All right, good morning, and thank you all for making it on the first, the early morning session on the last day. My name is Bob Sanders. This is Dr. Tony Aleman. We'll be talking to you about training in undersea and hyperbaric medicine and how you can use this training, how you can bring training into your own lives and into your own practice so that you can utilize undersea and hyperbaric medicine. We're going to give ourselves more of an introduction during the show, so I'll turn it over to Dr. Aleman to kick us off. Thank you. First thing in business, we have no disclosures. Our objectives for this session are we're going to talk about ways to get occupational doctors training in hyperbaric medicine. These are either short or long courses, and we're going to talk about all of them that may help you evaluate divers, commercial divers in your practice. We're going to talk about other training opportunities that you may actually be able to do some hyperbaric medicine as part of your practice. There's a bunch of them. First of all, we're going to talk about our path into how we got into hyperbaric medicine. Most of us in hyperbaric medicine kind of did it the way people do it in occupational medicine. You didn't start it. Most of us did not start out in occupational medicine. We start out in some other specialty, and then somehow we find our way into occupational medicine. Same thing happens in hyperbaric medicine. Very few of us went into practice saying, I want to be a hyperbaric doctor. Sometimes it's a personal interest. Am I interested in diving? We are both divers, and that's part of how we got into it. Did we have some occupational exposure? We have some of us that, like part of my experience when I was practicing in Louisiana, I started seeing a bunch of commercial divers. I said, wow, I better get trained in knowing how to deal with these divers. Then whatever, sometimes we may have been a patient in a hyperbaric medicine setting for some reason. My experience, I started out in family practice. After doing about eight or nine years in family practice, I decided I didn't like it. I could not cure anybody, and nobody did anything that you said. The hospital said, why don't you try this occupational medicine? I worked in occupational medicine for the hospital. Then I decided, well, I probably ought to go get trained. I went into fellowship or residency at Duke. Spent two years at Duke, and then went back to Louisiana. As I said, when I started doing occupational medicine in South Louisiana, saw a bunch of commercial divers. We had this little storm in New Orleans called Katrina, if you ever heard of that one. After that, I got a doctor to come join me in my practice. All he did was diving medicine. He was in his 70s, and I'm thinking, man, if something happened to him, I better get trained. I did another fellowship in hyperbaric medicine in New Orleans. That's how I got into it. I would not recommend doing it my way. If you're going to do it, just get all your training out the way. If you're unhappy or you want to enhance your practice, that's what we're here to talk about today. Dr. Sanders will tell you his experience. I took a slightly different path into my road to understand hyperbaric medicine. My trail actually started before I became a physician. I spent much of my career early on trying to avoid going to medical school. I truly believe that the most accurate television show, the most accurate medical drama out there is scrubs. Really felt that the social implications of going to medical school was what I didn't want in life. I was working in actually workers' comp compliance for the film and television studios when I had hit so many glass ceilings that I felt it was finally time to throw in the towel and go on to medical school. Throughout my life and my career, I was an avid diver and knew when I started medical school that I wanted to go on in diving medicine. I first got board certified in emergency medicine, but I knew from life that that was not a career path that I could do for 30 years. I cannot see myself at age 60 working day in and day out, nights, weekends, and holidays. As Dr. Alleman said, with patients who aren't necessarily there to get better, they're there to get fixed up so they can go back out and smoke, drink, and do what typical emergency patients want to do. I went to school, did my initial residency at the University of Pittsburgh. It was great to be back in a home state there, and then went on to the University of Hawaii to train in undersea and hyperbaric medicine. I have since worked for NASA as a flight surgeon currently, but before I was doing primarily diving medicine and occupational medicine as the medical director of NASA's big pool. That was a field that enhanced my life, something that I had a passion about from the very start. Let's talk a little bit about this, and why not leave it for the specialists? Why are we here? Why do we want to go back and take on this extra training? Why not just leave it to the specialists? Let's think about that. There are 39,000 board certified emergency physicians in this country. Dr. Alleman talked about primaries in family medicine or in internal medicine, as many of you would be. It gets narrowed down. In occupational medicine, there are only 811 actively board certified occupational medicine doctors in this country. It's getting narrower. The field is getting smaller. That's from the actual ABMS certification report of board certifications that they have offered over the last 10 years. In undersea and hyperbaric medicine, there are only 421 board certified docs currently in this country. Far fewer of those practice critical care or the urgent care, some of those topics we talked about yesterday, and even less practice undersea medicine. So there just aren't enough. We know that we need help. We know that we need other docs out there practicing and understanding the specialty. And that's why we want to bring it to you all and help you learn how you can enhance it into your practice. But do remember, we are a rare breed. So please, over the next hour, be very kind to us. What I'm going to do now is turn it over to Dr. Aleman to talk about this. We're going to start with some of the different types of additional training you can get. Now, we all know that board certification is the gold standard. So Dr. Aleman will talk about the approved undersea and hyperbaric medicine fellowships that are out there. But then we're going to start dividing it up. So I'm going to talk about the program for advanced training, our PATH program. We'll talk about some of the other unique additional continuing education programs that are offered by UHMS, the introductory course, and then even some other one-day courses that can help to bring in very focused aspects of undersea and hyperbaric medicine into your practice. So at this point, let me turn it back over to Dr. Aleman. So little did I know when I did my fellowship that patients still don't do what you say, but they sometimes get better in hyperbaric medicine. So I did a fellowship. Dr. Sanders did it the other way, which is he took the test when it was able to be taken as a grandfathering clause, and he got board certified a little different way than I did. I did my fellowship in New Orleans, and that was not too long ago. It was 2010 when I started mine. Right now, these are the fellowship programs around the country. LSU probably has the largest. They will take up to four or maybe even five a year, five fellows. Most of the programs either have one or two. So as you can see, with this many programs, you're not going to have that many hyperbaric boards-eligible doctors coming out every year, and unfortunately, we're all getting older and some of us are retiring. So in the fellowship, you're going to be credentialed one of two ways, the American Board of Preventive Medicine or the American Board of Emergency Medicine. All these fellowship programs are going to have, of course, hyperbaric chambers. Most of them have multi-place chambers. A few of them only have mono-place chambers. Some of them have both. When I trained in LSU, we had one multi-place chamber and we had several mono-place chambers. Once you finish this one-year training program, you're able to sit for the boards. If you are in emergency medicine, you have to take it through the American Board of Emergency Medicine. If you're not in emergency medicine, you take it through the Board of Preventive Medicine. It's the same test. I don't see why they make it such a big deal. So in fellowship, it's kind of like any other training program. You're going to have rotations every month. Some of these will be, when I was at LSU, I'd spend one month at the multi-place chamber and then one month at the mono-place chambers and kind of back and forth. We had a monthly dive conference, which Dr. Sanders and I still participate in. Everybody that's been through training or has interest can participate in the fellows dive conference. The reason being is that decompression sickness is a very rare disease. It only happens once in a great while. So when we get these, we want to share with everybody so that we can learn from everybody else's experience. In addition, they have monthly grand rounds. All the training programs are required to have weekly didactic lectures. We had once a month journal club. We were required to take exams, in-service exams, once a quarter, make sure we were keeping up with what we were supposed to be learning. And then we had a project that we were expected to present at the annual scientific meeting. In my fellowship, we also attended two courses that I'm going to talk about, the medical examiner divers and physicians training in diving medicine. And then part of our fellowship, we went to a similar meeting like this, the undersea and hyperbaric medical society annual meeting. So what do you do every day? Well, you might evaluate new patients for hyperbaric oxygen. Is this person appropriate, both inpatient and outpatient? We did a lot of wound care. Some of the programs are heavily focused in wound care, and some of them are heavily focused in research. In my program, we did a lot of wound care where we looked at wounds, diagnosed them, debrided them, et cetera, and then treated them to get them better. If they were appropriate for their hyperbaric oxygen, we would, of course, put them in the chamber and exam them before and after each treatment. So the fellowship training covers all of these conditions right here. Some of them are emergent, and we would have to take call just like you would for surgery or whatever. And if we had, let's say, a carbon monoxide poisoning, we may be called in to treat that patient at night or on the weekends. Other conditions, compromised flaps or grafts that needed to be treated very soon after they were discovered, we were also on call for that. So we've covered this a little bit yesterday, our indications. We're not going to go over that today, but these are the approved indications through the UHMS. Dr. Sanders is going to talk about the path. No, we all would agree that board certification is the gold standard for training, but we also know that how many of us can really pack up and move. As much as I respect the training at LSU, the idea of raising a family in New Orleans just isn't one that fits with my beliefs and practices necessarily. So now we wanted to make sure there's other pathways. I, for one, went through an unaccredited, in a sense, fellowship. I went through a practice pathway. At the time it was open, it's no longer open, but the UHMS saw how important that was to allow physicians who have a practice, allow physicians who are already working, who are already established in their communities, to get this additional training and to come up with something that is as close as humanly possible in a non-residential manner. The American Board of Medical Specialties is not interested in allowing under-seen hyperbaric medicine to do away rotations, to do away fellowships. In fact, very few fellowships are. And I know of one occupational medicine fellowship, it's the only one that I know of that allows you to not be really in the location of your primary hospital and just come in for certain periods. So the UHMS has put together a program for advanced training in hyperbaric medicine. It's a combination of online and in-person training. It's actually designed for physicians and mid-levels with the idea that we know we're going to need nurses, nurse practitioners, not to replace physicians in the practice, but to augment them. So why not put together training so that we can have all healthcare professionals practicing at the highest level possible? The goal is it's something that we can do in about a year, so it still fits the same kind of mold as we would see in a fellowship. It's about 100 hours of continuing education credits that you get, 6 to 12 months to complete. And again, the goal is to try to make it reasonable. I mean, yes, $2,000, $3,000 may seem like a lot at first, but when you're getting that 100 hours of continuing education and look at the quality of the education that's put together, then it's well worth the cost. It's a self-directed learning, nine blocks. We have reading assignments in some of the main textbooks that are out there. You'll have video presentations. And then one of the things that's very important to us is a skills lab, because how many of us have done a chest tube in the last year? How many of us have done myringotomies? How many of us have done some of these procedures that we might need any time you put a patient under pressure? Because hyperbaric medicine is a dive every time we put a patient under pressure. So we do the skills lab. We offer it twice a year. It's a one-day skills lab. And then there is an exam to complete so that we can make sure the quality of education is there. Again, we're focusing on those same indications, and you'll see these time and time again that Dr. Alleman posted just a few minutes ago. And these are all the different indications. But in addition, we also, as they do in a fellowship, that understanding the research that's out there and the education that's out there, the PATH program adds a segment on the investigational uses of hyperbarics. Because we want to educate our practitioners on what's coming up. Avascular necrosis is one of our newest indications. It was just approved within the last six months. If we didn't train over the last couple of years practitioners in those investigational uses, then how would they know how to adopt it once we get these uses, these indications approved? So again, that's our, I can't say gold standard, but that's the highest level of training shy of a fellowship that the UHMS recognizes. The Underseen Hyperbaric Medical Society, our national medical society. It's a very good program, and it is something that can be done in your own practice and augmenting your own practice wherever you might be practicing. Next we're going to start to talk about some courses that are a little bit more specialized, and one actually ends up with a certification. So I'll turn it back over to Tony. So, in occupational medicine we have the distance learning program, I think here at UPenn, where doctors can come in once a month or whatever, do some didactics, and then do their actual on-site stuff back in their hometown. We're trying to figure out a way to do that in hyperbaric medicine, and before I left Louisiana, I was trying to get them to do it there, but we're moving towards that. It's not in place yet. Even in Memphis, I practice in Memphis, we're going to try to start a fellowship program. However, as you know, anybody that's ever been involved with a residency or fellowship program, you've got a lot of work to do. And we don't, right now, our biggest obstacle is staff. We don't have the nurses, even, to think about doing a fellowship program. This is a course that I teach, I'm co-chair of this course, and I will say this, the next few courses that we're talking about, we've either taken, taught, or both these courses. So I did my first medical examiner diver's course probably 2003 or 2004, because soon after I moved back to Louisiana, I saw the need, and I took this course. My course was in Houston. This course is offered once a year through the UHMS, it's generally in New Orleans. In the past, they've had it some other venues, but this year, it's at the Intercontinental Hotel in New Orleans, and there's the dates. It's primarily geared towards teaching physicians, and the reason being is that commercial divers need to be examined by a physician, not a nurse practitioner or a PA. This course will teach the participant how to evaluate a variety of divers, commercial divers, public safety divers, scientific divers, recreational divers. Everybody in this room is in a location where you may be working with some of your public safety type of organizations, the fire department, the police department, et cetera, and all of these places may have a dive team, so if you're asked to evaluate these divers, you probably need this training. The topics we cover, and you're going to hear a lot of these over and over again, but we're going to talk about some physics, some gas laws, dive tables, computers, et cetera, and we're going to, in this medical examiner divers course, we're going to talk a lot about commercial diving equipment and what they do. Here's more topics. We're going to talk about problems associated with diving, some barotrauma, how you can get in trouble, oxygen toxicity. We're going to go over those commercial diving forms, what requirements do you have for commercial divers versus public safety divers versus recreational divers, et cetera. We have a session on looking at EKGs, audiograms, now everybody here knows all about audiograms, but most of the doctors that we get in our course are not occupational medicine physicians, they're some other kind of physician, so we have to teach them that. And at the end of the course, we have, well, we have exams every day and they're required to pass so much of it to get a certificate of completion. One thing that we do, we spend a half a day where we visit a commercial diving contractor, and that's very helpful to be able to go out to a company, look at their vessels, look at their hyperbaric chambers, and see and touch, feel all the equipment that they use. This course is approved by DMACC, it's a European Organization Diving Medical Advisory Committee, which is an organization in Europe that works with diving contractors around the world. And DMACC has approved our course as a Level 1 course, and it gives you about 32 hours of AMA, AMA credits. Right now, they have Level 1 DMACC courses in all these countries, including, of course, the United States, and I'm going to talk about the Level 2 course, which is more geared towards diving, accident, investigation, and treatment. So that is, it's a two-week course, it's about 83 hours of Category 1 credits, and again, it's approved by DMACC as a Level 2D course. Now, that doesn't mean much to you, but anyway. This year, it's in La Jolla, it's been in La Jolla the past three or four years, prior to that, it was at NOAA in Seattle. This is geared towards physicians who are really interested in learning more about diving and treatment of diving-related conditions. Again, we'll talk about some diving physics, pressure law, pressure and gas laws, we'll talk about oxygen toxicity, we'll get a little bit into some technical diving, we're going to, there's a skills lab on how to do a myringotomy and actually practicing and doing some, not on real people, but simulated. Return to diving after decompression sickness, barotrauma, we talk about medications. There's another skills lab where they're actually have hands on experience with some hyperbaric chambers. They do, there's a pool day where they spend a whole day at the pool and they'll, there's 10 stations around this pool and they'll do, let's say, a rebreather station at one, they'll do scuba at another, they'll do dive rescue, diver rescue training at another station. Anyway, so you go around all these stations and get a variety of types of training. In the past, at NOAA, they had commercial equipment. I'm not sure if we have commercial equipment at this course in La Jolla. They'll do a search and rescue type exercise, recover of an injured diver and transport. We get into a lot more physiology in this course than the medical examiner divers. We'll talk about specialized diving such as saturation diving. We only briefly cover that in the medical examiner divers course. We talk about heliox diving tables and then pretreatment of diving related injuries. We have sessions on using these treatment tables to treat decompression sickness, when you should, when you should not use a treatment table. There are certain conditions, diving related conditions where you don't treat with hyperbaric oxygen. You treat other ways. We also talk about commercial diving and occupational health surveillance. Most courses will touch on hazardous marine life. And then briefly, this course talks about fitness to dive. This is, if you're learning how to evaluate divers, this is not the course. This is more treatment. A lot of, they have suggested that maybe doctors should do the medical examiner divers course before they come to this, but we're not requiring that yet. They even do some, talk about some ultrasound in the chamber, diver death investigation, and they're going to talk about some forms and what have you. One day, we take a trip out to the military diving facility in San Diego, where they can talk about surface supply diving operations and emergency simulation. At the end of this course, they do have an exam, and if you successfully pass the exam, you get a certificate saying that you've, that you're, you have completed the level 2D course. Dr. Sanders is going to talk about the 40-hour introductory course. So, the course that Dr. Aleman talked about is a great course. It is involved, but it's diving medicine. So, what about hyperbarics? What about the general things we talked about yesterday? What if I want to learn how to work with wound care, or I want to have the knowledge so that I know when to refer my patient for a non-healing wound, or refractory osteomyelitis, or God forbid, I actually have a crush injury at work that a patient might benefit from hyperbarics. And ultimately, for the hyperbaric practitioner, what is probably the most important thing for all of us, that we can bill, right? I mean, honestly, isn't that one of the reasons why we're here and doing what we're doing? So, the 40-hour course is a one-week-long introductory course. It is approved by the Underseen Hyperbaric Medical Society, and with that approval, with that stamp of approval, the practitioner who completes this course now is eligible to bill Medicare. As far as practicing, obviously, that's going to be whatever your hospital or facility's credentialing practices are. But the introductory courses currently that are approved by UHMS are offered really throughout the country and even internationally as well. The courses want to give you an overview of all of hyperbarics and wound care and combine it down into 40 hours. Now, that's just not practical to make someone a specialist by any means. But it does give a very nice overview. These are CME courses as well. So, it'll give you a nice overview of what hyperbarics is capable of, covering obviously all the same topics that we've talked about in the other courses, plus use of something called oximetry, transcutaneous oximetry, TCOM, which allows us to look at the, it's an alternate way of measuring blood flow to the extremities in two different wounds. So, we can understand if they're hypoxic wounds that might scientifically benefit from hyperbarics. Again, this is a brief course. This just gives overviews of the different indications rather than giving a lot of detail. But it will go into details on fire safety, reimbursement, documentation as well. So, it's giving some practical education on how to practice hyperbaric medicine in addition to that brief overview. They will talk about treatment tables for indications beyond just diving medicine. And it will also talk about ethical issues and off-label use. Hyperbarics is still, you can go to the, go on the website, go to the, not the website, go just Google and you'll find a lot of places that are advocating hyperbarics for things that have no evidence. I was doing research once and found an organization that was talking about hyperbarics for your coma patient. And they charged $350 a treatment. They say after about 50 to 100 treatments, we see about 50% of our patients showing benefit. Now, if you go and look in the evidence, okay, if you're doing treatments five days a week and blah, blah, blah, that's about six months to a year, the average coma outside of hyperbarics lasts about the same amount of time. So, again, making statements and claims. That's why we do these courses. That's why that 40-hour course is good. Because it teaches you what is false and what to look for. And like with everything else where we're having some sort of indication or certification at the end, there will be an exam. But it's really not a difficult exam. Then we're starting to see a lot more wound care type courses and shorter courses. Courses that may then specialize just on decompression sickness or something that's just focusing on very, very narrow windows such as the physics and physiology of diving and diving medicine. You'll find some online wound care education partners as a large company that is offering this type of course. Diver's Alert Network is an organization that was initially formed through Duke University and now is an independent organization. But they put together a one-week-long course that would be at some nice, wonderful tropical island. You'll dive for half the day and you'll learn for half the day. It's about 20 hours of CME in these courses. And the goal is to give you more information on diving and hyperbaric medicine. Not a course that's going to result in certification. Not a course that's really designed to give you everything you need to know. But it's a great refresher. Or if you were trained, you took some diving training years ago and you want to refresh, this can give you some good information for it. The Mayo Clinic is putting together a, I want to say, it's not an introductory course because it's definitely in more detail than that. But still a brief course, a more overview course. Also in tropical locations. Also associated with daily diving. But the Mayo Clinic is really at some of the forefront of hyperbaric research and practice. And they've got a course going next month down in Mexico, in Cozumel, which is a wonderful place to dive if you haven't been there. Then there are other courses that are, again, trying to narrow the window so that we're not impacting people's practices very much. The UHMS is aware that many of you will see that recreational diver who has filled out a form. The way recreational diving works is you go into your dive shop and you fill out, you're given a form. A medical history form, a little over a page. And it says, have you had any of the following? If you check the box yes, then one of two things is going to happen. Either you're going to get sent to a doctor or the dive masters will come up to you and say, oh, I'm sorry. I think you may have made a mistake. You checked the asthma box. Oh, yes, but I have asthma. Oh, maybe you didn't understand me. If you check yes, I'm going to have to send you to a doctor and you're not going to be able to take this course tonight. So if you tell me you made a mistake and just cross that off, I can let you continue. And honestly, I saw that happen and it was really heartbreaking because I was just about to train my daughter in scuba and she watches how the industry practices. So anyone who checks yes to any number of things is told, go to your doctor, any doctor, any doctor. And like I said yesterday, the doctor I go to sign off on all my medical forms is my occupational medicine doc because she knows me better than my primary care. So these patients are going to come to you and they're going to ask you about, well, I want to take this diving class or I want to go on this diving trip and I need this form. Can I do it? Now, how many of you are divers or have a little bit of information diving medicine? Okay, a fair number of you. I was down in Roatan and the dive master came up to me and said, so you've got to see this letter. I've got a letter about a patient who's coming down, a diver who's coming down next week and she wants to dive with us. And her cardiologist sent the following note, approved to dive as long as this patient with CHF dives on 100% oxygen and limits her depths to 45 feet. All right, so if we did that, basically we would cause a seizure and seizing on scuba is not really compatible with life. So right, we know that there's a problem. So this spring, I guess June, this summer in San Diego, California, a wonderful place to go. UHMS as part of their annual scientific meeting is doing a one day pre-course to give practicing physicians an overview on diving medicine for the recreational diver. Not to train you how to certify and not certify, but to give you the evidence and the education you need to know when to ask the question of, this is beyond what we can say yes to. And that's really the most important thing. Obviously those, anyone who's a medically dependent diver who's got certain unusual medications or implantable devices or maybe have some neurologic issue that you don't understand, that's the easy ones to send to us, the specialists. But now what about someone who may be on an antidepressant and or someone who's on opiates? Can we let them dive? They're on chronic medications. They have cancer, they have active cancer. Can we let them dive recreationally? So this is a course to give you that overview to empower you to know when to say yes and when to say no and punt to the experts. Again, that course is June 15th this year in San Diego through the Anderson Hyperbaric Medical Society. For people who want to go into a lot more detail on diving medicine, but may not have two weeks or the cost of, I mean, just the cost of housing, of a hotel in La Jolla is more expensive than a course that's near and dear to my heart, which is one of the first courses I ever took was the Emergency Diving Accident Management course offered through the LA County USC Medical Center on Catalina Island. Now that program, it's a one week course. It's a lot of information on diving physics, physiology and decompression modeling and understanding of decompression. It's offered annually. We haven't set up a year for that course and I now am involved with the teaching of that course, but it's designed for normal people. So it's in a language that we can all understand. It's not taught primarily by physicians for physicians, but it's always has never had any problems passing muster for CME because the quality of the education and the level of the education is absolutely apropos for our practices. Actually, this is Dr. Allman's slide. Turn it back to him. So you've seen a lot of the things that we've talked about and it's, I guess a lot of it is gonna be covered in each one of these courses. The gas laws, pressure, oxygen toxicity, diving physiology, diving physics and barotrauma. All of these are gonna be probably in every single course you take and probably every time you take any kind of hyperbaric course of any sort. And that's just to let you know you can't escape talking about these topics. So we'll open it up for questions. Do you have any more comments? Well, just really a big part of this is we've given you a lot of overview of what's out there, but I would expect that there's gonna be a lot of what ifs or I've seen this or how do I approach? And that's why we wanted to save enough time to have more than just questions, but questions and discussions. So please, let's turn it over to you all now for the rest of this session. The two more complex diving classes that you mentioned, which I think both had certifications. Well, yes. And they have some overlap. What would make me decide I wanted to do one course or the other depending on what my goal was? I was kind of unclear on why I might do one versus the other. Okay, so the Medical Examiner Diver's Course, that's the one in New Orleans. It's a four-day course. That is designed to help you, and most of us in this room would be more interested in that course than the other course. That course will let you examine a diver and determine is this person fit to dive based upon all these conditions that they may or may not have in whatever setting, whether it be commercial diver, public safety diver, et cetera. So that's gonna be more of your interest. The two-week course is more towards diving accident management. How are you going to treat decompression sickness? And unless you're working with a hyperbaric chamber, you're probably not going to be treating it. Now, when I started this, when I started working in occupational medicine seeing these commercial divers, I was examining these divers and I would not get those diving decompression sickness calls. My partner, Dr. Serio, would get those and he would take care of those kind of treatments until I got trained and then I was qualified to do that myself. But again, if you're not working with a hyperbaric chamber, you're probably not going to be as interested unless you just love diving medicine. And some people love diving medicine. They just want to know everything they can. Just to add on to that, is there any requirement for public safety divers or commercial divers to be seen by any certified person versus what I've seen which is just random internal medicine people? Family medicine. Let's hear it for the random internal medicine people, the random doc. When's the last time I've heard that term? I like it. Yeah. So the ADCI, which is the American Organization of Commercial Divers, they have a, it's a document that says what are the medical requirements. And in that document, it does not specify a doctor that has been to any kind of training because there aren't enough of us. We need your help. If we could get enough people trained to do these diving exams, then somewhere down the road we could say, yes, you need to be seen by a doctor that's been to one of these courses. Now, the UHMS publicizes all the doctors and their contact information. If you've taken this course, then the ADC says go look at the UHMS website and see who's taken the course and then contact them. So I'm the chairman of the ADCI Physicians Committee and I get these calls all the time. Hey, can you tell me a doctor in Idaho? Well, that's going to be a wish. Because. If I can build on this, though. Sure. But so everything Tony said, I agree, Dr. Lamont said I agree with. However, there are a couple organizations such as IMCA, the International Marine Contractors Association, and DCBC, the Diving Control Board of Canada, that a lot of divers in the U.S. still work under those guidelines and those do have more specific requirements for the training, such as the Physicians, sorry, the Fitness to Dive, give me the full name, sorry, the Fitness to Dive, the New Orleans course. Medical Examiner Divers. Medical Examination of Divers course. And also to answer your, to give a different opinion on your first question, I absolutely agree the Medical Examination of Divers course is the course that we should all be taking and really should be built into medical schools. But that's another story. As far as the next step, for me, I chose the Catalina course, the Emergency Dive Accident Management out of LA County, USC. It's one week versus two weeks and I think it covers really well equivalent to the Physicians Training and Diving Medicine. So both are options, though. Yes, so when I was examining commercial divers, until I went to a DMACC level one course, the Medical Examiner Divers course, if I was examining a diver that was diving internationally, let's say in South Africa, and a lot of those companies specify you have to have a DMACC approved doctor doing your exam, then until you did that, if you got on the job site and you didn't have a DMACC examination, then they'd make you go get another exam. So all the DMACC, the doctors who have done a DMACC level one course, they'll be published somewhere to say these are the ones that we will accept. Now that DMACC certification expires after five years, so because the regulations change. We did, we're both on the ADC committee and our last publication change of the medical requirements was in 2018, where we're coming out with another one this year. So about every five years, the regulations change and you need to keep up with that. You also asked a question, we just talked a lot about commercial diving. Everything we said is the commercial diving, working for a contractor to do diving services. You asked a very, very good question about public safety diving. Public safety diving operates under an exemption from OSHA and while there are recommendations for health certification, there are no requirements out there and that's a huge problem and one of the reasons why we see a very high relative percentage of deaths in the public safety diving community and a lot of that has to do with fitness to dive and they're just not adequately cleared. So yes, and it gets even scarier. I worked for L.A. County Sheriff for many, many years as a diver, as part of their dive team and we were one of the premier dive teams in L.A. County along with L.A. County lifeguards. We had a fatality that happened and we had a multi-jurisdictional call out. We had a dive team that were aquatics divers. They were the dive team for the pools in Los Angeles County and so you have public safety divers who only dive in pools being thrown into the surf zone on a very rough day in L.A. County and didn't do well. No one got seriously injured that day, thank goodness, but so your public safety dive teams are an incredible, incredible variety of divers. Dr. Orford. Bob Orford, Mayo Clinic Emeritus. I was amazed by your presentation. Thank you very much. Thank you. It's extremely granular in terms of detail and it made me realize as a person who has done many FAA examinations and DOT examinations and those sorts of things over the years that are clearly regulated and doctors have to do one thing, one course, one examination, one certification as being that type of an examiner. Wow. I mean, there are 15 different ways to do this with diving medicine. So my question, maybe it's more of a suggestion, is would it be possible for UHMS to develop an algorithm, okay, that's the first step, as to how this pattern goes. If you're a physician who's entering this business and you want to know what's the best thing to do, you already told us what the best thing to do is the DMACC 1 or DMACC 2D, but if you don't want to do that, maybe because you're not going to be doing certain types of things, you would be able to set up on the UHMS website an algorithm that people could follow by asking them questions. Do you do hyperbaric? No. Okay, well, that just gets rid of half of these courses. Do you do, do you want certification for public safety diving? No. Okay, well, that gets rid of some more stuff. And then your physicians would be more easily able to find the right course than appears to be even possible. I was thinking to myself, I'm not that likely to take one of your courses, but I thought to myself, how do I choose from all of these courses? They all sound wonderful, but, you know, some are a lot longer than others and have a lot more detail. So that's my suggestion slash question. And a lot of times we'll get questions from doctors who may be interested and we'll try to direct them into, based upon what they're trying to accomplish, we'll direct them into what course they should take. Yes. Thank you. I do like your suggestion, though, of some way to filter out all these other courses so you know where to go. And I like that. When you first started your question, my initial gut response was, how do we guide someone? We've all heard the story, you put three doctors in a room and you're going to get four opinions. And now we have how many doctors in this room and how many opinions would we get? But I really like the approach of not guiding, not recommending any particular course, but giving that sort of flow sheet on what the courses offer and what they give you. And I think that's a fantastic idea that I will take back to our, to the Anderson Hyperbaric Medical Society. Thank you. So I have a quick, well, quick question. Not that I've heard what you've talked about. Every X amount of years I get these papers from a gentleman who dives to look under the bridges, and I'm, I just check off these boxes and now I'm extremely nervous now about checking off these boxes. So could you guide me a little bit as to what I, maybe online courses so I'm not, when I do check these boxes off, I'm sure of what I'm doing. Yes. So, okay, let me start. Because I can take this from more of an agnostic situation. When I came to NASA, we had our own internal practices for what qualified for divers. And then every doctor brought their own background and their own opinions into how they filled out the forms. ADCI, the Association of Diving Contractors International, in their 2016 revision, put together a document that's really designed to guide the physician through. So that is a great place to start. Because that is a document that is very well written. And so we actually adopted that at NASA as our guidance. And it's only after that that I got involved with ADCI because I saw the benefit to us. Then the next step is that initial course we talked about, that one-day course in San Diego, is a one-day overview. But ultimately the gold standard to answer the question is the physician, the medical examination of divers course, sorry, it's changed names over the years. And we had multiple courses over the years. But the medical examination of divers course will give you the whole big picture. But that's a four-day course. Four days? Yes. But it goes over the weekend. So you're only taking two days off of your practice. Very detailed. But so that would be the practice. ADCI guidelines look at that document, give you some initial overview. The one-day course that we're teaching at, through UHMS, or they're teaching, I'm not part of that course. I'm actually taking it. To give that guidance of when to say no and when to punt. And then the ultimate course that gives you the overview and the empowerment to make the decisions yourself. Hi. I'm Curtis Cummings, Navy Hyper Barracks trained. Not a Navy diver. I examine now public safety and scientific divers for years. Is the ADCI document available online? Yes, it is. And is there a charge? No. Ah, cool. Okay, great. And I'll have a couple of questions for you offline. Sure. With what Dr. Orford said, and an algorithm would be nice, although what might be best is to phone one of you because of this detail or that detail. Whom I see, I'm qualified with a certificate that's 24 years old. Not going to expire, but I should keep up. This kind of questions, other than I'm phoning you and reading Dan's publications, some other options for all of us would be good. Yeah. So you're right. The things change, always change. And at one time, the consensus standards, which is the ADCI document, was only available in print. Well, now it's available online. You had to buy the document at one time. And I think when it first went online, the ADCI was charging. But they let me, as the chairman of the Physicians Committee, disperse it to any doctor that wanted it free of charge. And now everybody can. Now, the document is 500 or 600 pages long. It's chapter two. So it's early in the document, chapter two. And just, I guess, The medical chapter only. It'll tell you how to conduct commercial diving operations. But the medical chapter of their consensus standard is what we're talking about. Yeah, you don't need to waste your time with the other stuff. Very few pages, maybe 10. Yeah. 20, actually. 20, OK. Excuse me, 20 pages. And a new revision is coming out this year. We submitted it. And it should be online within the next two months. Now, those of you that are like me, it's 20 pages without pictures. So when you allot the time to read it, you've got to remember there's no pictures. It takes a little longer. Oh, hi. Yeah, my name is Matthew Manigallum. I'm the chief resident of the University of Texas Health Science Center at Houston. This is new material for me. I loved the lecture. Thank you a lot. I learned a lot today. I had no idea about a lot of what you mentioned. So I have kind of two questions. My second one is quick. My first one is, what are the most common disqualifiers for a diver, medically related disqualifiers? So that list is actually pretty long. And I'll tell you some of my experiences. I was doing a lot of commercial diver exams. To be a commercial diver, you have to go to dive school for six to 12, six to eight to nine months, depending on which school you went to. And it cost about $30,000 to go to dive school. So we'd have these divers come in. And they'd come to my office just fresh out of dive school, all gung ho, I want to dive in the Gulf of Mexico, and I'm going to be a commercial diver. And they come to my office. Probably one of the most frequent things was weight. Next was other medical problems. And the list is long. I mean, psychiatric problems, they're on bipolar medications or whatever. The ADCI document says you can't be on any of these medicines. Look it up. There's a pretty comprehensive list now. Asthma is a disqualifying. Diabetes is disqualifying. Now, ADC, for commercial divers, so from a commercial dive standpoint, the list is very long as to disqualifying conditions. Recreational divers, it's much more inviting. So you asked the question, though, for recreational divers, what are the most common things? The answer would come down to what is the most common cause of death, medical-related cause of death in a commercial diver, and that's cardiovascular issues. So the number one disqualifier would be active cardiovascular disease and inability to exercise or risk that comes with that. So then the second would be, so I'd say cardiovascular and pulmonary respiratory issues would be the most common disqualifiers. But ultimately, in recreational diving, we have everything that you can imagine out there is actively diving today for better or for worse. So I had, last week, I had a policeman who wants to be on their public safety diving team, and he's got a seizure disorder taking medications. I said, well, when's your last seizure? Well, last year. And he wants to know if he could be cleared to be a public safety diver. I said, in my opinion, no. And I said, I'm going to call Duke up, see what their opinion is. So I called Duke up. They said no, too. So, I mean, we get, it's like, I've heard some people come in, oh, I have this defibrillator, can I dive? It's like, really? So you had a second question? Oh, yeah, yeah, sorry. This picture was staring at me in the face for a while. I was wondering if you could eventually explain what it is. My theory is volvulus. We were talking about Ilias. It's your slide. No, it isn't. Yes, no, it's on your slide. You put it in. I never saw the slide. Yes, you did. It's a question mark. It's just a question mark. Oh, I see. It's his slide, not mine. Hello. Thank you. It's a question mark. Do see me afterwards, because I want to talk to you about Grand Rounds at UT Health, because I was just talking to Baylor and all, so. Any other questions? Yes, sir. At the San Diego course, at your New Orleans course, is there a chance to dive? At the San Diego course, there is. You're going to, the pool day, you can get in the pool, do a rebreather, dive with a rebreather. Oh, good. Yes, there's, and I think at the San Diego course, and I'm sorry, I took the course when it was at NOAA in Seattle, so I know what it was then. I'm co-chair of the San Diego course. However, I've not actually taken that course, so I'm not sure everything goes on. But I think they have a commercial dive helmet that you could dive with the commercial dive helmet also. Yes. So that might be worth it. Folks who don't know, it's cold water diving off California, so you need a thick wetsuit. Yes, thick wetsuit. And we tell you, if you're coming to that course, we tell you, if you plan on diving, bring this, this, and this, so that you can. Not New Orleans? No, we don't dive in the New Orleans course. Right. Yeah, right. Any other questions? We're available. Thank you guys so much. We really appreciate this. We're so pleased with the number of people that attended this session, and it sounds like from the questions, you felt it very valuable, so thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

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