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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).

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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.


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The Thought Process Behind GUE’s CCR Configuration

GUE is known for taking its own holistic approach to gear configuration. Here GUE board member and Instructor Trainer Richard Lundgren explains the reasoning behind its unique closed-circuit rebreather configuration. It’s all about the gas!

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By Richard Lundgren
Header photo by Ortwin Khan

Numerous incidents over the years have resulted in tragic and fatal outcomes due to inefficient and insufficient bailout procedures and systems. At the present time, there are no community standards that detail:

  • How much bailout gas volume should be reserved
  • How to store and access the bailout gas 
  • How to chose bailout gas properties

Accordingly, Global Underwater Explorers (GUE) created a standardized bailout system consistent with GUE’s holistic gear configuration, Standard Operating Procedures(SOP), and diver training system. The system was designed holistically; consequently, the value and usefulness of the system are jeopardized if any of its components are removed.  

Bailout Gas Reserve Volumes

The volume of gas needed to sustain a diver while bailing from a rebreather is difficult to assess, as many different factors impacts the result— including respiratory rate, depth and time, CO2 levels, and stress levels. These are but a few of the variables. All reserve gas calculations may be appropriate under ideal conditions and circumstances, but they should be regarded as estimates, or predictions at best.

The gas volume needed for two divers to safely ascend to the first gas switch is referred to as Minimum Gas (MG) for scuba divers. The gas volume needed for one rebreather diver to ascend on open-circuit during duress is referred to as Bailout Minimum Gas (BMG). The BMG is calculated using the following variables:

Consumption (C): GUE recommends using a surface consumption rate (SCR) of 20 liters per minute, or 0.75 f3 if imperial is used.

Average Pressure (AvP or average ATA): The average pressure between the target depth (max depth) to the first available gas source or the surface (min depth)

Time (T):  The ascent rate should be according to the decompression profile (variable ascent rate). However, in order to simplify and increase conservatism, the ascent rate used in the BMG formula is set to 3 meters/10 ft per minute. Any decompression time required before the gas switch (first available gas source) must be added to the total time. One minute should be added for the adverse event (the bailout) and one minute additionally for performing the gas switch.

BMG = C x AvP x T

Note that Bailout Minimum Gas reserves are estimations and may not be sufficient! Even though catastrophic failures are unlikely, other factors like hypercapnia (CO2 poisoning) and stress warrants a cautious approach. 

Decompression bailout gas volumes are calculated based on the diver’s actual need (based on their decompression table/algorithm), and no additional reserve is added. 

It should be noted that GUE does not endorse the use of “team bailout,” i.e. when one diver carries bottom gas bailout and another diver carries decompression gas based on only one diver’s need. A separation or an equipment failure would quickly render a system like this useless.

Common Tech Community Rebreather Configuration

  • Backmount rebreather (note side mount rebreathers are gaining in popularity)
  • Typically, three-liter oxygen and a three-liter diluent cylinder on board (each hold 712 l/25 f3) 
  • Bailout gas in one or more stage bottles which could be connected to an integrated Bailout Valve (BOV).
Divers on the AP Diving Inspiration rebreather in typical backmount configuration. Photo by Martin Parker.
Cave diver in the DiveSoft Liberty sidemount rebreather. Photo courtesy of Marissa Eckert.

Containment and Access

Rather than carry bailout minimum gas (BMG) in a stage bottle, which is typical in the rebreather diving community, GUE has designed its bailout system as a redundant open-circuit system consisting of two 7-liter, 232 bar cylinders (57 f3 each) that are integrated into the rebreather frame, and called the “D7” system, i.e. D for doubles, 7 for seven liter. Note that GUE has standardized the JJ-CCR closed-circuit rebreather for training and operations.

Photo by Kirill Egorov.

These cylinders, each with individual valves, are linked together using a flexible manifold. This system holds up to 3250 liters of gas (114 f3), of which only about 10% is used by the rebreather as diluent. Hence, close to 3000 liters (106 f3) is reserved for a bailout situation. This gives a tremendous capacity and flexibility in a relatively small form factor for dives requiring additional gas reserves (when direct ascent is not possible or desirable). 

The following advantages were considered when designing the bailout system:

  • The D7 system is consistent with existing open-circuit systems utilized by GUE divers. A bailout system that is familiar to the user will not increase stress levels, which is important. A GUE diver will rely on previous experience and procedures when most needed.
  • The system contains the gas volumes needed according to the GUE BMG calculations as well as the diluent needed for a wide range of dive missions.
  • The system is fully redundant and has the capacity to isolate failing components, like a set of open-circuit doubles and still allowing full access to the gas.
  • The overall weight of the system is less, compared to a standard system with an AL11 liter (aluminum 80 f3) bailout cylinder. In addition, it contains 800-900 liters/20-32 f3 more gas available for a bailout situation compared to the AL11 liter system. Weight has been traded for gas.
  • The system does not occupy the position of a stage bottle which allows for additional stages or decompression bottles to be added.
  • If the ISO valves on each side were closed, the flex manifold can be removed and the cylinders transported individually while still full.

Bailout gas can be accessed quickly by a bailout valve (BOV), which is typically configured as a separate open-circuit regulator worn on a necklace, consistent with GUE’s open-circuit configuration. However, some GUE divers use an integrated BOV. After evaluation of the situation, while breathing open-circuit from the BOV, the user can transition to a high-performance regulator worn on a long hose if the situation calls for it.

The long hose is carried under the loop when diving the rebreather. The chances of having to donate to another GUE rebreather diver is low, as both carry redundant bailout. Still, GUE maintains that the capacity to donate gas must be present. The process is more likely to involve a handover of the long hose rather than a donation. 

Photo by Jesper Kjøller.

Still, if needed, such a donation is made possible by either removing the loop temporarily or by simply donating the long hose from under the loop. 

Bailout decompression gasses are carried in decompression stage bottles. If more than three bottles are needed, the bottles that are to be used at the shallowest depths are carried on a stage leash (i.e. a short lease that clips to your side D-ring to carry multiple stage bottles). Maintaining bottle-rotation techniques and capacity through regular practice is important and challenging, as this skill is rarely used with the rebreather.

Bailout Gas Properties

The choice of bailout gas is extremely important, as survival may well depend on it. It is not only the volume that is important, the individual gas properties will decide if the bailout gas will be optimal or not. As the D7 system contains both the diluent and bailout gas, both gasses share the same characteristic. The following gas characteristics must be considered when choosing gas:

Density

The equivalent (air) gas density depth should not exceed 30 meters/100 ft or 5.1 grams/liter. This is consistent with the latest research by Gavin Anthony and Simon Mitchell that recommends that divers maintain maximum gas density ideally below 5.2 g/l, equivalent to air at 31 m/102 ft, and a hard maximum of 6.2 g/l, the equivalent to air at 39 m/128 ft. You can find a simple gas density calculator here.

Ventilation is impaired when diving, due to several factors which increase the work of breathing (WOB); when diving rebreathers, the impairment is even more so. High gas density, for example, when diving gas containing no or low fractions of helium, significantly decreases a diver’s ventilation capacity and increases the risk of dynamic airway compression. CO2 washout from blood depends on ventilation capacity and can be hindered if a high-density gas is used. The impact of density is very important, and the risk of using dense gases is not to be neglected. Note that this effect is not limited to deep diving. Using a dense gas as shallow as 30 meters/100 ft reduces a diver’s ventilation capacity by a staggering 50%.

Narcosis

The (air) equivalent narcotic depth should also not exceed 30 m/100 ft, or PN2=3.16. Rebreathers and emergency situations are complex enough without further being aided by narcosis.

Oxygen Toxicity

The PO2 should be limited to allow for long exposures. GUE operating standards call for a maximum PO2 for bottom gases of 1.2 atm, a PO2 of 1.4 for deep decompression gases, and a PO2 of 1.6 for shallow decompression gases. GUE recommends using the next deeper GUE standard bottom gas for diluent/bailout when diving a rebreather in combination with GUE standard decompression gases.

Bailout gasses are not chosen in order to give the shortest possible decompression obligation. They are chosen in order to give the best odds of surviving a potentially life-threatening situation. 

Two GUE CCR divers in California. Photo by Karim Hamza.

In Summary

GUE’s D7 bailout system is flexible and contains the rebreather’s diluent as well as bailout gas reserves needed for a range of different missions. The familiarity the system, along with the knowledge that they are carrying ample gas reserves, gives GUE divers peace of mind. Choosing gases with properties that will aid a diver in duress while dealing with an emergency completes the system.

GUE did not prioritize the ease of climbing boat ladders or reducing decompression by a few minutes. These are more appropriately addressed with sessions at the gym, combined with finding aquatic comfort. Nothing prevents a complete removal of the entire system at the surface if an easy exit is needed.


Founder of Scandinavia’s Baltic Sea Divers and Ocean Discovery diving groups, and a member of GUE’s Board of Directors and GUE’s Technical Administrator, Richard Lundgren has participated in numerous underwater expeditions worldwide and is one of Europe’s most experienced trimix divers. With more than 4000 dives to his credit, Richard Lundgren was a member of the GUE expeditions to dive the Britannic (sister ship of the ill-fated Titanic) in 1997 and 1999, and has been involved in numerous projects to explore mines and caves in Sweden, Norway, and Finland. In 1997, in arctic conditions, he performed the longest cave dive ever carried out in Scandinavia. Richard’s other exploration work has included the 1999 filming of the famous submarine, M1, for the BBC; the side scan sonar surveys of the Spanish gold galleons outside Florida’s Key West in 2000; and the search for the Admiral’s Fleet, an ongoing project that has already led to the discovery of more than 40 virgin wrecks perfectly preserved in the cold waters of the Swedish Baltic Sea.

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