“The underwater world has its own laws. When diving, everything changes, there are other rules and different balances, but the human body is magnificent, it knows how to adapt. The 'diving reflex' or 'diving reflex' kicks in, a series of physiological adaptations that are activated in water almost as if to protect the vital organs: the heartbeats slow down and the small peripheral vessels contract, following the imperatives of a self-induced bradycardia to save oxygen and heat. Furthermore, blood pressure slowly increases, the so-called 'blood shift' (passage of blood) causes the blood flow to be redirected from the extremities to the chest. Paradoxically, cold shivers arrive together with a sudden sensation of relaxation and comfort, while at greater depths nitrogen could affect the ability to judge.". Pros and cons of underwater, a unique dimension that alternates fascination with challenges, even in terms of health: Lieutenant Enrico Moccia, a medical surgeon and expert in underwater and hyperbaric medicine, in service with the "Teseo Tesei" diving and raider group command (COMSUBIN) in La Spezia, talks to us about it.
Of Neapolitan origins and 'with the sea in his veins', Moccia is a special doctor in an elite department: he has made the motto of the military maritime health corps his own “Per undas ad valetudinem tuendam", or "On the waves to protect health", choosing to also deal with those who immerse themselves completely in those waves, such as the divers and the raiders of the Navy.
In 2013 he won the competition to become a medical officer of the normal roles, the doors of the Naval Academy of Livorno opened and he realized the dream he had dreamed of as a child: he became a 'doctor in uniform', connecting his personal passions for diving and for health, in the wake of the stories of his grandfather's military life. A figure who protects health as an element of connection and guarantee between water, earth, air and even space, because “The underwater environment - he explains - it is very similar to that of space, it is no coincidence that astronauts train in a swimming pool. 'From starfish to stars in the sky' is not just a metaphor, it is a highly representative concept of how diving and space are linked. In both dimensions, as is known, the condition of microgravity essential for astronauts who will go into space is simulated".
What is the path of a Naval Medical Officer and how do you specialize in hyperbaric diving medicine?
In my case, after the competition you enter the Academy already as members of the medical corps. To reach the goal of graduation I lived seven very intense years, as a soldier and as a student: the academic path is the one carried out in agreement with the University of Pisa, at the same time you continue the typical training of the Armed Forces. I specify that as a doctor it is possible to wear the stars also through the direct nomination competition for graduates in Medicine and Surgery, working in a wonderful institution like the Navy and taking advantage, just like the officers of normal roles, of all the opportunities connected to this chance: I independently decided to follow the post-graduate master's degree of II level in Underwater and Hyperbaric Medicine organized by the Scuola Superiore Sant'Anna of Pisa, a 2-year commitment that between internships and lessons, some also followed on board the ships on which I served, required a lot of tenacity and willpower, and which obviously bore fruit. Currently, however, you can opt for this same branch thanks to an agreement stipulated by the Navy with the University of Padua. The range of opportunities is varied, the activities proposed are truly many, for example I was able to study and carry out the cardiopulmonary stress test at the Monzino Hospital in Milan.
What are the possible health emergencies while diving?
As mentioned, for the human body, underwater is a challenge, a sort of 'request', to which we must physiologically 'respond'. The pathologies and variables are almost infinite, the variations in environmental pressure have incisive effects on all aspects: from the respiratory system to the cardiocirculatory, nervous and gastrointestinal systems. Cold water reduces our internal body heat up to about 5 times more than exposure to the same temperature, but to air; the increase in hydrostatic pressure temporarily modifies the eye's capabilities, so much so that - for a diving operator - objects may appear larger and closer. The volumetric modifications of gases with respect to atmospheric pressure can generate the so-called barotraumas, or trauma to the ear, paranasal sinuses. Diving with nitrogen-based mixtures, such as air, can also cause the famous 'Martini effect': a nitrogen narcosis that makes us drunk, just as if – every 15 meters of descent into the depths – we drank a glass of the alcoholic beverage from which this phenomenon takes its name, with related consequences on mood, orientation, and consciousness.
How does a hyperbaric diving doctor work and what is the first thing to do in case of critical situations?
We are ready for anything: we guarantee the health safety of pre- and post-dive activities, we take care of the compression profile, but above all the decompression profile of divers, deep sea divers, raiders and any underwater operator, always recommending a slow ascent to the surface, to reduce the risk margin of the formation of nitrogen gas bubbles as the atmospheric pressure decreases. We intervene behind the scenes, when it is necessary to treat a patient on land, perhaps in a hyperbaric chamber that is always positioned nearby, on the coast. But we also work on the front line, we provide health care on surface vehicles at sea, often with the nurse, to underwater operators who, day or night, face particularly challenging dives, such as seabed reclamation and mine clearance. The first thing to do, the most important aspect that makes the difference between life and death, between complete recovery or the onset of permanent damage, is the diagnosis: it must be imagined before the patient can reach us, alone or with the help of colleagues. We focus on the eventualities, we already think of a possible solution, the resuscitation protocol. The race against time is crucial, the visit must be carried out immediately, often even without the aid of the hospital equipment that we know and that would be impossible to bring on board. Obviously we always have our emergency backpack and the necessary devices for early intervention in the field. We rely on our own hands, on clinical sense: as a doctor I love to apply semiotics, a discipline that helps manage the situation through the observation of signs and symptoms.
Differences between a doctor in uniform and a civilian doctor?
The stars give us an extra edge. Military training is an added value, to the full advantage of problem solving: given that having a life in your hands is always an honor and a sacrifice, humanly and professionally, in the Armed Forces we are used to managing the typical problems of extreme conditions: from operational theaters abroad to the reduced medical supplies of a ship, through the difficulty of logistics in hostile situations and the consequent times of stabilization and safety of the patient, we immediately learn the value of resilience, of making the most of available resources, even if few. Deciding quickly, under stress and in the best possible way is a direct derivation of military leadership, a unique, very precious imprinting, which distinguishes us. The Navy in this sense is wonderful: it offers professionalizing courses for managing the limits of a ship compared to the potential of a structure on land. We learn to work in a team, to remain lucid, operational by default. We are trained to have important responsibilities that involve the entire crew, and to take charge of them: command and management, this is the extra step, the difference that depends only on you. The doctor on board is the manager of the health service, an essential consultant for the ship's commander who, in the end, decides whether to support his choices: with my commanders we have always gone in the same direction and with them I have established a precious relationship of mutual respect.
Does the military patient also have specific characteristics?
Of course, it is different on a clinical and psychological level, as a soldier he is able to communicate clearly and transparently, without giving in to anxiety. Colleagues are also our patients, and we are a family, unlike what could happen for a thousand reasons in civilian hospitals. Here we have the opportunity to spend time alongside each other for our respective activities, therefore to get to know each other: this makes you an important reference, you are their doctor, they are grateful for the diagnosis. As always, respect must be earned, and the emotion of succeeding is indescribable. We are soldiers in a world of daily challenges, we motivate each other, each distinguished by their specificities, each with their very important and indispensable role. The awareness, for everyone, is that we are here for a reason. We must make it count. Working at the underwater and raider group command (COMSUBIN) is an extraordinary journey, among extraordinary colleagues.
What was the experience that challenged you the most?
In the Central Mediterranean, on board a ship. When they notified me of the emergency I was in the infirmary: an extreme situation, we feared for the life of a person, we managed to stabilize her and bring her back to land healthy with the 'medical evacuation' procedure by helicopter. Always in those waters but on another occasion, during the operation "Mare Sicuro", we saved some fishermen who had felt ill on a fishing boat. I still remember when I called them back: they had tried to contact me to thank me. What can I say... an immense joy, as a doctor, to hear these words. Saving lives in extreme conditions is our core business, it is the distinctive trait of the Marina doctor.