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Life on the Coral Reef of the Florida Keys
by Patti Kirk Gross
Issue 9
Aquatic Medicine, Training, Education, Conservation Support
www.amtecs.global
Editor-in-Chief Chantelle Newman Editor Betty Orr Technical EditorS Gareth Lock Designers Allie Crawford, Sarah Crawford Medical and Diving Specialist Consultants Dr Anke Fabian Dr Adel Taher and Dr A Sakr Diving Consultants Dan and Betty Orr Jill Heinerth Advertising and Subscriptions Chrissie Taylor Newman Contributors Thank you to the following contributors: Gareth Lock, Ellen Cuylaerts,Ruth Mort, Dawn Kernagis,Dr Anke Fabian, Betty Orr, Deptherapy, Dr Richard Cullen, Chris Millbern, Coral Restoration Foundation, Patti Kirk Gross, Dan Orr,Betty Orr, Equated, Women Divers Hall of Fame, Chris Middleton, Rod Hancock,IMCA, Fourth Element, Jim Standing, Costantino Balestra, Peter Germonprec, AMTECS PHOTOGRAPHERS Cover image by Jessica Levy Gareth Lock, Jon Milnes, frantisekhojdysz, Georgejmclittle, cleanfotos, Monkey Business Images, Kamolrat, Stokkete, narin phapnam, Thinglass, Soren Egeberg Photography, Amanda Nicholls, Richard Whitcombe, Andrea Izzotti, Gustavo Frazao, leungchopan, lassedesignen, Beth Swanson, Lisa F. Young, Pathdoc, Thananya Apiromyanon, Africa Studio, Zerbor, Patti Kirk Gross, ID1974 Magazine address AMTECS Great West House, Great West Road, Brentford, TW8 9DF Telephone +44 020 8326 5685 EMAIL help@amtecs.global www.amtecs.global
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Letter from Editor By Gareth Lock
Life on the Coral Reef of the Florida Keys By Patti Kirk Gross
Diving Safety... A Culture By Dan Orr
The Dilemma of Hyperbaric Chambers By Christopher K. Millbern
Diving Beyond Recreational Limits By Costantino Balestra and Peter Germonpre¢
The Making of a Man and PADI Instructor By Richard Cullen
Today is a Good Day To Die By Gareth Lock
Sea Sickness – Mal de Mar By Anke Fabian
IMCA Safety Flash By IMCA
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Photo by Gareth Lock
Issue 9 | October 2016
Dear Readers, The Diver Medic has gone through a lot of changes the past couple of years and we are now really excited to introduce you to our new magazine owned by AMTECS. AMTECS is a non-profit organisation who are involved with Aquatic Medicine, Training, Education and Conservation Support. This edition is packed full of information and knowledge which will allow your aquatic explorations to be conducted more safely, and to have more fun at the same time. Dan Orr’s piece on checklists and culture are subjects close to my own heart and "indeed" the article I have written addresses the need to be more accepting of human error and behaviour. Without understanding the "why" it made sense to those at the time to make the decisions they did, we are not going to be able to improve things: simply telling someone not to run out of gas is like telling someone not to cross the motorway or freeway blindfolded. At first, checklists might appear to be a simple tool to improve safety and performance, but for them to be effective, they need to be designed well, they need to be part of the social fabric of the activity, and most importantly, they need to be used by the leadership roles within the industry. It is hard to use a checklist when the rest of the dive team doesn’t. I know, I have been there as the "odd one out" at the end of a week’s live-aboard as the only person using a checklist for my rebreather diving. Fundamentally we need to create the situation where safety measures, such as checklists, are used because divers recognise their value and want to use them, not because they have to use them: because if we have to do something, there isn’t the same long-term motivation to carry on. AMTECS is dedicated to improving the safety and well-being of those near to or in the aquatic environment. We achieve this through education, training and support. This magazine is only one part of that process. Please share this resource as widely as possible. We can reach one level of a network, your networks spread much further.
Gareth Lock, Human Factors Consultant and Trainer Human in the System
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Life on the
Coral Reef of the Florida Keys By Patti Kirk Gross
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ummer is the time for lemonade, vacations and relaxation. For divers in the sunny Florida Keys in the United States of America, it means shedding neoprene and lead to really enjoy the meaning of weightless diving. The clear turquoise water is warm and you can stay all day without the usual end-of-dive chill. For the Coral Restoration Foundation (CRF) dive team summer really means: dive, dive, dive. The overall growth rate of our important and once abundant reef building corals, staghorn (Acropora cervicornis) and elkhorn (Acropora palmata), accelerates dramatically as the winter chill melts and the Keys’ waters warm to a comfortable temperature for the corals and for the divers.
Photo by Patti Kirk Gross
CRF is a nonprofit ocean conservation organisation working to restore coral reefs through science, education and community involvement. Our innovative techniques are scalable, inexpensive, easy to duplicate and are making a difference throughout the Caribbean.
The Foundation was officially formed in 2007 although it’s Founder and President, Ken Nedimyer, has been experimenting with coral propagation techniques for many years. Today, CRF maintains five offshore coral nurseries throughout the Florida Keys Reef tract, which is the third largest barrier reef in the world. The Tavernier nursery, the Foundation’s largest, currently maintains over 500 coral “trees” with 100 genotypes of staghorn and 80 of elkhorn. CRF collects fragments from “corals at risk”. With the loss of additional coral species, we have new additions in the nursery including: blade fire coral, star coral, boulder coral and pillar coral. These coral fragments are being grown with a variety of innovative methods to determine which proves most effective. Eventually, the nursery-raised corals are fragmented and returned to select and permitted degraded reef sites to be “outplanted”. All corals are genetically tested and the integrity is maintained throughout each nursery. Corals fragments that are outplanted onto the reef sites are tagged with their specific genotype and planted in a strategic method to advance their natural recovery through broadcast spawning in order to boost diversity of their species on the reef. As a member of the CRF dive team, my summer is filled with coral related diving: from teaching my PADI Coral Restoration Diver Specialties through our Guest Diver Program to nursery maintenance tasks. I have had the pleasure of working with groups
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Photo by Patti Kirk Gross
It is not unusual for CRF to host over 1500 participants during the summer through this hands-on diving programme. The programme consists of a one or two-day experience that is offered to divers of all ages and skill levels. After a short classroom presentation, the students are able to become familiar with the restoration tasks prior to going into the open water. The blend of classroom instruction with open water dives allows for a total hands-on learning experience. Community involvement is important to the overall success of the CRF mission. We believe through education and involvement, the community at large will take ownership of the reefs located in their backyards. CRF annually hosts an educational and diving program called “Coralpalooza�. The event coincides with World Oceans Day and is designed to raise awareness within our community. This year we had 17 boats filled with over 200 divers that included CRF Team members, volunteers and CRF partners and spanned South Florida and the Caribbean. During the one-day event, teams outplanted 1,865 corals of staghorn and elkhorn corals onto 11 different reef restoration sites. Divers also conducted routine maintenance in offshore Coral Tree nurseries
Photo by Patti Kirk Gross
of young adults from Road Less Traveled and Dive with the Purpose. They spend several weeks focusing on marine conversation activities, learning to dive and participating in the coral restoration through our group dive programmes.
CRF partners with many local scientific research organisations. An ongoing collaborative project with CRF, National Oceanic and Atmospheric Administration (NOAA) and Nova University to restore elkhorn at a reef site in north Key Largo is in its third year. Historically, this site was one of the most prolific reefs for elkhorn corals, but has experienced a staggering loss. This ongoing collaboration analyses a variety of planting methodologies to increase natural reproduction at various strategic plant sites within the protected reef.
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Photo by Patti Kirk Gross
A beta test of our new online Citizen Scientist, Level One Monitoring Programme was launched during Coralpalooza. Divers collected valuable citizen scientist data on the growth and mortality of previously outplanted corals on multiple reefs. The programme is being refined and will have its official launch in August/ September, 2016. This training will create citizen scientists to independently monitor specific plant sights for growth and mortality. Their results are upload to the CRF scientists for analysation.
Photo by Patti Kirk Gross
Photo by Patti Kirk Gross In order to better work with those other scientific research organisations, I lead the collaborative crafting of our new Dive Safety Manual, my biggest accomplishment of 2016. The new manual follows the American Academy of Underwater Sciences (AAUS) protocols and allows the issuance of a CRF Scientific Diver Certification that allows CRF reciprocity with visiting partners. A top-notch Diving Control Board has been selected and approved while the manual is currently being implemented. This is a huge step for our small organisation. The month of August is one of the busiest and most fun months for the CRF Team. The coral nursery transforms into the largest coral laboratory in the world for the annual broadcast spawning event. The full moon gravitational pull triggers the coral spawning event at night. A mesh cover is lowered over each coral colony. A collection cup gathers coral reproductive cells that float upward. Each genetically unique coral colony is covered and soon tiny coral polyps begin releasing reproductive cells. Coral reproductive cells are carefully collected and taken into the labs where they are immediately mixed to ensure fertilization. This year the nursery will host a variety of partners from Aquariums, Universities and other governmental research organizations. With a little bit of luck and calm
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seas, we hope to collect a record amount of spawn for a variety of scientific research and for the future of coral reefs around the globe. The most exciting news to date for CRF is the award of a NOAA grant. It is entitled: “Large-scale Restoration ESA Threatened Coral Species in the Florida Keys National Marine Sanctuary”. The grant includes: $2.05 million in funding over three years. It involves an extension of CRF presence into the mainland of Miami/Dade. CRF will be taking the lead in a consortium of Acropora restoration efforts in partnership with NOAA. Over three years, we will outplant staghorn and elkhorn on eight reefs to restoration levels outlined by NOAA’s Acropora recovery plan. It will be a unique large-scale data set that researchers will be able to use to better understand coral survivorship. Our oceans are in trouble. Fortunately, many organisations are experimenting with a variety of methods to restore and repair reefs around the world. There is no “one-size fits all” method. Each is unique to its area of the world. Coral Restoration Foundation is laser focused on this ambitious project as we lead the charge with partners and collaborators. I am honored to be a participant of this cutting edge project. #doitforthecorals
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Photo by Jon Milnes
Issue 9 | October 2016
Diving Safety...
A Culture By Dan Orr, President
Whether the focus of your diving activity is the pursuit of scientific data to enhance the body of knowledge about the underwater world or purely recreational in the pursuit of experiences not available to our land bound friends, you want to make sure that all dives are done safely. There is no amount of scientific data or unique experiences worth someone’s life or health. In order to maximize your productivity or enjoyment, there are a few things you should consider:
Triggering Events in Diving Fatalities (as identified in the DAN research):
Prepare yourself, your partner(s) and your equipment with a checklist and a pre-dive ritual.
In reviewing those things that transformed an unremarkable dive into a tragedy, approximately 63% were either directly or indirectly related to problems with diving equipment. The use of a pre-dive checklist coupled with a consistent pre-dive ritual that each diver and buddy follow each and every time they dive could, potentially, reduce equipment-related issues that would initiate a cascade of events resulting in injury or death to one or more members of a dive group.
One of the most important things that came from the 2012 Rebreather Forum 3.0 was identifying the value of having a checklist (http://rubicon-foundation.org/News/ rf3-consensus). The consensus statement acknowledged that checklists should be rigorously followed both pre- and post-dive when diving rebreathers. The use of checklists, however, should be considered an essential part of all forms of diving. As past President of Divers Alert Network (DAN), I reviewed DAN’s analysis of over 1,000 diving fatality records in order to identify what “triggering events” transformed an otherwise unremarkable recreational dive into a tragedy.
• Insufficient Breathing Gas 41% • Entrapment 20%
If you are an individual who is trained and properly equipped to dive solo, and this article is not intended to be pro or con on that particular issue, the pre-dive process using a pre-dive ritual and checklist is equally important.
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Photo by frantisekhojdysz
Issue 9 | October 2016
Dive your experience, not your C-card. Make sure that you and your diving companions are fully qualified for the dive you are about to make. Just being certified is not enough for all diving situations. Your accumulated diving experiences, which includes all the skills and knowledge derived from them, will give you the skills to effectively manage the requirements of many diving situations. It is common in science diving programs for divers to be “qualified” to certain depths. These qualifications are based upon training and experience and help to reduce the number of diving accidents occurring in science diving programs. While no such qualification limitations exist in most areas of the recreational diving world, each and every diver must consider their past experiences and determine whether or not what they learned from past dives can allow them to meet any potential challenges on dives they are about to make. It is far better to make those decisions prior to signing up for a dive but it is never too late to “call” a dive if you feel the diving conditions may be beyond your ability. Never let someone talk you into a dive that may be beyond your capability. Be situationally aware. Every diver should be constantly aware of circumstances that could increase your risk during a dive. Your dive plan was based upon conditions and circumstances being as planned. When things don’t go as planned, you must be prepared to modify your dive to mitigate any increased risks. Working harder than expected during a dive because of stronger than anticipated currents, increased drag because of poor buoyancy control or carrying extra equipment or having to swim faster to keep up with a buddy or dive leader could all have a direct impact on your safety. Other circumstances such as accidently diving deeper or staying longer at depth than foreseen could also have an impact your dive safety. Being constantly aware of your situation (situational awareness) during the dive will allow you to make necessary modifications in your dive to mitigate any increased risk.
Knowing that increased workload, deeper diving and increased bottom time can result in increased inert gas absorption, modifying your dive plan by reducing your bottom time, diving shallower and/or increasing your safety stop can help to diminish increased risk. Many divers, especially older divers or those who would like to give themselves a level of increased safety, choose to use a Nitrox blend with their dive computers or dive tables as though they were using air. Using Nitrox blends as air has become increasingly popular for divers wishing to reduce their risks. Learn from each and every dive. Each and every dive should be a learning experience. Divers should discuss their dives focusing on what went right and what went wrong. Sharing freely all thoughts about the dive without risk of recrimination is vital to good buddymanship. By doing this, they learn from each dive and are constantly improving their approach to future diving experiences. Promote and perpetuate a culture of diving safety. The way to see real improvement in diving safety is for each and every diver to commit to making the sport better and safer. This can be accomplished by creating and perpetuating a “Culture of Diving Safety”. By definition a “Culture of Diving Safety” is the enduring value and priority placed on diver safety by every diver at every level of certification and experience. In order to work, it must include divers at all levels. Individual divers and buddy groups must commit to personal responsibility for safety. We must all preserve, enhance and communicate safety concerns and actively learn from past mistakes and the mistakes of others, applying safe behaviors based on lessons learned. Be safe and do your part to create and promote a Culture of Diving Safety! Safety is everyone’s responsibility. Dan Orr Consulting, LLC. danorr@danorrconsulting.com
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Photo by Georgejmclittle
Issue 9 | October 2016
Close or Closed: The Dilemma of Hyperbaric Chambers By Christopher K. Millbern, W-EMT, C.H.T., D.M.T.
It plays like a training video: a cold afternoon dive along the Oregon coast abruptly ends with a deep, distinct shoulder pain on ascent. As the group returns to shore, the local emergency medical services (EMS) is contacted. Jeff, the injured diver, is immediately assessed and put on oxygen. The group dutifully monitors his condition according to their recreational training. They are calm, cool and collected from start to finish. But what happens next?
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Unfortunately, Jeff didn’t make it far. His transfer was cancelled because the clinic didn’t have enough available staff for after-hours treatments. Returning to his hallway, another hour passed before facing a 150-mile trip to neighboring Washington to the nearest available chamber. Despite doing everything right, six hours would pass before beginning treatment. Jeff knew that chambers were nearby when he started diving, so why wasn’t that enough? Hyperbaric Oxygen Therapy (HBOT) is a wellunderstood necessity in the diving world and most field-active professionals have no problem recognizing the importance of rapid recompression in the event of an indicated diving injury. Despite this, many diving locations are facing mounting limitations to access to such treatments: often with little fanfare or acknowledgement that things have changed within the diving community. In 2011 Dick Clarke, President of the National Board of Diving and Hyperbaric Medical Technology (NBDHMT), called the lack of diver-ready hyperbaric facilities a “threat evolved to the point of crisis”. Things haven’t been looking up since then. This problem is not a revelation. Treating divers is simply not a lucrative financial endeavor. For some chambers there may only be a half-dozen cases
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that would justify the increased cost of emergency treatments even after grant programs and public funding are accessed. In the United States, major hospital centers now have to compete for wound healing patients, the financial anchor of HBOT, with an explosion of new non-emergent clinics that can operate without the array of costs that emergencyready physicians, staff, equipment and drugs require. Facilities that previously served as flagships for diving communities are now closing their doors, while others have committed to accepting only non-emergent cases. The resulting vacuum of qualified providers has even introduced a new phenomenon of wound-healing clinics being approached to provide treatment to patients they’re simply not prepared to perform. On more than one occasion, hospitals have referred patients to sites that have delayed or aborted recompression for even minor negative changes in the patient’s condition. While a patient rightly should not be put at-risk in an environment where staff are uncomfortable or treatment requirements exceed chamber capabilities, arranging another transport to a higher level of care can take hours or days and wildly inflates the cost of treatment. Even Divers Alert Network (DAN), who have radically increased the abilities of injured divers to find appropriate care around the world, continues to face this difficult choice. Is the best chamber the one that’s closest or the one that’s better prepared? The answer, as always, depends. Do your research and plan accordingly. Despite what your dive-buddy might tell you, writing down an address from your phone after searching “hyperbaric chambers near me” is not an acceptable accident management plan.
Photo by Kamolrat
Many divers, Jeff included, had never considered the answer. EMS personnel had instructions to bring him to the nearest emergency room (ER) where he was triaged in an overwhelmed hallway waiting two hours for confirmation of decompression illness (DCI). This hospital didn’t have a hyperbaric center, so a medical transfer was eventually arranged to the nearest wound-healing clinic with a chamber.
Photo by Monkey Business Images
Photo by cleanfotos
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Looking to the Future Amidst a growing problem, the solutions for chamber access remain limited. New research into revitalizing alternatives, such as in-water recompression, show extreme promise in some cases, but continued coordination between divers, hospitals and government agencies will be crucial for overall diver safety. Non-traditional thinking is going to be necessary to solve this evolving treatment availability crisis. One possibility is to encourage the use of fire departments in hightraffic dive sites as the next source of chamber operation and management. A department controlled chamber would have the advantage of utilizing an already on-call emergency schedule, being maintained properly and responsibly, being staffed with properly trained medical responders, granting additional treatment options for related conditions such as carbon monoxide poisoning and the ability to tap into volunteer coverage and community fundraising as needed. Many of the logistical challenges for operating both emergency medical care and machinery with oxygen storage are uniquely overcome if fire departments could be incentivized to participate. While this suggestion simplifies a much larger undertaking, the fact is that appropriately rapid hyperbaric access is an increasingly rare luxury. Keeping chambers in diving communities, not just major city centers, should be a priority to ensure rapid symptom resolution in every one of our patients.
Photo by ID1974
• The first item on your accident management plan should be the Hotline phone number for the Divers Alert Network organisation that serves your area. (See side bar.) Remember, verifying that a chamber is available one day may not mean that it available the next. The chamber may already be in use, it could be out of service for routine maintenance and unexpected personnel changes are just a few of the reasons a chamber could become immediately unavailable. A call to the appropriate DAN Hotline could save your time and your health. • Determine if your local chamber actually treats divers. Have they treated divers or other emergent patients before? Do they have on-call hours, a physician on site or staff that have been trained to deal with diving emergencies? • Can the chamber treat multiple divers? Injuries aren’t always isolated and having a contingency plan for two injured buddies will save critical time scrambling for chamber space. • If attached to a hospital, is there a separate emergency number for the hyperbaric unit itself? Some facilities allow divers to bypass ER admitting protocols, greatly hastening a diver’s access to treatment. • Living next to the best hyperbaric facility in the world won’t help if you only dive Saturdays, but they’re closed on weekends. Find out when and where your options are available and consider tailoring your diving around those schedules. • Do you know if you are far from care? Practicing more conservative profiles in remote locations should go without saying, but don’t fail to add conservatism to your accident plan as well. Make sure you have a way to transport an unconscious person to the facility of your choice and more than one way to contact EMS should electronics or radios fail.
• In truly rural areas with little medical support, check to see if any commercial or government facilities operate hyperbaric chambers in the area. While some private companies are comfortable helping in an emergency, contacting them first to make that arrangement is crucial. Some semi permanent installations may even have a method to pay for operational costs only on the days you’re diving if you have a larger operation or group to manage. Unfortunately for those of us in the United States, this advice tends to apply more to countries with fewer private liability issues.
Photo by Stokkete
When planning your next dive, get familiar with your treatment options and how they meet your group’s needs:
Photo by Thinglass
Photo by narin phapnam
Issue 9 | October 2016
International Divers Alert Network is made up of regional affiliates that have pledged to uphold the DAN mission and to operate under agreed to protocols. The primary functions of DAN is to provide hotline, emergency, safety and educational services. To find out more about the affiliate that provides these vital services in your area, visit their website: DAN Europe – daneurope.org DAN America – diversalertnetwork.org DAN Japan – danjapan.gr.jp DAN Southern Africa – dansa.org DAN Asia Pacific – danap.org
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Diving Beyond
Recreational Limits
Photo by Soren Egeberg Photography
Beyond recreational depths, the “technical” diving community pushes the frontier of “recreational” diving steadily to deeper and less-forgiving environments.
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The following article is an excerpt from the book “The Science of Diving: Things your instructor never told you” by Costantino Balestra and Peter Germonpre¢ republished with permission from DAN Europe.
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Photo by Amanda Nicholls
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"Rebreathers are typically quite unforgiving if the diver makes an error. These hightech devices require more detailed and exhaustive training, as well as proper maintenance including a far lengthier pre-dive check"
Photo by Richard Whitcombe
R
ebreathers, once almost exclusively used by the military, are now commonplace the world over. Blends of helium and EANx (enriched air nitrox) are more commonly available than ever, along with the training to use such mixtures. Using long-range scooters, technical divers are reaching further and further into caves, often with decompression schedules that are experimental in nature. Let us now look at some of the consequences of these developments. Firstly, the clinical manifestations of DCS (decompression sickness) are often different after breathing multiple gas blends on the way back up from 100m depth. Inner-ear DCS has become widely reported in just the last 25 years and, research has shown, is often associated with the “hole-inthe-heart”, known as a Patent Foramen Ovale (PFO). Consensus of medical opinion is that the risk of DCS in recreational divers with PFO is between 2.5-6.5 times higher than in divers without a PFO, so the risk is still so small that routine screening for a PFO is not justified. In technical diving however, divers go beyond recreational limits and often require decompression before surfacing. At least one technical diver training agency recommends screening for PFO before engaging in decompression dives. Rebreathers are typically quite unforgiving if the diver makes an error. These hightech devices require more detailed and exhaustive training, as well as proper maintenance including
a far lengthier pre-dive check. For example, if a recreational diver forgets to turn his SCUBA tank valve on then he will realise this when he first attempts to breathe and cannot suck any air. He will then normally be able to surface and have his valve turned on: an incident, not an accident. With many rebreathers however, if the diver forgets to turn on the oxygen cylinder, no immediate consequence follows. The oxygen already in the breathing loop however slowly and unnoticeably gets consumed - until the diver suddenly “blacks out” into unconsciousness and death, even with the mouthpiece in place. This is known to have happened in very shallow water. While the exact increase in risk over ordinary SCUBA diving is not yet known, the consensus of opinion is that rebreathers have a much higher mortality risk. A recent analysis estimates the increase in fatality risk between four and 10 times. Considering that the risk of fatality while diving open circuit is thought to be between 0.6 and 2.1 per 100000 dives, then the absolute risk of death on a rebreather may not be as high as some might expect. Even so, until recently, rebreather diving was specifically excluded from some recreational dive insurance’s coverage. As the situation becomes clearer, rebreather divers are now able to purchase insurance that is equal to that offered to recreational divers.
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Photo by Richard Whitcombe
"While the technology has progressed, there is a growing concern that basic diving knowledge is dropping to lower and lower levels"
Photo by Andrea Izzotti Another relatively recent development in recreational SCUBA diving is the availability to begin diving at a younger age. At least one major training agency now offers children SCUBA diving lessons from age 10, albeit with depth and supervision restrictions. Meanwhile, research into the effects of diving among children continues. Similarly, though at the other end of the scale, only now that SCUBA has been so widely available for 40 years are we starting to consider the long- term effects of diving. We know that bubbles often form in our bodies even after dives considered “safe”, and that these decompression bubbles cause measurable effects on the cells and function of the endothelium, the inner lining of our blood vessels. Will a lifetime of deep decompression diving cause memory deterioration or other undesirable late effects? A recent article suggested that there might be very minor changes in cognitive functions of recreational divers, however, with no negative effect on their “quality of life”. Nevertheless, there is some limited evidence available in professional divers. Meanwhile, diving is here to stay and it is easier than ever to learn to dive and, thereafter, to rapidly progress to ever-deeper depths. Dive equipment has never been so affordable either, or so user friendly. Indeed, most modern dive computers will display decompression information, or at least emergency decompression information, for repeated dives well beyond recreational limits. Before dive computers were common, older divers and medical specialists would have assumed, for example, that anyone diving to 50m would know that they best not dive there
again in the afternoon, that it is safer to allow at least a full day for their body to desaturate. However, it is not uncommon these days for divers to present to hyperbaric chambers with DCS after exactly such “unsafe” deep, repetitive dives. While the technology has progressed, there is a growing concern that basic diving knowledge is dropping to lower and lower levels. In many cases, modern dive course students do not even learn about the dive tables anymore, and fail to appreciate the relationship between depth and no-stop time or to learn the rules for exceptional exposures. It is little wonder then, that some divers may be learning these rules for the first time at their local hyperbaric chamber. Even in technical dive courses it has become rarer to learn dive planning with tables and, thus, the newly-minted technical diver might one day find himself unsure what to do when his rechargeable dive computers go flat during a long dive. Where to next? – The Future We predict the face-to-face component of diver training will continue to diminish. Over this century the Internet has become so commonplace that diving course students now regularly complete the cognitive development portion of the course online. It is only a matter of time before fully online dive courses become available. Already at least one rebreather manufacturer is offering online certification for their particular model of rebreather, with no face-to-face component.
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Photo by Gustavo Frazao It is also plausible that redundancy of specialised diving equipment will be more and more considered, leading to the development of very modular and redundant diving equipment. Such new concepts will probably ease the reconfiguration of equipment underwater in case of nonstandard and or emergency situations, allowing technical divers to rely on their equipment even more than now. Of particular concern to the “old school” technical diver is that the use of dive computers is being adopted as fail-safe for decompression planning. The marriage of PC-based decompression planning software and diver-worn wrist computers has been welcomed by recreational as well as technical divers but this should not mean the fundamentals of dive planning are allowed to be handed over to a computer. A solid grounding in the theory that underpins the relationship between diver's physiology, physical fitness, depth, time, decompression obligations and gas consumption gives a technical diver the ability to spot weaknesses and flaws in computer-based modelling. While dive computers continue to improve in reliability as well as the approximation of human tolerance for decompression stress, table based dive planning should continue as a staple of technical diver training. This is akin to learning the Slide Rule during the earliest availability of the electronic calculator when, until computing power matched the demands of scientists, engineers, etc., it was prudent not to abandon the old ways. We are in a developmental transition phase now and not yet quite ready to totally rely on dive computers. One training agency has even taken a stand against using them, because their success at safe decompression remains to be scientifically evaluated. Concomitant with this development is the worry that technical divers are swapping to dive computers and automated gas consumption calculations without a commensurate increase in their ability to respond to emergencies when these automated procedures fail the diver. This happens regularly, for example, when divers make repetitive dives to serious depths because “the
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computer didn’t give any warnings” or when they do not have enough gas for deco and surface earlier than planned because “the computer said I would have enough”. As we transit towards a reliance on technology let us keep sharp those skills that got us this far. More than one diver has had a total computer failure during deco and pulled out his trusty wet- notes for a contingency plan. Wearing more than one computer should not mean technical divers do not need to cut out-of-gas and contingency depth plans. The decompression of nonstandard dives, (e.g. reverse profiles, yoyo or repetitive diving), commonly seen in cave diving and to some extent also in deep diving, is not yet fully understood and possibly requires re-consideration in the face of new in-field research. Lastly, as our training and procedures evolve we urge all technical instructors to stay abreast of the latest research and technical developments. This can be done by attending conferences such as EuroTek, Techmeeting and/or OZTeK, reading technical diving magazines and participating in technical dive forums. So, our last word is: Soak up technical diving knowledge but be aware that not all of it is accurate. Half of what you’ve been taught is probably untrue – unfortunately, it is not yet known which half. So prudence and conservatism is the only sensible option. It is too much of a pity to have to treat a bent diver who was not aware of the risk he/she was taking when embarking on that dive! Published by Lambert Academic Publishing, it can be purchased online here, or can be ordered via any bookstore using ISBN number 978-3-659-66233-1. The book is sold at 49.90 €, and all royalties from the sales are donated to EUBS, to promote further diving medicine research.
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The Making of a Man and PADI Instructor Photo by
by Richard Cullen
“You hold soldiers’ hands from when they come onto the programme, when they are in that dark place and you don’t let go until we see the light and get back on our right paths, and we feel ready to let go” Trooper Danny Martin, Royal Scots’ Dragoon Guards
IN THE BEGINNING On a chilly November morning in 2011, I travelled down to the United Kingdom’s (UK) Defence & National Rehabilitation Centre for UK Armed Forces at Headley Court to see twenty-one year old, Chris Middleton. Chris was a trooper in the Royal Scots’ Dragoon Guards and nine days before his 21st birthday, on 19 August 2011, while on patrol in Afghanistan he stepped on an improvised explosive device (IED). His injuries were devastating, losing one leg above the knee and one below the knee, in addition to other blast injuries. I have been an active supporter of a programme called Deptherapy. It seeks to rehabilitate seriously injured British Armed Services members who have suffered serious injuries using scuba diving. On a Deptherapy trip to Florida a month earlier, Sarah Nuttall a sergeant in the Metropolitan Police Service who used to arrange our ease of movement through Heathrow on Deptherapy trips and was a family friend of the Middleton’s, told me Chris was in a very bad place mentally. After contacting Chris’ parents Julie and Lee, Chris agreed to see me. Before meeting Chris, I became aware that he had been an ultra-keen sportsman, played many sports but loved football and cross country running.
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Photo courtesy of Deptherapy
This is a very personal, up close, insight into one young man’s battle against life changing physical and mental challenges. I have been very privileged and humbled to be a part of his journey for nearly five years. At times the path he has walked has been difficult and there have been stumbles but even the greatest journey starts with the first faltering steps. Through the rehabilitation effects of scuba diving I have seen him grow as a man and as a prospective PADI Instructor. For me, writing this article has been extremely emotionally challenging but I have done so with Chris’ permission and active participation.
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Photo courtesy of Deptherapy
Issue 9 | October 2016
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Although Chris said nothing at the time, his thoughts were “…have just been blown up and lost my legs and you want me to go scuba diving”. But as it involved a week in Florida he thought “why not”. Chris, then found himself in a very dark place. This is not uncommon for those who have suffered life changing injuries and those who suffer from Post-Traumatic Stress Disorder (PTSD). There is still a stigma around mental illness and getting Chris to accept he has PTSD was a long process. Chris abused alcohol. Some abuse recreational drugs and others abuse both. During this period getting through to Chris was very difficult and those close to him found his situation distressing. To be honest, and Chris knows this, I was very close to cancelling his trip to Florida but eventually we worked through the situation. He joined fellow bilateral amputee Richard Ward (IED) and paraplegic Carlos Buckley, who had been shot through the spine, on the trip. Chris, even when he is in a dark place, can be very funny. Virgin Atlantic had upgraded us to Premium Economy and when a member of cabin crew came around he asked, “What is the difference between economy and premium economy?” The reply “mainly extra legroom.” To which Chris replied, “Guess I don’t need that!” KEY LARGO That week in Key Largo, Florida was to change Chris and Deptherapy forever. As Chris rolled off the front of Horizon Divers’ catamaran Cheeka View I wondered what he would make of the ocean. He surfaced next to me with a huge smile on his face, a smile that brought Dorothy ‘Dot’ Eaton (Diver Group) and Fiona Weir, who were covering the trip for the British Forces’ Broadcasting Service, to tears. At the time, Deptherapy operated three ocean based “try dives” preceded by a pool assessment. Chris was so taken with scuba diving that he issued a challenge: “I want to be a PADI (Professional Association of Diving Instructors) Diver, I can do this without legs as well as people who are able bodied. I know I can.” He went on to say that he did not wish to be issued with a Disabled Divers International certification card as it contained the word “disabled”. Chris was determined to qualify as a PADI Open Water (OW) diver and to be able to dive anywhere in the world with a buddy. I had never understood the “old” Deptherapy’s policy of three try dives, with no follow up. Where were the long term benefits? Chris’ idea of working towards a PADI OW certification and beyond seemed a better idea: a challenge and the ability to continue with diving after the programme. But no one had been really down the adaptive teaching route before so I returned home and looked at every PADI standard in the OW course and how each skill could be adapted to cater to a bilateral amputee while still meeting standards. There was no manual. I needed to work on my own in a pool to work out what each skill would look like. If you want to know how challenging this can be try the horizontal controlled emergency swimming ascent (CESA) without using your legs. Through sheer determination Chris and Richard completed their confined water dives and I had learned much about adaptive teaching.
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Photo courtesy of Deptherapy
Perhaps I should have been prepared, having been involved in Deptherapy for a couple of years, but I wasn’t. Chris came down in his wheelchair to meet me at security. What I saw was a young man, barely more than a kid, whose face was beaming. I have to admit there were tears in my eyes. Psychologically I had to take a step back. There is a huge issue at first meetings such as this that your instincts as a parent will come to the forefront. It is tremendously important that we treat those we work with as adults and not try to overwhelm them with sympathy or over assisting them. Neither Chris nor I can describe what happened that day but one thing we both know is that a very special friendship was formed.
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Issue 9 | October 2016
"Through sheer determination Chris and Richard completed their confined water dives and I had learned much about adaptive teaching"
Photo courtesy of Deptherapy
RED SEA Chris and Richard joined my wife and me at our apartment in Sunset Pearl, Sahl Hasheesh, Egypt to complete their open water dives, PADI Advanced Open Water and Nitrox courses. We dived with the Aquarius Dive Centre and the manager was a personal friend. The dive centre waived all charges for the guys and the friendship afforded them by the Egyptians was unbelievable. But the manager made it clear it was only because the guys were diving with me that they were allowed to dive. Normally they would not entertain divers with such injuries. My wife, Christine, was my support diver and has often remarked that from what she saw during those courses, no one should ever doubt the determination and bravery of disabled soldiers. Both men absolutely smashed the standards and returned home qualified PADI Advanced Divers. Unfortunately, Chris was to experience heterotopic ossification. This is a medical issue where broken bones and amputations have the bone remaining continue to try to grow and knit to the bone it still “thinks” is there. Twice Chris needed surgery to have bone growth removed. Chris also has thermal issues. Portland, Dorset United Kingdom based O’Three Ltd, made him a tailored wetsuit that seals around his stumps and has small eyelets to let water pass through. Chris decided that he wanted to continue his diving career with the goal of becoming the first bilateral amputee PADI instructor in the world. Sadly, there are too many in diving who think that becoming an instructor without having legs could only be achieved by cheating and breaching PADI standards. To those individuals I would say: first, your language is that of discrimination and second, open your eyes.
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RESCUE DIVER Chris continued his diving and last November he went with Scott ‘Biscuits’ Brown, a single leg amputee, to Davey Jones’ Locker dive centre in Thailand supported by Deptherapy Regional Representative Simon Mackay. The trip was sponsored by Sarah Waddington Solicitors and Deptherapy Patron, Dorothy ‘Dot’ Eaton, was also in attendance. Chris’ main goal was to complete his PADI Rescue course but he also completed, alongside Scott, a Technical Diving International (TDI) Sidemount course. The number two in charge of PADI Australia was there and commented that he was amazed that Chris hit every one of the Rescue Course standards. Well of course he did or else he wouldn’t have qualified. Scott commented that he didn’t know where Chris found the physical strength to lift the “victim” up the boat’s ladder. INVICTUS GAMES Chris decided that he wished to compete in the 2016 Invictus Games in Florida and he went for selection with a vengeance. Those who saw the BBC television programme “The Road to the Games” will not have missed Chris’ infectious enthusiasm as selection and training loomed. Many will have also seen Chris’ death defying blocks in the wheelchair basketball and rugby. Chris returned home with a Bronze medal for the rugby and a Silver medal for the basketball. DIVEMASTER As soon as Chris returned from Florida he started studying for his PADI Divemaster course. This would be Chris’ biggest challenge thus far. For him to score the necessary points in his water skills assessments his swims are going to have to be close to Paralympic qualifying times for someone with his level of disability. We started Chris’ programme on our June Deptherapy programme at Roots Red Sea. I asked Martin Weddell, the co-owner of Crowthorne based Divecrew, to be his mentor and Chris started working in the pool with the injured guys. Chris has a distinct advantage when teaching other amputees because he knows what we are asking them is possible, because he has done it. It is also far better to have him teaching the amputees as able bodied instructors have legs and, although we don’t use them when demonstrating the CESA and other skills to disabled students, Chris can demonstrate as it is. He also has the benefit of being around the same age as the guys he is working with. The water skills are a challenge but he wants to progress to be an instructor and we have identified that he needs to be able to explain to a class of able bodied divers how to do skills he will not be able to demonstrate, such as a giant stride entry. We worked on this at Roots and Chris responded positively to all his feedback and he developed well during the week. He successfully completed all his knowledge reviews and I think he will he will breeze through the exams. Sometimes Chris can be too enthusiastic, especially when working with the injured troops, and the week at Roots was a steep learning curve for him as he began to manage what is basic to his personality. Chris is a social animal and great company, articulate and humorous but the week at Roots took its toll and it was early to bed, early to rise for Chris. THE ROAD GOES ON AND ON For Chris this is a never ending journey, there will always be challenges, there will probably be times when he is in a dark place again and the demons that are PTSD will re-appear. He always has a reminder of that fateful day in Afghanistan, every time he looks down at his legs. But we should see Chris not as a victim, not as a young man who needs our sympathy, but as an inspiration: an example that determination and true grit can overcome adversity. For me I will be there to hold his hand whenever he needs it. That is what friends are for.
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"Many will have also seen Chris’ death defying blocks in the wheelchair basketball and rugby. Chris returned home with a Bronze medal for the rugby and a Silver medal for the basketball"
Photo courtesy of Deptherapy
Photo courtesy of Deptherapy
Photo courtesy of Deptherapy
Issue 9 | October 2016
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Photo by Gareth Lock
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Issue 9 | October 2016
Today is a
Good Day To Die By Gareth Lock We cannot improve if we don’t learn. We cannot learn if we do not understand. “The divers were instructed by the DM (dive master) to swim away from shore and then they were taken away down current and then spent the next 7 hours fighting for their survival in 25-foot high waves before being picked up some nine miles away...” “How stupid could they be? It is obvious that they should have ignored the DM’s instructions and swam to shore. That’s what I would have done”. “The instructor had a double cell failure in the rebreather which meant that the voting logic gave them erroneous information in terms do of the pO2 (partial pressure of oxygen) within the breathing loop. They carried on their dive despite numerous warnings provided by the controller that there was an issue. Unfortunately, the voting logic meant that the solenoid was instructed to fire and the diver suffer an oxygen toxicity seizure and drowned. Two of the three cells were approximately 40 months old, more than three times the recommended age and well outside the recommended limits...” “It’s obvious that he should have aborted dive when he had the warning. How stupid could he be? I’d never make that mistake”. These relate to two real adverse events. In the first no-one died, but in the second the instructor unfortunately perished despite being recovered from depth by his students who were taking an entry-level (Mod 1) closed circuit rebreather class. The incidents themselves are almost irrelevant to the main theme of this article. The reason? This article is going to focus on the way the diving community often makes negative comments which does nothing to improve learning. Often we hear negative and aggressive comments following incidents. Commentators are judging what happened without a full understanding of the situation. Instead, we need to encourage a culture of being able to talk about the mistakes we make, and more importantly, why it made sense to us to behave in the manner we did. Without this dialogue, we are not going to be able to prevent future adverse events because we need the story, not just the statistics of the number of people who die or get injured during scuba diving or apnea. It is impossible to teach everything in a course, therefore, we need to learn by proxy. Learn from your mistakes. Better still: learn from someone else’s.
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Photo by Gareth Lock
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Issue 9 | October 2016
"The problem when we discuss incidents after the event is that we have additional information which would reduce the uncertainty faced by those involved in the incident itself to almost zero" “Today is a good day to die”. Unless we are in an extremely depressed state, the majority of divers do not get up in the morning and decide: “Today is a good day to die”. Conversely divers, in the main, are trying to do the best they can with the resources they have available, whether is is: time, money, people, equipment or a combination of these. The decisions we make are influenced by what we notice going on around us, how that perception matches with previous models or experiences and their subsequent outcomes and what we think is going to happen next. This set of parameters are best described by the Mica Endsley’s Model of Situational Awareness and is represented by the continual cycle of: Notice; Think; Anticipate. (Please see diagram.) Once we have developed an understanding of the situation, we make a decision, execute the action linked to that decision, wait for an outcome and then proceed. While we are progressing through that decision cycle we are at the same time updating our library of experiences and long-term memory storage using the feedback loop shown at the top of the diagram.1
The problem when we discuss incidents after the event is that we have additional information which would reduce the uncertainty faced by those involved in the incident itself to almost zero. Fundamentally, we have a crucial piece that those involved didn’t have: we know the actual outcome rather than a “risk of an adverse outcome”. Consequently, we are now influenced by both outcome and hindsight biases.
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Photo by Gareth Lock
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Issue 9 | October 2016
"There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight" “There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of the fact”. Hidden QC. Clapham Junction Inquiry 2
Remember that those involved in an incident at the time are subject to “What you see or have is all there is”. Despite observers often commenting that it was “obvious” or it is “common sense” that this would happen, unless you have experienced such an event, then you are unlikely to have that “common sense”. Besides, if it was that obvious, don’t you think those involved might have carried on regardless? If you don’t believe me, think back to when you were a child and burned yourself because you touched something hot, despite your parents saying, “Don’t touch that, it’s hot”. To use an example more relevant to dive medicine, consider learning buoyancy control. The instructor (hopefully) told you about the need to only use small amounts of correction in terms of gas in/gas out of the buoyancy sources (drysuit or BCD/wing). The more you injected, the faster you ascended, which meant that if you arrived at your stop, you had to let out more gas. If you over compensated because of the increased pressure in the buoyancy device and let out more than you needed to, you sank and potentially ended up in a pendulum state alternating between too much positive and too little buoyancy. I certainly remember this happening during my Advanced Nitrox and Decompression Procedures class where it took my buddy and I almost 15 minutes to ascend from 21metres (when it should have taken six) because we were ascending mid-water without a delayed surface marker buoy (DSMB) as a reference line and referenced off each other. It was very embarrassing but we learned. We want to keep deviations as small as possible within the operating limits and use a feedback loop to maintain that minimum deviation. For example, as we learn to do something new we require a feedback loop if we are to improve. Otherwise you don’t know how to bring the system back under control. That feedback loop might be a friend or an instructor, preferably using something objective such as a video camera. The feedback needs to be honest and not just platitudes. It also needs to include how to solve the problem. There is no point in telling someone their buoyancy isn’t very good if you don’t tell them how to fix it.
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Photo by Gareth Lock
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Issue 9 | October 2016
"To operate at the pace we do in the modern world we need to take mental shortcuts all the time" Fortunately, adverse events rarely happen in diving. However, this means that we don’t get the direct experience of bad things happening and, as a consequence, our library of long term memories is often devoid of experiences that we can use as a reference. Even more important is the fact that we don’t have the pre-cursors or trigger information which led to the adverse event occurring in the first place, so we can’t spot them developing. Saying someone has poor situational awareness is flawed if they don’t know what to focus on in terms of gathering the information to base their decision on (see the situational awareness model). The following statement came from a recent United States train accident and is not, unfortunately, uncommon:
Question: Why did the train crash? Answer: Because the driver lost situational awareness.
Question: How do you know the driver lost situational awareness? Answer: Because the train crashed.
As you can see, without understanding why it made sense to the driver to make the decisions they did, we cannot improve things. Just substitute diver for driver, and crash as rapid ascent to make it more relevant to your own environment. For example, while you might know that a rapid ascent is bad and should be avoided, you might not know what to look for to prevent the ascent rate being too quick to control until it is too late. Unless you sit down with someone and talk through the event, you may not be able to understand what those triggers were so that you can look for them the next time. This change in perspective could influence your situational awareness. Worse still, you could decide on the wrong course of action because you have decided to act on intuition rather than choose an action that is evidencebased. This process is perfectly natural because when we don’t have a real experience to refer to, we pick the closest “model” in our long-term memory and try to make it fit. For example, those inexperienced divers who have had rapid ascents from depth often think that adding more weight is the way to prevent future rapid ascents. Unfortunately, in the majority of cases, it is the excess weight that has triggered the problem because there is now a larger bubble of gas that will expand and will need to be controlled during the ascent compared to a correctly weighted diver. This means the control needs to be better and more timely, with more gas dumped at the correct depths which introduces an additional level of skill required. Despite knowing that rapid ascents are bad, you would be none the wiser as to how to solve the issue. The way to resolve this is to get the weighting as accurate as possible initially so that the gas bubble is as small as possible. The problem with being critical of adverse events that occur during a dive is that the social backlash is often seen as a punishment for talking about “normal human behaviour”. Normal human behaviour is often called “human error”. Unfortunately, “human error” is really only possible to define or attribute after the event. If people knew they were going to make an error, they would normally stop themselves. The same can be said of “complacency”. To operate at the pace we do in the modern world we need to take mental shortcuts all the time. These are known as heuristics: “It looked like one of those, therefore it is one of those”.
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Photo by Gareth Lock
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Issue 9 | October 2016
"To improve matters we have to understand what the drivers of the decision making process were." These heuristics usually work and there is a positive outcome (or a non-negative outcome). This is often known as “efficiency”. Remember that just because you didn’t get injured or killed, it doesn’t mean it was “safe” or the “best choice”. However, sometimes our interpretation of the real world is flawed and the model we are using is, therefore, incorrect. The subsequent mental shortcuts we take may end up leading to an adverse event and this is often known as “complacency”. To improve matters we have to understand what the drivers of the decision making process were. That is, what shaped the actor’s situational awareness and decision making processes and why did it make sense to behave in the manner they did. This means we need to ask questions framed in a positive way or create a safe environment where people can provide the whole story. It might be that they didn’t have enough time, their training was inadequate, the dive centre was pushed for cash and couldn’t provide the requisite number of staff and so forth. If people do not feel that they can tell the truth for fear of being castigated in public (or subjected to litigation or punishment from the authorities), then only part of the story will be told: the part which has potentially crucial facts may be left unspoken. When people post their own personal accounts, the responses are normally a little more controlled and less confrontational. However, when third party reports are posted, this control isn’t always the same or positive. Therefore, the next time someone posts an accident report about a third party, think through the questions: “Why would it have made sense for those involved to behave in the manner they did?” “What drivers were they likely to have been pressured by to behave in the manner they did?” Not: “How could they have been so stupid?” or “Look, another Darwin Award winner”. We need to encourage a “Just Culture” so that divers (and other professionals) are able to talk about failure candidly, free in the knowledge that feedback will be provided in a positive frame rather than berating them for being “stupid”. References: 1 Toward a theory of situation awareness in dynamic systems. Endsley. 1995 2 Field Guide to Human Error, 3rd Edition. Sidney Dekker
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Sea Sickness – Mal de Mar By Anke Fabian
Many people have experienced sea sickness personally or, if lucky enough to not be afflicted oneself, it can often be observed in a less fortunate person suffering badly from it. It does not only occur on boats but may strike while being in any moving object: a car, a bus or a plane. That is why it can also be called motion sickness.
In diving the sea may be rough. At first, an uneasy feeling occurs in the stomach, then general malaise followed by nausea. Before long, the breakfast comes up over the ship’s rail. At a minimum, this can be very unpleasant and at its worse it can be dangerous, when lasting over a longer period, due to dehydration. Seasickness is a serious disease that threatens not only the health of the person concerned, but also impairs the reliable performance of everyone’s duties at sea: from the skipper to the ship’s engineer down to the dive buddy and dive instructor. Kinetosis originates from the Greek word kinein: to move. Motion sickness is the uncomfortable dizziness, nausea and vomiting that people experience when their sense of balance and equilibrium is disturbed by constant motion. Riding in a car, aboard a ship or boat or riding on a swing can all cause stimulation of the vestibular and visual systems that often leads to discomfort. Foreboding symptoms are drowsiness, chills, malaise, increased salivation, yawning, circulatory disorders and nausea. The first symptoms can escalate to uncontrollable vomiting, as well as, unbearable nausea and malaise. Responsible for those symptoms is the conflicting information released by our sensory organs (the vestibular organ, the eyes, balance receptors in muscles, tendons and joints and kidneys). Each individual’s sensitivity varies greatly in how they may succumb to motion sickness and the daily sensitivity may vary as well. Motion sickness is a common problem, with nearly 80% of the general population suffering from it at some time in their lives.
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"Seasickness is a serious disease that threatens not only the health of the person concerned, but also impairs the reliable performance of everyone’s duties at sea" Photo by lassedesignen
Photo by leungchopan
Issue 9 | October 2016
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Information on significant environmental influences such as the sense of spatial position, acceleration, movements and others are processed in the brain stem and cerebellum. This process cannot be influenced consciously. Given normal functioning, the brain sends information on how to facilitate ourselves in three-dimensional space. The brain stem receives its sensory impressions from the inner ear, place-receptors in the muscletendon transitions, eyes, stomach, kidney receptors and other nerve structures. The exact location of the hypothetical “failure center” in the brain, which compares the incoming sensations and causes seasickness, is still unknown. Fortunately, your brain is adaptable and seasickness usually ceases after a few days. Only in 5% -7% do the symptoms last for a longer period of time. One can reliably trigger symptoms of motion sickness while sitting unmoved and comfortably in a chair watching a fast roller coaster video from the driver’s perspective on a big screen. In this experiment, the symptoms are caused by the contradictory information sent from the sensory organs to the brain. Our eyes see acceleration and speed, inclination and tilt but neither the vestibular organs nor the space receptors of the muscles are sending the conform information. Motion sickness is caused by a mismatch of information. Another example of motion sickness due to mismatch of incoming information occurs in some people who get drowsy and nauseated when watching snowflakes falling while standing on solid ground. In general, this what happens on a boat in rough sea. We perceive contradicting information from the sensory organs. The Inner Ear The inner ear is an extended part of the brain and is primarily responsible for the sense of balance and spatial orientation. It is located behind the middle ear and only separated from it through two thin membranes (round and oval window). It is filled with liquor-like fluids, the endolymph and perilymph, that provide nourishment and guarantee a normal function. The inner ear consists of two parts: the cochlea (hearing) and the vestibular organ (sense of balance). Sense of Balance Because the world is three-dimensional, the vestibular system consists of three semicircular canals to monitor any movement and it allows spatial orientation in every dimension. Each semicircular canal is counter-balancing the other two, thus the three pairs are cooperating in a push-pull fashion. They are linked to the eyes by the vestibular-ocular reflex to stabilize images on the retina in head movements. The vestibular organ is a complex and complicated sensory system. Damage or malfunction lead to extreme vertigo, nausea and vomiting. The horizontal semicircular canal is located closely to the middle ear and can be irritated by cold or hot water thus leading to dizziness and vertigo. Damage could possibly occur due to coldwater exposure in ice diving or when affected by barotrauma and/or decompression sickness. Symptoms The symptoms of motion sickness manifest themselves in a wide variety of ways with different stages and intensity. The “queasy” feeling in the stomach area or frequent yawning are often the first signs we notice and you may also notice increased salivation, fatigue, chills or headaches. All those symptoms occur when the vegetative nervous system is activated and switches the organism to “pause-resting mode”. The Parasympathicus (part of the autonomic nervous system that can not be influenced) gains dominance, like after an opulent meal. If the influence gets stronger, nausea occurs, followed by vomiting and the first uncomfortable feeling turn into pure misery. Unfortunately, vomiting will not stop even if the stomach is empty.
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Photo by Beth Swanson
Issue 9 | October 2016
HUMAN EAR DIAGRAM
VESTIBULAR SYSTEM DIAGRAM
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In severe cases, motion sickness can lead to a very high level of suffering, incapacitating the patient completely. At that point, it may become dangerous. The body loses fluids that cannot be replaced orally. Severe life threatening dehydration, electrolyte imbalance and a shift in the acid-base balance sometimes require the stricken individual to seek hospitalization and intravenous treatment. Therapy Once the first symptoms are already manifest, there are few effective measurements other than medicaments. The advantage of using tablets or suppositories is the resounding effectiveness of the medication. The other side of the coin is that some of those drugs target the central brain, where motion sickness is caused, by producing a slightly sedative effect. This dampening effect with its associated sleepiness and drowsiness is incompatible with scuba diving. Other adverse effects, depending on individual sensitivity, may include dry mouth, blurred vision, difficulty urinating, stuffy nose and even aggravation of certain cardiac arrhythmias (Long QT Syndrome). Therefore, it is advisable to discuss all possible medications with one’s doctor or diving physician beforehand. The most common drug against nausea is Metoclopramide (MCP: trade name Paspertin). In general, it is well tolerated with few side effects but unfortunately, it is often not sufficiently effective against motion sickness. MCP accelerates the intestinal passage of food and fluids. Once nausea and vomiting have started, it is advisable to use suppositories or medicament eluting plasters instead of oral medication. Scopolamine and Butylscopolamin (trade name Scopoderm / Buscupan) are more effective. The drug works by slowing down the excessive activity of the autonomic nervous system. The most effective drug is Dimenhydrinate (tradename Vomex or Dramamine). The mechanism of action targets the central brain structure, thus nausea and vomiting usually cease quickly. Due to the slightly sedative side effects, one should not dive for approximately 24 hours after medication use. Fluid replacement In all cases of motion sickness, it is crucial to maintain sufficient hydration and electrolyte balance. Admittedly, it is not easy to drink when one feels nauseated and miserable. Water, even in small sips, is better than nothing though. Electrolyte enriched fluids are preferably recommended when tolerated. As a last resort, fluids can be replaced intravenously. Prevention Ideally, if one is prone to become very seasick they should stay on solid ground where their sense of balance works calmly and happily. But this is no option for divers or people who get motion sick in cars, buses, planes or trains. Preventive measurements should be implemented long before the first onset of symptoms. When going on boat trips it is best to start before boarding the vessel.
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Photo by Thananya Apiromyanon
Photo by Pathdoc
Photo by Lisa F. Young
Issue 9 | October 2016
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Ginger Since ancient times, Chinese sailors and fishermen have consumed ginger tea in order to defy seasickness. Nowadays one can buy candied ginger, ginger oil, drops or tablets. Since the active substances of ginger rests in its oily proportions, liquid extracts are most effective. In double blind studies ginger proved its effectiveness against placebos and is completely free of side effects. Acupressure Originating from Traditional Chinese Medicine, acupressure is a method using certain trigger points of the body. The main one used in motion sickness is located on the palmar side of the wrist. One can press on it with the other hand or, as a more elegant solution, get a “Sea Band” from a pharmacy and wear it before the challenging trip. The copper rivets on the bracelets stimulate the corresponding trigger points at the wrist with no side-effects.
Photo by Africa Studio Photo by Pathdoc
Behavior advice Generally speaking, the driver of a car or the skipper of a boat does not get motion sick. As a conclusion, it is advisable to put oneself in a similar position on any moving device if possible. On the sides, at the bow or stern the rolling and tilting movements are the greatest. Also staying in a cabin is not ideal. Try to keep the input of balance signals to your brain as low as possible by staying in the center of the vessel where there is the least movement. Look at the horizon or another stationary point (star, moon, clouds) to keep the visual signal input low. Avoid alcohol, sun, coffee and tobacco. If traveling by bus or car, choose a seat in the front and follow the drive with your eyes. Do not read a book or a map. On a train endeavor to place yourself in the direction of travel.
One of the preventive medications is Cinnarizine: the so-called “sailors drops” There is no dampening side effect, therefore, it is quite popular with sailors. Some people use it with a good preventive effect, but it is not as effective as a treatment medication. Unfortunately, it is not easy to obtain in some countries, such as Germany, but is available in others, such as Egypt. It is a so-called calcium antagonist, which influences the autonomic nervous system on an alternative route. The right dosage is important. In studies, 50 mg were effective in 65% of the collective body, while the clinical outcome with a dosage of 25mg was not better than the placebo group. All prophylactic measures should be tested before using on a dive and must be used before the first symptoms occur. Once manifested, seasickness usually needs more powerful drugs. Habituation The best therapy is training our brain to process the contradicting information in the correct manner. We can get used to the movements of the ship once our "brain’s computer“ is reprogrammed. It may take a couple of days though.
Photo by Zerbor
All Else Fails If everything else fails, there remains the wisdom of old English sailors: "The only cure for seasickness is to sit on the shady side of an old brick church in the country.”
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Issue 9 | October 2016
"The best therapy is training our brain to process the contradicting information in the correct manner." 55
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