11 y/o Surfaces with Convulsions

[GJC]

I'm not a doctor or a hyperbaric physiologist but I've been a diver for a while. When I read the story, my first impression was an expansion injury with neurological involvement (CAGE).

I would think medical exams could spot this but not sure what diagnostics would be used.

An arterial gas embolism big enough to cause loss of consciousness would probably be detected by CAT Scan with IV contrast that would show a blocked artery.

AGE would probably not have symptoms quickly resolved on scene as described in this case.

 

[Belzelbub]

I've seen six divers carried away in ambulances but have never seen that done, altho most of those were outside of the US.

Luckily, I’ve only seen a diver taken away by ambulance, but in that case, I never saw someone collect the gear. The paramedics did not collect the gear. Happened during a checkout dive. I brought the diver’s gear ashore, as the instructor was assisting the diver. I was allowed to close the valve, but instructed not to break down the gear at all, as it was going to be thoroughly checked out.

In talking with the instructor later, I do know that the gear and tank contents were analyzed, but no one came to collect it.

 

[John the Pom]

AGE seems like the likely hazard for an inexperienced diver in shallow water. However, I remember an incident in Sydney many years ago where a young instructor or divemaster ended up with apparent DCS following a couple of days of repeated "up and down" dives in a pool assisting with a training course or some event (my memory is hazy). Maybe there was a possibility of PFO - I don't recall.

We waited until our kids were 16+ before they did their OW training. I was concerned about maturity (although they are both very smart & sensible) and also about the potential for long-term effects of "silent" bubbles on growing bones etc. We had heaps of fun snorkelling, though!

 

[uncfnp]

I believe earlier it was reported he was flown to Nicklaus Children’s Hospital in Miami. Is there facilities to deal with dive trauma? A hyperbaric chamber? If not would this not rule out AGE? Or any other dive specific injury?

Not all “convulsions” are epilepsy nor even brain injury. It is possible to have seizure like activity with syncope.

 

[rjack321]

I believe earlier it was reported he was flown to Nicklaus Children’s Hospital in Miami. Is there facilities to deal with dive trauma? A hyperbaric chamber? If not would this not rule out AGE? Or any other dive specific injury?

Not all “convulsions” are epilepsy nor even brain injury. It is possible to have seizure like activity with syncope.

It is not uncommon at all to go to the nearest medical facility to get stabilized - even if they don't have a chamber. Sending an 11yo to a nearby children's trauma center makes sense. They have the expertise to figure out what is going on, even if they might have to transfer him for actual treatment.

It would be rare to stuff someone with ongoing convulsions or other acute injury in a chamber since that pretty much rules out giving them so many other treatments, e.g. if he had an aneurysm. The last thing you need is a mis-diagnosis trapping someone in a chamber for hours while they actually have another injury that can't even be evaluated nevermind treated in there.

 

[DandyDon]

Luckily, I’ve only seen a diver taken away by ambulance, but in that case, I never saw someone collect the gear. The paramedics did not collect the gear. Happened during a checkout dive. I brought the diver’s gear ashore, as the instructor was assisting the diver. I was allowed to close the valve, but instructed not to break down the gear at all, as it was going to be thoroughly checked out.

In talking with the instructor later, I do know that the gear and tank contents were analyzed, but no one came to collect it.

Yeah, that's about the best actions expected...
1: Ambulance leaves with the victim but never taking the gear.
2: At best, the tank is closed and kit kept together for analysis, but by then the chain of evidence is getting questionable.
3: You hear that someone checked the kit, but no details - hardly ever an expert gas analysis.

 

[rjack321]

Yeah, that's about the best actions expected...
1: Ambulance leaves with the victim but never taking the gear.
It's not like ambulances leave with car or aircraft or climbing or other sporting equipment either.

2: At best, the tank is closed and kit kept together for analysis, but by then the chain of evidence is getting questionable.
Yeah typically by someone who was there, maybe even the same instructor/technician who last serviced it.

3: You hear that someone checked the kit, but no details - hardly ever an expert gas analysis.
Having agencies require affiliated shops and fill stations keep a gas test kit on hand for use in a potential fatality wouldn't be cheap but it would definitely help.

 

[Belzelbub]

Yeah, that's about the best actions expected...
1: Ambulance leaves with the victim but never taking the gear.
It's not like ambulances leave with car or aircraft or climbing or other sporting equipment either.

Correct. They have a different goal. It’s always about getting the victim stable to transport to a medical facility for care.

Also, it’s worth noting that in most SCUBA accidents, foul play is not suspected. Maybe negligence in some cases, but that’s generally for a civil case, not necessarily criminal, though it could be.

2: At best, the tank is closed and kit kept together for analysis, but by then the chain of evidence is getting questionable.
Yeah typically by someone who was there, maybe even the same instructor/technician who last serviced it.

Yes. In the case I witnessed, it was taken by the instructor. He was in contact with his insurance company. His shop did not sell or service this diver’s gear. I am not sure who inspected the gear, though.

 

[Dr Simon Mitchell]

I get what you are saying and anything under the moon is a possibility, but it seems improbable to me that the convulsions were caused by something he did while diving. The depth was 20 feet deep but the kid was likely at least 3 feet off the bottom if not more, so his actual depth was likely not 20 feet. He obviously didn’t run out of bottom time. He obviously didn’t get oxygen toxicity unless he was diving with 100% oxygen, which is also extremely unlikely. Very doubtful he got DCS from diving at 17 feet. His whole dive is basically a safety stop, right?

Have a look at this abstract from a paper we published in DHM in September (by "we" I refer to my role as editor of the journal - I was not an author):

Arterial gas embolism breathing compressed air in 1.2 metres of water - PubMed

An arterial gas embolism big enough to cause loss of consciousness would probably be detected by CAT Scan with IV contrast that would show a blocked artery.

AGE would probably not have symptoms quickly resolved on scene as described in this case.

Neither statement is correct. If performed quickly enough a CT scan will sometimes pick up intravascular gas in the cerebral vessels, but mostly it does not because (unlike a solid embolus) gas redistributes. Probably because of that redistribution the natural history of CAGE often includes early spontaneous recovery after the initial onset of symptoms (which is often loss of consciousness).

Simon

 

[rjack321]

Have a look at this abstract from a paper we published in September:

Arterial gas embolism breathing compressed air in 1.2 metres of water - PubMed

Simon

Jeesh despite 1600 lifetime dives @Dr Simon Mitchell you're scaring me from getting back in the water at all. I "knew" a very shallow ascent could be an issue but to see 1.2m in print is scary. Since this publication seems to be behind a firewall can you tell us the calculated/modelled minimum depth AGE might be a risk? Less than a meter?