The Problem With Lung Squeeze
The tragic death last year of top American freediver Nicholas Mevoli sent shock-waves through the freediving community. Before this there had been accidents, yes, even deaths, but always in circumstances that were unusual, extreme or where basic principles of safety had been ignored. Here, though, was an example of the sudden and unexpected death of a top-level athlete during normal competition, with a strong and highly qualified safety team immediately on hand. In the weeks and months that followed, freedivers worldwide experienced a slow-dawning realisation that, holy shit, our sport might actually be quite dangerous. At first there were recriminations. People who had never been within a thousand miles of Dean's Blue Hole in their lives were strident in blaming the doctor, the safety divers, the organisers and Nick himself - anyone they could think of really - via Facebook, from the comfort of the their armchairs. As a comparative newbie myself at that time I remember being horrified by the venom in those words so soon after the event, and warmed a little by the insight of organiser William Trubridge who in his quiet way pointed out that death always serves to remind us of our own mortality, and naturally leaves us looking for answers.
A little more than 12 months on, we still have very few answers. No-one, not even, it seems, the pathologists, yet know how Nicholas Mevoli died. The assumption has always been that he suffered a massive lung squeeze but at least one other alternative exists. The post-mortem jury is still out, and it's still unclear whether the freediving medical team will have access to the full report once it's released: In deciding this, Nick's family will need to make a difficult choice between their own privacy, and a wider benefit to the freediving community as a whole.
Despite the obscurity of the facts, there have already been some very positive developments: Until recently, to talk about a 'freediving medical team' would be a huge exaggeration. The 'team' consisted of a few disparate individuals with little access to communication or consensus. Now there is a community of at least 6 highly qualified professionals including a research academic, a remote area specialist and several trauma and emergency physicians, most of them freedivers, who are all actively involved in discussion, research and process development around freediving safety. The video of the resuscitation attempt at the scene has been viewed by teams of experts from around the world and a consensus from their reports, among other things, was used to alter directly the procedures employed by the safety team at this year's Vertical Blue. No-one this year was seriously hurt.
More important than cure, though, is prevention. Whether or not Nick actually died of a lung squeeze, it seems likely that the repeated injuries of this type that he suffered in the lead-up to his death were contributing factors and, as such, lung squeeze has become the hottest topic in freediving safety this year. It's a common injury for freedivers, affecting virtually all top level athletes at one time or another, but despite this, almost nothing is known about its causes, mechanisms and consequences. We don't even really know how to tell if a diver is squeezed or not, or how seriously. Although it seems logical to assume that repeated small squeezes which are not given time to heal, may add up to make a serious injury more likely, the question remains: How long is 'long enough to heal'?
Freediving development agency AIDA have so-far been at the forefront of research in this area, funding a study by Erika Schagatay, Professor of Environmental Physiology at Mid Sweden University, the results of which are due out very soon. She's been looking at the way that Haemoglobin Oxygen Saturations and Heart Rate vary in squeezed and unsqueezed divers, and how quickly they return to normal. Anticipating the outcome of this study, the Roatan and VB organisers this year implemented a system of compulsory testing for athletes and gave the event officials powers to exclude people from further competition - provisions which are set to be rubber stamped when the AIDA rules are amended in January 2015.
At both these competitions, an O2 saturation less than 95% and/or heart rate greater than 110Bpm 30 minutes after surfacing required the athlete to report to the event medic for assessment of fitness to dive, frequently resulting in divers missing at least one day of competition. At this year's Vertical Blue, UK record holder Michael Board was one of those athletes. His experience highlights some difficulties in the objective assessment of fitness to dive, and the importance of openness among athletes about their injuries, as well as transparency in the decision-making processes used by officials. He's agreed to waive anonymity for the sake of getting this issue out in the open:
On his first day of competition, Mike announced 103m CWT, made it to the plate but started pulling at around 30m on the ascent, was assisted by the safety divers and blacked out just below the surface. He came round quickly and realised that he had a lung squeeze, the kind that, in training he might rest 2 or 3 days before diving again. He reported it to the event doctor (Tom Ardavany) and, having failed the first saturation test (and because of the blackout), was asked to come back for further examination. He did so, and this time, Tom found nothing untoward. At the judges' meeting later that day, Tom tells us that he reported Mike was fit and well but that, because of the small amount of blood he'd coughed up, Mike himself was going to voluntarily take 2 or 3 days off, a suggestion which Tom supported. The judges, however, over-ruled him and imposed a compulsory 3 day ban, requiring Mike to report daily to Tom for further examinations, something which Tom himself says he did not recommend. Mike appealed. In the meeting that followed (at which Tom was not present) the judges told him that the ban was given as a result of the blackout he had suffered, on the basis of medical advice, on which they were not qualified to comment. The lung squeeze was not mentioned. They offered a further meeting with Tom in attendance, which Mike declined.
All of this is completely within the rules. Both judges and doctor have the right to exclude an athlete if they feel that allowing them to dive is too risky, regardless of what the other may think. However, given that Tom was not, in reality, insisting on a ban, and the fact that other divers with arguably worse blackouts were not subject to bans, the explanation that the judges have given in this case doesn't seem to be entirely consistent. From the athlete's point of view, the determining factor in his receiving a ban was simply that he'd owned up to having a lung squeeze, a fact that wasn't lost on him as the competition went on.
After successfully completing the 103m dive 3 days later, Mike again suffered a small squeeze; smaller, in fact, than the previous one but this time said nothing, recognising it as an injury that in training wouldn't concern him at all. He passed the saturation test, rested out the next day and completed consecutive dives to 95m FIM and 56m CNF without any further symptoms of squeeze. Hmm.
Mike was one of the more honest athletes at the competition. I personally know of at least 3 other athletes who hid symptoms, even of quite serious squeezes, passed all the objective tests and continued to dive as they saw fit. Other athletes, including myself, who admitted to having a squeeze but still passed the tests were excluded. If we're to consider blackouts too, there were a lot to choose from: Two different athletes blacked out 3 times each during the course of the competition, with 11 out of 32 competing athletes picking up at least 1 red card for Blackout or Surface Protocol during the competition. None of them, to my knowledge, received bans for this.
I'm not about to join the trolls in baying for blood on the issue of blackouts in freediving (more on that coming soon), but I do think that if exclusions are made on the basis of a blackout, those exclusions should be applied to all athletes, and made using recognisable criteria. Let's not delude ourselves. We still don't have an objective way to determine whether someone is fit to dive or not. Even after Prof. Schagatay's research is published it's likely that further information and replication of her results will be required. It'll be a long time yet before a catch-all system is devised to diagnose lung squeeze and objectively determine how long an athlete should rest after an injury or blackout. For the moment, therefore, enhanced safety at competitions relies almost entirely on the honesty of the athletes, and the subjective assessments of the medic and the judges.
The officials at vertical blue this year did an incredible job under difficult circumstances. They're being asked to make life-and-death decisions on the basis of very little concrete information. From a safety perspective, they got it 100% right: There were no deaths, and no-one was seriously injured.
Herein lies the problem:
First: With our current level of knowledge, any decision taken to prevent an athlete from diving after a squeeze or a blackout, whether made by officials or by the athlete themselves, is made on the basis of a subjective, rather than objective assessment of the risk. This leads to conflicts between, athlete, medic and judges.
Second: In an environment where the most useful piece of information is the severity of the athlete's symptoms, high risk athletes, those who are squeezing regularly, or are determined to complete the dive at all costs, are precisely the ones who stand to 'gain' by dishonesty.
Third: A system that imposes compulsory bans on athletes who are honest about their injuries will serve to reduce the number of people who are honest. This applies also to divers who, like Mike, are highly experienced and essentially risk-averse.
How, then, can we create a culture and a competition environment where athletes feel able to admit to being squeezed and get access to appropriate medical care and advice, and where events can run even more safely than they already do? We're all feeling our way in the dark, but in the wake of Nick's death, attitudes are already changing. Many athletes at VB this year did come forward with injuries and were happy with the way that their situation was handled. Miguel Lozano, a high profile figure in the community publicly withdrew from the competition because of a lung squeeze injury, and received strong support - including a VB medal - for doing so. In this respect I believe that athletes, medics, judges, sponsors and the entire freediving community all want the same thing: Deeper, safer, more enjoyable dives.
Our task now is to solidify a change that's just beginning, embed it into freediving culture through education, discussion and the judicious use of regulation. In the second part of this report I'll suggest some ways in which that might be achieved. To many of us, this is an inflammatory issue. Here at Freedive-Earth, we're using the opportunity to introduce our new forum which we hope will become a hotbed of free diving gossip and serious discussion. If you've got a strong view on this issue, or if you want to look deeper, check it out right here.