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(Q) 05.22.11; Skin bends?
Dear DocVikingo,
I've had two incidents now that DAN can't confirm as DCI but which I'm certain are. The first was after a 190' dive in Cozumel in January. The dive was completed according to plan and without incident. Upon getting back on the boat my wetsuit felt tight on my upper arms. My arm also felt sunburned. Later I noted my right upper arm was very swollen and felt bruised. I did not associate it with the dive at the time and completed 3 more decompression dives during the next five days. No change in my arm during or after the dives. I called DAN when I returned home and was told this was not DCI. The swelling eventually subsided.
Friday I did a 200' dive in Carmel, CA. Again the dive was completed according to plan and without incident. I believe I was dehydrated at the start of the dive, and during the dive I shot the bag and reeled up it. It's not my best skill and I worked a bit hard at it. Once on the boat I felt a tightness in my left arm. Later I noticed both my right and left arms were quite swollen from the upper arm all the way down through my forearms. The skin feels sunburned and bruised, but looks normal. I breathed O2 for about and hour and a half when I got home with no change in symptoms. I called DAN again and they said again, that it didn't sound like DCI. In looking at descriptions on the internet though, it does sound like skin bends. DAN recommended a local Dr who I plan to make an apt with for an evaluation. It is now Monday and my arms are still swollen. I did two recreational dives on Saturday with no change in symptoms. Does this sound like DCI to you?
(A) 05.23.11
Hi c ,
Sorry to hear about these incidents. Surely theyre worrisome and unpleasant.
These dive profiles certainly are aggressive enough to form an inert gas loading sufficient to trigger an event of DCI.
Descriptions such as, "My arm also felt sunburned. Later I noted my right upper arm was very swollen and felt bruised." And, "...a tightness in my left arm. Later I noticed both my right and left arms were quite swollen from the upper arm all the way down through my forearms. The skin feels sunburned and bruised, but looks normal," would be an unusual presentation for DCI, although there is a relatively rare form of it that may manifest with such a picture.
You asked about "skin bends." Cutaneous DCS proper most commonly presents with a marbling/mottling of the skin (cutis marmorata) and itchiness (usually intense itchiness, but not always). It is most commonly, but not exclusively, seen on the torso and shoulders. Swelling of the upper extremities and a feeling of being bruised without evidence of discoloration are not consistent with the common usage of the term skin bends.
However, an unusual but kindred form of Type I DCI, known as lymphatic DCI, can occur when inert gas bubbles lodge in a lymphatic vessel and cause swelling under the skin. The swollen area(s) hold an indentation for a few moments when depressed (pitting edema). Also, typical is a peculiar pitting of the skin over the affected area, similar to the skin of an orange (known as peau d' orange). Lymphatic DCI may be without pain or accompanied by the sensation of being bruised. This sort of DCI most often involves the extremities, but I have been involved in several cases in which the breast(s) was affected. All of the later involved considerable soreness.
It usually clears on its own without permanent residuals, but does respond to timely recompression treatment. Be aware that resolution may take an extended period of time.
Preventive strategies involve the usual--conservative profiles, very gradual ascents, full completion of deco obligations/safety stops, use of EAN, maintaining excellent hydration, avoiding vigorous work/activity during or after a dive, etc.
It would be prudent to contact a hyperbaric/diving medicine specialist for evaluation of these incidents. To the best my admittedly limited knowledge, it would be very unusual for a healthy diver with normal cardiac status to sustain two such events. Amongst other things, the possibility of PFO should be ruled out.
In the meantime, the diver with such a complaint will want to insure that: thermal protection and BC/backplate fit properly and do not bind on or constrict the body in the area of the arms and shoulders; less than graceful handling of lift bags at depth is not causing some mechanical injury to the arms; and diving profiles are far more conservative than those described in this inquiry.
Regards,
DocVikingo
This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such.
Follow up from inquirer dated 05.25.11: Thanks for your insight! I did follow up with a hyperbaric doc locally who spoke to the medical director at DAN. I went in for a consultation and it was not skin bends, but lymphatic DCI. Apparently that's pretty rare, but not unheard of. We did a chamber treatment, but mostly as an experiment. Since the dive was days ago, the improvement would not be as dramatic. It did appear to help though. I will be undergoing further evaluation.
Dear DocVikingo,
I've had two incidents now that DAN can't confirm as DCI but which I'm certain are. The first was after a 190' dive in Cozumel in January. The dive was completed according to plan and without incident. Upon getting back on the boat my wetsuit felt tight on my upper arms. My arm also felt sunburned. Later I noted my right upper arm was very swollen and felt bruised. I did not associate it with the dive at the time and completed 3 more decompression dives during the next five days. No change in my arm during or after the dives. I called DAN when I returned home and was told this was not DCI. The swelling eventually subsided.
Friday I did a 200' dive in Carmel, CA. Again the dive was completed according to plan and without incident. I believe I was dehydrated at the start of the dive, and during the dive I shot the bag and reeled up it. It's not my best skill and I worked a bit hard at it. Once on the boat I felt a tightness in my left arm. Later I noticed both my right and left arms were quite swollen from the upper arm all the way down through my forearms. The skin feels sunburned and bruised, but looks normal. I breathed O2 for about and hour and a half when I got home with no change in symptoms. I called DAN again and they said again, that it didn't sound like DCI. In looking at descriptions on the internet though, it does sound like skin bends. DAN recommended a local Dr who I plan to make an apt with for an evaluation. It is now Monday and my arms are still swollen. I did two recreational dives on Saturday with no change in symptoms. Does this sound like DCI to you?
(A) 05.23.11
Hi c ,
Sorry to hear about these incidents. Surely theyre worrisome and unpleasant.
These dive profiles certainly are aggressive enough to form an inert gas loading sufficient to trigger an event of DCI.
Descriptions such as, "My arm also felt sunburned. Later I noted my right upper arm was very swollen and felt bruised." And, "...a tightness in my left arm. Later I noticed both my right and left arms were quite swollen from the upper arm all the way down through my forearms. The skin feels sunburned and bruised, but looks normal," would be an unusual presentation for DCI, although there is a relatively rare form of it that may manifest with such a picture.
You asked about "skin bends." Cutaneous DCS proper most commonly presents with a marbling/mottling of the skin (cutis marmorata) and itchiness (usually intense itchiness, but not always). It is most commonly, but not exclusively, seen on the torso and shoulders. Swelling of the upper extremities and a feeling of being bruised without evidence of discoloration are not consistent with the common usage of the term skin bends.
However, an unusual but kindred form of Type I DCI, known as lymphatic DCI, can occur when inert gas bubbles lodge in a lymphatic vessel and cause swelling under the skin. The swollen area(s) hold an indentation for a few moments when depressed (pitting edema). Also, typical is a peculiar pitting of the skin over the affected area, similar to the skin of an orange (known as peau d' orange). Lymphatic DCI may be without pain or accompanied by the sensation of being bruised. This sort of DCI most often involves the extremities, but I have been involved in several cases in which the breast(s) was affected. All of the later involved considerable soreness.
It usually clears on its own without permanent residuals, but does respond to timely recompression treatment. Be aware that resolution may take an extended period of time.
Preventive strategies involve the usual--conservative profiles, very gradual ascents, full completion of deco obligations/safety stops, use of EAN, maintaining excellent hydration, avoiding vigorous work/activity during or after a dive, etc.
It would be prudent to contact a hyperbaric/diving medicine specialist for evaluation of these incidents. To the best my admittedly limited knowledge, it would be very unusual for a healthy diver with normal cardiac status to sustain two such events. Amongst other things, the possibility of PFO should be ruled out.
In the meantime, the diver with such a complaint will want to insure that: thermal protection and BC/backplate fit properly and do not bind on or constrict the body in the area of the arms and shoulders; less than graceful handling of lift bags at depth is not causing some mechanical injury to the arms; and diving profiles are far more conservative than those described in this inquiry.
Regards,
DocVikingo
This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such.
Follow up from inquirer dated 05.25.11: Thanks for your insight! I did follow up with a hyperbaric doc locally who spoke to the medical director at DAN. I went in for a consultation and it was not skin bends, but lymphatic DCI. Apparently that's pretty rare, but not unheard of. We did a chamber treatment, but mostly as an experiment. Since the dive was days ago, the improvement would not be as dramatic. It did appear to help though. I will be undergoing further evaluation.
