Table of Contents

Descriptions Pages
1.0 Objective 3
2.0 Decompression Chamber 3
3.0 Equipment and Material 7
4.0 Procedure 19
4.1 Recompression Chamber Operation 19
4.2 Recompression Chamber Operation and Maintenance 24
5.0 Discussion 27
5.1 Case Presentation 27
5.2 Discussion Case Presentation 28
5.3 Recommendations by Author 29
5.4 Own View from Case Presentation 31
6.0 Conclusion 32
7.0 Appendixes 32

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1.0 Objective
 Basic Knowledge Decompression Chamber
 Basic Knowledge Decompression Illness (DCI) and Treatment
 Understanding Maintenance and Operation Decompression Chamber
 Recognize important of Decompression Chamber in Case Study

2.0 Decompression Chamber

Decompression chamber, also known as a recompression or hyperbaric chamber, is a

sealed compartment that is pressurized to mimic different levels of atmospheric
pressure.

Small chambers fit just one person, but larger versions can comfortably
accommodate up to ten individuals. They are perhaps most commonly used in scuba
diving as a way for divers to re-pressurize and get their bodies used to normal
atmospheric conditions after being underwater for long periods of time, but there
are also a number of medical uses. Chambers are often an important part
of carbon monoxide poisoning treatments, and can also be used to help people heal
from certain bacterial and radiation-related illnesses.

The purpose a decompression hyperbaric chamber is to allow surface-supplied gas

divers to complete their decompression stops in a chamber rather than underwater.
For this purpose, decompression chambers can be submersible in the water. For a
submersible chamber though, the hatch opens into a moon pool chamber. Then its
internal pressure must first be equalized to that of the moon pool chamber before
opening the hatch. More commonly, the hatch opens into an underwater airlock
similar to those used in submarines and underwater living habitats. In this case the
main chamber’s pressure stays constant, while it is the airlock pressure which shifts.

However, non - submersible decompression chambers are more common. The diver
surfaces and immediately enters the decompression chamber to complete the time
they would have normally spent underwater decompressing. This reduces the risks
for divers diving in cold waters or in risky underwater conditions.

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This method of decompressing is mostly used in the case of commercial diving, which
involves divers working for hours underwater at depths far beyond traditional
recreational diving. Because of which they also spends hours sometimes as long as
eighteen hours for the decompression process.

The main goal of decompression chambers is to manipulate the outside air pressure around a
person in order to influence his or her blood chemistry and oxygen intake. People don’t usually
need this sort of device unless they have spent a lot of time in an environment that has forced
their bodies to acclimate in extreme ways.

Deep-sea divers are one of the most common examples. Divers should very careful during
their ascent to sea level from they can suffer from “decompression sickness,” which is
essentially an increase in nitrogen in the blood; time in a chamber is often the only way to help
people in these situations recalibrate. Extreme cases of carbon monoxide poisoning and
radiation exposure can sometimes also be reversed with pressure therapy since the chambers
can help force peoples’ blood chemistry to raise or reduce oxygen levels as needed to get back
to normal levels.

The therapeutic principle behind hyperbaric oxygen therapy lies in its ability to
drastically increase partial pressure of oxygen in the tissues of the body. In other
words, cells repair themselves more efficiently when exposed to a higher oxygen
content via the blood. Although the hyberbaric chamber itself is the same in most
cases, it is used in different ways. There are two ways that this treatment can help
when it comes to s diving as below :

 Decompression Chamber: A hyperbaric chamber used by surface-supplied

(typically commercial) divers to make their decompression stops.
 Recompression Chamber: A hyperbaric chamber used to treat or prevent
patients suffering from decompression sickness.

The purpose a decompression hyperbaric chamber is to allow surface-supplied gas

divers to complete their decompression stops in a chamber rather than underwater.
This purpose, decompression chambers can be submersible in the water. For a
submersible chamber though, the hatch opens into a moon pool chamber. Then its
internal pressure must first be equalized to that of the moon pool chamber before
opening the hatch. Commonly, the hatch opens into an underwater airlock similar to
those used in submarines and underwater living habitats. In this case the main
chamber’s pressure stays constant, while it is the airlock pressure which shifts.

However, non- submersible decompression chambers are more common. The diver
surfaces and immediately enters the decompression chamber to complete the time
they would have normally spent underwater decompressing. This reduces the risks for
divers diving in cold waters or in risky underwater conditions. Not to forget, this
method of decompressing is mostly used in the case of commercial diving, which

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involves divers working for hours underwater at depths far beyond traditional
recreational diving. Because of which they also spends hours sometimes as long as 18
hours for the decompression process.

A hyperbaric chamber used for those divers who already have or show symptoms of
Decompression Sickness also known as decompression illness or the bends is known
mostly as a recompression chamber.

This occurs when as long as the diver remains at pressure, the nitrogen gas absorbed
by breathing compressed air underwater, presents no problem. However, when the
pressure around the diver decreases the nitrogen starts coming out of the tissues
back into the blood stream. If the pressure is reduced too quickly, the nitrogen starts
forming bubbles in the tissues and bloodstream rather than being exhaled, just like
when you open a bottle or can of soda, it releases the pressure causing the carbon
dioxide gas to lose its solubility and escape in the form of bubbles or fizz.

Recompression chamber is pressurized, it re-simulates the pressure conditions as if

the diver were underwater. By putting the patient back under pressure, it’s like putting
the cap back on a soda bottle, and stopping the fizz from escaping. The pressure causes
the nitrogen bubbles to become soluble again, thereby stopping them from escaping
from through the tissues and bloodstream.

The risky alternative to a recompression chamber is actually sending the diver back
underwater and under pressure to stop the gas bubbles that are causing DCS
symptoms. It is called In-water recompression and is only considered as a last resort
if the diver is too far from a hyperbaric chamber, and it’s a question of life or death. It
doesn’t treat DCS as well as an actual recompression chamber because, it lacks the
100% oxygen supply.

In a hyperbaric chamber used for recompression, the patient is delivered 100% oxygen
under the pressure of the chamber. Hyperbaric Oxygen Treatement (HBOT) serves the
dual-purpose of the oxygen encouraging the cells repair themselves more efficiently,
while at the same time eliminating the excess nitrogen from the blood. Which is why
it’s the most effective treatment of Decompression sickness and has become the
standard of care procedure to know the nearest facility offering this treatment.

Decompression illness (DCI) usually refers to one of two related conditions and both
are most commonly associated with scuba and deep sea divers.

When underwater, divers breathe compressed air that contains nitrogen gas at the
same pressure as the surrounding water. This accumulates in the diver's body tissue,
and is breathed out on ascent, providing that ascent occurs at a safe rate.

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When a diver swims to the surface too quickly (a rapid ascent), the nitrogen can form
tiny bubbles in the blood and/or body tissues, causing decompression sickness (DCS).

DCS may occur even if a person dives within the limits of their dive computer or
decompression tables and even if they complete a safety stop.

If a diver swims to the surface too quickly, and holds their breath while doing so (a
rapid breath hold ascent), the resulting reduction in the ambient pressure can cause
their lungs to over-inflate. This can cause the lung’s tiny air sacks to rupture, allowing
air bubbles to escape directly into the blood stream. These air bubbles can block the
flow of blood to different parts of the body, which is called arterial gas embolism
(AGE).

Signs and symptoms

The symptoms of DCI may include:

 fatigue
 joint and muscle aches or pain
 clouded thinking
 numbness
 weakness
 paralysis
 rash
 poor coordination or balance.
Unusual symptoms occurring within 48 hours after diving should be presumed to be
DCI until proven otherwise. The onset of DCI symptoms after 48 hours is unusual
unless provoked by ascent to altitude, that is flying.

Treatment

Hyperbaric oxygen therapy is used to treat DCI with

 compresses the bubbles (shrinks them)

 increases the rate at which nitrogen is removed from the body
 reduces the inflammation created by the bubbles
 improves the oxygen supply to body tissue.

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3.0 Equipment & Material
These requirement according recommended practise from U.S Navy Diving Manual
Revision 07 SS521-AG-PRO-010/0910-LP-115-1921.

Recompression chambers are used for the treatment of decompression sickness and
arterial gas embolism, for surface decompression, and for administering pressure
tests to prospective divers. Recompression chambers equipped for hyperbaric
administration of oxygen are also used in medical facilities for hyperbaric treatment
of carbon monoxide poisoning, gas gangrene, and other diseases. Double-lock
chambers are used because they permit personnel and supplies to enter and leave
the chamber during treatment.

The requirements for recompression chamber availability below in Table 18-1.

Most chamber-equipped U.S. Navy units will have one of seven commonly provided
chambers. They are:
 Double-lock, 200-psig, 425-cubic-foot steel chamber (Figure 18-1).
 Recompression Chamber Facility: RCF 6500 (Figure 18-2).
 Recompression Chamber Facility: RCF 5000 (Figure 18-3).
 Double-lock, 100-psig, 202-cubic-foot steel chamber (ARS 50 class and
Modernized) (Figure 18-4 and Figure 18-5).
 Standard Navy Double Lock Recompression Chamber System (SNDLRCS)
(Figure 18-6).

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  Transportable Recompression Chamber System (TRCS) (Figure 18-7, Figure
18-8, Figure 18-9).
 Fly-Away Recompression Chamber (FARCC) (Figure 18-10, Figure 18-11,
Figure 18-12).

Basic Chamber Components.

The basic components of a recompression chamber are much the same from one
model to another. The basic components consist of the pressure vessel itself, an air
supply and exhaust system, a pressure gauge, and a built-in breathing system (BIBS)
to supply oxygen to the patient.

Additional components may include oxygen, carbon dioxide, temperature and

humidity monitors, carbon dioxide scrubbers, additional BIBS systems for air and
treatment gases other than oxygen, a BIBS overboard dump system, and a
heating/cooling system.

Collectively these systems must be able to impose and maintain a pressure

equivalent to a depth of 165 fsw (6 ata) on the diver. Double-lock chambers are used
because they permit tending personnel and supplies to enter and leave the chamber
during treatment. The piping and valving on some chambers is arranged to permit
control of the air supply and the exhaust from either the inside or the outside of the
chamber. Controls on the outside must be able to override the inside controls in the
event of a problem inside the chamber.

The usual method for providing this dual-control capability is through the use of two
separate systems. The first, consisting of a supply line and an exhaust line, can only
be controlled by valves that are outside of the chamber. The second air
supply/exhaust system has a double set of valves, one inside and one outside the
chamber. This arrangement permits the tender to regulate descent or ascent from
within the chamber, but always subject to final control by outside personnel.

Fleet Modernized Double-Lock Recompression Chamber.

Modernized chambers (Figure 18-5) have carbon dioxide and oxygen monitors, a CO2
scrubber system, a Built-In Breathing System (BIBS), and an oxygen dump system
which together reduce the ventilation requirements. These chambers also include a
chamber environment control system that regulates humidity and temperature.

Recompression Chamber Facility (RCF).

The RCF series 6500 and 5000 (Figures 18-2 and 18-3) consists of two sizes of
standard double lock steel chambers, each with a medical lock and easy occupant
access. The RCF 6500 is capable of treating up to 12 occupants while the RCF 5000 is
capable of treating 7 occupants.

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The systems are installed in a facility to support training, surface decompression,
recompression treatment, and medical treatment operations. Each RCF includes
primary and secondary air supplies comprised of compressors, purification, and
storage for chamber pressurization and ventilation along with oxygen, mix treatment
gas, and emergency air supply to the BIBS system.

Each RCF has an atmospheric conditioning system that provides internal atmospheric
scrubbing and monitoring along with temperature and humidity controls for long
term treatment, gas management, and patient comfort. The RCF includes gas supply
monitoring, a fire extinguishing system, ground fault interruption and emergency
power. The RCF 6500 is equipped with a NATO mating flange. Both series have extra
penetrations for auxiliary equipment such as patient treatment monitoring and
hoods.

Standard Navy Double Lock Recompression Chamber System (SNDLRCS).

The SNDLRCS (Figure 18-6) consists of a Standard Navy Double Lock (SNDL)
recompression chamber and a gas supply system housed within an International
Organization for Standards (ISO) container.

The system is capable of supporting surface decompression, medical treatment, and

training operations. Air is supplied to the system using a Air Flask Rack Assembly
(AFRA) which is almost identical to the Air Supply Rack Assembly (ASRA) used in
supporting a FADS 3 DLSS. Oxygen is provided by four (4) cylinders that are secured
to the interior bulkhead of the ISO container. If an external supply of mixed gas is
available it can also be supplied to the chamber BIBS supply. The SNDL is a 54”
diameter, double lock recompression chamber.

It is outfitted with a stretcher, BIBS, gas monitoring systems, lights, and an

environmental conditioning system. The chamber can comfortably accommodate 4
divers in the inner lock and 3 divers in the outer lock. The ISO container houses the
gas supply systems and the chamber. It also provides a shelter from environmental
elements for the Outside Tenders and Diving Supervisor to conduct treatments. The
container is both heated and air conditioned as required and also includes a fold-
down desktop, a cabinet, lighting, and a vestibule.

Transportable Recompression Chamber System (TRCS).

There are three TRCS Mods.

 TRCS Mod 0 (Figure 18-7) consists of two pressure chambers. One is a conical-
shaped chamber (Figure 18-8) called the Transportable Recompression
Chamber (TRC) and the other is a cylindrical shaped vessel (Figure 18-9) called
the Transfer Lock (TL). The two chambers are capable of being connected by
means of a freely rotating NATO female flange coupling (Figure 18-7).

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  TRCS Mod 1 consists of just the TRC.

 TRCS Mod 2 is the TRCS Mod 0 which has had the 5000 psi upgrade ECP
installed allowing it to be used with an Air Supply Rack Assembly (ASRA).

The TRCS is supplied with a Compressed Air and Oxygen System (CAOS) consisting of
lightweight air and oxygen racks of high pressure flasks, as well as a means of
reducing oxygen supply pressure. The TRCS Mod 2 can use the TRCS Mod 0
lightweight air racks rated at 3000 psi or an ASRA rated at 5000 psi. The chamber is
capable of administering oxygen and mixed gas via BIBS.

An ECP upgrade is available for installing a CO2 Scrubber in the TL. A TRCS Mod 0 or
Mod 2 without a TL CO2 Scrubber is limited to one patient and one tender.

When a Level I Recompression Chamber is required or Surface Decompression dives

are planned, a TRCS Mod 0 or Mod 2 (with TL CO2 Scrubber installed) can be used.
When a Level I Recompression Chamber is not required, any of the three TRCS Mods
can be used.

Fly Away Recompression Chamber (FARCC).

This chamber system consists of a 60-inch double lock modernized chamber in a 20’ x
8’ x 8’ milvan (Figure 18-10 and Figure 18-11). The Fly Away Recompression Chamber
(FARCC) also includes a life support skid (Figure 18-12). In addition, a stand-alone
generator is provided for remote site power requirements.

Emergency Evacuation Hyperbaric Stretcher (EEHS).

The Emergency Evacuation Hyperbaric Stretcher (EEHS) is a manually-portable single
patient hyperbaric tube to be used to transport a diving or disabled submarine
casualty from an accident site to a treatment facility while under pressure. The EEHS
does not replace a recompression chamber, but is used in conjunction with a
chamber. The EEHS is small enough to allow transfer of a patient, under pressure,
into or out of many shore based recompression chambers owned by both the DOD,
and civilian medical organizations.

Standard Features.
Recompression chambers must be equipped with a means for delivering breathing
oxygen to the personnel in the chamber. The inner lock should be provided with
connections for demand-type oxygen inhalators. Oxygen can be furnished through a
pressure reducing manifold connected with supply cylinders
outside the chamber.

Inlet and Exhaust Ports.

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Optimum chamber ventilation requires separation of the inlet and exhaust ports
within the chamber. Exhaust ports must be provided with a guard device to prevent
accidental injury when they are open.

Pressure Gauges.
Chambers must be fitted with appropriate pressure gauges.These gauges, marked to
read in feet of seawater (fsw), must be calibrated or compared as described in the
applicable Planned Maintenance System (PMS) to ensure accuracy.

Relief Valves.
Recompression chambers should be equipped with pressure relief valves in each
manned lock. Chambers that do not have latches (dogs) on the doors are not
required to have a relief valve on the outer lock. The relief valves shall be set in
accordance with PMS. In addition, all chambers shall be equipped with a gag valve,
located between the chamber pressure hull and each relief valve. This gag valve shall
be a quick acting, ball-type valve, sized to be compatible with the relief valve and its
supply piping. The gag valve shall be safety wired in the open position.

Communications System.
Chamber communications are provided through a diver’s intercommunication
system, with the dual microphone/speaker unit in the chamber and the surface unit
outside. The communication system should be arranged so that personnel inside the
chamber need not interrupt their activities to operate the system. The backup
communications system may be provided by a set of standard sound-powered
telephones. The press-to-talk button on the set inside the chamber can be taped
down, thus keeping the circuit open.

Lighting Fixtures.
Consideration should be given to installation of a low-level lighting fixture (on a
separate circuit), which can be used to relieve the patient of the heat and glare of
the main lights. Emergency lights for both locks and an external control station are
mandatory.

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4.0 Procedure

4.1 Recompression Chamber Operation

Predive Checklist. To ensure each item is operational and ready for use, perform
the equipment checks listed in the Recompression Chamber Predive Checklist,
Figure 18-13.

Safety Precautions.
 Do not use oil on any oxygen fitting, air fitting, or piece of equipment.
 Do not allow oxygen supply tanks to be depleted below 100 psig.
 Ensure dogs are in good operating condition and seals are tight.
 Do not leave doors dogged (if applicable) after pressurization.
 Do not allow open flames, smoking materials, or any flammables to be
carried into the chamber.
 Do not permit electrical appliances to be used in the chamber unless listed
in the Authorization for Navy Use (ANU).
 Do not perform unauthorized repairs or modifications on the chamber
support systems.
 Do not permit products in the chamber that may contaminate or off-gas
into the chamber atmosphere.

General Operating Procedures.

 Ensure completion of Predive Checklist.

 Diver and tender enter the chamber together.
 Diver sits in an uncramped position.
 Tender closes and dogs (if so equipped) the inner lock door.
 Pressurize the chamber, at the rate and to the depth specified in the
appropriate decompression or recompression table.
 As soon as a seal is obtained or upon reaching depth, tender releases the
dogs (if so equipped).
 Ventilate chamber according to specified rates and energize CO2 scrubber
and chamber conditioning system.
 Ensure proper decompression of all personnel.
 Ensure completion of Postdive Checklist

Tender Change-Out. During extensive treatments, medical personnel may prefer to

lock-in to examine the patient and then lock-out, rather than remain inside
throughout the treatment. Inside tenders may tire and need relief.

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Lock-In Operations. Personnel entering the chamber go into the outer lock and
close and dog the door (if applicable). The outer lock should be pressurized at a rate
controlled by their ability to equalize, but not to exceed 75 feet per minute. The
outside tender shall record the time pressurization begins to determine the
decompression schedule for the occupants when they are ready to leave the
chamber. When the pressure levels in the outer and inner locks are equal, the
inside door (which was undogged at the beginning of the treatment) should open.

Lock-Out Operations. To exit the chamber, the personnel again enter the outer lock
and the inside tender closes and dogs the inner door (if so equipped). When ready
to ascend, the Diving Supervisor is notified and the required decompression
schedule is selected and executed. Constant communications are maintained with
the inside tender to ensure that a seal has been made on the inner door. Outer lock
depth is controlled throughout decompression by the outside tender.

Gag Valves. The actuating lever of the chamber gag valves shall be maintained in
the open position at all times, during both normal chamber operations and when
the chamber is secured. The gag valves must be closed only in the event of relief
valve failure during chamber operation. Valves are to be lock-wired in the open
position with light wire that can be easily broken when required. A WARNING plate,
bearing the inscription shown below, shall be affixed to the chamber in the vicinity
of each gag valve and shall be readily viewable by operating personnel. The
WARNING plates shall measure approximately 4 inches by 6 inches and read as
follows:

WARNING The gag valve must remain open at all times. Close only if relief valve
fails.

 Ventilation. The basic rules for ventilation are presented below. These rules
permit rapid computation of the cubic feet of air per minute (acfm) required
under different conditions as measured at chamber pressure (the rules are
designed to ensure that the effective concentration of carbon dioxide will
not exceed 1.5 percent (11.4 mmHg) and that when oxygen is being used,
the percentage of oxygen in the chamber will not exceed 25 percent).

 When oxygen is breathed from the built-in breathing system (BIBS), provide
12.5 acfm for a diver at rest and 25 acfm for a diver who is not at rest. When
these ventilation rates are used, no additional ventilation is required for
personnel breathing air. These ventilation rates apply only to the number of
CHAPTER 18 — Recompression Chamber Operation 18-21 people breathing
oxygen and are used only when no BIBS dump system is installed.

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 If ventilation must be interrupted for any reason, the time should not
exceed 5 minutes in any 30-minute period. When ventilation is resumed,
twice the volume of ventilation should be used for the time of interruption
and then the basic ventilation rate should be used again.

 If a BIBS dump system or a closed circuit BIBS is used for oxygen breathing,
the ventilation rate for air breathing may be used.

 If portable or installed oxygen and carbon dioxide monitoring systems are

available, ventilation may be adjusted to maintain the oxygen level below
25 percent by volume and the carbon dioxide level below 1.5 percent
surface equivalent (sev).

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4.2 Recompression Chamber Operation and Maintenance

Postdive Checklist is important due to ensure equipment receives proper postdive

maintenance and is returned to operational readiness, perform the equipment checks listed
in the Recompression Chamber Postdive Checklist, Figure 18-14

Scheduled Maintenance.
Recompression chamber shall adhere to PMS requirements and shall be pressure tested
when initially installed, at 2-year intervals thereafter, and after a major overhaul or repair.
This test shall adhere to PMS requirements and shall be conducted in accordance with
Figure 18-15. The completed test form shall be retained until retest is conducted. For a
permanently installed chamber, removing and reinstalling constitutes a major overhaul and
requires a pressure test. For portable chambers such as the TRCS, SNDLRCS, and FARCC,
follow operating procedures after moving the chamber prior to manned use. Chamber relief
valves shall be tested in accordance with the Planned Maintenance System to verify setting.
Each tested relief valve shall be tagged to indicate the valve set pressure, date of test, and
testing activity. After every use or once a month, whichever comes first, the chamber shall
receive routine maintenance in accordance with the Postdive Checklist. At this time, minor
repairs shall be made and used supplies shall be restocked.

Inspections.
At the discretion of the activity, but at least once a year, the chamber shall be inspected,
both inside and outside. Any deposits of grease, dust, or other dirt shall be removed and, on
steel chambers, the affected areas repainted.

Corrosion.
Corrosion is removed best by hand or by using a scraper, being careful not to gouge or
otherwise damage the base metal. The corroded area and a small area around it should then
be cleaned to remove any remaining paint and/or corrosion.

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5.0 Discussion

Occupational divers are exposed to hazards which contribute to the risk of

developing decompression illnesses (DCI). DCI consists of Type I decompression
sickness (DCS), Type II DCS and arterial gas embolism (AGE), developed from
formation of bubbles in the tissues or circulation as a result of inadequate
elimination of inert gas (nitrogen) after a dive. In Malaysia, DCI is one of the
significant contributions to mortality and permanent residual morbidity in diving
accidents. This is a case of a diver who suffered from Type II DCS with neurological
complications due to an occupational diving activity. This article mentions the
clinical management of the case and makes several recommendations based on
current legislations and practise implemented in Malaysia in order to educate
medical and health practitioners on the current management of DCI from the
occupational perspective. By following these recommendations, hopefully diving
accidents mainly DCI and its sequalae among occupational divers can be minimized
and prevented, while divers who become injured receive the proper compensation
for their disabilities

Below is Case Study from A Rozali, MComm. Med (Occup Health), H Khairuddin,
MMed (Occup Med), M S Sherina, MMed (Fam Med), B Mohd Zin, MPH*, A
Sulaiman, MPH regarding title Decompression Illness Secondary to Occupational
Diving: Recommended Management Based Current Legistation and Practice in
Malaysia

5.1 Case Presentation

The patient was a 42 year old Malay man who worked as a commercial diver in a
registered private company for the past ten years. He claimed that his company
sent him for basic training in diving to handle underwater construction. Although a
pre-employment medical assessment was done before joining the company, he had
not undergone any further periodic medical examination.

He had many dives without any complications prior to this incident. He also
registered and contributed to the Social Security Organisation (SOCSO). The patient
started his diving work at Pantai Remis, at 8.00am using SCUBA (self-contained
underwater breathing apparatus) with a single compressed air tank to secure a
tending line for salvage work, with several other divers. He did multiple dives at the
depth of 48 meters and made decompression stops at 10 meters and 5 meters
intervals before surfacing from each dive.

During the third dive, he suddenly noticed that he had run out of air in his tank. He
ascended immediately to the surface without doing any decompression stops. On
reaching the surface boat, he was found to be drowsy and was brought ashore. He
was rushed by his fellow workers to the nearest recompression chamber facility in
RMN Base in Lumut at 2.30 in the afternoon for recompression treatment.

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 However, he lost his consciousness on the way to the hospital. On admission, he
was unconscious (Glasgow Coma Scale 5/15). He was intubated and ventilated. Vital
signs were stable, with no sign of pneumothorax, or any external injuries. CT scan of
the brain showed no intracranial bleed, no midline shift and normal ventricles.
Cerebral oedema was minimal. He was diagnosed with Type II DCS with
neurological involvement and was treated with hyperbaric oxygen therapy (HBOT)
at 2.8 ATA (atmosphere absolute) for four hours and 45 minutes. He was
subsequently treated in the Intensive Care Unit (ICU) with mechanical ventilation
and daily recompression therapy. His condition improved subsequently and he was
finally extubated three weeks later.

By then he had completed 30 sessions of recompression therapy with some

progress and improvement. A pre-discharge assessment on the seventh week of
admission found a patient who was alert, rational and oriented with intact higher
cerebral function. There was paraparesis with upper limbs power 3/5 bilaterally,
paraplegia with lower limbs power 0/5 bilaterally, loss of sensation downwards of
thoracic 10 and urinary incontinence. On his request, he was referred to a
government hospital near his house for continuation of rehabilitation programme.

5.2 Discussion Case Presentation

This diver suffered from DCI Type II DCS with neurological (brain and spinal cord)
involvement. DCI of the brain is most usually due to cerebral AGE as a result of
bubbles becoming lodged in small arteries of the cerebral circulations. DCI of the
spinal cord is due to bubbles formation in the white matter as well as bubbles
obstructing arterial or venous flow in the spinal cord, most commonly at the lower
thoracic area, followed by lumbar and cervical level .

This explains the upper limb paraparesis, lower limb paraplegia, loss of sensation
below and bladder dysfunction of patient. The definite treatment is to recompress
in a compression chamber as soon as possible.

Delay in treatment may lead to permanent residual morbidity or death. The

outcome is more likely to be successful if treatment is begun within six hours after
the onset of symptoms. However, this depends on the availability and accessibility
of recompression chamber facilities, as well as the expertise of handling the
chambers. In Malaysia, there are several recompression chamber facilities available
to treat diving accidents mainly in the military setting as well as in a hospital
university and private health centres.

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5.3 Recommendations by Author

Based on the reported incident, this paper puts forward several recommendations:

Role of the Employer

The management of diving activities as an occupation in Malaysia should involve
mainly the role of the employer, who must comply with the legislative regulations
on diving currently enforced in Malaysia. There is a need for standards of good
practice in diving, which must be regulated and enforced to ensure diving injuries
can be prevented or minimized. A standard guideline for initial DCI treatment must
be introduced and taught to all dive operators, in order to enhance the success of
recompression treatment. Furthermore, an injured diver with disability must
continue to undergo rehabilitation for improvement of function and possible re-
employment.

Code of Good Practice

The Occupational Safety and Health Act (OSHA) 1994 clearly states that the role of
the employer is to secure the safety, health and welfare of persons at work against
risks to safety or health arising out of the work activities 8. The employer is required
to determine and secure all diving equipments as safe, ensure their divers follow
standard diving protocols on safety as well as send their divers for appropriate dive
training. These measures are done to ensure that diving work is done and
completed with minimal risk of injuries and fatality. It is therefore the responsibility
of a diving supervisor to regulate and monitor all diving activities at any diving site.
In the case of commercial diving, the dive supervisor must determine the daily dive
schedules, and ensure all divers carry out the necessary pre-dive checks prior to
getting into the water. All SCUBA divers must have the basic necessary diving
equipments which include depth gauge and pressure gauge. In Malaysia, there are
only a few training facilities for commercial / industrial occupational divers. The
Terengganu Safety and Training Centre (TSTC) is one of the registered training
centres which have provided courses such as Occupational Diving Course since
2004, in collaboration with International Technical Diving Agency (ITDA).

Medical Assessment Prior to Diving

The employer must also carry out pre-employment and periodic medical
assessments prior to diving to ensure that divers are fit to perform underwater
work. It should be noted that there is still as yet no legal obligation in Malaysia to
do medical assessment prior to diving for occupational diving activities.

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This situation also involves recreational SCUBA divers, who do not have the legal
obligation to undergo medical assessment. However, professional training bodies
require divers to declare their health status by filling a standard questionnaire and
medical opinion is only required if there are uncertainties about their fitness to dive
As a step to enhance safety in diving activities, the National Institute of
Occupational Safety and Health (NIOSH) has introduced the “Diving Medical
Examiner’s Course”, beginning in 2005 for registered medical practitioners to
conduct pre-employment and periodic medical examination for commercial diving
in accordance to industry standards .

In addition to that, the Department of Safety and Health (DOSH) has published a
protocol for underwater logging activities which contains procedures and checklists
for the enforcement OSHA 1994 for underwater logging activities as well as the
requirement of pre-employment and periodic employment medical examination
and medical surveillance.

Notification of Decompression Illness (DCI)

The OSHA 1994 requires an employer to notify the nearest DOSH office of any
occupational disease that has occurred in the place of work, within seven days of
the incident. The Act also requires every registered medical practitioner or medical
officer attending to a patient whom he believes to be suffering from an
occupational disease and injury to report the matter to the Director General (DG) of
DOSH. In this particular incident, although no report to the DOSH was forwarded by
the employer, case notification was done by the medical facility administering
recompression treatment. Upon receiving a report of diving-related illness or injury,
the DOSH has to determine the underlying cause of the incident in order for
remedial action to be taken, mainly to prevent similar occurrences in the future.
The enforcement officers have to investigate for further information regarding the
incident and daily diving schedule, the repetitive diving profile, as well as inspect
the workplace and relevant equipments.

Recommendation and corrective actions to administer and enforce the law have to
be taken to ensure that the employer complies with standard safety and health
regulations.

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5.4 Own View from Case Presentation

Based on case presentation a , agreed with recommendation by Author and with

advise to add others point as below :

Prior ,During and After Diving Operation shall have :

 Available DCC Deck decompression chamber. A pressure vessel for human

occupancy which does not go under water and may be used as a living
chamber during saturation diving, diver decompression or treatment of
decompression illness. Also called compression chamber, recompression
chamber, deck chamber or surface compression chamber.
 Available Diving Bell .A pressure vessel for human occupancy which is used
to transport divers under pressure either to or from the underwater
worksite. Also called closed diving bell or submersible decompression
chamber

Based on case presentation found that private company which the victim working
not provided above facilities during risky operation salvage work achieved ~ (-)50
meter water depth and without surface DCC Deck Decompression Chamber. The
victim suffers with DCI Type II DCS with neurological (brain and spinal cord)
involvement.

Above views based on recommended practise by NORSOK Standard Manned

Underwater Operations U-100 as stated below :

 Clause 8.5.2 Depth limitation Surface oriented diving shall not be carried
out at depths exceeding 50 msw.
When diving deeper than 50 msw a diving bell shall be used.
 Clause 8.5.3 Surface oriented pressure chamber For all surface oriented
diving operations a double-lock compression chamber shall be ready for
use. It shall be possible for the diver to reach maximum depth in the
chamber within time limits as specified in diving tables.

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6.0 Conclusion

Common to all diving operations is the concept of decompression which is the

controlled procedure by which a diver returns to surface pressure from the ambient
pressure of his working depth. As the working depth increases so does the time
taken to decompress; in addition, the longer the diver stays under pressure the
more the decompression time is needed. Decompression is necessary because the
diver breathing under pressure absorbs inert gas into his tissues and blood. The
decompression procedure allows this gas to be released gradually and thereby
avoid decompression sickness. Decompression sickness (the bends) is directly
attributable to a too-rapid reduction of pressure which can cause gas bubbles to
form in the body tissues from the dissolved gases.

Decompression chamber is necessary in Diving Operation with involves commercial

divers in deep water for life saving them. The proper maintenance and inspection
should be done on decompression chamber in routine or periodic for ensuring safe
condition.

7.0 References
 NORSOK Standard Manned Underwater Operations U-100
 Decompression Illness Secondary to Occupational Diving: Recommended
Management Based Current Legistation and Practice in Malaysia
 U.S Navy Diving Manual Revision 07 SS521-AG-PRO-010/0910-LP-115-1921.

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