Diver Medic and Aquatic Safety Mag Issue 3

DIVER ISSUE 3

and conservation

with Cristina

Education

Zenato

exploration

TEETH & DIVING

By Dr Peter tatton

diving safety

By DAN Orr

marine life hazards

By dr anke fabian

MEDIC

&nd AQUATIC SAFETY

ISSUE 03 | FEBRUARY 2015

A note from the Editor In a world of high standards, the dive industry has sadly been quick to accept minimums over the last 25 years. Very often it’s not the end user who encourages reduced standards but rather the training agencies; money is the motivator for taking shortcuts. The issue even affects the water rescue and recovery communities.

Skewed priorities underlie this issue. Sadly we often find that a shiny regulator with a new dive computer or a fancy new ice rescue tool take precedent over higher levels of skill. This takes the focus away from the ability to actually use the equipment reflexively or to understand why we use the equipment in the first place. With all the new equipment, do we have fewer injuries and deaths in the water?

We need to examine why skill levels are too often dropping.

Could it be that the people responsible for lowering standards haven’t acquired the skills themselves, or that they do not understand from where the skills arose, or their functions?

Unfortunately, the industry is faced with ever-shortened and minimal instructor training.

A mission of this journal is to report on what is happening in the dive and aquatic rescue and recovery industries in terms of performance, standards, and safety – with the goal that we can all strive to make aquatic activities more worthwhile, successful, and safe. Yet enough people need to speak up about lowered

standards and say “enough is enough; stop playing with people’s lives”.

We can only encourage. Many of the authors presenting in these and future issues were asked to contribute because of their years of dedication to raising the bar. Take, for example, Cristina Zenato with her boundless love of the sea and all its creatures. She demonstrates great caring and creativity, teaching thousands of divers how to better understand and interact with marine life and fragile ocean ecosystems in a way that is magical and responsible. Walt “Butch” Hendrick dedicated 50 years of his life to making divers and water rescue personnel more safety-conscious and more effective by creating procedures and equipment, now used as standard practice world-wide. Then there’s Gareth Lock who wants to promote safety through starting a data repository involving all aspects of diving safety and incident management. Dan Orr started in the 1980s speaking for the first time on accident management and emergency assistance with Dr Peter Bennett. Dan Orr we know is well-known for joining Divers Alert Network, and with all his influence in diving safety ultimately became DAN (Divers Alert Network) President and CEO. With contributors like these who are essential pillars in the industry and help to keep the standards high, we hope to offer the beneficial commentary that takes our industry back to the high standard it deserves to hold.

Photo by Annetje

Andrea Zaferes

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ISSUE 03 | FEBRUARY 2015 Editor-in-Chief Chantelle Newman Editor Elsibe Loubser McGuffog Technical Editor Andrea Zaferes Designers Allie Crawford, Sarah Crawford Medical and Diving Specialist Consultants Dr Anke Fabian Dr David Charash Diving Consultants Dan and Betty Orr Advertising and Subscriptions Chrissie Taylor Contributors Thank you to the following contributors: Walt “Butch” Hendrick, Kelly Ann Moon, Cristina Zenato, Amanda Cotton, Peter Tatton, Mark Rowe, John Bantin, Gareth Lock, Andy Torbet, Paul Haynes, Rod Hancock, John Newman, Aquamed, TeamLGS, Code Blue Nurses, Armand “Zig” Zigahn, Mediahouse, Beneaththesea.org, DAN Europe PHOTOGRAPHERS Amanda Cotton, Eyüp Alp ERMIS, Greg Cayman, Matej Kastelic, Rich Carey, Sergey Skleznev, Oksana Perkins, Annetje, Little Sam, MPS 197, Greg Trinity, Michal R, Wolta, Mark Rowe, John Bantin, Rolf E Staerk, Mony Halls, Rich Stevenson, Jon Milnes, Witty Bear, Azurek, Donikz, Paul Haynes, Patjo, Gareth Lock, Marcus Efler, Jubal Harshaw, Michael Taylor, Mark Rowe Magazine address The Diver Medic Ltd Great West House, Great West Road, Brentford, TW8 9DF Telephone +44 020 8326 5685 EMAIL info@dmaasm.com www.dmaasm.com

Contents A day in the life of a Media Safety Diver

By Andy Torbet

The Aftermath of a Fatal Diving Accident

By John Bantin

Through My Eyes

By Butch Hendrick

Your Teeth & Diving

By Peter Tatton

Caustic Cocktail Hazard

By Paul Haynes

Exploration, Education and Conservation

By Cristina Zenato

Where Have all the Divers Gone?

By Butch Hendrick

The Benefit of Case Study Know-how

By Gareth Lock

Diving Safety…Lessons Learnt

By Dan Orr

Marine Life Hazards - Part 1

By Anke Fabian

Can Microscopic Algae Help Solve Crime?

By Kelly Ann Moon

The €12 000 Mosquito Bite

By Mark Rowe

6 14 20 24 32 40 48 54 60 68 76 82

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DIVER MEDIC & AQUATIC SAFETY

A version of this story was first published in Sport Diver, June 2014

A DAY IN THE LIFE OF A

"The pros are simple - you're getting paid to go diving. And what's more, films don't happen at the sorts of locations chosen for commercial jobs"

MEDIA

SAFETY DIVER

By Andy Torbet

Having spent years behind the camera as a safety diver and dive supervisor before taking up a position in front of it more recently, Andy Torbet believes that the safety diver’s job can be one of the best on a production team. Here’s his take on it.

T

he pros are simple – you’re getting paid to go diving. And what’s more, films don’t happen at the sorts of locations chosen for commercial jobs (which involve boring tasks, boring surroundings, and nil visibility). It’s also fairly un-stressful as long as you know what you’re doing. The supervisor has all the organising, risk assessment, paperwork and responsibility; the underwater cameraman has to self-direct and get the shots; and the presenter has to be erudite, interesting, comprehensible and remember what the hell they’re meant to be talking about…which is harder than you think (which is why I often take notes on a slate).

Photo by Mony Halls

On the downside you do a lot of heavy lifting, not only your own kit but also much of the team kit and sometimes the presenters’ and cameramen’s kit too, depending on the individuals. I’ve tended to find that the more competent the diver, the more they want to look after their own equipment. Of course not every presenter and cameraman you look after is a top level diver with loads

of experience. Even though some of them have completed the HSE Part 4 Media course, I would not have some of them in the water without another diver looking after them…despite what you may read on their website or CV. The level of stress can escalate while supervising these individuals, but the dives tend to be fairly basic so you can be confident in getting them out in one piece. If you’re not 100% confident you can handle your charge from the bottom to the boat in any circumstance, then you probably shouldn’t be their safety diver. You also tend to get lumbered with the menial tasks like charging, mixing, labelling and testing, but I quite enjoy this and tend to do it anyway even when I am supervisor.

Recently, with more and more of my own projects and front-of-camera work, I’ve had to pull back from covering other’s safety on media shoots. However, one of my most recent outings was also one of the best, so it seems the appropriate example to use for this story.

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Last year I was busy filming when I got a phone-call from my friend Monty Halls. “Mate, I’ve had a show commissioned by Channel 5,” he said, “to do some tech-diving all around the world. The crew follows me as I simulate learning to dive deep, then go exploring underwater mysteries”.

“Well done, mate I’m very pleased for you,” I responded – but I really meant “I’m very jealous of you.”

“We’ve got Rich (Stevenson) and Dan (Stevenson – no relation) on underwater cameras and Kev Gurr as supervisor,” he added.

“Brilliant,” I said. Both Rich and Dan are also close friends of mine, and although I’d never met Kev I knew him by reputation. I was feeling even more envious.

“We need someone to run in-water safety,” he continued. “We want someone qualified and experienced to dive hypoxic trimix on rebreathers at depth and do some cave stuff.

We also want someone we know and trust… everyone wants you. Now I know you don’t do this sort of stuff anymore, but…”

“Whoa,” I said, interrupting him, “Mate, we all get onto telly to do cool stuff, in cool places, with our mates? This is exactly what you’re offering – who cares who’s in front of camera.

I’m in.”

The running joke throughout the series was “yeah, but Torbet’s on holiday” – which wasn’t far from the truth of how I felt. I was diving with people I knew and could trust to operate underwater professionally, in whose company I choose to dive even when we’re not on the clock, and I could just be a diver without the pressure of presenting. As far as I was concerned I had the best job on the project.

The example from this project I’ll use was from the first shoot in the Blue Hole by Dahab in Egypt, and a day went something like this: By the time the team arrived at the dive centre at dawn all our cylinders would be mixed and charged after the previous day’s dive. Since we’d be diving to between 60 metres and 100 metres, everyone on 8

"Your main job above the water topside is to do the jobs that anyone could do in order to allow the other members of the team the time to concentrate on their job-specific task"

this dive was experienced enough to be responsible for checking their own kit, including rebreather, diluent, oxygen and any bailout bottles for content and mixes and labelling appropriately. I’d normally try to do all my kit the night before, getting my cylinder filled first, including refilling the sofnalime and checking the rebreather. This way I could concentrate on team kit while everyone sorted their own equipment. I inspected any spare cylinders, emergency gases – checking the contents, analysing gases, making sure they were labelled and checking the regs worked. I’d then prepare the two team scooters, whose batteries I’d been charging overnight, and I’d hump all this kit, and my own, onto the transport.

By this time the rest of the guys’ kit was prepared, and I’d hump that through too, allowing them time to turn their attention to cameras, housings and light. As a safety diver, your main job above the water topside is to do the jobs that anyone could do in order to allow the other members of the team the time to concentrate on their jobspecific task, whether that’s setting up cameras, discussion content and scripts with the director, or carrying out any lastminute changes to the dive plan. You have no pressure on you out of the water, but the rest of the team still does – so you should be running around to make their lives as easy as possible.

In essence, if you can't lift lots of heavy stuff, you're not going to be much use.

It was a similar theme on site. While the rest of the team took care of cameras, script and their own kit, I’d help set up the site and assist where I could. On this particular day, we were running some incident scenarios to make sure our local support divers, who would operate as shallow water safety divers and surface cover under Kev’s supervision, were up to speed. And of course we needed a volunteer to act as the convulsing diver… need I say more? So after I’d been “saved” and we were all happy with the emergency drills and procedures, it was time to dive.

Photo by Rich Stevenson 9

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DIVER MEDIC & AQUATIC SAFETY

Normally, as a safety diver, you should be the last to your kit. You run around helping everyone else with theirs but should still be first in the water ready to receive camera, kit and people. However, when your team are this experienced, nanny-ing the other divers is not required and likely to earn you a short, sharp phrase of two words, the latter of which is ‘off’. I still made sure I was first in the water so I could help the others, especially the cameramen with the enormous housings and lighting set ups.

Once the four-man team was assembled in the water we began to descend.

I hung back a little so I could observe the rest as they glided downwards checking for bubbles in places they should be, any warning signs or simply things that didn’t look right – better to catch them early and in shallow water.

It’s not only a safety concern, but a quick spot can allow for the time and tissue profile to abort, fix the problem and still carry out the dive so a day’s filming isn’t wasted.

This is the purpose of a safety diver. His job is simply to think about the dive and divers; he is a full time buddy.

"Once the four-man team was assembled in the water we began to descend. I hung back a little so I could observe the rest as they glided downwards" 10

Photo by Jon Milnes

Presenters have a lot on their mind as do the cameramen. If diving is considered a job, then these guys are doing two jobs. So it’s your job to act as their backup, to double check their ppO2, their depth, their content gauges and that everything is ok. When I did a recent cave diving shoot with Rich, we got to 30m and the vis was appalling all the way down. I was thinking “What are we going to do? How do we still get a piece from this? What should be my line to explain this and still make the dive seem cool even though we can’t see anything?” What I wasn’t thinking was “you’ve just passed 20m and should

change your ppO2 set point”. It was a minor mistake, and Rich quickly brought my attention to it. It illustrates how we can all lose sight of the things we normally focus on when diving itself isn’t the only thing we need to focus on during a dive.

So down we went into crystal clear blue waters. The Blue Hole is an incredibly benign place, a warm, nontidal, sheltered shaft with nowhere to get lost. I should caveat this with “as long as you dive within your ability”, since the reason we were there was to investigate the reasons it has been the site of so many diving deaths. Most of my safety diving on media shoots has been in the UK, so needless to say the conditions are rarely as good as at the Blue Hole. One of the things I appreciate as someone who has worked underwater for 17 years is the lack of any need to wear gloves, or at least only one; it makes life so much easier.

This was to be Monty’s deepest dive, and as we hit 60 metres I watched him carefully perform every manoeuvre, check and drill flawlessly as well as maintaining the wherewithal to come up with improvised pieces to camera about the site, its history, the wildlife and the general where, how, who and why’s of the dive. Dan and Rich continued on to 100 metres. Moments like these are hard. I could see them down on the seabed and it looked spectacular. That was where I wanted to be, but I was needed where I was – that’s the job. As the boys ascended, we re-grouped and finally made the surface.

The other advantage of the safety diver’s job is that there is instant gratification and the removal of responsibility when the last man leaves the water. Kev has paperwork to do, checks to make, Rich and Dan worry and review their footage to make sure everything worked, and Monty is dragged off to deliver pieces to camera and to hope the underwater audio and visuals all worked. Me? As long as no one is dead, my job is done. Then it’s time to find something heavy to pick up.

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DIVER MEDIC & AQUATIC SAFETY

Photo by Rich Stevenson

ISSUE 03 | FEBRUARY 2015

"So it's your job to act as their backup, to double check their ppO2, their depth, their content gauges and that everything is okay."

DIVER MEDIC & AQUATIC SAFETY

The Aftermath of a

Fatal Diving Accident

By John Bantin

When someone dies in a diving accident there’s always an aftermath that usually embroils even those who were only there doing their best to help.

ISSUE 03 | FEBRUARY 2015

"They became distracted when one of the other divers appeared to me to be suffering a serious buoyancy issue"

David Graves was a well-respected journalist who died during a simple leisure dive in the Bahamas. He was on a press trip with a number of other British journalists with a view to writing a travel piece featuring scuba diving. Originally, the Bahamas tourist Office had planned that the invited journalists would dive the famous Blue Holes, flooded prehistoric cave systems complete with dramatic stalactites and stalagmites.

On the first day of trip, Jeff Birch, the owner of Small Hope Bay Lodge in Andros and their host, decided that none of them had the required diving proficiency to handle the serious overhead environments that these Blue Holes offered and took them instead first on a check-out dive when Mr David Graves was seen to run low on air and bolt towards the surface, before being intercepted by an attentive dive guide. That afternoon they all went to watch a shark feed underwater.

It was pure serendipity that I was with this group. I had attached myself to them when I discovered that my onward flight out to Bimini where I had intended to go was over-booked. The press trip to Andros had been arranged by The Dive Show, which is associated with Diver Magazine (UK) and for which I acted as Technical Editor at the time.

You can read the full account under Part 8, chapter 1, in my book, Amazing Diving Stories. I was present at that fateful dive and witnessed David Graves swim off from the group alone while the two dive guides who were looking after the journalists were distracted. They became distracted when one of the other divers appeared to me to be suffering a serious buoyancy issue during a carefully controlled ascent up the anchor line back to the boat. It appeared to me that this diver was in the process of losing her weightbelt with the possible hazard of a sudden and uncontrolled ascent. The situation needed the two guides to sort it out.

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Photo by John Bantin 15

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DIVER MEDIC & AQUATIC SAFETY

During this second dive, there were about ten people in the water including a couple of tourist divers. David Graves made a series of errors probably due to over-confidence combined with a lack of motor skills that he would have attained if he had gained more experience as a scuba diver. He should not have gone off alone and he never made it back to the boat. Sadly, he paid for these mistakes with his life.

When his lifeless body was recovered from the water, it fell to me and one of the dive guides to attempt to resuscitate him while the other drove the boat back to land. None of the other divers on board wanted or had the required knowledge or experience to help.

"None of the other divers on board wanted or had the required knowledge or experience to help."

However, the story did not end with our skilled yet ineffective efforts during the journey back to the American Naval Base on Andros, where medics pronounced him dead. Some of the other journalists surprised me by complaining that all this had ruined their holiday; I decided that the right thing to do was to return to the UK immediately to seek out his family and explain what had happened. I did not feel it was right to continue otherwise.

Of course, under Court rules, one may only answer the question and not offer any extra information. My answer was that we didn’t talk.

The reports did not ring true to me. Whether a couple of the journalists were suffering guilt for staying on and completing “their holiday” or not, I cannot say. Suffice to say that they seemed looking for someone to blame for the death of their colleague and I was somewhat surprised at a telephone conversation I had with a senior executive of Mr. Graves’ employer who told me that the dive centre was going to be punished.

“How long were you and Mr Birch under water together during that first dive?”

“About forty-five minutes.”

“And you are trying to tell the Court that you were together for forty-five minutes and said nothing to each other?”

“Yes.” The questioning would go on, trying to make me look as if I had something to hide. Eventually, the barrister made the error of asking me why we did not speak to each other during the dive.

“You cannot talk under water.”

I had cause to go over and over in my mind the awful events in the Bahamas. I had got bored during that crucial second dive and had returned to wait horizontally at twenty feet deep, watching the group below me gathered together by the two dive guides and led carefully up the anchor line of the boat. I was also surprised to see David Graves swim off purposefully and alone. I intended to caution him against that sort of action when he got back in the boat. Sadly, I never got that chance.

“I see you wear glasses.”

“Yes.” “Can you read this?”

He held up a copy of Diver Magazine revealing the pages of classified ads that are printed in a tiny font size. He was about twelve feet distant.

“No.” “Were you wearing your glasses under water?”

“No.” “So you couldn’t see what was happening.”

“I could see clearly what was happening.”

“Can you explain how?”

“I have prescription lenses in my diving mask.”

The man was previously totally unknown to me, but I had given him unprotected mouth-to-mouth resuscitation over a protracted period and had obviously imbibed some of his bodily fluids in doing so. Such exchange of bodily fluids with a stranger is not without medical risks. I rinsed my mouth out with a freshwater hose as soon as we arrived at the Naval Base but still considered I’d taken a risk to my own health. Under those emergency circumstances, what choice was there? Such decisions are made in the heat of the moment.

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The Bahamas appears to use a British Justice system. The newspaper employed a barrister (trial lawyer) whom I presumed to be a local. The intention of such a lawyer is to discredit the evidence of someone that is perceived to be a hostile witness.

Appearing in the witness box can be a daunting prospect, but if you are sure of the truth it is relatively easy to stick by it and resolutely not deviate despite these attempts of any barrister to discredit you. Those others with agendas gave testimony that was soon discounted. For myself, I withstood six hours of intense cross-examination, but luckily the cross-examining barrister, ostensibly representing the widow, had not bothered to do any homework and knew little about the subject of scuba diving. At times the procedure bordered on farce when he insisted on asking questions like, “What did you and Mr Birch (the dive centre owner) talk about while you were under water during the first dive?”

I went to a suburb of London where his wife and two young sons lived and went through the painful procedure of explaining why their loved husband and father would not be returning home. Soon, reports of what had happened were appearing in the British national newspapers, including the Daily Telegraph for whom David Graves had worked.

My involvement, though unplanned, did mean, nevertheless, that I was an important material witness and when the case eventually came to Court, I decided to go back to the Bahamas to bear witness in defense of the two dive guides and the dive centre. The case was scheduled on my birthday.

Some of the other journalists also attended the Court, but each seemed to be working to an agenda rather than the true events that I had seen unfold. The Daily Telegraph had sent one of its senior operatives, a hard-drinking heavy-smoking man, probably a stereotypical newspaper writer, to oversee events in the Bahamas.

He seemed to be cock-a-hoop that the dive guides and the dive centre owner were heading towards a manslaughter charge.

Photo by John Bantin

“Is this magazine (Diver Magazine) the one you work for?”

“Yes.” 17

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DIVER MEDIC & AQUATIC SAFETY

“I see that Small Hope Bay Lodge has placed an advertisement in this magazine. That means that they are a client of your employer, does it not?”

“I’m sure that the publishers of Diver Magazine found the USD$80 that Small Hope Bay Lodge paid for the ad very useful.”

"How could a perfectly fit 50-year-old man die while under water? It was a question posed in a newspaper report"

It would have been farcical if it had not been for the obvious anguish of the widow sitting a few feet away facing me. Why the Daily Telegraph chose to put her through all this was a mystery.

Nobody wants to hear that a loved one lost his life through a simple and stupid mistake. After three hours we retired for lunch.

The whole intention of an adversarial lawyer is to discredit a hostile witness. It can be a very unpleasant experience. However, I confess that I started to enjoy the afternoon better than the morning. I was present and witnessed what happened at the time and I knew my subject, which my adversary clearly did not.

There was only the nagging fear that the wigs and gowns of the lawyers, rather than the evidence, might impress the Coroner.

I constantly tried to introduce the subject of the deceased diving computer into my answers. I had taken the precaution of wearing an identical model on my wrist and I frequently added to my answers the unwanted (by the legal representative of the bereaved) information that it was all on the computer that he wore “identical to this one”.

Eventually the Coroner cottoned on and asked if David Graves had been wearing a diving computer. The other side begrudgingly admitted that he was. When the Coroner asked for a print-out from it they went into a huddle before declaring that it would take several months.

I found this strange because I had gone though the dive profile on his computer while his cadaver was still wearing it. I’d examined the pictures taken on his digital camera that were complete with time code. I’d done all this within a few minutes of getting back to the American Naval Base on that terrible day.

I’d also taken the precaution of getting the down-loaded data from the fateful dive printed out for myself, but I could hardly admit that I was standing with it in my pocket while in the witness box because I was not sure how legal it was to be in my possession. Of course, nobody had the wit to ask me although I had informed the barrister representing Small Hope Bay Lodge and its dive-guides that I had it. He seemed to think it was not necessary. I still have that print-out safely stored somewhere.

There was something else. The Daily Telegraph had hired the services of an expert-witness who had been out to the site, examined all the evidence and concluded that David Graves had gone off on his own, run out of air to breathe, shot to the surface but had been unable to stay there because he neither added air by mouth to his buoyancy vest (BC) nor dropped his weightbelt.

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Photo by John Bantin

What the people at the Daily Telegraph failed to appreciate was that the professional diving world is very small. I knew that their expert had told them this because by coincidence I shared an office desk with him and couldn’t help listening to the telephone conversations. Evidently it wasn’t what they wanted to hear and his services were terminated forthwith.

How could a perfectly fit 50-year-old man die while under water?

It was a question posed in a newspaper report. Thank goodness that, despite direction from the Coroner, the honest Bahamian jurors knew the obvious answer. He drowned.

It didn’t end there. It was silly season in the UK and the story of the case made front-page stories in the Telegraph, the Guardian and some other national UK newspapers. A few days after, I got a phone call from someone purporting to be a journalist from Private Eye, a British satirical magazine. She asked me if I would withdraw my evidence that I had given in Court. I told her I was under oath at the time and took that sort of thing seriously.

“In which case I am going to destroy you,” she announced.

What a shame these journalists never bother to do their homework nor let the truth get in the way of a good story. This is part of what Private Eye printed in issue 1089 on 19th September 2003 in which it reported the event and also made a virulent attack on PADI. It was titled ‘PADI Whacked’.

“The Eye also spoke to John Bantin, the contracted Technical Editor of Diver Magazine and whose sister organisation, The Dive Show, was one of the organisers of the press trip. Bantin was on the trip taking photos for The Dive Show and he had told the Coroner he had suggested to Birch that the divers should be escorted as a group and not be in buddy pairs because he believed they were not experienced enough to help each other.

He said he had seen David Graves rush to the surface on the first morning dive, leaving his buddy behind. Asked whether, in the light of the Coroner’s findings and the apparent failure of the group dive, Bantin now believed the buddy training system should have been reinforced rather than abandoned, he was unrepentant….”

This probably precipitated a barrage of letters from PADI diving instructors, because the Eye printed this example from a Mark Papp in the following issue. It adequately sums up the perspective from someone informed about diving: “Re: PADI Whacked, David Graves’ death was a very sad event.

He was obviously a well-liked colleague who is missed by those that knew him. Your article, however, misses a few points: Mr Graves wasn’t forced into going on the press junket. He wasn’t forced to dive. He wasn’t forced to ignore his training and stray from the group. He wasn’t forced to ignore his training by ignoring his air cylinder’s contents gauge.

Despite the apparent lack of attention from the dive masters there has to be a concept of personal responsibility somewhere down the line. Mr Graves was a qualified diver. His training warned him of the dangers of scuba diving, so why didn’t he apply common sense, obey his training and, in a hostile alien environment with only a limited duration life support apparatus, check his air frequently?

That he had close call on his first dive and yet apparently failed to check his limited supply of air on the second beggars belief.

Why do you, and some divers, assume that no matter what happens under water, somebody else will bail you out?

I’m confused by your organ’s attitude to this sad event. You seem reluctant to accept the inquest jury’s decision and imply that the “gross negligence manslaughter” verdict offered might have been more appropriate, despite your history of highlighting coroners pressuring jurors to return verdicts they are unhappy with. Also, have you lost your attitude towards personal responsibility?

I’m deeply sorry for Mr Graves’ family’s loss but also want to stem the rapidly increasing flow of liability litigation, which seems based on the inability anybody to accept personal risk, even when voluntarily in obviously hazardous situations.”

I think Mr Papp’s letter sums it up well.

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ISSUE 03 | FEBRUARY 2015

Through my eyes

By Butch Hendrick An objective response to the article by John Bantin, which you have just read, is worthwhile in noting the various angles on this difficult topic.”

The underwater world is an incredible place, exciting, with dynamics that change every minute. It is a world that brings with it the lore of adventure and sometimes danger. Like any adventurous sport, the underwater world attracts everyone from would-be hobbyists to experts. It beckons the young and the old, the strong too, and the weak for whom it can be a lair.

As in many adventurous sports there is danger. As we all know, where there is danger there is the potential of unexpected injury or death. And then there is the all-too-human question: whose fault was it?

Photo by John Bantin

DIVER MEDIC & AQUATIC SAFETY

"As in many adventurous sports there is danger. As we all know, where there is danger there is the potential of unexpected injury or death"

I recently read the book Amazing Diving Stories, a chapter of which is referred to in this journal. It discusses the sad loss of British journalist David Graves; he was on a diving trip to Andros Island in the Bahamas’ chain. Having been an expert witness in many diving accident cases over the last 45 years, I can truly understand the dilemma of being involved in a trial, which the writer of this article was trying to share.

However, for the moment I would like to look more into the diving accident itself and what led up to Mr Graves’ death. The writer John Bantin alluded to the fact that David Graves’ diving skills were possibly poor and his air usage was high. He stated that he personally witnessed David Graves purposely move away from the group, which was possibly the mistake that took his life. This raises the question: if the author saw Mr Graves swim away, whom did he notify that this was occurring?

Diving safety is a basic responsibility of everyone. Since the beginning of scuba we have said that basic diver safety is the responsibility of every diver. From the beginning of diver education we talked the buddy system and trained divers how to watch out for each other – why it was necessary and what to physically do. We are everyone’s buddy. The writer should have told one of the dive guides that a diver left the group alone. Did he leave the line on purpose to go see a fish? Did he leave the line because he was having a problem? Did he leave the line to go help someone else?

Observation skills: What would you do differently if you were in this scene?

One of the problems today is not only do we not teach buddies how to be observant, but we assume that we are only a buddy to one person. I do 20

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not expect, or even want, a nonleadership-level diver to chase a diver who may be putting himself in danger – but if a diver does see a potential problem, I hope that the diver will notify the divemaster. This is even more important today with the decline in the quality of divemaster training.

Everyone on the dive is a buddy. We each have dedicated buddies. If we are in a group with no assigned dive buddies, then we are all each other’s buddies. Is there a legal responsibility? No. Is there a moral responsibility? Absolutely.

But nowadays we are no longer capable buddies; we are near capable or poorly capable. No one has any responsibility anymore. It’s always someone else’s responsibility.v It’s time we reflect on everything that has been removed from diving, diving education and diving safety. It’s time for those of us that really care about divers, the industry and the environment to start thinking about taking our industry back.

"Divers run out of air?

Yes they do; sadly, more often than we like to think. Ask resort dive operators who fill more tanks than anyone else"

Observation skills: What would you do differently if you were in this scene?

Divers run out of air? Yes they do; sadly, more often than we like to think. Ask resort dive operators who fill more tanks than anyone else.

How hard is it to have it happen? Well, have you ever known anyone who ran out of fuel in his or her car? It happens. And that was with the fuel gauge staring you in the eyes very often with a flashing light or a bell tone or both just prior to being empty.

In my view, the writer should have immediately moved to one of the dive guides and communicated with hand signals that a diver left the line and was headed in a certain direction.

More often than not we do what we are taught – not what we are told.

To tell someone what to do is not to teach them, which is why we call it training. If the students do not see their instructors performing their own air checks with the same frequency that the instructors ask the student to perform them, then what message is being sent? Instructors need to walk the talk.

I’d like to state that Jeff Birch and the staff of Small Hope Bay Lodge are true professionals in the arena of of Caribbean diving. The staff of Small Hope Bay Lodge demonstrated their professionalism when they announced they would be conducting a checkout dive before any divers would be allowed to even think about diving the Blue Holes or any other possible overhead environments. Guides who are allowed to take divers to areas such as the Blue Holes need to be well-trained – it’s not their first time at the rodeo.

Back to the point at hand: it was stated that the dive guides had safely rounded up all the divers and were ascending when Mr. Graves elected to move away from the group. The dive guides had selected a dive profile that would fit with the group’s air consumption rates.

Dive guides will guide tourists on underwater excursions from point A to point B and back again. Their job includes attempting to herd divers in a controlled fashion. They work to not let one part of the group get too far ahead of another, to try and keep the stragglers and wanderers together with the main group, and to help keep divers above the maximum planned depth and do their best to make sure divers surface with at least the minimum planned air. Often these excursions are based on a time window, a specific time duration, which is based on history of air usage by the most common heavy breathers. Dive guides will often do group air checks several times throughout a dive. They will often turn a diver group around early due to heavy air usage by a diver or a group of divers.

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I would’ve liked to have read about the briefings and debriefings for each of the previous dives and certainly briefing prior to the tragic dive in question.

I would also have liked to have read about the rescue attempt and recovery of David’s body. How did the dive guides handle the divers they were delivering back to the surface? Did they ensure that all the other divers in their charge were safe? How quickly were they able to recover David and did the group of journalists feel that the dive guides did do their best? Was there any sort of debriefing for the journalists or critical debriefing to the dive guides? Professivonal dive guides take their jobs pretty seriously and to have lost a diver in their charge can haunt them throughout their lives.

Photo by John Bantin

Whose responsibility is it to train a diver to check or monitor the submersible pressure gauge and air usage while underwater? It all goes back to basic entry-level dive training. We discovered when a diver is “taught” properly, he or she learns to become reflexive with personal and buddy air checks. Air check training should begin the very first time a new student attaches the regulator to the tank and opens the valve, and when he or she shows the hand signal for how much air is showing on the pressure gauge. New divers should check and signal air pressure every time they turn their air on. When entering the confined water area and donning their BCD tank assembly, every diver should check and signal air pressure to their buddies with the instructor watching.

Air checks between buddies should be conducted every 5 to 7 minutes during confined water training. Every time students reach the bottom in

the deep end of the confined water training area, they should perform a buddy air check before any other skills are conducted to train them to, first thing, check air once at the planned depth during all open water dives. In short, new divers should learn to reflexively perform air checks every time they put their gear together, just prior to descending in the water column, upon reaching the bottom, and every 5 to 7 minutes throughout the dive, as well as when they arrive at a safety stop and every time they reach the surface. If you make a point of it during training, divers will remember it. And at least a few of those checks should be buddy air checks.

Perhaps what could have made a major difference here would have been the realisation that journalists do not necessarily make the best divers. A divemaster or instructor could have been sent on this trip to do nothing but be the safety diver. An escort who would have quickly picked up on poor diving skills within the group and fixed it by teaching them how to be better divers. This divemaster/instructor would be the first one in and the last one out – a mother hen, so to speak. Such an escort would enhance the overall trip enjoyment and learning experience of the journalists.

If the journalists had a better time and came home better divers, their reports to the general public and their readership would simply have been…You have got to do this; diving is simply incredible.

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ISSUE 03 | FEBRUARY 2015

DIVER MEDIC & AQUATIC SAFETY

YOUR TEETH AND DIVING

Having just finished my mid-morning dive from a liveaboard in the Red Sea, I noticed we had a couple of guest divers aboard. Apparently one of them, a lady in her early twenties, had aborted her dive due to “toothache”. The other divers on board were discussing what the most likely cause was and had concluded that it was trapped air in a filling.

As a dentist, I asked if I could help, and so, with the assistance of a dive guide who acted as translator we discovered the following: the lady had no fillings, saw her dentist regularly and, most importantly, had a cold. As her pain was from an upper back tooth I felt the most likely cause of her pain was maxillary sinusitis referring to a tooth. I’m recounting this incident as it is time to debunk some out-of-date beliefs surrounding modern dentistry and diving.

"As her pain was from an upper back tooth I felt the most likely cause of her pain was maxillary sinusitis" 24

Photo by Witty Bear

By Peter Tatton

Scuba diving has become a popular sport throughout the world.

The sport is made possible because divers breathe compressed gas via a regulator held in the mouth. Divers overlook the obvious, which is that this makes your teeth, mouth and jaws important in the enjoyment of diving. If any of these are in poor health, you can find yourself with teeth and gum problems or jaw joint pain. This cluster of problems is commonly called "diver's mouth syndrome".

Here's what you need to know.

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ISSUE 03 | FEBRUARY 2015

Photo by Azurek

"There has been very little research into dental pain incidences while diving"

Tooth-and gum-related problems: Barodontalgia is the medical term given to tooth pain initiated by changes in air (gas) pressure and is commonly referred to as “tooth squeeze”. It is possible for air to enter a tooth in two ways. Air under pressure can be forced into the tooth via cracks, crevices or via dental decay. Less commonly, gas previously dissolved in blood vessels within the tooth pulp becomes less soluble on ascent and bubbles form inside the tooth.

It is not just our teeth that potentially can be affected by air bubbles being trapped but also inflamed or infected gums. On ascent the (trapped) air will expand whether in the teeth or gums and is able to cause pain of varying intensity. This often manifests as toothache, bleeding, or far less commonly as a cracked or broken tooth. On rare occasions, teeth have even been described as exploding!

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Unfortunately there has been very little research into dental pain incidences while diving; reports tend to be sparse, dated and often extrapolated from aviation research done during and just after the Second World War. The little research done recently suggests that about 10% of divers have experienced some sort of dental discomfort at least once. Of this, the majority of such cases have been found to relate to undiagnosed dental disease or pain from areas close to the teeth.

So what as a diver can you do to prevent problems with your mouth?

Teeth: In the few cases in which there have been reports of defective dental fillings and crowns (commonly called caps) air had been

trapped between a dental restoration and the remaining tooth. When this air expands on ascent it can cause pain or in rare occasions the fillings or crowns can become dislodged.

It is also possible for some part of a tooth to break if it had already weakened in the past. This occurs with or without pain, and loose pieces of tooth now floating about in the diver’s mouth can pose a health hazard. If inhaled, coughing could occur, but – more worryingly – the bits could settle in the lungs and cause further problems; thankfully this is extremely rare.

Over the last decade or so, the way dentists restore teeth and the materials they use has changed enormously. They are less likely to use metal amalgam fillings, which rely on slight undercuts in the tooth cavity to hold them in. Dentists now

prefer to use resin based composite materials. These materials are both physically and chemically bonded to teeth. This allows for a much better fit and far less chance of voids becoming present between the filling and tooth. Resin materials are also regularly used nowadays to attach crowns (commonly known as caps) to teeth. Crowns fixed in this way have been shown to stay in better than when other materials are used.

As a diver, you can help yourself by having regular dental examinations, which must include adequate radiographs (X-rays). Tell your dentist if you have experienced an episode of pain or dental discomfort while diving. Try to give the practitioner as much information as possible; many will be unfamiliar with the concept of barodontalgia. If you need any fillings, ask for resin composite material to be used if possible.

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Roots: Problems relating to teeth pulp (the blood and nerve supply to the teeth) account for over 40% of recorded incidents.

These can often be difficult for your dentist to diagnose after the event, as the conditions in which they occurred can not be replicated in a dental clinic or practice; they would need a recompression chamber to repeat the conditions. You can help by recording as much detail as possible about the event immediately after the dive.

Photo by Donikz

Sinuses: The roots of your upper back teeth are often close to the floor of the maxillary sinuses, which are air-filled chambers in the skull between the eyes, nose and mouth. These sinuses are connected to the nose via small tubes that allow the passage of air. If these tubes become inflamed due to infection, then the passage of air becomes blocked and gives rise to pain, which is often reported as toothache. Reports indicate that 10% of diver tooth pain has been found to be referred sinus pain, and that’s why we are told not to dive when we have a cold or other upper respiratory tract infection. The incidence of sinus pain during descent is about double that during ascent; this is a useful fact to know as it can help in diagnosis.

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Diving after recent dental treatment represents about 10% of all reported cases of pain while diving. Good advice is not to dive if you are in the middle of dental procedures such as root canal treatment, teeth crowning or if temporary fillings have been placed in your mouth. If in any doubt, ask your dentist.

You should not dive within 24 hours if you required a dental anaesthetic for treatment. If you have any sort of dental surgery, such as a tooth extraction, then you should restrain from diving for at least a week. You should seek advice from your dentist about how long you will take to heal.

Mouthpiece-related conditions (jaw and muscle pain): Correct equipment will make your dive a pleasant experience and the correct size of mouthpiece should not be underestimated in the preparation. At first, divers may not notice the discomfort in their mouth caused by an ill-fitting mouthpiece because they are so distracted by the thrilling scenery of the underwater world. But once the dive is concluded and the mouth-piece removed, they often notice pain in their jaw joints or muscles around the mouth.

Similarly if you need crowns fitted, request that your dentist uses a resin composite material.

gum disease, which will present as pain when the air expands, or as bleeding.

Gums: It’s not just teeth that can present a problem. Your gums and their surrounding tissues, if not healthy, could also trap air. Infections around wisdom teeth are relatively common in adults in their late teens and twenties. While severe gum disease is generally associated with an older age group, it can affect people of any age. In these two conditions, the gum is infected and inflammation is present. Often associated with wisdom teeth there is a flap of gum under which air can pass and become trapped. A similar problem can occur with severe

Both dental and gum disease are preventable by adopting a good diet and practising good oral hygiene. Diving with a poorly kept mouth will increase your chances of having an incident and ruin your dive or dive trip. So why take the chance?

Over 50% of us have suffered with jaw joint pain at least once after a dive. If we already have some sort of temporomandibular joint syndrome, which is the technical term for jaw joint pain, diving exasperates the problem.

So far I’ve discussed what you can see (your teeth and gums), but what lies underneath are the roots of the teeth, which are embedded in jaw bones and in the upper jaw sinuses, which are in close proximity to the back teeth.

There are a few common factors that lead to jaw joint problems; these are stress, tooth clenching and having to move the lower jaw forward to obtain a firm bite on the regulator. Jaw joint pain is also seen more commonly

Photo by Donikz

"Diving with a poorly kept mouth will increase your chances of having an incident and ruin your dive or dive trip."

"Diving after recent dental treatment represents about 10% of all reported cases of pain while diving."

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DIVER MEDIC & AQUATIC SAFETY

amongst cold water divers. Cold water impairs the function of the lips, which means that the diver has to rely more on clenching the mouthpiece to hold it in place.

Jaw joint pain can present as headache, pain in the face or jaw, difficulty chewing, and a ringing in the ears. The entire problem should disappear quickly after diving. If jaw joint pain persists longer than a few days, the diver should consider visiting a dentist to evaluate for possible temporomandibular joint syndrome.

What can you do to reduce jaw joint pain?

Diving, even for experienced divers, contains some element of stress and quite often leads to tooth clenching, and this can be very destructive. Not only does it place abnormal pressure on your jaw joint and facial muscles, but it concentrates a lot of force onto a few side teeth. If any of these teeth have weaknesses, then toothache could occur.

Your regulator should fit comfortably in your mouth, and when you move your head there should be no tugging on the hose.

This could become part of your pre-dive buddy check. Once in the water, allow your lips to make a seal around the outer flange of the mouthpiece and practice biting only gently onto the bite platform. If you do not find this easy, consider changing your mouthpiece.

There are quite a few mouthpieces on the market. By choosing the most comfortable one, you can overcome problems with tooth clenching and having to move your lower jaw forward to hold the regulator in place. It is recommended to trial dive a number of mouthpieces in order to find the design with the least likelihood of causing joint pains; for a thorough test, you should dive for at least 15 minutes followed by a rest period of 15 minutes. Also, if you commonly dive in cold water then testing in a heated swimming pool can give false results.

Photo by Witty Bear

Alternatively, you could buy a semi-customised mouthpiece, which in use will require less muscle activity to hold the mouthpiece in place than a commercial type. If neither of these options works, then a fully-customised mouthpiece is reported to cause the least amount of discomfort, muscle pain and fatigue – but it is also the most costly type.

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If after a dive you do suffer from joint pain, then moist heat is the treatment of choice. Take some form of analgesic and apply a moist, comfortably hot washcloth to the painful region. Like other joint pains, the symptoms should subside with a little rest and basic care.

In this article I have covered the main dental-related problems that divers may encounter. My own recipe for diving free from dental trouble is to have a healthy mouth and a comfortable mouthpiece. These two key features are within the control of us all.

ISSUE 03 | FEBRUARY 2015

DIVER MEDIC & AQUATIC SAFETY

THE REBREATHER

CAUSTIC COCKTAIL

HAZARD

By Paul Haynes

I

"The burning pain in the mouth and throat was intense and an immediate involuntary reactive response caused me to exhale with considerable force" 32

Photo by Paul Haynes

will first share my personal account of alkaline-solution chemical burns. It was 1989 and only the second dive of my life; despite this the task seemed straightforward.

After pre-dive supervisor checks I was to descend to 7 metres with my buddy and, as fast as we could, follow the bottom laid wire cable for 1 000 metres to the other end of the ‘lake’. Once there we were then to work our way back to the start point carrying our rebreather and fins. This task was part of a combatant diver aptitude that I had volunteered for along with other Royal Marine Commandos. It was intended to demonstrate our potential suitability for future participation in a special operations selection and training course due to start later that year. The previous day we had received some basic instruction on the Drager LAR V closed circuit oxygen rebreather and associated emergency operating procedures. Despite being a complete novice diver, I felt reasonably comfortable with the task ahead, although a one-kilometre subsurface swim after having just completed an hour of intensive physical training was not particularly appealing.

As instructed we entered the water, checked each other for leaks, located the wire hawser and started swimming, knowing that successful completion of this task was a critical factor in deciding who would be chosen to go forward to the next phase. Things initially proceeded well and we were making good time. However, approximately 30 minutes into the dive I began to feel short of breath, unwell and confused. Instinctively I desperately wanted to go to the surface and breathe fresh air.

However, that would mean failing the task, so not knowing any different I assumed this sensation must be a normal part of rebreather diving and continued with the swim. Not long after this, breathlessness rapidly increased and it became ever more difficult to draw gas into my lungs.

"I was soon in severe respiratory distress and while inhaling, which by now required significant effort, I aspirated a strong caustic solution" The burning pain in the mouth and throat was intense and an immediate involuntary reactive response caused me to exhale with considerable force, spitting the rebreather mouthpiece out. This then caused loss of buoyancy as the rebreather began to flood and weigh me down. With nothing to breathe, I knew I needed to get to the surface quickly.

However, the ‘shock’ of the caustic burn had left me physically incapacitated, and with little gas in my lungs following the forceful rejection of the rebreather mouthpiece and caustic fluid, I was sinking and slipping into unconsciousness. I next became aware that I was on the surface thanks to my dive buddy, who fortunately for me was a trained military air SCUBA diver. Had it not been for him I would not have made the surface by myself that day – his quick response had saved my life. If I had been buddied with someone as inexperienced as I was, the outcome may have been very different.

Following the administration of basic first aid, I was sent to the medical centre where a naval diving doctor examined me. Unable to swallow or talk for the next two days as a result of the chemical burns, I was informed that I was extremely ‘lucky’.

Had the caustic solution gone just a little further down the trachea, the doctor would have signed me off as unfit for military diving, ending my career aspirations on the spot.

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Rebreather Diving Hazards Described above are classic symptoms of CO2 poisoning (hypercapnia) and alkaline solution chemical burns, or the so-called ‘caustic cocktail’.

On investigation it was found that the sealing gasket on the rebreather scrubber canister lid was not fitted correctly and approximately 1 centimetre of its length was displaced resulting in a broken seal. Over the course of the dive this had caused water to leak directly into the scrubber canister, initially soaking it to the point where absorption of exhaled CO2 was severely compromised. In addition, sodden CO2 absorbent material greatly increased breathing resistance (making breathing harder work). These factors, combined with the high work-rate and CO2 production, resulted in the hypercapnia symptoms

I initially experienced. Such symptoms might have suggested to an experienced rebreather diver that there was a potentially catastrophic failure of equipment. However, with the only 90 minutes of rebreather ‘experience’ I had accumulated by that point, and motivated by the desire to pass that phase of the aptitude, I incorrectly chose not to surface. As a consequence, continued flooding of the canister resulted in an increasing volume of strong caustic solution within the recirculation system (breathing loop), where it was subsequently aspirated. Both hypercapnia and ‘caustic cocktail’ are significant hazards for military and civilian rebreather divers, often being cited in accident reports as disabling agents and disabling injuries that led to a fatality.

Cause and Effect What then causes a ‘caustic cocktail’, and what are the potential injuries a first responder might encounter? All re-circulating underwater breathing apparatus (rebreathers) have to effectively remove exhaled CO2, the main by-product of respiration.

To do this a CO2 absorbent chemical is used. The absorbent typically used in rebreathers comes in a granular form, which is packed into the rebreather CO2 scrubber canister by the diver and periodically replaced (after approximately 3 to 4 hours of use).

The absorbent material used for diving rebreathers is soda lime, which comprises approximately 75% calcium hydroxide, 20% water, 4% sodium hydroxide and 1% potassium hydroxide. In normal use, exhaled gas passes through the canister soda

lime ‘bed’, whereupon CO2 is absorbed enabling CO2 ‘scrubbed’ gas to be re-breathed. However, this absorbent when mixed with water produces a highly corrosive alkaline solution that can cause chemical burns of varying severity depending on the alkalinity of the solution, the tissues involved and time of exposure. Ingestion of an alkaline solution can result in chemical burns of the mouth, throat and stomach. Inhalation of an alkaline solution can cause a reflex laryngeal (upper airway) or bronchial (lower airway) spasm, pulmonary tissue damage and Acute (Adult) Respiratory Distress Syndrome (ARDS). Although rare, clearly a ‘caustic cocktail’ is to be taken seriously as potential injuries can be severe and in the case of ARDS, life threatening.

"The absorbent material used for diving rebreathers is soda lime" 34

Photo by Paul Haynes

Diagnosis The signs of a rebreather diver who has experienced a ‘caustic cocktail’ can vary significantly. If the caustic solution is relatively weak and there has been minimum exposure, a diver may report nothing more than a bad taste, tingling sensation in the mouth or tongue, along with some discomfort. However, a diver who has aspirated a strong alkaline solution will likely be in significant distress, possibly with respiratory problems.

Other diving malady complications could arise due to a rapid uncontrolled ascent or omitted

decompression such as Arterial Gas Embolism (AGE) or decompression sickness. It is therefore critically important that first responders look out for signs and symptoms of these potentially latent diving illnesses as well as treating the immediate injury. In addition, in the case where there has been a slow and gradual ingress of water, as opposed to a sudden and catastrophic flood, the casualty might also exhibit signs and symptoms of hypercapnia such as confusion, severe headache, fatigue and memory loss.

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First Response Like any diving emergency, while ensuring the safety of others, the first response is to secure the casualty at the surface and get him or her as quickly as possible to a point of safety to enable an initial assessment and resulting treatment.

Chemical burns, in particular those caused by alkaline solution, turn tissue into a liquid viscous mass (liquefaction necrosis). Treatment requires the immediate and extended flushing of the injury with fresh water – far more flushing than you would for thermal burns. Therefore, repeatedly rinse the injury or mouth out with fresh water.

When you believe you have finished, repeat the rinsing process. If fresh water is not available use seawater. However, ensure that none is swallowed.

Once the situation is stabilised, evacuate to professional medical care as soon as possible. An old treatment protocol often cited is to rinse with a mild acidic solution such as vinegar or even cola in order to neutralise the alkaline. However, this is no longer recommended as there is the potential for further injury as a consequence of the acidic action on damaged tissues. In event of ingestion, do not induce vomiting as this may cause further tissue damage to the esophagus. If the casualty

is conscious, allow small amounts of water to be drunk and activate emergency medical services as quickly as possible.

If the eyes have been exposed to the alkaline solution, again repeatedly rinse with fresh water or eye rinse. Evacuate to professional medical care as soon as possible while continuing to flush the eyes with fresh water or eye rinse until relieved by medical professionals.

If caustic alkaline solution has been inhaled, pulmonary tissue damage may have occurred, disrupting gas exchange in the alveoli, a potentially life critical injury. As a consequence the casualty may have severe breathing difficulties. Therefore, administer oxygen at the earliest opportunity and activate emergency medical services as quickly as possible. If the casualty looses consciousness, proceed with basic life support protocols until relieved by medical professionals. Remember that those who might be left to clean up the dive site, in particular deal with the casualty’s rebreather, must exercise extreme caution. Rinse the rebreather with fresh / seawater and use gloves if you are required to handle the equipment.

"Chemical burns, in particular those caused by alkaline solution, turn tissue into a liquid viscous mass" 36

Photo by Paul Haynes

Prevention Preventing water ingress is a critical element of rebreather pre-dive preparation and use. To determine the watertight integrity of the recirculation system requires a thorough breathing loop negative and positive pressure test. A leak path or incorrectly assembled fitting may become sealed under positive ambient pressure during a breathing loop negative test, a leak only becoming evident when the internal breathing loop pressure is raised above ambient pressure during a positive test. It is therefore critically important to undertake a 3 to 5 minute positive and negative breathing loop test before diving or following disassembly of any part of the breathing loop. When in the water, the rebreather mouthpiece Dive Surface Valve (DSV) requires disciplined use to prevent water ingress. Whenever the rebreather is not being used, either at the surface or in the water, the DSV is to be left in the closed position, and so isolating the breathing loop. This discipline is absolutely essential, and instructors must pay particular

attention to rebreather trainees to ensure they correctly close the DSV at the surface and critically when underwater while undertaking skills such as emergency open circuit bailout procedures. If ever you suspect a trainee has not closed the DSV and water ingress may have resulted, abort the dive and check the condition of the breathing loop before diving again. Fine particles of soda lime dust readily dissolve in water significantly affecting the alkalinity of a solution. Therefore, a significant contributory aspect to the corrosiveness of a solution is the amount of soda lime dust in the CO2 absorbent.

Measures should therefore be taken to minimise the ‘dustification’ of the CO2 absorbent material such as minimising mechanical agitation during transport and storage. Also endeavor to separate dust from the larger soda lime granules during rebreather preparation by gradually filling the canister outdoors in a breeze. This becomes more relevant when using the last of the soda lime from large storage containers where the dust has settled to the bottom 37

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DIVER MEDIC & AQUATIC SAFETY

of the storage container and is in higher concentration. Although arguable excessive as a measure, some militaries sieve the soda lime to remove dust prior to canister filling and, because

of the dust encountered, insist on the use of Personal Protective Equipment (PPE) such as eye protection and a face mask.

Recognition and Resolution While every effort should be made prior to diving to ensure the watertight integrity of the breathing loop, rebreather component failure or damage can arise when underwater. Therefore, recognising the early signs of water ingress is essential to safe rebreather diving. If the leak is gradual, dependent upon where the water settles, early signs might be ‘gurgling’ noises, particularly upon inhalation. If this is experienced, you must immediately adopt a head upright orientation to force water to drain to the lower areas of the breathing loop and away from the inhale breathing hose. Then switch to open circuit bailout and abort the dive.

If the leak is directly into the scrubber canister

or water ingress migrates to the soda lime CO2 absorbent ‘bed’, the canister’s efficiency will eventually become compromised. One formal engineering report suggests that just 150ml of water poured into the scrubber canister of a popular rebreather results in a 3,5 fold increase in resistance to gas flow through that canister; an increase in work of breathing is therefore an early indicator of breathing loop water ingress. Also, the rebreather diver must be alert to symptoms of hypercapnia.

This can arise from either retained CO2 as a consequence of increased work of breathing from soaked absorbent material and resulting reduction in alveoli ventilation, or from inhaled CO2 as a result of loss of soda lime scrubbing capacity.

"recognising the early signs of water ingress is essential to safe rebreather diving."

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Photo by Paul Haynes

Equipment Impact An often-overlooked aspect of a ‘caustic cocktail’ is its impact to the rebreather, particularly electrical components. As described, the alkaline solution is potentially highly corrosive. This can result in significant material degradation as caustic solution migrates under osmosis into electrical cable insulation and onto printed circuit boards, and so on. Damage or potential damage may not be immediately apparent, fine copper wires and insulation can break down gradually under caustic action and become brittle over time. This may then result in a sudden and

potentially life-threatening electrical failure. It is essential, therefore, that all components are thoroughly rinsed in fresh water at the very earliest opportunity. If electronic components have been exposed to caustic solution, such as oxygen sensors, they should be discarded because correct future functionality cannot be assured. If there has been any delay to rinsing any exposed electrical components such as wires, the reliability and insulation integrity of the wiring can no longer be relied upon and a return to manufacturer for overhaul should be undertaken.

Paul Haynes is a mixed gas closed circuit rebreather Instructor Trainer and deep shipwreck explorer with a 25 year military, occupational and technical diving rebreather diving background.

For 10 years Paul managed the defence business for Divex Ltd., the world’s largest manufacturer of professional diving equipment, and he was an integral member of its rebreather design and test team, helping to develop advanced performance military rebreathers and underwater life support systems. As a founding member of Life Support Investigations Inc., a not-for-profit organisation established to support US Coastguard and law

enforcement rebreather accident investigations, Paul has been involved in the analysis of numerous rebreather fatalities, both civilian and military. Besides technical diving and instruction, Paul manages his own specialised defence diving consultancy business, training special operations forces, naval mine clearance diving teams, and law enforcement agencies in the safe use of various rebreather technologies and underwater equipment. www.haynesmarine.com Facebook: Haynes Marine 39

DIVER MEDIC & AQUATIC SAFETY

ISSUE 03 | FEBRUARY 2015

Exploration,

Education and conservation Cristina Zenato tells us her story My name is Cristina Zenato and I am originally from Italy. I grew up between the African savannah and the rain forest; in the early morning I would open the heavy curtains of my room and watch silver back gorillas jumping from tree to tree in the distance.

I grew up amidst the dark starry nights of a world without electricity and the distant sound of drums played at night around a fire; I listened to ancient wisdom and learnt at a very early age that coexistence with nature is the best way of living and that every animal plays a role, whether we want to recognise this or not. It’s a vital role in the big scheme of life, and it’s one that needs to be appreciated.

Since a very young age I had two dreams: to learn as many languages as I could and to become an underwater scuba ranger. My goal was to be able to be in the water every day and all day for work, have pet friends like moray eels and sharks and tell people what to do and not to do while in the water. In my innocent lack of knowledge I envisioned myself scuba diving and swimming all day long, without the need to come out of the water. I became a certified scuba diver “late” in life; I was 22 and through a series of coincidences and events I ended up in the Bahamas, at Unexso (the Underwater Explorers’ Society), where I took my open water class. I completed one more week vacation as planned, and then I went back to Italy for ten days during which I gave up my job, my car, my appointment, my boyfriend, and moved back to the Bahamas with a small gear bag and a duffle bag of clothes.

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Photo by Amanda Cotton

So from very early in my life I learnt the positive effects of loving the presence of animals like snakes, spiders, frogs, scorpions and bats, just to mention a few that normally trigger some negative responses in people. I learnt to understand them and to avoid them as much as possible when they cross my path. I also learnt that pointless destruction will only have a negative effect on us humans too.

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ISSUE 03 | FEBRUARY 2015

As I progressed in the world of diving through the necessary courses I decided to get involved with UNEXSO, one of the oldest dive operations in the world that was created thanks to the passion of divers in 1965.

Within 8 months I was working at Unexso. Twenty years later I am the dive operations manager of the company; I manage a crew of 20 divers and captains and a fleet of 7 boats. I coordinate various tasks – everything from reservation, front desk and the dive department, and I manage a non-profit programme that teaches Bahamians how to scuba dive all the way to rescue level, and then we employ them. To keep myself challenged I am also a technical and full cave diving instructor spending some of my free time exploring new caves. What I am best known for is my special relationship with sharks and the shark dive we have been running for the last 20 years.

People call me a lot of things, including the Shark Whisperer. To be honest, it is not my favourite nickname, but it was given to me for the special interaction I have with the sharks. I have worked with over 12 different species of sharks. I believe what I do with Caribbean Reef Sharks is not something that should be attempted with all sharks. What I do is welcome the sharks into my lap and by gently rubbing their nose induce a gentle trance, during which the animal lies motionless on the ocean floor and on my legs. During that time I can pet the shark, bring her to divers to touch her (it’s easiest to do this with the female sharks), as well as remove parasites and hooks.

There is obviously an inherit risk in what I do, but I follow strict procedures and I do wear protection while interacting with the animals. My work has spanned over twenty years, and I do believe in respect and understanding of the nature of sharks. In that also lies my belief that one size does not fit all and the work I do with Caribbean Reef Sharks can’t just be transferred to any kind of shark out there – each type of shark is different, also considering the sheer size of certain species and their teeth. My biggest fortune was to find a gentleman called Ben Rose who taught me about sharks and the gentle interactions you can have with them. To this day Uncle Ben, as I always call him, is a person I share questions and discoveries with. Ben has been a mentor and a fan all in one and I am honoured to call him my friend.

Because I’m passionate about sharks and caves, people think that I am a daredevil, adrenaline-seeking kind of person. Some don’t realise that, instead, my lifestyle requires a quiet personality, a desire to live, and an attention to detail that is above the average.

In most people’s imagination cave diving is squeezing through wormholes, facing dangerous risks of ceilings falling on you, getting lost and running out of air before reaching the surface and the light.

I don’t deny that cave diving is a dangerous activity, but I can also attest that cave divers are extremely well-trained and prepared individuals who learn to analyse their emotions, motivations and those of the people they are diving with. By the time a cave diver arrives at exploration of a cave, he or she has accumulated much time and

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Photo by Amanda Cotton

Being a cave explorer and a cave diving instructor requires work of meticulous planning, constant training and an appropriate mindset, supported by an even more appropriate gear configuration.

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ISSUE 03 | FEBRUARY 2015

experience. It is still an unknown world, one that provides great anticipation, as well as a higher level of inherit risk but also a higher level of satisfaction.

Cave exploring on Grand Bahama, where I have lived for the past twenty years, is still widely available and I have been able to complete some interesting dives.

As of December 2012 I was the first one to connect a land-based cave with an ocean blue hole, swimming from one to the other and back. It took five years of exploration, many attempts, more setbacks and then even more attempts.

This particular cave changes as it progresses between land and ocean.

Hydrological and environmental conditions affect the way the tunnels, the ceilings and the sediments form and move. While exploring, I realised very soon the two most dangerous aspects of this cave: 1. The brittle ceiling, formed of fossil reef and ancient limestone, which tends to fall in small little pieces as my exhaled bubbles hit it.

2. Certain chemicals in the water eat the line, leaving a delicate string that can dissolve into powder at my touch, potentially causing me the risk of losing the connection with the exit. Frequent checks of the line conditions are necessary to guarantee its integrity.

To the above conditions add the fact that the ceiling billows in clouds of orange bacterial growth. Every time it’s like finding my way out through thick orange juice.

The cave is also subject to strong tidal changes every six hours that cause siphons and springs at different times every day. The exploration of this system has been to this day the most dangerous and demanding I have experienced.

Although I have been in difficult situations, I cannot define them as frightening. Fear is not a sentiment I can allow to manifest when in certain situations. I either apply careful concern that prevents me from going any further or there is determined resolution once an unforeseen situation arises. Fear kills, for fear raises breathing rate, produces tunnel vision and limits rational responses.

I have been in tight places, I have been in places with no visibility, I have been in crumbling environments, and I therefore had to re-evaluate many situations and actions. Although I have on occasion taken double the time to exit compared to the time I took to go in, I have never been in near-death situations, or so I believe. I remember that once I became stuck, unable to move forward or back. I vividly recall the tingling that went down my spine, the dark images my mind conjured, and how I ducked my head and held my breath and let this dangerous wave of emotion wash over me. I realised that even a few seconds of those thoughts were dangerous and instead worked my way out methodically. I am often asked what it is that I find in caves. The most natural response is rocks (a wink and a smile go with this answer).

Ultimately in caves I find the lesson that teaches me the need to live and embrace the now. Cave diving is a highly demanding activity, which leaves only room to concentrate on what is happening in that instant. There is the decompression and the gas time, there is the time of now in this wonderful place, but there is no other time.

Photo by Amanda Cotton 44

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Photo by Amanda Cotton

DIVER MEDIC & AQUATIC SAFETY

The cave also does not change with time, whether it is of the day, the month, the year or age. When I am in a cave it can be raining, sunny, winter, summer, I can be 22 again or 43 and it does not matter. The cave holds a special time clock. For me it’s a form of meditation with the added bonus of an endless beauty and a story line always worth reading.

I do believe it’s the contact with nature and active work that makes me love so much what I do. Whether it is in caves, with sharks, on night or wreck dives, free diving or scuba in general, this is my return to a place of simple innocence.

I believe that nature, and the ocean in particular, is the answer to most of our ill feelings.

As humans we need more contact with our core and our origins. I strive to protect what is not only the source of my living, but also the source of my happiness and wellbeing.

I realised a long time ago that education is the key to conservation. I truly believe that if we can educate people, young and old generations about the value and importance of nature, the oceans, and our connection with nature, we will be able to further the efforts towards conversation. The biggest contribution I give towards conservation is perhaps the non-profit educational work on the island where I live.

Through a school programme, we educate young adults from grade 10 to 12 in the open water, advanced and rescue skills. This is part of their school curriculum. They are trained to become divers and boat captains and introduced to the world of marine biology.

Some continue into the scuba diving world, many become international captains and some become nature tour guides. The fact is they learn the tight relationship between sustainability and making a living and learn to take care of their environment in exchange for renewable provisions.

I have also been active in the campaign that several years ago concluded with the Bahamas declaring all shark species to be protected on all levels in Bahamian waters, recognising the valuable contribution that sharks make to the environment and also the economy of the country. My work has always been and continues to be about sharks and their vital role in the balance of the ocean.

I also work closely with the Bahamas National Trust in education about the value of fresh water supply and proper disposal of garbage and plastic. As a Marine Protected Areas consultant I have provided, through cave diving and exploration, the necessary data to extend the boundaries of several parks on Grand Bahama Island. This includes territory over caves (fresh water reservoirs), mangroves, inlets and blue holes.

I am a member of the Women Divers Hall of Fame and an active sponsor of their fundraising and educational programmes. I also host and support the scholars belonging to Our World Underwater Scholarship Society. I extend my educational programme to different parts of the world using technology and working through Skype Classroom. I always loved and believed in this quote and I use it as my mantra: “In the end we will conserve only what we love. We will love only what we understand. We will understand only what we are taught.”

Baba Dioum (1968)

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Cristina is member of the Women Divers Hall of Fame, The Explorers’ Club, the Ocean Artists Society and a Platinum Pro 5 000 receiver. She is a PADI MI and teaches classes at all levels.

She is in the process of becoming a PADI Course Director and soon plans to offer Instructor Courses. She is NSS-CDS and TDI Full cave and Technical instructor and specialises in Shark Courses at different levels.

For more information about Cristina’s work and her availability for presentations, talks and consulting work, please check her website www.cristinazenato.com or email her directly at czenato@gmail.com

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DIVER MEDIC & AQUATIC SAFETY

Where have all the divers gone?

By Walt 'Butch' Hendrick

I continue to have the opportunity, year after year, to work with and train hundreds of divers of all levels. These divers have received their basic to advanced specialties, as well as their dive master and instructor certifications, from a half a dozen different training agencies and no less than 100 different instructors.

I can’t help but realise I am witnessing a new era in diving education, which seems to be a continuous downward slide in both basic skills and knowledge levels.

Just watching divers put their basic gear together can be insightful. I can see which divers were taught to dive by an instructor who was certified to teach in the old-school way, more than 12 or 15 years ago. Then there are divers who are “taught” by an instructor in the new system of reduced standards.

My instructor staff and I are now witnessing between 15 and 20% of the newly certified divers we work with putting some portion or all of their dive gear together backwards or upside down. The most common statement that comes along with their embarrassment when we point this out is they were really never taught how to put their gear together, the reason being that they were shown once and never really taught.

There are countless studies to prove that repetition is vital for learning (to establish the pathways in the brain), especially in a practical application like diving – also flying a plane or driving a car, for that matter. A demonstration is not a lesson.

Photo by Little Sam

We try to make light of the problem, fix the problem by giving them a couple of memory cues for next time, and move on.

We are not only seeing this difficulty in our classes; we are seeing it in open water dive sites. Just go to the local quarries, lakes and other areas that are frequently used as open water training or certification dive sites, and watch what you see.

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You might also watch how many new divers exit the water shaking their heads demonstrating that they are not excited about their first underwater experiences. Again we are not the only ones seeing these problems; dive masters and instructors in dive resort operations all over the world are witnessing and discussing the same events daily.

Photo by Patjo

Part 2

It is not uncommon to see a buoyancy compensator mounted backwards on the tanks. As a result, regulators end up being mounted backwards and buoyancy compensators mounted way too low on the tank. This not only increases the chances of the regulator hitting the back of the diver’s head but also reduces any chance of proper buoyancy control.

Tanks mounted too high in buoyancy compensators will often cause divers to feel off balance, so making them think that they need to overweight; the combination of a tank too high and overweighed diver will directly affect body position in the water, which will continuously hamper every attempt for proper buoyancy control.

Let’s go back to teaching basic equipment skills; back to square one. Diver equipment is sexy, and most new divers actually are excited about learning how to use it. Just take a moment and think about the mask. It is the single most important piece of dive equipment we have. Without it we

couldn’t see the underwater world. So there would be no reason for the average person to go underwater, and the sport of diving would be nonexistent. Yet, with that said, a large portion of today’s divers can’t properly clear a mask underwater without holding their breath.

An even larger portion of today’s sport divers cannot succeed in performing the most important skill of comfortably breathing underwater without a mask or with a flooded mask, for at least one minute. These were mandatory skills since the first meetings on diver education in the early fifties.

I have been part of several discussions in the past year and a half, in a dozen parts of the world with true veteran dive instructors, discussing the new wave of lowered standards. If we don’t honestly address the problems we can’t even begin to fix them. We need to remember that the dive industry is run by divers and dive instructors, not the dive agencies.

Without us, the agencies can’t exist.

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The tank/regulator cannot deliver air to you when it is mounted backwards. Yes, we have seen this no less than five or six times in the past six months, and I witnessed it at an open water dive sight in Europe a few weeks ago.

Since we are speaking about rights, you not only have a right to have air (except for the inter-Spiro AGA, air always comes from the left). You also have a right to be free. The simplest way to remember how to properly don a weight belt is to remember you have a right to be free. So, pick the weight belt up with the free end in your right hand, thereby the buckle will be to the left. If the buckle has been mounted to the belt properly you will have a right-hand release thereby guaranteeing your right to be free. Two rights don’t easily make a wrong..

Why this topic? It happens to be a topic very close to my heart since it relates to the very first article I ever had published in 1964. I know some of you are now asking: has he ever learnt anything since? The answer to that is it’s still out for discussion.

What I have learnt how to do over the past 50 years is how to be observant.

Photo by MPS 197

Let’s begin with basic equipment set-up: Divers have the right to have air. Learn to start with a tank in an upright position directly in front of you with the on and off knob pointing to the right, which is the case no matter where they are in the world (all standard scuba tank valves are built the same with the on and off valve to the right); the O-ring and the open orifice for the first stage of the regulator will be pointing away. Thereby, if you pick up the buoyancy compensator (BC) and hold it in front of you as if you were going to put it on another person, then the BC strap will be pointing at the tank asking to be put in place. Again with the tank standing in front of you, and the on and off valve to the right (remember we have a right to have air) pick up the buoyancy compensator and hold it as if you were going to put it on another diver as if it was a jacket. Bring the tank band or bands down over the top of the tank and prepare to set it at its proper location or height.

At least 90% of all BC manufacturers have gone to the effort of using a hard pack mount, a dome or arch, which is on the tank side of the BC. This dome or arch will tell you within half an inch where the tank should be set for proper fit on almost every buoyancy compensator produced. Divers need to learn how to properly ratchet tank bands so they are secured to the tank, rather than what we see all too commonly, namely that tanks are too loose in the backpack. When a buoyancy compensator is properly fitted to a tank of any size, the band should be square or flat across the top when the tank is lifted by the BC alone. What we often see in today’s world, but don’t understand, is the tank band almost looks like a soft smile; this is a quick indication that the band is to loose and the tank will move or possibly even slide out of the mount.

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Metal, Middle, Bottom, Top Even veteran divers will sometimes discover that the tank strap has been removed from the buckle and needs to be re-threaded; this will often cause a dilemma in that the tank band can no longer be properly tightened. Yes, there is a graphic picture/ drawing on the side of many buckles; with a proper engineering degree, some divers will be able to figure it out. The quickest way to remedy this is to remember a simple phrase: metal, middle, bottom, top. With the tank band strap free and facing the buckled end, push the open end through the Metal bracket or u-shaped end; the other end of the strap will be attached there. Now come around and back through the Middle slot; without tightening come down and through the Bottom slot; now gently ratchet the band to the tank when you believe it is snug enough; take the open of the strap through the slot at the Top of the plastic or metal bracket and secure snuggly to the tank. That completes the four steps of Metal, Middle, Bottom, Top. When mounting the first stage of the regulator, remember you have a right to have air, and so the primary mouthpiece/second stage needs to come over the right shoulder. No matter which way the tank is pointing, the primary breathing mouthpiece/ second stage needs to be pointing in the same direction as the on and off knob on the tank valve. You have a right to have air, unless it’s an Inter-Spiro AGA full face mask, which comes over the left shoulder; all other primary second stage come over right shoulder. The on and off knob on the valve of the tank will always tell you which direction the primary mouthpiece/second stage should be coming from no matter which direction the tank is pointing. Remember the simple principle: Because you have a right to have air.

In the past nine weeks I’ve had the opportunity to observe divers of many different levels in three states and four countries. In one European country and in an active open water dive facility I had the opportunity to observe seven different divers in two different group’s don weight belts with left-hand releases. In one group of three they were completing their final open water dives for basic open water certification. An uneventful gear check was conducted by an instructor and dive master with no changes to any of the equipment; the group was paraded off for the final open water dive. Certification was about a half an hour away; once again it demonstrated that the only way you can have a responsible and thorough gear check is if you have a proper head to toe procedure. Good gear checks begin at the top of the head and work their way down every time; if something catches your eye, then double check it and triple check it. You need to know what to look for and how to look if you are going to be a responsible diver/buddy.

Why do diving standards require a right-hand release on the weight belt? It’s really quite simple. In the early 60s a new series of products exploded onto the diving scene: the first true inflatable

Observation skills: What would be the reason, if any, to hold a divers cylinder?

Photo by Little Sam

DIVER MEDIC & AQUATIC SAFETY

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DIVER MEDIC & AQUATIC SAFETY

Photo by Oksana Perkins

Observation skills: What would you do differently if you were in this scene?

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diving vests later to be known as buoyancy compensators. No, Scuba Pro had not yet changed the world with its diving stab jacket. Suddenly there were fitted horse-collar type life jackets that could be self inflated via an attached bottle or through the power inflator attachment from the first stage of the regulator, or orally inflated to any level by the diver themselves. This meant we no longer had to borrow life vests from under the seat on Eastern airlines (for some divers this was a hard habit to break).

teaching divers to add or remove air anywhere in the water column, and with the use of the left hand make themselves positively buoyant at the surface. In a true emergency, drop your belt and inflate your BC. It was quite astonishing to see how quickly divers became reflexive with this new piece of equipment. It was quite obvious, whether adjusting buoyancy plus or minus or trying to stay at the surface during a stressful period of time, that the reflexive side of the brain was causing the left-hand to be committed.

Companies like Buoy Fenzy, Nimrod and soon to come US DIVERS and DAYCOR started forging their way into a new era of diving safety. All but Buoy Fenzy (short-lived, but the best unit on the market at the time) had one thing in common: the oral/power inflator was on the left. We were now

If only we could have figured out how to train the reflexive side of the brain to tell the right hand to drop the weight belt.

Obviously since the left hand was now being rapidly trained to be committed to the buoyancy compensator, the right hand was left with one major job, release, remove and ditch the weight

belt. More often than not it takes a lot more than just opening the buckle to actually get the weight belt out from under the BC free of snags, and away from the body. Think about this: how many times during a normal 30-minute dive do you touch/ adjust a power inflator on the left, with the left hand? Versus in the same time window, how many times do you adjust/touch your weight belt with your right hand? Or practise its removal?

The weight belt should be the first thing off your body, before the BC for training and safety purposes. Not five or ten minutes after you have been on shore or the deck of a dive boat. How often do you see divers, especially new divers, walking around pre- and post-dives with their weight belts on? How many times during your diving career have you practised or been taught how to properly remove and ditch your weight belt, in full gear with the BC partially inflated?

The right-hand release did force the would-be rescuers of another diver to have to reach across the diver’s body to find the bitter end of the weight belt (which should be 6 to 8 inches in length) and release it.

Multiple studies proved that self-rescue was key as the first line of attack. The goal makes for competent independent divers who dove in buddy pairs, not near-capable divers who are relying on near-capable buddies.

I know you can’t believe it but, yes, in those days (some 50 years ago) we still believed in reflexive skills and the basic laws of reflexive learning. We still believed that responsible, competent, independent divers required a responsible, competent instructor.

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"It is much better to resolve small issues immediately rather than wait for them to snowball out of control with potentially fatal consequences"

The benefit of case study know-how

By Gareth Lock

The dive computer recorded an ascent from 54 metres to the surface in less than two minutes.

Errors normally take the form of one of the following: • Errors of omission or “lapses”. These occur when the diver comes up with a good plan but forgets to deliver all or part of it. For example, choosing the correct gas but forgetting to analyse it, which could be vital to pick up an error by the gas technician in incorrectly mixing it.

• Errors of commission or “mistakes”. These occur when the diver comes up with a poor or wrong plan (which he or she thinks is good) and then proceeds to execute it. For example, choosing the incorrect gas for the dive and thereby ignoring best practice – such as the appropriate gas for narcosis, or decompression efficiency or for pO2/MOD reasons.

• Violations. These are where there is a positive decision or intent to “break the rules” – whatever those might be – in a recreational activity, and is brought about by getting consensus opinion from enough people.

The majority of divers recognise that incidents do not normally have one root cause but are a network of contributory factors that come together to create the “perfect storm”. Furthermore, spotting how a number of individual errors or factors may lead 54

to an incident is incredibly difficult. Hopefully, by presenting case studies such as this one, where multiple failure points are identified, more divers will anticipate what might happen if they ignore such small or simple issues in their own diving: fundamentally, it is much better to resolve small issues immediately rather than wait for them to snowball out of control with potentially fatal consequences.

Incident The subject diver had planned to raise an anchor weighing approximately 150 to 200 kilograms from approximately 60 metres. Three weeks before the dive in question, the subject diver contacted the skipper and, after some discussion, it was agreed that the subject diver would talk through the details on the day of the dive with the skipper. The buddy and diver had had a detailed conversation a week before.

Unfortunately, those discussions did not align with what happened on the dive.

Prior to the day of the dive, the diver had spoken with the skipper about lifting the anchor and they decided that further discussions on the day of the dive would be required before the lifting operation took place to ensure that everything was clear.

However, on the day this conversation did not take place and the skipper did not see any specific lifting gear from the diver in question due to the multitude of cylinders at the rear of the boat on the deck area, therefore he assumed that it would not be happening.

As the last to fill in the log sheet, the subject diver wrote 21/2 as their bottom mix; everyone else was on trimix with amounts of helium commensurate with a 60 metre dive. The buddy was not aware of the subject’s backgas, and had incorrectly assumed the subject was using a helium-based mix. Better team skills would have meant that the buddy would have a clear head on this matter, and would check whether they are broadly matched in decompression obligation. The subject and buddy

Photo by Gareth Lock

In many cases, reading an account of an incident provides us details that we think would be obvious at the time if we had been in the dive, and so we question why the diver couldn’t spot what was going to happen. But hindsight does make it easy to spot the weak points in a scenario; it’s easy because the outcome is already known. That’s too late for the diver who lost his or her life. Yet providing case studies allows readers to improve their own knowledge or experience ‘bank’, so that when they come across a similar situation, they are better informed.

This allows for more robust decisions. Learning from mistakes is how we improve; we just need to make sure that those mistakes are survivable.

DIVER MEDIC & AQUATIC SAFETY

The subject diver and buddy were the last to jump in as the majority of the other divers were on CCR. The visibility was outstanding, probably 20 metres and very light.

Given the excellent visibility, it was agreed via hand signals to have a look around the wreck and to locate the anchor. After approximately 10 minutes, the subject returned to the lifting equipment, and using a small (approx 25 kilogram) lift bag attached, sent it to the surface using backgas.

The skipper saw this lift bag breech the surface and assumed that the subject diver had decided not to lift the anchor. The buddy of the diver had a similar thought process as no communication took place between the subject diver and himself before the bag was sent up.

Shortly after this the subject diver used a small sack and lift bag (approx 25 kilogram) to send up some pottery jars and crockery with the assistance of the buddy in filling the sack. The subject used a back gas regulator to send up this bag.

A few minutes later the subject diver and buddy observed the anchor in question. The buddy noted that the subject diver had withdrawn another (unknown) lift bag from their dive equipment; a ‘200kg’ lift bag. The subject diver attached the bag with webbing and a clip to the anchor and used their back gas to inflate it. Even though the bag was full, it only had enough lift to stand the anchor up, not lift it. The buddy approached and attached his 70kg lift bag and inflated it from his 50% stage, an 11 litre cylinder that had an excess of gas for this purpose. The anchor started to rise and went to the surface.

A minute or two later, the subject diver gave the signal to ascend, and also signalled that the buddy should put up a delayed Surface Marker Buoy (dSMB). This was not according to the plan, which had involved bagging off separately, and was also earlier than the planned maximum bottom time. The subject did not indicate any reason for beginning the ascent early and showed no sign of distress or panic. The pair rose up to approximately 55m, face to face, with the buddy reeling in. After some minor losses of buoyancy control, where the subject had risen to approximately 3 metres above the buddy, the buddy looked down at his computer again while reeling in to “catch up” with the subject. At this point 56

the buddy looked up at the subject who was now rising up the line very quickly and making a loud “shouting” noise. The subject disappeared from view very quickly, and the reel line was felt to be vibrating for about 2 minutes thereafter – this meant that the ascending diver was no longer either holding the line or ascending.

The buddy decided that as they had approximately 55 minutes of decompression to perform they would complete their decompression obligation.

On seeing the subject diver breech the surface, the skipper manoeuvred the boat, recovered the diver and proceeded to remove his equipment to start first aid. They declared a Mayday and then started CPR. Of note, when the hoses were cut during the equipment removal, little or no air escaped.

Unfortunately, despite the best efforts of the skipper, the diver was declared dead on arrival after being flown to the local A&E. He had died from internal injuries commensurate with massive expansion injuries to vital organs; as a consequence, no CPR would have saved him.

Analysis The details about the incident came from interviews with both the buddy and the skipper. However, only the deceased really knows everything that happened and therefore this analysis has to be taken in that light.

To make things easier to learn from, the analysis will be shown using the Bowtie model, according to which the “adverse event” is at the centre and controls are to the left of the centre and mitigations to the right: controls try to prevent the incident from occurring, mitigations minimise the impact of the incident when it does.

Judgement and narcosis: 55 metre to 60 metre is beyond the considered best practice for air diving given the debilitating effects of nitrogen narcosis at this depth; CO2, due to a more dense breathing gas, will contribute to narcosis too. The subject diver was trimix qualified, but their cylinders were out of date. This may have meant that they could not get a trimix fill and used their own compressor for the fill. Suffering from narcosis may have impaired the judgement of the subject diver and led to task fixation.

Narcosis would have likely accentuated the task fixation to find and raise this anchor.

Gas requirements and planning: At 55 metres and more than 200 kilograms, the anchor would have required more than 1 300 litres of gas to raise, which in twin 15 litre cylinder equates to approximately 45 to 50 bar. The divers had been at depth for approximately 20 minutes, which, assuming a SAC of 18l/min, would have equated to nearly 85 bar of gas. A breathing rate while working hard would be in excess of 18l/min. Gas planning needs to take into account both breathing gas and any gas required for the task at hand.

Photo by Marcus Efler

had not discussed in detail the decompression profile they were going to use as they had planned to bag off separately and carry out their deco independently once they had left the bottom. The buddy and subject were aware that their choice of deco gases (32% and 80% versus 50% and 100%) meant that the depth at which they would switch to their decompression gases would be different. The subject and buddy had agreed a 25 minute maximum bottom time and had discussed total run times. The subject was going to rely on the ascent as determined by his dive computer, and the buddy had a written plan and a number of ‘what if’ plans on a wrist slate to use in conjunction with two dive timers.

"On seeing the subject diver breech the surface, the skipper manoeuvred the boat, recovered the diver and proceeded to remove his equipment to start first aid."

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DIVER MEDIC & AQUATIC SAFETY

Team LGS Real Life Training for Real Life Operations Water Rescue - Recovery The most effective training and equipment

Preventative controls: As can be seen from the Bowtie diagram, there are at least 12 factors at the individual level that contributed to this fatality. A number of those could be individually removed and the incident would not have ended as it did. Furthermore, if some of the preventative controls had been more robust, then the incident may not have occurred either. For example, the buddy was using trimix and could have called “stop” or a thorough pre-dive brief could have identified the weakness in the plan or at least highlighted the “go/no-go” point.

Mitigating controls: The mitigating controls provide a backup if the adverse event does occur and, in this case, effective gas-sharing protocols and effective team-work could have prevented the situation ending in the manner it did. Many divers consider team or effective buddy diving as a preventative measure, when in fact it sits on both sides of the centre. A team member might stop you making the mistake in the first place, but they can also help you resolve the issues after the event.

Summary The ability to identify the contributory nature of incidents in real time is very difficult, therefore the best manner is to ensure that 58

the dive is planned and briefed effectively and then executed according to the plan. Importantly, a brief is not effective unless everyone knows what the plan is, who will do what, and when.

For recreational diving, the level of detail covered and checked can be minimal. However, for technical diving, the complexity and potential risks are higher and therefore the need to check understanding is heightened.

Fortunately incidents like this are rare. However, equally rare are incident reports that list significant details to allow divers to learn from other’s mistakes – context, decision-making, experience, and equipment configuration are all essential if we are to understand the causality of the incident.

Importantly, as much (or more) can be learnt from non-fatal incidents, and therefore these need to be reported in detail too. Therefore, please consider that when you submit a report to somewhere like DISMS (www.divingincidents.org), DAN (www.danap.org/accident/nfdir.php) or BSAC (www.bsac.com/incidentreport) you include a commensurate amount of detail, which would allow a complete stranger to recreate the incident – context is everything.

Learn from your mistakes; better still, learn from someone else’s.

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ISSUE 03 | FEBRUARY 2015

DIVER MEDIC & AQUATIC SAFETY

Diving Safety‌ Lessons Learnt

By Dan Orr Divers Alert Network (DAN) analysed nearly 1 000 recreational diving fatalities occurring between 1992 and 2003 from their accumulated fatality database. The analysis of these incidents provides useful safety insights for the entire industry.

DAN conducted a root cause analysis to determine what circumstances and events lead to recreational open-circuit diver deaths.

In this analysis, DAN researchers identified four different phases in the cascade of events leading to a fatality: the triggering event, the disabling agent, the disabling injury and, ultimately, the cause of death.

Triggering events are the earliest identifiable root causes that transform otherwise enjoyable recreational dives into emergencies. Identifying these triggering events is essential so divers can learn to avoid or manage them during dives.

Photo by Greg Trinity

In the DAN fatality analysis, the triggering events and their frequency (%) were identified as follows:

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Running out of breathing gas: 41% Entrapment: 21% Equipment problems: 15% Rough water: 10% Trauma: 6% Buoyancy: 4% Inappropriate gas: 3% Let’s review these triggering events in some additional detail.

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Equipment problems The third most common triggering event identified in the DAN fatality analysis was equipment problems. This triggering event caused 15 percent, or about 150, of the fatalities studied.

In my experience, it is probably more like “problems with equipment”, meaning the problems were most often a result of user error. These errors included improper use, failure to ensure correct configuration, lack of regular or qualified maintenance and insufficient familiarity with the equipment, especially in emergency situations. Dr George Harpur, an experienced investigator of dive fatalities in Ontario, Canada, says, “We are not able to document a single case in which equipment malfunction directly caused a diver’s death or injury. It has been the diver’s response to the problem that results in the pathology.”

Running out of breathing gas The most significant triggering event was running out of breathing gas. To put this in context, approximately 400 divers from the cases studied might be alive today had they been able to manage their breathing gas supply correctly. With pressure gauges a standard part of every diver’s equipment nowadays, running out of breathing gas underwater, especially before any other problems occur, should simply never happen.

Being “air aware” should be every diver’s primary safety mantra.

Always begin dives with a full cylinder of breathing gas, and end dives (standing on the boat, dock or shore) with breathing gas remaining. Before starting a dive, you and your diving partners should decide how to communicate information about your remaining breathing gas supplies and how frequently you will share that information during the dive. You should firmly establish a point at which you will begin making your way to the exit point or surface and, quite frankly, live by that decision.

When the first diver in your group reaches that predetermined point in your breathing gas supply, you and your partners must begin your return to the exit point. Even if you have significantly more breathing gas remaining than your partner when you turn the dive, the dive should be over for both of you. Simply letting your low-on-breathing gas partner return to the surface alone is not fulfilling your buddy obligation, and it is also putting your partner at significant risk.

Entrapment The next most common triggering event in dive fatalities is entrapment. Approximately 200 divers in the DAN fatality records, or 21 percent, found themselves trapped in an overhead environment and unable to get back to open water. An overhead environment is any dive in which the diver does not have direct, vertical access to the surface – such as a cave, cavern, wreck, under ice or when there is significant surface hazard. Every training organisation warns divers about the dangers of entering such environments without appropriate training, experience, planning and equipment. The way to mitigate the hazard of this triggering event is very simple: Don’t enter overhead environments without being fully qualified, experienced and prepared to do so. Quite literally, when in doubt, stay out!

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Knowing what triggers the cascade of events that, ultimately, leads to a diving injury or fatality only advances the discussion so far. For diving and divers to be safer, we must apply the lessons learnt from these tragic events. How can we, as divers, reduce the likelihood that these triggering events will cause problems for us?

"With pressure gauges a standard part of every diver’s equipment nowadays, running out of breathing gas underwater, especially before any other problems occur, should simply never happen"

Education Take full advantage of every opportunity to learn. Read dive magazines, spend time with experienced divers, attend dive club meetings, seminars and dive consumer shows, and check out dive safety lectures or seminars that may be available online. In other words, take advantage of every opportunity to learn and apply what you’ve learnt. More knowledgeable divers are safer divers. Get all the training and education you can in the type of diving you want to do, but don’t stop learning when you leave the classroom – treat every dive as an educational experience. Use any unexpected incidents that occur while diving as opportunities to brainstorm and discuss response options, contingencies and prevention strategies with your buddies.

Photo by Matej Kastelic

Many divers who dive in overhead environments (caves, wrecks, under ice, or where there are significant surface hazards) use the rule of thirds, which means that you use the first third of their gas supply for the dive, the second third for the exit from the overhead environment or the ascent, and the final third set aside for emergencies. This may seem conservative for open-water diving, but the idea of leaving a significant reserve for emergencies or other unexpected circumstances is absolutely relevant. Anything short of total management of your breathing gas puts you, your buddy and every diver in the vicinity at risk.

It’s important to remember that the equipment you use is truly “life-support equipment” and must be treated with the utmost care. Learn about all its features and functions, practise with it simulating the “worst case scenario”, and have it maintained regularly by a qualified equipment professional; take care of your gear so it can take care of you.

Practice Dive skills and emergency-management skills require constant practise and reinforcement. Many diving and emergency skills are complex psychomotor skills that require frequent practise to be used successfully in a crisis situation. Refresh your skills often, especially when you haven’t been diving in a while. Your certification card does not automatically qualify you for greater challenges. To truly be prepared for more advanced diving, slowly and methodically increase the complexity and task loading of your 63

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DIVER MEDIC & AQUATIC SAFETY

"The majority of reported cardiac related cases were associated with a pre-existing condition or were associated with the over-40 age group. It’s a good idea for everyone older than 35, whether or not they dive, to have an annual physical"

time to familiarise yourself with all new equipment in a controlled environment; if possible, do this under expert supervision before using it in open water. Although practise may not make you perfect, it will help you make the correct decisions and manage problems appropriately rather than trying to escape to the surface.

Experience The value of experience cannot be overstated. Divers with limited experience, including those returning to the sport after a long absence, are at greatest risk. According to the DAN fatality data, 88 percent of the divers died on the first dive of their dive series.

Consider that the number of dives in your logbook or the date on dives. Expand your horizons gradually, making sure you don’t outpace your training and your level of comfort. Certification is not the same thing as proficiency. Don’t dive your C-card, dive your experience.

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Health Approximately one-fourth of the fatalities in the DAN database involved cardiac-related problems. Amazingly, in 60 percent of the cases with cardiac involvement the divers had symptoms that they or their partners recognised such as shortness of breath, chest pain or fatigue, but they proceeded to dive anyway. Most divers are aware of the importance of good general health and fitness for diving, but comfort and wellbeing at the time of the dive are also important. If you’re not feeling up to a dive, don’t dive; wait and see how you feel later.

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Before diving, review your dive plan with your buddy to ensure you have a shared understanding of the dive’s goals. You’ll also want to agree on the route you’ll take and possible alternatives to your primary dive plan. It’s much easier to communicate the switch to plan B if you decided what plan B was before you descended. Establish the fact that anyone can terminate a dive at any time for any reason, even before the dive begins, without repercussions. Creating an environment in which divers feel comfortable making such calls builds a culture of safety.

The use of a pre-dive checklist is definitely recommended. At the latest Rebreather Forum, the development and use of predive checklists was identified as one of the most important factors in diver safety. Along with a checklist, I find it useful to develop and continually reinforce a pre-dive ritual. It should involve equipment checks, dive plan review, hand signal review, diver separation protocol review and out-of-breathing-gas procedure review.

This may seem unnecessary if you dive with the same people regularly, but these rituals are time well spent if they give you confidence and reduce the likelihood that you are unprepared to dive. The use of a checklist in conjunction with a pre-dive ritual is highly recommended. Never hear or say, “Don’t worry, I’ll take care of you.” That means one of the divers is not as qualified or prepared for the dive as he should be – a formula for disaster.

Anyone making a dive should do so only if he is fully prepared and wants to dive, not because someone else wants him to.

The majority of reported cardiac-related cases were associated with a pre-existing condition or were associated with the over-40 age group. It’s a good idea for everyone older than 35, whether or not they dive, to have an annual physical. A physical is also recommended following any change in an individual’s health status.

Divers might certainly benefit from having their physical exam performed by a physician trained in dive medicine. Remember that a physician who dives is not necessarily an expert in diving medicine. If you don’t know a physician trained in diving medicine in your area, contact the DAN Medical Department (www.dan.org).

The dive Once in the water, check each other to make sure all equipment is secure and in place, that there are no leaks, and that buoyancy is properly calibrated. Give and receive the OK signal from everyone in the dive party, initiate your preparatory ear-clearing procedures, and begin a controlled descent. Descending feet first using a fixed line makes it easy to stop the descent should the need arise, and it may be advisable if a current is present.

Photo by Greg Cayman

Pre-dive preparation As you prepare to dive, it’s a good idea for you and your buddy to configure and assemble your equipment as a team so you can identify anything that looks odd or out of place. This also provides an opportunity to familiarise yourselves with each other’s equipment. It is far better to familiarise yourself with your partner’s equipment before the dive when you have the time to ask questions rather than trying to do so when seconds may mean the difference between life and death for one or both of you. If boat diving, it may be helpful to set up your gear before the boat leaves the dock. This is especially true if you are subject to seasickness, since it minimises the amount of time you’ll spend on the rocking

boat deck. Note that hastily assembling your equipment in rolling seas while feeling nauseated increases the likelihood of potentially hazardous errors.

If there is any doubt about your preparation for the dive, make a short stop 15 to 20 feet below the surface to give and receive the OK sign before proceeding to the bottom. It is important to be situationally aware during all parts of the dive so if something occurs that could compromise your safety or increase your risk, you will be prepared to accommodate for it. If something occurs that does increase your risk (increased workload or other factors) you can mitigate that risk by reducing your bottom time, diving shallower or increasing your time at your safety stop. By being situationally aware, you will know when it’s time to call an end to the dive.

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Photo by Eyüp Alp ERMIS

DIVER MEDIC & AQUATIC SAFETY

It’s always wise to plan your dive and dive your plan, but you can modify your dive plan if conditions call for a more conservative approach. If you are working harder during the dive than anticipated, you may want to watch your air consumption more closely and possibly limit the time you spend at depth.

Scuba diving is a fantastic sport enjoyed by young and old alike. The focus should always be to maximise enjoyment while minimising risk. You overcome challenges in and under the water by thorough preparation, physical capability and the effective application of knowledge and skill.

As you move underwater, the slowest diver in your group should dictate your pace. Never assume another diver can keep up with you. If a recreational dive starts to feel like work, slow down – you or a member of your dive group may be doing it wrong. If you’re diving in a group of three and one diver decides to return to the surface, either end the dive as a group or escort the diver back to the exit point and make sure he is safely out of the water before continuing the dive.

References: • Buzzacott P, Zeigler E, Denoble P, Vann R. American Cave Diving Fatalities 1969-2007. International Journal of Aquatic Research and Education 3:162-177; 2009.

• Denoble P, Caruso J, Dear G, Pieper C, Vann R. Common causes of open-circuit recreational diving fatalities.

Undersea Hyperb Med. 35(6):393-406; 2008.

• Denoble P, Pollock N, Vaithyanathan P, Caruso J, Dovenbarger J, Vann R. Scuba injury death rate among insured DAN members. Diving and Hyperbaric Medicine 38(4):182-188; 2008.

• Orr D, Douglas E. Scuba Diving Safety. Champaign, Ill.: Human Kinetics, 2007.

• Vann RD, Lang MA, eds. Recreational Diving Fatalities.

Proceedings of the Divers Alert Network 2010 April 8-10 Workshop. Durham, N.C.: Divers Alert Network, 2011. ISBN #978-0-615-54812-8.

I would like to make it clear that recreational diving is inherently safe, but it can be very unforgiving of mistakes. There are millions of certified divers around the world making tens of millions of safe, enjoyable dives without incident every year.

But consider that there is risk in anything you do. Is this risk we divers subject ourselves to unreasonable? I firmly believe the answer is no. A degree of risk will always be part of scuba diving, but it is a risk we can identify and learn to manage.

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ISSUE 03 | FEBRUARY 2015

Marine Life

Hazards

Part 1

DIVER MEDIC & AQUATIC SAFETY

Bites, punctures, injuries and wounds

By Dr. Anke Fabian Hazardous incidents due to encounters with marine life can be varied. This fishing incident at the Red Sea, Egypt, provides just one example. It was 2007. Young Gamal was fishing for dinner. Out on his Zodiac he already had caught some smaller fish when suddenly a big barracuda hit the hook. He pulled it into the small vessel. But the barracuda was not ready to give up easily and fought for his life moving around and biting everything that was in the way, including Gamal’s foot. The sharp pain and profuse bleeding ended the fishing session abruptly. Soon the floor of the Zodiac turned red with blood mixed with water. Panic occurred immediately. The fish wouldn’t let go and so Gamal returned with the barracuda still clinging onto his right leg just above the ankle joint. On examination we saw the typical small but deep puncture wound, luckily missing the tibia vein by a few millimetres. No foreign body (e.g. a remaining tooth) could be detected in the wound. After thorough rinsing and cleaning with bottled drinking water and disinfection with betadine, we applied a broad pressure bandage for 30 minutes to stop the still ongoing bleeding. Open wound management, antibiotic powder, daily dressings and immobilisation with an ankle bandage led to an uncomplicated wound healing within 10 days.

Gamal had barracuda for dinner.

Photo by Rich Carey 68

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For centuries, the fascinating creatures and variety of habitats in the underwater world have founded a multitude of myths and fantasies. Over time and through scientific studies and experiences, we have come to realise that despite the wonders the sea holds, there is a danger lurking too, both from its flora and fauna. A number of these organisms have the potential to cause serious harm or even death to the unsuspecting or inattentive diver. The degree of harm caused often depends on the kind of injury, type and amount of venom injected, individual reactions, site of injury and the location of the accident (deep water victims are prone to drown after a harmful encounter with marine life). It is therefore imperative that all divers, especially those in the water on a regular basis, have a good understanding of hazardous marine life and can recognise and administer first aid in the event of a bite, puncture, or sting.

Injuries received from marine animals can be classified as follows: • punctures with or without injected toxins (sea-urchins, stonefish, scorpionfish, rays, cone snail); • bites with or without injected toxins (from sharks, pinnipeds eg. seals and walruses, biting fish, sea snakes, moray eels, cephalopods, eg. octopus, squid and cuttlefish); • stings (jellyfish, corals, anemones, sponges); and • injuries (surgeon fish, fishhook punctures, propeller injuries).

A stitch in time saves nine – prevention is, as always, the best cure. In order to prevent marine life injuries, it’s worth taking this good advice: • Don’t bother or anger marine life.

• Respect territories.

• Don’t feed underwater marine animals.

• Don’t touch anything underwater and never reach into holes.

• Stay clear of a reef, especially in a current of surf.

• Practise good buoyancy control.

• Don’t walk barefoot on a reef.

There is a code of behaviour underwater that works well, and which one should try to follow as much as possible. Everyone who participates in ocean activities of any kind should know about the basic techniques and rescue procedures. We’ve divided the discussion into two, since there is a clear difference in treatment depending on whether toxins are present or not.

Bites, punctures and wounds without injected toxins: Basic wound care is the same whether you’ve been cut by a kitchen knife or bitten by a barracuda. With marine wounds, however, the risk of infection is high. Ocean water, and the mouths and skins of marine animals host numerous bacteria, which are the leading cause of marine infections.

Some wounds are complicated by animal parts such as teeth or spines remaining in the wound. Fortunately, not every wound gets infected. It depends on various factors such as wound location (extremities, body or head), wound type (cut, crush-wound, puncture), number of bacteria and the injured individual’s immune system and allergic response.

Photo by Sergey Skleznev 70

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First aid wound care Wound cleaning: Check if there are foreign bodies in the wound by carefully pulling the edges of the skin open or pushing gently on the wound to feel if there is a stinging sensation. If there is an object in the wound or other embedded material, try to remove it either by rinsing with sterile water, or by using tweezers or tape. Do not remove: • if the item does not come out easily; • if the embedded object is large; • if the embedded object is stemming blood flow from a serious wound; or • if removing it is likely to cause more damage (for example, in the case of backward-facing barbs like on the spine of some stingrays).

If there is one of the above indications that you should not remove the foreign body, then a trained medical professional should remove it.

Rinse thoroughly. Don’t delay rinsing just because you have a lack of sterile supplies. If available, use bottled water. But never scrub an open wound with ocean water, which often contains large numbers of bacteria. This is contrary to the recommendation of using salt water to rinse stings from jellyfish. Note the difference between treating bites or stings: saltwater for stings from jellyfish (using sweet or drinking water would make the nematocysts burst and will cause more damage!) and fresh/drinking water for bites and wounds (less bacteria).

Antiseptic treatment: one common antiseptic is povidone-iodine solution (Betadine is an example). Use it in a dilution 1:10, as fullstrength povidone-iodine can cause tissue damage.

Puncture wounds: Clean and rinse puncture wounds like any other wound, being particularly alert for embedded objects. If you suspect something is inside a wound but cannot be extracted easily, see a doctor immediately. It could have a barbed hook so do not remove it yourself – when pulled out with force it can create more damage to the tissue.

Controlling bleeding: If a wound is bleeding, the loss of blood will inherently appear much greater than it actually is. Blood reddens the surrounding water and the amount of reddish liquid appears frighteningly high. Don’t panic – think and act reasonably and remain calm.

Get out of the water as quickly as possible. Press a clean cloth or bandage directly against the wound until bleeding stops. If bleeding persists, or if the edges of a wound are jagged or gaping, the victim will most likely need medical assistance in the form of suturing (stitches).

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Photo by Michal R 73

DIVER MEDIC & AQUATIC SAFETY

Apply a pressure bandage if the bleeding persists. Once applied, periodically check that fingers or toes near any compressed wound remain pink and warm. Only in very extreme arterial bleeds would the blood circulation of a whole extremity need to be completely restricted. If this is required, note the time of application. Release the tourniquet every 4 hours as not to cause hypoxic damage to the surrounding tissue.

ISSUE 03 | FEBRUARY 2015

Photo by Wolta

Bandages and plasters: Bandages (dressings) help control bleeding, and they protect cuts from sand, dirt and sun. However, bandages can also hide early signs of infection. Check under all bandages for warmth, redness and swelling, the first signs of infection.

Advanced medical treatment: Dependant on the medical knowledge and education of the people who provide first aid, one can treat infections, pain or allergic reactions with over-the-counter medication or medication prescribed by a GP (such as antibiotics, painkillers, antihistaminic tablets, and cortisone) and regular ointments. If the bitten part of the body gets numb or cannot be moved, see a doctor immediately.

Tetanus protection: All ocean wounds carry the risk of tetanus (lockjaw). Update your tetanus booster shot approximately every 5 years. If you aren’t sure about the date of your last tetanus shot, get a booster.

Bites, punctures and wounds with injected toxins: Injuries with injected toxins should be always considered as potential emergencies! As the amount of injected toxin will be unknown, you will not be able to predict the effect on the injured person.

The reaction will depend on the individual’s ability to cope with the venom, allergic reactions, amount injected and site of injection. The first symptom will often be immense pain, followed more often than not by panic in the affected person. Most toxins in marine animals are neurotoxins. These are made up of proteins in combination with tissue coagulating substances. The neurotoxins trigger peripheral nerve deficit (motor and sensory) or central organic dysfunctions with multi-organ failure, leading to a cardio-respiratory arrest.

These toxins can also cause severe allergic reactions. The tissue coagulating substances (such as hyaloronidase) lead to vast tissue necrosis with secondary infections.

First aid procedures for wounds containing injected toxins are basically the same as in wounds with no toxin injected, but there will inevitably be a need for further medical treatment. This could be as serious as a person requiring intensive care at a hospital. A person with an injury involving venom must see a doctor, even if the symptoms are only mild.

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Generally, the toxins are metabolized within 45 minutes – two hours.

Acute life threatening symptoms are not likely to appear after that time.

Even if no symptoms are showing within the first two hours, the victim should still be seen by a doctor as quick as possible after the incident.

However, late or chronic organic symptoms and allergic reactions can occur even after days, weeks or even months. For example, persistent pain in the injured area or extremity, recurrent swellings or reddening, and even reopening of old wounds have been reported.

Admittedly, such bites and punctures involving injected toxins that occur under water are rare but still a possibility, usually from sea snakes, stonefish, lionfish, or less commonly from a cone shell.

Applying heat using the Hot-Water Method is greatly debated but generally accepted. Opponents to it correctly point out the possibility of the complications of severe burns and scalds. However, if implemented in the right way, it is a great tool in first aid in some venomous marine life injuries such as those caused by stonefish, lionfish or rays. (A thorough discussion of this topic warrants an article of its own.)

Taking all the above into account, perspective is still important: no matter how harmful marine life injuries could be, humans remain the most dangerous creature in all the oceans.

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DIVER MEDIC & AQUATIC SAFETY

CAN MICROSCOPIC ALGAE HELP

SOLVE CRIME?

By Kelly Ann Moon Diatoms, which are microscopic algae that would have raised little or no attention years back, have now become a focus in aquatic forensics, opening doors to new investigative possibilities. These organisms have the potential to be useful in a variety of aquatic investigations. Diatoms can: aid in the diagnosis of cause of death; help estimate the post mortem submersion interval – the PMSI – to be explained below; help identify where the decedent was in water if the body was perhaps moved by the offender; and link possible suspects or evidence to the scene.

Frustules, which are often quite beautiful, are strong enough to be preserved in sediments for thousands of years, even after the organisms themselves have died, and it’s therefore this hard shell that can be useful when analysing evidence.

These organisms are photosynthetic, requiring them to live in water or damp environments exposed to sunlight such as oceans, lakes, rivers, streams, soil deposits and can even be found in the mud in an average backyard. As fossils, they are also known as diatomaceous earth, and are commonly used in abrasives, paints, fertilizers, insulation, and filters.

There are thousands of different taxa of diatoms and as many as a hundred can be in a given environment at a specific time. Different taxa can vary by size, shape, and living environment.

1. Aiding in diagnosis of cause of death Diatoms can be sensitive to environmental variables such as pH, seasonal variation, and different bodies of water, resulting in different populations of diatoms for every body of water. For example, some diatoms prefer living attached to the substrate of shallow, moving water areas 76

such as creeks, while others prefer deep lakes. What this means forensically is that a diatom expert is able to link evidence to a type of water: freshwater, shallow creeks, or ocean environment. This does not, however, mean that diagnosis is an easy process.

Photo by Jubal Harshaw

But what are diatoms? They are classed under Bacillariophyta and are unicellular plankton algae (phytoplankton) that reside in most fresh and salt environments. Many different taxa of diatoms can populate one body of fresh, salt, or brackish water and are identified by the hard silica shells called frustules that encase them.

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Misconceptions about testing and drowning The diatom test for drowning has been used in the past but is often misunderstood, resulting in many investigators considering the test useless. This is how the misconception arises: The test looks for diatoms in lungs, spleen or bone marrow. The conclusions in the past have been that if diatoms are found, the cause of death is deemed to be drowning, and if they are not found, the decedent didn’t drown. Neither of these conclusions is correct.

the body’s open cavities, such as the abdominal cavity.

For example, the spleen can be easily contaminated.

However, femur bone marrow is more protected than the spleen or the lungs. The supposition is that for a diatom population of the drowning medium to match the bone marrow, the decedent had to have inhaled water that contained diatoms. The diatoms then travelled from the lungs to the pulmonary capillaries, to the left side of the still beating heart, and to the bone marrow tissue.

In fact, new evidence shows that diatoms can be found in the tissues of decedents with no history of drowning, and not all drowning victims test positive for diatoms.

Similarly, if the diatom test is negative, then one cannot exclude the cause of death as drowning, since not all drowning victims inhale a sufficient concentration of diatoms, or the diatoms may not reach the tested tissues.

Testing samples from the skin, lungs, or muscle can contain diatoms from post-mortem exposure, and so may also create a false positive reading. In summary, there are many variables to consider. Even with these misunderstandings or false readings, the diatom test can be a crucial aspect of an aquatic investigation if analysed correctly.

The question, therefore, is not whether or not a cadaver tests positive for diatoms, but rather whether the quality and quantity of diatoms found in the decedent match the population of taxa of diatoms in the aquatic environment in which the body is found. In addition, were the tissues that tested positive granted protection from possible postmortem diatom ‘contamination’ caused by water entering

Drowning as a problematic diagnosis

Common findings that suggest drowning as a cause of death are froth of the mouth and nostrils, lung emphysema and edema, and pleural effusions. However, these findings are not exclusive to drowning cases and may not even appear in a victim who has drowned. Another problem arises in the diagnosis of drowning when the body is rapidly putrefied, which is common in warm waters.

The physiological basis for the diatom test is as follows: When a victim inhales diatom-filled water while they are drowning, diatoms can perfuse through the alveoli into the blood stream. The blood, which now contains diatoms, then circulates throughout the body, reaching peripheral organs and tissues. So, if diatoms are found in distant organs or

closed systems, and are of a great abundance, the cause of death is most likely due to ante-mortem drowning.

When performing a diatom test, the ideal sample would be obtained from the bone marrow inside the femoral bone, which is a closed system. The only way diatoms would be able to enter the bone marrow is when the heart is still pumping. If the victim was dead before he or she entered the water, it is unlikely diatoms would be able to circulate throughout the body and make their way into the bone marrow. A positive diatom test from the bone marrow most likely indicates an ante-mortem drowning.

Furthermore, the diatom test can aid investigators in determining a cause of death even when drowning is not directly evident in the circumstances in which the body is discovered or from autopsy results. For example, if a body was discovered nowhere near a body of water, or even charred beyond recognition, the diatom test can be of great assistance.

2. Testing for the post-mortem submersion interval (PMSI) One of the most important questions asked in a death investigation is time of death. If no one saw the person die, investigators have to use other means to estimate this answer. In aquatic cases, specifically, post-mortem submersion interval, the time the body 78

was immersed in water, is extremely helpful because a body may not resurface after a period of time so date and time of death can be very uncertain. Determining this time can be an important piece of evidence. A body never lies.

Photo by Michael Taylor

Drowning is the “process of experiencing respiratory impairment from submersion/immersion in liquid” according to the WHO. Unfortunately, drowning is a diagnosis of exclusion. There is no universally accepted medical test for drowning, since drowning is hard to detect.

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If a suspect’s story does not match up with the body’s PMSI, the suspect may not be revealing the full story.

So, the second use for the diatom test would be determining the PMSI. This test is often used in terrestrial environments, and then flesh-eating insects, such as blowflies and larva produce evidence. In water environments, algae, including diatoms that are associated with cadavers, allow investigators to better estimate the post-mortem submersion interval. The combination and abundance of algal species found on these nutrient-

releasing carcasses may be useful to investigators, and these variations can be directly correlated to the amount of time a body spends in the water.

To determine the post-mortem submersion interval (PMSI), an investigator must define which of the five stages of decomposition are being shown: submerged fresh, easy floating, floating decay, advanced floating decay, or sunken remains. By combining these observations with the analysis of diatoms and algae species, investigators will be able to better determine PMSI.

3. Pinpointing the location the body entered the water Not only will studying diatoms allow investigators to know the diagnosis and PMSI of a victim, but they can also be used to pinpoint the location where the victim could have been drowned or dumped. The ability to determine this is because every body of water

possesses its own unique species and abundance of diatoms.

Using diatoms to determine the location where the body entered the water is also used to link suspects and evidence.

4. Linking the suspect By determining the location where the body entered the water, scientists can match that sample to diatom samples tied to the suspect. There have been cases that found diatoms on a suspect’s clothing, car, or

shoes; those samples were matched to the samples found on the body, showing the suspect was in the same location where the body entered the water.

Commonly used test There is not one general method used to perform a diatom test. The scientist elects the method based on his or her own expertise. The most common approach used today is the acid digestion method. Although there are many variations to this method, the general test involves dissolving the sample in acid; nitric acid being the most globally accepted acid for this test. Acid is added to the sample and heated, usually for about 48 hours, until the sample is dissolved. The liquid is then cooled and placed in a centrifuge, a device that spins a liquid to separate the contents. The separated material is examined.

Because there is not a standard protocol for the performance of a diatom test, the results can differ greatly. The qualifications of an idyllic diatom test would be: a quick, simple digestion process that produces limited damage to diatoms and other phytoplankton; minimal organic residue; inexpensive reagents that are able to digest the diatom frustules without destruction, and devices that are originally diatom free. Even with less than flawless tests, a diatom test can assist in many different aspects of a drowning investigation, if read properly.

Because of its mixed reviews, the diatom test can be extremely controversial in the courtroom. In order to positively perform an unbiased diatom test, a blind test needs to be conducted: the person performing the final stages of the test should not know which samples came from where.

A hypothetical example of this strategy would be if a department wanted to try to match diatoms found on a suspect’s clothes to the pond where he or she dumped the body. Six possible samples are provided: 1) diatoms from the suspect’s clothing; 2) diatoms from the lake where the victim was drowned; 3) the bone marrow from the victim; and three controls such as 4) another body of water nearby; 80

5) water from a sink; 6) water from a water bottle. The controls do not have to be the same every time, there just needs to be samples that are not related to the case to reduce biasness. All six of these samples are placed in identical jars, with labels that the scientist performing the test would not understand. The scientist then determines that jars 1, 2, and 3 all match, however the origins of the samples are still unknown.

In summary, these microscopic algae have been important tools in the four ways we’ve discussed. However, the diatom test must be conducted and read correctly. If used properly, diatoms can significantly alter aquatic death investigations.

Photo by Jubal Harshaw

The Blind Test

ISSUE 03 | FEBRUARY 2015

DIVER MEDIC & AQUATIC SAFETY

The Travel Clinic

Let the fun begin

By Mark Rowe

Photo by Rolf E. Staerk

The €12 000 mosquito bite

During our travels we moved to St Martin (Dutch Antilles) from the Dominican Republic for a six-month stay before flying to Grand Cayman. I was working as a freelance diving instructor for Octopus Diving. This story is about an incident I experienced as a travelling, working dive professional, using DAN Europe medical insurance supplemented with DAN 365 medical cover. By telling my story I hope to illustrate the importance of insurance cover.

The Incident

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It started out as a mosquito bite; nothing much. But the bite got infected and turned into a small, hard pimple. This slowly got a little redder and bigger over a few days, resulting in me going to see the local doctor. The small rock-hard abscess refused to be squeezed, so I had to return to see him two days later. After trying to relieve the pressure unsuccessfully the doctor referred me to the hospital the same day.

time of going to the hospital there was no pain; I just had an awareness of the lump, and my forearm was quite swollen.

I drove myself to the hospital to get the arm checked out; a drive that was not a great idea, as I realised later. At the

It was then dressed and I left to drive home via the pharmacy.

After a local anaesthetic painkiller, the doctor made a small incision to one side of the lump and attempted to empty the contents, but little came out. He then packed the hole with gauze leaving a small tail poking out.

Small lump abcess

St Martin is a very small island with a single main road that circles it. When traffic is bad or there are road works, journey times can be a couple of hours for a few miles, and this day was one of those days. As I sat in the car going nowhere quickly my pain levels went up rapidly, the bandages grew tighter around my swelling arm, and my whole body began to shake. The pain level was extreme, an easy 9-10 for over an hour, supported by severe swearing and teeth gritting” – I later found out I was having toxic shock.

The pharmacy didn’t go well; I handed in the prescription and went to find a seat in a corner, while the public thought I was the local junkie going cold turkey. My wife Linda met me there and drove me home. After taking a couple of horse-sized painkillers and resetting the bandages more loosely, I retired to bed.

Sunday morning and I considered how the night had gone.

The pain throughout the night had remained around level five, and the arm had continued to swell, so Linda drove me back to hospital. Once in a consulting room, a doctor and a surgeon both examined the arm, recommending immediate surgery (Linda wasn’t happy and wanted to wait 24 hours but the surgeon explained waiting was really bad). I was admitted to the surgical ward, had blood samples taken for toxicology and then waited a few hours to be called down to the operating theatre. They were all very nice and soon the general aesthetic was flowing and I didn’t care about the pain anymore.

Photo by Mark Rowe

Open wound for two days to drain

The next two days were dull followed by crappy French food followed by more dull. The whole time I was hooked up to four intravenous drips: two antibiotics, one painkiller and one saline; unfortunately this made going for a pee much more difficult, but also much more frequent.

The boredom didn’t last long. Soon the toxicology results arrived showing that my arm was infected with staphylococcus type bacteria, so I was moved into an isolation room and now the nursing staff rarely come to visit. Later the surgeon visited and I got to see what he saw when the bandages are removed. Great – gaping open wound with pus flowing into it from more infection at the wrist.

I was back to the operating theatre again, after x-rays to see if the bacteria was producing bubbles around the bone. The surgeon wasn’t very happy and warned me that amputation was a possibility once he had investigated. I told him he must wake me up to tell me if they want to cut off the arm, then put me under again.

Photo by Mark Rowe 35

ISSUE 03 | FEBRUARY 2015

DIVER MEDIC & AQUATIC SAFETY

I found myself lying on the cold operating table pretty worried about the whole thing and how it would turn out. DAN hadn’t confirmed that they would cover the costs yet, but I guessed it would be fine and, really, that was the least of my worries considering my dire situation.

Post second operation, 7cm and only 3 stitches

I am happy to be typing this article with two hands; it’s easy to reflect and know how lucky I was, but some of that luck I created. I was able to live without working for six weeks. Others may want to get back in the water early because of financial need; if you can avoid it, don’t get wet and heal properly. A few more tips:

The isolation routine kicked in again and the boredom returned. The only good news was that DAN confirmed the policy and protection level of the ProGold with 365 Anytime medical cover that I have, and confirmed they would pay bills directly to the hospital.

The daily routine for the next two days was only broken up by my wife’s visits, which were great, but in typical hospital policy, never long enough, as well as interrupted by the nurse who came to change drips, dressings, and to take more blood for tests.

Photo by Mark Rowe

Six weeks of medical supplies - €711

Together we saw both the surgeon and the toxicologist and were given a shopping list of supplies I would need; it was a long list. I also had two blood test appointments made to ensure that the antibiotics I would be taking for six weeks don’t cause kidney and liver damage.

• Get good insurance for both diving and medical cover when travelling and working aboard. The total cost of this incident was €12 000.

• If it’s cheap insurance, ask why – they have to save money somewhere. Ask others if they know whether the insurer has paid a claim. Do some homework.

• Inform your insurance company early if you may need support; the better ones like DAN will give both hyperbaric and medical support advice.

• Read the fine print and understand what is covered and more importantly what is not.

• Seek early treatment of anything that doesn’t seem or feel right. Go to hospital if local doctors' advice or treatment doesn’t work, particularly aboard and in more remote locations.

• As dive professionals we are constantly getting bumps, cuts and scrapes. Look after these and if you have to get wet, use a good antibacterial body wash and use it every day.

Photo by Mark Rowe

About Mark Rowe

After leaving hospital, we spent several hours at the pharmacy while they made up the supply of drugs and dressing changing materials that I would need for the next six weeks.

Mark Rowe learnt to dive in 1989 in Sharm El Sheikh, Egypt, and has been captivated by the ocean’s beauty and silence when diving ever since.

He is PADI MSDT, SSI AOWI, BSAC Adv Inst, SSI TXR and PADI TecRec instructor, with qualifications up to full Trimix. He particularly enjoys diving caves and wrecks in the Sidemount configuration. Mark became a full time diving instructor in 2012 after retiring from the British Army as an officer in the Royal Engineers.

The eye-watering total bill for out-patient care was in excess of €1 000 – thank god for DAN again. I would have to wait for that payment to be agreed and processed before being reimbursed three months later.

During his career, Mark was Chairman of the Royal Engineers Sports Diving Association (RESDA) for four years, enabling him to part of the team that founded the UK BattleBack (Wounded Warrior) diver programme, training severely wounded service personnel in diving activities as part of their rehabilitation process.

The six weeks went by slowly except for the category 3 hurricane that went over St Martin; both land and sea took a battering, luckily for me I was dry anyway.

Every two days I had my dressing changed by Jessica, the local nurse. She would visit our apartment to change the dressing using the supplies I bought from the pharmacy; at €9 per visit it was money well spent.

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10 Stitches finally out – 15 days after the 2nd op

Outcome and advice

Two hours later and I was back in the isolation room with two arms and new bandages. I was already plugged into the 4way block and the IVs are dripping away again.

Friday started with another lousy breakfast, quickly forgotten when the surgeon arrived. After inspecting my arm and talking with other staff and the toxicologist, he said I could go home before lunch. I packed up the few bits of home comfort I had and which kept me sane, and then waited for my wife to come to collect me.

The healing went very well; mainly because I did exactly as I was told. There was a small risk of the bacteria returning or a secondary infection because of the open wound, neither which I wanted.

He is travelling the world and currently lives in Grand Cayman and works for DiveTech.

Photo by Mark Rowe

DIVER MEDIC & AQUATIC SAFETY

Medical Opinion of Mark Rowe's article

By David Charash (DO,CWS,FACEP,UHM)

The Diver Medic and Code Blue Education Ltd COMPETITION WIN a place on a DMT course (Diver Medical Technician course) worth £750.00

What does IMCA stand for?

"Divers are exposed to many form of bacteria in the various environments encountered in the oceans, lakes, and streams"

Photo by Mark Rowe

Photo by Sebastian Kaulitzki

Mark Rowe experienced a possible limb or life-threatening soft tissue infection. Skin infection is one of the most common medical problems for any action-orientated person but especially for divers (more about this below). Skin infection is also referred to as cellulitis or soft tissue skin infection. Our skin, the largest organ of the human body, serves as a protective barrier. Any loss of integrity of the skin can act as a portal of entry for common bacteria. The two most common bacteria include staphylococcus and streptococcus. Depending on the virulence of the bacteria, and host factors such as an individual's immune system, an infection can occur. Infection can develop in a localised area of the skin (cellulitis), or form a deep space infection (abscess). This infection can involve deeper structures such as muscle, ligaments, tendon or bones.

Signs of a soft tissue infection include redness, swelling, pain, localised heat, and can be associated with fever and chills.

Often preceding this infection is a history of some localized trauma, such as an abrasion or an insect bite. The patient may not recall any direct injury, but often on close inspection there will be some loss of skin integrity.

Medical evaluation is suggested as treatment typically requires appropriate oral antibiotics. As soft tissue infection can become very aggressive and spread to other parts of the 86

body or develop into a deep space infection, close monitoring and medical follow-up is required.

So, why is skin infection a common problem amongst divers?

Divers are exposed to many form of bacteria in the various environments encountered in the oceans, lakes, and streams.

High moisture content, closed, dark, tight spaces such as encountered in the use of our dive gear also increase our risk for developing soft tissue infections.

So what can you do as a diver to decrease your risk of developing a soft tissue infection? Avoid diving with a known open wound or skin abrasion as this can increase your risk for developing a bacterial soft tissue infection. If you have a chronic skin condition such as eczema or psoriasis, prior to actively diving, discuss with your primary care doctors or dermatologist best strategies for controlling those chronic conditions. Don't dive if you are experiencing a flare up of a chronic skin condition. Follow commonly accepted first aid practices after a skin injury from local trauma, or from a marine or aquatic injury.

In addition to having some form of health and dive accident insurance, every diver should consider taking a formal class in CPR/First-aid and Hazardous Marine Life. Safe diving begins and ends with a greater understanding of risk. It is the reduction of risk that will lead to a safer dive.

COMMERCIAL DIVERS

RECREATIONAL DIVERS

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The Diver Medic Technician course run by DAN Europe at Code Blue Education will teach you to be prepared, confident, and armed with the knowledge to take control and deal with virtually any diving based medical emergency. The course consists of theory and practical sessions covering a vast array of subject areas.

For more information please visit: www.thedivermedic.com or call 020 8579 3388 Conditions of competition: • You will find the answer on the following website, www.thedivermedic.com • Prize is provided by The Diver Medic • The closing date for the competition is midnight of the 30th June 2015 • The winner’s name will be drawn at random • The winner will be announced in the August 2015 issue of the DMAASM website • Employees DMAASM and The Diver Medic will not be allowed to enter the competition • The prize is non-transferable and there is no cash alternative • Multiple entries will be disqualified • The publishers decision is final • To enter the competition go to the competition page of www.dmaasm.com and submit your entry.

April 2015 The emotional and Spiritual journey connection between Amanda Cotton and Cristina Zenato, through an Art and Photography collaboration showcasing the connection with water and the feminine spirit, and the need to protect and nurture both

http://vimeo.com/114924516