1. RESCUE DIVER COURSE LESSON GUIDES
PADI Rescue Diver Course
RESCUE DIVER COURSE LESSON GUIDES
Knowledge Development Presentation Four
VII. Knowledge Development Presentation Four
Divers involved with a rescue are subject to great stress as a result of their need to react to the emergency and the risks faced in doing so. Well-trained professionals generally can respond to emergencies without stress interfering with rescue efforts. Similarly, it is vital for PADI Rescue Divers to remain calm while carrying out emergency procedures. After the emergency is over, however – especially one in which a severe injury or death occurred – emotional stress may overwhelm the rescuer. This section discusses actions divers can take to relieve the psychological effects following a rescue. Many dive incidents involve pressure-related injuries. Students learn that being prepared for a diver emergency requires understanding pressure-related injuries and the associated first aid. For a more detailed understanding about the identification of and care for pressure-related injuries, students may want to continue their education by taking specialized training in the subject. Accident management for pressure-related injuries can involve rescue breathing. Students will learn different techniques and the proper steps for administering rescue breaths in dive accidents. A diver may become unresponsive underwater or at the surface. Students learn the techniques and the procedures for handling the unresponsive diver underwater and at the surface.

2. Knowledge Development Four Overview
PADI Rescue Diver Course
Knowledge Development Four Overview
The Psychology of Rescue
Critical Incident Stress
Being Prepared for a Diver Emergency
Pressure-related Injuries
Accident Management
First Aid for Decompression Illness
Near Drowning
Rescue - Knowledge Development Four
Overview and Learning Objectives
By the end of this section, the student should be able to answer the questions in italics:
A. The Psychology of Rescue
Critical Incident Stress
• What is critical incident stress?
• What are 12 signs of critical incident stress?
• What actions should be taken to reduce critical incident stress?
B. Being Prepared for a Diver Emergency
Pressure-related Injuries
• What is meant by “decompression illness”?
• What are the signs and symptoms of decompression illness?
• What are the differences between air embolism and decompression sickness?
• What is the most common cause of lung overexpansion injuries?
• What are the causes of and signs/symptoms of air embolism, pneumothorax, subcutaneous emphysema and mediastinal emphysema?
C. Accident Management
First Aid for Decompression Illness
• What first aid steps should you take for a patient with suspected decompression illness?
• Why should a diver with suspected decompression illness remain lying down?
Near Drowning
• What is the difference between “drowning” and “near drowning”?
• What is the primary first aid for a serious near drowning accident?

3. Knowledge Development Four Overview
PADI Rescue Diver Course
Knowledge Development Four Overview
Responding to Diver Emergencies
Managing Unresponsive Diver Accidents at the Surface
Rescue Breathing Techniques
Unresponsive Diver Underwater
Equipment Removal
Rescue - Knowledge Development Four
D. Responding to Diver Emergencies
Managing Unresponsive Diver Accidents at the Surface
• What are the procedures to follow when rescuing an unresponsive diver at the surface?
• Why do you give rescue breaths to an unresponsive diver with no apparent heartbeat?
Rescue Breathing Techniques
• What are the techniques for mouth-to-pocket mask, mouth-to-mouth and mouth-to-snorkel inwater rescue breathing?
• What should you do if you think a diver has no pulse while in the water?
Unresponsive Diver Underwater
• What are the procedures for bringing an unresponsive diver to the surface?
Equipment Removal
• Where does equipment removal fit as a priority in a rescue?
• What are the suggested procedures and techniques for removing equipment from an unresponsive diver?
• What should you consider when removing equipment from yourself while dealing with an unresponsive diver at the surface?
• What circumstances would limit the removal of equipment from an unresponsive diver or yourself at the surface?

4. The Psychology of Rescue
PADI Rescue Diver Course
The Psychology of Rescue
Critical Incident Stress
Critical Incident Stress Defined
Signs of Critical Incident Stress
Actions to Reduce Critical Incident Stress
Rescue - Knowledge Development Four
A. The Psychology of Rescue
Critical Incident Stress
• What is critical incident stress?
• What are 12 signs of critical incident stress?
• What actions should be taken to reduce critical incident stress?

5. Critical Incident Stress Defined
PADI Rescue Diver Course
Critical Incident Stress Defined
What is critical incident stress?
A critical incident is an emergency involving a serious injury or death.
The acute stress it causes an individual may overcome or impair a person’s ability to cope emotionally.
This acute stress is called critical incident stress.
Rescue - Knowledge Development Four
A. Presentation Four – Speaker Notes:
The Psychology of Rescue
1. Critical Incident Stress
What is critical incident stress?
A critical incident is an emergency involving a serious injury or death. The acute stress it causes an individual may overcome or impair a person’s ability to cope emotionally. This acute stress is called critical incident stress.
1. Some effects of critical incident stress may appear right away and others after days, weeks, or even months have passed.
2. After being involved with a dive emergency, you may experience critical incident stress. It is most likely if the victim/ patient dies or remains disabled as a result.

6. Signs of Critical Incident Stress
PADI Rescue Diver Course
Signs of Critical Incident Stress
What are 12 signs of critical incident stress?
Confusion.
Lowered attention span, restlessness.
Denial.
Guilt or depression.
Anger.
Anxiety.
Changes in interactions with others.
Increased or decreased eating (weight gain or weight loss).
Uncharacteristic, excessive humor or silence.
Unusual behavior.
Sleeplessness.
Nightmares.
Rescue - Knowledge Development Four
What are 12 signs of critical incident stress?
b. Signs of critical incident stress include:
1. confusion
2. lowered attention span, restlessness
3. denial
4. guilt or depression
5. anger
6. anxiety
7. changes in interactions with others
8. increased or decreased eating (weight gain or weight loss)
9. uncharacteristic, excessive humor or silence
10. unusual behavior
11. sleeplessness
l2. nightmares

7. Actions to Reduce Critical Incident Stress
PADI Rescue Diver Course
Actions to Reduce Critical Incident Stress
What actions should be taken to reduce critical incident stress?
Do not leave critical incident stress untreated:
Seek professional help to prevent post traumatic stress disorder.
Critical incident stress debriefing sessions bring together groups of people experiencing critical incident stress with some of their peers and a trained mental health professional.
This process helps those with critical incident stress to share and understand their feelings while learning to cope.
Rescue - Knowledge Development Four
What actions should be taken to reduce critical incident stress?
c. Do not leave critical incident stress untreated.
1. Critical incident stress requires professional help to prevent post-traumatic stress disorder.
2. A process called critical incident stress debriefing brings together a group of people experiencing critical incident stress with some of their peers and a trained mental health professional. This process helps those with critical incident stress share and understand their feelings while learning to cope.

8. Being Prepared for a Diver Emergency
PADI Rescue Diver Course
Being Prepared for a Diver Emergency
Pressure-related Injuries
“Decompression Illness”
Signs & Symptoms of Decompression Illness
Differences Between Air Embolism & Decompression Sickness
Lung Overexpansion Injuries
Causes of and Signs and Symptoms of Lung Overexpansion Injuries
Rescue - Knowledge Development Four
B. Being Prepared for a Diver Emergency
Pressure-related Injuries
• What is meant by “decompression illness”?
• What are the signs and symptoms of decompression illness?
• What are the differences between air embolism and decompression sickness?
• What is the most common cause of lung overexpansion injuries?
• What are the causes of and signs/symptoms of air embolism, pneumothorax, subcutaneous emphysema and mediastinal emphysema?

9. Overexpansion Injuries and Decompression Sickness
PADI Rescue Diver Course
Overexpansion Injuries and Decompression Sickness
What are the differences between air embolism and decompression sickness?
Embolism results when a diver ascends while breath-holding.
Decompression sickness (DCS) results when nitrogen dissolved into the tissues comes out of solution and forms bubbles.
Rescue - Knowledge Development Four
What are the differences between air embolism and decompression sickness?
a. There are differences between decompression sickness and lung overexpansion injuries.
1. Decompression sickness (DCS) results when nitrogen dissolved into the tissues comes out of solution and forms bubbles. The bubbles block blood flow and have other damaging effects to the body. DCS usually results from pushing or exceeding dive table or dive computer limits.
2. Lung overexpansion injuries result when a diver ascends while holding the breath. The lung ruptures, forcing air into the bloodstream and/or other areas.

10. “Decompression Illness”
PADI Rescue Diver Course
“Decompression Illness”
What is meant by “decompression illness”?
The term decompression illness encompasses both decompression sickness and lung overexpansion injuries.
What are the signs and symptoms of decompression illness?
Pain in the joints, fatigue.
Dizziness.
Extreme fatigue.
Paralysis.
Unconsciousness.
Cardiac arrest.
Nausea.
Rescue - Knowledge Development Four
B. Being Prepared for a Diver Emergency
1. Pressure-related Injuries
What is meant by “decompression illness”?
What are the signs and symptoms of decompression illness?
c. The term decompression illness encompasses both decompression sickness and lung overexpansion injuries. Since emergency procedures for handling both are the same, there is no need to determine specifically which of the two caused the accident. Signs/symptoms of decompression illness include:
1. pain in the joints, fatigue
2. dizziness
3. extreme fatigue
4. paralysis
5. unconsciousness
6. cardiac arrest
7. nausea

11. Lung Overexpansion Injuries
PADI Rescue Diver Course
Lung Overexpansion Injuries
What is the most common cause of lung overexpansion injuries?
Lung overexpansion injuries result:
From breath-holding during ascent while on scuba.
When air is trapped in part of the lung during ascent.
Most common cause is a panicked ascent caused by running out of air.
Checking your pressure gauge frequently and getting to the surface with a reserve is the easiest way to reduce this risk.
Rescue - Knowledge Development Four
What is the most common cause of lung overexpansion injuries?
d. Lung overexpansion injuries result from breath-holding during ascent while on scuba or when air is trapped in part of the lung during ascent. The most common cause is a panicked ascent caused by running out of air. Checking your SPG frequently and getting to the surface with a reserve is the easiest way to reduce this risk.

12. Causes of and Signs and Symptoms of Lung Overexpansion Injuries
PADI Rescue Diver Course
Causes of and Signs and Symptoms of Lung Overexpansion Injuries
What are the causes of and signs/symptoms of air embolism and pneumothorax?
Air embolism:
Expanding air forces through alveoli into pulmonary capillaries.
Bubbles go to the heart, then the body, and block blood flow to the brain.
Stroke-like symptoms, sudden unconsciousness, paralysis, blurred vision, dizziness, bloody froth from the mouth, coughing, personality changes, cardiac arrest.
Pneumothorax:
Expanding air forces itself between the lung and the chest wall.
Signs/symptoms include severe chest pain, extreme difficulty breathing.
Rescue - Knowledge Development Four
What are the causes of and signs/symptoms of air embolism, pneumothorax, subcutaneous emphysema and mediastinal emphysema?
e. Lung overexpansion can result in four distinct injuries either independently or together.
Air embolism – results when expanding air forces through alveoli into pulmonary capillaries. Bubbles go to the heart and then on to the body, with the most serious injury blocking blood flow to the brain. Symptoms are usually sudden and rapid. It causes stroke-like symptoms including sudden unconsciousness, paralysis (usually one side of the body), blurred vision, dizziness, bloody froth from the mouth, coughing, personality changes, cardiac arrest.
2. Pneumothorax – expanding air forces its way between the lung and the chest wall (pleural cavity), partially or completely collapsing the lung. It causes severe chest pain and extreme difficulty breathing.

13. Causes of and Signs and Symptoms of Lung Overexpansion Injuries
PADI Rescue Diver Course
Causes of and Signs and Symptoms of Lung Overexpansion Injuries
What are the causes of and signs/symptoms of mediastinal and subcutaneous emphysema?
Mediastinal emphysema:
Expanding air finds its way into the chest cavity between the lungs, constricting the heart and lungs.
Signs/symptoms include difficulty breathing, fainting, shock and cyanosis.
Subcutaneous emphysema:
Expanding air accumulates under the skin around the neck and collar bone.
Signs/symptoms include neck swelling, voice changes, and difficulty swallowing.
Rescue - Knowledge Development Four
3. Mediastinal emphysema – expanding air finds its way into the chest cavity between the lungs, constricting the heart and lungs. It causes difficulty breathing, fainting, shock and cyanosis.
4. Subcutaneous emphysema – expanding air accumulates under the skin around the neck and collar bone, causing neck swelling, voice changes and difficulty swallowing.

14. PADI Rescue Diver Course
Accident Management
First Aid for Decompression Illness
First Aid Steps for Decompression Sickness
Keep the Diver Lying Down
Near Drowning
Difference Between “Drowning” & “Near Drowning”
First Aid for Near Drowning
Rescue - Knowledge Development Four
C. Accident Management
First Aid for Decompression Illness
• What first aid steps should you take for a patient with suspected decompression illness?
• Why should a diver with suspected decompression illness remain lying down?
Near Drowning
• What is the difference between “drowning” and “near drowning”?
• What is the primary first aid for a serious near drowning accident?

15. First Aid Steps for Decompression Illness
PADI Rescue Diver Course
First Aid Steps for Decompression Illness
What first aid steps should you take for a diver with suspected decompression illness?
Initial care is a combination of care and assessment:
Begin with primary assessment.
Encourage a responsive diver to lie down and relax.
Ask diver questions to complete the PADI Accident Management Workslate.
Have a breathing diver breathe oxygen.
Protect diver from excess heat or cold and manage shock.
Arrange for emergency evacuation and medical care.
Do not attempt to recompress a diver in the water.
Rescue - Knowledge Development Four
C. Accident Management
1. First Aid for Decompression Illness
What first aid steps should you take for a diver with suspected decompression illness?
a. The initial care of an injured diver is a combination of care and assessment.
1. Begin with a primary assessment. Contact emergency care. While providing and giving priority to BLS, assume an unresponsive diver has DCI.
2. Encourage a responsive diver to lie down and relax.
3. If possible, ask the diver questions to complete the PADI Accident Management Workslate. [Review slate with student divers.]
4. Have a breathing diver breathe oxygen. Breathing Diver – If using a nonresuscitator demand valve unit, place the mask on the diver’s face and instruct the diver to breathe normally. Nonbreathing Diver – If giving rescue breaths/CPR to a nonbreathing diver with a pocket mask, hook the mask oxygen inlet to the system’s continuous flow outlet.
5. Protect the diver from excess heat or cold – manage shock.
6. Arrange for emergency evacuation and medical care.
NOTE TO STUDENT DIVERS: Do not attempt to recompress a diver in the water. This procedure is only used rarely, where recompression is many hours away, and requires special equipment, training and supervision. Attempting this without meeting these requirements may worsen the situation, delay medical care and jeopardize the safety of the patient and other divers. Even with the equipment, training and supervision, inwater recompression isn’t used when there’s access to a hyperbaric chamber within a reasonable interval.

16. PADI Rescue Diver Course
Remain Lying Down
Why should a diver with suspected decompression illness remain lying down?
Field experience has shown:
That diver’s symptoms may worsen significantly after sitting up or standing.
That lying down assists blood flow to the brain and minimizes bubbles migrating to the brain.
Rescue - Knowledge Development Four
Why should a diver with suspected decompression illness remain lying down?
b. Field experience has shown that some divers’ symptoms worsen significantly after sitting up or standing. Remaining lying down is believed to assist blood flow to the brain and to minimize bubbles migrating to the brain.

17. Difference Between “Drowning” and “Near Drowning”
PADI Rescue Diver Course
Difference Between “Drowning” and “Near Drowning”
What is the difference between drowning and near drowning?
Drowning victim – someone who suffocates (or is asphyxiated) underwater and cannot be revived.
Near drowning – when someone suffers asphyxiation underwater, but is revived.
Regardless of the length of submersion, begin emergency care immediately.
Rescue - Knowledge Development Four
2. Near Drowning
What is the difference between drowning and near drowning?
a. A drowning victim is someone who suffocates (or is asphyxiated) underwater and cannot be revived. Near drowning occurs when a diver suffers asphyxiation underwater, but is revived.
A near drowning victim may display coughing, shortness of breath, rapid breathing, cyanosis (blueness) of lips, convulsions, unconsciousness, vomiting, cessation of breathing or cardiac arrest.
2. Regardless of the length of submersion, begin emergency care immediately.
NOTE TO STUDENT DIVERS: Medical treatment after near drowning is important because water may have entered the diver’s lungs. The water can cause slow damage that, if left untreated, will eventually cause the lungs to fill with fluid and lose their ability to obtain oxygen. This is called secondary drowning and can be fatal. For this reason, a near drowning patient should always be professionally examined, even if the patient appears completely recovered.

18. First Aid for Near Drowning
PADI Rescue Diver Course
First Aid for Near Drowning
What is the primary first aid for a serious near drowning accident?
The steps for near drowning first aid are:
Primary assessment.
If nonbreathing, begin rescue breaths.
If breathing, administer oxygen; keep the patient lying down.
Treat for shock and continue to monitor the patient’s lifeline.
Transport as soon as possible to a medical facility – even if the diver appears to have fully recovered.
Rescue - Knowledge Development Four
What is the primary first aid for a serious near drowning accident?
b. The steps for near drowning first aid are:
1. Primary assessment
2. If nonbreathing, begin rescue breaths
3. If breathing, administer oxygen; keep the patient lying down.
4. Treat for shock and continue to monitor the patient’s lifeline.
5. Transport as soon as possible to nearest medical facility – even if the diver appears fully recovered.

19. Responding to Diver Emergencies
PADI Rescue Diver Course
Responding to Diver Emergencies
Managing Unresponsive Diver Accidents at the Surface
Rescue Breathing Techniques
Unresponsive Diver Underwater
Equipment Removal
Rescue - Knowledge Development Four
D. Responding to Diver Emergencies
Managing Unresponsive Diver Accidents at the Surface
• What are the procedures to follow when rescuing an unresponsive diver at the surface?
• Why do you give rescue breaths to an unresponsive diver with no apparent heartbeat?
Rescue Breathing Techniques
• What are the techniques for mouth-to-pocket mask, mouth-to-mouth and mouth-to-snorkel inwater rescue breathing?
• What should you do if you think a diver has no pulse while in the water?
Unresponsive Diver Underwater
• What are the procedures for bringing an unresponsive diver to the surface?
Equipment Removal
• Where does equipment removal fit as a priority in a rescue?
• What are the suggested procedures and techniques for removing equipment from an unresponsive diver?
• What should you consider when removing equipment from yourself while dealing with an unresponsive diver at the surface?
• What circumstances would limit the removal of equipment from an unresponsive diver or yourself at the surface?

20. Procedures for an Unresponsive Diver at the Surface
PADI Rescue Diver Course
Procedures for an Unresponsive Diver at the Surface
What are the procedures to follow when rescuing an unresponsive diver at the surface?
Approach by calling out, splashing, getting attention.
Make contact to confirm the diver is unresponsive.
Turn a face down diver face up.
Rescue - Knowledge Development Four
D. Responding to Diver Emergencies
1. Managing Unresponsive Diver at the Surface
What are the procedures to follow when rescuing an unresponsive diver at the surface?
a. Approach an apparently unresponsive diver by calling out, splashing, etc. to get attention. Make contact and confirm that the diver is unresponsive.
b. Turn a face down diver face up. One way to do this is from above the unresponsive diver’s head. Cross your arms with your stronger arm on top, grasp his wrists and then uncross your arms. This will spin the diver over.

21. Procedures for an Unresponsive Diver at the Surface
PADI Rescue Diver Course
Procedures for an Unresponsive Diver at the Surface
What are the procedures to follow when rescuing an unresponsive diver at the surface? continued…
Establish buoyancy for you and the victim, and call for help.
Remove the victim’s mask and regulator, open airway and check for breathing.
If the victim is breathing, hold the airway open and protect from water while towing to safety.
If you establish the diver isn’t breathing, give two slow full rescue breaths.
Rescue - Knowledge Development Four
c. Establish buoyancy for you and the victim, and call for help.
d. Remove the victim’s mask and regulator, open the airway and check for breathing.
1. You may need to remove your mask, too, depending on the mask and the method you use for rescue breathing.
2. Look, listen and feel for breathing for 10 seconds.
3. In case of a suspected back or neck injury, check breathing before extending the unresponsive diver’s neck. This would be relatively rare in diving, but could be possible if the diver fell, struck something during an entry or were thrown by a wave. If suspecting back injury and there is no breathing, open the diver’s airway with the chin lift only (sometimes called “jaw thrust”) technique. Tip the head to extend the neck only if nothing else works to restore the airway.
e. If the victim is breathing, hold the airway open and protect it from splashes/water while towing to safety.
1. Be cautious to avoid turning the diver or pushing the diver’s face underwater.
2. Continue to monitor for breathing.
f. If you establish that the diver isn’t breathing, give two slow full rescue breaths.
1. In the water it can be difficult to determine if a diver with very weak breathing is actually breathing.
2. Giving rescue breaths to a diver breathing that weakly is unlikely to cause further harm.
3. Giving rescue breaths to a diver in respiratory arrest, on the other hand, may revive the victim shortly, such as in near drowning cases.

22. Procedures for an Unresponsive Diver at the Surface
PADI Rescue Diver Course
Procedures for an Unresponsive Diver at the Surface
What are the procedures to follow when rescuing an unresponsive diver at the surface? continued…
Give rescue breaths and evaluate how long it will take to get to safety (boat or shore).
If it appears you are less than five minutes from safety, tow the diver to safety while continuing to provide rescue breaths.
If it appears you are more than five minutes from safety, ventilate for one more minute while checking for movement or other reactions to the ventilations.
If movement is present, continue providing rescue breaths while towing to safety.
Rescue - Knowledge Development Four
g. Give rescue breaths and evaluate how long it will take to get to safety (boat or shore) .
If it appears you are less than five minutes from safety, tow the diver to safety while continuing to provide rescue breaths. Get the diver out of the water, continue rescue breaths and perform a circulation check. Begin CPR if necessary according to your CPR/first aid training.
2. If it appears you are more than five minutes from safety, ventilate for one more minute while checking for movement or other reaction to the ventilations. If present, continue providing rescue breaths while towing to safety.

23. Procedures for an Unresponsive Diver at the Surface
PADI Rescue Diver Course
Procedures for an Unresponsive Diver at the Surface
What are the procedures to follow when rescuing an unresponsive diver at the surface? continued…
If there is no movement or reaction to the rescue breaths, the diver is probably in cardiac arrest.
Discontinue rescue breaths and tow the victim to safety as quickly as possible.
Exit the water, perform a circulation check and begin CPR and resume rescue breathing.
You need to evaluate:
The environment, the victim’s condition, your condition, and other factors.
Rescue - Knowledge Development Four
3. If there is no movement or reaction to the rescue breaths, the diver is probably in cardiac arrest. Discontinue rescue breaths and tow the victim to safety as quickly as possible, exit the water, perform a circulation check and begin CPR/resume rescue breathing as you learned in your CPR/first aid training.
h. You need to evaluate the environmental conditions, the victim’s condition, your condition and other factors. If attempting to give rescue breaths in the water would present additional hazard to you or the victim, you may need to rapidly tow the diver to a safe area (in the water, or on a boat or shore) to begin.

24. PADI Rescue Diver Course
Rescue Breaths
Why do you give rescue breaths to an unresponsive diver with no apparent heartbeat?
The protocol is to give breaths for several reasons:
A heartbeat may be present.
Respiratory arrest often precedes cardiac arrest.
If you correct respiratory arrest, cardiac arrest may not occur.
Survival rate for respiratory arrest is much higher than the survival rate for full cardiac arrest.
Rescue - Knowledge Development Four
Why do you give rescue breaths to an unresponsive diver with no apparent heartbeat?
i. Earlier you learned that in the water, it’s difficult to determine whether a diver has a heartbeat. If there’s no heartbeat, rescue breaths don’t do any good. However, the protocol is to give breaths (if not yet out of the water) for several reasons:
1. A heartbeat may be present.
2. Respiratory arrest often precedes cardiac arrest. If you correct respiratory arrest, cardiac arrest may not occur. The survival rate for respiratory arrest is much higher than the survival rate for full cardiac arrest.

25. PADI Rescue Diver Course
Rescue Breaths
Why do you give rescue breaths to an unresponsive diver with no apparent heartbeat? continued…
The protocol is to give breaths for several reasons: continued…
In dive scenarios where the victim has only respiratory arrest, without rescue breaths the time before exiting the water would likely be long enough to trigger cardiac arrest.
If a diver is in cardiac arrest, and there will be a delay in giving CPR, early defibrillation, and other critical interventions – trying to immediately restart breathing is the best approach.
Research indicates that in a majority of cases breathing is restored in the first minute by mouth-to-mouth ventilation.
Rescue - Knowledge Development Four
3. In dive scenarios where the victim has only respiratory arrest, without rescue breaths the time before exiting the water would likely be long enough to trigger cardiac arrest.
4. If the diver is in cardiac arrest, and there will be a delay in giving CPR, early defibrillation, and other critical interventions, but because of the brief time involved in trying to immediately restart breathing, it is the best approach. Research indicates that in a majority of cases breathing is restored in the first minute by mouth-to-mouth ventilation, hence the justification of attempting inwater resuscitation immediately.

26. Techniques for Rescue Breathing
PADI Rescue Diver Course
Techniques for Rescue Breathing
Rescue Breathing Techniques
Mouth-to-pocket mask is the preferred method.
Has the added benefit of lowering communicable disease risk.
Regardless of technique used:
If rescue breaths need to be interrupted, precede the interruption with two slow rescue breaths.
Interrupt no longer than 30 seconds.
Resume regular ventilations with two slow breaths.
Rescue - Knowledge Development Four
2. Rescue Breathing Techniques
What are the techniques for mouth-to-pocket mask and mouth-to-mouth inwater rescue breathing?
a. You will learn and practice two methods of performing inwater rescue breathing: mouth-to-pocket mask and mouth-to-mouth.
1. Mouth-to-pocket mask rescue breathing is the preferred method because it’s the easiest and has the added benefit of lowering communicable disease risk.
2. However, the risk of communicable disease via mouth-to-mouth rescue breathing is extremely small, while the chances of helping the victim may be high (depending upon what caused the diver’s condition).
3. Regardless of the rescue breathing technique used, if rescue breaths need to be interrupted (such as for exiting on to a boat), precede the interruption with two slow full breaths, interrupt no longer than 30 seconds, and resume regular ventilations with two slow breaths.

27. Mouth-to-Pocket Mask Rescue Breathing
PADI Rescue Diver Course
Mouth-to-Pocket Mask Rescue Breathing
What is the technique for mouth-to-pocket mask inwater rescue breathing?
As you approach the unresponsive diver retrieve your pocket mask and prepare it for use.
Turn the victim face up, open the airway and check for breathing.
If the victim is not breathing, place mask on the diver’s face, thumbs on the mask and fingers on the bony part of the jaw.
Tilt head back to open airway.
Administer two rescue breaths.
If the diver does not resume breathing, give rescue breaths every five seconds as you tow the diver to safety.
Rescue - Knowledge Development Four
b. Mouth-to-pocket mask rescue breathing
1. As you approach the unresponsive diver retrieve your pocket mask from your BCD pocket (or wherever you store it) and prepare it for use.
2. Turn the victim face up (if necessary), open the airway and check for breathing as you’ve learned. If the victim’s not breathing, from above the diver’s head, place the mask on the diver’s face, thumbs on the mask and fingers on the bony part of the jaw. Tip the head back to open the airway.
3. Administer two rescue breaths. If the diver does not resume breathing, give rescue breaths every five seconds as you tow the diver to safety.

28. Mouth-to-Mouth Rescue Breathing
PADI Rescue Diver Course
Mouth-to-Mouth Rescue Breathing
What is the technique for mouth-to-mouth inwater rescue breathing?
Do-si-do method:
Take the hand closest to the diver’s feet and sliding it up under the diver’s arm and reach up and grab the diver’s BCD, hood or hair.
Head cradle method:
Place the hand closest to the diver’s feet under the neck and put the other hand on the diver’s forehead to tilt the head.
Rescue - Knowledge Development Four
c. Mouth-to-mouth rescue breathing
1. After finding the victim is not breathing, from the victim’s side, open the airway by taking your arm closest to the diver’s feet and sliding it up under the diver’s arm and reach up and grab the diver’s BCD, hood or hair.
2. Place your other hand on the diver’s forehead to tilt the head and open the airway, while pinching the nose. Using a rolling action, bring the diver toward you to provide rescue breaths. This is called the do-si-do method.
3. There are varying methods of opening the airway for mouth-to-mouth rescue breathing. If you are a lot smaller than the victim or if the victim is wearing a bulky exposure suit, it may be easier to place the hand closest to the diver’s feet under the neck and put the other hand on the diver’s forehead to tilt the head and open the airway, while pinching his nose. This is called the head cradle method.

29. Optional Rescue Breathing Techniques
PADI Rescue Diver Course
Optional Rescue Breathing Techniques
What is the technique for mouth-to-nose and mouth-to-snorkel inwater rescue breathing?
Mouth-to-nose is a variation of mouth-to-mouth.
Victim’s mouth is held closed and ventilations are made by sealing your mouth around the victim’s nose.
Mouth-to-snorkel
Place the snorkel in the victim’s mouth and give rescue breaths through the snorkel.
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4. Mouth-to-nose is a variation of mouth-to-mouth rescue breathing and used when choppy water conditions or equipment configurations make mouth-to-mouth ineffective. The victim’s mouth is held closed and ventilations are made by sealing your mouth around the victim’s nose.
d. Mouth-to-snorkel rescue breathing (optional)
1. Begin mouth-to-snorkel rescue breathing with two full mouth-to-mouth rescue breaths. If you decide to remove any of your or the victim’s equipment, do so while using mouth-to-mouth rescue breathing.
2. When you are ready to begin the tow, move above the diver’s head and make sure the snorkel is drained of water. Note that it must be a snorkel without a
Self-drain valve.
3. Place the snorkel mouthpiece into the diver’s mouth and hold it firmly in place between your middle and ring finger.
Use your index finger and thumb to block the nostrils, while your hand seals around the mouthpiece.
4. Make sure the tip of the snorkel remains out of the water at all times by holding it up with your other hand. Give rescue breaths through the snorkel.

30. PADI Rescue Diver Course
No Pulse
What should you do if you think a victim has no pulse while in the water?
Do not check for pulse or attempt CPR compressions while in water.
These procedures are difficult and ineffective, and will slow down the rescue process.
Rescue - Knowledge Development Four
What should you do if you think a victim has no pulse while in the water?
e. Remember that you do not check for pulse or attempt CPR compressions while in water. These are difficult and ineffective, and will slow the rescue process.

31. Bringing an Unresponsive Diver to the Surface
PADI Rescue Diver Course
Bringing an Unresponsive Diver to the Surface
What are the procedures for bringing an unresponsive diver to the surface?
Note the condition in which you find the diver.
If the regulator is in the diver’s mouth, place your hand over it and hold it in place, even if diver isn’t breathing.
If the regulator is out, don’t waste time replacing it.
Ascending with control is of the utmost importance; protect yourself to continue the rescue.
Rescue - Knowledge Development Four
3. Unresponsive Diver Underwater
What are the procedures for bringing an unresponsive diver to the surface?
a. When you find an unresponsive diver underwater, getting the diver to the surface takes priority over everything except your personal safety.
b. Circumstances will dictate the most effective steps in bringing up the diver.
The following procedures work in most situations:
1. Note the condition in which you find the diver: Is equipment in place? Is the regulator out of the mouth? Is the mask off ? Are there any clues of how the accident occurred? Don’t take too much time in gathering this information, but make an effort to remember details of what you find.
2. If you find the regulator in the diver’s mouth, place your hand over it and hold it in place, even if the diver isn’t breathing. If the regulator is out, don’t waste time trying to put it back in. Expanding air may prevent water from entering his lungs upon ascent.
3. Position yourself behind the diver so that you can keep the regulator in the mouth (if in). Hold the victim’s head in a normal position so expanding air in the lungs will escape naturally. Hold the BCD inflator hose up so you can vent it.
4. Ascending with control is of utmost importance. Protect yourself so you can continue to be a rescuer.

32. Bringing an Unresponsive Diver to the Surface
PADI Rescue Diver Course
Bringing an Unresponsive Diver to the Surface
What are the procedures for bringing an unresponsive diver to the surface? continued…
Start ascent by adding just enough air to become positively buoyant.
Control ascent by venting your and the diver’s BCD; you may need to drop the victim’s weights.
If you can’t control the ascent, let the diver ascend and regain contact at the surface; you may need to flare to control your ascent.
As you ascend think about the steps to take once you reach the surface.
Rescue - Knowledge Development Four
Start the ascent by adding just enough air to your BCD to become slightly positively buoyant. You’ll probably have to vent your own and the diver’s BCDs to control the ascent. If the diver is too heavy, you may need to release the diver’s weights.
5. If you can’t control the ascent, let the diver ascend and regain contact at the surface. You may have to flare out to control your ascent.
6. As you ascend think about the steps to take once you reach the surface. Mental rehearsal can save time and make your rescue efforts more effective.
7. At the surface, drop the diver’s weights if you haven’t already done so. This will make your surface rescue efforts easier.

33. Priority of Equipment Removal
PADI Rescue Diver Course
Priority of Equipment Removal
Where does equipment removal fit as a priority in a rescue?
Equipment removal from you or the victim has a low priority.
Exceptions are dropping weights to establish buoyancy.
Discarding anything that hinders effective rescue efforts is also a priority.
Remove equipment from the victim and/or yourself only as a means to an end.
Remove equipment if reduced drag and tow speed would offset equipment removal time.
Rescue - Knowledge Development Four
4. Equipment Removal
Where does equipment removal fit as a priority in a rescue?
a. During the rescue of an unresponsive diver, equipment removal from you or the victim has a low priority
1. Exceptions are dropping weights, yours and/or the victim’s as necessary, to establish buoyancy. Discarding anything that hinders effective rescue efforts is also a priority.
2. Priority goes to maintaining an open airway, providing rescue breaths and getting the victim to safety as quickly as possible.
b. Remove equipment from the victim and/or yourself only as a means to an end.
1. Equipment removal slows down towing, so it only makes sense to do so if the reduced drag and tow speed would more than offset the delay. This typically involves a long tow distance.
2. You may need to remove your and the victim’s equipment to get the diver ashore or on a boat. However, it may be faster to wait until you can do so standing in shallow water (for shore diving) or where you have help on the swim step (for boat diving), both of which make gear removal faster and easier.

34. Techniques for Removing Equipment from an Unresponsive Diver
PADI Rescue Diver Course
Techniques for Removing Equipment from an Unresponsive Diver
What are the suggested procedures and techniques for removing equipment from an unresponsive diver?
Think buoyancy.
Don’t ditch anything providing adequate buoyancy for you or the victim.
Logical order.
Use one hand to keep the airway open and the other to remove equipment.
Removal order isn’t important provided you progress logically.
Rescue - Knowledge Development Four
What are the suggested procedures and techniques for removing equipment from an unresponsive diver?
c. What to remove and when depends on the circumstances; just as it does when rescuing a responsive diver.
1. Think buoyancy – Don’t ditch anything you need to maintain adequate buoyancy for either you or the victim.
• In warm water the diver may not be wearing an exposure suit, so you may need to keep the diver’s BCD for support, but you might discard the tank to reduce drag.
• If the diver is wearing a buoyant exposure suit you might discard both the BCD and the victim’s tank to streamline the swim.
2. Logical order – You’ll use one hand to remove equipment with the other hand always keeping the airway open. A hand should always be on the airway.
• The order isn’t important, providing you progress logically. If necessary for adequate buoyancy, remove weight systems before deflating and removing the BCDs. Remember to disconnect dry suit low pressure hoses before removing the scuba units.

35. Techniques for Removing Equipment from an Unresponsive Diver
PADI Rescue Diver Course
Techniques for Removing Equipment from an Unresponsive Diver
What are the suggested procedures and techniques for removing equipment from an unresponsive diver? continued…
Keep a rhythm.
If you must give rescue breaths, remove equipment in between breaths.
Keep moving.
Continue to tow as well as provide rescue breaths while you remove your and the victim’s equipment as necessary.
Rescue - Knowledge Development Four
3. Keep a rhythm – If you must give rescue breaths, remove equipment in between breaths.
• Remove your and the victim’s equipment in small steps; don’t try to do too much at each step.
• Keep your rescue breaths rhythmic – removing a BCD, for example, may take several steps with rescue breaths interspersed.
4. Keep moving – Continue to tow as well as provide rescue breaths while you remove your and the victim’s equipment.

36. Removing your own Equipment
PADI Rescue Diver Course
Removing your own Equipment
What should you consider when removing your own equipment while dealing with an unresponsive diver at the surface?
The equipment you decide to remove or to retain for yourself may differ from the equipment you remove or retain from the victim.
Consider:
The distance of the tow.
Insuring adequate buoyancy.
A logical order for equipment removal.
Maintaining an open airway and giving rescue breaths.
Rescue - Knowledge Development Four
What should you consider when removing equipment from yourself while dealing with an unresponsive diver at the surface?
d. The equipment you decide to remove or retain for yourself may differ from the equipment you remove from the victim. Once again you’ll consider the distance of the tow, securing adequate buoyancy, a logical order for equipment removal, maintaining an open airway and giving rescue breaths.
1. You will most likely drop the diver’s weights, but if you’re wearing a buoyant exposure suit, you may want to keep your weights if they make it easier to orient your body for rescue breaths.
2. If wearing little or no exposure protection, dropping your weight assures buoyancy and has little effect on your inwater positioning.

37. Circumstances Limiting Equipment Removal
PADI Rescue Diver Course
Circumstances Limiting Equipment Removal
What circumstances would limit the removal of equipment from an unresponsive diver or yourself at the surface?
Conditions may make it wiser to retain your and the victim’s gear:
A short swim to safety is usually faster without removing equipment.
Surface conditions may make it better to retain your mask and snorkel; you may also need these to make an exit through surf.
You need fins to swim while helping the victim with your hands, but you may abandon them at the exit.
To protect yourself and the victim against exposure to cold you may decide to keep hoods and gloves and abandon them later.
Rescue - Knowledge Development Four
What circumstances would limit the removal of equipment from an unresponsive diver or yourself at the surface?
e. Apply judgment based on the circumstances to determine which equipment to remove. Remember your first priority is to maintain an open airway and to provide rescue breaths. Conditions may make it wiser to retain your and/or the victim’s gear.
1. As already mentioned, a short swim to safety is usually faster without removing equipment.
2. Surface conditions like choppy seas may make it better to retain your mask and snorkel. You may also need these for an exit through surf.
3. You obviously need fins to swim while aiding the victim with your hands, but you may have to abandon them at your exit point. [Explain to student divers that they will practice surfacing the unresponsive diver, inwater rescue breathing and equipment removal techniques in Rescue Training Session Four.]

38. Knowledge Development Four Review
PADI Rescue Diver Course
Knowledge Development Four Review
The Psychology of Rescue
Being Prepared for a Diver Emergency
Accident Management
Responding to Diver Emergencies
Rescue - Knowledge Development Four
Overview and Learning Objectives
By the end of this section, the student should be able to answer the questions in italics:
A. The Psychology of Rescue
Critical Incident Stress
• What is critical incident stress?
• What are 12 signs of critical incident stress?
• What actions should be taken to reduce critical incident stress?
B. Being Prepared for a Diver Emergency
Pressure-related Injuries
• What is meant by “decompression illness”?
• What are the signs and symptoms of decompression illness?
• What are the differences between air embolism and decompression sickness?
• What is the most common cause of lung overexpansion injuries?
• What are the causes of and signs/symptoms of air embolism, pneumothorax, subcutaneous emphysema and mediastinal emphysema?
C. Accident Management
First Aid for Decompression Illness
• What first aid steps should you take for a patient with suspected decompression illness?
• Why should a diver with suspected decompression illness remain lying down?
Near Drowning
• What is the difference between “drowning” and “near drowning”?
• What is the primary first aid for a serious near drowning accident?
D. Responding to Diver Emergencies
Managing Unresponsive Diver Accidents at the Surface
• What are the procedures to follow when rescuing an unresponsive diver at the surface?
• Why do you give rescue breaths to an unresponsive diver with no apparent heartbeat?
Rescue Breathing Techniques
• What are the techniques for mouth-to-pocket mask, mouth-to-mouth and mouth-to-snorkel inwater rescue breathing?
• What should you do if you think a diver has no pulse while in the water?
Unresponsive Diver Underwater
• What are the procedures for bringing an unresponsive diver to the surface?
Equipment Removal
• Where does equipment removal fit as a priority in a rescue?
• What are the suggested procedures and techniques for removing equipment from an unresponsive diver?
• What should you consider when removing equipment from yourself while dealing with an unresponsive diver at the surface?
• What circumstances would limit the removal of equipment from an unresponsive diver or yourself at the surface?