Specialist advice may improve patient selection for decompression therapy following diving accidents: a retrospective observational study.

BACKGROUND: Even in a landlocked country like Switzerland recreational diving is becoming more and more popular. Smaller lakes in the Alps are located at an altitude of 2500 m above sea level. The incidence of diving accidents among all helicopter emergency service missions and the consecutive medical knowledge about decompression injuries is low. Thus, a collaboration between the Swiss Air-Ambulance (Rega) and the divers alert network (DAN) was initiated to improve patient treatment and identification of decompression injury and necessity of hyperbaric oxygen therapy (HBO). METHODS: Retrospective observational study that includes all patients treated by the Rega which have been classified to have had a diving accident from 2005 to 2014. Patient and diving epidemiology was assessed and the impact of DAN collaboration on patient selection and identification of patients needing transport to HBO facilities were analysed. RESULTS: In the 10-year observational period 116 patients with diving accidents were treated by Rega. Mean patient age was 40 (SD 11) years and 95 (82%) were male. If the Rega emergency physician suspected a decompression injury (DCI), without DAN contact 27/28 (96%) of these patients were transported directly to a HBO facility, whereas with DAN contact only 53/63 (84%) needed transport to a HBO facility. DAN was involved in 66/96 (69%) of the cases with suspected DCI on scene, with a significant increase over time (p = 0.001). Mean flight time to HBO facilities was significantly longer (28.9, SD 17.7 min.), compared to non-HBO facilities (7.1, SD 3.2 min., p < 0.001). Due to specialist advice, patients may have been selected who finally did not need a transport to a HBO facility, although DCI was primarily suspected by the emergency physician on the scene. These patients experienced a significantly reduced flight time to the (non-HBO) hospital of 25.6 (SD 6.5) min. (p < 0.001). DISCUSSION: Collaboration of DAN and Rega may allow a safe patient selection and a consecutive reduction of flight time and costs. Due to international collaborations, evacuation to HBO-facilities for acute recompression therapy can be provided by HEMS within less than 30 min all over Switzerland. CONCLUSIONS: For diving accidents among HEMS missions, specialist advice by diving medicine specialists (DAN) appears mandatory to accurately identify and transport patients with decompression injury, as exposure of emergency physicians towards diving accidents and the diagnosis of DCI is low.

[Diving - fitness to dive: a challenge for the family doctor]. / Tauchen - Tauchtauglichkeit: Ein Thema für die Hausarztpraxis.

A certificate for divers should be based on expertise and risk assessment. The doctor needs knowledge of the divers history, diving technique, motivation and risk exposure.

Le certificat d'aptitude pour un plongeur est basé sur une appréciation des risques. Le médecin doit connaître l'anamnèse, la motivation et l'exposition aux risques d'un plongeur.

Telemedicine in the management of diving accidents: correlation of phone-assessed symptom severity with clinical findings.

INTRODUCTION: The object of this study was to evaluate to what extend the severity of decompression illness (DCI) assessed by a diving medicine specialist over the phone correlates with actual clinical findings. METHODS: The phone protocols of calls received by a diving medical hotline between January 2008 and December 2009 were analysed. Each case was followed up after completion of the treatment and categorized into one out of four severity groups according to the same standard protocol used for categorisation at the time of the initial hotline call. RESULTS: In 47 of 151 calls, DCI was suspected by the hotline experts. The initial estimation was coherent with the clinical findings in 37 cases, 9 were overestimated and one was underestimated. With the 95% bootstrap confidence interval 0.551 to 0.864 and computed weighted Cohen's κ coefficient = 0,721, the coherence between hotline assessment and clinical assessment can be considered as good. The five divers with minimal symptoms who were categorised as "no DCI possible" could not be followed up. CONCLUSION: We conclude that, despite some limitations to the study, particularly the limited sample size, a reliable assessment of the severity of DCI can be provided by a specialist-based telephone hotline.

Problems of a preclinical treatment algorithm for diving accidents: analysis of the Swiss hyperbaric situation.

Following recent changes in the medical infrastructure in Switzerland, the number of hyperbaric facilities fell from ten to two, and the existing algorithms for telemedical assistance of divers required review. A retrospective study of decompression illness (DCI) from 2004 to 2008 showed that many divers were asymptomatic at the start of hyperbaric treatment. Because of this and recent publications, we may need to modify in the future the decision to recompress a diver. The descriptive nomenclature for DCI was used to determine the probability that symptoms represent DCI. Secondly we evaluated the probability that symptoms may be due to other pathologies or of psychosomatic origin, and thirdly the potential of symptoms for sequelae and their degree of invalidism was estimated. This process will result in one of three therapeutic decisions. An absolute indication for hospital-based hyperbaric treatment. Immediate recompression if available or normobaric oxygen (NBO) with telemedical supervision and adequate monitoring; in exceptional situations, on-site chamber recompression or in-water recompression may be considered. NBO as a preventive measure for two hours and 'bends watch' for 24 h. A prospective study should confirm evidence of good treatment practice. The key for further improvements will be to better understand ambiguous symptoms and to differentiate so-called 'mild' neurological symptoms. As a consequence of the reduction in hyperbaric facilities, longer transfer and treatment delays have resulted. Therefore, there is a need for careful evaluation of the indications for hyperbaric treatment of injured divers and also of the need to install on-site chambers for professional diving operations.

Diving Accident Guidelines of the German Society for Diving and Hyperbaric Medicine: Summary version.

The following is a synopsis of the German Diving Accident Guidelines, which may be found on www.gtuem.org in German and English. It is the second revision of a guideline initially published in 2002. The first version was reviewed in 2005 and then revised and updated in 2008. It is valid until October 2011 when the next revision is scheduled. Each version was developed by a group of experts and was then presented to a consensus conference organised by the GTÜM. An independent international steering committee (jury) at the conference created the final document. This is the first version published in both English and German. The extensive reference list used in preparing this document is available on the GTÜM website.