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    Management of Mild or Marginal Decompression Illness in Remote Locations

    Added today (thanks DAN and our own Dr. Mitchell et. al.): Mitchell SJ, Doolette DJ, Wachholz CJ, Vann RD (eds.). 2005. Management of Mild or Marginal Decompression Illness in Remote Locations Workshop Proceedings. Durham NC: Divers Alert Network. 240 pages. RRR ID: 5523

    Quote Originally Posted by Consensus Statement 1
    With respect to decompression illness (DCI), the workshop defines "mild" symptoms and signs as follows:
    –limb pain 1,2
    –constitutional symptoms
    –some cutaneous sensory changes 3
    –rash where these manifestations are static or remitting 4,5 and associated objective neurological dysfunction has been excluded by medical examination.

    Footnotes
    1. The workshop agrees that severity of pain has little prognostic significance, but acknowledges that severity of pain may influence management decisions independent of the classification of pain as a "mild" symptom.
    2. Classical girdle pain syndromes are suggestive of spinal involvement and do not fall under the classification of "limb pain."
    3. The intent of "some cutaneous sensory changes" is to embrace subjective cutaneous sensory phenomena such as paraesthesiae that are present in patchy or non-dermatomal distributions suggestive of non-spinal, non-specific, and benign processes. Subjective sensory changes in clear dermatomal distributions or in certain characteristic patterns such as in both feet, may predict evolution of spinal symptoms and should not be considered "mild."
    4. The proclamation of "mild" cannot be made where symptoms are progressive. If the presentation initially qualifies as mild and then begins to progress, it is no longer classified as "mild" (see also Footnote 5).
    5. The possibility of delayed progression is recognized, such that the "mild" designation must be repeatedly reviewed over at least the first 24 hours following diving or the most recent decompression, the latter applying if there has been an ascent to altitude. Management plans should include provisions for such progression.
    Quote Originally Posted by Consensus Statement 2
    The workshop accepts that untreated mild symptoms and signs 1 due to DCI are unlikely to progress after 24 hours from the end of diving. 2

    Footnotes
    1. Mild symptoms and signs are strictly limited to those defined in Statement 1 and its footnotes.
    2. This statement does not hold where there is a further decompression, such as further diving or ascent to altitude, in the presence of mild symptoms.
    Quote Originally Posted by Consensus Statement 3
    Level B epidemiological 1 evidence indicates that a delay prior to recompression for a patient with mild DCI 2 is unlikely to be associated with any worsening of long term outcome.

    Footnotes
    1. Levels of evidence in American Family Physician (Internet). {Leawood(KS)}: American Academy of Family Physicians; c2004 {Cited 2004 Dec 6}. Available at: Levels of Evidence in AFP -- American Academy of Family Physicians
    2. "Mild DCI" is limited to those presentations exhibiting only "mild symptoms and signs" strictly as defined in Statement 1 and footnotes.
    Quote Originally Posted by Consensus Statement 4
    The workshop acknowledges that some patients with mild symptoms and signs after diving1 can be treated adequately without recompression. For those with DCI, recovery may be slower in the absence of recompression.

    Footnote
    1. The non-specific reference to "mild symptoms and signs after diving" is intentional. It reflects the fact that the manifestations may or may not be the consequence of DCI. The statement suggests that even if they are the result of DCI, full recovery is anticipated irrespective of the use of recompression although resolution may take longer. Importantly, "mild symptoms and signs" are strictly limited to those defined in Statement 1 and footnotes. Where symptoms and signs fall outside the spectrum of manifestations herein defined as "mild," standard management and therapy is indicated.
    Quote Originally Posted by Consensus Statement 5
    The workshop acknowledges that some divers with mild symptoms or signs 1 after diving may be evacuated by commercial airliner to obtain treatment after a surface interval of at least 24 hours, and this is unlikely to be associated with worsening of outcome. 2,3,4

    Footnotes
    1. "Mild symptoms and signs" are strictly as defined in Statement 1 and footnotes.
    2. It should be noted that most favorable experience with commercial airliner evacuations comes from short haul flights of between 1 and 2 hours duration. There is much less experience with longer flights.
    3. It was agreed that provision of oxygen in as high an inspired fraction as possible is optimal practice for such evacuations. In addition, the risk of such evacuation will be reduced by pre-flight oxygen breathing.
    4. It was emphasized that contact must be established with a receiving unit at the commercial flight destination before the evacuation is initiated.
    Quote Originally Posted by Editorial Notes
    Given the title of the workshop and proceedings, the reader who peruses these statements without a full appreciation of the discussion that led to their final wording may be confused by the absence of specific reference to remote locations. During the consensus discussion it became clear that ethical and legal concerns could be minimized if guidelines for important management decisions were applicable irrespective of the patient's location. Care was taken to make this so, and the consensus statements therefore do not specifically refer to DCI in remote locations. It is acknowledged, however, that the environmental and logistic characteristics of a remote location (such as weather, aircraft availability or material condition) may need to be considered in management decisions in the interests of patient safety, irrespective of the guidelines promulgated here.

    The statements are self explanatory, but the reader should note that some of them are heavily qualified with footnotes. These qualifications are non-negotiable components of the meaning of each statement, and the statements should not be quoted without reference to these footnotes. Of particular importance is the strict definition of mild symptoms and signs in Statement 1 and footnotes. All references to "mild" in the subsequent statements are linked back to this definition. It follows that Statements 2–5 should not be quoted without reference to Statement 1.

    Statement 4 is perhaps the pivotal outcome of the workshop. Its intent requires contextual explanation so that the concerns and commentary of the workshop participants are accurately reflected. The statement supports a decision not to recompress for mild symptoms and signs (as defined) after diving where, for example, there is suspicion the symptoms may not be caused by DCI, or where there are logistic or safety reasons to avoid evacuation, such as might exist in a remote location. Statement 4 also reflects the workshop consensus that if the symptoms are due to DCI but they fit the "mild" criteria, then medium to long term disadvantage to the patient is very unlikely if they are not recompressed. This is clearly quite different from a directive that "henceforth, all cases of mild DCI do not require recompression." Statement 4 should not be interpreted in this way. Statement 4 merely notes that some patients are unlikely to be disadvantaged by not being recompressed and provides the treating clinician with options for sensible decision making according to the prevailing circumstances. The word "some" is used intentionally to indicate that it is the clinician’s final decision whom to recompress or not. The statement cannot be generalized to allow treatment funding providers to make funding policy decisions about recompression for all mild DCI.

    A statement acknowledging the practice of in-water recompression was discussed but not included in the proceedings. The rationale for this deletion was the primary workshop focus on mild DCI. In view of the earlier determinations, especially Statement 4, in-water recompression was not an option likely to be pursued for patients whose presentation met the criteria for "mild" DCI signs and symptoms. In-water recompression was endorsed as an option for severe remote DCI management during the evolving clinical problem evolution (see hypothetic problem discussion), but no policy statements were generated. It’s deletion from the consensus statements should not be interpreted as rejection of its utility. The reader is referred to the proceedings of the UHMS in-water recompression workshop for more information (1).

    Similarly, an attempt to provide a consensus statement describing an appropriate time interval between recompression for DCI and flying, usually for the purposes of returning home, was rejected due to insufficient data. There was general agreement that more work is needed in this area.

    References
    1. Kay E, Spencer MP, editors. In-Water Recompression. Proceedings of the 48th Workshop of the Undersea and Hyperbaric Medical Society; 1998 May 24; Seattle. Kensington (MD): Undersea and Hyperbaric Medicine Society; 1999. 108pp.

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    Re: Management of Mild or Marginal Decompression Illness in Remote Locations

    Thank you Gene for posting this. There's a lot to digest and it's a very interesting look into how a group of med proffesionals make recomendations. Were you present and are the editorial notes yours? -Andy

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    Re: Management of Mild or Marginal Decompression Illness in Remote Locations

    Quote Originally Posted by silent running  View Original Post
    Were you present and are the editorial notes yours? -Andy
    I had to miss this one... It was in Australia and I could not get Duke to pay. :) The editorial notes are from the editors of the proceedings. Mitchell SJ, Doolette DJ, Wachholz CJ, Vann RD (eds.). Simon is here quite a bit so I am sure he could answer any questions. The executive summary by David Doolette also offered a good amount of insight.

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