Article: In-Water Recompression

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This diver Joe, is a total idiot.

You sound quite knowledgeable and experienced in matters relevant to this topic — I would like to subscribe to your newsletter.
 
The author of this article obviously wanted to fluff his feathers and strut his macho ego since he survived his fiasco. He also harks back to a primitive type of diver that have mostly have killed themselves off. Question one is what was he doing at 400 feet? Government ops to that extreme depth would require a chamber onsite. What were the protocols for emergencies established prior to this operation? Hiding with signs and symptoms because of ego is stupid and follows the pattern of irresponsibility prescribed by the author. He delayed his own treatment for 45 minutes while his condition deteriorated. Then, he jumps in like Tarzan and has to be saved from his own stupidity.

To prescribe in water recompression is ludicrous, dangerous and insane. Get to a chamber as quickly as possible. Never go back in the water and risk complications, like convulsions, blackout or pulmonary embolism. Administering pure oxygen is the immediate treatment during transport. It should be available onsite or onboard every diving operation. Most victims exhibit an improved condition and many signs and symptoms are even eliminated upon arrival at a treatment facility.

Sorry, i cannot disagree with you more.....As stated by a few others here, in water recompression saves lives. And if i was an hour from a chamber, heck yes i'd be there....I work in remote locations where a chamber is non-existent and all of our team KNOW in water recompression we are prepared for it with O2 and 50' hoses and regulators and ready to go at a moments notice---and I have been involved on one in-water recompression with one of my team members and two others i know have had their lives saved by in water recompression. Is this article talking to mr. and mrs. Smith to get back in the water with a tank? NO, duh! If you want to know about in water recompression and expand your horizons and skills.....do so. If you TRUST that while on a dive vacation in some remote location where the dive operator tells you they have a portable recompression chamber onboard or one nearby, well---i guess you are trusting. I've been involved in a few on site inspection and training sessions on large boats where they have them, and in most cases nobody knows how to use them....sure they took a course, but that was 8 years ago...then what fun to watch someone put one together---and see them fumble with parts and pieces....once again, TRUST is wonderful till it's you on the line.

I've been involved with in water recompression since 1999 and got the dive tables from a friend and put them to use many time....when covering safety procedures with our team. I think what you wrote is not well thought out and you might know that there are a number of us that do use in water recompression or know how to use it AND, the day it saves your life or that of a friend you'll be damned thankful.
 
…As stated by a few others here, in water recompression saves lives. And if i was an hour from a chamber, heck yes i'd be there....I work in remote locations where a chamber is non-existent and all of our team KNOW in water recompression ….

I concur. This story is more about ignoring symptoms too long, and probably getting flak from superior officers, than IWR itself. I get the impression that many of the anti-IWR posts are not based on the article but a knee-jerk reaction to “IWR is bad” that they read somewhere.

First, Joseph Dituri was a US Navy Diving Officer and recreational rebreather diver at the time, not your average AOW diver. He was physically close to a chamber but didn’t self-diagnose his symptoms accurately or soon enough — a common human condition which is also discussed. Here are two key quotes from the article:

“At the speed with which the symptoms were progressing, I believe I would not have made it. Not with the 10 minute ambulance ride to the chamber, or the almost assuredly 45 minute wait while doctors poured over my trying to figure out what was wrong. ”

<snip>

“I had the fleeting thought to go to the diving medical physician at Mobile Diving Salvage Unit where I was stationed, but was too embarrassed and did not want to face the ridicule or have to explain to the Navy what I was doing at 400 FSW on a weekend while on Liberty. ”

It is clear he knew in hindsight that he screwed up. It is also clear that IWR was effective enough to relieve his most serious and life threatening symptoms. Was his preparation for IWR complete and thorough? No. Was it adequate? Apparently, he’s walking around and able to tell the tale.

I know from career experience that a significant majority of DCS symptoms start subtle to mild. They are easily and commonly self-justified as a skin irritation, strained muscle, or over-worked joint pain. Commercial diving supervisors and divers were very well versed in the symptoms and there was no need to hesitate since a chamber was onboard. The same symptoms would have progressed to serious symptoms in most cases left untreated. We were often not positive it was DCS, but a chamber ride wouldn’t hurt and the diver was often ordered in the chamber within 10 minutes of detecting possible symptoms.

There are a multitude of choices we must make choosing the lesser of evils almost daily. No diver is guaranteed of never getting bent short of never diving deeper than 30'. Going deeper forces the well-informed diver to make a risk-reward assessment based on the dive profile (probability of getting bent) and the time to actually get to 60' on O2 in a chamber. IWR starts looking pretty damn good when that chamber is too far away and your option is dead or counting ceiling tiles in a rest home the rest of your existence. Better to prepare for IWR than either of the last two options… unless of course there is enough space on your dive boat or a 6000 Lb chamber and a couple of 2800 Lb compressors to run it.
 
It is nice to realize that now that some people are recognizing that there is not a one-size-fits-all best answer, we might proceed to developing training guidelines for IWD.
 
It is nice to realize that now that some people are recognizing that there is not a one-size-fits-all best answer, we might proceed to developing training guidelines for IWD.

There is quite a bit published already. Turning this information into a training manual wouldn&#8217;t be difficult. This is an excellent review of the literature and isn&#8217;t that far from a training manual.

In-water Recompression | Rubicon Foundation

---------- Post added July 18th, 2014 at 09:44 AM ----------

A few items are missing from the IWR kits that I have seen. I recommend two hoses from the surface with a valve manifold so the patient or tender/attendant can quickly switch the patient to air. Otherwise the patient has to purge the O2 out of a single hose to the boat. This will get the patient on air faster than switching on the surface in the event of actual or suspected OxTox symptoms. Ideally the tender and patient would be on FFMs with voice communications to the treatment supervisor.

There should also be a couple of stop-watches in the kit to make it easier for the on-deck treatment super to track air breaks. A notebook and pens are also needed to log the treatment.

Another is a weighted hang line attached to a small cherry buoy that is daisy chained to the boat. This will minimize jerking divers when you can&#8217;t the boat to a completely protect anchorage. The boat may actually need to drift if the current is running.

A really-well prepared IWR system would have to include hot sea water to manage hypothermia in all but the warmest waters. A real hot water suit is appropriate if the water is really cold.

Some mention it, but a high nutrition and easily digested liquid drink in a hydration bag is also important. All the recommended kits I have seen include a water hydration bag. You want to avoid chunks if the diver being treated barfs in the mask.
 
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As a true weekender I read all this with a sense of wonder. Would the "average" diver typically be in such a time/chamber crunch? I'm thinking, not. *Most* rec sites are within range of chambers, especially if helio evac is available (it's why I sign up for DAN coverage). So it's balancing the risk of bigger bubbles while breathing O2 during the wait for the evac, against the dangers (tox, chills, OOA, many more i would guess) of resubmerging while waiting for evac to arrive, in order to have smaller bubbles by the time they arrive.

And I/we won't have been to 400 feet.

If I'm in the middle of nowhere, many hours or days' delay for a chamber, then what have I got to lose by going back down? At worse I'll die in the pretty water rather than an aircraft or hospital. But all the risks or resubmerging have to be done perfectly, by experienced people with good crisis skills. Where do we find all this? Out in some far-off locale with tech divers and support staff, I would think, who probably have "what-if'd" it as a dry run and would know what they're doing.

So I think we are debating this for a very small piece of the dive community. Sort of like problems outer space where self-reliance is assumed, compared to ordinary Earth problems.
 
&#8230;So I think we are debating this for a very small piece of the dive community...

No doubt correct. For the most part, IWR is appropriate for expedition dives and liveaboards operating in very remote areas. Everyone agrees that IWR is a sorry substitute for a chamber, but is better than nothing with adequate preparation.

You don&#8217;t have to be a hyperbaric guru to undergo IWR, but the support team needs to be well trained and equipped &#8212; just like running a chamber.
 

The practice of in water recompression is not only dangerous and life-threatening, it harks back to a primitive time before recompression chambers were readily available wherever safe diving is supported.

So let's say you're over 100 miles off shore with no access to a chamber and you become symptomatic? What's your plan?

To prescribe it as a treatment for hyperbaric incidents is not only irresponsible but demonstrates a preponderance of ignorance of proper procedures.

There was just recently a symposium in San Diego discussing the application of this technique where folks like Richard Pyle and other industry experts discussed techniques and their applications. Seems there is some ignorance on your part to the prevalence of the problem and the caliber of diver attempting to solve it.

In water recompression is not an accepted procedure and never a protocol for treatment of a hyperbaric trauma.
Accepted by who? DAN and IANTD seem to disagree with you.

Question one is what was he doing at 400 feet?
Diving?

Government ops to that extreme depth would require a chamber onsite.
Heaven forbid we expect that mere civilians can do things better and more efficiently/effectively than "Government ops". When you sweep dirt and sticks away from your driveway, do you hire two people to stand 100 feet on either end of your driveway holding "SLOW/STOP" signs too?

To prescribe in water recompression is ludicrous, dangerous and insane. Get to a chamber as quickly as possible.
Per your logic: dead if necessary?

---------- Post added July 23rd, 2014 at 09:58 AM ----------

So I think we are debating this for a very small piece of the dive community. Sort of like problems outer space where self-reliance is assumed, compared to ordinary Earth problems.

Sure. The vast majority of divers aren't going to be that far away from a chamber and the vast majority aren't ever going to 400 feet and the vast majority aren't ever going to perform any amount of planned in water decompression. The practice and the example given isn't for the vast majority. For those of us who are pushing limits far away from logistical support, I can appreciate the work that's being done to give us options aside from chartering research vessels with topside chambers.
 
Here are some more IWR references:

Remote Dive Site Decompression Illness &#8211; How to Save a Divers Life
By Bret Gilliam
Posted on: March 20, 2014
In water recompression - How to save a life on a remote dive | SDI | TDI | ERDI

This is an important quote for this discussion:
It must be ingrained in divers to recognize and report DCI symptoms as early as possible. Unless you are dealing with extreme exposures and incomplete decompression, symptoms will usually not present while the diver is still underwater. But upon surfacing the clock is running.

Especially in remote locations with healthy divers, treat when in doubt. You might waist a little oxygen and inconvenience some friends but it may well prevent symptoms progressing that would prevent IWR, lifetime damage, or worse.

From DAN Europe
http://www.daneurope.org/c/document_library/get_file?folderId=13501&name=DLFE-121.pdf

Here is an article on Scubaboard member Doppler&#8217;s blog
Omitted Decompression and In-water Recompression (IWR)? some thoughts | Doppler's Tech Diving Blog
 

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