DCS or dehydration? What call to make

[Duke Dive Medicine]

I don't think that anyone can say with 100% certainty that the "right" or "wrong" call was made here, considering that this is third-hand information and is absent some important details. A "benign" 18-meter dive would probably not produce classic decompression sickness, and the symptom onset time doesn't support that diagnosis. The diver may have arterialized some venous gas emboli via PFO or other shunt, which can produce rapid onset of severe neurological symptoms that mimic AGE (and really is arterial gas embolism by definition, just not related to pulmonary overinflation). We don't know what the bottom time was and so can't tell the likelihood of occurrence of VGE. Also, the leg pain is a bit of a distraction - DCS pain in an extremity isn't associated with shunted bubbles. Like TSandM said, symptoms of DCI can improve with surface O2 but have an unfortunate tendency to reoccur when the O2 is discontinued.

The diver's symptoms could also be explained by dehydration and resultant electrolyte imbalance. Others have already touched on this, but there is a significant fluid redistribution when a diver exits the water. If the diver is already dehydrated, that fluid redistribution could result in a drop in blood pressure and produce confusion and lightheadedness. If the diver really was completely asymptomatic after an hour of rest and fluid resuscitation and didn't experience any symptom recurrence, that's probably the way I would lean.

Re the cost factor: that's a tough one. TSandM already pointed out that some other countries don't have EMTALA (Emergency Medical Treatment and Active Labor Act) laws like we do here in the U.S. Cost to the patient is always a consideration and can be more of less of an influence depending on the acuity of the injury. If a serious illness like AGE/neurological DCI is in the differential, I would tend to transport first and worry about cost later.

So, did they make the right call? Maybe. However, if there was any doubt, as others have already pointed out, it's a good idea to get professional medical advice. DAN is a great resource.

Best regards,
DDM

 

[IWantToBeAFish]

Thanks very much for all of your replies, some real important things to think about. Unanimously of course is that calling DAN should be a no brainer.

Weighing up cost vs symptoms is an interesting one. Im from the UK and while we have a good, free, national health scheme, I'm pretty sure we aren't financially covered for major overseas medical costs. There is a lot of attention given to us obtaining travel insurance to cover the costs in these situations. For backpackers this can be a major down payment which they just don't want to make.

When I did my EFR we were taught to ask if help was desired, the same could be true of evacuation if they were conscious? If they state that they aren't covered and don't want evacuation do we have a duty to honour that request?

Definitely lots of good stuff to think about anyway, particularly around first aid vs diagnosis. An important point indeed.

 

[TSandM]

In the course of my job, I serve as medical control for the local ambulance services. They are supposed to phone me any time they are called out and the patient decides not to accept ambulance transfer. In the US, you have a perfect right to refuse medical care, so long as you are competent -- if you are conscious and not disabled by intoxication, you may refuse care, even if it may threaten your survival to do so. This is the way I would handle someone on a dive boat, but if I owned the boat, I would document like crazy, including, if I had a phone or something that could do it, recording the victim tell me that he understood the risks and was refusing anyway.

 

[IWantToBeAFish]

Good point. Documentation is key for incidents anyway to assist the EMS so best to make it habit regardless of the action taken. Thanks