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Non-cooperative DCI patient

Discussion in 'Near Misses and Lessons Learned' started by klausi, Jul 4, 2015.

  1. klausi

    klausi Marine Scientist

    # of Dives: 2,500 - 4,999
    Location: Dumaguete, Philippines
    This incident happened a few months ago at a dive shop I don't work at anymore, but my intention is not finger pointing, but figure out what to best do in comparable situations?

    A diver arrived at our resort with his wife and friends. The diver had done many dives (1000+), but was 60yo, moderately overweight, and had suffered two heart attacks 8 years ago. He had a medical certificate stating that he was still fit to dive. He was not smoking (anymore?) but drinking alcohol regularly.

    Question 1: Should I have nevertheless rejected the person as a diver right away at this point? Can it be reasonably safe at all to dive with 2 previous heart attacks, even for easy recreational dives? Pointers to relevant studies are appreciated. I knew I was legally safe with the medical certificate, but that's not the main point - I just want everybody to be safe.

    The diver and his wife & friends typically did 3 dives per day, almost all on 32% nitrox. The dives in the region are usually 30 meter max, with most time spent at 20 m or less – not very challenging or deep dives. The water temperature that time of the year here is 27C.

    About 2 weeks into their vacation the diver somewhat collapse at dinner. He then went back to his room – I did not witness that part personally. At that point, the bar staff got me from my room nearby, with a brief description of what had happened. I am not a medical doctor, but I am quite well read in diving medicine, from my technical diving training and a long-time interest. I immediately suspected a DCI. On the way I ran into another guest who is a trained nurse, and asked her to come along, which she immediately agreed to.

    I found the patient sitting on his bed, visibly pale and shaken. His wife pointed out a large dark red spot on his abdomen – likely skin bends. I encouraged him to drink (which he had done, he said), left him with the nurse, and went to fetch our oxygen system. I also asked one of our bar staff to call an ambulance. Once I had gotten the oxygen, I assembled the system with the help of another guest and had the patient start breathing. I again left the nurse with him, and went to wait for the ambulance (it's not easy to find your way around the hotel property if you haven't been there).

    After about 10 minutes the ambulance arrived, but the patient refused to head to the hospital in it. Even without formal medical training it seemed clear to me that someone with his age, medical history and symptoms should be under medical supervision for the night. There is a decompression chamber in Cebu City which can be reached in 4 hours from Dauin, and a good hospital in Dumaguete, about 20 minutes from the resort I was at. Once at the hospital he would be already closer to the chamber, and under medical care for the transport, should it be necessary.

    Myself, the nurse, and the patient's wife tried to convince him multiple times to go to the hospital, but he refused to go (in front of several people). I explained that I was under the opinion that this could be a serious issue and that my recommendation was to go see a doctor. The red spot had not disappeared but taken a less intense red color (it was pinkish afterwards). He stated that he felt reasonably well. Eventually I sent the ambulance home (it was a free countryside volunteer ambulance, and the patient made no attempt to thank them or donate to them the next day).

    The patient decided to stay in his room and continue breathing oxygen. He asked for our 2[SUP]nd[/SUP] oxygen tank, which I gave him. He ended up only breathing one tank empty and was, at least superficially, fine the next day. Which I consider quite a bit of good luck! I certainly slept light that night, expecting to be woken up due to an escalating DCI.

    Question 2: There is nothing one can legally do to force an adult to accept medical treatment, correct? That's why sometimes Jehovah’s witnesses die from refusing blood transfusions, right? What is the proper procedure in such a situation? I was quite surprised that anyone would be rejecting medical help like that. I made sure he had stated his intention not to go to the hospital to me before witnesses. What else would there be to do?

    Incredibly, the patient, who had been difficult to deal with as a guest to begin with (other guests had complained about him) did not even thank me and the staff for our help. While his wife did thank us the day after the incident, she also took the opportunity to tell me that they “did nothing wrong” and that her hubby is in “top shape”. I told her that this wasn't quite the case, that this situation was potentially dangerous, and that diving was over for her husband on this trip. I recommended getting a EKG that day. They did not protest me not letting him dive anymore. They did, however, clearly take my advice as an insult and started complaining about everything and anything at the resort even more than before.

    Question 3: How do you best communicate to people ignorant in diving medicine that they are/were in trouble?
    Altamira and Peter69_56 like this.
  2. kombiguy

    kombiguy Instructor, Scuba

    # of Dives: 2,500 - 4,999
    Location: Palmetto Bay, FL
    What does, or did, the diver do for a living?
  3. chillyinCanada

    chillyinCanada ScubaBoard Supporter Staff Member ScubaBoard Supporter

    Interesting question kombiguy. :)

    How much time did the couple have left on their vacation before flying? Having had skin bends myself and worse than his appeared to be based on your description, I doubt you'd have gotten me into an ambulance either (at that point).

    I do find it interesting and perplexing that not only did the couple show no graciousness after all the help, the man had already offended other guests before the incident ever even happened.
  4. TSandM

    TSandM Missed and loved by many. Rest in Peace ScubaBoard Supporter

    I have no idea what the legal standard for dive operators or doctors in the Philippines is. In the US, if someone shows decision-making capacity, they have the right to make stupid decisions. In the ER, we require them to sign a form, documenting that we informed them of the risks of their decision, and that they are going to do it anyway. We also document meticulously what we said, what they said, and what risks were discussed. If I were in the situation of a dive op or resort that had a patient like this, I would document very thoroughly what the interactions were, and I'd make the person sign something attesting that he was advised to go for treatment and refused. He could have awakened paraplegic, and at least the US reaction to that would be immediately to sue anybody in sight for having allowed it to happen.
    klausi and chillyinCanada like this.
  5. farsidefan1

    farsidefan1 Loggerhead Turtle Rest in Peace

    # of Dives: 200 - 499
    Location: Salt Lake Valley, Utah USA
    Take to where the ocean is deepest, tell him there are lots of friendly whale sharks down about 300 feet but that NO ONE is allowed to dive with them. Darwin will take care of the rest.
    Midget, Dr. Lecter and scagrotto like this.
  6. tursiops

    tursiops Marine Scientist and Master Instructor ScubaBoard Supporter

    # of Dives: 2,500 - 4,999
    Location: U.S. East Coast
    Klaus, I think you did what you could. I like the idea of having them sign something that says they were informed of the risks and ignored the advice....and you can certainly say no signature, no more dives. And he signs that when he gets the oxygen. The fact that he took the oxygen means he has some awareness of his problem; the refusal to admit it and deal with it more overtly and publicly is his problem, not yours. I've met you at Aiyanar; you are a nice, personable guy. Don't take the problems of stupid people on your shoulders...you can't solve them, and it will eat you alive. Keep your emotional distance from such people. And don't let them return to the resort!
  7. redacted

    redacted Guest

    I, too, just want to be safe. Safe from foolish dive operators who would wait until a fully qualified customer shows up at their shop only to be denied service because someone of limited qualifications thinks he knows more than the doctors.

    Scratch another dubious scuba destination. To be fair, I had already scratched the Philippines as a destination based on previous similar threads by local dive professionals. In other words, this is not an isolated incident.
    Manneca likes this.
  8. tursiops

    tursiops Marine Scientist and Master Instructor ScubaBoard Supporter

    # of Dives: 2,500 - 4,999
    Location: U.S. East Coast
    Wow. Overreaction?
    "fully qualified" Really? Maybe his paperwork said that, but his body did not.
    Skipping the entire Philippines because some people are concerned about health? Hey, your choice.
  9. Manneca

    Manneca Barracuda

    # of Dives: 1,000 - 2,499
    Location: Memphis (TN, not, unfortunately Egypt)
    I agree with Extreme Poster. If someone has a medical certificate say s/he can dive, then a dive shop shouldn't second guess the medical certificate. He's and adult and knows what the risks are.
  10. tursiops

    tursiops Marine Scientist and Master Instructor ScubaBoard Supporter

    # of Dives: 2,500 - 4,999
    Location: U.S. East Coast
    Maybe you and awap are missing the point: he WAS allowed to dive. His body rejected the dive; now it is a new ball game. Now there is more info than a signature on a medical form.
    Midget, NorCalDM and oly5050user like this.

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