1. Comprehensive Healthcare Solutions How I learned to love “PRESSURE” The Joys of HBO

2. Comprehensive Healthcare Solutions “HAPPY” Patients

3. Comprehensive Healthcare Solutions Unhappy Patients Barotrauma (squeeze) Otic (ear) Pulmonary (lung) GI (colon) Dental (tooth) Sinus

4. Comprehensive Healthcare Solutions Sighing is a marker for stress

5. Comprehensive Healthcare Solutions Boyle’s Law

6. Comprehensive Healthcare Solutions Pressure-Volume Relationship

7. Comprehensive Healthcare Solutions Is Boyle’s Law an issue for every pressure vessel?

8. Comprehensive Healthcare Solutions Delta Sub

9. Comprehensive Healthcare Solutions Unhappy Patients Barotrauma (squeeze) Ear (most common) Pulmonary (most serious) GI (colon) Dental (tooth) Sinus

10. Comprehensive Healthcare Solutions Pulmonary Barotrauma Tissue damage Emphysema Pneumothorax Air embolism

11. Comprehensive Healthcare Solutions Lung Anatomy

12. Comprehensive Healthcare Solutions Mediastinal Shift

13. Comprehensive Healthcare Solutions Tension Pneumothorax

14. Comprehensive Healthcare Solutions Diagnosis Chest pain ↑ Blood Pressure ↓ Respiratory Rate ↑ Breath sounds ↓ Bell Tympany ← Hyper-resonance ← Tracheal shift →

15. Comprehensive Healthcare Solutions Chest Tube

16. Comprehensive Healthcare Solutions Questions?

17. Comprehensive Healthcare Solutions The Ear Under Pressure

18. Comprehensive Healthcare Solutions Why Talk About Ears Most frequent pressure related injury Poor understanding of equalization techniques Ear damage (Barotrauma) is… *PREVENTABLE*

19. Comprehensive Healthcare Solutions Pressure-Volume Relationship

20. Comprehensive Healthcare Solutions Ear at Sea Level

21. Comprehensive Healthcare Solutions Ear at 2.6 FSW

22. Comprehensive Healthcare Solutions Locked Ear at 3.9 FSW

23. Comprehensive Healthcare Solutions Forceful Valsalva

24. Comprehensive Healthcare Solutions The Present Strategy How do we most often judge middle ear equalization ability? Test of pressure??? Patient query??? “Reactive” instead of “Proactive” I HOPE NOT! }

25. Comprehensive Healthcare Solutions Objectives Recognize “Ear Fear” Assess pressurization effort with “Doc’s Technique” Become proficient in 3 methods of Middle Ear pressurization Learn PROACTIVE intervention

26. Comprehensive Healthcare Solutions What is “Ear Fear”? Pressure is uncomfortable Childhood pain -> adult fear Retrograde tear duct inflation Confusion over instructions

27. Comprehensive Healthcare Solutions Assessing Equalization Effort The Doc’s Technique: Watch The Nose Inflate! Palpate firmness of inflation and compare it to your own equalization effort Watch for “Excessive Effort”

28. Comprehensive Healthcare Solutions Otoscopy Identify landmarks Check mobility of the TM Verify TM bulge with presssurization of the middle ear

29. Comprehensive Healthcare Solutions Normal Ear

30. Comprehensive Healthcare Solutions Pneumatic Otoscopy

31. Comprehensive Healthcare Solutions Bony Exostosis

32. Comprehensive Healthcare Solutions Hemotympamum

33. Comprehensive Healthcare Solutions Video Otoscopy

34. Comprehensive Healthcare Solutions Pressurization Techniques Valsalva Maneuver (1704) Frenzel Maneuver (1932) Lowry Technique (1950s) Combination maneuver Pressurize and swallow

35. Comprehensive Healthcare Solutions Antonio Valsalva Pinch nostrils closed Increase pressure in chest Cheeks tight, not puffed out Should not be a prolonged effort engorgement – venous return never on ascent!

36. Comprehensive Healthcare Solutions Herman Frenzel “Luftwaffe” “The Throat Piston” Close vocal cords Pinch nostrils closed Raise the back third of tongue Feel “Adams Apple” elevate

37. Comprehensive Healthcare Solutions Advantages Does not adversely effect blood flow Independent of respirations Can be performed with mouth open Easy to teach and practice “Bobbing Adams Apple”

38. Comprehensive Healthcare Solutions Teaching Techniques Bazooka vs Otovent

39. Comprehensive Healthcare Solutions So Many Methods So Little Time Pressurization methods work best “Eustachian Tube Awareness” Combination methods work well but are harder to learn Perform effective technique “Early and Often”

40. Comprehensive Healthcare Solutions How Hard to Blow Never “forceful” - just “ADEQUIT” Never blow hard to relieve ear squeeze. Pressurization is a preventive maneuver Never perform a Valsalva on ascent. Use swallow, yawn or jaw thrust

41. Comprehensive Healthcare Solutions Doc’s Motto: Never give up… there is always a way In extreme cases consider PE tubes

42. Comprehensive Healthcare Solutions Summary Watch out for “Ear Fear” and the “Excessive Effort” sign Watch the nose for proper inflation Bob your Adams Apple Verify ME pressurization prior to treatment by watching the TM bulge

43. Comprehensive Healthcare Solutions Where to get more information Doc’s Diving Medicine Homepage “divingdoc.com”