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We have read with unsettling concerns, a recent article written by John Lippmann entitled “DAN Asia Pacific Safety Tip: In-Water Recompression”, citing a case of oxygen in-water recompression (OIWR) performed on a bent diver in the Philippines. Taken at face value, the article implies a somewhat haphazard decision to perform OIWR. A clearer appreciation of the circumstances surrounding the incident would however reveal that the decision to perform OIWR was far from careless and was in fact well justified. His article is also not entirely accurate, and however unintentional, insinuates incompetence on the attending crew who in fact successfully reversed the patient’s symptoms. To avoid altering that portion of the article at issue, and any context gleaned from the same, the entire paragraph is hereby quoted:

“The second diver developed symptoms of decompression illness after diving from a ’liveaboard’ in the Philippines. He was unconscious for a short time. The dive crew called the DAN AP Diving Emergency Service (DES) hotline and was linked to an experienced diving doctor. The operator indicated that its protocol was to use IWOR and asked the doctor for advice. The doctor advised that the diver should NOT be put in the water due to his unstable condition and that he should remain on the boat and breathe oxygen for several hours while arrangements could be made for further management. The diver improved significantly with the oxygen first aid, but, despite this and against the medical advice, the dive operator insisted that the diver do IWOR. Had he become unconscious whilst underwater it could have ended in a fatality and the dive operator’s position would likely be indefensible given that they had acted contrary to expert medical advice.”

There were only two reported DCS cases that were treated with OIWR while on a ‘liveaboard’ in the Philippines. Both transpired in Tubbataha, an atoll 14 hours away from the nearest medical facility, and at least another 2 hours by aircraft to the nearest operational chamber. Of the two incidents, only one was called-in to DAN which makes this incident easy to recognize. The patient in this case exhibited signs of cutaneous DCS. Over 12 hours had passed since his last dive. Symptoms included itchiness and rashes on his chest and abdomen. The patient fainted for about 5 seconds but was lucid and stable thereafter. Normobaric oxygen was administered using a DAN kit. During this time, the crew made attempts to call DAN since the patient carried DAN insurance. Unfortunately, two hours passed of unsuccessful attempts to get a doctor on the DES hotline. Meanwhile, a field neuro exam was conducted by crew members who were trained and qualified by a hyperbaric doctor. Since the neuro exam confirmed the patient’s coherence and stability, and because the effects of normobaric oxygen where still unremarkable after 2 hours of breathing, the crew made an educated judgement and proposed treatment with OIWR. The procedures and risks were explained clearly to the patient and his wife by a qualified OIWR practitioner, and consent was given in writing. By the time they were about to enter the water, DAN finally came on the line and advised the crew not to do OIWR. The patient was informed of DAN’s advice but instead preferred to go ahead with OIWR. In a recent email to parties concerned, the patient had this to say: “From review of the DAN article, it is concerning how is states, ‘the dive operator insisted that the diver do IWOR’ which is certainly not the case and needs to be clarified”.

After a treatment schedule of 90 minutes (TS1), the patient was brought aboard for examination. By this time, all his rashes had disappeared and he felt better than before the treatment. Anterior and lateral photographs of the patient’s thoracic and abdominal area were taken before and after recompression, and reveal complete resolution of cutaneous DCS signs post OIWR (these images are being withheld out of respect for the patient’s privacy). There were five crew members who carried out the treatment, all of whom were qualified OIWR practitioners. In consonance with Lipmann’s views on OIWR (or IWOR) a full face mask was used along with a stable platform designed expressly for this purpose which incorporates a smart and effective ascender/descender. The patient was hydrated prior to treatment and was stable. The treatment location was pre-established months in advance in case such need arose. It is a known area with ideal conditions, of having warm water, and with neither surf nor current. After OIWR, the patient was advised to visit a hyperbaric facility and the remarks from his examination state “Normal Neurological Examination at present”.

The Philippines is an archipelago with many remote diving destinations. To bring hope to areas with little chance of redress from decompression sickness, the Philippine Commission on Sports Scuba Diving (PCSSD) initiated a sponsored training program in the application of in-water recompression using oxygen. The program was launched in early 2016 and was conducted by Philippine Technical Divers (PHILTECH). PHILTECH has been using and developing a dynamic OIWR program since 1997 for its team of divers and underwater contractors, and have attended to numerous cases of DCS in and outside the workplace with a 100% success rate. The ‘liveaboard’ at issue had several of her crew trained under the same PHILTECH system sponsored by the PCSSD, and their decision to use OIWR was not as impulsive as the article implied. Drawing from their training, the crew exercised sound judgement in their decision to administer OIWR.

Issue aside, Lippmann’s take on OIWR is consistent with PHILTECH’s and we agree with his concerns as there are many divers who would attempt in-water recompression without proper training. Apart from many hours of academics and practice, the right equipment, conditions, and patient, are necessary to safely perform OIWR. It is likewise a perishable skill and must be practiced regularly. To be clear, this clarificatory post is not intended to downplay the hazards of misguided OIWR. Instead, it is written to provide a complete picture of the critical circumstances that took place during the case at issue (whose details were perhaps not available to Lippmann at the time of his writing), and to bring fair judgement to the aggrieved crew who otherwise performed their duties to the highest standards of competence and professionalism.

[The course of events as narrated above are a collection of individual statements from the crew and patient at issue, and have been accounted for here as diligently as possible.]

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