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2. Dive Injuries Case managers are especially sensitized to symptoms that may be a part of DCS. Frequency of symptoms common to DCS reported by callers to the MSCC is shown in Table 2.1.5.2-1. Table 2.1.5.2-1 Frequency of symptoms common to DCS reported by MSCC callers Pain 496 Paresthesia 280 Skin 183 Nausea 136 Constitutional 108 Motor weakness 90 Respiratory 74 Vertigo 70 Hearing 50 Headache 50 Cortical 48 Cerebellar symptoms 47 Bowel 19 Nystagmus 18 Tinnitus 13 None of the listed symptoms is exclusively caused by DCS, but there are some patterns that increase the probability that they are manifestations of DCS. Pain may have many causes, but pain in limbs and joints after a dive is highly suspect for DCS. Of course, other causes like injury and muscle strains are quite common. Divers should be prepared to endure specific questions about symptom details and previous medical history while the case manager attempts to evaluate the probability of DCS versus other possible causes that may be even more serious or even life-threatening. Just because one was diving does not eliminate the possibility that the new onset of pain may be something other than DCS. Paresthesia is the second most commonly reported symptom associated with DCS. It is often colloquially referred to as “numbness and tingling or “pins and needles” To divers, the paresthesia may seem quite specific for DCS but there are many other possible causes which can confound the diagnosis. Skin changes are reported more often in recent years since DAN and other educators have stepped up their effort to make divers aware of skin DCS symptoms. The diagnosis may be helped by providing a photograph of the affected area. MSCC received photos of a dozen such cases. Skin changes caused by DCS may appear as red dotted rash which can be confused with myriad of causes, and as a skin mottling (marblization) which post-dive can be caused by DCS. (see DAN skin DCS brochure and DCS booklet DCS) Nausea and constitutional symptoms after diving may raise suspicion but they alone do not make the diagnosis of DCS. Motor weakness soon after a dive, is highly suspicious of DCS. It must be taken seriously and treated as DCS until disproved. When it affects limbs, it is most likely caused by decompression sickness of the spinal cord but other causes are possible. When associated with other manifestations of DCS such as skin, pain and constitutional symptoms, the diagnosis is more certain. Here are several cases involving motor weakness. Case 2-01: Multi-organ manifestation of DCS The call came from a member of the staff of a liveaboard who had an injured diver onboard. The diver had completed only one day of diving. The depths ranged from 45 - 90 fsw (14 - 29 msw). According to the dive computer, all dives were within the normal limits and did not require mandatory decompression stops. The last two dives showed a rapid ascent. Upon surfacing from the last dive, the patient developed acute confusion, dizziness, generalized weakness (staggering), 46 Annual Diving Report – 2012-2015 Edition
2. Dive Injuries blotchy skin and itching throughout his abdomen. He also reported shortness of breath. He was placed in a sleeping bag and provided oxygen first aid. The liveaboard was 20 minutes away from the local port when the caller contacted DAN for consult and assistance in getting the member to medical care. The symptoms presented in this case (cerebral, respiratory, motor and skin) along with their post-dive onset and evolution fit the diagnosis of DCS with a high index of suspicion. Although it would be difficult to find another condition with such a presentation, a professional evaluation is still necessary as some signs and symptoms could indicate the coexistence of another serious condition or even a completely different cause that may not be recognized by medically untrained staff. Once the boat reached the port, EMS took over and got the patient to a nearby hospital with an emergency department and hyperbaric facility where the patient was evaluated and properly treated for DCS. Case 2-02: Know Thy Dive Computer! The call for consult came from a physician in a hyperbaric department of a major medical center. He had a 42-year-old male who was diving in a spearfishing tournament. The patient reported making four dives but he knew only his depths. He didn’t know his bottom times or surface interval times because the diver was unfamiliar with the computer he was using. His dives were to 33, 115, 100 and 108 fsw (10, 35, 30 and 33 msw respectively). The patient thought the computer may have advised no diving after the third dive, but he disregarded it and went on a fourth dive. That night, after the tournament, the patient developed left flank pain, motor weakness of both legs and disorientation. He went to a friend’s house and attempted to self-treat with surface-level oxygen. Two days later he went to the emergency department and was found to be ataxic with neurological deficits and left flank pain. He was treated on a USN TT6 with no extensions and experienced some degree of improvement. The following day he received another treatment on a USN TT5. His neurologic symptoms resolved but a slight left flank pain was still present. This was an obvious example of severe DCS. It appears that the diver did not understand his dive computer which provides the primary safety measure – the control of dive exposure. He also did not present himself immediately to the hospital but instead attempted self-treatment. While surface oxygen may help to alleviate symptoms, it is not sufficient treatment for most cases and recompression should be administered. This diver was lucky that his injury seemed to be limited at the outset and did not progress. Case 2-03: Surface oxygen did not suffice to prevent severe DCS after moderate exposure The caller is a 55-year-old male who dove that morning to 100 fsw (31 msw) for 17 minutes breathing Nitrox 32%. All of his time was at 100 fsw. The dive was still within the no-decompression limits and the diver completed a safety stop. Upon climbing back on the boat, he started experiencing lower abdominal pain. He decided not to dive anymore and treated himself with oxygen for a period of two hours until it ran out. About an hour afterwards, the boat arrived back at the dock and the diver went home. He called the DAN emergency hotline because his symptoms returned and got worse. The skin on his legs, back, and stomach and just about everywhere from the waist down was numb and prickly. He was experiencing difficulty walking due to weakness in his left leg. He said it felt like his muscles did not want to work properly and he was having trouble standing. He denied any changes in skin color. He had been drinking water all day but was unable to urinate. The case manager advised the caller that this is most likely a severe DCS and the caller agreed. Since he was only 10-15 miles from the medical center which has also a hyperbaric facility, he should have someone else drive him or call an ambulance. The caller said that since he drove himself home, he should be able to drive himself to the hospital. The case manager advised that this would be dangerous since he is already having trouble with his legs and his condition could worsen while driving. Patient was advised to call EMS and he did. Immediately after this call ended, the case manager called the charge nurse in the emergency department and advised of patient coming and that he needs immediate attention. An hour later, the case manager verified that the patient had arrived and been transferred to hyperbarics. Several hours later, towards the end of expected hyperbaric treatment, the case manager called the hyperbaric chamber again. He learned that the patient did not improve much with standard USN TT6 and was at that time in his first extension at 60 fsw (18 msw). Annual Diving Report – 2012-2015 Edition 47
Page 1 and 2: A N N U A L DIVING R E P O R T 2012
Page 3 and 4: Annual Diving Report 2012-2015 Edit
Page 5 and 6: Worldwide DAN Offices DAN is compri
Page 7 and 8: 1. Introduction Introduction Since
Page 9 and 10: 1. Dive Fatalities Section 1. Dive
Page 11 and 12: 1. Dive Fatalities Table 1.2-1 (con
Page 13 and 14: 1. Dive Fatalities Table 1.2-2 (con
Page 15 and 16: 1. Dive Fatalities 45 Florida (n=20
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Page 21 and 22: 1. Dive Fatalities Sea condition (s
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Page 25 and 26: 1. Dive Fatalities Table 1.7.2-1 (c
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Page 33 and 34: 1. Dive Fatalities the effectivenes
Page 35 and 36: 1. Dive Fatalities 1.11 Rebreather
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Page 41 and 42: 2. Dive Injuries 2.1.3 Where are Di
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Page 45 and 46: 2. Dive Injuries A typical evacuati
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Page 57 and 58: 2. Dive Injuries open water and at
Page 59 and 60: 2. Dive Injuries 2.2 Dive Injuries
Page 61 and 62: 2. Dive Injuries 1400 1200 Estimate
Page 63 and 64: 2. Dive Injuries Table 2.2-5 Diagno
Page 65 and 66: 2. Dive Injuries 100859397 29-year-
Page 67 and 68: 2. Dive Injuries Case number Case n
Page 69 and 70: 3. Diving Incident Reporting System
Page 81 and 82: 4. Breath-hold Dive Incidents Secti
Page 83 and 84: 4. Breath-hold Dive Incidents Numbe
Page 85 and 86: 4. Breath-hold Dive Incidents can r
Page 87 and 88: 4. Breath-hold Dive Incidents It is
Page 89 and 90: 4. Breath-hold Dive Incidents There
Page 91 and 92: Appendix A. Breath-hold Incident Ca
Page 93 and 94: Appendix A. Breath-hold Incident Ca
Page 95 and 96: Appendix B. Diving Related Fataliti
Page 97 and 98: Appendix B. Diving Related Fataliti
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Appendix B. Diving Related Fataliti
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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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