by Mark Cowan
I STARED straight into the empty chamber where the sickest of divers went, eyes hopeful as the world spun anti-clockwise around me. I sat in a wheelchair at St Luke’s Medical Center in Milwaukee shortly before midnight on August 7, and listened as Dr. Gerald Godfrey said the treatment for my complex case of decompression sickness would be relatively straightforward.
My world was spinning, literally and metaphorically. Vertiginous feelings had tipped my life on end after I had completed an uneventful summer afternoon dive in Lake Michigan, Wisconsin, eight hours earlier. I was unable to walk unaided, my balance had disappeared, and I couldn’t focus on anything because the horizontal and vertical hold on my vision had vanished.
Earlier that evening, doctors in a hospital emergency room wired me up to a heart monitor and administered fluids, oxygen, and an antihistamine (for nausea) to stabilise me. Then, they transferred me to St. Luke’s—home to one of the earliest hyperbaric medicine programs in the US—for treatment.
Three doctors were waiting for me when I arrived at the hyperbaric department at 11 pm. Three doctors? I guessed they were there because they had not seen anyone like me before; it turns out they had rarely seen divers with decompression sickness.
There are no good “bends” to get, but if there were, mine was not that kind. I had a case of pure or isolated inner ear decompression sickness. The manifestation of inner ear DCS was, in medical terms, incompletely understood and infrequently seen in divers. The small number of studies concerning the issue offered a perplexing series of possible causes.
Examining me, the doctors spoke of neurological deficit and labyrinthine dysfunction. They used names like Sharpened Romberg—a test to measure my balance—and they also used other gestures of their own design to expose the worst in me. Dr. Godfrey, my primary doctor, asked me to follow his index finger with my eyes. The further his finger moved to my left, the more my vision seemed to skip back and forth. He described this condition as “Left-beating nystagmus of the third degree.” “Nystagmus” sounded so disconcerting. (Nystagmus means abnormal eye movement.)
A video had been taken on my cell phone earlier that day by an ER doctor to help me understand what was happening with my vision. Watching the video some days later, I saw my pupils involuntarily bounce back and forth like a rubber ball.
While inner ear DCS is unusual, the therapy was the same as if I had been suffering from joint pain—a US Navy Recompression Treatment Table 6. The procedure was—as accepted medical wisdom goes—the gold standard for DCS, and five hours spent putting me back together again didn’t seem so bad.
Shortly before midnight, I was wheeled into the chamber, and the medic accompanying me closed the door behind us. I leaned back in the chair as the incoming gas hissed into my ears. When the chamber reached the depth of 18 m/60 ft, the medic placed a plastic hood over my head and opened the valve to let oxygen flush into my lungs. I breathed slowly and deeply and waited for my vision to stabilise.
After 20 minutes, the medic removed the hood, held her hand in front of my face and asked, “Can you follow my finger with your eyes?” As she moved her hand to my left my pupils beat back and forth.
Things will be better next time, I told myself.
Twenty minutes later, my balance had improved slightly, but the nystagmus was still beating. Next time? The medic called Dr. Godfrey and he watched through the porthole as my pupils still bounced back and forth.
Recovery was not going well. I had been in the chamber breathing high concentrations of oxygen for an hour under pressure, and right then I couldn’t see any improvement in my condition.
Earlier that afternoon, as the dive boat powered back to the port and I felt the waves of Lake Michigan wallow inside my head, I didn’t immediately suspect that anything was really wrong. My first thought was that I had early signs of motion sickness. My second thought was I needed to get some air. My third—if I had one—was that this was a sour end to a great day of diving.
Friends and I had spent the afternoon exploring the shipwreck of the SS Wisconsin, 40 m/130 ft down off the coast of Kenosha, Wisconsin. Once we got back to port, we had plans for dinner. There were stories to share and another dive to organise. Apparently, someone had found a way into the engine room.
The dive had gone as expected. Underwater, I had examined historic cars—including a Hudson Super Six automobile in the stern cargo hold—and I pushed further into the forward hold than I had been before. There, amid the debris, I saw the cargo of radiators stacked on pushcarts alongside furniture, ladies’ shoes, stoves, and rolls of hoses. That was a small slice of American Midwest history, right there in front of me.
After 39 minutes on the bottom, I began my ascent. The 17 minutes of decompression I had amassed was nothing onerous. After completing all my deco stops, and with my two computers clear, I surfaced and climbed up the ladder back onto the boat, happy. The skipper had taken a photograph of me minutes after I exited the water. There I was, sat on the dive bench, still wearing my rebreather, with a smile on my face.
But, as I sat there smiling, trouble was already bubbling inside my head. I couldn’t feel it, but that trouble was working from the inside out. An hour after the photograph was taken, it boiled over.
The first thing to go was control of my stomach. As the boat arrived in Kenosha Harbor and approached the quayside, I hung over the side and vomited.
The next thing I lost was my balance. Stepping off the boat, I set off toward my car. The ground pitched and pulled in odd directions beneath my feet like a carnival funhouse floor trick. I see-sawed across the car park, and my head felt fuzzy, intoxicated. To anyone watching, I probably looked like a drunk, too.
Then, my sight went haywire. Suddenly, I couldn’t tell left from right, up from down.
I dropped to the ground beside my vehicle.
“I think I’m in trouble,” I said to my buddy Robert Personen as he carried his bail-out cylinders from the boat. “Can I have your O2?”
As much as I didn’t want to admit it, I knew I was suffering every diver’s worst fear. I’d even written a book, Between the Devil and the Deep, about decompression sickness, published just three weeks earlier, and all the research I had done left me with no doubt about what was happening to me, and nothing about the situation was good.
In the chilly afternoon hours of August 7, I sat on the rain-soaked asphalt, propped against my car, sucking oxygen from the tank like my very life—and everything I had devoted almost 20 years to—depended on it. As the deep yanked at my sensory system like a gremlin inside my head, I had only one thought: What’s going to happen to me?
Between the Devil and the Deep Redux
WHEN I collaborated with Martin Robson to write about his battle with decompression sickness for Between the Devil and the Deep, I had no idea what it took to overcome a potentially life-changing injury. I’d managed to get through more than four decades without spending a single night in a hospital. It’s not that I hadn’t fallen out of trees as a child, or tumbled down a flight of 13 concrete steps that scarred my back, or sliced my hand open deep enough to see the bone, or cracked my head open on a garden step. It’s just that I seemed to have a durability that kept me on my feet.
So, on Monday morning, when I was wheeled into the private hospital room assigned to me by people who seemed to suspect a lack of response to treatment, I was defeated by hope and expectation. I’d fooled myself into thinking one treatment would put me back together again, but the ground beneath my feet still felt like it was trying to shake me down, and my vision remained unstable. I felt overcome with passivity as a nurse ordered breakfast for me, as a porter pushed me in a wheelchair between hospital departments for tests, and as I slept through my MRI scan.
I was wheeled back in the chamber on Monday afternoon for a second treatment using US Navy Treatment Table 9. Table 9 was introduced in 1999 to provide a dosing protocol for cases of incomplete resolution of DCS. I was taken down to the equivalent of 13.5 m/45 ft and told I would be given three 30-minute sessions of oxygen breathing.
Inside the chamber, there was nothing to do but read or watch television and I couldn’t do either. So, I closed my eyes, and my mind wandered. I thought about the SS Wisconsin and how much more there was to explore. I thought of everything I enjoyed about being underwater. I thought of the dive of that day. I accepted what had happened—as much as I could—but I still couldn’t quite believe where I was.
At the end of my first treatment, I had talked through the dive with the doctors. Scrolling through the log on my dive computer, I looked for a catastrophic event that could have explained the severity of my injury. I wanted to find a mistake—something I had overlooked underwater, something I could point the finger of blame at and say: ”Cowan, you idiot, look what you did!” I wanted to find something that said I didn’t have an undiagnosed medical condition that could change my life forever. There was nothing there.
During my third dose of oxygen, my vision suddenly stabilised. There was no warning, no gradual resolution; just an absolute change one would get from flicking off the power switch. One minute, I couldn’t focus, and the next, I could. Dennis Quaid appeared on the TV screen at the end of the chamber. I couldn’t hear him over the hiss of oxygen coming into my hood, but I could read the subtitles. The movie was Flight of the Phoenix and I tuned in just as Quaid was making his escape from the Gobi Desert on a makeshift aircraft rebuilt from the wreckage of his crashed plane.
The positive development inspired a new attitude toward my treatment, one I copied from Martin Robson. There is a passage in our book that resonated with me. It reads, “Like everything he did in life, Robson dealt with the here and now, what was in front of him. There was no point in trying to tackle the whole thing at once. After being ambushed underwater, he’d focused on what needed to be done to survive. One step at a time. Make it through one day at a time and figure out how to survive the next day when it was time.”
As I surfaced at the end of my second chamber treatment, I insisted on walking out of the chamber unaided.
Back in my room, I retrieved a notebook from the table beside my bed and, just like Robson, I wrote down everything I could remember about my condition. Then, just like Robson, I began to exercise. I paced the floor of the room. I repeated the test with my eyes closed. I tried walking heel-to-toe, as drivers must do during a roadside sobriety check, and I wrote down the results in the notebook (16 steps, wobbly). I stood on my left leg and timed how long I could hold my balance (20 seconds). I switched to my left leg (16 seconds). I switched back and tried to balance with my eyes closed (extremely difficult). I did it all again an hour later and noted the results. I assessed the stability of my vision and wrote that down: Looking to the right, stable, peripheral vision to the left blurred.
That evening, my wife Alison arrived at the hospital with fresh clothes and my toothbrush. She had been in the UK to celebrate her mother’s 80th birthday and was at the airport hotel on her way home when a friend called her.
“Mark’s okay, but he is in the emergency room,” he told her. “He had a problem after a dive.”
“Is he conscious?” she asked him.
Alison couldn’t sleep after that and had an anxious wait as she flew back into Chicago. For 18 hours, she had no idea what was happening to me, but she knew it probably wasn’t good. When Alison finally walked into the room, I tried to give the impression I was okay, but I couldn’t fool her. I looked hurt, tired, and vulnerable.
Seeing her was the best part of my day, though. For the first time, I could think about something else as she told me about the surprise trip to see family and how she sat there just holding her mother’s hand after three years apart. Then we talked about where she could get some dinner, and we talked about health insurance. Eventually, we talked about the incident.
“I’m not going to ask if you plan to stop diving,” she said.
I appreciated her concern, but right then I didn’t know if I had a say in that.
Facing the Worst
I WAS discharged from the hospital after four days and five chamber treatments totalling more than 15 hours. I left feeling better than I had when I arrived, but I was not fully healed. The nystagmus had disappeared in my right eye; in my left eye it was “very slight.” Doctors decided there would be no more chamber treatments for me. My condition had plateaued. There was nothing more my doctors could do. Recovering, whatever that looked like, was up to me.
I went home. During the day, I sat on the sofa and watched television until Alison finished work. There was not much else I could do because going for a walk along the lakefront near my home strained my eyes and my head. I felt like I had just emerged from a bar after a heavy night; my body moved at one speed while my head lagged a second behind. The world seemed to race past me, but I was in limbo.
I had left the hospital with one number ringing in my ears. It was not the number on the insurance bill. That did hurt, but not as much as the figure on page 20 of the International Consensus Standards for Commercial Diving and Underwater Operations the doctors handed to me. More precisely, the number on the sixth row of table 2.4.10, “Return to Duty after Diving Related Incidents.” According to the table, I had suffered a “Neurological injury needing several treatment tables to resolve,” and that meant I had to wait four to six months before a return to diving. Beneath the table was a kicker: “Persistent neurological deficits following diving-related incidents are generally disqualifying.”
The details contained in the table sat heavily on my mind and made me angry as I stumbled about at home. It felt good to be angry, to vent, to cry, because if I wasn’t angry I would have to face my fears: the fear that the neurological deficit might be persistent, the fear that bubble in my inner ear was going to be the last word on my diving, that the cornerstone of my identity could be taken from me.
“I’ll be okay, I’m always okay,” I said to my wife each time I went diving. Well, I couldn’t say that now, because I wasn’t okay, and I was scared. Scared of what I may have done to my life; scared because I was too young to have put limits on myself. I was physically fitter than I had ever been, I was racing triathlons, and I was excited by the possibilities of exploration offered by my rebreather. I had big plans for the next decade. Would I now not get a chance to dive the Windiate, Kamloops, or the Norman? To dive caves again? To test myself in another triathlon?
What a gnawing sense of waste. What a shocking spell of self-pity.
The feelings came from the same place—the scarcity of information. My doctors had turned to the standards for commercial divers because there was little research relating to the recreational diving world to assist them. There was little in the medical literature on inner ear bends at all.
Inner Ear DCS?
Physician Andrew H. Smith was arguably the first to describe the symptoms of inner ear DCS in 1873 when he noted both extreme deafness and vestibular problems in caisson workers building the Brooklyn Bridge. After that, however, the condition was infrequently recorded as a discrete clinical entity. It wasn’t until the 1990s that the problem was reported in sport divers breathing compressed air.
Even then, studies suggested inner ear decompression sickness (IEDCS) is a low-incidence event. According to one report, IEDCS accounted for approximately 0.005% of cases. Another estimated the rate at close to 3%. One report found most victims were injured following dives which had pushed no-decompression limits, omitted decompression stops, or violated ascent rates. Another found the potential for isolated events to occur randomly during otherwise uneventful deep technical dives that had gone according to plan.
Then there was the contradictory information about the causal factors on IEDCS. “The biophysical basis for this selective vulnerability of the inner ear to DCS has not been established,” one report stated. Another report suggested the inner ear offered the potential for considerable supersaturation, and therefore possible bubble formation, during the initial phase of a conventional decompression. The environment allowed bubbles to grow until they eventually obstructed the labyrinthine artery. Since this artery was relatively small, there was a low probability for a bubble to enter it, another report indicated. Further studies, however, found a possible link between IEDCS and Patent Foramen Ovale (PFO), a hole in the heart which can allow gas bubbles to shunt from the arterial system into the venous system.
Nothing about an inner ear decompression sickness seemed clear, which revealed that the scientific community had a lot of ideas but not much definite information. I was confused and needed to go in search of answers for myself.
NINE WEEKS after suffering DCS, I was strapped into a chair in a pitch-black chamber at Aurora Physical Therapy, Neurotology & Audiology in Milwaukee. A set of infrared video goggles sat heavily on my head. The chair rotated back and forth at varying speeds, and the cameras in the headset recorded my eye movement. The test examined the components of the vestibular system all the way to the brain stem. It measured my vestibulo-ocular reflex—how my eyes and vestibular system interacted— and kept my visual field in focus while moving my head.
The rotary chair was one of several overlapping and complementary tests I had agreed to because I wanted to quantify the scale of the damage caused by the bend, and because I wanted to address the concerns of my doctor. I had fully recovered, but he was concerned about the dangers of my return to diving if my vestibular system had not fully healed (I might “suffer vertigo, lose my mouthpiece, and drown,” he said). And, he was concerned I might suffer a second bend in the fully functioning side of the vestibular system (I could suffer vertigo). He seemed particularly concerned that I would return to diving at all.
After the rotary chair had finished spinning and the results were collated, I moved to another seat and put on another pair of goggles. The video head impulse test examined the three semicircular canals in each inner ear. I was first asked to focus on a dot drawn on a sticky note placed on the wall in front of me. The audiologist stood behind me and he jerked my head in different directions. The video goggles captured my eye movement and analysed the time it took to return to the dot on the wall. I donned another set of goggles for the caloric test, which involved the blowing of hot and cold air into my ear to test for dizziness. Then electrodes were placed on my cheeks and neck and measured muscle response as loud sounds were played into my ear for something called the Vestibular Evoked Myogenic Potential Test which examined the upper and lower branches of the inner ear.
Once the tests were completed and the results were analysed, I met with my consultant, Dr. Aaron Benson. He was surprised by the findings. I think he was expecting to see global labyrinthine defects. Instead, he told me that almost everything was normal. Tests on my vestibulo-ocular reflex found just one area of minor deficit which revealed itself when my head was jerked over my right shoulder. That finding was confirmed by one of the other tests and indicated the possible site of my bend.
“What’s neat about you,” Dr. Benson said, “is that I can tell you exactly where [your initial insult] localises to a very specific area; it’s your right horizontal semicircular canal. That’s where your deficit was.”
“Functionally, you have demonstrated resolution of the initial insult. The question then is: ‘Why there?’ It is hard to say. It is possible you had a little nitrogen bubble right there that caused you all this mischief. That really does speak to the randomness of this.”
While the tests pinpointed the spot where I was hit, they revealed nothing of what had caused the incident. “Don’t ask too many questions,” one friend told me. “It will drive you nuts.” I couldn’t help myself, though, I needed to know.
I sent a download of my dive to Martin Parker, managing director of AP Diving, with the hope he could spot something. “It looks like a benign dive,” he emailed back.
He asked several questions. Did I use a heated vest? No. Did I do any gas switches? No. Was I dehydrated? Not that thought. Fatigued? Possibly, I’d had a long bicycle ride the day before. When I came off the bottom, did I have to swim up or was I neutrally buoyant? Neutrally buoyant.
The possibility of a PFO was raised again and the details of another medical paper, this one from 2017, were shared with me. The study reported a total of 62 divers with DCS. In all cases, divers were tested for PFO and 29 were found to have one. The highest prevalence was found in divers with cutaneous and vestibular DCS—my bend. It was suggested I get checked for a PFO to be on the safe side.
I couldn’t help but think that if I had a PFO, I would have been aware of it before now. Over the course of almost 20 years of diving, I had completed more challenging technical dives in more difficult conditions than I was subjected to when I suffered my injury. However, I was told that a PFO might not be an issue on every dive. That was why many divers could complete many deep, long decompression dives without incident only to one day get a bend on a moderate dive.
So, now I’ve been referred to a cardiologist to have a transesophageal echocardiograph to test for a PFO, and we will see what that means for my future. If the examination does not find anything, I will continue to be at a loss to explain the incident and the cause of the bend will remain a bit of a mystery. I hate mysteries, I’m never satisfied with a mystery; there’s always a reason, I just need to find it.
You can find Mark and Martin’s book here, “Between The Devil And The Deep.”
Alert Diver: May I Bend Your Ear? (2015) by Michael Menduno
PubMed: Inner ear decompression sickness in sport compressed-air diving (2001) by Nachum Z, et al.
J Appl Physio: Biophysical basis for inner ear decompression sickness (2003) by David Doolette and Simon Mitchell
J Appl Physio: Selective vulnerability of the inner ear to decompression sickness in divers with right-to-left shunt: the role of tissue gas supersaturation (2009) by Simon Mitchell and David Doolette
DAN: PFO and Inner Ear DCS (2014) by Petar Denoble, MD, D.Sc.
PubMed: Pathophysiology of inner ear decompression sickness: potential role of the persistent foramen ovale (2015) by Simon Mitchell and David Doolette
InDEPTH: Everything You Wanted To Know About PFOs and Decompression Illness, But Were Too Busy Decompressing to Ask (2021) by Doug Ebersole M.D.
Mark Cowan is a journalist with over two decades’ experience in newspapers and television. He spent twelve years on the police beat covering the war on crime for a series of newspapers in Birmingham, UK, and reported on the peace-keeping operations in war-torn Kosovo while embedded with the British Army. He has worked on a number of documentaries, including the BAFTA-winning Gun Number 6 which was inspired by his original reporting on the realities of gun crime in the UK. He has been a diver for 20 years, is a PADI Master Scuba Diver Trainer, trained to use a rebreather in 2012, and learned to cave dive while researching and writing the book Between the Devil and the Deep, One Man’s Battle to Beat the Bends with co-author Martin Robson. He is an avid wreck diver and is now based in Chicago, Illinois.
Hyperbaric Chambers Are Turning Away Divers. Will There Be One Nearby When You Need It?
Unfortunately, it’s hard to make a business case for treating divers versus wound and burn care victims. As a result, many hyperbaric chambers no longer treat divers, leaving fewer facilities available for divers in need and increasing their post-dive time to treatment. InDEPTH editor Ashley Stewart reports on this growing crisis in the US and what can be done!
By Ashley Stewart
Steven Wells was diving on the scuttled wreck of the USS Oriskany off the coast of Florida in 2016 when a problem with his buoyancy compensator caused a rapid ascent to the surface.
Wells’ dive buddies followed the emergency action plan for the Oriskany listed on the Florida Fish and Wildlife Conservation Commission’s website at the time and brought Wells straight to Naval Air Station Pensacola, the nearest facility with a hyperbaric chamber. The facility turned him away because there was no one there to run it.
Wells was taken 30 minutes away to Baptist Hospital, which also has a chamber capable of treating his injuries, but the hospital had years earlier decided only to use it for wound care. Doctors there decided Wells would be taken by ambulance more than an hour away to Mobile, Alabama, the nearest facility that accepts divers.
By the time Wells arrived at the only chamber that would help him, it was too late.
“I got a call from the hospital saying, ‘Your husband is on life support. You need to get here now,’” Rachel Wells said of her late-husband of more than 23 years.
Julio Garcia — the program director of Springhill Medical Center’s wound care and hyperbaric facility where Steven Wells was to be treated — told InDEPTH that while no one can be certain how sooner treatment would have affected the outcome of Wells’ case, it would have given him the best chance for a full recovery.
Each year in the US, there are about 400 serious cases of decompression illness (DCI) — a category including both arterial gas embolism and decompression sickness — in divers, according to one 2020 paper. The Divers Alert Network (DAN) hotline dealt with 587 cases annually over the past five years.
The availability of hyperbaric chambers to treat decompression illness is something many divers take for granted. We try to avoid dive-related injuries through training, but expect treatment to be available when we need it.
The reality — as Steven and Rachel Wells tragically learned — is that only a minority of divers are close to care for diving-related injuries, according to medical professionals in the field. The estimates vary, but it’s generally believed there are about 1,500 hyperbaric medicine facilities in the US and only 67 are currently treating diving accidents, according to DAN.
The estimates vary, but it’s generally believed there are about 1,500 hyperbaric medicine facilities in the US and only 67 are currently treating diving accidents, according to DAN.
“The problem is only getting worse, not better,” Garcia, the Springhill Medical Center program director, said. Garcia has been sounding the alarm about this problem for more than a decade. His hospital takes patients from as far away as Florida cave country and treated 20 DCI cases in 2022. Those patients had an average transportation time of 11.5 hours, according to an InDEPTH analysis of Garcia’s records.
Florida stands out because it’s a popular diving destination, DAN Research Director Frauke Tillmans said, but the situation is not much better across the US. Many of the 1,500 hyperbaric medicine facilities, like Pensacola’s Baptist Hospital, have transitioned to treating wound care only for economic reasons. Emergency hyperbaric services are expensive to train and staff, and come with increased liability.
Time to treatment can be important in DCI cases
Time is of the essence when treating DCI. Divers Alert Network Director of Medical Services Camilo Saraiva told InDEPTH time to treatment is a “pivotal determinant” when it comes to outcomes for DCI patients. “Swift intervention significantly influences the effectiveness of therapeutic recompression,” Saraiva said.
Decompression sickness, for example, results from rapid changes in pressure and can form gas bubbles in body tissues. Initiating recompression therapy minimizes bubble size and number, Saraiva said, enhancing their elimination and reducing the risk of further vascular obstruction and tissue damage.
“The timely provision of hyperbaric oxygen therapy not only aids in bubble resolution but also mitigates the potential for neurological deficits and other severe complications, highlighting the critical role of early treatment in optimizing outcomes for DCI patients,” Saraiva said.
The 2018 paper “In water-recompression” stated delays to recompression in military and experimental diving are typically less than two hours and more than 90% of cases are completely resolved during the first treatment.
Frank K. Butler and Richard E. Moon, hyperbaric medicine experts, wrote in a 2020 letter to the Undersea and Hyperbaric Medicine journal editors suggesting a minority of patients who need life-saving hyperbaric oxygen treatment (HBO2) are close to a major hospital with a 24-hour emergency hyperbaric facility.
“Despite the urgent need for treatment, most hyperbaric chambers will decline to accept emergent patients at present,” Butler and Moon wrote. “Patients may eventually receive HBO2 but after a significant delay and a transfer of several hundred miles. Many never receive indicated HBO2, often resulting in poorer patient outcomes.”
Patients who are delayed treatment, they wrote, face the possibility in some cases of “death, permanent neurological damage, permanent loss of vision, or loss of an extremity, most of which would have been readily preventable had emergent HBO2 been administered.”
Why fewer chambers treat dive injuries
As recently as two decades ago, according to Butler and Moon, the majority of hyperbaric treatment facilities were available 24/7 to treat emergency patients. The percentage of those facilities now treating emergency patients is unclear, but it’s universally agreed the number has fallen significantly.
The reasons for the loss of emergency HBO2 facilities, Butler and Moon suggest, include “a better economic return when chambers focus on wound care patients as opposed to emergencies; the greater legal liability involved with treating high-acuity emergency patients; and the increased training and staffing requirements that would be required to manage critically ill patients — especially diving injuries and iatrogenic gas embolism patients.”
A letter from an administrator at Baptist Hospital — which sent Steve Wells to Springhill Medical Center — viewed by InDEPTH shows the hospital discontinued hyperbaric emergency services in December 2010, citing lack of staffing for specialty trained hyperbaric physicians who can provide 24-hour patient care. Baptist has yet to respond to InDEPTH’s request for comment.
There’s also the issue of pay. Garcia, the Springhill program director, said the current rate of pay for doctors who administer hyperbaric treatments regardless of length is around $150. A typical hyperbaric treatment for other conditions is about two hours. Diving treatments are usually six or seven, he said. “What doctor wants to get paid $150 to be up all night for seven hours, at that point making less than the technician?” Garcia said. “The fix is that healthcare payers need to pay more for the supervision of the treatment for diving injuries. Make it something that’s worth a doctor’s time besides the goodness of their hearts.”
Silence from lawmakers
Medical and diving organizations in 2020 sent a letter to the House and Senate, federal government agencies, governors of Florida and California, and the American Hospital Association expressing concerns about the lack of availability of chambers to treat diving injuries.
“There are approximately three million recreational scuba divers in the US,” the letter stated. “In the unlikely event that they suffer a diving-related injury, they trust that the US medical system will provide state-of-the-art care for their injuries, but the steadily- decreasing number of hyperbaric treatment facilities in the US willing to treat them emergently for decompression sickness or arterial gas embolism often places them at much greater risk than they realize.”
Garcia has on his own contacted lawmakers, reporters, medical systems — even private space companies like SpaceX because his facility is also the only one nearby treating altitude decompression sickness from space and air travel.
Little has changed, Garcia said.
Garcia showed InDEPTH a 2014 letter from a Defense Health Agency director who said, while there are three Undersea and Hyperbaric Medicine Society-accredited clinic hyperbaric medicine facilities and two additional facilities that can treat civilian emergencies, they are not staffed 24/7 and not designed for patients with other medical illnesses. Garcia at the time requested the creation of a federal grant to support the expansion of 24/7 hyperbaric services, but the director said that was outside of the agencies’ purview.
Two years after this exchange, Steven Wells was taken to and turned away from one of these facilities — the NAS Pensacola, listed on the Florida Fish and Wildlife Conservation Commission’s (FWC) emergency action plan at the time.
The Florida Fish and Wildlife Conservation Commission website now shows a map of the nearly 4,000 artificial reefs across Florida’s 1,350 miles of coastline. Two chambers, one in Mobile, Alabama, and one is Orlando, cover 500 of those miles densely packed with dive locations, according to Garcia.
The FWC website now shows a map of the nearly 4,000 artificial reefs across Florida’s 1,350 miles of coastline. Two chambers, one in Mobile, Alabama, and one is Orlando, cover 500 of those miles densely packed with dive locations, according to Garcia. A report from the University of West Florida estimated the sinking of the Oriskany, scuttled in 2006, generated nearly $4 million for Pensacola and Escambia County in the next year alone.
An FWC spokesperson said the agency provides diver safety reminders and recommended actions on its website “as a courtesy” and is not intended for emergency response. FWC and Visit Florida did not respond to inquiries about how much Florida’s government spends on advertising the artificial reefs and other diving activities, or whether any effort to expand the availability of hyperbaric facilities to treat the divers who show up as a result.
“My question is what is my husband’s life worth compared to your chambers,” Rachel Wells, Steven Wells’ widow said. “Why did he have to die?”
DIVER: A Crisis in Emergency Chamber Availability by Dan Orr (April 2022)
Divenewswire: A Crisis Lurking Below the Surface Emergency Hyperbaric Treatment Availability by Dan Orr (August 2021)
Undersea and Hyperbaric Medicine (2020): Emergency hyperbaric oxygen therapy: A service in need of resuscitation – an open letter by Frank K. Butler, MD, and Richard E. Moon, MD
InDEPTH: A New Look at In-Water Recompression (IWR) (2019) by Reilly Fogarty
Diving and Hyperbaric medicine (2018): In-water Recompression, Doolette DJ and Mitchell SJ
InDepth Managing Editor Ashley Stewart is a Seattle-based journalist and tech diver. Ashley started diving with Global Underwater Explorers and writing for InDepth in 2021. She is a GUE Tech 2 and CCR1 diver and on her way to becoming an instructor. In her day job, Ashley is an investigative journalist reporting on technology companies. She can be reached at: firstname.lastname@example.org.