An Attitude About Altitude

Unlike many of our contributors, Paul and I live in Johannesburg and not at sea level. So
when we are not “sea-diving” and rather diving “inland”, in order to satisfy our need to
be underwater, we always have to take altitude into account when planning our dives.
Realising that many divers live and dive “inland”, or at altitude, we contacted DAN-SA
for some guidance. We thought that the information, in the form of three articles, from
DAN-SA was good that we decided to publish all three. The first is a general article and
well worth reading to gain an understanding. The second is a case study and the third an
interesting set of questions.

Enjoy the read, it’s well worth reminding yourself of the fundamentals of altitude
diving.

AfricanDiver.com 1 Apr/May 09
 DAN discusses the considerations and
cautions of diving at altitude
by Dan Orr
When I was teaching an instructor training
course at Wright State University a few years
ago, the part of the course arrived when the
candidates were given topics for their final formal
lecture. The topics were all related to recreational
diving. The day of the formal presentations
arrived, and one memorable candidate (we’ll call
him “J.C.”) handed the evaluation panel the topic
slip he had been given the previous week. The
topic, typed in bold letters, stated: “ALTITUDE
DIVING.”
We recorded J.C.’s topic on our evaluation sheets
and awaited his presentation. He approached the
podium, organized his papers and visual aids and
proceeded to give the best lecture any of us had
ever heard on ATTITUDE DIVING.
As J.C. enthusiastically launched into his
presentation, the evaluators exchanged puzzled
glances but otherwise thoroughly enjoyed
the exceptional presentation. Only during the
question-and-answer period did it come up that
the topic was actually ALTITUDE rather than
ATTITUDE. J.C.’s response: He thought it must
have been a misprint since there wasn’t much
information available on diving at altitude.
Taking a cue from J.C., it’s fair to state that
diving at altitude may very well be one of those
areas in recreational diving that isn’t frequently
addressed. Why? Presumably because many
divers assume that diving takes place at sea level.
This assumption could not be further from the
AfricanDiver.com 2 Apr/May 09
truth. Tens of thousands of divers thoroughly
enjoy the thousands of lakes, rivers, quarries - not
to forget the Great Lakes. But I’m not going to
address (nor debate) the differences between
diving in fresh water versus salt water: Lets take
for granted that there are buoyancy, visibility, and
temperature differences between the two diving
environments. Regardless, they can be equally as
enjoying and exciting.
It’s diving at altitude we want to discuss. By
definition, altitude diving would be anything
above sea level. From a practical standpoint, it
generally applies to any altitude above 1,000
feet / 300 meters. Since diving at this or greater
altitudes involves returning to the surface at less
than one atmosphere, some consideration must
be made in order that the dives are made safely.
The many facts we have been taught about diving
at one atmosphere must be modified at altitude.
Decompression theory and the use of equipment
(dive tables, dive computers, depth gauges and
exposure suits) are the primary concerns that
must be considered.
Physiological Considerations
The main physiological consideration for diving
at altitude is the decrease in atmospheric pressure
and the resulting changes in the body’s ability to
absorb nitrogen.
From the standpoint of decompression theory,
ambient pressure determines the relative ability
of our bodies to absorb and release nitrogen.
When diving at altitude with a reduced
atmospheric pressure, the ambient pressure at
depth will be different from the same depth
in the ocean. Adjustments, therefore, must be
made to reduce the risk of decompression
illness. As a result, bottom time must be
decreased. In order to properly calculate
no-decompression limits at altitude, divers
must use high-altitude dive tables to obtain
their theoretical depth.
Along with adjustments to dive tables,
divers at altitude must reduce their ascent
rate: because of the decreased pressure at
altitude, an ascent rate of 30 feet per minute
is recommended. In addition, the depths
of safety stops must be modified. (Note:
safety stops are always recommended on all
dives regardless of depth or bottom time or
altitude).
It is also important to note the arrival at
altitude before the dive. Each of us reacts
differently to the physiological adjustments
the human body undergoes as the body
acclimates to decreased atmospheric
pressure. Some of these effects include
headache, nausea and mild disorientation.
Also, when arriving at altitude, the body has
excess nitrogen compared to the nitrogen
in the ambient air. This is similar to having
already made a dive. In other words, if the
diver has not equilibrated to the ambient
gases, the first dive must be considered a
repetitive dive.
Some consideration must also be made for
post-dive activities. Because a decrease in
atmospheric pressure and the fact that less
oxygen is available from the atmosphere at
altitude, routine tasks could easily cause a
diver to become short of breath. The best
AfricanDiver.com 3 Apr/May 09
advice is to take it easy before and after the
dive.
Equipment Considerations
Depth gauges - Depth gauges will give
false readings at altitude unless they are
equipped with altitude adjustments.
Bourbon tube, diaphragm and electronic
depth gauges all display a depth shallower
than the actual water depth unless they are
equipped with an altitude compensating
feature. Since these gauges are designed to
read ‘zero’ feet at 14.7 psi, it may actually
take several feet of depth to reach zero.
Capillary depth gauges, on the other hand,
read deeper than the actual depth. These
gauges are designed to measure pressure /
volume relationship of a bubble of air (in
this case thinner air than at sea level) within
the calibrated capillary tube.
Exposure suits - When a diver is wearing a
wetsuit, the reduced atmospheric pressure
at altitude may cause the trapped gas within
the neoprene to expand, creating more
positive buoyancy than at sea level. This
means the diver may require more weight.
A pre-dive buoyancy check is always a good
idea.
Dive computers - Remember, a dive
computer is a tool and, like any other
piece of diving equipment, it has design
limitations. While many dive computers
automatically compensate for changes in
altitude, divers must remember that once
turned on, the computer assumes that their
body is equilibrated with the ambient pressure. If not, the
information the computer is giving would be incorrect.
Read the instruction manual.
Diving at altitude can be just as much fun as a dive
anywhere else in the diving world as long as the right
attitude and the appropriate altitude adjustments are
considered.
When J.C. summed up his talk on ATTITUDE diving,
he gave us a few words of wisdom that apply to all diving
situations. “The better your attitude, the higher your
altitude.” he said.
Safe diving is as much attitude as it is activity. With the
appropriate attitude (and adjustments), you can make safe
dives regardless of the altitude. Thanks, J.C., for those pearls Taylor, Gary. Physiological Considerations for Diving at
of wisdom.
ALTITUDE SAFETY TIPS
r
Acclimate to altitude before making your first dive. If
you do not appropriately acclimate, you must consider Taylor, Larry “Harris.” Altitude Arithmetic. Sources, Sept./
the first dive a repetitive dive.
r
Use tables designed for use at altitude to determine
theoretical depth.
r
When doing altitude calculations, round all altitudes
up and depths down.
r
Reduce maximum ascent rates to 30 feet per minute.
r
Make a safety stop at the appropriate theoretical depth
for three to five minutes at the end of each dive.
r
Wait at least 12 hours before ascending to a higher
altitude (driving, hiking or flying) after a dive.
r
Do not dive above 10,000 feet / 3,048 meters without
additional training.
r
Check buoyancy for changes due to both fresh water
and altitude (e.g., wetsuit buoyancy problems).
r
The maximum depth for a dive at altitude is a
AfricanDiver.com 4 Apr/May 09
theoretical depth of 130 feet / 40 meters).
r
Move slowly and deliberately before and after an
altitude dive in order to prevent hypoxia (lack of
oxygen due to shortness of breath).
r
Follow normal safety procedures at altitude.
r
Know when to say when.
REFERENCES
Graver, Dennis. Diving A to Z. 1976.
Rossier, Robert. Altitude Diving. Dive Training, August
1995. pgs. 38-44.
Schwankert, Steven. Going Up To Get Down. Discover
Diving Magazine,
February 1996. pg. 25-27.
Smith, C.L. Altitude Procedures for the Ocean Diver.
NAUI 1976.
Altitude. Immersed,
Spring 1997. pgs. 43-45.
Taylor, Gary. Diving at Altitude. Immersed, Summer 1997.
pgs. 54-55.
Oct. 1994. pgs. 42-44.
Wienke, B.R. High Altitude Diving.
NAUI 1991.
Exceeding the Limits
by Daniel A. Nord
For one diver, a delay to treatment and pushing the limits
for altitude diving add up to a permanent delay in his
diving
The Diver: He is a 21-year-old recreational diver with a
lifetime history of approximately 30 dives within the last
two years. He considers himself a healthy young adult and
has a “clean slate” in his medical history. His last dive ended
about two hours before he called DAN’s 24-Hour Diving
Emergency Hotline.
The Incident: Earlier that day, the diver had completed
a series of two recreational air dives. He was diving in a
freshwater lake at an elevation of 1,120 feet / 342 meters
above sea level, not far from his home. Water temperatures
were chilly - around 50 degrees F / 10 degrees C. He
made his first dive to a depth of 113 feet / 35 meters;
total bottom time was 15 minutes. His dive, however, was
complicated at depth by symptoms of dizziness, confusion
and difficulty breathing. Sensing the possible effects of
nitrogen narcosis, he signaled to his buddy that he was
aborting the dive and began his ascent. At 87 feet / 26.5
meters, he noted that his symptoms had improved.
After a surface interval of two hours and 11 minutes, he
made a second dive to a depth of 30 feet / 9 meters for a
total bottom time of 30 minutes. He exited the water at
approximately 3 p.m. local time. Both dives included a
safety stop at 15 feet / 5 meters for roughly three to four
minutes. Besides the fact that the dives had been conducted
in 50-degree water, there were no other complicating
factors.
The Complications: After his first dive, the man felt a
numbness and tingling (known as paresthesia) throughout
the thumb and index fingers of both hands when he was
removing his wetsuit and gloves. Despite his underwater
episode of dizziness, confusion and difficulty breathing on
his dive, he attributed these symptoms of paresthesia to the
effects of swimming in cold water.
He noted that his symptoms became less intense during
his second dive, but returned shortly after he surfaced.
The symptoms persisted and remained unchanged until
his drive home, when he noted that the paresthesias were
spreading to include the middle fingers of both hands.
After this, he noted no additional symptoms. Changes in
elevation during his ride home were no greater than 100 to
200 feet (30 to 40 meters) in either direction.
When he arrived home, he contacted DAN’s Diving
Emergency Hotline. After a review of his diving and
personal medical history, DAN referred him immediately
to his local emergency room for a full neurological
evaluation. DAN’s on-call medic contacted the nearest
hyperbaric facility, 293 miles away, and provided the
attending hyperbaric physician with the diver’s history. The
hyperbaric physician provided support and consultation to
the local evaluating physician in the treatment of the diver.
When he arrived at the local hospital for a neurological
examination, the diver had a unilateral (one-sided) facial
droop. The attending physician placed him on 100 percent
oxygen. Within 15 to 20 minutes of breathing oxygen,
the diver showed a noticeable improvement. Despite this
improvement, the local attending physician decided to
monitor the diver for approximately four hours.
After this time, the hospital discontinued the treatment
with oxygen and discharged the diver, with instructions to
alert his attending physician if he experienced any return
of symptoms. The diver was somewhat fatigued, he noted,
when he went home.
By mid-morning on the following day, the diver felt
numbness and tingling throughout the first three fingers
of both hands. He returned to his local emergency
department for further evaluation. After a consult with the
hyperbaric physician, a family member arranged ground
transport to the hyperbaric facility. This transport involved
crossing two mountain passes with peak elevations of 4,400
feet / 1,342 meters and 4,265 feet / 1,300 meters. While en
route, the diver’s symptoms worsened at peak elevations.
He arrived at the hyperbaric center with recurring
symptoms of left facial droop in addition to left facial
sensory deficits (lack of sensation). Despite the complications and delays to treatment, this
case is remarkable for the diver’s excellent response to
While these late symptoms can suggest a viral disease or hyperbaric oxygen therapy after his first diving injury. Full
a pressure-related phenomenon to the seventh cranial recoveries are widely reported throughout DAN’s statistics,
nerve, they could not be ruled out as a complication of lending support to the recommendation to persist in
decompression sickness because of the delayed onset in the moving injured divers toward hyperbaric oxygen, despite
presence of his paresthesias. long delays.
The Treatment: At the hyperbaric oxygen (HBO)
treatment facility, now 42 hours after his symptom onset, Although the dives were not conducted at a significant
the diver was evaluated and treated with HBO. The altitude (1,120 feet / 341 meters), the failure to
recompression therapy was a U.S. Navy Treatment Table apply altitude corrections pushed him into obligated
6, which lasts nearly five hours. By the end of his initial decompression according to the Cross correction
treatment, the diver experienced a 70 percent relief of all guidelines developed for diving at altitudes greater than
his symptoms. After an evaluation the next day he received
a second five-hour HBO treatment and had complete relief
of all symptoms.
The Diagnosis: The diver had experienced decompression
sickness type II, or DCS-II. A favorable response to
breathing oxygen under pressure is compelling evidence for
the diagnosis of DCS.
The Discussion: There are several elements in this case
that could have resulted in long-term symptoms. The
first two are that the diver continued his diving with
possible symptoms of DCS; and his referral for hyperbaric
treatment was delayed 42 hours.
Nearly 17 percent of all divers with decompression illness
accounted for in DAN’s 1997 injury statistics reported
having experienced symptoms prior to their last dive
(for more information, see DAN’s 1999 “Report on
Decompression Illness and Diving Fatalities: Based on
1997 Data.”) Symptoms should be investigated fully as
soon as they occur. Recognizing an improvement of the
original symptoms at depth, as reported here during the
second dive, is not always demonstrative of decompression
sickness since other mitigating factors are possible, but it
should heighten the suspicion for possible DCS.
1,000 feet above sea level. Standard decompression tables were designed This recommendation, however, may not be suitable for the diver with residual
and calculated on the assumption that the divers using them were beginning neurological damage. Unfortunately, there is no clear evidence for a precise
and ending their dives within an ambient pressure of 1 atmosphere absolute recommendation. The best advice to the recreational diver with neurological symptoms
(ATA), or sea level. following decompression is to stop diving. Further neurological injury could place this
diver at significant risk for major residual neurologic injuries.
Interestingly, the U.S. Navy Standard Decompression Tables are recognized
and accepted for dive planning at elevations within 2,300 feet / 701 meters
above sea level. The application of some altitude correction model would
have added a more conservative time restriction for these somewhat
aggressive dives. Even though research teams have conducted decompression
dives at altitude with no reported cases of decompression sickness, it is
generally accepted that divers should avoid dives at altitude with obligated
decompression.

Bent Again: Despite his excellent response to hyperbaric therapy, this diver’s
story does not end with an uncomplicated resumption of diving. He returned
to open-water diving 10 months later and experienced another episode of
neurological decompression sickness. Unfortunately, treatment has failed to
fully resolve his symptoms after this second incident of DCS.

What is clear is that when treating decompression sickness its outcome can
retain a certain unpredictability. Decisions on the appropriate course of action
by treating personnel are sometimes clouded by issues such as lack of training,
lack of diving knowledge and/or diving medicine, transient resolution of
symptoms, logistic obstacles to definitive treatment and financial restraints.
Nevertheless, it is generally recognized that delays to HBO can jeopardize
a complete recovery, although many divers with long delays have recovered
fully.

Advising the diver who has been treated for decompression sickness on the
suitability of continuing to dive is a difficult task. Generally speaking, for
the diver who experiences DCS with mild, less intense symptoms that were
swiftly and effectively treated with no residual tissue damage, there are usually
no major problems in resuming diving.

AfricanDiver.com 6 Apr/May 09