Abstract: At approximately 4:00 p.m. on April 25, 1999, Employee #1 was treating a diver suffering from what was thought to be symptoms of the bends (decompression sickness). A back-up team consisting of a medical doctor, two registered nurses, and a technician, were also present. The patient was assessed and placed in a hyperbaric chamber, where Employee #1 was assigned to attend the patient. The chamber pressure was increased to 65 ft for about 25 minutes. The patient continued to experience sharp pains and the doctor ordered compression to 165 ft, with a slow descent of about 35 minutes and then remaining there for a period of time. Employee #1 reported feeling the effects of nitrogen narcosis while at 165 ft, and the depth was reduced and held at 65 ft for about 25 minutes. At that point Employee #1 was no longer needed in the chamber and she was decompressed to sea level without stopping at any intermediate depths. Shortly thereafter, she began to experience a sensation of heat and itching, like a skin rash. Employee #1 felt short of breath and thought she might be having an asthma attack, so she initiated treatment with her asthma reaction kit and epinephrine. When she began to have abdominal cramping, decompression sickness was strongly suspected and Employee #1 was returned to the chamber. By this time she had lost sensation in her lower and upper extremities. According to her medical records, Employee #1 presented the signs of catastrophic spinal cord injury which, given her exposure to depth in the decompression chamber, was likely due to massive nitrogen saturation. The cumulative effect of her time in the hyperbaric chamber, and at different depths, required that she receive oxygen and take stops during decompression to achieve adequate nitrogen desaturation. At the time this report was prepared, Employee #1 continued to be treated for paraplegia. The employer was cited for two serious accident-related violations: one for an ineffective communication system on matters of occupational safety and health, and one for ineffective training of employees in the hyperbaric unit.