The Following are excerpts from the Field Neurological Guide and Workbook by Andrea Zaferes and Walt "Butch" Hendrick Have you ever experienced unexplainable pain,weakness, numbness or tingling? Ever feel dizzy or unusually fatigued.At any point in your life have you experienced confusion, irritability or out-of-character behavior? Was it every annoyingly difficult to urinate or difficult to breathe? If you answered yes to any of these questions, then you have experienced at least some of the same signs and symptoms (s/s) experienced by gas bubble injury patients. Have you every experienced any of the above s/s after a dive? If yes, did you immediately ask for oxygen and activation of EMS? If not, why not? Did it occur to you that you might be experiencing a gas bubble injury or did you decide it was just one of those commonly experienced life annoyances? The 1988 DAN Accident Report provides a very telling quote: "We believe there are as many untreated as treated dive accident victims." DAN is doing a great job to change that, but the problem still exists. Because so many dive accident s/s are similar to commonly experienced problems, they can be easily missed or ignored. Divers too often ignore s/s completely, or they wait many hours or even days before telling themselves or anyone something may be wrong. To compound the problem, divers, dive leaders, EMS and hospital emergency department staff are not routinely taught an effective evaluation process to make a decision regarding whether or not the potential of a dive accident exists. A field neurological evaluation is an examination used to assist first responders, dive leaders and divers themselves in discovering s/s presenting in potential dive accident patient/victims. FNE results provide a basis for saying there is no evidence of a problem, potential s/s are present, or yes, there definitely is a problem.
The difference between a FNE and a secondary survey
A FNE is different than a standard secondary survey taught in first aid and EMS programs because it searches for more subtle neurological and behavioral abnormalities. A secondary survey typically searches for trauma, medical emergencies and more obvious neurological problems.
For example, a standard secondary survey checks hand grip strength and perhaps sensation of a finger or two. A FNE checks the sensation of three fingers on each hand to check functioning of cervical sensory nerves 6 to 8, checks grip strength, checks the fingers ability to remain spread upon inward resistance, checks the fingers ability to remain straight forward upon downward resistance, ... etc.
A lay person secondary survey checks the neck for possible cervical injury and other trauma. A FNE checks more closely for tracheal deviation, subcutaneous swellings, full neck swelling, distended neck veins, swallowing difficulties and loss of sensation.
Secondary surveys focus more on discovering internal and external trauma than do FNE's. Secondary surveys palpate the four abdominal quadrants and each limb checking for pain. Palpation in a FNE checks more for a loss or change of sensation than for pain. A FNE palpates many more areas, looking for more subtle, localized CNS and peripheral sensory and motor neurological problems.
FNE's are conducted repetitively to record problem progression, while complete secondary surveys are typically only performed once and are followed by the monitoring of vitals and any problem(s) found.
Is a FNE solely designed for dive accident situations?
Although this Manual refers to patients/victims of dive accidents, communication with past students demonstrates that the FNE is useful in a variety of applications including potential spinal injury, cerebral cardiovascular accident, head injury, and hypoxia situations found in both diving and non-diving situations. Repetitive FNE's are often an excellent method of keeping a patient occupied on something other than the problem while waiting for help to arrive or while enroute to the hospital.
FNE's can also be used to keep baseline records of dive members on public safety dive teams, scientific teams and commercial dive sites. Lifeguard Systems' instructors, for example, have discovered hearing loss problems, asymmetrical muscle strength, ... etc., that were unknown to the individual being demonstrated on during FNE training programs. The personal and team knowledge of such findings, along with perhaps a written record, could be helpful during the management of a potential dive accident situation of these same individuals.
When are FNE's performed and by whom?
1. FNEs can be conducted on site immediately upon discovery of a possible physical or behavioral s/s presentation.
2. They can be performed when a diver is discovered to be at risk of a potential dive accident because of a missed decompression stop, rapid ascent, computer failure, ...etc.
3. FNE's can be used to decide whether or not first aid oxygen administration and activation of EMS are warranted.
4. They can be conducted during first aid oxygen administration to record s/s progression at early and later stages of increased arterial and tissue oxygen partial pressures.
5. They can be part of a routine check-up procedure for working divers to have a baseline evaluation on file.
FNEs can decrease a delay in treatment by decreasing the latency for s/s recognition. For example, a woman experience vomiting, weakness, and a general feeling of being unwell was sent to her hotel room by her instructor husband after a dive to "rest up" while he went out to dinner. When he returned she was incontinent, and paralyzed from the waist down. If a dive leader had performed a field neurological on her after the dive they may have found lower extremity weakness and other DCS indications, thereby showing the husband there was more to it than exhaustion and sea sickness.
For example, upon superficial examination, a diver may present distressed breathing, which could have a variety of serious and not as serious causes. In some locations an EMT, BLS (basic lifesupport) ambulance would be dispateched instead of an ALS (advanced Lifesupport) rig. In less than thirty seconds a FNE of the same patient could discover shallow breathing, pain upon inspiration, slightly uneven chest rise, and a slight tracheal deviation. Such a report would far more likely result in immediate ALS (advanced life support) paramedic dispatch since a potential tension pneumothorax was probably described. Unlike an EMT, many paramedics can begin treating the problem enroute to the hospital.
While waiting for more advanced medical help, a FNE should be conducted every 15-20 minutes with proper records maintained to note if the s/s are worsening, stabilizing or seemingly improving. Conduct a second field neurological 10-15 minutes after oxygen administration has begun to note specific changes. If oxygen appears to relieve s/s then the possibility of the decompression illness is increased.
Anyone with the necessary knowledge and record keeping capability can perform a FNE. The information obtained from the FNE is used to help decide the next steps to take in the basic life support, first aid treatment and possibly the clinical treatment of the needy diver. Remember that aside from chest radiographs for possible lung overexpansion injuries and skull radiographs for gross pockets of air in the skull, there are no diagnostic tests, other than neurological examinations, to diagnose DCI. Neurological examinations are performed by hyperbaric physicians to determine whether hyperbaric treatment is dictated. Such examinations are also performed during multiplace chamber hyperbaric tests of pressure and treatment to discover patient progress.
If the patient is conscious, either a sitting or lying position can be used depending on the situation. If the needy diver is unconscious and breathing, or is in need of basic life support, there is a priority change and rescue breathing/CPR and/or oxygen should be administered immediately as dictated.
FNEs are used to assist the rescuer in recognizing abnormalities in:
· Level of Consciousness
· Sensation , Dexterity and Strength
· and other Neurological Functions
to decide the appropriate first aid treatment.
YOU MUST LEARN:
WHEN IN DOUBT, TREAT AS A DIVE ACCIDENT AND ADMINISTER OXYGEN !
When a FNE is conducted in a dive accident situation and there is any doubt of what the problem is, always assume and act as if the problem is decompression illness. Administer high flow oxygen and notify EMS and the receiving hospital that recompression treatment may be indicated. DAN and/or a local hyperbaric facility diving hotline can be called to help answer questions, and should be contacted by the receiving hospital.
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