DCI, dehydration or a cardiovascular-related event? In this recent case in PNG, DAN made the decision to evacuate the diver, and had to factor in the treatment he could possibly require once he underwent medical tests.
The diver was on a diving holiday in PNG and had completed one dive the previous day without issue, and three dives on the day of the incident:
Dive 1: 30m for 30 minutes with a 40 minutes surface interval.
Dive 2: 22m for 65 minutes with a 2 hour surface interval.
Dive 3: 20m for 50 minutes.
All dives had minimal time at maximum depth, with most of the time spent at 10m-12m. Safety stops were completed on all dives. Upon surfacing from the second dive he developed a headache but did not say anything. Upon surfacing from the final dive he looked and felt unwell. He had a headache, tingling in his arms and hands, dizziness and haziness.
He was placed on oxygen on the dive boat and taken back to the resort where he continued breathing oxygen via a non-rebreather mask at 12 litres per minute (l pm) in a reclined position. When he attempted to go to the bathroom he collapsed due to weakened legs and appeared to be in a semi-conscious state. When the call to DAN was made he had been receiving oxygen first aid for around 2-hours and the most of the symptoms remained.
Based on the information provided to the DAN diving doctors regarding the dive profiles and the diver’s medical history the diagnosis was not clear and could have been attributed to DCI, dehydration, or a cardiovascular event. Due to the seriousness of the symptoms DAN immediately contacted TravelAssist to implement emergency evacuation procedures.
While the evacuation options were being investigated the diver was required to remain breathing oxygen in a reclined position and to receive fluids. The operator was asked to monitor the weakness in the diver’s legs to ensure this did not evolve to paralysis and to ensure the diver could continue to urinate.
The plan was to evacuate the diver to Townsville Hospital for evaluation and possible chamber treatment. As it could not at this stage be confirmed whether the incident was dive-related or a non-dive medical situation, Townsville Hospital was considered the best option to ensure he received the care required. The hospital was notified and it was confirmed they could receive the diver for evaluation and co-ordination of treatment.
Upon arrival at the hospital the diver underwent neurological tests, all of which he completed well, except for the Sharpened Romberg test. The test involves the patient standing upright with one foot in front of the other (heel-to-toes) and with arms folded across the chest. The diver is then asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign, although several attempts may be made. Ideally, the diver can maintain the position (albeit with some wobbling!) for one minute.
From the tests conducted at the hospital the diagnosis was DCI, as such the diver received a US Navy Table 6 treatment (RN 62) and afterwards his Rombergs improved significantly.
He was discharged from hospital the following day with no residual symptoms and was asked to hold off flying home for several days given the severity of his symptoms. He decided to drive home over two days and did so without problems, other than fatigue. Happily, he is expected to make a full recovery.
EVACUATION COST: AU $57,000.
DAN COMMENT – Provided by John Lippmann
Although he described himself as very fit and went to the gym five times a week, the diver’s medical history included a triple heart bypass so the DAN doctors could not rule out a cardiac event when assessing his early symptoms. This fact also had to be taken into consideration when determining the most appropriate evacuation for the diver.
Of interest, back at the lodge when the diver was lying down and breathing oxygen, he reported only minor current symptoms but collapsed while going to the toilet. When the DAN medic asked if he had normal strength in his legs, he answered “yes”. However, when the medic asked the diver’s wife to hold down his legs and asked him to try to lift them against her force, he was unable to do so. This confirmed that he did have leg weakness that heightened the level of concern of the medic who then had to consider the possibility of progressive paralysis. The preferred option would have been to move the diver to a clinic to receive IV fluids and to have a urinary catheter inserted if it became necessary. However, the local clinic was very basic, and it was likely that the diver wouldn’t receive the required care. It was decided that the diver would be more comfortable where he was and was receiving better oxygen first aid at the dive resort than would be available at the clinic. Fortunately, this turned out to be a good decision as the diver improved substantially overnight.
As we come to the end of another year, many of you are likely to be making plans for overseas diving holidays for 2019. We hope the cases we have shared with you throughout the year have encouraged you to do your research BEFORE making a booking, to seek out operators that are prepared to help you (or a friend or loved one) should an incident occur.
Stay safe in 2019 and enjoy all your time underwater.