By John R. Yarbrough, Ph.D.
After a dive incident, while we provide due concern and care for the injured diver, we often forget to care for another set of divers involved: the survivors and witnesses of these incidents.
In dive injury or fatality incidents, we usually focus our immediate concern on the injured diver. For trained divemasters or instructors, or for divers who are accustomed to a leadership position, getting involved with the rescue incident is a natural reaction. They may initiate a search for a lost diver, do an in-water diver rescue, call for help, set up the DAN oxygen unit for use or provide cardiopulmonary resuscitation.
But there are many divers – and bystanders – who can do little to assist or feel they don’t know how or what to do. Or they are so overwhelmed by the urgency, the fright or the sheer unexpectedness of the event, they are mentally and physically immobilized. At best, they are uncertain about how to move forward with the rescue.
Recently I worked with the wife of an injured diver, who became the uncertain participant. While diving together, she had witnessed her husband having a heart attack. This was his first-ever cardiac episode, and it was quite severe. It frightened her badly. They were out of the country, on a small Caribbean island. As you might guess, there was only a local clinic: no hospital with critical care facilities was nearby.
When I discussed the diver’s condition with his wife, I asked her if she wanted to arrange an air evacuation to Miami for advanced medical care. Her answer was, "I don’t know, what do you think I should do?"
This question came from an experienced and well-educated diver. Did she have a momentary lapse of clear thought? In a sense, yes. The stress of a sudden burden in a true life-and-death situation had left her confused and unable to make a decision.
The doctor at the local clinic and the evacuation assistance arranged by DAN helped to get her husband to Miami for coronary care before a second coronary event occurred, which, on this small island, could have been fatal.
Psychological trauma does not just happen in near-fatal episodes, however. The following article details some of the feelings that onlookers may experience, whether they are directly or indirectly involved with the injured diver. It discusses a range of responses that are possible and offers some insight into dealing with your reactions.
– Joel Dovenbarger, Vice President, DAN Medical Services
According to statistics published by Divers Alert Network in its annual "Report on Decompression Illness and Diving Fatalities," 104 sport diving fatalities occurred during 1995, and 85 occurred in 1996, with an average of about 90 per year since 1980. In addition to these deaths each year, a significant number of diving-related incidents – barotrauma, out-of-air emergencies, onboard accidents, and the rare, but potentially fatal, encounters with marine creatures – are often reported.
While we always provide due concern and care for the injured diver, we often forget to care for another set of divers involved: the survivors and witnesses of these incidents.
Although recreational diving is a relatively safe sport, accidents and injuries are inevitable. And because recreational diving is not a solitary avocation, there will almost always be a witness or a "survivor" to any accident. In the case of boat charters or diving groups, the entire boat – non-diving passengers, divemaster, and boat crew – would be considered survivors.
Especially in the case of a fatality, these survivors may experience signs of post-incident stress, which may include:
- Difficulty in making decisions;
- Emotional shock or feelings of emotional numbness;
- Anger (directed toward self or others);
- Feelings of helplessness;
- Elevated pulse;
- Rapid breathing or feeling that you can’t get enough air with each breath;
- Tightness in the chest or pit of the stomach;
- Excessive sweating;
- Loss of appetite;
- Loss of energy and enthusiasm;
- Withdrawal from others and lapses into prolonged silences.
Although it’s termed "recreational," be aware that diving itself creates a special kind of stress – it places the body under a certain amount of physical and psychological stress. This in turn can often increase the impact of further, incidental stressors. Be aware also that these stress symptoms may mimic, or even mask, other symptoms, such as late decompression illness (DCI). For this reason, dive-related stress may be misdiagnosed or undiagnosed, and more often than mot may be left untreated.
Say, for example, that you are the first back to the boat after a 70-foot / 21-meter dive. You are well into you surface interval, enjoying an ice-cold soda and talking with your buddy and the dive crew about the barracuda you saw around the wreck below. As the minutes pass the other divers surface, including the divemaster. Ten minutes pass and all but two of the divers are back on the surface. Another five minutes pass, and the divemaster is now growing concerned.
Suddenly a diver pops up, signaling for help. The diver’s buddy lost consciousness while inside the wreck and there was no way to get him out without assistance. Even though the divemaster knows he will exceed the no-decompression limits, he elects to respond to the emergency. The crew lowers additional tanks to a decompression stop and summons emergency services. They manage to rescue the diver, but he will require extensive recompression treatment and hospitalization.
Following the incident, the remainder of the dives are canceled for that day, and you and the other divers return to your hotels. The cases of DCI – that of the rescued diver and the divemaster – are reportable incidents. They can be – and are – discussed. But, as a survivor, your subsequent emotional shock, restlessness, loss of appetite, moodiness, and uncertainty about going back into the water are noticed by no one.
What can you do, then? If you find yourself experiencing any of the signs of excessive stress following a dive-related incident, seek qualified medical attention first. If, after your own dive, you have numbness, tingling, or loss of sensation in one or more limbs or in the face, seek immediate help.
Following this, within the first 24 to 48 hours after witnessing a dive incident, keep these points in mind.
Remember that it’s OK to feel bad – in fact, it’s perfectly normal. Be aware that you may be grouchy, irritable or moody and that it may be easier to become angry about other, unrelated things at this time. Talk to your family, companions and other survivors about this, allowing them to understand your moodiness. This move can lessen the negative impact on personal relationships, in turn circumventing another source of additional stress.
One means of lessening the effects of traumatic stress has been through the use of trauma debriefing, or Critical Incident Stress Debriefing (CISD). These techniques, which consist of confidential group meetings between trained counselors, trained lay persons (e.g., in this case, non-involved divers trained in debriefing techniques), and involved survivors /witnesses/ participants, have been of major assistance to fire and EMS units, and are now being employed in a wide variety of "high-risk" settings, such as prisons, oil rigs, and the military. Teams of trained professionals are available at a moment’s notice to respond to emergencies in all 50 states, Mexico and the Caribbean, and a number of trauma units are capable of flying to any destination in the world within 48 hours of notification.
Contact numbers are: International Critical Incident Stress Foundation (410) 730-4311; Texas State CISM Hotline 800-452-6086. These offices can make referrals to other local teams.
Finally, if other means appear to fail, if symptoms persist, or if your stress reactions are severe, seek assistance from a licensed psychotherapist, preferably one who is familiar with the particular stresses associated with diving. Remember that self-help, talking with well-meaning others, and trauma debriefing are not the same as one-on-one psychotherapy.
Points to Ponder
1. Remember that these negative reactions are normal responses to excessive stress. You are not going crazy.
2. Reach out to others. Don’t isolate yourself. Humans are hard-wired as social creatures.
3. Talk to people. Tell them what you’re feeling. Don’t keep your feelings bottled up inside. Don’t build a wall around yourself.
4. Remember that others in your group are under a lot of stress also and are feeling the same way. Talk to them and allow them to talk to you. By helping them, you help yourself.
5. Stay active. Exercise is important, even if you don’t feel up to it. Walk.
6. Keep busy. Take a swim. Go sightseeing. Besides keeping you from dwelling on the incident, this makes the time pass faster . . . and time is one of the only real healers.
7. Eat nutritious and regular meals. Eat a little something, even if you don’t feel up to it.
8. Do not resort to the use of drugs or alcohol in an attempt to mask your feelings. This only makes the problem worse in the long run.
9. Don’t make hasty or long-term decisions- e.g., don’t terminate your vacation prematurely. Give it a day or two. Think it through when you are in a different frame of mind, but not right now.
10. Don’t fight nightmares or insomnia. These, too, are normal reactions and will lessen with time.
11. Don’t worry about immediately "getting back in the saddle," in spite of what well-meaning advisors may say. You may eventually be ready to get back in the water, or you may decide that recreational diving is no longer a sport for you. But this is not a decision that you have to make right away. Give yourself some time.
About The Author
John R. Yarbrough, Ph.D., is a psychologist with the University of Texas Medical Branch at Galveston. He also maintains a private behavioral medicine practice and lectures throughout the region.
- A decade of reporting: DAN’s 1998 report on decompression illness and fatalities is here. Alert Diver. (January/February, 1998), 8.
- According to personal communications with DAN, 1997 statistics will be published in late December 1998; no year-to-date tabulations for 1998 are available at this time.
- Mitchell, J. T. and Everly, G. S., Jr. (1995). Critical Incident Stress Debriefing (CISD): An Operations Manual for the Prevention of Traumatic Stress Among Emergency Services and Disaster Workers, 2nd Edition Revised. Ellicott City, MD: Chevron Publishing.