Shark diving has always appealed to me, partly because they’re such charismatic creatures and because of their size, grace, evolutionary success, ability to instill fear in humans, and role as custodians of the deep. They are a physical manifestation of the beauty and the perils of the waters that cover two-thirds of our planet. What else would have millions of Americans of both sides of the political aisle glued to TV screens every July. I am referring to Discovery’s shark week. Puerto Rico is not renowned for its shark diving, but there is a site on the southern part of the island (off a small town called Guanica) with a healthy population of Caribbean Reef Sharks. But this isn’t a story about reef sharks; it is a story of Murphy’s Law, that is, what can go wrong, will go wrong. And what the dive community and PADI can learn from Atul Gawande’s Checklist Manifesto. But before I get into that, I have to tell you a story of my recent Puerto Rican dive trip and how quickly things can go from bad to worse.
Diving Off The Port of Guanica
We set off for Guanica after a late night at a friend’s restaurant in San Juan. Incidentally, if you’re a foodie, you have to try El Nuevo Acuario in Isla Verde. Guanica is about a two-hour drive from San Juan. Because of the late-night festivities, both my son and I slept through the 5 am alarm. I woke up at 6 am, and in a very hurried frenzy, got my son and me out of the door in about 10 minutes flat (no small feat). The boat was to leave at 8 am, so we drove as quickly as is reasonably possible to the South. I called the dive shop and told them I would be running late. The dive operator said to me that it should be ok, but if we were any later, we should call and might need to reschedule. Pulling into the small town of Guanica was a relief, as I was pretty sure we would make the boat. We pulled up, and divers and staff were outside assembling gear and providing some instructions to what looked like a group of inexperienced divers. It was a small group as far as dive trips go, that is, only five divers in total.
We set off from the port of Guanica in a small dive boat. The smallest dive boat I have been a passenger on in over a decade of diving. The destination: a hanging section of the continental shelf off the southern-side of the island known as “The Wall”, aka the Puerto Rico trench. The trench forms several limestone karst plateaus before descending into an abyss greater than 5 miles in depth. It is the deepest trench in the Atlantic, and as such, is a great place to see pelagic or oceanic fish that inhabit large expanses of the undiscovered blue. These are the places where you are likely to see some of the largest and most awe-inspiring marine life, e.g., whales, sharks, manta rays, etc. “The wall” or Puerto Rican shelf is unique because of its proximity to shore.
Once aboard our diminutive dive boat, we set off for a dive site renowned for its healthy Caribbean Reef Shark population. The divemaster briefed us on the way out. The waves were three to five feet, with a strong current. Most dive briefings are somewhat perfunctory; that is, they tell you many things that being a certified diver, you should already know. But when conditions are rough, and visibility is poor, a dive briefing can be the difference between a challenging but safe dive and a dangerous and even deadly dive.
When we arrived, there wasn’t much space to assemble our gear. Because of the limited space, we all had to do what is called a back roll entry. Essentially, you roll back off the side of the boat. You can see this in some of those dramatic promotional videos of the military doing the back roll entry off moving zodiacs. Getting into the water in rough conditions can be a bit frightening for some, especially with strong currents. As we assembled bobbing up and down at the stern of the boat, the master diver was not in view. I was with my son and two other inexperienced divers. We decided to descend and get a tell on where the master diver had gone off too. The visibility was poor for Caribbean diving, that is, maybe thirty feet at maximum. We looked for about 5 minutes before ascending to the surface. At that point, we had drifted about 100 to 200 yards from the boat. The current was strong. So strong that I had to tow one of the divers against the current to get back to the dive flag. The young women suggested that we descend and make our way to the dive flag. Under conditions where visibility is good, this is an advisable way to get back to the boat. However, under conditions where the visibility is poor, and the current is strong, sound underwater navigation skills are necessary to successfully make your way back to the boat or dive flag. After a tiring tow that probably took somewhere between 5 and 10 minutes, we arrived at the dive flag. We descended together and met up with the divemaster, his colleague, and the only other diver on the expedition. At that point, I was just relieved that we were in the orbit of the dive staff and that I wouldn’t have to be responsible for most of the divers on the trip.
Diving: When Everything That Could Go Wrong Did Go Wrong
I had taken an underwater 360 camera with me on this dive to do some testing, so at that point, I was getting excited as reef sharks started emerging like ghosts from the murk. I then noticed the master diver toting a DSLR camera in an underwater dive case and strobes (underwater flash units) for taking images of the circulating sharks. He snapped a few pictures. The visibility, as I mentioned, was not particularly good, so I recall thinking that looking through a camera viewfinder instead of monitoring divers was pretty irresponsible. I kept a very close eye on my son at this point, as my confidence in the diving personnel was obviously in doubt. As the dive continued, my son signaled that he had to ascend. I kept an eye on him as he boarded the boat, and I started my safety stop. A safety stop is used on a diving ascent. When diving, you should always stop at 15 feet of depth to let the nitrogen dissipate from your bloodstream. As I hovered over the other divers, I could see the sharks swirling underneath like enormous tadpoles and the backlit boat above rocking back and forth. Safety stops can be pretty serene–you are suspended in the water column with not much to do but look at your surroundings. Suddenly, I saw my son Aidan dive from the boat and swim as though his life depended on it. I cut my safety stop short and ascended immediately. I looked at the befuddled skipper, and he pointed at a diver flailing on the surface about 150 to 200 yards from the boat. She was clearly in trouble. I set off after Aidan as quickly as was humanly possible. As I arrived, I could see the 27-year-old woman struggling to stay afloat. I could also see a seven-foot reef shark about 10 feet from the diver, making sharp angular movements. Though Caribbean Reef Sharks are not typically dangerous, they are opportunists and will not pass up an easy meal. As I got to the woman, it was clear she was delirious and had taken on water. My son said her buoyance control device (BCD) would not inflate, so I gave it another try. Nothing. She was out of air. When you are trained for a water rescue, you typically do it in a very controlled environment, e.g., a pool. Also, the person you are “rescuing” does not need rescuing. Under normal circumstances, I would have blown air into her BCD manually, but it was impossible with the rough dive conditions and her body thrashing about. I decided to get her on my torso, immobilize her, and start the tow. When a diver is out of air, the gear designed to preserve life can be the very thing that drowns a diver. Aidan was behind me, and I asked him to provide me with orientation as it is difficult to see where the small boat was. His quick wits and calm and cooperative action made an enormous difference and exemplified how one should behave in an emergency. I gave the woman my alternate air source, which she promptly spat out while squirming about. I tried reassuring her and asked her to try and breathe easy. At this point, I was concerned she would fall off my torso, so I gave her my air source instead of reaching back and grabbing the alternative source. She was finally breathing. The waves splashed over my head as we swam towards the boat. As I approached the stern of the small craft, I was as exhausted as I was pissed. The boat had not moved an inch, and there was no additional assistance from staff. I yelled “help” as I tried lifting the girl onto the swim platform. She pushed me down as my son tried handing me my air supply. Anyone familiar with water rescue will tell you that the greatest threat to the rescuer is a panicking swimmer. Concerned that she might push Aidan down, I yelled at him and pushed him away. I recall her pushing me down and looking at her desperate face under the surface. I made a final push, and the skipper grabbed her BCD. As her weight lifted from my torso, my fully inflated vest buoyed me to the surface. I started dry heaving as I had inhaled some water. The skipper turned to me and said, “Can you get Pedro?” To which I responded, “I can’t breathe.” The skipper and second staff member positioned her body on the transom. They transferred her languid body to the floor of the boat as I made my way up the swim platform. I got out of my dive paraphernalia and noticed that they weren’t administering oxygen (standard protocol in situations like these), so I yelled, “Where is your oxygen tank?” The skipper responded that it was in a green bin in the bow’s dry storage. Aidan retrieved it as Pedro made his way up the dive ladder. At that point, the oxygen started flowing, and I could see her breathing shallow breaths. She would survive. When we got to port, an ambulance was waiting and spirited her away. I later heard that she had water in her lungs but that she would make a full recovery. My son and I saved her life. The events and implications did not strike me until we were thirty minutes from the San Juan, but it was clear that everything that could have gone wrong on a dive did go wrong on that dive.
The Checklist Manifesto To Eliminate Danger
So back to the Checklist Manifesto, a book written by Oxford-educated physician Atul Gawande. In the book, Gawande makes the distinction between errors of ignorance and errors of ineptitude. The book’s focus is really on the latter category when we, as the expression goes, screw the pooch. That is a situation when an otherwise competent individual makes a preventable critical error (or series of errors) with severe consequences. To drive the point home, 150,000 people die in surgery every year. Out of those 150,000 deaths, about half can be attributed to avoidable human error. In North America alone, nearly 100 divers will die a scuba diving-related death this year. So how many of those are preventable, and what simple measures can be taken to reduce that number? According to Diving Medicine for Scuba Divers, of all scuba diving-related fatalities, “86% were alone when they died (either diving solo or separated from their buddy).” As I am not attempting to review all the factors related to dive fatalities comprehensively, I will dig into this one statistic. People do not die because they are alone per se. According to Proceedings of the Divers Alert Network, “the most frequent known root cause for diving fatalities is running out of, or low on, breathing gas, but the reasons for this are not specified, probably due to lack of data.” Poor gas management is, more often than not, a novice mistake. Veteran divers use much less air on a given dive than a newbie. Also, veteran divers are much more likely to check their air pressure regularly during a dive and have a better internal sense of gas management. Had the woman my son and I rescued not ran out of air, the near-drowning would have been avoided. Additionally, if she had not been separated from her dive buddy, buddy-assisted breathing could have been administered, and no drama would have been necessary. But she did run out of air, and she was alone as she struggled to stay afloat on the surface.
So what “checklist” measures or protocols could be used to avoid such a situation? Firstly, the Profesional Association of Diving Instructors (or PADI) and Scuba Schools International (SSI) could require a written buddy designation before every dive. In our case, there was an odd number of divers, and the person without an apparent dive buddy was also the person that required rescuing. For those that have not had the pleasure of diving, a dive buddy is more than a friend; it’s a lifeline. When you take an introductory scuba course, you learn the importance of having a dive buddy for doing pre-dive equipment checks, assuring an unfamiliar, nervous, or inexperienced diver, and providing an air source in the event that your buddy runs out of air or their equipment malfunctions. Dive buddies should ideally stay together for the duration of the dive because your dive buddy IS your redundant air supply. Requiring novice divers to ascend with their dive buddy in ALL circumstances could go a long way in preventing “poor gas management” errors from becoming deadly. We all consume air at different rates due to experience, weight, and several other factors. Many divers ascend without their dive buddy due to this discrepancy (who wants to cut an exciting shark dive short). However, if we were to require that diving pairs ascend together, it would significantly reduce gas management errors.
Another checklist item that could prevent poor air management would be to require divemasters (and dive staff) to check the air pressure of all divers at timed intervals, say every 15 minutes or so. For most dives, air supply checks are at the discretion of the diver. I have had one other close call while scuba diving, and not surprisingly, it was a novice diver on the Great Barrier Reef who had not managed his gas correctly. It was a night dive, and the guy did not check his pressure gauge at regular intervals, and unsurprisingly, he ran out of air and required a buddy-breathing ascent. Had checks been made at regular intervals, the divemaster could have easily assessed that this diver was critically low on air. Again, at the moment, these checks are really at the discretion of the dive operators. Now I don’t want to be a “Debbie downer” or drag on an otherwise good dive, but it seems that out-of-air issues could easily be resolved with a more formalized system of checks. After all, there is no buzzkill quite like an incapacitated or dead diver. It would be great to hear from the diving (and non-diving community) on how we can best address (in a practical way) the issue of injuries and deaths as they relate to running low or out of air. What do you think would be an effective measure or framework to eliminate the greatest danger to recreational divers?