Page 59 - AlertDiver_Winter2013

line and seemed to get frustrated on several occasions
when the line became entangled in features on the bottom.
Halfway through her 10-minute dive, she complained to
the topside tender of feeling strange and overheated. She
called off the dive, asked the tender to begin taking up
slack in the umbilical line and started to ascend.
At 8 feet, a safety diver who was watching her stated that
the diver’s eyes rolled back and her head fell forward. She
stopped ascending and quickly sank to 20 feet, where the
umbilical line stopped her descent.
The safety diver initiated emergency procedures, and
other divers in the water came to assist. During the
ascent, the rescuers noted that the diver was breathing
and described her as being stiff and sometimes twitching.
On the surface she was immediately towed ashore,
and her gear was removed. A certified diver medical
technician (DMT) was on scene, and he quickly cut the
diver out of her drysuit. Another member of the team
contacted emergency medical services (EMS) and was
told response time might be as long as 15 minutes due to
the location of the training. When the paramedics arrived,
the DMT provided them with his assessment, the diver’s
vital signs and interventions made.
Assessment and Evacuation
The DMT reported that the diver appeared to lose
consciousness in the water during ascent, and, based
on rescuer reports of twitching and muscular rigidity,
there was concern of possible seizure activity as the diver
was being brought to the surface. She was responsive to
verbal stimuli by that time and would open her eyes for
a few seconds when spoken to but was unable to follow
commands. Her vital signs (including blood glucose) were
checked and found to be normal except for a slightly
elevated blood pressure and heart rate.
The diver’s mental status precluded detailed neurological
evaluation, but potential concerns included arterial gas
embolism (AGE), hyperthermia and postictal state following
a seizure. The gas supply was thought to be safe; none of the
other divers who had used it that day reported any problems.
Rather than route the patient to the local hospital, the
emergency personnel decided to have her flown to a larger
facility 45 miles away due to the severity of the symptoms.
A helicopter had been placed on standby at the time of the
initial call, and it was ordered to launch within a few minutes
of the paramedic’s arrival at the scene of the accident.
During the flight the diver was sleepy but able to answer
some questions. The paramedics noted weakness on her
left side, and she experienced a seizure that lasted about
45 seconds. Due to the possibility of that being her second
seizure, she was given medication to prevent additional
seizures, and the medication made her very drowsy.
Diagnosis and Treatment
In the emergency department, the doctor diagnosed the
diver with AGE. This diagnosis was based on the fact that
symptoms began during ascent from a dive, the symptoms
noted during the ascent may have been associated with
impaired breathing (or even breath holding), there was
persistent unilateral (one-sided) paralysis, and the diver
had no known history of seizures. A CT scan of the diver’s
head showed no evidence of bleeding, and the risk of stroke
was minimal because of her health status and age.
She was transferred to the hyperbaric unit and treated in
a chamber. Her drowsiness made it challenging for the staff
to assess her response to treatment, and they reported that
during treatment she seemed to experience three periods
of “spacing out” that lasted 15 to 30 seconds each. After
treatment she was admitted to the hospital’s neurological
floor. She received an additional chamber treatment the
following morning due to persistent neurological deficits
on her left side.
The History
By the next day the patient’s family had arrived. After
discussing the incident with family members, she admitted
to the doctors that she had a history of complex partial
seizures and that she had discontinued her medications
so she could be a part of the dive team. She had not had
a seizure in years and had done many recreational dives
without incident. Of the two seizures she had experienced in
the past, both had occurred during periods of extreme stress.
Despite this revelation about the patient’s medical
history, the diagnosis was left as AGE. However, the
hyperbaric physicians and neurologists who treated this
diver wondered if her symptoms were actually the result
of a seizure complicated by a condition called Todd’s
paralysis (a type of paralysis that can follow seizures and
usually occurs on one side only). Todd’s paralysis resolves
spontaneously within hours or a couple of days; the average
time to resolution is about 15 hours.
Lending support to the suspicion of Todd’s paralysis
is the fact that hyperbaric treatment had no effect. The
physicians stated they probably would still have done the
initial chamber treatment even if they had known about
the diver’s medical history, but they probably would not
have treated her a second time because there was no
improvement after the first treatment and there was a
plausible alternative explanation for her state.
Fortunately for this diver, her underlying condition did
not warrant any medical treatment she did not receive.
However, her case serves as a compelling advisory to make
sure your dive medical officer — or dive buddy — is aware
of any medical conditions that could affect your diagnosis
or treatment if you are injured while diving. AD
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