Explore All Possibilities

Symptoms do not always point to just one definite cause, so it is often just as important to continue listening to the patient and exploring options that might not be immediately apparent.

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The Diver

The diver, a 32-year-old male, was an experienced recreational dive instructor. Approximately 18 months prior to the dive incident, he was injured in an all-terrain vehicle accident, suffering serious injuries to his face and skull. He required multiple surgeries to repair and reconstruct the orbit of his left eye, both zygomatic arches (cheek bones) and his maxilla (upper jaw). Some of the fractures entered the maxillary sinus cavity. The diver’s maxillofacial surgeon authorised him to return to diving after a prolonged recovery. He gradually resumed diving with no problems or complications.

The Dive

The diver was instructing a class of four students for their second day of open-water dives. The dive was planned with a beach entry and a brief surface swim to an area with a maximum depth of 9mt, accompanied by a certified divemaster and an experienced rescue diver. When the group began to descend, the instructor immediately experienced intense pain on the left side of his face from his cheek to his forehead. The pain quickly progressed from distracting to incapacitating.

The divemaster recognised that the instructor was having a serious problem and safely ascended with the students from about 5m. The rescue diver descended to assist the instructor, finding him on the bottom holding the left side of his face with one hand and securing his regulator in his mouth with the other. The rescue diver was able to assist the instructor in making a controlled ascent to the surface. They established positive buoyancy and reached shore. The pain was so severe that the divemaster called emergency medical services (EMS) and waited for an ambulance to arrive. The EMS crew performed a quick assessment and transported the instructor to the closest emergency department (ED), which was at the hospital where he had been treated for his previous injuries.

Medical Evaluation

The ED staff administered pain-relief medication. The attending physician examined the diver and promptly sent him for a CT scan of the head and face. Consulting the scans, the attending radiologist and maxillofacial surgeon who had previously treated him found no obvious signs of complications associated with the surgeries. The sinuses, orbit and other bones were healed, and no hardware had been displaced. There was no clear cause of the intense pain. The doctor prescribed pain medication and scheduled a follow-up appointment for the diver to see the maxillofacial surgeon.

The next day the diver called the DAN® Medical Information Line (+1-919-684-2948) and told the DAN medical staff about his experience. Because the most likely cause of his symptoms was a complication from his previous injuries, the caller sought a referral to an ear, nose and throat (ENT) specialist with dive medicine experience. Fortunately, a suitable ENT in the DAN referral network was near his home. The specialist, who also suspected a complication from the diver’s previous injuries, could not offer a solution other than to continue taking the medication and following up with his surgeon. Ten days after the dive, his pain persisted and was relieved only by the medication.

A Different Perspective

Despite the pain, the diver kept a scheduled appointment with his dentist for an unrelated issue. During the examination the dentist was able to localise the pain in an upper bicuspid (tooth between the canine and molar). After taking X-rays, the dentist determined that the root of the tooth had an abscess and the tooth was cracked. It is likely that during equalisation the diver unintentionally forced food, air or some other material into the tooth, which prompted pain associated with the exposed nerve. The dentist extracted the tooth, and there was purulent drainage from the socket, which is a sign of infection. The pain subsided as the fluid drained. By that evening the diver no longer needed to take pain medication, only an antibiotic to address the infection.

Conclusion

This case is an example of how easily prior medical history can become a focal point. A history of severe injury certainly warrants an evaluation of the previously affected areas, but this focus should not happen at the exclusion of other possibilities. The doctors, the specialist and DAN medics all lost objectivity to the physical discomfort of the patient. Fortunately, his situation was not life-threatening, although he required pain medication longer than he would have with a more thorough evaluation. It is imperative to try to avoid opiate use for any longer than necessary.

Every misstep is a teachable moment: All of us in DAN Medical Services learned from this case to remain diligent in our evaluations and avoid tunnel vision.

© Alert Diver — Q4 Fall 2018

Know Your Coverage

Are You Covered for Emergency Medical Evacuation and Dive Injury Treatment Costs?

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Recently, a DAN Member living and working in Thailand experienced DCI. He had just completed five days of diving with three to four dives per day while teaching.

On the final dive he experienced a rapid ascent from 14 meters. Following the dive, he immediately experienced extreme vertigo and vomiting.

He went to the local hospital and was kept overnight on oxygen. The vomiting subsided, but he was still dizzy and uneasy on his feet. All other tests came back negative. The doctor at the hospital recommended recompression treatment.

It was at this time that DAN was called to check the member’s coverage.

While we hope no diver has a situation like this, it does happen. So how do you know what your DAN membership and coverage can help you with?

Two Components to DAN World Coverage

When you become a DAN member, your membership includes Worldwide Medical Emergency Evacuation (up to US$150,000).

Membership alone does NOT cover treatment. When you are applying online for DAN coverage, you are asked to add on a level of Dive Injury Treatment Coverage. This dedicated coverage is designed for treatment costs associated with a covered in-water diving accident, which may require chamber or hospital treatment.

A very sick diver can require multiple recompression treatments, and a stay in hospital, and these costs can amount to tens of thousands of dollars.

When applying for DAN coverage we encourage you to review the treatment coverage options, and the coverage provided, and choose the treatment plan that best meets your diving needs.

And if you are not sure what coverage you have, we encourage you to contact the DAN World Membership Team. We are here to support our members and ensure you have coverage with a company you can trust.

Are You Covered for Emergency Medical Evacuation and Dive Injury Treatment Costs?

  • Membership benefits cover the costs associated with medical emergency evacuation but do NOT cover the cost of the chamber treatment.
  • If you are living and/or working in a coverable region, and experience DCI due to a covered diving accident, one of DAN’s treatment coverage options can help with the expenses that may arise as result of having to be treated in a chamber.
  • Once your DAN coverage is in place, you can dive with confidence knowing that your covered dives will be protected.

 

Infection from Crown of Thorns Puncture

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A DAN Member recently called for help following a puncture wound on his index finger from a crown of thorns the previous day. At the time of the injury he was offshore on his own boat. He proceeded to a point where he could take a fast day boat trip to the nearest hospital.

He had soaked his hand in hot water, which provided some relief, but he woke with a blue and swollen hand with further swelling and inflammation moving up his arm.

He was taking amoxycillin. The DAN doctor advised that he needed to proceed to a medical facility as soon as possible to be evaluated, and receive antibiotics and a possible tetanus shot.

After surgical removal of a small piece of spine which was still lodged in his finger, he spent the night in the hospital while receiving antibiotics. When DAN spoke to the member he was feeling much better, and the pain and swelling were subsiding.

The member recovered well and was able to return to his boat.

The following extract from an article in Alert Diver magazine by Joseph Becker, M.D., and Paul Auerbach, M.D., M.S, discusses treatment for starfish and sea urchin punctures.

STARFISH AND SEA URCHIN PUNCTURES

Starfish are common bottom-dwelling animals and contact by divers is usually accidental. The crown-of-thorns starfish is a species with particularly potent venom. The thornlike spines on the starfish’s surface are sufficiently sharp and stout to pierce a thick wetsuit. The spines release a toxin that can cause significant stinging pain as well as systemic symptoms such as nausea and vomiting.

Immediately immerse starfish puncture wounds in hot water to tolerance. A rescuer should test the temperature to avoid scalding the injured person. If the spines can be easily grasped without fragmentation, they should be removed and the wounds then washed with soap and water. Wounds should not be closed but may be dressed and bandaged. Puncture wounds are especially prone to infection, so treating physicians will consider antibiotic therapy, particularly if damage to deeper tissues is suspected or if the victim has an impaired immune system.

Sea urchin punctures may be treated similarly, although it is often difficult to achieve thorough removal of all spine fragments. The long, thin and brittle spines are likely to break off inside wounds, making identification and extraction challenging. Purple or black discoloration of the skin at the puncture site does not necessarily mean that a fragment is still embedded in the tissue. This “tattoo” may result from dye that has rubbed off the surface of the spine. If the discoloration persists after 24-48 hours, a retained spine fragment should be suspected. Spines or fragments penetrating deeply into tissues or joints

Read the full article: Marine Envenomations – Invertebrates

DAN, Can You Tell Me…

The DAN Medical Services team addresses a wide range of questions from members and non-members every day relating to diving health and safety. Over the past weeks, these questions have included intracranial hypertension, Bell’s palsy, the impact of taking supplements, pinched nerves and so much more! Here is a sample.

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DAN, can you tell me ….

Hi DAN, I have had a pinched nerve for a few days that is bothering my right thigh. I gave it a couple of days, but there is no real improvement. Last night we had some friends over and one mentioned it might be because of my wetsuit. Normally I dive in tropical water, but currently in cooler water, so I purchased a waterproof 5mm long wetsuit about 2 weeks ago. Do you think my pinched nerve has something to do with the wetsuit because it’s tight — a good fit rather than too small?

DAN Answer: The pain in your thigh in unlikely to be related to a snug-fitting wetsuit. This type of pain you describe, a pinched nerve feeling originates from deeper within the tissue. The pressure from a too-tight wetsuit is superficial. It is more likely related to lifting and maneuvering of heavy scuba gear or an injury.

 

Hi DAN, I have Bell’s palsy, partial paralysis on the right side of my face probably caused by an ear or throat infection. The infection is gone but the paralysis is still there. I am a commercial diver and was wondering if can I dive with this condition or if diving will make it worse?

DAN Answer: Bell’s palsy, as you are aware, causes unilateral facial weakness and pain. Although often transient, it can also be permanent. There are some risks to consider. Since pain and paralysis can also be symptoms of DCS, it can make the diagnosis and treatment of DCS more difficult. If your ability to blink on that side is decreased, you can develop corneal ulceration, which can be worsened by exposure to seawater and the extreme environment encountered in diving (wind, salty air, etc.). A common treatment for this condition is a drug called acyclovir (antiviral). It’s important to consider that this drug can lower the seizure threshold. With facial paralysis, there can be difficulty with firmly retaining a regulator in the mouth. This would be less of a risk for you with the helmet, but perhaps there are occasions when you use a regulator with a mouthpiece. It would be best to wait until you have completed all treatment, have had a recovery period, and have been cleared to dive by a doctor with dive-medicine experience.

 

Hi DAN, I’ve recently started a strength training program, and I am taking supplements to optimise my regimen. Are there any implications for diving regarding these supplements: Beetroot supplement 500 mg, Creatine 5gm, Beta alanine 4gm, Methylsulfonylmethane MSM 3gm, whey protein or fish oil?

DAN Answer: Supplements should not be an issue with diving. With that said, there are no research studies on the effects of supplements in the hyperbaric environment. Given that you are overall healthy and engage in regular exercise, the larger question is the potential side effects of the supplements.

The general recommendation is to be on any new medication or supplement for at least thirty (30) days to rule out any potential negative side effects or adverse reactions. Do discuss your desire to dive while taking these supplements with your health care provider.

Do you have a diving-related medical question? If so, send your question to DAN’s Medical Services team: https://www.diversalertnetwork.org/?a=medicemail.

Timeline of an Emergency Call

By Matias Nochetto, M.D.

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The DAN® Emergency Hotline receives an average of 5,200 calls per year. DAN medics and physicians work 24 hours a day, 365 days a year to provide emergency medical assistance to divers in need. No matter where they are or what they are doing, these dedicated medical professionals answer the call. The following is a timeline of a recent case that exemplifies how things unfold when a diver calls DAN in an emergency.

2:28 a.m. ET: Dutch Caribbean — Dive Resort
Mr. Smith, who is 56 years old, cannot sleep. His urge to urinate is painful, and upon sitting up in bed he realizes his legs are numb. He is unsure if he can even stand up. Something is wrong. He wonders, “Am I bent? How is this possible? I did everything right.” Mrs. Smith advises her husband to call DAN.

The DAN medical department has a tested and effective protocol that governs every call to the emergency hotline.

2:35 a.m. ET: Durham, North Carolina — Home of a DAN Medic
A DAN medic’s mobile phone rings. The operator passes along Mr. Smith’s name, phone number and location. Mr. Smith reports eight dives over the past two days and describes his symptoms. The DAN medic recognizes that this may be serious decompression sickness (DCS), which requires a timely response. The medic recommends that Mr. Smith seek an evaluation at the closest medical facility and call DAN once he is there so a medic can speak to the examining physician. Mr. Smith agrees to ask his dive buddy to help him get to the local clinic.

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2:45 a.m. ET
The DAN medic calls the hyperbaric chamber on the island to alert them of a possible case of DCS. This case will likely push the limits of the facility’s capabilities. The hyperbaric doctor on staff agrees this could be a spinal cord hit and alerts the staff.

3:05 a.m. ET: Dutch Caribbean — Medical Clinic
Mr. Smith and the evaluating physician call DAN for a consultation. The physician reports that his patient has bilateral lower-extremity weakness, decreased sensation and urinary retention. He agrees with DAN’s initial assessment that Mr. Smith likely has DCS. The DAN medic informs the physician that he has already alerted the local hyperbaric facility, and the physician arranges for an ambulance to transport the patient to the chamber.

3:45 a.m. ET: Dutch Caribbean — Recompression Chamber Facility
Mr. Smith requires assistance to get into the chamber because he cannot walk and has a urinary catheter in place. The hyperbaric physician had agreed to treat the diver, but upon examination he realizes the case requires a higher level of care than his chamber can provide. He administers an initial hyperbaric chamber treatment while the DAN medic begins arranging an evacuation to a better-suited facility.

4:05 a.m. ET: Durham, North Carolina — Home of a DAN Medic
The DAN medic contacts DAN’s medical director to brief him on the case; he concurs with the plan. The medic then contacts DAN TravelAssist, which arranges emergency medical evacuations, and briefs them on the case. It is determined that the most appropriate chamber facility for Mr. Smith is in Miami, Florida.

4:30 a.m. ET: Stevens Point, Wisconsin — DAN TravelAssist Headquarters
A DAN TravelAssist representative contacts Mercy Hospital in Miami, which agrees to receive the patient. They alert the treating physician at the chamber in the Dutch Caribbean that a medical evacuation is being arranged.

5:00 a.m. ET: Dutch Caribbean — Recompression Chamber Facility
Mr. Smith reports some improvement during the treatment. He is starting to feel his legs again but is still too weak to resume normal walking. The treating physician explains this is normal and is a good sign. This first treatment will be completed at 9 a.m. ET.

8:30 a.m. ET: Durham, North Carolina — DAN Headquarters
The medic is now at DAN headquarters. DAN TravelAssist confirms that an air ambulance has been contracted to conduct the evacuation, during which the aircraft will maintain sea-level pressure. They will be ready to take off from Ft. Lauderdale, Florida, at 9 a.m. ET and should arrive in the Dutch Caribbean at 12 noon ET.

10:00 a.m. ET: Dutch Caribbean — Recompression Chamber Facility
Mr. Smith has completed his first treatment, and the treating physician reports the patient has recovered some motor function and some sensation. Mr. Smith and his wife will be ready for the medical evacuation by noon.

11:30 a.m. ET: Dutch Caribbean — Airport
The treating physician, a nurse, a paramedic, Mr. Smith and his wife arrive at the airport, and the air ambulance jet lands soon afterward. After the jet refuels and personnel complete documentation, the patient, his wife, a flight nurse, paramedic, treating physician and the pilots board the plane, which takes off less than an hour after it landed.

3:35 p.m. ET
The air ambulance lands in Miami, where a ground ambulance is waiting on the tarmac. The travelers promptly clear immigration and customs under special emergency procedures.

4:15 p.m. ET
The ground ambulance travels 9 miles to Mercy Hospital in less than 20 minutes.

4:45 p.m. ET: Miami, Florida — Mercy Hospital
Mr. Smith is admitted to the hospital, and a hyperbaric medicine specialist receives him at the emergency department. The doctor and nurses perform examinations, draw blood, confirm the patient’s medical history, complete the necessary paperwork and contact DAN to confirm Mr. Smith’s insurance.

5:30 p.m. ET
The hyperbaric doctor initiates a second chamber treatment, a U.S. Navy Treatment Table 6.

10:30 p.m. ET
Following the treatment, Mr. Smith is tired but happy to be regaining strength. The hyperbaric specialist explains that he is doing well but that these cases are serious and need to be treated aggressively.

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Over the next two days Mr. Smith receives four U.S. Navy Treatment Table 5 hyperbaric treatments and has physical therapy between treatments. Medical staff remove the urinary catheter after the fourth Treatment Table 5. Mr. Smith still has residual weakness in both legs but can walk with less assistance.

In the next few days Mr. Smith has four U.S. Navy Treatment Table 9 regimens, and his residual weakness remains unchanged after each of the last three treatments. The treating physician realizes that Mr. Smith has reached a clinical plateau and that further hyperbaric therapy is of no value. Time and continued physical therapy are now the appropriate treatment.

After three months Mr. Smith recovers full strength in his left leg and has only a slight decrement in his right. After two additional months, the strength in his right leg also returns to normal.

© Alert Diver — Q1 Winter 2019

10 Things You Might Not Know About Decompression Illness (DCI)

By John Lippmann, Chairman and CEO of the Australasian Diving Safety Foundation (ADSF)

Remember that the term decompression illness (DCI) includes both decompression sickness (DCS) resulting from dissolved nitrogen (or another inert gas) being eliminated from a diver’s body tissues; and arterial gas embolism (AGE) which is caused by air entering the arterial blood because of a burst lung.

  1. DCI was first reported in 1667 in a snake – not a diver!
    Boyle (from Boyle’s Law) placed a viper in a vacuum and noticed a bubble forming in its eye.
  2. It’s possible to get a burst lung and subsequent DCI (arterial gas embolism) in as little as 1.2 m of water. If a diver fills his lungs with compressed air and surfaces without exhaling, there is enough pressure change in the first 1.2 m from the surface to over-expand the lungs sufficiently to cause a tear.
  3. Divers have suffered from DCS after ascending from depths as shallow as about 6-7 m. It used to be thought that one had to dive deeper than 10m before DCS was a risk, but this is now known to be untrue.
  4. Most divers (possibly around 90%) who get DCI have been diving within the limits of their dive computer or tables. However, the risk of DCI increases when a diver exceeds these limits. This indicates that the limits cannot accurately account for individual differences between divers and the various factors that can influence nitrogen uptake and elimination during a dive.  All divers should add conservatism to their decompression calculations, especially is the diving is purely recreational and dive time doesn’t need to be maximised.
  5. Bubbles form within divers’ bodies during or after many dives, especially repetitive and deeper dives. These bubbles can be detected using ultrasound and usually do not cause symptoms. Some divers “bubble” more than others. A slow ascent rate and doing a safety stop reduces the amount of bubbling and therefore the risk of DCI.
  6. Some divers are more susceptible to DCI than others. Divers with a patent foramen ovale (PFO),which is a common heart defect that can enable blood to flow across the heart, have a significantly higher risk of DCI (sometimes quoted as 2 to 8 times, depending on the size of the hole). Other factors such as being overweight, increasing age, lack of fitness and dehydration may also play a role although there is little hard evidence to support some of these beliefs.
  7. A mottled reddish/purple/bluish rash is an increasingly common sign of DCI and is often associated with the presence of a PFO. Skin-related DCI used to be relatively uncommon in recreational divers. However, over more recent years it has become far more common. Part of the reason for this could be the result of the more frequent and longer dives and shorter surface intervals enabled by dive computers.
  8. Oxygen first aid is often delayed, given using unsuitable equipment and for too short a period. Good oxygen first aid is very important in the management of DCI and this is often poorly done. To maximise the benefit, near-100% oxygen should be given from the time symptoms first occur, and continued until a diving doctor advises that it be stopped.
  9. Many dive operators in remote areas do not have access to a sufficient supply of oxygen to last until an injured diver receives appropriate medical care. It can sometimes take over 24 hours for an evacuation team to reach some remote locations so a large supply of oxygen is required. Check this out before you go on a dive trip to an area without good access to suitable medical care.
  10. About 120-150 divers are treated for DCI in Australia each year.

 

 

Whose Fault is it Really?

The Incident: A relatively inexperienced diver, armed with only an Open Water Certification that equipped him with a basic knowledge of skills and equipment (for diving to a recommended depth of 18m), decided to book himself on a wreck dive to 30m at a site known to have a strong current.

When making the booking, the diver expressed his lack of experience and apprehension about undertaking the dive, but the shop staff still booked him in for the dive.

The dive crew provided a dive brief, including depths and currents, and advice that the visibility may be poor. The diver was not assigned a buddy, rather told to stay with the group. This concerned him, but he followed along with the others. Diving without a buddy was considered normal as the divemaster was usually able to keep small groups together.

As advised, visibility on the bottom was poor, the group ended up separated, and the diver was left alone. Unable to locate the other divers, he panicked and made a rapid ascent to the surface where he lost consciousness and had to be retrieved from the water by the boat’s skipper.

As a result of the rapid ascent, he suffered a gas embolism and was lucky to survive.

Emergency

Who is responsible for this incident? 

Is it the dive crew who failed to provide buddy teams and lost contact with the diver? Is it the dive shop who allowed this inexperienced diver to book onto a dive he wasn’t qualified to do? Or is it the diver who knew better than anyone that he was not prepared to undertake this dive?

While everyone plays a part in this scenario, the diver needs to take substantial responsibility as he is ultimately responsible for himself. Firstly, he signed up for a dive, despite being apprehensive, as he knew it exceeded his experience and training. He then went along with the plan to dive without an assigned buddy, despite not being comfortable with this, and knowing from his training that it wasn’t right. At any time, the diver could have, and should have, aborted but he didn’t. However, in his defence, it is difficult for an inexperienced diver to judge what the demands of the dive may be.

Of course, the shop staff and the dive team also contributed significantly: The shop staff should have questioned the diver further and knowing the conditions didn’t match the diver’s training and experience, they should have signed him up to a more suitable dive. Further, the dive crew should have re-assessed his suitability for the dive. They should also have assigned buddy pairs, particularly in poor visibility.

Unfortunately, this scenario is not an uncommon story. I have previously written about knowing when to call a dive, yet divers continue to push their limits.

Bottom line: If you are not fully prepared for the dive, both mentally and physically, or you are not qualified or experienced to do the dive, abort. There is no shame in calling a dive. It is certainly not worth injuring yourself, or worse, to complete a dive.

 

Scott Jamieson

DAN World Regional Manager