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2. Dive Injuries 16 14 12 10 Count 8 6 4 2 0 Southeast Asia Caribbean Basin Mexico USA Central America Pacific South America At Sea Africa Location Figure 2.1.4-2 Origin of 62 cases of Travel Assist air evacuations in 2013 30 25 20 Count 15 10 5 0 Diagnosis Figure 2.1.4-3 Diagnoses of cases Travel Assist evacuated in 2013 42 Annual Diving Report – 2012-2015 Edition
2. Dive Injuries A typical evacuation case is described below. Case 2-14: Evacuation from a general hospital to medical center with expert diving medicine staff Caller is a 64-year-old male diver calling from Mexico and complaining of “rubbery legs”. He had completed a single 30 minute dive to 96 fsw (29 msw). About 40-60 minutes after surfacing, he noticed numbness on his upper thighs, an unsteady gait and tingling in both feet. He reported the dive as uneventful. He has completed this same dive several times with no incidents. He reports he is able to walk up and down the stairs but reports his legs “do not respond well”. Upon questioning, he further reported that this time he used a new wetsuit, and he had a “really hard time getting out of it”. Symptom onset apparently coincided with this effort. At this time he was advised that his symptoms should be taken seriously and he should immediately seek medical evaluation at nearest medical facility. He was asked to call DAN back once he had been evaluated. The working diagnoses included stroke and neurological DCI. Later that night DAN received a call from a local physician who evaluated this diver. He reported the patient exhibited an ataxic gait and decreased sensation over his thighs. The rest of the physical exam appeared normal. There were no signs of vestibular involvement. An EKG was performed with no abnormal findings. A consultation with a neurologist was scheduled and CT scan ordered to rule out a vascular injury within the brainstem. A few hours later (early next morning), a follow up call with the patient was confusing in that he claimed to “feel fine”, yet he stated the numb area extended from his upper thighs to lower abdomen. He also states that he was able to walk when he drove in, but is not sure he could do it now. When asked about urination, he responded that he has not been urinating at all, and is not sure he can initiate urination on his own. No urinary catheter had been prescribed. The patient said he overheard the local Spanish-speaking doctors talking about neurocysticercosis. The case manager inquired about it with the local doctors who said they have identified lesions compatible with neurocysticercosis (a parasitosis with neurological compromise), and are also considering Guillain Barré syndrome (a neurodegenerative disease) as part of their working diagnoses. DAN recommended evacuating the patient to a higher level of care for further diagnostic procedures, to which they agreed. The patient’s DAN membership was expired, but he had the financial means to cover the expense for this evacuation. The patient was medically evacuated to a university based hospital with a hyperbaric facility (Level 1+ recompression facility) within less than 24 hours from symptom onset. This hospital treats many injured divers and their physicians are expert in diving medicine. Upon admission, they diagnosed progressive neurological DCI with spinal cord involvement and neurogenic bladder. The patient received recompression therapy and ancillary care over the following three days showing significant steady improvement. Upon discharge, he returned to his home, where he continued with physical therapy. He made a full recovery about three months after the incident. Early diagnosis in this case was confounded with an atypical presentation which could have been caused by other diseases considered in this case and with a diagnostic thought process (heuristics) of local physicians who had not seen a case of DCS before. Because of his previous and uneventful experience with this dive profile, the diver ignored the possibility of decompression sickness. For the objective observer, it would be wrong to judge the dive exposure just based on maximum depth and duration of the dive. If the diver had spent most of the 30-minute dive time at maximum depth (square dive) then the severity of decompression stress would be significant. However, if he had completed a multi-level dive profile, the stress would be theoretically less. The details of the dive profile were not known in this case, so the worst case scenario should have been assumed. The number one concern of his initial treating physicians was a stroke. They also had sufficient reasons to include neurocysticercosis and a Guillain Barré syndrome in the list of potential diagnoses. They had been working their usual way to make a final diagnosis for almost12 hours. However, the evolution of symptoms over the time that included bladder involvement, clearly indicated to DAN that DCS should be considered at the top of the differential list. Local physicians had no experience with DCS but they wisely accepted recommendations and evacuated the patient. A local, hands on medical evaluation is indispensable. Just a phone call will never suffice to establish diagnosis with confidence and exclude other, possible life threatening conditions. Any qualified physician, regardless of specialty, has enough training and clinical skills to perform the requisite history and physical examination that can exclude other life Annual Diving Report – 2012-2015 Edition 43
Page 1 and 2: A N N U A L DIVING R E P O R T 2012
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Appendix C. Asia-Pacific Diving Dea
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Appendix D - Japanese Diving Certif
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Appendix D - Japanese Diving Table
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Appendix E. DAN Classification of H
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Appendix E. DAN Classification of H
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Appendix F. Glossary Arterial Gas E
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Appendix F. Glossary ness, paralysi
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Appendix F. Glossary typically in a
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Appendix F. Glossary Mixed-Gas Any
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Appendix F. Glossary Rebreather Sel
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Appendix F. Glossary Type I DCS (DC
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