Head injuries Unconsciousness

 Concussion (shaking of the brain, Casualty is unaware of their environment and does not respond normally to sensory stimuli.
conmoción. Ej. boxeador k.o.) Levels of consciousness: (have a poo) AVPU
1. Face pale A.- Alert. Open their eyes, talks spontaneously
2. Skin cold and clammy(pegajosa) V.- Voice response. Opens their eyes, groans or moves in response to
3. Breathing shallow (superficial) commands.
4. Pulse rapid and weak P.- Pain response. Opens their eyes, groans or moves in response to
5. Equal pupils pain stimulus
6. Nausea or vomiting U.- Unresponsive. No respond to stimulus
7. Brief or partial unconsciousness CAUSES:
8. Confused, possible memory loss  Head injury
 Compression (pressure on the A. Concussion. Loss of memory during periods of consciousness.
brain)accumulated blood may clot B. Compression. flushed face, slow breathing, pulse slow and strong
to press the brain) It’s a complication C. Fractured skull. Bleeding from ears, eyes, nose or wound on skull.
of concussion  Lack of oxygen
1. Face flushed (colorada) A. Suffocation/low blood oxygen
2. Skin warm and dry) B. Blood loss/shock. Lack of blood level in the brain.
3. Breathing noisy  Poisoning
4. Pulse slow and strong A. Drugs
5. Unequal pupils B. Alcohol
6. Usually deeply unconscious C. Fumes
7. Weak (debilitate) or paralysis to  Medical
one side A. Heart attack
STROKE (Infarto, ataque, golpe…) B. Diabetes
A stroke happens when the blood supply C. Epilepsy
to the brain is disrupted. A blood clot D. Stroke
blocks an artery.  extreme body temperature
 CAUSES A. Hypothermia. -2° normal heat
A. Cerebral thrombosis. A clot B. Heat stroke. +2° (cooling slowly no sudden)
obstructs the artery and Treatment: place in the recovery position and call medical help
deprives an area of blood.
B. Cerebral hemorrhage. A
ruptured artery causes extent of
bleeding
 SIGNS AND SYMPTOMS. DR ABC CHART
Similar to compression but in
addition…
A. Sudden severe headache 1. Check for dangers
B. Confused, emotional mental 2. Speak to casualty (support head)shake the shoulders
state like drunkness 3. Ensure clear airway, loosen tight clothing
C. Slurred or impaired speech 4. Check cervical spine head tild & chin lift
D. Dropping, dribbling mouth.
(torcida y babeante)
5. Check breath for 10 sec. look, listen & feel unconsciousness
E. Loss of blader or bowel control
 TREATMENT Not breathing normally: Breathing normally:
A. If conscious. Lay casualty down Help return 1. Check pulse-usually present
with head shoulders raised and Check dangers 2. Primary survey head to toe
supported.(semiincorporado) 30 good compressions 3. Turn patient in recovery position to protect airways
B. Loosen tight clothing, and don’t 2 breaths 4. Check ABC, cover the patient
give anything by mouth. 30 compressions 5. Help return
C. If unconscious. Check ABC, + 2 breaths until help arrives 6. Check ABC
place in recovery position, get 7. secondary survey & monitors ABC
help, carry out AVPU every 10
minutes.

PRESERVE LIVE
PREVENT DETERIORATION
PROMOTE RECOVERY

DECOMPRESSION PULMONARY BAROTRAUMA DPB

Is a syndrome. Gas leaving its natural confines and enter into the interstitial space within the lung, the pleural cavity or the
blood stream.
CAUSE: Boyles law. Expansion during ascent broke pulmonary tissues.
PREVENTION: Exhale during ascent
SIGNS &SYMPTOMS:
In all cases:
-sharp chest pain
-shortness of breath
-difficult or painful breathing
-coughs may product blood stained sputum

1
DECOMPRESSION PULMONARY BAROTRAUMA DPB

DPB MORE SYMPTOMS TREATMENT

Mediastinal & -Fullness in the chest or throat Breathing 100 % O2

subcutaneous -migrate into tissues of neck
enphisema (gas into -swelling &crepitating
interstitial tissue space in
mediastinum.
PNEUMOTHORAX -shortness of breath Breathing 100 % O2
Occurs when alveolar -cyanosis
gas escapes into the -reduced movements of neck
pleural space.
Tension -cyanosis Require draining
PNEUMOTHORAX -Shock
When the volume -unconsciousness
increases
ARTERIAL GAS -neurological symptoms US NAVY R.6 V.5 chap. 20 RCC. Recompression
EMBOLISM -similar than acute neurological decompression illness chamber:
Gas enter into the  Extreme fatigue  Dizziness
pulmonary  Difficulty in thinking  paralysis or weakness in the Fig.20.1 US NAVY R.6
microcirculation  Vertigo extremities V.5 chap. 20
 Nausea and/or vomiting  large areas of abnormal sensation
 Hearing abnormalities (paresthesias)
 Bloody sputum  vision abnormalities If pain is the only symptom,
 Loss of control of bodily  Convulsions or personality arterial gas embolism is
functions changes. unlikely and decompression
 Tremors  During ascent, the diver may have sickness or one of the other
 Loss of coordination noticed a sensation similar to that of pulmonary overinflation
 Numbness (entumecimiento) a blow to the chest. syndromes should be
 The victim may become considered.
unconscious without warning and
may stop breathing

GAS TOXICITY
ANOXIA NITROGEN NARCOSIS
(Complete lack of O2) SYMPTOMS: Filing of euphoria.
TREATMENT: decrease depth or change mix
HYPOXIA HYPERCAPNIA
CAUSE: Less than 0,16 PP, - 16 % on surface CAUSE: Inadequate ventilation of mask
SYMPTOMS:
SYMPTOMS: 1. Increase in respiration and pulse
1. Cyanosis 2. Headache
2. Increased heart rate (taquicardia) 3. Sweating (sudoracion)
3. Poor coordination 4. Dizziness (mareo)
5. Nausea
TREATMENT: More O2 6. Anxiety (ansiedad)
7. unconsciousness
TREATMENT: Stop work and flush through
HYPEROXIA
CNS (acute or rapid) central PULMONARY (chronic or CARBON MONOXIDE POISONING
nervous system slow) CAUSE: impure air. Se mezcla más rápido que el O2
CAUSE: Breath O2 above 1,5/2,8 CAUSE: Breathing O2 for
PP long periods at + 0,5 PP SYMPTOMS:
SYMPTOMS:
SYMPTOMS: 1. Tight (pression) in 1. cherry skin
V-Vision disturbances chest 2. breathless on exertion
E- earring (ringing, tinnitus) 2. Dry irritated throat 3. lassitude (atontamiento)
N- nausea 3. Dry cough painful 4. dizziness
T- twitching(temblor facial) (non productive) 5. tinnitus
I- irritability 4. Painful finger tips 6. confusion
D- dizziness (mareo) 5. Shortness of breath 7. loss of consciousness
8.
C-convulsions (CLONIC PHASE)
TREATMENT: TREATMENT:
RIGIDITY (TONIC PHASE)
1. Stop deco
2. Observe patient 1. Change gas supply.
TREATMENT:
3. Check for 2. RCC Administrating O2
1. Stop deco
neurological
2. Check for injury
symptoms
3. Protect airway

2
ACUTE DECOMPRESION ILLNESS (DCI)
Acute decompression illness is a syndrome of numerous possible manifestations
 Inert gas. Saturación que el cuerpo no soporta a + Prof. + PP de N
 Fallo durante la deco. Causada porque el cuerpo no puede eliminar las burbujas
 La capacidad de los pulmones no da abasto y se satura dejando pasar a la sangre el exceso de burbujas
 FARAMEN OVAL. Esta abierto y el gas pasa de aurícula (atrium) dcha. a la izq. Saltándose el paso a los
pulmones, por lo que regresa a todo el cuerpo otra vez.
 Decompression pulmonary barotrauma. DPB
1. Enfisema mediastinico y subcutáneo
2. Neumotórax
3. Tensión neumotórax
4. Embolismo arterial gaseoso. AGE. Arterial gas embolism
 Isquemia (ischaemia) mecanismo por el cual las burbujas obstruyen el riego del cerebro
Symptoms
 joint pain.
 cutaneous symptoms
 swelling and pain in lymph nodes.
 Type 2: similar than AGE

ACUTE DECOMPRESSION ILLNES MEDICAL DESCRIPTION

EVOLUTION: MANIFESTATIONS: TERMINOLOGY FOR ADITIONAL INFORMATION
-progressive Limb pain The time onset
-Static Girdle pain Gas burden
-Spontaneously Neurological Evidence of barotrauma
improving Audio-vestibular Response to decompression
-relapsing Pulmonary Results of investigation.
Cutaneous
Lymphatic
constitutional
TREATMEN: Call doctor, O2, compress to 18 m on O2, apply deco treatment if casualty doesn’t improve

ASPHYXIA (lack of O2
Obstruction of air External pressure to the neck (hanging, strangulation)
passages Drowning (ahogamiento)
Inhaled foreign bodies (blood, vomit, etc…)
Internal swelling of the throat tissues (burns, scalds, stings,
anaphylactic...)
Suffocation (pillow, plastic)
Chest or lung damage External compression (sand, damage by vehicle)
Blast injuries (explosives)
Pneumothorax injuries (ej. Sucking wound to the chest)
Paralysis of respiratory Electrocution
nerves and muscles Poison (strychnine, cyanide)
Weed killers (herbicides) toxic gases
Drugs, barbiturates, morphine
Diseases. Ej. Poliomyelitis, tetanus, stroke…
Non oxygen Gases
atmospheres Chemical fumes (glue)
Smoke
Altitude (co are absorbed by the blood)

Lung disease and illness Emphysema

Oedema
Acute pneumonia
Asthma/bronchitis
Continuous fits (convulsions)
Irritation of the lung tissue by inhalation of toxic fumes.

3
SURFACE DECOMPRESSION ON O2 9.8.3 U.S. NAVY MANUAL

To decompress the diver using the Surface Decompression on Oxygen mode, follow the in-water air
decompression schedule (top row) through the end of the 40 fsw water stop, then initiate surface
decompression following the rules given below. If there is no 40 fsw water stop in the air schedule, surface the
diver without taking any stops. In either case, start timing the surface interval when the diver leaves 40 fsw.
The required time on oxygen in the recompression chamber is shown in the next to last column of the Table.
Oxygen time is divided into periods. Each period is 30 minutes long; each half-period is 15 minutes long. The
first 15 minutes is always spent at 50 fsw in the chamber; the remainder of the oxygen time is taken at 40 fsw.
If the schedule requires only one half of an oxygen period, the diver spends 15 minutes breathing oxygen at
50 fsw in the chamber, then surfaces at 30 fsw/min. The repetitive group designator for a surface
decompression dive is shown in the last column of the Table and is the same as the repetitive group
designator for an air decompression dive.

Surface Decompression on Oxygen Procedure

1. Complete any required decompression stops on air 40 fsw and deeper.

2. Upon completion of the 40 fsw stop, bring the diver to the surface at 40 fsw/min. If a 40 fsw water stop is not
required, bring the diver from the bottom to 40 fsw at 30 fsw/min and then from 40 fsw to the surface at 40
fsw/min. Once the diver is on the surface, tenders have approximately 3 and a half minutes to remove the
breathing apparatus and diving dress and assist the diver into the recompression chamber.

3. Place the diver and a tender in the recompression chamber. The job of the tender is to monitor the diver
closely for signs of decompression sickness and CNS oxygen toxicity during the subsequent recompression.
When two divers undergo surface decompression simultaneously, the dive supervisor may elect not to use an
inside tender. In this case, both divers will carefully monitor each other in addition to being closely observed by
topside personnel.

4. Compress the diver on air to 50 fsw at a maximum compression rate of 100 fsw/min. The surface interval is
the elapsed time from the time the diver leaves the 40 fsw water stop to the time the diver arrives at 50 fsw in
the chamber. A normal surface interval should not exceed 5 minutes.9-16 U.S. Navy Diving Manual —
Volume 2

5. Upon arrival at 50 fsw, place the diver on 100 percent oxygen by mask. Instruct the diver to strap the mask
on tightly to ensure a good oxygen seal.

6. In the chamber, have the diver breathe oxygen for the number of 30-minute periods and 15-min half periods
indicated in the next to last column of the Air Decompression Table. The first period consists of 15 minutes on
oxygen at 50 fsw followed by 15 minutes on oxygen at 40 fsw. Periods 2–4 are spent at 40 fsw. If more than 4
periods are required, the remaining periods are spent at 30 fsw. Ascent from 50 fsw to 40 fsw and from 40 fsw
to 30 fsw is at 30 fsw/min. Ascent time from 50 to 40 fsw is included in the first oxygen period. Ascent from 40
to 30 fsw, if required, should take place during an air break.

7. Interrupt oxygen breathing with a 5-min air break after every 30 minutes on oxygen. This air time is
considered dead time. Oxygen time begins when the diver is confirmed to be on oxygen at 50 fsw.

8. When the last oxygen breathing period has been completed, return the diver to breathing chamber air.
9. Ascend to the surface at 30 fsw/min.

Surface Interval Greater than 5 Minutes.

If the time from leaving 40 fsw in the water to the time of arrival at 50 fsw in the chamber during surface
decompression exceeds 5 minutes, take the following action:
1. If the surface interval is more than 5 minutes but less than or equal to 7 minutes, increase the time on
oxygen at 50 fsw from 15 to 30 minutes, i.e., add one-half oxygen period to the 50 fsw chamber stop. Ascend
to 40 fsw during the subsequent air break. The 15-min penalty is considered a part of the normal surface
decompression procedure, not an emergency procedure.
2. If the surface interval is greater than 7 minutes, continue compression to a depth of 60 fsw. Treat the divers
on Treatment Table 5 if the original schedule required 2 or fewer oxygen periods in the chamber. Treat the
divers on Treatment Table 6 if the original schedule required 2.5 or more oxygen periods in the chamber.
3. On rare occasions a diver may not be able to reach 50 fsw in the chamber because of difficulty equalizing
middle ear pressure. In this situation, an alternative procedure for surface decompression on oxygen may be
used. Compress the diver to the deepest depth he can attain initially. This will usually be less than 20 fsw.

4
Begin oxygen breathing at that depth. Continue attempts to gradually compress the diver deeper. If the in-
water air or air/oxygen decompression schedule required only a 20-fsw water stop, attempt to compress the
diver to 20 fsw. If the in-water air or air/oxygen decompression schedule required a 30-fsw water stop, attempt
to compress the diver to 30 fsw. In either case, double the number of chamber oxygen periods indicated in the
table and have the diver take these periods at whatever depth he is able to attain. Oxygen time starts when
the diver initially goes on oxygen. Interrupt oxygen breathing every 60 minutes with a 15-min air break. The air
break does not count toward the total oxygen time. Upon completion of the oxygen breathing periods, surface
the diver at 30 fsw/min. Carefully observe the diver post-dive for the onset of decompression sickness. This
“safe way out” procedure is not intended to be used in place of normal surface decompression procedures.
Repetitive diving is not allowed following a dive in which the “safe way out” procedure is used.

Decompression Sickness During the Surface Interval.

If symptoms of Type I decompression sickness occur during travel from 40 fsw to the surface during surface
decompression or during the surface undress phase, compress the diver to 50 fsw following normal surface
decompression procedures. Delay neurological exam until the diver reaches the 50-fsw stop and is on oxygen.
If Type I symptoms resolve during the 15 minute 50-fsw stop, the surface interval was 5 minutes or less, and
no neurological signs are found, increase the 50 fsw oxygen time from 15 to 30 minutes as outlined above,
then continue normal decompression for the schedule of the dive. Ascend from 50 to 40 fsw during the
subsequent air break.

If Type I symptoms do not resolve during the 15 minute 50-fsw stop or symptoms resolve but the surface
interval was greater than 5 minutes, compress the diver to 60 fsw on oxygen. Treat the diver on Treatment
Table 5 if the original schedule required 2 or fewer oxygen periods in the chamber. Treat the diver on
Treatment Table 6 if the original schedule required 2.5 or more oxygen periods in the chamber. Treatment
table time starts upon arrival at 60 fsw. Follow the guidelines for treatment of decompression sickness given in
Chapter 20, Volume 5. CHAPTER 9—Air Decompression 9-41 If symptoms of Type II decompression
sickness occur during travel from 40 fsw to the surface, during the surface undress phase, or the neurological
examination at 50 fsw is abnormal, compress the diver to 60 fsw on oxygen. Treat the diver on Treatment
Table 6. Treatment table time starts upon arrival at 60 fsw. Follow the guidelines for treatment of
decompression sickness given in Chapter 20, Volume 5.

Table 9-2 summarizes the guidance for managing an extended surface interval and for managing Type I
decompression sickness during the surface interval

5
Us navy manual R. 6 vol. 3 Chap. 20.7.11
Oxygen Toxicity Symptoms in the Chamber
1. At the first sign of CNS oxygen toxicity, the patient should be removed from oxygen . Cut 02
supply, check for injury, protect airway and allowed to breathe chamber air. Fifteen minutes
after all symptoms have completely subsided,restart/ resume oxygen breathing at the point of
interruption.
2. If symptoms of CNS oxygen toxicity develop again or if the first symptom is a convulsion, take the
following action: 1. Remove the mask. 2. After all symptoms have completely subsided, decompress
10 feet at a rate of 1 fsw/min. For a convulsion, begin travel when the patient is fully relaxed and
breathing normally. 3. Restart/Resume oxygen breathing at the shallower depth at the point of
interruption.
3. If another oxygen symptom occurs, complete decompression on chamber air. Follow the guidance
given in paragraph 14-4.5 for permanent loss of chamber oxygen supply to compute the air
decompression schedule;
Multiply the remaining oxygen time by three to obtain the equivalent chamber decompression time on
air. If the loss (or O2 supply interruption) occurred at 50 or 40 fsw, allocate 10% of the equivalent air
or helium-oxygen time to the 40-fsw stop, 20% to the 30-fsw stop, and 70% to the 20-fsw stop. If the
diver is at 50 fsw, ascend to 40 fsw to begin the stop time. If the loss (or O2 supply interruption)
occurred at 30 fsw, allocate 30% of the equivalent air or helium-oxygen time to the 30-fsw stop and
70% to the 20-fsw stop. Round the stop times to the nearest whole minute. Surface upon completion
of the 20-fsw stop.

6
NITROX

10-2 EQUIVALENT AIR DEPTH

The partial pressure of nitrogen in a NITROX mixture is the key factor determining the diver’s
decompression obligation. Oxygen plays no role. The decompression obligation for a NITROX dive
therefore can be determined using the Standard Air Tables simply by selecting the depth on air that has
the same partial pressure of nitrogen as the NITROX mixture. This depth is called the Equivalent Air
Depth (EAD). For example, the nitrogen partial pressure in a 68% nitrogen 32% oxygen mixture at 63
fsw is 2.0 ata. This is the same partial pressure of nitrogen found in air at 50 fsw. 50 fsw is the Equivalent
Air Depth.

Partial pressure = absolute pressure x decimal percentage

7
8
9
10
Recompression Treatment With Oxygen. Use Oxygen Treatment Table 5, 6, 6A, 4, or 7, according to the
flowcharts in Figure 20-1, Figure 20-2 and Figure 20-3. The descent rate for all these tables is 20 feet per
minute. Upon reaching a treatment depth of 60 fsw or shallower place the patient on oxygen. For
treatment depths deeper than 60 fsw, use treatment gas if available.

11
Treatment Table 5. Treatment Table 5, Figure 20-4, may be used for the following:
 Type I DCS (except for cutis marmorata) symptoms when a complete neurological
examination has revealed no abnormality. After arrival at 60 fsw a neurological
exam shall be performed to ensure that no overt neurological symptoms (e.g.,
weakness, numbness, loss of coordination) are present. If any abnormalities are
found, the stricken diver should be treated using Treatment Table 6.
 Asymptomatic omitted decompression
 Treatment of resolved symptoms following in-water recompression
 Follow-up treatments for residual symptoms
 Carbon monoxide poisoning
 Gas gangrene

12
Treatment Table 6. Figure 20-5, is used for the following:
 Arterial gas embolism
 Type II DCS symptoms
 Type I DCS symptoms where relief is not complete within 10 minutes at 60 feet or
where pain is severe and immediate recompression must be instituted before a
neurological examination can be performed
 Cutis marmorata
 Severe carbon monoxide poisoning, cyanide poisoning, or smoke inhalation
 Asymptomatic omitted decompression
 Symptomatic uncontrolled ascent
 Recurrence of symptoms shallower than 60 fsw

13
Treatment Table 6A. Treatment Table 6A, Figure 20-6, is used to treat arterial gas embolism or
decompression symptoms when severe symptoms remain unchanged or worsen within the first 20
minutes at 60 fsw. The patient is compressed to depth of relief (or significant improvement), not to exceed
165 fsw. Once at the depth of relief, begin treatment gas (N2O2, HeO2) if available. Consult with a Diving
Medical Officer at the earliest opportunity. If the severity of the patient’s condition warrants, the Diving
Medical Officer may recommend conversion to a Treatment Table 4.
NOTE If deterioration or recurrence of symptoms is noted during ascent to 60 feet, treat as a
recurrence of symptoms (Figure 20-3).

14
Treatment Table 4. Treatment Table 4, Figure 20-7, is used when it is determined that the patient would receive
additional benefit at depth of significant relief, not to exceed 165 fsw. The time at depth shall be between 30 to
120 minutes, based on the patient’s response. If a shift from Treatment Table 6A to Treatment Table 4 is
contemplated, a Diving Medical Officer should be consulted before the shift is made.

If oxygen is available, the patient should begin oxygen breathing periods immediately upon arrival at the 60-foot
stop. Breathing periods of 25 minutes on oxygen, interrupted by 5 minutes of air, are recommended because
each cycle lasts 30 minutes. This simplifies timekeeping. Immediately upon arrival at 60 feet, a minimum of four
oxygen breathing periods (for a total time of 2 hours) should be administered. After that, oxygen breathing should
be administered to suit the patient’s individual needs and operational conditions. Both the patient and tender must
breathe oxygen for at least 4 hours (eight 25-minute oxygen, 5-minute air periods), beginning no later than 2
hours before ascent from 30 feet is begun. These oxygen-breathing periods may be divided up as convenient, but
at least 2 hours’ worth of oxygen breathing periods should be completed at 30 feet.

NOTE If deterioration or recurrence of symptoms is noted during ascent to 60 feet, treat as a recurrence
of symptoms (Figure 20-3).

15
Recompression Treatments When Oxygen Is Not Available. Air Treatment Tables 1A, 2A, and 3
(Figures 20-11, 20-12, and 20-13) are provided for use only as a last resort when oxygen is not available.
Use Air Treatment Table 1A if pain is relieved at a depth less than 66 feet. If pain is relieved at a depth
greater than 66 feet, use Treatment Table 2A. Treatment Table 3 is used for treatment of serious
symptoms where oxygen cannot be used. Use Treatment Table 3 if symptoms are relieved
within 30 minutes at 165 feet. If symptoms are not relieved in less than 30 minutes at 165 feet,
use Treatment Table 4.

16
17
20-3.7 Symptomatic Omitted Decompression. If a diver has had an uncontrolled ascent and has any
symptoms, he should be compressed immediately in a recompression chamber to 60 fsw. Conduct a rapid
assessment of the patient and treat accordingly. Treatment Table 5 is not an appropriate treatment for
symptomatic omitted decompression. If the diver surfaced from 50 fsw or shallower, compress to 60 fsw
and begin Treatment Table 6. If the diver surfaced from a greater depth, compress to 60 fsw or the depth
where the symptoms are significantly improved, not to exceed 165 fsw, and begin Treatment Table 6A.
Consultation with a Diving Medical Officer should be obtained as soon as possible. For uncontrolled
ascent deeper than 165 feet, the diving supervisor may elect to use Treatment Table 8 at the depth of
relief, not to exceed 225 fsw.

18
Treatment Table 8. Treatment Table 8, Figure 20-9, is an adaptation of Royal Navy Treatment Table 65
mainly for treating deep uncontrolled ascents (see Chapter 14) when more than 60 minutes of
decompression have been missed. Compress symptomatic patient to depth of relief not to exceed 225 fsw.
Initiate Treatment Table 8 from depth of relief. The schedule for Treatment Table 8 from 60 fsw is the
same as Treatment Table 7. The guidelines for sleeping and eating are the same as Treatment Table 7.

Treatment Table 9. Treatment Table 9, Figure 20-10, is a hyperbaric oxygen treatment table providing 90
minutes of oxygen breathing at 45 feet. This table is used only on the recommendation of a Diving Medical
Officer cognizant of the patient’s medical condition. Treatment Table 9 is used for the following:
1. Residual symptoms remaining after initial treatment of AGE/DCS
2. Selected cases of carbon monoxide or cyanide poisoning
3. Smoke inhalation
This table may also be recommended by the cognizant Diving Medical Officer when initially treating a severely
injured patient whose medical condition precludes long absences from definitive medical care.

19