detroit diver
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I received this email from a friend of mine a couple of days ago. She has given me permission to post this so that we might learn something from this tragic situation. She is a registered nurse, so some of this has medical terms that you might not be aware of. She returned from this trip last week.
I think there are a number of things that we can learn from this incident, but I'd like to know what all of you think about this.
"Ya'll know I went to Palau and Yap for a dive vacation. I was on a Peter Hughes live-aboard in Palau. It was the 2nd day, and there were 17 guests.
We dove a site called Pelilieu Cut. It starts out as a wall dive with a current similar to Cozumel. No big deal. The plateau ends in a point so the current meets, and it's high velocity. But it's where all the big stuff hangs out. (I swam with a marlin on my safety stop when I repeated this site, and there were a ton of shark). So the plan was to get dropped off in the blue by a tender, dive the wall for a bit (10 min or so), ascend to the crest of the plateau (40 feet) and hook the reef. My dive was all good. I was comfortable on the wall, and I had my hook out for the crest. But once I went over it, the current was ripping. One of my buddies (I dove with 2 guys all week--that's a whole other novel in itself.... I essentially was a solo diver the whole vacation.) grabbed me as I came over the crest because I was having trouble hooking. I hooked, but our combined body weight broke his hook, and he went downstream. The coral head I was hooked on promptly broke off, and I scrambled to hook again. Moments later, I was getting oriented. I noticed a female guest was next to me, and her mask was off. I thought it'd be scary for her to be blind and not know if anyone was around, so I grabbed her hand to reassure her. It was limp. I further assessed her and noted that her weight belt was off, 6 feet behind her. Her BCD was open with the hook on her right shoulder (it should be centrally located so you can disconnect it easily). Her eyes were closed, there were no exhaust bubbles (the reg was in her mouth), and she had plenty of air in her tank according to her gauge.
I tried to grab her with my right arm and disengage her hook with my left hand. I had a hard time fighting the current. I was reaching for my knife when the divemaster swam up and he cut the line and took her to the surface. I couldn't even unhook myself! I cut my own line and ascended to the surface.
I waited 18 min. at the surface. I was alone, but swam up to 2 buddy groups (they were 2 instructors and 2 new divers with only 12 dives each). They weren't dropped off in the blue, but on the plateau so they did a drift dive at 20 feet in the ripping current, and aborted the dive. They had no idea of what I'd seen at depth.
The tender had taken the victim to the big boat. There were 13 divers in the water that had to be picked up by the tender, so that's why I was on the surface for 18 min. There were 6 feet swells, and I had to breathe off my reg.
When I got on the tender, the husband was on board, and he had no idea. He thought she had only lost her fin.
We pull up along side the big boat, and I see a couple of guests performing CPR on the woman. I hopped on board and assessed the situation. They were doing effective CPR and were bagging her with 100% O2. In the meantime, we got an AED and a med box from the Aggressor. So I consolidated everything and evaluated what to do. There was one endotracheal tube, one IV catheter, 2 liter bags of saline, 3 cardiac bristojets (epi, NaCO3, atropine) and a bunch of epi pens (like what people use if they're allergic to bee stings).
Her mouth was full of water, so I did a finger sweep and removed the food particles and rubber bands off her braces. We tilted her in recovery position briefly to "drain" her, and then she was intubated. I gave the epi down the OET and bagged her. It wasn't effective in stimulating her heart. I put the IV in and ran the fluids wide open, and gave the bicarb and atropine. I consolidated a couple of the epi pens and gave them.
CPR had been going on for about an hour, and she miraculously regained her heart rate and spontaneous respirations. (It was agonal; therefore, no effective alone, so she was continued to be ventilated by hand with the ambu-bag on 100% O2.)
Timeframe check: We started the dive around 0800. Her heart rate came back at 0925, so she was down for approx. and hour and 1/2. That translates into poor perfusion of her brain=anoxic injury. (She wasn't fully "brain dead" because she was spontaneously breathing, although it was agonal, indicative of brain stem injury.)
We cut her wet suit off and applied dry blankets to warm her up. (the water temp was 84*F, air temp in the mid-80s) We strapped her to a back board, and lifted her to the tender. It's a faster boat, but it still took an hour to get to town.
I had 4 male guests help put her in the boat, and put them to work. One ventilated, one held the IV bag, and another continuously monitored her radial pulse. During the boat ride, 3 times the victim became bradycardic, and I gave her an epi pen. (I only had 3 left.) Her heart rate would tach away for a short while, and then slow down as the drug wore off. I supposed she was hypotensive, although I used up almost all the IV fluid and had no vasopressors. (Her nose and finger tips were showing lividity from lack of perfusion, whether from being hypotensive or clamping down from the epi is unclear.) Her pupils were mid-sized and fixed and she wasn't spontaneously moving any of her extremities or opening her eyes. (these indicate significant brain injury)
Once we got to the hospital, it was almost as bad as the boat. The crazy white girl went on a rampage. They knew we were coming, yet had no vent, no EKG, no pressors,.... I had an AED (but she was bradycardic or asystolic so I couldn't use it), but I hooked them up to their defibrillator and got an EKG reading. She was tachy in the 110s, with a significant ST elevation. Her BP was 70 palp. I requested some dopamine (a common pressor) and they didn't know what it was. So I put in 2 more IVs and hooked up some fluids at wide open to augment her BP.
Did I mention there was no vent? It took almost 1/2 hour for it to arrive, so she was bagged on 100% O2. Her pulse ox was 82% (normal=>95%). She more than likely wasn't oxygenating because of the near-drowning injury. I didn't have suction on the boat, and they didn't have it in the ER either.
I wanted to do an arterial blood gas (a common test that measures the gas levels in the blood) and they couldn't perform it. They didn't have the machinery.
I was in combat mode, bossing everyone. The MD in charge escorted me out to debrief. He was only a family practice doctor, but he was an American.
She ended up being "stabilized" and airlifted to Guam the next day. She died 3 days after the accident. (I don't know if her husband withdrew life support, or if she went into ARDS/pneumonia which lead to cardiac arrest.)
The fact that she "came back" after >1 hour of CPR is nothing short of miraculous. In the hospital, if a patient is in asystole for > 1/2 hour, everything is stopped. If you don't get a rhythm or any response after that long, it's not going to happen. (We call that "being dead" or "being really dead". A person with v-fib or v-tach has no pulse so is technically dead, but there's some electrical/physical activity still present, so it's possible to "reset" the heart by shocking it and augmenting the strength of the contractions with pressors. In asystole, there's nothing. So no oxygen is getting to the heart and brain, even though CPR may be in progress. The person is "really dead." It's not enough to perfuse the organs, so the person just becomes deader and deader. Does that make sense? So the fact that she was "dead" for > 1 hour, and had a heart rate is, again, miraculous.)
Back on the boat, we all "debriefed". Piecing the story together, the scenario goes as follows: The victim hooked on the reef. She lost a fin in the current, perhaps looked back to assess the situation, and lost her mask in the process. She panicked, dropped her weight belt, and tried to remove her BCD. What follows next, no one knows. She may have panicked, hyperventilated, and became unconscious. She had an abrasion on her forehead, so she may have hit her head in the current and became unconscious. The end result was that she was unconscious and drown. Although the reg was in her mouth, her nose was exposed, and the current was high velocity, and sea water likely could've entered and filled her lungs.
The time I hooked, discovered her, and the divemaster unhooking her was brief. I sensed no one around me. After the dive, my buddy said he was downstream, and she was released before he was able to get to us. He went to the surface with the DM, and assisted getting her on the tender and starting early CPR. He told me that everyone was downstream and was hooked. Everything that occurred was clearly visible, but no one did anything to help. Her husband was nowhere around, and witnessed nothing.
In my own personal debrief, I considered if there was anything I could've done differently. Rescuing her could've been quicker, I suppose, if I would've grabbed my knife in the first place. But, again, it was pretty quick, the time frame between once I discovered her and when she went to the surface.
An airlift would've been nice, but it wouldn't have changed the outcome.
As far as the drugs.... What good is having them or specialty items (like the OET, IV catheter, etc.) if no one is around that is trained/qualified to use them? This is a vacation live-aboard, not an ICU.
I filled out a bunch of incident reports and sent copies of it to DAN and PADI. Undoubtably the husband will sue Peter Hughes. The claim could be made that the dive site was for an expert diver, and there were many novice divers. There were 17 divers in the water, and one divemaster. Panic situations wern't mentioned in the briefing (for instance, I knew that if I didn't hook in the beginning, it wasn't a big deal. I had plenty of air on my back, and it would've been a longer drift dive.) Perhaps the victim felt obligated to remain hooked, or to hook in even though she wasn't comfortable (instead of just aborting the dive) which exacerbated the situation."
I think there are a number of things that we can learn from this incident, but I'd like to know what all of you think about this.
"Ya'll know I went to Palau and Yap for a dive vacation. I was on a Peter Hughes live-aboard in Palau. It was the 2nd day, and there were 17 guests.
We dove a site called Pelilieu Cut. It starts out as a wall dive with a current similar to Cozumel. No big deal. The plateau ends in a point so the current meets, and it's high velocity. But it's where all the big stuff hangs out. (I swam with a marlin on my safety stop when I repeated this site, and there were a ton of shark). So the plan was to get dropped off in the blue by a tender, dive the wall for a bit (10 min or so), ascend to the crest of the plateau (40 feet) and hook the reef. My dive was all good. I was comfortable on the wall, and I had my hook out for the crest. But once I went over it, the current was ripping. One of my buddies (I dove with 2 guys all week--that's a whole other novel in itself.... I essentially was a solo diver the whole vacation.) grabbed me as I came over the crest because I was having trouble hooking. I hooked, but our combined body weight broke his hook, and he went downstream. The coral head I was hooked on promptly broke off, and I scrambled to hook again. Moments later, I was getting oriented. I noticed a female guest was next to me, and her mask was off. I thought it'd be scary for her to be blind and not know if anyone was around, so I grabbed her hand to reassure her. It was limp. I further assessed her and noted that her weight belt was off, 6 feet behind her. Her BCD was open with the hook on her right shoulder (it should be centrally located so you can disconnect it easily). Her eyes were closed, there were no exhaust bubbles (the reg was in her mouth), and she had plenty of air in her tank according to her gauge.
I tried to grab her with my right arm and disengage her hook with my left hand. I had a hard time fighting the current. I was reaching for my knife when the divemaster swam up and he cut the line and took her to the surface. I couldn't even unhook myself! I cut my own line and ascended to the surface.
I waited 18 min. at the surface. I was alone, but swam up to 2 buddy groups (they were 2 instructors and 2 new divers with only 12 dives each). They weren't dropped off in the blue, but on the plateau so they did a drift dive at 20 feet in the ripping current, and aborted the dive. They had no idea of what I'd seen at depth.
The tender had taken the victim to the big boat. There were 13 divers in the water that had to be picked up by the tender, so that's why I was on the surface for 18 min. There were 6 feet swells, and I had to breathe off my reg.
When I got on the tender, the husband was on board, and he had no idea. He thought she had only lost her fin.
We pull up along side the big boat, and I see a couple of guests performing CPR on the woman. I hopped on board and assessed the situation. They were doing effective CPR and were bagging her with 100% O2. In the meantime, we got an AED and a med box from the Aggressor. So I consolidated everything and evaluated what to do. There was one endotracheal tube, one IV catheter, 2 liter bags of saline, 3 cardiac bristojets (epi, NaCO3, atropine) and a bunch of epi pens (like what people use if they're allergic to bee stings).
Her mouth was full of water, so I did a finger sweep and removed the food particles and rubber bands off her braces. We tilted her in recovery position briefly to "drain" her, and then she was intubated. I gave the epi down the OET and bagged her. It wasn't effective in stimulating her heart. I put the IV in and ran the fluids wide open, and gave the bicarb and atropine. I consolidated a couple of the epi pens and gave them.
CPR had been going on for about an hour, and she miraculously regained her heart rate and spontaneous respirations. (It was agonal; therefore, no effective alone, so she was continued to be ventilated by hand with the ambu-bag on 100% O2.)
Timeframe check: We started the dive around 0800. Her heart rate came back at 0925, so she was down for approx. and hour and 1/2. That translates into poor perfusion of her brain=anoxic injury. (She wasn't fully "brain dead" because she was spontaneously breathing, although it was agonal, indicative of brain stem injury.)
We cut her wet suit off and applied dry blankets to warm her up. (the water temp was 84*F, air temp in the mid-80s) We strapped her to a back board, and lifted her to the tender. It's a faster boat, but it still took an hour to get to town.
I had 4 male guests help put her in the boat, and put them to work. One ventilated, one held the IV bag, and another continuously monitored her radial pulse. During the boat ride, 3 times the victim became bradycardic, and I gave her an epi pen. (I only had 3 left.) Her heart rate would tach away for a short while, and then slow down as the drug wore off. I supposed she was hypotensive, although I used up almost all the IV fluid and had no vasopressors. (Her nose and finger tips were showing lividity from lack of perfusion, whether from being hypotensive or clamping down from the epi is unclear.) Her pupils were mid-sized and fixed and she wasn't spontaneously moving any of her extremities or opening her eyes. (these indicate significant brain injury)
Once we got to the hospital, it was almost as bad as the boat. The crazy white girl went on a rampage. They knew we were coming, yet had no vent, no EKG, no pressors,.... I had an AED (but she was bradycardic or asystolic so I couldn't use it), but I hooked them up to their defibrillator and got an EKG reading. She was tachy in the 110s, with a significant ST elevation. Her BP was 70 palp. I requested some dopamine (a common pressor) and they didn't know what it was. So I put in 2 more IVs and hooked up some fluids at wide open to augment her BP.
Did I mention there was no vent? It took almost 1/2 hour for it to arrive, so she was bagged on 100% O2. Her pulse ox was 82% (normal=>95%). She more than likely wasn't oxygenating because of the near-drowning injury. I didn't have suction on the boat, and they didn't have it in the ER either.
I wanted to do an arterial blood gas (a common test that measures the gas levels in the blood) and they couldn't perform it. They didn't have the machinery.
I was in combat mode, bossing everyone. The MD in charge escorted me out to debrief. He was only a family practice doctor, but he was an American.
She ended up being "stabilized" and airlifted to Guam the next day. She died 3 days after the accident. (I don't know if her husband withdrew life support, or if she went into ARDS/pneumonia which lead to cardiac arrest.)
The fact that she "came back" after >1 hour of CPR is nothing short of miraculous. In the hospital, if a patient is in asystole for > 1/2 hour, everything is stopped. If you don't get a rhythm or any response after that long, it's not going to happen. (We call that "being dead" or "being really dead". A person with v-fib or v-tach has no pulse so is technically dead, but there's some electrical/physical activity still present, so it's possible to "reset" the heart by shocking it and augmenting the strength of the contractions with pressors. In asystole, there's nothing. So no oxygen is getting to the heart and brain, even though CPR may be in progress. The person is "really dead." It's not enough to perfuse the organs, so the person just becomes deader and deader. Does that make sense? So the fact that she was "dead" for > 1 hour, and had a heart rate is, again, miraculous.)
Back on the boat, we all "debriefed". Piecing the story together, the scenario goes as follows: The victim hooked on the reef. She lost a fin in the current, perhaps looked back to assess the situation, and lost her mask in the process. She panicked, dropped her weight belt, and tried to remove her BCD. What follows next, no one knows. She may have panicked, hyperventilated, and became unconscious. She had an abrasion on her forehead, so she may have hit her head in the current and became unconscious. The end result was that she was unconscious and drown. Although the reg was in her mouth, her nose was exposed, and the current was high velocity, and sea water likely could've entered and filled her lungs.
The time I hooked, discovered her, and the divemaster unhooking her was brief. I sensed no one around me. After the dive, my buddy said he was downstream, and she was released before he was able to get to us. He went to the surface with the DM, and assisted getting her on the tender and starting early CPR. He told me that everyone was downstream and was hooked. Everything that occurred was clearly visible, but no one did anything to help. Her husband was nowhere around, and witnessed nothing.
In my own personal debrief, I considered if there was anything I could've done differently. Rescuing her could've been quicker, I suppose, if I would've grabbed my knife in the first place. But, again, it was pretty quick, the time frame between once I discovered her and when she went to the surface.
An airlift would've been nice, but it wouldn't have changed the outcome.
As far as the drugs.... What good is having them or specialty items (like the OET, IV catheter, etc.) if no one is around that is trained/qualified to use them? This is a vacation live-aboard, not an ICU.
I filled out a bunch of incident reports and sent copies of it to DAN and PADI. Undoubtably the husband will sue Peter Hughes. The claim could be made that the dive site was for an expert diver, and there were many novice divers. There were 17 divers in the water, and one divemaster. Panic situations wern't mentioned in the briefing (for instance, I knew that if I didn't hook in the beginning, it wasn't a big deal. I had plenty of air on my back, and it would've been a longer drift dive.) Perhaps the victim felt obligated to remain hooked, or to hook in even though she wasn't comfortable (instead of just aborting the dive) which exacerbated the situation."
