Ansell Pt Dive Incident

[JB]

Cram I have no doubt that you had Hyperventilation syndrome. Whether you also had DCI as well is the question. I wouldn't know where to start to sort it out at this time. Came across this article which might be of interest. It's a summary of a workshop on DCI in remote areas, on page 50 of this on-line mag.
http://www.africandiver.com/articles/issues/africandiver_issue9.pdf
I think footnote 4 is most pertinent your experience.
Cheers JB

 

[JonKranhouse]

JB,

Respectfully, the question to ask is not what else could have affected Cram, but rather why was HBOT delayed?

Cram’s symptoms resolved with pressure, so you cannot pretend he didn’t have DCS-2. It is irrelevant if Cram had symptoms of other relatively benign causation, as his DCS-2 was apparently (A) misdiagnosed, (B) Cram presented with events that precisely matched one of the textbook cases used to train coroners to diagnose dive fatalities (cited in this thread), (C) he was denied at least a “TEST WITH PRESSURE” after a costly helicopter trip, and (D) untreated DCS-2 can cause life-long disability.

The article you cite in African Diver cherry-picks excerpts from the “landmark” DAN / UHMS 2004 meeting and ignores conflicts between the attending physicians (cited in my earlier post that links to the 2004 meeting's actual transcript).

Read that transcript: DAN / UHMS doctors are subject to financial pressures by their very own licensing organization, which is also in the insurance business. Do you want to put your future health, blindly, in the hands of doctors who are in such a conflicted position?

60 years of US Navy medical doctrine was contradicted by this 2004 DAN / UHMS policy, made in spite of objections by hyperbaric MDs. I believe a “TEST WITH PRESSURE” as a diagnostic tool should not be denied by an insurance company, and that divers should not be bamboozled by an insurance company trying to cut its costs.

Sometimes a denied treatment may be accurate (i.e. mild DCS-1, accurately diagnosed). But there’s a significant, factual, peer-reviewed, PROVEN likelihood that DCS-2 will be misdiagnosed (see my earlier post), as apparantly happened to Cram. Until most DAN / UHMS MDs become licensed neurologists, their 2004 workshop’s “Consensus Statement” is, per some HBOT MDs, a recipe for inappropriate denial of treatment.

FACT: most hyperbaricists are not neurologists and they do a poor job at recognizing developing / subtle symptoms of DCS-2 (neurological), per peer-reviewed research (see my earlier post). For DAN / UHMS to justify delays or denial of HBOT in such a broad stroke, knowing that delayed HBOT for DCS-2 can cause life-long damage is, in my opinion, outrageous.

From the 2004 meeting (Page 208)
Dr. DAVID SMART: At the risk of saying, 'The emperor’s wearing no clothes,' we have had the whole paradigm shift here. ...We’ve now gone to a statement...that ...you can treat DCI without recompression, and we really have no evidence to suggest that that’s an appropriate response. Based on data presented yesterday, we’ve got a 70 percent success rate treating it with recompression. Do we want to go this sort of length?

From the African Diver article, footnote #3 on page 51 (emphases added):
...paraesthesiae (i.e. pins and needles sensation) that are present in patchy or non-dermatomal distributions (i.e. not likely to be related to a large nerve or spinal cord injury) suggestive of non-spinal, non-specific, and benign processes. Subjective sensory changes in clear dermatomal distributions or in certain characteristic patterns such as in both feet, may predict evolution of spinal symptoms and should not be considered “mild”.

If accurately diagnosing dermatomal vs. non-dermatomal sensations are pivotal to differentiating between Type-1 (or possibly CO2 imbalance) and Type-2 DCS, and Type-1 pain can mask Type-2 symptoms -- which could culminate in life-long disability if left untreated -- how do you square that with words from the CHAIRMAN of the 2004 meeting (page 188): Dr. DES GORMAN: Well, most doctors wouldn’t know what a dermatomal was if it walked up and bit them.

The desire of an insurance company to cut costs is not inherently sinister. But if doing so risks likely misdiagnoses that can cause long-term harm, then the rationale must be questioned, in my opinion. Notably, the DAN / UHMS 2004 meeting did not even consider the impact to long-term neurological impact, as revealed by a body of research, if DCS-1 or DCS-2 are left untreated.

 

[farsidefan1]

Unprovoked DCS is very annoying. Been there done that. In my case I was checked for PFO which tuned out to be positive. I had the corrective procedure done last December 23 (merry freaking Christmas). What is especially irritating is my profile was during a land based trip (Cozumel) Where my diving was much more limited than live aboards or Cocoview where I routinely enjoy 5 dives per day. I had 2 days of 2 dives and 4 dives on the last day. Be happy you were only given those few weeks dry, doc told me wait 6 months (which gave me plenty of time for the PFO procedure and recovery). Glad to hear you are ok. Was there any dehydration involved? That was also a contributing factor in my case - although unprovoked really = we will probably never be sure. Likely an accumulation of factors. Good luck when you resume diving.

 

[cram]

Was there any dehydration involved?

Quite possibly. I don't think I was any more dehydrated than usual, but I generally drink too much coffee and not enough anything else.

 

[JB]

JonKranhouse,
With respect, I am sorry I have touched a nerve, I notice you would be the first supporter of any conspiracy theory.
I don't want to get into a slinging match, but I firmly believe that he who shouts loudest, or uses the most bold print, or red print for that matter is not necessarily correct, and does not win the debate. I therefore feel compelled to inject some reason after these off the wall, out of context, misinterpreted statements.
I think the implications of misdiagnosis are equally bad in both directions. The path of least resistance is always the easiest, and leaves you less open to litigation/criticism, but at considerable predjudice to the patient. So the village idiot would recommend recompression for anyone with any symptom after diving, it takes someone with diving medicine knowledge to sort it out, and since this is mostly done over the telephone it is again easiest to just recommend recompression, and not stick your neck out when relying on second hand information. I believe that a diving physician who actually sees the patient and examines him/her would be the most appropriate person to make the call, and from what I've heard the most appropriate call was made.
I'm afraid that basic anatomy covers dermatomes, and certainly a diving physician would know what they are. It's not that hard, so before you rant on about this look it up. You are suggesting that crams' symptoms were due to 2 spinal lesions one in the cervical spine to account for his upper limb symptoms and one in the lumbar spine to account for the leg symptoms?? As for dermatomes:- for example L5 is the dorsum of the foot and the lateral shin to the knee, S1 is the lateral aspect of the foot and heel, L 4 is the medial aspect of the lower leg to the knee. Very different form tingling in all your toes!
Similarly C6 is the thumb and lateral aspect of the forearm extending to the elbow, C7 is the middle finger and C8 is the lateral aspect of the hand. Again very different from tingling in all fingertips.
Now just to throw the cat amongst the pigeons, there is a huge placebo effect in all things medical. So symptomatic improvement, does not necessarily equate to therapeutic effect. Hence the need for randomised double blind trials. The "text book case" was a similar scenario, but a hugely different clinical presentation, I think you are stretching it at lot - If I do a deep long dive and then climb a hill and feel tired, have I got DCI??
If you have a problem with medical insurance companies, that's one thing but I think it is rich for a lay person to second guess a qualified diving physician, who had the opportunity to see the patient/victim. To accuse him of being in the pocket of some insurance company is frankly libellous. The fact that he subsequently got recompressed, suggests skill and competence on the treating physicians part, ie. absence of fixation error "this doesn't make sense or fit the patterns, the time course is not what I expected so I'm going to do the safest thing under the circumstances, and not doggedly stick to my original diagnosis." Thank god there are still thinking physicians out there, practising for the benefit of patients and not for the benefit of lawyers.
I think cram is concerned, and really wants to understand what happened, and perhaps wonders if he truley had DCS or not. I think the only person in a position to answer those questions is his diving physician, and then the best he can do is give probabilities. Presumably he will have a contrast echo and if that shows a PFO then it makes DCI more likely and if negative less likely. Overall the presentation was atypical for DCI, and that's what makes it of interest, form a learning point of view for all concerned.
I, for one, am intrigued, and look forward to follow up.
Remember they are not out to get you. All doctors are not incompetent idiots. Most people have your best interests at heart. The world is a good place. I am now ducking for cover!!

 

[gummybun]

Primarily I am glad for cram, his recovery and the support that has been offered by his friends here. Very Nice.

Oh, I edited out the last bit - no need for it here...

I would just say that JonK was simply putting forward a fully referenced position that was meant to further inform and thereby protect the average diver. I don't think entering the discussion with phrases like 'conspiracy theorist', commonly used to dismiss both arguments and persons, is either fair or warranted. To be fair, he did preface his argument with the comment that one should always "consult licensed MD's" - and if I understand, we have yet to hear from one.

 

[cram]

Cram I have no doubt that you had Hyperventilation syndrome. Whether you also had DCI as well is the question.

Well, I had my follow-up appointment with the doctor today and his opinion is pretty much what JB said above. The symptoms I experienced were "textbook" examples of hyperventilation syndrome and the arterial blood gas confirms.

The only symptoms of DCS that I had are, unfortunately, also symptoms of hyperventiation syndrome which makes the diagnosis difficult. He did point out that the presentation of the paresthesia was very unusual for DCS, although I'm don't remember the explanation well enough to reproduce it here.

In any case, the end result is the same. To be on the safe side I have to assume that I did have DCS and plan accordingly.

 

[JonKranhouse]

Cram,
I am VERY glad you are OK; this incident should not diminish your love of nature and diving.

Gummybun,
THANK YOU for summarizing my motives precisely, which is to give recreational divers the facts necessary to question why and how the USA’s self-regulated dive industry has determined certain “standards of care.”

In the USA about 100,000 patients die from malpractice in and outside of hospitals each year. We are advised to take responsibility for medical decisions cooperatively with our doctors. But how can that be achieved if patients (i.e. divers) have pivotal information withheld?

JB,

All doctors are not incompetent idiots. Most people have your best interests at heart. The world is a good place.

I AGREE!!!
I never denigrated Cram’s attending physician - merely said that there are issues that we divers should be aware of should we ever need HBOT.

I presume you’re an MD by your post (your SB profile does not make that clear)?

I also presume that Cram’s HBOT MD in Vancouver has NOT read the entire 242-page PDF transcript of the DAN / UHMS 2004 2-day “Management of Mild or Marginal Decompression Illness in Remote Locations Workshop Proceedings.” I presume that ALL HBOT MDs are given the very brief “Consensus Statement” that was generated at that 2004 meeting.

I am not a doctor, but when I read the 242 page document I realized that doctors at this meeting had greatly differing opinions, because the new policy changed what had been US Navy medical doctrine for over 60 years. At the meeting the UHMS leadership, including those from countries with single-payer insurance, made it clear that cost controls for HBOT were an imperative, worldwide. I would be speculating to guess that perhaps the UHMS’ leadership is concerned that diving not get a bad wrap for hogging occupancy time when hospitals have installed HBOT chambers to capitalize on the bonanza in wound-care.

I'm afraid that basic anatomy covers dermatomes, and certainly a diving physician would know what they are.

I guess you missed that was NOT my quote - it was from the Chairman of the DAN / UHMS meeting lamenting that signs of DCS-2 in dermatomal areas are frequently missed by doctors, so please take up your objections with him.

You are suggesting that crams' symptoms were due to 2 spinal lesions one in the cervical spine to account for his upper limb symptoms and one in the lumbar spine to account for the leg symptoms??

Nope. I just quoted doctors who were at the 2004 meeting, and cited other peer-reviewed research by hyperbaricists, available at Rubicon-Foundation.org, which describe how OTHER symptoms frequently mask more subtle DCS-2 symptoms. If left untreated, the DCS-2 symptoms can evolve into greater complications.

The "text book case" was a similar scenario, but a hugely different clinical presentation, I think you are stretching it at lot - If I do a deep long dive and then climb a hill and feel tired, have I got DCI??

“hugely different clinical presentation”... True, a 30-year-old diver collapsed and died soon thereafter. Cram, 29, collapsed and needed a helicopter evacuation. Merely “feeling tired” is not how Cram presented.

In this era of the SEC ignoring warnings of Bernie Madoff for over 10 years, Big Pharma's multi-billion dollar fines, and Wall Street’s fleecing of taxpayers, we citizens must now fill the role that quality investigative journalism used to play. Back in 1978 I had the good fortune to intern for Terry Drinkwater when he co-anchored CBS’ west-coast evening news with Walter Cronkite (I wound up in narrative filmmaking instead of journalism). Have people been so lulled in our current age of celebrity tweets that they do not recognize when serious questions deserve to be asked? I hope that's not so.

My curiosity to find the truth after people die or are injured scuba diving wouldn't be so great if not for DAN being the progenitor of the myth often paraphrased by dive pros: "Diving is as safe as bowling." (cited here -- and detailed here, just above this image):

Sometimes divers screw up and there’s nobody to blame but the diver.

Sometimes, in my opinion, the industry’s “standards of care” put both consumers and dive pros in needless jeopardy.

And sometimes I bet there’s an HBOT MD feeling stuck between a rock and a hard place.

Readers may find this other thread about possible long-term effects of diving interesting - lots of information, links and sadly, controversy:

 

[TSandM]

I really don't know what kind of situation hyperbaric docs are in, and it may be different. But as an ER physician, I read a lot of things about controlling costs . . . clinical decision rules to try to avoid doing x-rays or CT scans on people who, research indicates, won't be likely to benefit from them. But when I am working, there is no one standing over me to tell me not to x-ray that ankle. I make my own decisions, and I make them based on the best information I have. I make them for the patient's benefit, the best I can, and that benefit includes making sure I diagnose and treat disease and injury appropriately but also minimize ER time, radiation and costs for the patient. I would be very surprised if many hyperbaric docs are making decisions not to treat suspected DCS because of cost issues, Jon. Remember that, first of all, we are human beings who have sworn an oath to treat our patients as best we can, and secondly, we are all deeply aware of the lawyers sniffing over our shoulders, and tend to overtreat rather than undertreat, to avoid the risk of a "failure to diagnose and treat" lawsuit.

 

[gummybun]

The only symptoms of DCS that I had are, unfortunately, also symptoms of hyperventiation syndrome which makes the diagnosis difficult. He did point out that the presentation of the paresthesia was very unusual for DCS, although I'm don't remember the explanation well enough to reproduce it here.

Well, that is very interesting and I am sure the diagnosis was well reasoned. I googled "paresthesia dcs" and got this - The line that stands out being,

This case reinforces the importance of careful clinical assessment of divers and illustrates the potentially wide differential diagnosis of DCS.

What I take away from this thread, is if one wants to be on the safe side, and that given a similar circumstance, 1) bully (within reason) for the 'better safe than sorry' chamber treatment, 2) Failing (1) - stay in or close to the hospital for a day or two in the event that you need the chamber, and don't head off deep into remote depths the jungle for the 'inland safari' half of your vacation.

Given that cram was lucky to have had a well versed MD and still, the diagnosis and symptoms of DCS still appears to be tricky to pin down.