Bent!

[Duke Dive Medicine]

Hindsight is always 20/20, but the OP should have immediately hailed the LA County Baywatch Paramedics at Catalina or US Coast Guard upon manifestation of initial symptoms, or at least just kept making way over to the Isthmus/Two Harbors landing at Catalina Island. . .

On what are you basing this statement? First of all, from his initial post it appears that Baywatch was contacted very quickly. It's likely that he was transported to Marina Del Rey on their advice (Tobin, correct me if I'm wrong). Second, he presented with chest tightness and difficulty breathing after meticulously following his decompression profile. What's the differential diagnosis, and would you rather have a patient with these symptoms at a tertiary care facility with both a hyperbaric chamber AND robust medical care, or a standalone hyperbaric chamber with ACLS capability?

We have one of the most capable chambers in the world, and I can tell you that we send every single diver we treat through our ED before we bring them here, partly for admitting purposes but mostly to ensure that everything else is ruled out.

As good as Catalina is, they don't have an X-ray machine or a CT scanner and they don't have a lab that can run cardiac enzymes. In the OP's case, as I said before, his symptoms were non-specific enough that evacuation to an ED for evaluation was entirely appropriate.

Unless you have complete diagnostic capability on board your dive boat or can POSITIVELY identify decompression sickness, you need to transport an injured diver to the nearest ED for evaluation. This is the advice that DAN gives, and ours is exactly the same.

 

[Jax]

Second, he presented with chest tightness and difficulty breathing after meticulously following his decompression profile.

Question -- Tobin's initial thought was "the chokes". Any chance there was a little IPE going on there? Would dehydration help, or hinder, the development of IPE? Just curious.

 

[Duke Dive Medicine]

Question -- Tobin's initial thought was "the chokes". Any chance there was a little IPE going on there? Would dehydration help, or hinder, the development of IPE? Just curious.

Probably not IPE in this case. Dehydration before or during a dive probably wouldn't have an effect on the development of IPE unless there was significant depletion of blood volume, in which case it could theoretically have a protective effect (not to say that people should dehydrate themselves to avoid IPE!!)

 

[daniel1948]

Tobin, thanks for sharing. I'm glad you made it.

Daniel

 

[mjsylver]

I'm so glad you got through your ordeal. I teach high school and SCUBA on the side, with your permission, I'd like to use your post and the follow ups as part of my lesson plan for my open water and advanced classes.

 

[cool_hardware52]

I'm so glad you got through your ordeal. I teach high school and SCUBA on the side, with your permission, I'd like to use your post and the follow ups as part of my lesson plan for my open water and advanced classes.

Feel free, hope it's helpful.

Tobin

 

[Kevrumbo]

On what are you basing this statement? First of all, from his initial post it appears that Baywatch was contacted very quickly. It's likely that he was transported to Marina Del Rey on their advice (Tobin, correct me if I'm wrong). Second, he presented with chest tightness and difficulty breathing after meticulously following his decompression profile. What's the differential diagnosis, and would you rather have a patient with these symptoms at a tertiary care facility with both a hyperbaric chamber AND robust medical care, or a standalone hyperbaric chamber with ACLS capability?

We have one of the most capable chambers in the world, and I can tell you that we send every single diver we treat through our ED before we bring them here, partly for admitting purposes but mostly to ensure that everything else is ruled out.

As good as Catalina is, they don't have an X-ray machine or a CT scanner and they don't have a lab that can run cardiac enzymes. In the OP's case, as I said before, his symptoms were non-specific enough that evacuation to an ED for evaluation was entirely appropriate.

Unless you have complete diagnostic capability on board your dive boat or can POSITIVELY identify decompression sickness, you need to transport an injured diver to the nearest ED for evaluation. This is the advice that DAN gives, and ours is exactly the same.

Simple straightforward triage as a First Responder (i.e. Boat Captain, Dive Master, Rescue Diver etc on the scene), based on initial reported symptoms and worst case scenario of a just surfaced conscious diver onboard in post-dive distress . . .Rule Out DCS and/or AGE. Radio-in, rendezvous & evacuate patient by Baywatch Paramedic Boat or US Coast Guard Helicopter to Big Fisherman Cove West End Catalina while underway at sea. Evaluate and begin Oxygen Therapy at Catalina Hyperbaric Chamber as necessary with attending Emergency/Hyperbaric Physician on-call & enroute, and then post-treatment assessment & stabilize for transport. Helicopter patient back to mainland LA/USC County General Hospital for further diagnostic work-up/treatment as needed for secondary conditions or comorbid pathologies. IMO, this is the preferred beginning of the standard chain of care for all dive accidents with suspected DCS/AGE --whether victim is conscious or unconscious; alert & oriented or in full cardiorespiratory arrest: the initial response and call for immediate aid should always be the same.

THIS ALSO IS STANDARD OPERATING PROCEDURE FOR ALL COMMERCIAL SPORTDIVE BOATS HERE IN OFFSHORE LOS ANGELES COUNTY FOR A DIVING ACCIDENT --TRANSPORT IMMEDIATELY TO THE CATALINA HYPERBARIC CHAMBER VIA BAYWATCH BOAT OR US COAST GUARD HELICOPTER ("WHEN IN DOUBT, CHOPPER 'EM OUT") . . . THIS IS THE BEST MOST PRUDENT COURSE OF ACTION TO TAKE AS EITHER A FIRST RESPONDER OR VICTIM!!!

And again, you don't need pre-approval or consultation with DAN to effectively implement this governmental service of LA County Dept of Health:
http://ems.dhs.lacounty.gov/MAC/MAC.htm
http://dornsife.usc.edu/hyperbaric/home/index.cfm

 

[Duke Dive Medicine]

Kev,

I hear what you're saying, and perhaps if the diver had been in the immediate vicinity of the Isthmus (e.g. diving off of Ship Rock) it may have been appropriate to take him there first for evaluation. Tobin wrote a great summary, but don't forget that you're seeing the entire evolution of his incident in a few paragraphs. His initial presentation was chest tightness, dyspnea and dizziness. A number of non-diving-related medical emergencies can also present this way; acute myocardial infarction, congestive heart failure with flash pulmonary edema, and pulmonary embolus come immediately to mind. His decompression appeared to have been reasonable when I ran it through V-Planner and DecoPlanner, which lowers DCS in the differential. *Edited based on below info about surface interval*

I'm not sure what your level of medical qualification is, but assume now that you're a medic who takes the call from Tobin's buddy on Ch 16. What you hear on the radio is something like "53 year old male with a history of mild hypertension treated with medication, has been exercising over the past year but was previously sedentary, experienced technical diver, appropriate decompression and ascent with no problems on the dive, now presents with chest tightness, difficulty breathing and dizziness."

Do you see where the waters get muddy here? This is not a clear-cut case of DCS. If it HAD been an MI (which the receiving hospital took great pains to rule out), transport to the Catalina chamber would have been the wrong choice. Yes, they can shock him if he goes into cardiac arrest, but I'm sure they would rather have had him treated appropriately in a hospital with a good heart center.

And again, you don't need pre-approval or consultation with DAN to effectively implement this governmental service of LA County Dept of Health:
County of Los Angeles - Department of Health ServicesUSC Catalina Hyperbaric Chamber

You don't need consultation or pre-approval from DAN for any treatment for a diving injury. This isn't unique to LA County. DAN may perform a utilization review if they think a diver is being treated to excess, but they don't need to approve initial treatment.

 

[rx7diver]

Effective surface interval was about 2 hours, not 1.Tobin

Tobin,

I am not familiar with the term "Effective Surface Interval." What exactly does this term mean, and how does it differ from "Surface Interval"? TIA.

Rx7diver

P.S. Thank you for your detailed description of your DCS incident.

 

[cool_hardware52]

Tobin,

I am not familiar with the term "Effective Surface Interval." What exactly does this term mean, and how does it differ from "Surface Interval"? TIA.

Rx7diver

P.S. Thank you for your detailed description of your DCS incident.

Many consider the surface interval to be from the time they leave the water and dive 1 and enter the water on dive 2.

We carry bit more gear, 2-3 additional bottles and scooters and some also take cameras. Much of this gear is clipped onto drop lines hung off the boat. It can take 4 divers a while get this gear sorted and attached, and we typically gear up and enter the water one at a time. Add to that surface checks, bubble checks, s drills etc. and we may be in the water for 10-20 minutes before we descend.

By effective surface interval I am referring to the time spent at the surface between dives, including the time spent gearing up etc. for dive two. We might start getting back into the water @ 1:45, but not start our descent until 2:00 or 2:05.

Tobin