COVID-19 Advisory

As you might imagine, DAN has received a number of enquiries regarding the current COVID-19 Pandemic.
 
We have already issued travel advisories for DAN Southern Africa Members, and for SouthAfricans there are the restrictions on travel issued by our President as part of the 21-day lock-down. Other countries in and outside our DAN Southern Africa region have issued similar restrictions, and these should be heeded.
 
There is a lot of fake news floating around, so we encourage you to verify facts and consult reputable sources for information.  The formal COVID-19 websites of the National Institute for Communicable Diseases contains up-to-date information and we will post (verified) information that is relevant to divers as they become available.
 
So, with that preamble, I want to start by saying that we will not be addressing the typical COVID-19 issues in this Factoid Issue, but rather selected responses to questions posed by DAN Members, including those who may still be in remote areas and may be wondering how to manage their limited resources optimally. There is something relevant for everybody.

Here are four questions we received that offer a backdrop for the answers we would like to provide:
 
Firstly: Could you help me to get a plan on how to assist somebody with breathing problems (due to Covid 19) with the oxygen that we keep here at the dive center?
 
Secondly:  As we are without any medical assistance in a remote area and would like to have a simple protocol to follow if any of my family gets sick and we have some oxygen available for diving emergencies. How much oxygen should we give? By what method; and for how long? Please advise.
 
Thirdly: I am a DAN O2 Provider and Instructor and have the following question for you: I have a DAN O2 rescue pack with two 6-Liter cylinders. Would a flow rate of 15 Lpm be of any use to a person with respiratory symptoms due to COVID-19? If not, what do you suggest?
 
And Fourthly: Could Hyperbaric Oxygen help people suffering from COVID-19
 
These are all very relevant questions. For the first three, I would like to refer you back to the downloadable DAN Guidebook “Prepare don’t Panic” which is on the DAN SA Blog. I do want to speak to the issue of oxygen utilisation, moving symptomatic individuals, and hyperbaric oxygen therapy, however.
 
Limited supplies of oxygen and difficulties in gaining access to specialised medical assistance are definitely some of the pressing challenges.

But, before addressing these, let us not forget the primary advice on social distancing, self-quarantining and self-isolation. Self quarantining means staying in the same building with other potentially exposed but asymptomatic individuals. Self-isolation, means isolating symptomatic individuals (where there is a very high suspicion that their symptoms are due to COVID-19 due to contact with other COVID-19 positive individuals or travel from high-risk areas). These individuals should keep themselves in a separate room and use only their own linen and cutlery.
 
The main concern is for individuals in self-isolation: when should one move them to further medical care and, if the decision is made to do so, how to optimise the use of any available oxygen?
   
To keep things simple I would like to offer four key considerations which may be relevant depending on the specific situation:
 
1. As with all our DAN First Aid Courses, Provider Safety is vital. So, wear gloves, and use or improvise masks and eye protection, if you do not have professional masks and splash guards, as necessary, but try to shield your own mouth, nose and eyes while assisting a symptomatic individual.

2.  Remember that there may be other diseases like influenza, tick-bit fever, malaria, traveller's diarrhoea or dysentery that may mimic COVID-19 infection and for which isolation may lead to a disastrous outcome completely unrelated to COVID-19, particularly malaria. If you are in a malaria area, and the individual started developing symptoms after being in an area with infected mosquito exposure for at least 7 days (especially if there are no or only incidental respiratory symptoms), please assume the high probability of malaria and treat them for it if fever and flu-like symptoms develop, while keeping the person isolated from other asymptomatic individuals. Refer to our material on malaria for this purpose. Also advise individuals who are still at risk of contracting malaria to implement the prescribed anti-malaria precautions, especially during the 21-day period of the lockdown, including taking doxycycline or Malarone/ Malanil and even Mefloquine (Lariam) as they are not going to be diving for a while, and the risk of malaria becomes greater than the risk of adverse medication reactions after 14 days.

3. Encourage honesty so that people admit symptoms earlier. If respiratory symptoms and breathlessness reach the point where the individual is showing obvious signs of escalating respiratory distress (and especially if there is relentless coughing, breathing at rates in excess of 25-30 per minute, or cyanosis (which is where the lips and skin takes on a bluish colour; this is a definite turning point in moving a symptomatic individual if there is a reasonable chance of getting to a higher level of medical care and respiratory support.

4. Lastly, the issue of Oxygen: Breathing oxygen via a demand valve remains the least wasteful way of providing oxygen. If the person has the strength to breathe through an O2 Demand Valve they should do this at a frequency that is just sufficient to offer some relief of critical symptoms.  Pulses of oxygen will allow supplies to last longer. If there is no oxygen demand valve, connect the oxygen supply to a pocket mask, set the flow rate on 0.5-1 Lpm oxygen and have the person breathe through the filter fitted to the Pocket mask. Using a pocket mask also protects those caring for the individual to some extent. Try to stretch your supplies as best you can while considering the distance and time to getting to medical care. Also, the longer the distance, the earlier you may want to consider moving the individual. Note that nasal prongs may aerosolise viruses; non-rebreather masks require flow rates that are too high and wasteful. So both of these are impractical with limited supplies of oxygen. Some serious cases can deteriorate rapidly within 2-3 hours, so do not delay cases where the suspicion of COVID-19 is high. Be aware of the potential fire risk when using oxygen in enclosed spaces and – as said before – rather give “bouts” of oxygen as required to ease symptoms as you make your way to a medical facility.

Importantly, we would advise you (as far as possible) not to attempt to treat a person getting ill with potential COVID-19.  

Some high-risk individuals have deteriorated quite fast and it is therefore important to have medical care available if this is possible, rather than thinking that oxygen alone would cure the disease.
 
In closing, just a brief comment on Hyperbaric Oxygen: It is not readily available and requires highly trained critical care staff who are familiar with the complications of using hyperbaric oxygen, if its use is to be considered in COVID-19 patients. It is most certainly not considered a standard of care at this stage. For those interested, a reference is provided on a series of cases treated with HBO. However, this is a relatively low level of evidence and should not delay getting persons to conventional intensive medical care.
 
Thank you for watching this DAN Factoid on oxygen and COVID-19. Please remember to refer to the guidebook on “Prepare, don’t panic”, by DAN.

We also invite you to visit the COVID-19 Updates section of our website, where you will find regular updates regarding the COVID-19 outbreak