Rescue of an Unconscious Diver Underwater

[boulderjohn]

refer again to the flow chart in the Alert Diver Article Alert Diver | Rescue of an Unconscious Diver ;the most controversial process box contains the legend "Head in neutral position -Ascend according to training agency recommendations". As originally taught by GUE and per UTD's current protocol, the go to DIR method that was always promoted as being the best implementation protocol was the Toxing Diver Rescue Technique.

I am not sure I understand the sentences I quoted above. Allow me to repeat what I think you are saying in my own words so you will have a chance to correct my understanding. You quote the flow chart box that says "Head in neutral position--ascend according to training agency recommendations," and then you indicate that the linked technique is the recommendation of GUE and UTD, so it is according to training agency recommendations.

Let's look at the paragraph that introduces and explains what led to that flow chart:

Our team used the Professional Association of Diving Instructors (PADI) Rescue Diver Manual as a starting point for the expected behavior of a rescue diver assisting a victim. Rescues were analyzed and reviewed in three phases: 1. preparation for ascent to the surface, 2. retrieval of the victim to the surface, and 3. procedures for the care of the victim at the surface. Special considerations for victims found with a rebreather were reviewed for each of these phases.
​

It's pretty clear from that explanation that "training agency recommendations" refers to PADI, not GUE or UTD. Even if the phrase was intended more generically (as in, SSI, SDI, NAUI, etc.), it does not refer directly to the UTD recommendations because in this (and many other situations as well), UTD has non-standard recommendations. If they had wanted you to follow UTD recommendations, that would have been specified, since they differ from what almost all others recommend.

 

[boulderjohn]

Can I be clear there is little room for hard dogma from anyone (including me) in relation to most aspects of this issue. So, I don't pretend to have definitive evidence based answers. However, I would make a couple of comments about that video.

Apparently Dr. Mitchell was not as clear as he had hoped in relation to his use of the word "dogma." As I read it, though, he was referring to the policies and thinking behind the video to which he refers. He is contrasting the approach of science (review evidence, draw conclusions, and then revise old thinking when confronted with new evidence) with the use of dogma (follow the dictates of whoever created the belief under all circumstances).

As you may recall, I was a UTD student for years, almost from the agency's beginning. During that time I was taught to follow the practice in their video. Here are some other quick memories from those years.

• When the first set of instructional materials for decompression theory came out, I gave my instructor a list of places where I had questions because the materials seemed to me to be wrong, or at least inconsistent with accepted decompression theory as I understood it. My instructor's response was that if I did not accept that teaching, then I had better drop out and find a new agency. That process was short circuited when apparently other people said the same thing in other places, and we were told the materials were going to be rewritten.
• Almost at the same time, I attended a webinar on UTD's version of Ratio Deco. One of the participants asked how they knew the system worked. Upon what studies was it based? The webinar instructor was the UTD owner (Andrew Georgitsis), and he said, "You have to have faith." She asked, "Faith in you?" "Yes," he replied.
• UTD contends that altitude does not have to be taken into consideration when planning dives. I was concerned because this contradicted all dive theory that I knew, and our group did all of its diving at altitude. We did some dives at nearly 11,000 feet. I asked Andrew how he knew that altitude had no effect, and he said he knew because he dives at Lake Tahoe without making any adjustments, and he does fine.
• As a part of the altitude discussion, I showed mathematically how gas volume (as in tissue bubbles or BCD/dry suit buoyancy) changes at altitude in comparison to sea level. I was told that the equation I used to make those comparisons made no sense and could be ignored. The equation I used was P1V1=P2V2, commonly known as Boyle's Law.

Those are just some examples of what I consider to be thinking that is governed by dogma rather than scientific reason.

 

[Kevrumbo]

@boulderjohn
@tbeck3579

Because of the ad hoc nature of an Unconscious Diver Rescue, there "is little room for dogma" as @Dr Simon Mitchell stated. Therefore even though he is an authority on Hyperbaric Medicine and diving in general, he admits to no pretense in having "any evidence based answers" to an overall authoritative simple protocol technique and viable solution to this grave scenario. Per the guidelines and flow chart of the review paper, the consensus also acknowledges performing the training protocols of the various diving agencies as instructed.

Summarizing @Dr Simon Mitchell 's professional opinion of the Toxing Diver Rescue Video -there is no guarantee that the victim will not have airway water intrusion during the rescue, and that the victim may end up drowning. But he also admits that since there is no dogma, and only impromptu situation specific procedural guidelines & recommendations with regards to the Toxing/Unconscious Diver Scenario, he "cannot claim that it definitively can't be done" -In other words relative to all other methods of rescue/recovery from depth (uncontrolled buoyant ascent; assisted rescuer controlled ascent w/ & w/o reg in mouth etc), it can't be any better or worse to try this rescue technique, given the risks of task-loading the rescuer and inducing potential comorbid pulmonary barotrauma in the victim.

@tbeck3579 , @boulderjohn : Dive Agency politics aside John (which is clearly off-topic & irrelevant), doesn't that make simple and better sense of what Dr. Mitchell wrote below?

@Dr Simon Mitchell said:
Hello Kev,

Can I be clear there is little room for hard dogma from anyone (including me) in relation to most aspects of this issue. So, I don't pretend to have definitive evidence based answers. However, I would like to make a couple comments about that video. . . There's a good chance that a rescuer would drown a diver in trying to do it [Toxing Diver Rescue]. Nevertheless, I refer back to my comment about dogma above, and have to admit that I cannot definitively claim it can't be done. . .

 

[tbeck3579]

@boulderjohn
@tbeck3579

Because of the ad hoc nature of an Unconscious Diver Rescue, there "is little room for dogma" as Dr. Mitchell stated. Therefore even though he is an authority on Hyperbaric Medicine and diving in general, he admits to no pretense in offering "any evidence based answers" to an overall authoritative simple protocol technique and viable solution to this grave scenario. Per the guidelines and flow chart of the review paper, the consensus also acknowledges performing the training protocols of the various diving agencies as instructed.

Summarizing Dr. Mitchell's professional opinion of the Toxing Diver Rescue Video -there is no guarantee that the victim will not have airway water intrusion during the rescue, and that the victim may end up drowning. But he also admits that since there is no dogma in regards to the Toxing/Unconscious Diver Scenario in general, he "cannot claim that it defintively can't be done" -In other words relative to all other methods of rescue/recovery from depth (uncontrolled buoyant ascent; assisted rescuer controlled ascent w/ & w/o reg in mouth), it can't be any better or worse to try this rescue technique.

@tbeck3579 , @boulderjohn : Dive Agency politics aside John (which is clearly off-topic & irrelevant), doesn't that make simpler sense of what Dr. Mitchell wrote below?

Dr Simon Mitchell said:
Hello Kev,

Can I be clear there is little room for hard dogma from anyone (including me) in relation to most aspects of this issue. So, I don't pretend to have definitive evidence based answers. However, I would like to make a couple comments about that video. . . There's a good chance that a rescuer would drown a diver in trying to do it [Toxing Diver Rescue]. Nevertheless, I refer back to my comment about dogma above, and have to admit that I cannot definitively claim it can't be done. . .
-------

(For reference, here is an example of established Scuba procedural Dogma that we all agree upon: Never hold your breath on a Controlled Emergency Swimming Ascent.)

Operative words: most aspects. Kev, I think everyone here is saying absent better scientific research... and we have decided what is best for us. Nobody here is "poo-pooing" new original thought, but most people will not dive on new original thought without some better evidence. As I said, it is your personal decision. It boils down to you and what you feel is right, and safe, and what you are willing to live with in terms of consequences -- science is not going to change that aspect -- only you can decide what's best for you with the information you have.

 

[Kevrumbo]

Operative words: most aspects. Kev, I think everyone here is saying absent better scientific research... and we have decided what is best for us. Nobody here is "poo-pooing" new original thought, but most people will not dive on new original thought without some better evidence. As I said, it is your personal decision. It boils down to you and what you feel is right, and safe, and what you are willing to live with in terms of consequences -- science is not going to change that aspect -- only you can decide what's best for you with the information you have.

Alright, elaborate on what you think @Dr Simon Mitchell means with the operative words: "most aspects . . ."

@tbeck3579 , this is just trivial semantics now, but go ahead and post objectively what you claim the qualifier "most aspects" refers to. Definitely one of the few aspects where all can absolutely agree that a particular "hard dogma" protocol applies in an Unconscious Diver Scenario is if rescuing the victim will cause serious harm to the rescuer (mandatory decompression obligations for example), therefore the last resort would be to send the victim up in an uncontrolled buoyant ascent to the surface. @tbeck3579 ,you will learn these procedures when you finally get certified and go on to Rescue Diver.

And @tbeck3579 , how would you ethically do "better scientific research" on the best procedures to rescue an Unconscious Diver? Obviously, you cannot directly test such a paradigm without doing serious or grave harm to test subjects, therefore you have to rely on evidentiary anecdotal accident accounts and recommendations from a board of professional experts.

Finally @tbeck3579, @boulderjohn, all @Dr Simon Mitchell was asked for, was his assessment of the Toxing Diver Rescue video. He replied there may be a chance that the victim might drown, but he also equivocated by stating he cannot say defintively that the technique can't be done. There is no other quantitative "better scientific research" that can be done other than offering his best qualitative professional diving and medical opinion.

@Dr Simon Mitchell said:
Hello Kev,

Can I be clear there is little room for hard dogma from anyone (including me) in relation to most aspects of this issue. So, I don't pretend to have definitive evidence based answers. However, I would like to make a couple comments about that video. . . There's a good chance that a rescuer would drown a diver in trying to do it [Toxing Diver Rescue]. Nevertheless, I refer back to my comment about dogma above, and have to admit that I cannot definitively claim it can't be done. . .

 

[IDCBali]

Oh my good, This Theard getting crazy.. Guysss i cant reply you one by one... this is not SPAM Im Real... Sorry if Im not respond.. my porpuse is only share that information...

 

[EricTheDood]

Kev's opinion can't be proven because he doesn't have good research to form a theoretical opinion and therefore can not provide statistical evidence to support it; it's called 'junk" science.

Kev's point is perfectly valid in his example scenario, deco stop at 21m on EANx50. You have a significant deco obligation, so guess what... you're not heading to the surface with a seizing diver. You're either going to shove a reg in his mouth and hope his seizure clears, or send him to the surface... alone.

This isn't "junk science" or "original thought". You've got a limited number of choices, and that's the reality of the situation.

 

[Dr Simon Mitchell]

Perhaps if the toxing diver was at a 6m O2 stop, then just grabbing the diver's head in a neutral position & swimming quickly to the surface would be the best tactic -but what about from a deeper 21m Eanx50 deco stop?

Hello Kev,

Irrespective of the depth, the rescuer will either feel comfortable (from the point of view of their own safety) to bring the diver to the surface immediately or not. If they are comfortable ascending, then they should do so, and more quickly than shown in the video. The consensus among committee members was that if the rescuer does not believe they can do this then they should not attempt to protect / manage the airway underwater during a prolonged ascent; they should make the diver positively buoyant and send them to the surface. This recommendation was based on a perception that effective airway protection underwater is challenging even for a short period, and probably impossible for a sustained period. The committee contained 4 experts in airway management. Having said this, we acknowledged that there are no relevant data, and we gave a balanced account in terms of real world examples. We cited one published case of a diver who was sent buoyant, unconscious and alone to the surface from 70m and who survived. We also cited an unpublished case of a rescuer who allegedly successfully managed a breathing diver's airway for a short period to complete decompression. One point that has not been mentioned in this debate is that many divers found unconscious underwater will not be breathing, and on a rebreather it would be very difficult to tell. If you held a non-breathing diver underwater for a prolonged ascent then they would definitely die.

Thus, to summarise, on balance we believe that rescuers should either bring an unconscious diver directly to the surface (faster than shown in the video), or send them buoyant to the surface. We do not believe that prolonged airway protection and management underwater is a generalizable intervention. That is not to say that it could never be done, and under some circumstances, a diver might be tempted to try it. But that would only be where there was reasonable certainty that all other options are either too dangerous for the rescuer, or non-survivable for the victim (maybe like the scenario you propose below....).

Also if I knew that boat crew surface rescue support would be some distance away because of current and swells for instance, or especially visibility conditions that would preclude the boat crew from immediately spotting the unconscious victim on the surface (i.g. Fog or thick marine layer developing during the dive -both common weather phenomena here in offshore California diving), I would rather take a chance at performing the toxing diver rescue as depicted in the video, instead of sending the victim up alone on an uncontrolled buoyant ascent to ultimately embolize and drown on the surface.

 

[LiteHedded]

Kev's point is perfectly valid in his example scenario, deco stop at 21m on EANx50. You have a significant deco obligation, so guess what... you're not heading to the surface with a seizing diver. You're either going to shove a reg in his mouth and hope his seizure clears, or send him to the surface... alone.

This isn't "junk science" or "original thought". You've got a limited number of choices, and that's the reality of the situation.

if you have a gas load that you feel is so significant (I can't imagine Kev is doing these kind of dives in the ocean) that you're going to send a toxing diver to the surface by himself, you need to have support divers in the water IMO.
I don't personally think launching your buddy to the surface like a polaris missile should ever be on the table. I'd rather be bent on the surface than underwater with a dead dive buddy floating above me. I think that diver's odds of survival are greater with you there keeping his head out of the water than by just hoping someone on a boat sees in time or he lands on the surface face up.

 

[Kevrumbo]

if you have a gas load that you feel is so significant (I can't imagine Kev is doing these kind of dives in the ocean) that you're going to send a toxing diver to the surface by himself, you need to have support divers in the water IMO.

Open Circuit Dives, 60m for 60min BT with minimum 120min deco TTS on Oite Destroyer. Just myself and a dive guide with a dive skiff driver only as surface support.

I don't personally think launching your buddy to the surface like a polaris missile should ever be on the table. I'd rather be bent on the surface than underwater with a dead dive buddy floating above me. I think that diver's odds of survival are greater with you there keeping his head out of the water than by just hoping someone on a boat sees in time or he lands on the surface face up.

Harshest toughest impromptu decision for any diver to make and commit. Agreed that in-water support divers rendezvous at first deco stops would somewhat ameliorate this worst case dilemma scenario.