Question about DCS

[Diver0001]

Thank you all for your replies. I am new to the board and very impressed with the massive amount of engagement. I will get his profile up as soon as I can get it from him. I only use "conservative" to describe the dive, because NDL on a Mares recreation dive computer is pretty conservative compared to the Cochran I used to use. It has Navy tables and much more aggressive. I can tell you my profile summary was 100ft max depth average depth 70 feet and 25 minute total dive time. I descended around 10 feet more into the wreck than he did and I hit my NDL by 1 minute. I did a deco stop at 45ft and a safety stop at 15.He did the stops with me even though his computer was not calling for the deco stop at 45ft.I think dehydration was more at play here. I drank fluids before the dive and he did not. As far as not recognizing as classic DCS I have been diving for 30 years, and I have never seen anyone bent. I imagined it as far less acute pain( I guess like an ache). This initially seemed like a Myocardial infarction the way it radiated down his arm and made him sweat. At least I will know more next time.

An average depth of 70ft (what is that, 20 metres?) seems a little deep to me. Most of my ascents, even ones where I go well over the NDL's don't give average depths deeper than about 15 metres. Just working on gut-feeling, even though you were clearly not pushing the NDL's by the end of the dive (you appear to have had a 14 minute buffer), the 70ft *average* depth gives me the feeling that the early part of the ascent could have been slower and/or the safety stop extended.

What I do, especially on dives where I've hit or gone over the NDL by no more than 10 min, is to put in 1 minute stops starting at 18 metres and then every three metres after that... so 18/15/12/9/6 and then sit on 6 metres for about the same amount of time that I was actually on the bottom. What this does is slow down the ascent to a firm 10m/min and give ample time for off gassing at a relatively deep last stop before ascending to 4.5 metres for the last 3 minutes of that.

Ordinarily, this leaves me with an average depth in the 10m/30ft range, which I would find more or less in line with my own expectations on a single recreational dive. For a deep bounce dive or significant deco dives I've had average depths in the 15-18m range (50-60ft) using this ascent protocol but never 70ft. I've never had one that deep in all the time I've been using a computer.

Obviously I wasn't there and I'm only arm-chair quarter-backing this..... but that profile does actually give me a red-flag on the surface of it.

R..

---------- Post added November 22nd, 2013 at 03:52 PM ----------

I have never seen anyone bent.

Neither have I, actually. I've been following this board for some time though (almost 12 years) and from the stories I've heard most people seem to describe it like having a burning knife stabbed into their body.

One guy I remember from years ago said something to the effect of, "you can be Rambo, Dirty Harry and Judge Dread all wrapped up into one and you'll still cry"

R..

 

[mmadiver]

We also need to know his other dives,surface intervals, nitrox or air.
I agree with the others who say I would have thought DCS immediately based on these symptoms 10 minutes after any dive.

The onset within 10min would indicate a POIS, the symptoms indicate AGE but could still very well be DCS. I've had two friends go down with type II from PFOs so its always a suspect in 'unearned' DCI.

It's a moot point though, the treatments are the same. Whoever treated him screwed up. He should of been pressed immediately. Doctors always want to do their MRIs and tests, waste of time.

 

[FinnMom]

I had to search the Internet for POIS. In case others were also stumped: pulmonary overinflation syndrome.

 

[Duke Dive Medicine]

Though leg numbness is a potential symptom of gas embolism, abdominal and leg pain are not. The symptoms are more consistent with decompression sickness, and the argument could definitely be made for a bubble contrast echocardiogram.

---------- Post added November 22nd, 2013 at 12:41 PM ----------

Whoever treated him screwed up. He should of been pressed immediately. Doctors always want to do their MRIs and tests, waste of time.

I disagree. I'm assuming you're an EOD diver from your photo; in fit, well-screened military divers, post-dive symptoms like this are more likely to be related to decompression illness, but civilian recreational divers come from a much broader section of the population and so are much more likely to have a comorbidity that could confound things. The fact that the individual has been diving only widens the differential diagnosis.

Best regards,
DDM

 

[doctormike]

I went through almost exactly the same thing (with regard to symptoms). This sounds like a classic spinal cord DCS hit: abdominal pain and then tingling/numbness/weakness in the legs.

I wrote up my experience with an extensive analysis (thanks, DDM!). This may be of interest to you and the rest of the members of this thread...

 

[tracydr]

---------- Post added November 22nd, 2013 at 11:21 AM ----------

The onset within 10min would indicate a POIS, the symptoms indicate AGE but could still very well be DCS. I've had two friends go down with type II from PFOs so its always a suspect in 'unearned' DCI.

It's a moot point though, the treatments are the same. Whoever treated him screwed up. He should of been pressed immediately. Doctors always want to do their MRIs and tests, waste of time.

I'm not seeing the AGE or POIS here, with abdominal and leg pain, it seems like it's clearly DCS. Or,as clearly as it could be. It amazes me that a doctor in the Bahamas can't recognize DCS but, I guess we really don't get any dive medicine in school. We should and I believe it should be part of ER rotations. At least, in school, it should be covered in our core rotations/classes. Once a doctor has been residency trained, if they are doing EM, they really should have some training in dive medicine.
We had a dive lecture at the 2012 National AOA conference and it was well attended. Unfortunately, it was given at a time that quite a few other good lectures were given.
That was probably the first actual lecture that I've ever had on diving emergencies.
To be honest, I think DCS is often a difficult diagnosis to make, especially with the recreational diver. There are so many other diseases in the differential that it is rarely clear cut. In fact, I had a dive last year, myself, that I believe I got slightly bent but I'm still not sure if I did. Which really me realize even more how difficult It can be to diagnose DCS. Is that sore shoulder or knee because I lugged all my gear up and down those steps or is it DCS? Am I just out of shape/arthritic/strained or injured, do I have the flu? Unless it's a clear cut case where the diver comes up too fast and immediately has severe pain,numbness, etc., it can be a really tough call. Sometimes, if its a left arm involved, symptoms can even mimic myocardial infarction. Which could seriously impair the likelihood of the diver getting out of the ED and into the chamber, since a cardiac workup can take many hours!

 

[mmadiver]

I'm glad to have the medical professionals adding to the discussion, for me these are the most valuable and enlightening discussions and look forward to getting more of your insights.

I'm assuming you're an EOD diver from your photo; in fit, well-screened military divers, post-dive symptoms like this are more likely to be related to decompression illness

Yes, I'm an EOD Diver. Also true that we have the benefit of well-screened, physically/mentally fit individuals who undergo regular dive physicals which alows us to rule out other conditions/factors - which admittedly has shaped my thought process here.

To walk you through my thought process of suspecting a POIS. The OP described the casualty as:

My dive buddy surfaced and then within 10 minutes of being on the boat was doubled over in pain. The pain was acute and affected his abdomen primarily before spreading to his extremities. His legs went numb a few minutes later.

So within 10mins of surfacing the diver is doubled over from acute pain in his abdomen. To me this reads as a typical description of a pneumothorax. The diver is exhibiting the tell-tale "guarding" while attempting to describe what he's feeling while hunched over. Is the pain truly in his abdomen or lower chest? Given the time frame <10min I'm leaning towards pneumothorax. Then the diver describes the pain spreading to other areas. Creeping "pain" is not associated with POIS or AGE. However having witnessed AGEs first hand, this may be a case where the diver attempts to explain the sensation or "ghost" feeling of an AGE as pain. The divers legs went numb a few minutes later; so now I'm really leaning towards AGE if I'm on the boat. However, AGE or DCS it doesn't really matter, he's exhibiting neurological symptoms and needs to be treated.

but civilian recreational divers come from a much broader section of the population and so are much more likely to have a comorbidity that could confound things. The fact that the individual has been diving only widens the differential diagnosis.

Would you mind expanding on this? What is the textbook answer for diagnosing and treating this diver on the civilian side? The diver is exhibiting neurological symptoms of a potentially life threating diving related illness <10min after diving, why wouldn't you press him immediately?
I also dive in a civilian capacity, so I welcome any knowledge that might make me more attentive to contributing causes in others.

Nothing showed up and after two hours of receiving oxygen he felt better.

This my primary issue with the treatment course of this diver. For us, it is procedure that once a diver suffering a diving related illness is administered O2 they will undergo a recompression treatment. The reason being is that the application of O2 of masks and alleviates symptoms without most effectively treating the underlying issue. Further, accurate diagnosis and tracking of the symptoms can no longer be done. Case and point, the diver was administered O2 for two hours and felt better, predictably the next day the symptoms returned. The medical professionals treating him obviously suspected AGE & DCS enough to administer O2, mask symptoms, and not fully treat him?


Thanks for reading. Looking forward to your guys thoughts on this.

 

[TSandM]

I've seen a lot of pneumothoraces, and have yet to see anyone present doubled over and complaining of ABDOMINAL pain. Not to say it couldn't happen, but it certainly would not be high on my differential diagnosis if I had seen this patient. DCS, however, would have been.

Without opening a can of worms, there is actually fairly little real evidence that one's hydration status is a major player in determining risk of DCS. (I had read this elsewhere, and heard it reiterated by Dr. Neal Pollock in one of the talks at DEMA this year.) Divers who contract significant DCS often show signs of volume depletion, but it is likely more due to the pathophysiology of the problem, with fluid lost into damaged tissue, than it is to have been a preexisting situation.

Susceptibility to bubbling, however, is highly idiosyncratic. As Dr. Michael Powell told us at a talk a couple of years ago, the research he did when developing the RDP (and with NASA) showed that some people basically won't bubble no matter WHAT you do to them, and other people bubble at the slightest provocation. So it is not entirely surprising that you and your buddy would have different physiologic responses to the same dive. This is part of what makes DCS such a mysterious malady.

This is a story consistent with neurologic, or Type II DCS, and this type of hit -- IF the profile for this dive and the prior ones doesn't raise any red flags -- is one of the indications for getting a PFO study.

 

[raftingtigger]

This my primary issue with the treatment course of this diver. For us, it is procedure that once a diver suffering a diving related illness is administered O2 they will undergo a recompression treatment. The reason being is that the application of O2 of masks and alleviates symptoms without most effectively treating the underlying issue. Further, accurate diagnosis and tracking of the symptoms can no longer be done. Case and point, the diver was administered O2 for two hours and felt better, predictably the next day the symptoms returned. The medical professionals treating him obviously suspected AGE & DCS enough to administer O2, mask symptoms, and not fully treat him?

O2 is used as a treatment for a variety of medical conditions. Just because they put him on O2 doesn't mean they even considered DCI, nor does it mean they didn't. 10 minutes post dive doesn't automatically mean a diving related injury. It could just as easily be a cardiac cause. I would hate to have them in a chamber with an MI and have them go into cardiac arrest in there. As DDM says, there are very good reasons to do an assessment BEFORE putting them in a chamber.

 

[seasher]

Regardless of whether the DCS hit was deserved or undeserved, dehydration is a big contributing factor. As a tender in the SSS chamber is Cozumel, I have seen many buddy pairs where one gets DCS and the other does not. Then it turns out that the one who got DCS was dehydrated.