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Thread: Immersion Pulmonary Edema (IPE) at 291'

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    RBW Member jaboothtx is an unknown quantity at this point jaboothtx's Avatar
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    Immersion Pulmonary Edema (IPE) at 291'

    I’ve had friends recommend that I NOT post this incident report because of the number of people who will flame me for one reason or another. However, I have a lesson to share that I hope will help someone else, and I refuse to let the bad behavior of a few people be to the detriment of the community.

    I will answer what I judge to be reasonable questions, and ignore everything else that is posted.

    In the spirit of learning for all,
    Jean Anne




    Immersion Pulmonary Edema Incident Report

    Date: 9/9/12
    Dive start: 13:03
    Dive end: 14:24
    Location: Wreck of the Kendrick, Florida Keys near Key West
    Dive gear: Inspiration rebreather: 10/50 diluent 1.2 setpoint; bailouts 15/50 and 50/10; Vision electronics at 30/85 gradient factor and Shearwater Predator backup at 30/85 gradient factor
    Surface conditions: sunny, approx. 92 deg, no current at surface, mild chop
    Reported bottom conditions prior to dive: 86deg to thermocline at 200’, 52deg at deck at 300’

    Profile: 291’/81 mins, completed decompression obligation + 10 min (Shearwater profile attached)


    With the reported cold conditions at the bottom, I borrowed a 5mil hood from one person and a 5mil wetsuit from another person, as all I had was a 3mil wetsuit & hood. My buddy dove his dry suit.

    The descent was uneventful. I noted the thermocline at 186’. It continued to get colder as we descended, and was 51.7deg at the deck of the Kendrick. Our plan was to swim along the deck until we got too cold, and then ascend. After a few minutes at depth, I had a tickle in my throat and coughed a few times. Visibility was easily 100’, and current was very mild. We swam slowly along the deck of the Kendrick, angling a bit upward because it was quite cold. I continued to cough a bit every 30 seconds or so. After about 10 minutes at depth, we were swimming over a hold between the smokestacks on the wreck, and I felt like I was working hard and breathing hard while diving (I’m an excellent swimmer and endurance triathlete, so this is not normal for me). I was getting really cold, and decided I didn’t want to work hard at depth while cold, so I signaled my buddy to ascend. We began our ascent and deco. I continued to cough occasionally.

    During the ascent, somewhere around 200’, I noticed a “gurgle” in my breathing. It felt like I was gargling water right behind the top of my breastbone, below my Adams’ apple. I continued coughing and gurgling, which was not normal. I had 52 min of deco remaining on my Shearwater computer at that point. I decided that I would simply focus on staying on the loop, exercising as little as possible, to get as far through deco as I could.

    As we got to the first deco stops in the 90’ range, we were back in the warm 86deg water. My buddy pulled back the hood from his dry suit to cool off. Since I was still coughing, he pointed at my throat, and I nodded, yes, still coughing.

    Around 70’, I was having a hard time breathing over the gurgling and was very hot, so I wanted to take off the borrowed hood. Ordinarily I’d just get off the loop, remove my mask, and pull off the hood, but it would have been very difficult to maintain proper deco stop depth while performing this operation. I decided that I already had enough stressors, and instead handed my scissors to my buddy and asked him to cut the hood off me. I asked him to cut the hood back from my forehead. He cut a bit (which helped with breathing), but then stopped when he cut off a hunk of my hair. We continued to deco for a few more minutes. Breathing continued to get harder. I grabbed my scissors again and this time pointed my buddy at cutting off the hood by cutting it downward under my chin. I was a bit cooler without the hood, and definitely better able to breathe over the gurgling as we continued to deco. My focus was entirely on my breathing and maintaining buoyancy so that I wouldn’t stress my lungs with exercise.

    As planned, we were intentionally doing a drift deco, and were to deploy a surface marker buoy (SMB) during the ascent. At 30’, my buddy pulled out his slate and asked me to deploy my SMB, and said he had lost his SMB at 40’. I pointed at the SMBs and reels attached to my bailout bottles, and gestured for him to go ahead. I took back the slate and asked him to deploy the SMBs, and to deploy both red SMB and yellow SMB, which is our boat signal for an emergency. He wrote back for me to do it, red only (which is our boat signal for divers decompressing below, no issues) – and that’s when I realized that he didn’t know I was in trouble. I wrote back for him to deploy the SMB, and he did – red only. I continued to focus on my breathing because I really wanted to finish deco before having to exit the water, and after a few more minutes, took back the slate, wrote that I was “badly bent” (I wasn’t bent, and I knew that I wasn’t bent, but writing “immersion pulmonary edema” was beyond me at that point), and asked him to deploy the yellow SMB, which he did with alacrity.

    The boat rapidly came to us as is our emergency protocol, and the safety diver entered the water with an open-circuit tank of O2. She offered it to me and was going to clip it to me, but I waved her off and wrote on the slate – “no exercise, can’t breathe” - I was quite worried that the O2 bottle would compromise my buoyancy and I would need to swim. The safety diver clipped the O2 bottle to my buddy and swam back to the boat to report in.

    We completed deco with me coughing and gurgling as I breathed. My buddy’s computer is more conservative, so for me it was deco cleared plus 10 minutes.

    On the live boat pickup, the captain placed the boat where I didn’t have to swim at all, and the safety diver removed my bail out bottles and fins in the water. As soon as I was on deck, many hands removed my rebreather and wet suit, and I got started breathing 100% O2. The improvement on O2 while we steamed the several miles to dock was very good – the coughing slowed down and the gurgling was only in the bottom of my lungs, not so much at the top. The ambulance was at dock when we got there. I refused the offered helicopter ride to the chamber, and asked them to take me instead to the local hospital to be treated for pulmonary edema, which they did. X-rays at the hospital confirmed pulmonary edema, and they kept me over night for observation, took another x-ray in the morning that showed significant improvement, and released me.

    Outcome is good, health is good, no lingering issues. I am scheduled for a precautionary echo cardiogram on Sept 26th, but neither my doctors nor I expect any issues. I have returned to my triathlete workout regimen.



    DAN-requested additions:
    · Gender : Female
    · Age: 49
    · total number of dives:
    • 2214 dives since 2/10/96, max depth 333’
    • 95 rebreather dives since 10/30/10, 106 hours, max depth 333’
    · number of dives in past year (and max depth range)
    • 211 dives this year, max depth 333’
    • 40 rebreather dives this year, max depth 333’
    · number of dives in past month (and max depth range)
    • 26 dives in past 30 days
      • 10 open-circuit dives, max depth 100’
      • 16 rebreather dives, max depth 291’
    · number of this dive in a continuous series (over how many days, and max depth range)
    • This was dive #7 in a continuous series over 4 days:
      • day 1: 218’/76 min and 212’/51 min
      • day 2: 208’/93 min and 197’/43 min
      • day 3: 209’/129 min and 207’/60 min
      • day 4: (this dive) 291’/82 min
    · treatment details from hospital stay (e.g., oxygen diuretics, steroids)
    • Was kept on oxygen from emergency room admission at 4pm until hospital admission at 9pm. Placed back on oxygen at doctor’s orders (precautionary) at approximately 11pm and stayed on oxygen until approximately 7am.
    • Drugs:
      • Albuterol 2.5mg inhalation, 6pm 9/9
      • SOLU-Medrol 125mg, 6:24pm 9/9
      • Lasix 40mg, 6:24pm 9/9
      • Lasix 40mg, 6am 9/10
      • Diamox 500mg, 10am 9/10
      • Protonix IV 40mg, 10am 9/10
    · time of the two x-rays
    • First x-ray at 4:30pm on 9/9/12
    • Second x-ray at 9:12am on 9/10/12
    · comment on previous history of immersion pulmonary edema
    • To my knowledge, I’ve never had immersion pulmonary edema before. I have 11 dives over 250’, and 27 dives between 200’-250’.

    ----------------------------------------------------------------------------

    Lessons:
    1. If you are having an issue but still able to complete the dive normally, make sure you communicate the issue to your buddy by writing it down. Hand signals aren’t good enough.
    2. For IPE, if you’re offered open circuit O2 at shallow depths, take the open circuit O2. The breathing resistance is lower than on your loop. (This makes sense after thought, but we’re all taught that “if the loop is good, stay on the loop” – which I did.)
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  2. #2
    RBW Member izze will become famous soon enough izze will become famous soon enough izze will become famous soon enough izze will become famous soon enough izze's Avatar
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    JJ

    Re: Immersion Pulmonary Edema (IPE) at 291'

    Excellent write-up. Thank you very much.

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    Re: Immersion Pulmonary Edema (IPE) at 291'

    Glad you are ok! thanks for your work on the Spree last week.

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    RBW Member thetrickster is on a distinguished road thetrickster is on a distinguished road thetrickster's Avatar
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    Re: Immersion Pulmonary Edema (IPE) at 291'

    Thanks, very informative. Glad all is okay!

    So the issue was lack of thermal protection?

    As you state you are triathlon training, which I take you have a low fat percentage.

    (10'c/51f) in 5mm - you were brave! Brr!!! I'm cold in 15'c with a semidry!

    Again, glad is all okay, and great you stayed in control/on the loop and got all deco out the way.

  5. #5
    RBW Member jaboothtx is an unknown quantity at this point jaboothtx's Avatar
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    Re: Immersion Pulmonary Edema (IPE) at 291'

    Speculation - and it's just speculation - is that the borrowed wetsuit/hood were too tight. It seemed to me that the wetsuit and hood were as tight as a normal 5mm wetsuit and hood, so who knows?

    Although I am an endurance triathlete, I am not a low body fat one. Unfortunately, that's just not the body that God gave me. I'm on the high end of the healthy range for females. However, I've completed some 25 half-ironman (70.3) triathlons since 2005, so I am fit - just not skinny. Bummer.

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    All IMVHO obviously... Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field has a reputation beyond repute Ben Field's Avatar
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    Re: Immersion Pulmonary Edema (IPE) at 291'

    Quote Originally Posted by thetrickster  View Original Post
    (10'c/51f) in 5mm - you were brave! Brr!!! I'm cold in 15'c with a semidry!
    BRRRRR, I'd have wanted a Drysuit for 10C or a thick-arse Semi-dry at the very least!

  7. #7
    Cognitive surrender TopLeft is an unknown quantity at this point TopLeft's Avatar
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    Re: Immersion Pulmonary Edema (IPE) at 291'

    Sorry for the circumstances. Thanks for the informative write up.

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    RBW Member kierentec is an unknown quantity at this point kierentec's Avatar
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    HH, Optima, rEvo, Explorer

    thank you for the write up.

    what would you consider your hydration level to be before the dive?

    I do not have a link to the report, but a physician friend of mine recently told me of a study on military swimmers, hydration and IPE, and that the swimmers who were excessively over-hydrated were significantly more likely to suffer from IPE.

    again, I have not read the report myself, and do not know if there is any validity to it at all, as I do not know much about the condition.

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    kissIT Ivojima is an unknown quantity at this point Ivojima's Avatar
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    Re: Immersion Pulmonary Edema (IPE) at 291'

    Thanks alot for the report, to be honest, i'd never heard of IPE before your post.

  10. #10
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    Over hydrated? I guess it's possible for people who drink massive amounts of water quickly or receive some type of intravenous fluid otherwise my first thought would be cardiac or vascular etiology that can exist in people who exercise extensively.

    Interesting writeup. I would like to hear more about hydration as well.

    And I'm glad you are okay, hope this is an isolated event.

    Sent from my She-er-water Per-redator!

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