Monday 15 February 2010

GLOC's PFO and where things are now

The first part of this was originally written in October once I got back from Malta and had my PFO test.

Well, I have been doing some fairly big dives with a PFO but I didn't know about it!!

The last dive I did in Malta (9 August 2009) was 15/40, 50% and 100%, 30mins at 63m and 65mins of deco from 21m up including 35mins on 100% at 6m (god that was boring!). The dive was really uneventful (apart from some cracking photos!) and when I surfaced I didn't have any issues. Handed the stages up to the boat and then climbed up the ladder onto the rib. No issues at this point. Dekitted and then sat on the tube of the rib and noticed some visual disturbances but no headache or muscle pains or anything else. Nothing too major, just a slight blurring, the sort of thing you get when you look at a light bulb too long.

I didn't say anything to anyone, just thought it was one of those things...besides no other symptoms. (Mistake 1)

We then went back into the harbour (20mins or so from surfacing) and during this period the visual disturbance disappeared, probably around 5mins or so, and I thought, no worries, just something transient.

Pulled alongside and then started to unload the boat which entailed lifting the kit from the RHIB up onto the quayside and then onto the back of a flatbed. At this point, the disturbances came back, again no other issues with regards to DCI. Mistake number 2, I didn't say anything to anyone. About 20 mins later, these disappeared again, so again, I thought no worries at the moment, but I probably need to see someone when I get back to the UK (last dive of the trip, flying home the following morning).

So, I get back to the UK and book an appointment with my GP and explained what had happened. This was quite funny as I knew far more about the link between PFO and migraine and PFO and DCI. He was going to put me in for an ECG which I said would be a waste of time that I needed a ultrasound test. Ended up him asking me to go away, let him know what he needed to do with regards to a PFO test and he would refer me!

I didn't do all of that. I spoke to a couple of people who put me in touch with Mark Turner at the Bristol Heart Institue who said that I probably did have a PFO even though I didn't have any other DCS symptoms but the only way would be to complete a test. To do this, I could wait 10 weeks or so for an NHS test once he had the referral paperwork or pay ~£500 for a private appointment in a week or so. Being the impatient person, and the fact I now had 2 T1 weekends that I was going to be diving on, I went for the private test.

I went up to Bristol 2 weeks ago to have the test which entailed doing a baseline scan of the cardiac area whilst lying on my left side and using an external ultrasound scan (Transthoracic Echocardiagram). Once this was done, I had some saline/blood mixture mixed with small amounts of air injected into my left forearm and a scan taken without conducting a valsalva clear. There were some bubbles present in this.

Then I was asked to do a big sniff (builder's sniff, Mark called it!!) halfway through the injection of more blood/saline/air and Mark immediately said "You have bubbles there" :( Then there was a valsalva for 15 secs which makes your head hurt, but there was limited crossing of bubbles with this, 2 more valsalvas with limited success and then another sniff, with more bubbles but not as much as the first sniff.

This is the [URL="http://www.imagesoflife-online.co.uk/PFO_Test.wmv"]sniff test [/URL]video clip! <
So, I have a PFO :) The stats Mark gave were something like 1:4 people have a small PFO but because most people don't dive this isn't an issue, however, there are major indications that a PFO increases a risk of stroke as it allows a clot to transfer from the veinous side of the blood system to the arterial (the same way bubbles do). 1:10 have a moderate PFO and about 1:100 have a PFO the size of the one I have!! However, the PFO can be fixed and there is a no-dive period of 3 months following the op when a very large percentage of PFOs are closed.

Mark thinks that the visual disturbances were caused by bubbles forming on the retina as the disturbances were not indicative of a bubble in the neural area where nerves would have been blocked/trapped etc.

Mark is in the process of writing up a report for my GP, so that I can get an op to fix it. I will not be doing any trimix diving until it is fixed and the only other diving I will be doing will be inside air NDL limits using high FO2 and using O2 at the 6m stop when I get anywhere close to that.

Getting bent knowing that I have a PFO is somewhat stupid so I am not going to push it even though diving means so much to me.

Looking back, I can make one of two assessments of why I haven't been bent...

1. I have been lucky...
2. The deco I have been doing has been good at stopping bubbles growing and the O2 has sorted the remaining stuff out.

What was different about the dive I did in Malta was the time it took from surfacing to getting back on shore. Most of the diving in the UK I have done has been done with a hardboat 1-3 hours from shore so I haven't had to hump kit around so close to the surfacing time. Simon Mitchell at EUROTEK last year said that the worst time to be doing anything strenuous is around 30mins from surfacing. Guess what!

So, you don't know you have a PFO until you

a. have a test,
b. get bent, then have a test,
c. have a stroke, then have a test.

I have done something like 10 T2 level dives and 50 plus T1 level dives and nothing has presented itself, until this time. Fortunately, when it did present itself, it was a fairly minor thing ;)

It has been hard for me to not go diving but then I have the rest of my life in-front of me, and to do something because it is there and bugger the consequences is just plain stupid for all concerned.

Hopefully you will have got something out this post....not least, own up to your buddies that something is wrong and then they can do something if you go tits-up quickly! Denial isn't just a river in Egypt! :D
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Update 15 February.

Last Friday, 12 February, I went into Bristol Heart Institute to see Dr Mark Turner and get my PFO closed.

I will update this in more detail shortly but suffice to say that I had a rather large PFO 7-8mm x 12mm. The average is around 3.5-5mm.

I need to go back in 6 weeks time to make sure things are healing and then 6 weeks after that to have a bubble test before I can go back diving.

In the 6 months since the bend, I have been diving twice, once for Scuba Santas in December, the other teaching UW photography in January. I really miss it and want to get back in the water. Hopefully I can, as I have a week booked to dive Shetland in July...

Sunday 14 February 2010

Course report: GUE Recreational ITC, November 2009 High Springs Florida

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I--
I took the one less traveled by,
And that has made all the difference

Robert Frost: The Road Not Taken (1915)

We all know that GUE instructors are amongst the best educators in the dive industry, but what exactly does it take to become a Fundamentals instructor?

Having participated in the November 2009 ITC in High Springs, Florida I thought I would share some of the highlights of the course and give you an insiders view of the Recreational ITC.

The Location.....

For the November Recreational ITC we were to be hosted by Extreme Exposure, High Springs. I had always wanted to dive the Florida springs, so the chance to combine 4 days fantastic diving with the GUE annual Conference and then straight onto the ITC was an unmissable opportunity. Doug Mudry and the team there were just fantastic, thanks guys. Hot coffee in the morning, great classroom and no shortage of gas, twinsets and sensible answers to our dumb questions! I couldn't think of a better base if you are going to North Florida.

The Prerequisites

In the spring of 2009 I took the decision to become a GUE Fundamentals instructor. We are lucky in the UK to have 4 instructors, including Director of Technical Training Rich Walker, so discussing my ambitions with Rich was the first step.

Unlike some of the other training agency's instructor training programs there is no 'zero to hero' route. The minimum is you must have passed GUE Fundamentals and either GUE Tech 1 or Cave 1 and you must have proof of at least 200 logged dives, with at least fifty dives in a single tank/cylinder, DIR configuration. At least twenty-five dives must have been in a double tank/cylinder configuration and at least ten with a stage bottle. But the most important prerequisite of being a GUE instructor is just like the prerequisite every other GUE course, it is having the right attitude.

That means not only always thinking about the safety and enjoyment of your team, in this case, students but also having a commitment to delivering the highest quality training possible. That's a big responsibility.

Although interning a fundamentals class is not a compulsory prerequisite I felt it would have been valuable for to see a class run in its entirety prior to the ITC. Personal commitments meant that it was unfortunately not possible for me. It really is going be a question not just your availability but of course availability in your location, especially if there are instructor candidates in your region who have already completed an ITC (more on that later) The key is to register as an intern via gue.com and discuss it with GUE HQ or your local instructor mentor.

The team

I was joined by 3 other candidates, Peter Brandt from Belgium (Team Koelakant) Rob Lee from the US (BAUE) and Ricardo Constantino from Portugal (SPE) The guys represented a great mix of backgrounds and interests from the wrecks of Jutland, to the deep reefs of California and cave exploration in Portugal. For me it showed the growing international presence that GUE divers and projects now have. And of course its great to make new friends from a global community.

The instructors

Its not very often you get to spend a week with two of the GUE communities most widely respected dive educators and explorers. Well that's exactly what we had with our ITC staff, Richard Lundgren and Mark Messersmith. We could not have asked for better instructors and mentors. Their experience of some of the most challenging exploration diving is matched only by their patience and understanding of diver education and development. They are also great company. If you get the opportunity to take a course with either of these guys, do it.

We were also joined by Jesper Berglund, Ed Gabe and Wojteck Filip (interning as an IT) whose insights into how to teach Fundamentals & Rec1 was greatly appreciated.

The Course

I am already an active instructor trainer with another agency and felt comfortable and confident with both in water and classroom teaching, but like every GUE course no matter how good you think you are, the bar is always just a little higher........

Like other agency Instructor development programmes the ITC is a developmental process not an evaluative one. However unlike other programmes there is no pass/fail exam at the end, it really is just the first step in becoming an instructor. The 7 days were split into 3 diving day and 4 classroom days. Essentially we were to teach a Fundamentals class (classroom, land drills and in water sessions) and at the same time be a student in 3 others!

As with other GUE courses it started in a nice relaxed informal manner and then increased the task loading during the week. We started with an introduction to the frame work for delivering academic topics, land drills and in water training. The presentation framework was not dissimilar to what I used before but with emphasis strongly on the principals of immediacy and primacy. This helps focus the learning on the just the most important relevant information. This ensures that time is invested on the 'need to know' not unnecessarily spent on the 'cool to know'.

The GUE approach to teaching is subtly different to that of mainstream recreational training. You are not just teaching out of a manual or off of a slate, you have know the material in side and out and know when and how to deliver it. And that will change from student to student. The key phrase that was drilled in to us was 'own the material'. We really started to understand that teaching Fundamentals is not about just repeating information, its about teaching something that is part of your diving 'DNA' and never missing an opportunity to teach or enhance a students skills or knowledge.

The standard for the academic presentations and field drills is high and to nail the timing and precision required is tough, in the ITC its 15 mins per subject, and I have to admit I really struggled to get it right.

With each presentation Richard and Mark began to crank up the pressure to show the areas that need development and refinement. All the time the feedback, good and bad is immediate. The areas that need improvement are clearly shown along with the 'tools' to fix it. And you are expected to fix it!

Its worth mentioning the in water sessions. These were held at a site called ' Blue Grotto' that gave us access to range of depths and room to work in. Its about an hour from High Springs and this made for long days. Each day we would have a couple of land drills and a dive from fundamentals to teach. There was always a candidate that was used as a video diver and a member of the IT team acting as a student and the slightest error in our demonstration or set up of the skill or control of the 'students' would result in it being exploited without mercy until you diagnosed it and fixed it. We were assured that they took no pleasure in this.

With the focus from the IT team on safety, control and positioning at all times the task loading is relentless, but we all felt our confidence and comfort increasing during the sessions. Particularly in relation to the post dive and video debriefs. It is worth noting that we all struggled initially with the steel 104's as none of had dived them before, but it was good lesson in learning to work with whatever you have when you travel to teach fundamentals.

In addition to the assignments from fundamentals we also had an afternoon in the water and classroom looking at the skills and theory of Recreational diver Level 1 with Jesper Berglund. There was were also a series of presentations from Mark and Richard on the origins and future of GUE and the vital training and quality control standards.

It was on these standards that we had the only part of ITC pre-study. About 3 weeks from the course we had been emailed a study guide and quiz from Dan Mackay. This was useful and I hope in the future that the pre study element takes a more formal structure and grows to include other topics such as the administrative aspects of working with GUE HQ and maybe the internet can play a part in delivering some of this material via gue.com

Fortunately one of the long academic days was broken up by the infamous ITC swim test and breath hold swim. Needless to say an hour in the cool, gin clear water at Ginnie springs is no real hardship! It is worth spending some time on your swim technique in the time leading up to your ITC or that can seem a very long 15 minutes!

Needless to say most nights we were beat, but as we had the assignments for the whole week there was always homework to do.

The last day (or is it the first day?)

By the last day we were tiered but happy in how far we had come. We were also given a chance to present any academic topics that we felt we needed additional feedback on.

At the end we were given very simple individual debriefs on how we did, what needs improving and what we have to do next. Of the two IE signatures that are required to become an active fundamentals instructor, only one is available at the ITC. The second must come from another IE. For all of us the way forward involves interning a number of Fundamentals classes before going to an IE (Instructor Evaluation) We are assigned a mentor to work with in the intern process and it is made clear that if the commitment is there from us, then GUE will provide all the resources needed to make us successful. It is only the availability of courses to intern on that dictate how long this will take. Although this may seem an onerous proses it ensures the on going high quality of the GUE instructors and the courses they deliver.

For all of us it left us with a new respect for exactly what it takes to be a GUE instructor and a real desire to take in everything Richard and Mark had shown and told us to become great GUE instructors one day.