I was recently asked to give a 30-minute after-dinner talk to the 3CPR Resuscitation Panel of the American Heart Association at their annual scientific meeting in Anaheim, CA. In the audience were scientists, cardiologists, anesthesiologists, anesthetists, emergency physicians, and resuscitation technicians. It was a multimedia event with professionally managed sound and video.
Knowing that the group would be well acquainted with the role of chance in medical procedures, I chose to use a segue from medicine into the topic of extreme adventures in military and civilian diving. The focus of the talk was on how chance can turn adventures into mis-adventures.
I revealed three areas where Navy Biomedical Research is expanding the boundaries of the state of the art in military and civilian diving. One area was in deep saturation diving, another was polar ice diving, and the third was breath hold diving.
As an introduction to polar diving, I wanted to create a video travelogue of my National Science Foundation-sponsored research and teaching trips to the Arctic (Svalbard) and Antarctica (McMurdo Station and vicinity.) These projects were spearheaded by the Smithsonian Institution, and my participation was funded in part by the U.S. Navy.
To begin the preparation of the video, I assembled my most relevant photos, and those taken by various team mates, and imported them into my favorite video editing software, which happens to be Cyberlink Director.
Then I went looking for potential sound tracks for the approximately 5 minute video. Considering the topic, I thought Disney’s Frozen would have familiar themes that might be acceptable. I rejected a number of YouTube videos of music from Frozen; most were too close to the original and included vocal tracks. Finally I came across the “Let It Go Orchestral Suite” composed by the “Twin Composers,” Andrew and Jared DePolo.
It was perfect for my application. I extracted the audio track from the Suite as shown on YouTube, imported it into Director, and lined it up with the nascent video track which included all images and other video segments.
To match the music to the video, I simply cut back on the duration for each of 97 images, keeping the other 5 videos in their native length. By experimentation, I found that 3.21 seconds per image resulted in the last image fading out as the music came to a close and the end credits began to roll.
On the first run through of the new video, I couldn’t find anything to complain about; which for me is rare. So I ran it again and again, eventually creating an mp4 file which would play on a large screen and home audio system. But I couldn’t help notice that the gorgeous score would sweeten at interesting times, and serendipitously change its musical theme just as the video subject matter was changing.
How fortunate, I thought. It was then that I began to realize that “chance” had worked its way into the production effort, in an unexpected way.
First, the music seemed to my ear to be written in 4/4 time, with each measure lasting 3.2 seconds, precisely, and purely by happenstance matching the image change rate. At a resulting 0.8 seconds per beat, or 75 beats per minute, that placed the sensed tempo in the adagietto range, which seemed appropriate for the theme of the music. (Without seeing the score, I’m just guessing about the tempo and timing. But that’s how it felt to me.)
The timing coincidence was rather subtle at first, but as the finale began building at the 3:39 minute mark, the force of the down beat for each measure became more notable, and the coincidence with image changes became more remarkable. There was absolutely nothing I could do to improve it.
In some cases the technical dissection of music can be a distraction from the beauty of the music, but I’ve done it here merely to point out that sometimes you just luck out. In this case it truly was a matter of chance.
In my mind, the DePolo Orchestral Suite makes the video. Hope you enjoy the show.
Blood pressure is not the only silent medical killer. Hypoxia is also, and unlike chronically elevated blood pressure, it cripples within minutes, or seconds.
Hypoxia, a condition defined by lower than normal inspired oxygen levels, has killed divers during rebreather malfunctions, and it has killed pilots and passengers, as in the 1999 case of loss of cabin pressure in a Lear Jet that killed professional golfer Payne Stewart and his entourage and aircrew. Based on Air Traffic Control transcripts, that fatal decompression occurred somewhere between an altitude of 23,000 feet and 36,500 ft.
In most aircraft hypoxia incidents, onset is rapid, and no publically releasable record is left behind. The following recording is an exception, an audio recording of an hypoxia emergency during a Kalitta Air cargo flight.
Due to the seriousness of hypoxia in flight, military aircrew have to take recurrent hypoxia recognition training, often in a hypobaric (low pressure) chamber.
As the following video shows, hypoxia has the potential for quickly disabling you in the case of an airliner cabin depressurization.
Aircrew who must repeatedly take hypoxia recognition training are aware that such training comes with some element of risk. Rapid exposure to high altitude can produce painful and potentially dangerous decompression sickness (DCS) due to the formation of bubbles within the body’s blood vessels.
In a seminal Navy Experimental Diving Unit (NEDU) report published in 1991, LCDR Bruce Slobodnik, LCDR Marie Wallick and LCDR Jim Chimiak, M.D. noted that the incidence of decompression sickness in altitude chamber runs from 1986 through 1989 was 0.16%, including both aviation physiology trainees and medical attendants at the Naval Aerospace Medical Institute. Navy-wide the DCS incidence “for all students participating in aviation physiology training for 1988 was 0.15%”. If you were one of the 1 and a half students out of a thousand being treated for painful decompression sickness, you would treasure a way to receive the same hypoxia recognition training without risk of DCS.
With that in mind, and being aware of some preliminary studies (1-3), NEDU researchers performed a double blind study on twelve naïve subjects. A double-blind experimental design, where neither subject nor investigator knows which gas mixture is being provided for the test, is important in medical research to minimize investigator and subject bias. Slobodnik was a designated Naval Aerospace Physiologist, Wallick was a Navy Research Psychologist, and Chimiak was a Research Medical Officer. (Chimiak is currently the Medical Director at Divers Alert Network.)
Three hypoxic gas mixtures were tested (6.2% O2, 7.0% and 7.85% O2) for a planned total of 36 exposures. (Only 35 were completed due to non-test related problems in one subject.) Not surprisingly, average subject performance in a muscle-eye coordination test (two-dimensional compensatory tracking test) declined at the lower oxygen concentrations. [At the time of the testing (1990), the tracking test was a candidate for the Unified Triservice Cognitive Performance Assessment Battery (UTC-PAB)].
As a result of this 1990-1991 testing (4), NEDU proved a way of repeatedly inducing hypoxia without a vacuum chamber, and without the risk of DCS.
The Navy Aerospace Medical Research Laboratory built on that foundational research to build a device that safely produces hypoxia recognition training for aircrew. That device, a Reduced Oxygen Breathing Device is shown in this Navy photo.
Whidbey Island, Wash. (Feb 16, 2007) Lt. Cmdr. James McAllister, from San Diego, Calif. sits in the simulator during a test flight using the Reduced Oxygen Breathing Device (ROBD). The ROBD is a portable device that delivers a mixture of air, nitrogen and oxygen to aircrew, simulating any desired altitude. Combined with a flight simulator the ultimate effect replicates an altitude induced hypoxia event. McAllister is the Director of the Aviation Survival Training Center at Whidbey Island. U.S. Navy photo by Mass Communication Specialist 1st Class Bruce McVicar.
Although NEDU is best known for its pioneering work in deep sea and combat diving, it continues to provide support for the Air Force, Army and Marines in both altitude studies of life-saving equipment, and aircrew life support systems. Remarkably, the deepest diving complex in the world, certified for human occupancy, also has one of the highest altitude capabilities. It was certified to an altitude of 150,000 feet, and gets tested on occasion to altitudes near 100,000 feet. At 100,000 feet, there is only 1% of the oxygen available at sea level. Exposure to that altitude without a pressure suit and helmet would lead to almost instantaneous unconsciousness.
A test run to over 90,000 feet simulated altitude.
Herron DM. Hypobaric training of flight personnel without compromising quality of life. AGARD Conference Proceedings No. 396, p. 47-1-47-7.
Collins WE, Mertens HW. Age, alcohol, and simulated altitude: effects on performance and Breathalyzer scores. Aviat. Space Environ Med, 1988; 59:1026-33.
Baumgardner FW, Ernsting J, Holden R, Storm WF. Responses to hypoxia imposed by two methods. Preprints of the 1980 Annual Scientific Meeting of the Aerospace Medical Association, Anaheim, CA, p: 123.
It’s been over three years since I posted a cautionary tale about oxygen sensors in rebreathers, and the calamities they can cause. Since then, the toll of divers lured to their death has been steadily mounting. In one week alone in April 2016, at almost the same geographical latitude in Northern Florida, there were two diving fatalities involving rebreathers. It is an alarming and continuing trend.
I know a highly experienced diver who starts each dive by looking at his diving equipment, his underwater life support system, and asking it that title question: How will you try to kill me today?
This deep cave diver, equally at home with open circuit scuba and electronic rebreathers, is not a bold cave diver. He is exceptionally cautious, because he is also the U.S. Navy’s diving accident investigator. He has promised me that his diving equipment will never end up in our accident equipment cage.
He and I have seen far too many of the diving follies where underwater life support systems fail their divers. But the crucible in which those fatal failures are often born are errors of commission or omission by the deceased.
Carelessness and an attitude of “it can’t happen to me” seem all too prevalent, even among the best trained divers. Divers are human, and humans make mistakes. Statistically, those accidents happen across all lines of experience: from novice divers, to experienced professional and governmental divers, and even military divers. They all make mistakes that can, and often do, prove fatal.
It is exceedingly rare that a life support system fails all by itself, since by design they are robust, and have either simple, fool-proof designs, or redundancy. In theory a single failure should not bring a diver to his end.
The “head”, triplicate oxygen sensors, oxygen solenoid and wiring leading to the rebreather CPU. Image from jj-ccr.com.
Are oxygen sensors trying to kill you? That depends on how old they are? Are they in date? Ignoring the expiration date on chocolate chip cookies probably won’t kill you, but ignoring the expiration date on oxygen sensors may well prove fatal. Complex systems like rebreathers depend upon critical subsystems that cannot be neglected without placing the diver at risk.
Oxygen sensors are usually found in triplicate, but if one or more are going bad during a dive, the diver and the rebreather can receive false warnings of oxygen content in the gas being breathed. We have seen a rebreather computer “black box” record two sensor failures, and it’s CPU logic deduced that the single working sensor was the one in error.
The controller’s programmed logic forced it to ignore the good sensor, and thus the controller continued to open the oxygen solenoid and add oxygen in an attempt to make the two dying sensors read an appropriately high O2. Eventually, the diver, ignoring or not understanding various alarms he was being given, went unconscious due to an oxygen-induced seizure. His oxygen level was too high, not too low.
Unlike fuel for a car or airplane, you can have too much oxygen.
Oxygen sensors do not fail high, but they do fail low, due to age. Rebreather manufacturers should add that fact into their decision logic tree before triggering inaccurate alarms. But ultimately, it’s the diver’s responsibility to examine his own oxygen sensor readings and figure out what is happening. The analytical capability of the human brain should far exceed the capability of the rebreather CPU, at least for the foreseeable future.
JAKSA high pressure 6-volt solenoid used in a Megalodon rebreather. NEDU photo.
Oxygen addition solenoids hold back the flow of oxygen from a rebreather oxygen bottle until a voltage pulse from the rebreather controller signals it to open momentarily. The oxygen flow path is normally kept closed by a spring inside the solenoid, holding a plunger down against its seat.
But solenoids can fail on occasion, which means they will not provide life giving oxygen to the diver. The diver must then either manually add oxygen using an addition valve, or switch to bailout gas appropriate for the depth.
Cut-away diagram of a 24-volt Jaksa 200 bar solenoid.
Through either accident or design, divers have been known to invert their solenoid spring and plunger, thereby keeping the gas flow open. In that case, oxygen could not be controlled except by manually turning on and off the valve to the oxygen tank. Of course, knowing when oxygen is too low or too high would depend upon readings from the oxygen sensors.
Suffice it to say that such action would be extremely reckless. And if the oxygen sensors were old, and thus reading lower than the true oxygen partial pressure, the diver would be setting himself up for a fatal oxygen seizure. It has happened.
Assuming a solenoid has not been tampered with, alarms should warn the diver that either the solenoid has failed, or that the partial pressure of oxygen is dropping below tolerance limits.
But as the following figures reveal, if the diver does not react quickly enough to add oxygen manually, or switch to bail out gas, they might not make it to the surface.
The three figures below are screen captures from U.S. Navy software written by this author, that models various types of underwater breathing apparatus, rebreathers and scuba. In the setup of the model, an electronically controlled, constant PO2 rebreather is selected. In the next screen various rebreather parameters are selected, and in this case we model a very small oxygen bottle, simulating an oxygen solenoid failure during a dive. On another screen, a 60 feet sea water for 60 minutes dive is planned, with the swimming diver’s average oxygen consumption rate set at 1.5 standard liters per minute.
On the large screen shot below, we see a black line representing diver depth as a function of time (increasing from the dashed grey line marked 0, to 60 fsw), a gray band of diver mouth pressure, and an all-important blue line showing the partial pressure of inspired oxygen as it initially increases as the diver descends, then overshoots, and finally settles off at the predetermined control level of oxygen partial pressure (in this case 1.3 atmospheres). Broken lines on the very bottom of the graph show automated activation of diluent add valve, oxygen add solenoid, and over pressure relief valve. Long horizontal colored dashes show critical levels of oxygen partial pressure, normal oxygen level (cyan) and the limit of consciousness (red).
Screen shot of UBASim results after an ill-fated 60 fsw dive.
The oxygen solenoid fails 53.7 minutes into the dive, no longer adding oxygen. Therefore the diver’s inhaled oxygen level begins to drop. Rather than follow the emergency procedures, or perhaps being oblivious to the emergency, this simulated diver begins an ascent. As ambient pressure drops during the ascent, the drop in oxygen pressure increases.
In this particular example, 62.5 minutes after the dive began, and at a depth of 13.5 feet, the diver loses consciousness. With the loss of consciousness, the diver’s survival depends on many variables; whether he’s wearing a full face mask, whether he sinks or continues to ascend, or is rescued immediately by an attentive boat crew or buddy diver. It’s a crap shoot.
So basically, the rebreather tried to kill the diver, but he would only die if he ignored repeated warnings and neglected emergency procedures.
What about your rebreather’s carbon dioxide scrubber canister? Do you know what the canister duration will be in cold water at high work rates? Do you really know, or are you and the manufacturer guessing? What about the effect of depth, or helium or trimix gas mixes? Where is the data upon which you are betting your life, and how was it acquired?
Scrubber canister and sodalime. NEDU PhotoNEDU photo.
Sadly, few rebreathers have dependable and well calibrated carbon dioxide sensors; which is unfortunate because a depleted or “broken through” scrubber canister can kill you just as dead as a lack of oxygen. The only difference is a matter of speed; carbon dioxide will knock you out relatively slowly, compared to a lack of oxygen.
But if you think coming up from a dive with a headache is normal, then maybe you should rethink that. It could be that your rebreather is trying to kill you.
Scientists and engineers love to argue, and unlike the case with politicians, compromise is not an option. Technologists speak for nature, for the truth of a universe which does not speak for itself. But when a technologist is wrong, they usually have to eat some crow, so to speak.
Stephen Hawkings, the famous cosmologist, freely admits his brilliant doctoral dissertation was wrong. Crow was eaten, and Hawkings moved on to a better, arguably more correct view of the universe.
Now, on a much less grand scale, this is my time for eating crow.
There has been quiet disagreement over the water temperature above which a scuba regulator is safe from free-flowing or icing up. Those untoward icing events either give the diver too much gas, or not enough. Neither event is good.
Based upon an apocryphal Canadian government study that I can’t seem to put my hands on anymore (government studies are rarely openly available), it has long been believed by the Canadians and Americans that in water temperatures of 38°F or above, regulator icing problems are unlikely. That temperature was selected because when testing older, low flow Canadian regulators, temperatures inside the regulator rarely dropped below 32°F when water temperature was 38°F.
U.S. Navy photo.
As shown in an earlier blog post, in 42°F water and at high scuba bottle pressures (2500 psi) in instrumented second stage regulators (Sherwood Maximus) second stage internal temperature dropped below zero Celsius (32°F) during inspiration. During exhalation the temperature rose much higher, and the average measured temperature was above freezing. Nevertheless, that regulator free flowed at 40 minutes due to ice accumulation.
Presumably, a completely “safe” water temperature would have to be warmer than 42°F. But how much warmer?
My European colleagues have stated for a while that cold water regulator problems were possible at any temperature below 10°C, or 50°F. However, as far as I can tell that assertion was not based on experimental data. So as we began to search for the dividing line between safe and unsafe water temperatures in another brand of regulator, I assumed we’d find a safe temperature cooler than 50°F. For that analysis, we used a generic Brand X regulator.
To make a long story short, I was wrong.
To understand our analysis, you must first realize that scuba regulator freeze-up is a probabilistic event. It cannot be predicted with certainty. Risk factors for an icing event are diving depth, scuba bottle pressure, ventilation (flow) rate, regulator design, and time. In engineering terms, mass and heat transfer flow rates, time and chance determine the outcome of a dive in cold water.
At NEDU, a regulator is tested at maximum anticipated depth and ventilated at a high flow rate (62.5 L/min) for a total period of 30 min. If the regulator free flows or stops flowing, an event is recorded and the time of the event is noted. Admittedly, the NEDU test is extremely rigorous, but it’s been used to select safe regulators for U.S. military use for years.
Tests were conducted at 38, 42, 45 and 50°F.
Next, an ordinal ranking of the performance for each regulator configuration and temperature combination was possible using an NEDU-defined probability-of-failure test statistic (Pf). This test statistic combines the number of tests of a specific configuration and temperature conducted and the elapsed time before freezing events occurred. Ordinal ranks were calculated using equation 1, where n is the number of dives conducted, E is a binary event defined as 0 if there is no freezing event and 1 if a freezing event occurs, t is the elapsed time to the freezing event from the start of the test (minutes), and k is an empirically determined constant equal to 0.3 and determined to provide reasonable probabilities, i is the index of summation.
Click for a larger image.
Each data point in the graph to the left represents the average result from 5 regulators, with each test of 30-min or more duration. For conditions where no freezing events were observed at 30 min, additional dives were made for a 60-min duration.
As depicted, 40-regulator tests were completed, using 20 tests of the five primary second stages and 20 octopus or “secondary” second stages. Regression lines were computed for each data set. Interestingly, those lines proved to be parallel.
A second stage of a typical scuba regulator. The bite block is in the diver’s mouth.
The “octopus” second stage regulator (the part going in a scuba diver’s mouth) differed from the primary only by the spring tension holding the regulator’s poppet valve shut. More negative mouth pressure is required to pull the valve open to get air than in the primary regulator.
The test statistic does not provide the probability that a given test article or regulator configuration will experience a freezing event at a given temperature. However, it does provide the ability to rank the freezing event performance of regulator configurations at various temperatures.
Our testing reveals that in spite of my predictions to the contrary, for the Brand X regulator our best estimate of a “safe” water temperature, defined as Pf = 0, is roughly 53°F for the standard or “primary” second stage regulator and 49° F for the octopus or secondary regulator.
For all practical purposes, the European convention of 50°F (10°C) is close enough.
Eating crow is not so bad. Some think it tastes a little like chicken.
Equation 1 came from J.R. Clarke and M. Rainone, Evaluation of Sherwood Scuba Regulators for use in Cold Water, NEDU Technical Report 9-95, July 1995.
As evidenced by Under the Pole diving expeditions, rebreathers are being used in some of the most isolated and frigid places in the world. Some of those dive missions are surprisingly deep (111 meters, 330 feet) and long, about 2 hours.
That gives me cause for pause.
I suspect most divers are aware of the 1/3 rule for gas consumption on an open circuit (scuba) cave dive. You should use no more than 1/3 of your air supply on the way in, leaving you with 1/3 for the trip out, and 1/3 of your gas supply available in reserve. Sadly, even that amount of reserve has not saved all cave divers.
Now that cave divers are using rebreathers, the rules, at least for some, have changed. Some savvy rebreather cave divers use the rule of doubles: Always have twice as much oxygen, twice as much diluent, and twice as much canister as you think you’ll need. That plus an open-circuit or semi-closed circuit bailout should keep you safe — in theory.
Gas supply is easy to measure throughout a dive; there is a pressure gauge for all gases. But what about canister duration? Most divers assume they will have more canister duration available than gas supply; which means they don’t need to worry about canister duration. That would be a good thing, if it were true. After all, how many manufacturers provide expected canister durations for various work rates and water temperatures? Maybe, none? Or certainly very few.
I would be very surprised if manufacturers could say with certainty that during a two hour dive in -2°C (28°F) water, at depths to 111 meters that the scrubber can provide double the duration needed. That would be four hours in -2°C water, at all potential diver work rates.
Some of you may say, “Under-the-ice-diving is not like cave diving, so the doubles rule is too conservative.” I invite you to think again. Under polar ice, is there ready access to the surface? Not unless you’re diving directly under the through-ice bore hole the entire time.
In the U.S. Navy experience, obtaining useful data on canister durations from manufacturers is difficult. Duration data as a function of temperature is practically nonexistent. Therefore I will share the following information gleamed from scrubber canister testing in extreme environments by the Navy. While this blogger cannot reveal canister durations for military rebreathers, the information on the coefficient of varation (COV) is not protected. (There is no way to figure out what a canister duration is based solely on the COV.)
The following 4-minute video gives a good introduction to the coefficient of variation.
All rebreather divers should know that canister performance declines in an accelerating manner as water temperature drops between 50°F and 28°F. But what your rebreather manufacturer may not know is that the innate variability of canister durations also increases as water temperature drops. The Navy has found that trend in all types of rebreathers.
So, while canister durations drop considerably in cold water, you’re also less certain about what your canister’s endurance is going to be, because of the increase in duration variability. When canister duration drops and variability increases, a diver’s margin of safety becomes a gamble. Personally, I don’t like to gamble under water.
Coefficient of variation (COV, mean duration divided by the standard deviation) of a typical rebreather. Each data point is the mean of five canisters (n=5).
In the U.S. Navy, published canister durations take into account mean canister performance, and variability. That is accomplished through the use of 95% prediction intervals. The greater the variability in canister duration, the lower the published duration.
This method of determining safe canister durations has been in use by the U.S. Navy since 1999. However, I do not know if manufacturers use similar statistically-based methods for publishing canister durations. If they or you do not take duration variability into account as you dive cold, you may be in for a shock. Due to the nature of statistics, you may have 9 deep, cold dives with no CO2 problems, but find yourself in bad shape on the 10th dive.
If you did have a CO2 problem, it wouldn’t necessarily be anyone’s fault: it could just be a result of canister variability in action.
So, diver beware. Give yourself plenty of leeway in planning rebreather dives in frigid waters. After all, you do not want to become a statistic, caused ironically by statistics.
If you have an interest in understanding the derivation of the prediction interval equation and its application, two videos of lectures by Dr. Simcha Pollack from St. John’s University may be helpful. Part I is found here, and Part 2 is found here.
Thanks to Gene Hobbs and the Rubicon Foundation, NEDU’s original report on the use of prediction limits to establish published canister durations is found here.
The following is reprinted from my article published in ECO Magazine, March 2015. It was published in its current format as an ECO Editorial Focus by TSC Media. Thank-you Mr. Greg Leatherman for making it available for reprinting.
It is the highpoint of your career as an environmentally minded marine biologist. The National Science Foundation has provided a generous grant for your photographic mission to the waters 100 ft below the Ross Ice Shelf, Antarctica. Now you’re on an important mission, searching for biological markers of climate change.
Under Antarctic Ice, photo by Dr. Martin Sayer.
Above you lies nothing but a seemingly endless ceiling of impenetrable ice, 10 ft thick. Having spent the last several minutes concentrating on your photography, you look up and notice you’ve strayed further from safety than you’d wanted. The strobe light marking the hole drilled in the ice where you’ll exit the freezing water is a long swim away. And, unfortunately, your fellow scientist “buddy” diver has slipped off somewhere behind you, intent on her own research needs.
You’re diving SCUBA with two independent SCUBA regulators, but in the frigid cold of the literally icy waters, you know that ice could be accumulating within the regulator in your mouth. At the same time, a small tornado of sub-zero air expands chaotically within the high-pressure regulator attached to the single SCUBA bottle on your back—and that icy torrent is increasingly sucking the safety margins right out of your regulator. You are powerless to realize this danger or to do anything about it.
At any moment, your regulator could suddenly and unexpectedly free flow, tumultuously dumping the precious and highly limited supply of gas contained in the aluminum pressure cylinder on your back. You’re equipped and trained in the emergency procedure of shutting off the offending regulator and switching to your backup regulator, but this could also fail. It’s happened before.
As you try to determine your buddy’s position, you’re feeling very lonely. You realize the high point of your career could rapidly become the low point of your career—and an end to your very being.
The preceding is not merely a writer’s dramatization. It is real, and the situation could prove deadly—as it has in far less interesting and auspicious locations. Regulator free flow and limited gas supplies famously claimed three professional divers’ lives in one location within a span of one month.
There is a risk to diving in extreme environments. However, the U.S. Navy has found that the risk is poorly understood, even by themselves—the professionals. If you check the Internet SCUBA boards, you constantly come across divers asking for opinions about cold-watersafe regulators. Undoubtedly, recent fatalities have made amateur divers a little nervous—and for good reason.
Internet bulletin boards are not the place to get accurate information about life support safety in frigid water. Unfortunately, the Navy found that manufacturers are also an unreliable source. Of course, the manufacturers want to be fully informed and to protect their customers, but the fact remains that manufacturers test to a European cold-water standard, EN 250. By passing those tests, manufacturers receive a “CE” stamp that is pressed into the hard metal of the regulator. That stamp means the regulator has received European approval for coldwater service.
As a number of manufacturers have expensively learned, passing the EN 250 testing standard is not the same as passing the more rigorous U.S. Navy standard, which was recently revised, making it even more rigorous by using higher gas supply pressures and testing in fresh as well as salt water. Freshwater diving in the Navy is rare—but depending on the brand and model of regulator in use, it can prove lethal.
The unadorned truth is that the large majority of manufacturers do not know how to make a consistently good Performing cold-water regulator. Perhaps the reason is because the type of equipment required to test to the U.S. Navy standard is very expensive and has, not to date, been legislated. Simply, it is not a requirement.
Some manufacturers are their own worst enemy; they cannot resist tinkering with even their most successful and rugged products. This writer is speculating here, but the constant manufacturing changes appear to be driven by either market pressures (bringing out something “new” to the trade show floor) or due to manufacturing economy (i.e., cost savings). The situation is so bad that even regulators that once passed U.S. Navy scrutiny are in some cases being changed almost as soon as they reach the “Authorized for Military Use” list. The military is struggling to keep up with the constant flux in the market place, which puts the civilian diver in a very difficult position. How can they—or you—know what gear to take on an environmentally extreme dive?
My advice to my family, almost all of whom are divers, is to watch what the Navy is putting on their authorized for cold-water service list. The regulators that show up on that list (and they are small in number) have passed the most rigorous testing in the world.
Through hundreds of hours of testing, in the most extreme conditions possible, the Navy has learned what all SCUBA divers should know:
• Even the coldest water (28°F; -2°C) is warm compared to the temperature of expanding air coming from a first stage regulator to the diver. There is a law of physics that says when compressed air contained in a SCUBA bottle is expanded by reducing it to a lower pressure, air temperature drops considerably. It’s the thermal consequence of adiabatic (rapid) expansion.
• Gas expansion does not have to be adiabatic. Isothermal (no temperature change) expansion is a process where the expansion is slow enough and heat entry into the gas from an outside source is fast enough that the expanded gas temperature does not drop.
• The best regulators are designed to take advantage of the heat available in ice water. The most critical place for that to happen is in the first stage where the greatest pressure drop occurs (from say 3,000 psi or higher to 135 psi above ambient water pressure (i.e., depth). They do that by maximizing heat transfer into the internals of the regulator.
• First stage regulators fail in two ways. The most common is that the first stage (which controls the largest pressure drop) begins to lose control of the pressure being supplied to the second stage regulator, the part that goes into a diver’s mouth. As that pressure climbs, the second stage eventually can’t hold it back any longer and a free flow ensues.
• The second failure mode is rare, but extremely problematic. Gas flow may stop suddenly and completely, so that backup regulator had better be handy.
• Second stage regulators are the most likely SCUBA components to fail in cold water due to internal ice accumulation.
• Free flows may start with a trickle, slowly accelerating to a torrent, or the regulator may instantly and unexpectedly erupt like a geyser of air. Once the uncontrolled, and often unstoppable free flow starts, it is self-perpetuating and can dump an entire cylinder of air within a few minutes through the second stage regulator.
• A warm-water regulator free flow is typically breathable; getting the air you need to ascend or to correct the problem is not difficult. In a cold-water-induced free flow, the geyser may be so cold as to make you feel like you’re breathing liquid nitrogen and so forceful as to be a safety concern. Staying relaxed under those conditions is difficult, but necessary.
• Water in non-polar regions can easily range between and 34°F to 38°F; at those temperatures, gas entering the second stage regulator can be at sub-freezing temperatures. European standard organizations classify ~10°C (50°F) as the cold/non-cold boundary. The Navy has found in the modern, high-flow regulators tested to date that 42°F is the water temperature where second stage inlet temperature is unlikely to dip below freezing.
• The small heat exchangers most manufacturers place just upstream of the second stage is ineffective In extreme conditions. They quickly ice over, insulating that portion of the regulator from the relative warmth of the surrounding water.
• Regulator “bells and whistles” are an unknown and can be problematic. Second stage regulators with multiple adjustments can do unpredictable things to heat transfer as the diver manipulates his controls. The last thing a cold-water diver should want is to make it easier to get more gas. High gas flows mean higher temperature drops and greater risk of free flow.
• Only manufacturer-certified technicians should touch your regulator if you’re going into risky waters. The technician at your local dive shop may or may not have current and valid technician training on your particular life support system. Don’t bet your life on it— ask to see the paperwork.
• Follow Navy and Smithsonian* guidance on handling and rinsing procedures for regulators in frigid waters. A single breath taken above the surface could freeze a regulator before you get your first breath underwater.
U. S. Navy reports on tested regulators are restricted. However, the list of those regulators passing all phases of Navy testing is available online. If your regulator, in the exact model as tested, is not on that list, do yourself a favor and don’t dive in frigid waters.
The original Editorial Focus article is found in the digital version of the March ECO magazine here, on pages 20-25.
There is nothing quite like a heart attack and triple bypass surgery to get your attention.
Even if you’ve been good, don’t smoke, don’t eat to excess, and get a little exercise, it may not be enough to keep a heart attack from interrupting your life style, and maybe even your life.
Post-surgical recovery can be slow and painful, but if you have an avocational passion, that passion can be motivational during the recovery period after a heart attack. There is something about the burning desire to return to diving, flying, or golfing to force you out of the house to tone your muscles and get the blood flowing again.
My return to the path of my passions, diving and flying, began with diet and exercise. My loving spouse suggested a diet of twigs and leaves, so it seemed. I can best compare it to the diet that those seeking to aspire to a perpetual state of Buddha-hood, use to prepare themselves for their spiritual end-stage: it’s a state that looks a lot like self-mummification. Apparently those fellows end up either very spiritual or very dead, but I’m not really sure how one can tell the difference.
The exercise routine began slowly and carefully: walking slowly down the street carrying a red heart-shaped pillow (made by little lady volunteers in the local area just for us heart surgery patients). The idea, apparently, is that if you felt that at any point during your slow walk your heart was threatening to extract itself from your freshly opened chest, or to extrude itself like an amoeba between the stainless steel sutures holding the two halves of your rib cage together, that pillow would save you. You simply press it with all the strength your weakened body has to offer against the failing portion of your violated chest, and that pressure would keep your heart, somehow, magically, in its proper anatomical location.
I am skeptical about that method of medical intervention, but fortunately I never had occasion to use it for its avowed purpose.
Eventually I felt confident enough to ditch the pillow and pick up the pace of my walks. In fact, I soon found I could run again, in short spurts. It was those short runs that scared the daylight out of my wife, but brought me an immense amount of pleasure. It meant that I might be able to regain my flying and diving qualifications.
Stress test, Public Domain, from Wikimedia Commons.
After that teaching adventure, I prepared myself for the grinder that the FAA was about to put me through: a stress test. Not just any stress test mind you, but a nuclear stress test where you get on a treadmill and let nurses punish your body for a seeming eternity. Now, these nurses are as kindly as can be, but they might well be the last people you see on this Earth since there is a small risk of inducing yet another heart attack during the stress test. Every few minutes the slope and speed of the treadmill is increased, and when you think you can barely survive for another minute, they inject the radioisotope (technetium 99m).
With luck, you would have guessed correctly and you are able to push yourself for another long 60-seconds. I’m not sure exactly what would happen if you guess incorrectly, but I’m sure it’s not a good thing.
And then they give you a chance to lie down, perfectly still, while a moving radioisotope scanner searches your body for gamma rays, indicating where your isotope-laden blood is flowing. With luck, the black hole that indicates dead portions of the heart will be small enough to be ignored by certifying medical authorities. (An interesting side effect of the nuclear stress test is that you are radioactive for a while, which in my case caused a fair amount of excitement at large airports. But that’s another story.)
The reward for all the time and effort spent on the fabled road to recovery, is when you receive, in my case at least, the piece of paper from the FAA certifying that you are cleared to once again fly airplanes and carry passengers. With that paper, and having endured the test of a life-time, I knew that I’d pass most any diving physical.
Vortex Springs, 2010
Having been in a situation where nature dealt me a low blow and put my life at risk and, perhaps more importantly, deprived me of the activities that brought joy to my life, it was immensely satisfying to be able to once again cruise above the clouds on my own, or to blow bubbles with the fish, in their environment. Is there anything more precious that being able to do something joyful that had once been denied?
A goofy looking but very happy diver sharing a dive with his Granddaughter, July 2014.
Without a doubt, the reason I was able to resume my passions was because I happened to do, as the physicians said, “all the right things” when I first suspected something unusual was happening in my chest. The symptoms were not incapacitating so I considered driving myself to the hospital. But after feeling not quite right while brushing my teeth, I lay down and called 911. The ambulance came, did an EKG/ECG, and called in the MI (myocardial infarction) based on the EKG. The Emergency room was waiting for me, and even though it was New Years’ eve, they immediately called in the cardiac catheterization team. When the incapacitating event did later occur I was already in cardiac ICU and the team was able to act within a minute to correct the worsening situation.
Had I dismissed the initial subtle symptoms and not gone to the hospital, I would not have survived the sudden onset secondary cardiac event.
The lesson is, when things seem “not quite right” with your body, do not hesitate. Call an ambulance immediately and let the medical professionals sort out what is happening. That will maximize your chances for a full and rapid recovery, and increase the odds of your maintaining your quality of life.
It will also make you appreciate that quality of life more than you had before. I guarantee it.
Cuvier’s Beaked Whale. Image from Wikimedia Commons.
It was a coincidence forty years in the making. I was recently at the Scripps Institute of Oceanography, talking to Scripps professor and physician Paul Ponganis about deep diving whales. He told me about the recent discovery that Cuvier’s Beaked Whale, an elusive whale species, had been found to be the deepest diving of all whales.
How deep I asked? One whale dived to 9,816 feet, about 3000 meters. At that depth, water pressure exerts a force of about 4400 pounds per square inch (psi), equal to the weight of a Mercedes E63 sedan pressing on each square inch of the whale’s ample body surface. That is a seriously high pressure, a fact that I knew well since I had once created that much pressure, and more, in a small volume of seawater in a pressure vessel at the Florida State University.
Early in my science career, I published my work on the effect of deep ocean pressure on intertidal bivalves, a mussel (Modiolus demissus) being among them. I found that if you removed the hearts of such molluscs (or mollusks) and suspended them in seawater, they would continue to beat. Furthermore, those excised hearts would beat when subjected to 5000 psi of hydrostatic pressure. As if that wasn’t surprising enough, the slight genetic differences between Atlantic subspecies and Gulf Coast subspecies of mussels resulted in the isolated hearts responding slightly differently to high pressure.
If you’ve eaten live raw oysters, a cousin to mussels, you’ve eaten beating hearts like the one in this photo. (Click to enlarge. Photo credit: rzottoli, Salt Marshes in Maine, at HTTP:// wordpress.Com )
The mussel Modiolus demissus in their natural habitat at low tide (Photo credit: rzottoli, Salt Marshes in Maine, at HTTP:// wordpress.Com )
Eventually, my research transitioned from invertebrates to humans. Humans, like intertidal mussels and clams, are not normally exposed to high pressure. But like my unwilling invertebrate test subjects, sometimes humans do get exposed to high pressure, willingly. But not so much of it. Deep sea divers do quite well at 1000 feet seawater (fsw), manage fairly well at 1500 fsw, but don’t fare well at all at 2000 fsw. That depth seems to be the human pressure tolerance limit due to the high pressure nervous syndrome, or HPNS. At those pressures, cell membranes seem to change their physical state, becoming less fluid or “oily” and more solid like wax. Cells don’t work normally when the very membranes surrounding them are altered by pressure.
The Beaked Whale is genetically much more similar to man than are mussels. Therefore, man is far more likely to benefit by learning how Cetaceans like whales tolerate huge pressure changes than we are to benefit from the study of deep diving (albeit forced diving) clams and mussels.
As I talked to Dr. Ponganis it was obvious to him, I suspect, that I was excited about learning more about how these animals function so beautifully at extreme depths. But to do that, you have to collect tissue samples for study and analysis in a laboratory. The only problem is, collecting useful tissue samples from living whales without hurting them may be a bridge too far. Humans rarely even see Beaked Whales, and if the Cetaceans wash up on shore, dead, their tissues have already been degraded by post-mortem decomposition, and are no longer useful for scientific study.
MIT’s RoboTuna; ca. 1994. Photo from Wikimedia Commons.
Potentially, here is a job for underwater Cetacean-like robots that when released in a likely Beaked Whale environment, can locate them, dive with them, and perhaps even earn their trust. And when the whale beasts least expect it, those robotic Judases could snatch a little biopsy material.
If only it were that easy.
Considering how difficult it would be to acquire living tissue samples, would it be worth the effort? Well, if man is ever to dive deeper than 1500 to 2000 feet without the protection of submarines, we must learn how from either the mussels or the whales. My bet is on the whales. Unlike mussels, the whales dive deep for a living, to catch their preferred prey, squid and deep sea fish.
What are arguably the first studies of the effects of high pressure on intertidal bivalves (mussels and clams) can be found here and here. Moving up the phylogenetic scale, Yoram Grossman and Joan Kendig published high pressure work on lobster neurons in 1990, and rat brain slices in 1991. I made the leap from mussels to humans by conducting a respiratory study on Navy divers at pressures of 46 atmospheres (1500 feet sea water), published in 1982. For a more recent review of high pressure biology applied to animals and man, see the 2010 book entitled Comparative High Pressure Biology. My theoretical musings about the mathematics of high pressure effects on living cells can be found here.
With time, these studies, and more, will add to our understanding of mammalian pressure tolerance. However, it may well take another generation or two of such scientific effort before we understand how the Beaked Whales make their record-breaking dives, and survive.
Clarke JR1, Moon RE2, Chimiak JM3, Stinton R4, Van Hoesen KB5, and Lang MA5,6.
1 US Navy Experimental Diving Unit, Panama City, Florida 2 Duke University, Durham, North Carolina 3 Divers Alert Network, Durham, North Carolina 4 Diving Unlimited International, Inc., San Diego, California 5 UC San Diego – Emergency Medicine, San Diego, California 6 OxyHeal Health Group, National City, California
Introduction
The San Diego Center of Excellence in Diving at UC San Diego aims to help divers be effective consumers of scientific information through its “Healthy Divers in Healthy Oceans” mission. In this monograph we explore a research report from the Navy Experimental Diving Unit (NEDU) that is leading some divers to think they should be cold if they want to reduce decompression risk. That is a misinterpretation of the report, and may be causing divers to miss some of the joy of diving. There is no substitute for comfort and safety on a dive.
Background
In 2007 NEDU published their often-cited report “The Influence of Thermal Exposure on Diver Susceptibility to Decompression Sickness” (Gerth et al., 2007). The authors, Drs. Wayne Gerth, Victor Ruterbusch, and Ed Long were questioning the conventional wisdom that cold at depth increases the risk of decompression illness. After conducting a very carefully designed experiment, they were shocked to find that exactly the opposite was true. Some degree of cooling was beneficial, as long as the diver was warm during ascent.
Discussion and Implications
There are some important caveats for the non-Navy diver to consider. First of all, it was anticipated that a diver would have a system for carefully controlling their temperature during the separate phases of bottom time and decompression. Most non-Navy divers do not have that sort of surface support.
Secondly, the “cold” water in the NEDU study was 80 °F (27 °C). For most of us, 80 °F (27 °C) is an ideal swimming pool temperature, not exactly what you are going to find in non-tropical oceans and lakes. The warm water was 97 °F (36 °C), also a temperature not likely to be available to recreational and technical divers.
When testing the effect of anything on decompression results, the Navy uses their extensive mathematical expertise to select the one dive profile that is, in their estimation, the most likely to identify a difference in decompression risk, if that difference in risk exists. In this case the profile selected was a 120 fsw (37 msw) dive with 25 to 70 min bottom time, decompressed on a US Navy Standard Air table for 120 fsw (37 msw) and 70 min bottom time. That table prescribes 91 minutes of decompression divided thusly: 30 fsw/9 min (9msw/9 min), 20 fsw/23 min (6 msw/23 min), 10 fsw/55 min (3 msw/55 min).
A total of 400 carefully controlled dives were conducted yielding 21 diagnosed cases of decompression sickness. Overwhelmingly, the lowest risk of decompression was found when divers were kept warm during decompression. The effects of a 9 °C increase in water temperature during decompression was comparable to the effects of halving bottom time.
That is of course a remarkable result, apparently remarkable enough to cause civilian divers to alter their behavior when performing decompression dives. However, before you decide to chill yourself on the bottom or increase your risk of becoming hypothermic, consider these facts.
Do you have a way of keeping yourself warm, for instance with a hot water suit, during decompression? If not, the study results do not apply to you.
Of the many possible decompression schedules, the Navy tested only one schedule, the one considered to be the best for demonstrating a thermal influence on decompression risk. Although it seems reasonable that this result could be extrapolated to other dive profiles, such extrapolation is always risky. It may simply not hold for the particular dive you plan to make, especially if that dive is deeper and longer than tested.
Most commercial decompression computers do not adhere to the U.S. Navy Air Tables; few recreational dives are square profiles. Furthermore, additional conservatism is usually added to commercial algorithms. NEDU is not able to test the effects of diver skin temperature on all proprietary decompression tables, nor should they. That is not their mission.
The scientific method requires research to be replicated before test results can be proven or generalized. However, due to the labor and expense involved in the NEDU dive series, it seems unlikely that any experiments that would determine the relevance of these results to recreational or technical diving will ever be performed. As such, it may raise as many questions as it answers. For instance, the original question remains; if you become chilled on a dive, how does that affect your overall risk of decompression illness compared to remaining comfortably warm? Unfortunately, that question may never be answered fully.
Thermoneutral temperatures for swim suited divers are reported to be 93 °F to 97 °F (34 to 36 °C) for divers at rest and 90 °F (32 °C) during light to moderate work (Sterba, 1993). So a skin temperature of 80 °F (27 °C) is indeed cold for long duration dives. If your skin temperature is less than 80 °F (27 °C), then you are venturing into the unknown; NEDU’s results may not apply.In summary, beer and some types of wine are best chilled. Arguably, divers are not.
Acknowledgments
Support for the San Diego Center of Excellence in Diving is provided by founding partners UC San Diego Health Sciences, UC San Diego Scripps Institution of Oceanography, OxyHeal Health Group, Divers Alert Network, Diving Unlimited International, Inc. and Scubapro.
Sterba JA. Thermal Problems: Prevention and Treatment, in P.B. Bennett and D.H. Elliot, eds., The Physiology and Medicine of Diving, 4th ed. (London: Saunders, 1993), pp. 301-341.
Photo taken from the author’s aircraft one stormy Florida Panhandle morning. (click to enlarge)
I was recently flying a private aircraft down the Florida Peninsula to Ft. Lauderdale to give a presentation on diving safety. As I continually checked the cockpit instruments, radios and navigation devices, it occurred to me that the redundancy that I insist upon in my aircraft could benefit divers as well.
In technical and saturation diving, making a free ascent to the surface is just as dangerous as making a free descent to the ground in an airplane, at night, in the clouds. In both aviation and diving, adequate redundancy in equipment and procedures just might make life-threatening emergencies a thing of the past.
Aviation
As I took inventory of the redundancy in my simple single engine, retractable gear Piper, I found the following power plant redundancies: dual ignitions systems, including dual magnetos each feeding their own set of spark plug wires and redundant spark plugs (two per cylinder). There are two sources of air for the fuel-injected 200 hp engine.
There are two ways to lower the landing gear, and both alarms and automatic systems for minimizing the odds of pilot error — landing with wheels up instead of down. (I’ve already posted about how concerning that prospect can be.)
I also counted three independent sources of weather information, including lightning detection, and two powerful communication radios and one handheld backup radio. For navigation there is a compass and four electronic navigation devices: one instrument approach (in the clouds) approved panel mount GPS with separate panel-mounted indicator, an independent panel mounted approach certified navigation radio, plus two portable GPS with moving map displays and superimposed weather. Even the portable radio has the ability to perform simple navigation.
There’s two of just about everything in this Arrow panel.
The primary aircraft control gyro, the artificial horizon or attitude indicator, also has a fully independent backup. One gyro operates off the engine-powered vacuum pump, and the second gyro horizon is electrically driven. Although by no means ideal, the portable GPS devices also provide attitude indicators based upon GPS signals. In a pinch in the clouds, it’s far better than nothing. Of course, even if all else fails, the plane can still be flown by primary instruments like rate of climb, altimeter, and compass.
There is only one sensitive altimeter, but two GPS devices also provide approximate altitude based on GPS satellite information.
Diving
But what about divers? How are we set for redundancy?
Starting with scuba (self-contained underwater breathing apparatus), gas supplies are like the fuel tanks in an aircraft. I typically dive with one gas bottle, but diving with two or more bottles is common, especially in technical diving. In a similar fashion, most small general aviation aircraft have at least two independent fuel tanks, one in each wing.
The scuba’s engine is the first stage regulator, the machine that converts high pressure air into lower pressure air. Most scuba operations depend on one of those “engines”, but in extreme diving, such as low temperature diving, redundant engines can be a life saver. While most divers carry dual second stage regulators attached to a single first stage, for better redundancy polar divers carry two independent first stages and second stages. Two first stage regulators can be placed on a single tank.
An H-valve for a single scuba bottle. Two independent regulators can be attached.
A Y-valve for Antarctic diving with two independent scuba regulators attached.
Even then, I’ve witnessed dual regulator failures under thick Antarctic ice. The only thing saving that very experienced diver was a nearby buddy diver with his own redundant system.
There is a lot to be gained by protecting the face in cold water by using a full face mask. But should the primary first or second stage regulator freeze or free flow, the diver would normally have to remove the full face mask to place the second regulator in his mouth.
Two regulators, one full face mask. Photo courtesy of Michael Lang and Scuba Pro.
Reportedly, sudden exposure of the face to cold water can cause abnormal heart rhythms, an exceedingly rare but potentially dangerous event in diving. If the backup or bail out regulator could be incorporated into the full face mask, that problem would be eliminated. The photo on the right shows one such implementation of that idea.
Nikki Smith, rebreather diver with open circuit bailout in her right hand. Photo courtesy of Rosemary E Lunn (Roz), The Underwater Marketing Company.
Rebreathers are a different matter. Most rebreather divers carry a bailout system in case their primary rebreather fails or floods. For most technical divers, that redundancy is an open circuit regulator and bailout bottle. However, there are options for the bail-out to be an independent, and perhaps small rebreather. (One option for a bail-out semiclosed rebreather is found here.) Such a bail-out plan should provide greater duration than open-circuit bailout, especially if the divers are deep when they go “off the loop”.
U.S. Navy photo by Bernie Campoli.
For some military rebreather divers, there is at least one complete closed-circuit rebreather available where a diver can reach it in case of a rebreather flood-out.
A commercial saturation diver with semi-closed rebreather backpack as emergency bail-out gas.
For deep sea helmet diving, the bail-out rebreather is on their back and a simple valve twist will remove the diver from umbilical-supplied helmet gas to fresh rebreather gas.
The most common worry for electronically controlled rebreather divers is failure of the rig’s oxygen sensors. For that reason it is common for rebreathers to carry three oxygen sensors. Unfortunately, as the Navy and others have noted, triple redundancy really isn’t. Electronic rebreathers are largely computer controlled, and computer algorithms can allow the oxygen controller to become confused, resulting in oxygen control using bad sensors, and ignoring a correctly functioning oxygen sensor.
The U.S. Navy has performed more than one diving accident investigation where that occurred. Safety in this case can be improved by adding an independent, redundant sensor, by improving sensor voting algorithms, by better maintenance, or by methods for testing all oxygen sensors throughout a dive.
In summary, safe divers and safe pilots are always asking themselves, “What would I do if something bad happens right now?” Unfortunately, private pilots and divers quickly discover that redundancy is not cheap. However, long ago I decided that if something unexpected happened during a flight or a dive, I wouldn’t want my last thoughts to be, “If only I’d spent a little more money on redundant systems, I wouldn’t be running out of time.”
Time, like fuel and breathing air, is a commodity you can only buy before you run out of it.
Disclaimer: This blog post is not an endorsement of any diving product. Diving products shown or mentioned merely serve as examples of redundancy, and are mentioned only to further diver safety. A search of the internet by interested readers will reveal a panoply of alternative and equally capable products to enhance diver safety.
I was recently asked to give a 30-minute after-dinner talk to the 3CPR Resuscitation Panel of the American Heart Association at their annual scientific meeting in Anaheim, CA. In the audience were scientists, cardiologists, anesthesiologists, anesthetists, emergency physicians, and resuscitation technicians. It was a multimedia event with professionally managed sound and video.
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