ADM Exploration Team • Emergency Action Plan Protocols
 
  The Emergency Action Plan (EAP) covers the following situations:
 

1. In-water Injuries
• DCI
• Type 1 - muscular-skeletal symptoms
• Type 2 - neurological symptoms
• Arterial gas embolism (AGE)
• Unconscious diver (indeterminate cause)
2. Non-returning Diver (includes recovery planning)
3. Dead diver with Body Readily Accessible (in- or out-of-water)
4. Surface Injuries (non-diving related)
Appendices
1. Emergency Contact Information
2. On-site Neurological Exam
3. In-water Recompression Considerations
4. Incident Report Form
NOTE: Each team member must read and understand the contents of
this document thoroughly prior to any diving or support activities.

 
  Emergency Assessment and Responses
 

Whether the individual is underwater or on the surface, this matrix covers the sequence of critical activities for following
situations where a diver or individual is:
• Unconscious
• Conscious with injury - DCI Symptoms
• Conscious with injury - Non-DCI Symptoms
• Missing or non-returning Diver
• Dead (location known)

Individual is… Out-of-Water In-water
Unconscious 1. Perform CPR as necessary.
2. Call EMS/911.
3. Inform the DSO.
1. Discovering diver should take steps to ensure
that the injured diver can continue to breathe. If
diver is not breathing, bring them to the surface
immediately.
2. Evaluate decompression of injured diver and
discovering diver.
3. Remove the emergency bottom timer and
inform the DSO. The discovering diver should
report the information to a support diver as
soon as possible. The support diver must then
immediately alert the DSO and give the injured
diver's bottom timer to the DSO. DSO to
evaluate risks of keeping diver at depth vs. an
immediate accent and related DCI risks.
4. If diver does not continue to breathe,
discovering diver or other support divers should
immediately bring the unconscious, nonbreathing
diver to the surface.
5. Initiate CPR.
Individual is… Out-of-Water In-water
Conscious with injury -
DCI Symptoms
1. Inform the DSO.
2. Monitor airway, breathing and circulation.
3. Provide oxygen.
4. Conduct on-site neurological exam.
5. Assess DCI type and severity (emergency,
urgent or timely) - see following chart, DCI
Assessment Matrix. Call DAN and EMS as
necessary based on severity of symptoms.
6. For Type I DCS only, evaluate In-water
recompression options (see Appendix 3).
Refer to the DCI Response Details section for
additional information regarding the DCI.
1. A support diver should get the back-up bottom
timer from the injured diver to give it to the
DSO.
2. Inform the DSO.
3. For Type I DCS only, evaluate In-water
recompression options (see Appendix 3).
Refer to the DCI Response Details section for
additional information regarding DCI.
Individual is… Out-of-Water In-water
Conscious with injury -
Non-DCI Symptoms
Examples:
• Broken Bones
• Head Injuries
• Neck/Spine injuries
• Heat Exhaustion/Stroke
• Punctures or lacerations
with heavy bleeding
1. Evaluate for life-threatening considerations.
Call 911 immediately for injuries that may be
considered serious or life-threatening (e.g.
chest pains, difficulty breathing, disorientation,
blood loss).
2. Inform the DSO.
1. Evaluate for life-threatening considerations.
Call 911 immediately for injuries that may be
considered life-threatening (e.g. chest pains,
difficulty breathing, disorientation, blood lose.
2. Inform the DSO of situation. DSO will also
identify others to assist with CPR and other
functions.
3. Administer first aid or CPR as appropriate.
Individual is… Out-of-Water In-water
Missing or non-returning  

1. Support divers collect all information they can
from other divers in the team that lost the diver
• Last seen at what location
• Time last seen
• Changes to dive plan, destinations, etc
• Other problems the diver may have
experienced
• Equipment lost diver may have or
definitely no longer had
2. Report information to DSO.
3. DSO to analyze time frame that lost diver could
"self-rescue" based on available breathing
media that the lost diver may have in their
possession. This is the "drop-dead" time. For
example, if the diver has enough gas for
another hour when contact was lost and they
were lost at 9pm, the drop-dead time is 10pm.
4. DSO to evaluate viability of sending a team
into the cave immediately. Given that this
situation will occur at end of an exploration
dive, there will most likely be no one able to go
into the cave further than a few hundred feet of
penetration, at best.
5. Once drop-dead time is reached, a recovery is
assumed to be necessary. Execute Recovery
Procedures.

Individual is… Out-of-Water In-water
Dead (location known) 1. Inform the DSO.
2. DSO to contact 911 / Sheriff's Dept.
Readily Accessible
1. In a diver is in the presence of the dead diver,
remove the emergency bottom timer so that it
can be provided to the DSO as soon as
practical. Diver must note the time the bottom
timer was removed.
2. Inform the DSO, if possible. Wherever
possible, the discovering diver should report
the situation directly to the DSO. In the event
this is not practical (i.e. discovering diver has a
decompression obligation), the discovering
diver should report the information to a support
diver as soon as possible. The support diver
must then immediately alert the DSO.
3. Confirm diver is not breathing.
4. Analyze diver, his/her equipment and the
conditions around the diver for documentation
and analysis purposes.
5. If necessary, secure body so that it does not
move.
6. Alert DSO if this has not already occurred.
7. DSO will document preliminary information.
8. DSO will contact the following, in this order:
a. 911 / County Sheriffs
b. Victim's Emergency Contacts
9. Plan recovery, select divers to perform
recovery and debrief recovery divers on site
data collection.
10. Wait for Sheriff's deputies to arrive.
11. Dispatch recovery divers.
Not Readily Accessible
1. Inform the DSO.
2. Execute Recovery Procedures.
 
  DCI Assessment Matrix
DCS Symptoms Signs Emergency Urgent Timely
  Type I
• Pain in joints and / or muscles of the arms, legs or torso
• Skin itch
Type II
• Dizziness, vertigo, ringing in the ears
• Numbness, tingling and paralysis
• Shortness of breath
Type I and Type II
• Unusual fatigue
Type I
• Weakness
Type II
• Difficulty urinating
• Confusion, personality
changes, bizarre
behavior
• Amnesia, tremors
• Staggering
• Coughing up bloody,
frothy sputum
• Collapse or
unconsciousness
Symptoms are severe and appear rapidly, within an hour or so of surfacing.
Unconsciousness may occur. Symptoms may be progressing, and the diver is obviously ill. The diver may be profoundly dizzy, have trouble breathing or have major abnormalities in consciousness. Obvious neurological injury is seen in altered consciousness, abnormal gait or
weakness.
Here, the only obvious
symptom is severe pain
that is unchanging or
has progressed slowly
during the past few
hours. The diver does
not appear to be in
distress except for the
pain, and the
neurological signs and
symptoms are not
obvious without a careful
history and examination.
Symptoms are either not
obvious or have
progressed slowly for
several days. Usually the
main signs or symptoms
are vague complaints of
pain or an abnormality of
sensation; the diagnosis
of DCI may be in
question. Obtain as
complete a diving history
as possible and do a
neurological evaluation.
 
  DCI Response Details
 

Determining the Urgency of the Injury
(Source: Diver's Alert Network)
The initial state of the affected diver will determine the order and urgency of the actions taken. Based on a
classification used by the U.S. Navy, the diver can be placed in one of three case categories:
• Emergency
• Urgent
• Timely
Emergency Cases
• By definition this will include:
• AGE,
• Type II DCS
• Type I DCS with severe pain and rapid movement of pain
• Symptoms are severe and appear rapidly, within an hour or so of surfacing.
• Unconsciousness may occur.
• The diver may be profoundly dizzy, have trouble breathing or have major abnormalities in
consciousness.
• Obvious neurological injury is seen in altered consciousness, abnormal gait or weakness.
These divers are obviously very sick, and a true medical emergency exists.


1. If necessary (e.g., if the diver is unconscious), begin CPR. DSO will contact EMS to coordinate
immediate action to have the diver evacuated. Check for foreign bodies in the airway. If ventilator or
cardiac resuscitation is required, the injured diver must be supine (lying on the back). Vomiting in
this position, however, is extremely dangerous; if it occurs, quickly turn the diver to the side until the
airway is cleared and resuscitation can resume in the supine position.


2. Use supplemental oxygen while administering breaths to increase the percentage of oxygen
received by the injured diver. Even if CPR is successful and the diver regains consciousness, 100
percent oxygen should be provided and continued until the diver arrives at a medical facility.


3. Call DAN. After stabilization and arrangements for evacuation, contact DAN for advice on the
nearest chamber location. DAN medical experts can get in touch with the receiving facility to assist
in diagnosis and, if necessary, treatment. Do this even if the diver appears to be improving on
oxygen. While awaiting evacuation, take as detailed a history as possible and try to evaluate and
record the diver's neurological status. These facts are useful to the receiving medical facility. If air
evacuation is used, cabin pressure should be maintained near sea level and not exceed 800
feet / 244 meters unless aircraft safety is compromised.


4. Place the diver in the lateral recumbent position, also known as the recovery position. This puts the
person on one side (usually left) with head supported at a low angle and the upper leg bent at the
knee. If vomiting occurs in this position, gravity will assist in keeping the airway clear.
Urgent Cases


• The only obvious symptom is severe pain that is unchanging or has progressed slowly during the
past few hours.


• Diver does not appear to be in distress except for the pain, and the neurological signs and
symptoms are not obvious without a careful history and examination.


1. Immediately place the injured diver on 100 percent oxygen and give fluids by mouth. Administer
800mg of Ibuprophen.


2. Contact DAN or the nearest medical facility for advice on what sort of transport is necessary and
where the diver should be evacuated to, even if symptoms improve or are relieved with oxygen.
Emergency air transport should not be necessary in these cases.


3. Designate a team member to drive the person to a medical treatment facility. Continue providing
oxygen until arrival at the medical treatment facility.


4. While awaiting evacuation, take as detailed a history as possible and try to evaluate and record the
diver's neurological status. This information will be useful to those at the receiving medical facility. If
air evacuation is used, cabin pressure should be maintained near sea level and not exceed 800 feet
unless aircraft safety is compromised.

Timely Cases
Symptoms are either not obvious or have progressed slowly for several days. Usually the main signs or
symptoms are vague complaints of pain or an abnormality of sensation; the diagnosis of DCI may be in
question. Administer 800mg of Ibuprophen. Have the diver contact DAN.

 
  Conducting an On-Site Neurological Examination
 

See the list and sequence of exam tasks at Appendix 2.
Information regarding the injured diver's neurological status will be useful to medical personnel in not only
deciding the initial course of treatment but also in the effectiveness of treatment. Examination of an injured
diver's central nervous system soon after an accident may provide valuable information to the physician
responsible for treatment.
The On-Site Neuro Exam (Appendix 2) is easy to learn and can be done by individuals with no medical
experience. Perform as much of the examination as possible, but do not let it interfere with evacuation to a
medical treatment facility.
Get the Dive History if possible. Obtain and document the following information for all suspected cases
of DCI:
• For 48 hours preceding the injury, get a description of all dives: depths / times, ascent rates,
intervals between dives, breathing gases, problems or symptoms at any time before, during or
after the dive;
• Ask for symptom onset times and progression after the diver has surfaced from last dive;
• Get a description of all first aid measures taken (including times and method of 100 percent
oxygen delivery) and their effect on symptoms since the injury;
• Record the results of the on-site neurological examination (described below);
• Make a description of all joint or other musculoskeletal pain including: location, intensity and
changes with movement or weight-bearing motions;
• Get a description and distribution of any rashes; and
• Provide a description of any traumatic injuries before, during or after the dive.

Timely Cases
Symptoms are either not obvious or have progressed slowly for several days. Usually the main signs or
symptoms are vague complaints of pain or an abnormality of sensation; the diagnosis of DCI may be in
question. Administer 800mg of Ibuprophen. Have the diver contact DAN.

 
  Background/Definitions on DCI
 

Decompression illness (DCI) is a term used to describe illness that results from a reduction in the ambient
pressure surrounding a body. DCI encompasses two diseases:


1. Decompression sickness (DCS) and


2. Arterial gas embolism (AGE).


DCS is thought to result from bubbles growing in tissue and causing local damage, while AGE results from
bubbles entering the lung circulation, travelling through the arteries and causing tissue damage at a distance by
blocking blood flow at the small vessel level.
U.S. Navy recompression treatment protocols for decompression illness are based on the classification
of DCI as either DCS I or DCS II.
• DCS I means that the diver has joint and / or muscle pain and that the examining physician has
found no indication of any symptoms of DCS II prior to beginning treatment.
• DCS II symptoms include neurological symptoms, such as numbness, tingling, muscle
weakness or bladder problems. Sometimes with DCS II, cardio respiratory problems can also
occur. This can arise from intravascular bubbling and includes symptoms like chest pain and an
irritating (to the throat and chest) cough. DCS II symptoms can range from mild to serious and
life-threatening.
The treatment for DCI is basically only recompression.
• The early management of air embolism and decompression sickness is the same. Although a diver with
severe DCS or an air embolism requires urgent recompression for definitive treatment, it is essential
that he be stabilized at the nearest medical facility before transportation to a chamber.

• Early oxygen first aid is important and may reduce symptoms substantially, but this should not change
the treatment plan. Symptoms of air embolism and serious decompression sickness often clear after
initial oxygen breathing, but they may reappear later. Because of this, always contact DAN or a dive
physician in cases of suspected DCI - even if the symptoms and signs appear to have resolved.

 
  Appendix 1 - Emergency Contact Information
 

For emergencies such as DCI and other internal or external injuries resulting from activities during a project
event, use the phone numbers below to contact the proper emergency personnel. In addition, the Incident
Report Form will be completed for all incidents and filed with the Dive Safety Officer (DSO).
Accident response and management will be coordinated by the DSO.

Hyperbaric Chambers listed by DSO for given project location

When You Call the DAN Hotline:
1. The Hotline numbers are answered at the switchboard of Duke University Medical Center. Tell the operator
you have a diving emergency. The operator will either connect you directly with DAN or have someone call you
back at the earliest possible moment.


2. The DAN staff member may make an immediate recommendation or call you back after making
arrangements with a local physician or the DAN Regional Coordinator. DAN Regional Coordinators are familiar
with chamber facilities in their area, and because they're qualified in diving medicine, they make
recommendations about treatment.


3. The DAN staff member or Regional Coordinator may ask you to wait by the phone while he / she makes
arrangements. These plans may take 30 minutes or longer, as several phone calls may be required.
This delay should not place the diver in any greater danger. However, if the situation is life-threatening, arrange
to transport the diver immediately to the nearest local medical facility for immediate stabilization and
assessment of his or her condition. Call DAN TravelAssist at 1-800-326-3822 (1-800-DAN EVAC) at this time
for consultation with the local medical provider.

 
  Appendix 2 - On-site Neurological Exam
 

Information regarding the injured diver's neurological status will be useful to medical personnel in not only
deciding the initial course of treatment but also in the effectiveness of treatment. Examination of an injured
diver's central nervous system soon after an accident may provide valuable information to the physician
responsible for treatment. The On-Site Neuro Exam is easy to learn and can be done by individuals with no
medical experience. Perform as much of the examination as possible, but do not let it interfere with evacuation
to a medical treatment facility.
Perform the following steps in order, and record the time and results.


1. Orientation
• Does the diver know his/her own name and age?
• Does the diver know the present location?
• Does the diver know what time, day, year it is?
Even though a diver appears alert, the answers to these questions may reveal confusion. Do not omit
them.


2. Eyes
• Have the diver count the number of fingers you display, using two or three different numbers.
• Check each eye separately and then together.
• Have the diver identify a distant object.
• Tell the diver to hold head still, or you gently hold it still, while placing your other hand about 18
inches/0.5 meters in front of the face. Ask the diver to follow your hand. Now move your hand up and
down, then side to side. The diver's eyes should follow your hand and should not jerk to one side and
return.
• Check that the pupils are equal in size.


3. Face
• Ask the diver to purse the lips. Look carefully to see that both sides of the face have the same
expression.
• Ask the diver to grit the teeth. Feel the jaw muscles to confirm that they are contracted equally.
• Instruct the diver to close the eyes while you lightly touch your fingertips across the forehead and face
to be sure sensation is present and the same everywhere.


4. Hearing
• Hearing can be evaluated by holding your hand about 2 feet/0.6 meters from the diver's ear and rubbing
your thumb and finger together.
• Check both ears moving your hand closer until the diver hears it.
• Check several times and compare with your own hearing.
Note: If the surroundings are noisy, the test is difficult to evaluate. Ask bystanders to be quiet and to turn off
unneeded machinery.


5. Swallowing Reflex
• Instruct the diver to swallow while you watch the "Adam's apple" to be sure it moves up and down.

6. Tounge
• Instruct the diver to stick out the tongue. It should come out straight in the middle of the mouth without
deviating to either side.


7. Muscle Strength
• Instruct the diver to shrug shoulders while you bear down on them to observe for equal muscle strength.
• Check diver's arms by bringing the elbows up level with the shoulders, hands level with the arms and
touching the chest. Instruct the diver to resist while you pull the arms away, push them back, up and
down. The strength should be approximately equal in both arms in each direction.
• Check leg strength by having the diver lie flat and raise and lower the legs while you resist the
movement.


8. Sensory Perception
• Check on both sides by touching lightly as was done on the face. Start at the top of the body and
compare sides while moving downwards to cover the entire body.
Note: The diver's eyes should be closed during this procedure. The diver should confirm the sensation in each
area before you move to another area.


9. Balance and Coordination


Note: Be prepared to protect the diver from injury when performing this test.
• First, have the diver walk heel to toe along a straight line while looking straight ahead.
• Have her walk both forward and backward for 10 feet or so. Note whether her movements are smooth
and if she can maintain her balance without having to look down or hold onto something.
• Next, have the diver stand up with feet together and close eyes and hold the arms straight out in front of
her with the palms up. The diver should be able to maintain balance if the platform is stable. Your arms
should be around, but not touching, the diver. Be prepared to catch the diver who starts to fall.
• Check coordination by having the diver move an index finger back and forth rapidly between the diver's
nose and your finger held approximately 18 inches/0.5 meters from the diver's face. The diver should
be able to do this, even if you move your finger to different positions.
• Have the diver lie down and instruct him to slide the heel of one foot down the shin of his other leg,
while keeping his eyes closed. The diver should be able to move his foot smoothly along his shin,
without jagged, side-to-side movements.
• Check these tests on both right and left sides and observe carefully for unusual clumsiness on either
side.
Important Notes:
• Tests 1,7, and 9 are the most important and should be given priority if not all tests can be performed.
• The diver's condition may prevent the performance of one or more of these tests. Record any omitted
test and the reason. If any of the tests are not normal, injury to the central nervous system should be
suspected.
• The tests should be repeated at 30- to 60-minute intervals while awaiting assistance in order to
determine if any change occurs. Report the results to the emergency medical personnel responding to
the call.
• Good diving safety habits would include practicing this examination on normal divers to become
proficient in the test.
• Examination of an injured diver's central nervous system soon after an accident may provide valuable
information to the physician responsible for treatment.
• The On-Site Neuro Exam is easy to learn and can be done by individuals with no medical experience at
all.

 
  Appendix 3 - In-Water Recompression Considerations
 

If a diver exhibits symptoms of DCS, the diver will have the option of going to a chamber or in-water
recompression. In-water recompression can only be used if the diver is experiencing Type I symptoms
(muscular/skeletal) pain. Any neurological symptoms will require a trip to a chamber if available.
• A three-hour surface interval will be required to allow the PO2 level (from incident-causing dive) to
decrease in the diver’s body before treatment. Have diver drink liquids to insure adequate hydration.
This will also allow time to fill tanks for tender-divers.
• In-water recompression can be performed at Weeki Wachee Spring (basin) if all shows have been
completed for the day.
• A full face mask must be used by the DCS diver at all times.
• At least one diver will remain (although they may rotate) in the water with the DCS diver at all times.
The following schedule is recommended; it is a composite of Australian and Hawaiian in-water treatments.
Total In-water time should be approximately 66 minutes.

In-Water Recompression
Depth Time Mix
90ffw 3 minutes EAN 50
80ffw 2 minutes EAN 50
70ffw 2 minutes EAN 50
60ffw 2 minutes EAN 50
50ffw 2 minutes EAN 70
40ffw 40 minutes EAN 70
20ffw 15 minutes 100% Oxygen


Modifications to the above tables may be necessary depending on the depth of pain perception. The
following comments are for illustrative purposes and not intended as rigid standards; circumstances will dictate
reasonable modification. In the event of deep pain (a helium bend), a TX dive will be necessary to drop to
220ffw. If pain is perceived at 10 or 20 ffw, the above table can be started at the 40ffw stop.