A REVIEW OF DAN EMERGENCY CALLS INVOLVING DIVING MINORS
MINORS HAVE BEEN DIVING FOR DECADES, but the incidence of scuba diving injuries among them remains poorly studied.
As opposed to most other outdoor recreational activities, the main challenge while scuba diving is managing the inherent risks of using life-support equipment to survive a hostile environment. Scuba diving requires a specific set of skills, and demonstration of those skills in a highly controlled environment such as a swimming pool may not readily transfer to the open-water environment.
Children are not small adults. Their body and organs are not just growing in size, they are also maturing in physiology and function. The prevalence of childhood asthma, for example, diminishes with age, demonstrating that the respiratory system is often still developing until teenagers become young adults.
During childhood, dramatic changes in the brain allow us to perfect decision-making processes, regulate emotions, detect threats, and activate appropriate fear-related behaviors in response to threatening or dangerous stimuli. Psychological immaturity can prevent minors from reacting to underwater emergencies with the same capacity as adults. Panic can lead to uncontrolled rapid ascents, increasing the risk of pulmonary barotrauma. Children can often lose focus and make mistakes, putting them at an increased risk for a number of threats.
Over the years, researchers have raised concerns about the effects of compressed-gas diving on minors, especially the potentially harmful effects of decompression stress on growth rates. But after decades of extensive diving by minors, including long-term follow-ups on cases of decompression sickness (DCS), there does not seem to be any evidence to support this theory.
The DAN Emergency Hotline is a remarkable observatory. In response to a number of cases involving minors who dive, DAN created a retrospective study to examine the types of injuries they experience. We analyzed records between 2014 and 2016 and identified 149 cases involving minors.
As part of her 2019 DAN Research internship in the medical department, then-undergraduate Elizabeth Helfrich came to DAN headquarters, analyzed the data under the mentorship of doctors Matias Nochetto, Camilo Saraiva, and Jim Chimiak, and published the study.1
results and discussion
We split the study data into the reason for call (initial concern) and the final diagnosis. DCS concerns were the most common reason for a call involving minors, accounting for 38 percent of the calls, followed by issues with ears and sinuses (ENT) at 26 percent. Pulmonary barotrauma (PBT) was suspected in 12 cases (8 percent) and arterial gas embolism (AGE) in six cases (4 percent).
Despite its prevalence as the most common reason for the call, DCS accounted for only 6 percent of the final diagnoses. Based on manifestations, four cases were neurological DCS, four were mild DCS, and one case was inner-ear DCS. Only one minor diagnosed with DCS reported having decompression obligations during the dive. As with adults, ENT issues were minors’ most common dive injury (32 percent).
Surprisingly, PBT accounted for 15 percent of the dive injuries. While no reliable data are available on the incidence of PBT in adult divers, the authors’ impression based on personal experience suggests that the number of PBT cases in minors trends much higher than in the general dive population. So we looked at this issue in more detail.
In seven cases of PBT there were confirmed reports of a rapid ascent; six of those involved confirmed or highly suspected anxiety. One child became anxious after practicing a controlled emergency swimming ascent during training; another reported an anxiety attack that led to breath-holding and a rapid ascent.
A child freediver planned a dive to 15 feet (4.6 meters) and then extended to 35 feet (10.7 meters) for unknown reasons. This child then had seizure-like activity underwater, right-leg weakness upon surfacing, and a final diagnosis of AGE. It is unreported if the child breathed from compressed air at depth, although that’s likely given the symptomatology and the treating physician’s diagnosis.
Three other minors likely became anxious at depth, leading to rapid uncontrolled ascents and consequent PBT. On four instances an event happened at depth that likely led to accidental breath-holding and PBT. Two of those cases resulted from issues with equipment: One child reported a free-flowing regulator, while another reported being overweighted. It is likely this last diver attempted to assist ascent by increasing lung volumes with deep inspiration and breath-holding.
One diver reported uncontrollable laughter underwater, another reported a “large belch,” suggesting they swallowed air at depth, and four had no identifiable reasons for injury. Also of interest is that two young divers with PBT noticed chest pain after the first dive but continued to dive for the day. It is unclear whether that might have contributed to the severity of the initial injury.
The role of anxiety as an injury’s trigger and the root cause is likely underrepresented. This could be due in part to the subjective nature of anxiety and possible behavioral bias from minors not always accepting and verbalizing their fears, among other possibilities. When considering the overall narratives, anxiety and consequent panic are woven throughout many cases.
REMARKS FOR THE INDUSTRY
When training individuals in vulnerable populations, no other group generates more polarization than young divers. Children often have a well-developed sense of adventure and a less-developed sense of mortality.
Chronological age is a poor predictor of maturity in minors. Albeit more cryptic and admittedly rather impractical, perhaps a reflection on the intersection between biological, psychological, and social age could more accurately predict the response of a person under adverse circumstances.
Just as dive professionals must be trained and hold certifications to teach wreck diving or to lead a group on a wreck, specialized training for teaching and guiding diving minors could be beneficial. This training should focus on children’s individual needs and unique behavioral aspects that make them more prone to certain incidents and injuries.
Diving minors should always be at arm’s length from an able-bodied adult diver who can closely monitor them, especially regarding comfort. As the diver matures and their response to stress becomes more predictable, the distance could gradually increase.
Safety enhancements can be made for open-water dives. Diving minors may not be reliable dive buddies due to their maturity, lower strength, and often unpredictable responses to threats. These discrepancies could compromise both divers’ safety, so a buddy system of two adults and a child would be more prudent, where one of the adults is someone who knows the youngster well and is sensitive to subtle cues of stress or discomfort — someone such as a parent or other close relative or guardian.
People who dive with children should understand and recognize the age group’s unique behavioral aspects to help prevent situations that could lead to severe injuries. With proper training and supervision, we can reasonably mitigate the inherent risks of a minor joining their family in exploring the underwater world. AD
1. Helfrich ET, Saraiva CM, Chimiak JM, Nochetto M. A review of 149 Divers Alert Network emergency call records involving diving minors. Diving Hyperb Med. 2023 Mar 31; 53(1):7-15. doi: 10.28920/dhm53.1.7-15. PMID: 36966517.
© Alert Diver — Q3 2023