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We have people treating themselves every day for a wide variety of illnesses and ailments with a pretty good success rate.

There would be no discussion if the diagnosis options were between a pulled muscle and a hematoma. The trouble with potential DCS is the diagnosis options range from the nearly insignificant to the deadly serious -- pressure and non-pressure related. Type 1 DCS symptoms can easily progress to Type 2, in minutes or hours, so the pressure (figuratively) is on.

There are very few (if any) maladies that a healthy diver would have that would be made worse by administering Oxygen. OK, that's a no-brainer. There are also very few problems with putting that diver in a chamber with the best medical talent you have onboard. Whatever first-aid that you can administer on deck can be done on the deck plates of a chamber. The patient is no worse off if you deiced it isn't DCS. Doing the same thing except the diver is over the side (or worse, off the beach) is a different story if your guess that it is DCS is wrong.

I have treated a lot of "suspected" DCS, a few "presumed" Type 2 DCS, and a few that were diagnosed by hyperbaric pros -- it isn't DCS until a doctor says it is. It was easy for us because we had a chamber, the divers were under 40, recently surfaced from a decompression dive, and we didn't have any treatment onboard for anything more serious anyway. Fortunately everyone's symptoms virtually resolved and they came out of the barrel smiling and joking.

The approach isn't so simple if you have to put a diver over the side on Scuba with little more than an O2 stage bottle and a slate. It isn't just convulsion and hypothermia to deal with. We could call for a hyperbaric doc and a chopper if the left side of the diver's face drooped or their conversation stopped making sense (we usually had a helipad onboard). An attendant diver for a patient on IWR probably wouldn’t be able to detect these symptoms, even if they were neurologists. All we had to do was "store" them in the chamber until the Cavalry showed up.

Don't get me wrong, I'm a HUGE proponent of IWR with a well-trained and prepared crew. IMHO, the key is to get a diver in the water and on O2 at the first hint that they "might" have DCS related symptoms. At that point, it isn't any different than making a reped that happens to be shallow and on Oxygen.


Nobody ever gave me grief about it, ...

Nobody? So that means I get be the first? BIG mistake mentioning something like that where I can see it. :)
 
To me, the difference between putting some Tiger Balm on a sore muscle and doing in-water recompression is the potential gravity of misdiagnosis and the higher risk of the treatment. Of course that risk is a continuum, and a simple case of type I joint pain seems (and may be) straightforward to treat, but diagnosing it isn't always as simple as it appears. There are a lot of misconceptions, some of which have been demonstrated previously in the thread. You and another poster both mentioned zebras - for the non-medical folks who may not have heard the saying, there is a well-worn piece of medical wisdom that says you don't look for zebras in a herd of horses. Before looking, though, one first has to be able to identify both horses and zebras and any other equids that may be around.

I have never heard this version of zebras before, the only versions i've heard have been based on the one Kevrumbo stated below. We agree that there is a potential for misdiagnosis, but the problem of uncertainty is always present in anything involving biology, the variables are so great we can't possibly know with absolute certainty what's going on. Where do we draw the line, 99% or 90% or 50% chance of being correct with our Dx?

No @Duke Dive Medicine , the aphorism as it applies to medical differential diagnoses is "When you hear hoofbeats, think horses -NOT zebras. . ."
(Zebra (medicine) - Wikipedia )

For an example, if a diver comes up to the surface face down and unresponsive -it's probably indicative of an AGE with near drowning, and NOT a "Carotid Artery Dissection."

If a tech diver comes up after an hour of a relaxed Oxygen Decompression and an unremarkable completed profile, and complains later of only sharp shoulder pain -it's probably an instance of an "unexpected" type I simple DCS slow tissue pathology, and NOT an impending sign of Myocardial Infarction. . .

Whoops. I got the zebra analogy bassackwards. Thanks. The edited version is how I heard it. You may have heard it differently.

And no, a face down unconscious diver on the surface is not "probably" anything. You spent enough time at the Catalina chamber to get a little bit of knowledge and I'm not going to argue with you about this, but there's another saying that's applicable to medical diagnosis and lots of other things: don't jump to conclusions. And another saying from Clint Eastwood as Dirty Harry: a man's gotta know his limitations.

Re the second case, granted, but that's not what was discussed in the thread.

Best regards,
DDM

In treating undifferentiated patients, you have to start somewhere, especially in a resource limited environment. The unconscious diver on the surface who is significantly overweight, was smoking on the boat and got winded walking down the dock with no gear and only got 5ft down before LOC is probably having a medical event, the otherwise healthy mid 20s diver doing his third aggressive dive of the day is probably having something closer to what Kevrumbo stated.

While my initial response in either case will be similar, my provisional Dx is vastly different and will change my diagnostic priorities and treatment after initial the initial resuscitation.

I work in remote areas, providing medical care with limited resources and equipment. Within a minute of seeing a patient they all have a "probably" Dx, then the remainder of my history and exam tries to confirm or rebut that Dx.

...
There are very few (if any) maladies that a healthy diver would have that would be made worse by administering Oxygen. OK, that's a no-brainer. There are also very few problems with putting that diver in a chamber with the best medical talent you have onboard. Whatever first-aid that you can administer on deck can be done on the deck plates of a chamber. The patient is no worse off if you deiced it isn't DCS. Doing the same thing except the diver is over the side (or worse, off the beach) is a different story if your guess that it is DCS is wrong.
...
Don't get me wrong, I'm a HUGE proponent of IWR with a well-trained and prepared crew. IMHO, the key is to get a diver in the water and on O2 at the first hint that they "might" have DCS related symptoms. At that point, it isn't any different than making a reped that happens to be shallow and on Oxygen.

If you have access to a chamber and related folks all this (IWR) is a pretty moot point.
Having a well trained team with all the IWR gear is a great idea, but isn't happening in the vast majority of remote dive sites.

Perhaps the discussion we should be having is when is IWR contraindicated?
If we are discussing who should be doing IWR and when:
My default answer to this is the same whether i'm training a rescue team, someone new to the remote medicine arena, or discussing medicine with my wife and her colleagues and residents (who work in an academic centre with all the bells and whistles).
When you get to a situation and go "WTH do i do now/WTH is going on/WTH is this going?" thats when you get help/use a lifeline/call DAN.

The threshold for IWR should be different for everyone/every team based on their skills, knowledge, experience and resources available.

Now going on a philosophical tangent: Will IWR be used inappropriately at some point, yes. No doubt about it. But if we try to establish a limit to IWR that will prevent all of these cases, it will be far too conservative and we will be missing out on timely treatment of a good many cases where IWR could provide a noticeable benefit to the patient.
As with most things in life, the pendulum will swing too far one way, and then too far the other (IWR used to be a taboo subject with no-one talking much about it, now it's becoming more accepted and agencies have courses on it, next people will overuse it and eventually the pendulum will settle somewhere close to the middle)
 
If you have access to a chamber and related folks all this (IWR) is a pretty moot point.

It depends a lot on how you define access. There's no debate that a chamber onboard makes IWR pointless. A chamber that is 4-12 hours away by the time you get ashore, sort through all the delays in transportation, diagnosis, clearance of insurance/payment, and get the chamber staff assembled can make IWR a very attractive -- depending on the support and symptoms.

IMO, the importance of time to treatment is vastly understated by the hyperbaric medical community worldwide because the whole system can't respond fast enough to make the difference. You aren't really bent after 12 hours since the great majority of dissolved diluent has already left your body. Your tissues are damaged from the bents at that point, not being damaged by diluent gas blocking blood flow. HBOT is a useful therapy but true DCS treatment is far too late.
 
It depends a lot on how you define access. There's no debate that a chamber onboard makes IWR pointless. A chamber that is 4-12 hours away by the time you get ashore, sort through all the delays in transportation, diagnosis, clearance of insurance/payment, and get the chamber staff assembled can make IWR a very attractive -- depending on the support and symptoms.

IMO, the importance of time to treatment is vastly understated by the hyperbaric medical community worldwide because the whole system can't respond fast enough to make the difference. You aren't really bent after 12 hours since the great majority of dissolved diluent has already left your body. Your tissues are damaged from the bents at that point, not being damaged by diluent gas blocking blood flow. HBOT is a useful therapy but true DCS treatment is far too late.

I have no real standing or formal education or "health industry insight" to judge this for merit, but that kind Sir makes a lot of simple common sense to me.
 
DO NOT TAKE THIS POST AS IWR RECOMMENDATIONS!!!
2 cents here,but we are....
12 to 24 hrs minimum to a chamber.
Trying to make a living.
Trying to return to diving as soon as practical.
We decompress soon as (very experienced) diver reports symptoms or shows them.
We will go deeper than 30' on 02 without a full face.
Some divers have returned to diving hours after IWR following seizures or paralysis.
One guy was IWR'd two days in a row,he later found out he had a PFO and found another vocation.

I'm thinking there may be a little more leeway than is indicated by some.YMMV

I would not hesitate to jump in rather than risk a permanent injury,fortunately I have yet to have any serious pain I could attribute to DCS.My pain seems consistent with age and a seriously injury prone youth of extreme sports.
 
If you have access to a chamber and related folks all this (IWR) is a pretty moot point. Having a well trained team with all the IWR gear is a great idea, but isn't happening in the vast majority of remote dive sites.
It depends a lot on how you define access. There's no debate that a chamber onboard makes IWR pointless. A chamber that is 4-12 hours away by the time you get ashore, sort through all the delays in transportation, diagnosis, clearance of insurance/payment, and get the chamber staff assembled can make IWR a very attractive -- depending on the support and symptoms.

IMO, the importance of time to treatment is vastly understated by the hyperbaric medical community worldwide because the whole system can't respond fast enough to make the difference. You aren't really bent after 12 hours since the great majority of dissolved diluent has already left your body. Your tissues are damaged from the bents at that point, not being damaged by diluent gas blocking blood flow. HBOT is a useful therapy but true DCS treatment is far too late.
How about a 6ATA capable double lock multiplace Recompression Chamber and facility with Advanced Cardiac Life Support utility that's strategically located for diving emergency triage either minutes away from the closest popular divesites, to at most 90 minutes ETA from divesites nearly 130 nautical miles away via USCG rotary wing? And always available on 24/7 stand-by as part of the local county government EMS/Rescue and Fire Dept, whether you have primary health insurance coverage -or as in the case of an indigent sea urchin harvester/diver- no insurance whatsoever? There's even no need to call DAN for consultation or pre-approval to start HBOT until long after the treatment in order to settle the insurance reimbursement.

IWR is never a last resort option here in Southern California, because all DCI cases with morbidity from simple type I DCS to acute near drowning AGE can be treated at an island 6ATA recompression chamber reserved only for the emergency treatment of diving accident casualties (and two more mainland 6ATA capable multiplace chambers as back-up at Univ of Calif Medical Centers in Los Angeles and San Diego).
 
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I would like to have more discussion on this apparent disagreement that has been unacknowledged so far:
So the US Navy, with its cadre of trained and experienced divers, extensive collective knowledge, and experience in diving medicine, thinks that evacuating a diver to a chamber that's 12 hours away is safer than IWR. There is also literature to suggest that delays in treatment are not as harmful as was once believed. A couple of examples are linked below:

Risk factors and clinical outcome in military divers with neurological decompression sickness: influence of time to recompression. - PubMed - NCBI
How delay to recompression influences treatment and outcome in recreational divers with mild to moderate neurological decompression sickness in a r... - PubMed - NCBI

We also know that time to treatment is a critical factor in the onset of DCS symptoms.

IMO, the importance of time to treatment is vastly understated by the hyperbaric medical community worldwide because the whole system can't respond fast enough to make the difference.
 
This is a fascinating subject and I'm very interested in the responses to John's post #67.
 
I would like to have more discussion on this apparent disagreement that has been unacknowledged so far:

Just like all the other topics,
There are always going to be 2 views.

Sidemount vs backmount
Buddy vs solo w/pony
Deep stops vs shallow stops
Freedive vs tanks
Open circuit vs CCR
Gloves vs bare hand
Trump vs Clinton

No one wins their argument
There will always be 2 camps of views

and you won't easily change a person's view.
 
Just like all the other topics,
There are always going to be 2 views.

Sidemount vs backmount
Buddy vs solo w/pony
Deep stops vs shallow stops
Freedive vs tanks
Open circuit vs CCR
Gloves vs bare hand
Trump vs Clinton

No one wins their argument
There will always be 2 camps of views

and you won't easily change a person's view.
I disagree.

Most of the items on your list involve personal preferences, and such arguments cannot be resolved. Other items can be supported to the point of near certainty through research. Whether vanilla ice cream is superior to chocolate is a matter of taste. The degree to which timeliness is important in recompression is something that can be studied, and those studies can potentially lead to conclusive results.
 
https://www.shearwater.com/products/swift/
http://cavediveflorida.com/Rum_House.htm

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