1. UNDERWATER AND HYPERBARIC NAVAL MEDICINE (Historic Perspective and Actual Situation)

2. HOW? Hyperbaric oxygen therapy: HOW? Hyperbaric chamber Cylinder shape Resistant to high pressures  Medical device type IIb ( CCE’s directive 93 / 42 from June the 14th 1993) Underwater and Hyperbaric Naval Medicine

3. One-place chamber: Pressurized with pure oxygen HOW? Hyperbaric oygen therapy: HOW? Multi-place chamber: Pressurized with air Underwater and Hyperbaric Naval Medicine

4. oro-nasal Cephalic tent Tracheal tube HOW? Hyperbaric oxygen therapy: HOW? Pure oxygen inhalation inside the chamber Underwater and Hyperbaric Naval Medicine

5. For what? Hyperbaric therapy: For what? To reduce the gas bubbles size (Boyle’s law: PV = C) Underwater and Hyperbaric Naval Medicine

6. ATA 1 3 Fi O2 0.21 1 Lung’s P O 2 100 mmHg 2193 Hb(O 2 ) 4 19.7 vol.% 20.1 Plasm O 2 0.285vol.% 6 Arterial PO 2 95-100 mmHg 2052-2193 Tissue PO 2 40 mmHg 402.8 For what? Hyperbaric therapy: For what? Increases the blood’s oxygen and reverts the tissues hypoxia (Dalton’s Law: Pp = Pt. Fi:%) (Henry’s Law: (Henry’s Law: Q = SPp) (FicK’s Law: dQ = P x  c dt x A) Underwater and Hyperbaric Naval Medicine

7. 1953 (S.S. - D.S.)1967 (S.S. - D.S.)1989 (CHM-LNH.)2001(CHM-LNH) 1992: Urgency Service ECHM and UHMS list 1994: professional divers certification 1995: commun service of the military force 3 branches NATO ADIV-P2 list Underwater and Hyperbaric Naval Medicine Portuguese Navy UHM Evolution

8. C.H.M. – L.N.H. (2001 ) Nitrox / heliox “Critical” patients 26 patients simultaneously Underwater and Hyperbaric Naval Medicine Portuguese Navy UHM Evolution

9. Individual hyperbaric sessions - urgency 97.627 Individual hyperbaric sessions - global Individual hyperbaric sessions - routine 99.390 1.763 CHM – Global Activity - 1989 – 2008 Consultations - Total 10.812 Underwater and Hyperbaric Naval Medicine

10. CHM – Global Activity - 1989 – 2008 Treated patients - Routine 1.254 2.836 Patients observed - Urgency 4.973 1.273 Patients observed - Routine Patients observed - total 3.703 Treated patients - Urgency Treated patients - Total 4.090 Underwater and Hyperbaric Naval Medicine

11. Origin (31.12.2008) % Hospitals ( 64 ) 4.976TOTAL % Observed patients Assistent Doctors Own iniciative 4.090 159 885 3.9323.480 576 3 19 7985 14 134 Treated patients CHM – Global Activity - 1989 – 2008 (origin of the patients) Underwater and Hyperbaric Naval Medicine

12. SUDDEN DEAFNESS LEG ULCERS DIABETIC FOOT RADIO-INDUCED CISTYTIS/PROCTYTIS/RECTYTIS MALIGNANT EXTERNAL EAR INFECTION CRITICAL ISCHEMIA NECROTIZING SOFT TISSUE INFECTIONS RADIO-INDUCED BONE NECROSIS DIABETIC RETINOPATHY / ISCHEMIC NEURITIS/PIGMENTED RETINOPATHY OSTEOMIELYTIS CHM ROUTINE TREATED DISEASES (1989 – 2008) Underwater and Hyperbaric Naval Medicine

13. Carbon monoxide poisoning Hydrogen sulphide poisoning Decompression sickness Gas embolism Gas gangrene Fournier’s gangrene Necrotizing soft tissues infections Radio-induced cistytis Sudden deafness CHM URGENCE TREATED DISEASES (1989 – 2008) Underwater and Hyperbaric Naval Medicine

14.  17 Dive and Hyperbaric Medicine Basic Courses (ISU04/ISU05) – 121 health military professionals  3 Underwater and Hyperbaric Medicine Post Graduation Course – 36 doctors  National Underwater and Hyperbaric Medicine Meetings– 1997, 1999, 2001  UHM Optional Chair – LUMF and Naval School– 92 4 rth year students  European Consensus Conference on the Role of HBO in Radio-induced Soft tissues Lesions - 2001 CHM – Instruction Activity Underwater and Hyperbaric Naval Medicine

15. CHM - Science Cooperation Activity  ECHM - European Committee for Hyperbaric Medicine  EUBS - European Underwater Baromedical Society  Action COST B14 – Oxygen Hyperbaric Therapy (European Science and Technological Cooperation in the HBO Research) Underwater and Hyperbaric Naval Medicine

16. CHM - Operational Activity  Permanent Therapy Support  Instruction and Training Courses for military divers and other personnel  Tolerance tests to oxygen and nitrogen under pressure  Chamber training to deep divers  Chamber functional and stress tests for the deep dive equipment Underwater and Hyperbaric Naval Medicine

17. Why? CHM Structural and Functional Evolution – Why? 1. Dive and hyperbaric Medicine – specific of Naval Medicine 2. Technological improvement of the military dive (deep dive) 3. Increased needs of medical support for the military dive practice 4. Maximal operational capacity of the CHM already attained Underwater and Hyperbaric Naval Medicine

18. How? CHM Structural and Functional Evolution – How?  Int Med; Y N & T; Cardiolgy  Pneumol; Ophtalmology  Gen & Vasc Surg  O R; Anesth & Rean  Neurosciencies; Motility Unit System Drive System Superv. Clinical Unit Operational Unit Invest Unit Medical Dep. Techn. Dep. Admin. Dep. CUHM Director Underwater and Hyperbaric Naval Medicine

19. for what? CHM Structural and Functional Evolution – for what? Maximize its functional capcity in order to: 1. Satisfy the naval operational dive increased needs of hyperbaric medical support 2. Initiate true investigational activity related to the dive and hyperbaric medicine 3. Develop the teaching, instruction and formation activities in the underwater and hyperbaric medicine field 4. Satisfy the civilian patients increased needs of hyperbaric medical support 5. Contribute for the maintaining of the Navy’s leadership in the UHM field and for the better individualization of the Naval Medicine Underwater and Hyperbaric Naval Medicine