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Getting to Grips with Narcosis

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By: Richard Devanney

To a new diver, thoughts of narcosis can be very mixed. Some may find it to be a scary prospect, whilst let’s be honest others will relish the thought of getting a free thrill during a dive, which may tempt them to go deeper than their certification and/or level of competence should otherwise allow. This contrasts with a cautious, risk-averse diver. They know narcosis as something to become familiar with in a controlled environment, before taking active steps wherever possible to minimize its effects on all future dives. Now some of you may be thinking “that’s rubbish, who wants to be risk-averse!”. My response to this is that you dear reader are exactly the person that this article is aimed at.

All divers have been taught the basics of what narcosis is

All divers have been taught the basics of what narcosis is, along with what they should do to reduce its effects during a dive. At open water level narcosis isn’t really of great concern, as it’s not usually noticeable by diver nor observant buddy up to the 18m (60ft) maximum depth range. For advanced divers going to 30m (100ft), it’s your new imaginary friend, sitting on your shoulders with its feet in the stirrups, poised and ready to take over the reins. But many will hardly notice its effects. Those that do should be able to cope fairly easily- there are always exceptions to this of course. But what about going deeper than 30m- how does it affect you then? Can you maintain control? At what point will it start to control you? These are kind of important considerations, so let’s delve a little deeper to find out more.

What’s in a name I hear you ask- It’s ok, I can’t really hear you. But seeing as you probably would have asked anyway, the nomenclature originates from the Greek word narke, and loosely translates to “numb”. But it has collected a few other familiar names over the years; “the martini effect” (ridiculous), “rapture of the deep” (I was hoping that when the rapture does come I can just go for a dive and let it pass me by) I’m sure there are more names but they will be equally silly. Most people call it Nitrogen (N2) narcosis because there’s more of it in your cylinder of air than oxygen. Yet there are some people- mainly technical divers, that call it inert gas narcosis, because you know, nitrogen is inert and they crave accuracy and order. Some even more anal tech divers go further and call it gas narcosis, because they want to outdo other tech divers in the accuracy and order stakes, and also because carbon dioxide and oxygen are also narcotic (though it’s unclear as to how narcotic one is relative to the other). But for the sake of concision, I’ll call it narcosis for the rest of the article because, a- I’m a lazy typist, and b- any excuse to wind up the online dive police.

Causes

As you go deeper during a dive, narcosis will increasingly affect you in numerous ways. If you continue descending beyond both your maximum depth and better judgment (whichever comes first!), it will eventually induce an anesthetic effect on you, and there hasn’t been an alarm clock invented that will wake you up from that slumber. Thankfully, deep air diving is not in vogue anymore so there aren’t as many stories of divers descending to oblivion as there used to be.

The exact mechanism of how narcosis works is not universally agreed upon, but the theory that most diving physicians agree on is the so-called Meyer-Overton hypothesis. This states that the narcotic effect of a gas relates to its solubility in the lipid (fat) phase of body tissues. The higher the solubility of body tissues, the more readily nitrogen (and other narcotic gases) will dissolve into them (as per Henry’s law). In this case, those body tissues are the nerve membranes of the brain. It’s believed that once enough nitrogen is dissolved into the lipid membranes, it will mechanically interfere with the transmission of signals between nerve cells.

The narcotic effect of gases on humans has been quantified in terms of their so-called Relative Narcotic Potency (RNP). Of the gases used in diving, helium has the least narcotic effect when breathed. At the other end of the scale, argon has the greatest effect, which is precisely the reason it is not breathed (along with it having a high gas density). Here’s the full list of diving-related gases, ranging from the breathable to the breathable but only under certain circumstances, to the “I would love to breathe that but it’s too expensive”, and ending with the “Superman can freedive indefinitely anyway so why is it even on the list?”:

  • Helium (least narcotic)
  • Neon
  • Hydrogen
  • Nitrogen
  • Argon
  • Krypton
  • Xenon- (most narcotic)

Helium is not narcotic at diving depths (though it affects the nervous system beyond the 100(ish) meter range due to the rate of compression- this is known as High-Pressure Nervous (or neurological) Syndrome- or HPNS. It affects the central nervous system and symptoms include myoclonic jerking and somnolence- basically, you uncontrollably shake and then fall asleep- almost the opposite of when your dog runs in its sleep).

Not being narcotic is one of the numerous reasons why helium is a good gas for deeper diving – if you can afford it

Hydrox- a mixture of hydrogen and oxygen has been used experimentally on very deep commercial diving projects by French company Comex, and when I say deep I mean humans standing on the sea bed at 500 meters deep (1,640ft). Theos Mavrostomos went to 701m (2,299 ft) in a chamber, just because he could.

However, because of its tendency to create large, messy, and often inconvenient explosions, hydrogen can only be used with 4-5% oxygen in the mixture, and therefore requires specialized equipment not to mention extensive training before it could be used- all at considerable cost. Neox- a mixture of neon and oxygen is a good alternative to helium as a deep breathing gas, as it is both not very narcotic and it doesn’t distort the voice unlike helium, but it’s very expensive to use (You can see a pattern forming here can’t you), and apparently if you do get DCS when using it, symptoms can be severe. Argon is only used to put in drysuits instead of air, and thankfully the regulator attached to the cylinder supplying it will not have a 2nd stage regulator attached, just in case you or your buddy are seeking out a Darwin award- it’s anoxic.

Symptoms

So what happens when we get narced? Do we take our regulators out to give to the fish? Generally, things are a little more subtle than that. If you descend to 30-40m (100-130ft) you may feel euphoric, lightheaded, or a little bit tingly. You may find that your ability to concentrate has reduced, and your ability to care has fallen commensurately with it. Other symptoms include perceptual narrowing (tunnel vision), altered perception of time, anxiety or paranoia, memory loss, and even a feeling of numbness. Many divers will insist that they feel nothing and think they are absolutely fine. If you ever find yourself diving on trimix between 30 and 60m (100-196ft), you will most likely have observed that, whilst you have a very clear head because you are breathing in less N2, anyone diving with you on air is noticeably slower when it comes to, well everything- communication, physical dexterity, and general coordination. Their situational awareness is almost non-existent. When watching them try to achieve a simple task, it’s all the more amusing to know that they won’t even remember how badly they were doing it- when they get back on the boat they will think that they were fine and that all their tasks were completed properly and efficiently- ignorance is bliss and relativity is difficult to gauge when everyone is riding on the same beam of light.

So how badly do these symptoms affect how in control you are during a dive?

Well, it depends on your susceptibility on the day and how deep you are; your sensitivity will change every dive; there are many factors that will influence how narced you feel on a given day. The lines are blurred as to how much of an influence each factor has on you. Tiredness, dehydration, alcohol or drugs (prescription and recreational), cold water (affects you much more than warm water), higher work of breathing, bad visibility, turbidity (particles in the water), seasickness, fear, vertigo, task loading, current, descent rate. That’s a big list of influences.

A build-up of carbon dioxide can also increase narcosis. Swimming against a current will make your breath harder, and breathing harder underwater is not very good for you because gas densities under elevated pressures are such that it is more difficult to move those gases in and out of the lungs. It’s bad enough when a regulator is forcing the air into your lungs; when you are on a rebreather you are doing the work so it’s even worse. The bigger the atom, the harder it is for you to move it. So it’s harder to expel CO2 from the lungs and consequently the body, which allows it to build up. CO2 is more narcotic than N2, but its effect on narcosis is not simply an effect of higher partial pressures of CO2. In the blood CO­2 is a dissolved gas in a non-compressible fluid, so partial pressure is not the only factor at play. If it was then we would not be able to go diving because levels would quickly prove fatal as we descend. In addition to narcosis, CO2 acidifies the blood and has anesthetic properties, so hypercapnia (or excess carbon dioxide) is not very good for you. CO2 is also a vasodilator so it has an influence on CNS oxygen toxicity risk. Basically, COis bad.

Staying in control

The thing about narcosis is, that it’s very easy to get complacent about it. There is such a thing called normalization of deviance. It’s not a diving thing, it’s a human thing, so divers do it because they are usually human. It’s basically becoming accustomed to bad/unsafe behavior because it’s done so much without any negative consequences that it’s not considered bad/unsafe anymore; it’s considered the norm. A great example is a professional videographer filming open water groups in between solo diving to get the shots they need, but without the qualification, training, and redundant gas source. Another example is not doing a full or thorough buddy check before diving. There are countless other examples. People continue bad behaviors because 99 times out of 100 nothing will go wrong. But something only needs to go wrong once.

With narcosis, you may feel anxious during a 30m dive, or just so spaced out that you hardly check your air and don’t keep track of your buddy. These are not good things, but you made it back to the boat so it must have been ok- you’ll just continue to deal with it. But what if something does go wrong, what if your buddy gets very low on gas and you need to share? Will you be able to act on this quickly and safely when you already have a head full of anxiety or are feeling mentally slow, or have poor motor skills- or all three? We know that most accidents occur because of numerous factors rather than one single thing. If something goes wrong, isn’t dealt with and it leads to another thing going wrong, then the odds may be stacked high against a safe outcome because there’s just too much going on in a critically short window of time. Call it the domino effect or the incident pit or whatever you want.

Now just so you know I’m not trying to be dramatic, I know that the chances are that for most people in the 30m (100ft) range and even the 40m (130ft) range, a low on air diver or BC malfunction etc will usually be dealt with to provide a safe outcome. They may be messy but hey, you’re narced. Remember by the time you’re back on board the boat you’ll think you did a great job of it anyway! This is just an article to hopefully make you ponder some things in your diving that you maybe don’t think about too much.

So how about at between 40m and 55m (130-180ft)?

I shouldn’t really have to mention that going beyond 55m on air is not a good idea, with narcosis being one reason why. You will be on another planet mentally and as you continue to descend you will find yourself completely incapacitated before the inevitable unconsciousness arrives. Some people don’t think you should really be going beyond 30m on air (yes I’m one of them, but I also know that trimix is prohibitively expensive). Yet at these kinds of depths, you really do have to exercise very conservative judgment about your ability to deal with things going right, along with your ability to cope and solve problems if things go wrong, not simply whether you will manage to do the dive with no issues. If you have any inkling whatsoever that you may not be able to handle yourself or your team mate being out of gas or tangled up, it’s probably time to get your trimix qualification. The helium in trimix offsets some of the nitrogen so you feel more clear-headed. The problem with doing these dives without trimix is that you are impaired remember, so you don’t have good judgment in the first place! You won’t really know until it all goes wrong. Sure, you can practice going to 50m and do some drills to see if you get better/faster/more efficient at them, but remember the trimix divers watching the air divers? Don’t kid yourself. A big part of risk management involves being honest with yourself.

Minimising narcosis

So what can you do about it? As with most things technical diving, risk management begins on land before you even start day dreaming about how great you look in a wetsuit. You’ll need to think about:

  • What’s your dive plan- how deep do you want to dive?
  • What do you want to achieve on the dive, what are your objectives, are they complex/simple?
  • What’s the weather like? Will it get choppy? Will there be a current? Could the weather change during the dive?
  • How cold is the water? Will there be a thermocline? Wetsuit or drysuit- heated vest?
  • Visibility good or bad, turbidity?
  • What’s the competence of your dive team? Is there a big difference in competence?
  • How many people are you diving with? Who is doing what?
  • Could you use gases other than air (helitrox or trimix)?
  • Will you free descend or use a shot, can you do a slow, staged descent?
  • Is it a decompression dive?
  • How good is your regulator, is it appropriate for the depth you want to dive in terms of ease of breathing, i.e. balanced?

If you think about it, none of the above are new things to think about

You should be considering them in some form or another on every dive. But you could also ponder your water entry, will you have to swim hard against a surface current to get to a descent line? Can you have a rest before descending? You shouldn’t be out of breath during a dive so being out of breath immediately before is a little bit silly. Can you descend in a slow and controlled way? Staging your descent and descending slowly can help reduce task loading with ear equalization, equipment comfort and settling into the dive. It will also provide a gradual increase in nitrogen exposure to the brain in terms of PPN2. This is extremely anecdotal but I personally don’t want to drop like a stone and find myself suddenly hit by a wall of fuzziness- but that’s just me.

Whether it’s a decompression dive or not is markedly different to a no-stop dive. The usual advice on narcosis is that if you don’t like the feeling then ascend and it will disappear. Whilst that’s true, for a deco dive the missing component of that is “in how long”. I have done many a deco dive where I know I am narced, and as I ascend and switch to 50% Oxygen…. Yep, still narced.. time to move up to 12m now, yep, still narced. There is a noticeable delay, even after breathing a gas with less N2 before the effects start to disappear. If you have to navigate back to a specific point during your ascent and the vis is not great, maybe take that into account.

Another consideration about decompression dives is the complexity of your plan

Technical divers plan dives, they also plan contingencies. Some plan contingencies of contingencies. Then they are all written on slates or wet notes to view during the dive. The main plan, over depth/over time, over both, one lost gas, another lost gas, multiple lost gases, minimum gas, ascent pressure, turn pressure. Many variations of these.

Dive planning is important, as is contingency planning

So what am I getting at? Well having 3 or 4 plans written down is all well and good, but what about when you’re narced, and you find that you have to actually use one of the backup plans? It’s stressful and can be complicated depending on how narced you might feel. Yes, practice practice practice I hear you say, but it’s the instructors saying that and it’s easy for them to say- it’s their job to dive every day. They will find these things easier, otherwise, why are you going to them? It’s a bit harder for people that do it as a hobby to get in anywhere near as much practice as they would like.

So here’s the real question, aimed at hobby divers. Who out there will tell me that they will immediately refer to their back up plan and utilize it correctly if a real emergency occurs at depth? It’s more likely a case of deal with the immediate problem, start heading up, and then at the first available opportunity take stock and think about how much you deviated from everything because there were more pressing things going on than referring to back up plans. By then all your plans could be completely irrelevant. So let’s get down to brass tacks and be realistic- how complicated is your plan? Can you simplify it anymore to make it easier to read/use when needed? This might be the way it’s written down, the way you compare total runtime to your bottom timer, it may even be as simple as ensuring that you have a dive computer with a stopwatch function (yes please in dive mode as well as gauge mode shearwater, hint hint). Why do you think you might go over depth or over time? Can you actually do the dive with a simple plan and back up plan in your head? Again, just things to ponder.

One of the biggest things to factor in is who you are diving with…

You may be lucky enough to have friends that you regularly dive with, who are sensible and you dive well together. That’s great. The alternative is when you dive with people you don’t know. Of course there will always be people with different levels of experience and competence and after all, diving can be a great way to meet new people and learn new things. I’m not talking about deep decompression dives either, just regular dives to 30-40m. I’m talking about a specific type of person. Basically, don’t dive with the person at the beginning of this article who’s aim is to get as narced as possible. They are rule-breakers, and in my opinion, potential life-takers. There are plenty of real-world stories of this kind of person ignoring a dive briefing and taking someone equally unskilled, inexperienced and unqualified inside a wreck or cave, to find themselves trapped, or find their way out but the buddy doesn’t. Swap wreck for depth and the outcome may be the same. Diving is not a competitive sport (Though I sometimes wonder that when browsing certain Facebook groups), and the laws of physics apply to everyone.

Like most things, diving procedures, equipment considerations and the like are not rocket science once learned properly, but there are numerous things to consider. One that is often neglected is risk management, and certainly risk management as it relates to narcosis. We often just get on with it and assume everything will be ok. But as I’ve said a few times you only need things to go wrong once. So be prepared, know your limits and set them accordingly not just based on yourself, but also based on who you are diving with, when, and where.

Maybe it’s time to see what the fuss is about with trimix.


To find out more about International Training, visit www.tdisdi.com.

 

From its humble beginning in 1994 to today, the group of training agencies Scuba Diving International (SDI), Technical Diving International (TDI), and Emergency Response Diving International (ERDI) form one of the largest diving certification agencies in the World – International Training. With 24 Regional Offices servicing more than 100 countries, the company today far exceeds the original vision the founders had when they conceived the idea on a napkin, sitting at a kitchen table in the early 1990’s.

Dive Training Blogs

Deptherapy returns to its Roots – Part 6

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Join Richard Cullen from Deptherapy for part 6 of his Blog about the charity’s recent expedition to Roots Red Sea, El Quseir, Egypt.

Thursday has dawned and it is down to the House Reef with an outgoing tide that is approaching slack so we can get in the water straight away.   Lots of chat about last night’s RAID O2 Provider session with Moudi.  Oatsie is talking about sidemounts and marine biology, Swars is looking forward to his first sidemount session this afternoon.

Moudi is supported by Oatsie this morning and doing some more skill work with Keiron.

Moudi running the guys through the RAID O2 Administrator Course

Corey was asking last night about what it is like at 30 metres, so I have decided that with Michael and Swars we will take him to 30 metres.  We are going to run a narcosis exercise so out comes the slate with the numbers 1 – 25 randomly placed in squares.  Corey’s task, in the dive centre, is as quickly as possible to touch each number in sequence.  He does it pretty quickly and Michael briefs him that he will need to do the same exercise at 30 metres.

Michael briefs the dive and we set off down the beach.  Corey has improved beyond measure and he is becoming a pleasure to dive with.  So we are off to follow the South reef to 30 metres where we will complete the second part of the exercise.

At 30 metres Michael hands Corey the slate; there is a considerable difference in the time to complete the exercise at the surface and at 30 metres.  There are lots of mitigating factors in how quickly you can identify the numbers and explaining a slower time at 30 metres than at the surface does not mean an individual is suffering from narcosis.  Identifying random numbers, if you run the exercise at the surface, several times with an individual over a number of hours can result in wide variations in the time taken to complete the exercise.

We finish the dive with Corey smiling from ear to ear and we have a discussion about depth and air consumption.  The second dive of the morning is a fun dive, then it is lunch in the beach restaurant.  After the burgers I am sure we will need to look at our weighting before the afternoon’s dive.

We will need to look at weighting after this lunch!

Corey and Keiron have got into the habit of recording their dives online using the RAID online log book which is a tremendous facility and as the instructor I can access that data.

Moudi and Keiron are going for a fun dive as are Corey, Oatsie, Michael and myself. Swars is getting kitted up for the first experience of sidemount with Guy Henderson.

Swars getting to grips with his sidemount cylinders

People often look at the relationships that exist between the dive team and our beneficiaries and try to extrapolate a similar relationship to disabled students they might have.  Our relationships are built up over a period of time, in some cases over many years.  We also provide 24/7 support and have chat groups etc on social media; we also meet up socially when we can.  It is somewhat different than a individual coming in to a dive centre and saying ‘I want to dive’. Your relationship is likely to be the same as any other student, you will teach them, they might stay with the dive centre or like many that will go on holiday to do some diving, you might never see them again.

Our main aim is to create a family atmosphere for our programme members, one where they feel secure and they are able to discuss freely with the team and fellow beneficiaries their feelings and needs.

Few dive centres are charities, and owners might want to consider costs of running a course for someone with a disability that might take more than the standard four pool sessions etc.  You may find the number of sessions and the staffing levels have to increase.  Many dive centres, because of their size and turnover are exempt from providing accessibility.  How will this affect someone who is a wheelchair user?  Can they gain access to the dive centre, the classroom, the toilet?  What are the changing facilities, can they get wheelchair access to the pool?

Lots of things to think about.

Roots’ beautiful reef

The reef is beautiful, so much aquatic life and the corals look splendid, especially the pinnacles.

A good day’s diving, Swars has really enjoyed his sidemount.

Lovely way to relax in the evening with the Roots BBQ, a fitting end to a great day.

Last day tomorrow and our final blog!


Find out more about the work of Deptherapy and Deptherapy Education at www.deptherapy.co.uk

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Dive Training Blogs

Deptherapy returns to its Roots – Part 5

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Join Richard Cullen from Deptherapy for part 5 of his Blog about the charity’s recent expedition to Roots Red Sea, El Quseir, Egypt.

After an evening of chilling out by the pool and in the bar, we are back to the Roots House Reef this morning, with Keiron continuing his RAID Master Rescue Diver Course and enjoying Moudi’s vast experience as he learns more about advanced buoyancy skills.

Not sure where the week has gone; it’s Wednesday already.  A few different things happening today… Oatsie who has just started at Hull University on a Marine Biology Degree Course wants to complete his sidemount course and this afternoon he is out with Guy Henderson to start his learning.  Swars also wants to do the course, as he wants to get into cavern and cave diving.  Swars will start his course tomorrow afternoon and both will spend a day being taught be Steve Rattle on Friday. Hopefully they will both be certified as RAID Sidmount Divers at the end of their training.

Tom putting his sidemount rig together under Guy’s watchful eye

The morning sees Swars and I working with Corey again and taking him through the remainder of skills and OW dives.  He is improving massively but we still have to work on trim and propulsion.

Keiron, unfortunately for him, has Oatsie and Michael for his diver recovery exercises; I am told there may well be an entanglement to deal with!

Conditions are perfect again as we all look forward to three great dives during the day.

90% of those we work with have mental health issues, mainly Post Traumatic Stress Disorder as a result of serving in various theatres of war.  If you read some adaptive teaching manuals, they have a task to ‘teach a student with PTSD a skill.’ Hmmmmm how is Oatsie, Swars, Michael or Keiron any different than a student who is free from any mental illness?  The answer is they are not, they are exactly the same. Do you talk to them differently, do you demonstrate skills differently?  The answer is no.

If they have a flashback or a panic attack, then you need to step back and provide whatever assistance is necessary but only if there is a risk of them hurting themselves.  All our team have to undertake and pass the two-day Mental Health First Aid (MHFA) course so we can intervene appropriately where the circumstances require it.

Do you know what a panic attack looks like?  Do you know how to respond to a panic attack?

Flashbacks most frequently occur at night time but some do experience day time flashbacks.  Flashbacks can lead to the individual feeling physically and mentally drained and can be triggered by anything that reminds them of the traumatic incident(s) they experienced.  Sometimes there might be a need for one of our medical team to be involved. Often a period of quietness, rest and possibly sleep is required.

Keiron and Corey on the House Reef

We have seen lots of our beneficiaries learn to manage their PTSD. As Chris Middleton said on a BBC programme:

“You can’t beat PTSD but you can learn to manage it.”

In addition to the scuba diving, Deptherapy also provides 24/7 support for our beneficiaries.  Beneficiaries are encouraged to attend the MHFA course with their partner, parent, relative or friend.

Many will have read comments from our beneficiaries, that once they put their heads under the water their demons disappear.  There are several factors to this: the peace, the quiet and the tranquillity that occurs underwater, the beauty of the corals and the amazing aquatic life.

Roots is very much like a retreat for us, we are miles away from any towns, there are no distractions, the nearest town is El Quseir, which is orthodox Muslim so there is no alcohol on sale.  The recent bypass of the main Safaga to El Quesir/Marsa Alam road means that at night time there is no noise, just a brilliant star lit sky.

Roots at night from the beach

Beneficiaries are encouraged to talk openly with the team and their fellow beneficiaries about their injuries/illnesses and provide overwhelming support for each other as Corey found on this trip.

Our aim is to create a family atmosphere and Roots very much contributes to the sense of family and wellbeing.

Sadly, we live in a world where those with mental illnesses are largely discriminated against.  Because few understand mental health, they are fearful of it and try to ignore it.  Please look at the Mind website or even better sign up to a Mental Health First Aid Course.  If you run a business then run the course for your staff, the benefits will be massive.

Back to the diving, Michael and Tom under Moudi’s close supervision gave Keiron some very challenging diver recovery exercises.  Poor Keiron, but he responded tremendously.

Swars, is working well with Corey, ensuring horizontal trim and making sure he uses effective arm strokes for his swimming. We are organising an SMB session, so he can work with different types of SMBs.

Although we haven’t told him, he has finished all his skills but we still have work to do on his trim and propulsion.  We want him to go beyond standards, we want him to be a very competent diver, who despite his devastating injuries, can self-rescue and support a buddy if in need.

The afternoon dive sees Michael joining myself and Swars with Corey.  This dive is about buoyancy, trim and propulsion.  Keiron is doing some more advanced buoyancy work with Moudi.

All roads lead to Roots, is this the future of Google maps?

Oatsie had a great dive with Guy using sidemounts and is looking forward to completing the sidemount course with Swars and Steve Rattle on Friday.

In the evening, and before dinner, Moudi runs the RAID O2 Administrator Course for all five beneficiaries. It is a qualifying part of Keiron’s RAID Master Rescue Diver course but we decided it would benefit all of the guys.

Tomorrow we have decided to take Corey to 30 metres and for him to complete a narcosis test. Join us back here tomorrow to find out how we get on…


Find out more about the work of Deptherapy and Deptherapy Education at www.deptherapy.co.uk

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