DCS treatment

[Duke Dive Medicine]

Retrospective studies like that are difficult to interpret, especially with the relatively short (1 month) followup time. DCS symptoms that don't resolve completely with hyperbaric treatment tend to resolve over time like DocV said, but it often takes more than just a month.

 

[h20_kat]

In the end I do think I got the right treatment given my situation. It just wasn't quick enough. I think that delay getting into the chamber probably is a reason why I didn't see a resolution of symptoms with all the treatments I had. Both the DAN doctor and the navy dive doctor have said this is likely to be the case. 5 treatments would ordinarily be sufficient for a mild/moderate case of neurological DCS. In retrospect I should have had a helicopter ride. In consultation with DAN I elected to take a ferry. I wasn't able to think clearly at all at the time and as I was alone I didn't have anyone to help me make decisions. The ferry left later than I was originally told it would, took longer than it should have and resulted in me being without oxygen for many hours and not able to get into the chamber until the following morning.

It is reassuring to hear that my remaining symptoms should resolve with time. I have been told this but it is hard to have faith!

Thanks everyone for your input. I appreciate the information (even if some is over my head!) and support.

---------- Post added October 25th, 2013 at 05:00 PM ----------

A few comments regarding other symptoms. The rash went away after a few days. I'm quite confident it was unrelated and was probably insect bites of some sort. I'm not sure what the sore back was about but it went away relatively quickly so could just have been from lying in an uncomfortable position?

I injured my ankle about 7 months ago, originally told it was sprained and only found out a month later it was broken. In the meantime I tried to walk on it too soon which is probably why it still bothers me so many months later. A few months after the break, once I started to be active again, my calf began cramping which I thought was secondary to the ankle. Both of these issues are currently under investigation but having to wait until DCS symptoms subside so the sports doctor can identify what is actually going on with my nerves. But interestingly, all ankle and calf pain went away during the chamber treatments and for several days afterwards. The oxygen seems to have helped. Too bad the pain is back now.

 

[Dr. Lecter]

I ended up having 5 treatments in the chamber in Fiji. The doctor there wanted to do a couple additional treatments but DAN felt I had had enough.

Would you mind clarifying something: did DAN refuse to pay for additional treatments recommended by the physician who was actually treating you? If so, did they point you to what language in your policy gives them the right to refuse to pay for treatment recommended by the physician at the chamber DAN arranged for you to be treated at? Do you know what DAN entity handles your policy (I know DAN USA has some different policies than DAN Europe)?

Suffice to say, I'd be frustrated by what you experienced as well. I'd also probably be a number of other, less pleasant, things than just frustrated.

In retrospect I should have had a helicopter ride. In consultation with DAN I elected to take a ferry. I wasn't able to think clearly at all at the time and as I was alone I didn't have anyone to help me make decisions.

When you contacted DAN, were you presented with the option of a helicopter ride? If so, what about the consultation caused you to elect the ferry? Do you think DAN would have covered your costs for the correct transport method, or was your inclination from the consultation that cost was a factor in their advice to you?

 

[h20_kat]

Dr. Lecter:

I'm not actually sure how it will all shake out. I have to submit my claim to my travel insurer first and then any remaining costs to DAN. I never even contacted my travel insurance at the time. It was more than I could deal with to just try to ensure I was getting adequate treatment. I provided my travel insurance info to DAN but they did not contact the company on my behalf. I was reassured by DAN that my treatment would be covered one way or the other. However, after the 5th treatment I was told that the 5th treatment was NOT authorized by DAN and therefore they might not be willing to pay for it. The treating doctor apparently only found out that DAN did not believe this 5th treatment was necessary after I was already in the chamber. The treating doctor wanted to potentially do a further couple treatments, assessing on a daily basis. I guess the answer to your question is Yes - DAN essentially did refuse to pay for additional treatments recommended by the doctor treating me.

I am a member of DAN Asia-Pacific as I live in New Zealand. However, since I ended up using DAN Travel Assist (which is USA based) to book new flights for me to return home, I have been told I have to file my claim through the American office.

 

[Duke Dive Medicine]

kat,

It's probably not as simple as "DAN refused to pay for my treatment." Any responsible insurance company will perform utilization review when considering medical treatments. The litmus test as to whether to continue hyperbaric treatment for a diving injury is symptom improvement. If a diver's improvement has plateaued, i.e. the symptoms no longer improve with hyperbaric oxygen therapy, then further chamber treatment will be very unlikely to be of benefit, even if the diver has residual symptoms. Some facilities will want to continue treatment even after the diver's symptoms no longer improve, and that's typically where the conflict occurs. Unfortunately the diver is caught in the middle, and your frustration is easy to understand.

Caveat: I don't speak for DAN and I'm not certain that's what happened in your case, but if you call DAN and ask them to explain, my guess is that's what they'll tell you.

Best regards,
DDM

 

[tracydr]

Retrospective studies like that are difficult to interpret, especially with the relatively short (1 month) followup time. DCS symptoms that don't resolve completely with hyperbaric treatment tend to resolve over time like DocV said, but it often takes more than just a month.

Would the increased oxygen possibly be helpful in resolving the symptoms?

 

[Duke Dive Medicine]

Not really. Long-term (say 15-20 or more treatments) is more beneficial for chronic tissue hypoxia like you see with radiation injury and diabetes.

 

[h20_kat]

When you contacted DAN, were you presented with the option of a helicopter ride? If so, what about the consultation caused you to elect the ferry? Do you think DAN would have covered your costs for the correct transport method, or was your inclination from the consultation that cost was a factor in their advice to you?

As mentioned, I was really unable to think clearly at the time. DAN said I needed to get to Suva to be checked out for possible DCI. They asked me about transport options. I said I didn't know. They said a helicopter could be a possibility. The resort said there was a ferry that day. DAN inquired about the time of the ferry and I guess decided it was reasonable - based on initial information it should have got me to the chamber in about 5 hours. However, the initial info wasn't accurate (leaving time and duration) and the ferry was not able to dock at Suva for several hours after arriving due to bad weather. The result of all that was that I did not get in the chamber until the following day. Even the hyperbaric nurse asked why the hyperbaric unit were not contacted to arrange a helicopter. She mentioned a tourist getting DCI on a remote island recently and being transported by helicopter to the chamber which was paid for by Tourism Fiji. I don't know if cost was a factor in the decision to not get a helicopter. There was some real issues with the resort's preparation for a diving emergency. They should have known to contact the hyperbaric unit for advice about a helicopter. They only had 2 1/2 hours of oxygen available as well!

---------- Post added October 26th, 2013 at 06:00 PM ----------

kat,

It's probably not as simple as "DAN refused to pay for my treatment." Any responsible insurance company will perform utilization review when considering medical treatments. The litmus test as to whether to continue hyperbaric treatment for a diving injury is symptom improvement. If a diver's improvement has plateaued, i.e. the symptoms no longer improve with hyperbaric oxygen therapy, then further chamber treatment will be very unlikely to be of benefit, even if the diver has residual symptoms. Some facilities will want to continue treatment even after the diver's symptoms no longer improve, and that's typically where the conflict occurs. Unfortunately the diver is caught in the middle, and your frustration is easy to understand.

Caveat: I don't speak for DAN and I'm not certain that's what happened in your case, but if you call DAN and ask them to explain, my guess is that's what they'll tell you.

Best regards,
DDM

My issue is I don't think DAN had enough info to go on to make a decision about whether my symptoms were still improving or not. The treating doctor essentially asked me how I was doing each morning when I turned up and made a decision about treatment based on my response. There was VERY limited assessment of my condition. I'm not sure if this was because the doctor did not know how to properly assess or because he was tired from coming off a 12 hour night shift and couldn't be bothered. I asked DAN if they had any assessment guidelines that they could provide to the doctor and that request didn't get any response (it was via e-mail). I felt very frustrated (still do) that there was no evidence provided to me as to why treatment was stopped. I heard the exact explanation you provided about symptom plateau but as I believe my symptoms were still improving I would have liked some empirical evidence to show otherwise.

If anyone has any info on HOW symptoms of DCS are evaluated, I would appreciate it. For instance, if a person has difficulty thinking (slow to process information, short term memory issues) - surely there must be a way to evaluate this and whether it is improving?

 

[Duke Dive Medicine]

My issue is I don't think DAN had enough info to go on to make a decision about whether my symptoms were still improving or not. The treating doctor essentially asked me how I was doing each morning when I turned up and made a decision about treatment based on my response. There was VERY limited assessment of my condition. I'm not sure if this was because the doctor did not know how to properly assess or because he was tired from coming off a 12 hour night shift and couldn't be bothered. I asked DAN if they had any assessment guidelines that they could provide to the doctor and that request didn't get any response (it was via e-mail). I felt very frustrated (still do) that there was no evidence provided to me as to why treatment was stopped. I heard the exact explanation you provided about symptom plateau but as I believe my symptoms were still improving I would have liked some empirical evidence to show otherwise.

If anyone has any info on HOW symptoms of DCS are evaluated, I would appreciate it. For instance, if a person has difficulty thinking (slow to process information, short term memory issues) - surely there must be a way to evaluate this and whether it is improving?

Any practitioner who treats diving injuries should be proficient in administering a detailed neurological examination. There's a pretty good one in the U.S. Navy Diving Manual available for download on the SUPSALV website, and they get more complex from there.

SEA 00C3 Diving Publications and Technical Documentation

Once baseline neurological function is established a more focused neuro can be administered to gauge improvement. Cognitive issues like the ones you're describing are more difficult to assess though, and require more specific testing.

If you need any info that is specific to your case, I recommend you contact DAN directly.

Best regards,
DDM

 

[Akimbo]

You can also download the US Navy Diving Manual Rev. 6 with Change A from Scubaboard. The SupSal site tends to change links so this one might be more reliable over time.