Unexpected Skin Bends--Why

[uncfnp]

Sorry to hear of your issues Guy. I have had similar problems but started around dive 150. First episode was after a week of fairly aggressive recreational dives in Florida. Since then I have had it happen diving Grand Cayman and Cozumel but by far the greatest incidents have been diving WPB Florida.

Interestingly, at least to me, it has never occurred in Bonaire where the last half the dive is at 30 to 15 feet, despite 3 to four dives a day for 6 to 7 days and often with 1 hour to less SI. The key for me seems to be a conservative algorithm and a loooong safety stop.

For Florida, I did get my Advanced Nitrox certification and treat those dives as deco dives with a very high conservate setting and O2 at my safety stop and while waiting on boat AND boarding boat. Sometimes I would even continue to breathe it while switching over my gear. I also started letting Eric or the crew lug all my gear (I use to pitch in and help schlep empty tanks at the dock but not any more).

The only thing I can think of that changed is that I put on about 10 pounds and my shape is apple plus female so much of it was belly. I think this was a significant change and I have since lost that weight. I am interested to see how my up coming Grand Cayman trip will go with again fairly aggressive boat dives and no readily available O2.

I did finely get checked for a PFO. The TTE showed bubbles but after I convinced an interventional cardiologist to try and get insurance to cover closure, a followup TEE did not show it.

Best of luck,

Lisa

 

[Mouth Breather]

Did you ever have itches, vision issues, any other symptoms after previous dives? I did but wrote it off to fatigue, dehydration etc. until my first technical dives. After the 3rd time getting bent I was diagnosed with a large PFO which I had closed. I think if I had stuck to recreational, maybe dove air profiles on nitrox etc. I would not have gotten bent any more though.

 

[Duke Dive Medicine]

Did you ever have itches, vision issues, any other symptoms after previous dives? I did but wrote it off to fatigue, dehydration etc. until my first technical dives. After the 3rd time getting bent I was diagnosed with a large PFO which I had closed. I think if I had stuck to recreational, maybe dove air profiles on nitrox etc. I would not have gotten bent any more though.

Hi Mouth Breather, did the PFO closure resolve your issues?

FWIW to sort of round out the skin bends information in the thread, there are two types of skin bends: type 1 bends, which are more itchy and hive-like and are not associated with shunted venous gas emboli, and cutis marmorata, which is more marbled/mottled and has been associated with shunted VGE and more serious DCS symptoms. PFO closure won't do anything for Type I rash but *may* be effective in decreasing the risk for DCS symptoms related to shunted bubbles.

There's an interesting article on unexpected DCS in the most current issue of Undersea and Hyperbaric Medicine. The authors propose a mechanism called the Gradient Perfusion Model to help explain "unexplained" DCS, which they propose labeling as "disordered decompression" or "disordering events". I haven't fully digested it, but the first author is Mike Strauss at Long Beach Memorial Hospital. Dr. Strauss is a hospital-based hyperbaric physician and a diving medicine expert. The abstract is linked below.

The Gradient Perfusion Model Part 1: Why and at what sites decompression sickness can occur. - PubMed - NCBI

Best regards,
DDM

 

[scubadada]

And the abstracts for parts 2 and 3. I wish I had access to the full articles, one must be a subscriber for access.

The Gradient Perfusion Model Part 2: Substantiation of the GPM with clinical cases. - PubMed - NCBI
The Gradient Perfusion Model Part 3: An extraordinary case of decompression sickness. - PubMed - NCBI

 

[guyharrisonphoto]

Guy, just to cover all the bases, did you check the O2 percentage in your tanks? Were you particularly cold on the two dives where you suffered skin bends? Regarding returning to diving, two weeks might not have been long enough to allow the inflammation from the first bends incident to resolve. Of course the recommendations you receive from the physician who sees you in person should take precedence, but I'd recommend waiting a minimum of 30 days after complete symptom resolution, and six weeks would not be unreasonable.

I'm afraid I don't have many recommendations for prevention aside from diving more conservatively. Tthis could mean switching to the air setting on your computer while diving nitrox, not diving the computer to the edge of the NDL, and lengthening your safety stop. If you have the training and equipment you could consider breathing 100% O2 at your safety stop as well. The hyperbaric physician may have more to offer you. May I ask where you're being seen?

Best regards,
DDM

@DukeDiveMedicine Thanks for getting back to me! To answer your questions, I did analyze my tanks on the boat and they were 35%. The dive was warm water, Florida in the summer. 83 deg. F. I had a 3 mil suit and was very comfortable. I see now that diving too soon negated my efforts to increase my computer conservatism and do longer stops on the second trip. I will wait 6 weeks for sure before I dive again.

I will increase the conservatism of my computer, I think, rather than dive on a setting that is not my breathing gas. Same effect but if something happens again people will have the accurate information from my computer. I will also go to 5 minute stops instead of 3. I suppose I could carry an 02 pony easily enough; would only need 13cf for the stop. My computer is very easy to do a gas switch. I will seriously look at that.

The hospital with the chamber was St. Mary's medical center in West Palm Beach. They referred me to an internist that is one of the docs who runs the chamber, Dr. Michael Chidester. I have never seen him before.

But, if you folks at Duke have someone in the Palm Beach/Ft. Lauderdale area that you recommend, please let me know here or by private message.

I am going to print and scan my dive profiles and post them here, if that would help.

Also, to answer some of the questions above, my wetsuit fits fine and not too tight.

I did not have any other symptoms at all after the dive or during the time the skin rash showed. When I finally got to the ER it was over 5 hours after the dive and they kept me on O2 and observation for a couple of hours and when the rash began to resolve they released me.

 

[Mouth Breather]

As far as I know Dr. Grobman of the Weston Cleveland Clinic is the only DAN Dr. in this area. That's ok because he's a great physician, I highly recommend him.

 

[guyharrisonphoto]

Sorry to hear of your issues Guy. I have had similar problems but started around dive 150. First episode was after a week of fairly aggressive recreational dives in Florida. Since then I have had it happen diving Grand Cayman and Cozumel but by far the greatest incidents have been diving WPB Florida.

Interestingly, at least to me, it has never occurred in Bonaire where the last half the dive is at 30 to 15 feet, despite 3 to four dives a day for 6 to 7 days and often with 1 hour to less SI. The key for me seems to be a conservative algorithm and a loooong safety stop.

For Florida, I did get my Advanced Nitrox certification and treat those dives as deco dives with a very high conservate setting and O2 at my safety stop and while waiting on boat AND boarding boat. Sometimes I would even continue to breathe it while switching over my gear. I also started letting Eric or the crew lug all my gear (I use to pitch in and help schlep empty tanks at the dock but not any more).

The only thing I can think of that changed is that I put on about 10 pounds and my shape is apple plus female so much of it was belly. I think this was a significant change and I have since lost that weight. I am interested to see how my up coming Grand Cayman trip will go with again fairly aggressive boat dives and no readily available O2.

I did finely get checked for a PFO. The TTE showed bubbles but after I convinced an interventional cardiologist to try and get insurance to cover closure, a followup TEE did not show it.

Best of luck,

Lisa

Thanks Lisa. I have done Bonaire for a week with 3-4 dives per day, but the profiles are shallower (no need to go 100' in Bonaire) and, like you said, often have 10 mins or more very shallow looking for macro stuff. No issues. Did a live aboard in Cuba in December. 4 dives per day. Usually started with a deep one (90') but often 10 min stops because photographing lots of sharks near the surface. Then a shallower coral garden dive, maybe one more to 60' and a nite dive usually limited to 40'. Also, multi-hour surface intervals between the dives (2 hours). No issues there.

I could also drop 15 pounds and am working on that right now.

I dive Jupiter regularly and am used to the square profile deep dives, and have done 7 such dives this year alone (along with shallower diving) but this just came out of the blue. I think I am going to go for the 02 pony rig.

 

[guyharrisonphoto]

Hi Mouth Breather, did the PFO closure resolve your issues?

FWIW to sort of round out the skin bends information in the thread, there are two types of skin bends: type 1 bends, which are more itchy and hive-like and are not associated with shunted venous gas emboli, and cutis marmorata, which is more marbled/mottled and has been associated with shunted VGE and more serious DCS symptoms. PFO closure won't do anything for Type I rash but *may* be effective in decreasing the risk for DCS symptoms related to shunted bubbles.

There's an interesting article on unexpected DCS in the most current issue of Undersea and Hyperbaric Medicine. The authors propose a mechanism called the Gradient Perfusion Model to help explain "unexplained" DCS, which they propose labeling as "disordered decompression" or "disordering events". I haven't fully digested it, but the first author is Mike Strauss at Long Beach Memorial Hospital. Dr. Strauss is a hospital-based hyperbaric physician and a diving medicine expert. The abstract is linked below.

The Gradient Perfusion Model Part 1: Why and at what sites decompression sickness can occur. - PubMed - NCBI

Best regards,
DDM

Is there any way to get access to the full articles? I would definitely like to read them.

 

[uncfnp]

I think I am going to go for the 02 pony rig.

Unless you already have a dedicated rig I would hold off until your followup appointment. Honestly I have no way to prove the O2 at the ss helps but I do like having it readily available if I do rash.

 

[Duke Dive Medicine]

Is there any way to get access to the full articles? I would definitely like to read them.

Hi Guy, unfortunately I can't attach them here without violating copyright laws. The full issue is available through the UHMS for about $25.

Best regards,
DDM