Cardiac Stress Testing and technical diving

Around this time every year, most of us hang up a new calendar, and polish up the New Year’s Resolutions. Like me, you probably have a few left over from last January 1. If you do, chances are good that one revolves around “getting fitter,” “getting in better shape,” or “working off all that Christmas pudding.” If that is the case, and you’re a diver, I’d like to suggest adding a slightly different twist for 2012.

During a few recent and very informal discussions with other tech instructors, one of the highest-ranking concerns has been the number of divers – particularly tech and rebreather divers – who have died of heart-related problems either while diving or soon after diving.

There are all kinds of issues that may have had an influence on incidents in the past, but the collective concern was how to help make 2012 a “better year” for the dive community.

One idea floated out was to ask students* to undergo a cardiac stress test as part of the list of prerequisites that need to be met before enrolling in advanced technical programs, such as CCR, trimix and advanced wreck and cave.

A cardiac stress test stimulates the heart – either by exercise or with intravenous pharmacological stimulation – and connecting the testee to an ECG. The American Heart Association recommends this kind of testing for patients with medium risk of coronary heart disease. This includes folks with personal risk factors such as smoking, a family history of coronary artery stenosis, people with hypertension, and folks dealing with diabetes and high cholesterol.

Who knows if it would make much of a difference, but what harm would it do? I’m old and get one for free every year through my insurance (BONUS!), and there is a level of comfort knowing that there are no serious issues with the old ticker.

I believe the cost of a cardiac stress test works out to about the same as the charter fees and fill costs for an open-circuit deep wreck dive. Worth the dough? I think so and certainly worth adding to that list of resolutions… Things to do in 2012!

* Students who have risk factors, or those 45 years and older.

Helitrox Decompression… class notes

What you need to know about Helium
(a supplement for techdiverTraining Helitrox divers)

As a Helitrox Decompression Diver, there are a few things you should know about helium, this new gas you can now add to your scuba tanks, since your TDI decompression procedures textbook does not cover this topic at all. Luckily, the vital stuff – the things you need to know to help keep you happy – can be summed up in a couple of pages. Please read on!

We can start off by looking at some of helium’s properties.

Anyone who has organized a kid’s birthday party and bought party balloons already knows helium gas is lighter than air: it’s actually many times lighter than air. For those with an interest in these things, a mole of helium has a mass of 4 grams compared to 32 grams for the same quantity of oxygen and 28 grams for the same amount of nitrogen.

Just in case you forget your high-school science, a mole is measurement of quantity – a specific number of elemental particles or molecules – used in chemistry. For example, a mole of Ideal Gas has a volume of close to 22.4 litres at STP (Standard Temperature and Pressure – 0 degrees Celsius, and one atmosphere or 101.2 kPa). An ideal gas is defined as a hypothetical gas in which all collisions between atoms and/or molecules are perfectly elastic and in which there are no intermolecular attractive forces. This is unrealistic behavior for a gas but we use it in diving because diving is not an exact science. In the context of diving, we can say that 22 litres of helium weighs 4 grams compared to around 29 grams for 22 litres of air.

Is any of this really vital to you as a Helitrox Decompression Diver? Nah, not really. However, it does help to show us why a cylinder filled with trimix, has buoyancy characteristics that are different to the same cylinder filled with air or oxygen: it has a tendency to float, the oxygen cylinder does not.

One other issue that relates directly to the mass of helium is work of breathing (WOB). The deeper we dive, the denser our breathing gas becomes and pulling a lung-full of gas into our body requires more work and effort. Using air or nitrox, you may have already noticed that your regulator – which performs perfectly at 20 or 30 metres – starts to feel a little “tighter” as you venture past 40 metres (132 feet). The WOB, even on a well-adjusted, high-performance regulator, increases noticeably as we descend deeper than 60 metres (200 feet). This increased workload can play a major role in carbon dioxide build-up in a diver’s blood, which of course affects respiratory function.

In short, gas density affects a diver’s comfort, safety and performance. Adding helium to our bottom gas effectively thins out that gas making it easier to breathe at depth. With 20 percent helium in your back gas, you may notice your regs have never breathed easier!

Back to our high-school chemistry for a moment: Helium is a member of a handful of elements known as Noble Gases. The term “noble” probably comes from the fact that these gases have their outer electron shell completely filled, and this makes them (Helium, Neon, Argon, Krypton, Xenon, and Radon) “aloof” and in most circumstance, nonreactive or inert. Noble gases do not bond with other elements. Helium is pretty typical in that it does not burn, does not mix with other substances to form stable compounds, and – as with its noble gas bunkmates – is monoatomic; in other words, it does not even like to associate with itself and hence we write ‘He’ and not ‘He2‘ as we do with O2 and N2. The behavior of helium as a Noble Gas is only a concern to us as divers when we need to make exact calculations to mix gases accurately. Coles Notes version: for a given pressure and temperature, one gets less He in a scuba cylinder (fewer moles) than air or oxygen (i.e. 200 bar of helium is NOT the same as 200 bar of oxygen).

OK, so notwithstanding the all of the points outlined above, one basic question remains: Why do we use helium? I am not trivializing the importance of floaty bottles, lessened WOB at depth and how many moles we can cram into an aluminum “80”, but what else is there to know?

Probably number one is that helium is – for the purposes of diving at depths attained by recreational technical divers – biologically inert. Since it is not narcotic and non-toxic, it makes a great diluent for nitrogen and for oxygen. Adding helium to keep the partial pressures of both those gases to manageable levels is the real reason for this course. Your classroom notes should include the basic “Dalton’s Law” calculations for the suggested bottom-gas mix to be used on the pinnacle dive for this course… a 30 minute exposure at 45 metres (150 feet).

Just in case you do not have those notes handy, here is the short-form:

Ambient pressure at depth of 45 metres = 5.5 bar

Target Oxygen Partial Pressure at depth = 1.30 bar

Target Nitrogen Partial Pressure at depth = 3.16 bar (same as air at 30 metres)

Vacant partial pressure (Ambient – (O2 + N2) = 5.5 – (1.3 + 3.16) = 5.5 – 4.46 = 1.04

So, we have to fill 1.04 bar with something other than oxygen or nitrogen to keep the levels of those two gases within a tolerable range. Easy, we can use helium because it is a “diver-friendly” gas.

Now, at some point, we have to let someone at a dive shop know what flavor of trimix (or Helitrox) we want them to mix, and so we need to convert partial pressures in bar to a percentage of the ambient pressure. In other words, we need to calculate the ratios of each of the gases used.

Here are those calculations: 1.3/5.5 x 100 = 23.6% Oxygen; 1.04/5.5 x 100 = 18.9% Helium; 3.16/5.5 x 100 = 57.4% Nitrogen (rounded numbers which do not quite add up to 100%).

I am not sure what the folks are like where you buy your fills, but I could not bring myself to ask my supplier for a mix with fractions such as 23.6 or 18.9. It makes more sense to round the numbers up to whole numbers, let’s say a 23/20, and that is what I would dive. For the record, TDI suggests the mix for this class at this depth cannot exceed a 25/20. I cut back on the oxygen pressure just a little because I believe it better suits the water conditions where I do most of my diving.

OK, just two more small issues to deal with. The first is perhaps the biggest myth surrounding dives using trimix. The myth is that ANY mix with helium is going to give a diver a much longer decompression obligation that diving air. This is patent bullshit. I simply cannot categorize it any other way.

Helium is said to have faster transit times than nitrogen in a diver’s body; it is absorbed and eliminated more rapidly than nitrogen. This does result in ascent schedules with a slightly deeper off-gassing ceiling, calling for running stops beginning deeper in the water column, but overall ascent times are shorter NOT longer. Here is an example that’s relevant to the type of diving you will do as part of the graduation requirements to earn certification.

A dive to 45 metres for 30 minutes breathing a 23/20 trimix and a EAN50 starting at 21 metres on the way up. Total runtime = 63 minutes.

Exactly the same parameters for the dive but substituting air for the trimix on the bottom and keeping the EAN50 deco gas for the ascent. Total runtime = 74 minutes!

OK, so perhaps there’s a difference because the trimix has 23% oxygen and air only has 21%. Here the same dive with an EAN23 instead of trimix and all the other stuff the same. Total runtime = 71 minutes.

No matter how you cut it, the ascent time on trimix is shorter. (By the way, the first running stop on the trimix ascent IS deeper by about three metres.)

OK, so with that myth busted, let’s move on. The final item is thermal stress and the role of helium in hyperthermia. Helium does a poor job of insulation and pure helium would make a very bad inflation gas for a diver’s drysuit. I have dived in a cave in 20-21 degree water using pure helium in my suit. It was not a wonderful experience: I strongly suggest you do not try it for yourself.

TDI suggests using an alternative suit inflation system to one’s back-gas when ANY helium is being used. This is a great idea if you are diving in an area with a marked thermocline; however, many divers diving in water 20 degrees and above, find very little thermal effect when using a gas with only a moderate amount of helium in it. During this course, you should not have more than one-fifth of your back-gas given over to helium. You may find it unnecessary to carry a separate drysuit inflation system in moderate to warm water conditions.

Oh, one last thing, sound travels about four times faster in helium than in air. One result of breathing helium is that it makes one’s voice sound like Donald Duck or Minnie Mouse. This Disney effect is really funny. However, be aware that pure helium or helium mixes that do not contain at least 21 percent oxygen, are dangerous and breathing them may result in hypoxia and death or serious brain damage. Keep helium away from kids!

Thanks for your attention.

Steve Lewis

TDI instructor-trainer

Omitted Decompression and In-water Recompression (IWR)… some thoughts

Occasionally, in fact with an almost predictably cyclic regularity, two questions that surface on the internet dive forums ask about missed decompression and/or in-water recompression (IWR).

My standard answer on a public forum is to suggest that when the diver shows signs or complains of DCS symptoms, notifying EMS, keep the diver on the surface, warm and hydrated, monitor for changes in their condition (a correctly conducted five-minute neurological exam is a decent protocol for this), have them breathe pure oxygen (preferably from a demand face mask), take notes that will be useful for EMS/Hyperbaric staff, and prepare for fast evac.

The suggested strategy for a diver who has omitted a “deco stop” or safety stop but is SHOWING NO SIGNS or who is NOT COMPLAINING OF ANY SYMPTOMS, is the same as above but without the call to EMS and rather than preparing for evac., collecting their kit for them and keeping them out of the water for at least 24 hours.

However, neither is a very good answer to the actual questions posed, and occasionally, I throw my hat in the ring… something like this.

The first step for anyone brave enough to attempt an answer is to define the differences between the two topics; and in particular, the circumstances that might necessitate the call for a diver to conduct an omitted decompression protocol, as opposed to those that indicate IWR as an option.

Let’s start with the easiest: Omitted Decompression.

The protocols for Omitted Deco are discussed and outlined in several technical diving student manuals – including a couple of TDI manuals – and the procedure is taught as part of TDI’s decompression and trimix courses. It is based on the protocol published in the US Navy Diving Manual and may only be attempted when the diver shows NO SIGNS and has no SYMPTOMS of DCS; and the omitted stop was no deeper than six metres.

There are a couple of other prerequisites relating to water conditions, weather conditions, thermal protection, available gases in sufficient volume, having a tender diver available to monitor the subject diver during the whole procedure, and the diver being in a position to return to the water within five minutes of surfacing.

All that as taken and confirmed: First, return to 12 metres and conduct the stop required at that depth by the original ascent schedule PLUS one quarter of the omitted three-metre stop time. If no stop was originally required, remain there for one quarter of the omitted three-metre stop time. Ascend to nine metres at a speed no greater than three metres per minute (the ascent speed for the whole procedure) and remain there for one third of the three-metre stop time. Ascend to six metres and wait there for half of the three-metre stop time. And finally ascend to three metres for one-and-a-half times the scheduled three-metre time.

Here’s the way that looks for an omitted or partially omitted deco stop at three-metres.

Depth (metres/feet) Original Stop (mins)/Gas Omitted Stop Procedure
12 metres/40 feet None/ bottom gas 3-minute stop
9 metres/30 feet 3 / bottom gas 4-minute stop
6 metres/20 feet 5 / oxygen 6-minute stop on oxygen if CNS allows
3 metres/10 feet 12 /oxygen (omitted) 18-minute stop on oxygen if CNS allows

For the record, I have tendered for divers who have missed all or part of a decompression schedule and for whom the missed deco protocol worked.

Now let’s attempt to clarify the issue of IWR. This is suggested when a diver surfaces and complains of symptoms (type one) and IWR is the ONLY option available… i.e. there is no hope of stabilizing them and getting them to a hyperbaric facility.

Important to establish first off that this is a highly risky endeavor. The risks of IWR include several minor issues relating to thermal stress and volume of gases needed, but the strong emphasis in the entire risk assessment analysis center on the subject diver getting worse far worse once in the water and becoming, for example, paralyzed and/or losing consciousness. Oh, and then dying.

Various protocols and tables for IWR have been developed over the years. The recognized tables include the Australian, the Hawaiian, the US Navy, and the Pyle tables… I believe Pyle’s modification to the Hawaiian table are the most “up-to-date.” I am reasonably sure that NONE carries sanction from the major sport agencies. The technical agency I teach for, that I do consultant work for, and on whose training advisory panel I served for several years, does not sanction IWR either. Essentially, within the context of recreational diving (tech or sport), IWR is simply NOT an option.

Just in case we wonder why, here’s a checklist of the minimum kit and personnel requirements for attempting IWR in a remote location.

  • A heavily weighted shot line secured in a sheltered spot where surface waves will not influence comfort of subject diver and/or the tender (who will be in the water) and treatment supervisor (who will be on the surface).
  • Some way to hold the subject diver in place… a climbing harness works as does a sidemount harness with some modifications
  • Stages in the shot line to hold the subject diver at a set position in the water column… prussik loops and a locking carabiner work if tied and anchored correctly.
  • Full-face masks with coms to the surface and each other
  • Surface supplied gas (oxygen et al) supplied to the subject diver via umbilical
  • An experienced tender and supervisor who have at very least certification and some background in hyperbaric treatment
  • Adequate and possibly additional thermal protection for both subject diver and tender
  • A valid IWR treatment “table”

As someone who is occasionally involved in expedition diving (the only situation I can imagine where the whole team would discuss IWR as part of the SOPs during pre-trip planning sessions), IWR is considered highly risky even when ALL the above, and a few more details, are available. It is also understood that IWR (just as recompression in a chamber on the deck of a boat or in a medical facility) may not resolve the issue. In other words, the subject diver may die.

The preferred option if a portable chamber is NOT AVAILABLE – and something many expedition leaders seem to have less hesitation using – is saline IV (intravenous) therapy, oxygen and the use of pain medication all administered by a practicing medical practitioner of some sort… NP, Paramedic, MD et al. It is therefore considered best practice to have at least one of these as part of the team on ALL expeditions to remote locations.

(For the record, I have been lucky enough to lead several expeditions to various spots where there may have been a temptation to use IWR, and I have certainly tried to make sure that at least one team member is an experienced diving MD. To date, one of my team has had to supervise an autopsy on one of our fellow team members, but we have not had to deal with IWR. Therefore, my first-hand experience in this issue has been ZERO.

You can read more at Gene Hobbs excellent online resource: