The Five-Minute Neurological Exam: don’t leave home without it!

I was somewhat surprised to learn that although the majority of technical divers believe in the value of the simple neurological exam — taught to students during decompression courses to identify signs of potential DCS — few carry a printed copy (or pdf on their phone or tablet) with them on their dives.

What follows is ONE of several versions that exist.  I use it because it seems the most comprehensive and straightforward. Regardless of if you opt to use this or another, remember to record the results, and in particular to note any abnormalities. If a dive buddy is evacuated for evaluation at a hyperbaric facility or even a hospital emergency department, sending a notarized copy of this with them may help them get treated more rapidly.

There are NINE test categories… #  1, 7 and 9 are key.

1. Orientation (these may sound facile but they may indicate real confusion in a otherwise normal-looking victim… do not omit them).

  • Ask diver for full name and age
  • Ask diver to state present location
  • Ask diver what time it is, what day of the week, the date and month

2. Eyes / Vision

  • Ask diver to count the number of fingers you display (do this several times using different numbers)
  • Check eyes together and then separately
  • Ask the diver to describe a distant object… something several metres (yards) away at least
  • Have diver follow your clenched fist with his/her eyes as you move it up, down, left and right in front of their face. Have them hold their head still and check that their eyes follow your movements smoothly
  • Check both pupils are equal in size

3. Face (muscles and nerves)

  • Ask the diver to smile and check there is symmetry in their expression
  • Have the diver whistle. Watch the “pucker”. Note any drooping of lips.
  • Have the diver close their mouth tightly and feel that their jaw muscles are equally tight
  • With their eyes closed, stroke the diver’s face, forehead and neck and ask them to describe the sensation. It should be similar

4. Hearing

  • Check hearing by rubbing your thumb and forefinger together with the diver’s eyes closed. See how close the fingers have to be to be audible.

Note: If the surroundings are noisy, ask bystanders to be quiet and have noisy machinery turned off if possible.

5. Swallowing Reflex

  • Have the diver take a sip of water and watch their “Adam’s apple” as they swallow to be sure it moves up and down

6. Tongue

  • Have the diver stick out their tongue. Note if it droops, moves to one side or other abnormal movements.

7. Muscle Strength

  • Place your hands firmly on the diver’s shoulders, have them “shrug”. Note if there is any difference in strength
  • Have the diver squeeze your fingers with both hands at the same time, notice any difference in strength. Have the diver hold his hands together at chest level and elbows high. Gently push and pull the elbows while the diver resists the movement. Notice any difference in strength
  • Check leg strength by having the diver lie flat and raise and lower the legs while you resist the movement

8. Sensory Perception

  • Check the diver’s ability to feel you touching them lightly starting at their shoulders and working down to cover their entire body. Compare degree of response on each side. The diver’s eyes should be closed while this is done.

9. Balance and Coordination

Note: Be prepared to protect the diver from injury when performing this test.

  • If possible, have the diver walk heel to toe and check balance and coordination. Make sure the diver does not fall!
  • Have the diver stand with feet together and eyes closed. Ask them to hold their arms straight out, and hold that position for half a minute at least. Be ready to catch them if they lose their balance or fall.

After the exam…

The diver’s condition or the environment may prevent you conducting one or more of these tests. Record any omitted test and the reason.

A cycle of tests should be repeated at 30- to 60-minute intervals while awaiting assistance in order to determine if any change occurs. Report the results to the emergency medical personnel responding to the call.

If there is a delay getting to a suitable recompression facility, repeat the test hourly.


5 thoughts on “The Five-Minute Neurological Exam: don’t leave home without it!

  1. As usual, great article Steve. One minor error in #5. It should read ‘watch their Adam’s apple”‘ rather than ‘what their Adam’s apple”‘

    Would it be significant if only one of the three key tests failed? The reason I ask is because on my last dive I got an ear infection and it threw off my balance. So #9 would have been a fail but #1 and #7 would have been a pass for me.

  2. Thanks Darrell. Corrected the typo.

    # 9 is a tough call because some folks have issues with that one on a boat to begin with. In your case, the infection would have been pre-existing, correct? That should be noted on the report.

    Worth bearing in mind that few of us are qualified to make a medical assessment based on the results of this examination… all that’s expected is to pass the information along to the Medical Team who WILL make the call: “Yep, this punter is bent!”

    • The infection wasn’t known at the time. I didn’t realize I had a sinus/ear infection until my wife accessed me.

      I finished the dive with a rash. I assume I got a rash diving near the Humber after a heavy rain fall but everyone thought I might be skin bent. In the end, assumed I was okay but let my wife know since she would be with me for the next 24 hours.

      If the rash didn’t go away or other symptoms appeared I would have had her call 911 and tell them I’m a scuba diver. My wife is very medically knowledgeable. If I didn’t have her I probably would have gotten medical help.

      I think these tests are better than nothing or wild guesses but I can see how you still have to make a judgement call, even with these tests.

      For example, you ask me what time it is, what day it is, etc. I don’t have a clue. If you asked me my age I’d have to think about it. You ask me what time and date I was born and I can tell you to the minute. It is the fact I never pay attention to the current time and date that makes it hard for me to know things like how old I am. However, if you give me the current time and date I can tell you how old I am.

      I used to race motorcycles. My left hand (clutch) was notably stronger than my right hand for grip strength. So #7 would throw many people off. I actually confused physiotherapists when I’d tell them I was right handed.

      Maybe it should also be added that if someone fails one of these tests, ask them if they know why they failed. Why’d I fail #7? I’d have an answer. Why’d I fail #9? I don’t know. Assume I’m bent and call for help (just thinking out loud).

      • Thanks for the comment. Interesting points, however, very important to note that while doing a five-minute exam, we ARE NOT making an assessment. We are neither equipped nor are we qualified to do so. We are simply making observations and taking notes… nothing more.

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