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2 members... 2 different incidents... one outcome


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#31 Jerrymxz

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Posted 13 August 2013 - 07:10 PM

When I walked around the back of my truck and saw Dave sitting on the bumper of his truck I ask him if he was all right. When he said : no. I knew what I had to do.

To everyone reading this: don't hesitate! Make the call. Get oxygen (or Nitrox) if that's what you have. Get to professional medical treatment and raise holy cane if you think it isn't going as well as it should.

Dave glad you're doing well buddy!!!

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#32 Greg@ihpil

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Posted 13 August 2013 - 08:01 PM

Thank you Kamala, for those comments!!!!!!!!!!!! Is DAN turning into a Cash cow..? Just like their Insurance for Equipment....As you may recall from Roatan..

BTW Dave , Glad you pulled through..All the Best to you Take it easy..
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#33 ev780

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Posted 13 August 2013 - 09:03 PM

OK everyone hold on a bit. Tooth is right. There is a mosaic of laws, rules, regulations regarding how a medical emergency is handled. It is very state specific and sometimes even region, county, or city, specific. I will talk in generalities here but I won't be far off of the mark. Divers Alert Network is not EMS. They are a glorified insurance company and sometimes not even that. Once you call 911 you set in motion a series of events that DAN has no control over nor legal authority to change. The local EMS has a set of protocols and/or regulations that must be followed. There are a lot of variables but safe to say that an ambulance will generally take you to the closest emergency room. Sometimes they can bypass the closest but there is a complicated algorithm to make that determination. Once you hit the door of an ER, a Federal law called EMTALA (Emergency Medical Treatment and Active Labor Act)takes over. The ER must stabilize you and transfer you to the appropriate facility. These laws are made on a pile of dead bodies and BS lawsuits and although at times cumbersome, they help ensure that you are not transferred to a cardiac center when you need a trauma center. Or a trauma center when you need an OB. Or refused care because you have no insurance. (the antithesis of a scumbag lawyer, the scumbag hospital that will only treat you if you can pay) There is a series of procedures that must be followed. Again, DAN has no say in how this is done. A good ER will listen to the experts and transfer the patient as needed. But they have to find an appropriate hospital, find a receiving doc, get an available bed and arrange the available transport. Not always an easy task. Transport resources are scarce, expensive, and triaged to those with the most need.

Again DAN is not, and cannot be involved in any of those decisions. I can go on and on as to why the laws are they way they are but they are there for patient protection and in general are a good thing.

So now what do you do? First, do as Jerry did. Make sure the EMS crew knows what they are dealing with. Scream from the rooftops if you have to. Unless you are on the coast, it is highly unlikely that the EMS crew or the physician has a clue about DCS. Embolic problems are a bit different but this is too long already and I will leave that lie. DCS is just not a call we see that often. The good news is that unless they decide to turn off the oxygen, which they won't, there is not much a run of the mill paramedic can do about DCS. You won't get better but you won't get worse either. There is only one thing you need and other than oxygen and some symptom control paramedics just can't help much except get you to the chamber. Next make sure that the ER knows the situation and now get DAN on the phone and find a chamber. Hopefully the DAN doc can talk to ER staff and help grease the wheels and do some instant education. But at this point, you are at the mercy of the system you are in at the time.

I am sorry this got a little more wordy than I wanted but, it is VITAL that everyone understand that DAN in not a substitute for EMS and proper emergency treatment. DAN's transportation stuff applies when you are in a foreign land or when there are no local resources to move you. DAN will take much longer than local systems. But even then they have no authority to change any laws regarding transport.

I hope that helps. Dan (Scubatooth) are both paramedics and can help with this discussion . So please ask more questions.

Fred

Edited by ev780, 13 August 2013 - 09:03 PM.

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#34 Greg@ihpil

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Posted 14 August 2013 - 05:35 AM

ev, I understand regarding the LAWS have their place and with good intentions for all concerned. However the fact that DAN reacted or responded the way they did is not in line with what they preach or teach..
As quoted by Kamala, below
"In both instances the patient was unable to call for themselves so others did it for them. No one was asking for medical info or updates on a specific person...they were simply trying to get the ball rolling and GIVE information to DAN. No one said "have you called 911? Have you talked to TravelAssist" "Do any of the local docs need assistance with diving question?" They took the information and that was it.My understanding is you call DAN and Travel Assist (which appears to be part of DAN now) if you have DAN and they take over from there making the triage decisions you made...i.e. do they need a bus or a airbus? What hospital should they be routed too? If the person taking the call says "Thank you" and does nothing or does not offer to call you back or direct you to call Travel Assist next so you know the chain of care has started how do you know if anything has happened? DAN insists you call them first so they can help do exactly what you said. And if DAN is NOT responsible for assisting with proper DCS related triaging... then how do you educate local EMS/EMT people to make the right decisions?"

K,I'll be curious to read what the response is from DAN.Also, I would like to hear how Dave does regarding any claim to DAN.
If the Dr.B. from Chicago is following this, can you offer a perspective? And what happen when you went to the chamber?


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#35 WreckWench

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Posted 14 August 2013 - 07:48 AM

Ok first let me work to do my part in diffusing some of the fire/flames I threw into the mix in my frustration over it taking so much time to get one of the patients from point A to B and into a chamber.

Secondly FRED your comments are spot on and have shed some much needed and very valuable light on the circumstances. (Bill and I will be drafting correspondence for our local EMS, the local hospitals and DAN in order to IMPROVE how diving incidents are handled in the future in this area.)

Third my goal is to BETTER UNDERSTAND how this whole process works INCLUDING the role of DAN or DiveAssure in the process so that I as a trip leader and as an individual will be in a better position to assist others.

In backtracking a bit I notice the words "EVACUATION" on the card.... I'm going to guess that refers to int'l trips only and not local emergencies which would make sense. ALSO NOTE that all my interaction until now has been with DAN or DiveAssure on an int'l trip and never locally in the US. Thinking about it, I'm sure they are handled differently which would also make sense. AGAIN Fred's comments helped to educate me.

And I'm going to guess that DAN simply wants you to notify them of all incidents as they will become future claims AND if the local medical personnel treating someone has any questions THEY can call DAN. In my personal experience to date, if it is an int'l emergency they do not interfere or are even involved in the initial treatment of the emergency...they are only involved from an 'insurance involvement' and if the patient has to come home either dead or alive...hence the words "evacuation".

So I am going to read over DAN's website to see what they say about the handling of claims and/or their involvement and what their role is both as an insurance carrier and as a health adviser.

I am sorry that I got frustrated...because the role of EMT's and emergency responders is now so convoluted and complicated...its become so far removed from the lay person who sees actions that do not make sense to them. Then if they ACTUALLY do something that does not make sense...you tend to get 'hot' and fortunately this forum has allowed me to vent some of that steam BEFORE we start our dialog of change here locally and perhaps with DAN. Kamala

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#36 ev780

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Posted 14 August 2013 - 10:23 AM

Ok first let me work to do my part in diffusing some of the fire/flames I threw into the mix in my frustration over it taking so much time to get one of the patients from point A to B and into a chamber.

Secondly FRED your comments are spot on and have shed some much needed and very valuable light on the circumstances. (Bill and I will be drafting correspondence for our local EMS, the local hospitals and DAN in order to IMPROVE how diving incidents are handled in the future in this area.)

Third my goal is to BETTER UNDERSTAND how this whole process works INCLUDING the role of DAN or DiveAssure in the process so that I as a trip leader and as an individual will be in a better position to assist others.

In backtracking a bit I notice the words "EVACUATION" on the card.... I'm going to guess that refers to int'l trips only and not local emergencies which would make sense. ALSO NOTE that all my interaction until now has been with DAN or DiveAssure on an int'l trip and never locally in the US. Thinking about it, I'm sure they are handled differently which would also make sense. AGAIN Fred's comments helped to educate me.

And I'm going to guess that DAN simply wants you to notify them of all incidents as they will become future claims AND if the local medical personnel treating someone has any questions THEY can call DAN. In my personal experience to date, if it is an int'l emergency they do not interfere or are even involved in the initial treatment of the emergency...they are only involved from an 'insurance involvement' and if the patient has to come home either dead or alive...hence the words "evacuation".

So I am going to read over DAN's website to see what they say about the handling of claims and/or their involvement and what their role is both as an insurance carrier and as a health adviser.

I am sorry that I got frustrated...because the role of EMT's and emergency responders is now so convoluted and complicated...its become so far removed from the lay person who sees actions that do not make sense to them. Then if they ACTUALLY do something that does not make sense...you tend to get 'hot' and fortunately this forum has allowed me to vent some of that steam BEFORE we start our dialog of change here locally and perhaps with DAN. Kamala



Kamala,

There are frustrations for even the people inside the system. It is complicated, sometimes inflexible, and different depending on where your feet happen to be planted at the moment.

Your plan is a great one!!! Most local EMS and hospitals love to have conversations about how to improve. They have people who's entire job is to work on these things. Meetings happen daily in systems like this to address incidents that do not go well. Engage them, offer your expertise, and they will respond. Might be at glacial speed but if you have a good system they will listen. If you have a great system you will get more that you bargained for. In a good way.

In EMS there is only about 2 or 3 degrees of separation. I know some people in North Carolina that can probably hook me up with the right people in your area. Just let me know.
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#37 Scubatooth

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Posted 14 August 2013 - 01:02 PM

Kamala

You are correct on evacuations. Inside the US the protocols and methodologies for transferring patients is pretty much well laid out, by federal law and even insurance companies don't dare interfere. On the International air medical transport you want to talk about a logistical challenge it can be a nightmare. This is where DANs experience really helps as they have the contacts and resources to get the appropriate aircraft, pilots, medical crew, fuel, supplies, permits/visas. None of that comes cheap and if you go arranging it on your own you could get a deal or screwed as international air medical transport can runs 100's of Thousands of Dollars.

Some dive accidents require a very specialized medjet (Gulfstream IV)that can be pressurized to sea level so that the on-board hyperbaric chamber can keep the patient compressed/treated in flight. That is not a cheap aircraft and running this set up burns alot of jet fuel and reduces the range big time. Normal range on a GulfStream IV is 3800-4200 nautical miles (roughly 0.7-1.0 gallons of Jet-A (~$4.75-$6.00 a gallon) per mile, this jet gets 1/3 of that when pressurized to sea level and chamber in operation. There are other specialized medjets similar like this but this is the only one I know of in the United States.

I know of two international evacuations one from: (Do not ask for further details as not going to happen)
* Germany back to the US: from start to finish took 3.5 days as the aircraft had to be repositioned from Seattle to Chicago then to Munich and back to Chicago (10hr Flight time each way, plus 4 flight hours each way for repositioning). Total cost 125K paid in cash by the family of the patient. This is a very good price considering jets for trips like this are typically $8-14K per flight hour just for the aircraft not including medical crew, supplies and misc.

* CZM-MIA - This was for a Type II DCS Hit with AGE. The specialized G4 mentioned above was sent on this trip. Cozumel to Miami direct is 557 miles but most pilots will round this to 650-700 miles for alternate airport and ATC /En-Route changes. Flight time of 80 mins each way and used 4800 gallons of fuel. Cost of evacuation was >$300K by the time it was all said and done total cost for treatment, evacuation and rehab over half million.

Setting up a plan with local EMS is actually a very good idea as will establish a report with local fire EMS and get familiarity on both sides. Will help in the event of an accident

Fred - Thank you on EMTALA I brain farted the term, even though something I deal with all the time either with 911 or transfer side of things.

Edited by Scubatooth, 14 August 2013 - 02:22 PM.

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#38 jesterdiver

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Posted 14 August 2013 - 01:35 PM

So glad to hear Dave and Charles are doing better. My thoughts are with the both of you. Jerry, "you can be my wing man anytime"! (Top Gun reference) I recently took my Rescue Diver course and it was specifically geared towards Dutch Springs, and you seemed to follow the playbook perfectly!

And I'm beyond happy that we've got someone as passionate as Kamala on our side! I won't dive abroad without you! Wench, your passion is what generated this discourse, and as a result we are all more educated, and unlike most other forums, this group of divers really keeps the focus on the greater good of it's fellow divers. So thank you to all who have contributed their knowledge and expertise in this area, it is appreciated!

#39 Dave L

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Posted 14 August 2013 - 02:40 PM

Just to add some further information. As I said I was very fortunate where my incident happened. Everyone seemed to know what to do and what was going on. I know Jerry got pretty frustrated in calling DAN but in hindsight, easy to do now that I'm back home and okay, there was little they were going to add to my situation. Note I said my situation. My incident happened in the close area to the U of Penn. All the EMT and emergency personnel appeared to be at least partially aware of scuba diving issues. It really helped to have Jerry standing there with my dive computers explaining what had happened. I'm sure that really helped to focus everyone in the right direction.

I called DAN this morning to start a case file for when the bills start coming in. They were very polite and helpful. This was not the emergency number but the insurance number. Nobody said I should have called them on Saturday, when it happened, or that I needed prior approval for the helicopter ride. They are also number 3 on my insurance company list. So we will see over the next months how things go.

All in all, having a great dive buddy and being in a prime hospital area go along way to getting the proper help. I shudder to think of this happening in some of the more remote and 3rd world places I have dived.

Great discussion on a subject that usually gets swept under the radar.

Dave

#40 ScubaTurtle

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Posted 14 August 2013 - 03:56 PM

Dave and Charles, I'm glad to hear that you both got out of this OK. It's definitely unfortunate that it occurred but as has been pointed out the right reactions can and do prevent further injuries and speed the recovery.

Glad to hear everyone is OK and it seems like they might be able to dive again sooner than they originally thought! Posted Image

#41 WreckWench

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Posted 15 August 2013 - 08:11 AM

And I'm beyond happy that we've got someone as passionate as Kamala on our side! I won't dive abroad without you! Wench, your passion is what generated this discourse, and as a result we are all more educated, and unlike most other forums, this group of divers really keeps the focus on the greater good of it's fellow divers. So thank you to all who have contributed their knowledge and expertise in this area, it is appreciated!


Thank you! I know I speak for everyone when I say "its nice to be appreciated". Kamala

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#42 ev780

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Posted 15 August 2013 - 09:18 PM

I had a conversation with Jerry today and with Dave's permission I have a little more to add to this discussion. Jerry reiterated that the dive profile was very safe and no violations occurred. I hate the term "undeserved" but the DCS hit from this dive would be unexpected for sure. Jerry did a field neuro exam, activated EMS, oxygen was applied early, and the medics responded aggressively and transported to the proper hospital. Dave was evaluated there and flown to the hyperbaric center which all was arranged reasonably quickly. Never as fast as you think but that is another subject. When Jerry hit the first ER, he spoke with a resident and attending physician that were very sharp indeed and listened to what Jerry had to say. They were working on three possibilities, BPPV, which I mentioned earlier as Benign Paroxysmal Postural Vertigo; inner ear barotrauma; and inner ear DCS. After several tests and exams, they went with inner ear DCS. Jerry asked a question as to how the doc made a determination as to suspected inner ear DCS vs the BPPV and the resident stated that the horizontal nystagmus test made the difference. A nystagmus test is that test where you follow someone's finger without moving the head. A positive test is when your eye gets to the end of it's range and has these tiny horizontal jumps back to center. Here is a great video......



See those little jumps? According to the docs Jerry talked to , in BPPV this will settle down after a few seconds when the brain figures out what is happening and compensates. In Inner Ear DCS it will not. I am going to yell this next part on purpose. ANYTIME YOU SEE A HORIZONTAL NYSTAGMUS IN A SOBER PERSON, THEY GO VIA AMBULANCE TO THE NEAREST TRAUMA CENTER. This exam is just a tool not a way to definitively diagnose anything. In any event nystagmus in not a good thing. So add this to your repertoire in a neuro exam. It is a safe test and will tell you lots about the brain of the patient. Next time you are out drinking with friends do this test and watch the results. Good practice. Of course you have to be sober enough to judge the results.

So in the end this is most likely an inner ear DCS hit. Dave is still undergoing testing and treatment so that diagnosis may change. Here is a great article describing Dave and Jerry's day. It is out of Munich and has a very good summary of inner ear DCS.

http://www.divemeddo...s-inner-ear-dcs


Does any of this sound familiar? Classic presentation.

Interestingly, the literature suggests a link between a right to left shunt and inner ear DCS. The most common shunt is PFO (Patent Foramen Ovale) The Foramen Ovale is the little hole in your heart that seals up quickly after birth. In some it remains open (patent) and generally is not a problem. In diving and extreme athletics it might be.

Here are several abstracts of studies showing that this is indeed a serious thing and not as rare as first thought.

http://www.ncbi.nlm....pubmed/22400449

http://www.ncbi.nlm....pubmed/11359165

http://www.ncbi.nlm....pubmed/14660917

It is really easy to blow off dizziness but with inner ear DCS that will not likely happen as the symptoms are severe and rapid. But then again so is BPPV.

Dave, I looked and looked for some long term outlooks on recovery and return to diving. I was unable to find much good news. The recovery is long and slow. But generally the symptom subside. DAN may have a better handle on the long term prognosis but the interweb was pretty weak on this information. Not uncommon as long term follow up is hard to do. But you were treated early and aggressively and that looks to be the key. Hang in there and keep us posted. And for sure tell us what you learn from DAN.

So I am now done. I have researched this thing to death and I know my scientific curiosity got the best of me, but I learned a thing or two and I hope this helps others somewhere down the line. Thanks Dave for opening up your case so we could learn from you.

Edited by ev780, 15 August 2013 - 09:21 PM.

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#43 Dave L

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Posted 16 August 2013 - 04:40 AM

Fred, thanks so much for all the information. They are pretty sure it is inner ear DCS. You are right about the severe and rapid dizziness. When it hit me there was no denying I had a problem. I had to keep my eyes closed to keep from falling to the ground. We will just have to see what develops. I'm not due to go back to Penn for an evaluation for another month. They gave me some hope things will improve but obviously no guarantee.

Dave

#44 Jerrymxz

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Posted 16 August 2013 - 06:42 AM

Fred, that is a fantastic summation of the clinical events with the explanations and definitions to make it understandable. I was just a guy who was put in a situation and I did the best I could using the training I have. I do have reservations about the time it took to get Dave transported to the chamber. We got oxygen administered at 1305L and the Helo arrived at1711L. That's a 4 hour laps. I understand the doctors were having issues trying to arrive at a diagnosis. Had they been able to confirm it as BPPV then the airlift and hyperbaric treatments would have been unnecessary. The doctors were on the phone with someone who had knowledge of dive medicine. The resident was talking to them on a cell phone and came into Daves room to get specific information from me concerning the dives. It's been said that no one thinks events happen quickly enough. I know the er team did everything they could but I can vouch for the fact it is frustrating sitting there watching the clock tic.

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#45 dive_sail_etc

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Posted 16 August 2013 - 07:15 AM

I have never read a more thorough, logically compiled, technically documented treatise on a specific DCS incident as I find in this topic thread. Dave aka Dave L, Very glad to learn you are feeling 100% better and by all appearances on the mend. Huge kudos to Jerry aka Jerrymxz, whom I would like to formally nominate as the Dive Buddy of the Year for a) not ending his DB duties once back on land and b) demonstrating the skills both diagnostic and strategic to effect the best and most rapid reaction possible. Plus he was able to provide such a detailed on site report to the first responders which proved essential in providing a sound foundation for further analysis. Of course the EMS, ER and chamber teams who all performed so superbly will go largely unknown but most certainly are acknowledged for their critical time sensitive contributions in providing their make-or-break first response care for Dave's DCS.

That said, I also want to offer for I believe everyone here some additional thanks to Dan aka Scubatooth, Fred aka ev780, Jerry aka Jerrymxz (yet again) and Kamala/Bill for their combined contributions in this thread to flesh out and make understandable the technical minutiae and nuance surrounding Dave's DCS incident in particular and DCS emergency response, from assessment to triage to treatment, in general. Even Jerry's sense of frustration felt with DAN response and, per his post an hour ago, the time it took to get Dave formally diagnosed and into the chamber was conveyed in a way I can grasp and translate into a smarter emergency call tree (call 911 FIRST and STAY ENGAGED with EMS) in future potential DCS situations. The resulting information so much better prepares us to help our buddies and provide useful information to qualified first responders, and IMO is the platinum standard for what a diving community should aspire to be. I am prouder than ever to say I am part of the SingleDivers.com community.
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