Your Risk Diving in Remote Locations

Some of the best diving on the planet is situated in some of the most inhospitable locations. I guess thats what draws us there. There are things we really need to understand (properly understand) about the actual risks associated with this. Hopefully this text will help you get a better grasp of whether remote location diving is for you.

Technical diving is inherently dangerous and while every effort is made to conduct this expedition safely, there is always the potential risk of injury.  This is why we bring a physician on these trips. This is a substantial advantage for most scenarios. There are some important points you need to understand in relation to the presence of a physician and the treatment they may be able to offer.

Your Medical fitness to partake in remote diving

It’s a known fact, that the older we get, the wider we become, the less fit we are. Our bodies sometimes just don’t work as well as we want them to. Deciding to come on a dive trip located in the far reaches of the world might not be the best idea for you. If you have any medical issues that you need constant medication for, you are 65 or over, markably obese or have never been for a check up from a diving doctor before, that you go and have a full medical examination. In the best interests of your own health and safety, the comfort of others onboard too, having a medical will really help you make an informed decision as to whether this trip is for you or not. Also talking to your doctor and explaining exactly what you are thinking of doing in such a remote location, with little medical facilities and at 30-60 hours away from any western medicine, will also give you perspective. If you are strongly advised against going, this might seem unfair preventing you from fulfilling your lifelong goals, but the alternative is far worse if something happens.  If you want to have a chat, please feel free to contact Pete Mesley

Medical Assistance on Lust4Rust Trips

• First, the physician is not paid for this “service” and there is no fee.  Although they are highly qualified specialists including several among the world’s best known diving physicians, they are not licensed to practice medicine in the location of this expedition.  They are effectively present in the capacity of an on-site “good Samaritan”. They will render assistance whenever possible if you wish, but this cannot be interpreted to mean that they will be unfailingly available 24/7.  For example, they do participate in the diving activities, meaning that they may be unavailable temporarily while they are diving.   
• Second, despite the availability of the physician and a reasonably comprehensive medical kit, it should be clearly understood that the standard of care you may receive in the event of an emergency falls far short of that available in the large comprehensive hospitals found in your home towns. The truth is that medical emergencies are much more likely to result in an unfavourable outcome in remote locations despite the best “heroic efforts” undertaken by those involved. This is not a reflection on the physician’s capability, but merely reflects the fact that this location lacks many of the drugs, instruments, support staff and equipment that might be necessary to comprehensively treat all types of diving and other types of emergencies.
• Third, the most likely significant diving medical emergency is decompression illness (DCI) and there are several potential treatment options. It is important that you carefully consider and, where relevant below, indicate your acceptance (or not) in respect of these options before they are actually needed. The purpose of providing you with this information now is to allow time for you to consider this information and ask questions, and to avoid you having to make decisions in a hurry or under stress if an “emergency” situation should occur. Acceptance of any treatment option is not final and you can always change your mind at any time.  As always it is paramount that divers adhere to accepted safe diving practices and especially safe decompression algorithms and attention to detail in rebreather preparation.  Safety starts with you the diver and is ultimately your responsibility!

The treatments we may recommend for DCI depend to some degree on the severity of the symptoms. Some mild symptoms can be treated adequately with oxygen breathed at the surface alone. This is an option we sometimes suggest for symptoms like pain and rash. This would involve breathing oxygen, probably via a regulator, for several hours to assess the response. We might also suggest the use of intravenous or oral fluids, and drugs like anti-inflammatory pain medication.

The most effective therapy for DCI, especially for more serious symptoms, is recompression and oxygen breathing. The best way of administering this treatment is in a hyperbaric chamber, but recompression can also sometimes be undertaken “in-water”. Either or both of these may be options in the remote location we are visiting. We will discuss each option and its advantages and disadvantages below.

Recompression in a hyperbaric chamber.

Recompression and oxygen breathing in a hyperbaric chamber is the gold standard therapy for DCI. The most common protocol involves initial compression to 2.8 ATA (18msw equivalent) with oxygen breathing (interspersed with several “air breaks”) for about an hour, before decompression to 1.9 ATA (9msw equivalent) for several more hours of oxygen administration (and air breaks). This treatment takes just under 5 hours, but may be lengthened if the symptoms are severe and slow to respond. The chamber is compressed with air, and you breathe oxygen from an oro-nasal mask. You will be accompanied in the chamber, either by the doctor, a nurse (if available) or another diver. The chamber may be small, hot and uncomfortable. Nevertheless, a chamber is usually the safest means of administering hyperbaric oxygen and it will often be our first choice treatment method if available. However, there are some important considerations:

• In the face of very severe symptoms and instability in your condition, we may not be comfortable recompressing you in a locally available chamber at all, and you will need emergency evacuation to a larger and better equipped centre by whatever means we can achieve this. It is vital that you have dive accident insurance if you wish to avoid paying for this yourself. Such situations are extraordinarily rare, but they can and do occur.
• There will often be a charge for chamber use and/or evacuation, and again, it is vital that you have dive accident insurance if you wish to avoid paying this yourself.  These fees can be quite expensive!
• Chambers in remote locations are often not available in a timely fashion if at all, which might force us into considering the in-water recompression option (see below), or proceeding with an evacuation if symptoms are very serious and / or in-water recompression is not feasible or acceptable to you.
• There are risks of hyperbaric oxygen treatment in any chamber. There may be middle or inner ear barotrauma during compression if the occupants fail to equalise pressure in their ears. This is usually not a problem for divers who are used to doing this, but it might be unavoidable in the very rare and unlikely event that we had to recompress an unconscious diver who cannot equalise pressure. There is a risk of cerebral oxygen toxicity, particularly when breathing oxygen at 2.8ATA. The most severe manifestation of this is a seizure (“epileptic type fit”). This can almost always be managed safely without harm to the victim by simply removing the oxygen mask, waiting for the seizure to stop, and allowing the patient to wake up. This occurs in about 1 in 500 – 1000 diver recompressions. There may also be pulmonary oxygen toxicity but this usually involves subtle and reversible symptoms, such as mild chest pain and dry cough, which do not cause significant problems.
• If we use a recompression chamber and the treatment is funded by an insurance company like DAN there will almost certainly be an expectation on the part of that company that there will be no further diving during the trip. They would not likely be prepared to fund further treatment if the diver returned to diving and had another event.  Diving insurers will therefore expect that diving activities will not continue for the remainder of the trip for this diver.
• Even if you have treatment in a hyperbaric chamber, there is no guarantee that it will produce a good outcome.    In very serious cases PERMANENT INJURY AND/OR DEATH COULD RESULT DESPITE ANY RECOMPRESSION OR MEDICAL THERAPY.  Rarely, DCI can even get worse in spite of recompression treatment! You may require multiple recompressions and, in addition, in serious cases your condition may be such that we feel you are best served by evacuation to a better equipped centre either before or immediately after any recompression treatment we can offer locally. We will do our very best to assist with a timely evacuation.  However timely evacuation can be logistically difficult in remote locations.
• If you are able to make your own decisions, your decision is FINAL regarding any treatments so rendered. If you are unable to make decisions (ie unconscious), the physician and/or your dive buddy will act in your best interest to provide the best medical treatment possible given the circumstances.

In-water recompression (IWR)

If the recompression chamber is unavailable, we may consider oxygen breathing in the water at a shallow depth around 6m for a period of up to 2 hours as a treatment option. This is typically done using a down-line suspended from the boat or a buoy, and the diver is accompanied at all times. The process of decision-making about IWR is complex and highly dependent on the circumstances. It is impossible to describe the related decision-making logic applicable to every scenario here. However, in principle, we usually avoid IWR if symptoms are very mild and fall into the category that the diving medicine community believes can be adequately treated with surface oxygen. Similarly, we will not recompress in-water if the patient is too sick to be safe in the water, or there are other patient factors or logistical complications that render the process unsafe. Please note, that the parameters for conducting IWR are very small and all aspects of diver saferty is taken into consideration very carefully.

An advantage of IWR is that it is “universally available” on expeditions like this. We almost invariably have divers with the appropriate training and experience in managing oxygen breathing underwater, and we usually have the equipment to undertake the procedure ready in hand. The most important clinical advantage of IWR is that we can institute it very quickly after the appearance of ominous symptoms, and there is strong anecdotal evidence to support the belief that this rapid response is likely (but not always) going to result in symptom improvement or resolution.

IWR carries a number of risks including the possibility of having to terminate it if the victim’s conditions worsens, and logistic complications arising from cold, adverse environmental conditions, the onset of darkness, poor communications and other factors. The most serious complication is the possibility of cerebral oxygen toxicity with the occurrence of a seizure underwater. This could lead to drowning. This is why we normally avoid the treatment of mild symptoms with IWR; we perceive that the risk may outweigh the benefit. To reduce this risk (unfortunately we cannot eliminate it) we limit the inspired PO2 to approximately 1.6 ATA in most circumstances.

What happens after treatment for DCI?

No matter how treatment is achieved (be it surface oxygen, IWR, or recompression in a chamber) decisions have to be made about what happens next, and these are heavily influenced by the nature of the symptoms and the response to treatment. One of the advantages of having a physician practiced in neurological evaluation on site is that we can be confident in our evaluation of a victim’s condition after we have treated them. If symptoms do not resolve with recompression this will typically contraindicate further diving and signal a need for repeated recompressions. If this cannot be achieved locally (and sometimes even if it can) an evacuation may be necessary, especially if the symptoms are serious.  Such evacuations could and most likely will alter the itinerary of the trip.  The permission of all participants in the trip is implied should the health/welfare of a fellow diver be at risk without evacuation.

If the symptoms do completely resolve with the locally instituted treatment then difficult decisions often arise around the issue of further diving on the trip. It should be clearly understood that the most common advice in non-expedition scenarios following any diagnosis of DCI, even if mild and completely recovered, is for the diver to have a period of abstinence from diving of around a month. This advice is based on little data, especially across the range of mild symptoms, and is deliberately conservative. Nevertheless, it must be clearly understood that if a diver successfully treated for DCI wishes to guarantee against recurrence of symptoms, potentially including more serious manifestations, then they should choose not to dive again on the trip.  If a diver chooses to resume diving after an incident, this choice is obviously contrary to the common advice. Not surprisingly, if you ask the physician to take responsibility by making the decision for you they will have no choice but to advise you not to dive. If you wish to make your own choice, the physician will usually be happy to discuss the relevant issues in detail (see below) so that you can make a properly informed decision.

A choice to return to diving involves highly nuanced and context-sensitive discussions about risk vs benefit in which the physicians are usually happy to participate. These discussions draw heavily on considerations like the severity of the symptoms suffered by the victim and their specificity for DCI. If a diver suffers serious symptoms that were clearly caused by DCI it is likely the physician will INSIST on no further diving, even if there is a full recovery. However, it is recognised that these trips are unique and very expensive opportunities, and that many divers would wish to continue diving after successful treatment for a minor symptom, particularly if there is doubt that it was caused by DCI. This has occurred on these trips in the past where, for example, a diver develops a rash or isolated pain thought due to DCI and successfully treats it with surface oxygen or IWR, has a couple of days off, and chooses to return to more conservative diving (by padding decompression and / or limiting diving to one dive per day). It is reiterated that while the physicians will participate in discussions of these matters, the divers must accept responsibility for making a decision to return to diving, and for any consequences that arise.

In sum, it is well known that technical diving carries with it inherent risks.  We have gone to great lengths to mitigate these risks and constantly re-assess our safety protocols and practice.  While we have thought and prepared for most scenerios it is impossible to be prepared for every possible contingency. Ultimately safety starts and ends with you the diver.

An opportunity to ask questions in relation to any of these matters will be provided before diving begins at the start of the trip

Operators who choose not to have a Chamber & Medical personnel onboard

One of the biggest problems when undertaking remote location diving with operators who are not adequately prepared for such trips is putting added stress on everyone onboard the boat. Let’s say for example, someone comes out the water and they aren’t feeling well at all . They might not know exactly what is wrong with them, but they know that something is not right. There will be a reluctance to come forward to the dive operators and say something is wrong. This could be as a result of a lot of things. Peer pressure, the fear that this might be the end of diving on their “once in a lifetime trip”. Or the fear that if they need treatment, the dive boat will have to head back to shore (some 30 hours away) to evacuate the diver, which will result in the end of the trip for the rest of the boat. So they basically go and hide away in their room and hope for the best that it will all go away. This is not the culture we want to install in divers.

Now, not in all cases can a chamber be carried onboard the vessel or have medically trained people to offer assistance. But as long as everyone knows, understands and acknowledges this BEFORE they sign onto the trip, then when a person gets bent and the trip ends on day 3 of their expedition, it’s been agreed upon beforehand and its just part of the trip. They understand that there are no refunds, no compensation for the trip ending prematurely. No nothing. Thats all part of Expedition Style diving.

Choosing a properly prepared operator will make all the difference.