Returning To Diving After A Concussion
When and how should you return to diving following a traumatic brain injury? GUE’s NextGen Scholar, Kiwi water woman Annika Andressen spent eight months figuring out the answers to those questions with the help of Dr. Simon Mitchell, after suffering a concussion while surfing. Here is her tale of sloggin’ the noggin.
by Annika Andresen
Header image courtesy of Jack Austin, Dive Tutukaka . Other photos courtesy of A. Andresen unless noted.
It’s pretty safe to say that 2020 wasn’t the year anyone was expecting.
You might have read on my social media recently that I have been cleared to dive! Eight months ago I experienced a concussion from a surfing accident. It’s been a long (and, at times, really frustrating) recovery as I learned how to let myself rest, but one of my biggest questions was, “How will this affect my diving?”
So I thought I would share my journey over the last eight months, including my injury, my rehabilitation, and things to be aware of when returning to diving.
Here in New Zealand, we had a quick government response toward COVID, going into an immediate one-month lockdown and another further three weeks under tight restrictions, and initially, New Zealand successfully stamped out the virus. The first weekend out after restrictions eased, there was an awesome east coast swell and I was dying to get back in the water. My boyfriend Josh and I met one of my best friends up north before heading out to the coast to catch some waves.
I will be the first to admit that the waves were quite steep and bigger than I was used to. As I stood up on my first wave, I fell forward over my board and into the water. As the wave crashed over me, the water slammed my head into the seafloor below, catching the sand bottom beneath my chin. At the same time, my board had flung around, and the rail of the board hit the back of my head, breaking the fiberglass.
Despite this, I was feeling quite relaxed knowing I could hold my breath for over three minutes. I thought to myself, “Ouch that hurt,” but then waited patiently for the wave to pass before coming to the surface. As I stood up in the surf, I felt slightly dizzy but not bad enough to put me off surfing. I signalled to Josh to keep an eye on me and I went back out to catch the next wave. Learning my lesson from before, I stayed in the white water, enjoying the freedom of being in the ocean. An hour later, we returned to the beach for a hot shower and headed home. It wasn’t until I woke the next morning that I realized something was wrong.
It felt like I had the worst hangover. My head felt like it was in a clamp that was crushing my brain. The room was spinning, and I struggled to walk, using the walls to support me. Later that day, I called one of my best friends to ask what I should do, and she urged me to go to the A&E (accident and emergency facility). There, the doctors diagnosed a concussion.
After a week off work, the vertigo and the clamp-crushing head pain had stopped, but I still had a constant headache, and my heart rate was all over the place. I walked to the top of my driveway and my heart rate peaked at 180bpm. I realized then that this wasn’t going to be an overnight fix.
What Is A Concussion?
A concussion is a type of traumatic brain injury caused by a bump, blow, or jolt to the head or a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.
In the months following the injury, despite not having any alcohol, I felt like I had a constant hangover. A team from Advanced Personnel Management (APM) took on my case to help me recover while easing back into work. The biggest shock was my initial assessment at the physio. The first test: walk across the room and pick up a pen on the floor on the way. Easy right? Well, as soon as I tried to pick the pen up and stand up, I immediately fell over. The second test involved my having to follow the doctor’s pen with my gaze as he moved it back and forth in front of my eyes. Also easy right? I didn’t realise it, but my physio said I blinked constantly as I tried to follow the pen. This was because my brain couldn’t process all the information, and the blinking was a coping mechanism to give my brain a break.
Through these tests, I found I had lost all my balance, eye tracking was difficult, and the ability to process information decreased significantly. I couldn’t articulate my thoughts and had trouble speaking. My hearing was impacted, as I couldn’t tolerate any loud sounds or multiple people speaking, and I wasn’t able to regulate my heartrate: all as a result of a concussion. Being in a car at night-time when it was raining was my worst nightmare—moving bright lights and fast windshield wipers were not a good combination.
To assist my recovery, the team at APM gave me a pair of fancy earplugs, blue light glasses, and some exercises to do. The hardest part was to get the balance right between rest and activity, while letting my brain recover. If you know me, you will know I am not great at prioritising rest. I eased back into my work as an educator, starting with two hours, then four hours, and slowly getting to half days in schools. Loud classrooms and VR headsets proved a challenging setting, but the struggles were balanced by the fantastic support I had from the BLAKE team. I also found afternoon naps to be amazing!
Four months after the injury, I was able to work a full day, and my headaches were intermittent, only increasing if I did too much exercise or didn’t get enough rest. But then I wanted to see if I was able to get back in the water. This period had been my longest time out of the water since I learned to dive in 2013.
Diving After A Concussion?
I am no doctor and, to be honest, I really had no idea about the risks associated with scuba diving after a concussion, so I reached out to Dr. Simon Mitchell to hear his thoughts. For those who don’t know him, Dr. Mitchell, is an incredible physician specialising in occupational medicine, hyperbaric medicine, and anaesthesiology, as well as being someone who is highly respected in the global diving community. He has a Wikipedia page and received the Rolex Diver of the Year Award in 2015. I felt so honoured that he emailed back and agreed to catch up. Trying not to be a fangirl, I was grateful for the facemask hiding my massive smile and excitement as I met Simon outside Auckland Hospital.
We discussed my injury and the symptoms associated with my concussion. I had not lost consciousness nor had I experienced any amnesia; therefore, my injury was classified as a mild concussion. Injuries with a loss of consciousness for 30 minutes to 24 hours or a skull fracture are considered moderate. Severe concussions are injuries that include loss of consciousness or amnesia for more than 24 hours, subdural hematoma, or brain contusion. I consider myself very lucky that my concussion was only mild.
There is little known about concussions, and research in this area is difficult, as every injury is so different. Although Simon explained that one of the major risks for scuba diving after a concussion was an increased risk of seizures, this risk varies according to the severity of the traumatic brain injury and is reflected in the correlation between trauma and seizures.
We did a couple of tests, focusing on my balance by standing with one foot in front of the other, with my hands on my shoulders, and with my eyes closed for one minute. I had been practicing my physio exercises every day and was stoked that I completed the one minute without falling over!
Despite having only a mild concussion, there was still a small increased risk of a seizure. Simon acknowledged that no one can ever guarantee that there will be no problems, so I accepted the unknown (but almost certainly small) degree of increased risk, and Simon gave me some advice to help me ease back into diving.
The first precaution was to understand which gas I was breathing. Increased partial pressures of oxygen can be known to increase the risk of seizures; therefore instead of diving nitrox, diving with air at 21% oxygen was recommended while I eased back into diving. Avoiding physical exertion and task loading on a dive—swimming into a strong current, instructing and guiding diving, or any activities that would raise my heart rate and increase symptoms—was also suggested. And finally, Simon’s last piece of advice was not to push depth for the first couple of months; instead to stick to open water dives (shallower than 18 m/60 ft).
But this meant I could dive again!!! And I was very, very excited about this. We concluded our catch up with epic diving stories and some amazing photos that Simon had taken on his incredible journeys on different diving expeditions.
Cleared to Dive!
Being cleared to dive, I eagerly called a couple of my friends and asked if they would join me for my first dive back. We chose to dive at Goat Island, New Zealand’s first marine reserve, and where my open water course was held.
We hit a maximum depth of 5 m/16 ft for an hour as I enjoyed being back in the water, chasing fish, looking for crayfish, and following Steph’s trusty navigation. It was so good to get back in the water, just in time for summer.
It has been three months since my first dive back in the water. If you follow my social media, you will know that over the summer, every spare minute I have is normally spent being on or in the water. I have been very lucky to have two weeks off work where I got to explore unfamiliar territory in the cooler waters of Waihau Bay, the most eastern part of New Zealand. And, although I wasn’t scuba diving there, it was great for freediving practice and just being back in the water. The second week of my holidays was spent in my favourite place up north in the sunny Tutukaka, where I have been able to scuba dive as much as I can while sticking to Simon’s advice and slowly increasing my depth.
For the first couple of months, I limited my dives to a maximum depth of 18 m/60 ft, avoiding physical excursion. During the last couple of weeks I have been increasing my depth limit to 30 m/98 ft, constantly monitoring how I am feeling and if any symptoms recur. I have been ensuring as well to make sure I drink plenty of water and allow for more rest and sleep than usual, both before and after diving.
Last weekend was a great test to see how I was after a full weekend of diving at the Mokohinau Islands. I completed four dives, my longest being 71 minutes, and loved every moment of it! We saw bronze whaler sharks, pilot whales, dolphins, a baby octopus, a little blue cod (unusual for this area), hundreds of schooling koheru, and a silver and yellow bait fish. The excitement I felt and the smiles on my face didn’t stop the whole weekend.
My next step in the next couple of months is to start diving with nitrox and work towards more technical diving later on in the year. Hopefully, by that stage, I will be able to travel and will be ready to take Global Underwater Explorers (GUE) Tech 1 and Cave 1 courses.
This is my own personal account of my injury. I wanted to share my experience and some scuba diving precautions after a concussion. If you have had a traumatic brain injury, no matter how slight, be sure to seek medical advice and clearance before returning to diving.
You can follow Annika’s blog here.
InDepth: Jumping into the Deep End by Annika Andresen
InDepth: Meet GUE’s NextGen Scholarship Winner
GUE’s first NEXTGen scholar, Annika Andresen is a virtual reality environmental educator for BLAKE NZ, connecting thousands of young Kiwis with their marine environment. Annika holds a Master of Architecture degree, where her thesis investigated the role architecture plays on the connection people have with their environment. During her studies, Annika worked as a dive instructor for Dive! Tutukaka, and was the President of the Auckland University Underwater Club. Annika has just been awarded the New Zealand Women of Influence Youth Award for 2019. Using her natural enthusiasm and infectious personality, Annika hopes to educate others to understand and cherish our unique environment and to better protect it for the years to come.
Does The Sport Diving Community Learn from Accidents?
Do we learn from accidents as a diving culture and, as a result, take the actions, where needed, to improve divers’ safety? Though we might like to think that’s the case, the reality is more complicated as human factors coach Gareth Lock explains in some detail. Lock offers a broad six-point plan to help the community boost its learning chops. We gave him an A for effort. See what you think.
by Gareth Lock
Learning is the ability to observe and reflect on previous actions and behaviours, and then modify or change future behaviours or actions to either get a different result or to reinforce the current behaviours. It can be single-loop, whereby we only focus on the immediate actions and change those, e.g., provide metrics for buoyancy control during a training course, or double-loop where the underlying assumptions are questioned, e.g., are we teaching instructors how to teach buoyancy and trim correctly? The latter has a great impact but takes more time, and more importantly, requires a different perspective. Culture is the ‘way things are done around here’ and is made up of many different elements as shown in this image from Rob Long. Learning culture is a subset of a wider safety culture.
Regarding a safety culture, in 2022 I wrote a piece for InDEPTH, “Can We Create A Safety Culture In Diving? Probably Not, Here’s Why,” about whether the diving industry could have a mature safety culture and concluded that it probably couldn’t happen for several reasons:
- First, ‘safe’ means different things to different people, especially when we are operating in an inherently hazardous environment. Recreational, technical, cave, CCR and wreck diving all have different types and severities of hazards, and there are varying levels of perception and acceptance of risk. The ultimate realisation of risk, death, was only acknowledged in the last couple of years by a major training agency in their training materials. Yet it is something that can happen on ANY dive.
- Second, given the loose training standards, multiple agencies, and instructors teaching for multiple agencies, there is a diffuse organisational influence across the industry which means it is hard to change the compliance-focus that is in place. From the outside looking in, there needs to be more evidence of leadership surrounding operational safety, as opposed to compliance-based safety e.g., ensuring that the standards are adhered to, even if the standards have conflicts or are not clear. This appears to be more acute when agencies have regional licensees who may not be active diving instructors and are focused on revenue generation and not the maintenance of skilled instructors. There is very little, if any, evidence that leadership skills, traits or behaviours are taught anywhere in the diving industry as part of the formal agency staff or professional development processes. This impacts what happens in terms of safety culture development.
- Finally, the focus on standards and rules aligns with the lowest level of the recognised safety culture models – Pathological from Hudson. Rules and standards do not create safety. Rules facilitate the discussion around what is acceptably safe, but they rarely consider the context surrounding the activities at the sharp end, i.e., dive centres and diving instructors and how they manage their businesses. These are grey areas. There is a difference between ‘Work as Imagined’ and ‘Work as Done,’ and individual instructors and dive centre managers must both ‘complete the design’ because the manuals and guides are generic, and manage the tension between safety, financial pressures, and people (or other resources) to maintain a viable business. Fundamentally, people create safety not through the blind adherence to rules, but through developed knowledge and reflecting on their experiences, and then sharing that knowledge with others so that they, too, may learn and not have to make the same mistakes themselves.
The proceeding discussion brings us to the main topics of this article, does the diving industry have a learning culture, and what is needed to support that learning culture?
What is a learning culture?
In the context of ‘safe’ diving operations, a learning culture could be defined as “the willingness and the competence to draw the right conclusions from its safety information system, and the will to implement major reforms when their need is indicated.” (Reason, 1997). Here we have a problem!
The industry is based around siloed operations: equipment manufacturers, training agencies, dive centres/operations, and individual instructors. Adopting a genuine learning approach means that the barriers must be broken down and conversations happen between and within the silos. This is very difficult because of the commercial pressures present. The consumer market is small, and there are many agencies and equipment manufacturers that are competing for the same divers and instructors. Also, agencies and manufacturers have competing goals. Agencies want to maximise the number of dive centres/instructors to generate revenue, and one of the ways of doing that is to maximise the number of courses available and courses that can be taught by individual instructors e.g., different types of CCR units. Manufacturers don’t want to realise the reputational risk because their equipment/CCR is involved in a fatal diving accident, but they also want to maximise their return on investment by making it available to multiple agencies and instructors. The higher-level bodies (WRSTC, RTC, and RESA) are made up of the agencies and manufacturers that will inherit the standards set, so there is a vested interest in not making too much change. Furthermore, in some cases, there is a unanimous voting requirement which means it is easy to veto something that impacts one particular agency but benefits many others.
This will be expanded in the section below relating to information systems as they are highly interdependent.
What safety information systems do we have in the diving community?
Training agencies each have their own quality assurance/control/management systems, with varying levels of oversight. This oversight is determined by the questions they ask, the feedback they receive, and the actions they take. These are closed systems and based around compliance with the standards set by the agency – sometimes those standards are not available to be viewed by the students during or after their class! Research has been carried out on some of this quality data, but it appears to have focused on the wrong part e.g., in 2018, a paper was published by Shreeves at al, which looked at violations outside the training environment involving 122 diving fatalities. While the data would have been available, a corresponding research project involving fatalities inside the training environment was not completed (or if it was, it wasn’t published in the academic literature).
As the ex-head of Quality Control of a training agency, I would have been more interested in what happened inside my agency’s training operations than what occurred outside, not from a retributive perspective, but to understand how the systemic failures were occurring. I also understand that undertaking such research would mean it would be open for ‘legal discovery’, and likely lead to the organisation facing criticism if a punitive approach was taken rather than a restorative one.
Safety organisations like Divers Alert Network collect incident data, but their primary focus is on quantitative data (numbers and types of incidents), not narrative or qualitative data – it is the latter that helps learning because we can relate to it. The British Sub Aqua Club produce an annual report, but there is very limited analysis of the reported data, and there does not appear to be any attempt made to look at contributory or influential factors when categorising events. The report lists the events based on the most serious outcome and not on the factors which may have influenced or contributed to the event e.g., a serious DCI event could have been caused by rapid ascent, following an out-of-gas situation, preceded by a buddy separation, and inadequate planning. The learning is in the contributory factors, not in the outcome. In fairness, this is because the organizations do not have to undertake more detailed investigations, and because the information isn’t contained in the submitted reports.
Research from 2006 has shown that management in organisations often want quantitative data, whereas practitioners want narrative data about what happened, how it made sense, and what can be done to improve the situation. Statistical data in the diving domain regarding safety performance and the effectiveness of interventions e.g., changes to the number of fatalities or buoyancy issues is of poor quality and should not be relied upon to draw significant conclusions.
What is required to populate these systems?
There are several elements needed to support a safety information system.
- Learning-focused ‘investigations’.
- Competent ‘investigators’.
- Confidential and collaborative information management and dissemination systems.
- Social constructs that allow context-rich narratives to be told.
Learning-focused ‘investigations’. The diving industry does not have a structured or formal investigation or learning process, instead relying on law-enforcement and legal investigations. Consequently, investigations are not focused on learning, rather they are about attributing blame and non-compliance. As Sidney Dekker said, “you can learn or blame; you can’t do both”. The evidence that could be used to improve learning e.g., standards deviations, time pressures, adaptations, poor/inadequate rules, incompetence, and distractions… are the same elements of data that a prosecution would like to know about to hold people accountable. Rarely does the context come to the fore, and it is context that shapes the potential learning opportunities. “We cannot change the human condition, but we can change the conditions in which humans work.” (James Reason). Rather than asking ‘why did that happen’ or even ‘who was to blame’, we need to move to ‘how did it make sense to do what they did’. ‘Why’ asks for a justification of the status quo, ‘how’ looks at the behaviour and the context, not the individual.
Competent ‘investigators’. As there isn’t any training in the diving domain to undertake a learning-focused investigation, we shouldn’t be surprised that the investigations focus on the individual’s errant behaviour. Even those ‘investigations’ undertaken by bodies like DAN, the NSS-CDS Accident Committee or the BSAC do not involve individuals who have undertaken formal training in investigations processes or investigation tools. A comprehensive learning review is not quick, so who is going to pay for that? It is much easier to deflect the blame to an individual ‘at the sharp end’ than look further up the tree where systemic and cultural issues reside. The education process for learning-focused investigations starts with understanding human error and human factors. The Essentials class, 10-week programme, and face-to-face programmes provide this initial insight, but the uptake across the industry, at a leadership level, is almost non-existent. Four free workshops are planned for Rebreather Forum 4.0 to help address this.
Confidential information management system. Currently, no system allows the storage of context-rich diving incident data outside the law-enforcement or legal system in a manner that can be used for learning. After discussions with senior training agency staff, it appears that as little as possible is written down following an incident. When it is, it is shared with the attorney to enable the ‘attorney-client’ privilege to be invoked and protected from discovery. If internal communications occur via voice, then the potential learning is retained in the heads of those involved but will fade over time. Furthermore, if they leave that role or organisation, then the information is almost guaranteed to be lost.
Social Constructs: Two interdependent elements are needed to support learning: psychological safety and a “Just Culture.” With the former, the majority of modern research strongly suggests that it is the presence of psychological safety that allows organisations to develop and learn (Edmondson, 1999). Edmondson describes numerous case studies where organisational and team performance was improved because incidents, problems, and near-misses were reported. Paradoxically, the more reports of failure, the greater the learning. It was not because the teams were incompetent; they wanted to share the learning and realised that they could get better faster with rapid feedback. They also knew that they wouldn’t be punished because psychological safety is about taking an interpersonal risk without fear of retribution or reprisal – this could be speaking up, it could be challenging the status quo, it could be saying “I don’t know”, or it could be about trying something new and coming up with an unexpected outcome.
The second requirement is a Just Culture which recognises that everyone is fallible, irrespective of experience, knowledge, and skills. This fallibility includes when rules are broken too, although sabotage and gross negligence (a legal term) are exceptions. Neither a Just Culture nor psychological safety are visible in the diving industry, although some pockets are present. To support psychological safety (proactive/prospective) and a Just Culture (reactive), there is a need for strong, demonstrable leadership:
- Leaders who have integrity – they walk the talk.
- Leaders who show vulnerability – talking about their own mistakes including the context and drivers; leaders who want to look at organisational issues inside their own organisation – not just point fingers at others problems.
- Leaders who recognise that human error is only the starting point to understand something going wrong, not the end.
‘…the will to implement major reforms…’
This is probably the hardest part because learning involves change. Change is hard. It costs cognitive effort, time, and money, and this has an impact on commercial viability because of the need to generate new materials, to educate instructor trainers/instructors and divers about the change and do it in multiple languages. Unless there is a major external pressure, e.g., the insurance companies threaten to withdraw support, things are unlikely to change because there aren’t enough people dying in a single event to trigger an emotional response for change. For example, in the General Aviation sector in the US approximately 350 people die each year, but if these deaths happened in airliners, it would mean two to three crashes per year, and this would be considered unacceptable.
In 2022, more than 179 people died diving in the US. (personal communications with DAN)
The most radical changes happen when double-loop learning is applied.
NASA did not learn from the Challenger disaster because it focused on single-loop learning, and when Columbia was lost, the investigation unearthed a lack of organisational learning i.e., double-loop learning. Chapter 8 from the Columbia Accident Investigation Board provides many parallels with the diving industry. The recent changes to PADI drysuit training standards following a fatal dive on a training course provide an example of single-loop learning – fix the ‘broken instructor’ and clarify course training requirements. The double-loop learning approach would be to look at self-certification and the wider quality management across the agency/industry; however, such an approach has significant commercial disadvantages across the board.
Creating a Learning Culture
The previous paragraphs talk about many of the issues we’ve got, but how do we improve things?
- Move to using a language that is learning-based, not ‘knowing’-based. This video from Crista Vesel covers the topic relatively quickly. This includes not using counterfactuals (could have, should have, would have, failed to…) which are informed by hindsight bias. Fundamentally, counterfactuals tell a story that didn’t exist.
- Look to local rationality rather than judging others. Move from who (is to blame) and ‘why did you do that?’, to ‘how did it make sense for you to do that?’. Separate the individual from the actions/behaviours and stop applying the fundamental attribution bias where we believe the failure is due to an individual issue rather than the context.
- Look to break down the barriers between the silos and share information. Ultimately, the stakeholders within the diving community should be looking to create a safe diving environment. Throwing rocks and stones at each other for ‘incompetence’ is not going to help.
- Adopt the Five Principles of Human and Organisational Performance as outlined in this blog.
- Build ‘If Only…’ or something produced for the recreational market, into training programmes at the instructor trainer, instructor, and diver level. This way the culture can slowly change by telling context-rich stories that have ‘stickiness’. However, this requires a fundamental shift in terms of how stories are told and how risk is portrayed in the diving industry.
- Finally, recognise we are all fallible. Until we accept that all divers are fallible and are trying to do the best they can, with the knowledge they have, the money they have, the resources they have, the skills they’ve acquired, and the drivers and goals they are facing, then we are unlikely to move forward from where we are, and we’ll keep choosing the easy answer: ‘diver error’.
InDEPTH: Examining Early Technical Diving Deaths: The aquaCORPS Incident Reports (1992-1996) by Michael Menduno
InDEPTH: The Case for an Independent Investigation & Testing Laboratory by John Clarke
Gareth Lock has been involved in high-risk work since 1989. He spent 25 years in the Royal Air Force in a variety of front-line operational, research and development, and systems engineering roles which have given him a unique perspective. In 2005, he started his dive training with GUE and is now an advanced trimix diver (Tech 2) and JJ-CCR Normoxic trimix diver. In 2016, he formed The Human Diver with the goal of bringing his operational, human factors, and systems thinking to diving safety. Since then, he has trained more than 450 people face-to-face around the globe, taught nearly 2,000 people via online programmes, sold more than 4,000 copies of his book Under Pressure: Diving Deeper with Human Factors, and produced “If Only…,” a documentary about a fatal dive told through the lens of Human Factors and A Just Culture.
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