Earned, Un-earned or Predisposed?

[DandyDon]

Wow, look at those shot SIs! No mention of Nitrox here? I would think it'd help a lot, but really - that's brutal diving.

 

[Divedoggie]

Sounds so much like a hit my last Inst took at Santa Rosa. He's more careful after this second one, but then he never really admitted to the first one.

In this case, between the pain and the fear of permanent disability, I imagine extreme care will be taken now and in the future. He knows he is Soooo lucky that he is ok.

 

[Bubbletrubble]

Just a few questions:

• What was the medical team's final diagnosis at the hospital?
• Was the Valium (diazepam) administered for the back spasms?
• Why was magnesium given?
• Were the CK enzymes (CK total, CK-BB, CK-MB) tracked during the entire course of the patient's hospital stay? If so, what were the results? Were troponins tested?
• On the day following the incident, why did the instructor do a Table 5 treatment instead of a Table 6 treatment?
• Did the instructor have a history of upper back pain, back spasms, or radiculopathy?
• At any time after surfacing, did the instructor exhibit any other abnormal neurological signs (problems with speech, confusion, loss of consciousness, numbness, etc.)?
• Can you elaborate a little on the chronological altitude profile? Specifically, at what altitude does the patient live and over what time period did he travel to the lake at 4300 ft.? (Or perhaps he lives at the same altitude as the lake.)

Just curious. It's great to hear that the instructor has made a full recovery.

[FYI, "prone" = lying face-down on one's belly and "supine" = lying face-up on one's back.]

 

[Divedoggie]

Here are some answers and perhaps further questions.

Just a few questions:

• What was the medical team's final diagnosis at the hospital?
  
  I don't have access to the final diagnosis and release papers, but my understanding is that the Dr. in charge of the ER that night had seen a number of scuba related incidents related to new students having anxiety. There was a small language barrier and a bit of resistance from the Brazilian Dr, in this small town, to accept DAN recommendations, and to accept that the patient and I were experienced "professionals" certified to teach 1st aid/cpr and familiar with DCI.
  
  I think the final diagnosis was anxiety attack. Patient actually demanded to stay on O2 under care until morning. The Dr was ready to release him when the symptoms resolved. He was released with 2 diazepam pills and two potassium supplement pills, with directions to follow up with personal Physician at home.
  
  
• Was the Valium (diazepam) administered for the back spasms?
  
  Diazepam was administered for anxiety and muscle spasm. Patient was not having visible anxiety. In fact he was remarkably calm and directed during entire incident. It was possibly administered secondarily for spasm, but he was showing no sign of back spasm at the ER. His symptoms were paralysis of lower limbs and right arm with intense pain in inner hips.
  
  
• Why was magnesium given?
  
  I have no idea. They said it would help the muscles.
  
  
• Were the CK enzymes (CK total, CK-BB, CK-MB) tracked during the entire course of the patient's hospital stay? If so, what were the results? Were troponins tested?
  
  Initial blood draw showed the 309 CK total. No other blood was drawn. I saw one comprehensive panel as I identified earlier.
  
  
• On the day following the incident, why did the instructor do a Table 5 treatment instead of a Table 6 treatment?
  
  He apparently was showing only mild symptoms in his hands and shoulders which were resolved in the chamber by the time they decided whether they were going with Table 5 or Table 6.
  
  
• Did the instructor have a history of upper back pain, back spasms, or radiculopathy?
  
  I know he has worked physically for years and sometimes complains of back pain. I remember him having regularly scheduled theraputic massage. I suppose radiculopathy is possible but undiagnosed. Do you suspect impingement?
  
  
• At any time after surfacing, did the instructor exhibit any other abnormal neurological signs (problems with speech, confusion, loss of consciousness, numbness, etc.)?
  
  No he specifically asked us to keep an eye on him. He was clear, focused and in control mentally the entire time. He did say that his hand went numb before the entire arm became useless. We suspected heart attack and took his pulse which was steady at 70. We suspected stroke or possible AGE but he responded immediately to O2 and the IVs.
  
  
• Can you elaborate a little on the chronological altitude profile? Specifically, at what altitude does the patient live and over what time period did he travel to the lake at 4300 ft.? (Or perhaps he lives at the same altitude as the lake.)

Just curious. It's great to hear that the instructor has made a full recovery.

He lives at 5000 feet. The travel period is about 8 hours by car. There is a pass that goes up to 8000 feet about half way through the drive. He showed no signs of any trouble going over pass or afterward.
The DMs and I did 3 more dives the next day before the drive. No problems for any of us.

[FYI, "prone" = lying face-down on one's belly and "supine" = lying face-up on one's back.]

Thank you for the clarification. I prefer to say what I mean. I know better.

 

[DandyDon]

Okay, I am biased as I have long thot that we have a problem with doctors in my small, rural town: "If they were good, they wouldn't be here." I guess my feelings are unfair, but I am just not a trusting person. I've encountered several quacks in larger cities over the years as well...

I don't have access to the final diagnosis and release papers, but my understanding is that the Dr. in charge of the ER that night had seen a number of scuba related incidents related to new students having anxiety. There was a small language barrier and a bit of resistance from the Brazilian Dr, in this small town, to accept DAN recommendations, and to accept that the patient and I were experienced "professionals" certified to teach 1st aid/cpr and familiar with DCI.

I think the final diagnosis was anxiety attack. Patient actually demanded to stay on O2 under care until morning. The Dr was ready to release him when the symptoms resolved. He was released with 2 diazepam pills and two potassium supplement pills, with directions to follow up with personal Physician at home.

It sounds like your friend is lucky to have survived that physician with no lasting problems.

 

[TSandM]

Not many physicians are familiar with diving accidents. Many physicians have internalized, over time, the concept that "often wrong, but never in doubt" is a desirable state of affairs. (In other words, never let the patient see that you have any uncertainty or ignorance.)

Benthic has posted, somewhere, a link to a good article about DCS that he recommended divers carry. I don't recall where it was, but Brian uses the name username on many boards. Giving a physician something written that he can carry off and peruse is often more constructive than arguing with him.

I will agree, to a point, with the idea that rural physicians may not have the same degree of sophistication as urban ones. But some of us practice in rural settings for reasons which have nothing at all to do with our professional competence.

 

[DandyDon]

I will agree, to a point, with the idea that rural physicians may not have the same degree of sophistication as urban ones. But some of us practice in rural settings for reasons which have nothing at all to do with our professional competence.

Yes, I am sure that is true in some cases and my blanket cynicism is probly excessive.

I also talked with a doctor in Lubbock once who owned and operated a multi-unit hyperbolic facility who told me he once treated a kid for the bends after riding up the Carlsbad Cavern elevator. :silly: So what do you do when you realize you're talking to a quack?

Based on what I have read in this thread tho, I think my feelings are more warranted here. The diving was aggressive, done on air I presume, far from experienced dive doctors - really a risky combination. When DAN disagrees with the local physician, I think it's time to request transportation assistance.

 

[Bubbletrubble]

I don't have access to the final diagnosis and release papers, but my understanding is that the Dr. in charge of the ER that night had seen a number of scuba related incidents related to new students having anxiety. There was a small language barrier and a bit of resistance from the Brazilian Dr, in this small town, to accept DAN recommendations, and to accept that the patient and I were experienced "professionals" certified to teach 1st aid/cpr and familiar with DCI.

What specific intervention(s) did DAN physicians recommend?

Did the treatment team ever consider anti-inflammatory treatment? Just curious.

I think the final diagnosis was anxiety attack. Patient actually demanded to stay on O2 under care until morning. The Dr was ready to release him when the symptoms resolved. He was released with 2 diazepam pills and two potassium supplement pills, with directions to follow up with personal Physician at home.

That's interesting.

Were sodium, potassium, calcium, and magnesium blood levels ever assessed?

• Why was magnesium given?

I have no idea. They said it would help the muscles.

I have read a couple of journal articles on the use of magnesium to treat tetany (sustained muscular contraction) in certain patients. If the patient's blood tests were otherwise normal, then I think their reason for administering magnesium was a little strange. Then again, I'm certainly not an expert on this.

Interestingly, magnesium may have been helpful for other reasons. Magnesium can serve as a cerebral and peripheral vasodilator. It is also a well-described non-competitive antagonist of the NMDA receptor found in neurons. Blockade of the NMDA receptor has been shown to prevent/minimize excitotoxic neuronal death. Both of these functions of magnesium would be helpful in the setting of ischemic stroke (or possibly AGE).

• Did the instructor have a history of upper back pain, back spasms, or radiculopathy?

I know he has worked physically for years and sometimes complains of back pain. I remember him having regularly scheduled theraputic massage. I suppose radiculopathy is possible but undiagnosed. Do you suspect impingement?

Given the limited clinical info we have on this thread, DCI would have placed very high on the differential. However, radiculopathy should have been considered as well. It's too bad that a comprehensive neurological exam wasn't performed and repeated at regular intervals. It would have been informative to localize sensory and motor deficits during the acute course.

Thank you very much for patiently answering all of the questions. Eight dives in one day with several relatively fast ascents and short surface intervals at high altitude adds up to significant decompression stress on a diver.

 

[boulderjohn]

Kent,

When doing days like this (and we do have days like this), our instructors all use Nitrox.

Still, it is a brutal schedule, and I am not sure that dive shops realize how physically demanding it is when they schedule things like this.

Was this at Santa Rosa? Was the pass you were talking about Raton Pass? If so, then the bigger problem is the elevation gain prior to reaching Las Vegas. You will gain a couple thousand feet elevation gain almost immediately out of Santa Rosa, then hold steady for a long time before Raton, crossing which will add surprisingly little to the altitude at which you have been driving for several hours.

Altitude is a real question in dives in this area. In our group it is very controversial, since we are UTD divers, and UTD says that altitude has no effect on DCS and can be disregarded. (I don't agree.) I posted some questions about this in the Ask Dr. Decompression forum after a diver got a bad DCS hit in Santa Rosa, but my question was pretty much ignored by everyone.

I would sure like to have some of the deco heavyweights jump in on this question.

 

[DandyDon]

Altitude is a real question in dives in this area. In our group it is very controversial, since we are UTD divers, and UTD says that altitude has no effect on DCS and can be disregarded. (I don't agree.)

I think you made a good case otherwise in your thread http://www.scubaboard.com/forums/rocky-mountain-oysters/312479-warning-travel-santa-rosa.html

I posted some questions about this in the Ask Dr. Decompression forum after a diver got a bad DCS hit in Santa Rosa, but my question was pretty much ignored by everyone.

Not really ignored. No one agreed with the suggestion and you didn't offer the reasons why they say that.

So yeah, altitude matters - lots! Try boiling a 3 minute egg at altitude.