Save a scuba diver

Question

You're working in the ED when EMS brings you a patient who had been scuba diving that day. They report that they had run out of air and had to make an emergency surfacing and that they were diving all weekend. They report extreme pain in the joints, shortness of breath, and a headache. They also report numbness in their fingers and dizziness. You note that they are not able to walk from the stretcher to the bed without assistance by their friend as they are very unsteady and appear to be having problems walking. Their friend tells you that they also may have aspirated seawater once they got to the surface and panicked. Your patient was given oxygen on the boat and at the marina and has been sent to your hospital. They insist that they are fine but are forgetful and appear to zone out in between questions.

The friend states "he was pushing too hard and went from 60 feet down to the surface immediately because he ran out of air."

What condition do you expect they might have? How can you support them now? And what treatment will you expect to be ordered for your patient?

Answer 1

Decompression Sickness (aka "the Bends", caused by a too-rapid ascent during diving. Nitrogen bubbles form in the blood and tissues, blocking blood vessels, which causes pain and can cause a stroke. This is a high-priority patient (ESI triage level 2). He'll need oxygen via a non-rebreather mask, cranked all the way up to 15 Liters. You'll need to put him on a full cardiac monitor and start two large-bore IVs. Neuro-checks every hour. Fully un-dressed and in a gown so you can check blood-flow to his extremities frequently. I'd expect the doctor to order an EKG, a Chest x-ray, and a stat Head CT. Make sure the Respiratory Therapist is aware of this patient and also keeping an eye on him. Monitor and alert the doctor for any new/worsening chest pain, cough, shortness of breath, tachycardia, declining oxygen levels, weakness, or neurological changes. Notify the charge nurse, so they can start working on securing a hyperbaric oxygen chamber STAT. Prepare for admission/transfer.

Answer 2

Going by all the symptoms provided it sounds like the patient has decompression sickness (DCS).

However, there are other issues presented that should not be ignored!! His friend reported that your patient may have also aspirated sea water AND panicked, PLUS he was given oxygen on the boat.

While 100% oxygenation is best, it is vital to stabilize the patient until he can be placed in a hyperbaric chamber and be treated by a specialized team.

The nurse should worry about the oxygen given on the boat which is usually a mixed form of oxygen (fatal for pt's w/DCS)!! Swallowing seawater can also be toxic to humans due to the salt that the kidneys cannot filter and fluid loss will be great (osmosis) which can present with the same type of symptoms. Let's not mention all the bacteria and possible infections as well as aspiration pneumonia!

First and foremost it is vital to take a complete history and investigate all that had conspired during his dives over the weekend (if the friend is willing to give the information and the patient consents) because it looks like he states that he is okay and nursing ethics will come in play in regards to HIPAA and patient rights.

Plus an extensive physical assessment along with frequent neuro checks are essential. Ambulating him so soon (from a gurney to bed) when he is presenting with confusion is not wise in a trauma center, and a fall seems likely and will cause further injury. Nursing rule #1, if a patient comes in on a gurney, then he should be transferred to the bed until a complete assessment can be done.

In any case, the ER nurse can closely monitor and assess for other injuries other than DCS like barotrauma (burst lung), nitrogen narcosis, pressure injuries, perforated eardrum, neck injuries, and unconsciousness or confusion. Manage pain so that he does not further injure himself, and also prevent more anxiety. Each of these has a set of signs and symptoms that should be considered.

So, when getting questions like this one or real patients like this one....use your nursing process, assessment skills, prioritizing the situation, and considering what kind of treatment would be best without further injuring the patient.

As a critical care nurse, I would ask the friend to stay in the waiting room for a bit, do my physical assessments (pulmonary, cardio, neuro, etc) first and document all my abnormal findings, draw lab (STAT on electrolytes) and get an EKG and ABG before providing 100% oxygenation. All while keeping a patent airway, maintaining cerebral perfusion, temperature regulation (using a bair hugger if needed), frequent vitals, and neuro checks. Then non-sedative pain management. This followed by extensive health history, current history, and weekend activities while pulling out all possible signs/symptoms that may have presented earlier, including educating the patient on the importance of investigating and inquiring information from the people he was with over the weekend. To prevent any ethical violations, it is necessary to educate the patient and not coerce, but to get him to better understand the risks of not knowing and the benefits of knowing all that transpired prior, during, and post-diving.

You see if the regulator was still in his mouth, then his airway was probably protected from water entry during his ascent and I would then worry about lung expansion and compression fractures that could lead to an embolism. Therefore, I would want immediate decompression and oxygenation. He was given oxygen and I then worry about it being a diving tank oxygen mixture often seen on boats and worry about toxicity (oxygen, carbon monoxide, or nitrogen narcosis) which would interfere with the previous treatment and cause serious lung damage and seizures or unconsciousness. If he had ascended to the surface slowly, then I would not consider the above issues, but he did panic, so I have to assume that he ascended fast, which would cause pressure injuries to joints, bones, lungs, head, ears, etc.

It's a lot to think about and I have never come across such a situation thank goodness! But, the most important thing to do is to assess, reassess, monitor, and document the heck out of all your findings! Because what one person may not think is important...really is the difference between life and death.

This patient's most likely treatment will be recompression in a hyperbaric chamber within 24 hours as permanent damage and residual handicap is imminent without it.

Hope that helps!