DCI--speed of evacuation & treatment outcome.+

[DocVikingo]

Going thru my files and located this.

Possibly a twenty hour window? Quite interesting. Suggests that evacuation to a treatment facility for mild DCI should not be unduly hasty if it entails significant additional risks.

“Undersea Hyperb Med. 2010 Mar-Apr;37(2):133-9.

Triage and emergency evacuation of recreational divers: a case series analysis.
Zeindler PR, Freiberger JJ.

Center for Hyperbaric Medicine and Environmental Physiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.

Abstract

INTRODUCTION: It is unknown if the benefits of rapid treatment always outweigh the risks of emergency evacuation for recreational divers. To investigate current triage practice, we reviewed a three-year consecutive series of evacuations and analyzed the relationship of evacuation completion time (EvCT) to outcome in the decompression illness (DCI) cases.

METHODS: Checkbox-keyword searches of calls to Divers Alert Network (DAN) between 4/06 and 2/09 identified cases for review.

RESULTS: Of 24,275 calls, 107 were evacuations. Median EvCT, (defined as time from injury to arrival at treatment facility) was 20 hours (mean +/- SD, 27.3 +/- 27.2). Indications were: DCI 56% (60), medical illness 28% (30) or trauma 16% (17). Twenty-five percent of medically indicated evacuations were for pre-existing conditions. One-third of all DCI air evacuations (17 of 51) were for mild cases (pain or tingling only). EvCT and presentation severity were not significant predictors of DCI outcome; however, early data (< 6 hours) was sparse.

CONCLUSION: More data are needed assess the benefits of faster evacuations. However, in real-world scenarios with EvCTs in the 20-hour range, time did not influence outcome. Risk-benefit analysis of emergency transport is advised, especially for mild cases of DCI with a low probability of symptom progression.”

Regards,

DocVikingo

 

[tbone1004]

if it's only minor joint bents, I have heard of people going longer than that, and often times it's because it won't present itself until after you get back home anyway and most people attribute it with being sore. If it's skin bends I'd want my butt rushed to the hospital ASAP as that can lead to many many bad bad things... Much less concerned with immediate treatment of joint bends though.
Interesting Duke is saying not to rush immediate evacuation. I've seen USCG choppers get sent out and unless it was skin bends they were turning around and said just come back in, not worth the hassle of getting the patient on board to save an hour or two.

 

[Duke Dive Medicine]

Dr. Zeindler is a Canadian Army physician and was one of two hyperbaric fellows at Duke last year. This was one of his projects, and we had a lot of discussions about inappropriate use of air evacuation assets. It doesn't just happen with divers; last year we had two fully conscious, subacute CO poisoning victims fly in from out of state via two separate helicopters. Both aircraft bypassed two fully capable emergency chambers.
The question is one of acuity, need for emergent treatment, and possible consequences of treatment delay vs. the risk that an aircrew takes every time they fly, not to mention evacuate someone from a boat via winch and litter.

I've seen USCG choppers get sent out and unless it was skin bends they were turning around and said just come back in, not worth the hassle of getting the patient on board to save an hour or two.

Tom,
This makes no sense to me. Can you provide details for these incidents? If this is really the case, we need to do some quick educating of some Coasties.

 

[tbone1004]

Yeah. We had a couple last summer in Florida where the boats where close enough in shore that the CG dropped down, evaluated them and unless they were really showing signs of DCS they told them to just turn the boat in. These ended up being very very MINOR cases of possible DCS, and were showing in knees primarily after they climbed up out of the boat. The CG deemed it safer for the patient to head back on the boat and wait the extra hour or so to get to a chamber. Have heard of cases like this on the coast here as well. Captains freak out and call the coast guard out, and when they get there for eval they leave a guy on the boat for proper o2 admin. and just turn the boat back.

 

[Duke Dive Medicine]

Yeah. We had a couple last summer in Florida where the boats where close enough in shore that the CG dropped down, evaluated them and unless they were really showing signs of DCS they told them to just turn the boat in. These ended up being very very MINOR cases of possible DCS, and were showing in knees primarily after they climbed up out of the boat. The CG deemed it safer for the patient to head back on the boat and wait the extra hour or so to get to a chamber. Have heard of cases like this on the coast here as well. Captains freak out and call the coast guard out, and when they get there for eval they leave a guy on the boat for proper o2 admin. and just turn the boat back.

It's definitely prudent for them to evaluate how serious the DCS is and determine from that whether they'll transport the diver. It sounded from your other post like they were using skin bends as go/no go criteria, which is what I was questioning.

 

[tbone1004]

not as a go no go, but if it was skin bends it was definitely a go. From what the guy on the boat was telling us afterwards it seemed like unless the guys were literally bent over or were showing visual signs of DCS they wouldn't lift them out. If it was similar to what I had when you guys bent me, then there is clearly no reason to life flight them off of a boat...

 

[Duke Dive Medicine]

not as a go no go, but if it was skin bends it was definitely a go. From what the guy on the boat was telling us afterwards it seemed like unless the guys were literally bent over or were showing visual signs of DCS they wouldn't lift them out. If it was similar to what I had when you guys bent me, then there is clearly no reason to life flight them off of a boat...

Can you please explain the "you guys bent me" thing for the readers? That makes it sound like we stood over you wringing our hands with glee as you turned blue and screamed in pain.

I think Anna was the only one doing that.

 

[tbone1004]

sorry...
I did the flying after diving study. I have knee problems as it is, and when I was back at the hotel I was on the stairs and developed a bubble in my left knee. Everyone felt bad except for my physician, who as mentioned was laughing at me the whole time saying I was unfit for life. She's an awesome doc though and made the treatment entertaining.
Good experience though, and dinner with Mike and Schiz and Anna was hilarious too

 

[Kevrumbo]

Going thru my files and located this.

Possibly a twenty hour window? Quite interesting. Suggests that evacuation to a treatment facility for mild DCI should not be unduly hasty if it entails significant additional risks.

&#8220;Undersea Hyperb Med. 2010 Mar-Apr;37(2):133-9.

Triage and emergency evacuation of recreational divers: a case series analysis.
Zeindler PR, Freiberger JJ.

Center for Hyperbaric Medicine and Environmental Physiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.

Abstract

INTRODUCTION: It is unknown if the benefits of rapid treatment always outweigh the risks of emergency evacuation for recreational divers. To investigate current triage practice, we reviewed a three-year consecutive series of evacuations and analyzed the relationship of evacuation completion time (EvCT) to outcome in the decompression illness (DCI) cases.

METHODS: Checkbox-keyword searches of calls to Divers Alert Network (DAN) between 4/06 and 2/09 identified cases for review.

RESULTS: Of 24,275 calls, 107 were evacuations. Median EvCT, (defined as time from injury to arrival at treatment facility) was 20 hours (mean +/- SD, 27.3 +/- 27.2). Indications were: DCI 56% (60), medical illness 28% (30) or trauma 16% (17). Twenty-five percent of medically indicated evacuations were for pre-existing conditions. One-third of all DCI air evacuations (17 of 51) were for mild cases (pain or tingling only). EvCT and presentation severity were not significant predictors of DCI outcome; however, early data (< 6 hours) was sparse.

CONCLUSION: More data are needed assess the benefits of faster evacuations. However, in real-world scenarios with EvCTs in the 20-hour range, time did not influence outcome. Risk-benefit analysis of emergency transport is advised, especially for mild cases of DCI with a low probability of symptom progression.&#8221;

Regards,

DocVikingo

Well . . .I unwisely waited and tried to treat myself overnight with O2 and NSAID pain meds --and woke up with acute pain the next morning:
http://www.scubaboard.com/forums/near-misses-lessons-learned/264517-type-i-bends-hit-chuuk.html

IMHO/IME, if the pain begins to manifest within minutes after surfacing, treatment or evacuation for clinical HBOT should be immediately initiated --or worst case scenario at a remote divesite location: IWR

 

[Duke Dive Medicine]

Kev,
The study authors don't advocate delaying treatment of a diver with minor DCS. The point was to look at delays in treatment vs. treatment outcomes. For minor DCS (defined as pain or tingling), the data the authors analyzed indicated that a delay in treatment up to 20 hours did not influence the treatment outcome. This supports their contention that medical personnel should analyze the risks and benefits of different evacuation methods when determining how an injured diver will be transported. Again, the authors are NOT advocating delaying treatment for DCS, they're just saying that for minor DCS hits, it's reasonable for medical personnel to consider transporting the diver by boat and/or ground ambulance vs. aircraft, which carries a higher risk.
Best regards,
DDM