Don’t Assume

The diver was a 28-year-old male who had been certified for three years and completed more than 100 dives. He had no known medical problems, took no regular medications, exercised regularly and had no recent illnesses or injuries.

He and a companion made two boat dives off the Gulf Coast of Florida. The seas were calm, and there was no appreciable current. The first dive was a multilevel dive to 90 fsw for 30 minutes with a surface interval of 1 hour and 10 minutes. The second dive was also multilevel to a maximum depth of 80 fsw for 32 minutes. Both dives were completed on air, and the diver reported no difficulties or problems with either dive.

While climbing the boarding ladder after the second dive, he experienced a sudden onset of acute pain in his right lower back just above the beltline. The pain intensified and progressed from his back to his flank and into his lower abdomen. He did not report the symptoms to the boat crew and was decidedly uncomfortable on the 45-minute boat trip back to the dock. He informed his companion of his pain during their 20-minute drive home. Unable to find a comfortable position, the diver noted his pain came in waves of high intensity. In addition to the pain, he experienced a strong pressure sensation in his bladder and the continual urge to urinate.

Eventually he contacted DAN® and described his symptoms to the medical staff. At the time of his call, he was trying to decide whether he should travel 10 minutes to his local hospital or make a 90-minute drive to the nearest medical facility with a hyperbaric chamber.

The question of where a diver should undergo initial evaluation is a common dilemma. The concern usually stems from a lack of confidence in the local medical facility to adequately evaluate and manage diving-related illnesses. In the heat of the moment, such a concern can prompt divers to travel great distances to reach a chamber facility, often bypassing much closer medical care. However, it's been DAN's experience that this is unnecessary, as the fear of inadequate local medical care is largely unfounded.

The level of diagnostic sophistication or the personal experience of a given medical staff cannot be predicted. Despite the fact that a hospital may not see a lot of diving-related cases, one cannot assume that the staff is unfamiliar with the proper management of diving accidents. Emergency department physicians unfamiliar with diving injuries are consistently more motivated to seek help and often consult DAN.

Keep in mind that even if a hospital has a hyperbaric chamber, the diver will still usually undergo initial evaluation and stabilization in the emergency department. It is essential to deliver prompt emergency care and to rule out other possible disorders before treating decompression illness (DCI). Sometimes the diagnosis of DCI actually results from the exclusion of other diseases, so a timely and thorough evaluation is of key importance.

Another little-known piece of the prehospital triage puzzle relates to chamber availability — and chambers are not always available. The receptivity of a hyperbaric medicine department is subject to multiple variables, including operating hours, staffing, patient load and maintenance. In addition, not all hyperbaric departments are set up for treatment of decompression injuries or after-hours care. Just because a chamber might be close does not mean it is available. DAN's chamber referral database keeps chamber variables constantly updated so that if you do require hyperbaric care, you are assured of arriving at a facility that's ready to treat you.

The desire to minimize the period from symptom onset to treatment initiation for DCI is an understandable and relevant consideration, as it is generally accepted that the earlier the treatment begins, the better chance a patient has of a favorable outcome. Each situation varies, but DAN's general recommendation is to resist the urge to diagnose decompression illness on your own and to seek local evaluation first.

Divers are not alone in thinking they have to go to the nearest chamber facility first. A common desire among first responders trained in diving accidents is to arrange for transportation to the nearest chamber when DCI is suspected. The intent is absolutely understandable, but it can be misguided. It is important to remember that not all diseases associated with divers are decompression-related. Emergency rooms can investigate other possible causes of illness, such as heart disease and pulmonary barotrauma. They also have abundant oxygen supplies and can administer IV fluids and attend to other medical issues.

If a diver requires transfer to another hospital for hyperbaric treatment or specialist evaluation, that transportation is best done under medical supervision. Medical crews can continually monitor and administer oxygen and IV fluids while under way. In the unfortunate event that a diver's condition deteriorates during transport, medical crews can provide appropriate and immediate care. If driven by a friend or family member, appropriate evaluation could be delayed and acute changes in health status left untreated.

The DAN medical staff encouraged the diver to seek evaluation at the closer hospital. Upon examination, the final diagnosis was a kidney stone. The symptoms reported could have been DCI, but they also suggested other possible medical problems. The frequently listed signs and symptoms associated with DCI are not exclusive to decompression disease. Had this diver driven to the nearest chamber on the premise that his complaints were a manifestation of DCI, he would have unnecessarily endured a longer, painful trip and potentially put himself in greater danger.

Don't assume that a symptom you're experiencing is DCI simply because you've been diving; get yourself to the nearest medical facility and in the care of those trained in emergent care. A full evaluation is an important step in proper diagnosis and treatment. Remember, too, that DAN stands ready to assist both you and medical professionals, whether it's simply providing information or arranging transport to another medical facility.

© Alert Diver — Summer 2010