ISSN: 1981-8963

Cavalcante ES, Freire ILS, Dantas BAS et al.

DOI: 10.5205/reuol.7944-69460-1-SM.0910201507

Fishermen victims of decompression sickness...

ORIGINAL ARTICLE
FISHERMEN VICTIMS OF DECOMPRESSION SICKNESS: STUDY IN A NAVAL
HOSPITAL
PESCADORES VTIMAS DE DOENA DESCOMPRESSIVA: ESTUDO EM HOSPITAL NAVAL
PESCADORES VCTIMAS DE ENFERMEDADES DESCOMPRESIVAS: ESTUDIO EN HOSPITAL NAVAL

Eliane Santos Cavalcante1, Izaura Luzia Silvrio Freire2, Bruno Arajo da Silva Dantas3, Cleonice Andra Alves
Cavalcante4, Andra Tayse de Lima Gomes5, Francisco Arnoldo Nunes de Miranda6
ABSTRACT
Objective: to describe the sociodemographic and epidemiological characteristics of artisanal fishermen who
suffered decompression sickness treated at a Naval Hospital in the Northeast of Brazil. Method: an
exploratory study with quantitative approach carried out in a Naval Hospital of the Northeast during the
period of February to April 2014. The population was made up of 28 fishermen who have suffered
decompression sickness between 2009 and 2013. The project has the approval of the Research Ethics
Committee, CAAE 20818913.0.0000.5537. Results: all individuals were male and 53.6% were aged between 31
and 40 years. The highest number of cases happened in 2010 (42.9%) in low season (75.0%) and in the North
Coast (96.4%). The paresthesia and pain in upper and lower limbs appeared in 67.9% cases and 57.1% were
using protective equipment. Conclusion: male sex and ages between 31 and 40 years predominated. The
greatest number of cases occurred in 2010, during the low season, and victims were coming from the North
Coast. Descriptors: Occupational Accidents; Decompression; Diving.
RESUMO
Objetivo: descrever as caractersticas sociodemogrficas e epidemiolgicas dos pescadores artesanais
atendidos em um Hospital Naval do Nordeste Brasileiro que sofreram doena descompressiva. Mtodo: estudo
exploratrio, com abordagem quantitativa, realizado em um Hospital Naval do Nordeste, no perodo de
fevereiro a abril de 2014. A populao foi composta por 28 pescadores que sofreram doena descompressiva
entre 2009 e 2013. O projeto foi aprovado pelo Comit de tica em Pesquisa, CAAE 20818913.0.0000.5537.
Resultados: todos eram do sexo masculino e 53,6% na faixa etria entre 31 e 40 anos. O maior nmero de
atendimentos foi em 2010 (42,9%), na baixa estao (75,0%) e acidentes no Litoral Norte (96,4%). A parestesia
e dor nos membros superiores e inferiores ocorreram em 67,9% dos casos e 57,1% usavam equipamentos de
proteo. Concluso: predominou o sexo masculino, na idade entre 31 e 40 anos. O maior nmero de
atendimentos foi em 2010, na baixa estao, e as vtimas eram provenientes do Litoral Norte. Descritores:
Acidentes de Trabalho; Descompresso; Mergulho.
RESUMEN
Objetivo: describir las caractersticas sociodemogrficas y epidemiolgicas de los pescadores artesanales
atendidos en un Hospital Naval del Nordeste Brasilero que sufrieron enfermedades descompresiva. Mtodo:
estudio exploratorio, con enfoque cuantitativo, realizado en un Hospital Naval del Nordeste, en el perodo de
febrero a abril de 2014. La poblacin fue compuesta por 28 pescadores que sufrieron enfermedades
descompresiva entre 2009 y 2013. El proyecto fue aprobado por el Comit de tica en Investigacin, CAAE
20818913.0.0000.5537. Resultados: todos eran del sexo masculino y 53,6% tenan entre 31 y 40 aos. El
mayor nmero de atendimientos fue en 2010 (42,9%), en la baja estacin (75,0%) y accidentes en el Litoral
Norte (96,4%). La parestesia y dolor en los miembros superiores e inferiores ocurrieron en 67,9% de los casos y
57,1% usaban equipamientos de proteccin. Conclusin: predomin el sexo masculino, en la edad entre 31 y
40 aos. El mayor nmero de atendimientos fue en 2010, en la baja estacin, y las vctimas eran provenientes
del Litoral Norte. Descriptores: Accidentes Laborales; Descompresin; Buceo.
1

Nurse, PhD Professor in Nursing, School of Nursing, Federal University of Rio Grande do Norte/EEN/UFRN. Natal (RN), Brazil. E-mail:
elianeufrn@hotmail.com; 2Nurse, PhD Professor in Nursing, School of Nursing, Federal University of Rio Grande do Norte/EEN/UFRN. Natal
(RN), Brazil. E-mail: izaurafreire@hotmail.com; 3Nurse, Master Student, Postgraduate Program in Nursing, Federal University of Rio
Grande do Norte/PPGENF/UFRN. Natal (RN), Brazil. E-mail: bruno_asd@hotmail.com; 4Nurse, Professor, School of Nursing of Natal, PhD
student, Postgraduate Program in Nursing, Federal University of Rio Grande do Norte/PPGENF/UFRN. Natal (RN), Brazil. E-mail:
cleoandreaeen@gmail.com; 5Nurse, Master Student, Postgraduate Program in Nursing, Federal University of Rio Grande do
Norte/PPGENF/UFRN. Natal (RN), Brazil. E-mail: andrea.tlgomes@gmail.com; 6Nurse, Professor PhD in Nursing, Nursing
Department/Postgraduate Program in Nursing, Federal University of Rio Grande do Norte/DENF/PPGENF/UFRN. Natal (RN), Brazil. E-mail:
farnoldo@gmail.com

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INTRODUCTION
Brazil has a long coast line parallel to a
large interior space which is irrigated by a
wide range of hydrographical basins with
many rivers, of diverse volumes of water, with
predominantly tropical climate characterized
by high temperatures in most parts of the
country and during more than half the year.
These factors favor fishing activity.1
Workers of these coast areas live in a
situation of precariousness and danger, where
accidents and death are frequent events,
whether by typical diseases of diving such as
drownings
and
shipwrecks,
or
by
decompression sicknesses. It was probably due
to these conditions that fishing making use of
compressors was banned in 1995 by the
Ordinance No. 43,2-3
Decompression sickness, also known as
decompression illness, air embolism or
paralysis of divers, occurs when gases
dissolved in the blood and tissues form
bubbles that block the flow of blood, causing
pain, neurological symptoms that range from
mild confusion to abnormal brain functioning.4
It is noteworthy that other areas of the
body such as the spinal cord are especially
vulnerable to this injury. The symptoms that
may seem less important such as paresis in the
arm or leg may precede irreversible paralysis
unless the case is treated immediately with
oxygen and recompression. The inner ear may
be affected in a manner that the person feels
severe vertigo. These signs and symptoms may
appear immediately or during the first 60
minutes after the return to the surface, but
some symptoms may appear up to 48 hours
after diving.4
Certain
precautions
can
prevent
decompression sickness. For instance, the
diver must ascend at the maximum pace of 10
meters per minute, making pauses of three
minutes every five meters; the diver must
avoid more than one dive per day; maintain
hydration and respect intervals of 24 hours
between diving and flying. Moreover, the
diver must know the basic and physiological
principles of diving and decompression tables
and must learn the exact time needed and
depth involved.4
It is also important that rescuers know the
disorders related to diving, to provide initial
care and initiate as soon as possible the
preparation for transport to the emergency
room or treatment in the hyperbaric chamber,
which consists of a procedure of introducing
the patient in a closed chamber where the
person is subjected to pressures up to three
times higher than the atmospheric pressure.
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Fishermen victims of decompression sickness...

This mechanism causes a strong increase of

oxygen pressure in the blood resulting in the
reduction of nitrogen pressure, which is
considered the causative agent of this type of
injury. Hyperbaric sessions last, in average,
20-30 minutes.3-4
Taking into account the abovementioned
considerations,
the
following
research
question was posed: what are the
demographic
and
epidemiological
characteristics of artisanal fishermen who
suffered decompression sickness treated at a
Naval Hospital in Northeast Brazil?
There is a situation of concern in this
context, since these fishermen carry often
irreversible consequences, remaining without
medical social and hospital assistance and,
thus, becoming relegated to poverty and
family dependence. The results of this study
will certainly raise awareness among health
professionals of the need to prevent this
occurrence.
In order to understand more deeply this
reality, this study is proposed and aims at
describing
the
sociodemographic
and
epidemiological characteristics of artisanal
fishermen who suffered decompression
sickness and were treated at a Naval Hospital
in Northeast Brazil.

METHOD
Descriptive
exploratory
study
with
quantitative approach performed at a Naval
hospital in the northeastern of Brazil, which is
configured as a technical body of the Health
System of the Navy, whose activities and
organizations are regulated by the Naval
Operations Command.
Data collection took place from February to
April 2014. The population was made up by all
artisanal
fishermen
who
suffered
decompression sickness between the years
2009 and 2013, and who underwent treatment
in a hyperbaric chamber in that hospital,
totaling 28 people.
An instrument constituted of two parts was
used for data collection: the first consisted of
sociodemographic data of the fisherman such
as gender, age and marital status. The second
part included variables related to years when
fishermen had occurrences: season, whether
low summer (April to September) or high
summer (October to March); place of
occurrence (north or south coast coast); signs
and symptoms presented; use of personal
protective equipment (PPE) and depth in
fathoms (one fathom is equivalent to 2.22
meters).

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Fishermen victims of decompression sickness...

The survey was conducted by researchers

using as basis the secondary data related to
the
accidents
treated
in
hospital
decompression
chamber,
which
were
tabulated and analyzed using descriptive
statistics.
Subsequently,
results
were
organized in tables and graphs and presented
in terms of relative and absolute frequencies.

project was previously submitted to ethical

evaluation by the Research Ethics Committee
of the Federal University of Rio Grande do
Norte (REC/UFRN) and approved under the
Certificate of Presentation for Ethics
Assessment (CPEA) N 20818913.0.0000.5537.

The study met the ethical principles

governing research involving human beings, as
recommended by Resolution no. 196/96 of the
National Health Council, supplemented and
updated by Resolution no. 466/12. The

The study population consisted of 28 male

artisanal fishers, most of them (53.6%)
belonged to the age group between 31 and 40
years old and were married (35.7%), as shown
in Table 1.

RESULTS

Table 1. Sociodemographic characterization of fishermen who

have suffered decompression sickness, 2015.
Sociodemographic characterization

20 - 30

17.9

31 - 40

15

53.6

41 - 50

21.4

> 50

7.1

Married

10

35.7

Single

25.0

Stable union

3.6

28

100.0

Age (years)

Marital status

Total

Figure 1 shows the occurrence of

decompression sickness according to the year
and it shows the highest number of events

occurring in 2010 (n = 12), followed by the

year 2009 (n = 8).

Figure 1. Distribution of cases of decompression sickness among

fishermen assisted at the Naval Hospital from 2009 to 2013, 2015.
The Figure 2 presents data on the
occurrence
of
decompression
sickness
according to seasons, which are known as high

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season (summer) and low season (other

seasons). It was observed that most of the
events occurred in the low season (75.0%).

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Fishermen victims of decompression sickness...

Figure 2. Occurrences of decompression sickness among

fishermen according to season of the year between 2009 and
2013, 2015.

Regarding occurrences of decompression

sickness distributed by location, there were

more occurrences reported for the North

Coast (96.4%), as seen in Figure 3.

Figure 3. Cases of decompression sickness among fishermen

according to location of the event between 2009 and 2013, 2015.

Regarding signs and symptoms experienced

by
fishermen
who
suffered
from
decompression sickness, paresthesia and pain
in arms and legs prevailed, reported in 67.9%
cases, followed by spinal cord injury in 57.1%
cases. A notable rate of 25.0% of deaths
among fishermen was found. Notable too was

the fact that more than half of the fishermen

had made use of personal protective
equipment (PPE) (57.1%) and claimed to be in
dive depths between 21-30 fathoms (32, 1%)
at the time of the accident, followed by 11 to
20 fathoms (28.6%) (Table 2).

Table 2. Characterization of the time of accident, 2015.

Accident characterization
Grievances presented
Pain and paresthesia in arms and legs
Spinal cord injury
Death
Other (convulsion, ischemic injury and AMI) *
Use of Personal Protective Equipment
Yes
No
Depth of the accident (in fathoms)
0 - 10
11 - 20
21 - 30
31 - 40
41 - 50
61 - 70
Not informed
TOTAL
*
Acute myocardial infarction.
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19
16
7
3

67.9
57.1
25.0
10.7

16
12

57.1
42.9

1
8
9
4
1
1
4
28

3.6
28.6
32.1
14.3
3.6
3.6
14.3
100.0

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DISCUSSION
Concerning the profile of researched
individuals, the unanimous presence of male
sex was expected and it is observed in other
studies. This fact leads to reflection on the
sexual division of labor in the context of
asymmetric power relations existing between
men and women, anchored in a series of
elements considered to be specific of "man"
and "woman".4-6
Artisanal fishing is still one of the main
economic activities and livelihood for most
households in coastal communities of the
Northeast, thus justifying the marital status
and productive age of the majority of
fishermen who have suffered decompression
sickness. However, the presence of young
people in fishing activities is determined by
social and cultural factors, where passing the
knowledge of fishing activities on from
parents to children is considered a family
tradition. In addition to this explanatory fact,
labor
market
still
offers
insufficient
opportunities in certain cities or regions,
causing young people to look for fishing
activities to survive.7
The reduced number of fishermen in older
ages has scientific basis. Studies show that
after the age of 40 years, the number of
morbidities associated with this type of work
reaches significant values. These problems
include ergonomic causes and even injuries
that cause disability in fishermen.8
Regarding the classification of the number
of related accidents per year, period and
location, there is evidence of direct
connection to climatic conditions, besides the
social behavior of local population and
visitors. The high percentage of accidents in
2010 is explained by the increase in fish
production in that year, that is, with
increasing production amounts, working hours
also increase, as well as exposure to the risks
typical of these activities. The lack of use of
PPE also contributes to this, which was
observed in 42.9% of the studied population.9
Large boats destined to various functions
often use precautions to minimize the risk of
accidents such as the use of Personal
Protective Equipment (PPE). It is noteworthy
that the occurrence of accidents or any other
grievance at sea generates by itself a number
of problems to be faced by the crew of these
vessels. A range of problems are involved in
accidents that happen at the sea, beginning
from the lack of resources for an alleged first
aid until the time needed to make such
grievance is resolved. No less usual, in the
case of small boats of fishing or diving, the
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Fishermen victims of decompression sickness...

worst conditions of vessels, difficult access to

fishing sites, and lack of adequate knowledge
of other fishermen to act promptly during
these grievance contribute to the problem.10
Artisanal fishing exposes fishermen to
ergonomic
(posture
problems),
natural
(incidence of sunlight on the skin and eyes,
chills, cold winds, strong waves), physical
(lesions on the hands and feet), chemical
(contact with poisonous secretions or
chemicals) and biological (contact algae and
fecal coliforms) hazards.11
The PPE is intended to fulfill an important
role in health and safety of the worker and,
however, the fact is that when the equipment
is not adjusted to users, it generates
discomfort and in some cases, this discomfort
causes rejection of its use. In this sense, the
Regulatory Norm NR-6 defines PPE as any
device or product for individual use used by
the worker intended to protect against risks
that may threaten their safety and health.12-3
The use of PPEs among fishermen is
considered as unexplored resource, besides
the fact that there is no supervision of the use
of these devices by any public institution, this
way leaving the responsibility for fishermen
themselves.11,14
The period of year is relevant in the sense
of classification by dates. During the period of
low season (April to September) climate
favors
fishing
practice,
leading
to
intensification of activities. In addition, there
is little tourism on the beaches what, in turn,
contributes to pollution of the coast, adding
to the increase of waste thrown into the sea
through underground sewers that hinder the
practice in high summer. In the state of Rio
Grande do Norte, production of fish is
economically important in the North Coast of
the state. Thus, the practice of fishing is also
enhanced in this region, what is reflected in
the findings of this research.9
Diverse types of grievances related to
decompression sickness were observed in this
research. Several factors predispose the diver
to these diseases, among them those related
to
equipment
failures
and
improper
technique, such as violation of decompression
tables that increase nitrogen input in the
tissues during the dive and delay its release
during the ascendance, trouble to float, rapid
ascendance, lack of air and failure of the
regulator.4
There are factors that have to do with the
condition of the diver, such as poor fitness,
advanced age, female gender, hypothermia
and the use of alcohol or drugs. Other factors
are linked to the environment, such as
extreme temperatures, revolved waters,
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traveling by airplane after diving, intense

physical exercise in the deep, narcosis by
nitrogen and altered carbon dioxide blood
partial pressure.4
Among the results presented here regarding
grievances of fishermen, pain and paresthesia
of the arms and legs were prevalent. This
form of decompression sickness results from
the
formation
of
bubbles
in
the
musculoskeletal system, typically occurring in
one or more joints. The joints most commonly
involved are shoulders, hands and ankles. The
pain is described as intense articulate, with
sensation of friction while in movement. The
pain begins gradual, then deep, inconvenient,
of mild to high intensity. Victims often try to
relieve the pain flexing the joints. Although
this form of decompression sickness presents
no risk of death, it indicates that there are
bubbles in the venous circulation and it can
lead to more severe forms if not treated.4
The second most important injury affecting
the investigated fishermen was spinal cord
injury. The white matter of the spinal cord is
considered vulnerable to blistering and
nitrogen is highly soluble in myelin. The most
common location of this decompression
sickness is the lower thoracic spine, followed
by the lumbar/sacral and cervical regions. The
most common signs and symptoms are pain in
the low back and heaviness in the legs. In this
form of decompression sickness, the patient
usually gives vague statement in an attempt
to describe strange sensations or paresthesia
which can progress to weakness, numbness
and paralysis. Intestinal and bladder
dysfunctions are also referred, leading to
urinary retention.4,15-6
The results of the present research also
revealed that the percentage of deaths was
significant among the artisanal fishermen.
Fishermen often lack knowledge of techniques
and security measures in diving, many suffer
decompression illness and several have died,
according to local reports, especially those
who are dedicated to lobster fishing. Besides
illegal under Brazilian law, fishing with
compressor is done in a dangerous manner,
where divers breathe through a hose
connected to a gas cylinder provided with
oxygen and coupled to the engine of the
boat.17
Despite being considered informal work,
accidents and deaths resulting from the
practice of fishing are not excluded from
official statistics. This reality came to call
attention after a National Campaign for
Accident Prevention for this group of workers,
which showed that official results gave the
false impression that the number of
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occupational accidents in the state of Rio

Grande do Norte was minimal. However,
anecdotal reports warned that the use of
compressed air in the lobster fishery would
generate large number of serious accidents,
including fatal accidents.14
A research conducted by the regional
police station of Rio Grande do Norte pointed
out that 86.4% of divers have already suffered
at least one accident as a result of pressure
changes from the dive. Data show that 12
deaths were reported due to decompression
sickness within a period of two years in only
two of the 32 lobster producer communities of
the state.14
Fishermen were injured mainly at depths
between 21 to 30 fathoms or the 46.62 to 66.6
meters, besides instances in even greater
depths. The account held by the Labor auditor
inspector in Rio Grande do Norte in 2003
reports that the shortage of lobster
contributes to make the worker immerse in
ever greater depths. Although the vast
majority of dives are carried out at 30 or 35
meters deep, there are reports of dives of 80
meters, with exclusive use of nitrogen. To
avoid the effects of narcosis, nitrogen should
be replaced by helium gas in the mixture with
oxygen (heliox) in diving more than 50 meters,
but this does not occur.14
Besides the gravity of diving deep without
the use of proper equipment, the pace at
which the dives are performed add to the
problem. On this point, literature states that
this should occur at most once or twice a day,
followed by appropriate rest period. In the
coast of Rio Grande do Norte, divers report
more than ten daily individual dives. The
frequency is determined by the need to catch
lobsters, never by the diver's safety. The time
of duration of dives is also exceeded.4,14
It is noteworthy also that the grievances
caused by fishermen practices can cause a
series of intensive care demands, toward
severe patients, resulting in a process often
aggressive and painful, and generate high
costs and low percentage of full recovery of
damages.18

CONCLUSION
With
respect
to
sociodemographic
characterization, there was a predominance
of males, mostly aged between 31 and 40
years and married. Regarding the number of
calls for decompression sickness, it was found
that the highest number was in 2010, during
the low season and victims mainly coming
from the North Coast.
When it comes to the characterization of
the accident, it was observed paresthesia and
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pain in the arms and legs in most cases. In

addition, more than half of the victims were
wearing personal protective equipment. Most
of accidents happened between 21 and 30
fathoms of depth.
The economic factor is present, in a
relevant way, in the sense of limited labor
market, with no other prospects for
employment and income in the cities studied.
With the economic potential generated by the
fishing practice associated with the financial
deficit of this group of workers, production in
the activities tends to be intense at certain
periods. Consequently, the workload increases
proportionally, predisposing these workers to
risks and injuries generated by the practice in
unhealthy environments and without adequate
support. In this context, the proper use of PPE
was absent in most cases of accidents.
Findings of this study corroborate the
assumption that all aspects checked in the
practice of these fishermen determine the
exposure and the level of harm attributed to
the studied fishers. Thus, the presence of
deaths and serious injuries indicate the level
of exposure in which fishermen are working or
are being subjected to. However, this context
imposes on them the continuity of their
habits, given the prevailing low academic
level, leading to lack of knowledge about the
real and potential risks, staying still stuck to
its financial difficulties and the high cost of
adequate PPEs.
Additionally, one of the extremely
significant difficulties for the preparation of
this study was insufficient quantity of
publications in the scientific literature that
address the theme.

ACKNOWLEDGEMENTS
We express our thanks to the Legal Advisor
of the Capitania dos Portos, Mr. Cicero
Resende (Capito-de-Corveta - RM1 - T), for
allowing our access to legal files of the
fishermen
submitted
to
hyperbaric
decompression after diving accident on the
coast of RN state.

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DOI: 10.5205/reuol.7944-69460-1-SM.0910201507

ISSN: 1981-8963

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Submission: 2015/03/10
Accepted: 2015/09/03
Publishing: 2015/10/01
Corresponding Address
Eliane Santos Cavalcante
Escola de Enfermagem de Natal/EEN
Universidade Federal do Rio Grande
Norte/UFRN
Campus Universitrio
Bairro Lagoa Nova
CEP 59078-970 - Natal (RN), Brazil
English/Portuguese
J Nurs UFPE on line., Recife, 9(10):9520-7, Oct., 2015

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