Problems of a preclinical treatment algorithm for diving accidents: analysis of the Swiss hyperbaric situation.

Following recent changes in the medical infrastructure in Switzerland, the number of hyperbaric facilities fell from ten to two, and the existing algorithms for telemedical assistance of divers required review. A retrospective study of decompression illness (DCI) from 2004 to 2008 showed that many divers were asymptomatic at the start of hyperbaric treatment. Because of this and recent publications, we may need to modify in the future the decision to recompress a diver. The descriptive nomenclature for DCI was used to determine the probability that symptoms represent DCI. Secondly we evaluated the probability that symptoms may be due to other pathologies or of psychosomatic origin, and thirdly the potential of symptoms for sequelae and their degree of invalidism was estimated. This process will result in one of three therapeutic decisions. An absolute indication for hospital-based hyperbaric treatment. Immediate recompression if available or normobaric oxygen (NBO) with telemedical supervision and adequate monitoring; in exceptional situations, on-site chamber recompression or in-water recompression may be considered. NBO as a preventive measure for two hours and 'bends watch' for 24 h. A prospective study should confirm evidence of good treatment practice. The key for further improvements will be to better understand ambiguous symptoms and to differentiate so-called 'mild' neurological symptoms. As a consequence of the reduction in hyperbaric facilities, longer transfer and treatment delays have resulted. Therefore, there is a need for careful evaluation of the indications for hyperbaric treatment of injured divers and also of the need to install on-site chambers for professional diving operations.