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March 2012    Download the Entire Issue (PDF) Available to the Public Vol. 38, No. 3   RSS Feed for Undercurrent Issues
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A Shock to Divers’ Hearts

can portable defibrillators lower heart-related dive deaths?

from the March, 2012 issue of Undercurrent   Subscribe Now

Jan Raczycki was diving the James C. King in Ontario's Fathom Five National Marine Park last July, when he became distressed 90 feet down. Pulled from the water, other divers tried to save him with CPR on the charter dive boat (there was no divemaster) and back on land, but their efforts were no use. Raczycki, 49, died, and the coroner said a pre-existing heart condition likely caused it.

The calamity reveals how self-reliant divers are expected to be, and that when things go wrong on a dive, it's up to the dive buddy and any others to attempt a rescue, regardless of their ability or experience. Also, the Baby Boomer generation that popularized scuba diving is aging, and that increases health risks during dives. According to Divers Alert Network (DAN), at least one quarter of the 80 to 90 diver fatalities in North America annually are attributed to heart problems.

George Harpur, medical director of the Tobermory Hyperbaric Facility and the coroner who pronounced Raczynski's death, said fitness to dive has been a problem for the past decade due to divers' increasing average age. The mean age of the nearly 250,000 North American DAN members is in the mid-40s. "One of the biggest differences we see now is that a number of deaths aren't essentially diving deaths - - faults related to diving technique - - they're often deaths while diving, because the demographics of divers has changed," Harpur says. Also, they're wealthier now and can purchase gear that lets them do riskier things.

Great strides have been made in equipment and training to reduce diving fatalities from the peak level in the mid-1970s, when 150 deaths occurred. But Harpur said there are two big threats for more divers now. One is cardiac dysrhythmia, where the heart gets out of rhythm. The other is pulmonary edema of immersion, where the force of water's pressure and coldness on divers causes fluid to accumulate in the heart and lungs, forcing both to work harder.

But perhaps Raczycki's death, and those of other divers with heart-related issues, could have been prevented. Given that heart problems are a significant cause of death in diving, having portable heart defibrillators, which automatically reset the heart, on board might be a good idea.

The automated external defibrillator (AED) has recently become an important medical tool. Trained nonmedical personnel can use these simplified electronic machines to treat a person in cardiac arrest. The AED guides the user through the process by audible or visual prompts without requiring any discretion or judgment. The American Heart Association states that at least 20,000 lives could be saved annually by prompt use of AEDs. Once priced at $3,000, AEDs are now priced at under $1,000 for small office or home use. Advocates are pushing for AEDs to be placed in public spaces like stadiums, malls, airports and casinos. And state legislatures are getting actively involved, passing laws to encourage broader availability of AEDs.

For divers, the question is should dive boats carry AEDs, or even have medical oxygen aboard? The devices are recommended by DAN, and they're on Coast Guard vessels in the U.S. and Canada (one was used in the unsuccessful effort to save Raczycki when the Coast Guard arrived).

Defibrillators don't seem to be carried on Indonesia-based liveaboards. Travel booker Liveaboards- Indonesia states that none of the boats it represents - including the luxury boats Seven Seas, Seahorse and MSY Damai - - have them on board. When we contacted those boats, they didn't reply. Clay McCardell, president of the U.S.-owned Explorer Ventures, says his liveaboard fleet has had AEDs for the past four years, and crew are trained to use them, but they have thankfully not yet needed to use them.

Peter Hughes, a liveaboard fleet veteran who is now running the M/V Galapagos Sky, says the same thing, but he questions the validity of an AED as a cure-all. "Dive boat operations and circumstances are different, depending on many variables, not least the difference between a day boat and a liveaboard dive boat. The M/V Galapagos Sky, like all Galapagos liveaboards, conducts 100 percent of its diving activities from small, inflatable pangas. There is no safe, secure, dry storage easily available aboard the pangas, so our AED is stored safely and under the watchful eye of our captain -- on the bridge of the liveaboard! In the event of an incident where the AED might 'save a life,' the incident will likely happen while diving or on the surface after diving waiting for pick up. This means getting the patient to the AED will take some time - - getting the diver aboard the panga, figuring out what to do with the other seven divers, transporting the diver to the mother ship and using the AED as required. The time lapse and moving the diver from panga to liveaboard takes time, and creates hardship for the patient. So the question about whether portable AEDs should be common on dive boats is not easy to answer with a simple yes or no."

Then there's the matter of training. Non-medical personnel can be trained to use AEDs, but some experts wonder whether these devices that were used only in hospitals till a few years ago are simplified enough, or training is extensive enough. Richard Page, a cardiologist and heart-rhythm specialist, believes they are. He cites a study recently published in the journal Circulation. Investigators in Seattle did a small study with both paramedics and sixth graders using AEDs to practice saving lives of mannequins. The sixth graders delivered a shock in 92 seconds, while the paramedics accomplished it in 60 seconds. "So it is better to be trained, but almost anyone can figure out how to use an AED," says Page.

Bret Gilliam, a licensed maritime captain, dive professional for more than 40 years and Undercurrent contributor, says the use of AEDs should be standard practice on all dive boats, whether large liveaboards or smaller day boats. "They are affordable, and training is simple. Just like having oxygen aboard was initially resisted by some, the use of such gases for decompression sickness and embolism in the field is a primary tool in first response. Indeed, 100-percent oxygen breathing is such an effective aid that patients can recover from DCS without recompression. In 2005, I treated an embolism victim who was initially unresponsive with positive-pressure, 100-percent oxygen while evacuating from Cocos Island to Panama. We could not recompress an unconscious patient in the water, so heading for Panama 36 hours away and flooding her with oxygen was the only treatment, along with IV fluids. She fully recovered. AED units are the next evolution. All operators should embrace them."

Still, time is of the essence. Every minute that passes without treatment reduces one's chances of survival by 7 to 10 percent, the American Heart Association reports. And as Hughes states above, multiple minutes can pass between getting a distressed diver from the dive site back to the boat where the AED is located.

Gilliam says, "Peter Hughes notes that he has to store his unit aboard the main vessel and that this could be a factor due to delay. The unit needs to remain plugged into its charging station to be ready at any time. But it can be scrambled quickly to a panga via a stand-by inflatable, or the victim can be brought back and the unit could be waiting and used immediately. The timeframes will usually work. AEDs are invaluable in the field, and can mean the difference between life and death. I urge all of my consulting clients worldwide to have these aboard, and for every crew member to be trained in their use with regular safety drills for contingencies of all sorts."

The rate of diving deaths isn't comparable to what's going on in other sports, says DAN research director Petar DeNoble. He says that in jogging, there are an estimated 13 sudden cardiac deaths per 100,000 participants, compared to nine per 100,000 divers in recreational scuba. And 90 DAN member deaths every year "isn't necessarily a crisis in the sport." But, he adds, " Joggers jog year-round, and divers dive 20 days per year . . . You still have to admit that for the exposure, the risk in diving is definitely greater than in jogging."

While the merits of AEDs are not specific to the dive industry, neither is heart disease - - and its risks. While DAN supports the availability and training of AEDs, their effectiveness must be kept in perspective, says spokesperson Christine McKittrick. "While their use can prove instrumental, they cannot cure underlying heart disease."

DAN is trying to reduce the risk of cardiac-related dive deaths by doing a survey to determine if members should be required to undergo annual medical exams to qualify for its medical liability insurance. Survey results should be ready this spring.

- - Vanessa Richardson

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