fbpx
Connect with us

Education

A New Look at In-Water Recompression (IWR)

What is your best option if you or a team-mate get bent at a remote diving location, that is more than two hours from a chamber? If you are prepared—that means having the right equipment and know-how—the new consensus among the hyperbaric docs is to treat with In-Water Recompression (IWR).

Published

on

by Reilly Fogarty

Header Image: Photo courtesy of DAN.

Depending on who you ask, in-water recompression (IWR) is either a critical life-saving tool for experienced divers or a fast-track to becoming a case report. Casually dropping it in conversation is a great way to make hyperbaric medicine experts froth at the mouth, and it’s the stuff that insurance underwriters have nightmares about. Putting a diver back in the water after a serious injury is not something to be taken lightly. Managing the diver requires significant training and equipment, as well as the training to diagnose a diver before treatment and manage them and any possible complications afterwards. 

Even in ideal conditions, recompression (in-water or in a chamber) is not guaranteed to eliminate or even ameliorate symptoms, and there’s a very real possibility that divers may exit the water in worse shape than when they entered due to oxygen toxicity, natural symptom progression, or further exposure to the elements. Despite all of this, the practice has been saving lives in some of the world’s least hospitable environments for decades, and recent research has shown that there may be even more reasons to consider IWR. 

Divers Decompressing. Photo courtesy of DAN.

At the recent International Rebreather Meeting in Ponza, Italy, Simon Mitchell, Ph.D., presented a new take on IWR taken from In-Water Recompression, a paper he recently published with David Doolette, Ph.D. The pair propose that IWR may be the best option in a much broader array of situations than previously thought, and that it should be applied in situations where a diver is at risk of losing life or limb, a chamber is more than two hours away, and the team is appropriately trained and equipped for the protocols. 

Illustration of the Australian In-Water Recompression Treatment from “In-Water Oxygen Recompression: A Potential Field Treatment Option for Technical Divers, aquaCORPS # 5 BENT, JAN93. Graph by Richard L. Pyle

First, a little background: IWR tables vary, but most modern protocols involve administering oxygen at 30 fsw/9 msw for one to three hours. Historically, these protocols have varied widely, from the use of oxygen down to 60 fsw/18 msw to “deep air” spikes down to 165 fsw/50 msw. The supporting evidence underlying these practices and the extent of testing also vary widely. Up until the last decade or so the practice was considered foolhardy at best and dangerous at worst by most experts, and was reserved as a tool of last resort for divers who got bent in areas where recompression in a chamber wouldn’t be possible for days.  At the time, the leading researchers were working under the assumption that delay to recompression had little or no effect on post-treatment outcomes, and both the logistics of sourcing open-circuit gas supplies and managing oxygen toxicity risk made it difficult enough to organize that most experts avoided broaching the subject. 

In the past decade many of these concerns have found technological workarounds or have seen a reversal in best-practices. Increasingly, injury data is showing that minimizing time to recompression is key to positive outcomes in cases of decompression sickness (DCS) of all types, and the difficulty of providing oxygen to divers has diminished dramatically with the proliferation of rebreather use. IWR today may just require an injured rebreather diver and their buddy to reenter the water and clip into a hangar with an extra cylinder of oxygen and some way to maintain a patent airway (via full face mask, mouthpiece, or gag strap). Our understanding of oxygen toxicity and the applicable risk factors has improved, as has our ability to diagnose and manage serious DCS, but the combination of factors seems to have come together without much notice until Mitchell and Doolette took on the project of standardizing and promoting a procedure. 

Divers Decompressing. Photo courtesy of DAN.

Citing retrospective analyses of military and experimental dives that showed complete resolution of DCS symptoms during the first treatment (and often within minutes of initial recompression) in 90 percent of cases, the two advocate strongly for a delay to recompression of less than two hours. Realistically, a promptly diagnosed condition and initiated IWR protocol could have a diver back under pressure in half that time or less, but there is little research into whether recompression in that short period notably improves outcomes. The primary protocols outlined in the paper involve the use of oxygen for one to three hours at 30 fsw/9 msw, a notable departure from what most non-commercial and non-military divers are used to in terms of oxygen exposure, but they are widely accepted and have significant research backing. 

In addition to the hazards of CNS oxygen toxicity, convulsions in the water, and symptom progression in a difficult environment, Doolette and Mitchell highlight both the inability to further evaluate patients in the water and the lack of applicable medical interventions. IWR is not a cure-all, nor is it something to be undertaken on a whim, but it has been a viable option for decades for those appropriately trained and equipped, and it’s refreshing to see those at the forefront of the industry promote the evidence-based practices we need in order to save divers in extreme situations. 

Additional Resources:

From the editors: If you and your team are diving in remote locations, you might consider getting the appropriate equipment and training (or training yourselves) to conduct an IWR protocol in the field. Here are some additional resources:

In-Water recompression As An Emergency Field Treatment for Decompression Illness by Richard L. Pyle and David A. Youngblood

In-water Recompression, Doolette DJ and Mitchell SJ 

Rubicon Foundation IWR Papers:

Interested in the most recent research on dive medicine? Continue reading more Medical articles.


Reilly Fogarty is a team leader for its risk mitigation initiatives at Divers Alert Network (DAN). When not working on safety programs for DAN, he can be found running technical charters and teaching rebreather diving in Gloucester, MA. Reilly is a USCG licensed captain whose professional background also includes surgical and wilderness emergency medicine as well as dive shop management.


Education

Instructor Burnout Survey: Multi-Languages Below

Help Polish PADI course director Joanna Kannenberg complete her in-depth research into “instructor burn-out.” Instructors, please answer her (multi-language) survey.

Published

on

By

Header image courtesy of Joanna Kannenberg

English

IT CANNOT WORK WITHOUT YOU, dear diving instructors! I’m Joanna Kannenberg and diving is my passion. As a Course Director, I have been training diving instructors worldwide for over 20 years. The current global situation gives me the time for my long-planned doctoral thesis on burnout risks in our professional group. Many only see the sunny side of our work and only we know about the darker side.  

In order to make the largest possible well-substantiated study, I need as many completed surveys as possible! Please answer the questionnaires and also forward the link to your diving instructor friends / employees.  

Thank you for your help! See you under water ☺ https://burnout.webankieta.pl

Español

NO FUNCIONA SIN VOSOTROS, queridos instructores de buceo!

Soy Joanna Kannenberg y bucear es mi pasión. Como Course Director, he dedicado más de 20 años a formar instructores de buceo por todo el mundo. La actual situación mundial me ha dado el tiempo necesario para preparar la tesis doctoral que tenía planeada desde hace mucho tiempo. Mi tesis versa en los riesgos de “quemarse del trabajo” en nuestro ámbito profesional. Muchos solo ven el lado soleado de nuestro trabajo y solo nosotros conocemos el lado más oscuro. 

Para hacer el estudio más amplio y bien fundamentado, necesito  cuántas más encuestas completadas como sea posible. Por favor, responde a las preguntas de la encuesta y envíasela a tus amigo / empleados que sean instructores de buceo. 

¡Gracias por tu ayuda! Nos vemos bajo el agua ☺! 

(Las encuestas están disponibles bajo el enlace en inglés, alemán, ruso, polaco, español y árabe): https://burnout.webankieta.pl/

Deutsch

OHNE DICH GEHT ES NICHT, liebe Tauchlehrer/innen!

Ich bin Joanna Kannenberg und Tauchen ist meine Leidenschaft. Seit über 20 Jahren bilde ich als Course Director Tauchlehrer/innen weltweit aus. Die jetzige globale Situation gibt mir die Zeit für meine schon lange geplante Doktor-Arbeit über Burnout Risiken in unserer Berufsgruppe. Viele sehen nur die sonnige Seite unserer Arbeit und nur wir wissen, dass es auch die andere manchmal gibt. 

Um eine möglichst groß fundierte Studie zu erstellen, brauche ich von euch viele ausgefüllte Umfragen! Bitte beantworte die Fragebögen und leite den Link auch an deine Tauchlehrerfreunde/mitarbeiter. 

Vielen Dank für deine Hilfe! Man sieht sich unter Wasser ☺ 

(die Umfragen gibt es unter dem Link in: Deutsch, Englisch, Russisch, Polnisch, Spanisch und Arabisch): https://burnout.webankieta.pl/

Polski

BEZ WAS TO SIĘ NIE UDA, drodzy instruktorzy nurkowania!  

Nazywam się Joanna Kannenberg i nurkowanie to moja pasja. Jako Course Director od ponad 20 lat szkolę instruktorów nurkowania na całym świecie. Obecna sytuacja globalna dala mi szanse na zajecie się od dawna planowaną rozprawą doktorską na temat ryzyka wypalenia zawodowego w naszej profesji. Wielu ludzi widzi tylko słoneczną stronę naszej pracy i tylko my wiemy, że czasami jest też druga.  

Aby badanie było możliwie jak najbardziej wiarygodne, potrzebuję od Was wielu wypełnionych ankiet! Bardzo proszę o wypełnienie kwestionariusza, a także przekazanie linku znajomym / współpracownikom – instruktorom nurkowania.  

Dziękuję Wam za pomoc! Do zobaczenia pod wodą ☺ 

(ankiety dostępne pod linkiem w językach: polskim, angielskim, niemieckim, rosyjskim, hiszpańskim i arabskim): https://burnout.webankieta.pl/

Pусский

ЭТО НЕ ПОЛУЧИТСЯ БЕЗ ВАС, дорогие инструкторы по дайвингу!

Меня зовут Джоанна Канненберг и уже много лет дайвинг является моей главной страстью. В статусе Курс-Директора я обучаю инструкторов по дайвингу по всему миру более 20 лет. Нынешняя глобальная ситуация дала мне время для моей, давно запланированной докторской диссертации. Объектом исследования являются  риски выгорания в нашей профессиональной группе. Ведь многие видят только светлую сторону нашей работы, и только мы знаем обратную сторону.  

Для того чтобы сделать максимально обоснованное исследование, мне нужно получить как можно больше завершенных опросов!  

Пожалуйста, ответьте на эти анкеты, а также перешлите ссылку своим друзьям / сотрудникам, которые являются инструкторами по дайвингу.  

Сердечно благодарю вас за вашу помощь! Увидимся под водой ☺ 

(опросы доступны по ссылке на английском, немецком, русском, польском, испанском и арабском языках): https://burnout.webankieta.pl/

العربية

! ﻻﯾﻣﻛﻛﻧﻰ اﻟﻌﻣل دﺑوﻧﻛم ,ﻋازاﺋﻰ ﻣدﺑرﻰ اﻟﻐوص ﻻ
ﻧاﺎ ﺟوﻧاﺎ ﻛﺎﻧﯾﻧﺑﯾرج واﻟﻐوص ھو ﺷﻐﻔﻰ ﺑﺻﻔﺗﻰ )Course Director (؛ﻗاوم ﺗﺑدرﯾب ﻣدرﺑﻲ اﻟﻐوص ﻓﻰ ﺟﻣﯾﻊ اﻧﺣﺎء اﻟﻌﺎﻟم ﻻﻛﺛر ﻣن 20 ﺎﻋﻣﺄ .
ﻧﻣﯾﺣﻧﻰ اﻟوﺿﻊ اﻟﻌﺎﻟﻣﻰ اﻟﺣﺎﻟﻰ اﻟوﻗت ﻻطروﺣﮫ اﻟدﺗﻛوراه اﻟﻣﺧطط ﻟﮭﺎ ﻧﻣذ ﻓﺗره وطﯾﻠﮫ ﺣول ﺧﻣﺎطر اﻻرھﺎق اﻟﻣﮭﻧﻰ ﻓﻰ ﻣﺟﻣوﻋﺗﻧﺎ اﻟﻣﮭﻧﯾﮫ.
رﯾى اﻟﻛﺛرﯾون ﻓﻘط اﻟﺟﺎﻧب اﻟﻣﺷرق ﻣن ﻋﻣﻠﻧﺎ .وﻧﻌﻠم ﻧﺣن ﻓﻘط اﻟﺟﺎﻧب اﻟﻣظﻠم 
نﻣ اﺟل اﺟراء اﻛﺑر دراﺳﮫ ﻣﻣﻛﻧﮫ ﻣدﻋوﻣﮫ ﺟﯾدا ,اﺣﺗﺎج اﻟﻰ اﻛﺑر ﻋدد ﻣﻣنﻛ نﻣ

ﻻاﺳﺗطﻼﻋﺎت اﻟﻣﻛﺗﻣﻠﮫ 
رﯾﺟﻰ اﻻﺟﺎﺑﮫ ﻠﻋﻰ اﻻﺳﺗﺑﯾﺎﻧﺎت وﻛذاﻟك ﻋاﺎده ﺗوﺟﯾﮫ اﻟارﺑط اﻟﻰ  ﻣدرﺑﻰ اﻟﻐوص
ﺻادﻗﺎﺋك / وا اﻟﻌﺎﻣﻠﯾن
ﻛﺷرا ﻟك ﻋﻠﻰ ﺳﻣﺎﻋدﺗك ! اراﻛم ﺗﺣت اﻟﻣﺎء

ﻻاﺳﺗطﻼﻋﺎت ﻣﺗﺎﺣﮫ ﺗﺣت اﻟرﺑاط ﺎﺑﻟﻠﻐﺎت اﻻﻧﺟﻠﯾزﯾﮫ  ,اﻻﻟﻣﺎﻧﯾﮫ , اﻟروﺳﯾﮫ
ﻟاﺑوﻟﻧدﯾﮫ , اﻻﺳﺑﺎﻧﯾﮫ  وﻟاﻌرﺑﯾﮫ(, اﻻﺳﺑﺎﻧﯾﮫ  وﻟاﻌرﺑﯾﮫ

https://burnout.webankieta.pl



Continue Reading

Thank You to Our Sponsors

Subscribe

Education, Conservation, and Exploration articles for the diving obsessed. Subscribe to our monthly blog and get our latest stories and content delivered to your inbox every Thursday.

Latest Features