DIVERS IN DENIAL
The most experienced divers have been known to ignore the signs of decompression illness - especially if their brains have been affected. Their buddies should take over the decision-making for them, says Marguerite St Leger Dowse of the DDRC. But, as case histories show, it doesn't always happen.
Bent on Destruction
It was five years ago, at the Undersea and Hyperbaric Medical Society's Annual Scientific Meeting, that a young woman, a clinical hyperbaric professional who has given lectures to hundreds of divers on decompression illness (DCI) and denial, stood up and presented a paper about her own inability to admit that she had had a bend!
She told the audience it had been three days before she could be persuaded that she had had a hit and needed treatment. By then she was seriously ill and paraplegic.
"Humiliation" was the word she used to describe a diver's feelings on realising that he or she was bent. "Unless one is unconscious, bleeding or foaming at the mouth, the diver, and often the diving friends, are consciously or unconsciously unable to accept the reality of a decompression injury," she said.
Last May a diver (we'll call him Ben Dee) arrived at the Diving Diseases Research Centre (DDRC), Plymouth, with a neurological DCI. He had waited nearly 24 hours before seeking treatment and was in extreme pain, incapable of heel-to-toe walking. He could not perform a test of cerebral function.
What, you might ask, makes Ben so special? After all, recent study of the past seven years' complete data at DDRC shows that nearly 30 per cent of divers waited more than 12 hours before seeking treatment. Well, Ben Dee not only has more than 700 dives to his credit and is an advanced BSAC grade, but he is a practising psychiatrist, and his wife a medical practitioner. You might expect Ben to be the last person to deny that he had experienced a DCI hit!
Why do divers do this? It's human nature to blot out potential problems, fear of the unknown, fear of the treatment, fear of the outcome, fear of being never able to dive again. "If I ignore it, it will go away," seems to be the attitude.
"Denial" is an issue recognised as working against the successful outcome of a diving incident, and it's well documented, with data from the Royal Navy and the DDRC's Men & Women in Diving study. The attitude within certain diving circles to "getting a bend" is almost comparable to the AIDS "it won't happen to me" syndrome. Add in the chances of rusty knowledge of the signs and symptoms, and you have a potential "mismanagement of DCI" on your hands.
Because the diving research team at DDRC has been interested in DCI and denial for some time, and frequently treats divers in denial, it was decided to try to shed a little more light on the events and thought processes involved in Ben Dee's case.
Consecutive-day diving, multi-dive days, whisky, beer and minimum surface intervals to squeeze in a last dive before returning to the UK formed the backdrop. Severe pain in his shoulder while lifting bottles off the boat was Ben's first indication that all was not well.
"I think I know what this is," he thought to himself. Then, as the pain subsided after about five minutes into a dull ache - "like toothache" - the silent self-debate began. "Do I press the panic button or not? What's the threshold for doing something about it? What about travel arrangements and inconvenience to the others in the group?"
Visions of helicopters, coastguard: "What did I do wrong? If I request the use of surface oxygen, that in effect presses the panic button. Best if I don't." Denial.
How did the dive group react? No doubt appropriate action would have been taken had the symptoms been obvious, but Ben was not unconscious, paralysed, bleeding or foaming at the mouth. The others were aware that something was amiss, but as Ben was a "senior and experienced" member of the group, they were reluctant to take the initiative, choosing instead to let him make the decision. "It's your call, what do you want us to do?" Denial.
Driving to the ferry in a minibus over the hills reinforced Ben's self-diagnosis - it made the pain worse. "This must be DCI, but the pain is liveable with," he thought. Denial.
He spent a sleepless night on the ferry. The pain was worse but he thought: "The ferry is at sea and this is not a good place to push the panic button, so I'll leave it." Denial.
Driving home, the pain increased again while crossing hills, though Ben did not consider his driving skills to be impaired. Denial.
Back home, the closest Ben got to admitting that there was a problem was to say he "didn't feel well". Denial.
He did phone the DDRC to discuss the pain in his shoulder, which he said might or might not have been directly related to diving - but effectively argued himself into believing the latter to be the case. Denial.
It wasn't until he had visited the local supermarket with his wife and driven home uphill, with the pain yet again becoming worse, that his wife took the decision-making out of his hands. After speaking to DDRC again, it was decided to drive to Plymouth for treatment. Action.
By now Ben was in too much pain and too sick to drive himself. It was about 24 hours since the onset of the first symptoms when he arrived at DDRC.
With their medical backgrounds, the outcome of the neurological assessment was a considerable blow to both Ben and his wife. Neither of them had ever considered the episode to be anything other than a pain-only bend (Type 1 in "old" parlance) and then only grudgingly from Ben's point of view. So they were shocked and distressed to discover that he had significant cerebral impairment.
On arrival at DDRC he couldn't move his arm, and was protecting it. As far as the medical team was concerned, his arm was the least of his problems! He had a serious cerebral bend and was really sick.
Just because there is pain in one area of the body doesn't mean that bubbling isn't affecting other parts. Typically a lay person or dive buddies home in on the area of obvious symptoms and so can miss more covert problems.
Delayed treatment can resulted in residual effects because the trauma of bubbling is allowed to continue without check.
Ben received an initial treatment of five and a quarter hours in the chamber, with six follow-up treatments, and was lucky enough to make a good recovery.
The "take-home message" is that others in a group must assume responsibility for taking action to ensure the well-being of a diver who displays possible signs and symptoms of DCI. Never assume that the diver with the problem is in a position to make a reasoned judgment concerning management of the incident. The chances are that he or she isn't.
The very nature of a DCI is that it can disturb thinking, resulting in impaired judgment and reactions. Personality changes may also take place and not be restored to normal until several weeks after treatment. Ben's wife can testify to this effect.
It could also be that because Ben had an unrecognised cerebral bend, his judgment was flawed regarding his shoulder pain. So the last person to make a decision concerning his own well-being and treatment would be the diver/patient, whatever his social standing, academic ability or diving seniority. And beware of all-male group bravado and the belief that "chaps are not meant to complain!"
There is no humiliation or shame (words used by both divers in this article) in using the O2 kit and admitting that there might be a problem. The sooner dive buddies ensure that the victim visits a chamber, the less chance there is of residual effects. Phone for advice and act on it.
No one is invincible. The diving fraternity tends to assume - wrongly - that if you got a hit you took a risk. Anecdotal data shows that over and over again divers arrive at a chamber with a DCI unable to reconcile themselves to the fact that they have a bend. They repeat endlessly: "I didn't do anything wrong," or: "The computer said it was OK!"
Many believe that if they have stayed within tables they will not get a bend, just as others ignore the old rule of "deepest dive first" and doggedly follow the computer display options!
The dive computer will not "look after you". Computers and tables often assume the best case rather than the worst. At the end of the day it's only a set of mathematical calculations, oblivious that you have been imbibing best malt and beer the night before, are tired, over-weight and so on.
Divers need to be better educated in these matters. Perhaps greater emphasis should be placed on the psychology of a DCI. Explaining how successful prompt treatment can be, and providing an overview of what to expect in a chamber, might help to allay divers' fears.
It takes an expert in diving medicine to assess the extent of a DCI. Symptoms that might seem mild could be severe. And be aware that those symptoms might occur on surfacing or up to 36 hours later.
If the diver has flown or driven to any height, the delay could extend to 48 hours. So if a diver has breathed compressed air or another gas mixture in the past 48 hours it should be assumed that, until proved otherwise, you are dealing with a diving accident.
Make this coming diving season a responsible one, and don't be another denial statistic!
STEPPING IN: WHAT TO DO
Mild DCI symptoms may be described as fatigue, skin rashes or itching. The patient should be reassured and given basic first aid. Give 100 per cent oxygen, about a litre of plain water or still isotonic fluids in small amounts (no fizzy drinks) and place the patient in the recovery position on their left side.
If there is complete relief after 30 minutes, keep the patient under constant supervision and contact a diving doctor for further advice.
If there is no relief after 30 minutes, call the emergency services. Maintain the patient on 100 per cent oxygen, monitoring closely, and keeping him in the recovery position. Arrange immediate evacuation to the appropriate medical/hyperbaric facility.
Serious symptoms are pains, unusual weakness, pins and needles, dizziness, severe cough, shortness of breath, visual disturbances, staggering, paralysis, unconsciousness and/or convulsions. Contact the emergency services as soon as possible, and administer 100 per cent oxygen.
If the patient is conscious, able to talk and able to tolerate it, administer fluids in small amounts (about a litre, nothing fizzy). Place the victim on the left side, monitor pulse and breathing. Do not give pain-killing drugs and do not waste valuable time trying to elevate the patient's feet (opinion has changed on this previously taught procedure).