number of AIDS incidents nationally. If this
ratio of incident to population were carried down to the total number
of divers, the percentage still remains at approximately 0.2% of the
dive community.
Medically speaking,
the amount of blood material in saliva is generally not of concentration
to transmit the HIV virus. Add to this fact that the salivary fluid
is rinsed and diluted in the passing of one piece of equipment to another
diver, the chance of transmission is reduced even further.
I have much greater
concerns over such organisms such as Psuedomonas, Staphlococcus, and
Herpes which grow in copious amounts in the human mouth. All of these
can do serious harm to the recipient. I feel that a national program
of infection control should be initiated and implemented as soon as
possible.
With my rental
equipment I use a chemical sterilizer known as CIDEX. This chemical
is not generally available to the public, but a number of other methods
of sterilizing are available to the general dive community.
--Mike Hoover, NAUI
12504; Chambersburg, PA (Registered
Respiratory Therapist, Registered Cardiopulmonary Technician)
[Note: Single copies
of the CDC's Universal Precautions for Prevention of Transmission of
HIV, Hepatitis B Virus and other Bloodborne Pathogens in the Health
Care Setting and Recommendations for Preventing Transmission of HIV
and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures
are available free from the National AIDS Clearinghouse, P.O. Box 6003,
Rockville, MD 20850, telephone (800) 458-5231.]
