The Oxygen Administration "Ritual"

by

Larry "Harris" Taylor, Ph.D.

 This material is copyrighted and the author retains all rights. This article is made available as a service to the diving community by the author and may be distributed for any non-commercial or Not-For-Profit use.  

All rights reserved.

 This article is based on material presented in the authorís DAN O2 Provider Class.  

This is a discussion of the "ritual" as presented in class. While it is easy to remember, it is not a substitute for "on-hands" training.

The author believes every diver should have DAN O2 training (or its equivalent).

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Oxygen is defined as a drug in many nations of the world. In the US, before a first responder (or any medical professional, for that matter) administers a drug, the recipient of the treatment must be informed

1. what is being administered, 

2. why it is being administered, and 

3. how it will be administered 

This process of informing the potential drug recipient of the nature of the intended treatment  is called :"informed consent." It is a legally necessary step before asking for permission to proceed with the therapy. (i.e.. A person needs to be informed of the procedure before they can consent to treatment.) In teaching a DAN O2 class, I use what I call "the ritual" to insure that everyone trained is on the same page with respect to meeting this very important legal requirement of informed consent prior to drug administration. Before students practice oxygen administration skills, I  suggest that this 4-part ritual is a convenient method for meeting the  requirements for informed consent.

First, I tell them the ritual has four parts:

1. "This is oxygen."

2. "It will make you feel better."

3. "It works like this."

4. "Would you like to try some?"

Then, I point out that these simple four statements are the basis of an informed consent process. I then do an "annotated version" (in other words, what I am really saying is ...)

1. "This is oxygen"

The gas in the cylinder is a substance, oxygen, defined as a drug in the US Pharmacopoeia (abbreviated USP 'cause most folks can't spell or pronounce Pharmacopoeia (g) ) The USP is a collection of chemical standards that define the chemical tests and purity standards for all legally defined drugs in the US. Those outside the US need to consult their own compendium of drug standards.

2. "It will make you feel better"

The reason why I propose to give you the drug called oxygen is because it has been well established (dating back to the mid 1800's) that high concentrations of oxygen will reduce the signs and symptoms of the dive malady, DCI, that is causing your discomfort. (see Why100 % Oxygen is a Dive Site Necessity ).

3. "It works like this"

At this point in time, I inhale from the demand inhalator mask (as a final check to make sure the gas is flowing and everything is functional) and then clearly remove the mask from my face (so recipient can see I am not exhaling into the mask) and exhale.

In class, I have multiple extra masks, and if anyone is uncomfortable with this brief skin contact, a fresh mask can be exchanged at this point in time, but exhaling away from the mask minimizes risk of disease transmission.

This does two  things:

1. The route of administration for this drug, oxygen, I am proposing to give you for relief of your pain and discomfort, is oral-nasal  administration via inhalation using a demand inhalator valve and tru-fit mask.

The mask should be clear to visualize recipient's exhaled breath once treatment has begun. Also, should the oxygen recipient vomit, the expelled material is visible (an opaque mask is undesirable 'cause it hides everything).

2. It "tests the wine." 

It clearly demonstrates to a potentially stressed person that you are not asking them to do anything that you, yourself, would not do.

4. "Would you like to try some?"

On the basis of the information I have just given you, I am now asking for formal, legal permission to administer the drug oxygen.

I then demonstrate the ritual on a student acting as a diver with a problem and the students begin their practice session with this skill.

Some additional things to consider;

I believe it is important to:

1. accept a diver's refusal. They have made an "informed consent" decision and this must be respected. Use your persuasive powers to convince them to accept the gas, but force cannot be used. Wait until permission has been obtained before beginning treatment.

2.  maintain eye contact with the diver suffering from the dive malady being treated so that it is clear to everyone that you are speaking to the intended drug recipient. This also begins building trust between first responder and the diver being treated.

3. speak in a calm, reassuring voice.

4. tell the diver everything you are doing. (Divers with DCI  are under emotional stress and, in the supine (flat on the back) position,  they can not see all that is occurring. Telling them your actions will help reduce their anxiety.)

"I am now going to place the mask on your face ... relax  ... and breathe normally."

5. After you have placed the mask on the affected diver and they have taken a few breaths, ask them to assist you in their treatment by holding the mask in place. Tell them that you are going to place their hand on the mask and that it is important that THEY maintain a good seal. This focuses their attention and frees your hands for other matters.

6. If the diver is wearing glasses, the chances are quite high that these glasses will interfere with the mask seal. Since seeing is impaired when glasses are removed, people are often hesitant to remove them, especially under stress. So, first gently place the mask on the face. Then, suggest the glasses are a treatment obstacle and ask to remove them  ...put them in a place known and accessible to the diver on oxygen.

7. Most folks, especially males, will cross their legs in the supine position. This places pressure on the legs at the ankles and interferes with lymphatic circulation. This may impede the off-gassing process. So, if the legs are crossed, ask the person receiving oxygen to un-cross them. Also, check for restrictive clothing and jewelry ...loosen where appropriate. (This may seem trivial, but there is a documented DCS hit in the Great Lakes region that began in the hands. It is believed the proximate cause of the hit was restricted circulation from anti-nausea wrist bands worn under a dry suit. So, restricted circulation can be a problem.)

8. Document times, gas and delivery method used and patient responses to assist medical professionals in obtaining an accurate evaluation of patient history.

9. Keep the diver on oxygen until the gas is exhausted or relieved by a higher medical authority.

Conclusion

Since this ritual is easily remembered, presentation of the sequence of events as a "ritual" is an effective teaching technique for insuring that Oxygen Providers clearly meet the requirements for informed consent when dealing with administration of the drug Oxygen, 

To support my belief that this ritual is remembered, I will relay the  following incident.

For many years, I taught the DAN Oxygen Provider class at the Chicago dive convention, Our World Underwater. Several years after I finished teaching there, as I was walking down the hallway towards the exhibits, some vaguely familiar people approached me. As we passed each other, they looked at me, grinned broadly  and, as a chorus,  said, "This is oxygen, it will make you feel better." I  briefly smiled, then, but, as an instructor, I am still smiling on the inside 'cause they obviously remembered their lesson.

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 About the Author:

Larry "Harris" Taylor, Ph.D. is a biochemist and Diving Safety Coordinator at the University of Michigan. He has authored more than 100 scuba related articles. His personal dive library (See Alert Diver, Mar/Apr. 1997, p. 54) is considered by one of the best sources of information in North America.

  Copyright 2001-2004 by Larry "Harris" Taylor

All rights reserved.

Use of these articles for personal or organizational profit is specifically denied.

These articles may be used for not-for-profit diving education