Lessons to be learned-Death in Palau

[tracydr]

Although this is the most likely cause of the accident I have to wonder if the ST elevations meant that she had an MI< precipitating the entire event?

 

[tracydr]

"I agree that way too many instructors never teach the basics of neutral buoyancy. I hope that this could never be said of me."

Boy is that the case. I was appalled that my best friend just got her c-card and couldn't even dive horizontal. She said that as she was ascending from each dive her feet went above her head. She did every safety stop upside down and still got her card.
My roommate on the live-aboard I did in Sept had never been in the water except for her OWC which she got for that trip. She panicked her first dive because she couldn't clear her ears.
What scares me is that after the 25 dives she did that week she has now gotten her nitrox, advanced, and believe or not her rescue diver!! All with 25 dives plus whatever lake dives she did for her cards.
I have about 150 dives and am just now doing rescue. I'm finding it a challenge but one that I'm now ready for. I can't even imagine trying to do it at 25 dives and feeling that it was worthwhile at that point in my diving. (other than what I learned to save myself!)

I think that inexperienced divers have no idea what dangers lie ahead, esp. on a dive like the one described.
If she didn't know to be frightened, how would she know to abort?

 

[pterantula]

tracydr:

I fully agree that it boggles sensibility when someone can be cert'd "advanced" with so few dives (I did it too, and I questioned it every step of the way...) - but I disagree on your final point: rescue diver training should be done as soon as possible, preferably near OW/AOW training.
Rescue training should really be incorporated into OW, with additional training being geared toward more advanced techniques; if you can't identify stressors and maintain a rational approach to "what the hell do I do NOW!?" from your first few dives, you shouldn't be diving.
Some people have naturally cool responses to stress and potential panic, but many don't, and while stress & rescue courses can't fix this they do at least open your eyes to signs & solutions.

This in itself I believe helps divers identify conditions and situations in which they may be over their heads, where they can decline dangerous dives - something an OW card absolutely does not do.

(I can only guess that S&R courses are kept separate from standard OW/AOW training as part of the gradual dumbing-down of dive training, in the effort to make for easier entry to the industry/sport. If instructors came out and said "Diving: one of the few leisure activities that could easily kill you," we would have a much, much smaller industry....)

 

[emttim]

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 didn't read through the entire thread because I have to go take care of some stuff today, but after seeing CPR rescuscitation after over an hour of being down, I'm simply amazed.

Due to my profession, I was able to understand all the medical terminology, and my question is this: What in the **** is an ER doing without even having a suction!? The fact that the ER you transported the patient to was so poorly equipped to handle run-of-the-mill emergencies means it's an almost certainty that future people will die from the "care" or lack thereof at that facility. I understand not every hospital in the world is going to be like it is in the U.S., but on the other hand, every ER (and hospital) should have basic equipment such as suction.

With a BP of 70/P, HR 110ish, agonal respirations, along with the obvious neurological deficit and the fact she had to be rescuscitated, it was kind of a foregone conclusion that she wasn't going to make it. It's hard enough to get someone back with CPR, but unless I've forgotten the statistics, most people that do come back code later and die. I definitely think this should be an example of why there are limits on every diver's skills that may change quite often but should not be overstepped. Thanks for sharing.

 

[SandCrawler]

I can't say enough about my past instructors. They were passionate about diving, about keeping students alive, and they were independent so they weren't obligated to sales in the dive shop.

That said, the training I'd prefer to see more of would include instructors really testing your comfort level. It might turn off some divers, but isn't that the idea? Is it fair for me to say that instructors should make their best effort to teach and challenge and, if needed, be willing to deny a cert or insist on more training before signing off? "But what about my trip schedule?!"

I guess it's like any other profession... you've got a lot of great instructors, and then you've got a few people out for a buck.

 

[spydeedyves]

I have struggled with the appearance that training, while it is touted as being the paramount issue in diving, is financially motivated. I firmly believe that OW certification should include IN DEPTH training for self rescue. While I understand that time simply could not allow training for every scenario in the OW class, it could and should be included in the written part of the training. As a Marine, Firefighter, Police Officer and father, I could not possibly train for every scenario. However, KNOWING what is out there has allowed me to at least be partially prepared and not panic when the stuff hits the fan. That being said, the operator of any dive site/operation has a responsibility to the divers and the families of the divers using their operation. The training of their divers should be taken into account by those supervising the dive. You can tell me that "I dived beyond my limits, it's my fault." You may be right, but are you willing to look at my wife or children and say this? Did I truly know that I was in over my head? Have I been properly trained to evaluate the dive prior to entering the water? I can say that, as an OW diver, I was not. I have a cool head and am comfortable under water. I try to plan for contingencies in every aspect of my life and have a profound respect for the water and the fact that humans can't survive in that environment without help. I'm not trying to bash any certifying agency or instructor, I just think that we need to change a few aspects about the current training practices as well as who is responsible for whom when facilitating dives. These incidents are tragic and my heart goes out to all who were affected by them.

 

[Code Monkey]

I have a couple things to say in reply to this but I can't figure out how to link them. On the whole, I agree with what you're saying.

Thought one. My wife has always complained that, when we got our open water certification, the implication was that we were ready to dive -- anywhere. I know some dive ops require an advanced certification but we certainly didn't need one to dive Pelileu (sp?). It would be nice if the certification agencies could explain that and explain why you should get further training.

A (slightly) separate point is that, as far as my reading of the DAN statistics each year goes, panic seems to be the number one killer of divers. It's one thing to find yourself over your head (we've all been there) but it's another to panic when it happens. It would be really great if the dive agencies could spend more time on dealing with this aspect of the sport.

 

[kevink]

Who revived this thread and how is it stuck on diver training and training agencies.

There is not a certification in the world (unless someone in Palau is writing one) that is going to teach you to snorkel over the tip of Peleliu and determine if the bottom conditions are acceptable for you and your buddy to attempt the dive. If you want to spend two weeks to a month out there learning how to judge the bottom conditions that would be another story. I spent a year out there.

Part of the reason you take a local guide is to have someone to give you the lay of the land, and hopefully guide you to somewhere that is within your comfort and experience level.

I had a couple of friends come out, get certified, and they were doing Blue Corner before they left (they were not AOW certified either), but they had experience with currents and hooking in.

Does an advanced certification help you at a place like Peleliu? Probably not, but at least 10 drift/hook dives under your belt would certainly be helpful, unless it is a calm day down there.

As far as their being limited medical capabilities out there...It is a country of 20K people in the middle of the pacific. Once you step out of the US, you are on your own forget about helicopters, ALS, ACLS, etc. If you are in the medical trade, and you have some down time on a surface interval, stop in to the hospital/clinic of your tropical locale of choice, they are normally friendly and will afford you some level of professional courtesy. I think I have three under my belt now. You won't find a Level I trauma center, but I have found they were appropriate for the location and population they served.

 

[Thalassamania]

A (slightly) separate point is that, as far as my reading of the DAN statistics each year goes, panic seems to be the number one killer of divers. It's one thing to find yourself over your head (we've all been there) but it's another to panic when it happens. It would be really great if the dive agencies could spend more time on dealing with this aspect of the sport.

More training equals less panic. Do you see any agencies beefing up their entry level course? I don't. All I see is separately priced products that people may or may not deign to take.

 

[Doc Intrepid]

NEW DUDES---

CHECK DATES.

This thread was started in the Spring of 2003.

Before you revive old threads, ensure there is a reason to respond to a five year old thread rather than starting a new one.

Most of the guys and gals in the thread in 2003 are no longer with us today...

Thanks,

Doc