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. 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.)
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.)
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 NDA News.]Questions for the next issues:
Questions for the next issues:
For the July/August issue: "Should an instructor/dive operator be permitted to confiscate a C-card on the spot for obviously incompetent/unable divers? Why/why not?"
For the September/October issue: "Should NAUI and the other dive certification agencies take a stronger environmental stance with regards to protecting our underwater resources? Why/Why not?"
All members are encouraged to respond. This column is for you, the membership, to develop. Answers should be kept fairly brief, preferably no more than two or three paragraphs. Responses to each question will be collated by the editor, condensed if necessary, and printed in this section. New questions may also be posed for discussion. Questions should be concise, and should stimulate a wide cross‑section of the membership. Include with your responses or questions the following information: your name, address, phone number, NAUI membership number, dive‑related employment, past diving accomplishments, and a review of your dive teaching experience. Send your materials to Jeffrey Bozanic, c/o NDA News, P.O. Box 14650, Montclair, CA 91763‑1150.
Compiled and Edited by Jeffrey Bozanic, NAUI 5334L
Sources, May/Jun 1990, (2:3), pp. 9-14.
NAUI Members' Forum #17
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