Why not treat DCS yourself?

[doctormike]

Yeah, I was very happy with the care at Jacobi. From what I understand, they are the only center in the NYC area that does emergency recompression. There are a number of places that do elective cases like wound care, etc...

 

[WetSEAL]

First of all, I really appreciate everyone for throwing in their 2 cents. There is certainly a lot of comment bait that would be tempting to reply to, but upon reflection, I feel like engaging with some of the more personal comments would only distract from and reduce the probability of getting my remaining questions answered.

Therefore, instead of responding to anyone directly, I am going to try and summarize the issue more clearly based on what I have learned from you all, and see if you can help me resolve any remaining confusions. I'm not trying to lecture anyone here. I'm not the expert. I'm the student, so if you disagree with the principles of my assessment below, I'd be happy to hear why (except for pedantic disagreement that is merely made for the purpose of arguing, please don't do that).

The standard recommended treatment for DCS is hyperbaric oxygen therapy. Ie, breathing oxygen under pressure. In a nutshell, this treatment "reduces the injurious effects of systemic gas bubbles by physically reducing their size [due to the increased pressure] and providing improved conditions for elimination of bubbles and excess dissolved gas [by increasing oxygen content in your breathing gas]."
Hyperbaric medicine - Wikipedia

If a diver is equipped with high O2 concentration breathing gas, it is easy to replicate those same two conditions which are known to be helpful (higher pressure, higher O2 concentration). It's much more cost effective than going to the ER/urgent care, and it's also much more timely to simply jump back in, which means that symptoms can potentially resolved much sooner. It is known that the sooner DCS is treated, the better the chances of recovery are. So why, then, it is generally recommended that divers delay immediate IWR treatment in favor of a more expensive and less timely chamber treatment?

Well, there seems to be four primary reasons that I'm hearing for why IWR is dangerous and should generally not be recommended:

1) Conditions in the present moment might make it unsafe for the diver to enter the water. For example, some of the bad symptoms of DCS include seizures, unconsciousness, confusion, unexplained behavior, vision loss, paralysis, vomiting, etc (Decompression sickness - Wikipedia). If the diver is suffering from any of those conditions, IWR is clearly not a safe option. Additionally, there are any number of other reasons -- perhaps lightning storms, equipment failure, etc, and many more.

2) The second reason is that, although DCS conditions might currently be mild and easily manageable...symptoms are known to rapidly get worse over time, so what if some of those terrible aforementioned DCS symptoms (eg, seizures, unconsciousness) were to develop during an IWR session? The result would probably be fatal.

3) The diver might get oxygen toxicity from breathing a high concentration of O2 at depth. Some of the symptoms of oxygen toxicity include convolusions, etc (Oxygen toxicity - Wikipedia) so this could be very dangerous at depth.

4) It's not realistic to stay under the water long enough to simulate the pressure and time conditions that a hyperbaric chamber can offer.

Those are the main reasons I'm hearing for why IWR is generally not recommended. Now let me address them.

I have no disagreement with reason #1 above. If conditions in the moment make getting in the water unsafe, there's no question...a chamber ride is the only option.

I am highly skeptical of reason #2, because we know that when the diver goes under pressure (eg, in a hyperbaric chamber, or under water) this causes an immediate reduction in the physical size of the gas bubbles -- or to quote my first link, "reduces the injurious effects of systemic gas bubbles by physically reducing their size." As such, one would expect some immediate relief of DCS symptoms after going under water (increased pressure), rather than a worsening of DCS symptoms.

Have there been any known examples of a person who has mild DCS symptoms (no seizures), then later developing seizures as a result of DCS, after getting into a hyperbaric chamber / going under water pressure? If not, then this just seems like fear mongering.

As for reason #3, I don't understand why oxygen toxicity during IWR would necessarily be any more of a risk than oxygen toxicity during a standard Nitrox dive. My understanding is that in both cases, you'd simply need to respect the max exposure time limits based on your PP02 in the exact same way as for a Nitrox dive.

For example, if you're breathing 100% O2 at a depth of 15 feet, then that's 1.45 ATM of pressure, so you're PP02 is 1*1.45 = 1.45. According to this table, your maximum safe exposure time for a single dive is somewhere around 135 minutes, or 2 hours and 15 minutes. Shearwater and the CNS Oxygen Clock - Shearwater Research

Obviously, you couldn't use that for calculating a safe IWR time, because this would be at least your second dive, so you'd have to take into account any cumulative oxygen from the previous dive in which you got DCS as well.

So...on point #3, it seems that not every diver is going to have the equipment or knowledge to know how to stay within a safe oxygen level...but for those advanced divers that DO know how to monitor their "oxygen clock" and stay below safety limits for oxygen toxicity, it seems that #3 is not really an unpredictable risk, rather it's something that can be avoided with proper training.

Lastly, on point #4, it may be true that you can't simulate the full pressure and duration of a hyperbaric chamber, but we already know we're talking about a case of mild DCS symptoms (if you had extreme conditions, it wouldn't be safe to enter the water), and even if you can't do it for the full duration as a chamber might, that doesn't seem like a reason not to IWR at all, because you can still at the very least provide immediate relief and reduction of DCS symptoms, and then see if your symptoms after treatment still warrant a chamber trip.

Am I missing something? Because based on this summary, to me, it seems that divers with sufficient Nitrox training to know how to avoid oxygen toxicity would be wise to keep O2 bottles on-hand and consider IWR as a first choice in most circumstances for immediate treatment if they ever show signs of mild DCS...yet for some reason that isn't the recommendation, and I don't understand why not.

My suspicion, and reason for creating this thread, is that it's just simpler to say "go to a chamber" as a catch all, rather than pointing out that if you have the proper training, IWR might actually be cheaper, more immediate, and hence also safer option for mild cases of DCS.

 

[Dsix36]

Something you are missing is that IWR is done much deeper than 15' and the statistics of o2 seizure in water is much higher than in a chamber due to immersion effect. A seizure in itself is not the problem, the result of it during IWR being drowning, is the problem.

 

[Jack Hammer]

I suggest you run the numbers for your CNS % after an hour at 30' on O2.

Hint: it's like 25x what it'd be for an hour at 20'.

 

[GJC]

First of all, I really appreciate everyone for throwing in their 2 cents. There is certainly a lot of comment bait that would be tempting to reply to, but upon reflection, I feel like engaging with some of the more personal comments would only distract from and reduce the probability of getting my remaining questions answered.

Therefore, instead of responding to anyone directly, I am going to try and summarize the issue more clearly based on what I have learned from you all, and see if you can help me resolve any remaining confusions. I'm not trying to lecture anyone here. I'm not the expert. I'm the student, so if you disagree with the principles of my assessment below, I'd be happy to hear why (except for pedantic disagreement that is merely made for the purpose of arguing, please don't do that).

The standard recommended treatment for DCS is hyperbaric oxygen therapy. Ie, breathing oxygen under pressure. In a nutshell, this treatment "reduces the injurious effects of systemic gas bubbles by physically reducing their size [due to the increased pressure] and providing improved conditions for elimination of bubbles and excess dissolved gas [by increasing oxygen content in your breathing gas]."
Hyperbaric medicine - Wikipedia

If a diver is equipped with high O2 concentration breathing gas, it is easy to replicate those same two conditions which are known to be helpful (higher pressure, higher O2 concentration). It's much more cost effective than going to the ER/urgent care, and it's also much more timely to simply jump back in, which means that symptoms can potentially resolved much sooner. It is known that the sooner DCS is treated, the better the chances of recovery are. So why, then, it is generally recommended that divers delay immediate IWR treatment in favor of a more expensive and less timely chamber treatment?

Well, there seems to be four primary reasons that I'm hearing for why IWR is dangerous and should generally not be recommended:

1) Conditions in the present moment might make it unsafe for the diver to enter the water. For example, some of the bad symptoms of DCS include seizures, unconsciousness, confusion, unexplained behavior, vision loss, paralysis, vomiting, etc (Decompression sickness - Wikipedia). If the diver is suffering from any of those conditions, IWR is clearly not a safe option. Additionally, there are any number of other reasons -- perhaps lightning storms, equipment failure, etc, and many more.

2) The second reason is that, although DCS conditions might currently be mild and easily manageable...symptoms are known to rapidly get worse over time, so what if some of those terrible aforementioned DCS symptoms (eg, seizures, unconsciousness) were to develop during an IWR session? The result would probably be fatal.

3) The diver might get oxygen toxicity from breathing a high concentration of O2 at depth. Some of the symptoms of oxygen toxicity include convolusions, etc (Oxygen toxicity - Wikipedia) so this could be very dangerous at depth.

4) It's not realistic to stay under the water long enough to simulate the pressure and time conditions that a hyperbaric chamber can offer.

Those are the main reasons I'm hearing for why IWR is generally not recommended. Now let me address them.

I have no disagreement with reason #1 above. If conditions in the moment make getting in the water unsafe, there's no question...a chamber ride is the only option.

I am highly skeptical of reason #2, because we know that when the diver goes under pressure (eg, in a hyperbaric chamber, or under water) this causes an immediate reduction in the physical size of the gas bubbles -- or to quote my first link, "reduces the injurious effects of systemic gas bubbles by physically reducing their size." As such, one would expect some immediate relief of DCS symptoms after going under water (increased pressure), rather than a worsening of DCS symptoms.

Have there been any known examples of a person who has mild DCS symptoms (no seizures), then later developing seizures as a result of DCS, after getting into a hyperbaric chamber / going under water pressure? If not, then this just seems like fear mongering.

As for reason #3, I don't understand why oxygen toxicity during IWR would necessarily be any more of a risk than oxygen toxicity during a standard Nitrox dive. My understanding is that in both cases, you'd simply need to respect the max exposure time limits based on your PP02 in the exact same way as for a Nitrox dive.

For example, if you're breathing 100% O2 at a depth of 15 feet, then that's 1.45 ATM of pressure, so you're PP02 is 1*1.45 = 1.45. According to this table, your maximum safe exposure time for a single dive is somewhere around 135 minutes, or 2 hours and 15 minutes. Shearwater and the CNS Oxygen Clock - Shearwater Research

Obviously, you couldn't use that for calculating a safe IWR time, because this would be at least your second dive, so you'd have to take into account any cumulative oxygen from the previous dive in which you got DCS as well.

So...on point #3, it seems that not every diver is going to have the equipment or knowledge to know how to stay within a safe oxygen level...but for those advanced divers that DO know how to monitor their "oxygen clock" and stay below safety limits for oxygen toxicity, it seems that #3 is not really an unpredictable risk, rather it's something that can be avoided with proper training.

Lastly, on point #4, it may be true that you can't simulate the full pressure and duration of a hyperbaric chamber, but we already know we're talking about a case of mild DCS symptoms (if you had extreme conditions, it wouldn't be safe to enter the water), and even if you can't do it for the full duration as a chamber might, that doesn't seem like a reason not to IWR at all, because you can still at the very least provide immediate relief and reduction of DCS symptoms, and then see if your symptoms after treatment still warrant a chamber trip.

Am I missing something? Because based on this summary, to me, it seems that divers with sufficient Nitrox training to know how to avoid oxygen toxicity would be wise to keep O2 bottles on-hand and consider IWR as a first choice in most circumstances for immediate treatment if they ever show signs of mild DCS...yet for some reason that isn't the recommendation, and I don't understand why not.

My suspicion, and reason for creating this thread, is that it's just simpler to say "go to a chamber" as a catch all, rather than pointing out that if you have the proper training, IWR might actually be cheaper, more immediate, and hence also safer option for mild cases of DCS.

It looks to me like you under the impression that the faster you start recompression after symptoms the better you will be. This is not true because if you have symptoms, you have bubbles that have formed. Recompression makes the bubbles smaller, but does not drive the gas back into solution (liquid with no bubbles). It only reduces the size of the bubbles. It takes many, many hours for those bubbles to dissolve and go away entirely.

Immediately after the bubbles have formed, tissues of the body are damaged. It may take days to months for those tissues to heal, and some damage may be irreversible.

So once you have symptoms, bubbles have formed and tissue damage has occurred. Initially it's hard to predict how much damage has been done. Immediate in water recompression may make you feel better but it doesn't fix the bubbles (just made them smaller). Unless you are really far far away from a chamber and are prepared to do the same hyperbaric treatment table you would get in a chamber and you have medical professionals on hand that can treat your damaged tissues, you're going to be better off seeking medical care and finding a chamber than attempting in water recompression on your own.

 

[Kevrumbo]

It looks to me like you under the impression that the faster you start recompression after symptoms the better you will be. This is not true because if you have symptoms, you have bubbles that have formed. Recompression makes the bubbles smaller, but does not drive the gas back into solution (liquid with no bubbles). It only reduces the size of the bubbles. It takes many, many hours for those bubbles to dissolve and go away entirely.

Immediately after the bubbles have formed, tissues of the body are damaged. It may take days to months for those tissues to heal, and some damage may be irreversible.

So once you have symptoms, bubbles have formed and tissue damage has occurred. Initially it's hard to predict how much damage has been done. Immediate in water recompression may make you feel better but it doesn't fix the bubbles (just made them smaller). Unless you are really far far away from a chamber and are prepared to do the same hyperbaric treatment table you would get in a chamber and you have medical professionals on hand that can treat your damaged tissues, you're going to be better off seeking medical care and finding a chamber than attempting in water recompression on your own.

Goals of Surface Oxygen Therapy in suspected DCS Syndrome case:
-Bubble Resolution through Denitrogenation (bubble contents almost pure nitrogen).
-Surround bubble with high oxygen environment
-Diffuse Nitrogen out of bubble into blood.
-Nitrogen transported to the lungs and exhaled.

Augmented with IWR for simple type I DCS only, goals are:
-Pain alleviation with Bubble size reduction.
-Best compromise oxygenation of hypoxic tissues and reduction of tissue edema with regard to Oxygen Toxicity risk factors at no deeper than 9msw/30fsw (1.9ATA).

Bubble size Reduction:
-Best compromise treatment at 1.9ATA on Oxygen, with theoretical reduction at 80% of Original Pathological Bubble Diameter (or 20% decrease in occluding size).

For reference, standard chamber HBOT Table 6 Treatment at 2.8ATA: bubble diameter size is 70% of original (or 30% decrease in occluding size). And at 6ATA breathing Nitrox50 or Heliox 50/50 (ppO2 is 3.0 bar max) Table 6A for AGE: critical bubble diameter size at 55% of original (or a vital 45% decrease in stroke-causing occluding size).

For Type 1 DCS only:

The modified Australian IWR Method as taught by UTD has either 30, 60 or 90min choice of prescribed O2 breathing therapy at 9m/30ft depth (10min O2:with a 5min Air Break); and then a very slow 0.1 meter-per-minute (0.3 feet-per-minute) ascent to surface breathing 10min on O2 with 5min Air Break.

So choosing 60 minutes of O2 time at 9m for example, you breath 10min on Oxygen, and then take a 5min break on Air for a total bottom time of 90 minutes (Air Breaks add to the total bottom time and do not count or accrue credit into the O2 time at 9m), and on the slow 0.1mpm O2 breathing ascent you have to hold at depth after every 1 meter of ascent for the 5min Air Break, before starting again the 0.1mpm O2 breathing ascent –a total time to surface of 135 minutes. So the total treatment time would be 90min bottom plus 135min ascent equals 225 minutes. Can be done with an AL80/11L cylinder of Oxygen and another of Air on Open Circuit. . .

 

[Storker]

First of all, I really appreciate everyone for throwing in their 2 cents. There is certainly a lot of comment bait that would be tempting to reply to, but upon reflection, I feel like engaging with some of the more personal comments would only distract from and reduce the probability of getting my remaining questions answered.

Therefore, instead of responding to anyone directly, I am going to try and summarize the issue more clearly based on what I have learned from you all, and see if you can help me resolve any remaining confusions. I'm not trying to lecture anyone here. I'm not the expert. I'm the student, so if you disagree with the principles of my assessment below, I'd be happy to hear why (except for pedantic disagreement that is merely made for the purpose of arguing, please don't do that).

The standard recommended treatment for DCS is hyperbaric oxygen therapy. Ie, breathing oxygen under pressure. In a nutshell, this treatment "reduces the injurious effects of systemic gas bubbles by physically reducing their size [due to the increased pressure] and providing improved conditions for elimination of bubbles and excess dissolved gas [by increasing oxygen content in your breathing gas]."
Hyperbaric medicine - Wikipedia

If a diver is equipped with high O2 concentration breathing gas, it is easy to replicate those same two conditions which are known to be helpful (higher pressure, higher O2 concentration). It's much more cost effective than going to the ER/urgent care, and it's also much more timely to simply jump back in, which means that symptoms can potentially resolved much sooner. It is known that the sooner DCS is treated, the better the chances of recovery are. So why, then, it is generally recommended that divers delay immediate IWR treatment in favor of a more expensive and less timely chamber treatment?

Well, there seems to be four primary reasons that I'm hearing for why IWR is dangerous and should generally not be recommended:

1) Conditions in the present moment might make it unsafe for the diver to enter the water. For example, some of the bad symptoms of DCS include seizures, unconsciousness, confusion, unexplained behavior, vision loss, paralysis, vomiting, etc (Decompression sickness - Wikipedia). If the diver is suffering from any of those conditions, IWR is clearly not a safe option. Additionally, there are any number of other reasons -- perhaps lightning storms, equipment failure, etc, and many more.

2) The second reason is that, although DCS conditions might currently be mild and easily manageable...symptoms are known to rapidly get worse over time, so what if some of those terrible aforementioned DCS symptoms (eg, seizures, unconsciousness) were to develop during an IWR session? The result would probably be fatal.

3) The diver might get oxygen toxicity from breathing a high concentration of O2 at depth. Some of the symptoms of oxygen toxicity include convolusions, etc (Oxygen toxicity - Wikipedia) so this could be very dangerous at depth.

4) It's not realistic to stay under the water long enough to simulate the pressure and time conditions that a hyperbaric chamber can offer.

Those are the main reasons I'm hearing for why IWR is generally not recommended. Now let me address them.

I have no disagreement with reason #1 above. If conditions in the moment make getting in the water unsafe, there's no question...a chamber ride is the only option.

I am highly skeptical of reason #2, because we know that when the diver goes under pressure (eg, in a hyperbaric chamber, or under water) this causes an immediate reduction in the physical size of the gas bubbles -- or to quote my first link, "reduces the injurious effects of systemic gas bubbles by physically reducing their size." As such, one would expect some immediate relief of DCS symptoms after going under water (increased pressure), rather than a worsening of DCS symptoms.

Have there been any known examples of a person who has mild DCS symptoms (no seizures), then later developing seizures as a result of DCS, after getting into a hyperbaric chamber / going under water pressure? If not, then this just seems like fear mongering.

As for reason #3, I don't understand why oxygen toxicity during IWR would necessarily be any more of a risk than oxygen toxicity during a standard Nitrox dive. My understanding is that in both cases, you'd simply need to respect the max exposure time limits based on your PP02 in the exact same way as for a Nitrox dive.

For example, if you're breathing 100% O2 at a depth of 15 feet, then that's 1.45 ATM of pressure, so you're PP02 is 1*1.45 = 1.45. According to this table, your maximum safe exposure time for a single dive is somewhere around 135 minutes, or 2 hours and 15 minutes. Shearwater and the CNS Oxygen Clock - Shearwater Research

Obviously, you couldn't use that for calculating a safe IWR time, because this would be at least your second dive, so you'd have to take into account any cumulative oxygen from the previous dive in which you got DCS as well.

So...on point #3, it seems that not every diver is going to have the equipment or knowledge to know how to stay within a safe oxygen level...but for those advanced divers that DO know how to monitor their "oxygen clock" and stay below safety limits for oxygen toxicity, it seems that #3 is not really an unpredictable risk, rather it's something that can be avoided with proper training.

Lastly, on point #4, it may be true that you can't simulate the full pressure and duration of a hyperbaric chamber, but we already know we're talking about a case of mild DCS symptoms (if you had extreme conditions, it wouldn't be safe to enter the water), and even if you can't do it for the full duration as a chamber might, that doesn't seem like a reason not to IWR at all, because you can still at the very least provide immediate relief and reduction of DCS symptoms, and then see if your symptoms after treatment still warrant a chamber trip.

Am I missing something? Because based on this summary, to me, it seems that divers with sufficient Nitrox training to know how to avoid oxygen toxicity would be wise to keep O2 bottles on-hand and consider IWR as a first choice in most circumstances for immediate treatment if they ever show signs of mild DCS...yet for some reason that isn't the recommendation, and I don't understand why not.

My suspicion, and reason for creating this thread, is that it's just simpler to say "go to a chamber" as a catch all, rather than pointing out that if you have the proper training, IWR might actually be cheaper, more immediate, and hence also safer option for mild cases of DCS.

So to summarize: after ten pages where trained medical personnel and highly trained, accomplished and competent divers have told you why IWR very seldom is a good idea, with links to the current DCI expert consensus on the topic, you still believe that you are right and the experts are wrong.

I'm reminded of the old saying about leading a horse to the water. And, of course, Dunning-Kruger.

 

[WetSEAL]

So to summarize: after ten pages where trained medical personnel and highly trained, accomplished and competent divers have told you why IWR very seldom is a good idea, with links to the current DCI expert consensus on the topic, you still believe that you are right and the experts are wrong.

I'm reminded of the old saying about leading a horse to the water. And, of course, Dunning-Kruger.

The consensus you speak of is simply not accurate. Many of the replies over these 10 pages have been from VERY experienced divers who have argued a case for IWR. Do none of the people below count as trained competent divers to you?

Many of the people against IWR haven't given any specific reason, but have just insulted me for asking, or sarcastically recommended that I go and try to kill myself.

Another large group of people have not recommended IWR, and given specific reasons for why not, but most of the reasons given don't make logical sense and can be easily debunked, and when I try to calmly ask for an explanation of their reasoning, they don't even attempt to explain themselves or address any of the points I raised, and instead just switch over to ad hominem attacks against me or my experience level. Those are not behaviors that I find particularly convincing.

My experience level is not relevant to my question. I don't even have to exist for the question to be relevant.

A few months back I wrote up an article on IWR for Underwater Speleology, but it hasn't apparently gone to print yet, so I've got it on the internet too.

A Frank Discussion on In-Water Recompression – Dive Gainesville

I recently got bent and became paralyzed before I reached 50'. I used IWR before ever exiting the water to relieve my symptoms. I had a full support team for the dive and we were all active tech divers and knew the risks. As others have already stated, IWR can be a very valuable tool ...In my case, I believe it prevented permanent paralyses at the least and probably saved me a lot more than that, possibly even death.

In-water Recompression | Rubicon Foundation

You are unlikely to die by redoing a bunch of deco. So those of us who have been bent and at the scene of a mildly bent person often escort them back in the water. Prompt treatment now being more useful than a chamber ride 8+ hours from now...Even if it doesnt completely fix them, between 30 and 60 mins of extra deco (thermal units being a big consideration) will almost assuredly attenuate their symptoms. Bringing an extra 40cf of O2 really isnt magic. Or going back in to the depth symptoms resolve on CCR. Happens ALOT more than you probably realize.

A lot of the replies here are criticizing the idea that a diver would do DIY treatment instead of going to a chamber. But what about as well as going to a chamber? If you start having symptoms and have a tank of O2 on board you'll obviously use it. But what about going back down a few meters at the same time while waiting for the chopper/ambulance etc? Would there be any additional risk here? If not, would your overall treatment benefit at all from having this moderate but immediate re-compression?

For Type 1 DCS only:

The modified Australian IWR Method as taught by UTD has either 30, 60 or 90min choice of prescribed O2 breathing therapy at 9m/30ft depth (10min O2:with a 5min Air Break); and then a very slow 0.1 meter-per-minute (0.3 feet-per-minute) ascent to surface breathing 10min on O2 with 5min Air Break.

So choosing 60 minutes of O2 time at 9m for example, you breath 10min on Oxygen, and then take a 5min break on Air for a total bottom time of 90 minutes (Air Breaks add to the total bottom time and do not count or accrue credit into the O2 time at 9m), and on the slow 0.1mpm O2 breathing ascent you have to hold at depth after every 1 meter of ascent for the 5min Air Break, before starting again the 0.1mpm O2 breathing ascent –a total time to surface of 135 minutes. So the total treatment time would be 90min bottom plus 135min ascent equals 225 minutes. Can be done with an AL80/11L cylinder of Oxygen and another of Air on Open Circuit. . .

 

[Jack Hammer]

In short, decompression is a highly complicated subject with some portions and triggers unknown. The treatment of the symptoms of decompression illness is also a complex subject. Unfortunately, making sense of it is not as simple as reading an article on Wikipedia and trying to rationalize it.

 

[doctormike]

Those are not behaviors that I find particularly convincing.

No one is obligated to convince you of anything.

You continually depict this discussion as "pro-IWR" vs. "anti-IWR", despite experienced divers taking the time to discuss the nuances of this complex field with you.

Eventually, you will be left with only people who tell you what you want to hear.