Freediving Lung Squeeze - Part 2
The Way Forward: Enhanced Freediving Safety for 2015 and Beyond
Since the tragic death of US Freediver Nicholas Mevoli at Vertical Blue in 2013, standards of competition safety have been very much in the spotlight. Safety teams - most notably at Roatan and Vertical Blue - , AIDA and the freediving community as a whole have thought hard about how to improve safety with new AIDA rules ratified in the early part of 2015. Safety standards at VB this year were surely the highest seen at any freediving competition in the history of the sport and, for the first time, the majority of athletes who suffered a squeeze, and every athlete who blacked out, were subject to rigorous testing and monitoring to determine their subsequent fitness to dive. Innovative though they are however, these measures were not infallible and some divers still slipped through the net; a fact which highlighted the need for honesty and responsibility amongst competing athletes. With that in mind, the first part of this report identified 3 main difficulties in raising standards of safety still further, particularly as far as the issue of lung squeeze is concerned:
- With our current level of knowledge there is no objective way to determine an athlete’s fitness to dive following an injury or blackout. Athletes, medics and judges are all forced to make subjective assessments of risk on the basis of limited information which leads to differences of opinion and, potentially, to conflict between them.
- Of the limited information that we do have, the most useful thing is usually the severity of the athlete’s symptoms (how much blood, how breathless do they feel etc). Because of this, “high-risk” athletes – those who are determined to continue diving even after suffering an injury - are the ones who stand to “gain” the most by hiding their symptoms.
- When an athlete comes forward with an injury, exclusion often seems like the most appropriate way to protect them from further harm, but a system that imposes compulsory exclusions on people who are honest is likely to reduce openness and honesty amongst athletes. On the whole, Medics, Judges and the majority of Athletes seem to agree that the key to improving safety at competitions and in training is to create a culture where openness and honesty about injuries like lung-squeeze is normal. In this part of the report I’ll argue that grass-roots education, more autonomy for athletes and an emphasis on the medic-athlete relationship are the way forward in developing this kind of culture.
Uncomfortable though it may be, the death of Nick Mevoli is probably the most valuable educational tool that we have in raising awareness about the dangers of lung squeeze. As discussed in the previous part of this report the exact cause of Nick’s death is still not known, but it seems likely that lung squeeze in one form or another played a role. In teaching my own intermediate and advanced students about lung squeeze then, I always mention Nick by name and emphasise three particular points: 1. Unlike a blackout, a significant lung squeeze presents a huge problem for even the most well-trained and well-equipped safety teams, particularly in a low-resource setting. 2. Even small squeezes should be taken seriously – at the very least they make a significant squeeze more likely. 3. Lung squeeze doesn’t come from nowhere. It’s almost always a sign that some aspect of technique, attitude or relaxation is not right. Rest and re-assessment are required after a squeeze to allow the lungs to heal, and to understand the underlying causes of the injury. I believe it’s by educating the next generation of competitive freedivers in this way that we can have our greatest effect on the culture that they, and we, will inherit. With this in mind, I feel strongly that all freediving educational systems should include a discussion of lung squeeze at an intermediate stage as a minimum. The discussion should, I think, focus on points 2 and 3 above, emphasising the ability of (and the need for) the athlete to take time to heal and to make changes in technique, attitude and/or relaxation before trying the same dive again.
More Autonomy for Athletes
In part 1 I talked about the way that the UK’s Mike Board was handled after a blackout and squeeze during VB 2014. Whether or not we were right, Mike, myself and several other athletes looked closely at the way that situation unfolded and came to the conclusion that if we admitted to having a squeeze, regardless of the size, we were going to be excluded for at least 3 days. This directly affected the honesty of at least one of these athletes when they themselves were squeezed later. For me, this gets to the heart of the issue: Athletes will only disclose their symptoms honestly when they feel that to do so will be in their best interests. On the whole, athletes now recognise that squeeze presents a significant risk to their safety and actively want to seek expert medical advice about their fitness to dive after an injury. None of us, in short, wants to be the next one to die. Most top-level divers have experience of squeezes in training, recognise the severity of their symptoms compared to previous injuries and know how long it normally takes them to heal – to the best of their knowledge - completely. That said, athletes also want to dive and, even in the context of a system that supports honesty, will feel a certain pressure to conceal their injuries, even to the extent of deceiving themselves. Regardless of the actual processes by which exclusions are made, where there is a perception that those decisions are arbitrary, or favour the interests of the judges or organisers over those of the competitors, the result will be less openness and honesty amongst the athletes. In an environment where comparatively little is known about the injuries we’re dealing with, the experience of an athlete may be the most valuable resource that the medic and judges have at their disposal. In order to support the growth of a culture of openness and honesty, therefore, and to ensure that any decisions made by the officials are good ones, it’s absolutely critical there is full consultation with athletes and that their opinion, character, experience, knowledge of themselves and of their injury is taken into account. Wherever possible, I think that voluntary rest should be recommended in favour of compulsory exclusion.
The Medic-Athlete Relationship
The main problem with trying to create a culture of openness around lung squeeze by allowing athletes more autonomy is that, to put it bluntly, some athletes will still be reckless. If an athlete manages to conceal their symptoms completely, passes the objective tests and seeks no help from the medic, there’s not a lot the safety team can do. A thornier problem, though, arises when an athlete does come forward with an injury but downplays the extent of it, suggests a course of action which seems reckless, or ignores medical advice. There’s so little objective information available about how to diagnose severity, predict risk or suggest treatment that any decision taken ‘against’ an athlete by medics or judges will be subjective at best and at worst, completely arbitrary. Healthcare professionals of all kinds make subjective, non-arbitrary decisions on the basis of limited information every single day. Doctors in particular spend most of their time trying to interpret and combine information from a variety of sources (including, often, something as vague as a character assessment of the patient) none of which is exact, coherent or entirely reliable.
In modern medicine, all treatment decisions are taken ‘in partnership’ with the patient. The clinician gives advice and information, leaving the patient to make their own autonomous decision about what they want to do. This is why I think that the competition medic is the best person to make a decision about an athlete’s fitness to dive, advise them about a sensible course of action, and make an exclusion in situations where it’s absolutely necessary. This clearly confers a responsibility on the medic themselves, and the safety team as a whole to be well prepared for their roles and in possession of the latest information and research; a responsibility that the VB safety team last year took very seriously. In contrast to your average healthcare professional, the training of competition judges focusses mainly on the application of a set of coherent rules for which objective assessment criteria are available. Even where subjectivity exists (grab/no grab, airway under/over the water etc) video footage is usually available in the event of a protest. As representatives of AIDA, and having, as they do, the final word on most aspects of safety, judges also bear a lot of responsibility for the overall safety of the competition. As the media age dawns for the sport of freediving they will begin to bear additional responsibility for the way the competition is perceived by the press, and by outside observers. Judges all come from a variety of professional backgrounds too, and this may also affect the way they make subjective decisions: A lawyer, for example, seems likely to be more sensitive to organisational risks, whereas a paramedic might be more concerned with risks to an individual. Influenced, perhaps, by the quoted article and others like it, during the VB competition this year, a statement was released saying that 5 athletes had been excluded because of injuries and blackouts, a signal to the world, perhaps, that the new safety systems were working.
Although well intentioned, it’s exactly this kind of statement which will create a pressure on the organisers of future competitions to be seen to be excluding people as a means to ensure their safety. Insofar as this increases the use of exclusions over voluntary rest, contributes to a culture of ‘us and them’ between athletes and judges, and reduces honesty, it’s destructive. In short, I think that the newly-ratified AIDA rule which, at least in the manner in which it was implemented last year, seems to suggest that Judges, as well as event medics, have the right to exclude an athlete from competition, is wrong. I feel strongly that Judges, on the whole, lack the training and expertise necessary to make meaningful decisions about fitness to dive, which is and should be the function of the medic. Although trying to “err on the side of caution” will help to protect athletes in the short term, in the longer term it will only serve to alienate athletes from the structures designed to keep them safe. Exclusions will only help the growth of an honest and open culture within the sport if they are made by someone with the natural authority to make them, and after full consultation with the athlete concerned. If this situation is well handled now, even after the initial shock at Nick’s death has faded, the majority of athletes will still see it as common sense to ask for advice from the experts on hand. The experts in this area, and the officials least likely to be influenced by concerns about bad publicity, are not the judges, but the event medics. If they’re given ample time to take a history, examine the athlete, conduct investigations, discuss the injury with the athlete themselves and understand their point of view before giving advice, I predict that most injury situations can be safely resolved without compulsory exclusion. This practise will support, rather than stifle the growth of an open, honest freediving culture which is already beginning.