Diving medicine, also called undersea and hyperbaric medicine (UHB), is the diagnosis, treatment and prevention of conditions caused by humans entering the undersea environment. It includes the effects on the body of pressure on gases, the diagnosis and treatment of conditions caused by marine hazards and how aspects of a diver's fitness to dive affect the diver's safety. Diving medical practitioners are also expected to be competent in the examination of divers and potential divers to determine fitness to dive.
Diving medicine deals with medical research on issues of diving, the prevention of diving disorders, treatment of diving accidents and diving fitness. The field includes the effect of breathing gases and their contaminants under high pressure on the human body and the relationship between the state of physical and psychological health of the diver and safety.
In diving accidents it is common for multiple disorders to occur together and interact with each other, both causatively and as complications.
Diving medicine is a branch of occupational medicine and sports medicine, and at first aid level, an important part of diver education.
The scope of diving medicine must necessarily include conditions that are specifically connected with the activity of diving, and not found in other contexts, but this categorization excludes almost everything, leaving only deep water blackout, isobaric counterdiffusion and high pressure nervous syndrome. A more useful grouping is conditions that are associated with exposure to variations of ambient pressure. These conditions are largely shared by aviation and space medicine. Further conditions associated with diving and other aquatic and outdoor activities are commonly included in books which are aimed at the diver, rather than the specialist medical practitioner, as they are useful background to diver first aid training.[citation needed]
The scope of knowledge necessary for a practitioner of diving medicine includes the medical conditions associated with diving and their treatment, physics and physiology relating to the underwater and pressurised environment, the standard operating procedures and equipment used by divers which can influence the development and management of these conditions, and the specialised equipment used for treatment.[1]
Scope of knowledge for diving medicine
The ECHM-EDTC Educational and Training Standards for Diving and Hyperbaric Medicine (2011) specify the following scope of knowledge for Diving Medicine:[1]
Physiology and pathology of diving and hyperbaric exposure.
The ECHM-EDTC Educational and Training Standards for Diving and Hyperbaric Medicine (2011) specify the following scope of knowledge for Hyperbaric Medicine additional to that for Diving medicine:[1]
Physiology and pathology of diving and hyperbaric exposure.
HBO-Basics – effects of hyperbaric oxygen – physiology and pathology
Clinical HBO
Chamber technique (multiplace, monoplace, transport chambers, wet recompression)
Mandatory indications
HBO Recommended indications
HBO Experimental and anecdotal indications
HBO Data collection / statistics / evaluation
HBO General basic treatment (nursing)
HBO Diagnostic, monitoring and therapeutic devices in chambers
Risk assessment, incidents monitoring and safety plan in HBO chambers
The signs and symptoms of diving disorders may present during a dive, on surfacing, or up to several hours after a dive. Divers have to breathe a gas which is at the same pressure as their surroundings, which can be much greater than on the surface. The ambient pressure underwater increases by 1 standard atmosphere (100 kPa) for every 10 metres (33 ft) of depth.[2]
The disorders are caused by breathing gas at the high pressures encountered at depth, and divers will often breathe a gas mixture different from air to mitigate these effects. Nitrox, which contains more oxygen and less nitrogen is commonly used as a breathing gas to reduce the risk of decompression sickness at recreational depths (up to about 40 metres (130 ft)). Helium may be added to reduce the amount of nitrogen and oxygen in the gas mixture when diving deeper, to reduce the effects of narcosis and to avoid the risk of oxygen toxicity. This is complicated at depths beyond about 150 metres (500 ft), because a helium–oxygen mixture (heliox) then causes high pressure nervous syndrome.[2] More exotic mixtures such as hydreliox, a hydrogen–helium–oxygen mixture, are used at extreme depths to counteract this.[3]
Decompression sickness (DCS) occurs when gas, which has been breathed under high pressure and dissolved into the body tissues, forms bubbles as the pressure is reduced on ascent from a dive. The results may range from pain in the joints where the bubbles form to blockage of an artery leading to damage to the nervous system, paralysis or death. While bubbles can form anywhere in the body, DCS is most frequently observed in the shoulders, elbows, knees, and ankles. Joint pain occurs in about 90% of DCS cases reported to the U.S. Navy, with neurological symptoms and skin manifestations each present in 10% to 15% of cases. Pulmonary DCS is very rare in divers.[4]
Pulmonary barotrauma and arterial gas embolism
If the breathing gas in a diver's lungs cannot freely escape during an ascent, the lungs may be expanded beyond their compliance, and the lung tissues may rupture, causing pulmonary barotrauma (PBT). The gas may then enter the arterial circulation producing arterial gas embolism (AGE), with effects similar to severe decompression sickness.[5] Gas bubbles within the arterial circulation can block the supply of blood to any part of the body, including the brain, and can therefore manifest a vast variety of symptoms.
Nitrogen narcosis is caused by the pressure of dissolved gas in the body and produces temporary impairment to the nervous system. This results in alteration to thought processes and a decrease in the diver's ability to make judgements or calculations. It can also decrease motor skills, and worsen performance in tasks requiring manual dexterity. As depth increases, so does the pressure and hence the severity of the narcosis. The effects may vary widely from individual to individual, and from day to day for the same diver. Because of the perception-altering effects of narcosis, a diver may not be aware of the symptoms, but studies have shown that impairment occurs nevertheless. The narcotic effects dissipate without lasting effect as the pressure decreases during ascent.[6]
Helium is the least narcotic of all gases, and divers may use breathing mixtures containing a proportion of helium for dives exceeding about 40 metres (130 ft) deep. In the 1960s it was expected that helium narcosis would begin to become apparent at depths of 300 metres (1,000 ft). However, it was found that different symptoms, such as tremors, occurred at shallower depths around 150 metres (500 ft). This became known as high-pressure nervous syndrome, and its effects are found to result from both the absolute depth and the speed of descent. Although the effects vary from person to person, they are stable and reproducible for the individual.[7][medical citation needed]
Although oxygen is essential to life, in concentrations significantly greater than normal it becomes toxic, overcoming the body's natural defences (antioxidants), and causing cell death in any part of the body. The lungs and brain are particularly affected by high partial pressures of oxygen, such as are encountered in diving. The body can tolerate partial pressures of oxygen around 0.5 bars (50 kPa; 7.3 psi) indefinitely, and up to 1.4 bars (140 kPa; 20 psi) for many hours, but higher partial pressures rapidly increase the chance of the most dangerous effect of oxygen toxicity, a convulsion resembling an epileptic seizure.[8]Susceptibility to oxygen toxicity varies dramatically from person to person, and to a smaller extent from day to day for the same diver.[9] Prior to convulsion, several symptoms may be present – most distinctly that of an aura.
Treatments
Treatment of diving disorders depends on the specific disorder or combination of disorders, but two treatments are commonly associated with first aid and definitive treatment where diving is involved. These are first aid oxygen administration at high concentration, which is seldom contraindicated, and generally recommended as a default option in diving accidents where there is any significant probability of hypoxia,[10] and hyperbaric oxygen therapy, which is the definitive treatment for most conditions of decompression illness.[11][12]
The administration of oxygen as a medical intervention is common in diving medicine, both for first aid and for longer term treatment.[12]
Normobaric oxygen administration at the highest available concentration is frequently used as first aid for any diving injury that may involve inert gas bubble formation in the tissues. There is epidemiological support for its use from a statistical study of cases recorded in a long term database.[13][14][15]
Recompression treatment in a hyperbaric chamber was initially used as a life-saving tool to treat decompression sickness in caisson workers and divers who stayed too long at depth and developed decompression sickness. In the 21st century, it is a highly specialized treatment modality found to be effective for treating many conditions where the administration of oxygen under pressure is beneficial.[16]
Hyperbaric oxygen treatment is generally preferred when effective, as it is usually a more efficient and lower risk method of reducing symptoms of decompression illness, but in some cases recompression to pressures where oxygen toxicity is unacceptable may be required to eliminate the bubbles in the tissues in severe cases of decompression illness.[12]
Availability of recompression treatment is limited. Some countries have no facilities at all, and in others which have facilities, such as the US, some hospitals do not make them available for emergency treatment.[17]
Fitness to dive, (or medical fitness to dive), is the medical and physical suitability of a person to function safely in the underwater environment using underwater diving equipment and procedures. Depending on the circumstances it may be established by a signed statement by the diver that he or she does not suffer from any of the listed disqualifying conditions and is able to manage the ordinary physical requirements of diving, to a detailed medical examination by a physician registered as a medical examiner of divers following a procedural checklist, and a legal document of fitness to dive issued by the medical examiner.
The most important medical examination is the one before starting diving, as the diver can be screened to prevent exposure when a dangerous condition exists and a baseline established. The other important medicals are after some significant illness, where medical intervention is needed and has to be done by a doctor who is competent in diving medicine, and can not be done by prescriptive rules.[18]
Psychological factors can affect fitness to dive, particularly where they affect response to emergencies, or risk taking behaviour. The use of medical and recreational drugs, can also influence fitness to dive, both for physiological and behavioural reasons. In some cases prescription drug use may have a net positive effect, when effectively treating an underlying condition, but frequently the side effects of effective medication may have undesirable influences on the fitness of diver, and most cases of recreational drug use result in an impaired fitness to dive, and a significantly increased risk of sub-optimal response to emergencies.
Education and registration of practitioners
Specialist training in underwater and hyperbaric medicine is available from several institutions, and registration is possible both with professional associations and governmental registries.
Education
NOAA/UHMS Physicians Training Course in Diving Medicine
This course has been presented since 1977, and has been influenced by internationally accepted training objectives recommended by the Diving Medical Advisory Committee, the European Diving Technology Committee, and the European Committee for Hyperbaric Medicine. The course is designed for qualified medical practitioners, but may be useful to others who work in the field of diving safety and operations.[19]
The course is to train physicians to recognize and treat diving medical emergencies. Subject matter includes:[19]
The standard drawn up jointly by the European Committee for Hyperbaric Medicine and the European Diving Technical Committee defines job descriptions for several levels of diving and hyperbaric physician: Education and assessment to these standards may be provided by institutions of higher education under the leadership of a Level 3 Hyperbaric Medicine Expert as defined below. Certificates of competence may be issued by a nationally accredited institution or an internationally acknowledged agency, and periodic recertification is required.[1]
Level 1. Medical Examiner of Divers (MED) minimum 28 teaching hours.
The MED must be competent to perform the assessments of medical fitness to dive of occupational and recreational divers and compressed air workers, except the assessment of medical fitness to resume diving after major decompression incidents.
Level 2D. Diving Medicine Physician (DMP) minimum 80 teaching hours.
A DMP must be competent to perform the initial and all other assessments of medical fitness to dive of working and recreational divers or compressed air workers, and manage diving accidents and advise diving contractors and others on diving medicine and physiology (with the backup of a diving medical expert or consultant).
A DMP should have knowledge in relevant aspects of occupational health, but is not required to be a certified specialist in occupational medicine.
A DMP should have certified skills and basic practical experience in assessment of medical fitness to dive, management of diving accidents, safety planning for professional diving operations, advanced life support, acute trauma care and general wound care.
Level 2H. Hyperbaric Medicine Physician (HMP) minimum 120 teaching hours
An HMP will be responsible for hyperbaric treatment sessions (with the backup of a hyperbaric medicine expert or consultant)
An HMP should have appropriate experience in anaesthesia and intensive care in order to manage the HBO patients, but is not required to be a certified specialist in anaesthesia and intensive care.
An HMP must be competent to assess and manage clinical patients for hyperbaric oxygen therapy treatment
Level 3. Hyperbaric medicine expert or consultant (hyperbaric and diving medicine) is a physician who has been assessed as competent to:
manage a hyperbaric facility (HBO centre) or the medical and physiological aspects of complex diving activities.
manage research programs on diving medicine.
supervise a team of HBO doctors and personnel, health professionals and others.
teach relevant aspects of hyperbaric medicine and physiology to all members of staff.
Gesellschaft für Tauch- und Überdruckmedizin e. V.
Society for Diving and Hyperbaric medicine
German standards for education and assessment of diving medical practitioners are similar to the ECHM-EDTC Standards and are controlled by the Gesellschaft für Tauch- und Überdruckmedizin e. V. They include Medical Examiner of Divers, Diving Medicine Physician, Hyperbaric Medicine Physician, Chief Hyperbaric Medicine Physician and Hyperbaric Medicine Consultant.[23]
Schweizerische Gesellschaft für Unterwasser- und Hyperbarmedizin
Swiss Society for underwater and hyperbaric medicine.
Österreichische Gesellschaft für Tauch- und Hyperbarmedizin
Austrian Society for Diving and Hyperbaric medicine.
Austrian standards for education and assessment of diving medical practitioners are controlled by the Österreichische Gesellschaft für Tauch- und Hyperbarmedizin They include Medical Examiner of Divers, Diving Medicine Physician, Hyperbaric Medicine Physician, Chief Hyperbaric Medicine Physician and Hyperbaric Medicine Consultant.[25]
Registration
The American Medical Association recognises the sub-speciality Undersea and Hyperbaric Medicine held by someone who is already Board Certified in some other speciality.[26]
The South African Department of Employment and Labour registers two levels of Diving Medical Practitioner. Level 1 is qualified to conduct annual examinations and certification of medical fitness to dive, on commercial divers (equivalent to ECHM-EDTC Level 1. Medical Examiner of Divers), and Level 2 is qualified to provide medical advice to a diving contractor and hyperbaric treatment for diving injuries[27] (equivalent to ECHM-EDTC Level 2D Diving Medicine Physician)
Australia has a four tier system: In 2007 there was no recognised equivalence with the European standard.[28]
GPs completing the first tier four- to five-day course on how to examine divers for 'fitness to dive' can then add their names to the SPUMS Diving Doctors List
GPs completing the second tier two-week diving medicine courses provided by the Royal Australian Navy and the Royal Adelaide Hospital, or the two-week course in Diving and Hyperbaric Medicine provided by the ANZ Hyperbaric Medicine Group, qualify to do commercial-diving medicals.
The third tier is the SPUMS Diploma in Diving and Hyperbaric Medicine. The candidate must attend a two-week course, write a dissertation related to DHM and have the equivalent of six months' full-time experience working in a hyperbaric medicine unit.
The fourth tier is the Certificate in Diving and Hyperbaric Medicine from the ANZ College of Anaesthetists.
Training of divers and support staff in relevant first aid
Divers
A basic knowledge understanding of the causes, symptoms and first aid treatment of diving related disorders is part of the basic training for most recreational and professional divers, both to help the diver avoid the disorders, and to allow appropriate action in case of an incident resulting in injury.[27]
Recreational divers
A recreational diver has the same duty of care to other divers as any ordinary member of the public, and therefore there is no obligation to train recreational divers in first aid or other medical skills. Nevertheless, first aid training is recommended by most, if not all, recreational diver training agencies.[29][30][31]
Recreational diving instructors and divemasters, on the other hand, are to a greater or lesser extent responsible for the safety of divers under their guidance, and therefore are generally required to be trained and certified to some level of rescue and first aid competence, as defined in the relevant training standards of the certifying body. In many cases this includes certification in cardiopulmonary resuscitation and first aid oxygen administration for diving accidents.
Professional divers
Professional divers usually operate as members of a team with a duty of care for other members of the team. Divers are expected to act as standby divers for other members of the team and the duties of a standby diver include rescue attempts if the working diver gets into difficulties. Consequently, professional divers are generally required to be trained in rescue procedures appropriate to the modes of diving they are certified in, and to administer first aid in emergencies. The specific training, competence and registration for these skills varies, and may be specified by state or national legislation or by industry codes of practice.[27][32]
Diving supervisors have a similar duty of care, and as they are responsible for operational planning and safety, generally are also expected to manage emergency procedures, including the first aid that may be required. The level of first aid training, competence and certification will generally take this into account.
In South Africa, registered commercial and scientific divers must hold current certification in first aid at the national Level 1, with additional training in oxygen administration for diving accidents, and registered diving supervisors must hold Level 2 first aid certification.[27]
Offshore diving contractors frequently follow the IMCA recommendations.
Diver medic
A diver medic or diving medical technician is a member of a dive team who is trained in advanced first aid.[33]
A diver medic recognised by IMCA must be capable of administering first aid and emergency treatment, and carrying out the directions of a physician, and be familiar with diving procedures and compression chamber operation. The diver medic must also be able to assist the diving supervisor with decompression procedures, and provide treatment in a hyperbaric chamber in an emergency. The diver medic must hold, at a minimum, a valid certificate of medical fitness to operate in a pressurized environment, and a certificate of medical fitness to dive.[34]
Training standards for diver medic are described in the IMCA Scheme for Recognition of Diver Medic Training.[34]
Ethical and medicolegal issues
Experimental work on human subjects is often ethically and/or legally impracticable. Tests where the endpoint is symptomatic decompression sickness are difficult to authorise and this makes the accumulation of adequate and statistically valid data difficult. The precautionary principle may be applied in the absence of information allowing a realistic assessment of risk. Analysis of investigations into accidents is useful when reliable results are available, which is less often than would be desirable, but privacy concerns prevent a large mount of information potentially useful to the general diving population from being made available to researchers.
This section needs expansion. You can help by adding to it. (July 2020)
Long-term effects of underwater diving
Diving and other hyperbaric exposure has a well established connection with several acute conditions such as decompression illness and barotrauma. Recovery depends on the severity of the injury and the treatment, and is often complete. The possible long term health effects of diving are less known, particularly in cases where no clinical symptoms were recorded over the diver's career. Dysbaric osteonecrosis has long been associated with hyperbaric exposure requiring staged decompression, and has become a notifiable industrial disease.[35]
Other conditions that affect quality of life associated with long term diving that have not been conclusively connected to the activity include persistent neurological
abnormalities, reductions to lung function, accelerated hearing loss and accelerated cataract development.[35][36]
Subclinical effects can occur without immediately noticeable presentations of decompression sickness, as is shown by dysbaric osteronecrosis and hearing deficiencies developing over the longer term in professional divers. Recreational divers may also be at risk for long term development of symptoms affecting the lungs, eyes, ears, and central nervous system.[37]
Decompression illness has been studied since the condition was recognised, and as the methodology has improved, shortcomings in earlier studies have been become apparent. One of the problems of much medical research on diving disorders is the lack of a control group to determine baseline function. Another is that there are few standardised techni1ques for diagnosis consistently used by the researchers at different centres, making comparisons of dubious validity.[37]
Besides osteonecrosis and hearing losses, there is no substantial consensus about what the long term risks actually are, but the medical literature and anecdotal evidence both suggest that there are potential chronic long-term detrimental effects of diving.[38] However evidence that recreational diving has a measurable effect on life expectancy is inconclusive.[38]
Pulmonary function
In some cases, long term lung function change have been recorded after a single deep saturation dive.[35]
Thorsen et al 1990 compared observations of saturation divers with matched controls, and found changes consistent with small airways dysfunction which suggested cumulative long term effects of diving exposure on lung function. The change in vital capacity was not considered to have a large effect on the diver's health, but shows that divers may develop some air flow obstruction by narrowing of the airways. The general tendency of reduction in pulmonary diffusion capacity with age may be increased in divers. These changes are associated with a decrease in exercise tolerance.[37][39][40]
Exposure to hyperbaric oxygen may increase the risk of permanent changes to the lens of the eye, such as cataracts. The presence of nuclear cataracts and reversible myopic shift has been attributed to oxidative damage to the lens proteins. Myopic shifts are usually reversible and resolve within days to months, but cataracts are permanent and if sufficiently advanced will require lens replacement surgery. This is hypothesized to be an effect of lifetime accumulated exposure to oxygen.[36]
Skeletal system
Dysbaric osteonecrosis (DON) has long been recognised as a long term health effect of diving and compressed air work. Survey results for these populations show variable incidence of DONs. There seems to be a threshold of inert gas load or decompression stress needed to induce the condition, but the actual values remain obscure.[35]
Hearing loss
There is evidence that deafness is more prevalent in divers, with loss at most frequencies compared to non-divers of the same age. Some divers are known to have hearing loss caused by acute barotraume, but there is also evidence of general hearing deterioration occurring faster than in non-divers, particularly in professional divers, probably due to high air flow noise levels in helmets and during chamber compression, and from noisy tools. Divers appear to be at greater risk for long term cochlear-vestibular damage and associated high frequency hearing loss.[37]
Cardiovascular
A survey in 2017 of 768 former divers revealed that
high blood pressure was more likely to be reported by divers who did not take a dive-free day after 3 days of strenuous diving. Divers with more than 150 professional dives per year or more than 2000 air dives per year were more likely to experience myocardial infarction or angina than divers with fewer than 50 professional dives per year, and less than 2000 air dives. They reached the conclusion that male former divers are more likely to experience these symptoms than the general population, but did not claim this to be specifically caused by diving, as it could have been a consequence of the associated strenuous physical activity.[41]
Central nervous system
A 1991 study on saturation divers indicated significantly higher deficits in the central nervous system th the control group in the time span of one to seven years since their last deep dive. The symptoms included difficulties with attentional control (mental concentration) and paraesthesia in the feet and hands, abnormalities associated with lumbar spinal cord and more abnormal electroencephalograms than the control group. These abnormalities were correlated with deep diving, air diving, and saturation diving, and a history of decompression sickness.[42]
However, though neurological effects are routinely observed during deep diving, and transient neurological effects occur in some divers after deep dives, more recent (2011) long term epidemiological studies give conflicting and inconclusive results, and more research is needed to resolve this issue.[43]
Hemelryck et al (2014) conclude that while accident-free scuba diving may have some long term effects on short term memory, there is insufficient evidence to assume that general cognitive functions are affected.[44]
DCIEM is a combined military and civilian research organisation to research the operational needs of the Canadian Forces in all environments.[citation needed]
The Divers Alert Network (DAN) is an international non-profit organization with regional branches supported by donations, grants, and membership dues, for assisting divers in need. The DAN Research department conducts significant medical research on recreational scuba diving safety, and the DAN Medicine Department provides support for divers worldwide to find answers to their diving medical questions.[45]
The main objective of DDRC is research into diving medicine. The Centre is also an education and training base providing diving medical, clinical and hyperbaric courses.
DMAC is an independent committee with the purpose of providing advice about medical and safety aspects of commercial diving. They publish guidance notes about various aspects of diving and diving medical practice, and run a scheme for approval of courses in diving medicine.[46]
European Committee for Hyperbaric Medicine
The ECHM is an organisation to study and define indications for hyperbaric therapy, research and therapy protocols, standards for therapeutic and technical procedures, equipment and personnel, and related cost-benefit and cost-effectiveness criteria.
It is a representative body with the European health authorities, and works toward cooperation among scientific organizations involved in the field of Diving and Hyperbaric Medicine.[47]
Membership of the committee includes doctors practicing diving medicine in Northern Europe, representatives of relevant health authorities, medical representatives from relevant navies, and a diving safety officer nominated by the International Marine Contractors Association.
The European Underwater and Baromedical Society (EUBS) is a primary source of information for diving and hyperbaric medicine physiology worldwide. The organization was initially formed as the European Underwater and Biomedical Society in 1971.[48]
National Board of Diving and Hyperbaric Medical Technology
The National Board of Diving and Hyperbaric Medical Technology (NBDHMT), formally known as the National Association of Diving Technicians, is a non-profit organization for the education and certification of qualified personnel in the fields of diving and hyperbaric medicine in the US.[49]
The Diver Medic Technician (DMT) program is designed to meet the specific medical care needs of commercial, professional and scientific divers that often work in geographic isolation.[50][51] DMT's are specifically trained for the various diving hazards found at remote work sites.[50] The curriculum covers a wide range of topics from barotrauma to treatment of decompression sickness.[52]
The Certified Hyperbaric Technologist (CHT) program is tailored to meet the specific safety and operational needs for biomedical devices within the department, and the necessary knowledge and skills to administer clinical treatment.[53] The curriculum covers a wide range of topics including hyperbaric chamber operations to transcutaneous oxygen monitoring.[54]
The Certified Hyperbaric Registered Nurse (CHRN) program is a subspecialty for registered nurses,[55] sometimes referred to as baromedical nurses.
Southern African Underswater and Hyperbaric Medical Association
The South Pacific Underwater Medicine Society (SPUMS) is a primary source of information for diving and hyperbaric medicine physiology worldwide. The organisation supports the study of all aspects of underwater and hyperbaric medicine, provides information on underwater and hyperbaric medicine, publishes a medical journal and holds an annual conference.[57][58]
SPUMS offers a post-graduate Diploma of Diving and Hyperbaric Medicine.
^ abcBrubakk, Alf O; Neuman, Tom S, eds. (2003). "9: Pressure Effects". Bennett and Elliott's physiology and medicine of diving (5th Revised ed.). United States: Saunders Ltd. pp. 265–418. ISBN978-0-7020-2571-6. OCLC51607923.
^Abraini, JH; Gardette-Chauffour, MC; Martinez, E; Rostain, JC; Lemaire, C (1994). "Psychophysiological reactions in humans during an open sea dive to 500 m with a hydrogen-helium-oxygen mixture". Journal of Applied Physiology. 76 (3): 1113–8. doi:10.1152/jappl.1994.76.3.1113. eISSN1522-1601. ISSN8750-7587. PMID8005852.
^Powell, Mark (2008). Deco for Divers. Southend-on-Sea: Aquapress. p. 70. ISBN978-1-905492-07-7.
^Neuman, Tom S (2003). "10.5: Arterial Gas Embolism and Pulmonary Barotrauma". In Brubakk, Alf O; Neuman, Tom S (eds.). Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. pp. 557–8. ISBN978-0-7020-2571-6. OCLC51607923.
^Bennett, Peter B; Rostain, Jean Claude (2003). "9.2: Inert Gas Narcosis". In Brubakk, Alf O; Neuman, Tom S (eds.). Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. p. 301. ISBN978-0-7020-2571-6. OCLC51607923.
^Clark, James M; Thom, Stephen R (2003). "9.4: Oxygen under pressure". In Brubakk, Alf O; Neuman, Tom S (eds.). Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. pp. 358–360. ISBN978-0-7020-2571-6. OCLC51607923.
^Clark, James M; Thom, Stephen R (2003). "9.4: Oxygen under pressure". In Brubakk, Alf O; Neuman, Tom S (eds.). Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders Ltd. p. 376. ISBN978-0-7020-2571-6. OCLC51607923.
^Williams, G.; Elliott, DH.; Walker, R.; Gorman, DF.; Haller, V. (2001). "Fitness to dive: Panel discussion with audience participation". Journal of the South Pacific Underwater Medicine Society. 31 (3).
^ abcKnight, John (June 2000). "Certification in diving and hyperbaric medicine in America and Australia". SPUMS Journal. 30 (2).
^ abcd"Diving Regulations 2009 of the South African Occupational Health and Safety Act, 1993", Government Notice R41, Government Gazette (#32907), 29 January 2010
^Davis, Michael (September 2007). "The Editor's offering: Diving medicine education". Diving and Hyperbaric Medicine. 37 (3).
^The Diving Medical Advisory Committee DMAC, November 2001, Provision of First Aid and the Training of Divers, Supervisors and Members of Dive Teams in First Aid, DMAC 11 Rev. 1,
^Hemelryck, W; Germonpré, P.; Papadopoulou, V; Rozloznik, M.; Balestra, C. (December 2014). "Long term effects of recreational SCUBA diving on higher cognitive function". Scand J Med Sci Sports. 24 (6): 928–34. doi:10.1111/sms.12100. PMID23902533.
^Vann RD (2007). Moon RE, Piantadosi CA, Camporesi EM (eds.). "The History of Divers Alert Network (DAN) and DAN Research". Dr. Peter Bennett Symposium Proceedings. Held May 1, 2004. Durham, N.C.
^Josefsen, L; Woodward, C; Lewis, D; Hodge, J; Camporesi, EM (1997). "The nursing role in hyperbaric medicine". Undersea and Hyperbaric Medicine (Annual Meeting Abstract).
Brubakk, A. O.; Neuman, T. S. (2003). Bennett and Elliott's physiology and medicine of diving (5th Rev. ed.). United States: Saunders Ltd. p. 800. ISBN978-0702025716.
Edmonds; Thomas; McKenzie & Pennefather (2010). Diving Medicine for Scuba Divers (3rd ed.). Carl Edmonds. Archived from the original on 27 November 2010. – free download of complete text
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This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed.Find sources: Bácum Municipality – news · newspapers · books · scholar · JSTOR (July 2013) (Learn how and when to remove this template message) Municipality in Sonora, MexicoBácum MunicipalityMunicipalityCountry MexicoStateSonoraCounty seatBácumArea • Tot...
1994 studio album by Robert PalmerHoneyStudio album by Robert PalmerReleased7 September 1994[1]StudioLogic Studios (Milan, Italy)Genre Blue-eyed soul funk hard rock worldbeat[2] Length47:43LabelEMIProducerRobert Palmer, Stephen HagueRobert Palmer chronology Ridin' High(1992) Honey(1994) Rhythm & Blues(1999) Singles from Honey Girl U WantReleased: 1994 Know by NowReleased: 1994 You Blow Me AwayReleased: 1994 Honey is the twelfth studio album by British singer Robert...
Military campaign, 1240 to 1241 First Mongol invasion of PolandPart of the Mongol invasion of EuropeThe Mongols at Legnica display the head of Duke Henry II of Silesia (a 15th-century illumination from the Legend of St. Hedwig)Datelate 1240–1241LocationParts of eastern and southern PolandResult Mongol victory; Polish armies decisively defeatedBelligerents Golden Horde Kingdom of Poland Margraviate of Moravia Knights Templar Holy Roman EmpireCommanders and leaders BaidarKadanOrda KhanSubutai...
Artikel ini membutuhkan rujukan tambahan agar kualitasnya dapat dipastikan. Mohon bantu kami mengembangkan artikel ini dengan cara menambahkan rujukan ke sumber tepercaya. Pernyataan tak bersumber bisa saja dipertentangkan dan dihapus.Cari sumber: Abdul Kadir Karding – berita · surat kabar · buku · cendekiawan · JSTOR (Sept 2022) Abdul Kadir KardingInformasi pribadiLahir(1973-03-25)25 Maret 1973Donggala, Sulawesi TengahKewarganegaraan IndonesiaSuami/is...
Cette liste présente les matchs de l'équipe du Costa Rica de football par adversaire rencontré. Sommaire : Haut - A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A Afrique du Sud Confrontations entre l'Afrique du Sud et le Costa Rica en matchs officiels[1] : Confrontations contre l'Afrique du Sud # Date Lieu Match Score Compétition 1 11 octobre 2003 Potchefstroom Afrique du Sud - Costa Rica 2-1 Match amical 2 8 octobre 2015 Liberia Costa Rica - Afrique du Sud 0-1 Match amica...
Malaysian badminton player In this Chinese name, the family name is Kwan. Badminton playerKwan Yoke Meng关义明Personal informationCountryMalaysiaBorn (1966-01-11) 11 January 1966 (age 57)Kuala Lumpur, MalaysiaHeight1.75 m (5 ft 9 in)Years active1984-1993HandednessRightEventMen's singles Medal record Representing Malaysia Men's badminton Thomas Cup 1992 Kuala Lumpur Team 1990 Tokyo Team Asian Games 1990 Beijing Men's team Asian Championships 1989 Shanghai Men's tea...
Liga Super MoldovaNegara MoldovaKonfederasiUEFADibentuk1992Jumlah tim10Tingkat pada piramida1Degradasi keLiga 1 MoldovaPiala domestikPiala MoldovaPiala internasionalLiga ChampionsLiga Konferensi EropaJuara bertahan ligaSheriff Tiraspol (gelar ke-21) (2022–2023)Klub tersuksesSheriff Tiraspol (21 gelar)Televisi penyiarYouTubeInstagramSitus webFMF.md Liga Super Moldova 2022–2023 Liga Super Moldova (bahasa Moldova: Super Liga) adalah kompetisi sepak bola tingkat tertinggi di Moldova....
American painter Not to be confused with William Edward Scott. This article uses bare URLs, which are uninformative and vulnerable to link rot. Please consider converting them to full citations to ensure the article remains verifiable and maintains a consistent citation style. Several templates and tools are available to assist in formatting, such as reFill (documentation) and Citation bot (documentation). (September 2022) (Learn how and when to remove this template message) William Edouard S...
Biografi ini memerlukan lebih banyak catatan kaki untuk pemastian. Bantulah untuk menambahkan referensi atau sumber tepercaya. Materi kontroversial atau trivial yang sumbernya tidak memadai atau tidak bisa dipercaya harus segera dihapus, khususnya jika berpotensi memfitnah.Cari sumber: Zoe Abbas Jackson – berita · surat kabar · buku · cendekiawan · JSTOR (Maret 2022) (Pelajari cara dan kapan saatnya untuk menghapus pesan templat ini) Zoe Abbas JacksonZ...
American director and writer The topic of this article may not meet Wikipedia's notability guideline for biographies. Please help to demonstrate the notability of the topic by citing reliable secondary sources that are independent of the topic and provide significant coverage of it beyond a mere trivial mention. If notability cannot be shown, the article is likely to be merged, redirected, or deleted.Find sources: Anna Rose Holmer – news · newspapers · books ...
Vortilon adalah perangkat aerodinamis tetap pada sayap pesawat yang digunakan untuk meningkatkan penanganan pada kecepatan rendah. Vortilons terdiri dari satu atau lebih pelat datar yang melekat pada bagian bawah sayap dekat terdepan, sejajar dengan arah penerbangan.[1] Ketika kecepatan berkurang dan pesawat mendekati stall, aliran lokal di tepi terkemuka dialihkan keluar, ini komponen spanwise kecepatan sekitar vortilon yang menciptakan pusaran mengalir di permukaan atas, yang member...
Australian ballerina Kurlow dances for Swans for Relief in 2020 Stephanie Kurlow is an Australian dancer and ballet student often credited as being the world's first Hijabi Ballerina. Kurlow was born to an Australian father and Russian mother.[1] She grew up in the suburbs of Sydney and began dancing at the age of two. Stephanie stopped dancing at the age of nine in 2010 as there were no dance studios that catered to her beliefs.[2][1] Inspired by Stephanie's dream, he...
Norwegian jazz musician This article has multiple issues. Please help improve it or discuss these issues on the talk page. (Learn how and when to remove these template messages) This biography of a living person needs additional citations for verification. Please help by adding reliable sources. Contentious material about living persons that is unsourced or poorly sourced must be removed immediately from the article and its talk page, especially if potentially libelous.Find sources: Bugg...
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