DIVE ACCIDENTS

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DIVE ACCIDENTS

• TOM MILLINGTON, MD
• WOUND MANAGEMENT, HYPERBARIC
• THERAPY DIVE MEDICINE
• THOUSAND OAKS, CA

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BASIC PHYSIOLOGY

• BOYLES LAW, DALTONS LAW AND HENRYS LAW
• MAJOR MEDICAL COMPLICATIONS INCLUDE DECOMPRESSION
  ILLNESS, AIR EMBOLISM, AND BAROTRAUMA (SQUEEZES)

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DALTONS LAW

• LAW OF PARTIAL PRESSURES
• TOTAL PRESSURE OF A MIXTURE OF GASES IS EQUAL TO
  THE SUM OF THE PARTIAL PRESSURE OF EACH COMPONENT
• P(t) P (O2) P(N2) P(x)

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HENRYS LAW

• AMOUNT OF GAS DISSOLVED IN A GIVEN VOLUME OF
  FLUID IS PROPORTIONAL TO THE PRESSURE WITH WHICH
  IT IS IN EQUALIZATION
• Y P(Y) / P(t) x 100
• EXPLAINS DCI AND ALSO HYPEROXYGENATION WITH HBO2

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RATES OF DCS AND DEATH 1998 TO 2004

• 1998-2004 STATS FROM DANS PDE DIVES 0 TO 5 DCS
  CASES PER 10,000 WARM WATER DIVES
• BETWEEN 11 AND 18 FATALITIES PER 100,000 MEMBERS
  PER YEAR
• CANADAS ABACUS PROJECT 3 DEATHS OUT OF 146,291
  AIRFILLS 0.002 RATE
• THIS DATA FOR A LIMITED POPULATION
  SAMPLEEXTRAPOLATE WITH CARE

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74 OVERWEIGHT OR OBESE 45 OBESE OR MORBIDLY
OBESE2004 STATISTICS
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CAUSES OF DEATH
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PRIMARY DIVE ACTIVITY

• SIGHTSEEING 45
• WRECKDIVING 22
• SPEARFISHING 8
• STUDENT 8
• NIGHT DIVE 5
• PHOTOGRAPHY 5
• TEACHING 5
• CAVE DIVING 3

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BAROTRAUMA

• SQUEEZE CONDITION WHICH OCCURS WHEN A DIVER
  CANNOT EQUILIZE PRESSURE DIFFERENTIAL BETWEEN AN
  AIR-CONTAINING SPACE AND THE AMBIENT WATER
  PRESSURE
• MIDDLE EAR SQUEEZES, SINUS SQUEEZES, TOOTH
  SQUEEZES

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BAROTRAUMA

• WET (OR DRY) SUIT SQUEEZE SUIT TOO LOOSE, SKIN
  BECOMES CAUGHT IN FOLDS OF SUIT, CAUSING PAIN,
  RED WELTS AND STREAKS

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DECOMPRESSION ILLNESS

• INITIAL SYMPTOMS OF DCS AND CAGE ARE SIMILAR
• SAME TREATMENT FOR BOTH
• NEW RECOMMENDATION DCI, FOLLOWED BY ORGAN
  SYSTEM, EVOLUTION OF SYMPTOMS, TIME OF ONSET, GAS
  BURDEN, COEXISTING BAROTRAUMA

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DECOMPRESSION ILLNESS

• EXAMPLE ACUTE PROGRESSIVE NEUROLOGICAL DCI WITH
  BILATERAL LEG WEAKNESS AND NUMBNESS, 30 MINUTES
  AFTER A DIVE, MODERATE GAS LOAD, NO BAROTRAUMA

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TYPE I DCS

• FOUND IN 10 TO 20 OF SPORTS DIVERS
• LIMB PAIN, SKIN BENDS, EXTREME FATIGUE
• OUR NEUROPSYCH STUDIES AND PAUL HARSCHS SPECT
  SCAN STUDIES INDICATE THAT ALL LIMB PAIN ONLY
  CASES HAVE CEREBRAL INVOLVEMENT, AND SHOULD BE
  TREATED WITH TABLE 6

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DECOMPRESSION SICKNESS

• A WIDE VARIETY OF SYMPTOMS WHICH OCCUR WHEN INERT
  GAS DISSOLVED IN TISSUES DURING A DIVE COMES OUT
  OF SOLUTION AND FORMS BUBBLES IN BLOOD STREAM AND
  TISSUE (BRAIN, SPINAL CORD),
• CAUSED BY RAPID LOWERING OF AMBIENT PRESSURE ON
  BODY AFTER A DIVE

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TYPE II DCS

• PULMONARY (CHOKES) FROM BUBBLES IN PULMONARY
  ARTERY
• TRIAD OF CHEST PAIN, DYSPNEA, COUGH
• USUALLY OCCURS AFTER DEEP DIVES OR BLOW-UPS IN
  COMMERCIAL DIVES

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TYPE II NEUROLOGICAL

• MOST COMMON TYPE
• SYMPTOMS INCLUDE VISUAL (BLURRED, FIELD
  DEFECTS, SCINTILLATING SCOTOMOTA) HEADACHES,
  MOTOR WEAKNESS OR LOSS, SENSORY LOSS,
  PARESTHESIAS, COGNITIVE DEFECTS, SEIZURES,
  PARALYSIS OF BLADDER

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ONSET OF SYMPTOMS

• MALAISE, RASH, CONFUSION, RESPIRATORY TROUBLE,
  OCCUR IN FIRST HOUR ACCORDING TO 2004 STATS
• PAIN AND PARESTHESIAS TOOK AN AVERAGE OF AN HOUR
  OR MORE TO OCCUR2004.
• PAIN AND SENSORY MOST COMMON IN 2004

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TYPE II NEUROLOGICAL

• SPINAL CORD HIT LOW BACK PAIN, LOW ABDOMINAL
  PAIN, LEG WEAKNESS, BLADDER PARALYSIS
• INNER EAR DCS (STAGGERS) DIZZINESS, NAUSEA AND
  VOMITING, TINNITUS, HEARING LOSS. SEEN MORE WITH
  HELIUM MIXES

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TIME OF SYMPTOM ONSET

• OF DIVERS WITH SYMPTOMS WITHIN 2 HOURS 70
• OF DIVERS WITH SYMPTOMS AFTER 2 HOURS BUT LESS
  THAN 24 HOURS 24
• 0F DIVERS WITH SYMPTOMS AFTER 24 HOURS 7
• DAN STATISTICS 1987

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ATTRIBUTES FOUND IN DCI CASES

• EXERTION 55
• CURRENT 50
• lt 2 YEARS EXPERIENCE 30
• FATIGUE 28
• RAPID ASCENT 24
• BUOYANCY 15
• WITHIN LIMITS 86
• NO DECO 85

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ATTRIBUTES TO DCI

• MULTILEVEL 65
• gt 80 FSW 70
• REPETITIVE DIVE 66
• MULTIDAY DIVES 52
• Source DAN 1993-1997 statistics

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PATHOPHYSIOLOGY

• WHERE DO BUBBLES COME FROM?
• VENOUS SYSTEM?
• IN PERIARTERIAL FAT?
• ON ROUGH SURFACES (TENDON, FASCIA)?
• IN CENTRAL NERVOUS SYSTEM WHITE MATTER?
• IN CEREBRAL SPINAL FLUID?

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PATHOPHYSIOLOGY

• ASCENT SPEED IS ONE OF MOST IMPORTANT FACTORS
  INFLUENCING HOW MANY BUBBLES ARE FORMED.
• SOURCE ALF BRUBAKK, 1999 SPUMS CONFERENCE

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PATHOPHYSIOLOGY

• GRADE 2 TO 3 BUBBLES WERE FOUND IN OVER 1/2 OF
  DIVERS STUDIED BY DOPPLER ON DAN LIVEABOARD STUDY
• ONLY ONE DIVER HAD DCI
• SOURCE RICHARD MOON, 1999 SPUMS CONFERENCE

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PATHOPHYSIOLOGY

• THERMAL AFFECTS
• IF COLD DURING THE DIVE, VASOCONSTRICTION OCCURS,
  LESS NITROGEN AVAILABLE TO TISSUE
• IF COLD DURING SAFETY STOP OR BETWEEN DIVES,
  VASOCONSTRICTION OCCURS, LESS NITROGEN OFFGASSED.
• IF WARM ON THE DIVE, VASODILATION OCCURS, MORE
  NITROGEN ABSORBED BY TISSUES

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TRIBONUCLEATION

• WHEN SURFACES SEPARATE IN A LIQUID, NEGATIVE
  PRESSURES ARE CREATED BY VISCOUS ADHESION CHANGES
  IN THAT LIQUID
• THIS FORMS BUBBLES FROM TURBULENCE
• MORE TRIBONUCLEATION CAUSES MORE BUBBLES

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TRIBONUCLEATION

• EXERCISE BEFORE DIVING
• HEAVY WEIGHTLIFTING TO MUSCLE SORENESS WITHIN 24
  HOURS OF DIVING CAUSES HIGH PRECORDIAL DOPPLER
  BUBBLES AND HIGHER INCIDENCE OF DCI

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TRIBONUCLEATION

• EXERCISE WHILE DIVING
• ACCELERATED INERT GAS LOAD BY INCREASED PERFUSION
• SUBJECTS EXERCISED IN CHAMBER HAD 64 GREATED
  NITROGEN ELIMINATION AFTER DIVE COMPARED TO
  NON-EXERCISING CONTROLS

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TRIBONUCLEATION

• EXERCISE AFTER DIVING
• THE BODY ALREADY HAS SILENT BUBBLES, OR IS
  NEAR-SATURATION IF DOING DECOMPRESSION DIVING.
• EXERCISE WILL INCREASE TRIBONUCLEATION AND MORE
  BUBBLES FORM, INCREASED DOPPLER SCORES
  DOCUMENTED, INCREASED INCIDENCE OF DCI

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RECENT STUDY OFEXERCISE AND DIVING

• SCANDINAVIAN STUDY THAT EXERCISE 20 HOURS BEFORE
  DIVING LOWERS RISK OF DCI.
• MAY INCREASE NITRIC ACID WHICH DILATES VESSELS
  AND LOWERS BUBBLE ADHESION TO ENDOTHELIUM.
• MEDICATIONS IN FUTURE?

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PREVENTION OF DCS

• PRE-DIVE ADMINISTRATION OF VIT C AND E SHOWS A
  POSITIVE EFFECT OF VASCULAR ENDOTHELIAL FUNCTION.
  MAY PREVENT NEGATIVE EFFECTS OF DIVING ON
  VASCULAR FUNCTION
• NOT DIRECT EVIDENCE OF PROTECTIVE EFFECT AGAINST
  DCS
• Obad, Dujic. Journal Physiology

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PATHOPHYSIOLOGY

• AUTOCHTHONOUS BUBBLE GROWTH
• AXONS IN BRAIN AND SPINAL CORD ARE INSULATED BY
  FATTY TISSUE WITH HIGH NITROGEN TENSION
• BUBBLES FORM NO WHERE NEAR BLOOD VESSELS DUE TO
  THAT NITROGEN TENSION
• BECKMAN, ET AL, FOUND THAT 86 FEET IS DEPTH WHERE
  THIS OCCURS.

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NEURON
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OXYGEN TREATMENT
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Diving First Aid

• CPR
• Assess the scene
• Check responsiveness Are you ok?
• Alert EMS Call 911, VHF Channel 16 (Bystander
  assist)
• Control any severe bleeding with direct pressure
• 1. AIRWAY head-tilt, chin lift
• 2. BREATHING look, listen, feel (5-10 secs)
• look in mouth for airway obstruction
• give 2 normal breaths until the chest
  rises
• clear airway if necessary
• 3. CIRCULATION Immediately begin chest
  compressions after 2 complete rescue breaths
• 30 Compressions 2 Breaths (about 3 cycles
  per min)
• 4. AED Deliver 1 shock as prompted by the AED
  followed by immediate CPR

• DIVING ACCIDENT MANAGEMENT
• 1. Rescue victim and primary assessment
• 2. Activate emergency procedures per dive plan
• 3. CPR and/or administer First Aid including 100
  oxygen
• Secure victims dive computer and scuba
  equipment
• Contact Diving Safety Office [phone]
• Submit accident Report
• PHONE NUMBERS
• DAN [phone] or [phone]
• DAN TravelAssist (800) DAN-EVAC or (919)
  684-3483 Dr Millingtons Exchange 805
  370-2415

OXYGEN ADMINISTRATION AIRWAY
BREATHING CIRCULATION
BREATHING DIVER NON-BREATHING DIVER
Demand Mask
Non-Rebreather Mask Pocket Mask
FIELD NEURO-EXAM 1. Orientation name, place and
time 2. Eyes movement, peripheral vision, and
pupil size 3. Face sensation, smile, bite and
whistle 4. Hearing hearing equal on both sides,
abnormal sounds 5. Swallow watch Adams
Apple 6. Shoulders shrug resistance 7. Arms and
hands sensation, grip strength, resistance 8.
Legs DUI check, leg strength and resistance
WOUND MANAGEMENT HYPERBARIC THERAPY CENTERS
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TREATMENT OF DCI

• THERE IS NO CLINICAL DATA TO SUPPORT THE USE OF
  ANY TREATMENT TABLE EXCEPT TABLE VI ALF BRUBAKK
  SPUMS 99
• FOR SERIOUS CNS SYMPTOMS
• AVOID HYPOTHERMIA
• NO GLUCOSE
• NO HYPOTONIC I V SOLUTIONS
• AVOID HYPERCAPNEA (NO HYPERVENTILATIONS)

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TREATMENT

• TIME TO TREATMENT IS THE MOST IMPORTANT IN
  DETERMINING THE OUTCOME OF A DECOMPRESSION
  ACCIDENT
• SOURCE ALF BRUBAKK, SPUMS 99

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TREATMENT

• VARIABLES WITH SIGNIFICANT RISK OF POOR OUTCOME
• AGE OVER 35
• DELAY TO TREATMENT
• FURTHER DIVING AFTER ONSET OF SYMPTOMS
• WALKER, SPUMS 99

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EVIDENCE BASED MEDICINE

• AHA GUIDELINES FOR CLINICAL EFFICACY
• CLASS 1 CONDITIONS FOR WHICH THERE IS EVIDENCE
  AND/OR GENERAL AGREEMENT THAT A GIVEN PROCEDURE
  OR TREATMENT IS EFFECTIVE
• CLASS 2 CONDITIONS WHERE THERE IS CONFLICTING
  EVIDENCE AND/OR A DIVERGENCE OF OPINION ABOUT THE
  USEFULNESS OF A PROCEDURE OR TREATMENT

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AHA LEVELS OF EVIDENCE

• A DATA DERIVED FROM MULTIPLE RANDOMIZED
  CLINICAL TRIALS
• B DATA DERIVED FROM A SINGLE RANDOMIZED TRIAL
  OR NONRANDOMIZED STUDIES
• C CONSENSUS OPINION OF EXPERTS

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EVIDENCE BASED MEDICINE

• 2A WEIGHT OF EVIDENCE IS IN FAVOR OF
  USEFULNESS
• 2B USEFULNESS IS LESS WELL ESTABLISHED BY
  EVIDENCE
• CLASS 3 CONDITIONS FOR WHICH THERE IS EVIDENCE
  AND/OR GENERAL AGREEMENT THAT THE TREATMENT IS
  NOT USEFUL AND IN SOME CASES MAY BE HARMFUL

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WHAT ABOUT DEHYDRATION?

• 2 RECENT STUDIES CONFIRM NEED FOR RESTORATION OF
  FLUID BALANCE
• BOUSSUGES ET AL STUDIED 10 SUBJECTS WITH
  ECHOCARDIOGRAPHY AT BASELINE AND 1 HOUR FOLLOWING
  25 MINUTE 34 METER DIVE
• ALL HAD EVIDENCE OF BUBBLES (7 HAD GRADE 3
  BUBBLES)
• LEFT ATRIAL AND LEFT VENTRICULAR DIAMETERS
  DECREASED 2 TO 3 MM POST DIVE AND PEAK VELOCITY
  FOR TRICUSPID REGURGITANT FLOW INCREADED AFTER
  DIVE

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WHAT ABOUT DEHYDRATION?

• AUTHORS CONCLUDED THAT HYPOVOLEMIA AND VENOUS GAS
  EMBOLISM EXPLAIN CHANGES IN ECHOCARDIOGRAPHIC
  FINDINGS
• THEY RECOMMEND ORAL REHYDRATION FOLLOWING DIVING
• REHYDRATION WAS FELT TO BE ESPECIALLY IMPORTANT
  IN THE SETTING OF REPEATED DIVING

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WHAT ABOUT DEHYDRATION?

• STUDY IN J OF AVIATION, SPACE AND ENVIRONMENTAL
  MEDICINE REPORT STUDY OF 2 GROUPS OF PIGS
  COMPRESSED TO 110 FSW FOR 22 HOURS, THEN SURFACED
  DIRECTLY
• ONE GROUP REMAINED HYDRATED WITH ACCESS TO WATER
  DURING DIVE, THE OTHER GROUP HAD NO ACCESS AND
  WERE GIVEN I V DIURETIC DURING DIVE

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WHAT ABOUT DEHYDRATION?

• HYDRATED GROUP (31) HAD 9 CARDIOPULMONARY DCS, 8
  CNS AND 4 DEATHS
• DEHYDRATED GROUP (26) HAD 19 CARDIOPULMONARY, 6
  CNS, AND 9 DEATHS
• CONCLUSION HYDRATION SIGNIFICANTLY AFFECTED
  INCIDENCE AND TIME TO ONSET OF DCS
• DIVERS NEED PLENTY OF WATER BEFORE AND BETWEEN
  DIVES

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FLUIDS FOR REHYDRATION

• TREAT HYPOTENSION, INCREASE TISSUE BLOOD FLOW,
  REVERSE HEMOCONCENTRATION
• DO NOT USE IV FLUIDS CONTAINING GLUCOSE
  (HYPERGLYCEMIA)
• ORAL GLUCOSE CONTAINING FLUIDS OK

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FLUIDS FOR DEHYDRATION

• USE ISOTONIC FLUIDS TO AVOID REDUCTION IN PLASMA
  OSMOLALITY
• CLOSEST TO IDEAL ORAL FLUID IS GATORAIDE
• END POINT IS NORMAL BLOOD PRESSURE AND URINE
  OUTPUT gt 1 ML/KG/HR

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SURFACE (FIRST AID) OXYGEN

• CONDITION

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FLUIDS EVIDENCE BASED
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DIFFERENT TREATMENT FOR TECH DIVERS?

• MOST CRITICAL IS PROMPT ARRIVAL AT CHAMBER. THE
  LONGER THE DELAY, THE HIGHER INCIDENCE OF
  TREATMENT FAILURE.
• PANELS AT TECH CONFERENCES AGREE THAT OXYGEN ASAP
  IS BEST FIRST AID
• IF NEAREST CHAMBER IS MONOPLACE NAVY 6 THERE IS
  APPROPRIATE. PT MAY STAY ON 6 WITH EXTENSIONS.

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DIFFERENT TREATMENT FOR TECH DIVERS?

• IF MULTIPLACE CHAMBER WITH ONLY OXYGEN AS
  TREATMENT GAS, THAT IS ALSO APPROPRIATE
• IF MULTIPLACE CHAMBER WITH MIXED GAS
  CAPABILITIES, THAT IS THE BEST OF ALL WORLDS.
• DIVERS SHOULD EVALUATE THE ABOVE BEFORE TECHNICAL
  DIVING

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ADJUNCTIVE TREATMENT

• SURFACE O2, FLUID RESUSCITATION, MAINTAIN BP,
  AIRWAY MANAGEMENT, AVOID INCREASES IN BLOOD SUGAR
  (INTRACELLULAR ACIDOSIS), AVOID HYPERTHERMIA
• CORTICOSTEROIDS? ROUTINE DOSES SHOW NO
  IMPROVEMENT. SPINAL CORD TRAUMA DOSE NOT
  EVALUATED YET.
• IF IN REHAB, HIGHER INCIDENCE OF DVT

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POOR RESPONSE TO TREATMENT

• PATIENTS WITH PROGRESSIVE NEUROLOGICAL SYMPTOMS
  (WITHIN 24 HOURS)
• GO TO COMEX 30
• ALF BRUBAKK RECOMMENDS COMEX 30 WITH 50/50 NITROX
• CONSIDER LIDOCAINE
• NAVY TABLE VII? NOT MUCH BETTER THAN TABLE VI
  WITH FOLLOW-UPS. MOON,SPUMS

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WHATS NEXT?

• LIDOCAINE SAME DOSE AS CARDIAC. AFFECTS
  INTRACELLULAR CALCIUM LEVELS IN NEURONS, MAY ALSO
  STABILIZE NEUTROPHIL IN THE LEUKOCYTE-BUBBLE-ENDOT
  HELIUM INTERACTION
• FLUOROCARBONS LARGE AFFINITY FOR INERT GASES.
  FUTURE POTENTIAL?

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ALTERNATIVE THERAPY

• ACCIDENTS IN REMOTE LOCATIONS WHERE TRANSPORT IS
  DIFFICULT OR DANGEROUS MILD TO MODERATE
  SYMPTOMS SHORT DELAY BETWEEN ACCIDENT AND
  TREATMENT
• FLUIDS
• SURFACE OXYGEN
• IN-WATER OXYGEN RECOMPRESSION
• PORTABLE RECOMPRESSION CHAMBER

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UNDERWATER OXYGEN TREATMENT

• ADVANTAGES
• INCREASED NITROGEN ELIMINATION
• AVOIDS INCREASED NITROGEN LOADS (AIR
  RECOMPRESSION)
• INCREASED OXYGEN TO TISSUES
• DECREASED TISSUE ISCHEMIC DAMAGE
• SOURCE EDMONDS, SPUMS SEPT 95

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UNDERWATER OXYGEN RECOMPRESSION

• SURFACE SUPPLIED OXYGEN TO 30 FT
• TIME 30 TO 90 MINUTES, DEPENDING UPON SEVERITY
  OF INJURY
• ASCENT RATE 4 MINUTES/FOOT
• SURFACE ONE HOUR ON OXYGEN, ONE HOUR OFF
• AIR BREAKS DURING UNDERWATER TREATMENT
• APPROPRIATE DIVING MED FOLLOW-UP

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UNDERWATER OXYGEN RECOMPRESSION

• EQUIPMENT
• LARGE (G SIZE) O2 CYLINDER WITH STAGE REGULATOR
  SET AT 80 PSI
• 40 FEET HP HOSE
• FULL FASK MASK FOR DIVER
• HARNESS OR TRAPEZE SEAT FOR DIVER
• WEIGHTED SEAT AND DIVER
• ATTENDANT ALWAYS PRESENT. ASCENT CONTROLLED BY
  SURFACE TENDERS
• THIS IS FIRST-AID--DOES NOT REPLACE RECOMPRESSION
  IN CHAMBER!

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AIR EMBOLISM

• SYMPTOMS OCCUR DURING ASCENT OR SHORTLY AFTER
  SURFACING. IF SYMPTOMS OCCUR AFTER 15 MINUTES,
  DCS IS DIAGNOSIS
• SYMPTOMS INCLUDE UNCONSCIOUSNESS, SEIZURES,
  DIZZINESS, PARALYSIS, ANESTHESIA OR PARESTHESIA,
  SHOCK, VISUAL DISTURBANCES, CARDIAC ARREST!

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AIR EMBOLISM

• DIRECTLY RELATES TO BOYLES LAW
• CAN OCCUR IN WATER AS SHALLOW AS FOUR FEET
• CAUSED BY EXPANDING GASES IN LUNGS UNABLE TO
  ESCAPE DURING ASCENT DUE TO VOLUNTARY OR
  INVOLUNTARY BREATHHOLDING, PULMONARY
  OBSTRUCTIONS, CYSTS, SCARS, MUCOUS, ETC

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AIR EMBOLISM

• OFFICIALLY THE SECOND LEADING CAUSE OF DEATH IN
  DROWNING

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DIFFERENCE WITH AGE

• ISOLATED AGE TO THE BRAIN MAY NOT CAUSE
  HEMOCONCENTRATION
• BRAIN EDEMA MAY CAUSE INCREASED ICP, LEADING TO
  FURTHER ISCHEMIA
• FLUID RESUSCITATION MAY NOT BE NECESSARY

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GUIDELINES FOR AGE Rx
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GUIDELINES FOR AGE Rx
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LONG TIME FREE DIVER

• PT WAS DOING ONLY 5TH OR 6TH SCUBA DIVE AFTER
  CERTIFICATION. ON 3RD DIVE OF DAY (60 FT-45FT-40
  FT) BEGAN ASCENT AND PANIC OCCURRED WHEN HE SAW A
  DIVER WITH SPEARGUN COME NEAR HIM.
• REMEMBERS NOTHING ELSE

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LONG TIME FREE DIVER

• DAUGHTER STATES HE ASCENDED AFTER HER, SEEMED O K
  FOR A MINUTE, THEN IT HURTS
• SHE TURNED AROUND AND HE WAS STARTING TO SINK
  UNDER WATER
• DIVE MASTER GOT HIM TO BOAT IN RESPIRATORY
  ARRESTSTARTED CPR

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LONG TIME FREE DIVER

• FLOWN TO HOSPITAL WITHOUT CHAMBER, WHERE HE WAS
  ADMITTED AS NEAR-DROWNING
• HAD MRI, CEREBRAL ANGIOGRAM
• NEXT MORNING DECIDED HE WAS DCI VICTIM AND
  DECIDED TO GO TO UCLA, AS HE WAS ON VENTILATOR

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LONG TIME FREE DIVER

• AFTER WAITING ALL DAY FOR WEATHER TO CLEAR FOR
  HELICOPTER TO UCLA, FINALLY CALLED US.
• PT RECEIVED MORE THAN 24 HOURS AFTER ACCIDENT.
  VENTILATED AND SEDATED
• ASPIRATION PNEUMONIA ALREADY DEVELOPING

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LONG TIME FREE DIVER

• TREATED WITH NAVY VI, AND NAVY V NEXT DAY, THEN 2
  MORE DAYS OF 2.4 ATA FOR 90 MINUTES
• IN ICU FOR 5 DAYS, AND ON FLOOR FOR ANOTHER 3 OR
  4 DAYS
• AFTER EXTUBATION HE WAS MENTALLY AND
  NEUROLOGICALLY CLEAR

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LOBSTER DIVER

• DIVER IN HIS EARLY 20S DIVING FOR LOBSTER FROM
  BEACH--NO DEEPER THAN 30 -35 FEET
• FAIRLY SIGNIFICANT SURGE, MANY ASCENTS TO CHECK
  HIS LOCATION
• AFTER DIVING HAD HEADACHE, BACKACHE, ATTRIBUTED
  TO ASSERTION

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LOBSTER DIVER

• FAMILY NOTED PERSONALITY CHANGES.
• MILD TINGLING IN HANDS AND THIGHS ALSO STARTED
• DAN WAS CALLED AND HE WAS REFERRED TO US
• TREATED WITH TABLE 6 WITH COMPLETE RESOLUTION OF
  SYMPTOMS
• MILD DCI FROM MULTIPLE ASCENTS AND HEAVY EXERTION

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