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Diving and Hyperbaric Medicine Volume 47 No. 2 June 2017 127
A technical diving-related burns case: treatment in a remote location
Fiona C Sharp1, Martin DJ Sayer2
1 Fiona Stanley Hospital, Murdoch, Western Australia
2 West Scotland Centre for Diving and Hyperbaric Medicine, Scottish Association for Marine Science, Dunbeg, Oban,
Argyll, Scotland
Corresponding author: Fiona C Sharp, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA 6150, Australia
sharpief@doctors.org.uk
Abstract
(Sharp FC, Sayer MDJ. A technical diving-related burns case: treatment in a remote location. Diving and Hyperbaric
Medicine. 2017 June;47(2):127-130. doi: 10.28920/dhm47.2.127-130)
Injuries suffered as a result of a rebreather oxygen explosion and fire occurred to a diver on vacation in the island state of
Chuuk, Micronesia. The medical and logistical management of the diver in a remote location are described. The mechanism
of both the fire and the subsequent blast and burn injuries are discussed. Prevention of and preparation for such incidents
are discussed in the context of the increasing frequency of dive and adventure travel to remote areas.
Key words
Burns; Fire or explosion; First aid; Medical kits; Rebreathers/closed circuit; Remote locations; Case reports
Introduction
Chuuk (or Truk) Lagoon, is part of the Chuuk State of
Micronesia in the Western Pacic. It is a popular destination
for wreck diving with many Japanese World War II
shipwrecks lying in tropical waters.1 The depth of some of
the wrecks in the lagoon attracts technical and rebreather
divers to Chuuk. Recreational technical diving methods and
related decompression issues have been reviewed recently.2,3
Chuuk is considered a remote diving location as medical
facilities in the islands are limited and the commercial airline
link via the island of Guam, which occurs once every one to
two days, is frequently subject to cancellations and delays.
In 2013, a group of rebreather, technical and open-water
scuba divers visited Chuuk to dive the wrecks. With
organizational support from a diving travel company, the
local dive operation provides helium, nitrox and oxygen to
support rebreather, trimix and enriched air decompression
diving. Compressed gases with oxygen percentages (PO2)
ranging up to 95% require special handling and precautions
to prevent oxygen fires through frictional or adiabatic
heating.4 This case report describes the management of
a critical incident caused by the explosion of a cylinder
of oxygen-rich gas and the attached rebreather fire.
Management is discussed within the context of a remote
location.
Case report
An experienced, 37-year-old male diver suffered a serious
injury on the fth dive day of the trip. The incident occurred
on the dive boat prior to leaving the dock. Three rebreather
divers had placed their equipment on a small, motorized
diving boat (see cover) after setting up and checking them on
land, where the divers had also performed their pre-breathe
routines.5 On completion of their preparations, the divers
had turned off the cylinders to wait for departure.
With the rebreather on the oor of the boat, the diver leant
over and turned on the diluent and oxygen cylinders; the
oxygen cylinder had a water capacity of 3 litres (L) and
was assumed to have been pressurized to approximately
200 bar. The oxygen rst stage regulator exploded, causing
a blast injury to the diver’s hand (Figure 1) and the top of
the rebreather caught re (Figure 2). The subsequent re
burnt the diver signicantly on the left upper arm (Figure
3), shoulder and neck; his lower arm and face were also
partially affected. The diver promptly and voluntarily fell
over the side of the small boat into the 1.5 m deep water to
cool the burn. The rebreather burnt itself out, with no-one
else injured, and minimal damage to the boat. The diver was
removed from the water after approximately ve minutes,
and cooling of the burns continued under an outdoor
shower. He was visibly shaken with a rapid, weak pulse of
approximately 120 beats per minutes (bpm); blood pressure
was not monitored at that time.
The travel company responsible for this diving group has a
policy of employing a physician trained in diving medicine
to accompany technical and deep diving expeditions. In the
present case, the group doctor was a specialist anaesthetist
(FCS) who was on-site when the explosion occurred and
so was in immediate attendance. The diver was placed on a
chair under the shower as he was getting syncope. He had
severe pain from the burn on his arm. After removal of a
short sleeve rash-guard, a full thickness burn was evident
distal to the sleeve (Figure 3), with a partial thickness burn
Diving and Hyperbaric Medicine Volume 47 No. 2 June 2017
128
surrounding this area. There was no evidence for or any
symptoms of an airway burn or other signs of blast injury.
His eardrums were not examined.
Cooling with freshwater continued in the diver’s hotel room.
IV cannulation was achieved with some difculty, and
analgesia and sedation were administered (morphine 15 mg
IV, midazolam 10 mg IV total) with good effect. Antibiotics
(cephazolin 2 g) and IV uids (Plasmalyte 2 L total) were
commenced after checking for allergies. Wound care was
provided with antiseptic cream (Sulphasalazine) and cling-
lm dressings. The patient’s blood pressure was taken for
the rst time and was 150/110 with a heart rate of 120 bpm.
Pain relief was supplemented with oral paracetamol and his
pain score remained 6 out of 10 on an analogue scale. With
the supply of morphine now exhausted, a supply of oral
analgesics was obtained from local sources (paracetamol/
codeine 500 mg/30 mg, ibuprofen 200 mg and tramadol
100 mg). With these medications the diver was more
comfortable that evening and was able to ambulate and eat.
The patient and buddy arranged for transfer back to Australia
for denite care on the next ight available from Chuuk,
three days following the injury. The plastic surgical unit
at an Australian hospital advised by phone on on-going
management of the patient’s injuries. The wound was
cleaned in the shower prior to dressing with an application
of silver sulfadiazine and continued wrap with the cling lm.
On day two, the patient awoke with malaise, lethargy and
was apathetic. He was dehydrated with marked oedema of
Figure 2
The rebreather after the re with explosive and thermal damage to
the oxygen cylinder (A), the damaged head of the rebreather (B),
burnt counter lung (C) and scrubber casing (D)
Figure 1
Blast injuries to the diver’s hand
Figure 3
The diver’s arm after being cleaned on day 1
Diving and Hyperbaric Medicine Volume 47 No. 2 June 2017 129
the left arm and the wound dressing had an offensive smell.
The wound was redressed after cleaning in the shower,
and the antibiotic dose was increased. He increased oral
uids whilst keeping his arm elevated; the analgesics were
continued with good effect. He had improved sufciently
the next day to be repatriated to Australia under medical
escort. On the morning following his arrival to his home
city he underwent debridement and skin grafting to the arm
wound. He has healed well with minimal scarring.
Discussion
Diving with closed-circuit rebreathers on wrecks in relatively
deep water offers numerous advantages. These include
the lack of bubbles, their gas efciency and the optimized
decompression that constant PO2 diving permits.6 There are
many confounding factors associated with wreck diving but,
in general, studies of decompression illness (DCI) indicate
incident rates of between 0.25 and 1.12 cases per 1,000
person-dives for wreck diving7,8 compared with rates of
between 0.05 and 0.10 for other recreational scuba diving.9−12
The added risks of using mixed gases are largely unknown,
but studies of diving deaths show that using a closed-circuit
rebreather possibly carries a four- to ten-fold increase in the
risk of dying while diving.13 The combined additional risks
of diving wrecks using rebreathers, while also in remote
locations with limited medical support, are the reasons that
many tour groups will employ physicians with practical
experience in emergency medicine.
Previous reports of treating diving accidents in remote
locations have focussed mainly on DCI from the perspective
of managing that illness alone and the potential effects
delays in treatment may have on subsequent outcomes.14−17
Chuuk does have a stand-alone recompression facility but
this is only sporadically operational, depending on whether
the technical operator is on the island. The lack of many
fundamental medical services complicates the treatment of
non-DCI diving-related incidents.
Diving rebreather res are very rare. Of 153 incidents
reported during a series of 14,000 rebreather dives
undertaken by the French military, none involved explosions
or res.18 A re has been reported in a Canadian underwater
mine-countermeasure rebreather unit.19 In that case, the
re occurred as the oxygen cylinder was being opened by
the diver while on the surface; the subsequent investigation
indicated that the origin of the re was in the rst stage
regulator. There has been one case reported of a technical
diver, diving at a depth of 90 m, sustaining severe burns
when wearing a drysuit along with four air-activated heat
packs.20 The burns were caused by the exothermic chemical
reaction of the heat packs accelerating out of control because
the diver was using his decompression gas, which contained
83% oxygen, for suit ination.
The risk of an oxygen cylinder re is low; for example, it
has been estimated that there are several million medical
oxygen cylinders in service in the UK annually, that are lled
many times each year with very few reported incidents.21,22
One UK incident of an oxygen cylinder that exploded in an
intensive care unit causing a fatal burn injury was reported in
2013,21 with a further three oxygen cylinder res occurring
in the UK during a recent four-year period.22
It is suggested that the oxygen re in the intensive care unit
was caused when the cylinder valve was turned on;21 this
was the same in the present case. The internal design of a
cylinder valve includes O-rings, valve seats and lubricants,
all of which will have an auto-ignition temperature (AIT).
Components designed for high-pressure cylinders have AIT
values of over 300OC in a 100% oxygen environment.22
Impeding the flow of pure oxygen from high-pressure
cylinders causes instantaneous compression and adiabatic
heating. If that heating exceeds the AIT of one or more
of the valve components then spontaneous ignition can
occur; that ignition releases more energy which raises the
temperature further igniting other adjacent materials with
higher AIT. This is known as a “kindling chain” whereby
the re escalates rapidly in the valve causing an explosion.22
Reducing the likelihood of adiabatic heating of oxygen
decreases the probability of res and explosions and is why
valves on high content oxygen cylinders should be a ‘needle’
design. However, there is still a need to open needle valves
slowly when dealing with high-pressure oxygen.
The present case reports on a cause of morbidity (burns and
blast injury) other than DCI when diving on rebreathers and
in a remote location. Non-governmental deep-diving groups
travelling to remote locations where medical support may
be lacking should have available to them sufcient medical
supplies, medical expertise and communication options as
deemed appropriate by the group’s organisers. There are
many published examples of medical kits that should be
available to support diving operations or remote expeditions,
such as that of the Diving Medical Advisory Committee in
the United Kingdom.23 The contents of the medical kit will
be determined by a variety of factors, including the training
and skills of personnel involved, medical registration and
local drug regulations, the geographical location and its
available health service resources, meteorological conditions,
whether ship- or shore-based and weight limitations (e.g.,
for commercial ights).17,24 The contents of kits used by the
authors in different settings can be obtained by contacting
them. What did turn out to be essential in the present case,
so that narcotics could be included, was that a letter of
recognition that the kit was for use by a qualied medical
practitioner was carried along with copies of the doctor’s
current Medical Board certicate; one copy accompanied
the medical kit while the doctor carried another copy.
In the present case, even though a comprehensive medical
kit was carried, there was still a need to seek additional
supplies as soon as it became apparent that the treatment
would become prolonged. An assessment of what medical
support is likely to be available in the location to be visited
Diving and Hyperbaric Medicine Volume 47 No. 2 June 2017
130
should be used to prioritise what is in the medical kit, whilst
accepting local legal restrictions. However, treatment should
always be started immediately based on what the treating
physician or other has to hand. Wider area searches should
only be initiated after the patient has been stabilised.
Conclusions
Deep-diving and rebreather divers, along with remote dive
expedition organisers should always be cautious of the
use of cylinders containing pressurised high concentration
oxygen gases. Divers should continue to remember or to be
reminded to turn on oxygen cylinders slowly and to avoid
contamination of rst-stage valves in particular. Some
diving-related travel companies employ physicians with
specialist knowledge in diving medicine (and preferably
with emergency medicine experience) to accompany deep
technical-diving orientated expeditions. In planning a
medical kit to support such expeditions, it is possible that
involved organisers, paramedics and physicians may become
overly focused on the potential management of DCI. This is
understandable; however, because oxygen res are known to
occur with rebreather systems and other non-DCI problems
are by far commoner, the medical kit should reect this.
Remember the adage, “expect the unexpected”!
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Acknowledgements
We thank the patient for his permission to present his case. We
are grateful for the inputs from Dr Richard Harris and Professor
Robert van Hulst who improved the quality of this report markedly,
Conicts of interest and funding: nil
Submitted: 14 February 2016; revised 13 September 2016; 19
April and 03 May 2017
Accepted: 06 May 2017
