© 2009 Underwater Science Ltd – DIVERS Emergency Life Support Incident Report Card

NAME: SURNAME: DOB: (Y/o) ADDRESS: Phone No:

M /F
NOK Contact: Completed By: Signed:

1. SCENE ASSESSMENT / PRESENTATION: 4. MEDICAL HISTORY:

Presentation: Rapid Ascent ↓LOC Allergies:
Time Hrs
Missed Deco Vomited Medication:

Collapse Alcohol
Date: Past Medical History: Last Oral Intake:
Fitting Drugs
Rebreather Instructor
Location:
Chest Pain Diver

Other Student Fracture (#) Burn Foreign Body Events:

Non-Diver Abrasion Laceration Swelling

2. PRIMARY SURVEY: 3. SECONDARY SURVEY: 5. DIVING HISTORY:

Response: ALERT VOICE Time: H H M M H H H M M H H H M M H Max Depth: Msw
PRESSURE UNRESPONSIVE Resp. Rate: Duration: Plan Deco
Airway: Normal Clear SpO2: No. of Dives Today: 1 2 3
Injury OBSTRUCTED Peak Flow: Multiple Days: Yes / No
Oxygen: 12-15L/Min H H M M H BP: Gas Mixes: Bottom Deco
SpO2: % H H M M H Pulse: First Presentation: Before During After
Breathing: Normal NOT NORMAL CRT: How long after
BVM H H M M H Glucose: Surfacing? <2 Mins <20mins >20mins
TWELEVLAP: Trachea Wounds PEARL: Yes / No Yes / No Yes / No
Has the problem
o o o
worsened since Yes No
Emphysema Larynx Temp: C C C presentation?
Distended Neck Veins Previous DCI? Yes No
Narrative:
Circulation: CRT< 2 Secs CRT > 3 Secs Previous PBT? Yes No
PULSE: BP / Neurological Muscular/Skeletal Pulmonary
AED Defibrillator: Deployed H H M M H Lymphatic Cutaneous Constitutional
 © 2009 Underwater Science Ltd – DIVERS Emergency Life Support Incident Report Card

DELS UTSTEIN TEMPLATE FOR CARDIAC ARREST DATA COLLECTION: NEUROLOGICAL ASSESSMENT OF THE INJURED DIVER:
Date of Arrest: D D M M Y Y Y Y Time: H H M M H H H M M H H H M M H

Patient Name: ROMBERG TEST: Normal / Abnormal Normal / Abnormal Normal / Abnormal
Sex: M /F CRANIAL NERVES: Normal / Abnormal Normal / Abnormal Normal / Abnormal
Age: Years (Estimated): DoB: MUSCLE STRENGTH: Normal / Abnormal Normal / Abnormal Normal / Abnormal
Cardiac Arrest Determined By: (Name:) Hrs SENSATION: Normal / Abnormal Normal / Abnormal Normal / Abnormal
Qualification: Narrative:
Cause of Arrest (If Known):
Location of Cardiac Arrest: In-Water Surface
o
Estimated Time Underwater: Mins Water Temp: C
EMS Activation: Hrs By:
Treatment Before EMS Arrival: Airway Management BVM Ventilation
Chest Compressions CPR
AED Defibrillation Manual Defibrillation
First Defibrillation Shock: H H M M Hrs By:
ROSC: H H M M Hrs
EMS Arrival: H H M M Hrs Call Sign:
EMS Departure: H H M M Hrs
Receiving Hospital:
Casualty Qualification:
Diver Training Agency:
Number of Dives Completed: <10 11-50 51-250 251-500 >500
st
Year of 1 Qualification: Y Y Y Y
HSE Notified: Yes / No / Not Yet
Date of HSE Notification: D D M M Y Y Y Y

F2508 (Incident)
HSE Form Completed:
F2508A (Disease)
MEDICAL IN CONFIDENCE UPON COMPLETION – NOT FOR DISTRIBUTION