Diving Scenario

Scenario:

You are on a BA flight home from a wonderful expedition in Labi Forest Reserve Brunei. 2 weeks of jungle exploration with no medical emergencies. About an hour into the afternoon flight, you hear some panic coming from a couple sat a few rows in front, one of whom you overheard complaining about shoulder pain whilst boarding the craft. The panic starts to grow and eventually one of the pair start calling for help.

Sophie - 24 years old (patient) + James – 25 years old (friend)

P/C

- Dry cough

- Difficulty breathing

- Very anxious

- Pleuritic substernal chest pain

Students must:

- Introduce themselves + gain consent for examination

- Mark the time

- Complete a full A-E

- Take a detailed collateral history to elicit more clues

Signs + Symptoms:

A – Clear, Alert and Orientated - alert and oriented to person but struggling to speak due to breathlessness B – Respiration 31 rpm, O2 sats 85%, Chest expansion equal, percussion hard to tell due to plane noise but notice surgical emphysema (bubble wrap) and swelling by chest and shoulder, auscultation seems normal, no tracheal deviation C – Pulse 122 bpm, BP 141/92 mmHg, Cap refil <3 secs, Heart sounds normal, non-elevated JVP D – Glucose 7.1, AVPU – A, Temp = 36.8C, Eyes – PEARL E – Swelling around left shoulder and feel bubble wrap skin by left shoulder and parts of left chest.

Further history:

- Allergic to nuts, sesame

- Takes COCP

- No past medical history + denies any history of cardiac problems, looks otherwise to be in good shape.

- Has been on a diving holiday, diving in the Miri - Sibuti Coral Reefs National Parks. They wanted to get one last dive in before they came home so did a dive early this morning.

- Dive profile – 30m for 5 mins, 22 metres for 10 mins, 18 metres for 36 mins, forgot to do safety stop but said she felt fine. Only complaint is achey shoulder which started about 2 hours after the dive.

After 10 mins Sophie deteriorates.

New Signs + symptoms

- Responsive to pain

- Drowsiness

- Pulse 134 BPM

- RR 25 rpm

- Temp 36.8 C

- O2 81% (if O2 not sourced and given) – 87% if on O2

- Plane must emergency land

Students must:

- Inform pilot of medical emergency and hand over to ground medics

- Provide SBAR handover

- Maintain and monitor patient vitals

- Treat effectively (source O2 – BA airways and some other commercial airways can give oxygen to one passenger)

Diagnosis:

Sophie is suffering from Pulmonary decompression sickness (the chokes) and MSK decompression sickness (the bends)

Decompression sickness (DCS) is a systemic disorder resulting from excessive gas formation in the tissues and venous blood. During diving descent, increased atmospheric pressure causes gases like nitrogen to cross the alveoli into the pulmonary circulation and dissolve in blood. As a diver ascends, the atmospheric pressure decreases, and these gases can come out of solution forming bubbles in the tissues or venous blood. Whilst at sea level the body is offloading gas as fast as it can. Ascending to altitude on a flight decreases atmospheric pressure further causing any remaining gas to come out of solution and form bubbles again. The bubbles cause an inflammatory reaction by activation of complement system, neutrophils, and microparticles. Bubbles can also damage the endothelial lining causing increased vascular permeability leading to tissue oedema. Vascular bubbles formed in the systemic capillaries may be trapped in the lung capillaries, blocking them. If this is severe, the symptom called "chokes" may occur and this can lead on to neurological dcs. Both are life threatening.

DCS Signs & Symptoms

The Chokes: Pleuritic substernal pain, dyspnea, and cough. The patient may be tachypneic, tachycardia, and cyanotic

The Bends: Dull, aching pain, most commonly affecting the shoulder and elbow joints. Patients may have a vague sensation of numbness around the joint. Physical exam may demonstrate erythema, swelling, or pain with range of motion.

Treatment

- Supplemental oxygen + IV fluids (help process of reabsorption)

- Immediate descent and transfer to hyperbaric chamber

- The friend should also accompany for assessment and decompression as they too are at risk

Given the severity of DCS, treatment should be started as soon as suspected. Hyperbaric chamber therapy is the cornerstone of treatment. The Diver’s Alert Network https://www.diversalertnetwork.org should be contacted to discuss additional management and locating the nearest available hyperbaric treatment facility. If air transport is required, an aircraft capable of maintaining sea level cabin pressure should be used. If a helicopter is used, the flight crew will need to fly at the lowest altitude possible altitude, preferably under 1000 feet. In addition to HBOT, intravenous fluids and supplemental oxygen via a non-rebreather should be initiated immediately as they help bubble resorption.