DCS & Neurological Complications...??? Request for help.

[SHHHHHH...]

Hi Board Members,

I'm hoping for insight from some someone that has experienced DCS 2 and subsequent nerve damage or understands dive medicine/neurology. I am experiencing a number of "neurological complications" with many examples listed in this article (Request Rejected) ~two weeks after a DCS 2 w/ mild neuropathy diagnosis. My symptoms are of the less severe variety but the headaches/confusion suck.
Backstory: Surfacing from dive #4 of 6 (93 ft actual feet at an altitude of 6,500ft) was when symptoms began. Two more dives at 60+ foot actual depth for 30-45 mins (3 dives/day for 2 days). Wanting to recompress for pain relief after #4, and figuring I was fine due to very conservative ascents, I unknowingly practiced "in-water recompression." Looking back, a multitude of risk factors were at play: altitude (1st altitude dive), fitness level vs. level of exertion, multi-dive profile, and continuing to dive after bending, top the list- some bad decisions...36 hours later, I got into a chamber ASAP per ER doc for a 5 hour "dive" Navy table 6, a night's stay in a lovely hospital bed, and a a 3 hour "dive" for breakfast after my hospital bacon. Then went back into the chamber for a 2 hour "dive" the next morning after I woke up literally "bent" at knees and hips. 10 hours total in that acyrlic flammable coffin. I was then told that my treatment had "plateaued" and residual symptoms are likely nerve damage- that I should follow up with a GP then a dive specialist. The hyperbaric unit was quite busy and they wheeled the next wound care patient into the chamber immediately after I exited. About a 1/2 dozen chambers- all packed. Saw the GP and he did what most medical professionals have done; shrug their shoulders, or call DAN. GP just told me to let him know what the specialist says and come back in a month. While understandable, it is surprising how few medical professionals have a basic understanding dive physiology.

So now my question, what the expletive is happening? I need to wait until I can get in with an undersea person to get answers. Hyperbaric units and attending docs don't do follow up, just routine wound care. Maybe its economics, but trying to figure out some basics like is this a wait & see, likely to take X amount of time at a minimum, symptoms expected to worsen or at maybe just get more annoying as they persist? Any insight is helpful and please be gentle. Thank you! By the way, my age is not 20, add about 15. Not sure how that happened...

 

[cerich]

Not a medical professional and just my thoughts, I could very well be wrong

60 ft dives (even without adjusting for altitude) IMHO will possibly relieve symptoms at depth but are sure not where you want to be to treat DCS. In other words I don't think you had any inadvertent in water re-compression.

Actual depth to me means that you could run a string in a strait line to the surface and the length of string is the actual depth. So your 93ft dive was equivalent to a 115 ft dive.. your 60ft dives work out to 74ft or so..lot of nitrogen loading when you spend 30-45 mins. I would expect that those two dives made things worse, not better.

Overall i would put your dive profiles in the VERY aggressive zone, not conservative no matter how slow your assent rate.

However that is what it is and done...but before you get back to altitude diving I suggest you look into the planning more. We all mess up so beating you up isn't going to help

Given how rare DCS is to the populations, I am amazed how many docs do know anything about DCS..

Find yourself one that does.

To the treatment, obviously there may be cost/insurance considerations but ultimately you need to decide how aggressive you want to pursue treatments and if so find a doc that agrees with you Some friends that have had bad type 2 hits have continued regular chamber rides for months..and the effectiveness varies as I would expect because there are a ton of variables in play.

Regarding number of rides you took in the immediate aftermath, many I know have done many more than you did. The resolutions varied with some having no defects after to not having much progression.

If I got bent and treatment early my personal push would be to be pretty aggressive in trying to maximize treatments the first week or two...when the best chance of mitigation of damage is.

Once again, I am not a med pro, not giving you professional advice as a dive pro (my advice is follow your doctors advice) and just talking about my observations of others that have gotten bent and their journey and how I "think" I would approach it

 

[Frontpointer1000]

Shhhhh...
First off, I'm glad you are relatively ok. That's a relief, it could have been much worse. I agree that planning could/should help, and avoidance is the best practice, etc etc. Chalk this up to a good learning experience and dont beat yourself up to much, but a little bit is ok.

I agree that was some pretty aggressive diving. If interested, please supply the following information so we can more clearly analyze the situation:

Specific dive profiles. Begin with this information:
1. Actual elevation of dive site (name of site?)
2. Did you fly or drive there? How much time did you spend at that elevation prior to diving?
3. Your profile says home is portland, OR. This makes your base elevation 50 feet which is basically sea level. Please confirm, or had you been higher for some time?
4. Water temp and exposure protection.
5. Each dive profile. Actual depth and calculated theoretical depth, total dive time, safety stop time and depth, then average depth for each dive.
6. Surface intervals (for the over night portion, did you stay at that elevation or did you go up or down?
7. Miscellaneous info: how was your hydration status before diving and throughout all dives? Did you consume alcohol during or after the dives (the overnight surface interval?) Did you consume caffeine? Did other divers have similar profiles? Anyone else bent? What kind of computer are you diving? Was it set to your elevation (suunto?) Did you have any conservative factors thrown in?
8. Lastly, how is your health? Weight, BMI? On any medications?
**alot of this is scademic, because you got bent, and some might say this stuff doesn't matter, bc bent is bent. Nonetheless, identifying risk factors to mitigate future DCS events is where the true value of analysis is.**

On to diagnosis and treatment.
You state "neurological complications" and "mild neuropathy" then headaches and perhaps some difficulty processing or a feeling of cloudiness (my words). Those terms are too vague. I'd want to know specifics and where you are feeling (or aren't feeling) the neuropathy. Numbness? Tingling? Pins and needles? Weakness? Itching? Pain? Loss of proprioception? All of those are elements of neuropathy. What and where are your symptoms?

Finally, an apology and an explanation.
I apologize for my medical colleagues. Everyone is too busy and too overworked. Everyone genuinely wants to help but sometimes the little things get forgotten. And honestly, it's hard to find someone that really understands the medical side of dive physiology. DAN should be instrumental in this. As an active diver and critical care/emergency physician, I can honestly say I AM NOT QUALIFIED TO TRULY develop a treatment plan, simply because this is not my area of expertise. I believe most other physicians fall into this category as well.

You need:
1. A DAN doctor. Call them.
2. Neurologist
3. Hyperbarics physician

*I'm happy to discuss offline, no need to post anything to the SB world, or publish what you think may be helpful for others to learn from. PM me if you would like.

Man, that was long. Sorry.

 

[Duke Dive Medicine]

SHHHHHH...

Interesting case, thank you for sharing this. First, a 60' dive on a breathing mix is not in-water recompression (which is generally inadvisable anyway), it's another dive. You are living some of the more minor consequences of continuing to dive when you suspect you have DCS so there's no need to beat that horse any more.

From your description, it sounds as if your medical team treated you in accordance with the standard of care, which is hyperbaric oxygen therapy with serial followup treatments until symptoms resolve or improve to a plateau, i.e. no improvement with continued HBO2 therapy. If their assessment is accurate (and you've provided no reason to think it isn't), further hyperbaric treatment at this point is highly unlikely to be of benefit. We send divers who have residual neurological symptoms after appropriate hyperbaric treatment to a neurologist for long-term followup, and we advise them not to dive if they have any residual symptoms. It's not an economical question, it's that hyperbaric physicians wouldn't have much more to offer you until you want to be evaluated for returning to diving.

With a respectful hat tip to my EM colleague, more specific questions about dive profiles, surface intervals, elevation, temperature, etc are excellent in a situation where diagnosis has not yet been made but are probably of little benefit at this point since you have been already diagnosed and treated for an "explained" DCS hit, i.e. we can point to the behavior that likely brought it on. Consultation with DAN at this juncture is not essential either, for the same reasons.

Resolution of residual neurological DCS symptoms is highly individual. Time will tell how much you will recover. As cerich observed, you may have residual symptoms for years, and you may recover fully after a few months. Again, a consult with a neurologist who is familiar with diving injuries would be a wise course of action. If you're in Portland, Providence Portland Medical Center has a hyperbaric unit. I recommend you contact them to see if they can make a recommendation.

I'm sorry this happened to you, and I hope that readers may derive some benefit from your experience.

Best regards,
DDM

 

[Frontpointer1000]

...more specific questions about dive profiles, surface intervals, elevation, temperature, etc are excellent in a situation where diagnosis has not yet been made but are probably of little benefit at this point since you have been already diagnosed and treated for an "explained" DCS hit, i.e. we can point to the behavior that likely brought it on.

Agreed. However, I recommend analyzing your dive trip to the detail above to provide insight into how one can further mitigate potential DCS issues in the future.

**alot of this is academic, because you got bent, and some might say this stuff doesn't matter, bc bent is bent. Nonetheless, identifying risk factors to mitigate future DCS events is where the true value of analysis is.**

 

[Duke Dive Medicine]

Concur - a thorough analysis of the behaviors that led to this would be worthwhile. From his post, it looks like he's well on his way to this.

Are you affiliated with Intermountain? If so they have a hyperbaric fellowship that's tied to ours. A diver/ED/critical care/undersea medicine doc would be a great combination!

Best regards,
DDM

 

[SHHHHHH...]

Hi All,

Thank you very much for taking your time to respond- the insights are very helpful.

This is the first time I am hearing advice to follow up with a neurologist (vs. a dive doc?). If someone is willing to speak to the difference between what dive doc and a neurologist's capabilities/limitations likely are in this scenario, it would be much appreciated. I did have a negative MRI after chamber treatment #2. This advice may send me on a different path with next steps (reached out to a couple of undersea specialists yesterday- hoping to hear back Monday) but don't want to waste anyone's time either. Maybe I was just told in hyperbaric to see a dive doc in 30 days anticipating a need for a return to dive assessment, since I was pretty clear that I hoped to continue diving as soon as possible?

Similarly, if any can speak to the pathophysiology of the nerve damage piece, particularly the headaches and associated "difficulty processing or a feeling of cloudiness," it would be much appreciated. There's also an element weakness/lethargy. Additionally, I am trying to figure out how to explain to my boss why my brain keeps "farting" and give him some tangible information to work with me on as I continue to act "less smart" for lack of a better way to put it. I've had the urge to tell people to please speak 2x more slowly than normal, but recognize that is an absolutely ridiculous request...

To further elucidate for educational purposes as requested, I think this was a perfect storm. I am very diligent about hydration, but that wasn't enough. Other's dive profiles matched mine with no DCS. I have never had DCS before this but have always dove at sea level. I did notice the "thin air" at altitude and by the start of dive 3 (day 1) felt out of gas, and was huffing and puffing to get back into the water (shore entries- 55F water temp - 7ml wetsuit, 3 ml hood & vest- 3ml gloves, 5 ml boots). The SIs were chilly, chilly! and we all wanted back in to get warm, so maybe the well known cold water risk factor applied to the SIs? Cold helped the nitrogen loading? Air temp was 40s-50's in wetsuits. My BMI, 6" tall, 205 lbs BTW. Apparently, hot tubs aren't a good idea after diving either, and hitting the hot tub topped my to do list when I got back to the hotel on that cold mountain. The first dive the next day (dive 4) was the dagger and continuing to dive was flat out stupid. Hindsight, I should have backed off the gas pedal big time and see no reason to not follow DANS more conservative decompression guidelines. If I am given the go ahead to dive again, which I feel slipping thru my fingers with each additional headache, I plan to avoid altitude dives and implement very stringent, possibly multi level deco stops (true stops)...great opportunity to hover & meditate (eyes open of course).

Thank you, you all are amazing and obviously a tremendous wealth of knowledge!

Sincerely,
S

 

[SHHHHHH...]

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[Duke Dive Medicine]

SHHHHHH...

Re the neurologist vs the diving physician, your condition has gone from being an acute issue that a diving physician can actively intervene in to a more chronic condition which may be better monitored by a neurologist since that's the nature of your symptoms. It's not that a diving physician can't assess your neurological symptoms and monitor your recovery arc, it's more that this is a neurologists's specialty. Either one would be adequate, but we tend to refer our divers with chronic residual symptoms to the neurologist who works with us. Perhaps the diving physicians you contacted can provide a referral.

Re the pathophys, your neurons are recovering from an acute hypoxic and/or inflammatory injury presumably caused by inert gas bubbles, and this can take a good while. A note from a local hyperbaric physician or neurologist to that effect may help you explain things to your employer.

I hate to ask, but did you adjust your decompression for diving at altitude? Cold can be a factor in off-gassing as well, but (as you surmised) getting in a hot tub immediately after diving is ill-advised. I'm not sure what you mean by DAN's more conservative decompression guidelines, but diving more conservatively by using Nitrox (set your computer to air for an added safety margin) and not pushing your computer to the edge of the algorithm are good places to start if you are cleared to return to diving. If you plan on implementing decompression stops I strongly recommend you get trained in technical diving; this is not something that should be undertaken without proper training.

Best regards,
DDM

 

[SHHHHHH...]

Thank you DDM!! While I have professional interests on the academic side with your sporting rivals up the hill, I'll take the Blue Devils any day from here on out! Was just wanting to get pointed in the right direction by a competent person, so many, many, thanks! No worries regarding your computer question- altitude was adjusted for. That said, I did push the algorithm to the limit and the "yelling at me" beep was apparently not functioning, so noticed the limits were exceeded X number of minutes afterward. I was relying too heavily on mirroring others' profiles, but as was either stated or implied there are too many individual variables to let a computer do all the thinking. Another very, very hard lesson learned and one I hope to take back into the water. One more question if I may overstay my welcome , when docs say "no return" if "residual symptoms," is there a general rule of thumb for how long "residual" tends to be for neurons to heal, or am I likely already in the "residual symptoms" category as a result of symptoms following HBO2 therapy? I will not return to dive if advised not to by the dive doc performing my physical evaluations (I have mouths to feed and the kids to be here for) but don't want to miss out on a lifetime of diving if I can implement multiple safety precautions such as the ones you suggested. Getting quite physically fit is also something I believe I can do to get me ready again. I thought I read that DAN recommends adding 10ft to a safety stop, but will re-vist safest deco protocols for various profiles...

Thank you!