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How did they, like that guy, he was on the ground, he was hyperthermic. Why was he on the ground? People just don't lay on the ground behind cursed liquors and soak up the sun. Why was he on the ground? Did he have a stroke? Did he have a heart attack? I don't think we ever really... He had head trauma, but I don't know if maybe he was assaulted. We could never figure it out. Consider calling ALS. We can give him cool IV fluid. Look for a mechanism of injury. Stay hydrated yourself. Use appropriate standard precautions, gloves, protection. Remember how the patient interacts with you in the environment. The more altered they are, you're going to know it. Introduce yourself. Ask about the chief complaint. Perform a rapid scan. Avoid that tunnel vision. Oh, it must be just hyperthermia. It could be something else. Unless the patient is unresponsive, the airway should be patent. It's not an airway issue unless they're vomiting, right? Or unless they're seizing. 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If you're going to swim out to a person, do not, if they're conscious, do not touch them. Do not let them touch you. Give them a blanket, a sheet, your shirt or something. Let them grab it and drag them in. If you have to drag them physically, grab them around the neck, by the hair if you have to, and drag them. Don't worry if they go under the water. You're rescuing them. Don't let them touch you. If they get a hold of you, they're going to drag you under. Okay? If a patient is not floating, if there's a little water, then an organized rescue effort is needed. So, of course, we talk about, you know, in the spring, summer or fall, if you have a patient that goes in the water and they're not rescued in the water and they have to call the dive team. Now, there's a few. Wisconsin has a dive team. Auburn has a dive team. District 7 has a dive team. But dive team follows, a friend of mine runs the Auburn one. He used to work for us, Brian. And they have a very specialized set of protocols and procedures when they set up. They'll rush to a scene, but they're not just going to jump in the water. They've got to put on their gear, make sure their gear works properly, then they go in. It's probably 20, 25 minutes. So, in the spring, summer or fall, if a patient's underwater for 20, 25 minutes, they're dead. It's not rescue. It's recovery. But in the wintertime, when the water is 30 degrees, it may be a rescue because there's a condition called the mammalian dive reflex. It's a vasovagal reaction. If I hit cold water, my airway immediately closes up, my heart rate drops, my blood pressure drops, and I go unresponsive. And provided I'm rescued before everything relaxes, no water will get in my lungs and I can survive. It's called the mammalian dive reflex. So, in the wintertime, it's a rescue. Spring, summer or fall, it's usually a recovery. Resuscitation efforts. Never give up on resuscitating a cold water drowning victim. You're never dead unless you're warm and dead because of the diving reflex, the mammalian dive reflex. Does anybody here a diver? Is anybody a diver? I'm not a diver, so I like to have divers in the classroom because they can correct me if I'm wrong. But, let's talk about it. Diving can have three problems. You can have problems at the descending, problems at the bottom, and problems coming up. Problems coming up are the worst. So, first of all, descent injuries caused by the sudden increase in pressure as a person dives into the water. You haven't just swam to the deep end of a pool, right? And you get that pressure in your head, pressure in your teeth. It affects the lungs, sinus cavities, middle ear, teeth, and face. Usually, patients will self-correct. Too much pressure, you'll go back up to the surface. You really have to be acclimated to deep diving and those pressures, right? So, patients will go to the surface. Can you have injuries from that? Yes. Can you have a rupture of your ear? Yes. Your eardrum? Yes. Can you affect your lungs? Yes. But, as a general rule, the pain causes the diver to come back up. But, again, a perforated tympanic membrane, ooh, that hurts. Emergencies at the bottom occur rarely. Usually, it's a faulty connection with the diving gear, whether you're breathing your carbon dioxide or, let's say, you're diving. We see this a lot for people, professional divers, where they have air pumped down to them. They have air, instead of air tanks, they go down with air that comes from a tube with a thousand-foot hose. And what happens is the pump runs, a lot of them run by gasoline. So, here's the oxygen intake and here's the exhaust manifold. So, the exhaust's coming out this way, oxygen's coming in here. The wind blows, it shifts, and the wind starts blowing the exhaust over here and starts taking the exhaust in and down the tube. You can start rebreathing carbon monoxide and you can get confused at the bottom. The problem with it is most people who have bottom emergencies will get scared and they will ascend rapidly. And then you have ascent problems, right? And this is the problem that we have. Your ascent emergencies. These usually require aggressive resuscitation. You breathe, the air you breathe is 21% oxygen. 21.5% oxygen is 1% inert gases, argon, helium, carbon dioxide, all that. And then 78.5% nitrogen. Nitrogen is a filler and it gets in your body and it gets absorbed into your blood and into your plasma. And what happens is because nitrogen has a different air percentage or a different air volume than oxygen, it dissolves in the blood and it can foam up. Do you ever take a Coca-Cola and you drop it and you get that foam at the top of it? Well, that can happen. Blood can foam up. If I take a Coca-Cola and I open it, what happens to it? What does the foam do? The carbon dioxide comes out of the solute and foams up because I released that pressure. So if I take a Coke and I open it, you get the whoosh. Sometimes it flows over because the dissolved carbon dioxide in the fluid releases rapidly. Same thing happens if I come up too fast. The bubbles of nitrogen or the nitrogen in my blood begins to foam up just like opening a Coke and I get these bubbles of blood and it causes problems. So we can have one of two problems. First thing is the air embolism. Remember that bubbling of the blood when I come up too fast? Well, I can develop a big air bubble and that big air bubble can block blood flow and it can cause an air embolism. And a pulmonary embolism is one of the few things that cause instantaneous death in humans. So what happens is I come to the surface and almost immediately at the surface I start coughing, having chest pain, maybe coughing up blood, difficulty breathing. That's a pulmonary embolism. That's an air embolism. It happens right away, just within a few minutes after ascent. It'll happen on the boat. And it can be life-threatening, but it will happen on the boat. The bends, also called decompression sickness, is different. This can take hours to develop. And what happens is, unlike that air bubble that develops, these are just smaller bubbles that when the blood foams and it gets stuck in your joints and the blood vessels in your abdomen, and that's why it causes the bends, because you bend over. Oh, this hurts so bad. That's why they call it the bends. You get it for multiple conditions. If you ascend too rapidly, you know, when you dive, you have to go an atmosphere, I think it's, what is it, nine feet or something like that is an atmosphere. So every nine feet you hit another atmosphere. You're only supposed to go down so quickly, like it's like 30 seconds per atmosphere or whatever it is. You descend at a certain rate. You ascend at the same rate. If you go up too fast, that's when your blood foams up. So let's say I know I got 30 minutes of dive, 30 minutes of air in my tank. It takes me 10 minutes to dive, so I know I have to do 10 minutes to ascend, so I get 10 minutes on the bottom. But I'm following this moray eel who keeps giving me the dirty stink eye, and I'm following along, and I look at my dive computer, my watch, and oh shit, I only have five minutes to ascend. And I swim up to the top. That's when I'm going to develop the bends. Okay? Too long of a dive to do deep of a depth. You're only supposed to dive to a certain depth a certain number of times per day. And again, I'm not a diver, so I can't give you the specifics, but you're not supposed to dive, like you're not supposed to do a major dive of more than 50 feet more than once a day for more than 30 minutes or something to that effect. Or repeated dives within a short period. Or fly within 24 hours after diving. You know, I'm an avid diver. I go to the Caymans, do a week's dive and love it. I'm going to get one last dive before I fly out tonight. So at 9 o'clock in the morning, I go do a 50 foot dive, get some really good pictures and whatever. Now, 12 hours later, I'm on an airplane flying and I go up to 30,000 feet. That's like a 60,000 foot difference. So that pressure changes in my lungs. And it's not when I go up, it's when I come back down for the landing, I start, foam starts building up in my blood as the nitrogen comes out of concentration. And then you develop the bends. I don't get the bends on the boat, I don't get it on the plane, I get it in the airport or I get it in a taxi on the ride home or I get it in bed at home. So these patients will be bent over, maybe coughing up blood, pain in the joints, pain in the abdomen. And you ask them the history and they're like, yeah, I was diving this morning or yesterday. And you're like, okay, that's the bends. If you respond to the shore and they're coming in and saying the patient immediately when they got out of the water started complaining of shortness of breath, coughing up blood, then that's a pulmonary embolism, which can be life-threatening right away. Okay? These patients need to have that pressure that blows bubbles of blood, that nitrogen forced into the body and they do that with a hyperbaric chamber. They call it a decompression chamber, but a hyperbaric chamber. They have one at Haywood because they use it for wound care. Remember I told you it forces oxygen on the wounds to help them heal? They have one at Haywood. They have it at UMass. They have it at St. V's. They have one at Concord for wound care. They have one at Woods Hole. They have them in Boston. They have them in Springfield. So what happens is you may call medical control. You're coming from the water. You suspect the bends and they may direct you to a hospital. You may pass Athol to go to Haywood because they have a hyperbaric chamber. You go to the closest appropriate facility based upon medical direction. What will happen is they'll put you in the hyperbaric chamber and they'll force oxygen at many atmospheres. They'll literally set it to 50 feet underwater. That same pressure, but instead of water, it's oxygen. And that oxygen at high pressure forces the nitrogen back into your blood. And then they slowly let the pressure out as if you were ascending. So they literally make you dive again. But you don't dive in water. You dive in a hyperbaric chamber full of concentrated oxygen. Complications of decompression sickness would be blockages of tiny blood vessels causing pain. You could have heart attacks, strokes. That's why they call it the bends because patient doubles up or bends over in pain. You may find it difficult to distinguish between aneurysm and decompression sickness. No, you won't. It'll be easy because it all depends on how quickly it came on. If it came on very rapidly, that's an aneurysm. If it came on over a longer period of time that includes joint and abdominal pain, it's decompression sickness. Both of them need to be treated in a hyperbaric chamber. So it doesn't matter. Dive emergency is a dive emergency. Here's your hyperbaric chamber. Why don't we take five minutes? Take a break. Take a break. So I don't think I'm going to be here Thursday. Can I do the test Tuesday? Why don't you give me here Thursday? I'm going on a trip. Where are you going? I'm taking a trip. Oh, yeah. What are you going to do? Relax. Go on. Yeah. If you're not going to be... I mean, I highly recommend that you're not going to be taking the test. You're going to have to make up the practical. Yeah. How can I do that? You'll have to make that up at the end. Okay. But if you're not going to be here, you can take it on Tuesday. You'll have to be here by four. That's fine.