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Incident Insight: Triage

The profound importance of Triage decisions made by physicians is applied to multiple patients to determine which patient should receive medical care first.
 
In situations involving multiple patients, medical professionals apply a principle known as “triage”. This is a process in which potential patients are categorised according to the severity of their illness or injury. The intention is to prioritise those most ill or injured and who would benefit most from prompt treatment. Triage requires skill, experience and professional objectivity. When making decisions in a patient’s best interest, the resources have to be considered.
The Divers

The incident took place at a marine-research facility on a remote, sparsely populated Caribbean island. The facility frequently hosted groups of students as part of their outreach programme to assist with underwater studies. Management of the facility contacted the local dive operation with what they thought was at least one dive accident patient (a 55-year-old professor), along with three potential others (students who were between the ages of 18 and 20).

The dive centre was staffed by a physician trained in diving medicine, a certified hyperbaric technologist (CHT) trained by DAN to perform neurological examinations and a nurse. An operable multiplace hyperbaric chamber (capable of handling two patients) and a tender was on site and available.

After confirming details about the patients over the phone with management at the research facility, the CHT urged them to transport all four divers to the dive centre for evaluation.
The Incident

Each of the four divers performed two dives, all of which were unremarkable. All dives were within no-decompression limits, safety stops were performed and no rapid ascents were reported. Six hours post-dive, while walking through the communal cafeteria, the professor collapsed. Lower-extremity motor function was compromised and he reported an overall ill feeling. 

Not long afterward, the three students complained of similar symptoms.
The Evaluations

Upon arrival at the dive centre, oxygen and oral fluids were administered to all four patients. They were then examined by the physician and the CHT.

Upon examination, it was determined that the professor had weakness in both his lower extremities. After the diagnosis was confirmed between the onsite dive physician, the CHT and DAN, the hyperbaric chamber was readied.

Because of space limitations in the dive centre, the students were unable to be evaluated in seclusion from each other. All three were together in the same small room where histories were presented and examinations performed. They could not help overhearing the questions as well as each other’s responses. They all reported the exact same symptoms and complaints as their professor.

Based on the initial evaluations, there were four patients in need of hyperbaric oxygen therapy (HBOT), but the chamber could only accommodate two at a time. The two patients who could not receive immediate HBOT could continue oxygen therapy until the chamber was available.
But who was going to receive immediate treatment and who was going to wait?

The facility contacted DAN, seeking assistance with the logistics of patient care. The DAN medic placed a conference call to DAN’s attending physician for consultation. Each patient’s case was reviewed, with attention to physical examinations, objective findings, reported symptoms and dive profiles.

All agreed that based on objective examination findings and the seriousness of his symptoms, the professor was in most need of treatment. The possibility of evacuation was also considered.

The initial examination results of the three students, however, were ambiguous and non-definitive. The decision was made to re-evaluate each student without the others present. Though this meant that the patient being re-evaluated would go without oxygen for a short period, the diagnostic gain was deemed worthy and they proceeded accordingly.
Re-Diagnosis

The on-island team performed individual evaluations and examinations of each student. Two of them were found to have no objective findings of decompression sickness (DCS). The third student was more assertive about his complaints. Despite the absence of objective findings, DCS could not be ruled out. The third student was included with the professor for HBOT.

The individuals who were not in the chamber continued to breathe oxygen and were continuously monitored.
Results

After completion of a US Navy Treatment Table 6, a chamber treatment requiring a minimum of almost five hours, the professor was evacuated to a facility in Miami for further treatment and additional therapy. He was diagnosed with Type II DCS, involving the spinal cord.

The student who received HBOT reported that his symptoms resolved after the treatment, but he returned the next day for evaluation of new and different, though non-specific, symptoms. The on-site physician chose not to provide further HBOT, but continued to monitor him. The symptoms he reported over the next day were inconsistent and resolved completely over the next 48 hours. The students who continued with oxygen therapy alone refused further treatment. They ultimately reported complete resolution of their complaints within the first hour after presentation and HBOT was no longer indicated. A diagnosis of DCS for these two patients could not be confirmed or dismissed.
Discussion

As diving injuries often have nebulous symptoms and can be difficult to diagnose, a call to DAN can be a vital link in the care of divers in need. In this case, the physical attributes of the medical facility complicated the triage process. The on-island team did a commendable job under very trying circumstances. Contacting DAN was an important aspect of patient care that ensured effective treatment and eventual evacuation to an appropriate facility. An extra set of trained eyes and ears can always help.

In emergency situations, recognising a problem and responding properly are important steps toward optimising outcomes. When observing a friend or dive group member suspected of being injured, it is not unusual to become concerned for one’s own welfare. Humans as a species are subject to the power of suggestion. The situation may be complicated when it involves multiple patients, emotions and group dynamics.

It is important for each individual to try to remain as calm and objective as possible regarding his or her own situation. This is a delicate and precarious balance to try and maintain. When an injury or medical issue develops, denial can delay proper evaluation and treatment. Resist the temptation to jump to conclusions, but consider evaluation by a medical professional. The integrity of any evaluation depends on objective findings:
  • When assessing injured divers, perform the evaluations as privately as possible.
  • Examination for confirmation by more than one appropriately trained individual may be helpful.
  • Perform ongoing examinations to evaluate changes in the condition.
  • Document all objective findings.
Whether you are a new, advanced or professional diver, with concentration and focus, these reminders can promote more efficient triage, a more accurate diagnosis and a more thorough resolution.

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