>Once the two instructors had the man on the dock they began CPR. Sheri walked quickly up the hill to the parking lot to retrieve the oxygen unit, the first aid kit and emergency phone. To her dismay the van was locked; she ran back down the hill and began rifling through her colleagues' backpacks to find the keys to the van. She found a cell phone and placed a haphazard call to emergency medical services (EMS). At this point Jill was exhausted from performing CPR alone since the time they got Jimmy out of the water. She began yelling at Sheri, ordering her to move faster and to come help. Sheri's reply was thick with frustration and colorful language.
>Sheri found the keys, ran back up the hill and acquired the emergency equipment from the van. She made it back down the hill and onto the dock where she flopped to her knees, opened the oxygen unit and stared blankly at its parts — the unit had been disassembled in a rescue class the previous week. Jill saw Sheri freeze up and asked her to take over CPR. Jill set up the oxygen unit and administered supplemental oxygen to Jimmy. At about that time some of Sheri and Jill's colleagues surfaced and asked what was happening. Twenty-four minutes had elapsed since Jimmy's buddy asked for help; Sheri and Jill were depleted, fatigued, frustrated and desperate for relief.
>"Time! End scenario! End scenario!" bellowed their evaluator. It was a drill — an in-service training scenario — but you wouldn't know it by the reactions of the two emotional instructors. Jill was shaking and visibly angry. Sheri cried and immediately got defensive. Everybody was aware it was a training exercise, but it was this group's first full-blown emergency simulation, and it featured many of the complexities of a real incident. Gone was the modular training familiar to students in CPR, oxygen provider and first aid classes. In its place were confounders including sand, wetness, adrenaline, sweat, emotions, wetsuits, confusion, shouting and disorder — the true benefits of realistic training scenarios.
>In-service training is on-the-job education or skills development designed to improve staff members' capabilities. Its importance for dive professionals cannot be overemphasized. Although this type of training is most commonly associated with police forces, EMS crews and lifeguards, recreational industries including snow sports and whitewater paddle sports practice it as well. The risks inherent to scuba diving mean dive professionals may be called on to act with competence, proficiency and professionalism when an incident occurs.
>Dive professionals attend training-agency meetings and trade shows, and they take courses to maintain their CPR, first aid and oxygen provider credentials every two years. Although these are all important aspects of their continuing education, meetings and courses cannot fully prepare people for situations that require split-second decisions in stressful circumstances — circumstances such as kneeling, sopping-wet, over an unresponsive diver in heavy seas while dive buddies are crying hysterically. That's where realistic training comes in.
>In-service emergency training should be mandatory for all staff who supervise or lead divers at dive centers, resorts, charter operations, educational institutions, public-safety departments or commercial-diving companies. This includes teaching assistants, assistant instructors, divemasters, dive control specialists, instructors, instructor trainers and course directors.
>Who Should Do It?
>Dive professionals aren't the only links in an injured diver's chain of care, and a chain is only as strong as its weakest link. At any given dive site there are other people who would play a part in an emergency plan's execution. Coordinate training exercises with these associated parties, which include pool staff, dive-site personnel and boat crews. Dive professionals should contact the aquatics director of the pool where they train and discuss their interest in creating a coordinated emergency plan for scuba activities that take place in the pool. The plan should be tested in a combined training exercise involving the dive professionals and the lifeguards. Both parties will learn a lot. This approach is also relevant to dive boats and managed dive sites.
>Another group to engage when conducting training simulations are any divers with advanced (or higher) certifications. These divers make great bystanders, victims or dive buddies. They've already shown an interest in learning more about diving, and their involvement in an emergency simulation might motivate them to take a CPR, oxygen provider or rescue diver course. Plus, these divers will appreciate the opportunity to observe their local dive professionals improving their preparedness and skills.
>Planning: Great emergency simulations incorporate as many elements of real-life incidents as possible. It's often the subtle nuances of these scenarios that throw the curve balls to staff. For example, a diver showing signs consistent with decompression sickness acting defensive about his dive profile and insisting he is not bent adds realism and a dynamic not encountered in most training courses. Dive accidents are never routine; they include twists and turns and differ substantially from one another. A great place to get ideas for fresh and engaging scenarios is the Incident Insight column of Alert Diver.
>Elements of Great Training Scenarios
>Set the Stage: Scenarios should never put any participants or bystanders in harm's way. Supervisory staff should oversee and orchestrate the training at all times and should notify anyone in the vicinity who is not participating that training is taking place.
>Another key to successfully setting the stage is establishing rules and parameters for the scenario. Do not set up participants to fail by neglecting to explain the nature of the training or declare what areas are off limits. Instruct participants on how they should call for help, and make sure they know who is an available bystander and who is a nonparticipating evaluator. Be mindful of how the training could go wrong, and take steps to prevent those outcomes.
>Rope off the training area, and post signs to inform passersby that they're witnessing a training exercise. Make sure to appropriately manage any hazards to participants or the public. Be careful of equipment that gets strewn around the site, and ensure it is picked it up reasonably promptly to minimize the training's impact on others.
>Give key players such as "victims" and "bystanders" precise instructions on what to say and do. Allowing them to improvise or freelance can be problematic and may complicate the scenario in ways that don't enhance learning.
>Evaluators: Keep at least one person out of the scenario to act as an evaluator. The evaluator should take notes and monitor a stopwatch to note when key events occur. The evaluator's record should include both good and bad decisions and actions; it will serve as the basis for the debriefing at the end. The evaluator should monitor not only the training exercise but also activities outside the exercise, since the public or the setting may necessitate changes to the scenario. If the training needs to be stopped, all participants must be prepared to pay attention to the evaluator if he or she intervenes.
- Cell phones: Preprogram a number into a cell phone that can be used to simulate a call to EMS. A person at the other end of the line should be standing by to play the role of a 911 operator and ask the caller questions about the emergency. Since a cell phone could become wet or damaged during a scenario, you might wish to use a dummy phone and conduct conversations out loud.
- Bystanders: Have some individuals designated to create background noise or distractions. Prepare grieving, horrified and/or helpful bystanders to make comments such as, "Oh no! This is awful!" or "How may I help?"
- Victims: If someone is playing the role of an unresponsive diver, that person should be as limp as possible. Dead weight adds surprising and realistic difficulty to patient transport.
- Old wetsuits: Have participants prepare unresponsive victims for CPR and the application of AED pads by actually cutting retired wetsuits off a person or manikin.
- Training units: Realistic training exercises can be hard on equipment. If possible, designate oxygen units and first aid kits that are functional but can get wet, sandy and slightly banged up.
- Timing: Allow an appropriate amount of time to pass until "EMS arrives" on scene. According to national EMS response-time data, the interval between a scenario's phone call for help and the theoretical arrival of EMS should be about 8 minutes in urban locations and 10 minutes in rural areas.
>Critiques must be nonjudgmental and participant-focused, and evaluators should guide the conversation toward discussions of how improvements can be made. Evaluators should also highlight the consequences and relative importance of staff members' actions or inaction during the scenario. They should not overdramatize individuals' faults; they should remind participants that a primary goal of the exercise was to provide an opportunity to make mistakes in a low-consequence setting. This approach will keep staff appreciative of in-service training rather than viewing it as an embarrassing burden.
>Document: At the end of all training simulations, make a list of every person involved, and record the date and some details about the scenario. This documentation is a good way to track staff-member participation and may also be helpful in the event of legal action. Dive professionals and their employers might be viewed more favorably when defending a lawsuit if they can demonstrate a focus on accident management with detailed in-service training records.
>The two biggest arguments against conducting emergency training exercises are cost and time. Employers pay staff for the time, and without income to offset it that time can weigh heavily on a budget. Employers should create a separate budget for in-service training and, if possible, schedule trainings for times when the staff is already together. Trainings can be conducted at inexpensive locations such as pools, beaches or lakes. Opinions vary on how often in-service training exercises should be conducted. Whether they're run monthly, quarterly or semiannually is up to the dive professionals and their employers and may depend on the size and scope of the business and the size of the staff.
>The Cost of Not Doing In-Service Emergency Training
>For those who dismiss in-service emergency training exercises as impractical or unnecessary, consider this: After a dive accident is not a good time to discover problems. Scuba diving is fun, and most dive professionals are not often reminded that it can be deadly. When an incident occurs it may be immediately obvious to all parties that certain staff members have not kept up their skills and knowledge. The time, energy and cost associated with reviewing a serious incident with the training agency, insurance companies, investigators, law-enforcement officials and attorneys will dramatically exceed the cost of frequent, realistic training scenarios.
>© Alert Diver — Fall 2013