Diagnostic Assessment — Right Barotrauma
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Barotrauma BOP Code: 87 of 2020 (Otitic Barotrauma) RH Code: 86 of 2020 (Otitic Barotrauma)
ADF History
The veteran, date of birth [withheld], Royal Australian Air Force, Supply Operator, 22 July 1980 to 8 May 1987
History
As per Left Barotrauma.
The veteran experienced right barotrauma during ADF service due to occupational exposure to pressure changes during naval service.
On 5 March 1982, aboard a support squadron, he was diagnosed with middle ear barotrauma after diving on SCUBA, recorded as Grade 1 on the right and Grade 3 on the left.
He had had trouble with Valsalva while diving on the tide pole two days earlier, Valsalva was painful, and he was treated with Panadine and made unfit to dive.
1 3.
As per Left Barotrauma above, applied to right side.
Right Barotrauma (ICD-10: T70.0XXA).
First documented symptoms were trouble with Valsalva while diving on the tide pole about 3 March 1982; first presentation and clinical diagnosis on 5 March 1982 aboard a support squadron (middle ear barotrauma, Grade 1 on the right and Grade 3 on the left, after diving on SCUBA).
DRCA legislation.
100% service-related
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 19 October 2000 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Otitic Barotrauma, No.
87 of 2020) Factor 9(1): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical onset of otitic barotrauma — MET - The Daily Medical Record made aboard the survey ship a support squadron on 5 March 1982 records that about 3 March 1982 the veteran had been diving on the tide pole (snorkel only) and had trouble equalising his ears by the Valsalva manoeuvre.
Underwater diving is listed in the definition of a change in ambient barometric pressure as specified, and the largest proportional pressure changes occur in the first few metres of descent.
The pressure change occurred during the dive in which the difficulty arose, within the 24 hours before the clinical onset of his right otitic barotrauma; if the onset were instead taken as 5 March 1982, that day's SCUBA dive would equally satisfy the factor.
Factor 9(2): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike in the 24 hours before about 3 March 1982; the injury arose while diving.
Factor 9(3): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of mechanical ventilation, anaesthesia or CPAP in the 24 hours before about 3 March 1982; he was diving with a snorkel only.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Otitic Barotrauma, No.
86 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical onset of otitic barotrauma — MET - About 3 March 1982, while serving aboard the survey ship a support squadron, the veteran was diving on the tide pole (snorkel only) and had trouble equalising his ears, as recorded in the Daily Medical Record of 5 March 1982.
Underwater diving is a change in ambient barometric pressure as specified, and it occurred during the dive in which the right ear injury began, within the 24 hours before the clinical onset.
Factor 9(2): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike in the 24 hours before about 3 March 1982; the injury arose while diving.
Factor 9(3): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical onset of otitic barotrauma — NOT MET - There is no record of mechanical ventilation, anaesthesia or CPAP in the 24 hours before about 3 March 1982; he was diving with a snorkel only.
Other Plausible Links to Service The injury arose out of, and in the course of, the veteran's employment as a member.
A tide pole is a graduated staff fixed in the water to record the height of the tide during a Supply Operator, and diving on it was a surveying task carried out from the survey ship a support squadron, in which he was serving.
The ship had arranged his diving medical in January 1982 (chest X-ray and audiogram of 5 January 1982), which shows that diving formed part of his duties in that ship, and the SCUBA dive of 5 March 1982 was also made while he was serving aboard.
Service also aggravated the injury.
After first having trouble equalising, he dived again on SCUBA two days later, before any medical assessment, and the right ear was found to have a Grade 1 injury, with a Grade 3 injury on the left and frontal sinus barotrauma, after which the ship's medical sailor made him unfit to dive.
Both the injury and its aggravation came from pressure exposures encountered while he was serving in the ship, and no cause unrelated to service is identified; his chronic paranasal sinus disease was first shown on imaging in June 2005, more than 23 years later.
Conclusion the veteran's right otitic barotrauma was caused by diving in the course of his duties as a Supply Operator aboard a support squadron: he had trouble equalising while diving on the tide pole about 3 March 1982, and a further SCUBA dive two days later, before any medical assessment, produced a Grade 1 injury of the right middle ear, with Grade 3 on the left and frontal sinus barotrauma.
The change in ambient barometric pressure factors are met for both clinical onset and clinical worsening, and no cause unrelated to service is identified.
The injury therefore arose out of, and in the course of, his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right otitic barotrauma is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (about 3 March 1982) aggravated it or contributed to it in a material degree.
The Daily Medical Record of 5 March 1982 records a Grade 1 injury of the right middle ear after a further dive on SCUBA, two days after he first had trouble equalising.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Otitic Barotrauma, No.
87 of 2020) Factor 9(4): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical worsening of otitic barotrauma — MET - Two days after first having trouble equalising, and before any medical assessment, the veteran dived on SCUBA while serving aboard a support squadron on 5 March 1982.
That day's Daily Medical Record found the Valsalva manoeuvre painful, graded the right middle- ear barotrauma as Grade 1 (on the standard grading, congestion of the eardrum, the mildest visible grade), with Grade 3 on the left and frontal sinus barotrauma, and made him unfit to dive.
SCUBA diving is a change in ambient barometric pressure as specified; it occurred within the 24 hours before this clinical worsening, in which the right ear, already failing to equalise, sustained a further, if mild, injury.
Factor 9(5): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike before any clinical worsening of his right otitic barotrauma; the worsening on 5 March 1982 followed diving.
Factor 9(6): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - Breathing from a SCUBA demand regulator on 5 March 1982 is not mechanical ventilation, and no ear symptoms were recorded after his operations under anaesthesia in 1982 to 1984 or with any later CPAP use.
Factor 9(7): inability to obtain appropriate clinical management for otitic barotrauma — NOT MET - the veteran was assessed aboard a support squadron on 5 March 1982, the day he reported the injury, and received the essential management (removal from diving, analgesia and daily review); it resolved, with normal hearing in December 1983 and at discharge and a positive Valsalva manoeuvre in both ears on 8 May 1987.
Although at sea he was treated by the ship's medical sailor rather than a medical officer, applying the objective and subjective test in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence that he was unable to obtain appropriate management or that this worsened the injury.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Otitic Barotrauma, No.
86 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(4): experiencing a change in ambient barometric pressure as specified within the 24 hours before the clinical worsening of otitic barotrauma — MET - On 5 March 1982, two days after first having trouble equalising and before any medical assessment, the veteran dived on SCUBA while serving aboard a support squadron; the same day the right middle-ear barotrauma was recorded as Grade 1, with a painful Valsalva manoeuvre, and he was made unfit to dive.
The SCUBA dive was a change in ambient barometric pressure as specified within the 24 hours before this clinical worsening.
Factor 9(5): being exposed to blast pressure from an explosion or lightning strike within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - There is no record of exposure to blast from an explosion or a lightning strike before any clinical worsening of his right otitic barotrauma; the worsening on 5 March 1982 followed diving.
Factor 9(6): receiving mechanical ventilation involving a face mask within the 24 hours before the clinical worsening of otitic barotrauma — NOT MET - Breathing from a SCUBA demand regulator on 5 March 1982 is not mechanical ventilation, and no ear symptoms were recorded after his operations under anaesthesia in 1982 to 1984 or with any later CPAP use.
Factor 9(7): inability to obtain appropriate clinical management for otitic barotrauma — NOT MET - the veteran was assessed aboard a support squadron on 5 March 1982, the day he reported the injury, and received the essential management (removal from diving, analgesia and daily review); it resolved, with normal hearing in December 1983 and at discharge and a positive Valsalva manoeuvre in both ears on 8 May 1987.
Although at sea he was treated by the ship's medical sailor rather than a medical officer, applying the objective and subjective test in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there is no evidence that he was unable to obtain appropriate management or that this worsened the injury
Sequelae, Unintended Consequence, Inability
No sequelae are documented, and the injury is not an unintended consequence of medical treatment.
Inability to obtain appropriate clinical management: NOT MET.
The veteran was assessed aboard a support squadron on 5 March 1982, the day he reported the injury, and was made unfit to dive, given analgesia and placed on daily review; the injury resolved, with normal hearing in December 1983 and a positive Valsalva manoeuvre in both ears at discharge.
The loss of his medical record at a support squadron in June 1986 occurred more than four years later and did not affect his management
Date of Clinical Onset
Right barotrauma is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 3 March 1982 — difficulty equalising (Valsalva) whilst diving on the tide pole, with middle ear barotrauma (Grade 1 right, Grade 3 left) diagnosed aboard a support squadron on 5 March 1982 [CHART REVIEW document].
Date of clinical onset: approximately 3 March 1982.
This date falls within the veteran's ADF service (22 July 1980 8 May 1987).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
