Decompression Accident in North Sulawesi

[Freewillow]

If I had been bent and was told by a dive medicine specialist not to dive right away, thinking about the possibility of permanent neurological injury would be more of a concern than the fine print on my insurance policy and the potential cost of treatment.

Dear Doctor Mike, I have several hyperbaric doctors as friends and I got very different opinions fromthem when it comes to what to do after the accident. If you can prove to the scientist that I am, that a dive to 12m with a nitrox @ 80% nitrogen whould have put me @ a serious risk of neural consequences, I would be with you. So please come with your demonstration. I am happy to learn, seriously.

 

[rsingler]

I don't want to speak for @doctormike , but not having had recompression, it is not unlikely that bubble nuclei persisted, and perhaps at a site that had not been giving you symptoms.
Certainly they were smaller after your repeated oxygen therapy, but the physics of wall tension tells us that extinguishing that smallest remaining bubble is the most difficult.
With a remaining silent bubble nucleus, re-exposure to high partial pressures of nitrogen might prompt that nucleus to expand, putting pressure on a neural structure adjacent to, or surrounding it.

My feeling is that Mike was simply saying that it's easier to become symptomatic from pre-existing bubbles that expand, than for new bubbles to form from an otherwise modest subsequent dive, no matter what your other nitrogen loading is.
Does that make sense?

 

[doctormike]

Dear Doctor Mike, I have several hyperbaric doctors as friends and I got very different opinions fromthem when it comes to what to do after the accident. If you can prove to the scientist that I am, that a dive to 12m with a nitrox @ 80% nitrogen whould have put me @ a serious risk of neural consequences, I would be with you. So please come with your demonstration. I am happy to learn, seriously.

As a scientist, you are probably aware that there is not going to be an evidence based medicine study that will give you your actual risk.

But let me ask you this. If you are so sure that your 12m dive with EAN 80 soon after an episode of decompression sickness has zero risk of another episode of DCS, then why do you care if the insurance wouldn't cover you? After all, you have several friends who are hyperbaric doctors. If they are guaranteeing you that you are safe, then you won't need the insurance, right?

 

[Freewillow]

Hi, @Freewillow. I get the sense that you are feeling like you were left out in the cold and in your words, DAN was useless given where you were diving. Can you please elaborate on this? I think it's an important point to discuss because many of us have DAN, and some don't have DAN that are considering DAN, etc. It's not often that I run into a member who has had to really utilize the services and benefit from their membership and policy so I'd like to understand it more.

I don’t get the sense that you were on your own, necessarily, but that they did not deem your case as requiring a medical evacuation immediately (serious enough) and that they thought it was treatable with oxygen. My understanding from attending a couple DAN seminars is that they do not always medically evacuate and do not always bring people to chambers depending on location and severity. Would you say that is a fair assessment or what was communicated to you? Do you feel like they should have acted differently and if so, how?

Thanks.

I outofoffice, your assumption is correct. Most of the issue came from the fact that I had no way to call them from my personnal phone. My mistake, as I have explained earlier.

The problem was that I had, like DAN, to rely on communication line with the Murex organisation. The problem was that lines were cut quite frequently, therefore communication was not ideal.

A few points:

I was clearly told by DAN that the chamber in Anilao was not operational - something they found out in a few hours - and that any evacuation, if needed, would take a minimu of 24 hours to be organised. So think about being on your bed, with O2 and thinking that if things are getting worse, no chamber is avalable for the next 24/36 hours. Not a very attractive prospect.

DAN wrote in an email that they were trying to contact me. It did not happened. On the other hand, I got an email "conversation" with the Belgian Doctor via Email. DAN Europe should have tried to discuss with mia via email when they realised that this was the best way to communicate with me.

DAN also promissed me to contact me the following morning via phone. This also did not happened. Luckilly, I had the email adress of Dr Germompré, the DAN medical consultant . We exchanged a couple of email and he advised me to take an intiinflammatory drug together with 2 extra hours of oxygen. This helped solve the few remaining symtoms.

I hope this is clear. In summary Dr Germompré did a great job, by phone first and followed up by email. The administrative side of DAN Europe, was trying to stick to the phone that was unreliable.

 

[outofofficebrb]

Dear Doctor Mike, I have several hyperbaric doctors as friends and I got very different opinions fromthem when it comes to what to do after the accident. If you can prove to the scientist that I am, that a dive to 12m with a nitrox @ 80% nitrogen whould have put me @ a serious risk of neural consequences, I would be with you. So please come with your demonstration. I am happy to learn, seriously.

Hi, @Freewillow. It sounds like you have very qualified and experienced professionals that you can consult if you have several hyperbaric doctors as friends. I would imagine that would be better than any advice that strangers on an internet would give you, especially when most of us on Scubaboard are not doctors.

I would imagine most doctors and divers would tell you to not dive so soon after being bent. I don't think there needs to be any scientific data to show or explain why but that it would also be prudent given the possible severity and outcomes, especially in a location you deemed yourself as being very remote when you already feel like DAN was unable to help you.

 

[Freewillow]

I don't want to speak for @doctormike , but not having had recompression, it is not unlikely that bubble nuclei persisted, and perhaps at a site that had not been giving you symptoms.
Certainly they were smaller after your repeated oxygen therapy, but the physics of wall tension tells us that extinguishing that smallest remaining bubble is the most difficult.
With a remaining silent bubble nucleus, re-exposure to high partial pressures of nitrogen might prompt that nucleus to expand, putting pressure on a neural structure adjacent to, or surrounding it.

My feeling is that Mike was simply saying that it's easier to become symptomatic from pre-existing bubbles that expand, than for new bubbles to form from an otherwise modest subsequent dive, no matter what your other nitrogen loading is.
Does that make sense?

You have a point: the presence of "hidden" bubbles that coud create a symptom aftherwards. But for the suggested dive, just make the math. Nitrox @ 80% O2 gives you at 12 m a PPN2 of : 2,2 bar x 0,2 = 0,44 bar. Since the PPN2 on the surface is 0,8 bar, there is NO POSSIBILITY of further N2 bubble formation, on the contrary. Am I crasy, do I miss something?

As a scientist, you are probably aware that there is not going to be an evidence based medicine study that will give you your actual risk.

But let me ask you this. If you are so sure that your 12m dive with EAN 80 soon after an episode of decompression sickness has zero risk of another episode of DCS, then why do you care if the insurance wouldn't cover you? After all, you have several friends who are hyperbaric doctors. If they are guaranteeing you that you are safe, then you won't need the insurance, right?

The day you discover a doctor that can gives you a warranty, let me know. I have worked all my life with doctors of various speciallity and I have a great respect for their contribution to mankind. But let me remind you that even if it uses science, medecine is an art, not a science

 

[outofofficebrb]

I outofoffice, your assumption is correct. Most of the issue came from the fact that I had no way to call them from my personnal phone. My mistake, as I have explained earlier.

The problem was that I had, like DAN, to rely on communication line with the Murex organisation. The problem was that lines were cut quite frequently, therefore communication was not ideal.

A few points:

I was clearly told by DAN that the chamber in Anilao was not operational - something they found out in a few hours - and that any evacuation, if needed, would take a minimu of 24 hours to be organised. So think about being on your bed, with O2 and thinking that if things are getting worse, no chamber is avalable for the next 24/36 hours. Not a very attractive prospect.

DAN wrote in an email that they were trying to contact me. It did not happened. On the other hand, I got an email "conversation" with the Belgian Doctor via Email. DAN Europe should have tried to discuss with mia via email when they realised that this was the best way to communicate with me.

DAN also promissed me to contact me the following morning via phone. This also did not happened. Luckilly, I had the email adress of Dr Germompré, the DAN medical consultant . We exchanged a couple of email and he advised me to take an intiinflammatory drug together with 2 extra hours of oxygen. This helped solve the few remaining symtoms.

I hope this is clear. In summary Dr Germompré did a great job, by phone first and followed up by email. The administrative side of DAN Europe, was trying to stick to the phone that was unreliable.

Can you please explain what you mean by having to rely on Murex to communicate with DAN and what is meant by lines of communication being cut quite frequently? Are these dropped calls or are you relying on people to relay messages? Given the amount of communication problems that you have slowly let us on to, is it possible that perhaps DAN tried to contact you but because they are going through a middle man (Murex), that the message got lost along the way or there was a miscommunication?

I am also confused about how Anilao comes into play here...I am thinking Anilao in the Philippines. You are closer to Manado or other chambers in Indonesia. The idea of getting worse and not having a chamber is scary. Did they tell you that it would be *24 hours to organize as in arrange logistics-wise* or that it would be *24 hours before you would be in a chamber receiving treatment*..or *24 hours before someone would be there to pick you up*? (I ask because these are all very different and have different implications.)

I feel terrible you got bent and am glad you are okay. I want to understand the whole DAN process a bit more and hope that you don't feel like I'm interrogating you.

 

[Dan]

.....If you can prove to the scientist that I am, that a dive to 12m with a nitrox @ 80% nitrogen whould have put me @ a serious risk of neural consequences, I would be with you. So please come with your demonstration. I am happy to learn, seriously.

You meant oxygen, not nitrogen.

 

[outofofficebrb]

Just make the math. Nitrox @ 80% O2 gives you at 12 m a PPN2 of : 2,2 bar x 0,2 = 0,44 bar. Since the PPN2 on the surface is 0,8 bar, there is NO POSSIBILITY of further N2 bubble formation, on the contrary.



The day you discover a doctor that can gives you a warranty, let me know. I have worked all my life with doctors of various speciallity and I have a great respect for their contribution to mankind. But let me remind you that even if it uses science, medecine is an art, not a science

You said it yourself....Medicine is an art, not a science. We could argue that diving within tables and computer limits is also an art, not a science. Nothing is ever 100% guaranteed and plenty of people, yourself included, get bent diving within these limits. Rather than focus on why you couldn't go diving afterwards and how DAN was incorrect in their assessment of whether you could or couldn't dive afterrwards, I think the focus should be what caused your bends and what you could have done differently to prevent it from happening next time. You were diving within limits and it still happened. I would be more concerned about that. It means that if you dove within limits post-bends, theoretically, even if you couldn't get bent according to science, the art aspect suggests otherwise.

 

[Freewillow]

you are right 80% oxygen, the opposite is pretty close to air