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Alert Diver Article The diver: The diver is a healthy male who is 32 years old. He has no known medical problems and takes no regular medications. He is an experienced, frequent diver with advanced training, including nitrox. His general health and fitness are good. The dive: The dive was a planned decompression dive off the northeast Atlantic coast, to a maximum depth of 120 feet (37 meters). The dive, which took place from a boat, was pleasant, with no accidents or near-misses reported. The running time of the dive, which includes bottom time and decompression times, totaled 71 minutes. The diver's breathing gas was 31 percent enriched air nitrox.
During the dive, the diver in question switched to 50 percent EAN for his deeper decompression stops; he then switched to 80 percent EAN for his decompression stops, starting at a depth of 30 feet (9 meters).
The complications: Within five minutes after surfacing, the diver reported pain in both elbows. He rated the pain as being a level of five out of 10. A few minutes later he experienced acute vertigo and nausea and had difficulty moving around the boat. The boat crew provided him with 100 percent oxygen for 30 to 35 minutes. Only the elbow pain resolved during that time.
The boat was still 30 minutes from shore. Uncertain of what to do, the diver then contacted the DAN® on-call medic for guidance. The medic advised the diver to get evaluated at the nearest hospital as soon as the boat docked.
The transport: The medic and the diver were able to establish that the closest hospital was able to treat injured divers and would thus be appropriate. The medic also recommended that the dive buddy contact local emergency medical services and have an ambulance meet them at the dock. The diver declined this assistance, and his companions drove him to the hospital. This meant that the oxygen could not be maintained and a medical professional would not evaluate him until he arrived at the hospital. In the meantime, the DAN medic had contacted the local hospital emergency room; they were expecting the diver.
By the time he arrived at the hospital, the elbow pain returned at the same level as before. He continued to experience acute vertigo and nausea. On examination, the physician determined that the diver had reduced strength in both arms, balance problems, difficulty walking and an involuntary rapid eye movement known as nystagmus. The diver himself was unaware of the weakness and nystagmus. These are the types of symptoms that may not be obvious, and the examiner needs to know what to look for. The treatment: The physician initiated treatment for the injured diver in the hyperbaric chamber with a U.S. Navy Treatment Table 6 (TT6). The diver's symptoms improved greatly but did not completely resolve. Because of his continued dizziness and feeling "off balance," the diver returned to the chamber the next day, where he received a U.S. Navy Treatment Table 9 (TT9). The vertigo and balance problems continued despite this second treatment. He received an additional four TT9 treatments to completely resolve all his symptoms. In total, the diver received one TT6 treatment and five TT9 treatments over six days. The lessons: It is obvious that despite planning, breathing gas selection and proper execution, dive injuries such as decompression illness can still occur. This is a reminder of how we are still learning about the nature of decompression injuries and how different individuals have unique responses to the same exposure. The diver and his companions recognized the need to provide oxygen, for which they should be commended. Providing surface oxygen can sometimes affect symptoms in a dramatic fashion. The advantage of contacting EMS is that they can continue providing oxygen, which can help lessen or prevent symptoms from recurring. We cannot say with certainty that continuous oxygen in this case might have changed the outcome, but physiologically it will limit the effect of nitrogen by helping flush it from the body. DAN speaks often with divers who experience partial or complete symptom relief with surface oxygen alone. Because of this relief, divers sometimes believe that oxygen is sufficient treatment. While oxygen is helpful, further evaluation is needed. Oxygen is an excellent first aid intervention, but symptoms can return. DAN has documented many such cases. Even if symptoms appear to have completely resolved with surface oxygen, physician evaluation and possible chamber treatment are almost always recommended. Delving deeper: Occasionally DAN has been criticized for sending divers to be evaluated by a physician even when the symptoms appear minor. As this case illustrates, what the diver reported and what the physician found on examination were different. Divers are not going to be aware of some signs and symptoms, which can be subtle. Divers may not know specific signs and symptoms to look for. This is why the DAN Medicine staff will often recommend an evaluation by a healthcare professional, even in the face of subtle symptoms. Through no fault of his own, the diver is often unaware of the full extent of the injury. Although hyperbaric oxygen therapy is effective in treating decompression illness, not all cases will resolve with just one treatment; at times, multiple treatments are necessary, especially in serious cases. DAN routinely works with hospitals for evaluating, transferring and providing appropriate therapies. DAN also encourages divers to seek training for recognizing diving injuries and providing appropriate care. Skills learned in these programs are the first steps in providing assistance. Proper training is essential, but there is no substitute for professional medical evaluation and intervention. DAN will alway s participate and provide the support needed to achieve that goal. Honing Your Skills If you're interested in learning how to better recognize and treat diving injuries, DAN has the appropriate courses for you. Oxygen First Aid for Scuba Diving Injuries As a recreational diver, you can receive training to provide vital first aid that can make a difference to a scuba diver with decompression illness. The DAN Oxygen Provider Course provides entry-level training in the recognition and management of possible dive-related injuries using emergency oxygen first aid.
Oxygen First Aid for Aquatic Emergencies This course trains nondivers and professional rescuers (such as lifeguards) to recognize near-drowning / submersion incidents and other aquatic medical emergencies and to provide basic life support including the use of oxygen first aid.
Advanced Oxygen First Aid for Scuba Diving Injuries This advanced-level program is designed to train existing DAN Oxygen Providers to use the MTV-100 or a Bag Valve Mask while providing care for a non-breathing injured diver.
First Aid for Hazardous Marine Life Injuries Serious hazardous marine life injuries are rare, but most divers experience minor discomfort from unintentional encounters with fire coral, jellyfish and other marine creatures. This course teaches divers to minimize these injuries and reduce diver discomfort and pain.
Automated External Defibrillators for Scuba Diving More than 10 percent of all dive fatalities are actually caused by cardiovascular disease, according to DAN dive accident and fatality statistics. This course teaches divers and other interested parties to provide care for sudden cardiac arrest including the use of automated external defibrillators (AEDs).
Basic Life Support for Dive Professionals The remote nature of dive accidents, whether a few hours from shore or days from civilization, frequently requires more advanced levels of care than are offered by traditional or entry-level CPR programs. On-Site Neurological Assessment for Divers Learn how to conduct a neurological assessment on a potentially injured diver in this course. The information gained in this assessment can help convince a diver of the need for oxygen first aid and help a dive physician determine the proper treatment.
Dive Accident First Aid for Nondivers This program is designed for nondivers and teaches them how to recognize the warning signs of decompression illness and help provide care for a diver involved in a dive emergency. Diving First Aid for Professional Divers This program is intended for divers who are required to have first aid, CPR and oxygen first aid training prior to diving as part of their job responsibilities. It combines the key skills of CPR and first aid training with the DAN Oxygen First Aid for Scuba Diving Injuries, AEDs for Scuba Diving and First Aid for Hazardous Marine Life Injuries courses. Diving Emergency Management Provider Program (DEMP) Learn the knowledge and skills from several courses into one single approach to dive emergency management. Diving Emergency Specialist (DES) Learn about DAN's recognition program for divers who are interested in dive safety. © Alert Diver November / December 2008 |
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