DCS Fact Sheet for the Emergency Room

[dreamdive]

Anecdotally in the past, I have heard that the time from ER to Chamber can be extremely long. A friend of mine recently suffered his first but serious DCS hit. As DCS is thankfully relatively rare, it appears that EMS and ER personnel are not very well versed in "First Aid" of DCS and the need for early decompression in a chamber for serious hits.

Here is a "DCS Fact Sheet for the Emergency Room" that hopefully facilitates recognition and prompt treatment. The phone number is for the US. Feel free to modify this document for your special needs, the file is listed at the end

Take a picture of it with your phone, since you most likely have that with you.

___________________________________________


Attention ER Physicians:
Decompression Sickness Treatment Protocol

First line treatment: 100% Oxygen
Definitive treatment: Recompression in a Decompression Chamber

Time is of the essence!

An injured diver should be assessed for any non-DCS life threatening problems and treated accordingly. If the diver is stable and the clinical diagnosis of DCS is made, transfer to a decompression chamber should be arranged. Divers Alert Network (919-684-9111) will help identify a suitable chamber.

Keeping a ‘bent’ diver in your ER longer than to rule-out whether he/she is stable to enter a decompression chamber may be a disservice. If you do not have a chamber on-site and need to arrange for transfer to a chamber, please initiate ASAP.

The sooner a ‘bent’ diver gets to a decompression chamber the sooner his/her symptoms abate. Delay in treatment may result in irreversible damage or longer and repeated chamber treatments.

Pathophysiology of DCS:

Nitrogen bubbles absorbed during a dive are coming out of solution too fast and cause symptoms of DCS.

Symptoms:
· Joint Pain
· Marbling of the skin
· Vertigo, Dizziness,
· Weakness, Paralysis
· Unusual behavior, Severe fatigue

Symptoms may improve with oxygen but may progress nevertheless!

Treatment of a DCS patient:

If not already, place the patient on 100% O₂ with a non-rebreather. This will create a concentration gradient favoring the elimination of remaining nitrogen bubbles. If the patient is not breathing adequately, assist ventilation.

Assess and treat non-DCS problems first.

Keep the injured patient in a horizontal position. Do not place them head-down.

Once the diagnosis of DCS is made and the patient is stable, arrange for treatment in a decompression chamber. Call DAN at 919-684-9111 to determine the nearest staffed chamber available for treatment.

The patient needs to be recompressed in a chamber to decrease the size of nitrogen bubbles. Hyperbaric oxygen also delivers oxygen to tissues distal to occluded areas or edema caused by nitrogen bubbles, thus preventing distal ischemia.

Additional web-information.
1. The Four R&#39s of Managing a DCI Injury ? DAN | Divers Alert Network ? Medical Dive Article
2. Decompression Illness: What Is It and What Is The Treatment? ? DAN | Divers Alert Network ? Medical Dive Article

By Claudia L. Roussos MD

View attachment dcs ER fact sheet.docx
_____________________________________________


To place this in context, here is Mr. F's story:

Mr. F is a 45-year old healthy diver who never got bent before. He has logged multiple deep dives to 300 ft. OC and CCR. He has been an instructor for many years and started diving as a teen.

On this particular day, Mr F. was finishing up teaching an entry-level rebreather course. Part of the course requirement is to complete 10 minutes of deco. Prior to surfacing, Mr. F pulled the anchor off the wreck.

Soon after taking off his gear, he knew “something” was wrong. He started feeling weakness and numbness in his legs and immediately asked for oxygen. Following boat protocol, EMS was notified to meet them on the dock for transport to the emergency room.

Once inside the ambulance, Mr. F requested to be placed back on oxygen. Since the EMS personnel were not perceiving Mr. F in any respiratory distress, they did not see the necessity. Mr. F was reassured that he is getting plenty of oxygen from breathing air. Mr. F kept insisting and explaining that he is suffering from decompression sickness and that oxygen is absolutely vital. Mr. F finally received oxygen during his ambulance ride to the nearest emergency room.

This ER was part of regional trauma center but without a decompression chamber. Mr. F encountered the same difficulty and this time demanding to be placed on oxygen. The treating physician was given the history and Mr. F’s assessment that he is suffering from severe DCS. He provided the physician with the number for DAN and that he needs to be transferred to a decompression chamber immediately.

Mr. F’s symptoms did not improve with oxygen but immediately worsened without it. His legs were getting more numb and weak as he spent the next five hours in that ER. Mr. F insisted that he needed to be treated in a decompression chamber. Finally, he was transferred to another facility’s ER but one that had a chamber. He would spend another 1.5 hour in that ER prior to finally seeing the inside of a decompression chamber.

Over the next few days, it took seven chamber rides to restore Mr. F to baseline.

 

[C Dub]

Fantastic post dreamdive! Saved to phone. Thank you!

 

[fisheater]

Excellent idea!

I made it into a .pdf and emailed to myself, so I could open (and save) it in iBooks. I also printed out two copies, one for my dive log binder and one for my dive first-aid kit.

THANKS!

 

[Duke Dive Medicine]

Great post Claudia! I might add that even if symptoms resolve completely on surface O2, the patient still needs to be evaluated by a hyperbaric physician and probably treated in a chamber. Also, small point but it's generally ok for DCS patients to be treated and transported in the position of comfort vs remaining in a horizontal position. Of course medical needs would override this but the vast majority can sit up, eat, and drink as tolerated.

 

[dreamdive]

Great post Claudia! I might add that even if symptoms resolve completely on surface O2, the patient still needs to be evaluated by a hyperbaric physician and probably treated in a chamber. Also, small point but it's generally ok for DCS patients to be treated and transported in the position of comfort vs remaining in a horizontal position. Of course medical needs would override this but the vast majority can sit up, eat, and drink as tolerated.

Hello and thank you for your response! Any additional recommendation from you is much appreciated.
I had this "fact" sheet reviewed by a colleague who is also a board certified ER doc. Her assessment was that it would be helpful.

Claudia

 

[Akimbo]

Anything that gets a non-diving ER Doc to call DAN ASAP is a good thing! They should probably shorten the summary to:

1. Put patient on pure oxygen

2. Call DAN (919) 684-9111, ID# 5555555

Docs tend not to read information provided by patients very carefully, especially in an ER.

 

[dreamdive]

Anything that gets a non-diving ER Doc to call DAN ASAP is a good thing! They should probably shorten the summary to:

1. Put patient on pure oxygen

2. Call DAN (919) 684-9111, ID# 5555555

Docs tend not to read information provided by patients very carefully, especially in an ER.

Akimbo I cannot quite agree with you. But the bold letters and red color of the fact sheet follows your suggestion.
ER docs don't just blindly follow (or better) ought not blindly follow directions. Giving them a quick overview allows them to be more effective.

 

[Akimbo]

Akimbo I cannot quite agree with you...

You have probably had better experiences with non-diving ER docs than I have. The primary reason to get them in contact with DAN is they have far more credibility than the diver/patient… and they are likely to pay for it. This is not a criticism of your post; in fact I think it is excellent. However, concise is better in a triage environment.

 

[uncfnp]

Claudia. I love the idea and thank you for starting the process but at least in part I have to agree with Akimbo.

Some docs don't react well when a patient presents them handouts printed from an Internet web site. And regardless, each and every ER doc I know wants to cover all the bases.

I wonder if an approach that simply presents the history of a recent dive and alerts the medical provider to the risk of DCS and requests 100% O2 and a call to DAN while other emergency care is given and deferential diagnoses are ruled out might be better received.

 

[dreamdive]

One will never fit all. Mr. F did just what you suggested and his care to a chamber was seriously delayed. He was given oxygen by nasal cannula rather than by a non-rebreather mask. That makes a huge difference regarding the concentration of oxygen delivered to the patient.

The fact sheet was signed by an MD to give it professional credibility.

There always will be circumstances where no matter what you do, the outcome will not be affected. Just look at this a tool and resource to hopefully affect a more positive response in not all but some cases.

As usual, your comments and perspectives are welcome.