Diving Medicine in Malaysia - The Department of Social and ...

Diving Medicine in Malaysia
Lt Kol (Dr) Halim Mohamed
Institute of Underwater and Hyperbaric Medicine
Armed Forces Hospital Lumut
1

Scope
• Introduction
• Development of IUHM
• Decompression Illness (DCI) in Malaysia
– Demography
– Presentation
– Treatment and Outcomes
• Conclusion
2

Decompression Illness
6

Cerebral Arterial Gas Embolism (CAGE)
8

CAGE
• Symptoms usually start during or
immediately after surfacing (85% < 5
minutes of surfacing)
• Symptoms
– LOC
– Paralysis or weakness
– Numbness
– Dizziness
– Blurred vision
– Disorientation
– +/- symptoms of Pneumothorax,
Pneumomediastinum, Subcutaneous
Emphysema
9

Henry’s s Law
The amount of gas that will dissolve in a liquid
is directly proportional to the partial pressure of that gas.
pN 2
pN 2
pN 2
pN 2
pN 2
ingassing
pN 2
pN 2
Equilibrium (Saturation)
pN 2
Outgassing
(supersaturation)
12

Decompression Sickness (DCS)
• The formation of inert gas bubbles in blood and body
tissues when a diver returns to a lower pressure
environment.
13

DCS - Pathophysiology
• Direct bubble effects
– blockage - tissue hypoxia, venous
congestion, direct pressure,
• Indirect bubble effects
– leaky capillaries, sludging, , activation of
platelets, coagulation, fat emboli from
damaged tissues, histamine release.
14

DCS – Symptoms and Signs
• 90% within 15 minutes to 12 hours after surfacing
• Symptoms and Signs
– Pain, in the joints of arms, legs or trunk
– Paralysis or Weakness
– Numbness or paraesthesia
– Tiredness, Nausea, Headache, Dizziness, Unusual Fatigue
– Rash & Itching
– Chest tightness or shortness of breath
– LOC, altered level of consciousness.
– Loss of balance
– Change in Personality
– Visual disturbance, Speech disturbance
– Convulsions
– Hearing Loss / Tinnitus
– SOB, Haemoptysis
16

17
Loss of consciousness
Headache
Fatigue
Urinary retention
Visual symptoms
Shortness of breath
Rash/Itch
Convulsions
70
60
50
40
30
20
10
0
Symptoms and Signs
(Source: Institute of Underwater and Hyperbaric Medicine Jan 1996-Dec 2004)
Numbness/Paraesthesia
Pain
Weakness/Paralysis
Dizziness/Vertigo/Nausea/Vomiting
Number of Cases

Oxygen Recompression Therapy
• Mechanism:
– Decrease bubble size (Boyle’s s Law)
– Hasten nitrogen elimination (Henry’s s Law)
– Increase oxygenation to hypoxic areas
– Reduces secondary bubble effects
20

Dept of Diving and Hyperbaric Medicine
21

Demography
(N=159)
DCI cases treated at Dept of Diving Medicine, AFH Lumut
between 1st October 1996 and 31st December 2003
25

Incidence
50
45
40
35
30
Cases
25
20
15
1
5
1
45
2
10
5
17
20
1
7
21
16
1
11
4
7
0
1996 1997 1998 1999 2000 2001 2002 2003
Year
Arterial Gas Embolism
Decompression illness
26
(Source: IUHM Jan 1996 - Dec 2003)

Demography and Dive Characteristics
Mean
(SD)
Range
Age (years) 31.5 (8.4) 15 - 57
Gender Male: 141 Female: 18
Dive Experience (years) 3.2 (5.3)
0 - 33
27

Demography and Dive Characteristics
Mean
(SD)
Range
Age (years) 31.5 (8.4) 15 - 57
Gender Male: 141 Female: 18
Dive Experience (years) 3.2 (5.3)
Dive:
Depth (m) 28.3 (17.5)
No of dives
Dive Profile
2 (median)
Non-Provocative: 56 (35)%
Provocative: 103 (65%)
0 - 33
5 – 75
1 - 10
28

Demography and Dive Characteristics
Mean
(SD)
Range
Age (years) 31.5 (8.4) 15 - 57
Gender Male: 141 Female: 18
Dive Experience (years) 3.2 (5.3)
Dive:
Depth (m) 28.3 (17.5)
No of dives
Dive Profile
Delay to Initial Emergency
Treatment (hours)
2 (median)
Non-Provocative: 56 (35)%
Provocative: 103 (65%)
3.3 (2.7)
Delay to Recompression (hours) 12.3 (9.7)
0 - 33
5 – 75
1 - 10
1 - 12
5 – 48
29

Incidence
Commercial -
Others
13%
21 8
Military
5%
75 55
Commercial - UW
Loggers
47%
Recreational
35%
30

Underwater Logging
32

Convulsions
Rash/Itch
33
Shortness of breath
Headache
Fatigue
Urinary retention
Visual symptoms
Loss of consciousness
70
60
50
40
30
20
10
0
Symptoms and Signs
N = 158
Numbness/Paraesthesia
Pain
Weakness/Paralysis
Dizziness/Vertigo/Nausea/Vomiting
Number of Cases

Spinal/Cerebral
Symptoms and Signs
Cerebral
32%
Missing
Neurological (66%)
N = 158
9%
Periph
1%
Spinal
57%
94
51
3
Musculoskeletal (32%)
CVS / RS (2%)
Missing
4.8%
Others
9.5%
Site of Pain
Upper Limb
23.8%
Spine/Trunk
33.3%
Lower Limb
34
28.6%

Treatment Outcomes
Mild Residual
Symptoms
17%
Severe
Residual
Symptoms
15%
27
23
108
Full Recovery
68%
35

Other Complications
• Cranial diabetes insipidus (3 cases)
• Lobar pneumonia (2 cases)
• Pulmonary oxygen toxicity - nil
36

Residual Paraplegia / Paraparesis
Results
37

Outcomes
SEVERE RESIDUAL DEFICITS
(N=14)
Results
Residual Numbness/P
16.7%
Res Urinary Incontin
16.7%
Residual Paralysis
66.7%
39

DCI Incidence and Mortality Rates
• Oil rig divers of Gulf of Mexico:
– Incidence of DCI:
• 9.6 per 100,000 dives
– Diving Deaths:
• 2.49 per 1000 diver per year.
• UW Loggers in Tasik Banding:
– Incidence of DCI:
• 76 cases for 5-yr 5
period Jan
97-Dec 02
• = 15.2 cases / yr
• = 27.8 per 100,000 dives*
– Diving deaths:
• 6 cases for 5-yr 5
period Jan 97-
Dec 02
• = 20 deaths per 1000 diver per
year*
*Based on 2.5 dives / diver / day; 60 working 42 divers
each day at Tasik Banding throughout the year.

Workplace Assessment
• All untrained divers
• Inappropriate diving equipment
• Inappropriate diving techniques /
procedures
• No oxygen / safety equipment / first aid
equipment on board
• Diving at Altitude 1300ft ASL
• Repetitive, multi-day diving
• Strenuous dives
• Cold water temperatures
43

Workplace Assessment
44

Prevention
45

Training
46

Training
47

Medical Assessment Prior to Diving
800
700
668 656
Jumlah Pemeriksaan
Activities
600
500
400
300
200
328
452
534
408
547
502
545
100
0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Tahun
Source: IUHM Annual Returns Nov 1996 - Dec 2004
48

Medical Assessment Prior to Diving
800
700
668 656
Jumlah Pemeriksaan
Activities
600
500
400
300
200
328
452
534
408
547
502
545
100
0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Tahun
Source: IUHM Annual Returns Nov 1996 - Dec 2004
49

Field Medical Support for Diving Ops
50

Malaysian Diving Emergency Hotline
51

Wound Clinic
Hyperbaric Chamber
Department of Diving and Hyperbaric Medicine
Compressor, Air Banks, Air Dryers and Filters
LOX
58

Submarine Medicine
60

0.5 ATM
Pressure
6000 m
62

Cerebral Arterial Gas Embolism
(CAGE)
63

Boyle’s s Law
“Pressure is inversely
related to Volume”
P ∝ 1/V
P1V1 = P2V2
64

Barotrauma
• Damage to tissues of gas-containing organs due to
changes in ambient pressure
65

Pulmonary Barotrauma
67

Pulmonary Barotrauma
68

Cerebral Arterial Gas Embolism (CAGE)
69

CAGE
• Symptoms usually start during or
immediately after surfacing (85% < 5
minutes of surfacing)
• Symptoms
– LOC
– Paralysis or weakness
– Numbness
– Dizziness
– Blurred vision
– Personality change
– Disorientation
– +/- symptoms of Pneumothorax,
Pneumomediastinum, Subcutaneous
Emphysema
70

Decompression Sickness (DCS)
72

Decompression Sickness (DCS)
• “Formation of bubbles in blood or body tissues on returning
to a lower pressure environment, due to inadequate
elimination inert gas dissolved in body tissues”
73

DCS - Pathophysiology
• Direct bubble effects
– blockage - tissue hypoxia, venous
congestion, direct pressure,
• Indirect bubble effects
– leaky capillaries, sludging, , activation of
platelets, coagulation, fat emboli from
damaged tissues, histamine release.
74

DCS – Symptoms and Signs
• 90% within 15 minutes to 12 hours after surfacing
• Symptoms and Signs
– Pain, in the joints of arms, legs or trunk
– Paralysis or Weakness
– Numbness or paraesthesia
– Tiredness, Nausea, Headache, Dizziness, Unusual Fatigue
– Rash & Itching
– Chest tightness or shortness of breath
– LOC, altered level of consciousness.
– Loss of balance
– Change in Personality
– Visual disturbance, Speech disturbance
– Convulsions
– Hearing Loss / Tinnitus
– SOB, Haemoptysis
75

DCS – Types / Classification
Traditional:
– Type I - Skin, Lymph-node, Muscle, Joint
– Type II – Neurological, CardioRespiratory, , Inner Ear
76

DCS versus CAGE
• Diagnostic confusion
• Same treatment modality
• Decompression Illness = DCS + CAGE
– Descriptive classification (e.g. Acute Neurological
Decompression Illness)
79

Oxygen Recompression Therapy
• Mechanism:
– Decrease bubble size (Boyle’s s Law)
– Hasten nitrogen elimination (Henry’s s Law)
– Increase oxygenation to hypoxic areas
– Reduces secondary bubble effects
80

Demography
(N=159)
DCI cases treated at Dept of Diving Medicine, AFH Lumut
between 1st October 1996 and 31st December 2003
82

Incidence
50
45
40
35
30
Cases
25
20
15
1
5
1
45
2
10
5
17
20
1
7
21
16
1
11
4
7
0
1996 1997 1998 1999 2000 2001 2002 2003
Year
Arterial Gas Embolism
Decompression illness
83
(Sumber: Statistik Jabatan Perubatan Selam 1996-2004)

Incidence
Commercial -
Others
13%
21 8
Military
5%
75 55
Commercial - UW
Loggers
47%
Recreational
35%
84

Underwater Logging
86

Demography and Dive Characteristics
Mean
(SD)
Range
Age (years) 31.5 (8.4) 15 - 57
Gender Male: 141 Female: 18
Dive Experience (years) 3.2 (5.3)
0 - 33
87

Demography and Dive Characteristics
Mean
(SD)
Range
Age (years) 31.5 (8.4) 15 - 57
Gender Male: 141 Female: 18
Dive Experience (years) 3.2 (5.3)
Dive:
Depth (m) 28.3 (17.5)
No of dives
Dive Profile
2 (median)
Non-Provocative: 56 (35)%
Provocative: 103 (65%)
0 - 33
5 – 75
1 - 10
88

Demography and Dive Characteristics
Mean
(SD)
Range
Age (years) 31.5 (8.4) 15 - 57
Gender Male: 141 Female: 18
Dive Experience (years) 3.2 (5.3)
Dive:
Depth (m) 28.3 (17.5)
No of dives
Dive Profile
Delay to Initial Emergency
Treatment (hours)
2 (median)
Non-Provocative: 56 (35)%
Provocative: 103 (65%)
3.3 (2.7)
Delay to Recompression (hours) 12.3 (9.7)
0 - 33
5 – 75
1 - 10
1 - 12
5 – 48
89

Convulsions
Rash/Itch
90
Shortness of breath
Headache
Fatigue
Urinary retention
Visual symptoms
Loss of consciousness
70
60
50
40
30
20
10
0
Symptoms and Signs
N = 158
Numbness/Paraesthesia
Pain
Weakness/Paralysis
Dizziness/Vertigo/Nausea/Vomiting
Number of Cases

Spinal/Cerebral
Symptoms and Signs
Cerebral
32%
Missing
Neurological (66%)
N = 158
9%
Periph
1%
Spinal
57%
94
51
3
Musculoskeletal (32%)
CVS / RS (2%)
Missing
4.8%
Others
9.5%
Site of Pain
Upper Limb
23.8%
Spine/Trunk
33.3%
Lower Limb
91
28.6%

Treatment Outcomes
Mild Residual
Symptoms
17%
Severe
Residual
Symptoms
15%
27
23
108
Full Recovery
68%
92

Other Complications
• Cranial diabetes insipidus (3 cases)
• Lobar pneumonia (2 cases)
• Pulmonary oxygen toxicity - nil
93

Prevention
97

Training
98

Training
99

Diving Medical Examinations
800
700
668
Jumlah Pemeriksaan
Activities
600
500
400
300
200
328
452
534
408
547
502
545
100
0
1996 1997 1998 1999 2000 2001 2002 2003
Tahun
Source: DDHM Annual Returns Nov 1996 - Dec 2002
100

Diving Medical Examinations
800
700
668
Jumlah Pemeriksaan
Activities
600
500
400
300
200
328
452
534
408
547
502
545
100
0
1996 1997 1998 1999 2000 2001 2002 2003
Tahun
Source: DDHM Annual Returns Nov 1996 - Dec 2002
101

Field Medical Support for Diving Ops
102

Malaysian Diving Emergency Hotline
103

104