by Doug Ebersole M.D.
Header image courtesy of Virginie Papadopoulou. Remaining images courtesy of Doug Ebersole.
Patent foramen ovale (PFO) is an important topic in diving as the appreciation of its relationship to decompression illness (DCI) grows within the community. More than 1200 scuba divers from around the world are affected each year by DCI. Although the incidence of DCI is relatively low, ranging from about 1 episode per 10,000 dives (0.01% per dive) to about 10 episodes per 10,000 dives (0.1% per dive), depending on the nature of the dive, the presence of a PFO is felt to increase the risk five to 13-fold (1, 2, 3). As a result, an understanding of the link between PFO and DCI, as well as various treatment options, is vitally important to divers, and the health professionals who treat them.
Incidence and Anatomy
A PFO is an integral part of the normal fetal circulation. Normally, a portion of the blood from the inferior vena cava passes from the right atrium to the left atrium through the PFO during fetal life, bypassing the lungs. At birth, pulmonary blood flow increases greatly, increasing left atrial pressure. The resulting atrial pressure differences compress the septum primum against the septum secundum, functionally closing the PFO. Anatomic closure of the PFO occurs later in infancy in most people but is incomplete in approximately 25% of the population (4, 5), leaving these individuals at risk for right to left shunting.
PFO diameters are quite variable in size ranging from 1-19 mm/0.04-0.75 in, with the average size being larger in older adults (4), suggesting PFOs may continue to enlarge during life. The cause of this is unknown, but in part may be due to known elevations in right heart pressures with aging causing the pressure difference between the left atrium and right atrium (which keeps the PFO closed) to lessen. This may result in “larger” PFOs in older adults.
The Relationship of PFO to DCI
In 1986, it was first suggested by Wilmhurst and colleagues that a cardiac right to left shunt may be important for a paradoxical gas embolism in scuba divers (6). Subsequently, the importance of PFO for DCI in divers has been further investigated (1,7, 8, 9). As mentioned above, the risk of DCI in sport divers is quite low but is increased by at least five-fold in the presence of a PFO (1, 2, 3). Additionally, the average number of ischemic brain lesions as seen on MRI in experienced divers with PFO has been reported to be twice as high as in divers without PFO (11). The etiology and clinical significance of these findings are unclear but may represent multiple subclinical paradoxical embolic events across the PFO.
Both transthoracic echo (TTE), a cardiac ultrasound performed from the chest wall, and transesophageal echo (TEE), a cardiac ultrasound performed from the esophagus, have been used for the diagnosis and assessment of PFO. TTE is considered the preferred diagnostic test of choice as it is noninvasive. However, given its better visualization of the atrial septum, TEE, while more invasive, is much more accurate than TTE and can be used if, despite a negative TTE, there is still a high index of suspicion that the patient has a PFO.
Including a “bubble study” with the echocardiogram, either TTE or TEE, will increase the likelihood of diagnosing a PFO if it is present. This is done by connecting two syringes of saline with a small amount of air with a stopcock and then “swishing” the two syringes back and forth to “agitate” the saline, making small “microbubbles” that will be seen on ultrasound imaging. Visualization of microbubbles passing from the right to left atrium through the visualized foramen ovale is diagnostic of a PFO. In clinical practice, the actual site of right-to-left shunting may not be convincingly visualized or recorded for technical reasons. If the echo demonstrates microbubbles appearing in the left atrium immediately after arriving in the right atrium, then the presence of a PFO can be presumed. If bubbles appear in the left atrium more than five beats after they appear in the right atrium, then the possibility of shunting from another cardiac source (such as an anomalous pulmonary vein) or from a pulmonary source (such as a pulmonary arteriovenous malformations) must be considered.
Of note, while the injection of “agitated saline” is routinely done via an arm vein due to convenience, it has been shown that using a femoral vein in the leg is more accurate (12-13).
No specific guidelines exist for PFO closure in people who have decompression illness, but the options are to stop scuba diving, decrease the depth and/or time of dives to limit the inert gas load, or undergo percutaneous PFO closure. Some divers decide that they have many other interests and diving is not that important to them. These divers will frequently give up the sport.
Other divers who enjoy the sport but dive infrequently often opt for diving “conservatively” to limit their bubble-load. This might involve no-decompression diving, limiting depths to less than 30m/100ft, diving nitrox on air profiles, making prolonged safety stops (greater than the recommended 3-5 min) at approximately 4-6m/15-20 ft at the end of their dives, and limiting the number of dives per day to one or two. Tech divers could also opt to dive more conservatively depending on their risk tolerance.
People who make their living through scuba diving—instructors and divemasters, for example—and tech divers who enjoy more aggressive types of diving such as deep wrecks, cave diving, rebreather diving, and mixed gas diving often elect percutaneous closure of the PFO. This also holds true for divers who have had recurrent “unexpected” DCI events despite diving conservatively as defined above.
The types of decompression illness that appear to be associated with PFO include cerebral (stroke-like symptoms), spinal (paralysis or urinary retention), cutaneous (skin bends), and inner ear (vertigo). DCI manifested by joint pain is felt NOT to be associated and, therefore, should not prompt evaluation for PFO.
A recent study reported the results of conservative diving practices after an episode of DCI (14). Eighteen divers in this study had a right-to-left shunt, nine were small and nine were large. Mean follow-up was 5.3 years (range 0-11 years). Four of these divers had undergone PFO closure and had no episodes of DCI in follow-up. The absolute risk of suffering DCI before examination for the remaining 14 divers with right-to-left shunt and no closure was 23.5 DCI events per 10,000 dives for those with a small shunt compared to 71.6 events/10,000 for those with a large shunt.
After following the recommendations for conservative diving practices, the DCI risk at follow-up fell to 6.0 per 10,000 dives in the small shunt group and zero in divers with the large shunt. The major limitation to this study is its small sample size, but the results suggest a need for more studies of conservative diving practices for divers with right to left shunts.
When DCI has occurred, especially after so called “undeserved” cases of DCI, divers are often encouraged to seek screening for a shunt and some diving medical societies classify these divers as ineligible to return to diving (15). There are also several diving medical specialists who recommend that divers with a history of DCI and a positive right-to-left shunt, undergo closure if it turned out to be a PFO, even though there is no clear evidence to indicate that this intervention reduces the risk of DCI or neurologic events (16-19).
However, in a 2011 study of 83 scuba divers with a history of DCI and a follow-up of 5.3 years, 28 divers had no PFO, 25 had a PFO closure, and 30 continued diving with a PFO without closure (20). At the beginning of the study, there were no significant differences between the groups in the number of dives, dive profiles, diving depth, or cumulative dives to more than 40 meters of salt water (msw).
After follow-up, while there were no differences between the groups with respect to minor DCI events, the risk for major DCI was significantly higher in the divers with PFO and no closure than in divers with PFO and closure or divers without PFO. Although this offers new evidence that PFO closure reduces the risk for major DCI, the authors do not recommend closure in all divers with a history of DCI but rather recommend further studies to confirm these results.
A recent Divers Alert Network (DAN) funded study from our institution (21) also suggested selected divers with recurrent decompression illness may benefit from PFO closure. Seventy-seven patients with recurrent decompression illness and documented patent foramen ovale were enrolled. Please note this was not a randomized trial. Patients themselves decided whether to have PFO closure or to dive conservatively after the PFO diagnosis was made. This obviously imparts some bias into the trial. Fifteen patients were excluded for various reasons, leaving 62 patients who were followed prospectively for 5-6 years.
The baseline demographics which included age, gender, years diving, total number of dives, and number of dives per year were very similar in the two groups as was the number of divers who stopped diving or dived less after suffering decompression illness. A greater proportion of divers in the “PFO Closure” group had “large” PFOs. The follow up in the PFO closure group was six years and in the Conservative group was 5.5 years.
The 42 subjects in the PFO closure group had an incidence of decompression illness of 12.9 episodes per 10,000 dives prior to PFO closure and then had a statistically significant (p<0.05) reduction to 2.7 episodes per 10,000 dives after PFO closure. The 20 participants in the Conservative group had an incidence of decompression illness of 13.4 episodes per 10,000 dives. After 5.5 years of diving conservatively without PFO closure, the incidence of decompression sickness was 3.4 episodes per 10,000 dives, but this did not meet statistical significance given the small number of subjects.
Percutaneous PFO Closure
The closure procedure for a patent foramen ovale is relatively painless and is done nonsurgically using a needle stick into a femoral vein. Imaging during the procedure is done with a combination of fluoroscopy and ultrasound imaging, either TEE or intracardiac echo. The most common device in use in the United States is the Amplatzer PFO Occluder [see photo above]. This is a wire mesh made out of nickel and a titanium alloy. The device is filled with securely sewn polyester fabric to help close the defect. It is deployed through a small catheter which has been placed across the PFO. The procedure takes about an hour and patients are usually discharged home the same day or the following morning.
Conclusions and Recommendations
The South Pacific Underwater Medicine Society (SPUMS), the United Kingdom Sports Diving Medical Committee (UKSDMC), and the Undersea and Hyperbaric Medical Society (UHMS) have all weighed in with formal recommendations on patent foramen ovale and decompression illness. Their recommendations are:
- A routine screening for PFO at time of dive medical fitness assessment is not necessary
- Consideration of investigating for PFO should be for divers with:
- History of DCI with cerebral, spinal, cutaneous or inner ear symptoms
- Current or past history of migraine with aura
- History of cryptogenic stroke
- History of PFO or ASD in first-degree relative
- If screening is performed:
- It should be performed in centers well practiced in the procedure
- Transthoracic echo (TTE) with agitated saline is the preferred first test
- Provocative maneuvers (Valsalva, sniff) should be performed
- In the case of positive tests: A large shunt or unprovoked shunt is associated with certain forms of DCI (cerebral, spinal, inner ear, and cutaneous). Small shunts are associated with a lower but poorly defined risk of DCI
- If a PFO is demonstrated, options include:
- Stop diving
- Dive more conservatively
- Close the PFO
- The diver should not return to diving after PFO closure until satisfactory closure has been confirmed
My final thoughts:
Should all divers be screened for a PFO?
No. There is approximately a five-fold increased relative-risk of DCI in patients with PFO, but the absolute risk is still quite small
Should all divers with DCI be screened for a PFO?
No. Twenty-five percent of the population has a PFO so one would expect a similar percentage of divers with DCI to have a PFO. Not all scuba dives have the same risk of DCI. To paraphrase James Carville’s famous quote from the first Clinton presidential campaign, “It’s the bubbles, stupid”. The issue with decompression sickness is the inert gas “bubble load”, not the PFO. However, episodes of DCI in “low-risk” dives (especially neurologic, inner ear, or “skin bends” events) or multiple “undeserved” DCI events should prompt investigation for PFO.
Should all divers with DCI and PFO have a PFO closure?
No. Options for divers with PFO and DCI include discontinuing diving, instituting more conservative diving practices, or PFO closure. Recommendations should be made on a case-by-case basis based on the DCI event(s), the type of diving being performed by the diver involved, and the risks of PFO closure.
What does the header image (above) depict?
It is an image of a heart with a PFO. Clinical bubbles were injected in the vein of the person for diagnosing the PFO, you can see that they completely fill the venous chambers (left side of the image), and because there is a PFO a few bubbles can also be seen in the arterial chambers (pointed out by the white arrows – there’s likely a lot more, if you notice the bottom of the right side is brighter compared to the rest of those chambers and that’s actually because some tiny bubbles are crossing through). Note, the “clinical bubbles” I refer to, are agitated saline contrast which are large enough that they are filtered by the lungs and don’t appear in the arterial chambers unless there is a PFO.—V. Papadopoulou
- Wilmshurst, PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers. Lancet. 1989;334:1302-1306.
- Torti SR, Billinger M, Schwerzmann M. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J 2004;25:1014-1020.
- Bove AA. Risk of decompression sickness with patent foramen ovale. Undersea Hyperb Med 1998;25:175-8.
- Hagan PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17-20.
- Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol 2001;38 (3): 613-623.
- Wilmhurst PK, Ellis BG, Jenkins BS. Paradoxical gas embolism in a scuba diver with an atrial septal defect. Br Med J (Clin Res Ed) 1986;293:1277.
- Moon RE, Camporesi EM, Kisslo JA. Patent foramen ovale and decompression sickness in divers. Lancet 1989;1:513-14.
- Germonpre P, Dendale P, Unger P, et al. Patent foramen ovale and decompression sickness in sport divers. J Appl Physiol 1998;84:1622-6.
- Germonpre P, Hastir F, Dendale P, et al. Evidence for increasing patency of the patent foramen ovale in divers. Am J Cardiol 2005;95;912-15.
- Gempp E, Blattearu J, Stephant E, et al. Relation between right-to-left shunts and spinal cord decompression sickness in divers. Int J Sports Med 2009;30:150-3.
- Schwerzmann M, Seiler C, LippE, et al. Relation between directly detected patent foramen ovale and ischemic brain lesions in sport divers. Ann Intern Med 2001:134:21-4.
- Schuchlenz HW, Weihs W, Hackl E, Rehak P. A large Eustachian valve is a confounder of contrast but not of color Doppler transesophageal echocardiography in detecting a right-to-left shunt across a patent foramen ovale. Int J Cardiol 2006;109:375-80.
- Gin KG, Huckell VF, Pollick C. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol 1993;22:1994-2000.
- Klingmann, C, Rathmann N, Hausmann D, et al. Lower risk of decompression sickness after recommendation of conservative decompression practices in divers with and without vascular right-to-left shunt. Diving and Hyperbaric Medicine 2012;42(3):146-150.
- [Swiss Underwater and Hyperbaric Medical Society. Empfehlungen 2007. Der Schwiezerischen Gesellschaft Fur Unterwasser-und Hyperbarmedizin Zum Tauchen Mit Einem Offenen Foramen Ovale][cited 2012 June11]. Available from: http://www.suhms.org/downloads/SUHMS%20PFO%20Flyer%20d.pdf(German)
- Scott P, Wilson N, Veldtman G. Fracture of a GORE HELEX septal occluder following PFO closure in a diver. Catheter Cardiovasc Interv 2009;73:828-31.
- Wahl A, Praz F, Stinimann J, Windecker S, Seiler C, Nedeltchev K, et al. Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients. Swiss Med Wkly. 2008:138:567-72.
- Saguner AM, Wahl A, Praz F, et al. Figulla PFO occluder versus Amplatzer PFO occluder for percutaneous closure of patent foramen ovale. Catheter Cardiovasc Interv 2011;77:709-14.
- Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366:991-9.
- Billinger M, Zbinden R, Mordasini R, et al. Patent foramen ovale closure in recreational divers: effect on decompression illness and ischaemic brain lesions during long-term follow-up. Heart. 2011;97:1932-7.
- Anderson G, Ebersole D, Covington D, Denoble PJ. The effectiveness of risk mitigation interventions in divers with persistent (patent) foramen ovale. Diving Hyperb Med 2019 Jun 30;49(2):80-8
InDepth: No Fault DCI? The Story of My Wife’s PFO (12.2019)
InDepth: Undergoing PFO Surgery as a Team: Deana & Bert’s Excellent Adventure (12.2020)
InDepth: Uncovering the Link Between PFO and Inner Ear DCS (5.2019)
European Heart Journal: European position paper on the management of patients with patent foramen ovale. Part II – Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions (JAN 2021)
Dr. Douglas Ebersole, MD is a cardiologist specializing in coronary and structural heart interventions at the Watson Clinic LLP in Lakeland, Florida. He is also an avid technical, cave, and rebreather diver and instructor. He can be reached at firstname.lastname@example.org.
Who You Gonna Call (in an Emergency)?
In the immediate aftermath of a diving fatality, law enforcement needs to locate an emergency contact for the accident victim. If that person’s phone is locked, social media accounts private, and there’s no emergency contacts for friends or family, it will likely fall to you as a dive buddy, to locate the needed critical information. This can add unbearable stress to an already bad situation. The solution is to be prepared, as Buck Buchanan and Wally Endres with Christine Tamburri and Robert Zink explain.
by Buck Buchanan and Wally Endres with Christine Tamburri and Robert Zink. Images courtesy of the authors unless noted.
According to the 2020 DAN Annual Diving Report, 189 diver fatalities were reported in 2018 across all categories, including recreational, technical, breath-hold, commercial, public safety, and military diving operations. There were 228 diver fatalities reported in 2017. Despite the 17% decrease in fatalities from 2017 to 2018, divers are still dying and there is a lot to learn from these incidents.
Dive accidents happen, not only to reckless divers, but also to the most cautious, most well prepared, most highly trained divers in the world. While we may not want to think about it, the reality is that dive-related emergencies can happen at any time to any diver on any dive. Because of this possibility, all divers should be proactive in their efforts to mitigate the effects of chaos and confusion being added to those of shock and grief.
Whether a diver experiences a minor injury or is the unfortunate victim in a fatal accident, the need for easily accessible and reliable emergency contact information is crucial. This article dives into the importance of such precautions as well as provides specific tips for how to carry them out.
Why is Emergency Contact Information (ECI) important?
Imagine you and a buddy are on a weekend diving getaway. You could be in your home town or half-way around the world. Nevertheless, the sun is shining, the water is crystal clear, and all is well with the world. Soon after submerging, tragedy strikes, and your buddy—maybe even your best friend—never resurfaces. Suddenly, your perfect day has changed your life forever. What happens next can be handled either efficiently or chaotically, depending on the emergency contact information (ECI) on hand.
In the immediate aftermath of a tragedy, law enforcement needs to locate an emergency contact for the accident victim. If that person’s phone is locked with no known passcode, their social media accounts are private, and nothing in their wallet or on their dive gear points to any ECI for friends or family, you as the dive buddy, will need to help locate critical information. Doing this, while dealing with your own shock, adds almost unendurable stress.
Law enforcement’s primary role in any fatality investigation is to secure evidence, to identify the victim, to determine cause of death, and to make proper notifications to next-of-kin. This standard process changes in most, if not all, diving accidents that result in a death because most law enforcement agencies are either ill-equipped, untrained, or unaccustomed to handling a diving fatality.
Consequently, the more identifying information available, the easier it is for law enforcement to be effective. It should also be noted that most law enforcement agencies are not equipped to properly secure an underwater crime scene or to recover a deceased diver at depths.
ECI is a crucial piece of documentation. When a victim is seriously injured or dies, the need to contact someone in their network is necessary to initiate the next steps in the process. These steps may include providing a medical history to help EMS respond accordingly, arranging transportation home from a remote dive site, and/or notifying loved one(s).
Without ECI, an injured diver may be left on their own for hours. In cases where they are unable to advocate for themselves, medical professionals may be forced to make uninformed decisions for care. In the unfortunate case of a fatality, the lack of accessible ECI may mean that families are unaware for hours, days, or even weeks, not knowing the fate of their loved one.
Planning ahead and ensuring that ECI is available is part of “getting our affairs in order.” Divers should make available all vital information needed to assure that their loved ones will be reached in a timely manner.
Emergency Contact (Point of Contact) vs. Next-of-Kin
An emergency contact can be a close friend, a relative, a co-worker, a neighbor, a dive buddy, a mentor, a pastor, or other trusted persons in your life. Remember, naming an emergency contact is not to be taken lightly. This is the person that will be contacted in the event of an unexpected, life-changing event, and often this individual will be the one tasked with informing other people close to the accident victim.
A next-of-kin contact is the closest living relative to the injured or deceased. In some cases, this person may have legal authority to make decisions.
It is important to understand the difference between these two terms so that a diver can choose who to list as their emergency contact. News of this nature is very traumatic for all loved ones, especially significant others. Certified divers understand the inherent risks that they are taking. Even if family members who are not divers think they understand the risks, the shock of losing a loved one is devastating. It may, however, be less traumatic if that horrible news comes from someone familiar to them. For example, the diver may choose to list their best friend as their emergency contact, knowing that a friendly face can soften the tragic news. With this information available, law enforcement would notify the listed emergency contact, and that person would notify the spouse or close loved one.
In the event that there could be estate or legal implications, the decision to use next-of-kin as the emergency contact should be considered carefully.
The More Information the More Efficient
The Emergency Contact
After deciding who is to be listed, it is critical to obtain their most up-to-date contact information. At minimum, the following information should be listed and easily accessible:
- Full Name of the Person to be Contacted
- Relationship of the Person to be Contacted
- Phone Number(s) of the Person to be Contacted
In addition, it is recommended that the following information also be included:
- Email Address of the Person to be Contacted
- Full Street Address of the Person to be Contacted
The more information available, the easier it will be for medical staff or law enforcement to understand the full scope of the relationship between the injured individual and the emergency contact.
It is important to remember that a situation does not instantly resolve when an emergency contact is reached. All divers should be proactive in their approach to ensure that medical staff and law enforcement have quick and easy access to not only ECI in the event of an incident, but to personal information as well. The next section discusses ways in which to house these details but, at minimum, the following personal data should be accessible:
- Full Name
- Date of Birth
- Phone Number
- Email Address
- Full Street Address
- Primary Care Physician Contact Information
- Pertinent Medical History (i.e., Known Allergies, Recent Surgeries, etc.)
- Blood Type
Solutions for All Divers
Gathering ECI and personal information are just two steps in the process of preparing for the event of a dive accident. To be of value, these pieces of information must be easy to obtain quickly. Divers need to be aware that, for their buddies and fellow divers, being unable to contact someone close to an injured or deceased diver is the last place they want to be in the aftermath of a traumatic experience.
These following lists are not comprehensive, but represent simple solutions that all divers can start using TODAY to ensure their ECI and personal information are able to be accessed at a moment’s notice.
Emergency Contact Options
Smartphone Emergency Contact Features (Apple/Android)
Both platforms offer many features that typically include emergency access to a medical ID in the event that the owner becomes incapacitated. Although most people are unaware that this is available, in most cases, a quick internet search will give easy setup guidance.
Visible Gear Solutions
Divers love to label their gear for a number of reasons, but very few make their ECI easily accessible by adding it to their kit.
Duct Tape/Vinyl Tape
Some divers put a piece of tape on their backplate, canister light, or even cylinders that lists emergency contact information. This solution is fast, easy, and cheap.
Dog tags can be attached to a backplate or sidemount harness, or even tucked into a set of wetnotes. These typically contain ECI, as well as one or two pieces of personal information (i.e., blood type, allergies, etc.).
Smart Emergency Stickers by Dive Signs
Technology buffs will love this commercially available option. Dive Signs has created a sticker that can be placed on any non-metal surface, such as on a dive crate, on a certification card, or maybe even on a drysuit bag, and it contains a near field communication (NFC) tag. With one tap of a smartphone, anyone can have access to pre-filled emergency contact and personal information that can be easily programmed by the diver. They can be purchased here: Smart Emergency Stickers
Divers constantly need to communicate underwater. Most use hand signals, some use slates, but a common tool is wetnotes. ECI can be written on the first page for easy access after an incident.
Save-a-Dive Kit Solutions
In similar fashion to labeling dive gear, duct tape/vinyl tape can be put on the inside lid of a save-a-dive kit to list ECI. As an alternative, a printed or hand-written list (preferably laminated) can be used. It should be noted that this method likely won’t do any good if the dive buddy doesn’t know it exists and its location.
These opt-in systems are put in place for law enforcement in the event of an emergency and they are typically linked to a driver’s license. At this time, these services are only available in a few US states, with Florida having over 19 million participants.
The following form can be filled in, then printed and placed in a known location so that it is easy to access in the event of an emergency.
The most basic form of documentation, this is easy to add to a save-a-dive kit, in the console of a car, or in another secure location. This list can also be printed and laminated so that it is durable and easy to read.
Some divers may opt for advanced directives that provide instructions for medical care and only go into effect if the injured diver cannot communicate their own wishes. An emergency binder may contain additional information, including passwords, financial and insurance information, a will, and/or government documents such as a passport and social security information. If this route is taken, it is important to understand who has access to this information and when it is invoked.
The Divers Alert Network (DAN) Medical ID Tags offer divers an easy way to display important information that may help medical personnel respond quicker and more effectively in the event of a dive emergency. An ID tag displays a diver’s name, DAN ID number, date of birth, drug allergies, and an emergency contact. This information can help public safety officials make informed decisions about their care, even if they are unable to advocate for themselves.
Each individual diver will have their own method of listing an emergency contact and ensuring their personal details are comprehensive and accessible. Some divers may use suggestions from the lists above, and some divers may design their own ways of housing this important information. Regardless of the documentation method, there are three important points to remember:
List More than One (1) Emergency Contact
Life happens, and sometimes even the most reachable individual is away from their phone, so it is important to list more than one emergency contact.
Update Information when Anything Changes and Review on an Annual Basis
Information is only useful if it is kept up-to-date. Any time information changes, it should be updated on the emergency contact sheet or a personal information list. It is also good practice to review all information on an annual basis to ensure that it is accurate. An easy way to remember to review this information is at the same time as an annual cylinder visual inspection. In addition, the diver should ask their emergency contact to update them with any changes they might have.
Never List a Dive Buddy as an Emergency Contact
This one may seem obvious, but on any given day, one dive buddy has the other listed as an emergency contact. Unsurprisingly, this becomes useless if either buddy has an incident on the dive. As such, it is best practice to list someone who is never a dive buddy as an emergency contact and, again, to verify and update both your and their details.
No one expects an accident to happen to them.The fact is that even the most cautious diver may one day find themself in the middle of an incident, needing quick access to emergency information. All divers are encouraged to be proactive and to ensure that ECI and personal information are accurate and readily accessible. Making a conscious effort during all pre-dive briefs to discuss where and how to access ECI in the event of an emergency is good practice.
This article is dedicated to Ben Strelnick (NREMT, W-EMT) who died on May 26, 2023, while cave diving at Jackson Blue Spring in Marianna, Florida. He was a medic at Divers Alert Network (DAN), and was an avid diver who always put others before himself. The inspiration for this article was drawn from the lack of ECI following Ben’s death and the hardships that followed. Ben wanted nothing more than for people to dive and to do it safely, and he would without a doubt encourage others to plan ahead so that their future dive buddies, friends, and family could get through any type of tragedy with as little pain as possible.
About The Authors
Buck Buchanan and Wally Endres (NREMT, DMT) are co-owners of Dive911, LLC, a Central Florida-based dive training facility that specializes in instructor professional development and public safety pedagogy. Buck is an SDI/ERDI Instructor Trainer Evaluator and Ambassador who has 35+ years of experience in teaching, commercial diving, and heavy salvage. Wally is a Course Director, Public Safety Instructor, and former law enforcement officer who has 25+ years of experience in risk management operations and OSHA compliance consulting. Christine Tamburri (SDI Instructor) and Robert Zink (former law enforcement officer and crash reconstructionist) were also consulted in the composition and viewpoints of this article.