Société Belge de Médecine Hyperbare et Subaquatique asbl
Belgische Vereniging voor Overdruk- en OnderwaterGeneeskunde vzw

Position of the Belgian Society for Diving andHyperbaric Medicine on Oxygen First Aid for DivingAccidents
November 15, 2020a) Introduction
In October 2019 the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG)
has organized a Workshop on the matter of Oxygen Administration as First Aid in case of
diving accidents, by persons who ‘do not belong to one of the categories legally authorized
to administer oxygen without direct order and supervision of a medical doctor’. During thisWorkshop, after having exposed the legal and non-legal aspects of the matter, an open
discussion was held with active participation of members of the SBMHS-BVOOG and theother participants (many of whom representing the different Belgian diver federations).
The act ‘administration of oxygen’ is described in the ‘Official list of technical nursing actsallowed for registered nurses’ (Annex I to the Royal Decree of 18 June 1990: Royal Decree
determining the list of technical nursing acts) as a ‘B1’ act (B1: ‘acts for which no medicalprescription is required’). Furthermore, a position statement issued in 2018 by the TechnicalCommission for Nursing (TCAI-TCV) reads “unlicensed persons who perform this technicalact, are punishable by law (Law on the exercise of health-related professions of 10 May
2015, Art.23.1)”. This article does not discriminate, regarding the necessity to administeroxygen, between medical or traumatic situations causing a decrease of the oxygen
saturation in the blood, and specific diving injuries. This article does not discriminate either
between the administration of oxygen in a ‘repeated’ or ‘chronic’ way and theadministration ‘in cases of emergency’. Whereas the administration of oxygen to divers
suffering from well-defined diving-related pathologies is described by national andinternational diving medicine associations as a ‘specific case’ of emergency first aid, thispoint of view is not shared by the CTAI-TCV.
The Board of the SBMHS-BVOOG finds it necessary to make a Position Statement in thismatter, as a basis toa) ensure, as much as possible, that adequate first aid is delivered in case of diving
accidents, not only in Belgium but also abroadb) engage a discussion with the Lawmaker, in order to create more legal clarity in thisspecific issue.

Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.beWebsite: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

b) Workshop presentations
The workshop was organized in the Auditorium of the Military Hospital in Neder-overHeembeek, Brussels, as a regular scientific meeting of the SBMHS-BVOOG, on October 12th,
2019. All presentations are freely downloadable in PDF format from the SBMHS-BVOOG
website (www.sbmhs-bvoog.be).
c) Considerations‘Oxygen administration as first aid for diving accidents’ is a very specific form of medical firstaid, which is not comparable to oxygen administration for other diseases and accidents.
When considering this unique situation for diving pathologies, the following factors must be
taken into account:
1. Divers, who participate in underwater activities in Belgium or in the context of oneof the Belgian diver federations, or those who hold an internationally recognized
diving certification (CMAS, PADI, SSI, IANTD, or other), have in the vast majority
knowledge of the basic physical condition and medical fit-to-dive criteria to safely
undertake this activity. They have subjected to a yearly basic medical fitness
examination, and/or are informed by international organizations such as the Divers
Alert Network (DAN Europe) as to the importance of a good physical and mental
health and to the possible medical risks incurred while diving.
2. Many divers have received additional training in first aid for diving accidents,
including the skills to administer oxygen in a safe way, either by following a(compulsory) training module while pursuing higher certification, or by taking part in
optional courses ‘diver-first-aid’ or ‘DAN Europe Oxygen Provider’ or ‘DAN Europe
First Aid Provider’ courses.
3. Diving physiology is complex, and concerns factors such asa. Immersion
b. Respiratory changes
c. Exercise physiology
d. Saturation and desaturation of ‘inert’ (non-metabolic) gases
These factors are responsible for the fact that despite an optimal medical andphysical condition and preparation, and the scrutinous following of accepted
procedures regarding decompression from depth, a certain risk remains for thesudden occurrence of diving-related pathology, requiring urgent medical first aid.
These pathologies are thus happening to people that – in the vast majority of cases –do not have primary cardiac or cerebral disease. The basis for emergency first aid forall of these diving related conditions is immediate administration of 100% oxygen(see below).

Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.be
Website: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

4. The procedures that have been adopted in Belgium for Emergency Medical Services
consist of a chain of ‘actors’, regulated by ‘112 Central Dispatch’ operators:
a. Immediate first aid provided by ‘112 Ambulances’ which are manned bycertified ambulance personnel; these have at their disposal a ‘’book ofprotocols’ indicating specific paramedical actions to be taken in case ofcertain pathologies or symptoms (‘Procedures and Standing Orders’).
b. The optional availability of a ‘Rapid Medical Interventions’ vehicle (MUG –Medische Urgentie Groep; SMUR – Service Mobile d’Urgence Medicale) witha medical doctor and registered nurse that are specialized in emergency
medicine. These have complete autonomy for therapeutic decisions.
c. Possible deployment of a ‘Prehospital Intervention Team’ (PIT) with acertified paramedic and nurse (holding a Specific Certification for Emergency
Nurse), in those areas of the country where it is difficult to provide aMUG/SMUR team with sufficiently short delays.
In most cases, for a diving-related accident, the Book of Protocols of the 112
Regulation would mandate the immediate dispatch of a 112 Ambulance and also aMUG/SMUR or PIT Team. The mean maximum travel time of such an ambulance inBelgium is fixed at 15 minutes for 95% of calls. Many places where Belgian divers arepracticing their sport however are in ‘blind spots’ where these ‘maximum travel
times’ are impossible to attain: Namur/Philippeville, Tournai, Jodoigne, Aywalle; oralso, the North Sea or the Eastern Scheldt areas.
5. Without any exception, international recommendations for first aid in case of divingrelated accidents mention the importance of immediate administration of 100%
oxygen. The rational for this recommendation is based on animal experimentationand years of experience in military and professional diving. The importance of amaximal FiO2 (as close as possible to 100% of oxygen) bears a direct relation with thespecific pathophysiology of diving accidents:
a. Decompression sickness: during ascent from a dive, nitrogen (inert gas)
bubbles may form in the bodily tissues and blood, which act as gas emboli toobstruct small (capillary, venous or arterial) blood vessels. This causes local
ischemia which may rapidly become irreversible. The only way to rapidly
dissolve these gas-emboli is to reduce the nitrogen pressure in the inhaled air
and alveoli to zero, and replace it with oxygen. That way,i. the cells in the affected tissue will, despite the inevitable presence ofoedema and extravasation of fluids, be provided with as much oxygenas possible (anti-ischemic effect)
ii. the inert gas pressure in the tissues will be reduced rapidly to minimallevels, allowing the inert gas from within the bubbles to re-diffuse
into the tissues, decreasing the volume of the bubble and making it,eventually, disappear.
The longer this ischemia is allowed to persist, the more important
inflammatory reactions and cell necrosis will become, reducing thetherapeutic effect of a subsequent treatment with hyperbaric oxygen (in apressure chamber). Optimal first aid with oxygen and rehydration thus play
an important role in the chances of a good result from the definite
Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.be
Website: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

treatment. The persistence of neurological, vestibular or orthopedic sequelae
of diving accidents may cause lifelong disability and have a profound effecton the quality of the remaining life in these often young persons.
b. Cerebral air embolism caused by pulmonary overpressure: here, actual airemboli are swept into the pulmonary veins and thus in the arterial
circulation, to end up (predominantly) in the cerebral blood vessels. Hereagain, just like Basic Life Support, 100% oxygen is crucial as emergency firstaid, and for the same reasons as above. It is most effective whenadministered within minutes (see also the recent Guidelines by the UK
Intensive Care Society, Reference 3).
c. Immersion Pulmonary Edema: this particular affliction is characterized bypulmonary edema, occurring while the diver is at depth and provoking theneed for emergency ascent. However, the dyspnea and shortness of breath
which started at depth (caused by arterial hypoxemia) actually increases
during ascent because the partial pressure of oxygen in the alveoli decreases
with decreasing environmental pressure. Due to this hypoxia, divers may lose
consciousness before reaching the water surface (and most likely drown) or,
they may develop cardiac ischemia at or near the surface. While waiting for
positive pressure ventilation (CPAP), cardiac monitoring and possibly
administration of diuretics, administration of as high as possible a
concentration of oxygen will save lives. Vastly underreported, the exact causeof this pathology is multifactorial and in many cases difficult to ascertain.
6. The diagnosis of all these conditions is almost exclusively made on clinical grounds,
based in the nature and time of occurrence of the symptoms, but also taking into
account the preceding dive (depth, dive time, breathing gas, incidents during thedive) as well as clinical features and medical history of the diver. While diving in
Belgium, all divers have the benefit of almost immediate (within minutes)
consultation with an experienced diving medicine (specialist) physician, through thetoll-free telephone number 0800-12382, who can pinpoint with near-certainty adiagnosis based on these data. This physician can also recommend logical andoptimal first aid measures while awaiting Emergency Medical Services to arrive.
Once the patient is take care of by EMS, this physician is available for telephone
consulting and recommendations regarding the best medical care and the mostappropriate evacuation strategy (e.g. emergency medical transport towards theclosest hyperbaric facility). If, in concertation with the MUG/SMUR physician, it isconcluded that it does NOT concern one of these specific diving pathologies, themedical care can be continued following the general recommendations (amongothers, restriction of the concentration of oxygen to be given).
7. Not administering oxygen upon (suspicion of) these clinical syndromes, asrecommended by international expert panels in diving medicine, can be considered a
medical fault and/or ‘non assistance of a person in vital danger’, thus subjecting one
to possible criminal charges. Administering oxygen in a competent manner (‘legeartis’) by a diver first aid-provider, on the instructions of an experienced, certified
Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.beWebsite: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

diving medicine specialist (be it over the phone) would never lead to criminal
charges being laid unless done so by the victim; even then, the ‘culprit’ would becovered by his/her diving insurance for the possible financial consequences of an(unlikely) conviction.
d) Recommendations:
1. For diving accidents, administration of 100% oxygen by qualified and certified divers
is essential to maximize the chances of complete cure with no or only minimal
sequelae, even so if a hyperbaric oxygen treatment can be started within a shortdelay.
2. The possible negative effects of 100% oxygen, as indicated in the generalrecommendations for emergency first aid, do not weigh against the certain
advantages in the case of diving pathology. Moreover, after arrival of the Emergency
Medical Services, it can be decided in concertation with the diving medicine
physician on the phone, to discontinue the administration of 100% oxygen. In case of
non-necessity, the maximum duration of this ‘too high dose’ of oxygen would be at
most one hour.
3. Divers should continue to receive a thorough education in recognizing emergency
situations that need oxygen first aid, as well as in the correct and safe administrationof 100% oxygen with the specific available first aid materials (type of mask, flowrate,…). It is recommended that diving medicine specialists or –organizations,because of the very specific nature of diving-related pathology, give these courses.
This education should also encompass the supplementary measures and precautions
in relation to the propagation of the SARS-CoV2 virus, in order to make certain that it
does not impede the rapid administration of oxygen.
4. Divers must be encouraged to seek immediate telephone consultation with a diving
medicine physician in all cases of diving-related pathology to receive precise
instructions and formal (oral) authorization to administer oxygen (and other first aid
measures). Information on how to reach this telephone ‘hotline’ is alreadycommunicated to all Belgian divers through the diving federations and DAN Europe.
5. The legal dispositions and texts dealing with oxygen administration as a first aid
measure need to be adapted as soon as possible, to allow oxygen administration bytrained divers to injured divers, according to the above-described modalities.
e) References:
1. 2018. Advies van de Technische Commissie voor Verpleegkunde in verband met
zuurstoftoediening door duikers. Available from:https://organesdeconcertation.sante.belgique.be/sites/default/files/documents/tcv_questrep_2015-2018.pdf accessed July 17 2020
2. Mitchell SJ, Bennett MH, Bryson P, Butler FK, Doolette DJ, Holm JR, Kot J, Lafère P.
Pre-hospital management of decompression illness: expert review of key principles
and controversies. Diving and Hyperbaric Medicine. 2018 March;48(1):45–
5.doi.10.28920/dhm 48.1.45-55.). Available fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467826/, accessed July 16; 2020.
Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.beWebsite: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

3. UK Intensive Care Society 2020: Management of Patients With Gas Embolism:Guidance For Intensive Care And Resuscitation Teams. Available fromhttps://www.sbns.org.uk/index.php/download_file/view/1557/559/&usg=AOvVaw1
1waZfhdEeumqLZfFITYfs, accessed July 16, 2020.
4. Gesellschaft für Tauch- und Uberdruck-Medizin (GTUeM) Diving Medicine Guideline(Leitlinie Tauchunfall der GTÜM). Available fromhttps://www.gtuem.org/files/319/072-001l-s2k-tauchunfall-2014-10.pdf, accessed
July 16, 2020.
5. DAN Europe Flowchart. Available fromhttps://www.daneurope.org/c/document_library/get_file?uuid=e5b99856-c50b4761-b54f-d7f9426056bb&groupId=10103, accessed July 16, 2020.
6. Zideman DA, Singletary EM, De Buck EDJ, et al. 2015 International Consensus on First
Aid Science with Treatment Recommendations: Part 9: First aid. Resuscitation 95(2015) e225–e261. Available fromhttp://dx.doi.org/10.1016/j.resuscitation.2015.07.047 , accessed July 17, 2020.
7. Singletary EM, Charlton NP, Epstein JL et al. 2015 American Heart Association andAmerican Red Cross Guidelines Update for First Aid. Circulation 2015;132[suppl2]:S574–S589. DOI: 10.1161/CIR.000000000000026
https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000269 , accessedJuly 17, 2020For the Board of SBMHS-BVOOG:(signed)(signed)(signed)Dr Guy Vandenhoven
President

Dr Peter Germonpre
Board Member

Dr Jean-Pierre Rezette
Board Member

Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.beWebsite: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109