1. Knowledge Development Three
Question 1
Question 6
Question 2
Question 7
Rescue - Knowledge Review Three
Question 3
Question 8
Question 4
Question 9
Question 5
Question 10
Prescriptive

2. Knowledge Review Three – Question 1
What is an emergency action plan? What five areas of information should it include?
Information you need in the event of a dive accident at a particular dive site.
1. Sequence of steps.
2. List of local emergency phone numbers.
3. A script for what to say when calling emergency services.
4. Procedures for responding.
5. Procedures for completing required reports.
Rescue - Knowledge Review Three
1. Emergency Action Plans
What is an emergency action plan?
a. The most effective emergency responses result from effective teamwork, which reduces the risks for both rescuers and victims. Preparation increases the speed and efficiency with which you handle an emergency situation.
1. An emergency action plan is simply the information, for where you’re diving, that you will need in the event of a dive accident .
2. Have an emergency action plan for the sites you visit, and practice using these plans for handling a variety of emergencies with other Rescue Divers and higher level divers. Practice with an emergency action plan helps identify hazardous areas where problems are most likely, refine your responses to them, and confirm the completeness of your plan.
b. Your emergency action plan should consider your team: yourself, other divers, the local emergency response team (EMS or local fire department), and appropriate local medical services. To the degree feasible, involving these in forming emergency action plans makes them more efficient and more effective. [You might consider arranging for your group to have an in-service training session with outside emergency personnel to practice procedures.]
What five areas of information may an emergency action plan include?
c. A thorough emergency action plan considers likely required measures before you need them, and may include some or all of the following:
1. The sequence of steps to follow as required by the local environment
2. A list of emergency phone numbers [Remind students that these include the numbers discussed in Knowledge Development Session Two.]
3. A script for what to say when calling in emergencies – especially helpful when delegating untrained bystanders to make a call for you
4. The procedures for responding to, moving and transporting an injured diver out of the area to within reach of emergency medical care
5. Procedures for completing accident and incident reports.
Prescriptive i

3. Knowledge Review Three – Question 2
What is meant by “Basic Life Support”? What types of dive accidents can require BLS?
BLS involves monitoring and enacting emergency procedures for patient respiratory and/or cardiovascular system failure.
Dive accidents include: drowning, decompression sickness and lung overexpansion injuries, prolonged exposure to heat or cold, and exertion beyond physical limits.
Rescue - Knowledge Review Three
B. Being Prepared for an Emergency
1. Basic Life Support for Dive Emergencies
What is meant by “Basic Life Support”?
a. As you know, Basic Life Support (BLS) includes monitoring and enacting emergency procedures for patient respiratory and/or cardiovascular system failure, which cuts off oxygen to the body, making death imminent.
What types of dive accidents can require BLS?
1. Dive accidents involving drowning, decompression sickness and lung overexpansion injuries can cause respiratory and/or cardiac arrest. Heavy exposure suits in hot weather can cause heat stroke and heat exhaustion. Prolonged exposure to cold water can cause hypothermia.
2. Diving is a physical activity with physical stress. For predisposed individuals exerting beyond their physical limits, this can lead to heart attack or stroke. These are not dive accidents per se, but the activity of diving can be the trigger just like any other sport.
3. BLS in dive accidents requires rescue breaths for a nonbreathing diver using mouth-to-pocket mask, mouth-to-mouth or other ventilation methods. As you’ll practice, rescue breathing may be started in the water.
4. For a diver with no heartbeat, BLS requires CPR chest compressions. Compressions cannot begin until you remove the victim from the water.
Prescriptive

4. Knowledge Review Three – Question 3
Explain how time affects BLS.
Without oxygen, brain damage can occur in four to six minutes.
After six minutes brain damage is likely and after ten minutes it is almost certain.
Rescue - Knowledge Review Three
How does time affect Basic Life Support?
b. As you recall, you want to begin BLS as soon as the need is recognized. Time is critical because without oxygen, brain damage can occur in four to six minutes. After six minutes, brain damage is likely and after 10 minutes it is almost certain.
c. In diving circumstances, one challenge is that the need for BLS may not be recognized as quickly, and you may not be able to begin it immediately due to the need to exit the water, and due to possible difficulties when exiting the water.
d. Because time is critical, as a Rescue Diver keep time in mind when you formulate plans for helping a diver who needs or may need BLS.
1. Focus action on beginning rescue breaths/CPR as soon as possible, without compromising your own safety.
2. Part of BLS procedures includes contacting the local Emergency Medical Service (EMS) system as soon as possible. In a diving context, you may have a delay before you can begin CPR, but not in contacting EMS. For example, you may be a ten minute swim from shore with a victim, but able to yell for someone to contact EMS. This brings emergency medical care to the site ten minutes faster.
Prescriptive

5. Knowledge Review Three – Question 4
What are the steps, in order of priority, for conducting a primary assessment? How can diving circumstances affect each step?
Steps for primary assessment
Diving circumstances
Assess the situation.
Water conceals potential dangers.
Establish responsiveness.
Turn diver face up in the water.
Call for help.
Contacting help may be difficult.
Establish an airway.
Protect victim’s airway from water.
Check for breathing.
Use techniques for doing so in water.
Check for circulation.
Don’t bother checking for a heartbeat.
Check for bleeding.
Can’t use pressure points through exposure suit.
Manage shock.
Get the diver out of the water.
Rescue - Knowledge Review Three
C. Accident Management
1. Emergency Care
What are the recommended steps, in order of priority, for conducting a primary assessment?
How do diving circumstances affect primary assessment?
a. As you know, primary assessment is the process of assessing a victim/patient’s situation and condition. In dive accidents, you follow the same steps you’ve learned, but the environment may affect your assessment.
b. Primary assessment steps include:
1. Assess the situation – look for hazards that may cause further harm to you or the injured diver.
• Was the victim stung by an organism that could sting you?
• Be aware of boat traffic, waves, current or other diving hazards.
• If entering the water, beware of submerged objects or other hazards.
2. Establish responsiveness.
• Shake the diver. Turn a face down diver who does not respond face up.
3. Call for help as soon as possible if the diver does not respond, or if it’s clear help’s needed.
4. Establish an airway if the diver is unresponsive. In the water this calls for special techniques that you’ll learn and practice later.
5. Check for breathing. If the diver is not breathing, start rescue breaths. In the water this calls for special techniques that you’ll learn and practice later.
6. Check for circulation (heartbeat). If the diver has no heartbeat, begin CPR. However, it’s difficult to determine heartbeat in the water, so this step differs from primary care when you’re out of the water.
• You must get the diver out of the water onto a hard surface to perform CPR.
• Because it’s difficult to determine heartbeat in the water, the protocol is that you don’t try until out of the water. If the victim isn’t breathing, you will begin rescue breaths and tow the victim to boat or shore as quickly as possible to further the assessment, including checking for circulation, and begin CPR if necessary. (More about these procedures later in the course.)
7. Check for bleeding – if the diver is breathing and has a heartbeat, determine if there is any serious bleeding that must be controlled.
• In dive contexts, a responsive victim will usually know if and where there’s a substantial injury (bite, cut, etc.); check these for serious bleeding.
• Direct pressure will work in the water. It may be difficult or impossible to use pressure points through an exposure suit. Elevation of an arm may be effective for short periods.
• For bleeding from the leg, it may be most effective for the victim (if responsive) to apply pressure (if possible) while you tow.
• The body’s clotting mechanism may be slowed by water, so getting the victim out of the water is a priority.
8. Manage shock – the previous steps are part of shock management. Out of the water, shock management continues as you learned in the EFR course.
c. Out of the water, continue rescue breathing, CPR and/or first aid and monitor the patient’s ABCD’S until a medical professional takes over.
Prescriptive

6. Knowledge Review Three – Question 5
What is the procedure for treating shock, and how may dive accident circumstances affect it?
Primary assessment.
Maintain body temperature.
Keep the diver lying down.
Elevate the diver’s legs, except when head or chest injury, heart problem, stroke or fractures are present.
Give nothing by mouth.
Contact emergency medical care.
Continue to monitor the ABCD’S.
Rescue - Knowledge Review Three
What is the procedure for treating shock, and how may dive accident circumstances affect it?
f. Procedure for treating for shock includes:
1. Primary assessment
2. Maintain body temperature.
• This may require removing a wet exposure suit. With a very weak patient, you may have to cut it off.
• In hot climates, you may need to provide shade to protect a patient from sun exposure and overheating.
3. Keep the diver lying down.
• This not only treats for shock, but is a first aid step specific to treating decompression sickness and lung overexpansion injuries. (More about this later in the course.)
4. Elevate the diver’s legs, except when head or chest injury, heart problem, stroke or fractures are present.
5. Give nothing by mouth.
• Responsive patients with suspected decompression sickness or lung overexpansion injury may drink water to maintain hydration.
• Do not allow the patient to sit or stand. Have the patient drink small sips lying down.
6. Contact emergency medical care (if not done already).
7. Continue to monitor the ABCD’S.
Prescriptive

7. Knowledge Review Three – Question 6
What are the differences between heat exhaustion and heat stroke, and how should you handle each?
Heat exhaustion
Heat stroke
Body’s ability to cool becomes taxed.
More serious condition. Rising temperatures exceed the body’s cooling mechanisms.
Profuse sweating, nausea, dizziness, weakness, and faintness.
Dry flushed skin, hot to the touch, and does not perspire.
Body temperature is near normal with cool clammy skin.
Core temperature rises and may result in tissue damage and permanent disability.
Begin with primary assessment, move patient to cool, shaded area.
Begin with primary assessment, immerse patient in cool water, or apply wet towels.
Rescue - Knowledge Review Three
2. Thermal Problems
What are the differences between heat exhaustion and heat stroke, and how do you treat each?
a. The body maintains its core (internal) temperature at approximately 37ºC/98ºF.
1. The body uses mechanisms to promote cooling or generate heat as necessary to main this temperature.
2. If conditions exceed the body’s ability to maintain temperature, the diver may suffer from hyperthermia (too much heat) or hypothermia (too little heat).
b. Hyperthermia generally occurs before a dive when a diver wears a heavy exposure suit in a hot climate. Exercise can compound the problem.
c. Heat exhaustion occurs when the body’s ability to cool becomes taxed.
Symptoms include profuse sweating, nausea, dizziness, weakness and faintness. The body temperature will be near normal with cool, clammy skin.
2. For suspected heat exhaustion, begin with primary assessment. Move the patient into a cool, shaded area. Have the patient remove the exposure suit, drink water (up to a litre/quart). If symptoms don’t subside within 30 minutes, contact emergency medical care.
d. Heat stroke occurs when rising temperatures exceed the body’s ability to cool.
1. Symptoms include hot, dry, flushed skin. The patient is hot to the touch and does not perspire.
2. Heat stroke is like a high fever that can destroy tissue and cause permanent disability. Consider it immediately life threatening.
3. Begin with primary assessment. Get the patient into a cool area, remove the exposure suit and immerse the patient in cool water or apply cool wet towels. Contact emergency medical care while monitoring the patient’s lifeline.
Prescriptive

8. Knowledge Review Three – Question 7
What are seven signs and symptoms of hypothermia?
1. Shivering.
2. Numbness.
3. Blueness in the fingers, lips and toes.
4. Loss of coordination.
5. Weakness and confusion.
6. Body systems fail.
7. Loss of consciousness.
Rescue - Knowledge Review Three
What are seven signs and symptoms of hypothermia?
e. Hypothermia occurs when the body cannot maintain its internal temperature and begins to cool.
1. Hypothermia usually results from diving in cool water with insufficient exposure protection, but can occur from failing to wear adequate protection before or after a dive in cold climates.
• Heat loss inevitable in all but the warmest water
• Exposure suits slow, but do not entirely stop heat loss
• Heat lost through breathing as well as into water
2. Signs and symptoms begin with shivering, numbness and blueness in fingers, lips and toes (may be difficult to see underwater). As hypothermia worsens, the diver loses coordination, becomes weak and confused. In severe cases, body systems fail, shivering stops and the patient loses consciousness.
3. Short of immediately life threatening symptoms, hypothermia has three effects that concern diving.
• Cold distracts the diver from safety related tasks.
• Extremity numbness impairs manual dexterity.
• More advanced hypothermia impairs mental processes.
4. In some instances, hypothermia can occur or become more severe after a diver leaves the cold environment.
• This is believed to be caused by flow of cooled blood to core as circulation restores.
• Can be just as severe as hypothermia that occurs on the dive.
• First aid is the same.
Prescriptive i

9. Knowledge Review Three – Question 8
Explain what to do to help a diver with the following underwater problems.
Underwater problem
What to do?
Overexertion.
Have diver stop and rest.
Uncontrolled descent.
Signal to diver to add air to the BCD.
Excessive buoyancy.
Go to the surface and get the right weight.
Cramps.
Stretch and message the cramp.
Entanglement.
Have victim stop while you disentangle.
Entrapment.
Ensure adequate air.
Passive panic.
Assist diver to the surface.
Active panic.
Prevent a rapid ascent.
Rescue - Knowledge Review Three
What do you do to help a diver with these underwater problems: overexertion, uncontrolled descent, excessive buoyancy, cramps, entanglement, entrapment, passive panic and active panic?
d. How you help a diver with an underwater problem varies with the circumstances.
1. Overexertion – Have an overexerted diver stop all exertion and rest. Preferably, make contact and have the diver hold onto something stationary. Encourage the diver to relax and resume breathing normally by signaling or writing on your slate.
2. Uncontrolled descent – You can often stop an uncontrolled descent by signaling the diver to add air to the BCD and level off. If this doesn’t work make contact with the diver and arrest the descent by grasping the BCD or tank valve, then adding air to the BCD.
• If a diver has extreme negative buoyancy, such as with a flooded dry suit, you may need to drop the diver’s weights.
• A properly weighted recreational diver in a wet suit or skin suit should not have an uncontrolled descent, even with a failed BCD. However, it can occur with an over weighted diver.
• Tec divers generally tend to start a dive with significant negative buoyancy due to the extensive equipment and gas required. For this reason, a properly equipped tec diver has at least two means of buoyancy control.
3. Excessive buoyancy
• Escort an underweighted diver to the surface and get the right amount of weight.
• If you are close to a diver when a runaway ascent begins, make contact and correct the problem quickly. Use the quick dump on the diver’s BCD if possible, and reduce your own buoyancy by dumping air from your own BCD.
• If the diver’s inflator is stuck, disconnect the low pressure hose.
• If you can’t stop or reasonably control the ascent, let the diver go. Try to signal to the diver to flare out the arms and legs and remain horizontal to create drag to slow the ascent.
4. Cramps – For a cramp, stop and have the diver rest the cramped muscle. Help the diver stretch and gently massage it to increase circulation and pull out the cramp.
• You learned how to assist another diver relieve cramps during your PADI Open Water Diver course. You apply the techniques you learned at the surface or underwater.
• Cramps occur most commonly in the calf; you can stretch a calf cramp yourself by grasping the fin tip and pulling it toward you while you push with your leg. You can assist a cramped diver by holding the fin tip for the diver to push against.
• After releasing a cramp, have the diver rest for a few moments, then continue at a slower, less forceful pace. Abort the dive if necessary.
5. Entanglement – Signal the diver to hold still while you disentangle. Cut the diver free only if necessary, and be cautious.
6. Entrapment – Entrapment is rare, but possible.
• Your first concern will be ensuring adequate air supply for the diver while working to free the diver.
• If you believe you won’t be able to free the diver before you run out of air, it may be best to ascend and get more air, if possible, while the victim still has the most air remaining. If you decide to do this, mark the site so you can return easily with additional tanks.
• You may also consider leaving your scuba unit with the trapped diver and make an assisted or emergency ascent.
• An improperly trained and improperly equipped diver(s) may also enter an overhead environment (cave or wreck) and lose his way out. Unless you’re both properly trained and properly equipped for the particular overhead environment, do not, under any circumstances, attempt to rescue a diver believed lost in an overhead environment. Doing so is more likely to result in a double fatality than a rescue.
7. Passive panic – If you suspect passive panic, approach from the front and signal, “Okay?” If you get no response, go behind the diver and, holding the regulator in place, take the diver to the surface. Help the diver from behind because passive panic may change to active panic without warning. Once you reach the surface, establish buoyancy for yourself and the victim. Tow the diver to safety.
8. Active panic – A diver with active panic underwater will likely bolt for the surface.
• You want to prevent a rapid, breath-hold ascent.
• For a breathing diver (regulator in place) simply hanging on and flaring out will usually suffice to control the ascent rate.
• If the diver is breath-holding, a delay is your best bet at getting him to resume breathing before ascending too far.
• If the victim is out of air, delaying the ascent may get the diver to signal you for an alternate regulator, or the diver may simply go for the one in your mouth.
• A panicked diver who has dropped the regulator is probably breath-holding. Slow the ascent as much as possible while giving your alternate air source. A panicked diver doesn’t usually respond rationally, so you may have to push the mouthpiece into the victim’s mouth while lightly depressing the purge button so the second stage remains clear.
• Once you reach the surface with a panicked diver, establish positive buoyancy for the diver. Monitor the diver because lung overexpansion injuries are possible and may require further rescue and care. If the diver doesn’t calm down, use the procedures you’ve learned for rescuing a panicked diver at the surface.
Prescriptive i

10. Knowledge Review Three – Question 9
List the steps you should take if you discover a diver is missing.
1. Call for emergency help while finding out where the diver was last seen.
2. Assign spotters.
3. Determine if missing diver left without telling anyone.
4. Assign divers to begin underwater search.
5. Send two or more skin divers to mark the search area with buoys.
Rescue - Knowledge Review Three
2. Missing Diver Procedures
What steps should you take if you discover that a diver is missing?
a. How you respond to a missing diver depends on the resources you have, but upon realizing that a diver is missing, put the following steps in motion as practical:
1. Have someone call for emergency help (EMS, coast guard, etc. as appropriate for the area) while you find out where anyone last saw the missing diver.
2. Assign spotters to look in that area for bubbles and to direct rescuers to the area if they spot bubbles. Have them use binoculars if available.
3. Try to determine if the missing diver may have left without telling anyone. Have someone check for the diver’s clothes, gear bag, automobile, etc.; call the diver’s cell phone.
4. Immediately assign qualified divers to don scuba equipment and head to the area where the diver was seen last to begin an underwater search.
5. If available and appropriate to the conditions, send out snorkeling teams to search from the surface (faster than scuba divers). They can search while others prepare scuba, and can mark the search area with buoys if appropriate.
Prescriptive

11. Knowledge Review Three – Question 10
What considerations should you take into account when implementing a search for a missing diver?
1. Have a procedure to recall searchers.
2. Permit searches in buddy teams only.
3. Begin searches where someone last saw the diver.
4. Either qualified divers or yourself and a buddy begin the search.
5. Search for 30 minutes, until you find the victim, you reach your limits, or until relieved by professionals.
Rescue - Knowledge Review Three
What considerations should you take into account when implementing a search for a missing diver?
e. When searching for a missing diver, keep in mind the following considerations:
1. Have a way to recall searchers to save time when someone finds the missing diver – this is especially important aboard a boat that must leave to get a diver to emergency medical care.
2. Permit searches by buddy teams only. Also make sure searchers have ample air and no decompression time to perform the search. Rescuer safety takes priority; don’t permit search divers to jeopardize themselves. Have someone keep track of searchers to account if they’re all back when the victim comes out of the water.
3. Begin the search based on the best guess of where anyone last saw the missing diver. Currents don’t usually move an unresponsive diver very much on the bottom.
4. If you don’t have qualified divers present for the search, you may need to choose a buddy and begin the search yourself.
5. Search for 30 minutes, until you reach the safe limit of air supply, no decompression time or exposure for the searchers, or until relieved by professional assistance.
6. If the missing diver has not been found, turn the search over to professionals.
Prescriptive

12. Knowledge Review Three – Question 1
The information, for where you’re diving, that you will need in the event of a dive accident.
Have an emergency action plan for the sites you visit.
Rescue - Knowledge Review Three
Return

13. Knowledge Review Three – Question 2
Monitoring and enacting emergency procedures for patient respiratory and/or cardiovascular system failure, which cuts off oxygen to the body, making death imminent.
Rescue - Knowledge Review Three
Return

14. Knowledge Review Three – Question 3
Time is crucial because without oxygen, brain damage can occur in four to six minutes.
After six minutes, brain damage is likely.
After 10 minutes, brain damage is almost certain.
Rescue - Knowledge Review Three
Return

15. Knowledge Review Three – Question 4
1. Assess the situation.
2. Establish responsiveness.
3. Call for help.
4. Establish an airway.
5. Check for breathing.
6. Check for circulation.
7. Check for bleeding.
8. Manage shock.
Rescue - Knowledge Review Three
Return

16. Knowledge Review Three – Question 5
Shock is a state in which profound depression of vital body processes occurs.
Sustained shock is a critical condition that can have permanent effects, even death.
Rescue - Knowledge Review Three
Return

17. Knowledge Review Three – Question 6
Heat exhaustion - the body’s ability to cool becomes taxed.
Profuse sweating, nausea, dizziness, weakness and faintness.
Body temperature is near normal with cool, clammy skin.
Treatment:
Begin with primary assessment.
Move patient to a cool, shaded area.
Remove exposure suit, drink water and, if symptoms don’t subside within 30 minutes, contact emergency medical care.
Heat stroke - rising temperature exceeds the body’s ability to cool.
Hot, flushed skin.
The patient is hot to the touch and does not perspire.
Treatment:
Begin with primary assessment.
Move patient to a cool, shaded area.
Immerse patient in cool water or apply cool wet towels.
Contact emergency medical care and monitor lifeline.
Rescue - Knowledge Review Three
Return

18. Knowledge Review Three – Question 7
Hypothermia occurs when the body cannot maintain its internal temperature and begins to cool.
Shivering
Numbness and blueness in fingers, lips and toes.
Loss of coordination.
Weakness and confusion.
Body systems fail.
Shivering stops.
Patient loses consciousness.
Treatment:
Begin with primary assessment.
Take an alert patient with mild hyperthermia to warmth, dry the person, rewarm by covering the head and applying heat to the neck, armpits and groin.
For severe hypothermia, contact emergency medical care and protect patient from further cooling.
Leave rewarming to EMS; rewarming is complicated.
Rescue - Knowledge Review Three
Return

19. Knowledge Review Three – Question 8
Overexertion
Have the diver stop, rest and hold onto something.
Encourage the diver to relax and to resume normal breathing.
Entanglement
Signal the diver to hold still while you disentangle.
Excessive buoyancy
Help the underweighted diver to the surface and get more weight.
On a runaway ascent, make contact and correct the problem quickly.
Cramps
Stop and have the diver rest the cramped muscle.
Stretch and gently massage the muscle to increase circulation.
Uncontrolled descent
Signal to the diver to add air to BCD and level off.
If the diver is extremely negative drop weights.
Remember, Tec divers have at least two means of buoyancy control.
Entrapment
Ensure adequate air supply for the diver while working to free the diver.
Passive panic
Establish buoyancy for yourself and the victim at the surface.
Tow the diver to safety.
Active panic
You want to prevent a rapid, breath-hold ascent.
Rescue - Knowledge Review Three
Return

20. Knowledge Review Three – Question 9
How you respond to a missing diver depends on the resources you have.
Rescue - Knowledge Review Three
Return

21. Knowledge Review Three – Question 10
Make sure searchers have ample air and no decompression time to perform the search.
Rescuer safety takes priority.
Rescue - Knowledge Review Three
Return