Diver Medic Magazine Issue 8 May 2016 by Diver Medic and Aquatic Safety

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Issue 8

Are You Really Prepared to Dive? by dan orr

Diving Smartly with Sharks BY Cristina Zenato

www.ibum.org Our BOD and staff Richard Sadler, M.D. , F.A.C.S. - Medical Director Harry Whelan, M.D., CAPT U.S. Navy (ret) - Director of Research Carla Renaldo, D.O. Dick Rutkowski, Founder Jeffrey Bertsch, CHT Jon Dembo, CHT Morgan Wells Ph.D. Joseph Dituri, M.S., CDR U.S. Navy (ret) The International Board of Undersea Medicine (IBUM) exists to train hyperbaric chamber operators, diving medical technicians, clinical hyperbaric technicians, and hyperbaric physicians as well as educate and increase safety for those who work in the hyperbaric field including certifications to the highest international standard for hyperbaric facilities. Hyperbarics, Chamber Certification and Diving Research...Simplified! Our research department has first rate research fellows in hyperbarics who are pushing the technical frontier and publishing our results. Aside for our internal research, we seed hyperbaric medicine and diving research throughout the world to help improve our community. We tackle research problems that organizations historically shy away from.

Editor-in-Chief Chantelle Newman Editor Betty Orr Technical EditorS Andrea Zaferes, 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: Betty Orr, Andrea Zaferes, Teamlgs, Dan Orr, Dr Anke Fabian, Gareth Lock, Jill Heinerth Rod Hancock, Code Blue Nurses, WDHOF, Dan Consulting, Cristina Zenato, Dan Vale, Steve Millard, Joseph Dituri, Dr Richard Sadler, Fourth Element, Aquamed, DAN Europe, Innosonian Europe PHOTOGRAPHERS Cover image by Victor Douieb, Michael Kazma, Teamlgs, Cristina Zenato, Wilson, North Woodsman, Anke Fabian, Gareth Lock, Steve Millard, Chrissie Taylor, Innosonian Europe, Ethan Daniels, Guryanov Andrey, Kevin J King, Hasrullnizam, Sergiy Zavgorodny, Pazargic Liviu, Yvan, think4photo, James Steidl, Angelo Giampiccolo, Semen Lixodeev, A. and I. Kruk, Elisei Shafer, Dudarev Mikhail, Rich Carey, dotshock, Aaron Amat, Alexkich, V. J. Matthew, Eddy Raphael, Thomas Duerrenberger, Cara-Foto Magazine address The Diver Medic Ltd Great West House, Great West Road, Brentford, TW8 9DF Telephone +44 020 8326 5685 EMAIL info@thedivermedic.com www.dmaasm.com www.thedivermedic.com

Contents 4 Search Time Limits 6 Are You Really Prepared to Dive? 10 Diving Smartly with Sharks 17 Saturation Diving 22 Chamber Dives - A Critical Review 30 Human Factors Skills In Diving - Course Review 32 The Diver Medic - Course Review 40 Brayden - The Future of CPR 44 Letter from Editor

By Chantelle Newman By Andrea Zaferes By Dan Orr

By Cristina Zenato By Dan Vale

By Dr Anke Fabian By Gareth Lock

By Steve Millard

By Rebecca Boughey

IBUM JOURNAL In-Water Recompression Consensus Statement and Guidelines by Joseph Dituri M.S.CDR, US Navy Saturation Diving Officer (ret)

Selected Readings in Human Factors Science Part 2 - Accidents and Cognitive Processes by Richard Sadler M.D. FACS

44 50

Photo by Michael Kazma

Issue 8 | May 2016

A Letter from the Editor... Do you understand the proper way to approach marine life? In this issue of the Diver Medic Magazine we have a compelling article from Cristina Zenato who shares her extraordinary way of getting close to her “babies”, the sharks. This unique situation is specifically designed for maximum safety for both her and her sharks and part of the touching program has helped to protect the sharks all over the Bahamas. Reading her article will help you understand why it is no easy task. Other articles in this issue provide both enlightenment and entertainment: Dan Vale tells of his trials, tribulations and risks as a Commercial Diver. Dr. Anke Fabian gives us a critical review on dry “chamber” dives and answers the question, “Should we be risking the health and safety of our divers by doing a dry dive?” The Scientific Journal of the International Board of Undersea Medicine article on In-Water Recompression by Joseph Dituri has already made people look at whether in-water recompression could change the ways of DCI treatment or not. We hope you enjoy our magazine and we encourage you, our readers, to have your say by writing us and we will publish your letters on our new page, “Letters to the Editor”.

Chantelle Newman Editor in Chief 5

Photo by

"Too often divers push themselves in an unspoken competition to extend search times"

Photo by Ellen Cuylaerts

Photo by

SEARCH TIME LIMITS IN

LOW TO ZERO-VISIBILITY SEARCH OPERATIONS By Andrea Zaferes

here are a variety of factors that should set the maximum time limits on searches in low to zero visibility water. Too often divers push themselves in an unspoken competition to extend search times. This can decrease search effectiveness and safety. Lifeguard Systems has a 20 minute with a possible five minute extension for such searches that have a maximum depth of 15 metres (50 feet) with a possible three metre (ten foot) extension. This standard is reduced by five minutes for searches under the ice and sometimes in dives deeper than 12 metres (40 feet). Divers with high surface air consumption rates (SAC) will also need a reduction in dive time, as will be discussed. Let us begin with the factors that limit search time.

AIR When 11.1 litre/204.1 bar (80 cuft/ 3000 psi) are used, divers should be back on deck or shore with a minimum of 68.95 bar (1000 psi). The 15-

25 minute/15-18 metre (50-60 foot) limits allow almost all properly trained divers to return with well over 68.95 bar (1000 psi).

Concentration – the Mind’s Eye Diver’s should keep their eyes closed in low to zero-visibility searches and use their mind’s eye to visualize everything they are touching with their hands, body, and legs. How long can you keep your concentration, your mind’s eye working, without any interruption? We have

found that most divers start decreasing their ability to continuously and optimally concentrate after 20-25 minutes. This is especially true when searching in areas with lots of bottom debris or tall and thick grass, or when searching for smaller objects such as handguns.

Belief you will find it It is 0200 hours: you’re on the bottom in blackwater searching. After ten minutes of searching what does the little voice in your head say? After fifteen minutes what does it say? In the next few minutes how many of you have

heard a voice, or just had the feeling of, “I’m not going to find it on this dive.” Once that feeling arises, even if we are barely conscious of it, our searching effectiveness decreases.

Photo by Ethan Daniels

Photo by Guryanov Andrey

Photo by Ethan Daniels

Photo by Ellen Cuylaerts

Photo by Kevin J King

Photo by hasrullnizam

Diver fitness A person who is cold is not searching well. A person who is dehydrated is not searching well. A person who is fatigued or breathing heavily is

not searching well. Such fitness variables can all be exacerbated with increased dive times.

Tender and Profiler (Scribe) Concentration Primary tenders should never take their eyes off their divers. It can take seconds for a diver to surface, spit a regulator out and descend back down. Tenders and profilers need to maintain constant and vigilant attention to the primary diver who is diving. They watch the diver’s breathing rate and quality, and watch the spatial relationship between the diver’s search line and exhalation bubbles to become immediately aware of snags. They make sure that the diver’s search speed is appropriate for the size of the

search object and the bottom conditions. They draw the diver’s search sweeps on the profile map to document what areas were covered. They periodically estimate how much air the diver has left based on the diver’s personal SAC and breathing rate. These are just some of what these critical surface personnel must do. No more than 20-25 minutes followed by a break during diver changes is a safe duration of time to be able to maintain this effective vigilance.

Diver Cycling And also keep in mind that a diver may be sitting as a 90% ready diver, and then cycled into the backup diver slot before being deployed as a primary diver. Imagine if divers were allowed to dive for 30, 40, or even 50 minutes. That would

mean a diver might have to sit in gear for one to two hours before diving as a primary diver. This is not optimal for real search dives. This problem is greatly compounded when diver’s need to be recycled.

Diver recycling Diver’s who are allowed to do 40-50 minute searches are spent. They need to be dressed down, hydrated, perhaps warmed up, and spend a little time in rehabilitation before they can dive again. On the other hand, a diver completing a 15-25 minute dive can have his cylinder replaced with a full one, drink a bottle of water, and be rotated to the 90% ready diver position if environmental conditions are not too severe. A

team of three divers and two tenders can rotate through nine dives in four to five hours with the 20-25 minute dive time limit. This is particularly important for teams that may not have many divers available at one time. Recycling also applies to tenders and profilers as well. This cannot be safely or effectively done with longer search times.

Nitrogen on-gassing When a 15-25 minute dive time limit is combined with a 50-60 foot minute maximum depth divers can perform multiple dives in a day

without entering decompression profiles. This is important because not enough divers and very few dedicated tenders are very dive table savvy.

Are You REALLY

Prepared to Dive?

By Dan Orr, President Dan Orr Consulting, LLC.

Photo by Sergiy Zavgorodny

Issue 8 | May 2016

"In scuba diving, failing to prepare can have catastrophic and potentially deadly consequences"

Preparation should begin long before you arrive at the dive site. First of all, you must make sure that you are physically and emotionally fit to dive. Fitness to dive should include making sure that you are in good health with exercise tolerance allowing you to be able to cope with the potential physical demands of the dive you are likely to make. Organizations such as Divers Alert Network (DAN) recommend that all divers over the age of 35 have an annual physical examination, preferably from a physician familiar with diving medicine. If you don’t have or know of a physician familiar with diving medicine near you, the DAN Medical Department can help you find a DAN referral physician in your area or region. DAN also recommends a physical examination any time there is a noticeable change in your health. If you are going to be diving in conditions with the potential for demanding currents or wave action, it might be good to begin an exercise regimen to make sure you are prepared for these conditions.

Photo by TeamLGS

any years ago, when I started the diving program at Wright State University in Dayton, Ohio, we would use a variety of meeting rooms on the campus since the university was new and growing rapidly. The most unique was the Gross Anatomy Lab where the student desks were interspersed between bins containing cadavers and various preserved body parts. I remember the nervous looks on the student’s faces as they anticipated the Zombie Apocalypse to begin at any moment! Eventually, our classroom sessions were moved to a meeting room in the newly completed athletic complex. Scrawled on the walls in many of these rooms were various phrases to instill spirit in the athletes. There is one particular phrase that I will always remember and one that I incorporated into my personal diving philosophy: “Failing to prepare is preparing to fail”. This is valuable in the world of competitive athletics where failure to prepare could result in the loss of a critical game or match but in scuba diving, failing to prepare can have catastrophic and potentially deadly consequences.

It is also important to take a good look at the dive you are going to make so that your collective diving experience is equal to the demands of the dive. Your recent diving experience and not your certification card (C-card) should be your guide to deciding what dives you should make. Your C-card gives you the right to go diving. Your recent diving experiences gives you’re the tools and skills to help you dive safely. Just because you are a certified diver doesn’t mean that you can dive under all diving conditions. If you have the opportunity to dive where you have little or no previous experience, it would be a very good idea to seek some advice and assistance. That assistance can come in the form of dives under the supervision of a diving professional or diving with a local dive club or group with experience in the area. Probably one of the most important things to know is that you always have the right to say “No”. If you feel that the dive you would like to make is beyond your ability, it is far better to say “No” than to put yourself or your diving companions at risk.

Photo by Sergiy Zavgorodny

Once you are confident that you are, indeed, fit to make the dive you’re considering, you need to make sure that your equipment is also ready for the dive. Your equipment needs to be inspected and maintained by a trained and qualified equipment technician annually or, like your health, any time there is a noticeable change in its performance. Even though your equipment has been inspected and/or repaired by a qualified professional your pre-dive preparation should always include a thorough inspection of all external rubber parts (mouthpiece, hoses, fin straps) by you and your diving companions before each and every dive. Any evidence of cracking or splitting should result in immediate replacement from your personal “Save-A-Dive Kit”. Researchers at DAN reviewed nearly 1,000 diving fatalities and identified “triggering events” that turned a relatively unremarkable diving experience into an emergency that led to a fatality. Over half of the triggering events in diving fatalities were either directly or indirectly related to what DAN has identified as “equipment problems”. After having reviewed the data, I am of the opinion that these particular triggering events should actually be labeled as “problems with equipment”. “Problems with equipment” does not mean equipment failure but a failure on the part of the diver to use the equipment properly either during pre-dive preparation or during a dive.

This leads us to the next and probably most important area of pre-dive preparation and that is practice of basic diving and emergency skills. If you have been away from diving for some time, you should get some practice of basic diving skills (buoyancy control and basic equipment familiarity) before once again venturing out into openwater. If that is not possible or practical, the first dive or two you make in openwater should be in a shallow, benign site with plenty of clear water and bottom reference. As part of the preparation for openwater, you and your diving companions should practice emergency skills such as how to manage out-of-air emergencies including emergency ascents and how to jettison weights in an emergency.

Photo by Sergiy Zavgorodny These and many other actions are complex psychomotor skills requiring regular practice and reinforcement to be able to be used in a crisis. If you donâ&#x20AC;&#x2122;t have recent familiarity with critical emergency skills, you cannot hope to successfully manage an emergency situation potentially allowing an otherwise enjoyable diving experience to initiate a cascade of events that could cost you or your diving companions dearly. When packing for your dive trip, a checklist is important to reduce the likelihood that you will forget something essential. The checklist will also help prevent something from being left behind on your return home. As identified as a critical safety step in all forms of recreational diving

during Rebreather Forum 3 in 2012, a checklist should also be used as an essential reminder of all essential steps in thorough preparation for diving. In conjunction with a checklist, a consistent pre-dive ritual is important to make sure you are thoroughly prepared for the dive. If you are taking medications (prescribed or over-thecounter) during the diving experience, it might be good to get advice from the DAN medical team to make sure the medication or the underlying medical condition is compatible with safe diving. If the medication is deemed safe to dive with, if youâ&#x20AC;&#x2122;ve never taken it before, it might be wise to have some non-diving experience with the medication to make sure it does not make you drowsy or have other side effects incompatible with safe diving.

Photo by Sergiy Zavgorodny

It is also good advice to be well hydrated and rested before diving. Hydration is an important component of diving safety allowing you body to function well under diving conditions. Hydration is a real factor for divers traveling long distances to exotic dive destinations. The lack of sleep and dehydration can quickly turn a vacation into something far less desirable. A well-hydrated diver will have clear and copious urine. It is also wise to rehydrate following a dive to make sure you replace fluids lost during a dive. If boat diving, it is advised to configure and check your equipment while the boat is still at the dock and in calm water. Waiting till you are at the dive site and subject to wave action and boat movement, may cause you to make mistakes that could have serious consequences later. It is also important that you prepare at a pace that is comfortable for both you and your diving companions. Never allow circumstances, such as time pressure, to prevent you from being thoroughly prepared for the dive. The same thing applies to the dive itself. Once in the water, you should always swim at a pace that is comfortable for you and you buddy. You should never be forced to “keep up” with others. Once in the water, if surface conditions allow, a quick visual check of your diving companions is a good idea before the descent begins. After you have equalized your ears, and begin your descent, you may want to make a short “safety stop” at a depth of 10 feet-15 feet just make sure that everything is “OK” with your diving companions. At that “stop”, you give and receive an “OK” from your diving companions before continuing on to your planned depth. During the dive, you should continue to monitor and share critical information with your diving companions always being aware of what’s going on during the dive so that you can adjust or modify your dive plan to accommodate for anything that could increase your risk and compromise your safety. This “situational awareness” is essential in safe diving. If anything occurs to increase your risk (such as swimming against stronger currents or wave action than anticipated), you can mitigate those risks by making some alterations in your dive plan including diving shallower than planned, reducing your planned bottom time and/or increasing your safety stop on the ascent. Remember, “Failure to prepare is preparing to fail” but proper and complete preparation prepares you to thoroughly enjoy one of the greatest sports our planet has to offer. And, for those that are involved in mission-oriented diving, thorough preparation allows you to focus on the tasks at hand maximizing your productivity.

Photo by Pazargic Liviu

Issue 8 | May 2016

Diving Smartly With Sharks by Cristina Zenato

Photo by Eddy Raphael

Issue 8 | May 2016

The diver, or better the shark feeder, stands in the middle of the sand, sharks swirling around him. Sunlight filters through the clear Bahamian water as the sand slowly settles back to the ocean floor along with the sharks after the little commotion. He is looking down at his hand, a surprised expression on his face: a mix of fear, relief and incredulity. He lifts his hand towards me, stretching out his thumb and displaying an untouched appendage and neoprene glove sticking out of a severed chainmail glove, the top missing. 17

'The beauty of sharing the water with these animals is that they can really tell the difference between the person carrying the food and the people not carrying the food.'

He has just been bitten by a Caribbean Reef Shark while on a shark feeding dive and made a simple mistake of timing and placement of the food presented to the incoming shark. I look over, certain that the only issue will be replacing the glove. The Neptunic Sharksuit is made for professional divers and videographers working in close proximity to certain sharks and food to prevent damage from accidental bites. And it works. Shark dives and shark feeding dives have grown incredibly popular. Twenty-two years ago when I started as a feeder there were very few operators and divers feeding sharks in a continuous and organized manner. Today it is a wide spread activity and, thanks to sharks and their high tolerance of our presence and intrusions, it is for the most part a very safe activity. There are over 500 different species of sharks and most of them are harmless to humans due to their size, shape and diet preferences. However, there are few species that have become the divers’ and adventurers’ favorites to share time and space in the water without any protection. This includes but is not limited to Tiger Sharks (Galeocerdo cuvier), Lemon Sharks (Negaprion Brevirostris), Bull Sharks (Carcharhinus Leucas), Great Hammerheads (Shpyrna Mokarran), Oceanic White Tips (Carcharhinus Longimanus) and sometimes even Great White Sharks (Carcharodon Carcharias). The beauty of sharing the water with these animals is that they can really tell the difference between the person carrying the food and the people not carrying the food. With minimal set up following specific rules and regulations the dives are generally safe. However, we still need to think in terms of when an incident will occur rather than if. The questions arise: Are we ready? Have we thought through all

the issues related with feeding and diving with large animals that have several rows of teeth? Here are a few of the considerations I would suggest divers, operators and future feeders and handlers to consider when entering the water to feed and handle sharks: 1. One size does not fit all. What is achieved and done with one species of shark will not always be safe to achieve with a different species of shark, either be cause of the strength of the animals or because of point three. Welcoming a Caribbean Reef Shark into my lap and letting it rest on my leg while I pet it on the head will not always work when attempted with a different species of shark. We need to take into consideration not only the size but a variety of factors that may determine if the shark will be relaxed enough to accept a certain kind of behavior, feeding or handling. 2. Size does matter. The bigger the shark means the bigger the mouth, the bigger the teeth and the more powerful the bite. A bite will differ substantially depending on that fact alone. This brings into consideration a whole list of other factors. 3. “It is true that no one can harm the person who wears armor. But no one can help either” – Kristin Hunter. Wearing the suit does serve as good protection against accidental bites. The problem occurs when wearing the armor gives us a false sense of security and we feel it is acceptable to drop our caution towards the animals. Using the protective suit in the wrong setting and with sharks of a size different than for what it was tested is not protecting us. Instead it puts us at risk.

Photo by Cristina Zenato

Issue 8 | May 2016

Photo by Thomas Duerrenberger 4. Murphy knows how to scuba dive. We are humans and we all make mistakes. Even the most well thought through plan and emergency procedure can have flaws. Have we thought of what can go wrong and taken the most effective precautions to resolve the potential issues? If we are diving in an area where surfacing away from the main vessel is potentially dangerous due to the species of sharks we are diving with, is the vessel equipped with a small dingy or a lifeboat? Divers encounter problems and vessels fail and sink. Do we have the required training and equipment to compensate for what could occur when taking a trip out to sea on a vessel? 5. “Good work ain’t cheap; cheap work ain’t good” Norman Sailor Jerry Collins. Service falls under the work category. It would be great if good work also came cheap but when we talk about remote locations, vessels, fuel, diving with wild animals, and other factors, it is important to consider the services provided. Are the emergency kits on board the appropriate type? How qualified is the crew to handle an accidental shark bite? Does the vessel have a specific trauma kit?

6. Get Paradise to share the blame. The locations where sharks are found and these dives take place are beautiful, pristine, untouched and at times remote. Have we thought about the evacuation plan in the event of a medical emergency? What are the time frames to call for help and to receive assistance? What kind of evacuation? If the boat ride is two hours from the shark dive location, so is the return trip. Can we use air evacuation? For example, if you are visiting the Bahamas and need to enter the USA in an emergency coast guard helicopter in order to receive medical care, you can only do so if you have the correct visas in your passport, unless you are American. The ESTA (Electronic System for Travel Authorization) does not qualify. Do we have all of the correct paperwork? Have we requested our guests to have that paperwork? It is time we understood, as both operators and consumers that a shark dive is not simply throwing morsels of fish in the water and jumping in. Careful thought should be given to the factors we have mentioned and, perhaps, more. We need to realize that the high tolerance of these animals towards our presence and work can become an issue if the proper planning has not taken into consideration all of the possible scenarios, including the most unlikely.

DIVING By Dan Vale

n a world thirsting for wealth and strapped by the necessity of petroleum it was inevitable the search for recoverable reserves would take the oil industry into the wilds of the offshore oceans.

So it was in the fall of 1982 when I joined the diving crew of the Sedco 706, a semisubmersible deep seadrilling platform operated by Mobil Oil. The 706 was drilling exploratory wells offshore Newfoundland in an attempt to realize the full extent of the Hibernia oil find which was discovered several years earlier. Their quest was taking them ever farther out into the Grand Banks, a large area of continental shelf extending offshore from the coast. The diving was going ever deeper: 76 metres (250 feet), 152 metres (500 feet), and now to 222.5 metres (730 feet). Cha-ching! I could not believe my good fortune. Only two years out of dive school and here I was, zipping up my survival suit in preparation to board the huge Okanagan helicopter for the two-hour ride out to the rig. Normally, a diver of my limited experience would not see such a plum contract for several more years, but I had an ace in the hole. Part of my two year

Associate of Science degree program in Underwater Technology was certification as a Diver Medic. Very few schools were offering this training and I was one of two divers in my area with the ticket when the call came in. And the other guy was out of town. Beauty. I worked for Can-Dive Services, a Canadian subsidiary of the giant diving contractor "Oceaneering International." Oceaneering required a Diver Medic in saturation at depths below 182 metres (600 feet). As the 706 was moving from 152 metres (500 feet) to 222.5 metres (730 feet), I was offered the opportunity to be part of the deepest saturation dive ever conducted in Canadian waters. I told them I thought I could fit them in. During the flight out I recalled the tragedy of the "Ocean Ranger", another semisubmersible rig (the largest in the world at the time) which foundered in a horrific gale some ten months earlier, not ten miles from the vessel I was about to join. Eighty-four men bailed into the sea that night, clad in nothing but jeans and t-shirts, as the rig sank in 76 metres (250 feet) of cold North Atlantic water. There were no survivors.

I recalled the tragedy of the "Ocean Ranger"... which foundered in a horrific gale some ten months earlier 22

Photo by Yvan

SATURATION

Issue 8 | May 2016

"Only two years out of dive school and here I was, zipping up my survival suit" 23

I snapped out of my melancholic reverie as the helicopter began to circle the 706 in preparation for landing, affording me my first glimpse of the massive structure. From the crowded main deck rose the giant derrick, a structure designed to facilitate the coupling, uncoupling and storage of the long stands of drill string used to "make hole." Eight huge cylindrical legs called caissons support the upper framework of the vessel, and they are, in turn, connected at their bases to two equally massive, laterally mounted pontoons. Within these catacombed pontoons are the pumps that act to shuttle water between compartments to provide even trim for the rig. Ballast water can be pumped in or out of these pontoons to settle the rig higher or lower in the water. Deck loading is an equally critical factor in vessel stability and is the sole domain of the barge master. This enormous floating work platform is held in place by eight massive anchors. Pontoon mounted thrusters provide propulsion for surface sailing and assist the rig to remain on station in weather. Making hole in the seafloor is a multi-stage process. At certain times in a routine "drilling program," human hands, or robotic arms, are needed. When things screw up, divers become very important commodities, as the cost of drilling offshore is astronomical and time is money. (For a primer on offshore drilling, read the thread "If the bottom is firm, why does it squirm?) The rig was proceeding to its' next drilling location and it would be several days before they were ready

to drill or "spud in" the new well. The initial phase of the drilling process would require divers on the bottom causing the entire ship's company to be busy preparing for the work ahead.

When things screw up, divers become very important commodities, as the cost of drilling offshore is astronomical and time is money. After settling into my quarters I was introduced to the diving crew and together we set off to review the saturation diving system. The centerpiece of any saturation system is the "tankage", a series of pressure vessels or chambers flange mated together. When the 706 was constructed, a Reneau "B" 304.8 metre (1000 foot) saturation system was built into the main deck, adjacent to the drilling moon pool. The tankage consisted of a four man living chamber, a transfer under pressure chamber (t.u.p.c.), a secondary three man living chamber (for emergency use) and the communications and environmental control were all housed in the control van. The contributing sub-systems included hydraulics, pneumatics, electrics, electronics and various compressors, pumps, generators and hot water elements. The bell was

Photo by Wilson

"Bell atmosphere, diver's breathing gas, electrics and hot water were supplied by umbilical from the control van. " 24

Photo by James Steidl mated to the t.u.p.c. with a removable, hydraulically actuated clamp. Between the bell and the t.u.p.c. was a "trunking space", essentially a 0.61 metres (two foot) long, 0.91 metres (36 inch) diameter tunnel. To launch the bell, the divers would transfer from the t.u.p.c. to the bell thru this trunking space: hatches on each side would be closed and dogged and the atmosphere in the trunking would be vented to the atmosphere. The clamp would be removed and the bell would track away from the t.u.p.c. on a hydraulically actuated skid. A bell moon pool door would open and the bell would be raised clear of the skid by a bellhandling winch. It would then be lowered 18.3 metres (60 feet) thru the "air interface" to the surface of the sea. Bell atmosphere, diver's breathing gas, electrics and hot water were supplied by umbilical from the control van. The bell also carried a number of externally mounted high pressure onboard gas bottles as emergency backup. Electrically powered carbon dioxide (CO2) scrubbers removed excess CO2 and hot water heaters kept the atmosphere warm in all system tankage. The environmental control unit (e.c.u.) was charged with the task of maintaining reasonable humidity levels in the system and gave us the most trouble.

pre-dive baseline medicals on the divers, and assist with general system readiness. Out on deck, huge supply boats hovered close in while cranes hoisted supplies onboard, including vast "quads" of breathing gas for the diving system. Pure helium, various pre-mixes and one hundred percent oxygen (O2) had to be analysed, manifolded together and plumbed thru to the control van. In the closing days before committing to saturation, we worked around the clock in two 12-hour shifts to insure all was ready when the call came to dive. At 0230 hours the green light was given to saturate. "Building an atmosphere..." Two divers and I entered the living chamber and watched with a â&#x20AC;&#x153;wee dramâ&#x20AC;? of trepidation as the outside tenders closed and dogged the hatch. With all hatches secure, compression of all tankage (excluding the emergency living chamber) began on air and continued to a pre-determined depth where the desired oxygen pressure was attained, the remainder of the press continued utilizing one hundred percent helium. The metabolic consumption of O2 was made up as necessary to maintain a constant partial pressure of oxygen (PO2) of .45 atmosphere absolute (ata) to .5 ata. Compression to 216.4 metres (710 feet) salt water

"Only two years out of dive school and here was, zipping my survival As theI"medic-in-sat" it was my up responsibility to inventory suit" and ready all emergency medical supplies, perform

(storage depth) took a little over four hours. The PO2 and PCO2 levels, depth and the divers well-being were continuously monitored by life support technicians (LST's) in the control van, and a continuous log of all activity was kept. While saturated, we were visually monitored 24 hours a day by video cameras (ordinarily not an inconvenience, but I could never get used to having a b.m. on closed circuit TV). During the press we remained quiet, diligently observing one another for any indications of trouble. As we neared the 213 metre (700 foot) level, the increasing density of the atmosphere made breathing a bit of a chore and I remarked: "Man, this gas breathes like peanut butter!" Not an incredibly funny line by any stretch, but I sounded just like Donald Duck and the guys exploded into laughter. The noise they made cracked me up and we cackled on like a gaggle of drunken ducks until the supervisor requested we regain control. That remains the greatest sustained bellybusting laugh of my life. At 216.4 metres (710 feet) we were up and moving stiffly about the complex, flapping towels up and down to agitate the somewhat stratified atmosphere. I say stiffly because the increased pressure had forced most of the synovial fluid from our major joint tissues, causing friction as bone scraped against bone (the condition known as "compression arthralgia" would all but disappear in a few days as the fluid worked its way back). In time we realized we were quite hungry so we decided to order in (all meals are "take out" in a saturation system). While saturated, all our meals, linen changes and other needs were

"sent down" to us using a medical lock: essentially a small (0.3 metres [one foot] diameter by 0.61 metres [two foot] long) through a bulkhead transfer chamber. It had a hatch on each end. With the inner hatch closed, the outside tender could "take the lock" by venting it to surface. He would then load it up, close the hatch and radio us the go-ahead to take the lock back down to depth. We achieved this by opening a valve that would allow chamber atmosphere into the lock and compressing it back to storage depth. We would remove the contents, reload the lock with whatever we wanted to "send up" and radio topside to once again vent the lock to surface.

the increased pressure had forced most of the synovial fluid from our major joint tissues, causing friction as bone scraped against bone Our options for dinner were piped in over the communication system and for the next twenty minutes I attempted to relate our menu selections. Though the control van was equipped with helium unscrambling radios, the technology had not advanced to the point where helium affected speech was totally intelligible. One had to acquire a "helium ear" to decipher the garbled squawking. After half an hour of guess work we had the

Photo by Angelo Giampiccolo

"As we neared the 213 metre (700 foot) level, the increasing density of the atmosphere made breathing a bit of a chore" 26

Photo by Wilson job of ordering almost complete save for my drink order: I wanted milk, but no matter how many times I said it, it came out as "hmoinck". Finally, in desperation, I mustered up my best "Moo." Oh, you want milk. Why didn't you say so? The work began. The first order of business was to establish and level a guide base on the seafloor: no easy task as the bottom had the consistency of loon-poo. We soon settled into a daily routine. We were not required on bottom every day and we passed the time reading pulp fiction and intently studying a wide variety of medical journals. Once a day we would shower in the t.u.p.c. using a conventional showerhead. Wastewater would collect in the bilge to be evacuated to external holding tanks at the conclusion of showering. Gang showers were necessary to save on helium as a significant amount of atmosphere was needed to flush the bilge. Strong anti-bacterial soap was used to ward off skin infections brought on by elevated humidity levels. Originally scheduled for seven days, we had now been down for fifteen, with little progress on bottom. The diving had been frustrating but routine. The drillers were scratching their heads to come up with new ways to solve their problems. Day 16 began with an order to dive, but this day would not be routine, it was to be a day of near disaster.

this day would not be routine, it was to betwo a dayyears of near disaster. "Only out of dive school

and here I was, zipping up my survival suit" A typical dive to the bottom (a "bell run") ran eight hours, with each man taking a four-hour turn in the water. In preparation to dive, the man who is to enter the water first crawls into the bell to perform pre-dive checks and to load any needed supplies. When all is ready, he returns to the t.u.p.c. to suit up with the other diver. Thermal protection is afforded by hot water suits. With both divers in the bell, all hatches are closed and dogged in preparation for the venting of the trunking space. I would stand by the outer hatch in the t.u.p.c. to verify a good seal and to observe the launching of the bell. On this day, as I stood by for launch I was confounded to see the supervisor race from the control van to the bell to a point where I could no longer see him. Hot on his heels were the LST's and the outside tenders. I called out to topside to ask what was going on but received no reply. After what seemed an eternity, the Supervisor came over the radio, out of breath and thoroughly frightened. He informed me the divers were returning to the living chamber and I was to check them over.

Several minutes later I understood why. The bell has four hatches, two open outward, two inward. Hatches one and two are located on the side of the bell and hatches three and four on the bottom. Between three and four is another "trunking space" that the diver must pass thru to enter the water. The bell is sent to bottom with hatch three open and tied back. As the bell enters the water and descends, the divers observe hatch four to insure it seals. Prior to launch, hatch three is closed. This hatch utilized a quarter turn valve to allow pressure equalization of the trunking space with internal bell pressure. As the divers entered the bell to make the dive, one of them unknowingly kicked open this valve, allowing bell atmosphere to escape prematurely into the trunking space. In effect, the bell was now rapidly ascending, and no one knew why. Outside the bell, people were scrambling all over in a desperate attempt to isolate the leak: inside the bell, the bellman was systematically closing all valves in sequence as per protocol for such an emergency. In the protocol, hatch three equalization valve is the second to the last valve to be closed. The bell ascended 33.5 metres (110 feet) in just under one minute.

The Bell acended 33.5 metres (110 feet) in just under one minute.

The divers were shaken, stirred, but otherwise unharmed. For the moment. After a time the divers re-entered the bell and made an uneventful run. With the divers back in the living chamber, the bell was brought to surface and a rising stem type valve that could not be inadvertently kicked open replaced the quarter turn valve. We were now into our 23rd day of saturation and the weather had made a turn for the worse. An early winter storm was building and the entire vessel was battening down. At the height of the storm, the rig was being battered by waves reaching 21.3 metres (70 feet). The constant pounding of waves against the steel structure set the steel to singing, not unlike a high-tension wire in a windstorm. The sound was amplified in the chamber as the vibrations reverberated through the thick steel bulkhead. I lay in my bunk and tried to relax. While the rig did not heave to and fro like a conventional ship, it did rise and fall in a strange sort of dance as the giant heave compensators on the anchor windlasses paid out and recoiled wire with the passing of each mountainous wave. Every so often a monster wave would create a cacophony of torturous sound as it smashed into the hollow caissons. In those moments I waited breathless, convinced a caisson had collapsed from the pounding seas, anticipating the sickening list that would signal the end of days. On and on the storm raged and soon my mind was filled with dark images of disaster and death: for should the rig founder, I was surely doomed. Normal

Photo by North Woodsman

"On and on the storm raged and soon my mind was filled with dark images of disaster and death." 28

Photo by V. J. Matthew ascent from such depth took five and a half days. An emergency ascent would take three days. I knew the drill. Should the rig face imminent risk of sinking, we were to retreat to the bell, which would be lowered to bottom and abandoned. To survive, we had 24 hours of breathing gas, lung powered scrubbers, mummy-style sleeping bags and a transponder to signal our location. A rescue vessel would have to locate us, retrieve us and race us to shore to be mated up with a compatible decompression chamber before we asphyxiated, froze or otherwise expired.

Should the rig face imminent risk of sinking, we were to retreat to the bell, which would be lowered to bottom and abandoned. Just when I thought I was going to go stark raving nuts, I remembered what a buddy had told me he did in such circumstances. He called it VMC or "Vicious Mind Control." With all your mental powers, focus on the positive. Take yourself away from where you are and go somewhere nice.

Breathe slow and deep: concentrate. After five minutes of that I ordered up some sedatives and passed out for the remainder of the gale. I called it SSOSS or "Sedated Sleep of the Scared Stiff." At the conclusion of our 28th day in saturation we began our ascent to surface. Around 143.2 metres (470 feet), both divers exhibited signs and symptoms of bends. The procedure is to halt the ascent and decend to a depth of significant relief. The divers were then to breathe treatment gas (higher PO2) for specified periods by a builtin-breathing-system (BIBS) mask. After several treatment sessions the divers showed significant improvement, but not complete resolution of symptoms. It was decided to resume our ascent and continue close observation of the divers. On day 35 we emerged from our cocoon. The divers returned home for follow-up treatment. It was postulated that both divers formed bubbles during their unscheduled ascent in the bell. I continued to travel out to the 706 for the next two years as regular diving crew. More adventures followed. Why I remember a time when...

Photo by Dr Anke Fabian

Chamber Dives - A Critical Review

By Anke Fabian

Non-therapeutical “dry-dives” in a decompression chamber are frequently practiced at various diving depths all over the world. The dive may be for diagnostic reasons to evaluate equalisation problems, a need to evaluate fitness-to-dive in professional divers (for example fire brigade or police divers in Germany), for manned equipment testing, as a “nitrogen wash-out” for dive guides and instructors at the end of a diving season or as a “fun deep-dive” down to 50 metres framed by a dive medical seminar.

and responses with the goal to determine their tolerance to nitrogen narcosis. This depth is used as it is deeper than the recommended limit for sport divers by most diving associations and it is where nitrogen narcosis is normally experienced. A side benefit of this training is the practical illustration of Boyle’s Law (the principle that at a constant temperature the volume of a given mass of gas is inversely proportional to its pressure) through the compression of materials such as tennis balls, balloons or pieces of neoprene.

One of the approved goals of a fun deep-dive in a decompression chamber is to test an individual’s response under an increased nitrogen partial pressure where nitrogen narcosis (also called rapture of the deep) may occur. The range of symptoms caused by nitrogen narcosis is highly variable. As one of the symptoms may closely resemble those of alcohol intoxication, the dangers of experiencing it while being underwater are obvious. One way to test an individual’s nitrogen tolerance is a deep dive (up to 50 metres) in a chamber, performed under controlled conditions with medical supervision. It is meant to evaluate the individual’s reactions

It might appear that these tests and seminars could play a decisive role in the determination of diving safety and selfassessment underwater. However, the question arises: is the “dry chamber dive” comparable to the “wet water dive”, even when performed under the same physical conditions. The answer is no. The laws of physics are certainly equally valid in a dry dive but the nitrogen saturation during a chamber dive is not comparable with the nitrogen saturation underwater. First, no muscle movement is required while being comfortably seated in a chair. Maintaining a resting heart and breathing rate considerably reduce the nitrogen

uptake. Secondly, the higher temperature in a chamber reduces the solubility of nitrogen in the tissues (temperature dependency of the solubility coefficient, according to Henry’s law). Taking those facts into consideration, one can assume conversely, that if the smallest symptoms of nitrogen narcosis occur within controlled chamber conditions, they certainly will be pronounced under water. Therefore, a single successful deep dive in a decompression chamber is not a free-ticket to perform an equal dive in the open water nor should one imagine oneself safe. Additionally, our general body response for nitrogen bubbles varies from day to day depending on our hydration status, alcohol consumption, amount of sleep and countless other factors. The preconditions that can trigger decompression sickness or favour nitrogen narcosis under water vary day by day. Conversely that means if any symptoms of nitrogen narcosis occur readily in a chamber deep dive, one should certainly stay away from this depth in the open water. Fun deep-dives in a hyperbaric chamber are only feasible under strict safety measurements, with conservative dive profiles and an unrestricted fit-to-dive certificate. Also the diver should be over 18 years old. If one does not take it as a guarantee for any future safe 50-metre dive, one can actually learn a lot. Another issue is the “nitrogen washout” or “nitrogen clean-up”. It is performed in a decompression chamber by a “hyperbaric oxygen session or treatment”. It means a chamber dive with one to several cycles of 100% oxygen inhaled via a mask: usually between six and fifteen metres. The idea is to get rid of the residual nitrogen comparable with a late treatment for decompression sickness through hyperbaric oxygen therapy (HBOT). Keep in mind that

Photo by Dr Anke Fabian

Issue 8 | May 2016

the maximum oxygen depth (MOD) in a hyperbaric session does not refer strictly to the usual scuba diving recommendations as oxygen is used as a “medicament” and must only be applied under the strict supervision and attendance of a hyperbaric specialist. Application of 100% oxygen as a medicament comes with risk and the side effects do not justify the questionable benefits of a “nitrogen-washout” as a preventive measure in the absence of any decompression illness symptoms. The participants in a wash-out are usually dive guides and instructors with high residual nitrogen saturation but they are not suffering from decompression sickness nor are they hyperbaric patients. No diver needs a wash-out. Providing an HBOT for the purpose of a wash-out would be comparable to taking an antibiotic in the absence of an infection. Why should we put our diving staff in a chamber exposing them to risks rather than taking better care beforehand by reducing the in-water exposures to a reasonable level? To make them feel safer or to allow them to dive even more after the treatment? Chamber dives with oxygen (HBOT) are an effective method to cure various diseases and the only therapeutical measurement for decompression sickness and air embolism in divers. In addition, chamber dives are performed for diver’s training (according to strict guidelines), testing of dive or dive medical diagnostics, and investigations. If a diver wishes to take a chamber dive just for the experience, to overcome the fear of a decompression chamber or even just for the fun, it should be performed only to a shallow depth without oxygen. Using the chamber dive to wash-out nitrogen should no longer be acceptable and is incompatible with serious dive safety standards.

HUMAN FACTORS SKILLS

IN DIVING COURSE REVIEW by Gareth Lock

“I didn’t know the value of this course until I attended it. A comprehensive and thorough course, which was a real eye opener for human behaviour that could affect someone in the diving environment. I have learned many lessons, and hope to use them in my training and instruction.”

Steve Millard, AIDA Instructor Trainer

outcomes are not just applicable to diving, but have equal relevance to the participant’s personal and professional non-diving world too. This testimonial received two days after the course finished demonstrates this: “I received some information regarding my performance as part of a team, painful at the time, but accurate and valuable to me. Major problem at work with one of the contractors who had caused a major issue by disobeying what I had told him to do. Despite being incredibly angry inside, I managed to calm down and tell him that his lack of ability was no reason for ignoring the requirements of the job. He told me that he disagreed with me on the necessity of changing to read the live database, thus he implemented something else. Without the insights into teamwork gained on Monday and Tuesday, I would have ended up verbally abusing him.” - CS, PADI OSWI

Photo by Gareth Lock

Photo byk Ethan Daniels

The first official “Human Factors Skills in Diving” class took place at The Diver Medic’s classroom in London, 8 and 9 February 2016. The course attendees included Global Underwater Explorers’ (GUE’s) Technical Training Director Richard Walker, Scuba Schools International (SSI) Instructor Trainer Cat Braun, Association Internationale pour le Développement de ľApnée (AIDA) Instructor Trainers Rolf Wiberg and Steve Millard, and Chantelle Newman from The Diver Medic, along with five other divers and instructors from around the United Kingdom and Ireland. The goal was to expose them to a globally unique course to improve personal and team performance by teaching skills that have roots in high performing teams from civil and military aviation, healthcare, air traffic management, nuclear power and other high reliability and high-risk operations. As you can see based on where these courses originated, the positive

Issue 8 | May 2016

Photo by Gareth Lock

Photo by A. and I. Kruk

Photo by Gareth Lock Photo by Rich Carey

Photo by Elisei Shafer

Photo by Gareth Lock

Photo by Dudarev Mikhail

Photo by grafikfoto

Issue 8 | May 2016

The “Human Factors Skills in Diving” course ran over two days and was based around six key themes with four computer-based teamwork exercises used to reinforce and demonstrate the application of these themes. The themes are the same as the diagram in the last edition of The Diver Medic magazine: decision making, situational awareness, communications, teamwork, leadership and followership and performance shaping factors that include stress and fatigue. These themes have been developed over time from research into aviation pilot and crew performance (Crew Resource Management) and healthcare teams (Non-technical skills - NOTECHS) and are commonplace when looking to develop human performance within teams. Observing some of these skills directly can be hard, so behavioural marker schemes have been developed to allow observers and assessors a means by which the presence and effectiveness of these skills can be captured ready for the debrief. While there was a total of seven hours of theory delivered over the two days, the key learning didn’t happen during the simulated space missions but rather in the student-led reflective debriefs which happened afterwards. These used a specific positively-biased framework that looked at the individual’s contribution to the team along with what

the team could have done better for both the team as a whole, but also to support the individuals within the team. There is a very conscious effort to steer away from “negativebased” debrief points as these only leave the student focusing on what they did wrong, and don’t normally provide them with the means by which they can improve and aim for excellence in subsequent exercises. Teaching students to be reflective is essential if they are to continue debriefing their own diving after such a course. As identified during the familiarisation mission, GemaSim has been specifically developed to introduce information overload, uncertainty, ambiguity, stress and conflicts within the individuals and the team. Each mission setup consists of two laptops set up back-toback so the two users on one side cannot see the other two users’ screen. Each screen has an incomplete set of mission information or controls so the two laptop teams have to work together to solve problems in a time constrained and stress induced environment. The missions include 15 minutes of planning and 45 minutes of execution during which they have to navigate stars, planets, undertake popup and planned tasks. At the same time they must take into account the changes in routing caused by the dangers of space.

The key learning outcomes for the students were: • The tangible evidence that using structured briefs or communications such as checklists increased the performance of the team and the likelihood of a successful outcome. • The skills to be assertive which can sometimes be a real challenge when there is an authority gradient (implied or explicit). • To be clear in their communication so that the information only needed to be said once. • Demonstrate the value of a positively-biased reflective debrief as a way in which learning points can be delivered and then more easily applied to the next mission. Rather than focus on what not to do next time, look at what needs to be done, develop that and then make it happen. • Recognition that teams all have strengths and weaknesses, they all go through the same evolution process, and that to have an effective team, you have to have effective leadership.

The missions themselves are run against the clock and also against the other team using a scoring system that penalises incorrect decisions or mistakes. If only one team is

present, then the scores are against a running scoreboard from previous courses. Each course’s scores are logged (anonymously) and

over time this will provide tangible evidence to show improvement has happened within the course. However, teaching someone to pass a course is not enough: these skills need to be transferred to the diving, work or personal environment. To ensure that the goals the students set at the end of the course are sustained, a series of follow-up emails are sent out after course completion to reinforce the learning and to check on the progress of the “Human Factors Skills in Diving”. The final two emails will ask graduates what has changed in their own behaviours, and have they had any specific examples of the positive value of the course. Collecting evidence such as this is essential to show the wider diving population the value of undertaking this sort of training, either as a standalone course, or as something that the agencies may need to include in their instructor and diver development programmes. The three teams (two in this course plus one pilot class) all made massive improvements both in terms of the time taken to complete the mission (no one has yet to complete the first mission) and also the scores achieved.

be common place in the same way that “Crew Resource Management” and “Human Factors” is no longer a bolt-on in aviation, it is an integral part of it. Healthcare is learning and developing, but it still has some way to go. Indeed, I am involved in delivering training and coaching using the same GemaSim system to staff within Intensive Care Units. However, there is a key point that needs to be considered when looking at the development and delivery of such programmes. This programme is not a PowerPoint presentation or a course that can be delivered by eLearning methods. It requires face-to-face interaction in a controlled, stressful environment with teamwork, real-time communications, high workloads and time critical decisions that can be exercised, developed and debriefed in a reflective manner. Stress is required because we each have a finite resource of mental capacity. If the stress levels are low, then there is enough capacity to hold a “mask” up hiding true behaviours and traits, therefore true learning does not happen. However, if the stress levels rise, there isn’t enough capacity

Photo by Rich Carey Photo by dotshock

"commonplace " These skills should be

to operate and hold the mask up, causing the mask to drop: then the true behaviours come out. When things go wrong underwater, there may not be the capacity to hold the mask up, therefore we need to develop skills in a stressful environment.

While this article might appear to be a sales pitch for a specific course, it isn’t intended to be that way. After the course I was asked by one of the students if I would be happy to continue to deliver this course on my own, or would I be happier if these materials ended up in training organisations’ instructor and diver development programmes? My response? I am not precious about this: these skills should

Until there is a level of competency in these skills across the diving community, trying to conduct this training in an underwater or diving environment is going to be a challenge and the gains will not likely materialise. Therefore, while the course is aimed at divers, providing this instruction topside, with no diving, is essential.

Photo by alexkich

Photo byk Ethan Daniels

Improvements in scores ranged from 150425%. Interestingly enough, the team that made the greatest improvement in scores also had the least experienced team members when it came to teamwork and leadership when they started.

Photo by Dudarev Mikhail

Photo by Aaron Amat

Photo by Dudarev Mikhail

COURSE REVIEW by Steve Millard

Photo by

I wanted to share the great experience I had with the Diver Medic Technician course I attended that was run by Chantelle Newman. DAN Europe, at Code Blue Education, runs the Diver Medic Technician (DMT) course. It really teaches you to be prepared and gives you great confidence to control and deal with any diving related medical emergency. It is both theory and practical based.

I have wanted to improve my knowledge past this basic level for many years, therefore, when I found out there was a course running in Brentford, London with The Diver Medic, I just had to do it. The course prerequisites are: the student must be over 18 years of age, rescue diver certified (or equivalent) or have held a first aid at work certificate. They should also

hold at least a current EFR/ Basic Life Support (BLS)/First Aid Certification. This course was certainly a much higher level of knowledge than I have been exposed to before. The course was headed by Chantelle Newman. In South Africa Chantelle became the youngest female diver to be National Association of Underwater Instructors (NAUI) certified and qualified in 1985. She has brought together her passions for diving and medicine to increase diving safety awareness worldwide. She founded The Diver Medic Facebook Group and the magazine Diver Medic. She was only the second female to develop a Diver Medic Technician (DMT) Course accredited by the International Marine Contractors Association (IMCA) for commercial divers and DAN Europe for recreational divers, a course which Chantelle remains the only female able to teach. She is on the DAN Europe Training Committee, and is a regular speaker at the United Kingdom (UK) dive shows. Chantelle has recently been inaugurated into the Women Divers Hall of Fame 2016 and continues to work on projects related to dive safety and education.

Photo byk Ethan Daniels

My first aid background started with an emergency first aid course in 1991, I did several other first aid and lifesaving qualifications over the next few years and I became an examiner and instructor for first aid in 1993 through an Occupational Health consultancy. I have maintained some form of lifesaving and first aid qualification for nearly the entire 25 years since that first course and have held qualifications with the Royal Yachting Association (RYA), British Canoe Union (BCU), British Sub-Aqua Club (BSAC), Scuba Schools International (SSI), Emergency First Responder (EFR), Association Internationale pour le Développement de l’Apnée (AIDA) and several other notable agencies. In turn, I have also qualified hundreds of First Aiders and rescue trained staff myself.

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Photo by Chantelle Newman

Photo by Cara-Foto

Photo by Steve Millard

Issue 8 | May 2016

All of the staff used by Code Blue are industry professionals. This is important because this is not a course you want to do with amateurs. I have observed in certain areas of the diving industry a near desperation by some Instructors to try and make money from skills they have not actually mastered themselves. They simply sign off through an agency or scrape together a basic curriculum vitae (CV) of skills and pretend they are going to offer value for money. If their primary objective is short-term financial gain from skills they don’t even possess, then the outcome will be courses with little value no matter what they charge. Code Blue is one of the organisations that I deem are doing it correctly: they know their stuff and they are highly experienced in their field. My advice is to seek out operators of this calibre when trying to improve yourself, especially where safety is involved. The trainers were personable yet professional and knowledgeable. They put together a course that was hands on, fun and very educational too.

lung and stomach noises, test for pulse, blood pressure and it was hooked to a unit that could show deterioration or improvement depending on your actions. You could also perform normal CPR as you can do on standard dolls. It meant that the many real life scenarios we were given were very realistic giving a true benefit to the course. There was a mid-course test on the first Friday and then on the following Thursday we had a multiple-choice exam that we had to achieve at least 75% on in order to pass. On the last day we did a practical exam that we also needed to pass in order to get our certificate. The DMT course was put together for commercial divers working remotely, so that they could deal with diving emergencies. The perceived risks of commercial diving are higher, but in fact more incidents occur. The DMT is a ten day course and you receive the DAN Europe “DAN Recreational Diver Medical Technician” certification, which is valid for two years.

"I have observed in certain areas of the diving industry a near desperation by some Instructors to try and make money from skills they have not actually mastered themselves"

The first day of the course we were given a large Diver Medic manual to use during the course and the equipment used was exceptional. We were provided with numerous pieces of equipment and DVDs along with the manual. During the class, many of the provided items we needed to use, such as, needles, gloves and sutures were disposable. Although this must have cost a lot of money to put together, it is what they have chosen to do because quality is their main goal. The primary manikin was the best I have ever used in a course. You could inject it, listen to its

I would recommend this course to anyone wanting to further his or her first aid knowledge to an advanced level. I also would endorse this course for all teaching first aid instructors because knowing those next steps gives insight into what you should be doing to help a casualty. Scuba and Freedivers would benefit from this course so that they would be in a position to help fellow divers in an emergency. And I think career industry professionals should strongly consider taking this course, as they are regularly responsible for their students. I believe that this course will certainly save lives. Check out the new 5 day course Chantelle has created for Recreational divers in the USA called Field Diver Medic/First Responder course starting in August 2016 in Tampa and November Pre-DEMA. DAN Europe will be starting their new 5 day DAN Recreational Diver Medic course soon too. Contacts for the course: info@thedivermedic.com www.thedivermedic.com www.facebook.com/groups/thedivermedic

Photo byk Ethan Daniels

Two weeks prior to the course we were given several online DAN Europe self-study courses to review. It was a great refresher in oxygen first aid, automated electronic defibrillator (AED) use, hazardous marine life injuries, first aid, decompression theory and on-site neurological assessment. I really brushed up on my knowledge and learned new information before attending the course and that set me up for a good learning experience. In addition it also got me a couple of extra qualifications along the way too.

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Photo by Steve Millard

from left, Marco, Steve, Chantelle (Instructor), Milan, Neil, Anthony

Photo by Chrissy Taylor

Photo by Chantelle Newman

Issue 8 | May 2016

BRAYDEN EDITORIAL DIVER MEDIC

The Award Winning Brayden CPR Manikin is a highly innovative and effective way to teach CPR and enable students to learn the “how to” and “why to” in an intuitive and easy to understand manner. It is the first cost effective manikin to provide real time feedback of CPR performance with the additional capability of allowing users to visualise how CPR effects coronary and cerebral blood flows. This novel and innovative capability allows the Brayden manikin to occupy a unique position among other competitors currently available.

Photo by Innosonian Europe

Issue 8 | May 2016

(The Brayden manikin has three sets of interrelated LED lights that illuminate in direct relation to the depth and rate of compressions performed and these allow the quality of compressions to be assessed in an easy and intuitive way. The Brayden manikin is fully compliant with both the European Resuscitation Council (ERC) 2015 Guidelines and the American Heart Association (AHA) 2015 Guidelines. Dr. Carl Gwinnutt, Emeritus Consultant, Salford Royal Hospitals NHS Foundation Trust said: “The ERC 2015 Guidelines for Resuscitation identify the usefulness of feedback from devices during CPR training as a way of improving trainees’ skill acquisition and retention. The Brayden manikin achieves this in an innovative and effective way and allows trainers to assess objectively whether chest compressions are being delivered in accordance with recommendations, rather than simply relying on making a subjective estimation” Being able to see how CPR is having a direct effect on the flow of oxygenated blood to the brain, reinforced with an audible clicker if required, increases the speed at which skills can be both learned and retained. This helps increase the confidence and competence in performing CPR when required. As a result, the Brayden manikin is now held in high regard by leading key opinion leaders in Resuscitation. Professor Douglas Chamberlain, prominent cardiologist and founder of paramedics in Europe, said: “This training manikin is a useful addition to those currently available. The light effects to show likely sufficient coronary and cerebral flows is novel and will be an effective stimulus for improving the quality of compressions” Dr. Pascal Cassan, Head of the International Federation of Red Cross and Red Crescent Societies said: “The Brayden CPR training manikin is a new tool which helps improve the comprehension of

the effects of cardio-cerebral resuscitation and facilitates the evaluation of the quality of chest compressions”. The Brayden manikin was designed and developed by a team of innovative young engineers at Innosonian Inc. It is exciting times for this young and dynamic organisation and the growth in sales of the manikin across the world has been impressive. Demand in Europe has necessitated the recent creation of a local subsidiary, Innosonian Europe. This new company will help the European distribution network grow and will be able to give additional support to end users and distributors alike. Dr. Jonathan Smart has recently joined Innosonian Europe and said: “I have been in the European resuscitation business for many years and continue to act as a voluntary First Responder for my local UK NHS Ambulance Service. This experience has taught me why good quality CPR is essential for maximizing the survival of cardiac arrest patients. The Brayden manikin is an excellent and cost effective new addition to help improve CPR skills and thereby improve patient survival. Being a new, small and nimble organization, Innosonian Europe are able to listen to the needs of the market and quickly introduce change when required. We have done this recently to further improve feedback of compression and ventilation performance and make the Brayden manikin fully compliant with the 2015 ERC and AHA Guidelines. I look forward to continue to work with the resuscitation community and our Distributor partners to enable us, together, to develop even more exciting new products to help improve patient survival and outcomes”. There are at present two models of Brayden manikin available: the Brayden Advanced with LED lights and the Brayden Basic with no LED lights. In the Advanced model there are two choices of LED colour: red or white. The functionality of the lights is the same: the colour choice is simply down to individual preference.

Photo by Innosonian Europe

Issue 8 | May 2016

Photo by Innosonian Europe The Brayden manikin looks and feels realistic and is anatomically correct, giving people a better understanding of what to expect when performing CPR. Students are able to perform basic upper airway management functions. Expired air is filtered and expelled from the back of the manikin to improve hygiene. The latex free skin is compliant with ROSCH and REACH regulatory requirements. It is easy to clean and defibrillator pads can be removed quickly and easily without leaving a sticky residue. The Brayden manikin is durable as well as cost-effective. Built to last, with few moving or replaceable parts, it has been tested to endure in excess of 1,000,000 compressions. It can also be either battery powered or mains operated. A set of batteries will last for 160,000 compressions. James Crawley, a Team Leader of a large UK Ambulance Community First Responder (CFR) group recently said: “Our remit is to train members of the public in basic life support, CPR and AED use. Traditionally we have used “Anne” manikins but when the Brayden manikin was launched we decided to try it out because it represented much better value for money. When it arrived the first thing we noticed was the quality of construction and the mechanical mechanisms which were extremely good. When we started using it fully with the lights switched on, we thought the visual feedback offered by the Brayden manikin was excellent and made it really easy to explain CPR to “lay people”. Everyone we have trained using the new Brayden manikin

has loved working with it, and it has significantly enhanced the value of the training we can give – so much so that we have now purchased 5 Brayden’s for when we run our larger training sessions and also recommended it to our fellow CFR groups in the area. This simple to use product is great to use, a significant enhancement on any other product on the market, easy to maintain and is very competitively priced without compromising on quality or function”. We believe that the Brayden manikin is a new class of CPR manikin. It is highly intuitive and provides real time visual feedback of the key parameters of CPR performance but at a price which most training organisations can afford. It requires no other piece of additional equipment so is quick and easy to set up and use. Within seconds of using the Brayden manikin, a user can quickly become competent at performing good quality compressions and ventilations. Students can quickly see and understand exactly what they are doing which helps improve knowledge retention. To find out how you can get your “hands on” a Brayden manikin, please contact: enquiries@innosonian.eu or visit www.innosonian.eu or follow Brayden on: Twitter: https://twitter.com/BraydenManikin Facebook: https://www.facebook.com/ braydenCPRmanikin

Photo by Innosonian Europe

Issue 8 | May 2016

The International Board of Undersea Medicine (IBUM) offers hyperbaric chamber operators, diving medical technicians, clinical hyperbaric technicians, and hyperbaric physicians training as well as educates and increases safety for those who work in the hyperbaric field including certifications to the highest international standard for hyperbaric facilities. We are Hyperbarics, Chamber Certification and Diving Research...Simplified! This is the IBUM Journal. It consists of peer reviewed scientific papers which are referenced and note studies and research performed. www.ibum.org

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In-Water Recompression Consensus Statement and Guidelines by Joseph Dituri M.S.CDR, US Navy Saturation Diving Officer (ret)

On April 28-29 2014 in San Diego, California, a group of noted dive industry professionals met to discuss the topic of In-Water Recompression (IWR) with the intent of polling industry leading physicians and divers in the use and practice of IWR. The panel consisted of Richard Sadler, M.D., FACS, CDR; Joseph Dituri USN (ret), M.S.; Simon Mitchell, MB ChB, PhD, FANZCA; Craig Jenni, JD; Richard Moon, MD, CM, MSc, FRCP(C), FACP, FCCP; and Richard Pyle, PhD. The following is a consensus statement and list of guidelines that came from the invited speakers and the input of dive industry professionals. A consensus statement is a recommendation or general guidelines developed using available evidence and expert opinion in areas where high quality clinical data is limited or does not exist for controversial clinical dilemmas. These guidelines are systematically developed recommendations that assist the practitioner and diver in making decisions. These recommendations may be adopted, modified, or rejected according to needs and constraints and are not intended to replace local institutional policies. They are NOT to be considered a standard or “best practice” for emergency response of decompression illness (DCI). Their use cannot guarantee any specific outcome. These guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They represent basic recommendations that are supported by a synthesis and analysis of the current literature, expert opinion, and open forum commentary combined with any existing data. These statements represent the opinion, beliefs and best judgments of the aforementioned subject matter experts. As such, they are not necessarily subjected to the same level of formal scientific review as standards. Each person, institution or practice should decide individually whether to implement the principles in this statement based on a careful evaluation of risk versus benefit, and on the sound judgment of the participants involved situation at that time. Statements: • The definitive emergency response of DCI continues to be a combination of pressure and oxygen in high concentrations. • Oxygen and pressure are preferred over surface oxygen alone in the emergency response of DCI. • It is determined that IWR is a viable methodology for first aid (an intermediate step) prior to definitive emergency response of DCI. • Immediacy of emergency response with oxygen and pressure may be fundamental to effect optimal outcomes in selected symptomatic divers. • The intrinsic advantage of immediacy in IWR surpasses the potential risks for appropriately selected symptomatic divers. • IWR has potential for improving outcomes in those divers with symptoms that have rapid onset and a poor prognosis. • IWR is rarely a complete and sole emergency response for DCI. All symptomatic divers of DCI shall, if they opt for IWR, be evaluated by a physician knowledgeable in diving and hyperbaric medicine as soon as possible following IWR. Recommendations for implementation of IWR: • During IWR the diver must be accompanied by a tender. • The effectiveness of IWR will be lessened if the diver becomes cold, therefore, maintenance of optimal thermal comfort is important. • Indications: While acknowledging the potential benefits of IWR, the potential risks of IWR limits its applications to those divers with symptoms associated with poor outcomes (Appendix I: Tier System) and severe pain.

• Emergency response time should extend 60 minutes after the resolution of symptoms and the total emergency response time must NOT exceed 120 minutes at depth. • The emergency response protocol should be terminated at any time if deemed necessary by either the tender or diver/ symptomatic diver. • The breathing mixture should be as close as possible to 100% oxygen (with the goal of achieving a PO2 [partial pressure of oxygen] of 1.6 bar/atm): mixtures containing less than a minimum FiO2 (fraction of inspired oxygen) of 0.80 (80% inspired oxygen concentration) should not be used for IWR. • Emergency response depth should not exceed 6 metres (20 feet), even if the breathing mixture contains less than 100% oxygen. • Periods of breathing air (“air breaks”) are not required due to additional complexity. • The planned ascent rate should be 0.3 metres (1foot)/minute if possible. • In the event of an emergency (such as loss of consciousness in the treated diver) a rapid ascent should be made to the surface. If the diver is convulsing and the mouthpiece is retained, (for example, during use of a retaining strap or if a full face mask is used) ascent should be delayed until the seizure has stopped. If the mouthpiece is not retained, an ascent should be made immediately, even if the convulsion continues. • If symptoms return during ascent from the planned IWR, the diver may return back to 6 metres (20 feet) if the total time at 6 metres (20 feet) has not yet exceeded 120 minutes. • After exiting the water following IWR, the symptomatic diver must not re-enter the water even if symptoms recur. • Mild activity (for example, gentle finning movement) is acceptable and encouraged during IWR. • For severe DCI (for example, paralysis), judgment will be required to weigh the benefits of quicker IWR with short delay to evacuation versus immediate evacuation to a hyperbaric facility that may be many hours away. Consultation with an offsite diving medical expert is recommended. Practical and logistical considerations for equipment: • Pre-emergency response informed consent of all potential IWR participants should ideally be obtained. In order to facilitate this, a webinar or video on line should be used where IWR is explained and a standard waiver is signed. Trained IWR divers should practice IWR regularly in order to maintain proficiency. • A regulator retention (gag) strap is strongly recommended to hold the regulator in place in the unlikely event of an oxygen seizure. (Appendix II: Airway Protection) • The use of a full face mask is recommended for trained users. Significant caution is advised for the untrained user. (Appendix II: Airway Protection) • While rebreathers are recognized as a potential tool for administration of oxygen during IWR, their use in IWR by divers untrained in their use should only be attempted under expert supervision. • The symptomatic diver’s depth should be controlled by the use of a stable reference line. • Control of the diver/symptomatic diver and in water tender should follow the principles outlined in the sidebar. • A community database of IWR incidents and outcomes will be maintained by Duke University (http://dukedivemedicine.org/) for Gallant Aquatic Ventures International and the general public. This information will be shared freely with all interested parties.

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The group determined the most important information required during assessment of an injured diver and IWR is a timeline or chronology of events, along with key relevant data describing the symptomatic diver and circumstances of the incident. The following information should be captured: 1. Age 2. Race 3. Gender 4. Symptomatic diver’s training level (recreational/technical/none) 5. Dive profile/breathing gas(es) 6. Time of symptom onset 7. Order of symptom progression 8. Time of symptom resolution 9. Surface oxygen use and duration 10. IWR protocol/complications, temperature/thermal protection 11. Free narrative space 12. Outcome/degree of recovery (complete/partial/none) and whether diver was referred for evaluation, hyperbaric emergency response, and others 13. Name and contact information of reporting individual Diver control Principles: 1. Some form of positive contact with the diver/symptomatic diver is mandatory. The diver/symptomatic diver must never be un-tethered. Examples of Positive Control: a. Diver/symptomatic diver is connected to the down line with a separate line. b. Diver/symptomatic diver is tethered to the accompanying diver with a line. c. The use of a quick release (snap) shackle in either case is reasonable. 2. The surface support team and tender should be prepared for a sudden deterioration of the diver/symptomatic diver. 3. If reasonably foreseeable adverse conditions cannot be mitigated, the IWR protocol should be terminated. Appendix I: Tier System Tier I Common non-specific symptoms that may not be DCI and do not represent a significant threat. Lethargy Nausea Headache Tier II Symptoms and signs that are likely to be DCI but which are not likely to result in neither permanent injury nor death. Lymphatic obstruction (swelling under the skin) Musculoskeletal pain (Note: Pain arising in the hip [especially both hips at once], abdomen or spine may be referred from spinal cord involvement. Be particularly alert for progression to Tier III symptoms in these patients). Rash (May vary from fine red rash to blotchy bruised appearance, and may be itchy or sore. The rash is often localized to one body area, but may be more generalized). Subjective sensory changes (Altered skin sensation and “tingling”)

Tier III Symptoms and signs that are likely to be DCI (or arterial gas embolism) and that indicate a risk of permanent injury or death. Changes in consciousness or obvious confusion Difficulty with speech Walking or balance disturbance Sensory loss (such as numbness) that is obvious to the diver or examiner Weakness or paralysis of limbs that is obvious to the diver or examiner Bladder dysfunction (inability to pass urine) Sphincter (bowel) dysfunction Loss of coordination or control in the limbs Shortness of breath NOTE: This classification of DCI symptoms and signs is intended to aid selection of subjects for IWR. It is not intended as a guide to selection of divers for referral to definitive care. To be clear, all divers with symptoms in any of the tiers should be discussed with a diving medicine expert as soon as possible. Appendix II: Airway Protection Protection of the symptomatic diver’s airway is of paramount importance. The workshop consensus recommendation of a maximum oxygen partial pressure of 1.6 bar/atm minimizes but does NOT REMOVE the risk of seizure. The consequences of aspiration underwater are potentially life threatening. Options to mitigate this risk of aspiration are discussed herein. All previous IWR protocols require or strongly advocate the use of a full face mask (FFM), primarily to mitigate the consequences of a hyperoxia-induced seizure underwater. These previous protocols also incorporate breathing near 100% oxygen at depths in excess of 6 metres (20 feet), where the inspired oxygen partial pressure is in excess of 1.6 bar/atm. As advantageous as a FFM may be in the event of a seizure underwater (for reducing the probability of drowning), the use of a FFM also imposes some difficulty (and risk) for divers who are not trained in their use: particularly in terms of diver comfort level, proper fit and sealing,and (depending on the specific style of mask) techniques for clearing water from the mask and performing the Valsalva maneuver. In the context of these recommendations, a maximum depth of 6 metres (20 feet) is advocated for IWR (a depth at which near 100% oxygen is commonly breathed by technical divers for decompression). At 6 metres (20 feet), the incidence of hyperoxia induced seizure is extremely low and the potential net benefits of using a FFM depend on the degree of training and familiarity the afflicted diver already has with this equipment prior to attempting IWR. Therefore, a “gag strap” is recommended in cases where the symptomatic diver is not already trained in the proper use of a FFM, or when a FFM is not available. The purpose of the gag strap is the same as the full face mask, to prevent loss of the mouthpiece/gas supply and to provide a degree of airway protection in the event of loss of consciousness. Although more controversial than a full face mask for this purpose, the gag strap is arguably supported by data. Gemp et al[1] reported 54 underwater loss of consciousness events in military divers leading to only three fatal drownings. In this series there were 26 cases of central nervous system (CNS) oxygen toxicity with seizures, with an 11.5% major complication rate: two deaths (caught under a barge) and one non-fatal moderate water aspiration. The use of the Drager-style gag strap with strap and lip sealing flange was used in all cases. Although this is an uncontrolled series, and notwithstanding the potential for other factors to influence outcome in the military setting, the unexpectedly high survival following these events suggests that gag straps are effective in most cases. Improvisation of gag straps by divers is not encouraged.

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However, a recent informal survey of a few manufacturers by a former US Navy diver revealed a lack of familiarity with a regulator retention strap save for the ones that are available for specific rebreathers. It, therefore, does not appear that a purpose-built, commercially manufactured regulator retention strap would be readily available to divers, possibly encouraging improvisation, with mixed results. It has also been suggested that involuntary contraction of the masseter muscles during a grand mal seizure could result in damage to the mouthpiece, possibly leaving fragments in the mouth or causing a leak. It must be noted that this study involved the use of the Drager gag strap, which has several important design features that probably enhance efficacy. Similar straps can be purchased and are recommended. Full Face Mask: This is the traditional “best practice”. Advantages include: 1. The airway is maximally protected (not perfectly) from ambient water in the event of a seizure. 2. Should a seizure occur, the tender has more options for a controlled ascent. 3. Allows for communication with the symptomatic diver if appropriately wired. 4. Adds additional thermal protection. 5. Lessens jaw fatigue by not requiring a mouthpiece. Disadvantages include: 1. Minimum cost of approximately 500-750 USD. 2. It may not be an adequate fit to the symptomatic diver’s face. 3. Optimal safe use requires training, including techniques on clearing, purging, and adjusting the usual five point strap system. 4. Vomitus may be difficult to clear, creating a second risk of aspiration. 5. The FFM may not be suitable for use with a rebreather. Judgment should be used when making the decision to use a Full Face Mask. Regulator Retention Strap (“Gag Strap”) This consists of a strap around the head/neck attached to the second stage regulator and a rubberized flexible flange around the mouth, preventing loss of regulator and a barrier to water in the event of seizure. Advantages include: 1. Costs less than a FFM, with an estimate of less than 100 USD. 2. Requires minimal training. 3. Quick to set up and implement. 4. Reduces jaw fatigue during long dives. 5. Acceptable effectiveness. (A published report [Gemp] demonstrated three deaths from 54 seizures). Disadvantages include: 1. Not as protective of the airway as a FFM. 2. Properly designed devices are not widely available. [1] Gempp E, Louge P, Blatteau J-E, Hugon M. Descriptive epidemiology of 153 diving injuries with rebreathers among French military divers 1979-2009. Mil Med 2011;176:446-450

Richard Sadler M.D. FACS Selected Readings in Human Factors Science Part 2 - Accidents and Cognitive Processes

In Part 1 of this series, we explored the various theoretical frameworks of Human Factors psychology in accidents. The predominant taxonomy proposed by the Human Factors Analysis and Classification Systems (HFACS) will be used to organize the material. Most of these papers demonstrate failures at multiple levels, but each demonstrates an especially good example within its subgroup. Part 2, Accidents and Cognitive Processes, will focus on actual failures in order to understand both what and how operators were thinking. Examples from aviation, surgery, diving and military accidents will be examined. The crucial point is to understand that Human Factors failures and potential solutions are present in many domains. 1. Organizational Influences: Subgroups; Management, Climate and Process Space Shuttles Challenger (STS 51L) and Columbia (107) Rogers Commission (June 6, 1986). “Report of the Presidential Commission on the Space Shuttle Challenger Accident. Columbia Accident Investigation Board NASA.gov 2003. Although the facts and lessons of the shuttle accidents have been previously reviewed in depth, a quick review is still relevant for this discussion. Challenger was most notable for the failed “O-ring”, causing the explosion. But the concept of “normalization of deviance” will forever be linked to the Challenger. Acceptance of unsafe parameters that becomes normalized procedure will ultimately result in failure. To quote consulting physicist Richard Feynman, “For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.” The poor communications, group decision-making, and the dangers of groupthink (discussed in part by Andy Davis in issue number 7) are all examples of “organizational influences” as discussed in Part 1. It is part of the required readings for engineers seeking a professional license in Canada and other countries. Columbia demonstrated a different type of poor “organizational influences”. After sustaining wing damage from broken heat tile, NASA declined to use Department of Defense resources to evaluate the damage. The CAIB could not determine if the damage was repairable. However, the failure to assess that damage, much less attempt repair is an example of organizational complacency and arrogance.

2. Unsafe Supervision: Subgroups; Inadequate, Inappropriate, Failure to Correct and Violations. The human factor in cardiac surgery: errors and near misses in a high technology medical domain  Jane Carthey, Marc R. de Leval and James T. Reason Ann Thorac Surg 2001;72:300-305. Human factors research in cardiac surgery: opportunities and pitfalls Jane Carthey, Marc R. De Leval, James T. Reason, Vernon T. Farewell and David J. Wright Clinical Risk 2001 7:85.  Two papers from the domain of cardiac surgery are highly recommended. Complex, multi-step heart operations that have little margin for technical or procedural error are excellent examples of endeavors that have multiple failure points, much like closed circuit diving. The studies show the number of errors committed by different operating teams was about equal. However, the difference between the best and worst performing teams in terms of mortality and outcome show that superior results are correlated with the ability to “rescue”. That is, to recognize a real or potential threat, and take the appropriate corrective action sooner. The lower performing teams demonstrated Inadequate Supervision and Failure to Correct Problem. To be clear, the inadequate supervision does NOT refer to personnel management. Instead, it is failure to supervise your team’s actions. The ability to correct a problem early in the failure cascade is the mark of superior performers in any domain.

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3. Preconditions for Unsafe Acts: Subgroups; Substandard Conditions and Practices of Operators Normal people working in normal organizations with normal equipment: System safety and cognition in a midair collision Paulo Victor Rodrigues de Carvalho, Jose Orlando Gomes, Gilbert Jacob Huber, Mario Cesar Vidal, Applied Ergonomics 40 (2009) 325–340. In 2006, a Brazilian 737 GLO 1907 and an Embraer Legacy Jet 600XL collided head on in clear skies, resulting in the loss of the 737 and all souls. This is an example of Reason’s “Swiss cheese” model in the extreme. Normal Air Traffic Management routines were followed, all crews were optimal, and there was no emergency, equipment failure nor inclement weather. There were at least an additional seven layers (slices of cheese) of procedures designed as “fail safe” to keep traffic separated. In short, the TCAS (Traffic Collision Avoidance System) in 600XL placed itself in standby mode. However, there is no audible alarm for this, and the visual indicator is difficult to perceive on the display. Since the aircraft were in an area of limited radio communication, no one operator was aware of the entire picture. Thus, in spite of multiple layers of modern technology and procedural redundancy, the accident occurred. This accident emerges as a complex phenomenon within the normal variability of the system functioning. “This accident and accidents in other safety-critical systems have complex patterns of emergence, where coincidences, unexpected links, and resonance, substitute the old bullets such as equipment failure probability, linear combinations of failures, human errors, and so forth.” In short, this is an example of both Substandard Conditions of Operators and Substandard Practice of Operators. Human Factors Report on the Tenerife Accident; ALPA Study Group Roisch, Babcock, Edmunds 1978. On Sunday, March 27, 1977, at Los Rodeos Airport (now Tenerife North Airport), a Dutch KLM 4805 (747) and Pan Am 1736 (747) collided on the runway, resulting in the deadliest airline crash in history. Ultimately, it was determined that the senior KLM pilot started takeoff in low visibility, being unaware of the Pan Am 747 crossing the runway in the fog, resulting in collision. However, it was determined that the KLM pilot believed he had a valid clearance. This error was enabled by environmental preconditions, organizational influences, and language barriers confusing cockpit communications. This exemplifies the Substandard Practice of Operators. It is the root source of the “crew resource management” skills being used today. The current iteration of CRM is 6th generation, and is known as Threat and Error Management. These factors in combination set the stage for the critical error of starting takeoff without safe and definitive clearance. Lieberman HR, Bathalon GP, Falco CM, Morgan III CA, Niro PJ, Tharion. The fog of war: decrements in cognitive performance and mood associated with combat-like stress. Aviat Space Environ Med 2005; 76(7, Suppl.): C7–14. In a study of SEAL candidates and US Army Ranger candidates, both groups demonstrate the severe degradation of cognitive abilities with the known stressors of sleep deprivation, hunger, cold stress, and the psychological stress (nowin challenges) of a Hell Week scenario. These decrements exceed those of alcohol intoxication, and are only somewhat mitigated by previous training. Most importantly, these decrements are apparent on Day 1, strongly suggesting Adverse Physiologic States and Mental Limitations are always a potential factor. This reinforces the need to closely examine diver readiness on a daily basis. Errors in the heat of battle: taking a closer look at shared cognition breakdowns through teamwork; Wilson, Salas, Priest, Andrews. University of Central Florida and the USAF Research Laboratory, Mesa, AZ, Human Factors, April 2007.

Demonstrated in the “Fog of War”(above), physiological stressors degrade effective decision-making. This paper analyses the events that led to the fratricide of Pat Tillman, NFL star and US Army Ranger, in Afghanistan. The number of potential failure points is sobering, but solutions can be had with awareness. The best teams excel in communication, coordination and cooperation and their subsets, with striking similarity from the domains of surgery and aviation. Both of these examples of combat stress demonstrate the Substandard Condition of Operators. Most interestingly, the strengths of the best teams in elite forces and in cardiac surgery all demonstrate team familiarity, cohesiveness stability. Human Factors and Operating Room Safety, El Baridissi

4. Unsafe Acts: Subgroups: Decision, Skill and Perceptual Errors, routine and Exceptional Violations A Pre-dive Check; An evaluation of a Safety Procedure in Recreational Diving: Part 1 Chris Acott SPUMS Journal Vol 25, No. 2 1995 The above (Acott) from the civilian diving domain should disabuse one of the notion that simple recreational diving is immune from the failure modes seen in surgery, aviation and military diving domains. This study asked 55 certified recreational divers to evaluate equipment for “readiness” to dive. The equipment was set up with nine errors. Only two divers identified all the faults, four divers detected eight faults and, most alarmingly, four divers failed to detect any fault. These divers were volunteers selected at a diving equipment show, thus presumably motivated. Yet these results demonstrate glaring Skill and Perceptual Errors. The non-technical causes of diving accidents: Can U.S. Navy divers learn from other industries? O’Connor P, UHM 2007, Vol 34, No. 1 Pgs 51-59. This paper by O’Connor looks at US Navy diving by conducting Critical Incident Interviews from Navy divers. The most common Failures were leadership and situational awareness, particularly in risk and time assessment. The patterns of failure are the same, regardless as to whether or not the incident was a near miss, injury or fatality. Specific faults were complacency, fatigue and inexperience. O’Connor notes that this is also seen in civilian accidents, with inexperience and lack of training being operant.

Summary: The domains of surgery, aviation, combat, military and civilian diving all have common Human Factors failures. Relevant lessons include: 1. Complex (tightly coupled) systems (e.g. Space flight, heart surgery, CCR (re-breather diving), exhibit multiple failure points, where any single event may not prove catastrophic, but the cumulative effects can be disastrous. This “failure cascade” is recognized and corrected sooner by the superior operators and teams. The NOTECHS (Non-Technical Skills) or soft skills to achieve this superior result will be discussed in Part 3. 2. Effective teamwork depends on a complex interaction (e.g. “Errors in the heat of battle”) of organizational influences and human traits. Ineffective teamwork results in a loss of shared cognition, diminished confidence and poor decision making. 3. Complacency, lack of training, fatigue and stress are routinely demonstrated in both military and civilian diving accidents. Part 3, Countermeasures, will give examples and discuss techniques developed to prevent these Human Factors failures. We will show that the behavioral markers of excellence include commitment, self-belief, positive imagery, mental readiness, full focus, controlling distractions and constructive evaluation (i.e. learning from previous events).