DAN has become aware of several instances in which non-U.S. medical providers subjected injured divers to medically unnecessary diagnostic testing before administering definitive care. Such testing involves procedures that deviate from widely accepted standards of practice, do not contribute useful information to guide treatment decisions, involve some risk to the patient, delay urgent treatment needs, and increase the overall cost of care. Research addressing why medically unnecessary procedures are performed identified several factors; common among them were motivation for financial gain in a fee-for-service payment environment, medical oversight problems, poor medical problem solving, and a corrupt moral climate (DuBois JM, et al. 2017). For decompression illness, the primary means of diagnosis are the patient’s report of the incident and the events preceding it along with a physical examination (including a comprehensive neurologic exam).
One example of a medically unnecessary test is a “bubble study” (Doppler or transthoracic echocardiogram [TTE]) as part of the diagnostic process for decompression illness (DCI). While circulating bubbles (venous gas emboli [VGE]) following diving is a well-known and commonly observed phenomenon of decompression physiology, the bubbles’ role in the genesis of decompression sickness (DCS) is the subject of ongoing research. Researchers have found that VGE are often present in the absence of signs or symptoms of decompression sickness, so it is widely accepted that the presence of bubbles following diving does not represent a diagnosis of DCS but simply serves as an indication of the degree of “decompression stress.” DCS may occur in the presence or absence of VGE. A bubble contrast study involves the use of ultrasound technology to identify a patent foramen ovale (PFO), a known DCS risk factor. However, a bubble study serves no useful purpose in the management of an acute injury and may delay urgently needed medical care. Sadly, some unscrupulous medical providers use these studies routinely, knowing that the almost guaranteed presence of bubbles will persuade divers that recompression therapy is necessary.
Another recent example of a medically unnecessary procedure involved computed tomography (CT) scanning. The diver in question was diagnosed with “severe decompression illness requiring immediate recompression.” However, CT scans of the skull, thorax, and abdomen were ordered anyway. The results of these scans were not available before recompression commenced, were not used in the diagnosis or treatment decisions, and delayed the needed recompression therapy. There are certainly instances in which one might expect advanced imaging such as CT or MRI to be employed if a plausible, non-diving-related medical condition is indicated.
Divers need to know that charges for the types of studies described above are generally not reimbursable under dive accident plans offered by DAN or other carriers. If a question of coverage arises, DAN seeks a second opinion from a third-party panel of experienced board-certified diving medical officers to assist with claims adjudication.
If you have symptoms after a dive, are being considered for recompression therapy, and have any concerns or questions about your care, please call the DAN Emergency Hotline (+1-919-684-9111) for expert information for both you and the physician team caring for you. In areas where these sorts of questionable practices have been identified, DAN has partnered with the most reputable local service providers and incorporated them as part of DAN’s Preferred Provider Network (PPN) to ensure our members receive the care they need and will not face charges for unnecessary and uncovered tests or diagnostic procedures.