Diver Medic and Aquatic Safety Mag Issue 2

DIVER ISSUE 2

By Rolf Wiberg

Buoy Diving

By Nathalie Bock

Diving by the Book

By John Bantin

&nd AQUATIC SAFETY

are

you

aware?

Freediving Safety

MEDIC

drink

dive

ISSUE 02 | NOVEMBER 2014

A note from the Editor Diving your limits and beyond Why do some divers try to push their limits? I’m sure you have heard this many times before. There have been, to date, 101 deaths at the Blue Hole on the coast of the Red Sea, North of Dahab. A total of 100 men and one woman have lost their lives at this venue. The Blue Hole is also known as the Divers' Graveyard, graphically portrayed by Monty Halls and his team on Channel 5 TV in the UK. However, limits are not only pushed in the Blue Hole, and deaths do not only occur in the Blue Hole. Take Thomas Canyon (front cover) located in the straights of Tiran in Egypt as another example.

Thomas Canyon is one of the finest dives in the northern Red Sea, typically finest for Trimix Divers. The canyon itself is quite narrow with three arches, the first is at 45 metre, and the second is at 65 metre depth. As you pass under the second arch, the canyon opens out into a large void; as you continue descending the canyon drops to around 100m.

This dive should just be done by experienced technical divers, as decompression stops can be very difficult with the strong currents.

So why do recreational divers push their limits knowing full well this dive should be done just by technical divers?

Thomas Canyon too has had its fair share of deaths, again due to lack of training and divers going beyond their skill limits.

How do we stop divers going beyond their limits and training competence? I do not think we can, as we will always have the rule benders and incompetent chancers. However, let’s continue to promote safe diving practices and do what we can to help people understand the risks of pushing beyond their limitations.

Dive Safe Always!

Chantelle Newman Editor in Chief

ISSUE 02 | NOVEMBER 2014

Editor-in-Chief Chantelle Newman

Editor

6

Diving Deaths... What can we do?

By Mark Powell

Elsibe Loubser McGuffog

Are you Prepared?

TECHNICAL Editor

by Chantelle Newman and Dr George Schroeder

Andrea Zaferes

DESIGNERS Allie Crawford, Sarah Crawford

Advertising and Subscriptions Chrissie Taylor

chief Medical EDITOR George Schroeder MD www.Oceanicrenaissance.vpweb.com

Contributors Thank you to the following contributors: John Newman, Kelly Ann Moon, Ryan Crawford-SUUNTO, Butch Hendrick, Rod Hancock, Mark Powell, DAN Europe, Rolf Wiburg, Natalie Bock, Judy Schroeder, Claire Gwinnett, Laura Walton-Williams, Dr Suzanne Gaskell, John Bantin, TeamLgs, Dr Anke Fabian, Ron Edely, Jason Brown, Gareth Lock, Trish Skywalker

PHOTOGRAPHERS Matej Kastelic, LukaTDB, Gareth Lock, feel4nature, sfam photo, Richard Whitcombe, John Bantin, Antonio Gravante, Claudio Dias, jannoon028, Kevin J King, Donsimon, Wen-ho Yang, Nejron Photo, Andrey Yurlov, Jovana Milanko, Paul Cowell, Xavier Marchant, Zlikovec, Marisa Estivill, Filipe Frazao, Tachjang, Kichigin, Hong Xia, Photographee.eu, Yiorgos GR, Mark Powell, Takasu, 1000 Words / Shutterstock.com, Ketmanee, Dirk Ercken, Vadim Ratniko, Kokhanchikov, Ken Durden, Pat Hastings

Magazine address The Diver Medic Ltd Great West House, Great West Road, Brentford, TW8 9DF

Telephone +44 020 8326 5685 EMAIL info@dmaasm.com www.dmaasm.com

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12

Freediving Safety

By Rolf Wiberg

24

Buoy Diving

By Nathalie Bock

32

Air Embolism Emergencies

By Dr George Schroeder et al.

Where have all the divers gone?

38

By Walt 'Butch' Hendrick

46

Forensic Underwater Crime Scene Investigation Q&A

52

Are you drink-dive aware?

By Dr Suzanne Gaskell

56

Diving by the Book

By John Bantin

A Tragic Accident or Homicidal Drowning?

66

62

A Very Special Case

By Dr Anke Fabian

DIVER MEDIC & AQUATIC SAFETY

Diving

Deaths...

What can we do?

By Mark Powell 6

During a two-week period at the end of August and the start of September, six diving-related fatalities were reported in the UK. This caused significant discussion on social media sites. Why is there such a high number? Why was 2014 such a bad year? What was the cause? What can we do about it? In this article, I will attempt to answer some of these questions, although the answers may not be the ones that you would expect.

The first questions to address are why there were so many fatalities in this two-week period? And why is this year so bad for fatalities? It was the six fatalities in a two-week period at the end of August and beginning of September that generated the interest but the actual situation is, apparently, even worse. These six fatalities came after five in June and another five in July. A total of six fatalities involved five in the last week of August and one in the first week of September. This meant that there were five fatalities in each of June, July and August. Before we do anything else it is important to check that the assumptions within the questions we have asked are actually true. Is it unusual for there to be six fatalities within a two-week period and is 2014 an unusually bad year? For UK diving fatalities, we are fortunate that BSAC has published an annual incident report since 1965 and maintains a database of incidents since 1998, so we have good data on UK diving fatalities going back to 1998.

There were five fatalities in April 2001 followed by six in May. There were another six in June 2004.

There were five fatalities in August 2009, April 2010 and also May 2013. So it appears that this number of fatalities in a short period of time is unusual but far from unique. On the other hand, having three consecutively bad months is unusual and since 2000 the highest level of fatalities in a three-month period has been eleven in March-May 2001 and then ten in May-Jul 2004. In both cases, these periods occurred in years with higher than the average number of fatalities.

With 15 fatalities in a three-month period, it would indicate that this year is likely to be a very bad year. Fatality numbers for 2014 give a total of 16, which are almost exactly the same as the average number of 15 for each year over the last 14 years.

The reason for this is that although there were five fatalities in June, July and August and another in September there have been no other fatalities in the rest of the 2014 reporting period.

Until the start of June, 2014 has been an incredibly good year with no fatalities at all. At the start of June, we would have said that 2014 was shaping up to be a very safe year.

This means that the two-week period at the crossover of August/ September was irregular, as was August as a whole. The period

Photo by Gareth Lock

DIVER MEDIC & AQUATIC SAFETY

June-August was very uncommon and yet 2014 will be looked back on as a very typical year. This is not such a surprising result as it might seem. With such small numbers, it is very difficult to analyse patterns and draw conclusions.

With few data sets it is not unusual to see this effect, known as clustering, where what seems highly uncommon in the small scale proves to be completely normal when looked at as part of a bigger picture. Of course, any fatality is one too many, and just because the number over the year is typical it still doesn’t mean that there was not some common factor. This leads on to the second set of questions. What were the causes and what can we do about it? The assumption behind these two questions is that so many fatalities in such a small timeframe must be caused by some fundamental factor or factors and that this primary factor has come to the fore during the period in question. Nevertheless, 2014 was not unusual in the number of fatalities overall, and from an admittedly incomplete analysis, it appears that the causes of the accidents are representative of previous years. There has been a significant analysis of scuba diving fatalities, including reports by Acott (2005), Denoble et al. (2008) and Cumming et al. (2009).

One of the problems with trying to prevent accidents is that we often know what the result was but not the initial cause of the accident. Denoble et al (2008) used the concept of root cause analysis to determine what happened. Root cause analysis attempts to identify the initial trigger that started the incident and together with the behaviour or circumstances, known as the disabling incident, causes the disabling injury which is responsible for the resulting death.

The trouble with many diving accidents is that we may know the cause of death if the body is recovered, but this rarely helps identify the original trigger, and so it is often impossible to determine what caused the incident. However, what we do know is that in cases where we can identify the initial trigger, we tend to see the same pattern of triggers occurring time after time. These can broadly be grouped into three main areas: health and age issues, woeful technique or skills and lack of judgement. The obvious next step would be to take action to reduce these initial triggers, but this is not always as easy as it seems. Instead, a more sophisticated approach must be taken to look at the specifics of each of the major areas.

Health and age issues have played an increasing role in diving fatalities in recent years. Age, in particular, has attracted a lot of attention as the BSAC incident report has highlighted that around half of diving fatalities happen to divers over 50 years of age.

Many of these incidents are due to health problems rather than equipment or judgement issues so this is not to say that divers over 50 are more dangerous, but they do seem to be at more of a risk. This of course should not be a surprise. The older you 8

"The trouble with many diving accidents is that we may know the cause of death if the body is recovered, but this rarely helps identify the original trigger"

ISSUE 02 | NOVEMBER 2014

get the more risk you have of suffering a health-related problem, which may not be diving-related but may occur when in the water. The question is: what if anything can we do about it?

The simple answer is that if we banned anyone from diving once they reached the age of 50, then we could halve the number of diving fatalities. However, this is not a practical or even desirable solution. The question should not be what can we do but should we do anything? The numbers are too small to be statistically significant, but it appears that the fatality rate among divers over 50 is less than the fatality rate of the general population over 50. This would mean that a diver who was over 50 would be to a smaller extent likely to have a health-related problem than a non-diver who was over 50.

This does make some sense as an active lifestyle may help to reduce these problems. If true this would mean that if we banned divers over 50 from diving, then the diving fatalities would drop by half but the chances of the ex-divers suffering a health-related problem would increase.

I find the numbers are not reliable enough to make specific statements such as this, but the point is that there may be some health issues that we can never remove and may not want to. However, that does not mean that we should just ignore health-related issues; many divers live a far from healthy lifestyle and should be encouraged to try to improve their general health and fitness. This is for their benefit but also for the benefit of their family and, in this case, for the benefit of their dive buddies.

If a person suffers a fatal heart attack or stroke in the street or a pub, then that will be a very difficult time for anyone with them, but if the same were to happen on a dive, then the recovery of the body and subsequent police investigation is likely to be even more traumatic for all of those involved.

While we may not be able to do much about reducing age, health and fitness-related issues other than encouraging a healthier lifestyle, the same is not true about poor technique or skills. This is an area where improvements can definitely be made. Every year the incident report contains several incidents where a relatively minor trigger results in a fatality.

An event that the diver should have been able to foresee, prevent or deal with turns into something much more serious.

If we can address this area, then there is the potential for reducing the number of fatalities.

There are a number of reasons for unsatisfactory technique and skills. It is not usually directly attributable to substandard training. Most of the skills involved are covered adequately in training, although not always. However, the skills are not practised amply, and skill fade becomes an issue when that Photo by Gareth Lock

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DIVER MEDIC & AQUATIC SAFETY

skill becomes a requirement. This occurs because divers do not practise sufficiently. Many divers believe that diving itself is practice enough, but this is not the case. It is interesting that diving is most likely the only activity where this occurs. Golfers will practise their putting and driving, footballers will practise their skills, runners, martial artists, cyclists, triathletes and the participant of almost all other activity's practise or train in order to improve their performance at the actual activity.

This means that there may be divers who have done hundreds of dives but have not practised key skills for many years.

They may feel they are experienced divers but, in actual fact, may not be as well prepared to deal with a problem than a newer diver who has practsed those skills more recently. Simply spending time in the water does not necessarily improve your skills and may, actually, cause the ability to deal with a problem to deteriorate if you do not practise those particular skills.

This lack of practice often comes to the fore during some form of equipment failure. In theory, we should be able to deal with any equipment failure using backup equipment, by employing the relevant skill or by working with our buddy or teammate. In practice, problems occur because the right backup equipment is not carried, is faulty or the diver is not used to using it. The emergency skills and buddy skills are rusty or non-existent. This lack of practice is exacerbated by the fact that diving is an extremely safe activity, and major issues do not occur with great frequency. As a result, a diver can go for hundreds of dives without any problems occurring.

The lack of practice described above together with not taking sufficient backup equipment are both examples of lack of judgement, the other major contributory factor in diving incidents.

This results in divers getting into situations that they should never have gotten into.

Once again the fact that, generally, diving is relatively safe means that divers can show a monumental lack of judgement time and time again and yet get away with it because nothing goes wrong on the majority of dives. The impact of nitrogen narcosis is a good example of this.

Nitrogen narcosis starts to have a noticeable impact on dives beyond 30 metres and becomes a major issue beyond 40 metres.

However, it is still common for some diver to dive well beyond this limit using air.

The analysis of the BSAC incident reports presented in Cummings et al (2010) illustrates five cases at depths of 60, 57, 55 and 51 metres where the narcosis incurred by diving on air was a contributory factor. Other examples of woeful judgement include diving with known defective equipment, diving in unsatisfactory conditions, compromising on safety precautions and diving with unknown buddies.

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Photo by Gareth Lock

ISSUE 02 | NOVEMBER 2014

One of the problems in dealing with these situations is that any one of these factors on their own would not have caused a problem, and many divers will have dived with a number of these factors in place on numerous occasions and would have gotten away with it. The other problem in dealing with these situations is that the divers in question do not usually make these decisions in ignorance. They take decisions that they would criticise in others and would agree in hindsight were bad decisions.

The psychological reasons for this are numerous and would need several additional articles to cover fully.

The most positive thing that has come out of this spate of fatalities is an increased interest in diver safety and the desire to ask what can be done. It is natural to ask this question. After all, the diving community is relatively small and many of us may have known one or more of the divers involved. Even those that did not know them personally will be wondering what can be done to try to ensure they do not get into the same situation. Unfortunately, there is no simple answer. The obvious things we can all do to increase diver safety is to encourage people to look after their health and fitness a bit more, practise basic skills and adopt a safer attitude to their diving. However, we all know that, and I am sure all the divers involved in the fatalities also knew that and yet these fatalities still occurred. Changing the attitude to diving and introducing a safer overall culture is an incredibly large and complicated problem, but with support and determination, it is not an insurmountable problem.

"The most positive thing that has come out of this spate of fatalities is an increased interest in diver safety and the desire to ask what can be done"

Photo by Gareth Lock

Mark Powell Mark Powell is a TDI/SDI Instructor Trainer and a member of the TDI Training Advisory panel. He represents TDI/SDI on the British Diving Safety Group and lectures regularly at dive shows throughout the world on accidents, diving safety and decompression. Mark is also the author of Deco for Divers.

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DIVER MEDIC & AQUATIC SAFETY

The Travel Clinic

Are you Prepared?

by Chantelle Newman and Dr George Schroeder

Photo by Dirk Ercken

Are you thinking of travelling soon? Are you prepared? Do you have your travel arrangements? Do you know what vaccinations you need? Will you require anti-malarial prophylactic medications, for example, especially in tropical, sub-tropical regions of the world? Perhaps you even need antibiotics that will protect you and treat traveller's diarrhoea, also known as 'Montezuma's Revenge', when travelling to Mexico and Central America.

Water and food-borne illnesses are particularly burdensome to divers and water sports enthusiasts, and these are often preventable, with just a few simple precautions – such as working correctly with anything consumed orally: Start with: Hot foods being hot and consumed as soon as possible after cooking. Cold foods should be cold and consumed right after removal from proper refrigeration, especially in the tropics.

Remember that in spite of ice cubes being frozen, if made with contaminated water, in regions of the world 12

lacking chlorination, they present the risk of melting into your cocktail, thereby releasing germs into your exotic refreshment, even though your drink and container were handled in a perfectly exemplary sanitary manner by your waiter.

In addition, remember always to use a straw, which you have un-wrapped yourself, for sipping those drinks, and avoid contact with the edge of any glass directly with your lips and mouth in order to prevent hepatitis and notwithstanding when everything else goes well NEVER DRINK {Alcohol} & DIVE.

ISSUE 02 | NOVEMBER 2014

Food ought to be served in covered dishes, to prevent access, by insects and other bugs, and / or parasites. It is safer and more advisable to use sealed and sanitized eating utensils, which you have opened yourself. After use, recycle. This presents a perfect moment to educate, especially if it is not custom in that country to recycle.

Share information about how to discard of rubbish responsibly, especially non-biodegradable plastics, which should not go into the oceans and waterways. Recycling can help save our fragile and precious seas.

Avoid walking barefoot on the beach or along the margins of dense vegetation near the beach. The possibility of direct contact with the soles of your feet, with the urinary and fecal remnants of rodents, and other exotic vermin can produce such conditions like Leptospirosis, Cutaneous Larva migrans, and a large variety of terrestrial and marine organisms may lead to a broad variety of skin rashes, both pigmented and raised, accompanied by swollen lymph glands, fever, and sometimes even more serious generalised medical syndromes and illnesses.

Even so, do not let all of this dissuade you from enjoying your holiday; as long as you follow some basic precautions, and common sense guidelines, you have every prospect of experiencing a fabulous vacation and Dive trip to a safe region on the Globe with access to knowledgeable medical personnel.

Just think... it is possible to contract a grave and intractable medical condition from staying home and simply working improperly on your Aquarium, with un-gloved hands.

Fish-handlers' Granuloma – caused by a serious germ – Mycobacterium Marinum, may take weeks or months to manifest and require months of medical and surgical care presuming it is properly recognised, evaluated, and dealt with.

Travelling can be exciting but also stressful for some of us, even before we get to go on holiday and even sometimes on holiday too.

Going to another country may be very daunting as to know whether you have packed everything you need. Here is a little help: What to pack?

Sunscreen – attempt to purchase sunscreen that is labelled “broad spectrum” this means it protects you against both; UVB and UVA rays. Ensure you get sunscreen with a sun protector factor (SPF) of at least 20.

Insect Repellent – research has shown that products that contain the chemical DEET (N, N – Diethyl-meta-toluamide) are the most effective insect repellents against mosquitoes,

Photo by Ken Durden

DIVER MEDIC & AQUATIC SAFETY

Photo by Kokhanchikov

ticks, fleas, harvest mites and many other bugs if used correctly. DEET products can be applied onto clothing and skin and are available in sprays, sticks, roll-on and creams; 100% DEET when applied can be effective up to 12 hours. When using DEET on your skin for the first time, try to use a very small amount, around the size of the tip of your tiny finger first and leave for five to 15 minutes. If you develop redness, blisters or itching, then seek medical advice on what other products you can use as you may have a DEET allergy.

Anti-diarrhoea pills – Traveller’s diarrhoea is the most common illness affecting travellers. Diarrhoea is when there are three or more unformed stools in 24 hours passed by a traveller, accompanied by nausea, bloating and abdominal cramps. Traveller’s diarrhoea is more common in the developing worlds, where rates exceed 60% compared to advanced countries. A drug used to relieve the symptom is loperamide, but should not be overused. In most countries, it is available generically and under brand names such as Lopex, Dimor, Fortasec, Lopedium, Gastro-Stop, Pepto Diarrhoea Control, Imodium and Lomotil. Ensure you read the label of any drug before use. Do not take anti-diarrhoea drugs if there is blood in your stools, or if you have a high temperature (check with your pharmacist). Do not give anti-diarrhoea drugs to your child, seek medical advice first.

Anti-spasmodic, to treat abdominal cramps ought to be avoided, and pharmaceuticals such as Motilium – have recently been removed from the market in many but perhaps not all countries and therefore, you are well advised to seek qualified medical assistance, evaluation and treatment.

Rehydration sachets – most travel clinics advise travellers to carry rehydration sachets when travelling in developing countries. As a safeguard, it will not harm you to add some sachets to your travel kit. Rehydration sachets contain rehydration salts consisting of sugars and salts (anhydrous glucose, sodium chloride, potassium chloride and sodium bicarbonate). They are used to replace body fluids lost as a result of acute diarrhoea.

Anti-malarial drugs – Anti-malaria medications, also known as antimalarials, are designed to prevent or cure malaria. Mosquitoes may cause an inconvenience because of local reactions to the bites themselves and from the infections they transmit. Mosquitoes spread malaria, yellow fever, dengue and Japanese encephalitis.

Remember garlic, Vitamin B and ultrasound devices do not prevent bites. Recommendations for drugs to prevent malaria differ by country of travel and can be found in the country-specific tables of the Yellow Book.

Recommended drugs for each country are listed in alphabetical order and have comparable efficacy in that country. See the link for more information on the country you may be travelling too – www.cdc.gov/ malaria/travelers/country_table/a.html Antihistamines – Antihistamines are mainly used to treat hay fever (seasonal allergic rhinitis), hives (urticaria), itching (pruritus) and insect bites and stings. They may be used to help reduce feeling sick

Photo by Vadim Ratniko

ISSUE 02 | NOVEMBER 2014

"Pain is a signal from our body that something is not right"

Photo by Ketmanee

(nausea) and vomiting. Antihistamines are available as tablets (oral antihistamines), creams (topical antihistamines) and nasal sprays. They work by blocking the effects of a protein called histamine. Many antihistamines are available over the counter at a pharmacy, although some require a prescription. Here are some brands of antihistamines, Atarax, Benadryl, Clarinex, Dramamine, Optimine, Quenalin, Zyrtec, Cinnarizine and Piriton. Some antihistamines cause drowsiness, and once again excessive alcohol use ought to be avoided.

Pain relief medication – Pain is a signal from our body that something is not right. It can be due to a physical injury or some kind of illness. Most types of physical pain can be treated with pain relievers. Over-the-counter medications are good for many types of pain. Analgesics (pain relief) such as acetaminophen (Tylenol) or paracetamol are used to treat mild or moderate pain and can also be used to reduce temperature in fevers.

Commonly prescribed medication such as codeine can be used alone or in combination with other analgesics for stronger pain, such as dental pain, menstrual pain or migraines. Non-steroidal anti-inflammatory drugs (including aspirin) are used to reduce

pain associated with inflammation, such as sports injuries, and can also be used to relieve fever. Always seek medical advice before taking any off the shelf medication. What a lot of people do not realise is that their prescribed medication may not be suitably compatible when being used with certain over-the-counter medication and may cause serious health issues.

Diabetics should arrange for an adequate supply of materials and equipment, for blood sugar testing, because travellers are likely to experience inordinate delays in obtaining authorised access to such supplies in most countries, and ought to bring their own lancets, test strips, Glucometers etc.

Contracting airborne diseases can be minimised by use of tight N-95 masks, which are the recommended barrier method, particularly on long international flights with prolonged exposure to re-circulated air in the aircraft cabin, which places air travellers at risks for inhalation of particulate droplet spread of viruses and other organisms.

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DIVER MEDIC & AQUATIC SAFETY

"Treating a jellyfish sting by urinating on it may, in fact, cause someone even more pain, rather than relief"

Photo by Pat Hastings

First-Aid Kit – The Lifesystems World Traveller Kit is a very comprehensive first-aid kit and has the following items included in the kit: primary care leaflet, fabric plasters, woven bandage, crepe bandage, triangular bandage, gauze swabs, paracetamol, loperamide, ibuprofen, low adherent dressing, medium dressing, eye pad dressing, fabric dressing strip, wound closure strips, zinc oxide tape, micropore tape, duct tape, scalpel, hypodermic needles and syringes, forehead thermometer, antiseptic wipes, scissors, tweezers, safety pins, powder free vinyl gloves. The Lifesystems Traveller Kit is the basic kit without the needles and syringes. However, going to your local supermarket or pharmacy you can make your own kit up with the list provided.

Check out some first-aid kits and travel product available by going to www.lifesystems.co.uk and for the US and Canada www.adventuremedicalkits.com You might want to add products for marine life injuries, like 5% acetic acid (vinegar is roughly 4%-8% acetic acid by volume) for jellyfish stings. Unfortunately, in the real world treating a jellyfish sting by urinating on it may, in fact, cause someone even more pain, rather than relief. Urine can, in reality, aggravate the jellyfish's stingers into releasing more venom. Another item that may help is a heat pack: in the event you don’t have hot water on hand, using a heat pack stored in your first-aid kit will help relieve some pain from a 16

stingray or stonefish injury. Ultimately water heated up to a temperature of 40 to 50ºC, but limiting the contact to prevent scalding burns, is the best treatment for sea urchins, devil fish, scorpion fish, stonefish and stingrays. Certain marine venoms and toxins may be treated with anti-venoms, which may not be available everywhere. Australia and the Great Barrier Reef coastal regions will have some of the best and most experienced and skilled emergency rescue personnel as well as doctors, nurses and medics, who implement standardised protocols for rapid triage, evacuation and possible expedient treatment, including hyperbaric oxygen therapy for scuba divers, suffering from a variety of medical conditions associated with diving.

Travel Insurance – this is the most important product when travelling, never leave without it! What travel insurance does, of course, is to prevent you from going broke if something actually does go wrong. There might be rare cases where someone without insurance got air-lifted out at sea. Without insurance, your costs for possible repatriation may cause you to have to re-mortgage your house, but honestly, your chances of being killed by a falling coconut are probably greater in the long run.

Travel safe always!

DIVER MEDIC & AQUATIC SAFETY

A thought on freedive safety

BY ROLF WIBURG Beginner divers have a fear of what happens when you hold your breath over an extended period to a point where you slip into unconsciousness, and that primarily keeps them away from freediving. If you ask a freediver about this subject, he will say the fear is unjustified, that you can learn how to hold your breath effectively and know your limits. The fear comes from lack of knowledge and fear of the unknown. During the last 10 years the sport of freediving has grown exponentially.

Are freedivers adrenaline seeking daredevils?

The contradiction here is that for a successful dive you need to be very calm and in control, managing a slow heart rate. This stands to reason. Feeling safe is essential in order to be calm, to perform a successful freedive.

For the last 20+ years we have had an organisation in freediving called AIDA (Association Internationale pour le Developpement de L’Apnee) according to which l’apnee is derived from a-ponia meaning ‘without breathing’.

AIDA was formed in early 1992 in France by a group of freedivers to promote freedive safety and the development of the sport. AIDA has grown to be the biggest freedive organisation of today. There are other organisations but AIDA played the lead historical role and has moved the sport forward. This association implemented the safety features of today together with the top athletes of the sport.

As a result of that, we are looking at a vast number of safety mechanisms put in place to make several steps of safety redundancy during dives. If one system fails, which is unlikely, there is another to take its place.

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"During the last 10 years the sport of freediving has grown exponentially"

"There are no recorded fatal accidents in pool freediving under the safety rules of AIDA"

ISSUE 02 | NOVEMBER 2014

AIDA has been recording official dives (competition and recorded attempts). Those have reached about 35 000 dives, not to mention the training dives, which most likely accounts for over ten times that number. So that would give us approximately 350 000 dives, with only one fatal accident to date when using the AIDA safety standards. I will briefly comment on that later.

On the poolside there will be a doctor with an EMS kit in anticipation of a near drowning incident and includes O2 (oxygen) apparatus. Ideally competition organisers will also alert the local hospital and make sure the time between the competition site and the EMC is minimal. That can very well mean having an ambulance on site, if that is possible. In water there will be one or two safety freedivers per performer.

These are trained in safety with simulated problems much like lifeguards, evaluating if the diver is at a problematic stage and how to deal with it if it happens. They are most likely instructors and judges.

The most frequent occurrence is surfaced divers suffering from cerebral hypoxia with symptoms from light muscle spasm developing further to a blackout, in which case the body will lose posture and a laryngospasm will follow to block the airways momentarily. Keeping the airways out of the water is prime objective. Blow, Tap and Talk (BTT) method has been adopted and is highly successful in bringing the diver out of a blackout.

There are no recorded fatal accidents in pool freediving under the safety rules of AIDA. Although fatalities have happened, they have been the result of solo training and a total lack of the fundamental safety features that have been developed.

The pool scene is easier to manage than the open water depth, as you can see the diver throughout the whole dive, making it easier to spot changes in body character and rhythm, meaning the diver goes stiffer towards the end of a dive and most likely will speed up in frequency or stroke pattern. A noticeable release of air is another signal that the diver is developing hypoxia and has a build up of CO2 which begins to affect him.

As for depth, the same set-up applies as with the pool: having the doctor on the side or at the actual place of diving (pontoon), but will require a boat ride for the doctor. I would argue the most common set-up is a pontoon with a steel bar leading the dive line via two wheels with locking capabilities, such as found on sail boats. On one end of the line is the bottom weight with 10 to 14 kilograms and the other side holds the suspended counter ballast with at least three times the bottom weight.

Lines are frequently measured and counterweight release timed. The freediver is attached to the descend/ascend line via a lanyard that is clipped on to the line and secured to the freediver. There have been incidents where this lanyard has come loose, but judges responsible for the event will ensure the lanyard is correctly attached and are now being overly hard when testing them.

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DIVER MEDIC & AQUATIC SAFETY

There used to be scuba safety divers, but in recent years these have all but disappeared for several reasons; the added safety is questionable. The gas refill costs and expenses for equipment replacement are reaching astronomical proportions when several consecutive dives beyond 100 metre are done. There is also the question of the scuba divers' safety as well, where buddy systems are doubling costs for their inclusion.

It is now reasonable to assume the freediver has arrived close to the target depth as fish finders and other types of sonar keep reasonable and respectable track on the diver’s progress. The diver is also monitored by a hand line to feel the diver and a precise call of the dive depth i.e. turning point etc. If the diver is not clearly turned after a certain amount of time the counter ballast will be deployed for a recovery and in nearly all cases bring a diver up in less then 60 seconds. The best and most useful safety are at the deep safety point.

Depending on the competition, depth may vary from 10 metres to 30 metres; there can also be a freediver on an UW scooter down to 80 metres, but then they are limited by what they can do. Rule of thumb is a third of the dive to be covered. Deep dives being made are not a one off. The athlete is set to a slow progress adaptation and it is not possible to just dive deep; the pressure will stop anyone not being progressively adapted.

AIDA has restricted the use of a sledge that attaches to the depth line in terms of validating record as there is a predominant lack of knowledge to the physics and physiology related to this sort of diving. There simply is too little data to establish it as a safe method and diving at that level will ultimately be for a handful of elite divers, doing specific attempts rather than competing in it.

I mentioned a fatal accident that happened at the end of 2013. Any sport and activity will have a set of boundaries or code of rules that aims towards the majority of the individuals performing in that sport. But there will always be the deviating statistics. Predispose genetics, attitude and/or lack of knowledge that goes beyond reasonable expected performance. That said, rules are changing and adapting to real events as well as taking theoretical scenarios into consideration. It is highly unlikely the chain of events that lead to the diver’s death will be repeated. There is no safe activity; you have to apply risk assessment to everything and make an informed decision. One of the major issues free diving has been facing is the lack of knowledge, but as parallel to scuba diving, we have been able to draw some similar conclusion for pressure related injuries.

So what about the normal snorkel off the reef then? I would like to offer three general forms of advice: 1. Never ever freedive alone.

Most of us find it common sense but for some, being alone is too tempting. However, due to the complexity of our bodies, even the most trained freediver sometimes experiences problems underwater.

2. One up, one down.

When someone dives, having someone watch over them is probably the diver’s best bet of getting help quickly. And it can be done while the other diver is venting out CO2 and preparing for his own dive.

3. Do not over weight yourself.

There will be a need for not breaking the positive buoyancy, but the point is that you will be positive on the surface and the swim back to surface will be easier at the time when you need it.

Of course, you can never replace a practical freediving course with text read information.

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"Deep dives being made are not a one off, the athlete is set to a slow progress adaptation and it is not possible to just dive deep"

DIVER MEDIC & AQUATIC SAFETY

Photo by Gareth Lock

ISSUE 02 | NOVEMBER 2014

Buoy Diving Everyone should use one

By Nathalie Bock Article provided by DAN Europe.

"Do not think lightly about using a surface marker buoy."

Diving near boats, everyone should use one.

An extract from a blog tells of the tragedy that can happen on a holiday. This is going to be the latest write-up of this journey, a holiday which has abruptly come to an end, and it should be written to make others aware. These past months have been extraordinary with amazing things we have seen.

Without this last blog, the story will just not be complete. Second reason why this blog needs to be written is because, for me, it is a hard and emotional story (BE AWARE!). At the moment, I live by the day. I don't want to talk about what happened or what is still to come. Not yet anyway; I only want to talk about the bits and pieces that I can handle at that moment. This writing will be the exception.

The third reason why this blog has to be written is because there are lessons to be learned by other divers. I hope that when you are finished reading, you

feel the importance of using a surface marker buoy during your safety stop. EVERY TIME AND IN EVERY PLACE!! We share the water with boats, and everyone makes a mistake now and then: either you get lost or drift off or boats accidentally enter a diving area. You can get angry about that, but this will not help you in case you get run over. Prevention! Do not let this happen to you, what has recently occurred to me.

However, let me start by telling how special Eke is.

He got me out of the water, feared for my life, held pressure on my wounds, realising it could have been him. He never left my side, coping with his own emotions, continuously translating Spanish into Dutch and vice versa, organising and coordinating so many things, kept everyone back home totally informed, and so much more. I would have been nowhere without him. “Eke, I love you dearly."

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DIVER MEDIC & AQUATIC SAFETY

It's Thursday, May 9th. The ingredients of the day are: a dive site at the Galápagos Islands about one and a half hours off shore, one boat (ours), four crew members of which two are dive guides and, besides us, seven other divers.

At 50 minutes into the dive, Eke points out a turtle to me.

Wow! I look for the guide to see if we have time to stay with the turtle for a short moment, but I see he's busy hand signalling with the two other divers in our group.

One of them is low on air and has previously agreed this will end the dive for all. The dive guide accompanies the buddy team away from the rocks, so they can safely start their ascent. He then joins us again to look for the turtle at around 12 metres deep. The whole dive has been shallow, so we still have enough air. Unfortunately, we have run out of time, because we agreed not to dive longer than one hour. There will be no rejoining the turtle. At 57 minutes into the dive, the dive guide gives us the signal to start our ascent and our safety stop: always a harsh reality at the end of any dive. However, this ascent is different. A ‘fourth’ member joins us: a curious fish. He follows us closely until we reach a depth of five metres. At this depth, our divers have to wait three minutes before returning to the surface.

The fish, curious and brave as can be, stays with us and swims from diver to diver keeping less than half a metre distance. When the three minutes are up, we wave the fish good-bye and slowly go up to the surface. The fish is still there at three metres and also at two. So funny. What does this fish want? Eke stays a brief moment longer at two metres depth to say his good-byes. I make it to the surface.

position to lift me on board. I feel people get hold of me and how they unbuckle my diving equipment.

I surrender; it's all up to my rescuers now. I get lifted on board and laid down on a soft bench. My leg follows as well.

First, I think Eke has found my leg, but then I realise I can wiggle all five of my toes. My leg is attached. I still have my leg. And I can move my toes. Hope! I need oxygen right away. I need to breathe so much oxygen, that enough will reach my foot and toes, so they get a chance to be saved.

Once everyone is aboard the boat, Jen from Australia and Lynzi from England move super fast. Within 30 seconds, they turn a weight belt into a tourniquet and place this tight about my leg. Jen is standing on my right-hand side and is managing the scene in a more than perfect way.

She has complete overview, delegates tasks and talks to me. Above me, I see Eke's face. I hear him say that he loves me, and that I should try to remain calm. His eyes and his trembling voice tell me that this is something he can hardly do himself. My mind remains fully focused, never before had to ask myself the question whether I was going to live. My head stays very clear; I do not feel any loss of consciousness. I understand the bleeding is under control, and I can still wiggle my toes. "Yes, I will survive this." I tell Eke and Jen that all will be fine in the end I truly believe.

“Why is there still no oxygen”?

The following takes place in less than a second:

When I get my head above the surface, I see the side of the bow in front of my face. The boat is moving at distance less than a metre. The captain could never have seen me.

All alarm bells are ringing. I cannot get away. I'm going to be run over. In a split second, I realise that I have to avoid the bow colliding right into my face. I try to turn over at my left shoulder and get the dive tank between myself and the boat and perhaps a bit of depth. This does not work. I feel a light suction, and the fast rotating propeller blades grasp my left leg and release it again. The boat has passed.

Right behind me, Eke surfaces, unaware of what just happened. I lift my leg out of the water, but it's gone.

Where my knee should have been, I see a stump. I have lost my leg. I don't feel pain and don't feel panic. I start to scream as loud as I can. Everybody must know immediately something is desperately wrong. Eke sees my injury and inflates my buoyancy compensator with a burst of air and drops our weights. Within seconds, the boat is in the right 26

A short discussion, whether we should wait for the other four divers to end their dive as if on cue, they actually appear at the surface. They board the boat in no time, and we leave immediately at the maximum speed for the main island, still one and a half hours away. Several persons support my leg, and they place towels around my knee.

Finally, there is the emergency oxygen, and when I tell them, I am getting cold, they immediately cover me in more towels. I feel no pain, and I feel completely calm and fully awake. “Today I will not die."

I can hear lots of radio communications with the shore.

The captain slightly changes direction. We are not heading for the harbour anymore but directly for the airport.

I have to be transported to the mainland hospital, about 1 000 kilometres away, as soon as possible. Medical assistance on the airport is ready to receive me. Some people from the dive shop are on their way to our hotel to collect all our personal belongings and bring them to us at the airport. Still fifty more minutes by boat, they tell me.

ISSUE 02 | NOVEMBER 2014

"In a split second, I realise that I have to avoid the bow colliding right into my face"

Photo by feel4nature

DIVER MEDIC & AQUATIC SAFETY

"The doctor gives me IV fluids, emergency oxygen and the first pain medication.

Under my leg they put two aluminium pins to stabilise my leg"

Photo by sfam photo

ISSUE 02 | NOVEMBER 2014

I still see Ekes face right above me. He seems calm again.

He tells me how great I'm doing. I am still fully focused.

“I am going to survive this."

When we reach the shore, we have to wait a couple of minutes because the ambulance has parked in a different spot. People come on board the boat with a stretcher, which they place under me then they lift me. My leg is not in a stable position anymore and rolls from left to right.

This hurts badly, especially my knee. The ambulance brings us a couple of hundred meters to the first aid post at the airport. The doctor gives me IV fluids, emergency oxygen and the first pain medication. Under my leg, they put two aluminium pins, to stabilize my leg. When I get cold, they cut me out of my wet wetsuits and replace it with towels and blankets. I hear fierce discussions about where I should be brought next. Person in command decides that I must be transported to the mainland immediately. I'm very lucky that the last commercial flight is delayed by quite a bit, so there is enough time to handle all procedures and formalities and get me on that flight. I asked one of the dive guides to stay close to me all the time, because he's fluent in Spanish and in English. He has been such a great value in helping with all conversations with both rescuers and the authorities.

I don't know exactly how long I've been lying here, but all of a sudden we are moving. At last, we are going. An ambulance takes me to the airplane; the pins remain under my leg to give support. They carefully carry me up to the air-stairs and into the plane, but one of the pins gives way.

When someone on my right-hand side lowers the stretcher a tiny bit, my knee moves in that direction. Pain! I scream and for a short moment they put me down on the floor of the already fully boarded airplane. I manage to explain which movement they have to avoid, alleviating me from agonising pain. They lift me again and carefully put me on the last row of seats (including my two metal pins).

Once the doctor who accompanies me on the flight has declared that I won't die during the flight, we take off.

Eke is sitting backwards on a seat directly in front of me and keeps the pins and my knee in position. Next to him, the face of a friendly hostess appears. She is going to take care of me during the whole flight. She immediately gives me emergency oxygen. I look at my hands and see that they are covered in blood. Then I notice the blood on all the seats and stow tables. I'm still very conscious, and I can wiggle my toes. I'm going to stay alive, and we're now on our way to a very modern private hospital, and placed in the care of an excellent orthopaedic surgeon. Within one and a half hours, we arrive in Guayaquil and from there the ride to the hospital that takes five minutes by ambulance. The doctors there have a discussion to decide on which actions

to take. In the meantime, I go through the process of having extremely painful x-rays. I get everyone’s attention by calling to them: "Look! I can move my toes. Please save my leg!" It is 10 pm. I say good-bye to Eke. Finally, the moment of liberation is there. I get to breathe anaesthetic gas. When I feel I'm drifting away, I wave to the anaesthesiologist.

Today is Thursday May 23rd; tonight will be the sixteenth and also the very last night in this hospital. Tomorrow we'll fly home! This whole day I have no control over my emotions. Tears of happiness: tomorrow we will fly home.

I have had multiple surgeries. On the day of the accident, Thursday, they cleaned the wounds and put a bandage around them. On Friday morning, they did the same. This needed to be done first to prevent infections. On Monday, they fixed all fractures and closed the wounds. I have three fractures: just above my knee, my knee itself and my ankle.

I also have deep cuts and damage to my muscles.

The surgeon told me he couldn't believe that, seeing the damage to my leg, my artery and my nerves were still intact. He used 21 bolts and two plates to put my leg together again.

He promises me that within a couple of months, I will fully recover, and that I will keep all of my leg’s functionality.

He's a bit more pessimistic about my knee. Some bone fragments are missing, and my kneecap doesn't have a smooth surface anymore because of the damage. This will cause erosion over time, and this is why I'll probably have to have my knee replaced in a dozen years or so.

Recovery right after the surgery went with ups and very painful downs. All the personal support messages that I got from Holland as well as from Ecuador gave me a lot of strength. I thank you a lot! Even more support I got from Eke. There have only been a few times that he was not directly at my side. There is a large couch next to my bed.

This is where Eke has lived during those two weeks. He has taken care of me, translated as much as possible for me, tried millions of times to get the nurses into an action mode, continuously kept contact with the emergency desk of the insurance company, held almost daily meetings with the financial department of the hospital about the payment of the fast-growing bills, kept everyone back at home well informed, but more than all... helped me through all the unyielding and painful moments, day and night. I know how tough this has been for you. I would have been nowhere without you. “I love you."

Tomorrow we will fly home. At 7 pm there will be a direct flight from Guayaquil to Amsterdam. We'll fly business class. At Amsterdam Schiphol Airport an ambulance will 29

DIVER MEDIC & AQUATIC SAFETY

"This is where our dream journey ends, but we will be back soon for sure. We still have to do many more dives here, but only with a surface marker buoy."

Photo by Marisa Estivill

ISSUE 02 | NOVEMBER 2014

take me directly to the hospital in Amsterdam. We are already in contact with an excellent surgeon of this hospital. They know I'm coming. I think I will only stay in this hospital for a couple of days, so the medical team can decide on a plan for the near future. I'll need a lot of support in the upcoming months.

This is where our dream journey ends, but we will be back soon for sure. We still have to do many more dives here, but only with a surface marker buoy. This is not only applicable for us, but also for all other divers all over the world. This is going to be my mission. This is where I want to put my story to use.

Now it is time to let my emotions run free again: TOMORROW WE WILL GO HOME!!!

Nathalie Bock, PADI IDC Staff Instructor 31

DIVER MEDIC & AQUATIC SAFETY

Air Embolism Emergencies George Schroeder MD., M.S., FACEP, FAAUCM Col (Ret) M. Lawrence Kaplan, MD, DABUCM, DABFM, FACFEI John Spallino, M.D., FACP

Introduction: Scuba diving has been steadily rising in popularity. Most diving injuries are consequences of the significant changes in gases and pressure resulting from expansion of respiratory gases upon descent and ascent. The clinical manifestations of a scuba or freediving injury may be seen anywhere during or shortly after a dive, including up to 24 hours or later after diving.

Intrapulmonary and environmental pressures are gradually equalised by slow exhalation during ascent from any dive. PBT (pulmonary barotraumas) is a direct consequence of inhaled air or gas that is unable to escape through the normal airways (breath-holding on ascent with pulmonary over-inflation) leading to a likely rupture of parenchymal tissue into one of three sites: 1. pulmonary capillaries – causing AGE (arterial gas embolism)

Boyle’s law of physics states that at constant temperature, volume of a gas varies inversely with pressure applied and physiological consequences, which explains pressure-related diving diseases (namely, barotrauma). Scuba divers are breathing various kinds of compressed gas mixtures such as nitrox (nitrogen + oxygen), heliox (helium + oxygen), and trimix (helium, nitrogen and oxygen). In order to reduce or prevent incidences of pressure-related diving disorders, especially in diving to depths beyond 30 metres, divers are subject to the risk of pulmonary over-inflation, as pressure is reduced, and inversely volume expands on ascent. In accordance with Boyle’s law: Volume of gas at 30 metres (4 bar) will double at 10 metres (2 bar) and double again at 0 metre (1 bar) – at surface.

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2. intrathoracic perivascular sheaths – mediastinal emphysema 3. pleural cavity – leading to pneumothorax Air or gas finding its way to the left side of the heart, left atrium or left ventricle then proceeds to arterial circulation, and with an upright diver or patient sitting during perhaps a neurosurgical procedure, may very likely be propagated into the carotid arteries, which may then lead to cerebral air or gas embolism. Venous air or gas embolism is less serious and usually non-fatal unless a significant amount of air or gas bubbles traverse septal defects from right to left side of the heart.

ISSUE 02 | NOVEMBER 2014

Photo by Yiorgos GR 33

DIVER MEDIC & AQUATIC SAFETY

Pathophysiology: Arterial Gas Embolism is a direct result of expansion of respiratory gases with dangerous entry of gas into the pulmonary circulation as well as a syndrome of paradoxic air embolism via septal defects or a patent foramen ovale (PFO).

Immersion alone increases cardiac preload with central blood pooling and a rise in cardiac output and increased blood pressure. Pulmonary overpressure or “burst lung” is another mechanism for arterial gas embolism. Barometric pressure decreases as the scuba diver on compressed air ascends with a closed glottis or a freediver takes a breath of compressed air at depth and then ascends. As mentioned above, unavoidable pulmonary over-inflation as determined by Boyle’s Law states that with constant temperature, volume of a gas is inversely proportional to pressure directly impacting rising intra-pulmonary pressure on alveolar-capillary interface, upon ascent of any diver. Henry’s Law states that amount of a gas dissolved in a liquid is directly proportional to the partial pressure of that gas.

When pressure rises due to the following: • breath-holding on ascent; • dynamic Airway collapse in non-cartilaginous airways; • low pulmonary compliance, especially when not distributed evenly throughout the lungs; • then dangerous bubbles may form in the diver’s circulation Experimental findings have revealed that intratracheal pressures of 10 kilopascals or ascending from 52 metres to 36,5 metres are all that is required for this to occur. Distension of alveoli leads to rupture, alveolar leakage of gas and extravasation of gas into the arterial circuit.

Origin of bubbles in the circulation may arise from three sources: • paradoxic gas embolism = venous gas embolism with breach of pulmonary vascular filter; • patent foramen ovale (PFO); • tear of pulmonary parenchyma with entry of gas into pulmonary venous outflow.

Typically a small number of systemic venous bubbles enter the pulmonary arterial tree and are then eliminated through the lungs, which are able to trap small amounts of air and excrete it into alveoli, from arterioles. As the diver takes his first breath after surfacing, extra-alveolar gas enters the torn blood vessels, then migrates to the left side of the heart, then air is distributed systemically as emboli are sent to various areas of the body as determined by buoyancy and depth as well as influenced by thermoclines.

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ISSUE 02 | NOVEMBER 2014

Photo by Photographee.eu

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DIVER MEDIC & AQUATIC SAFETY

Arterial gas emboli arise from gas bubbles in pulmonary capillaries – pulmonary veins to the left side of the heart – possible rare coronary artery emboli or internal carotid and vertebrobasilar arteries to the brain – cerebral artery embolism with a clinical presentation of stroke depending on the region of the brain affected.

Cerebral artery gas embolism is a consequence of foam or bubbles blocking arteries of 30-60 micron calibre leading to distal ischemia, astrocyte and neuronal swelling. As the gas or air bubble passes over the endothelium, distal cellular effects (within 1-2 minutes) cause release of PMN (polymorphnuclear WBCs). The gas, or bubbles, has surface effects causing local swelling, downstream coagulopathy (blood clotting disorder) with focal haemorrhages. Immediate increase in permeability of the BBB (blood brain barrier), loss of cerebral auto regulation, is associated with a rise in ICP (intracranial pressure) as well as rise in blood pressure.

A phenomenon of “NO Re-flow” occurs with post-ischemic impairment of microvascular perfusion, arising from coagulation Factor VIII interacting with the prostaglandin system and possibly other blood tissue factors, and therefore, is also sometimes seen

Photo by Hong Xia 36

during plasmapheresis procedures (plasma, the fluid part of the blood is removed from the cells) or in hemodialysis (helps removal of waste products from the blood) patients.

Clinical manifestations: 1. CNS (Central Nervous System): will include disorientation, visual field, convulsions, cognitive impairment, and unconsciousness and more.

2. ENT (Ear, Nose and Throat): bloody froth from nose or mouth, air bubbles in retinal vessels of eyes and laryngospasm (muscular contraction of vocal cords blocking flow of air).

3. Cardiopulmonary: asphyxia, cardiac valvular dysfunction, increased blood pressure and haemoptysis (coughing up blood).

4. GI / GU (Gastrointestinal / Genitourinary): nausea, vomiting and incontinence.

5. Derm (Skin): marbled, peripheral cyanosis (blue tint in fingers or extremities) and subcutaneous emphysema (when gas or air is in the layer under the skin).

ISSUE 02 | NOVEMBER 2014

Treatment: • Ensure early recognition and prompt intervention by professionals, also to prevent potentially fatal complications, such as cerebral edema, stroke, MI or renal failure.

• Ensure safe and expedient transport to regional hyperbaric centres for HBOT, after proper recognition, diagnosis, stabilisation and triage of all patients identified with AGE (arterial gas embolus) or air embolism.

• As immediate relief, ensure correct positioning of the patient: apply the Trendelenburg position (lie the patient flat with feet higher than head level).

• Provide a high flow of supplemented oxygen.

• Promptly alert the DAN (Diver Alert Network).

Prevention: • Avoid precipitous rapid ascent while breath-taking following proper gradual recompression during ascent.

• Avoid air travel or high altitude activities after diving.

• Avoid penetrating injuries to head, neck, axilla, chest, abdomen and pelvis.

• Get proper medical clearance prior to diving.

• Most importantly, ensure maintenance of certification and diver training, with emphasis on strict avoidance of breath-holding on ascent while diving.

• Studies have shown decreased incidence of air embolism and arterial gas embolism in divers who have engaged in vigorous aerobic activity within 2 hours prior to diving, as well as in those who have reduced any obesity or unnecessary body weight.

(NB. The above rendition of the extensive medical paper has been reduced in volume and medical intensity due to relevance for the reader.

We apologise to the authors and those readers who have extensive medical knowledge including those with professional medical skills).

THIS PAPER HAS BEEN ACCEPTED FOR PRESENTATION AT THE ANNUAL SCIENTIFIC ASSEMBLY OF THE SPECIAL OPERATIONS MEDICAL ASSOCIATION – December 2014, Tampa, Florida USA.

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DIVER MEDIC & AQUATIC SAFETY

Where have all the divers gone?

Part 1 - An introduction Butch made his first dive with his father in 1955, grew up in Puerto Rico in one of the first diving resorts in the world, at age 13 was taking tourists in underwater excursions by 1960, became a YMCA instructor on March 1968 (had to wait till the age of 21) and a NAUI instructor in July, became an honorary PADI instructor in 1969 (a gift from John Cronan), and worked as a safety diver in underwater habitats. Butch has had the

By Walt 'Butch' Hendrick

opportunity to train well over 20 000 divers worldwide from civilians, to scientists, to public safety police, fire, and military. He created the do-si-do two, the rescue throw bag, and introduced in-water mouth-to-mouth in 1967 to the WSI for lifeguards and later for NAUI. After working on more than 12 Instructor Training Courses, Butch ran his first ITC as a NAUI Course Director in 1977, and has run at least 35 ITCs since, all over the world. Butch received the first DAN-Rolex Diver of the Year Award and received many other awards such as the South African Paramedic Achievement, British Sub-Aqua Club Outstanding Contribution to Diving and the International Leonard Green Stone for Major Contributions to Diving, including the American Academy of Scientific Diving NOGI Award. Butch has been published over 200 occasions, spoken at more than 300 dive conferences, and has had multiple TV appearances as a dive and rescue expert on such shows as CNN, Discovery Channel, and news organisations.

Butch is also an accomplished skier, shooter, boater, and airplane pilot among other things.

In the early 1950s scuba diving was in its infancy. Many new diving enthusiasts were energised with the idea of teaching others to not only enjoy, but to love, the sport of scuba diving. In the years to come many of these would-be scuba instructors would later be referred to as the great pioneers of sport diving.

There were divers like Lee Prettyman, who was one of the first ten YMCA instructors and possibly the first African American Instructor in the US, Jim and Eugene Cahill, Harry Hawk and Joe Vogal of the early United States Navy UDT era, Walter Hendrick Sr., Al Tillman, Tom Mount the cave diving pioneer, Bert Killbride, Jonathan Banks from England, Glen Egstrom who developed circuit training to create strong divers and who along with others such as Walter and Al created NAUI. These and many others from around the world had all begun teaching civilians how to scuba dive.

ISSUE 02 | NOVEMBER 2014

Photo by Paul Cowell

Each of the above pioneers appears to have at least one or two things in common. They wanted to train the best scuba divers possible, they wanted the new divers to be independent, capable divers who had a strong skill base with a solid understanding of the physics and physiology that applied to scuba diving as it was understood in that era.

It didn’t take long for each of these independent scuba enthusiasts/would-be scuba instructors to realise that national standards were needed in order to make scuba diving safe and that a certification card would be needed in order for the divers to refill their scuba tanks. A minimum set of standards would establish a guaranteed minimum capability for new divers. Butch recalls, “I remember as a boy sitting and listening to my dad and many of the individuals listed above as they discussed what standards meant. They all agreed there should be a minimum number of hours especially as it pertained to confined water skills, and they determined upon a range of 20 to 26 minimum hours.

Every diver needed to know how to swim well, especially as we did not have buoyancy compensators in those days and certainly didn’t have submersible pressure gauges yet.

The closest things we had to an underwater life vest was the old UDT inflatable swimmer vest or the inflatable life jackets that could be removed from under the seats from Eastern Airlines. Our idea of a submersible pressure gauge was knowing how to plan our air supply, understand the depth and pressure differential in which we were diving, and sometimes carrying more than one watch.

Andre Galerne had not yet asked Roland Puton to build him an underwater watch, so we didn’t have Rolex dive watches yet.

I can remember the unanimous agreements that every diver must be capable of properly placing their gear together, blindfolded. At 10 years old I became a guinea pig, “if he can do it, anybody can do it,” and so I began my nearly 60 years of scuba diving around the world and 50 years teaching others to dive.

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DIVER MEDIC & AQUATIC SAFETY

Every diver needed to not only be capable of clearing a mask underwater in any physical body position (upside down, horizontal face up and face down, etc.), but also able to complete all skills with no mask whatsoever. The original basic mask clearing standard, which I still believe should be used today, required all divers to be capable of comfortably breathing without a mask for about one minute, then replacing the mask and breathing with it flooded for about one minute, clearing the mask, then removing the mask, replacing and clearing it again.

It also required that all divers could confidently clear a mask with or without scuba.

Every diver needed to be able to kick properly and strongly, as well as function with only one fin. Every diver would know how to remove and replace (ditch and don) all their gear underwater with confidence.

Divers had to be able to properly weight themselves for different environments and exposure conditions. Critically, every diver would train how to reflexively open, remove, and fully release (ditch) their weight belt.

All divers would have strong snorkeling skills and perform several different types of clean, smooth, quiet surface dives.

Though primitive at the time, every diver would demonstrate that they could rescue and tow a buddy 200 to 250 yards.

It was unanimous that every diver needed to understand basic physics and physiology. Not just how to say Boyle's law, Dalton’s law, Henry’s law and Archimedes' principle, but to know what they actually meant and how they applied to the human body as it descended and sooner or later ascended in the water column.

In those days we understood why an atmosphere is 33 feet in saltwater at sea level and 34 feet in fresh water, and how the feet per atmosphere changes with altitude (14.7 psi /atm divided by .445 psi/fsw (feet salt water) and .432 psi/ffw (feet fresh water) respectively)”.

So, sometime in the early 50s, organised sport diving instruction found its beginning with LA County Divers and then the YMCA forging its way to be one of the first nationally/internationally recognised sport diving certification agencies in the world, with the British Sub Aqua Club, BSAC, finding its way to a platform with similar standards at approximately the same time. And of course there was CMAS, and later on NAUI. About this same time groups like the Boston Sea Rovers with divers like Frank Scally, Stan Waterman, Walt Hendrick, Peter Gimbel, Commander George Bond, and many others began to create educational platforms where divers could gather for diving educational conferences.

Over the next 20 years, agencies such as PADI, NASDS, SAUU and several others would find their way into the underwater 40

certification world. Sport scuba diving was about to explode with enthusiasts from all walks of life wanting to learn to dive and explore this incredible yet reachable new frontier. With masks on, minds open to new adventures, and often camera in hand, the oceans of the world were about to be invaded under the guise of exploration.

Soon the United States and British Navy diving manuals would be replaced with the likes of the New Science of Skin and Scuba and Joe Strykowski’s Diving for Fun. While Dr Lee Summers wrote diving manuals for Sea Grant at the University of Michigan and created the first US national scientific and commercial diving standards, Dennis Graver a prolific writer would forge onto the scene in the late 70s and produce a series of manuals for PADI. Sport scuba diving as we knew it was about to explode to reach its heyday with Lloyd Bridges and Jacques Cousteau telling the world it’s time to explore the new frontier.

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Photo by Kichigin

The Killbrides and Hendricks started dive resorts in the Caribbean in the early 60s, with the Hendrick family installing and running the first non-military hyperbaric chamber to treat dive accident victims. By the late 70s, early 80s, sport scuba diving was evolving around the world with resort operations opening their doors to tourists in many of the most exotic dive locations the mind could imagine. Wreck diving and cave diving were becoming the new rage and professional dive boats like the Wahoo and the Sea Lion were coming of age and would often leave divers standing on the pier for there was no more room.

In those days we taught people to love diving, we taught them to be strong independent capable divers, we taught them to dive with buddy but not to be buddy dependent. The divers and dive instructors of the 1980s were constantly seeking out the great masters in order to learn more.

They wanted to understand and then master buoyancy control and other advanced diving skills, they actually wanted to be capable of realistically rescuing a buddy both at depth and at the surface.

Divers are human beings, and as human beings we like to be challenged, we like to be good at things. We don’t often ask what is the least we can do. But rather, more often, what more can I learn?

Quite sadly about this same time the dive agencies believed there was a need for making hundreds of new instructors and, with the onslaught of instructors, began the reduction in diving standards at all levels.

During many of the national standards meetings some argued for hours that learning to dive was too difficult, that standards 41

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had to be lowered in order to make it easier for everyone, swimmers, non-swimmers, physically fit or not, to learn how to dive.

What started this drive to create masses of new instructors, and then instructor trainers? How much money does a training agency make when new divers are certified? Perhaps a diver pays $10 for a card and $15 for a book including a patch. And perhaps later another similar amount if the diver progresses to advanced or other specialty certifications. Compare that $25 to $50 to the hundreds of dollars the training agency makes when an instructor is newly certified (training materials, registration fees, etc.), followed by hundreds of dollars every year when the instructor has to pay annual dues, insurance fees, and purchase updated materials. And some agencies, like PADI, figured out how to keep the instructor training certification process fees by mandating their instructors be certified by a headquarter Examiner, rather than an independent Course Director as NAUI and other agencies had.

Then the agencies could sell Instructor Trainer and Course Director Training, certification and materials. Oh, and don’t forget about the mandatory Instructor and Instructor Trainer/ Course Director updates with associated material costs. The agencies realised that the money was in making instructors, not in certifying strong, qualified divers.

Hence, the agencies changed the way we teach. The scuba diver programme was no longer designed to make strong, competent, confident divers who knew how to kick, who would only laugh if a fin knocked off their mask at 60 feet during a night dive, who were comfortable doing a long surface swim in waves, and who understood the importance of air and nitrogen dive planning and were capable of performing the necessary calculations. The scuba diver training programme was now designed to be something that any Tom, Dick, and Mary could teach. And with that drop in standards for teaching divers, there came a large drop in instructor training standards.

The training agencies realised that they were not going to get hundreds, or even thousands, of divers to pay and work to become scuba instructors if the system remained status quo. What was the status quo? It was a system that created knowledgeable, experienced, highly skilled instructors. You first had to have 250 dives and you had to be sponsored by an already certified instructor with whom you assisted during numerous classes. The sponsoring instructor would be evaluated by the training agency by your performance during the instructor training course to keep up standards at all levels. You walked in the door of the Instructor Training Course (ITC), filled out paperwork, handed in the sponsor’s letter, and sat down to four hours of written exams. While the ITC staff corrected the exams you did your swims, snorkeling exercises, demonstrated a rescue, performed a full scuba ditch and don, and then demonstrated all the basic skills in the deep end.

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Then you gave a lecture of your choice from a list of topics.

You then came back into the room to see who would remain to take the ITC. Today you need less than half the dives, and don’t have to have any experience teaching and assisting with classes. You could be certified as an instructor without ever seeing a diver panic or helping stop a diver from bolting to the surface, without ever weighting a diver, fixing a poor fin kick, or having any understanding of how different people learn.

The modular training system was not designed to teach divers; it was designed so that anyone could teach scuba diving.

Today’s scuba training is not designed for the diver; it is designed for the mediocre instructor.

The argument came that dive instructors did not need to be strong swimmers and nor did they require the underwater skills at levels required at that time. Dive instructors, and

ISSUE 02 | NOVEMBER 2014

Over the past 60 years, a student still asks the same first six questions: 1. How much does it cost?

2. Do I have to be a good swimmer?

3. How long does it take?

4. Will I be able to go diving anywhere when I am done?

5. Do you supply equipment?

6. Can I get a discount if I bring my wife and friends?

Those are pretty much the same questions that would-be divers ask today. Here are the answers today.

1. Except for the cost of equipment, training costs less than it did in the 1980s.

2. You don’t even have to know how to swim anymore.

3. About a quarter of the time that it used to take.

4. Yes, same answers 50 years ago.

5. Yes or we rent it.

6. Usually yes.

Oddly enough, not one of the first most common six questions asked by prospective students, not even one of the first 10 questions asked, is “can you reduce the standards so it will be easier for me”. However, our industry, specifically the training agencies, are continuously saying we have to make it easier for people to get into scuba diving, standards are too high, prerequisites are too demanding. Yet the diver dropout rate is increasing at an alarming number. There seems to be a positive correlation between diving standards and the number of divers actively diving. The more standards are lowered, the fewer divers actively dive. True, that correlation does not mean causation, but in this case I believe it does.

students alike, did not require a true understanding of physics and physiology as it pertained to the scuba diver; if they wanted to become that advanced they would do it on their own. In fact, it was argued that instructor trainers and course directors did not require the skill level or knowledge level of the existing instructor protocol. Hence, as diving expanded, the standards to be a certified diver were compromised.

It has been stated that today’s diver does not really want to learn how to be a great diver, they just want an experience – “they just want to do a few dives a year while on a cruise ship.” Is that the cause of the problem or is that the result of the lowering of standards and a compromised diver education system.

In the 1960s and throughout my life of teaching diving, I found that students have always wanted to learn more once they realised there was more to learn. No one wants to be mediocre and, if anything, divers will seek performance levels equal to, or as close as possible to that which is demonstrated.

Quite interestingly, if we look at diving and compare it to many of the other industries that we continuously evaluate ourselves against, or with which we believe we are in competition, we may find that the other industries have not reduced their standards by much or at all.

Consider the fast growing Goldenman Triathlons, Tough Mudder, and similar competitions where thousands of people can spend thousands of dollars between fees and travel expenses, for which they train hard for months or years, in order to participate in a one-day event, for which perhaps they get a T-shirt and a bag. Even with all of the new advancements in equipment, snow skiing is no easier or less expensive to learn how to do now than it was 20 years ago, it still requires an enormous amount of time and hard work with constant striving to raise one’s skills and endurance.

Skiing is exciting and provides adventure and challenge just as diving did twenty years ago. Today’s diving is effortless and just takes a weekend to master. Your grandparents and a 10-year-old kid can do it.

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For the new enthusiast anxious to get his or her first solo flight, learning to fly and achieving a pilot’s licence is no easier now than it was 35 years ago, even though much of the equipment has improved so dramatically that the plane can almost fly itself. Every student still needs to learn how to perform basic chart navigation and understand set and drift course versus heading, despite the new GPS and other tools that will do it all for you. You practise skills until they become reflexive in realistic situations, including contingency skills such as stalls and spins. There are diving certifying agencies today that say instructors do not have to teach dive tables if students will be using computers. So how can divers understand that when their computer lists out all the maximum dive times from 130 feet (40 metres) to the surface after they just did a 33 foot (10 metre) dive, that doesn’t mean they can jump in to do a 90 foot (30 metre) dive?

With all the advancements in equipment, learning how to skydive is not much easier today than it was 20 years ago.

The performance levels or standards required to become a certified parachutist have not been lowered.

Whether you start out spending $500 or $5 000 learning how to shoot, skeet and trap is still going to take a lot of time.

After 1 500 to 2 000 attempts at shooting clay pigeons, you may start to get pretty close to your first perfect hundred.

Thirty years ago Advanced Diver actually meant something.

Today you can literally jump from an entry level scuba diver class to an advanced class and with just those six more dives call yourself Advanced. What other activity or sport allows such a misnomer?

If people pay to sit on stationary bicycles along with ten other sweaty people for hours of spinning classes, will they not pay for “finning” classes? So why can’t divers gain strong water skills while becoming physically fit with finning and skin diving classes? The answer is because, as many of us who have been teaching diving for 30 or more years agree, too many of today’s new dive instructors do not have these skills themselves.

Then there is the debate of “is diving safer today than it was 30 years ago?” The answer is no, even with safer regulators, computers and gauges. Buoyancy compensators are safer today except for the myriad of integrated weight release systems that make it challenging to nearly impossible for divers, buddies, and dive leaders to successfully, rapidly ditch dive weights during actual emergencies.

The lowering of training standards has not led to safer diving despite the statistics that some experts show during conference presentations. The problem with statistics is that when you say something like there are only 20 out of every 44

100 000 divers has a dive accident, that 100 000 is basically imaginary. If that number is based mainly on certification numbers, and you apply an 80% drop-out rate, that brings it down to 20 000. Just speak with the dive stores that closed in the last decade and those still around, talk to managers of dive resorts and quarries, and ask them about the numbers of customers they have now versus the past. And of the divers who still do say they dive, how often do they dive? Thirty years ago it was common for divers to do 50 or more dives annually – we dove on weekends and could easily do 20 or more dives during one dive trip. Yet 50 dives annually are very unusual today for divers under the age of 40. Diving is an aging population. Today’s “diver-divers” are becoming an endangered species and usually are 40 years or older. So when comparing statistics of accidents per 100 000 divers keep in mind that each certified diver is diving far less often today than he or she did in the past.

Are there fewer fatalities per 100 000 certified divers today than 30 years ago? Perhaps, but just the advance of medicine in general, the oxygen and defibrillators on modern dive sites,

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decades. The following numbers are approximations of 20 years ago to today.

Photo by Xavier Marchant

and the coordination of treatment from DAN and other modern organisations should alone have reduced the fatality numbers. So, in respect of treatment once a diver is out of the water, yes, diving is less likely to be fatal. But are there less near-misses, accidents, and fatalities per dive today than 20 years ago? The answer from what we can see occurring today is no.

Where is the world of scuba diving heading?

For the last 45 years, this writer has had the opportunity to conduct advanced diver training worldwide for hundreds of divers annually. These students come in with certification levels from entry-level to course director, and who were trained by other instructors representing a myriad of certification agencies. The first part of my diving career began with teaching diving and running dive boats out of my family’s dive resort in the 1960s in Puerto Rico for divers who came from all over the world. This time also included running divers through hyperbaric chamber treatments, so we learned about what went wrong. The following assessment of divers today comes from working with more than 20 000 divers over these

• 5 or 6 out of 500 students might not remember how to properly put their gear together. Today 10 to 15 out of 100 have problems.

• 10 to 15 out of 500 students might not be able to breathe without a mask on. Today 15 to 20 out of 100 can’t clear a standard sport diving mask and a greater number than that cannot breathe without one.

• 15 to 20 out of 500 students might not be able to kick.

Today 15 to 20 out of 100 can’t move through the water with a fluid kick or without the use of their arms. Many cannot move a hundred feet from shore without becoming winded due to inefficient kicks and ineffective modern fins.

• 20 to 30 out of 500 students might be severely over weighted. Today 20 to 30 out of 100 because they are breathing at the top of the aspiratory/inspiratory portion of the lung filling the lungs on every breath and using way too much energy between arms and legs to understand what proper weighting means. I was told that ‘add weight’ is the standard response; they were not taught how to breathe and how breathing affects buoyancy.

• 20 to 30 out of 500 students would have breathing rates of over 15 breaths per min per minute equaling surface consumption rates (SAC) greater than 40 psi or greater per minute.

• Today more than 30 students out of 100, as stated above, simply add more weight to compensate for their lack of understanding on proper weighting.

• 40 to 50 out of 500 students did not maintain a log book.

• Today 40 to 50 out of 100 do not maintain a log book many do not even have one.

The instructors who have been working with me who have more than twenty years teaching experience agree with the above, such as the late George Safirowski, as well as Andrea Zaferes, Bryan Duffer, and Brian Bowers.

A coined phrase from several years ago was the "responsible diver code". However, to be "a responsible diver" one first requires "a responsible instructor” who was taught by "a responsible instructor trainer” who was given guidelines and standards by "a responsible certifying agency". We don’t need more new divers dropping out because they know they are not ready, we need more new divers to be taught to be strong and confident and love diving. A call to action is needed now. We need to save scuba diving from the diving industry. The industry is dictating to us. We should be dictating to it.

We look forward to your comments and questions, which will be addressed in the next part in this series. Send your feedback to info@dmaasm.com 45

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ISSUE 02 | NOVEMBER 2014

FORENSIC UNDERWATER CRIME SCENE INVESTIGATION Q&A Dr Claire Gwinnett and Dr Laura Walton-Williams are forensic scientists and qualified divers from Staffordshire University, England. Both Claire and Laura conduct for the police, public and other forensic providers, in a range of biological and trace evidence analyses and teach forensic investigation techniques across the UK and Europe. Laura and Claire are the course leaders for the Underwater Crime Scene Investigation course, which combines the theory of underwater crime scene processing and the practical application of diving skills for the safe recovery of evidence that may be crucial in solving crimes.

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1

What Is Underwater Crime Scene Investigation?

Underwater Crime Scene Investigation, or Underwater CSI, is the technique of gathering as much evidence relating to an underwater crime scene in order to assist in convicting the criminal offender. It involves the processes of identifying potential underwater crime scenes and then locating, documenting, recovering and analysing evidence collected from these scenes of crimes. It may be that the crime itself occurred underwater (for example, in murder cases when victims are placed in the trunk of a vehicle and that vehicle is then submerged, resulting in the death of the victim) or that an item, such as a weapon, has been placed underwater in an attempt to dispose, conceal or remove potential evidence from it. Either way, Underwater CSI requires the investigator to be experienced in crime scene examination as well as working in an underwater environment.

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What Kind Of Criminal Cases Require This Type Of Investigation?

The types of criminal cases that might require Underwater CSI are vast. More than 70% of our planet's surface is underwater (oceans, seas, rivers, canals, lakes, keys, etc.) and therefore there is great potential for these locations to be involved in the commission of a crime. Due to the labour required to analyse and search underwater scenes, this type of analysis normally happens in serious crimes such as murders and cases involving missing persons. Bodies of water will be searched for discarded evidence or for the presence of a body by police divers. This search may take the underwater investigator into rivers, quarries, lakes and even sewers. An example of such can be seen in the very recent case of the missing Latvian girl, Alice Gross, which involved the meticulous searching of over three miles of waterways in order to try to find clues into her whereabouts.

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What Types Of Evidence Might An Investigator Be Looking For?

Much of the time, police divers are searching for weapons that have been disposed of in water ways in order to destroy evidence. These weapons can be knives, firearms and baseball bats, all of which have to be handled gently and secured quickly so as not to lose any evidence. Criminals also use water to dispose of mobile phones; this type of evidence can be very useful as information can still be retrieved from devices after exposure to water. In some instances, the evidence being searched for can be large, which makes it easier to find but more difficult to retrieve from the water. Cars, vans and human bodies require specialist equipment and skills to bring to the surface but are all valuable sources of evidence.

Photo by Matej Kastelic

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Photo by LukaTDB

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What Additional Challenges Does Underwater CSI Involve?

Much like "traditional" crime scenes (i.e. land based scenes), no two underwater crime scenes are the same. Personnel involved in the examination of underwater crime scenes are still required to ensure that the same stringent forensic processes used in the examination of land based crime scenes are upheld, such as protection of the scene from tampering, or ensuring that evidence is recovered in a secure fashion. Many of the techniques that are applied to land based scenes can also be applied to underwater scenes; they just require additional stages or alternative, innovative approaches. For example, on a land based scene, if you need to communicate with a fellow CSI (Crime Scene Investigator) you can just call over to them. Underwater, this may be possible with radios, but in most cases police divers communicate by hand signals, written messages, or rope pulls. There is also the additional challenge of trying to locate evidence that may have been moved by the current, may have been interfered with by the local wildlife, may be covered by the sediment or may just not be visible due to the nature of the body of water you are searching in.

On land there are always risks associated with the examination of crime scenes. These include, but are not limited to, the presence of the offender at the scene, concealed sharps, weapons, body fluids and explosive chemicals. In underwater scenes these risks may also apply and in addition it is necessary to consider the inherent risks associated with carrying out the examination underwater, such as becoming trapped and running out of air. Recreational diving is often carried out in beautiful clear waters, where conditions are such that the diver can spend the maximum time possible enjoying the view. Police diving is often carried out in hazardous environments, where water conditions are such that they will conceal evidence. This means that the examination of underwater crime scenes often puts further strains on the diver, additional to those experienced during recreational diving.

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What Processes Are Involved In Underwater CSI?

The initial stage of Underwater CSI involves locating the crime scene. It is often important to consider in underwater scenes this will be likely to include both the entry point to the body of water as well as the final resting point of the evidence, and all areas in between.

Once these areas have been defined, it is vital to protect these scenes and the potential evidence located within these areas. This can be easier said than done when considering the environment you are working in – constantly changing and often without defined boundaries. A thorough search of the scene is then required, and there are several different search methods that are implemented at underwater scenes depending on the scene location. For example, the type of search you would conduct if the scene was adjacent to a pier or bank would differ to that used in the middle of a large quarry.

During the search it is extremely important that the scene is fully documented and that any pieces of information relevant to the investigation are recorded. This will involve the production of contemporaneous notes, sketches, photographs and videos. Finally, any evidence will need to be recovered appropriately and analysed for further information that could aid the investigation. There are specific techniques involved in the recovery and analysis of evidence from an underwater environment that need to be understood by the investigator in order to maximise the potential for gathering useful evidential information.

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What Does Staffordshire University’s Underwater CSI Course Involve?

The Underwater CSI course delivered at Staffordshire University is unique in its kind in the UK, with no other forensic science course including the theory and practical elements of Underwater CSI. Staffordshire University’s Forensic and Crime Science Department is a leader in its delivery of forensic education, research and consultancy and consists of experts in all areas of forensic investigation. The course is delivered in the new £30 million Science Centre, Staffordshire University’s grounds, a local swimming pool and the Ecclestone Delph, old stone quarry with up to 30 meters of depth (for the open water diving sessions). The course has been designed to be a balance of the theory of crime scene investigation and the practical aspects of diving for the search and recovery of evidence. The course provides an insight into what it really means to be a police diver, including some of the dirtier work that’s involved. Participants in the course will experience how to document a crime scene, handle, retrieve and package different types of evidence, coordinate an investigation that involves the searching of water and learn how information from crime scenes can help reconstruct the events that have occurred in crime. It also provides opportunities to see what happens to evidence retrieved from water and how these items can be analysed for fingerprints, fibres and body fluids.

Claire and Laura hosted a talk titled Death in Depths at the Birmingham Dive Show on 25 and 26 October 2014.

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ARE YOU

'DRINK-DIVE' AWARE?

By Dr Suzanne Gaskell Diving is one of the safest and most enjoyable recreational sports.

It is not uncommon for divers to enjoy a cold beer after a dive, but could you be putting yourself at risk by your alcohol intake? Not only does alcohol affect health acutely but overuse leads to long-term consequences. Furthermore, the effects of alcohol have been implicated in many diving accidents. This article aims to encourage divers to be mindful of their alcohol intake when diving and raise awareness of the potential health consequences.

How big is the problem?

Just 50 years ago, the United Kingdom had one of the lowest alcohol consumption levels in Europe. Over the last decade, people’s attitudes towards alcohol have changed. Now 83% of people who regularly drink above the recommended units do not think it is harming them.

It has become increasingly acceptable to drink excessively, resulting in higher rates of alcohol-related crime, Emergency Department attendances and chronic diseases. This alcohol related harm costs the taxpayer £21 billion per year.

Governmental statistics show that young males are at highest risk for alcoholrelated problems. The profile of the average diver is young and male and therefore at the highest risk of excess alcohol intake making the issue of alcohol and diving particularly relevant. In 2013, PADI had over 22 million certified divers worldwide. The average age of these was 29 and 65,5% were male. This means that 52

13 million divers would fit into the highest risk bracket for alcohol-related problems.

A questionnaire of 800 divers in the UK, completed by the Diving Diseases research centre, Plymouth, published these startling results: • 34,5% divers admitted consuming alcohol six hours to less than 30 minutes before diving.

• 39,78% of that group admitted they had gone diving when unfit to drive a car.

• The same study also found that 71% of divers treated for DCS in 2009 had consumed alcohol in the preceding 24 hours.

Effects of alcohol on diving Alcohol has negative effects on global cognitive functioning, a prerequisite for safe diving. The Divers Alert Network (DAN) published diving accident statistics

ISSUE 02 | NOVEMBER 2014 Photo by Nejron Photo

"Alcohol has negative effects on global cognitive functioning, a prerequisite for safe diving"

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"While there is little evidence directly linking alcohol with an increased risk of decompression sickness, it certainly causes dehydration"

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in 2007. Out of the 183 deaths that year, 74% of these were due to drowning. Major factors causing drowning are uncontrolled ascents and and buoyancy problems, usually because of lapses in concentration or sound judgement.

Alcohol causes dehydration. While there is little evidence directly linking alcohol with an increased risk of decompression sickness (DCS), it certainly causes dehydration, which is an established risk factor for DCS. It also has significant long-term effects by increasing the risk of liver disease, diabetes, high blood pressure, bowel and breast cancers. Most of these diseases present insidiously and it is therefore important that divers not only pay attention to the quality of their equipment, but also to the quality of themselves.

The calorific content of alcohol is high with one pint of a strong lager containing approximately 200 calories. This equates to a twenty-minute run on the treadmill.

While there are no restrictions on weight in recreational diving, it is worth noting that 74% of divers who died in 2007 were overweight.

How can we reduce the risk?

Ask yourself the following four questions: • Have you ever felt you should cut down on drinking?

• Have people annoyed you by criticising your drinking?

• Have you ever felt bad or guilty about your drinking?

• Have you ever had a drink first thing in the morning?

If you answer yes to two or more of the questions, there is a 93% chance you are a ‘problem drinker’. You can visit the government’s drinkaware.co.uk website or speak to your doctor for advice on how to cut down effectively.

Although it sounds obvious, do not dive while under the influence of alcohol and remember that alcohol from the night before can still be in your system.

Always re-evaluate your fitness to dive before each dive and employ the attitude of "if you are not fit to drive, then do not dive".

Alcohol: do you know the facts?

What is a unit of alcohol?

10 millilitres of pure alcohol.

How do I know how much alcohol is in my drink?

Alcohol content is usually expressed as a percentage of the whole drink "alcohol by volume (ABV)". Therefore, the size and strength of the drink determines the number of units. For example, 12% ABV means that 12% of the volume of the drink is pure alcohol.

How long does alcohol take to wear off?

On average, it takes one hour to metabolise one unit of alcohol. The legal limit for driving is 35 micrograms of alcohol per 100 millilitres of breath. Most people think that this means two units, however, a person's ability to metabolise alcohol is affected by many factors such as age, sex, weight and type consumed.

How much is an acceptable intake?

Photo by Andrey Yurlov

The UK government recommends a maximum of two to three units per day for women and three to four units per day for men. A 175ml glass of wine or one pint of 4% beer is equivalent to two units each.

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Photo by John Bantin

DIVING

BY THE BOOK

By John Bantin I like to think experienced divers fall into three distinct groups.

The first group are those who seem to have side-stepped gaining any theoretical knowledge whatsoever and dive happy in a haze of what might have been a theory. They do not dive by the book, because they did not bother to read or understand it!

Then there are those who have learned it well and followed the strict disciplines recommended by their respective training agencies. They know the book by heart and would never go beyond what it says. This constitutes the majority of divers and thankfully it does or there would be far more accidents than there are.

Finally, there are those who understand what they are doing but are prepared to make certain decisions that the second group might find hard to stomach. They understand the book but are prepared to take calculated risks.

she was. Instead of descending to retrieve the trainee, the divemaster concluded that it would constitute a second dive without sufficient surface interval, so she stayed on the surface and left the trainee to her own devices. She should have taken what she perceived as a risk and went under, Instead, the trainee drowned. It was a tragedy as a result of someone choosing the wrong rule to follow.

The recommendations offered by any training agency can be misleading if treated as hard-and-fast rules.

Her duty-of-care towards her charge should have overFor example, a diving instructor went in the ruled any misplaced ideas water at a well-known British inland site with a number of students and a divemaster about surface intervals. to help. One of the students was apparently having some difficulty and was not enjoying the dive so the instructor signalled his divemaster to escort her back to the shore.

The divemaster ascended with the trainee to a shelf at approximately six metres from the surface, there the divemaster lost control of her buoyancy and bobbed above the surface leaving the trainee diver where

I was an ordinary passenger on a 'live aboard' diving the famous Shark Reef wall at ‘Ras Mohammed’ when I noticed that one of the group's members was seen way down below us. I was at 30 metres depth, and we were all breathing Nitrox 32, which has a highest operating depth of 38 metres at the highest partial pressure of oxygen of 1.6 bar or 32 metres at ppO2 of 1.4 bar.

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Ignoring the training agency rules, I swam down to the offending diver who by now was at nearly 60 metres deep. He appeared to be rather oblivious to where he was. I took his arm and drew him back up to 30 metres depth, signalling that he should keep his eye on his computer. It was not long before I noticed him once more deep below me. I swam quickly towards him feeling rather angry and drew him back up to 20 metres from the surface, signalling once more that he should look at his computer. It was then apparent that he was not wearing one. Twice we had exceeded a ppO2 of 2.2 bar, and I was peeved that as I was older, it would be me most likely to get injured by this miss-adventure.

When we finally reached the surface, I rather angrily told him that he could not be doing such a wall dive in clear water without any way of knowing what his depth was. He retorted that he had not worn his computer because it had broken. It went into SOS mode on the previous dive. He should not have even been in the water!

He was one of the first groups of divers I mention, but luckily he appeared to suffer no ill-effects, and we flew home to the UK twenty-four hours later.

According to the book, we should both be dead or at least injured.

The majority of amateur divers appear to fall into the second group, and a few are quick to criticise anyone who breaks the training agency rules irrespective of circumstances. I know one, for example, who sent a stinking letter to Diver Magazine after I wrote and published a report on a Nitrox gas-switching computer and had revealed that I had dived with two independent tanks, one filled with air and the other with Nitrox 36. I used the air tank for the deeper part of my dive and switched over only to the other once I had reached a shallow enough depth so that I did not exceed a ppO2 of 1.4 bar. I then switched the computer setting to match.

He was angry that I had taken a tank of Nitrox beyond its operating depth, even though I was not breathing from it. He chose

to ignore the fact that the other divers in my group were using single tanks, as was normal for that sort of leisure dive. I, on my part, had presumed I had added safety by taking two tanks. He wanted to know what I would have done at 50 metres of depth if my regulator had suddenly ceased to work.

In that event, I would have breathed off the regulator with the Nitrox 36 and ascended immediately to a safe depth.

Oxygen toxicity is affected by exposure both in time as well as depth/pressure.

I find that the format of two independent tanks, one containing air and one of Nitrox to be useful for certain dives, although it is not featured in any training manual to my knowledge. Diving on the wreck of the San Francisco Maru in Truk Lagoon, for example, it is convenient to breathe air from the bottom and then switch over to the Nitrox tank to speed up decompression (or add safety) once the A-Frame of the wreck is attained at around 30 metres deep.

A friend of mine, a man who prefers living life risk free, went all the way to Truk Lagoon but omitted to do this the most famous and probably the best dive at the location, because he had not done a technical diving course. It was his choice and who am I to object? My wife enjoyed several dives on the San Francisco Maru. She reads a novel while doing the long decompression stops that are required (even with Nitrox 32 in the second tank) on the decompression bar of our dive boat, mv.Odyssey. She never once put the wrong regulator in her mouth because she started with air and only switched to the other regulator when she reached shallow enough depth, changing her computer mix setting to match. It is not rocket science, but it is not in the book. It is if you side-sling the tank but not if you wear it on your back.

Of course, this is not a substitute for technical diving with twin tanks of bottom gas, plus a sling-tank of travel gas and another of deco gas on dives that require that. It is just a way of adding safety to a leisure dive that others might do on a single tank.

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Photo by John Bantin

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John Bantin’s new book is now available on Amazon: http://www.amazon.co.uk/Amazing-Diving-StoriesIncredible-Beneath/dp/1909911151/ref=sr_1_1?ie=UTF 8&qid=1412777237&sr=8-1&keywords=john+bantin

Photo by John Bantin

Before the term 'technical diving’ was coined, I dived with technological diving pioneer Rob Palmer using three mixes and four tanks. However, in those longgone days, contrary to common practice now, I carried my travel gas and my deco gas on my back and side-slung my tanks of bottom gas in the belief that I would always need to travel and decompress, but I might decide to jettison my sling-tanks.

Of course, I would never tell you that. You might think I was a dilettante!

People love rules and love to apply the rules to others before they have stopped to think about the ramifications.

When I first did a formal side-mount course, we got an angry letter from someone who insisted that tanks should have a manifold in case of a regulator failure. They did not stop to think that with side-mounts, you had complete control of tank valves without any party-trick manoeuvres and can access all the gas out from a tank, even if that particular regulator is in a permanent free-flow mode.

Funnily enough, I have often dived with that third group of divers who know what is in the book but also know it was written by people like themselves. For example, back in the day when the Belgian Navy was working with a max. ppO2 of 2.2 bar, many pioneer divers like Rob Palmer decided that, as there was no record of anyone suffering a ppO2 hit at more than 1.6 bar, it should be the limit for maximum operating depths.

Later, the training agencies formalised things and decided that they wanted to be ‘safer’. It was as much a political decision as a technological one.

One technological training agency went for a limit of 1.5 bar whereas another bigger one decided on 1.4 bar. The BSAC committee, as ever compromising, at first decided, therefore, to settle on a limit of 1.45 bar until someone realised it would make the math near impossible for the intellectually challenged diver. The fact about the matter is that this is all about numbers. I am told by a hyperbaric chamber operator who habitually recompressed

people to the equivalent of 18 metres (close to a ppO2 or 2 bar) using pure oxygen that the perceived wisdom is that they should expect an oxygen toxicity hit among patients in the order of one-in-tenthousand, but I certainly do not recommend you test that underwater.

There are training agencies that suggest a diver should use a helium mix if going deeper than 30 metres. It is a recommendation I dove at Bikini Atoll with Fabio Amaral at a time when it was impossible to get helium at such a remote spot. We regularly dove to 55 metres deep twice a day, using air and decompressing on Nitrox80 once we were back up to 9 metres. I do not think there is any record of any of the large numbers of divers hosted by him or the dive-guides that came after him at Bikini Atoll Divers ever getting an oxygen hit.

The founders of the original technical training agencies often do deep descents using air, but once they started the technical diving agencies. They had to stop because it was not in the books of rules they had written. To be caught breaking their own 'rules would have been commercial and political dynamite. The ‘book’ was designed to encompass the needs of those in the group of divers I mentioned – not highly experienced ex-US Navy divers.

Back in the day when I started diving we had a choice of air to breathe or nothing.

We believed that it was unsafe to exceed 80 metres, so we never exceeded 65metres.

That was when diving was dangerous and sex was safe!

A of ppO2 of 1.4 bar, air will only allow you to get to 54 metres deep and by the latest books, you should be out-of-your-head with nitrogen narcosis at that point. Watch out for my next blog. I am sure it will be just as contentious!

By John bantin

rebreather diver & author 61

DIVER MEDIC & AQUATIC SAFETY

A Tragic Accident or Homicidal Drowning?

Andrea Zaferes and Walt Hendrick, Lifeguard Systems and RIPTIDE az@teamlgs.com www.teamlgs.com • An adolescent drowns in a lake where he frequently swam, and it is ruled accidental. Twenty years later his brother confesses that he and his friends watched a man drown the teenager.

• A woman is found drowned in a bathtub. The ruling is accidental drowning. When the woman’s husband drowns his second wife, the truth is discovered. Both were murders.

*RIPTIDE and a private investigator. Find blatant red flags of foul play.

• A boyfriend strangles his girlfriend and then places her body in the bathtub to stage her death as an accidental drowning.

• A man strangles his wife to death, places her body in her vehicle, submerges the vehicle to stage an accidental drowning due to a traffic accident.

• An investigation for possible foul play ensues when a non-swimmer, a college student is reported missing. When he is found submerged off a friend’s dock, the investigation • An infant is intentionally drowned in a sink by his mother’s boyfriend, who then dries the infant, dresses him with a immediately ceases. Accidental drowning is ruled. Later, 62

ISSUE 02 | NOVEMBER 2014

demonstrated that a large percentage of drowning incidents are homicides staged as accidental drowning, either not sufficiently investigated or not investigated at all. There are several reasons for this. “Tragic accident” is too common as a mindset – one that can cause tunnel vision.

The warning signs normally found on homicide victims or at the scenes are rarely present, and law enforcement and medical personnel are not trained to recognise the red flags specific to homicidal drowning. The body may not have been recovered. Rescue personnel may destroy evidence. Because drowning evidence is usually circumstantial rather than hard, cases are difficult to investigate and prosecute. Hence drowning cases may be pushed back when case loads are heavy. The drowning determination by a process of exclusion can make it difficult to prove whether a victim drowned or was disposed of in the water. Witnesses are often “grieving” family members, which adds to the “tragic accident” mindset.

Very importantly, if a drowning is investigated, it is usually motivated by hindsight, after valuable scene evidence has been lost. Therefore, a standard information-gathering incident form to use on every drowning incident would be very helpful.

We believe that as many as twenty percent of child drowning incidents may be homicides. And as we learn more, we suspect that “female” may be a red flag for foul play in illogical child and adult drowning.

Land and water deaths are treated differently. A hunter finds the body of a young man in the woods. A detective, crime scene technician, and coroner arrive to search for signs of foul play. The site is taped off, and an officer is stationed to prevent scene contamination. The exact position and condition of the body are documented. Potential evidence is collected.

Photo by 1000 Words / Shutterstock.com dry diaper, and places him on the changing table to stage a SIDS death (Sudden Infant Death Syndrome). The death is ruled as SIDS until new information is obtained and a second autopsy is performed; the manner is ruled as homicide and the young man is convicted.

The initial determinations of these incidents as accidental drowning events are not uncommon. What we believe is unusual is the discovery of their red flags and the ensuing investigations. How many other homicides are being missed? We believe far too many.

Our experience with thousands of law enforcement units, dive teams, and medical personnel internationally has

What if a fisherman discovers this body underwater, and similarly, neither the cause nor the manner of death is obvious? Our experience shows that “accidental drowning” is the most likely mindset for arriving personnel. The dive team is called in to recover the body, which may or may not be bagged as it is dragged to shore. Are the body’s exact condition and location documented, along with wind, current, and depth? Are water samples taken? Are detectives and a medical examiner called in? Are the underwater and shore areas taped off and searched for possible evidence? Many departments have to answer “no” to most, or all, of these questions.

Compare a dispatch for a toddler found dead positioned at the bottom of basement steps in her home. Compared to a call for a toddler found drowned in a bathtub. The crying mother states that she went to answer the phone, was gone for less than two minutes, and when she returned, found Sally not moving. How are these incidents managed? Are crime scene 63

DIVER MEDIC & AQUATIC SAFETY

technicians called in? Is the house well photographed? Are scene temperatures taken? Are family members, neighbours, and babysitters interviewed? Is the family checked for any previous child or spouse deaths? The answers are likely to be “yes” for the basement incident and “no” for the drowning. Without obvious evidence, to the contrary, the occurrence of drowning is typically treated as a tragic accident.

The tendency to see drowning incidents as accidents may cause red flags and evidence to be missed at every level of personnel from first responders to medical examiners.

Compounding this is that drowning scenes present little or no typical signs of foul play. Victim trauma, signs of struggle at the scene, and signs of previous abuse, are not typically visible to pure-drowning homicide incidents (i.e. no other violence or cause of death other than drowning).

We are quick to perceive foul play when victims have a bullet in their head or bricks tied to their body, or when the available information is illogical. The vast majority of drowning homicides that do get declared in research papers and coroner accounts involve additional forms of violence, such as strangulation, stabbing, or beating.This is not evidence that the majority of drowning homicides include other forms of violence; rather it more likely demonstrates that police and medical personnel more frequently recognise such aggravated drowning homicide incidents, miss, or fail to gain convictions on, pure-drowning homicides.

Holding a child’s head underwater in a tub takes not much effort. The small amount of water splashed from the tub is easily wiped away. A non-swimmer pushed into deeper water may not even have subcutaneous bruising. Pure-drowning homicides can be medically undetectable, are effortless to perform, require no perpetrator skill, require little or no clean up. The body does not need to be disposed of, and the perpetrator often receives much sympathetic attention and possibly accidental death life insurance money.

• A father calls for help when his four-year-old son drowns in a bathtub. Deputies find the father performing CPR. RIPTIDE contacted the investigators, who had accepted accidental drowning, and helped investigators obtain a confession of premeditated murder.

• An infant death is ruled as SIDS by an experienced medical examiner. A later ‘tip’ sparks an investigation. The mother’s boyfriend drowned the infant in a sink because it cried.

• While on a boat with her family, a young girl falls out and drowns. Accidental drowning is ruled. Two years later the mother admits that the father hit the girl out of the boat.

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Photo by Takasu

Keep your investigative mind alert when responding to drowning incidents. Ensure that hospital physicians notify police about all drowned or near-drowned patients.

Pathologists should routinely check the full torso for subcutaneous bruising and other signs of foul play on drowning victims. This is especially important when there are no witnesses, the witnesses knew the victim prior to death, or when the drowning incident seems illogical. If examination of the victim’s lungs does not show evidence of water aspiration, other causes of death must be considered. Departments should consider homicidal drowning investigation training.

We also recommend a standard incident form be used on all drowning incidents to better collect and recognise potentially valuable evidence of foul play. This record would also provide research data. If you would like a sample of such a form to review, please contact us.

ISSUE 02 | NOVEMBER 2014

"The tendency to see drowning incidents as accidents may cause red flags and evidence to be missed at every level of personnel from first responders to medical examiners"

*RIPTIDE, a nonprofit organisation, devoted to homicidal drowning investigation and research, recovery operations, and public safety diver and water rescue technician accident prevention.

If you have, or have had, any drowning incidents, please contact us. RIPTIDE, a non-profit organisation, collects case files, autopsy reports, scene and autopsy photographs, and 911 tapes for analysis. The data is used to help medics, law enforcement, prosecutors, coroners, and pathologists identify whether a drowning is accidental, suicidal or homicidal. RIPTIDE also offers assistance with investigations. We also look forward to your questions and comments and to sharing information: RIPTIDE Tel/fax (845) 657-5544, POB 594 Shokan NY 12481, Fax 845-657-5549 az@teamlgs.com

References: 1. Copeland A. Homicidal drowning. Forensic Sci Internat 1986; 31:247-252.

2. Fanton L, Miras A, Tilhet-Coartet S, et al. The perfect crime: myth or reality? Am J Forensic Med Pathol 1998; 19:290-293.

3. Lucas J, Goldfeder LB, Gill JR. Bodies found in the waterways of New York City. J Forensic Sci 2002; 47:137-141.

4. Missliwetz J. Stellwag-Carion C. Six cases of premeditated murder of adults by drowning. Arch Kriminol 1995; 195:75-84.

5. Oishi F. A typical case of homicide and head injuries. Tokyo ika daigaku Zasshi 1970; 28:541-548.

6. Pollanen MS. Diatoms and homicide. Forensic Sci Internat 1998; 91:29-34.

7. Trubner K, Puschel K. Todesfalle in der Badewanne. Arch Kriminol 1991; 188:35-46.

8. Heinemann A, Pusche K. Discrepancies in homicide statistics by suffocation. 1996; 197:129-141.

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A very special case

by Dr Anke Fabian Photo by Filipe Frazao

ISSUE 02 | NOVEMBER 2014

The 27-year-old T is a PADI Open Water Diver with 40 dives. He undertook his first diving course in Australia, in 1998, holding a valid dive medical

Incident number one In 2000, T (as we have decided to call him for convenience) again went backpacking to Australia. He booked a two-day diving safari going to the outer Great Barrier Reef.

He completed seven dives in 48 hours, but well - he had booked a non-limit diving package after all. He dove in a three millimetre Long John Neoprene suit, 15 litre cylinder (compressed air) and a Mares Tutor dive computer. The dives went well with clean profiles between 33 metre and 15 metre without any problems. Besides the regular safety stop, the profiles were of non-decompression type, and the dive computer kept astonishingly quiet considering the amount of residual nitrogen times he had collected. Four hours after the last dive T developed pain in the right shoulder, especially while lifting up his arm, and a rash with itchiness, mainly on his body stem. The well-trained crew reacted promptly, and T received four sessions of 30 minutes of 100% oxygen. Already on arrival in the harbour, the symptoms almost ceased. The consulting hotel doctor didn’t initiate a further recompression treatment. The shoulder still hurt a little, but not a lot.

Everything was not as bad as it could have been and T was happy that he had gotten off as lightly as this. Just 48 hours after this incident T laced his backpack on his shoulders and flew home to Germany. During his travels – at the stop-over in Singapore, he suffered repetitive pain in his right shoulder. No skin rash or itchiness - the 'diver’s fleas' seemed not to have travelled with him. Nevertheless, T reconsidered. Was there not something he heard in his diving course about decompression sickness symptoms getting worse while flying?

After landing in Germany, T introduced himself to a German centre for diving and hyperbaric medicine with the question of decompression sickness. After analysing the dive profiles, a physical examination and considering the symptoms, the diver medical specialist decided for a late recompression treatment under the diagnosis DCS type 1 with shoulder bends. In 'dubio pro reo' (when in doubt). It worked. Following five recompression treatments (HBOT schedule) T was free of symptoms. That apparently verified the diagnosis.

Three months later, T went for a renewal of his dive medical and was happy to get cleared by the diver medical specialist.

DIVER MEDIC & AQUATIC SAFETY

Photo by Tachjang

Incident number TWO Then, 12 weeks after the first incident, T dared to go back diving in a local lake. He wore a seven millimetre neoprene suit with hood and gloves, a 12 litre air tank and his usual Mares dive computer.

It was meant to be a “psychological comfortable dive” with the simple task to fix some underwater buoys in ten metres depth.

What started worry-free turned out to be quite strenuous and after 20 minutes bottom time, the scuba tank was down to 60bar. The happiness about a successful dive lasted only a short time as the well-known symptoms came back after the dive: severe shoulder pain on the right side and skin rashes with itchiness all over the body excluding the face. The symptoms did not allow disassembling his dive gear himself.

Really shocked, he immediately went to the nearest deco chamber and once again received a recompression treatment (US Navy table 5 and follow up HBOT schedules). Like the first time, the improvement was considerable and recompression could be ended after six treatments with the patient being free of all symptoms.

By now, the dive doctor reconsidered. Well, the treatment had worked out and improved the patient’s condition, but how can those symptoms possibly occur after such a dive profile? A mere 20 minutes at 10 metres do not justify even the diagnosis of a non-deserved DCS. It was time for a thorough investigation. Could it be due to a *PFO? However, thereupon a comprehensive bubble test proved negative. Everything was determined to be ok here.

Maybe it is an allergy? The diver was examined by a dermatologist, but all tests on typical allergens came out negative. Nothing discoverable there. Could it be a shoulder disorder? The orthopaedic examination of the shoulder was positive and showed the symptoms of a so-called Rotator Cuff Syndrome. This is a disorder of a certain group of muscles around the shoulder known to be very painful while lifting up the arm or rotating it backwards.

Well, did the diver have an infestation of “lice and fleas”? What about the possibility of DCS and an orthopaedic disorder? The orthopaedic doctor prescribed physiotherapy and antiphlogistics.

The dive doctor prescribed a “ban to dive” for at least three months and asked the diver to make a follow-up appointment for himself after completion of that period. * A Foramen Ovale is a small hole located in the atrial septum that is used during fetal circulation to speed up the travel of blood through the heart. Normally the foramen ovale closes at birth when increased blood pressure on the left side of the heart forces the opening to close. If the atrial septum does not close properly, it is called a patent foramen ovale.

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"the well-known symptoms came back after the dive: severe shoulder pain on the right side and skin rashes with itchiness all over the body"

ISSUE 02 | NOVEMBER 2014

Incident number THREE AND A SOLUTION TO THE PROBLEM After three months, the diver introduced himself to the consulting rooms of the dive doctor.

He was completely free of symptoms. The physical examination was without pathological findings. T was given a new dive medical. The doctor was careful though and recommended a shallow test dive. T felt a little anxious while walking the 200 metre from the parking lot to the shore entry of a local lake wearing his seven millimetre neoprene suit, hood and 12 litre cylinder. He descended for 10 minutes to five metres and ascended at a snail’s pace.

The result: shoulder pain on the right side, skin rash and itchiness.

By now, the dive doctor was not surprised. He sent T to do an MRI of the right shoulder and asked him to come in the ambulance the next day bringing his diving suit, BCD and tank.

He asked T to gear up and just walk ten minutes inside the centre. The result: shoulder pain on the right side, skin rash and itchiness. All symptoms occurred on dry land!

PROBLEM SOLVED The MRI showed a partly ruptured Rotator Cuff. The symptoms deteriorated regularly caused by the weight and pressure load on the shoulder by the BCD and cylinder. The dermatologist’s test for a neoprene allergy showed positive. HBOT therapy reliably worked due to its high anti-inflammatory and decongestant effect.

Diagnosis Deterioration of a pre-existing rotator cuff syndrome, neoprene allergy, DCS could be excluded.

Conclusion Not every joint pain and skin disorder which occurs in diving is related to DCS. Itchiness after diving does not prove diver has fleas.

Meantime, T is back in the water. He is diving in a neoprene-free, dry suit or Lycra stinger suit. The shoulder was operated on successfully. He could undertake an advanced diving course, and the dive doctors had a chance to learn something from this example.

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PUBLIC SAFETY DIVE TRAINING SEMINARS

WITH INTERNATIONALLY RENOWNED GUEST SPEAKER ANDREA ZAFERES

UK DIVING & AQUATIC SAFETY SEMINAR NOVEMBER 2014 Aquatic Death and Homicidal Drowning Investigation 18/19 November with optional day 20th November doing hands on investigation - £250 (£50 for extra day) Two day course 27/28 November - £250

Underwater Forensic Seminar for Civilians 24 & 25 November (1 day courses) - £85 each

Sport Diving Contingency Plan Workshop 24 & 25 November (6:30pm - 9:30pm) - Two evenings fee: £85

Field Neurological Evaluation 22 November (two days - £120 plus £20 for NAUI/PADI/ACUC certification card. Venue: London (9am-5:30pm)

Ultimate Underwater Movement 23 November (one day - 3hrs workshop/3hrs pool work) - £85

Photo by Jovana Milanko

For more information visit: www.DMAASM.com chrissie@dmaasm.com 07912 123 703

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The course consists of theory and practical sessions covering a vast array of subject areas.

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Photo by Sebastian Kaulitzki