Recommendation for diver with suspected DCI/DCS that needs to go up stairs to get help

[scottgrizzard]

Situation: Devil's Den is a dive site in Florida with a long set of stairs leading into the cavern, with a slightly submerged platform at the bottom (too deep to perform CPR). Several cenotes in Mexico have a similar setup.

The question: if a diver ascends with signs/symptoms of DCI/DCS, after removing the gear, is it better to have the diver walk up the stairs where help is easier to access, or should you bring the O2 kit and other help to the diver at the bottom of the stairs, to avoid them "cavitating" their system?

What should the diver do?

 

[RGDiver]

I am not an an expert on this but having been to Devils Den and knowing how steep the stairs are (almost vertical) I would leave the diver on the platform area with BC inflated while other divers stabilize them while administering oxygen and call for EMS to have the diver removed on a flat stretcher assuming the diver was conscious/breathing. EMS would then transport the diver to the local hyperbaric chamber. Assuming the diver was not breathing and if surface rescue breaths failed—requiring CPR, I guess one would have no choice but to get the diver to flat/hard surface and that would require getting the diver up the stairs which is problematic in a number of ways.

 

[DiveLikeAMuppet]

If the diver is already showing DCS symptoms right after surfacing or even on the last stop, you want to get them out of the water to prevent hypothermia and drowning once the symptoms worsen.

I would be worried about the diver falling down from the stairs, so you probably need a team of people to carry them out (ideally on a stretcher).

Not sure how easily can you get EMS to a cenote in Mexico - you might need to transport your casualty somewhere by yourself, at least out of the jungle.

 

[kinoons]

I haven’t seen the stairs in question beyond the provided photo, but from what you describe I’d hazard a big guess that the diver isn’t going up those on a stretcher.

I spent 10 years as a paramedic working in the field. When faced with needing to get someone up or down stairs (I’ll admit it was almost always down) we used a stair chair.

It’s basically a folding chair with handles on the top and bottom to allow to rescuers to carry someone up or down stairs.

Really cool chairs had tank treads on the back that were geared to roll slowly down the stairs.

Gurneys are pretty crazy heavy, we would never take them up or down stairs when empty. Even more so not loaded

We did have backboards and scoop stretchers, but for stairs those presented their own issues - mainly how do you not drop the patient off the backboard or stretcher. You could strap someone in but once you got them approaching vertical it didn’t work as well and shifting weight was a danger to whomever was carrying the patient. Also the rescuer on the bottom takes nearly all the weight with these devices. Ideally you have four people trying to carry one - the limitation of a stairwell often meant only two could do this, and now you’re back to using the chair.

Routinely we did not have access to a rescue basket, but depending on the setup at the dive site that might be an option. It’s something that rescuers would need to be trained in. While I’ve been exposed to high angle rescue training, I never did any actual rescues.

 

[rjack321]

In both cases you are 4 to 12 hours from actually entering a hyperbaric chamber. Walking up 10-30meters of stairs is chump change. Exit and get them to a higher level of care as fast as reasonably possible, do not delay transporting them to care because you're stressed about stairs. If they can walk (minus their gear) get moving now.

 

[rjack321]

I haven’t seen the stairs in question, but from what you describe I’d hazard a big guess that the diver isn’t going up those on a stretcher.

I spent 10 years as a paramedic working in the field. When faced with needing to get someone up or down stairs (I’ll admit it was almost always down) we used a stair chair.

It’s basically a folding chair with handles on the top and bottom to allow to rescuers to carry someone up or down stairs.

Really cool chairs had tank treads on the back that were geared to roll slowly down the stairs.

Gurneys are pretty crazy heavy, we would never take them up or down stairs when empty. Even more so not loaded

We did have backboards and scoop stretchers, but for stairs those presented their own issues - mainly how do you not drop the patient off the backboard or stretcher. You could strap someone in but once you got them approaching vertical it didn’t work as well and shifting weight was a danger to whomever was carrying the patient. Ideally you have four people trying to carry one - the limitation of a stairwell often meant only two could do this, and now you’re back to using the chair.

Routinely we did not have access to a rescue basket, but depending on the setup at the dive site that might be an option. It’s something that rescuers would need to be trained in. While I’ve been exposed to high angle rescue training, I never did any actual rescues.

The example diver can walk. Don't go waiting 20+ minutes for EMS to arrive and fiddle with backboards and whatnot for a walking patient. Get them to a higher level of care as fast as you can. That might mean driving them yourself or might mean calling 911 for an ambulance - if they'll bring you someplace useful. More than one person has ended up with delayed hyperbaric care (in FL and elsewhere) because they got brought to a facility that couldn't help them. You have to make a judgement call about the most efficient, safest, and useful strategy.

 

[kinoons]

The example diver can walk. Don't go waiting 20+ minutes for EMS to arrive and fiddle with backboards and whatnot for a walking patient. Get them to a higher level of care as fast as you can. That might mean driving them yourself or might mean calling 911 for an ambulance - if they'll bring you someplace useful. More than one person has ended up with delayed hyperbaric care (in FL and elsewhere) because they got brought to a facility that couldn't help them. You have to make a judgement call about the most efficient, safest, and useful strategy.

I agree - the point I was making is that carrying the person out is going to be quite the production that likely will not “save” any potential worsening of their DCS vs getting them to proper treatment ASAP, to include walking out if possible.

 

[DiveLikeAMuppet]

I agree - the point I was making is that carrying the person out is going to be quite the production that likely will not “save” any potential worsening of their DCS vs getting them to proper treatment ASAP, to include walking out if possible.

If the diver is showing DCS symptoms still in the water, they are guaranteed to get worse … so you are better off getting them up and out of the cave while they cooperate.

 

[Rilelen]

Another thing to consider at Devil’s Den in particular is that the water level can fluctuate quite wildly. At its lowest that platform is completely dry or may have an inch or two of water. At its highest, there may be four feet or more of water on the platform, with water covering the handrails. Really not an option to render effective first aid standing in four feet of water.

 

[Duke Dive Medicine]

Situation: Devil's Den is a dive site in Florida with a long set of stairs leading into the cavern, with a slightly submerged platform at the bottom (too deep to perform CPR). Several cenotes in Mexico have a similar setup.

View attachment 848066

The question: if a diver ascends with signs/symptoms of DCI/DCS, after removing the gear, is it better to have the diver walk up the stairs where help is easier to access, or should you bring the O2 kit and other help to the diver at the bottom of the stairs, to avoid them "cavitating" their system?

What should the diver do?

This is a great question and brings up the transport dilemma that @kinoons called out. The diver who is most severely ill and in need of rapid evacuation may not be able to make it up the stairs. Ideally, a team would have at least talked through this circumstance prior to the dive. If there's not a formal plan in place, I would say that if feasible, put the diver on O2 as soon as possible and then carefully consider the method for safely carrying them up, including who's going to carry the O2 bottle. A diver with who is ambulatory could be helped out of their gear, placed on O2 then assisted up the stairs while being observed for worsening symptoms.

Best regards,
DDM