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