Reasoning for no-dive times after DCS hit

[Kharon]

So what are the options when you have a crazy military dive doc on a power trip that tells your commander you are never allowed to dive again? (The power trip is so bad, her husband got himself involved and is not in my unit and he's not a physician.) She stated from the start that she will use the same criteria as her Navy working divers, but we're talking recreational diving. Her reason was also taking into consideration a possible PFO which the cardiologist doesn't see.

Do the words "second opinion" sound familiar? As far as rec diving, who the eff (commander or not) can dictate that. I'd tell them to stuff it - nahh - I wouldn't tell them a damn thing.

 

[Akimbo]

Do the words "second opinion" sound familiar? As far as rec diving, who the eff (commander or not) can dictate that. I'd tell them to stuff it - nahh - I wouldn't tell them a damn thing.

That is one option, but there are consequences for disobeying a direct order. It's not like you can just quit because you don't like your boss. They also pay for your health care and the reason for being off duty for medical reasons isn't private information like it is for civilians.

 

[xtremesk8ter314]

That's a loaded question. If you post details of the incident(s), any dives leading up to it/them, and the physician's recommendations, maybe one of us can help you make sense of them.

Sorry about that, I'm still a little peeved by how she went about what she did and how her husband tried to pull the rank card. Anyway, a little over two months ago we had a long dive with mixed teams. It was around a 3 hour dive, our average depth 50ft with a maximum depth of 90ft. The dive was planned around 32% Nitrox but one other person and myself were diving CCR. Through many factors that SHOULD NOT have happened, one diver had three cylinders of air. We go through with our dive and at the completion of our safety stop, I glance over and notice 100 minutes of deco remaining! (But that's another discussion.)

I signal the other divers to surface and shot up an surface marker. I had him take all three of his cylinders down to pretty much nothing, had another diver go down and pretty much give him the rest of his gas, and so on with the next. When all the gas was given up, I switched to OC bailout and put him on my loop at 1.3ppO2. We were doing this at a depth of 20'. When the oxygen cylinder was done, we do a slow ascent to the surface and strip off all his equipment except wetsuit to keep his workload to a minimum. He started complaining of pain in his knees, lower back, headache, and nausea. We take him to the military medical facility and they transported him to a military hyperbaric chamber. The delay in recompression was about 2.5 hours; Treatment Table 6A was used to treat Type II DCS.

Post treatment evaluation of cognitive, motor, sensory, reflexes, vision, etc. was done and found to be okay. Same goes for the 24hr follow up. Dive physician ordered 30 days of dive and altitude restriction (not to exceed 1200 ASL), no physical exercise, no lifting objects in excess of 25lbs, no standing for extended duration, and hydrate often. Physician made referrals for EKG, Echo with bubble study, CT and MRI within the next week. She stated that while he was in the Army diving for only for fun, she would hold him to the same medical fitness requirements of a Navy working diver and that all follow up tests were standard protocol for the Navy.

After the bubble study, the dive physician calls and said the diver had a PFO and it is unlikely that he will be able to dive again another consult was requested for cardiology. 46 days after the incident, the cardiologist examined the echo and said there is no suggestion that there is a PFO and "even if there was a PFO it would be very small and no physician in his right mind would even try to close it up on a 19 year old. It's just too risky and outweighs the benefits." In the medical note, the cardiologist wrote that there is no medical contraindication to pursue diving recreationally and technically and that the decision to dive be limited to factors such as the inherent risk. There is no PFO found and no reason to recommend any PFO closure procedure.

The diver, that weekend, took that as a green light and went on a single shallow dive (35-40ft for 40mins). At the surface interval he bumps into the dive physician who, for lack of better military jargon, chews him out in public calling him a stupid idiot that's going to hurt himself and that she will add another note on Monday. What takes the cake if when her husband (who is in the Army) steps up and says he's disobeying a direct order from a commissioned officer. The diver calls his command and they tell him to get a copy of the medical notes on Monday so they can be reviewed and to have a conference call with the physician.

The new medical note recommends placing the diver on an indefinite dive restriction, but it does not go into any detail on why that determination was made. US Navy Diver manual - "Divers diagnosed with AGE or Type II DCS may be medically cleared to return to diving duty 30 days after initial diagnosis and treatment by a DMO, if initial hyperbaric treatment is successful and no neurologic deficits persist." While physicians may only make recommendations to service members, his command made the call and ordered him to never dive again so it would be in violation of military law to go back into the water.

We are baffled more than anything really. Is there something we missed medically or is she upset because another doctor backdoored her diagnosis? I thought she was a great dive physician; she lost my respect when she lost her cool in public and brought her husband into it (he is not a physician.)

 

[Duke Dive Medicine]

Thanks for the clarification sk8ter.

Here's my interpretation of the events. Please correct me if I'm wrong.

1. Diver makes some very poor decisions and ends up with 100 minutes of unplanned decompression.
2. Diver ends up bent despite the rest of the team's best efforts.
3. Diver gets treated and is asymptomatic after treatment.
4. Initial read on the bubble contrast echo was positive for PFO, diving physician asks for a cardiology consult and recommends that the diver refrain from diving.
5. Cardiologist reads the echo as "no PFO", says he thinks the diver should be cleared.
6. Diver makes another dive before being cleared to dive by the DMO and probably before the DMO has had a chance to review the cardiologist's note.
7. DMO sees him after this dive and blows a gasket.

If I'm right about the sequence of events, I can empathize completely with the DMO's reaction. Perhaps she wasn't operating on all of the available information but you have to admit that from her perspective, this diver has demonstrated consistently bad decision-making.

Re clearance to dive: by necessity, military divers are held to much higher standards of fitness than recreational divers. There are some significant differences when clearing someone to dive, or to return to diving after an incident of DCI. Though there are some parallels and absolute contraindications to diving that would apply to both sets of divers, in general we would not apply military standards to recreational divers when making fitness-to-dive decisions.

Given the information that you have provided about the diver's treatment, if he is asymptomatic after hyperbaric oxygen therapy, negative for a PFO and has no other underlying comorbidities, there would be no PHYSICAL reason not to clear him to dive. On the other hand, there may well be a behavioral reason and that's what the DMO is doing.

Best regards,
DDM

 

[xtremesk8ter314]

Thanks DDM for adding some perspective. It's always nice to bounce off ideas off of others.

At any rate, he is still pursuing this. He's taking his medical notes and exam results and having them evaluated by other dive medical professionals and seeking their expert opinion.

 

[DougCoDiver]

I got hit this past week with DCS. Last two dives were D1 30m for 25 min /w 5 min at 5m stop, SI 40 min, D2 15m for 35 min /w 5 min at 5m. Breathing EAN 32. both dive were well within NDL. Started feel ill about an hour after the dives were over. Ended up at the hospital, refered to chamber doc and spent 5 hours in chamber. Doc reccomended no fly for 72 hours and no dive for 3 weeks. This happened in Playacar.

background I live at 6700 ft. dove after 1 day at sea level. day 1 single dive, day 2 1 morning dive and 1 afternoon dive, day 3 was above dive.

 

[JohnnyC]

FWIW if this ends up in front of the JAG, if her Army husband got involved it's called Unlawful Command Influence and is illegal under the UCMJ and at best is an Article 15 for him. However, it's not clear that he actually did anything other than being a blowhard.

As far as being back on topic, it sounds like Duke Dive Medicine has it pinged correctly. Sounds very similar to some of the stuff I've seen with flight docs giving guys DNIF's. They don't like it when they get backdoor'd on stuff like that.

 

[chillyinCanada]

Just an aside, if this doesn't eventually go in the diver's favor, I wonder if the diver will stay in service.

 

[Agility]

Last two dives were D1 30m for 25 min /w 5 min at 5m stop, SI 40 min, D2 15m for 35 min /w 5 min at 5m. Breathing EAN 32. both dive were well within NDL. Started feel ill about an hour after the dives were over. Ended up at the hospital, refered to chamber doc and spent 5 hours in chamber. Doc reccomended no fly for 72 hours and no dive for 3 weeks. This happened in Playacar.

background I live at 6700 ft. dove after 1 day at sea level. day 1 single dive, day 2 1 morning dive and 1 afternoon dive, day 3 was above dive.

IMHO Dive 4 of the series might have been within NDL but not "well within" but at the fringe if the 35min were spent at 30m.
dialling in any sort of conservativity factor would likely have required deco.

 

[DougCoDiver]

IMHO Dive 4 of the series might have been within NDL but not "well within" but at the fringe if the 35min were spent at 30m.
dialling in any sort of conservativity factor would likely have required deco.

25 min at 30m. My guess would be that Dive 4 was the precipitating factor.