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By Douglas Ebersole, MD
Header photo by Becky Kagan Schott, Selfie with Jitka Hanakova.
Historically, technical diving has been a male-dominated sport; however, that is changing. In fact, at this year’s Bonaire Tek event in October, there were 24 women in attendance, representing almost 30% of the attendees. Little attention has been paid to issues unique to women in technical diving. This article will address a number of these. Specifically, it will discuss the risk of decompression illness (DCI) in women versus men, changes in risk of DCI at various times during the menstrual cycle as well as the effects of oral contraceptives, pregnancy, cosmetic and reconstructive surgery, menopause, and cardiovascular health.
In an attempt to show full transparency, I am NOT a woman, and I fully understand that immediately puts my credibility into question. However, I have lots of family and friends who are women technical divers, and I reached out to them for help deciding on topics to approach. Thanks to my wife, who is a rebreather diver; our daughter, who is a rebreather instructor; Jill Heinreth, Becky Schott, Mel Clark, Jo Mikutowicz, and Rosemary “Roz” Lunn for their input. I also heavily referenced a textbook by Caroline Fife, M.D. entitled Women Under Pressure.
Decompression Illness and Gender
When looking at women and the risk of decompression illness, three factors bear consideration. First, do women and men differ in their risk for decompression sickness when under the same decompression stress? Second, what (if any) effect does a woman’s menstrual cycle have on her risk for decompression sickness? And, finally, what is the data on decompression sickness risk while on oral contraceptives?
The data we have on DCI risk based on gender is retrospective and inconclusive. In a paper in Undersea Biomedical Research in 1987, Zwingelberg looked retrospectively at Navy divers, 28 women and 487 men, with a combined 878 training dives with equal representations of exposures. In this study there was no difference in risk of DCI by gender.
In 1992, in Undersea Biomedical Research, Robertson retrospectively looked at 111 cases of DCI in Australia. In this report, women had a 4.3 times greater incidence in Type II decompression sickness compared to men.
In 1993, Vann reported on this issue using the Divers Alert Network (DAN) flying after diving data and published in Aviation Space and Environmental Medicine. His data also suggested that women had a higher risk of Type II decompression illness compared to men and had more residual symptoms. However, he mentioned that it was unclear if the incidence was truly higher or if there was reporting bias.
In another study in Aviation Space and Environmental Medicine in 2002, St. Leger Dowse sent questionnaires to divers (53% men and 47% women). This data suggested that before controlling for diving patterns, women had a 1.67 time greater risk of DCI. However, after controlling for diving patterns, men actually had a 2.57 time greater risk of DCI.
Finally, Hagberg reported in Undersea and Hyperbaric Medicine in 2003 on 1,516 male and 226 female diving instructors and dive masters who self-reported their incidence of DCI. This data set contained thousands of dives of various types and showed a risk of DCI for men of 1.52 per 1,000 dives and a risk of DCI for women of 1.27 per 1,000 dives.
In conclusion, the differences in dive profiles in the available observational data make it impossible to draw firm conclusions regarding the effect of gender on DCI among scuba divers.
Decompression Illness and the Menstrual Cycle
A woman’s menstrual cycle is typically 28 days and is controlled by the interactions and levels among three hormones: estrogen, progesterone, and testosterone. Several retrospective studies have tried to correlate the risk of decompression illness at various times during the menstrual cycle. In 1998, Lee et al, reviewed 73 records and found 35% of DCI events occurred within the first five days of the menstrual cycle.
In 2006, St. Leger Dowse reviewed more than 50,000 dives and 11,000 menstrual cycles in 570 women. This showed the highest incidence of diving problems was in the first week of a 28-day cycle while the lowest risk was in week three. She then also reported in 2006 the results of 250 prospective DCI records and found the highest incidence of DCI was in the first week while the lowest incidence was in the third week of a 28-day cycle.
While the data above for menstruating women suggests a higher risk of DCI in the first week of their cycle, the data for women on birth control pills is less clear. These women have a pharmaceutically driven menstrual cycle. While studies have assumed a 28-day cycle in these women, St. Leger Dowse in the Journal of Obstetrics and Gynecology in 2007 reported that only 42% of women on oral birth control pills had a 28-day cycle. The remainder ranged from 21 to 60 days. As a result, the data on DCI in women on birth control pills is clouded, inconclusive, and confusing.
In conclusion, the mechanism of risk across the menstrual cycle is not known, but hormonal fluctuations may be a possible factor. And one final note – while menstruation may decrease exercise tolerance due to anemia and volume depletion, it does NOT increase the likelihood of shark attack.
Pregnancy and Diving
Human data on the effects of hyperbaric oxygen on the fetus are limited. In 1980, Bolton reported in Biomedical Research on 109 women who dived before and during pregnancy compared to 69 women who dived before pregnancy but stopped diving once pregnancy was diagnosed. Babies born to women who dived during pregnancy had lower birth weights, more respiratory difficulty, and birth defects, including hemivertebrae, absence of a hand, a ventricular septal defect, coarctation of the aorta, and pyloric stenosis. It should be noted that there were no birth defects in the babies born to women who stopped diving when they learned they were pregnant.
Once again, St. Leger Dowse chimed in on this issue. She reported in Obstetrics and Gynecology in 2006 on retrospective data from 1990-1992 and prospective data from 1996-2000 on 129 women who continued to dive, either purposely or inadvertently, during their pregnancy. This involved 1,465 dives during 157 pregnancies. Of note, while only 65% of women stopped diving during the first trimester of their pregnancy in 1990-1992, by 1996-2000 this number increased to 90%. For the total population, the incidence of spontaneous abortion was 14% and the serious birth defect rate was 2.7%, which is similar to the rate in nondivers.
Of course, if DCI occurs in a pregnant woman, the fetus also becomes a patient. Because of fetal blood flow, venous bubbles in the mother will be arterialized into the systemic circulation of the fetus through the foramen ovale, which could be devastating. Of note, there is no data on fetal injury related to maternal hyperbaric therapy.
There are other issues with diving during pregnancy not related to decompression stress. Pregnancy increases total body water and swelling of mucous membranes, making equalization difficult. Two-thirds of women have nausea and vomiting, or “morning sickness,” in early pregnancy. Additionally, gastric reflux (heartburn) is very common during pregnancy and is already common with immersion for any diver.
After vaginal delivery, women should refrain from diving for 21 days postpartum to allow time for the cervix to close so as to lessen the risk of ascending infection. After cesarean delivery, most obstetricians recommend refraining from diving for 4-6 weeks.
The issue for diving during breastfeeding is the risk of marine bacteria colonizing on the skin, resulting in mastitis in the mother and bacterial diarrhea in the infant.
Diving and Breast Augmentation
In the early 1980s, Divers Alert Network began receiving calls about the concern of dissolved gas expanding on a commercial flight home putting stress on the seams of breast implants. In 1988, Vann reported in Plastic and Reconstructive Surgery on the results of hyperbaric followed by hypobaric conditions on a variety of saline and silicone implants. Depths were as deep as 120 ft/37 m and dives times of up to 72 hours. Then, after a 21-hour surface interval, the implants were taken to 7000 ft/2.1 km for two hours and then to 30,000 ft/9.1 km for two hours to simulate loss of cabin pressure. The implant volume increased 1.0-4.0% at the surface, 0.0-5.0% at 7000 ft/2.1 km, and 4.0-12.0% at 30,000 ft/9.1 km. Saline implants were less affected than silicone implants, all bubbles resolved over time, and the volume change was not enough to risk rupture.
Post operatively after breast augmentation, women should wait 4-6 weeks before returning to diving and avoid putting tight shoulder straps over the implants to avoid undue pressure. Finally, while saline implants are neutrally buoyant, silicone implants are negatively buoyant.
Diving, Smoking, and Oral Contraception
Fourteen percent of women age 14-44 use oral contraceptives. These birth control pills have been shown to increase the risk for forming blood clots resulting in stroke, heart attack, deep venous thrombosis (blood clots in the legs), and pulmonary emboli (blood clots in the lungs) in women who smoke. While nonsmoking women on birth control pills who are less than 35 years of age have no increase in risk compared to nonsmoking women not on birth control pills, women who smoke have a significant increase in the risk for these conditions.
Compared to nonsmokers who are not on birth control pills, women who smoke less than one pack per day while on birth control pills have a three-fold increased risk of these conditions, while smokers of more than one pack per day have a 23-fold increased risk.
Diving and Menopause
Twenty-two percent of women divers making more than eight dives per year are 55 years of age or older. During menopause, women are at a much higher risk for osteoporosis than men due to a baseline lower bone density, followed by the loss of estrogen which accelerates the rate of bone demineralization. The average age for menopause is 50 years, and bone loss increases dramatically after this. Significant bone loss will be seen at 60-70 years and fractures begin occurring at 70-75 years. Thankfully, there are now treatments to blunt this bone loss. Women with significant osteoporosis of the spine should be cautious about walking while wearing scuba cylinders due to an increased risk of vertebral crush fractures.
Cardiovascular Disease and Menopause
The leading cause of death in women is cardiovascular disease. In addition, approximately 100 U.S. and Canadian divers, both women and men, die while scuba diving each year. Twenty-five percent of those over age 35 have a cardiac cause. While the risk for cardiovascular death is quite low in premenopausal women, after menopause, the risk for women quickly becomes comparable to that of men. As a result, all women, like their male counterparts, should be vigilant in controlling the risk factors for cardiovascular disease, emphasizing blood pressure and cholesterol control, screening for and treating diabetes, and avoiding smoking in addition to exercise and weight control.
- Women are at increased risk for decompression illness during the first week of their menses.
- The risk of decompression illness for a woman on oral contraceptives is unclear.
- A woman diver should stop diving as soon as she knows or suspects that she is pregnant.
- Breast implants can swell when going from hyperbaric (diving) to hypobaric (air travel) environments, but not enough to risk rupture.
- Women, especially those on oral contraceptives, are at a much greater health risk if they smoke.
- Osteoporosis with aging can put women at risk for spinal compression fractures.
- Cardiovascular health is as important a concern for women as it is for men.
Douglas Ebersole, MD, is an interventional cardiologist at Watson Clinic in Lakeland, Florida, and the Director of the Structural Heart Program at Lakeland Regional Health. He is also an avid technical diver, cave diver, and CCR trimix instructor, as well as cardiology consultant to Divers Alert Network (DAN).
The Life & Times of a West Coast Photogrammetrist: Could it be the Almirante Barroso?
Seattle-based instructor and photogrammetrist Kees Beemster Leverenz recounts the challenges he and his team faced trying to amass sufficient detailed footage of a mystery steamship lying 75m/250 ft beneath the Red Sea, while Murphy hammered away on the team and their equipment. What’s a photogrammetrist to do?
by Kees Beemster Leverenz
Header image and photos courtesy of K. Leverenz unless otherwise noted.
[Ed.note: Be sure to make the jump on Leverenz’s 3D model ]
About four minutes into the dive I realized I should have listened to Faisal. Nine divers in three teams, myself included, had made it to around 40 m/130 ft when the warm calm water of the Suez gulf turned into a torrent. The thick rope that connected the surface to the wreck went from vertical to nearly horizontal, and started shaking due to the powerful water flow. With a rebreather, two decompression cylinders, and a camera, I could only make headway if I turned my scooter to its maximum speed and kicked as hard as I could. Even then, progress was slow. The wreck was 37 m/120 ft away, resting in just over 75 m/250 ft of clear blue water. We had a long way to go.
Faisal Khalaf—the proprietor of Red Sea Explorers and our deep diving guide for this trip—had told us what to expect. Perhaps “warned” is a better word. However, besides being a talented diver, Faisal is an excellent storyteller with a flair for the dramatic. This had led me to believe he was being theatrical during the dive briefing in the morning, describing surging currents underwater despite placid surface conditions. He was not exaggerating.
The flow was strong, and our three dive teams resorted to a combination of negative buoyancy, scootering, kicking, and pulling ourselves hand-over-hand down the rope to get to the wreck. As I struggled against the current, another bit of the dive briefing drifted through my head: We were less than a kilometer from one of the largest shipping lanes in the world, and it would be quite dangerous to get swept off the line. Even if a large container ship could spot a diver (they can’t), and they wanted to turn, they’d be unable to. The turning radius of a modern container ship is measured in kilometers.
Around 60 m/200 ft, the wreck came into view for the first time: an enormous hulk, with two anchors at the bow and a large twin steam boiler at the stern. Schools of giant trevallies—each over a half meter long—darted around the wreck feeding on other marine life sheltering in the hull. On that first dive, our nine divers landed somewhat ungracefully in the protection provided by the thick steel of the wreck, which acted as a break-water to shield us from the powerful current that had challenged us on the descent. We got our bearings, breathed deep, and began our dive.
Faisal believes this wreck is the remains of the three-masted steel-hulled Brazilian steam corvette SC Almirante Barroso, sunk in 1893 when it struck the rocks of Al Zait. The SC Almirante Barroso was on a training mission for Brazilian Navy Cadets, and was attempting to circumnavigate the globe when it went down. Thankfully, the crew of the SC Almirante Barroso were rescued by the English ship Dolphin, but the wreck’s exact location remains a mystery. Although the identity of this wreck has yet to be confirmed, the location, size, and type of wreck matches closely.
Imaging A Mystery
This was my first encounter with the mystery ship, a single day expedition to an exciting new wreck in the midst of my first visit to the Red Sea. It was one of the more challenging dives I’ve ever done, somewhat surprising given the generally forgiving conditions in the Red Sea. It was a lesson in the fact that cold water and poor visibility aren’t the only thing that can make a dive difficult. Our team was one of several to visit the wreck since its discovery in early February of 2018. Previous dives had focused on taking pictures, shooting video, and searching the debris for something that would confirm its identity. However, the identity of the wreck remained an open question.
A little over eight months after my first visit, Faisal invited me to come back for the 2020 Wreck Exploration Project to try to create a 3D photogrammetry model of the wreck. The 3D model would make it easier to take measurements and to share the discovery with experts, and to perhaps allow us to unravel the mystery at the bottom of the Red Sea.
For those readers unfamiliar, the process of 3D photogrammetry relies on taking high-quality photos of every bit of a wreck, each image overlapping the last. If done correctly, sophisticated software can process the images and generate a photomosaic in three dimensions. Precise measurements can be taken from this model. However, even a small gap in the chain of images can make the whole process fail.
While we had a skilled crew and a roster of talented divers for the 2020 Wreck Exploration Project, the powerful current would make the process of taking the thousands of photos necessary exceedingly difficult, perhaps even impossible. There was only one reasonable way to conquer the currents while simultaneously taking photos, and that was to mount my camera on a scooter and take pictures on the go. This wasn’t something I’d done before.
In preparation for the challenge, I consulted two friends on their equipment preferences and bought the scooter camera mount they both recommended. I had it shipped from Italy, and it was set to arrive a week prior to my departure for Egypt. I thought a week would be more than enough time to test the scooter mount. Of course, I was wrong.
When the scooter camera mount arrived, I was shocked to discover that it didn’t work with my camera’s underwater housing. The mount used metric M6 screws to secure a camera, not the imperial ¼-20 screws my housing used. An adapter plate was available, but even if I ordered it, it would never arrive in time. Thankfully I was able to call in a favor from my friend Koos DuPreez, and we spent a day at his workshop machining an adapter from scratch. Another friend, Fritz Star, was able to give me some syntactic foam to make the scooter mount neutrally buoyant. Thanks to their generous help, my gear was ready to go for the project with a whole 24 hours remaining before my flight took off!
Hail Hail The Gang’s All here
The next morning, I started the three hops necessary to get to Egypt. First from Seattle to Washington DC, then from Washington DC to Zurich, and finally from Zurich to Hurghada. I was met at the airport by a smiling man holding a sign with my name on it. He was one of the Red Sea Explorer’s staff, sent to help shuttle me through airport security and ferry me to the MV Nouran, which would be our base of operations for the week. Considering the wide array of electronics, photo gear, and dive equipment I was traveling with, as well as the challenges of navigating airport security in a foreign country, his help was most welcome. We made it through the airport, and after a short ride through town, I arrived at the dock—exhausted but eager to see if we could make it happen.
The team for this trip was originally eight strong, a small complement for the MV Nouran which could fit 24 if all her berths were filled. On arrival, I discovered that three of our divers had to drop out due to last minute complications. That shrunk our already small dive team even further. At the time of departure, the team consisted of only five divers able to safely dive the wreck: Faisal Khalaf, Kirill Egorov, Dorota Czerny, Marcus Newbold, and myself. Bernard Djermakian and Olga rounded out the team as the ship’s dive guides. While they weren’t trained to dive deep enough to reach the mystery wreck, they are both experienced divers who could act as in-water support if needed. A most welcome addition.
With such a small team and such a large boat to dive from, I immediately spread out my camera equipment on one of the MV Nouran’s four dining tables, to take stock of which pieces of dive gear survived three country’s worth of baggage handlers. I’d brought three video lights to use during the photogrammetry project. Even though I can only use two lights at a time, experience has taught me that having a spare is a good idea. Many of my diving instructors have taught me the same lesson. It was a good tip, as my quick check revealed quickly one of my three lights had broken in transit. A small but essential O-ring was protruding in a way that wouldn’t be repairable until I returned to the United States. I sent the manufacturer a message, and they confirmed what I already believed to be true: the light shouldn’t be taken in the water. I was down to the bare minimum: two lights.
The next morning, the Nouran departed with the team in high spirits and with high hopes. We wanted to waste as little time as possible, so we planned our first and second diving days to be on the mystery steamship. If all went to plan, we’d have the opportunity to dive the wreck four, maybe five times.
In addition to the mystery steamship, Faisal had secured two more leads for the Wreck Exploration Project. First, he wanted to explore a newly discovered wreck laying in 30 m/100 ft of water near an oil field. It had been scanned by a well-equipped survey ship in the area, and the wreck was definitely interesting but had never been explored. Second, he wanted to explore a pit at 95 m/310 ft near the wreck of the SS Rosalie Moller. The pit was said to contain the bow of an unknown wreck, but the only divers that had been there weren’t able to confirm anything. Of course, the team was excited by the prospects, so these two targets were added to the itinerary.
Managing Mister Murphy
On the morning of February 27, 2020, Marcus and I jumped in the water with our rebreathers, deco bottles, scooters, and my camera for our first dive of the project. Conditions were good, and currents were calm at the surface. However, we both knew the docile surface conditions betrayed nothing about the powerful flow below us. Several enormous cargo ships coasted by, carrying goods to and from Europe and Asia via the Suez Canal.
We made the short surface swim to the downline, and I decided to do a quick check of my gear before we descended, knowing that we’d incur a decompression obligation in the fight to get to the wreck itself. I examined my camera first: it was fine. My right-hand side video light also worked, and after flipping it on, it was bright even in the bright light of the midday sun. I moved to examine my left-hand side video light, and was immediately disappointed. I turned it on and I was met with several quick flashes—the death throes of the LED contained in the light—then nothing. I looked at the front of the device and discovered that its dome port was half full of salt water. It had flooded in the time it took to swim to the downline.
I shouted to Marcus about the problem and we immediately turned tail to get back to the Nouran to try to salvage our first dive of the trip. We were able to jury-rig a working light out of the corpse of the light that broke in the water and the remains of the one that broke in transit. We were back in business, in the water shortly, and on the wreck in record time.
Once we reached the bottom, I breathed a sigh of relief. After the logistical challenges and the three back-to-back flights, after all the planning and the broken lights, after the custom machining and the calling in of favors, we were here and ready to go. Blue light filtered through the deep water. Visibility was excellent. Hundreds of yellow fish were schooling around the wreck. It was time to get to work.
Marcus and I made several circuits of the wreck, doing our best to get the images we’d need for the photogrammetry model. I started the process with a circuit around the base of the wreck, making sure to capture the two anchors that lay beautifully under the bow. I then moved on to capturing the ground around the wreck, and finally I made several passes over the top of the mystery steamship, to capture the steam boilers, stove, and other debris that lay inside. The scooter-mounted camera worked beautifully, and we managed to achieve good coverage in under an hour. With our primary job complete (at least for now), we made our way back to the upline to start paying our tedious penalty for deep wreck exploration: decompression. We surfaced 202 minutes after we descended, excited to see the results of the day’s work.
In the afternoon, over lunch, I started a test run of Agisoft Metashape (the software used to create photogrammetry models). The test run was complete by dinnertime. The 3D model was more complete than I’d hoped, but less complete than I would have liked. With powerful currents running perpendicular to the wreck, staying in position was much easier on the sides of the wreck where the current was tempered by the structure of the ship itself. At the bow and stern, the weaker currents along the side of the wreck became an unobstructed flow. The sudden change in water speed makes it difficult to get the chain of images necessary for a 3D model. Despite my best efforts, the challenging conditions meant I wasn’t able to get the images I needed. The model had broken at the bow. We’d need to add more images in a subsequent dive.
The next day, the weather cooperated, and we had an opportunity to return to the wreck. Kirill and Dorota descended first, with Marcus and me following a few minutes behind. We added the pictures I believed were necessary to complete the model (and a few hundred extras, just to be sure), and then took to exploring the interior of the wreck, taking some fun pictures along the way. Sadly, we weren’t able to find anything that positively identified the wreck. We made our way back to the upline, pulled the anchor from where it’d lodged in the hull of the wreck and made the long ascent to the surface for the second time in two days.
The test processing of the model after day two showed that we’d almost certainly achieved our goal ahead of schedule. I didn’t have the computer hardware aboard necessary to complete the model, so final processing would have to wait until I returned to Seattle.
We shifted gears to explore our secondary target: the shipwreck in the oilfield. After documenting this new target, we believe it to be the wreck of an oil tender called the “Texaco Cristobal.” We also explored the pit near the SS Rosalie Moller, which was just as deep as we’d been told but far less interesting. We dubbed it the “pit of despair,” and I won’t be going back. I doubt anyone will. Although not without challenges, we’d had an extremely productive first four days of the project.
We were fortunate that the early days of the project were fruitful, as the remaining days of the project were fraught with issues. Dorota caught a bad cold, and was unable to dive for the remainder of the trip. This whittled our small dive team down to just four divers. Then (thanks to a scheduling mishap) Kirill had to depart early. He packed up and loaded his gear on a small sailboat, which took him back to port and to the Hurghada airport for his trip back home.
Our dive team was down to just three: Faisal, Marcus, and me. Fortunately, Irene Homberger was leading a trip on the Nouran’s sister-ship the Tala and was able to supplement our tiny team for a dive or two, before hopping back onto the Tala. Still, the final dives of the trip were funny: three divers diving from a ship built to comfortably accommodate 24 divers, 10 crew, and two dive guides.
We had two final dives on the mystery steamship to try to make a positive identification. Powerful winds kicked up on the second to last day, big enough to wash across the deck of the Nouran. Faisal, Marcus, and I geared up and got ready. The Nouran made several passes over the wreck, but we collectively made the decision to skip the dive. The conditions simply weren’t safe, despite the fact that the team was eager and enthusiastic to try to identify it. We dove another nearby wreck, the Ulysses, instead and were lucky enough to have a delightful encounter with an eagle ray during our dive.
Our final day of diving on the mystery steamship was safe, but uneventful. No artifacts were discovered, no markings were found, and the ship remains unidentified. The data we collected was enough to complete the 3D model. We’ve distributed the 3D model to the usual suspects: experts, researchers, and other interested individuals, but to no avail. While we still hope and believe the mystery steamship is the SC Almirante Barroso, its identity remains unknown.
We’ll just have to go back.
Here is Leverenz’s 3D model of the mystery steamship.
GUE offers a course in photogrammetry: GUE Photogrammetry.
Kees Beemster Leverenz is an enthusiastic diver and GUE instructor from Seattle, Washington, who enjoys getting in the water as often as possible. He has been deeply involved with GUE Seattle since it was founded in 2011. Currently, Kees is contributing to both local and global photogrammetry projects, as well as assisting with cave and wreck exploration projects whenever possible.
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The Life & Times of a West Coast Photogrammetrist: Could it be the Almirante Barroso?
Seattle-based instructor and photogrammetrist Kees Beemster Leverenz recounts the challenges he and his team faced trying to amass sufficient detailed...