Some things that I learned the hard way about decompression illness ("DCI",
"DCS", or "the bends"):
- 85% of people treated for decompression illness were diving within limits
imposed by tables or a dive computer (i.e., most people struck by DCI are
following the rules)
- the symptoms of DCI as described in PADI and SSI SCUBA instruction are not a
complete list
- partly because of confusion over symptoms, most people who get DCI are never
properly diagnosed or treated
- a liveaboard dive cruise can significantly increase your chance of getting
DCI, makes proper diagnosis less likely, and may delay treatment
Here then is my decompression illness story.
I'm a novice diver, certified with 5 beach dives in Hawaii in 1991 topped up
with 11 dives in three days from a liveaboard out of Cairns, Australia in 1992
(see
http://www.photo.net/nz/australia) and
two more dives in the Caymans in 1994. During those 18 dives, I'd never had any
problems of any kind. I never considered myself at any risk of the bends because
I tend to consume air rapidly.
Following six years glued to the keyboard, in August 2000, I went out for a
6-day cruise to the Coral Sea out of Townsville, Australia with Mike Ball Dive
Expeditions (
www.mikeball.com). There were
19 other divers on the boat. Every one of these 19 people did more dives, longer
dives, and deeper dives than I did. Yet I got ill and they did not. Mike Ball
requires and supplies dive computers. I used one throughout this trip. At all
times the computer showed that I had ample time remaining at my current depth for
a no decompression stop ascent.
I felt pretty bad during much of the trip. We started off with a 10-hour drive
through rough seas. Even with a Scopalamine patch on, I felt a bit seasick.
Several other passengers and crew were vomiting. Few people reporting having
slept well. Keep in mind that dive boats aren't luxurious floating cities like
the Love Boat. We were on Spoilsport, which is considered Australia's
finest liveaboard, staying in a "premium" cabin, and yet the noise of the engines
when moving is thunderous. The hull of a powerboat acts as a resonator for all
the diesel engine noise and, even if you're wearing earplugs, you might have a
tough time sleeping from the noise of the engines alone. This night we had the
noise plus the seas were rough enough that we were actually pitched up into the
air from the mattress regularly.
Bottom line is that I was a bit tired on the first day of diving but felt good
because I wasn't actually green and vomiting like some of the other passengers.
While equalizing on the second dive (out of 24 possible), I bruised my right
eardrum a bit. Upon visiting a doctor following my return, I learned that I had a
wax buildup in this ear and that was probably why it was tough to equalize.
Lesson: Get a dive medical or at least a regular physical before any new
collection of SCUBA dives.
By the second day my ear felt better and I enjoyed three dives to about 17-18
meters. After three or four days I found that I was unable to read with my
eyeglasses on. I'm nearsighted but normally I read with my glasses. One of the
precautions against taking scopalamine is for people with glaucoma so I figured
that this was a side effect of the patch, though I'd used these patches 10 or 15
times before with no such effect. Early in the morning on the fifth day of the
trip, I had a really bad headache, I felt pressure behind my eyes, and my right
arm ached as though I'd had a tetanus shot in the biceps. Was it from the three
dives the day before (23m, total bottom time 27 minutes; 20m, 28 min; 17m, 25
min; all multilevel dives)? Headache is not listed as one of the symptoms of DCI
in the PADI and SSI books. Or was the headache from the scopalamine patch? And
the arm ache a result of a crewman opening a door into my elbow the day before?
Jason, the captain, put me on 100% oxygen as a precaution. This is the
traditional first-aid given to DCI sufferers. The oxygen did not give me any
relief and the Mike Ball staff said that was a sign against it being DCI since a
DCI sufferer will usually feel better after 30 minutes of oxygen. Jason also
telephoned the hyperbaric chamber at Townsville General Hospital and spoke with a
technician there. It was the judgement of the tech that my symptoms could best be
accounted for by the scopalamine and the elbow whack. A helicopter ride and
treatment in the chamber seemed unnecessary.
I took the scopalamine patch off. The arm ache cleared by mid-morning. My
headache cleared by the afternoon. Talking to the crew and the other passengers
reassured me. All of them had convinced themselves that they'd gotten bent.
They'd felt or imagined twinges and were sure that they needed hyperbaric
treatment. But in every case it turned out that they were simply paranoid. There
are 1 million people diving every year in Queensland and only 120 are treated in
Townsville's hyperbaric chamber. 1 chance in 10,000!
I did a dive to 14 meters for 40 minutes to watch a shark feed and then did a
40-minute multilevel night dive, to a max depth of 14 meters. I suffered from
some stress and fatigue at the end of the night dive, however, as we overshot the
boat and there was a strong current flowing away from the deco bar. Mike Ball had
buddied me up with Kevin, a volunteer divemaster, who'd done about 60 dives
before this trip. He saved my butt by helping me fin back to the boat. Some rough
times were predicted so I took an English seasickness remedy, Sturgerol, from
another diver.
Overnight we drove through rough seas for 10 hours to get to the wreck of the
Yongala, a coastal steamer that sank 12 miles off the coast of Queensland
in 1911 with 120 lives lost. This is considered one of the world's best wreck
dives. However, conditions in the morning were challenging. Few had gotten a good
night's sleep. The noise of the engines and the rough water, nearly as bad as the
first night's sail out, was enough to wake almost anyone. There was a substantial
surface swell, the sky was intermittently gray, and we had reports of a strong
current down on the wreck.
One of the good things about diving with a first class outfit like Mike Ball
is that they spend a lot of time preparing the site. They dropped two lines to
the wreck, one on the stern and one on the bow. So it would be possible to
descend and ascend on the lines, important for doing the decompression stops that
Mike Ball insisted on even if the computers did not. At the bottom of each line,
in about 15 meters of water, the Mike Ball crew had left a spare SCUBA tank and
regulator for anyone who was low on air. If you came up on the far line you could
just raise your hand to get picked up by a Zodiac rather than pull your way back
to the boat.
I was buddied with my girlfriend Eve Andersson, who'd done her open water
certification dives on board the Spoilsport. We asked for help from the
crew and they sent Kevin, the volunteer divemaster, with us again. My plan was to
descend on the line nearest the boat, drift with the current to the second line,
then ascend to the surface and ask for a Zodiac pickup. Short, sweet, no finning
against the current. I let Kevin overrule me. Pointing to the crashing up and
down of the Spoilsport, he said that it was tough to get back onto the
boat from the Zodiac and we'd be better off just staying in the neighborhood of
the first line and coming back up.
We executed a modified version of Kevin's plan. The current took us fairly
quickly all the way to the other end of the boat. Then we proceeded to swim back.
I watched my tank pressure gauge drop from 140 bar to 40 sickeningly fast. We
were back on the first line but rather than grab the spare tank, Kevin had me
breathe from his octopus regulator. He still had more than 100 bar (Lesson: be
in really good shape before a challenging dive and work out with your fins doing
a bunch of snorkeling.). We did the safety stops with me breathing from his
octopus but it wasn't much fun because something about the arrangement kept
flooding my mask. We did a 2-minute stop at 10 meters and a 3-minute stop at 5
meters and then ascended. I went back on my own tank to pull myself back to the
boat along a surface line. The waves were too rough for me to feel that I could
snorkel comfortably so I stayed with the regulator and watched the pressure drop
from 30 to less than 10 bar. Just like it says in the books, it became a bit
tougher to draw breath. I made it back to the boat but couldn't get on
immediately. The swell was causing Spoilsport to crash up and down hard
enough to crack anyone's head open. So the crew was on the dive platform telling
divers exactly when to approach. I got on with maybe one more breath left in my
tank.
There are a whole lot of lessons to be learned from the preceding. One is
probably to be more assertive about insisting on an easier dive plan. Second is
to not be shy to grab the spare air tank. Third is to wait for a better day (as
it happened the second dive that morning on the Yongala had much reduced
surface swell and hardly any current).
The PADI and SSI books don't list being scared as a contributing factor to
DCI. But they do list "fatigue" and "vigorous exertion". "Weakness" is also
listed as a symptom of DCI. So it is possible that I had trouble finning against
the current on the Yongala dive because of DCI picked up from previous
dives and that the effort of the dive itself made the DCI worse. The poor night's
sleep wouldn't have helped either. My profile on the dive was reasonable. I was
down at 26 meters only for about 5 minutes then mostly up around 17 meters. My
total bottom time would have been about 20 minutes. It was a no-decompression
dive by the PADI tables and the dive computer certainly gave me ample margin.
That said, after the Yongala dive, I was finished. I was exhausted and
collapsed on my bunk. A terrible headache developed within half an hour and I
tried some oxygen (the tank was still in our cabin). I felt a little bit better
towards the afternoon as we drove back towards Townsville and managed to come up
on deck to gaze out at the horizon. When I got off the boat at 4:00 pm, I was
dizzy and had a headache. So I hopped in a taxi to a local dive physician's
office and presented my symptoms. His diagnosis:
- based on a wax buildup in my right ear, it looked like I'd had a minor ear
infection
- the pressure of diving had pushed the infection into my sinuses and that was
the cause of the headache
- the other symptoms were side effects from scopalamine
I was put on a course of antibiotics and sent back to the hotel.
Facing the Music
It was 8:00 am. Twenty four hours after my last dive and three hours before
the first of a series of flights that would carry me back to the US, ending my
three-week sojourn in Australia. My headache was terrible and I was a bit
lightheaded. Not as dizzy as the previous afternoon but it seemed like a
reasonable precaution to visit the hyperbaric medicine department at Townsville
General Hospital. They were very polite and organized on the phone and agreed to
see me immediately at 9:00 so that I could get cleared and proceed direct to the
airport for my 11:00 am flight.
Dr. Webb was on duty. He's an anesthesiologist normally but was filling in for
the head of hyperbaric medicine. He listened to my report. He tested my balance
by making me stand with one foot in front of the other, clasping my hands to
opposite shoulders, closing my eyes and seeing how long it took me to topple over
(15 seconds; 60 is normal). He tested the comparative sensation in left and right
sides using light touch with cotton balls, sharp and dull needles, and cold
versus not-cold objects. My right hand was considerably less sensitive than the
left one. He tested my mental abilities by timing me count backward by 7s from
100 and by asking me to remember a sentence.
Dr. Webb offered no opinions until the end of the consultation: "You have
decompression illness and need treatment in the hyperbaric chamber."
I struggled against this diagnosis as best as my fogged mind could. I cited
the fact that my diving was within the limits of the computer. Dr. Webb pulled
out a very conservative set of dive tables from a Canadian organization and noted
that it recommended longer decompression stops for a 28-minute dive to 26 meters.
He put little faith in dive computers, saying that they were based on animal
studies. In any case, he'd had patients who got DCI in swimming pools or on their
open water certification dives. Headache wasn't on the list of common DCI
symptoms. He said that the entire recreational diving industry was deeply
confused about what was and what was not a symptom of DCI. In fact, headache and
flu-like symptoms were fairly common. Because they aren't listed, a lot of divers
get DCI and wrongly attribute it to the flu. I asked him to consider the
possibilities that all of my symptoms were explained by a sinus infection or
Scopalamine. Finally he crushed my resistance by saying "You don't feel right, do
you?"
The chamber was in use that morning for a scheduled 1.5-hour "dive" to benefit
wound patients. This is the main use of hyperbaric facilities worldwide. If a
wound is poorly supplied with blood, most typically because the patient is
diabetic, 30 treatments with pressure and 100% oxygen often help. Divers with DCI
are treated initially with a 5-hour "dive" and that was scheduled for 1:00
pm.
During the rest of the morning I found out some more unpleasant facts about
DCI. I would be forbidden to fly in a commercial aircraft for three weeks
following my last treatment. I tried to make the best of this. I would drive or
take the train down to Sydney and work from the bosom of the University of New
South Wales's excellent computer science department. Wrong! There was a series of
200-meter high hills between Brisbane and Sydney and the road or train would keep
me up there for a total of 20 minutes. That might bring back all the DCI symptoms
as the nitrogen bubbles expanded further. I could go north to Cairns or south to
Brisbane but not inland or south to Sydney. I couldn't do anything too rugged in
this rugged part of Australia, though, because strenuous exercise was forbidden
for at least two weeks following the final treatment. Alcohol was prominently
restricted as well, something you might expect when there is a huge drive-through
liquor store just half a block from the hospital, but I'm not a drinker normally
so I wasn't upset about that.
Into the Chamber
The basic
theory behind DCI is that your body has respired out most of your excess
nitrogen. However, it didn't get rid of enough of it quickly enough. The residual
nitrogen formed itself into bubbles too large to diffuse through blood and
tissues. The objective of recompression is to squeeze the bubbles down small
enough that they can diffuse through tissue again. To encourage those bubbles to
diffuse out through your lungs, you breathe 100% oxygen in the chamber. I.e.,
there is no nitrogen in your airways and at least some nitrogen in your tissues.
So the diffusion of the nitrogen will all point up and out of your mouth.
Recompression and oxygen is not 100% effective, however. If a bubble is really
big it might not be compressed down small enough in the 18m of pressure that you
get (they can't bring you down lower because otherwise the oxygen becomes toxic).
If a bubble has become coated with protein, it may be more tenacious than a
regular bubble and persist. This is why it will take some weeks following
treatment for maximum recovery.
Some people get what Dr. Webb called a "fit" from the pure oxygen under
pressure. So they stick an IV in you before the first long dive and the
treatments are done with one nurse in the chamber and one nurse outside the
chamber with the technician. If there is an adverse reaction to the oxygen, they
can easily pump drugs into your system to revive you.
During most of the first treatment, I just lay down on the bed, opposite
Mardi, one of the nurses. I did a bit of reading towards the end and found that
my concentration was considerably improved compared with the morning.
The rest of the week
Each day for the rest of the week, I
would get evaluated in the morning by Dr. David Griffiths, the head of hyperbaric
medicine. He tested my pulse, my temperature, my blood, and X-rayed my sinuses to
rule out the possibility that some of my symptoms were explained by an infection
(all tests were negative). My headaches were slowly getting better and, by the
morning of the fourth treatment, I was able to balance for 60 seconds. Hanging
around the unit, I learned more about DCI. One patient's had no symptoms other
than a personality change: "He became a complete arsehole," said one of the
nurses. Over a three month period, this diver lost his wife, his kids, and his
job. Even after three months, hyperbaric treatment partially restored his former
personality.
Townsville is a pleasant place and
after three treatments I was able to visit the Billabong Sanctuary, where you can
cuddle a koala, hold a python, watch the staff almost hand-feed huge crocodiles,
pet kangaroos, and be walked on by Australian parrots. After my fourth treatment
I was able to take a ferry out to Magnetic Island and poke around a bit. But
basically I was an invalid and this was the sanitorium life a la Mann's Magic
Mountain. I had the worst headaches of my life, was worn out and tired from just
getting up and walking two blocks to the hospital, and felt like I would never
get better. It is extremely depressing. I was only able to get by day to day
because my girlfriend Eve rearranged her life and stayed with me for the week of
treatment.
The Future (for me)
I'm back to work officially, remotely supervising some projects back at
ArsDigita. I've rented a car and am trying to drive down to Brisbane to give a
couple of lectures at the university. Eventually I will make it down to UNSW in
Sydney and then home. Dr. Griffiths tells me that I might be headache-free in a
week and that I can hope for a complete recovery though it sure seems hard to
believe right now.
Liveaboards and Decompression Illness
I built my Web site in order to share what I've learned in the hopes that it
would be useful to others. So here is something I think that I've learned about
liveaboard diving boats: a liveaboard dive cruise is a great way to get DCI. On a
liveaboard trip, there is nothing to do except dive. You will be doing more dives
per day than if you were at a beach resort with other options.
Liveaboards tend to move at night. Smallish power boats are extremely noisy.
If you are a light sleeper, you won't get much sleep. Fatigue puts you at
increased risk of DCI according to the PADI and SSI books. Even more of a problem
is that if you are tired after a dive you won't know whether it is due to the
sleepless night or the dive itself. Do you have DCI or did you just sleep
poorly?
If you've any tendency toward seasickness, you may have some problems. If you
actually get sick you'll be dehydrated and that puts you at increased risk for
DCI. If you take medication and then feel odd at some point in the trip, you
won't know whether the discomfort is a side effect of the medication or related
to your dive.
One of the best tests for DCI is the balance test that I had every day in
Townsville General Hospital. I think you should test yourself at home to
establish a baseline and then on every dive day. If you're on a liveaboard dive
boat, you'll never know whether or not an inability to balance is due to the
rocking of the boat or a case of DCI.
Patent Foramen Ovale (PFO)
Before taking up SCUBA, it might be worth getting tested by a cardiologist for
Patent Foramen Ovale (PFO). The procedure takes about one hour. Depending on whom
you ask, PFO afflicts 5-15 percent of the population and increases the risk of
DCI by a factor of three. PFO is a disqualifying condition for U.S. Navy
divers.
I asked a cardiologist friend to explain this and here is what she said:
A Patent Foramen Ovale (PFO) is a small hole between the right upper
chamber of the heart (right atrium) and the left upper chamber of the heart (left
atrium). It is covered by a flap of tissue on the right side of the heart so that
there is not usually continuous flow. It is a vestigial structure from embryonic
development. In the developing fetus, oxygenated blood comes from the mother via
the umbilical cord into the venous system of the fetus. In order for the tissues
to get adequate oxygen, the blood is shunted from the right atrium (venous side)
to the left atrium (arterial side) via the foramen ovale. At birth with the first
breath, the abrupt pressure change closes the foramen ovale. However, in 10-15%
of the population, this hole does not completely close.
A PFO is diagnosed by a cardiac echocardiogram which is an ultrasound of the
heart. Rarely can blood flow be seen across the PFO as it is usually too small,
so agitated saline bubbles are injected through an IV catheter in the arm and
these tiny bubbles can be seen crossing the PFO on the echocardiogram. There is
no risk to the patient with this test.
The majority of people will never know they have a PFO as there are usually no
medical consequences. They are at slightly higher risk for having a stroke
compared to the general population, but there are no preventative steps taken
unless a stroke happens. There may also be an associated with migraines. Current
studies are being conducted to determine if closing the PFO with a small closure
device will make a difference in these patients.
The one group of patients where a PFO might make a difference is in divers.
The danger is in the potential to develop small bubbles in the venous system
either during ascension or during decompression. These small bubbles can cross
over into the arterial system and cause decompression illness (DCI). It has also
been suggested that divers with PFOs can have MRI evidence of multiple brain
lesions. Several studies have suggested that divers with DCI have a significantly
higher incidence of PFOs than the general population.
If you are a diver with a PFO you should be aware that you are potentially at
much higher risk for developing DCI. Some physicians will recommend that you not
dive at all. Other recommendations include more conservative dives and certainly
no dives that require decompression stops. Also, the newer oxygen-rich gas
mixtures [Nitrox] may also help although there is no conclusive
data.
After my experience with DCI, I was tested for PFO. The test was negative,
i.e., I should have had half the risk of DCI of a person in the general
population with an unknown PFO status.
More:
http://scuba-doc.com/pfo.htm.
Oh yes, the money
One of the refreshing things about Townsville General Hospital is that they
treat the patient first and worry about the money later. It was only after three
days that they gently told me that they'd been given the brushoff by Blue Cross
when they inquired as to whether my treatment was covered. They made all the
phone calls back to the US so that I wouldn't have to be bothered. The total bill
was about USD$2500, which I paid by credit card. Lesson: if you're American
and want health care, you really do have to be rich, even if you're insured in
theory..
More important than the money was the warmth of the staff at Townsville
General. They ordered lunch for me the first day without being asked. They
anticipated my questions and needs. There were no lengthy bureaucratic waits or
procedures. The staff tend to dress casually and don't try to distance themselves
from the patients. It sucks to be ill (you can't say "sick" in Australia because
it means vomiting) but if you're going to be ill there really isn't a better
place than the hyperbaric unit at Townsville General Hospital.
Am I going to dive again?
Dr. Griffiths says that I can SCUBA dive again in six weeks. The people that
get DCI on their certification dives are told that diving isn't for them. But
there are plenty of people who do hundreds of dives, get DCI randomly, and then
go on to do hundreds more dives happily. Do I think I'm prone to DCI? Obviously
to some extent. I did not have any of the risk factors mentioned in the SCUBA
books except for fatigue. I'm not a drinker. I'm not grossly overweight. I'm not
really old (nearly 37). I was careful to drink a lot of fluids throughout my boat
trip. On the other hand, I've dived successfully in the past.
Some of the factors in my favor on the 11 dives that I did in 1992:
- the boat did not move at night so I did not lose sleep and wasn't fatigued
(it was an economy trip and we only went to the nearby Barrier Reef rather than
way out to the Coral Sea)
- it was summer and the water was warmer (28 degrees versus 22 or 24 on this
trip); being cold in the water is a risk for DCI
- I kept to shallower repetitive dives because I was using the PADI tables
So if I absolutely had to dive, I'd be willing to risk another full month of
hospital treatment, convalescence, and imprisonment in Australia. But who
absolutely has to SCUBA dive? Most of the good coral reef sights are within 10
meters of the surface, oftentimes closer to 5 meters. And the shallower they are
the more vibrant the colors from sunlight. You can see these sights just floating
on the surface with a snorkel and see them well by getting good at free diving
(the dive instructors on Spoilsport would regularly free dive down to 15
meters to secure lines and oftentimes to 30 meters or more for fun). I very
happily snorkeled a full mile across a bay in Hawaii once and then snorkeled a
mile back in the other direction. I saw eagle rays, sea turtles, and a school of
dolphins. The beauty of the snorkel is that you can breathe while floating at
your natural level. So you can just stop and rest at any time. Still, if you're
lazy or out of shape SCUBA is a good crutch for getting below the surface but
being out of shape is probably an increased risk for DCI.
SCUBA is essential when you need to remain in a fixed position underwater. If
you want to be a great underwater photographer, you'll need to SCUBA dive. To
rescue a diver or salvage a sunken item you'll need to SCUBA dive. SCUBA is good
when the surface is rough. You can descend to 5 or 10 meters and be out of the
surge and also not have to worry about getting water into your snorkel. If you
love visiting wrecks (sunken ships), SCUBA is probably going to be required. Most
wrecks are fairly deep and most people will have trouble getting good enough at
free diving/snorkeling to visit them unaided.
So my plan for future underwater sightseeing is the following:
- sleep on shore in a nice hotel bed
- only visit shallow dive sites (stuff worth seeing at 10 meters)
- only visit those sites on days when the sea is absolutely flat so that I
don't get seasick getting out there and so that it is easy to snorkel
An ideal fit to this plan is some kind of tropical lagoon where the hotel room
is right on the beach and the reef is swimming distance from the beach. If I were
to SCUBA dive, I'd want it to also be under these same conditions. I'd do it once
or twice on any given day, using Nitrox (see below) and following the most
conservative tables that I could find. It would have to be in a place where I
could easily get a medi-jet or helicopter flight out to a decompression chamber
(it turns out that any jet interior can be compressed to sea level; they just
need to fly somewhat lower (burns more fuel) and compressed the interior harder
(also burns more fuel)). If I had to be home by a specific date, that
decompression chamber would itself have to be in a place with a road or rail link
to my home in Boston.
Lessons
Remember that any dive involves a risk of decompression illness. There is some
research that suggests that, based on examination of burst retinal blood vessels,
subclinical tissue damage occurs after every SCUBA dive.
- get a dive medical or at least a regular physical before any new collection
of SCUBA dives; you want to establish what your baseline health is and pick up
any minor problems such as earwax
- follow the tables, not a dive computer
- only dive on days when you feel 100% great; then if you don't feel 100% great
when you come out of the water, you'll know why
- never dive on compressed air, not even for your first five certification
dives; unless you're going below 110', it is always safer to breathe Nitrox (36
percent oxygen) -- Nitrox has a reputation for being complex and for being
best-suited to advanced divers but unless you desperately need to save $10 per
dive it is crazy to use air [I learned to dive when Nitrox was not commonly
available and had no idea that it was appropriate for ordinary shallow dives--I
almost surely would not have gotten bent and you'd not be reading this article if
I'd simply pulled Nitrox bottles off the rack instead of air during my week in
Australia]
More
October 2000 Epilogue
It is now two months since I left Townsville General Hospital. I think that
I'm just about completely recovered. One of the difficulties in recovery has been
that the symptoms of DCI are so varied and subtle. Two weeks after leaving the
hospital, I caught what I think was either food poisoning or a stomach flu in New
South Wales. I had a headache and was tired. Was it from the bug or a relapse of
DCI? It was impossible to say and therefore much more worrying than a normal
stomach problem.
The flight back was horrible. I did not get any obvious DCI symptoms but I had
terrible stomach and body aches by the time the LA to Boston flight was getting
close to landing. After a long weekend in Boston I still had headaches. My
doctors at the MIT HMO scheduled a brain MRI. It turned out normal and about a
week later the headaches subsided.
Bottom line: about six weeks of pain and terror that my mental processes would
be permanently compromised.
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