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A Descriptive Study of Decompression Illness

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A Descriptive Study of Decompression Illness ORIGINAL ARTICLE M-JEM Vol. 1 No.1 (2016) A DESCRIPTIVE STUDY OF DECOMPRESSION ILLNESS AMONG SCUBA DIVERS TREATED WITH HYPERBARIC OXYGEN THERAPY AT A MILITARY HOSPITAL-BASED RECOMPRESSION FACILITY IN PENINSULAR MALAYSIA Fazriyati Jamhareea, Abu Yazid Md Noha, Tuan Hairulnizam Tuan Kamauzamana, Ariff Arithra Abdullaha , Junainah Nora aDepartment of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150 Kelantan, Malaysia Correspondence to: Dr. Tuan Hairulnizam Tuan Kamauzaman MBcHB (Leeds) MMed (Emerg) USM Department of Emergency Medicine School of Medical Science Universiti Sains Malaysia 16150 Kubang Kerian Kelantan, Malaysia Email: [email protected] Telephone number: +6 0129875007 Fax number: +6 097673219 11 ORIGINAL ARTICLE M-JEM Vol. 1 No.1 (2016) ABSTRACT Background: Diving related illness has become a public health concern, as there is an increasing number of divers worldwide. However, the incidence of Decompression Illness (DCI), a medical disorder as a result of sudden reduction of ambient pressure, remains generally low. This paper describes the patterns of decompression illness treated in a military hospital-based recompression chamber facility in Peninsular Malaysia from year 2000 until 2010. Objective: The objective of this study is to determine the patterns of decompression illness patients treated with Hyperbaric Oxygen Therapy (HBOT) in a military hospital-based recompression chamber facility in Peninsular Malaysia. Methodology: A retrospective descriptive study was carried out to utilize secondary data from Hospital Angkatan Tentera Lumut, Perak from 1st January 2000 to 31st December 2010. A total of 96 cases were included in this study. Results: Most of the patients were male (94.8%), recreational divers (43.0%), non-smokers (56.3%), with no previous medical illness (85.4%), who had dived with compressed air (78.0%), had less than 5 years diving experience (56.3%), were non-instructors (75.0%), and had body mass index between 18.5 to 24.9 kg/m2 (59.4%). Interestingly, 25% of the patients developing DCI dived to less than 10 meters depth, 35.4% of them went for a single dive and 71.9% performed safety stops. The majority of the patients had symptoms starting within 12 hours after surfacing (85.4%), mainly within the first 3 hours and many had neurological manifestation (61.5%). Only 16.7% of the patients treated with HBOT had therapy commenced within 6 hours from the onset of symptoms and 93.8% from this group had complete recovery. Overall, 76.0% of patients had full recovery after HBOT. Conclusion: Diving activities must be closely monitored. Medical surveillance as well as legislations related to diving activities in Malaysia are essential to improve SCUBA discipline and to reduce mortality and morbidity of DCI in the future. KEYWORDS: Diving, Decompression Illness, Hyperbaric Oxygen Therapy 12 ORIGINAL ARTICLE M-JEM Vol. 1 No.1 (2016) INTRODUCTION Kenyir Lake treated at a state government hospital.6 The divers presented with severe Underwater diving is performed for cardiorespiratory and neurological various reasons including commercial, disturbances, resulting in two deaths, while recreational, military, and scientific the others survived after recompression exploration. Diving related illness has treatment. In addition, there were 21 cases become a public health concern, as there is of DCI treated at the military hospital in an increasing number of divers worldwide. the Royal Malaysian Navy Base in Lumut However, the incidence of Decompression from November 1996 to 1999, also related Illness (DCI) is generally low. DCI is a to underwater logging in Temenggor and term used for medical disorders resulting Kenyir Lakes.7 Underwater logging from decompression from a higher to contributed to 86.2% (n=56) of DCI as lower ambient pressure.1 This causes compared to commercial diving.6 Forty- bubbles formation in the vessels and body seven underwater loggers (83.9%) tissues resulting in ischemia, mechanical presented with Type II DCS with severe damage, or inflammatory derangements.2 neurological involvements and 14 (26.9%) DCI encompasses two disease entities: of them suffered permanent residual Arterial Gas Embolism (AGE) and disability with limbs weakness, paralysis Decompression Sickness (DCS).1, 3 AGE is and bladder dysfunction.8 The aim of this caused by entry of bubbles of gas into the study is to determine the patterns of arterial circulation through a shunt of decompression illness in patients treated patent foramen ovale or resulting from with HBOT in a military hospital in alveolar capillaries rupture following a Peninsular Malaysia from year 2000 until pulmonary barotrauma.1, 4, 5 On the other 2010. hand, DCS is caused by circulating bubbles of inert gas in blood and tissues resulting from super saturation during METHODS decompression as the rate of ambient A retrospective analysis study over pressure reduction that exceeds the rate of a period of 11 years was undertaken based inert gas to be washed out from the 1 on medical records extracted from a tissues. The symptoms vary and the military hospital in Peninsular Malaysia severity of clinical presentations depends from 1st January 2000 to 31st December on the size, number, and location of 3 2010. Only cases that were categorized as bubbles. DCS is typically classified into decompression illness requiring HBOT Type I and Type II DCS. Type I DCS were included in the study. The cases with includes musculoskeletal, cutaneous missing data or medical records were manifestation and constitutional symptoms excluded from analysis. We considered for whereas Type II DCS is characterized by each diver: demographic data (age, gender, neurologic and systemic manifestation BMI, smoking, alcohol consumption, past commonly presented with numbness, medical illness), diving profiles (years of muscle weakness, psychological or motor 1, 2, 4 experience, training level, type of diving abnormalities. The occurrence rate for activities, depth, total dive time, safety DCI in operational open water dive varies stop practice, type of tank, type of dive from 0·01 - 0·019% for recreational either single or repetitive), clinical divers, to 0.095% for commercial divers 1 manifestation (onset of symptoms after and 0.03% for US Navy divers. In surfacing, types of clinical presentations) Malaysia, cases of DCI and its sequelae and treatment (time to treatment from have been reported among occupational onset of the symptoms). Permission to divers. In 1998, there were six cases of conduct the study was obtained from the DCI related to underwater logging in Commanding Officer of the respective 13 ORIGINAL ARTICLE M-JEM Vol. 1 No.1 (2016) military hospital, the Director General of ear disturbance. Minor DCI was the Malaysian Armed Forces Health characterized by skin manifestations, Services Division and Universiti Sains paraesthesia, musculoskeletal pain, Malaysia Human Ethics Committee. abdominal discomfort and constitutional Definitions symptoms. In this study, types of diving activities Statistical analysis were defined as follows; (1) Recreational Data were analysed with statistical diving where divers use SCUBA for software (SPSS, version 22, SPSS Inc., recreational purposes or as a hobby, (2) Chicago, IL USA). Descriptive analysis of Commercial diving when heavy salvaging the demographic and diving related data or engineering work was performed (the were conducted. Results were presented as work might be done deeper than 54 metres frequency (percentage) for categorical and air was usually supplied from the variables and mean (standard deviation) surface to the diver via a hose for longer for numerical variables. duration of diving), (3) Military diving when there was involvement of armed service personnel in salvaging military RESULTS equipment, explosive ordinance disposal, A total number of 175 patients general ship maintenance, clandestine were treated for diving related injuries in diving operations and antiterrorist Hospital Angkatan Tentera Lumut from 8 activities. Incomplete recovery was January 2000 to December 2010. defined as residual symptoms that However, only 96 cases were reviewed in remained permanently after undergoing this study after considering the inclusion series of complete treatment therapy. and exclusion criteria. Figure 1 shows that Safety stop was defined as a compulsory the highest number of DCI requiring pause during ascend to the surface at 3-5 HBOT was in the year 2005 where 17 metres depth for 3-5 minutes for cases were reported and the lowest were decompression requirement during a dive. three cases in year 2003. There was an 2 Severity of DCI was classified based on average of 10 cases of cases of DCI treated symptoms. Major DCI was characterized with HBOT per year. by cognitive impairment, central nervous system dysfunction, visual disturbances, loss of consciousness, amnesia and inner 14 ORIGINAL ARTICLE M-JEM Vol. 1 No.1 (2016) 18 17 16 14 14 12 11 10 9 9 8 8 8 7 Number of Number cases 6 5 5 4 3 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Figure 1 : Total cases of decompression illness (DCI) from year 2000 until 2010 Socio-demography infection prior to the event. Concerning years of experience in diving, 43.8% of Most the divers were recreational divers (n=41, 43%) followed by commercial them had more than 5 years of experience. divers (n=33, 34%) and military divers Most of the divers in the study were non- (n=22, 23%). The majority of the treated instructors (75.0%). divers were male (n=91, 94.8%) (Table 1). The mean (SD) age of the divers was 32 (8.67) years and ranging from 19 to 61 years old. Most divers (59.4%) had BMI less than 25 kg/m². 56.3% (n=54) of the divers were non-smokers. 9.4% of patients consumed alcohol but more than 12 hours prior to the dive whereas the rest of the divers did not consume alcohol at all. The majority of the divers in our study did not have any previous medical history (PMH) (85.4%).
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