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By Mark K. Delegal, Esq., and Jan Gorrie, Esq.
Pennington, Moore, Wilkinson, Bell & Dunbar, PA
News: After surfacing with decompression illness, instead of being taken to a hyperbaric chamber three minutes from where his boat was docked, a diver was transported to a hyperbaric chamber 90 miles from the scene, delaying treatment for several hours. The delay in treatment allegedly resulted in severe injuries to the patient, including paralysis. A jury returned a gross verdict of $31 million, which was subsequently lowered to $22 million by the judge. The case has been appealed.
Background: On his birthday, the plaintiff, a recreational diver, decided to go fishing and scuba diving with a few friends despite the fact the weather was less than ideal on that October day. They had no food or water on board, but they all had been drinking beer. At about 3:30 p.m., the rains cleared and the group was about 15 miles offshore when they decided to do a 90-foot dive to a submerged barge. The plaintiff had been diving about 30 minutes and was on his ascent when he began feeling extremely weak. After surfacing, he called to those in the boat to come get him. The diver was in so much pain his friends had to pull him into the boat. His vision was blurry and his legs both tingled and were numb. He and his friends believed he was suffering from decompression sickness,and called the Coast Guard. They were instructed to take the injured diver to the Coast Guard dock.
In the meantime, the Coast Guard notified Divers Alert Network (DAN), a worldwide authority on diving injuries, and described the diver’s condition. DAN personnel recommended giving the diver 100% oxygen and intravenously administering normal saline to address dehydration. The Coast Guard also called the local Emer-gency Medical Services (EMS), which notified the local hospital about the incoming patient. The emergency room physician then contacted the hospital at the local Navy base to see if it could care for the patient in its freestanding hyperbaric chamber. Though civilian patients generally are not accepted for treatment at military facilities, a Navy physician agreed to take the patient and began assembling the chamber’s medical team. However, a senior physician at the community hospital determined that it would be better to have the hospital’s helicopter pick up the patient and transport him to a coastal hospital 90 miles away that had a more sophisticated hyperbaric chamber.
The critical care beds at the Naval facility had been closed earlier that day, and the senior physician thought the appropriate bed might be available at the other hospital.
The ground EMS vehicle met the boat at the dock. The EMS crew started the saline IV and gave him oxygen. Unsure where to take him, EMS contacted the emergency room physician at the community hospital, who said that the helicopter would be picking up the diver and transporting him to the hospital with the hyperbaric chamber.
Unfortunately, that was when things started going wrong. No one had notified the helicopter crew of the incident and the air ambulance did not have sufficient fuel for the 90-mile trip to the hospital with the hyperbaric chamber. The helicopter did initially transport him to the community hospital emergency department, where allegedly the next in the series of mishaps occurred. The patients IV was changed from normal saline as was recommended by DAN to D5W.
Normal saline had been recommend for its ability to hydrate patients, which in turn generally helps prevent nitrogen in the tissue from coming out of solution and causing permanent damage to the spinal cord. The D5W solution is known to cause the spinal cord to swell, making it more likely to contribute to permanent damage. In addition, by changing the flow from constant flow to keep the vein open instead of helping to hydrate the patient, the line was merely kept open.
At around 6 p.m., the Navy hospital called and asked for the patient’s location. The Navy’s chamber was ready and the appropriate medical team had been assembled. The community hospital emergency physician informed the Navy that the patient had been stabilized and would be transported to the other hospital with the hyperbaric chamber.
Thirty minutes later, the helicopter transported the diver to the other hospital. En route, the helicopter maintained an altitude of 1,000 feet. During the flight, the patient experienced so much pain that he was given painkillers. When the diving accident victim arrived at the hospital with the hyperbaric chamber, he was paralyzed from his right shoulder to his feet and was blind.
There was no physician on hand to begin recompression therapy, as it seemed that the receiving hospital had not been contacted to prepare the chamber or assemble the requisite medical team. Given the potential for additional delay in care, the chamber technician violated hospital policy and began to treat the diver. While the plaintiff’s sight and upper-body paralysis were restored, the diver’s legs remained paralyzed. He had little or no control over his bowels or bladder and was in constant pain.
The plaintiff claimed that the series of mishaps significantly delayed his obtaining care necessary to address his condition, a severe case of the bends. He held that the community hospital personnel were responsible for delaying his initial transportation, administering the wrong IV fluid, aggravating his condition with unnecessary medical helicopter transports, and ultimately delaying his access to appropriate care and hyperbaric chamber treatment.
The plaintiff also claimed that the coastal hospital, located in a community where diving is promoted, was negligent for not having a specific protocol for handling injured divers with the bends.
The hospital responded that the diver knowingly engaged in a dangerous sport and did so carelessly. The hospital maintained that the plaintiff had been reckless by diving too long and too deep, which was the irreversible cause of his injury. It also averred that the diver had not been drinking water during the day but had been drinking beer before the dive so he was not well-hydrated, which contributed to his having a more extreme case of the bends.
It is rare that divers experience such symptoms before reaching the surface, which indicates he probably suffered from Type III decompression illness, which is more resistant to treatment — the person simply remains paralyzed and there is nothing that can be done for them. The hospital said DAN recommends that patients should be examined in an emergency room for assessment and treatment of concurrent injuries, such as near drowning and head trauma, before being taken to a chamber.
The jury sided with the diver, awarding him $31 million, which was subsequently reduced to $22 million by the judge.
What this means to you: Hospitals located on the coast or near areas known for commercial or recreational scuba diving, particularly those operating hyperbaric chambers that treat diving accident victims, should at a minimum maintain protocols and procedures on the care and treatment of diving accident victims. Even those engaging in a potentially dangerous sport have an expectation for appropriate medical care in the event of an accident.
It is generally recommended that, when available, diving accident victims be treated in hyperbaric chambers located within hospitals, as opposed to freestanding units. While the Navy’s chamber was not located within the naval base hospital’s walls, it is not considered freestanding. Even in the treatment of lesser-injured persons, divers undergoing decompression treatment for the bends can experience adverse affects, which require the full backup of additional medical personnel and equipment as well as a critical care bed.
And it stands to reason that the more complicated the case, the greater the potential need for other medical care — and the greater chance for side emergencies such as oxygen seizures. Particularly, if a more extreme case of Type III decompression illness is suspected, the treat-ment may be of such duration and complication that a multimember chamber team and the most sophisticated equipment is desired, observes Rick Herrick, hyperbaric chamber director at Jackson Memorial Hospital in Miami.
This diver had extreme symptoms. Based on the information regarding the dive, it seems more likely that he had been diving longer and deeper than indicated. The diver may also have been more dehydrated than suspected, perhaps through heavy drinking or seasickness. The water temperature and his diving equipment may also have factored into the severity of his condition. The dive was on the borderline of safety based on standard dive tables in effect at the time of the incident. Since then, the tables have been modified and the dive would be considered more risky than before. While the severity of his symptoms would lead to more critical diagnosis, accuracy of the circumstances of the underlying incident are helpful to determine the best course of treatment, Herrick says.
Unless it’s impossible to avoid, it is not recommended that bends victims be airlifted at more than 1,000 feet because the decrease in pressure can aggravate the condition.
As for the air transport of victims of diving accidents, hospitals and other entities operating air ambulances, even if the facility does not have a hyperbaric chamber, should have policies in place for dealing with persons with the bends. This is particularly true for air ambulance services located near diving spots. Protocols should address flying altitudes, information on the closest chambers, best treatment practices, and how to contact DAN. While raised by the plaintiff as an issue of negligence, it is generally considered acceptable patient care to fly at the standard helicopter altitude of 1,000 feet, notes Herrick.
For hospitals housing hyperbaric chambers with services available to diving accident victims, service should be available around the clock. Depending upon the use and demand for the service, 24-hour coverage can be maintained by an on-call team. Diving-accident victims are generally received through the emergency room and the acceptance of the patient is determined by the facility, not those operating the chamber. Given the potential need to provide the gamut of medical services, the chamber’s manager or medical director should be consulted to assist in the assessment of diving emergencies at the facility. If the chamber is closed to diving victims, then all appropriate personnel in the hospital should be notified. This may include the transfer center, attending emergency room physicians, local EMS providers, and the administrator on duty, Herrick says.
Scuba diving is potentially dangerous, but when health providers and facilities are located in or near diving spots, medical personnel should be educated and trained on how to manage the care of injured divers. At the minimum, this may merely entail recognition of the potential for the bends and knowing who to call for assistance. As with many medical conditions, time is of the essence, and so there should be as few delays as possible in getting the accident victim to the right place by the right means, concludes Herrick.
Malcolm Keith Rawson vs. Baptist Hospital Inc. No. 90-6078 CA 01, Escambia County (FL) Circuit Court.