Recompression And Medical Ethics

[boulderjohn]

This thread is directed to any of the many fine ScubaBoard participants who are professionals in the field of medicine. I hope there can be either a reasonable explanation or a good correction for any misunderstanding I might have regarding the issue I am about to describe.

Scuba is currently experiencing a rapid uptick in what had previously been a slowly growing problem--the number of hospitals refusing to treat scuba divers with suspected decompression illness, even when they have both the required equipment and the staff expertise to do so. Everyone knows that treatment for both decompression sickness and lung overexpansion injuries should begin as soon as possible after diagnosis, and the failure to provide such treatment in a timely manner can be fatal.

The reason usually stated for refusing to provide such treatment is profitability. Recompression chambers are most profitable for a hospital when they are used to treat a number of patients for a variety of injuries simultaneously and without the need for personnel to be in the chamber with them. A scuba diver's recompression schedule will usually be different from the schedules used to treat these other patients, meqaning that diver will be treated alone, and that diver will need to have attention. This apparently is unacceptable to a growing number of hospitals.

I know that this is happening a lot in cave country--north Florida--where decompression sickness should be considered a significant threat. A recent DCS case involved a ScubaBoard regular who had to drive to Valdosta, Georgia, to find treatment.

It seems very strange to me that a hospital can refuse to treat people under these circumstances. I'm wondering about the ethics of it all.

 

[Kevrumbo]

In obvious acute cases like AGE/DCS type 2 with gross signs & symptoms, a dive accident victim will always treated by a hyperbaric facility, but in subtle type 1 cases with hidden yet developing symptoms, there's a chance of being medically "dispositioned" for the next available hyperbaric facility as an outpatient. "Profitibility" is not why some cases are initially untreated (and ethically never a legitimate reason) --It all depends on how the victim presents and is assessed & triaged by medical personnel.

The point is as an informed diver suffering from a dive accident with either acute or latent developing signs/symptoms of DCS, you're gonna have to impress upon medical personnel the potential seriousness of the situation AND INSIST on getting an immediate Hyperbaric consult (DAN) and treatment at the nearest available facility. Just tell them you are experiencing intractable pain and now having shortness of breath (the "chokes" --which is one of the most serious of delayed symptoms of type 2 Pulmonary DCS), and you will receive emergency treatment at a proper hyperbaric facility.

(Here in Southern California, all dive accidents in which the Los Angeles County Dept of Health Emergency Services chain of care is activated are automatically referred to an LA County ER/Hyperbaric Physician on-call 24/7, with the victim medevac'd to the Catalina Hyperbaric Chamber for treatment as necessary --no approval or permission from DAN is needed; nor will treatment ever be refused or transferred to another facility because of the patient's ability to pay or lack of medical insurance).

 

[Duke Dive Medicine]

In obvious acute cases like AGE/DCS type 2 with gross signs & symptoms, a dive accident victim will always treated by a hyperbaric facility, but in subtle type 1 cases with hidden yet developing symptoms, there's a chance of being medically "dispositioned" for the next available hyperbaric facility as an outpatient.

Kev,

This is not the case, and if it's happening, it's not standard of care for diving injuries. First, John is correct in saying that only a limited number of hyperbaric facilities will treat diving injuries, or emergencies of any kind for that matter. That's why we encourage injured divers to present themselves to the nearest emergency department vs. the nearest hyperbaric facility, because they may well be turned away (or find the doors locked if it's after 4:30 pm). Most outpatient hyperbaric facilities are attached to wound care centers, many of which are staffed by personnel with no experience in treating diving injuries or other emergencies. Even those that advertise the ability to treat divers may not have experience - I've personally walked chamber staff through a treatment table 6 via the phone - which is why divers with "subtle" symptoms will (or should) be evacuated to a hyperbaric facility that takes emergencies, including divers, and not just an outpatient wound care clinic that has a hyperbaric chamber.

The decline in numbers of emergency hyperbaric facilities is a well-known and much-lamented issue in the hyperbaric community, and we are at a loss as to what to do about it. I think it's a disservice to patients to take that capability away; however, it's very expensive to staff a 24/7 emergency hyperbaric facility and the return on investment is a consideration to the decision-makers. Divers aren't even the most common emergency at most 24/7 chambers. The Duke facility sees far more carbon monoxide poisoning patients in a given time than diving injuries. Many hospital clinics operate at a net loss; however, they're clinics that a large hospital is "expected" to have, e.g. an orthopedic clinic (caveat: I don't know the financials of any orthopedic clinics). Whether an emergency hyperbaric clinic is "expected" is also a consideration, and many decision makers think that it is not.

Best regards,
DDM

 

[Kevrumbo]

Kev,

This is not the case, and if it's happening, it's not standard of care for diving injuries. First, John is correct in saying that only a limited number of hyperbaric facilities will treat diving injuries, or emergencies of any kind for that matter. That's why we encourage injured divers to present themselves to the nearest emergency department vs. the nearest hyperbaric facility, because they may well be turned away (or find the doors locked if it's after 4:30 pm). Most outpatient hyperbaric facilities are attached to wound care centers, many of which are staffed by personnel with no experience in treating diving injuries or other emergencies. Even those that advertise the ability to treat divers may not have experience - I've personally walked chamber staff through a treatment table 6 via the phone - which is why divers with "subtle" symptoms will (or should) be evacuated to a hyperbaric facility that takes emergencies, including divers, and not just an outpatient wound care clinic that has a hyperbaric chamber.

The decline in numbers of emergency hyperbaric facilities is a well-known and much-lamented issue in the hyperbaric community, and we are at a loss as to what to do about it. I think it's a disservice to patients to take that capability away; however, it's very expensive to staff a 24/7 emergency hyperbaric facility and the return on investment is a consideration to the decision-makers. Divers aren't even the most common emergency at most 24/7 chambers. The Duke facility sees far more carbon monoxide poisoning patients in a given time than diving injuries. Many hospital clinics operate at a net loss; however, they're clinics that a large hospital is "expected" to have, e.g. an orthopedic clinic (caveat: I don't know the financials of any orthopedic clinics). Whether an emergency hyperbaric clinic is "expected" is also a consideration, and many decision makers think that it is not.

Best regards,
DDM

That's a pathetic excuse DDM, and shows the poor state of emergency/urgent care for DCS patients over there in North Florida. So what are y'all gonna do about it?

Even eighty-three-hundred miles away from you, Truk Lagoon has what can be considered a level 5 trauma facility and has a privately run multiplace Recompression Chamber on-call that can treat emergent DCS cases. They have phone consult with a Hyperbaric Physician -in Sydney Australia over 3200 miles away- when they run their HBOT Table 6.

By comparison, talking a North Florida private chamber operator through a Table 6 Treatment from 600 miles away in Durham North Carolina USA is not a huge communication logistic issue --is it not DDM??

Here in Southern California, unlike most Hyperbaric facilities in the nation & worldwide, we are fortunate to have the best run, most reliable non-profit Hyperbaric Chamber and County & Federal Government Emergency Medical Services support on Catalina Island specifically dedicated to treatment of diving accidents and acute DCS/AGE cases only, 24/7. Perhaps it's time for you divers with some state & local corporate sponsorship (Dive Rite, Halcyon, Univ of Florida -etc) to set-up or re-establish a similar system out there in Cave Country.

At least have some form of organized rotating 24/7 Recompression Chamber coverage amongst the private operators in the immediate region. . . !

 

[doctormike]

Wow, that's a pretty harsh response to someone who took the time to write a thoughtful explanation of the situation. Especially someone with a great deal of experience and insight into hyperbaric infrastructure. Especially someone who has been so helpful to divers on this board over the years...

 

[boulderjohn]

I would fully expect that a recompression chamber in an area like Truk Lagoon, an area with a tiny local population serving a huge number of divers coming from all over the world, would have a chamber dedicated to diving. I would expect the same in Cozumel and other famous dive destinations.

Neither I nor DDM were talking about locations like that.

 

[Kevrumbo]

I would fully expect that a recompression chamber in an area like Truk Lagoon, an area with a tiny local population serving a huge number of divers coming from all over the world, would have a chamber dedicated to diving. I would expect the same in Cozumel and other famous dive destinations.

Neither I nor DDM were talking about locations like that.

And so it begs the question John: why doesn't N. Florida have a dedicated chamber, with the major attraction being the world class & renown cave diving and training?

Wow, that's a pretty harsh response to someone who took the time to write a thoughtful explanation of the situation. Especially someone with a great deal of experience and insight into hyperbaric infrastructure. Especially someone who has been so helpful to divers on this board over the years...

So DDM explained the situation --what else is going to motivate y'all down there to start implementing smart solutions?

This is your ideal solution & model: How the Chamber is Funded > USC Catalina Hyperbaric Chamber > USC Dana and David Dornsife College of Letters, Arts and Sciences

In the meantime, why can't you recruit and train volunteer Chamber Crews and rotate 24/7 stand-by with tacit cooperation & use of facilities from the local private chamber operators? Work out the legalities and make it happen!!!

 

[Duke Dive Medicine]

That's a pathetic excuse DDM, and shows the poor state of emergency/urgent care for DCS patients over there in North Florida. So what are y'all gonna do about it?

Even eighty-three-hundred miles away from you, Truk Lagoon has what can be considered a level 5 trauma facility and has a privately run multiplace Recompression Chamber on-call that can treat emergent DCS cases. They have phone consult with a Hyperbaric Physician -in Sydney Australia over 3200 miles away- when they run their HBOT Table 6.

By comparison, talking a North Florida private chamber operator through a Table 6 Treatment from 600 miles away in Durham North Carolina USA is not a huge communication logistic issue --is it not DDM??

There's a big difference. On one hand, you have experienced chamber operators and medics treating a diver for which they need medical consultation. On the other, you have a crew in the Midwest (not North Florida, I don't believe I said that) who'd never run a Table 6 but had the medical training and experience to deal with complications in the chamber.

And so it begs the question John: why doesn't N. Florida have a dedicated chamber, with the major attraction being the world class & renown cave diving and training?

So DDM explained the situation --what else is going to motivate y'all down there to start implementing smart solutions?

This is your ideal solution & model: How the Chamber is Funded > USC Catalina Hyperbaric Chamber > USC Dana and David Dornsife College of Letters, Arts and Sciences

In the meantime, why can't you recruit and train volunteer Chamber Crews and rotate 24/7 stand-by with tacit cooperation & use of facilities from the local private chamber operators? Work out the legalities and make it happen!!!

You're welcome to come to North Carolina, or North Florida, or wherever you want, pitch that idea to the attending physicians at the emergency chambers and the potential host hospital chamber and see who will bite.

Best regards,
DDM

 

[lv2dive]

Kevin, while cave divers have a large voice on the Internet, our actual numbers are relatively small. Cave divers are but a small fraction of the tourist population that visit the area to enjoy the gin-clear springs and other park attractions. Truk is a primarily a diving destination- N FL happens to have diving, great diving, in fact, and for cave divers, it is a dive destination - but it is much more than that for the rest of the population.

 

[Jax]

What we really need is someone to win the lottery . . .

Have you folks looked at the Catalina Island Decompression Chamber? Run by volunteers. Funded by donations.

Would that be possible in Florida? I would think so.