DAN Chamber Policy

Question:
INJURED DIVER PROTOCOL: EMERGENCY ROOM FIRST?

Answer:
Introduction: a recent bulletin in DiveStyle, a South African Diving Magazine, challenged the standard recommendation to injured divers "to go to the nearest emergency room before being referred to a recompression chamber", by presenting the outcome of a lawsuit (see below).

PERSEVERANCE PAYS OFF
American Keith Rawson, a paralysed scuba diver who suffered DCI when he returned to the surface too quickly, has been awarded $31,3 m by a US jury. After the dive, off Pensacola in north west florida, Rawson claimed doctors at the Baptist Hospital in Pensacola caused his legs to become paralysed by sending him first to the emergency room instead of a hyperbaric chamber. The doctors argued that their decision saved Rawson's life and that his legs would still have been paralysed even if he had gone into the hyperbaric chamber. The jurors nevertheless handed down the award, a record verdict in that county. Rawson's legal battle has involved two court cases, drawn out over five years. in 1995, a $7,88m verdict in his favour was reversed because his attorney made derogatory remarks about the defence experts who gave evidence for the hospital. In 1997, a verdict in favour of the hospital was dismissed because the court was held to have improperly allowed the late addition of evidence from a defence expert.

COMMENTS FROM DAN SOUTHERN AFRICA
A recent article in DiveStyle, "Perseverance Pays Off", applauded the legal pursuit and ultimate triumph of a diver, paralysed by decompression illness. The diver successfully sued the treating hospital for initially referring him to the emergency room rather than sending him directly to the recompression chamber. The case was actually quite complex, and the success of the suit eventually pivoted on the fact that the immediate referral to the chamber was delayed for other than medical reasons. Nevertheless, this case may have raised some questions regarding the standard recommendation of the Divers Alert Network (DAN) to refer injured divers to the nearest 24 hour Emergency Room or Casualty before referral to a recompression chamber. DAN would like to respond to these possible concerns or questions, and demonstrate why referral to an Emergency Room remains the preferred general recommendation.

Decompression illness (DCI), although an inherent risk of scuba diving, is fortunately quite rare. It occurs once or twice for every 10 000 dives. Other diving disorders are far more common. They include ear squeeze or Swimmer’s Ear infections; motion sickness, nausea and dizziness; back, muscular and joint injuries; boating injuries, lacerations and trauma; marine animal envenomations; aspiration of water, drowning and near drowning; heat and cold disorders; etc. In addition, divers are not exempt from ordinary human frailties and may suffer from heart attacks, stroke, asthma or diabetes and their consequences. Therefore, while sudden pain or impairment following a dive should always alert a diver or first responder to the possibility of DCI, this does not mean that it necessarily is. Moreover, to provide empirical recompression for all cases of sudden illnesses – occurring during or following a dive – is not only inappropriate, but may be harmful and delay definitive care (e.g. dissolving the clot in an occluded coronary artery) in many cases.

The purpose of recommendations and protocols in emergency medicine is to ensure that immediate and life threatening problems are managed in order of priority and urgency. This is exemplified in the ABC (Airway, Breathing, Circulation) of basic life support. Similarly, the standard recommendation of DAN to arrange emergency medical assistance and transfer to the nearest emergency medical facility is intended to ensure a consistent, reliable way of providing effective emergency care for most dive injuries. More often than not, recompression is not indicated, and even if ultimately required, the recompression facility has the benefit of notification and preparation time, and the reassurance that other potentially serious causes of the injured diver’s condition have been excluded or treated.

Even where the diagnosis of decompression illness is highly likely, there are several reasons why it is not necessarily the best option to rush the injured diver directly to the nearest recompression chamber:

· The nearest hyperbaric chamber is not always the best suited to treat a particular type of DCI. There are only six out of seventeen hyperbaric chambers in our region that are equipped to treat unconscious, unstable or non-breathing divers without needing additional dive medical expertise, emergency medical assistance and equipment to do so. Of these, only four are actually within a hospital where there is immediate access to intensive care, x-ray examination, and admission facilities. The others are only able to treat relatively minor and stable cases of decompression illness. Taking a seriously injured diver to such facilities – without adequate preparation – may actually make matters worse.

· Many hyperbaric chambers are not set up to provide a 24 hour service and it will generally take some time to get a hyperbaric team ready to treat an injured diver. It has happened on several occasions that an injured diver is rushed to a recompression chamber only to find the facility closed or out of service.

· Many facilities only have access to a single doctor familiar with, and trained in, treating decompression illness. When this person is absent, there is often no-one willing or able to handle the casualty.

· Some chambers operate at irregular hours or by appointment only.

· Most hyperbaric treatment chambers are in a state of continuous evolution. Telephone numbers and even physical locations may change. This is the primary reason why DAN does not give out the contact numbers for recompression chambers. The numbers given today, are not always valid tomorrow, and it is dangerous to rely on potentially outdated information in an emergency.

While there are always exceptions, and additional factors such as transport times, methods, distances and the severity of an injured diver’s condition will affect the management decisions in each case, primary referral to the nearest emergency room is most likely to avoid serious pitfalls and is able to ensure appropriate and continuous care. DAN supports this process throughout by co-coordinating, not only the evacuation of the injured diver, but also by assisting with the assessment and management of the injured diver at the emergency room, and with the notification and eventual referral to a recompression chamber where needed.

For all the abovementioned reasons, DAN continues to recommend that injured divers first be taken to the nearest Emergency Room or Casualty for stabilisation and assessment, before referral to a recompression chamber.

General Guidelines for the Management of Injured Divers:
The primary and historic mission of DAN is to provide a 24-hour hotline for injured divers. As a part of this function, DAN maintains all the relevant information on the recompression facilities and emergency services in the region and is able to provide assistance, advice or medical direction as needed.
The general recommendations of DAN in managing an injured diver are to:

1. Assess and treat life threatening problems first. Follow the ABC of Basic Life Support.
2. Keep the injured diver in a horizontal position. Provide assisted ventilation or Cardio Pulmonary Resuscitation (CPR) if required.
3. Administer 100% Oxygen, ensuring that the patient is breathing adequately. If not, provide mouth-to-mouth, mouth-to-pocket mask, or assisted ventilation.
4. Provide oral fluids only if the victim is fully conscious and able to drink unaided.
5. Call DAN on 0800 020111 or +27(0)11 242-112 for advice, assistance and evacuation as needed. DAN can assist greatly by:
· dispatching the emergency services if required
· notifying the receiving medical facility about the injured diver’s condition and time of arrival, and
· assisting health care professionals to arrange for recompression if required.

If the injured diver’s condition is stable, transport should be arranged to the nearest 24 hour Casualty Centre. If the diver’s condition is unstable, they should not be moved. Life support should be continued while awaiting the arrival of the emergency services at the scene.

 

In addition to these actions required in an emergency, consider the following:

 

Join DAN and encourage other divers to join. Without your membership contributions, this valuable service would not exist.

 

Take the DAN Oxygen Provider Course to understand and be confident in the administration of emergency oxygen first aid. Contact DAN for more information