DAN. Divers Alert Network Biomarkers for scuba diving causes of death: A review of 1000 autopsies Outline of the project, the background Diagnoses of the causes of death in scuba divers are hampered by many factors including variation in the understanding of diving physiology between medical examiners. Often there may be a delay between death and recovery, and differentiating between diagnoses can be difficult. Drowning is often the easiest choice and most diving deaths are simply attributed to drowning. A careful review of five hundred diving fatality files held by the Divers Alert Network (DAN), the world’s foremost diving safety research organization, has shown that often the circumstances of a diving fatality strongly suggest a cause of death other than drowning. This is important because injury prevention interventions are most effective when based upon evidence, and misclassifying causes of death masks targetable risk factors for preventive interventions. The objective of this project will be to extract medical examiner autopsy reports from diving fatality files held by DAN. Much of the information can be extracted electronically from the thousands of electronic cases held in our ACCESS database. The most recent one thousand cases where autopsies were conducted will be exported into Excel, then the intern would access each physical file to locate the autopsy and to enter additional data. Ultimately, a multivariate analysis will identify which biomarkers are, or are not, associated with which causes of death in divers, after adjusting for age, sex, height and/or weight. This could assist medical examiners determine cause of death more accurately, thus enabling risk factors for diving deaths to be identified more certainly, leading to the design of appropriate safety interventions. Also of high interest will be the prevalence of alcohol, cannabinoids, illicit drugs, and medications for anti-depression, hypertension and other common conditions. During the internship one or two American interns will probably also be working at DAN on similar research. This year (2016) DAN hosted two interns and we researched divers who hunt for lobster. In Florida the last Wednesday and Thursday in July see between 30,000-50,000 recreational scuba divers diving for lobster. On average one diver dies per day, many get hospitalized and many more are likely injured but escape our notice. This year I took the interns to Florida to conduct a survey of hunter-divers, and to observe divers hunting for lobster. The trip should took four five days. No trips are planned yet for 2017 but an opportunity to participate in a field-trip might eventuate.

Divers Alert Network • 6 West Colony Place • Durham, NC 27705 USA • Medical & General Information (919} 684-2948

DAN Emergency Hotline (919) 684-9111 • Fax (919) 490-6630 • Medical Fax (919) 493-3040

DAN. Divers Alert Network Tasks/responsibilities of the intern DAN have been hosting summer interns every year for the last 18 years, indeed I was an intern here in 2007 during my PhD. Typically, interns work on a main project that interests them but they are also exposed to a range of research studies. This year, as well as researching lobster divers our interns worked on an epidemiology analysis of diving injuries, and spent a day at Duke University assisting with a NASA decompression study for extra-vehicular activity (‘spacewalking’). Our day starts around 8am when the first staff member usually arrives, the building officially opens at 8.30am and everyone is here by 9am. People start leaving from 5pm, the last usually leaves at 6pm. Forty hours per week is the norm, as is a 30-minutes break for lunch. Our interns work on modern computers and have their own desks, usually their own phones, there are 50 staff here currently and we enjoy regular social events such as birthdays, holidays and celebrating American culture (4th of July, etc). The work environment is pleasant and comfortable. The intern would typically arrive, make a coffee, greet everyone, line-up tasks to complete such as a pile of fatality files to sort through, catch-up with e-mails and enter data, meet with other members of the research team to discuss cases, plan and prepare for fieldwork trips, occasionally work on a presentation and/or a research paper. Knowledge and skills to be acquired by the intern Before arriving in North Carolina the intern will be invited to complete two online units covering Research Ethics. This project has Ethics Committee approval and the intern will need to be added to the protocol. Concurrent with settling in, the intern will soon organize a regular work pattern of data entry, data storage, back-up and data security, all essential skills for future researchers. As the data-set grows then possible analysis methods will be discussed, including logistic regression, mixed-effects modeling, T-tests, etc. The intern will not be expected to master these, but will learn to appreciate how important the correct test is rather than simply look for a small p-value. The pitfalls of scientific publication are another area our interns are exposed to. Few actually end up publishing but occasionally some do. Each intern is given an opportunity to write something for the lay diving community too, and to present their research before leaving. Information about the city or region Durham is located in beautiful North Carolina. The weather in summer is hot, the evenings are warm and humid, perfect for barbeques in the back garden. The countryside is lush forest, there are spectacular gardens at nearby Duke University and, indeed, three of the best universities in the world are located here so the city is filled with tens of thousands of visitors.

Divers Alert Network • 6 West Colony Place • Durham, NC 27705 USA • Medical & General Information (919} 684-2948

DAN Emergency Hotline (919) 684-9111 • Fax (919) 490-6630 • Medical Fax (919) 493-3040

DAN. Divers Alert Network There are music events, art exhibitions, more restaurants than can be visited in one summer, there are hiking trails in the hills and the coast is just two hours away for weekends at the beach. North Carolinians are renowned for being extra polite and it is quite normal here for everyone to call each other “ma’am” or “sir”. There are a number of ‘dive parks’ nearby, converted open pit mines with sunken aircraft and boats for divers to visit. Indeed, three of these dive parks have pre-historic ‘paddle-fish’ in them and freshwater jellyfish appear in summer, indicating the good health of the water environment. When we travel to Florida the weather is hot and sunny, so an intern who enjoys cooling off with a swim or a dive in the sea would enjoy the trip more than one who needs air conditioning. In conclusion An internship at DAN is highly sought after. Interns that spend a summer at DAN are exposed to science, research, publishing and generally work with minimum supervision. Our goal is to share our passion for science, and diving science, so our interns finish the summer with a better understanding of what it takes to succeed in medical science. It is a measure of the environment here that four of us ex-interns have returned at a later date and now work here full time. I certainly hope next year DAN can host a RISE intern here in North Carolina, to work on a scuba diving medical science project ultimately aimed at saving lives.

Yours faithfully,

Peter Buzzacott, MPH, PhD. Director, Injury Monitoring and Prevention Divers Alert Network Ph: +1 (919)-684-2948 ext 1627 E-mail: [email protected]

Divers Alert Network • 6 West Colony Place • Durham, NC 27705 USA • Medical & General Information (919} 684-2948

DAN Emergency Hotline (919) 684-9111 • Fax (919) 490-6630 • Medical Fax (919) 493-3040