Appeared in DIVER August 2006

All set for a surface RESCUE
Are you confident of being able to tow an unconscious diver and give rescue breaths at the same time Do you actually know what rescue breaths are John Liddiard provides an emergency refresher

THE STANDARD DIVER-RESCUE TRAINING EXERCISE involves finding an unconscious non-breathing diver under water, lifting the victim to the surface, then administering rescue breaths and towing the victim to shore or a boat, where more comprehensive resuscitation can begin.
We covered the first part of this exercise, the controlled buoyant lift (CBL), in March last year, but you dont need to go digging through your DIVER back issues or searching before continuing. The topic of towing a casualty while administering in-water rescue breaths has a much wider scope, and is not simply a follow-on to lifting a casualty from the depths.
You might find a diver floating face-down and not breathing on the surface. Or perhaps it isnt a diver at all - it could be any swimmer from a beach who has fallen into difficulties and is noticed by you on your return from a shore dive.
Like many divers who were trained earlier than the past couple of years, I always think of the resuscitation part as AV (Artificial Ventilation), or EAR (Expired Air Resuscitation). Rescue Breaths is just the latest term for the same old thing.

Ensure buoyancy
On getting an unconscious diver to the surface or finding one on the surface, first make sure that they are going to stay there and not sink.
The drill begins with grabbing hold of the victim, turning him onto his back and making sure that he is going to stay on the surface by inflating his BC and removing his weightbelt.
If the victim is wearing a rebreather, it is also important to close the rebreather mouthpiece at this stage. Failure to do so could result in the rebreather loop flooding, and the victim losing 10kg of buoyancy.
Once the victim is secured at the surface, provide a good, frantic distress signal to anyone who may be watching or in a position to help.
The various training agencies have slightly different procedures, with BSAC and PADI recommendations summarised in the panel opposite.
Whatever the procedure, at some point the procedure could involve administering rescue breaths in the water and towing the victim to safety.
The basic objective is the same as on dry land - to transfer air from the rescuers lungs into those of the victim. There are various ways of achieving this, but before looking at my favoured method, heres why other methods may not be so suitable in UK waters.

Oops, I dropped the pocket mask
I dont like relying on mechanical aids, by which I mean pocket masks or snorkels. A diver who depends on a pocket mask when giving rescue breaths needs to have the aid with him at all times so that he can reach into a pocket, remove it from its protective cover, and put it into use. What does he do without the aid
Imagine the scenario, with the pocket mask typically buried at the bottom of a BC pocket. The victim is on the surface, waves are breaking, and both rescuer and victim are getting sloshed about.
The rescuer reaches a thickly gloved hand into his pocket, fumbles among all the junk, pulls the mask out, fumbles again while trying to pop it open, and drops it. The mask floats, so he chases after it as it gets blown away, towing the victim until he catches it and starts again.
Some pocket masks have a bit of elastic to secure them, but it needs two hands to seal the mask in place so that you can give rescue breaths.
Get it slightly wrong, and the rescuer actually seals a puddle of water over the victims mouth and nose, then blows the water into his lungs.
A pocket mask has a more appropriate role on a boat or on dry land, particularly when you come across a random casualty in the street in need of resuscitation.
You dont know what nasty diseases you could pick up from direct contact, so the mask barrier keeps the rescuer from coming into mouth contact with saliva, blood or any other bodily fluid.
The mouth-to-snorkel technique used to work quite well, as long as the rescuer made sure the snorkel didnt contain any water and used a simple J-tube snorkel. But how many divers carry a traditional snorkel, if any Most models these days have all sorts of purge valves - and a snorkel can be dropped.

The kiss of life
Mouth-to-mouth resuscitation, the kiss of life, is the traditional approach to administering rescue breaths.
It works best while stationary in calm water. In rough water, making an effective seal without filling the victims mouth with water can be difficult. If it is necessary to tow the victim, getting into position to administer mouth to mouth means that towing has to halt while the rescue breaths are being given, so the rescuer is switching between towing and rescue breaths a few times each minute. It simply isnt efficient.

By a nose
Any diver trained by a UK agency will know the answer. Mouth-to-nose has long been the primary technique of administering in-water rescue breaths with all the UK training agencies. It comes from experience and assessment of just what is practical and possible in home diving conditions.
US agencies, including PADI, teach mouth-to-nose as an optional variation on mouth-to-mouth. UK-based PADI instructors usually make a point of including mouth-to-nose in-rescue training because it is a more appropriate technique for local conditions.
Mouth-to-nose doesnt require any special equipment. It is easier to make a seal over a nose than over a mouth. The seal can be from slightly above the victim, so it is easier for towing to continue as breaths are given. It works well with rolling the victim towards the rescuer, so the rescuer doesnt have to waste effort climbing above the victim.
There are some disadvantages. The victims nose could be blocked - hardly likely, as he shouldnt be diving in that case. The technique can also blow snot into the victim, which, while nasty, is not a unique hazard as it can also happen with a pocket mask, and mouth-focused techniques can project anything the victims mouth has collected into the lungs.
Making an assessment of all of this while towing an unconscious and non-breathing diver is not something on which to dwell. Far better just to go for the nose and get on with giving rescue breaths and towing him to safety.

The demo
Our demonstration is by Suzy (the rescuer) and Nina (the victim) at Colona Dive Centre in Hurghada.
We start from a relaxed tow, as in the main picture, Suzy holding Ninas pillar valve in her left hand. Other holds that may be convenient include the victims left shoulder-strap or armpit.
To administer rescue breaths, Suzy uses her right hand to pull on Ninas chin, with her right forearm as close to Ninas head as possible, ideally running along the side of her head.
Pushing out and up with the left hand, while pulling back by bending the right arm, will both roll Nina towards Suzy and gently straighten her neck.
Suzys right elbow rests beneath Ninas right shoulder, acting as a lever to help straighten the neck and also as a support, so that while Nina rolls, she doesnt just pull under.
The trick is to do all the rolling and neck-straightening before the victim is too close to the rescuer. Leave it too late, and the rescuers elbows get in the way.
At no point does Suzy have to climb. Ninas nose is rolled into her mouth, and the seal made mouth-to-nose.
At the same time, Suzy seals Ninas mouth with her right hand by pinching her lips together between fingers, or fingers and thumb, or simply by gagging her with the palm or closed fingers of Suzys right hand.
The gagging method is usually best when wearing gloves. The main thing is to avoid pulling against the victims throat with any leftover fingers and choking her.
The seal made and Ninas mouth closed, Suzy breathes out to inflate Ninas lungs. The seal is then released, allowing Nina to exhale.
Suzy can either hold Nina in position ready for another cycle, or relax her arms to make towing easier, repeating the whole roll, pull in, straighten and seal process next time a breath is due.
It sounds simple, but whatever your preferred technique, to keep the rescue breaths going while towing a victim takes a fair bit of practice. Then, like riding a bicycle, it suddenly clicks.

Towing and rescue breaths using the mouth-to-nose method

A pocket mask - there are good reasons for not using these

Rescuer Suzy grips victim Ninas pillar valve and pushes up and out to roll Nina towards herself.

By rolling Nina towards her, Suzy stays low in the water, and it is the roll that brings the Ninas nose to Suzys mouth.

Ninas mouth is sealed with Suzys right hand

  • Administer rescue breaths for 1 minute (10 breaths).
  • If spontaneous breathing does not return, tow to safety administering rescue breaths at a rate of 2 breaths in 15 seconds.
  • Before recovering into a boat or landing, administer rescue breaths for 1 minute.
  • Remove kit and land/recover as quickly as possible without interruption for further rescue breathing.
  • On shore or boat, if breathing has not returned begin CPR.

  • Assess responsiveness and check for breathing.
  • If not breathing, give 2 rescue breaths
  • If breathing is restored, tow to safety, intermittently checking that victim is still breathing.
  • If not breathing and less than 5 minutes from safety, tow victim to safety while giving 1 rescue breath every 5 seconds.
  • If not breathing and more than 5 minutes from safety, tow victim to safety while giving 1 rescue breath every 5 seconds. After 1 minute, check for movement or other reaction. If present, continue providing rescue breaths while towing.
  • If, more than 5 minutes from safety and after 1 minute, movement or reaction is still absent, the victim is probably in cardiac arrest and needs advanced life support, which will be available only on the shore or boat. Discontinue rescue breaths and tow victim to safety as quickly as possible.
Details: PADI Rescue Diver Manual

  • Over-inflated BC prevents the victims neck extending - let some air out.
  • Tight chest straps on BC prevent victims lungs expanding - release chest straps.
  • Victim gets dunked under water during rescue breaths - roll the body more and do not climb on it. The rescuer should be able to give rescue breaths while just floating, without having to swim up at all.
  • The rescuer cannot get close enough to the victims nose - chances are that the rescuers elbows are in the way. The rolling of the victim and neck-extension needs to be completed before the victim is pulled all the way in to the rescuer.
  • While giving rescue breaths, air escapes through victims mouth - tighten the right hand over the mouth. During training, the victim should be unable to breathe out through the mouth.
  • The victims neck is twisted - when rolling the body, roll the whole body, not just the neck. The rescuer needs to push up with his left hand. During training, the victim will be unable to swallow if his neck is properly extended.
  • The tow is making no progress and the rescuer is getting out of breath - this is usually down to either poor finning technique or climbing over the victim instead or rolling his body. A tendency to bicycle really shows when towing.