Immersion Pulmonary Edema

[Cave Diver]

Doc's,

I suggested Denise to cross post this report in the diving medicine forum to see if anyone has some further input on the cause of this incident.

On Friday I did a dive at JB ending around 12:30 p.m. lasting 47 minutes with a max depth of 92' and an avg depth of 50.

On Saturday I did one at Hole in The Wall ending around 12:40 p.m. lasting 53 minutes with a max depth of 86' and 51' for the avg depth.

The incident occurred during my dive on Sunday July 4th. The diving ended at 1:00 p.m. and the total time was 23 minutes with a max depth of 94' and an avg depth of 51'.

I started feeling a pressure on my chest just after descending through the chimney and I stopped near the jump on the right hand side. This was probably approximately 15 minutes into the dive. I was having trouble breathing and I thumbed the dive and started heading back out with my buddy following.

During the exit I was coughing violently and was purging the reg to try and get more air. Coming out of the cavern zone I was literally crawling on the ground to exit.

When I got to where I could stand in about chest high water upon exiting the cave I was coughing up pink frothy sputum. Some people on the shore came to assist me. When they were finally able to remove my hood and drysuit, my face was blue and my lips white with some foam on my lips. I don't think they were divers and someone called 911 when I said that I needed to see a Dr.

I was taken to Jackson County Hospital by ambulance from JB and was there approx 2 hours before being transferred to Southeast Alabama Medical Center in Dothan, AL where I was seen by Dr. Rao, a cardiologist. I was given enzymne tests every 6 hours and numerous ekgs, echocardiogram, heart cath, lung and leg crt for embolisms, clots. Everything was normal except an elevation in thyroid. They did not tell me how much.

I don't know all the technical terms but asidosis levels recorded at Jackson Hospital suggested I was within 1 to 3 minutes of suffocation from fluid in my lungs.

My computer did not show my ascent was too fast, it just told me to slow down. the nitrogen and oxygen loading were within normal ranges. I did not aspirate any water. The last approx 150 to 200ft i was purging my reg in my mouth to try to ease the labor of trying to breathe. Interestingly enough the doctor at the Jackson Hospital was told to use positive pressure to force air down into my lungs to displace the fluid.

Jackson Hospital said they were not familiar with dive related incidents so they immediately contacted DAN. DAN was told my symptoms and they said it sounded like IPE and told them to start a drip of lasik ? which flushes your body of excess fluid and to administer the mask they were using with oxygen with positive force or to do a c pap or a tube down my throat. I am a member of DAN and I truly believe they were very helpful to the doctors and staff.

Upon being transferred to the next hospital they continued to administer the same two procedures and started the tests on my hearts. Enzyme and ekg tests were done at the first hospital and they were on the phone with the cardiologists giving him this info. When my cardiologists continued to test and rule out heart related problems, I asked him to contact DAN and he did. They gave him info which is in the following link:

DAN Divers Alert Network : Immersion Pulmonary Edema

I talked to DAN the afternoon before leaving the hospital. They gave me the contact information for the 2 doctors closest to me that dealt with dive related incidences and they are both pulmonary doctors. He asked me to follow up with them before diving again because he had done all the tests he could do to determine what the cause was and he had found no cause.

The only thing that showed up at all was an elevated thyroid level. I attribute this to a doctor who was treating me for an underactive thyroid who was not monitoring me close enough and 6 weeks ago increased my dosage from 120mg a day to 180mg a day and did not retest me. My cardio doctor asked me to see an endocrinogist and he said I probably didn't even need the thyroid medicine to begin with. He took me off of it and I am to follow up with both doctors in 4 to 6 weeks as well as see one of the DAN doctors.
That is pretty much all I can think of at the moment.

 

[cutlass]

Acidity is a key measure of metabolic status. In surgery it is one of 3 key measures of life status, the other two being hypothermia and coagulopathy.
Lasix (furosemide) is a common type of diuretic used to lower fluid volume thereby relieving tissue congestion, pressures, and heart workload.
CPAP (continuous positive airway pressure) is a common respiratory intervention short of intubation (air tube down the throat).

IMO there are some things to think about but to comment on a cause from this distance would be unfair to all. The appointed follow-ups are appropriate and hopefully will sort things out.

FWIW as a general comment: Endocrinologic/hormonal treatment is a tricky business because so many body systems are affected. It follows that responses are quite individualistic in terms of both time and degree, even with the same therapy and person at different stages of his life and lifestyle. Some effects may be fairly quick; e.g. insulin. Others may take weeks, even months, to have meaningful effect. And within these, exceptions may occur. This is just the nature of the beast.

 

[captdaveb]

I experienced pulmonary edema in January, in Cozuzmel. My deepest depth was about 70'. I noticed "a little heaviness" in my chest on the way down but attributed it to the excitement of the dive. By the time I finished and surfaced, foregoing the 3 minute safety stop, I was "gurgling"
and knew I was in trouble. I was in limits for everything, other than the safety stop. As I was getting back on the boat(drift dive) I passed out and woke up in an ambulance. By the time I got the the clinic in Cozumel I was able to walk. We had come on a cruise ship and I was told I could not reboard because the doctor had forbidden it. I am a diabetic, well controlled. They gave me lasiks to rid me of the fluid buildup, but had no idea of how to control my blood sugars. I was in there for 2 days until flying out via air ambulance, where I went home and spent 3 days in ICU getting everything right again. The high blood sugars almost shut down my kidneys. I have had tests on my heart to rule out problems there, and the doctors have found nothing that could have caused this. My GP, whom is a diver, wonders if CO2 might not have been an issue. I am planning on diving next week, my first since the incident, but will be in a well controlled place, and more aware of what to look out for. Note: If you don't already have DAN, you should get it! They were there when needed! Also, when in Cozumel remember they don't treat you without cash and will do everything they can to keep you as long as they can, we were essentially prisoners until DAN set up the air evac.

 

[Cave Diver]

I experienced pulmonary edema in January, in Cozuzmel. My deepest depth was about 70'. I noticed "a little heaviness" in my chest on the way down but attributed it to the excitement of the dive. By the time I finished and surfaced, foregoing the 3 minute safety stop, I was "gurgling"
and knew I was in trouble. I was in limits for everything, other than the safety stop. As I was getting back on the boat(drift dive) I passed out and woke up in an ambulance. By the time I got the the clinic in Cozumel I was able to walk. We had come on a cruise ship and I was told I could not reboard because the doctor had forbidden it. I am a diabetic, well controlled. They gave me lasiks to rid me of the fluid buildup, but had no idea of how to control my blood sugars. I was in there for 2 days until flying out via air ambulance, where I went home and spent 3 days in ICU getting everything right again. The high blood sugars almost shut down my kidneys. I have had tests on my heart to rule out problems there, and the doctors have found nothing that could have caused this. My GP, whom is a diver, wonders if CO2 might not have been an issue. I am planning on diving next week, my first since the incident, but will be in a well controlled place, and more aware of what to look out for. Note: If you don't already have DAN, you should get it! They were there when needed! Also, when in Cozumel remember they don't treat you without cash and will do everything they can to keep you as long as they can, we were essentially prisoners until DAN set up the air evac.

Hi Dave, welcome to the board! Glad to hear you survived the incident! I think many of us would appreciate any other details you can share. Depth, length of dive, any other warnings or signs you experienced, especially over the previous day or so. Any other medical conditions, thyroid, etc?

Thanks for sharing your story! If you haven't seen this thread yet, you may wish to take a look at it: http://www.scubaboard.com/forums/ac...ident-near-miss-jackson-blue.html#post5350568

 

[PatW]

The below quote is from DAN on IPE:

The number of IPE cases has increased. Why the increase is unclear. The condition itself is not clearly understood, but since it is occurring more frequently, divers should know about it.

whenever you see something like "the condition itself is not clearly understood" in any scientific report, the translation is "we don't know what is going on here".

It sounds pretty dern scary to go through. I am glad you two got through it.

 

[Cave Diver]

The below quote is from DAN on IPE:

The number of IPE cases has increased. Why the increase is unclear. The condition itself is not clearly understood, but since it is occurring more frequently, divers should know about it.

whenever you see something like "the condition itself is not clearly understood" in any scientific report, the translation is "we don't know what is going on here".

It sounds pretty dern scary to go through. I am glad you two got through it.

I wonder if the actual number of cases are increasing, or if it's just being caught and identified now instead of being labeled something else?

 

[TSandM]

That's a very good point, John. I still wonder if some of the deaths due to "drowning" may well have been IPE (especially the unexplained buddy separation/death cases). And there may well have been cases where people survived, but the diagnosis was congestive heart failure from another cause, or even water aspiration (when the water was actually not exogenous at all).

 

[PatW]

That's a very good point, John. I still wonder if some of the deaths due to "drowning" may well have been IPE (especially the unexplained buddy separation/death cases). And there may well have been cases where people survived, but the diagnosis was congestive heart failure from another cause, or even water aspiration (when the water was actually not exogenous at all).

Good point. Given the way it occurs, I can easily see even a very capable diver perishing from IPE. You pass out from lack of oxygen because your lungs are full of fluid and your mouth opens and it is all over. It would look like drowning and the final cause of death might just be drowning. But the cause of the emergency would be IPE. Also, given the relatively low number of cases, it wouldn't be an obvious thing to look for unless one of the investigators was familiar with it.

 

[Anti-Hero]

I'm guessing here the buildup of fluid in the lungs isn't simply water, and almost certainly not salt water. Wouldn't an excess of "fluid" in the lungs that isn't consistent with exogenous drowning be a good indicator of IPE?

 

[Duke Dive Medicine]

I'm guessing here the buildup of fluid in the lungs isn't simply water, and almost certainly not salt water. Wouldn't an excess of "fluid" in the lungs that isn't consistent with exogenous drowning be a good indicator of IPE?

Anti-hero,
The whole thing, including a rehash of Denise's story, gets covered pretty well here in a recent thread:
http://www.scubaboard.com/forums/diving-medicine/76172-non-cardiogenic-pulmonary-edema.html
Cheers,
DDM