Diagnosing decompression illness (DCI) is kind of a nightmare. It’s usually a diagnosis of exclusion. Many times the patients’ complaints are vague. “My left arm hurts,” might be one. Could it be a heart attack, could it be an overuse injury, or is it dive related?
DCI encompasses both decompression sickness, DCS (the bends) and barotrauma (to include arterial gas embolism or AGE). The difference is usually onset. DCS can manifest up to 48 hours following diving, barotrauma symptoms manifest much faster, usually 15 minutes or less after surfacing. The most important thing is obtaining a thorough history. If the patient dove within the last 48 hours then there’s a possibility it’s DCI. If the patient has had multiple dives over the last several days, the possibility increases. If the patient is suddenly short of breath immediately after surfacing, the possibility of DCI is high. This post will focus on DCS with a follow-up post on barotrauma in the near future.
DCS can be caused by a number of reasons. Staying too deep for too long is one. Being dehydrated is another and every diver becomes dehydrated when diving. Factor in the usual post dive activities divers are known for, namely mass quantities of alcohol ingestion, dehydration becomes a significant factor. Obesity and lack of physical fitness also contribute. Goofballs can totally get bent, as this video tries to demonstrate.
The reality however, is any diver can suffer DCS at any time, even if they dive a “safe” profile.
Regardless, treatment includes IV bolus, high-flow O2, monitor, and transport to the nearest facility, ideally one with hyperbaric capabilities. If the patient begins feeling better on high-flow O2, that’s diagnostic for DCI. Continue high-flow O2 for as long as possible and do not let them refuse care. If the patient really wants to leave, call medical control and have them speak directly with a physician. Another great resource is the Divers Alert Network (DAN).
DAN, located in Durham, NC, has a dive medic on call 24/7. I’ve called them from around the world and gotten someone on the phone immediately. Where I work we’re fortunate to have dive medicine physicians on duty round the clock, in other areas that’s less likely. DAN will work with local providers to ensure proper patient care.
Treat other concerns appropriately. Where things might get a little hazy is if you’re ruling out an MI. My example in the beginning was taken from an actual call. A 50 year old male patient complaining of left arm pain, is overweight and not physically active, goes on vacation and makes several dives over the course of 2 days. Is his arm hurting because he’s more active then normal, suffering an MI or is it DCS? Given the information above and the following info, let me know in the comments what you would do.
P: 88 RR: 18 B/P: 142/88 SpO2: 98% on room air 12-lead EKG: sinus rhythm, no ST elevation