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GUE History: Towards A New and Unique Future (2004)

Here in this 2004 white paper, Jablonski presents the rationale, controversy, and evolution of the DIR system, discusses the rise of alternative DIR groups and how they differ from GUE, and charts out a new direction for the organization, all of which makes for fascinating reading for diving history buffs.

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The Evolution of DIR

by Jarrod Jablonski, Preface by Michael Menduno

Preface

Standardization of equipment, gases and dive protocols are accepted and viewed as the norm in military and commercial diving. However,  the idea of creating standards for sport diving teams in order to improve their safety and performance was, to say at the least, controversial in the 1990s when technical diving was just emerging. But that’s exactly what George Irvine, then the director of the Woodville Karst Plain Project (WKPP), and training director Jarrod Jablonski, did with the development of their groundbreaking “Doing It Right” (DIR) system of diving, which evolved from the earlier “Hogarthian” approach to cave diving developed by WKPP co-founder Bill ‘Hogarth” Main.

There’s little doubt that the DIR system garnered even more controversy as a result of Irvine’s pugnacious “my-way-or-the-highway” online persona, which arguably detracted from DIR’s importance. Jablonski went on to establish Global Underwater Explorers (GUE) in 1998, with the DIR system at its core. In fact, GUE’s membership magazine “QUEST” was originally named dirQUEST.

By 2004, Jablonski and Irvine’s system inspired the rise of a number of DIR groups around the world, each unaffiliated with GUE, and each with its own focus and nuance. This created some confusion and additional controversy surrounding what constituted GUE standards in comparison to other DIR groups. As a result, Jablonski authored an article titled, “Toward A New and Unique Future,” in the Summer 2004 issue of dirQUEST, which is reprinted below. Following that issue, the “dir” was dropped from the title of magazine, which was renamed “QUEST.”

George Irvine and Jarrod Jablonski. Photo courtesy of the GUE archives.

In his treatise, Jablonski recounts in some detail the need, evolution, and clarification of GUE’s DIR standards, as well as discussing the rise of alternative DIR groups, the confusion that it caused, and the decision to take GUE in a new unique direction. His thesis makes for fascinating reading for diving history buffs like me. 

In addition, he made several notable points which struck me as I read it.  First, Jablonski pointed out that DIR was misunderstood from the beginning. Specifically, that it was NOT an indictment of non-DIR equipment configuration or practices, but rather an effort to promote uniformity among dive teams. There is more than one way to “do things right.” The key is to decide on a standard and stick with it.

Second, Jablonski concluded that DIR was a necessary, but not sufficient, condition of being GUE. In other words, GUE was bigger than DIR and encompassed a wider set of standards and practices. Those included the practice of “civility,” which was likely added in response to Irvine’s actions at the WKPP.

Interestingly, when viewed today, GUE’s standards have clearly demonstrated their robustness. In fact, one could argue that many of GUE’s standards, such as a pre-dive checklist, streamlined equipment, nitrox vs air, cylinder marking and gas switching protocols, as well as more conservative gas parameters—OK, not everyone has bought into helium beyond 100 ft/30m, yet—have been extremely successful in that they have largely been adopted by the technical diving community. Here’s what Jarrod Jablonski had to say back in 2004.

The article makes for fascinating reading for diving history buffs like me. 

Toward A New and Unique Future

by Jarrod Jablonski, GUE Founder and President

The history of underwater exploration is filled with striking personalities and noteworthy actions. However, underwater exploration took on a new form with the emergence of scuba diving. Initially driven by commercial and military interests, underwater exploration using scuba grew to include sport divers, who embraced underwater exploration as their life’s passion and who sought to develop the best tools possible to complement their exploration needs. While the sport was in its infancy, and choices were limited, these divers did not vary greatly in terms of their equipment and configuration.Furthermore, given that training options at the time were also limited, these divers also shared very similar techniques.

As more people took up scuba diving, however, variation in equipment, training, and equipment configuration grew. With ever-growing numbers of people finding pleasure in open water, no decompression diving, a collective identity emerged reflecting the interests of recreational diving participants. An entire industry would soon follow to serve these interests. Concurrently, another identity would take shape, one tied to a group of divers, some coming from within recreational diving, some from without. These divers pushed the limits of recreational diving, exploring increasingly more demanding environments; e.g. caves, deep wrecks and ice. Over time, these two groups would diverge and each would follow its own trajectory. The somewhat vague (in part arbitrary) categories of “technical” and “recreational” diving can be used  to describe these two trajectories.

Given the different orientations of recreational and technical divers, it should come as no surprise that different training practices, equipment choices, and configurations would emerge to answer to the wants of each. The evolving idea of what it meant to be “recreational” led to some divergence regarding what one needed to know to remain safe during dives of minimal difficulty. As a result, dive training tended to become shorter, with minimal treatment of topics such as gas planning, breathing gas concerns, decompression, and crisis management. Likewise, this shift led to greater variation with respect to equipment choices and to how this equipment would be configured.

However, the needs of technical diving generally required greater knowledge of these areas, more precision, more attention to detail, refined skills, practiced crisis management, a sound configuration, and well-crafted and well-maintained equipment. Conventions foreign to the recreational diving community, such as the “thirds rule,” the use of a long hose and a redundant regulator, emerged specifically to address the needs of the technical diver. However, in time, it became apparent that the more precision and proficiency that was required to pursue exploration-level technical diving, the more the need for a unified system. That’s because it was impractical, if not impossible, to operate efficiently as a team if individuals were not functioning under a common set of constraints.

George Irvine and Jarrod Jablonski
George Irvine and Jarrod Jablonski. Photo courtesy of the GUE archives.

Regardless of environment, there is substantial variation among divers with respect to both the value they place on efficiency and how intensely they seek to extend the limits of their diving practice. I would argue that the position that divers take on issues of efficiency is largely tied to the nature of their diving. For instance, it is clear why early divers did not consider standardization an urgent need. That’s  because their diving was less aggressive and thus less likely to demand a high level of efficiency.

However, as diving became more aggressive and more complex, the benefits of precision and efficiency become progressively more obvious; individuals undertaking such dives quickly realize the benefit of standardizing nearly all aspects of their diving to make it more efficient. So, when evaluating different equipment configurations—from those used in the early days of underwater exploration, to those representing “Hogarthian” ideas (discussed below), to the evolving principles of “Doing It Right”—it is useful to keep in mind the importance of efficiency in dealing with complexity.

As a greater number of divers (both recreational and technical) discover the value of efficiency as a means of improving the quality of their diving, standardization in training and equipment, seems the likely future of the practice of diving. The public first became aware of the movement toward standardization and of its value, when the Hogarthian diving system became popular. This scheme was composed of a rough set of ideas and equipment recommendations that served as useful standards for measuring desirable aspects of diving equipment configurations.

Cultivated by a small collective of cave explorers, i.e., Bill Gavin, William “Hogarth” Main, Lamar English, George Irvine, and myself, the idea behind this “system” was that there were preferred methods of configuring equipment, and that these methods had a profound effect upon diving efficiency. Bill Main invested considerable time seeking the most streamlined configuration possible, which resulted in his middle name being chosen to represent the overall system.

Though useful, the Hogarthian system did not require a specific piece of equipment or a particular configuration. Therefore, it did not provide divers with an objective diving standard that would ensure efficiency in the water and was thus limited in its utility. However, by promoting the idea that a careful selection of equipment and configuration could substantially impact the success of a dive, Hogarthianism introduced a dynamic new paradigm to divers and encouraged them to seek improvement through minimalism and streamlining. Armed with this new perspective, many divers (myself and the above explorers included) sought to assemble the most efficient equipment configuration possible, often sharing our findings with the public at large.


Jarrod Jablonski. Photo courtesy of the GUE archives. 

Rather than provide divers with an objective standard to assemble their configuration, Hogarthianism offered a loosely-knitted set of ideas or philosophy  that, in the interest of diver efficiency, promoted an ethos of careful gear selection. However, the lack of an objective standard did not permit divers to understand what exactly constitutes a Hogarthian diving configuration. Instead the “system” varied according to how different advocates of Hogarthian diving saw the links tying together equipment, streamlining, and efficiency.

This disparity of opinion, along with Hogarthianism’s singular emphasis on equipment (versus general diving practice) led to considerable confusion among the diving public (it was extremely difficult to standardize what, was largely subjective in nature). Eventually it became clear that both a more complete system and greater standardization were needed. To be as useful as possible, the components of the system would need to be objectively arrived at and standardized. George Irvine and I, having worked extensively with the Hogarthian system, and having written at length about it, worked toward this new paradigm. We named this  new paradigm “Doing It Right” or DIR.

As the first holistic scuba diving system ever crafted, “Doing It Right” began to gain significant popularity in the mid-1990s; a key component of its success was the detail and care that guided its growth. By adhering firmly to standardization, DIR initially faced opposition from diving quarters that saw the loss of “personal preference” as a notable sacrifice. Even so, with the gradual recognition that it is impossible for a team of divers to be efficient in the water without notable uniformity in equipment, training and configuration, opposition began to erode and continues to erode to this day. That’s because divers have begun to realize that there is a significant penalty in terms of wasted energy and effort for stubbornly seeking to maintain an individual “style.” Why reinvent the wheel alone when there is a proven system that ensures safety, efficiency, and success in the water?

Because DIR’s insistence on standardization is frequently misunderstood, it sometimes becomes a source of tension among divers. That’s because some see the insistence on uniformity as an indictment of practices that do not abide by DIR principles. However, there is nothing essentially hostile or critical about DIR; in its most basic form, it is ultimately pragmatic, promoting the concept of uniformity within and among teams of divers.

Because DIR’s insistence on standardization is frequently misunderstood, it sometimes becomes a source of tension among divers. That’s because some see the insistence on uniformity as an indictment of practices that do not abide by DIR principles. However, there is nothing essentially hostile or critical about DIR; in its most basic form, it is ultimately pragmatic, promoting the concept of uniformity within and among teams of divers.

To be fair, there is a certain degree of legitimate tension generated by imprudent advocates of DIR. Having personally benefited from the system, they take it upon themselves to become almost evangelical in their promotion of what they understand to be its tenets. Nevertheless, this is not an intrinsic weakness of DIR; all successful movements have their zealots.

By crafting a set of objective standards meant to regulate diving practice, DIR triggered a paradigm shift in diving, one that will forever modify the way that divers evaluate their diving. It is now part of our ethos to believe that divers acting cohesively and with shared purpose are more efficient. Nonetheless, considering standardization in isolation is unfair to the system’s holistic approach.

DIR Principles

As a well-defined, standardized system, DIR was designed to maximize efficiency across multiple environments in order to promote safety and fun. Among its key principles are:

Unified Team

Central to the DIR diving system is the concept of a unified team. This system pairs divers of similar capacity within an environment that they are properly prepared for. Teams of individually capable divers produce a level of safety and efficiency beyond what is capable while diving independently. Few things are as rewarding as diving within a group that maintains a similar degree of care and focus. Any diving activity where the concept of a team is marginalized will always fail to maximize its potential with respect to fun and safety.

Preparation

For DIR, preparation for diving involves five primary components. These are: pre-dive preparation, mental focus, physical fitness, diving experience, and dive planning. Divers who try to circumvent any of these areas are not adequately prepared for the dive and stand a good chance of experiencing reduced comfort, a missed dive opportunity, or even a dangerous situation. With ill effects, far too many divers assume that dive preparation begins the day or even hours before the dive.

Streamlined Equipment

The elements comprising a standard DIR equipment configuration have been endlessly discussed and are now well known. For those seeking more information on this subject, please refer to my book, “Doing it Right: The Fundamentals of Better Diving.”

In short, the DIR configuration was designed to work in a majority of situations and to ensure safety and promote a diver’s efforts, not undermine them. Streamlined and minimalist in nature, the DIR configuration was designed to maximize divers’ efficiency while minimizing their risk. Items should not hang free or protrude from divers’ bodies, increase drag or cause entanglements.

Balanced Rig

The DIR rig is a carefully weighted rig; one that ensures that while divers are not over-weighted, they are able to hold a decompression stop in the face of a catastrophic gas loss. This requires a careful assessment of the component parts of one’s configuration, and how these each impact statically and dynamically, on the buoyancy characteristics of the configuration as a whole.

Cylinder Labeling

DIR embraces the uniform practice of marking cylinders with the Maximum Operating Depth (MOD) in a clear and easily identifiable manner, and utilizing only this data to identify bottles. This practice prevents divers from becoming accustomed to unreliable identification procedures.

Standard Gases

DIR promotes reliance on standard gas mixes for all phases of diving. “Standard gases” help to insulate divers from the risks of inappropriate gas ratios, provide a common platform for cylinder marking and gas mixing, ensure team symmetry, and vastly simplify decompression logistics.

Conservative Gas Parameters

DIR promotes conservative gas parameters for all phases of diving. Among these are: Equivalent Narcotic Depths (END) of less than 100 ft/30 m, the partial pressure of oxygen (P02) during the working phase of the dive of 1.4 ATA or less, and P02s of 1.6 ATA or less for decompression. To offset the toxic effects of oxygen, nitrogen, and carbon dioxide, DIR recommends the liberal use of helium together with the conservative use of oxygen.

GUE Diving

To a careful reader, a casual review of diving history will reveal a movement toward greater standardization. DIR’s place in history is assured, given its role in introducing a new paradigm to the diving public, one where standardization provides divers with the key to efficiency, safety, enjoyment and success. Though there is still variation among divers, in time, the desire for proficiency will force them to migrate toward a known paradigm that through its insistence on standardization, ensures phenomenal success in both extreme diving projects and in recreational applications. For this reason, the trajectory that the history of diving will follow will speak volumes to the impacts of the DIR movement.

George Irvine diving with the WKPP. Photo courtesy of the GUE archives.

With all great movements, comes inevitable corruption and fragmentation. Today, DIR has spread to every corner of the globe, with self-appointed DIR groups emerging in dozens of different countries. Given their physical separation, their lack of centralized direction, their own specific agendas, beliefs, power struggles, and constraints, these satellite groups cannot help but to promote a version of DIR that is uniquely their own. Many of these “versions” of DIR bear little resemblance to the original, however well-intentioned and devoted to the founding principles of DIR these groups may be.

The unavoidable division of DIR is the result of many factors, ranging from breakdowns in channels of communication, to differing interpretations, to personal agendas, to private experiences, to power plays, to simple disagreements among proponents. As individuals and groups adopt DIR they will often make choices very different from those that I and other founders of DIR would have made. As a result, it is necessary for us to recognize that DIR will be repurposed by those it has influenced in ways that serve their own interests. Nonetheless, in the end, I believe that these systems that adopt DIR can only benefit the future of the diving industry. Even so, I believe that to enhance the safety, fun and efficiency we sought to ensure when we first started to build DIR, it is necessary for us to ensure greater standardization across additional domains.

From the outset I believed that divers’ training, their equipment, their configuration, their knowledge, and their skill set should all contribute to greater safety and enjoyment in the water. That was the reason I founded GUE. The DIR system is at the core of GUE training. That is not surprising, given the extent to which my efforts helped to shape both DIR and GUE. However, with the passage of time, GUE has shaped its own identity, one that is not identical to that of DIR. And though being DIR is a necessary condition of being a GUE diver, it is not a sufficient condition; it is not enough.

There is more to being a GUE diver than being DIR. Among other things, it entails a standardized measure of competence (training), a commitment to civility, and also to non-smoking, aspects to which DIR in-itself does not speak.

There is more to being a GUE diver than being DIR. Among other things, it entails a standardized measure of competence (training), a commitment to civility, and also to non-smoking, aspects to which DIR in-itself does not speak. Over time, GUE vice-president and long-time DIR supporter Dr. Panos Alexakos and I came to see that there was really no way to reign in the growing number of interpretations by DIR advocates; it would be a waste of resources and energy to struggle with them over the correct interpretation of DIR. With this in mind, we have struck out on a new road, a distinctly GUE road that looks fondly upon DIR as the foundation that can empower the organization toward a new and unique future.

Did you enjoy this article? Watch the original DIR 2004 DVDs now on GUE.tv.


Jarrod Jablonski is an avid explorer, researcher, author, and instructor who teaches and dives in oceans and caves around the world. Trained as a geologist, Jarrod is the founder and president of GUE and CEO of Halcyon and Extreme Exposure while remaining active in conservation, exploration, and filming projects worldwide. His explorations regularly place him in the most remote locations in the world, including several world record excursions at 300 ft to cave penetrations in excess of 24,000 ft/7 km; these dives include bottom times of 12 hours with total immersions near 30 hours. Jarrod is also an author with dozens of publications, including three books and more forthcoming, as well as several awards for lifetime achievement, including the 2018 DAN-Rolex Diver of the Year, 2016 Eurotek and 2015 Golden Trident. He successfully completed his first Ironman in April 2019.

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No Fault DCI? The Story of My Wife’s PFO

What does it mean if you keep getting bent, even when you follow all the rules? Avid tech diver James Fraser recounts his and his wife’s Deana journey of discovery that led them to realize she had a PFO. Does any of this sound familiar? Read on!

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Breathing O2

by James Fraser

All photos courtesy of James Fraser

When you follow all the rules and still get decompression illness, what’s up?

The person I hold most dear in this life has now had three incidents of decompression illness (DCI) over a two-year period. The latest episode required recompression, so we began investigating her frequent illness to determine if there was a possible solution. Deana is a very conservative diver, diving within her training, computer limits, and dive planning tools such as Deco Planner. On all of the dives where she had DCI, her training, tools, and dive profiles say she should not have gotten bent. But she got bent just the same.  

DCI is a risk for any diver, even when following the rules. However, we have to remember that DCI is a potential sports injury, no different than a football player risking a concussion. Despite this fact, DCI seems stigmatized, and people feel ashamed to admit it happened to them. So Deana and I decided to share her experiences with DCI, to help others realize, Sh*t, I mean, DCI happens! Experiences with DCI should be shared, so that the diving community can continue to learn, grow, and be safer divers. 

Some background

Deana Fraser has been a registered nurse (RN) for over 25 years, and received her BSN in 2002. Throughout her career, she has specialized in ER, ICU, and OR nursing. Currently, she manages the Overlake Operating Roomin Bellevue, Wash. When Deana is not managing the OR, she is usually diving in the extreme conditions of the Pacific Northwest (PNW), where all dives are cold (46-55℉/8-13°C), dark, and wonderful. Deana has been a recreational diver since 2004, and loves diving in Seattle and the surrounding areas as often as three days a week. It is her number one passion. 

She just completed her Global Underwater Explorers (GUE) Technical 1 course (normoxic trimix) in September 2019, and as of this article she has completed over 500 dives, 150 during 2019 alone. Deana always looks forward to expanding her skills and experience in the recreational and technical diving arena. 

Deana is also a breast cancer survivor; she was diagnosed with Stage Two breast cancer in May 2016, and underwent a lumpectomy and six weeks of radiation treatment, until July 2016. She is in full recovery, but continues to take Tamoxifen (20mg) daily. This information is not intended to draw any type of correlation of breast cancer and DCI, but to give all details about Deana’s fitness and health in respect to her history with DCI.

Deana is one of those people that lets nothing hold her back. She was not able to dive for a few months after her radiation treatment, so she turned to her second love: hiking. She proceeded to hike over 200 miles (dragging her husband with her) over the next six months while she was recovering. Deana has been cancer free for over three years now and is back to her first love of diving. When she returned to diving, she pursued her dream of technical diving and signed up for GUE Fundamentals in 2017. She has been unstoppable since then and again has dragged her husband along for the ride. 

After cancer treatment, Deana spent a lot of time building up her strength and dexterity in order to pack double 100s over the rocky beaches of the PNW. She trained relentlessly to reach the goal of being a GUE Tech 1 Diver, a mission that she accomplished. In addition to her regular dives, Deana leads a weekly Skills Refinery Dive, offering opportunities for other local divers to hone their techniques and commit to excellence. Many are working on their GUE Tech skills to prepare for Tech 1. Deana is not done with her education and has dreams of completing GUE’s Tech 2 course in the future. Now that you know the type of person Deana is, let’s talk about the reason she and I have written this article. 

Look, James. I Got Stung by Something!

Deana and I went on a 16-day trip to the Maldives in April 2018. We spent the first week at Olhuveli Beach Resort resting, flipping our internal clocks, and doing a few recreational shore and boat charter dives. The second week, we joined up with our local Seattle dive group on Blue Force One, a fantastic live-aboard charter, for seven days of additional recreational diving; no dives on this trip were below 100 ft/30 m. On day three of diving on Blue Force, after her second dive, Deana talked to me about being stung on her abdomen. She presented with redness, point tenderness, and stinging in an area about the size of a silver dollar. She was wearing a full length 3mm wet so it definitely was not something she would have brushed against during the dive. She took a Benadryl, feeling that something stung her, got some sleep, and by the next morning it had cleared up. Deana continued diving for the rest of the trip and had no further symptoms. We now suspect that she had a minor case of skin bends, based on the other two episodes she has had since. 

Deana and I also dived in Loreto, Mexico, six months after the Maldives, in October 2018, and performed  ten dives over four days with a max depth of 80 ft/24 m; Deana showed no symptoms of DCI.

Could I Have Skin Bends?

In April this year, 2019, Deana and I were in Hurghada, Egypt, on a live-aboard dive trip with Red Sea Explorers aboard MV Nouran. Deana had completed eight recreational nitrox dives over three days, the deepest dive being 98 ft/30 m, when she showed signs of skin bends. Below are the dive profiles of the two dives the day she presented with skin bends. She again had symptoms of stinging and itching on her thighs and abdomen and point tenderness. The area was larger than the first experience she had in the Maldives.

First dive of the day: Double 12L tanks with nitrox 32 after 11 hour surface interval
Second Dive: Double 12L with nitrox 32 after 3:23min surface interval.

Deana again wondered if it was some kind of sting or allergic reaction and asked me and some of the more experienced divers for our opinions. A couple of the more senior technical divers on board agreed: Her symptoms looked and presented like skin bends. Deana went on 100% oxygen (O2) for a few hours, and the symptoms went away. She took the next day off and then continued to dive recreationally with more conservatism for the remainder of the trip. One other person on the trip who was doing Tech 1 level dives also showed signs of skin bends; they were treated with O2 and continued to dive for the rest of the trip with no further issues. 

After this episode we thought about the Maldives: Since it presented the same way and resolved itself with some time and O2, we now assumed that was also an incident of minor skin bends. 

Skin Bends Again, But Nothing a Bit of O2 Can’t Fix

Deana and I were attending Tek week at Buddy Dive in Bonaire. We were both looking forward to a week of Tech 1 dives (Max depth 170 ft/50 m, max deco: 30 min), as this was Deana’s first trip since passing her course. We had done three dives total over days one and two at recreational depths on nitrox 32 (32% oxygen, 68% nitrogen) with no required deco. 

On day three we planned to dive to 150 ft/46 m on trimix 21/35 (21% oxygen, 35% helium), with 25 min bottom time with a gas switch to nitrox 50 at 70 ft/21 m. Our decompression profile used GUE modified deco based on Deco Planner with 2 min stops from 70 ft/21 m to 30 ft/10 m and a 16 min stop at 20 ft/6 m. The total planned run time for that dive was 58 min. At the start of our ascent, our average depth was only 132 ft/40 m, as we had worked our way slowly up the reef after hitting a max depth of 152 ft/46 m.

Deco Planner Dive Profile
Perdix Shearwater Dive profile using GF20/85

After a three-and-a-half-hour surface interval, we planned a 100 ft/30 m dive on nitrox 32 with a bottom time of 40 min with a gas switch to 100% O2 at 20 tf/6 m for 10 minutes for added conservativism. Total run time for that dive was 69 min, as we extended our 20 ft/6 m stop a lot longer to just hang and enjoy the reef. 

Deco Planner for Dive 2
Perdix Shearwater Dive profile using GF20/85

Roughly two hours after this dive, Deana complained of itchy stinging skin on her hips and abdomen; she described it as being like stinging nettles. She was not concerned as this felt like what she had in Egypt, so we put her on 100% O2 for about an hour and a half and all symptoms resolved. Deana and I considered this a minor issue, and we did not talk to anyone about the symptoms since they quickly resolved. No further issues were experienced that evening. 

It is here that human factors really played into the scenario. Deana and I made the mistake of not talking about the issue we had just experienced. We found out later the next day that Dr. Douglas Ebersole (cardiologist and consultant to Divers Alert Network) and the late Dr. Fiona Sharp (diving physician and anesthetist) were active participants of Buddy Dive Tek week. If we had spoken up, we most likely would have been able to talk to one or both of them and potentially decide not to dive the next morning. However, hindsight is 20/20, and we just didn’t feel the need to talk about it since Deana’s symptoms had been resolved. 

The next morning Deana felt fine and showed no rash or issues from the previous day. She wanted to do the planned trimix dive to 150 ft. It was the same profile as the previous day’s dive, and the dive went without issue. We had completed an 18-hour surface interval, and Deco Planner showed we could dive the same profile with no additional decompression obligation. 

Deco Planner confirmed our assumption of being clear after 18 hours

About 45 min to an hour post dive, Deana complained of similar skin pain and stinging, but this time it extended down her thighs. When we returned to shore, we shared her symptoms with the technical diving supervisor, Mr. G, and placed her back on medical O2 for about two hours. This resolved the stinging, but Deana showed edema in her thighs, hips, and abdomen and deeper tissue pain. She had resolved to sit by the pool and have a Corona while I took a nap beside her to see if it would resolve itself. 

We Called DAN

About an hour later Deana said, “We have DAN insurance, maybe we should call them and get their advice.” She placed a call to DAN, and within minutes was talking to Dr. Matías Nochetto. After a thorough assessment, Dr. Nochetto stated that, while they cannot diagnose over the phone, there were enough signs and symptoms to recommend we go into the ER and be assessed for DCI. DAN said that Bonaire had a hyperbaric chamber with an excellent team, and they gave us contact information for some of their team members. I cannot say enough good things about how DAN took so much worry away, offered a wealth of knowledge, and confirmed the direction we should take. 

We followed DAN’s advice and told Mr. G what the plan was. Mr. G told us that Dr. Douglas Ebersole was one of the guest speakers and an active diver, and he located him for us before we went to the ER. Dr. Ebersole performed a neurological assessment in the parking lot and talked to Deana about her symptoms. He concurred that she needed to be assessed at the ER, and he felt she was showing signs of lymphatic DCI; his opinion gave us peace of mind, that while her condition wasn’t critical, it should still be checked at the ER. 

After listening to Deana’s diving history over the last few years, he suggested undergoing a Transthoracic Echo (TTE) bubble study to rule out a Patent Forum Ovale (PFO), as this could explain her susceptibility to DCI. PFOs exist in almost a third of the population; although the condition isn’t rare, the condition can be activated due to the pressures exerted on our bodies at depth.

I drove Deana to the Bonaire ER, where the nursing team did a thorough assessment and showed great care, humor, and understanding. The ER nurse who took initial care of Deana was also a paramedic and technical diver and was wonderful to work with. After a full assessment, the ER doctor, who was not a diver, suggested that Deana made a poor choice in deciding to continue diving after a possible bout of skin bends. Deana later mentioned this comment to the ER nurse, adding that the doctor was not a diver and so likely didn’t understand. The ER nurse just smiled and agreed with her. 

We were then visited by one of the hyperbaric physicians, who completed Deana’s neurological exam, which showed no signs of neurological DCI. He diagnosed her with DCI of the lymphatic system and said that recompression would be necessary to treat her symptoms. He gave her a saline IV and a Table 5 treatment in the chamber.

Deana did her 2.5 hour run in the chamber and did not notice any improvement in the pain or edema. However, her doctor told us that the pain and swelling of lymphatic DCI does not go away right after a chamber ride like with other types of DCI; DAN confirmed this when they followed up with us the next morning. We were told that the edema could take a few weeks to normalize. By the next day the pain had decreased, and Deana felt she was recovering. She did not dive any more on this trip, but still had a happy, positive demeanor, and she was the life of the party: Everyone wanted to know all about her chamber ride and experience. 

Without undermining the risks associated with DCI, I want to mention the general positive outcome of this experience: we learned a great deal about Type 1 DCI, no one at our resort made Deana feel like she did something wrong, and everyone offered their support and understanding. 

In Search of a PFO

In closing, I want to offer clarity on some frequent inquiries we’ve received about this story. Some suspected that dehydration may have played a part, but as an RN, Deana had more than doubled her water intake and was always staying hydrated. While dehydration can be a contributing factor to DCI, we do not feel that it was an issue in this case. People also asked about her alcohol intake. By the time of her second DCI hit that required recompression, she had had three Coronas and one mixed drink in three days. Her alcohol consumption was not an issue.

After coming back to the United States, Deana saw Dr. James Holm, who is one of the leading hyperbaric physicians at Virginia Mason in Seattle, and was highly recommended by DAN. Dr. Holm did a follow up examination and agreed that, based on her history, dive profiles, and the lymphatic DCI experience, Deana should get a TTE bubble study to check for a PFO. Deana scheduled a TTE through Overlake Hospital’s Advanced Cardiac Imagery Department. The results revealed that she does, in fact, have a mild-to-moderate PFO.

This diagnosis was bittersweet, as it explained why Deana had frequent incidents of DCI while diving within limits, but it now puts Deana in a position to weigh the risks and determine her next course of action. Both Dr. Holms and Dr. Aviles, an interventional cardiologist who diagnosed the PFO, did not recommend rushing into a PFO repair, which they said was not a silver bullet that would guarantee a DCI-free future.

Both physicians offered several suggestions for Deana to consider: 

1. Stop diving, as this eliminates any risk of DCI in the future. For Deana this is not an option.

2. Modify her dive profile to be more conservative: diving only once per day, diving nitrox 32 but basing her profiles as if she was diving air, and/or extending her decompression profiles and safety stops.

3. Have the PFO repaired, knowing it is not a guarantee, and continue diving being as conservative as possible. 

Dr. Aviles did say that if Deana plans on continuing the frequency and type of diving she has been currently doing, getting the PFO repaired is probably her best option. These are all choices that divers who have been diagnosed with a PFO have to wrestle with, and there is no right or wrong answer. While Deana is considering her options, she will look to be more conservative with her dives. 

Like all types of higher risk sports, divers choose to accept the risk of being injured. For most divers, this is an acceptable risk, so we can enjoy the experiences we so cherish in exploring our aquatic environment. As divers we need to continually educate ourselves so we can make well-informed decisions that attempt to lower our risk of being injured. 

Deana and I highly recommend Gareth Lock’s work on human factors for understanding how our decisions play into potential diving accidents. However, even with research and advancements in technology at our disposal, we still don’t understand DCI. There is no guarantee, even if we follow all the rules, that we will not get bent unless, of course, we stop diving. It is a risk we all take when we submerge beneath the water. 

We have been amazed by the number of people we have met who discovered that they had a PFO in a way similar to Deana. Many have chosen to have their PFO corrected, though some have not, but all of them have been willing to share their experiences with us, helping us make a more informed decision. Next time you or a teammate shows any signs of DCI, tell someone and have it checked out. Sharing our experiences makes us safer, more educated divers. 

Photo by Myra Wisotzky

Additional Resources:

Gareth Lock, The Bend is Uninteresting…The Related Decisions Are Much More So


James D. Fraser is a PADI MSDT and NAUI Scuba Instructor and has been diving in the Pacific Northwest for over 30 years. James currently lives in Seattle, WA, with his wife and dive teammate Deana Fraser. Both James and Deana work at growing the local diving community and sharing their passion with all who are interested.  James recently embraced technical diving, becoming certified as a Technical 1 diver with Global Underwater Explorers. James and Deana have had opportunities to travel all over the world to experience their passion in amazing places such as Egypt and the Maldives. James currently works as a Cyber Security Director with a Fortune 500 Defense Contractor and has been a residential construction business owner as an Emergency Medical Technician (EMT). James wants to expand his knowledge in the diving field and grow his experience in technical diving.

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