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Uhm 2013
Uhm 2013
5 Divers Alert Network, America; Anesthesiology Dept., Duke University, Durham, NC, USA
In order to investigate causative factors, root cause with rough water, buoyancy trouble, equipment
analysis (RCA) was applied to 351 Australian com- trouble, and gas supply trouble. CAGE was asso-
pressed-gas diving fatalities from 1972-2005. Each ciated with gas supply trouble and ascent trouble,
case was described by four sequential events (trigger, while cardiac cases were associated with exertion,
disabling agent, disabling injury, cause of death) that cardiovascular disease, and greater age. Exertion was
were assessed for frequency, trends, and dive and diver more common in younger cardiac deaths than in
characteristics. The average age increased by 16 years, older deaths. Asphyxia became less common with
with women three years younger than men annually. increasing age. Equipment-related problems were
For the entire 34-year period, the principal disabling most common during the late 1980s and less so in
injuries were asphyxia (49%), cerebral arterial gas 2005. Buoyancy-related deaths usually involved loss
embolism (CAGE; 25%), and cardiac (19%). There of buoyancy on the surface but decreased when buoy-
was evidence of a long-term decline in the rate of ancy control devices were used. Countermeasures
asphyxia and a long-term increase in CAGE and to reduce fatalities based on these observations will
cardiac disabling injuries. Asphyxia was associated require validation by active surveillance.
____________________________________________________________________________________________
In 2005, DAN AP began incorporating Project Sticky- The disabling injury was determined using criteria
beak data into a broader dive fatality database, which similar to those described by Denoble [5] as follows:
includes data from elsewhere in the Asia-Pacific, and (a) Asphyxia: asphyxia with or without aspiration of
now produces annual Australian diving fatality reports water and with no indication of a prior disabling
[6-9]. Following ethics approvals from various state injury. (In this study, Asphyxia was defined as a
coronial and heath ethics review boards in Australia, condition arising when the body was deprived
DAN AP gained access to diving-related deaths of oxygen, causing unconsciousness or death [10]).
(including compressed-gas, snorkel and breath-hold (b) Cerebral arterial gas embolism (CAGE): gas in the
divers) recorded in the National Coronial Information cerebral arteries with or without evidence of lung
System (NCIS) as well as more detailed information rupture.
from various state coronial offices. This has overcome (c) Cardiac: acute episode of chest discomfort signaled
some of the obstacles to data collection. by the diver, distress without obvious cause, history
The DAN AP database was used to identify relevant of cardiac disease, or autopsy findings.
cases and the likely sequence of events involved in the (d) Trauma: witnessed trauma, traumatic findings at
accidents. This study was conducted under general ethics autopsy.
approval from The Human Research Ethics Committee, (e) Decompression sickness (DCS): signs or symptoms,
Department of Justice, Government of Victoria, Australia. autopsy findings.
(f) Other: stroke, cerebral hemorrhage, etc.
Sequential analysis (g) Unknown: body not recovered, no autopsy available,
In accordance with the methods used by Denoble et al. no indications of disabling injury at autopsy.
[5], accident descriptions for all Australian dive-related In addition to the accident sequence, we investigated a
fatalities between 2003-2006 inclusive (n=81) were variety of other information from the reports, including
studied by a panel of experts and classified into a the experience of the victims, weight management,
sequence of four events defined below. These experts BCD management, remaining gas, buddy situation,
included one of the authors (JL), three dive physicians, the depth at which the accident occurred, the gender
a retired judge and a diving instructor/researcher. Agree- and age of the victim and whether or not high levels of
ment on the classifications was reached by consensus. anxiety or stress appeared to have been a major trigger.
Two of the above group, including one of the authors Determination of the presence of anxiety or stress
(JL) then retrospectively analyzed all reported cases was generally made on the basis of witness reports,
from 1972-2002 inclusive. This was done individually the victim’s lack of experience and/or other factors such
and differences were discussed and resolved. as the witnessed presence of water in the mask early in
In general, information available in the case descrip- an accident sequence.
tions, and autopsy reports improved with time. In part,
this seemed the result of a growing awareness of the Statistical analysis
special requirements of a diving autopsy by coro- Software
nial pathologists. Statistical analyses were performed using the open source
Events in the accident sequence were defined as [5]: statistical package R [11,12]. Pareto charts were plotted
1. Trigger. The earliest identifiable event that appeared using the additional library qcc [13]. This software is
to transform an unremarkable dive into an emergency. available from the R archive network [14]. Additional
2. Disabling agent. A hazardous behaviour or circum- R code used in our analysis is available on request.
stance that was temporally or logically associated
with the trigger and perhaps caused the disabling Trends in accident counts
injury. Since diving accidents are rare events, it is reasonable
3. Disabling injury. An injury directly responsible for to make the working assumption that annual accident
death or incapacitation followed by death due to counts follow a Poisson distribution. Trends in the
drowning. number of accidents over time were investigated ini-
4. Cause of death (COD). COD was specified by the tially using loglinear Poisson regression. This assumes
medical examiner and could be the same as the that the predicted mean number of accidents in a par-
disabling injury, or could be drowning secondary ticular year, µ, depends on the calendar year, x, through
to injury.
_____________________________________________
logistic regression model, equation [2], was then fitted
Figure 1. Annual compressed gas fatalities
in Australia 1972-2005 and subsequent calculations performed as above.
Gender differences
The frequency of each type of accident was broken
15
Results
From 1972 to 2005 inclusive, there were records of
5
_____________________________________________ _____________________________________________
Figure 2. Triggers identified Figure 3. Disabling agents identified
in 292 diving fatalities in 275 diving fatalities
100%
100%
250 300
Cumulative percentage
Cumulative percentage
75%
75%
100 150 200
Frequency
Frequency
50%
50%
25%
25%
50
0%
0%
0
0
gas supply-related
ascent-related
CVD
buoyancy-related
entrapment
other
shark
other medical
other
equipment-related
gas supply-related
rough water
exertion
anxiety-stress
buoyancy-related
________________________________________________________________________________
Table 2. Constituents identified within each disabling agent category
(n = 313; 38 cases with unidentified triggers were omitted)
26% gas supply-related, mean age 33, 85% male 21% ascent-related, mean age 36, 80% male
Gas contamination Breath-holding on ascent
Gas supply interruption Gas sharing on ascent
Inappropriate gas Rapid ascent
Out of gas Tank slippage
Weight belt detachment
16% CVD, mean age 50, 92% male 12% buoyancy-related, mean age 31, 75% male
Evidence at autopsy Inadequate buoyancy control underwater (- or +)
Medical history Lack/loss of buoyancy on surface
Self/witness description of indications
11% entrapment, mean age 30, 88% male 8% other, mean age 34, 87% male
Blow to head
Crocodile attack
Hypothermia
Inadequate decompression
Laryngospasm
Narcosis / CO2
Propeller
Vomiting underwater
3% medical condition, mean age 44, 100% male 3% shark, mean age 30, 90% male
Aortic aneurysm
Cardiomyopathy
Cerebral aneurysm
Duodenal ulcer
Epilepsy
________________________________________________________________________________
__________________________________________________ _____________________________________________
TABLE 3. Relative occurrence of disabling injuries Figure 4. Disabling injury identified
(n = 311; 40 cases w/unidentified disabling injuries omitted) in 311 diving fatalities
100%
Disabling Frequency Male Female Mean age
75%
Cumulative percentage
CAGE 25 84 16 36
Cardiac 18 91 9 48
Frequency
Trauma 5 93 7 31
50%
100 150
DCS 1 100 0 35
__________________________________________________
Other 2 100 0 47
25%
Disabling injuries
50
The disabling injuries identified were asphyxia, cerebral
0%
0
arterial gas embolism (CAGE), cardiac, trauma, decom-
asphyxia
CAGE-PBT
cardiac
trauma
other
DCS
pression sickness (DCS), and other, which included
stroke and gastrointestinal hemorrhage. The frequencies
of the various groups of disabling injuries are shown in
Table 3 and Figure 4. The predominant disabling injury
(49%) was asphyxia from the inhalation of water while _____________________________________________
diving. CAGE was thought to have contributed to one- Figure 5. Causes of death identified
quarter of the deaths and cardiac involvement to 18%. in 315 diving fatalities
__________________________________________________
100%
200 250 300
75%
Cumulative percentage
Cause of Frequency Male Female Mean age
__________________________________________________
death (%) (%) (%) (yrs)
Frequency
50%
Drowning 56 82 18 33
100 150
CAGE / PBT 21 86 14 36
Cardiac 16 88 12 48
25%
Trauma 5 93 7 31
50
DCS 1 100 0 35
__________________________________________________
Other 2 100 0 47
0%
0
drowning
CAGE-PBT
cardiac
trauma
other
DCS
__________________________________________________ __________________________________________________
TABLE 5a. Triggers and disabling agents TABLE 5b. Triggers and disabling agents
associated with asphyxia (n = 153) associated with CAGE (n = 76)
__________________________________________________
Trigger p-value odds ratio (95% CI) __________________________________________________
Trigger p-value odds ratio (95% CI)
Rough water < 0.001 11.2 (3.5, 36) Gas supply trouble < 0.01 3.11 (1.34, 7.2)
Buoyancy trouble < 0.01 7 (1.6, 31)
Equipment trouble < 0.05 2.93 (1.2, 6.9) __________________________________________________
Disabling agent p-value odds ratio (95% CI)
Exertion < 0.001 0.0127 (0.0012, 0.13) Ascent trouble < 0.001 >30
Gas supply trouble < 0.05 0.298 (0.115, 0.774)
__________________________________________________
Disabling agent p-value odds ratio (95% CI) __________________________________________________
CVD < 0.05 0.049 (0.0014, 0.118)
Gas supply trouble < 0.001 15.4 (6.4, 37) For CAGE, gas supply trouble was the only significant trigger,
Buoyancy trouble < 0.001 9.5 (2.7, 33) while ascent trouble was the most important disabling agent.
__________________________________________________
CVD < 0.001 0.0129 (0.0014, 0.12) For example, running out of air as a trigger followed by rapid
ascent as a disabling agent was a common occurrence.
Rough water, buoyancy trouble and equipment trouble were the
However, in cases where the disabling agent was a gas supply-
most significant triggers for asphyxia, while gas supply trouble
problem, the trigger was rarely (if ever) gas supply-related,
and buoyancy trouble were the most significant disabling agents.
and CAGE was not implicated as the disabling injury.
Exertion and CVD had odds ratios (OR) of less than 1, indicating
these factors were associated with other disabling injuries rather __________________________________________________
than asphyxia.
TABLE 5c. Triggers and disabling agents
_____________________________________________ associated with cardiac events (n = 57)
Figure 6. Age and calendar year over the observation __________________________________________________
Trigger p-value odds ratio (95% CI)
period for males and females. Fitted trends in age
for males (solid line) and females (dashed line). Exertion < 0.001 >30
Gas supply trouble < 0.05 0.058 (0.0065, 0.52)
45
__________________________________________________
Disabling agent p-value odds ratio (95% CI)
40
while CVD was the only disabling agent. Gas supply trouble or
rough water without exertion were rarely associated with
cardiac injuries and were predictive of other disabling injuries,
as discussed in Methods.
30
_____________________________________________ _____________________________________________
Figure 7. Estimated trend in the prevalence of CVD or Figure 8. Proportion of cases where exertion was the
other medical condition as the disabling agent against trigger, as a function of age of victim. Shaded band
diver age. Shaded band is 2-standard-error confidence is 2-standard-error confidence interval. Dots show
interval. Dots show averages over 3-year age groups. averages over 3-year age groups.
% of disabling agents that are CVD or other medical
100
100
80
80
% of triggers that are exertion
60
60
40
40
20
20
0
0
20 30 40 50 60 70 20 30 40 50 60 70
Age Age
those whose dive purpose was “research.” This was 40 implies that the only route to cardiac injury in this
probably attributable to an association between gender age group is exertion, while the dip around ages 50-
and professional occupation. Experience, depth of ac- 60 is consistent with a less important role for exer-
cident, weight belt status, and buddy status were also tion in older divers, who are at greater natural risk of
evaluated, but no significant associations were found. cardiac injury. The involvement of exertion in younger
Cardiovascular disease (CVD) was believed to be divers may be indicative of undiagnosed or occult
the disabling agent in 16% of the cases. The preva- CVD, as suggested by Mitchell and Bove [23].
lence of CVD and other medical conditions as the dis-
abling agent increased significantly with age (p < 0.001; _____________________________________________
Figure 7). Denoble et al. (18; Figure 2) found younger Figure 9. Proportion of cardiac injury cases where
males had greater CVD involvement than younger the trigger was exertion plotted against diver age.
females, but the difference disappeared at about age Shaded band is 2-standard-error confidence interval.
60. In our data, the difference between genders was Dots show 3-year averages.
not significant, probably due to small annual numbers.
100
_________________________________________________________________________________________
Figure 10. Prevalence of the three main disabling injuries against diver age.
0 20 40 60 80 100 Left to right: cardiac, asphyxia and CAGE. Dots show averages over 3-year age groups.
0 20 40 60 80 100
20 40 60 80 100
% of injuries that are asphyxia
% of injuries that are cardiac
Figure 10 shows the prevalence of the three main The most common disabling agent was gas supply
disabling injuries plotted against diver age. Dots show trouble (26%), with running out of gas most frequent.
averages over three-year age groups, and fitted trends Ascent trouble (21%) was next, with rapid ascent the
were obtained using smooth GAM logistic regression. greatest problem. Cardiovascular disease (16%) was
The proportion of cardiac injuries increased with age, prominent in older males. Buoyancy trouble (13%) usu-
and the proportion of asphyxia decreased with age, ally involved loss of buoyancy on the surface.
both highly significant (p < 0.001), while injuries due to Entrapment (11%) was less common as a trigger and
CAGE were not associated with age. Gender was not more common as a disabling agent secondary to triggers
significant for cardiac injury, which affected only six such as silting or narcosis.
females.
Trends in diving fatalities
Discussion The results described above represent averages over
Overall fatality characteristics the 34-year observation period and were generally
The average age of diving fatalities in Australia increased similar to those of Denoble et al. [18], Cumming et al.
by 16 years from 1972-2005. Women who died while [19] and Richardson [20]. Conclusions based on many
diving were three years younger than men in the same years of pooled data, however, do not necessarily
calendar year (Figure 6) and increased in proportion reflect the present, which is of greatest interest to diving
from 7% to 22% of total fatalities – probably reflecting safety, and was most closely approximated in our
greater involvement of women in recreational diving data by the year 2005. This is apparent in Figure 11,
rather than greater hazard. Overall, the most common which illustrates statistical trends from 1972 to 2005.
disabling injuries were asphyxia (49%), CAGE (25%) Triggers showing trends over time included equip-
and cardiac events (18%). Asphyxia was commonly ment-related problems that were greatest during the
associated with rough water, buoyancy trouble, equip- late-1980s (Figure 11a) but have become less frequent
ment trouble, and gas supply trouble. CAGE was com- since then. This could reflect improved design or bet-
monly associated with gas supply trouble and ascent ter diver training and familiarity. A surprising finding
trouble, while cardiac injuries were associated with (Figure 11b) was that anxiety or stress seemed to have
exertion, cardiovascular disease, and greater age. increased significantly and particularly so in women.
Equipment trouble and gas supply trouble were the Determining whether anxiety or stress was present
most common triggers, each accounting for 18% of could be difficult, however, and this result should be
accidents. Rough water was also prominent, being iden- interpreted cautiously.
tified as the likely trigger in 15% of the accidents. Figure 11c shows that buoyancy-related disabling
Exertion (11%) occurred primarily in older males, while agents decreased over the observation period, and Fig-
anxiety/stress (11%) was disproportionally represented ure 12 suggests this decrease was related to BCD use.
in females. Buoyancy trouble (5%) was also a rele- The smooth estimates of proportions in Figure 12 were
vant trigger. derived by GAM logistic regression with normalization
_________________________________________________________________________________________
Figure 11. Trends over time for triggers, disabling sgents, disabling injuries and cause of death.
Confidence limits for the fitted trends are 2-standard error. Dots are 3-year averages.
Triggers
a. equipment-related (p=0.015) b. Anxiety/Stress (p<0.001)
80
80
60
40 60
40
20
20
0
0
1975 1980 1985 1990 1995 2000 2005 1975 1980 1985 1990 1995 2000 2005
Year Year
Disabling agents
c. buoyancy-related (p<0.001) d. Ascent-related (p=0.002) e. CVD-related (p=0.026)
% of injuries that are ascent-related
80
80
80
% of injuries that are buoyancy
60
60
40
40
40
20
20
20
0
1975 1980 1985 1990 1995 2000 2005 1975 1980 1985 1990 1995 2000 2005 0 1975 1980 1985 1990 1995 2000 2005
Year Year Year
Disabling injuries
f. Asphyxia (p<0.001) g. CAge (p=0.003) h. Cardiac injury (p=0.0039)
% of injuries that are cardiovascular
% of injuries that are CAGE-related
80
80
80
% of injuries that are asphyxia
60
60
60
40
40
40
20
20
20
0
1975 1980 1985 1990 1995 2000 2005 1975 1980 1985 1990 1995 2000 2005 1975 1980 1985 1990 1995 2000 2005
Year Year Year
Cause of death
i. Drowning (p<0.001) j. CAge (p<0.001) k. Cardiac (p<0.001)
% of deaths that are cardiovascular
% of deaths that are CAGE-related
80
80
80
% of deaths that are drowning
60
60
60
40
40
40
20
20
20
0
1975 1980 1985 1990 1995 2000 2005 1975 1980 1985 1990 1995 2000 2005 1975 1980 1985 1990 1995 2000 2005
Year Year Year
_____________________________________________
increase in BCD use, both in the diving population and
Figure 12. bCD use among diving fatalities.
in the recorded fatalities. A causal relationship may be
conjectured but cannot be explored using these data.
100
[22].
Disabling injury and cause of death showed similar
0
despite accumulating occult cardiac disease. The recent spurious due to confounding (e.g., apparent correla-
diving fatality workshop addressed this problem and tions due to parallel changes in the diver population
provided recommendations for diving physicians and a and diving practice), diagnostic bias (e.g., a greater
self-assessment questionnaire to assist older divers in propensity for investigators to impute anxiety to
deciding whether to seek medical advice [24]. The inexperienced rather than experienced divers),
observation that exertion is strongly associated with or missing data effects (e.g., some types of accidents
cardiac events argues for careful selection of dive are intrinsically more likely to result in incomplete
sites to avoid environmental conditions that might lead data).
to heavy exercise (Figure 8). • Limited annual case data. An average of 10 fatalities
The suggestion that anxiety or stress is an impor- per year is a small number, making it difficult to
tant trigger, especially in women, is new and warrants investigate complex relationships between multiple
further investigation for confirmation due to potential variables in the presence of trends over time. This
for diagnostic bias, as noted above. Nonetheless, it is is reflected in the very wide confidence intervals
reasonable that careful selection of dive sites to avoid obtained for some of the odds ratios. However, the
rough water and exposures beyond a diver’s training main associations and trends were statistically well
and experience might help reduce anxiety or stress. established over the 34-year period. Low numbers of
The interventions and countermeasures mentioned female deaths meant that gender effects were difficult
above seem plausible enough, but whether they would to investigate. Some of the p-values are inaccurate,
be effective cannot be known without active surveil- since they were based on the usual chi-squared
lance. Active surveillance is widely used in public health approximation to the likelihood ratio test, which
but requires continuous, systematic, and timely obser- is a poor approximation in small samples.
vation, with rapid dissemination and communication to • Regional conclusions. The report describes the
the public [25]. Continued surveillance of this nature Australian experience, and some findings may not
is essential if recreational diving safety is to improve. extrapolate to other locations. Comparisons with
other regions may eventually require regional
Limitations variables such as water temperature, marine life,
There were inevitable limitations and uncertainties sea state, reporting and investigation protocols
associated with our investigations. These included: and expertise, etc.
• Incomplete case data. Fatalities were sometimes not • Absence of information on divers at risk. Without
witnessed, various people collected information over a denominator, our analysis of factors affecting
34 years, and autopsy methods have improved. disabling injuries had to be made for a given injury
Future efforts should standardize all phases of fatality relative to all other injuries. This problem arises
investigation to improve data accuracy and in many epidemiological and safety studies.
completeness. • Lack of currency. The most recent year investigated
• Classification of cases into a sequence of four events was 2005, some seven years ago. An ideal surveil-
(trigger, disabling agent, disabling injury, cause of lance system would publish results annually within
death). This requires a single choice for each event not more than two years of the current year.
which may omit important factors in some cases.
Acknowledgments
A longer sequence of events might be useful.
We acknowledge Monash University National Centre for
• Difficulties in establishing unambiguous cause- Coronial Information for providing access to the National
and-effect relationships in survey data. Some of our Coronial Information System (NCIS), State and Territory
main findings relate to correlations between triggers, Coronial Offices, various police officers, dive operators
disabling agents and disabling injuries. These and divers who provided information on these fatalities.
conclusions are necessarily provisional and require We also thank Dr Harri Kiiveri (CSIRO) for comments on the
continuing active surveillance. Correlations may be statistical analysis and Scott Jamieson for organizing the data.
n
____________________________________________________________________________________________________
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