Nascholing Capita Selecta Duikgeneeskunde, AMC, February 11, 2012 1/4
Capita Selecta Duikgeneeskunde
Medical aspects of compressed air work at sea level and altitude
A refresher course for physicians of NVAB and NVD and others care professionals.
Date: Saturday February 11, 2012.
Location: Ziedses des Plantes Zaal, B1-120, AMC, Amsterdam.
Chairman: Dr. G.H. Visser, neurologist, chairman Med. Committee Dutch Underwater Federation
8h45 Welcome and registration
9h15-9h20 Dr. N.A.M. Schellart, Opening address.
9h20-9h35 T.P. van Rees Vellinga, MD, Delta Medicine BV and AMC. An introduction to caisson
medicine; learned from the past.
9h35-10h05 Dr. N.A.M. Schellart, Assoc. Prof., Biomed Eng & Physics, Decompression theory.
10h05-10h45 J.Cl. Le Péchon, MSc, MEng, JCLP Hyperbarie, Paris, Risk assessment when working
under pressure in the dry.
10h45-11h00 Questions and case studies (speaker and participants)
11h15-11h55 Prof. Dr. W. Sterk, Dadcodat, The use of gas mixtures during deep caisson and tunnel
11h55-12h10 Questions and case studies (speaker and participants)
12h10-12h50 J.C. Le Péchon, MSc, MEng, JCLP Hyperbarie Paris, Altitude problems in pressure
12h50-13h05 Questions and case studies (speaker and participants)
14h00-14h40 Prof. Dr. W. Sterk, Dadcodat, Long (de)compression in caisson and
14h40-14h55 Questions and case studies (speaker and participants)
14h55-15h35 T.P. van Rees Vellinga, MD, Delta Medicine BV and AMC. The prevention of infections and
15h35-15h50 Questions and case studies (speaker and participants)
16h50-17h15 Evaluation of the examination.
17h15 Closing address and refreshments.
For fees and accreditation see the registration form at the last page.
By car via highways A9 or A2 (in both directions turn off at Amsterdam Z-O, exit S111/A9) and follow “AMC” road signs. You
can park free of charge at one of the parkings without barrier located at the east or west side of the buildings.
By subway: line 50 or 54, direction Gein, get off at Holendrecht. Signs point to AMC
By rail: line Amsterdam-Utrecht, get off at NS station Holendrecht.
After leaving train or metro: AMC is to the right in front of you (it is a 12 min walk to room G4-123.)
Route to room B1-120:
Take the main entrance (clinic), go straight; pass through the main hall and then turn left to the elevators (and stair case) of
building B. Go to the first floor and, after leaving the elevator, turn left. You will find B1-120 directly in front of you.
Nascholing Capita Selecta Duikgeneeskunde, AMC, February 11, 2012 2/4
The general mission of the “AMC Capita Selecta Duikgeneeskunde”.
The Capita Selecta Duikgeneeskunde, refresher courses in dive medicine, are given by the Academic Medical
Centre (AMC), which is a one-board cooperation of the medical faculty of the University of Amsterdam (UvA) and
the academic hospital with the UvA. This hospital has a special position amongst the Dutch academic hospitals; it
is the seat of the Boerema tank, the cradle, of Dutch and even European hyperbaric medicine.
This new type of refresher courses, offered to all professionals concerned with diving medicine, has a typical
‘Alma Mater’ character.
Primarily, the Capita Selecta of the AMC present comprehensive education in dive and caisson medicine
arranged by medical discipline. Additionally, new developments and insights are taught as they occur in the
academic hospitals and medical faculties globally. This implies that, in the lessons, the characteristics of disorders
are discussed, including their differential diagnostics and treatment, from the point of view of the present
academic state of the art.
Resuming, the Capita are marked by a natural mix of education in specific fields of dive medicine and to bring the
participants up-to-date with the latest developments in the discipline, for instance in cardiology, ophthalmology
etc. Also, the Capita will pay attention to the requirements for the medical examination of the divers.
The Capita are aimed at “basisartsen” (non-specialized physicians), first line physicians, sport- and occupational-
physicians, dive and hyperbaric-physicians, clinical doctors and hyperbaric paramedics.
In general, the lecturers are affiliated with academic hospitals and medical faculties, and have an international
reputation in patient care. They have experience with academic education, are active in research and have an
international reputation as is evident from their papers.
To maintain a low participatory threshold, the venue is easily to reach and centrally located. Moreover the course
is set up to be low-budget.
Aim of Caisson and hypobaric medicine
This course aims to offer insight to the dive physician in how to medically supervise caisson and tunneling
projects irrespective of the ambient pressure, in such a manner that DCS and other medical risks are minimized.
The course can be seen as an advanced refresher course. Therefore having previous knowledge of elementary
diving medicine is a distinct advantage, though not an absolute prerequisite.
This refresher course is given under the responsibility of the Academic Medical Centre, Univ. of Amsterdam (Nico
Schellart, course director and Tjeerd van Rees Vellinga, adjunct course director and AMC). The organization is
undertaken by the Stichting Duik Research (SDR) and Biomedical Engineering & Physics, AMC (Prof. Dr. Ir.
A.G.J.M. van Leeuwen, chair).
An application for accreditation will be submitted to the NVD and NVAB, and NDC (under reserve). The content of
the course fulfils the requirements of DMAC&EDTC&ECHM 2010.
The program comprises 6.0 of oral contact hours.
More information and the application form can be found at www.duikresearch.org.
SDR is a non-profit organisation aimed to promote dive safety in the widest sense. The SDR is an organisation
run exclusively by volunteers.
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Tjeerd van Rees Vellinga An introduction to caisson medicine; what we have learned from the past
A comprehensive review is given about the medical history of caisson and tunnelling work with emphasis on what went wrong
and the lessons that were drawn from DCS incidents.
Nico Schellart Decompression theory
A quick refresher will be given on the physics (gas laws) and physiology (perfusion and diffusion) of decompression theory and
phenomena. Then, models for the assessment of DCS risk and models of venous gas embolism will be discussed. Single
phase (Neo-Haldanian; parallel and serial models) and dual phase (gas and liquid) theory will be treated, such as VPM.
Jean-Claude Le Péchon Risk assessment for working under pressure in the dry
Occupational safety precautions should be based on risk assessment. Working in the dry under pressure requires that workers
breathe compressed gases in hyperbaric chambers as well as in a pressurized working environment. There are two major
sources of danger to cope with. The first relates to the consequences of breathing under pressure and the changes on human
physiology this will cause. The second one is dealing with the dangers created by the hyperbaric environment and the tools
used in a confined situation that may hamper emergency responses to accident at the worksite. Both these lines are reviewed
in a logical order, actual cases will be used to illustrate the safety responses. A set of basic safety rules that can be brought
together to ensure safe working conditions is proposed.
Wouter Sterk The use of gas mixtures during deep caisson and tunneling labour
Conventional compressed air work is done to 4 bar (absolute). However, the need for ever deeper caisson and tunnelling work
is growing, particularly in our densely populated river deltas. Because of nitrogen narcosis and increasing risks for DCI,
alternative gases and gas mixtures have to be used. The use of oxygen, nitrogen, helium and trimix and their limitations will be
discussed. Also incidents with tunnelling labour will be discussed.
Jean-Claude Le Péchon Altitude problems in pressure exposure
We consider the environment normobaric when the pressure ranges between 0.1 bar above the local pressure (or 1 m
underwater and about 0.1 bar below the standard sea level pressure of 1 bar, or at 1000 m of altitude. The 1 bar (absolute)
mark is not a threshold; however it is used as reference for normal living condition for most of humans on Earth. When one
needs to live or work at low pressure, specific adaptations and/or procedures are required. When one needs to work under
increased pressures, equally specific techniques and precautions must be implemented (see Risk assessment….). When
one wants to work at increased pressures from a low pressure environment, all the procedures discussed in the previous
lessons need to be revisited. Similarly all these concepts apply to lower pressures than previous exposed to, such as happen
with acute mountain sickness, aviation, space exploration and EVA, tunnelling (diving) at altitude or flying after hyperbaric
exposure (or after diving). Practical examples of such situations are used to demonstrate the physiological mechanisms
involved and to clarify how these issues should be considered when preparing the appropriate working safety rules.
Wouter Sterk Long (de)compression in caisson and tunnelling work
To allow for efficiency, working in compressed air conditions, requires long exposure times. This also means long
decompression times and an increased risk of DCS.
Furthermore decompression tables for compressed air work need to be more conservative than for diving. To reduce
decompression times and to decrease the risk of DCS, in the last decades the use of oxygen has been introduced. But oxygen
too has its limitations. Also, work at even higher pressures needs alternative gas mixtures. Furthermore, modern diving
techniques like saturation diving have to be used to enable this work. The pro’s and con’s of “bounce diving” versus saturation
techniques will be discussed. Studious cases will be discussed. Some possible late damage to compressed air workers will be
mentioned as well.
T. P. van Rees Vellinga The prevention of infections and microbiological hygiene
The DMAC protocol for Saturation Diving Chamber Hygiene will be discussed. This protocol is the basis for chamber hygiene
but its scope is too limited as will be made clear. The implementation of ear inspections, swabs and environmental swabs on
every third day will be discussed in relation to the prevention and to therapeutic interventions. The extended protocol allows for
an early warning system to prevent problems. Cases of own practice and the literature will be discussed.
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Jean-Claude Le Péchon graduated as a biochemical engineer from INSA in Lyon in 1963 and as a marine biologist from Nice
University. He has been employed at the Musée Océanographique of Monaco as a scientific diver as well as in the
Conshelf III Experiment (the undersea habitat sponsored by Jacques-Yves Cousteau). Later he joined CEMA in Marseilles
(J.Y. Cousteau) to do research on breathing gases and to develop procedures for very deep dives (1000 m with animals;
500 m with humans) and was a test diver in the Saturation II simulated dive at 400 msw. From 1973 to 1986, he served with
CG DORIS, an offshore and civil engineering diving company. In 1986 he founded JCLP Hyperbarie, a global consultancy
agency/ bureau specialized in questions related to life support and safety under pressure (commercial diving, tunneling, space
and hyperbaric medicine). He has been involved in more than 75 tunneling projects with compressed gas mixtures, up to 6.9
bar and as well as in saturation "diving" technology. Although retired, he is still teaching physiology and the technology
of diving- and hyperbaric medicine at several universities in France and all over the world. He is a National Instructor
for SCUBA diving (Air, Nitrox and Trimix) and holds a deep sea commercial diver certification since 1974. He has published
many papers in magazines, books and international congresses etc., and often speaks at international congresses on
different topics concerning diving, hyperbaric medicine and compressed gas work.
T. P. van Rees Vellinga obtained his MD at the Free University of Amsterdam and has specialized in occupational medicine.
He is a Dive Physician B (with the National Dive Centre) and has published papers about several medical aspects of
caisson and tunneling work. He is research fellow at the Coronel Institute (for Occupational Medicine) of the Academic
Medical Centre of the University of Amsterdam. He is president of the Society for Dive Medicine (NVD) and an avid
recreational diver. Founder and director of Delta Medicine BV, operating with a hyperbaric chamber in the hospital of
Nico Schellart received his MSc (c.l.) in Biology at the University of Amsterdam (UvA) and has specialized in physiological
biomedical physics. He investigated visual information processing of the retina, resulting in a PhD in 1973 (UvA). He is an
associate professor with the dept. of Biomedical Engineering and Physics of the AMC and is currently serving as associate
editor of “Medical and Biological Engineering and Computation”. He has investigated multi-sensory information processing in the
brain, both animal and human. Since 1998 he lead a research group concerned with basic and clinical EEG and MEG research of
the visual and auditory system. He has studied the brain and the visual system under hypoxic and hyperoxic conditions both in
the lab and in the field and introduced HBO treatment for patients with cerebral radiation damage. He published these
dysbaric and HBOT studies in addition to his neuroscience papers and has contributed to a number of textbooks. He was
publisher of a free electronic Textbook on Medical Physics and teaches diving physiology. He has tested the technical and
physiological performance of dozens of dive computers (www.duikresearch.org), and is a recreational scuba- and freediver.
Wouter Sterk (1938) obtained his MD at the University of Amsterdam in1966 and joined the Diving Medical Centre of the
Royal Dutch Navy until 1975. In 1973 he received a PhD at the University of Utrecht with the thesis entitled: “Respiratory
mechanics of diver and diving apparatus”. In 1975 he registered as anesthesiologist after obtaining his training at the
Academic Hospital of the University of Utrecht. From 1975 on he is DMO for diving companies, caisson and tunneling
projects and director of Dadcodat.
In 1993 he was appointed as Professor in Underwater Physiology at Leiden University. From 1995 to 2009 he was
medical director of the Institute for Hyperbaric Medicine with several settlements in the Netherlands and afterwards until 2010
Interim medical director at the DDRC Hyperbaric Medical Centre, Plymouth, UK. Worldwide, he supervised various tunneling
projects and is one of the most experienced students of the precordial Doppler technique. He developed the current
professional diving tables in use by the Dutch National Dive Center (NDC) and was an enthusiastic recreational diver.