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Diving Emergencies: A Sea of Controversy
Letters to the Editor / Resuscitation 61 (2004) 237–243
Diving Emergencies: A Sea of Controversy We read with interest the letter by Drs. Dey and Poff regarding our recent review on diving emergencies. The letter brings up a number of issues which are common to review articles. To begin with, a general review in a journal like Resuscitation cannot possibly include all the detail that highly-interested specialist clinicians might like to see. There are journals and textbooks entirely devoted to diving/ aerospace medicine, and it was not our intention to replicate those treatises in a short, general review article of a broad topic. Drs. Dey and Poff opine that our review article lacked “logical order of progression.” We will leave that decision to each reader; however, the manuscript is subtitled and divided in an outline form in a consistent manner, not unlike other reviews. The authors of the letter raise issue with our discussion of the simple Weber test in the diagnosis of middle ear barotrauma and are of the opinion that we should have discussed audiometry. This specialized test is not part of the routine physical examination unlike the simple tuning fork assessment. In addition, Drs. Dey and Poff state that we made “unqualified statements supporting the use of vasoconstrictors, myringotomy, and antibiotics.” In fact, we merely listed commonly used therapeutic modalities and indicated that myringotomy may be required and that antibiotics could be prescribed. We are puzzled and concerned about some of the additional statements made by Dey and Poff in their letter. Specifically, they allege that we did not “allude to the contribution a condition causing airway obstruction . . . may make [on pulmonary barotrauma].” Perhaps if they had taken more time to read our review thoroughly, they would have been less disappointed. In our discussion of pulmonary barotrauma and pulmonary contraindications of diving, we clearly discussed airway obstruction and asthma (p. 174). We did not discuss CAGE in our manuscript in great detail, although we did discuss arterial gas embolism as the second most common cause of death. Clearly, some readers might have liked more detailed discussion, but in fact, arterial gas embolism could warrant a comprehensive review as a topic on its own. We were criticized for not reporting that Hagen’s data on the relationship of right-to-left shunt and paradoxical embolism, as it was determined from autopsy studies. The reference by Hagen et al. [41] was clearly cited allowing any interested reader a complete review of the methodology used. Moreover, addressing the neuropsychiatric issues, the paper by Hopkins and Weaver was cited with its review of neuropsychiatric manifestation in decompression sickness. Drs. Day and Poff have misinterpreted our discussion of oxygen therapy. It was not our intention to imply that tracheal intubation was required in all diving accidents,
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nor do we believe that is the connotation of our writing. With regards to adjunctive therapies, the authors of this lengthy letter are critical of our lack of discussion of lidocaine. The Undersea and Hyperbaric Medicine Society position statement concludes that lidocaine is not indicated and is not standard of care. Corticosteroids and anticoagulants, unlike lidocaine have been prescribed frequently for various injuries due to embolism, etc. Because of their frequent use, we chose to discuss them and clearly indicated the lack of current evidence supporting their use. Perhaps we should have listed calcium channel blockers, acupuncture and all other potential adjunctive therapies. Unfortunately, we had space limitations. In conclusion, a review article represents an attempt to highlight important information regarding a specific subject. It is impossible to include all the detail that some readers would like. Like all papers published in Resuscitation, these articles are subject to peer-review to ensure their readability and soundness of the content. We will certainly consider the comments of Drs. Dey and Poff should we be asked to write another review on this subject. Joseph Varon The University of Texas Health Science Center St. Luke’s Episcopal Hospital 2219 Dorrington, Houston, TX 77030, USA Corresponding author Tel.: +1-713-839-1170; fax: +1-713-839-1467 E-mail address: [email protected] (J. Varon) Antonio DeGorordo Universidad Autónoma de Tamaulipas, Tampico Tamaulipas, Mexico 28 January 2004 doi:10.1016/j.resuscitation.2004.01.027
Diving Emergencies The recent paper entitled “Diving Emergencies” [1] presents a pleasant introduction to some of the myriad maladies affecting underwater divers. A more accurate title would be “Compressed Gas Diving Emergencies”. The significant afflictions which are unique to breath-hold diving were not discussed. Not all of the illnesses which were presented occur in breath-hold diving. Why did Resuscitation publish this article? Accidents from the direct or indirect effects of pressure rarely require resuscitation. Drowning and cardiac emergencies are the most common causes of death in diving. Surprisingly, they were not discussed in the article. One would expect Resuscitation to be interested
Diving Emergencies: A Sea of Controversy We read with interest the letter by Drs. Dey and Poff regarding our recent review on diving emergencies. The letter brings up a number of issues which are common to review articles. To begin with, a general review in a journal like Resuscitation cannot possibly include all the detail that highly-interested specialist clinicians might like to see. There are journals and textbooks entirely devoted to diving/ aerospace medicine, and it was not our intention to replicate those treatises in a short, general review article of a broad topic. Drs. Dey and Poff opine that our review article lacked “logical order of progression.” We will leave that decision to each reader; however, the manuscript is subtitled and divided in an outline form in a consistent manner, not unlike other reviews. The authors of the letter raise issue with our discussion of the simple Weber test in the diagnosis of middle ear barotrauma and are of the opinion that we should have discussed audiometry. This specialized test is not part of the routine physical examination unlike the simple tuning fork assessment. In addition, Drs. Dey and Poff state that we made “unqualified statements supporting the use of vasoconstrictors, myringotomy, and antibiotics.” In fact, we merely listed commonly used therapeutic modalities and indicated that myringotomy may be required and that antibiotics could be prescribed. We are puzzled and concerned about some of the additional statements made by Dey and Poff in their letter. Specifically, they allege that we did not “allude to the contribution a condition causing airway obstruction . . . may make [on pulmonary barotrauma].” Perhaps if they had taken more time to read our review thoroughly, they would have been less disappointed. In our discussion of pulmonary barotrauma and pulmonary contraindications of diving, we clearly discussed airway obstruction and asthma (p. 174). We did not discuss CAGE in our manuscript in great detail, although we did discuss arterial gas embolism as the second most common cause of death. Clearly, some readers might have liked more detailed discussion, but in fact, arterial gas embolism could warrant a comprehensive review as a topic on its own. We were criticized for not reporting that Hagen’s data on the relationship of right-to-left shunt and paradoxical embolism, as it was determined from autopsy studies. The reference by Hagen et al. [41] was clearly cited allowing any interested reader a complete review of the methodology used. Moreover, addressing the neuropsychiatric issues, the paper by Hopkins and Weaver was cited with its review of neuropsychiatric manifestation in decompression sickness. Drs. Day and Poff have misinterpreted our discussion of oxygen therapy. It was not our intention to imply that tracheal intubation was required in all diving accidents,
239
nor do we believe that is the connotation of our writing. With regards to adjunctive therapies, the authors of this lengthy letter are critical of our lack of discussion of lidocaine. The Undersea and Hyperbaric Medicine Society position statement concludes that lidocaine is not indicated and is not standard of care. Corticosteroids and anticoagulants, unlike lidocaine have been prescribed frequently for various injuries due to embolism, etc. Because of their frequent use, we chose to discuss them and clearly indicated the lack of current evidence supporting their use. Perhaps we should have listed calcium channel blockers, acupuncture and all other potential adjunctive therapies. Unfortunately, we had space limitations. In conclusion, a review article represents an attempt to highlight important information regarding a specific subject. It is impossible to include all the detail that some readers would like. Like all papers published in Resuscitation, these articles are subject to peer-review to ensure their readability and soundness of the content. We will certainly consider the comments of Drs. Dey and Poff should we be asked to write another review on this subject. Joseph Varon The University of Texas Health Science Center St. Luke’s Episcopal Hospital 2219 Dorrington, Houston, TX 77030, USA Corresponding author Tel.: +1-713-839-1170; fax: +1-713-839-1467 E-mail address: [email protected] (J. Varon) Antonio DeGorordo Universidad Autónoma de Tamaulipas, Tampico Tamaulipas, Mexico 28 January 2004 doi:10.1016/j.resuscitation.2004.01.027
Diving Emergencies The recent paper entitled “Diving Emergencies” [1] presents a pleasant introduction to some of the myriad maladies affecting underwater divers. A more accurate title would be “Compressed Gas Diving Emergencies”. The significant afflictions which are unique to breath-hold diving were not discussed. Not all of the illnesses which were presented occur in breath-hold diving. Why did Resuscitation publish this article? Accidents from the direct or indirect effects of pressure rarely require resuscitation. Drowning and cardiac emergencies are the most common causes of death in diving. Surprisingly, they were not discussed in the article. One would expect Resuscitation to be interested