After dive oxygen: shouldn’t the diver decide?

[freewillie]

After dive oxygen: shouldn’t the diver decide?

Let’s face it: there are a lot of facts and fiction about the use and alleged misuse of oxygen. Ask any diver about this and you’re bound to have to wade through a litany of myths interlaced with a few facts, a number of unfounded phobias and lots of apocryphal anecdotes. Ask the captain or crew of a dive charter or live aboard and watch those myths, phobias and anecdotes compound geometrically due to the specter of legal ramifications. It’s like we’re living through the voodoo gas days all over again, and I just don’t think it’s necessary, wise or legally defensible. In fact, a friend recently went through a lot of this on a dive boat that I have the utmost respect for and I don’t think he should have had to. It’s my opinion that he should have been allowed to make a decision about whether to use oxygen on his own with no interference. Unfortunately, I see this same rule and attitude on most every boat I’ve been on. I think they are afraid of oxygen, afraid of making a decision for you about oxygen and that their rules are based on their misunderstands and phobias about oxygen. I am starting this thread in an effort to begin a dialog on what I see as a diver’s right to use oxygen on the surface as they see fit. It should be viewed like we view oxygen bars or an athlete using oxygen after a strenuous play: as simply a non-event. It’s time to remove the stigma from using oxygen and give the decision to the diver and not base it on simple inflexible rules. To that end, I’ll list a few of the facts and myths as I see them and invite everyone, including medical doctors and captains, to chime in. Heck, you might add a perspective I had not thought of or forgotten to include. You might even change my mind if you can provide real facts and studies that contradict my understanding. I don’t expect to go unchallenged here and neither should you, so let’s remain civil and hash this out.

• · Fact: Oxygen is not a drug. While it has therapeutic value, it will not cause hallucinations or other deleterious effects on a relatively healthy adult breathing it at one atmosphere. Be assured that we’re already addicted to it and that there’s a lot of money to be made when drug companies treat it like a drug. That doesn’t mean we should treat it like Oxycodone or even alcohol.
• · Fact: Oxygen is fairly accessible. There are very few barriers to obtain oxygen, even medical oxygen. You can get a prescription for it, but that’s really not needed, nor should it be.
• · Fact: Oxygen is highly therapeutic. There are many benefits to be had from breathing pure oxygen, and this is especially true for divers and for those undergoing certain stressors. If you’re feeling tired or sluggish, fifteen minutes of oxygen therapy is better than a cup of coffee. That’s been my anecdotal experience.
• · Fact: Oxygen is used by deco divers. If it can be used safely beneath the water, then why not above it? In reality, oxygen only becomes a problem if you take it too deep but this isn’t a thread about using oxygen as a deco gas.
• · Fact: there is no contraindication for using oxygen excepting a fire being present.
• · Myth: Only a doctor should take you off of oxygen. If they didn’t put you on it, why do you need them to take you off of it?
• · Myth: Using oxygen requires a call to DAN. If there’s an accident, this should be a standard protocol, but not for prophylactic use.
• · Myth: Using oxygen contraindicates further diving. This myth should be apparent since deco divers often make additional dives.
• · Myth: Only oxygen providers can or should administer oxygen. While I certainly believe that every Scuba diver should take a class on handling compressed gasses, I think that this would and should be enough. Every first aid class should cover the use of oxygen.
• · Myth: Oxygen is explosive. In actuality, oxygen is an accelerant, not an explosive.

Based on this, I would like to see dive boats change their policies in regards to after dive oxygen. First, oxygen should be freely available and offered after any incident such as an accident, missed stop (safety or obligated), long surface swim or any time a diver seems to have undergone stress. “Would you like some oxygen?” should be a common question on a dive boat. Second, captains and crew should never, ever try to talk someone out of using oxygen. You’re setting yourself up for litigation by doing this. Rules that limit a diver’s actions afterwards effectively do this and should be eliminated as well. Thirdly, the diver and only the diver should have the final call on whether to use oxygen or not. Letting the diver decide their own fate, as it were, is the best way to limit your legal exposure and to maximize their feeling of empowerment which is critical during an incident. I certainly understand that it’s your boat, so it’s your rules, but we divers have options too. I know what works best for me and will naturally gravitate to those businesses that cater to my needs and wants.

Caveat: my use of the word oxygen in this thread refers to pure or medical oxygen and this is not a thread about the relative merits, dangers and pitfalls of using oxygen as a deco gas. Get the training for that, please, and discuss it in a different thread.
Additional Caveat: I am not a medical doctor by any stretch of the imagination. I used to fix sick networks. Now I own/manage ScubaBoard, am a Social Media consultant and teach Scuba. My standard medical advice is “I don’t know. Why don’t you ask a physician?”

I'm going to try and keep this brief since I have a lot of paper work to get through before my kid's spring break next week. But to those who are unaware, unlike NetDoc I am an actual MD. I read briefly through the current posts and was hoping to see TSandM's opinion but haven't a post yet.

First there is very little benefit to oxygen in an otherwise healthy adult. I know you see athletes (football players in particular) inhale oxygen during games. But because of something known as the oxygen hemoglobin curves all of the oxygen in your blood is carried by a molecule call hemoglobin. The actual amount of oxygen dissolved in the blood in negligible. For those who disagree I'm sorry, but it's true. The calculations are such that at 100% oxygen at 1 ATM you could at most deliver 15 ml/min. Your tissues require around 250 ml/min so it's not even close. So the use of oxygen may make you feel better psychologically but it in fact does little to improve oxygen levels in your blood.

Second, for either DCI/AGE situations the use of oxygen will help improve symptoms. So in either case a diver suspected of a dive related injury should be placed on oxygen as soon as possible. For triage purposes you will also divide the injury into 3 different categories 1) emergent 2) urgent and 3) timely. The first is an emergency. Diver needs immediate attention. Second is urgent, diver needs care but not at the same speed and can wait a little bit even a few hours. Third, generally took several hours if not days before symptoms were suspected to be dive related and you have at least several hours to treat the patient.

Now, even if symptoms improve with oxygen the diver still needs to be seen and stabilized by medical professionals then transported to a chamber to receive hyperbaric therapy. So the fact that the symptoms improve with supplemental oxygen does not mean the diver does not require medical attention. Quite the contrary. Until you can determine the underlying cause of the symptoms you need to keep treating the diver as if they have suffered a DCI/AGE incident.

So getting back to Pete's point that it should be entirely up to the diver is not necessarily okay from the other side of a medical practitioner. If you are feeling tired and sluggish after a dive that tiredness or fatigue may very well be a sign of DCI. As stated earlier it might if not should get better with oxygen. So how do you determine that you are simply tired and felt better after oxygen therapy; or, you are having DCI and you need to see a doctor? The fact is you can't tell based on symptoms and response to oxygen. So your initial premise that you should be able to use oxygen and you alone should be able to determine when to start and stop is a little faulty to begin with.

As a medical professional you are always taught to start the list of possible diagnosis with the most dangerous life threatening ones first and the least dangerous ones to the patient last. The first diagnosis thoughts should always include what will kill my patient. Let's take chest pain for example. Things like aortic dissections, ruptured aortic aneurysm, pulmonary emboli, and obviously heart attacks are all on the first list. Relatively benign conditions like heartburn come last because nobody dies from heartburn. But you can't walk into an emergency room and say you have chest pain then get upset that the doctors and nurses want to start treating you for a possible heart attack right from the start. You can sit in the waiting room for hours with heartburn, you might be dead if you sit in the waiting room for hours with a heart attack.

So the question becomes when you want to trigger the use of oxygen you are essentially starting the trigger for something much more serious. Since you can't tell (using the chest pain analogy) how dangerous the situation is you have to play it out until the conclusion once the ball starts rolling. So if you didn't think it was that serious to start then you shouldn't be using the boat's oxygen supply that is there for an actual emergency. If you think that a dive boat should provide oxygen to divers to help with tired and fatigued divers then you are essentially advocating that they dive boat provide assistance for divers to determine on their own whether or not they have a life threatening condition. As I tell my patients, you don't really have the knowledge and training to make those determinations so I would prefer you simply come in to the office or more likely go to the emergency room and get checked out.

What I have noticed from patients when they call with chest pain they want be to tell them over the phone they are not having a heart attack. Unfortunately I can't tell them that until they have an EKG and blood test. Sometimes it's easy to tell and they go home from the ER in a few hours. Sometimes it take overnight testing to make sure they are not having a heart attack. And every once in a while they are actually having a heart attack. About 10 years ago a patient wanted to be seen for that very scenario. They insisted their chest pain was really heartburn but when I looked at the EKG they were in fact having a heart attack. Fortunately they did well but it could have been a disaster. So ever since I've changed my policy that I always send patients to the ER for evaluation. And that's not because I'm afraid I'm going to get sued. It's because if you are having a heart attack you don't want to waste the time from being seen here in my office and then going over to the hospital by ambulance, you should be in the ER where they can get a cardiologist and get you into the cath lab asap.

Since the risk factors for DCI/AGE are missed safety stops and stress like long surface swims or any accident in general the question "do you need oxygen" is the equivalent of asking might you possibly have a dive related injury. And since that dive related injury might get better with oxygen you wouldn't be able to tell if you are simply tired or have something more serious you sort of need to have the events unfold medically. To me it's an all or none issue.

Wow, that was longer than I expected.

 

[drrich2]

FreeWillie's post helped congeal some concerns I've had with this thread, such as this blurb:

So getting back to Pete's point that it should be entirely up to the diver is not necessarily okay from the other side of a medical practitioner. If you are feeling tired and sluggish after a dive that tiredness or fatigue may very well be a sign of DCI. As stated earlier it might if not should get better with oxygen. So how do you determine that you are simply tired and felt better after oxygen therapy; or, you are having DCI and you need to see a doctor? The fact is you can't tell based on symptoms and response to oxygen. So your initial premise that you should be able to use oxygen and you alone should be able to determine when to start and stop is a little faulty to begin with.

Okay, now in other threads, we've had some contentious debates on the forum about divers choosing to deny any medical conditions on liability waivers for dive boats/dive op.s, on the grounds the diver believes him/herself fit to dive and does not wish to go to the time, hassle, cost, etc…to get a Doctor (who may know squat about scuba diving) to sign a paper 'blessing' him to dive, in many cases doing little to change risk & putting the Doc. in the 'line of fire' for a malpractice suit in the event of a bad outcome, in addition to the other bad news such entails.

So, if you admit you've got mild high blood pressure or that it's well-controlled on med.s that you have an extensive track record diving on, doesn't matter. You've got to have an accepted professional care giver do that form for you.

That's the liability-driven reality of dive boat op.s today.

So, these same op.s are going to let divers have oxygen on demand 'for no reason,' look the other way and assume it's all good?

Regardless of whether you think they should, or could, or it's worthwhile if only on upscale boats looking for amenities to differentiate themselves, or it might help the occasional diver…I don't see it happening.

Richard.

 

[TSandM]

I just hadn't had the time or energy to wade in here, but freewillie's post says a lot.

One of the unique medical risks of diving is decompression sickness, and the immediate treatment for that is oxygen. The problem with DCS, though, is that the symptoms are protean and there is no definitive test for the condition. A diver who is unduly fatigued at the end of the diving day may be exhibiting the earliest symptoms of DCS -- or he may have stayed up a bit too late or had too many margaritas the day before. The diver with some nausea may be bent, or may be seasick, or may have eaten something untoward, or may, in the worst case, be having a heart attack . . . in which case there are more and more data to show that putting a patient with normal lungs on oxygen may make the damage WORSE.

So oxygen is not entirely benign, and by itself, is never considered adequate therapy for DCS, which includes evaluation by a physician and possible recompression. If a diver pulls the cord on a dive boat to signal DCS and gets put on oxygen, I would consider it negligent of the boat crew not to get that diver into the hands of a medical professional for further evaluation, even if the symptoms abated. I am glad to hear that a lot of boat insurance companies require that, because it makes sense.

This leaves the diver with equivocal symptoms in an awkward place. On the one hand, you might want oxygen to make sure you don't end up with paralysis. On the other hand, you know that, if you pull that trigger, the cascade of events is going to discommode not only you, but quite possibly every other diver on the boat. As a result of that, there may be some reluctance to admit to DCS symptoms, which is a bad thing -- but keeping everybody on the boat from sucking oxygen because their knees hurt might be a good thing.

It's a risk-benefit assessment, which is where I live in my job. The diver assesses the risk, and if he begins to feel that it is falling way too far on the side of a significant hit, he asks for oxygen and accepts that he will be through diving and may have adversely affected the trip for everyone on the boat. Now, if he makes that assessment and the boat still refuses him oxygen, that's unacceptable, but not completely astonishing. I have been appalled at reading several accounts of divers presenting to EMERGENCY DEPARTMENTS who have been refused oxygen -- oxygen, that we put on everybody for a hangnail. A dive boat should stand ready to provide oxygen to someone who requests it, but it may be reasonable to do a quick triage assessment to make sure you aren't dealing with a nervous novice who's sore from climbing the ladder. (I'm thinking about a drive home early in my diving career, where a shoulder hurt horribly, and I spent the whole drive fretting about whether I was bent. We had been no deeper than 40 feet, I think.). If the triage assessment concludes that the profile and the symptoms are compatible with -- not suggestive of, just compatible with -- DCS, the diver should be provided oxygen and the emergency procedures algorithm should be followed.

So I guess my answer is that yes, in the vast majority of cases, a diver should be able to request oxygen and get it. But that diver has to accept the whole cascade of events that follow such a request and provision. And on rare occasions, the boat crew should be able to reassure a diver that there is no reasonable possibility that the symptoms represent a decompression injury, and refuse to provide oxygen. But if they do that, they bear the entire liability if they are wrong.

 

[dumpsterDiver]

I can understand the Doctor's position.. which is very simple and can be summarized as: Take one hit of oxygen on the boat and the trip is over for everyone and we are activating the EMS. I think that has been the general, conservative position for a long time.

The problem with this directive is that it serves as a significant deterrent for anyone to tell the captain or DM that they are feeling unwell. Another problem with this protocol is that there is considerable anecdotal evidence that breathing oxygen on the surface does seem to adequately "cure" mild cases of DCS in SOME instances. I related my personal situation, which was an example of it.

On a commercial spearfishing boat operating 15-20 hours offshore, I have seen numerous examples of people sucking on oxygen on the surface because they took another (minor) hit in the (for example) left elbow.

I can also confirm that a diver arriving on the surface with a terrible CO2 headache can be relieved almost immediately and miraculously with only a few minutes of oxygen on the surface.. no doubt about that.

Netdoc seems to be arguing for a less conservative approach with respect to administration of oxygen. My feeling is more along the lines of.. if the guy brought his own oxygen and he is obviously not in some serious discomfort, than maybe it makes sense for management to simply "look the other way".

Hell the military operated for a long time under the "Don't ask/ Don't tell" policy which is no more ridiculous than the "look the other way" procedure.

 

[KenGordon]

Both the doctors say it is all or nothing.

Yet only 40% of treated, bent divers got first aid oxygen. How could that be improved?

If in the example of a sore shoulder above, O2 had been used and it had not improved wouldn't that be reassuring? And if it had then a trip to the chamber.

As for risk factors, I think getting in the water is the main one. I met two bent divers when visiting the pot. One had flown back from Egypt and been diagnosed in London. He had done the wet bit of an OW course there. He had complained of issues and been fobbed off. His maximum depth was 16m. The other had been diving locally with novices to maybe 15m.

The current scheme of all or nothing works well for an uncaring or uninformed boat. Have the bent diver be too afraid to ask for help, they get off at the end of the day, recover or not over night, skip dives or not the rest of the week and fly away. No feed back loop from the pot at home. Sorted, next please.

Actually I don't think that boats don't care. But I do think that fear of the consequences is a reason why people fail to seek proper attention.

 

[drrich2]

Actually I don't think that boats don't care. But I do think that fear of the consequences is a reason why people fail to seek proper attention.

Your input brought to my mind another question, a politically incorrect question since publicly/officially there's only one 'correct' answer, but I wonder what the real world answer would be to this question...

What % of divers, mildly suspecting themselves to be 'a little bent' (e.g.: some soreness in a shoulder or other joint, unusual fatigue) but otherwise 'okay,' if on a live-aboard or similar possibly 'once in a life time exotic & expensive trip' would choose to keep on diving anyway? Even if they cut back to 3/day instead of 5, dove shallower, etc...?

The politicly correct answer would be you must stop diving, notify boat crew at once, breathe 100% O2, DAN is phoned ASAP, etc...

But how do the numbers break down for what people actually choose to do?

Richard.

P.S.: Ken, one of the potential consequences you mentioned would be that if you open your mouth about it publicly on a dive boat, you forfeit much of your control of the situation/prerogative to make your own decisions. Unless of course you were going to choose to do what the boat policy said anyway.

 

[KenGordon]

P.S.: Ken, one of the potential consequences you mentioned would be that if you open your mouth about it publicly on a dive boat, you forfeit much of your control of the situation/prerogative to make your own decisions. Unless of course you were going to choose to do what the boat policy said anyway.

This is my point. If knowing that asking for O2 because you feel wrong, or had a poor ascent or whatever but can still stand up and even pass the 5 min exam, leads to a disproportionate response then fewer people will ask. Some of those will have been bent.

This is all on top of the general denial of illness and the specific denial of DCS..

 

[kr2y5]

if the guy brought his own oxygen and he is obviously not in some serious discomfort, than maybe it makes sense for management to simply "look the other way".

Just wondering whether this is actually an option, or whether the boat crew is compelled to react, since otherwise they would potentially be risking a lawsuit (especially when there are likely to be multiple witnesses that they were aware of the condition, and looked the other way). What legal obligation does the crew have in such a case?

 

[bakodiver391]

This discussion is going around in circles. Having been on the front line of this type of situation for for years I will sum up my thinking. A dive professional is walking a tightrope. Too authoritarian and divers will not report symptoms for fear of instigating the whole back to port/ ems notification/ no further diving scenario. I think all the MDs who have weighed in are bound to the most conservative viewpoint by their professional standing, yet there ARE hyperbaric physicians out there who are more liberal, you just don't see them posting here.
The obverse is that if you are too liberal, and allow someone to continue diving, or don't get them to medical care, obviously they could get much worse, and you have a greater emergency on your hands, and the attendant duty of care. I firmly believe that there should be non-emergency O2 available to divers. This lowers the barrier to divers seeking help, and offers 2 separate and valuable benefits. One, it helps put the possible DCS case "on ice", buying you time to put other measures in place if need be. In all but the worst cases, this time "on ice"can extend to 12 hours or more, where little or no further damage is being done and possible great theraputic benefit is being provided. Two, oxygen therapy provides a diagnostic tool to determine what is actually happening. One of three things will occur: the patient will feel better, the patient will feel the same, or the patient will feel worse. In the first case, continue the therapy until full resolution and discontinue diving for 24 hours. In the second case, monitor closely while continuing therapy and consulting with experts. In the third case, start a full-blown medevac or hyperbaric treatment response. The point is that oxygen therapy is a valuable diagnostic TOOL that should be used. Not an end-of-the-world scenario that strikes fear in the hearts of divers. This post is based only on personal experience and I do not pretend to give medical advise to anyone.

 

[beanojones]

If you're still referring to the non-incident I mentioned, re-read my post. This time for comprehension. Nowhere was the word "rapid" used. Nowhere.

Now it's time for the generic diver (certainly not you personally) to relive the situation from someone else's perspective, which is the point about opening up the generic diver's awareness. It is not about you. It is never about you. The people who think everything is about them, and their wants,.....

The generic diver came up fast enough in an unintentional ascent that an observer asked if the generic diver wanted to go on O2. I did read the post, and that, and not anything else about the story is what stuck out for me. That generic diver was acting is such a way that a third party had concerns about the generic diver's well-being.

That's not the normal response to someone surfacing. That is, however, a normal response to someone obviously coming up fast and out of control, because from the surface all the observer gets is the end result.

The generic diver (certainly not you personally) was diving under someone's else aegis. If the generic diver wants to have full freedom, then that generic diver needs to be diving in a situation where they are not under someone else's care, and thus threatening to involve someone else in their mishaps, liability-wise.

If the generic diver is diving under someone's aegis, then they are. And just as in NetDoc's story, that third party is making evaluations about the diver's competence, the diver's safety, and their own liability in such. If NetDoc did not get that those three things were being evaluated by Diveaholic throughout the dive, then he is missing the very point of the story he himself told. (Even though he was later told explicitly he was being evaluated throughout the dive.)

I think it is easy for people who do not do this for a living to forget that that we are working, and protecting our futures with every boat trip, and every dive we do with someone under our care even if it is a fun dive, is a risk. And all risks have to be evaluated.

If the generic diver want to go on the boat's O2, then the generic diver can. But the Coast Guard and EMS are being called and the boat's going back to the dock, because the story at that point is not about the generic diver or whether the generic diver misses the second dive. In the mind's of the captain, and the dive crew, it is on whether or not this is their last day of work.

You get to do one more dive, or the boat crew gets to continue working at their careers.

It is not about you and whether you get to do a second dive.

Ignore the fact that the worst thing rarely happens, because somehow the statistically improbable case of possible DCS has already occurred. Now that we are here, here we are.

---------- Post added April 3rd, 2015 at 05:47 AM ----------

I think all the MDs who have weighed in are bound to the most conservative viewpoint by their professional standing, yet there ARE hyperbaric physicians out there who are more liberal, you just don't see them posting here.
.

Are you saying there are hyperbaric physicians who think if someone has DCS, they can just breathe oxygen on the surface interval and then go on their second dive?