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First Aid for Freedivers
by Joe Tobin, Mike Grummel, Mako Fukuwa, and other FDL members

Freedivers and spearfishers often visit remote locations that may put them many hours or days from a hospital, should a medical emergency occur. The types of injuries divers are likely to have include lacerations (shark bites, propellers, etc.), puncture wounds (from spearshafts), and stings (poisonous fish and jellyfish). The most serious injuries are when blood loss occurs. To the diver, this is usually to an extremity (arm or leg). This FAQ topic gives some advice on what to do in such a situation. The time to consider these things is now. You are doing what most people do not do. You know the risks, so think the unthinkable and prepare yourself well.

Note: None of the information here should replace common sense. Not putting yourself in a dangerous situation is the first and best advice you can get.

Be Prepared
The best way to handle an emergency is to be prepared before the emergency happens. The following list has some of the things that you should be thinking about whether you are planning a boat dive off a remote reef in Indonesia or a beach dive off San Diego.

Think ahead and plan for trouble.
If you haven't taken a first aid course, sign up for one. A class tailored toward trauma and injury/accident aid, as opposed to the basic first aid course, would be more appropriate for the diver. The more medical training you take, the more confidant you will feel in a crisis.

Have a well stocked first aid kit.
Have a radio on your boat. Make sure everyone on your boat knows how to use the radio and who to call and on which channel.
Will you be able to describe where you are so that rescuers can find you?
Do you know what rescue services are available in your area and how long it will take them to get to you? Is it faster to wait for help or return to the harbor/beach.
Do you feel confident in your ability to provide basic first aid until help arrives?
When you are diving, can you signal the boat? Do you have a whistle or compressed air horn, mirror, flares, etc.?
If you are in an area where cell phones work, have one in a waterproof bag. Make sure your emergency numbers (911, Coast Guard, etc.) are saved in memory. Prefixing the name with A_ will alphabetize them at the top of the list. For example, make A_Coast Guard the entry for the Coast Guard's number and it will come up first.
Always use sterile material when placing it in an open injury. This is often difficult in remote locations and you may be forced to use what is available.
Be prepared, be proactive, and act decisively.

First Aid Kit
It's not what is in your first aid kit that will save a life or reduce suffering, but what is in your head! Just the same you should have a well stocked first aid kit and know how to use it. What you put in your kit will depend largely on the training that you have. Here are some suggested basic items to bring:

A first aid book. Highly recommended is the pocket size book Wilderness and Travel Medicine by Eric A. Weiss available from Adventure Medical Kits, P.O. Box 43309, Oakland California, U.S.A. You can also find this book at Amazon.com. This book is filled with valuable information on emergency medicine in the remote setting and ideal to have on hand. If you were to buy one book for your first aid kit, this is the one you would want to have.
Pocket mask for rescue breathing
Tourniquet
Latex gloves. Always use gloves when around body fluids (other than your own).
Sterile bandaging supplies- enough to manage large wounds
Providone Iodine Solution 10% (dilute 1:10 with water to use for cleaning wounds)
Scissors
Tape
Triangular bandage
Vinegar and/or meat tenderizer for jellyfish stings. (There is a product called "Safe Sea", a lotion that is supposed to protect you from the stings of jellyfish, sea lice, and even fire coral. If you have tried this, please email the FAQ editor with your review.)
Also consider the following medications. Consult with your doctor for recommended over the counter and prescription medications available in your part of the world and instructions on use:

Antibiotics
Diphenhydramine - for mild allergic reactions
Non-steroidal anti-inflammatory drug such as Ibuprofen or Motrin
Anti-diarrhea medication
Pain medication
Make a list of the nearest hospitals or medical clinics that would be available to you as well as their phone numbers and a map of their locations. Collect any phone numbers of air ambulance service or rescue groups that may be called upon in a crisis. Consider DAN insurance as they can assist in any accident that happens in the water. Your local scuba shop can put you in touch with DAN.

Blood Loss
A diver who has lost a lot of blood may not show a lot of active bleeding. How is this possible? If a diver gets hit by a shark and suffers a lacerated artery, he will bleed heavily. By the time the injured diver makes it to safety, it is possible that a substantial amount of blood may have already been lost. Having been in the water at the time of the injury means that all the lost blood has been dispersed in the water making it difficult to assess the injured diver brought to shore or the deck of a boat. A person who badly cuts himself on a saw in the garage for example, will be found in a pool of blood making it obvious that his blood loss was substantial. The diver on the other hand, will be coming out of the water leaving this valuable blood evidence behind, which may delay attempts at identifying and controlling massive bleeding. If a diver arrives at the boat or shore with a laceration that looks bad but is not bleeding much, assume that there was major bleeding and apply direct pressure to the wound and then begin to asses the situation. It may be that the diver has already lost so much blood that there is just not that much blood left. By applying direct pressure immediately you may save what little blood is left. If it turns out that things are not as bad as you first thought, then you've done no harm.

Pale skin is something you should look for. This is a result of the body constricting blood vessels at the surface of the skin to compensate for lost blood. Weak or absent pulses at the wrist are another indicator. Check you own pulse now. It has a certain feel to it doesn't it. In a victim of significant blood loss, the pulse at the wrist will feel thready or almost imperceptible. This is due to the body constricting every blood vessel in order to compensate for the lost blood.

The heart will speed up to compensate for lost blood so it will feel rapid. The amount it speeds up can be different for each victim, but a weak feeling resting pulse rate of 90 to 120 or so accompanied by pale skin and an injury capable of leading to major blood loss can be signs of serious blood loss. There are many other signs but these are some of the more common ones.

To control blood loss, do the following:

Apply direct pressure
Elevate the extremity
Use pressure points
Use a tourniquet

1. Apply Direct Pressure
Use of direct pressure, elevation of the injured extremity and pressure points, followed by applying a tourniquet as a last resort are the steps to controlling bleeding. Once you do any of these things, you will need to continue this until help arrives.

Find the spot where the blood is coming out, and then take a large wad of gauze, place it over the area and push on it, hard. Very hard. This will stop 80%-90% of bleeding problems. If you are controlling bleeding with direct pressure and then you release pressure after a period of time, bleeding may begin again so don't let stop what you are doing. Have another person take over if you get tired.

You cannot depend upon a severely injured victim to keep direct pressure on his own wound. You would be amazed at the strength needed to MAINTAIN direct pressure upon a major blood vessel! Even someone with a slight build is tough to maintain after a short while. The bigger the person, the more effort required. The injured party might still be alert and willing but the combination of shock and loss of blood plus the physical effort could cause a rapid loss of consciousness and a resulting fatal loss of blood.

2. Elevate
If you need a little more help stopping the flow of blood have them elevate the affected part in the air. This is a little more difficult if the injury is on the trunk of the body and it may not be feasible.

3. Use Pressure Points
If this still dose not stop the bleeding, try putting pressure on an artery above the injury. The easiest way to describe how to do this is to put your finger just above the injury and work your way toward the head and when you find a pulse, push on it very very hard. This is also most useful for arms and legs (much harder to do on the trunk of the body). The common place to find a spot like this, on an arm or leg, is where the limb bends. Feel on the inside of the bend, for example look at your own arm and feel on the inside of the wrist, elbow, and shoulder. You would be able to find a pulse if you look long enough. This works the same on the leg as well. The arteries on the leg are deeper so you have to push harder.

Finding Pressure Points
There are basically only four pressure points with respect to bleeding from an extremity. They can easily be located by knowing a few land marks. The first two are under the biceps. To locate this draw an imaginary (or real) line around the middle of your upper arm, now flex your arm so you can see your biceps, now just below the muscle no the line is where this pressure point is. To check that this is the right spot, push on the spot and you should feel a pulse. In the event you are trying to stop severe bleeding push with two or three finger tips until there is no pulse (there by stopping all flow from this artery) or until the bleeding stops. There is one on the right and the left, making up the first two.

Now lay flat on your bed, in shorts or with nothing, notice the crease your upper leg makes where it meets the pelvis this is the inguinal line. Now simply find the midway point and push with your whole palm. Again you should feel a pulse if you are in the right spot. Again there is one on either side. The advantage to this method is that it only stops the majority of blood flow and still allows for peripheral flow of blood to continue. In the event an artery or vain is cut or torn its first reaction is to contract and spasm or clamp down. This action is why a tourniquet is usually not needed but if bleeding can not be stooped by direct pressure (pressing on the wound with a dressing or in extreme cases your bare hand), elevation (something as simple as throwing a dive bag under there feet), and the pressure points above a tourniquet may be needed.

If you have to drive the boat while your bleeding buddy is not able to apply pressure to the dressing on his own, you can apply a pressure dressing. Placing a weight belt over the dressing might help a little, but a little movement and unnoticed loss of direct pressure could be ultimately fatal. In this case a tourniquet may be necessary. Learn more about pressure dressings in your first aid course.

4. Use a Tourniquet as a Last Resort
Tourniquets are a last resort. This should only be employed if

All of the above techniques have been done properly and you still have severe bleeding.
Professional help is not close at hand. If you know a major blood vessel has been severed and there is only the two of you or you have no other help, then you may have to take an 'educated' risk and use a tourniquet just to free yourself to do other life-saving functions like calling for help, locating your position, pulling the anchor, operating the vehicle, etc.
The person you are trying to help is going into profound shock.
If you choose to apply a tourniquet the limb below the tourniquet will likely have to be removed later. This is why knowing how to control bleeding with direct pressure, elevation and pressure points is vital since they almost always work making a tourniquet unneeded. However, if bleeding cannot be controlled then you have to apply a tourniquet to the injured limb but consider this a last resort.

If you have a blood pressure cuff, place it approx. 1 inch (25mm) above the injury and inflate it to 10 mm above the systolic pressure, or if that doesn’t make any sense to you, pump it up until it stops bleeding.

If you do not have a blood pressure cuff do the following.

Placed approximately 1 inch (25mm) above the injury, take a flat piece of fabric no narrower than 2 inches and wrap it around the limb twice, so the fabric crosses in the front. It is important not to use any thing thinner than 2 in. like rope or cord, because of the damage that it will cause. If it is the only thing available and it truly is a life saving act, you will be faced with a difficult decision. Use the cord and possibly save a life, but it will cost the limb.
Tie it on top of its self in the back.
Now using a stick or rod or what ever is available and slide it beneath knot you just tied and the first layer of the fabric and twist it. This should bunch up the top layer of fabric and pull the bottom layer very tight. Do this until the bleeding stops.
In all cases, the time applied and the location of the tourniquet should be marked on the person and explained to any medical person that you turn this person over to.

Shock
Shock is defined as, inadequate blood flow to the cells of a tissue or organ. This can be further simplified to say that not enough nutrients are getting to where they are needed, the most important nutrient being oxygen. It is important to note that the use of supplemental oxygen is of great benefit to a person who is in shock or going into shock. If oxygen is available use it. Oxygen will not hurt any one unless they have a debilitating lung disease, and as this would preclude them from being a diver, oxygen will only help.

The cause of shock could be for a variety of reasons, such as bleeding internally such as you might see with a blunt injury to the abdomen, external bleeding which may be caused by a severe laceration or puncture wound, and lastly is a distributive problem most commonly in severe allergic reactions. The best way to treat shock is stop it before it happens by stopping the bleeding before they lose enough to put them into shock. Unfortunately, external bleeding is the only type of blood loss that allows for this type of intervention.

Shock progresses differently from person to person, but basically each person goes through these three stages: Compensated, Uncompensated, and Irreversible shock.

Compensated shock - Compensated shock is the stage in when the body recognizes that it does not have enough blood to circulate around all the tissues. In short the body will start shunting blood to the central of the body where the blood is needed mostly for circulation in the main organs i.e.. Brain, Heart, liver, kidneys, in which without perfusion to these organs, you cannot function. With the body shunting blood away from the peripheral sites I.E. the arms and legs, you'll find the extremities may become cold, also the heart rate will increase, Blood pressure at this time may not drop that much or it may drop very little, if the body is compensating.

Uncompensated shock - Uncompensated shock. The body cannot compensate for its blood loss your Vital signs may start altering and you'll start seeing changes in the body as the shock worsens, a late sign of shock is the drop in Blood Pressure, at this time is when Us EMS professionals will start putting in relatively large quantities of fluid in the patient to help them compensate.

Irreversible shock - Irreversible shock, is when the body has lost so much blood that it can't compensate at all. You'll see altered mental status in the victim, Vital sign changes may be bad, Blood pressure is not good, and not high enough to indicate good perfusion, even with IV fluid it is tough to help this person.

Treating Shock
When a person goes into shock there body pushes the blood from the skin to the heart, lungs, brain and key internal organs. This is why they appear pale. There are steps you can take to reduce the impact of shock until medical care is reached.

After you have controlled bleeding, you should elevate the legs. This will help maintain blood pressure. Place them on their back and put their feet 12-20 inches or so in the air. An easy and affective way to do this is lay them on a carpeted floor or on a blanket and put their feet on a chair, if no chair is available use a dive bag. If you are on the beach you can lie them down with their head toward to ocean. (Please do this far enough up the beach that the waves don’t drown them!) This is known as the shock position. This is used whenever any one is in shock or might be going into shock and dose not have any trouble breathing. In the case of troubled breathing, allow them to find there own position of comfort be it sitting or standing. Do not lay them flat. They probably will not let you, anyway.

Keep the victim warm by conserving body temperature. Use a blanket if one is available. If they have a wet suit on, consider leaving it on. It will help push the blood away from the skin and to the core of the body where it is needed, but if they are too hot or you cannot get them warm, it must come off. Don't forget how much heat is lost through the head, a hat or towel can be used to prevent heat loss from the victims head.

Keep yourself calm and then reassure and calm the injured diver. Handle the victim gently; no high speed bone jarring boat rides, no high speed car rides down the highway. All movement of the victim should be as gentle as possible. All these things help until emergency medical aid arrives or until you reach the hospital.

A Shark Bite Scenario
Suppose your buddy gets bitten by a shark, what should you do? Naturally, there is no one answer to this question, as there are so many variables that could be present. However, here is some advice based on a hypothetical shark attack:

The first thing to do is fend off the attack. It seems that in many instances, regardless of the type of shark involved, an attack is short and fast with the shark retreating after the initial attack. If this was the case then your next step would depend on your circumstances.
The next objective is to get out of the water but even if the boat or land was just a short swim away, a diver could still bleed to death or lose massive amounts of blood so your FIRST PRIORITY would be to STOP THE BLEEDING. Chances are good that you would be dealing with an injury to an extremity so direct pressure at the site of the wound or control of bleeding using pressure points in addition to direct pressure would be used. This will be a challenge to do in the water but could make a big difference for the victim so must be done.
If the victim is able to and can be coached on how to control his own bleeding, this will free you up to swim him to safety. If he can't do this then you will have to do it and at the same time start moving to safety. If you can get help to come to you, then call for help.
There are so many variables here that it difficult to tell you what will be the best thing to do but if you can remember to control bleeding after ensuring an open airway and breathing, then you will buy time for the victim to reach medical care. Once out of the water, elevate the injured extremity to further help in bleeding control. This is where your first aid course will come in handy.

Stings
Most poisonous marine species, whether urchins, stingrays, or scorpionfish, contain a protein-based venom or toxin(s). Hot water (as hot as you can stand) is the best immediate treatment. Soak the affected area for at least 30 minutes. The heat denatures the venom and provides immediate relief. In fact, with many of the species found in Southern California, this is often the only treatment needed. (If you are in a boat, you may be able to use the hot water that comes from the exhaust.) As with any puncture wound, be sure the victim is current on his or her tetanus shots and if not, make it so. Sometimes there will be part of a barb or spine remaining in the wound, in which case a hospital visit would be in order to get it properly removed and avoid subsequent infection.

Jellies and Corals
Jellies and corals are another matter entirely. Generally, peeing on the wound is not the best bet. The theory is that the pH shift will denature the venomous proteins. Vinegar or rubbing alcohol is often used for the same purpose. In reality, different species react differently to this, and in some cases the urine/vinegar/alcohol can fire off any unfired nematocycts on the wound, resulting in more damage. If you've got nothing else, use this technique at your own discretion.

These animals are divided into two basic types. The first group is the true jellies, or scyphozoans, whose stings are usually not life-threatening. Treatment for fire coral, while obviously not a true jelly, is the same. Recommended first aid is to pick off any remaining tentacles (preferably NOT with your bare hands) and wash the wound with HOT water. A paste of meat tenderizer or papain (papaya extract) applied directly to the wound for 5-10 minutes will deactivate the poison and any remaining stinging cells. Note that this will not do anything to reduce pain. An allergic reaction could be life-threatening, so watch for signs (shortness of breath, severe swelling, etc.).

The second, often deadly group includes hydrozoans (Portuguese Man-O-War) and cubozoans (Box Jellies and Sea Wasps). Unfortunately, for these types of stings, removal of tentacles and washing the wound with hot water are about all you can do. Generally speaking, there is NO very effective treatment for these types of stings (short of an epinephrine injection), which has resulted in this basic guideline: DO NO HARM. Unless you really know what you are doing, you should seek immediate medical attention without attempting further treatment. The defense mechanisms of these animals are highly evolved--they contain many different types of venom and treatments which are helpful with one type of sting are often harmful with another.

Sea Lice
If you get stung from sea lice you may feel a stinging on your face, neck or along other wetsuit openings. Medical treatment may take 3-4 days before you are well, here's a home rememedy sent to the Freedive List that works faster:

The day after getting stung, when the rashes start to swell and a bit of liquid starts to come out, wet each spot and rub salt into it until the top layer of skin breaks and red specks appear. Sound gross? Well, it feels great! You get to scratch it, it takes the itch away and the salt dries it up right away.

A better way is, if you are lucky enough to have loads of hot water, fill the tub up with super hot water, dissolve 1/2 to 1 pound of table salt into the water, get in, soak for 10 min., rub raw salt into the stings until skin is broken and red spots appear, soak 10 min more, get out without drying. Presto, itch gone, spots dry up without having to go through the oozing stage, in just 2 days.

Urchin Spines
There are different kinds of urchins, and people have varying responses to them. The urchins that some people consider "harmless" may cause another person a great deal of trouble. For this reason, seek medical attention as soon as possible. Note that many doctors don't know how to treat urchin spines. There have been several stories on the list of doctors who didn't know what they were doing, so find a doctor who does.

The spines are brittle and have tiny barbs, which combine to make them very difficult to remove. Spines are particularly bad when you get them in your knees, elbows, and knuckles, and medical attention is absolutely necessary. If they aren't bothering you much and aren't showing signs of infection, many people also suggest just leaving them in, as they will eventually dissolve (though this may take years). If you want to try and remove them yourself, see the Opinions people expressed below.

The Divers Alert Network Medical FAQ says to use hot water to relieve pain; field remedies such as piss or vinegar do not work. Remove the readily visible spines but don't dig around. Do not intentionally crack embedded spines, remove surgically if necessary.

Opinions
If the spines are exposed, you may have luck pulling them out with tweezers. When they are in too deep for that, then you need to wait for 2 - 3 days for the spines to get a little puss around them. When the colour bleaches out of them, then they are about ripe for harvest. The puss greatly eases the situation, and they often pop out if squeezed, although sometimes a little more coaxing with said needle and tweezers is still required. Be warned, though, sometimes your digging needs to be quite deep and it hurts like hell. If they are in deeper than that, then you might need to get them cut out by a surgeon, otherwise they can apparently sometimes get moved around in your bloodstream and pop out somewhere else. Apparently, anyhow. The deep ones can sometimes stay there for years if not removed.
I have had good luck soaking the affected area in lime juice. Any citric will work as it is the acid that brakes it down. I prefer limes because it goes so well with the tequila. Tequila is taken internally (except for the youths on the list).
I've had them last for at least a couple of years as well. They (mine anyway) did finally disolve. I had one in the back of my left heel that was there for ages.
I have urchin spines that are over 3 years old that are still there. The skin has healed over them and they are clearly visible through the skin. They don't hurt anymore, but they are still visible. Maybe I just haven't had them long enough. Or maybe it depends on the urchin or the individuals body chemistry. Or maybe just the dye is left under the skin.
I've been impaled on various types of urchins (known as "wana" in hawaii) dozens of times throughout my life. Pissing on it does work. Over spring break I impaled a dozen or so spines into my calf while trying to hide my leg in a cave. While initially it hurt pretty bad, after I pissed in my suit several times the pain dissapated and when I was done diving and took off my suit there wasn't any swelling, only 13 black spots that dissapeared after a few days. No Biggie.
Not all urchin spines seem to be equal. From what I understand, the California kind are relatively harmless (I've been poked, but never had any break off in me) But in a surfing magazine I saw some pictures of what some tropical ones could do. A surfer in tahiti or indonesia stepped on an urchin, and some spines worked their way in, got infected, and he had some half-dollar sized open sores on his ankle where the fragments had eventually worked their way to. It looked very painful.
I had a freind almost lose a foot from a California urchin spine. It went into his heel to the bone and they didn't get all of it out, and it caused a bone infection.
I used to tell all my buddies years ago (when we dove for abs alot) that sea urchins were the most dangerous animal in the sea. Ive had at least 4 other buddies have a real bad experience with urchins.

FROM
http://worldspearfishing.com/safety.php

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OZAN YILDIRIMIN ABİSİ-1970