Elevating the Standard of Care

In late 2015, as part of DAN’s Recompression Chamber Assistance Program (RCAP), DAN sent staff to Saba to help improve medical care for divers.

Saba is a small island, with fewer than 2,000 residents in its 5 square miles of steep forested mountains. Lovingly referred to by its inhabitants as the "Unspoiled Queen of the Caribbean," the diminutive Dutch municipality attracts tens of thousands of tourists to its scenic vistas and pristine waters each year. Most visitors to Saba return home with stories about the volcanoes they climbed, the reefs they explored and the locals they met. Most will not have had any reason to use the island's medical facilities. But the unfortunate few who do become sick or injured on Saba will find themselves in good hands.

Such was the case during last winter's Saba Day — an annual islandwide celebration of local culture — when a local dive operation activated emergency medical services (EMS) to investigate a possible case of decompression sickness (DCS) on one of its boats. The diver had recently surfaced after a moderately aggressive dive when symptoms began. By the time the dive boat arrived at the pier, medical personnel were waiting to assess the patient's symptoms and administer oxygen. The patient demonstrated signs and symptoms that suggested a mild case of neurological DCS.

While there's no such thing as a good day to get the bends, this was as close to that as possible: Three DAN® representatives were in Saba, and for the first day in years a fully staffed and operational hyperbaric chamber was only meters away. If the incident had occurred any earlier, the diver would have needed to be evacuated to a neighboring island, but this was the day the staff at Saba's Fort Bay chamber had completed their formal training through DAN's Recompression Chamber Assistance Program (RCAP) and was prepared to receive patients.

The process of reopening the chamber began when Kai Wulf, parks manager for the Saba Conservation Foundation and longtime DAN supporter, applied for a DAN RCAP grant. RCAP is an International DAN (IDAN) initiative designed to provide assistance to recompression chambers in need and, through the international DAN organizations, has served more than 120 underfunded chambers around the world since its inception. Typically these chambers are on small islands in remote locations and are sustained by whatever money they make treating patients or by charging nominal fees through local dive operations. DAN provides RCAP grant beneficiaries with the training, equipment and emergency support they need to deliver quality care to injured divers.

Saba's chamber is a perfect example of the type of operation poised to benefit from RCAP. Donated by the Netherlands to Saba in 1991, the decommissioned naval chamber is humble but well maintained and in good operational condition. Because of Saba's small population, however, the island has only two practicing doctors and not much collective clinical experience treating divers. The Fort Bay chamber and its staff required training and support.

The Saba Conservation Foundation’s hyperbaric chamber at Fort Bay

To provide this support, DAN sent Matías Nochetto, M.D., Marty McCafferty, EMT-P, DMT, and Eric Schinazi, CHT, to Saba for a weeklong site visit. Nochetto, DAN's director of medical programs, runs DAN America's regional RCAP program out of DAN headquarters in Durham, N.C. As a DAN medic for the past 13 years, McCafferty is frequently a main point of contact in dive medical emergencies. Schinazi, a certified hyperbaric technician (CHT) at Duke University Medical Center, often works with DAN because of his vast expertise with hyperbaric chamber operations.

The RCAP outreach project in Saba had three primary goals: Perform a risk assessment, conduct training for chamber operators and attendants, and establish relationships with the local physicians and chamber staff. Risk assessments are tailored to each facility and allow DAN to make safety recommendations and create a customized plan to help each chamber conduct its own future inspections and basic maintenance. During the Fort Bay inspection, for example, Schinazi discovered that the chamber's fire extinguisher was out of service — a level-one risk that would prohibit the chamber from reopening. The team was able to service it and leave it in operational condition with instructions for preventative maintenance.

The team conducted training modules, introducing, reviewing and practicing essential skills with the chamber operators and attendants. Nochetto also conducted a three-hour session for three local doctors and 12 nurses that included lectures about recompression therapy, oxygen first aid for scuba diving injuries and a series of case reviews. According to Dr. Gijs Koot, one of Saba's two practicing physicians, "I learned more in those three hours than I learned in a week the last time I underwent training."

Establishing relationships with remote chambers is one of the most mutually rewarding elements of the site visit, as it makes future emergency calls run more smoothly. "When you spend a few days with these people, share meals with them and get to know them, you bond with them," Nochetto explained. "Then when they have a case it is easy for them to pick up the phone and call. That's great for us because we won't make blind referrals; it's great for them because they know we won't send them a patient they're not equipped to handle; and last but not least, it's great for divers because we will only send them where they can be treated effectively." Koot reiterated Nochetto's sentiment, saying that the visit "makes future calls for advice much smoother now that we know each other."

Saba Health Care Foundation’s A.M. Edwards Medical Center

When the Fort Bay chamber received its new patient, the RCAP visit was nearing its end. Within 15 minutes of being notified that the diver was demonstrating symptoms, Nochetto was at the pier with the attending physician, Gina Boorsma, M.D., and the EMS crew, McCafferty was in scrubs and ready to join the patient and other attendant in the chamber for the duration of treatment, and Schinazi was helping staff prepare the chamber. It was the first treatment conducted in that chamber in years, and for most of the staff it was their first time treating a patient.

"Nobody likes to hear about a diver developing DCS," Nochetto said, "but this ended up being an extraordinary opportunity. Not only did the staff have the opportunity to put their skills to use immediately after training, but they also demonstrated their commitment to providing exceptional treatment and did a wonderful job." After a U.S. Navy Treatment Table 6 recompression treatment with two extensions, the patient emerged almost completely free of symptoms.

With its chamber now up and running and chamber staff properly trained, Saba can add recompression therapy to its repertoire of medical capabilities. By raising the level of its operation, the clinic serves not only the dive community, but also any members of the Saba community who may require hyperbaric treatment for other medical conditions.

Overall, the visit was constructive for the Saba chamber team and the DAN team alike. "It was quite an experience," McCafferty recounted. "Everything I saw showed me they really wanted to know how to take care of people when necessary. I would feel very confident if one of our members needed treatment in Saba." Then he added, "And I can't even remember the last time I ate fish that fresh."

© Alert Diver — Q2 Spring 2016