After dive oxygen: shouldn’t the diver decide?

[The Chairman]

Symptoms of DCS are fuzzy, to say the least, the use of Emergency Medical procedures and supplies should not be.

We agree: the symptoms are fuzzy. To me, that means that treatment is also kind of fuzzy too. It's why DAN wants you to call them before you show up at a chamber.

I would rather a boat's Oxygen supply not be so limited that I feel I might be putting others at risk by effecting my own treatment. That's a disincentive, a stigma and a stumbling block to getting help. It's like going to sea with a single bilge pump and one that can only pump out a smallish leak. I expect, you'd want reasonably LARGE pumps and in multiples. You might even have a hand driven one aboard in case the electricity failed. A captain shouldn't have to blink an eye in regards to volume if one of his divers needs oxygen. He still shouldn't have to worry about reserves when that diver's buddy goes on oxygen too. If that's not the case, then you don't have enough oxygen on board. I want the boats I am on to be 'loaded for bear' when it comes to that. That's my idea of adequate preparations.

 

[Carl_F]

In most of the first aid for divers, including a missed deco stop, it tells us to administer O2 and check for symptoms. Why would breathing O2 by itself require a visit to the hospital?

As a recently certified Dive Guide / Dive Con, I'd not hold back O2 for anyone who asks for it. But I'd also be calling EMS. The O2 on the boat in the kit is for medical emergencies. If you ask for O2 from the medical kit, I'm not going to make the medical judgment that you don't need EMS. It's being provided as first aid and the things that O2 is provided as first aid, I am not qualified to treat beyond providing first aid. You can decline the ride to the hospital with the EMS if you want.

If you get angry with me and grab my phone and insist on not calling EMS, then I'm not going to provide first aid O2. The O2 in the first aid kit is there for emergencies that warrant first aid. It's not there for the general customer to just pass around taking a hit.

If you want non-first aid O2, by all means bring your own. I'll even rent you a bottle at the shop given the correct certification. I may ask why you're using it to ensure it's not a medical emergency but beyond that, I don't judge.

---------- Post added March 31st, 2015 at 02:51 PM ----------

Awesome fiction dude, you should write a novel. What if you put that same diver into an ambulance, and the moon falls on it as it's on the 20 mile stretch, and it slides into Florida Bay??? Who's gonna get sued then? What if, what if, what if. I have yet to hear of a dive op being sued for giving a diver in distress oxygen. Have you? Let's not allow our imagination to run wild in the 'what if' department. That's how phobias are propagated and that's why there are so many myths circulating about using oxygen. Logic would indicate that it's far more likely that a diver would sue over being denied oxygen, than being offered it. While I have no way to accurately quantify it, I would put that at least to a thousand to one odds.

Umm, the difference is that one scenario is plausible (1:1000), the other not (1:infinity).

I don't take 1:1000 discrete event odds with my life or my livelihood.

 

[KenGordon]

If I were closer I'd offer you all to come to my house, run up and down the stairs and then breath off the gas of my choice to see if you can tell the difference between 100% and 21%.

For example see Skeptical Scalpel: Why supplemental oxygen is not considered a performance-enhancing drug

On a boat I expect O2 to be available to anyone at any time for any reason. I don't think it is a good plan to blackmail divers into not using it with what amounts to threats about calling an ambulance or helicopter.

Here the ambulance, helicopter and chamber (food included) are all free of charge, if anyone really thinks there is a problem they will be called. The coast guard have a duty doctor to talk things through. It is a major hassle though, also nobody wants to be bent and denial is a symptom of DCS. Giving people another reason to stay quiet is poor in my opinion.

 

[Crowley]

Great discussion!

Before I start I'm going to make the following points:
- my work is purely recreational - it was very rare to have tec/deco divers on my boats as we only had one tec instructor at the time and we carried extra 02 just for those divers, just in case.
- I have put divers on oxygen because they were clearly bent
- I have put divers on oxygen because they were symptomatic and later diagnosed as bent
- I have put divers on oxygen because they were symptomatic and later diagnosed as not bent (hung over, in at least one case)
- I have put myself on oxygen twice as a prophylactic - not because I was stupid but because I had undertaken emergency activities that violated recreational dive protocol

When it comes to who makes the decision, some of this has been covered before but in all my cases, it was me, possibly in consultation with other instructors on the boat (and with either DAN directly or the local DAN-affiliated hyperbaric physician if necessary and if possible).

Firstly - when it comes to availability and price - in my last job in Indonesia, Oxygen was readily available but we had to bring it to the island I worked on from mainland Bali. It took three days to get a fill - one to send over the tanks, one for the fill and a third to bring them back. Although the 02 fill itself was inexpensive, the transport fees were 50 dollars per tank. We couldn't just dish it out willy-nilly because even if we charged for it, there would be the possibility of not having any full tanks at all, with a three-day turn around for the fill. We kept spares, of course, and we could have borrowed from other dive centres, but we worked on the principle of necessity, not general availability because - as has been pointed out by other posters - doing so may well have prevented us from dealing with a real emergency.

When it comes to litigation - in 2006 a Japanese diver sued the divemaster and dive op he was diving with in Thailand because the guide was concerned he was DCS symptomatic. The prosecution claimed that the divemaster/instructor was at fault because he didn't have a certificate to prove that he was qualified to provide emergency oxygen, even though provision is covered in the PADI Rescue Diver Course. I don't have the details to hand but this was related to me by the head of DAN Asia Pacific in Thailand, somebody with whom I used to work quite closely and therefore I have no reason to doubt the authenticity of his report and if he is to be believed, this was the reason that PADI brought out their dedicated 02-provider speciality a year later. I've always followed my training which is to say "this is Oxygen, it might help you, it won't hurt you, can I give it to you" sort of thing but there are those people out there who will sue McDonalds because they burned their lips on a hot cup of coffee....

If we could magic it out of the air inexpensively then we could all have a puff on the 02 on the way home and that would be grand but equally, the risks involved in recreational diving for minor decompression violations are very small. The general rule is 8 minutes for exceeding an NDL by less than 5 minutes and not diving for 6 hours or 15 minutes (or longer, time and air permitting) for greater than 5 minutes and not diving for 24 hours whilst monitoring for signs and symptoms of DCS. In my professional career I've had to make a small number of extended safety stops with divers who made small deco violations, bearing in miind that those rules apply to dive tables and even the most conservative of Suunto computers clear them more rapidly - I've had to make extended safety stops with two divers (out of thousands) because they broke the 5 minute rule and we barred them from diving the next day and gave them all appropriate advice and to report to the dive centre in the morning. In both cases there were no issues.

As an instructor/DM/guide it's quite a difficult decision to make when it happens and yes, it's better to err on the side of caution but you have to take the logistics of the whole operation into consideration. If a diver makes a minor (recreational) decompression violation on the first dive of the day, am I going to put him or her on 02 when we have two more dives to make? Nope, not unless they become symptomatic, because otherwise I risk depleting the available supply for other divers who really might need it later in the day.

So who makes that decision? Me - as the person who has responsibility for the safety of all divers on that boat - I make that decision. If a diver approached me asking for 02 because they only made 2 minutes of the standard 3 minute safety stop (and none ever have), I'm going to refuse, because I have to weigh the risk of that diver having DCS (extremely unlikely) against the possibility that I might deprive somebody who really needs it later in the day, given that I have a very limited supply.

Cheers,

C.

 

[uncfnp]

Some people would call that denial of medical care and bring up the subject of death panels. IJS. And I'm also just repeating what I've heard before, in kind of a devil's advocate sort of way. I remember in a DAN-bashing thread a year or more ago that if DAN didn't recommend evacuation and chamber treatment, they were being a cheap insurance company.

Ah yes, I can see the potential for conflict of interest. In such a case DAN is providing two services, triage for dive medicine and insurance. Tough line to walk. But ultimately, at least in the ideal world, the decision to seek additional medical care is in the diver's hands. And that's true for all health insurance. DAN is not the first to be accused of denying coverage for "needed" medical care.

(hijack over)

 

[Wookie]

Ah yes, I can see the potential for conflict of interest. In such a case DAN is providing two services, triage for dive medicine and insurance. Tough line to walk. But ultimately, at least in the ideal world, the decision to seek additional medical care is in the diver's hands. And that's true for all health insurance. DAN is not the first to be accused of denying coverage for "needed" medical care.

(hijack over)

There is an important distinction, however. When you call the DAN emergency folks, you don't get anyone having anything to do with insurance. You get either Marty (the medic) or the emergency on call after hours chamber physician. They don't really care about insurance, in fact, they don't even ask if you are a member of DAN or whether you have insurance. The only thing they care about is your profiles, your general state of health, and what signs/symptoms are presenting themselves. It's important to get it right in the USA, because right after talking to DAN, a US liveaboard captain will be talking to the USCG flight surgeon or the S&R dispatcher, who will ask exactly those same questions. Insurance never comes up until way later in the process, like, after you get out of the chamber.

I was denied O2 and a chamber ride when I took a vestibular hit in Cozumel. I don't know if O2 would have helped. I know the chamber ride would have, because when I finally went 4 or 5 or 6 days later, it cured me. Well, of some things. The chamber tech in Cozumel said I couldn't be bent. No way no how.

 

[Bob DBF]

We agree: the symptoms are fuzzy. To me, that means that treatment is also kind of fuzzy too. It's why DAN wants you to call them before you show up at a chamber.

The DAN Dr on call makes a prognosis and decides whether to continue treatment or not, is different than a first aid responder making medical decisions for the victim. Once Emergency Medical supplies are used, it is in fact a medical emergency and should be treated as such.

A responder to a problem that involves treating a diver with Emergency Medical O2 should not be deciding the victim's course of treatment, that should be turned over to a medical professional ASAP. Would you bring back a drowning victim with CPR, then say "go on about your day"? In both cases you are expecting the first aid provider to make a doctor's decision rather than be a path to proper treatment.

I would rather a boat's Oxygen supply not be so limited that I feel I might be putting others at risk by effecting my own treatment. That's a disincentive, a stigma and a stumbling block to getting help. It's like going to sea with a single bilge pump and one that can only pump out a smallish leak. I expect, you'd want reasonably LARGE pumps and in multiples. You might even have a hand driven one aboard in case the electricity failed. A captain shouldn't have to blink an eye in regards to volume if one of his divers needs oxygen. He still shouldn't have to worry about reserves when that diver's buddy goes on oxygen too. If that's not the case, then you don't have enough oxygen on board. I want the boats I am on to be 'loaded for bear' when it comes to that. That's my idea of adequate preparations.

I would agree with you on this, but until boats carry unlimited O2 I would still like a distinction between discretionary and Emergency supplies.



Bob
------------------------------------
"This is scuba board, where problems are imagined or overstated......and chests get thumped about what some would do about those "problems" "- PullMyFinger

 

[Wookie]

Once Emergency Medical supplies are used, it is in fact a medical emergency and should be treated as such.

Bob

Out of curiosity, can you envision a medical emergency where first aid is rendered, but no followup is necessary?

 

[descent]

... I would rather a boat's Oxygen supply not be so limited that I feel I might be putting others at risk by effecting my own treatment. That's a disincentive ...

Yes. Tragedy of the commons.

The emergency oxygen in the first aid kit is finite, scarce, and must be shared, just like the fuel for the engines, or the remaining potable water if the desal fails more than a few hours from port.

 

[bakodiver391]

There are a lot of interesting points here, and since I am involved in remote location technical diving I thought I'd chime in. As others have said, there is a difference between prophylactic and treatment use. I think there is also a huge difference between a recreational six pack day boat and an offshore tech liveaboard. I've run a six pack, and while I've always had the DAN emergency pack I always have an additional Al 80 of O2 for prophylactic use. This eliminates the barrier to using the boat's emergency supply and the same tank can be used for IWR. I've never felt the average DAN kit has enough volume unless you are less than 1/2 hour away from another source. It's also about removing barriers to people asking for O2. If you have a deco tank set up, just passing the diver a reg and telling them to suck on it is no big deal. In technical diving, there is no clear line between extended deco on the deck and O2 therapy. Many divers will continue to breath their deco cylinder, or stay on the loop, for 10 minutes or more, after the dive. It means nothing, and if you told every one of them that they would not be diving again you soon would not be in business. We offer everyone the option of going on O2 at any time, with no stigma and no follow up unless they ask for it or are clearly incapacitated. Again it's about removing barriers to getting help. On a tech boat there should never be a problem with adequate supplies of O2. On a six pack recreational trip, I think charging for prophylactic use of O2 is reasonable, but there should be a tank available that is separate from the emergency supply. As others have said, DAN does not automatically want to medevac, and in my experience, in non-neuro cases, they will not. Bottom line, on tech boats, the O2 will be there, on rec boats, it might pay to bring your own deco bottle.