A 34-year-old man in a wet neoprene suit is hauled onto the dock with salt drying white on his lips and a grimace locked across his jaw. He keeps pointing to his shoulder and chest, where the pain seemed to arrive almost before he did. The dive master says he surfaced “too fast,” then got confused on the boat and now says his left arm feels weak. The tank is on the deck, the logbook still open, and no one has yet decided whether this is just barotrauma.
— What’s your move? Read on.
Before you read
- What is the one call that changes disposition for suspected decompression illness?
- Which symptoms require you to think beyond the lungs and ears?
When to Think of It
Any post-dive patient with neurologic symptoms, chest pain, dyspnea, severe joint pain, or abnormal behavior after a rapid ascent, breath-holding, equipment malfunction, or missed decompression stop. Think of decompression sickness, arterial gas embolism, pulmonary barotrauma, and immersion pulmonary edema when the story comes from the water.
Sick or Not Sick
The single fork: Is there neurologic involvement or arterial gas embolism concern? If yes, treat as time-sensitive hyperbaric emergency; if no and symptoms are mild and isolated, evaluate for barotrauma and other mimics, but don’t dismiss the dive history.
The First Fifteen Minutes
- Remove from water, give 100% oxygen by nonrebreather mask at 15 L/min now when any dive-related injury is suspected, because it improves inert gas washout and supports ischemic tissues.
- If hypoxic or tiring, escalate to bag-valve-mask ventilation or intubation with lung-protective settings; avoid aggressive positive pressure if pulmonary barotrauma is possible, because it can worsen pneumothorax or gas embolism.
- If hypotensive after suspected arterial gas embolism or severe barotrauma, give isotonic crystalloid 1–2 L IV as needed, because volume supports perfusion in a potentially ischemic insult.
- If seizure occurs, give lorazepam 2 mg IV, repeat once as needed because benzodiazepines abort convulsions while oxygenation is restored.
- If tension pneumothorax is suspected clinically, perform immediate needle decompression or tube thoracostomy without waiting for imaging, because positive-pressure expansion of trapped pleural air can be fatal.
- Avoid nitrous oxide and unnecessary air transport if hyperbaric capability is available on the ground; nitrous expands closed gas spaces, and altitude can worsen bubble expansion.
Definitive Care & Disposition
Consult a hyperbaric medicine center early for any suspected decompression sickness, arterial gas embolism, or significant neurologic symptoms; recompression is the definitive therapy. Obtain chest imaging if barotrauma is suspected, but do not delay oxygen and consultation. Admit most symptomatic patients; ICU if altered, hypoxic, hemodynamically unstable, or with pulmonary/neurologic complications. Mild isolated ear/sinus barotrauma may be discharged with strict return precautions and dive restriction after evaluation.
How This One Kills
The killer miss is labeling an arterial gas embolism or neurologic decompression illness as “ear barotrauma” or “post-dive fatigue,” then delaying recompression while bubbles continue to injure the brain and spinal cord.
The Differential — What Else Looks Like This
- Benign post-dive musculoskeletal pain — lacks neurologic findings, chest symptoms, or dive-profile red flags; confusing it with decompression illness can cost the patient the hyperbaric window.
- Acute coronary syndrome — chest pain may overlap, but the dive history plus concurrent neuro symptoms or pulmonary signs should pull you away from a primary cardiac explanation.
- Stroke — focal deficits can look identical, but the temporal link to ascent and possible coexisting joint pain/chest symptoms points toward gas embolism until proven otherwise.
- Anxiety/panic — hyperventilation and distress can accompany serious dive injury; missing the physiologic cause delays oxygen and recompression.
The Second-Day Story
Older divers, patients with alcohol on board, or those who surfaced hours earlier may present with vague fatigue, shoulder ache, subtle confusion, or “just not feeling right” rather than the textbook neuro collapse. Repeat the dive history carefully: depth, bottom time, ascent rate, missed stops, repetitive dives, flying after diving, and breath-holding events. Any unexplained neurologic or cardiopulmonary complaint after diving should keep decompression sickness and arterial gas embolism on the table.
Back to Our Patient
Back to our patient: the 34-year-old in the neoprene suit has chest pain, shoulder pain, and new confusion after surfacing too fast, which puts decompression illness and arterial gas embolism high on the list. He gets 100% oxygen immediately, a focused neuro exam, chest evaluation for barotrauma, and urgent hyperbaric consultation while you assess for pneumothorax and hemodynamic instability. Because he has neurologic symptoms after a rapid ascent, he is treated as a hyperbaric emergency rather than simple ear pain. He is admitted and transferred for recompression therapy.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“34-year-old man with chest and shoulder pain plus confusion after scuba diving, surfaced rapidly and then became altered on the boat. He has no preceding trauma, no fever, and no clear cardiac history; the key positive is neurologic change after a dive, with chest discomfort raising concern for pulmonary barotrauma or arterial gas embolism. On exam he’s mildly disoriented, oxygen saturation is low-normal on room air, lungs are clear without obvious unilateral absent breath sounds, and he has shoulder tenderness without deformity. I’m giving 100% oxygen now, checking for pneumothorax and focal deficits, and I’ve called hyperbarics because this is concerning for decompression illness/arterial gas embolism. He needs close monitoring and likely recompression.”
Study Directive
- Draw a 3-column comparison from memory: decompression sickness vs arterial gas embolism vs pulmonary barotrauma.
- Drill the “dive history five”: depth, time, ascent rate, missed stops, repetitive dives/flying.
- Practice a 30-second neuro exam for post-dive patients and identify the findings that trigger hyperbaric consultation.
- Review the contraindications/risks of air transport and nitrous oxide in suspected gas-related injury.
Recent Literature
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Review or guideline Underwater and Scuba Diving Accidents
A current EM-focused overview of scuba and underwater emergencies, useful for bedside recognition of barotrauma, decompression illness, arterial gas embolism, oxygen toxicity, and when to give high-flow oxygen and arrange hyperbaric consult