Multiple cases of skin bends - what now?

[Rusty Shackleford]

Allergic reaction to wetsuit?

 

[Celt]

The first skin bend was classic, alcohol lowers the body’s core temperature and blood leaves the extremities to protect the vital organs, jump into a hot shower and the skin which is the largest organ in the body suddenly heats up resulting in a skin bend, I could be wrong but we were told never have a hot bath or shower after a deco dive, especially if you feel cold. My advice stay away from the booze if you plan on diving and you’ll be fine.

 

[Marie13]

The first skin bend was classic, alcohol lowers the body’s core temperature and blood leaves the extremities to protect the vital organs, jump into a hot shower and the skin which is the largest organ in the body suddenly heats up resulting in a skin bend, I could be wrong but we were told never have a hot bath or shower after a deco dive, especially if you feel cold. My advice stay away from the booze if you plan on diving and you’ll be fine.

Not just after a deco dive. After diving, period.

 

[Lorenzoid]

I like to remember the adage that “all dives are deco dives,” and weigh how aggressive the diving may be along with possible contributory factors such as dehydration. I have on occasion dived the day after a boozy dinner, or after arriving on a long international flight, but limited myself to baby dives—nowhere near NDL. If I were doing a planned deco dive, I would avoid alcohol entirely. Not to mention hot tubs/showers.

To echo another reply, the second instance, which occurred 77 hours after the dive, is really intriguing. I have been under the impression that DCS appearing after about 48 hours is almost unheard of. Still, it has been said that the mechanism underlying skin bends may be different than other types of DCS, so who knows.

 

[chillyinCanada]

I'm not a doctor either nor am I a tech diver but I have had skin bends twice, with the mottling and deep tissue pain.

I lost pounds and have not had a recurrence. As was suggested earlier, you should definitely try losing 20# minimum.

Are you not going to be satisfied with being a recreational diver rather than proceeding on your tech journey?

My understanding is that your career is entirely in the dive business, though as much or more in management. Please correct me if I'm wrong.

I'm not sure who would be looking at you as less of a man . . .other than yourself. First, this is a physiology problem and has nothing at all to do with manliness. Fix your own thoughts on this matter and should you indeed have a "friend" that thinks you are less manly because of this, then let that person free from your life because they are not worthy of you. Nor does your "friend" have the right mindset for a diver. Remember, that anyone can call a dive at any time and no one is to look askance!

In your case, you may only be calling any future technical diving.

I'm sure that's personally disappointing but nothing that's worth dying or being crippled for.

As for your second bend, 77 hours later? I've never heard/read of such a thing. Are you positive that it was indeed a bend?

And did you ever have any deep tissue pain along with the mottling and itch on either occurrence?

 

[Duke Dive Medicine]

Hi,

to be honest, this is one of the more difficult posts I have made as I feel my career and one of the big loves of my life is on the line. Also being a dive pro that got bent twice, it seems that my career has stopped in it's tracks, and that I'm seen as a 'lesser' diver by my peers.

But inspired by a recent article by Gareth Lock I also feel that as true professionals we should openly discuss the not so great stories about our development as diver. For myself to learn, but also for my fellow divers.

About me
I'm a male, 45 years old. I'm 187 cm / 6'2" tall, and weigh about 110 kg / 220 lbs. I would certainly consider myself overweight, but not obese.
I'm in decent shape, do run the occasional 5K about twice a week.
In terms of medical history, there are no serious issues. There is a history of Cavernous hemangioma in my family passed down my mothers side. My brother and sister have been diagnosed with it. I haven't tested it but would assume I most likely have it too.

My diving history
Haven been diving since 1990, and as pro (recreational instructor) since 2013. In total I have done about 1,300 dives up to 50 mt / 165 ft. A relative small number for a dive pro as I have never worked for a 'dive factory' and often combined with 'dry' roles as manager and boat crew.
Since 2016 I have been pursuing technical diving and am currently certified at Tec50 diver open circuit, and CCR Mod 1 / air dil. I have done about 50 hours on CCR and around 15 OC tech/deco dives.
My goal is to pursue further technical diving development, using Trimix and potential a tech instructor.

DCS case 1
My first case was after a 'mild' OC tech dive in April 2017. This was up to 40 mt / 130 ft, with just over 15 min at depth. The dive was planned using GF 30/85 and executed as planned, including deco on 50%.
About an hour or two after the dive I noted an itching and skin rash. Initially thinking this was due to the nice hot shower I just had, I quickly realized it was a skin bend. I went to the hospital, went on O2, and was released after a few hours. The rash started subduing after being on the O2.

This bend I feel might be earned. It was a bit more agressive GF setting and resulting dive profile. More importantly, I had a a boozy lunch the day before, so was certainly dehydrated and not in the best shape.

Attached are the dive profile and picture of the skin bend.
View attachment 525639
View attachment 525640

DCS case 2
My second case was in November 2018. This was a recreational / non-deco CCR dive up to 30 mt / 100 ft, total dive time just over 100 minutes. I have checked the computer log, at no time were any deco obligations occurred during the dive. The GF used was 40/70, the more conservative I use nowadays.
The DCS symptoms manifested itself about 77 (!) hours after completion of the dive. This was following a 8K run and hot shower. In this case it was no rash, but more a marbling. There was no itching or any other sensation.
I drove myself to the hospital, went on O2, and took a Table 5 chamber ride. I noticed no difference in how I felt, neither did the marbling subdue much in the treatment.

View attachment 525641
Dive profile (ignore the ceilings, these are calculated by the Subsurface logging software and do not reflect actual ceilings taking into account gas used / pPO2)

View attachment 525642
Marbling before treatment

View attachment 525643
Marbling after Table 5 chamber treatment

Follow-up
After the second DCS incident, I did a TTE bubble study for PFO. That came back negative. However, my technical diving development been stagnated with my current instructor not feeling comfortable pursuing Trimix certification with me.

Therefore I have been talking to some well-regarded experts in this field, including the amazing @Dr. Doug Ebersole to form an opinion if to continue (technical) diving. The feedback I receive can be roughly divided into 2 camps.
a) Your history is the best indicator of your susceptibility - do not pursue technical diving, and consider giving up diving all together.
b) You most likely have no PFO but might be more susceptible to DCS - dive conservatively and it is reasonable to pursue Trimix diving.

I have also questioned doing further tests, such as a TEE bubble study or a CTA. The feedback I get if a PFO can't be detected with a TTE and it requires a TEE, it most likely is so small that that the benefits of closing it are debatable.

What next...
Currently I feel I'm standing at somewhat of a dead end. I feel there is no clarity whether I can pursue (technical) diving, or whether any additional tests would be beneficial. Or if the results of further tests would change anything in my decision - either no PFO detected so no explanation for my DCS incidents - or very small PFO detected so no use in closing.

So my post is here for several reasons:
a) To tap in the collective (medical) wisdom here what might be going on with me.
b) Anybody been in the same situation? What did you do?

Thanks in advance for your contributions!
Menno

Hi Menno,

The first case *may* be explained, but I'm at a loss to explain the second. As you probably know, it would be highly unusual for DCS to manifest that far out, and it is almost certainly not due to dissolved gas. You could have had a subclinical DCS with some inflammation that was exacerbated by the physical exercise, but that's about all I can come up with. Your case may be deserving of a writeup in the literature, especially since the details are so well-documented. Tagging @Dr Simon Mitchell here - Simon, have you ever seen anything like this?

As to what that says about your future technical diving, if you're otherwise healthy, I don't see why you couldn't continue and dive more conservatively, but that's a recommendation best made by a physician who can examine you in person. Do you live on Grand Cayman?

Best regards,
DDM

 

[Compressor]

Thank you Duke Dive Med.
Common to both cases is a hot shower. I believe that this is not advisable as it may hasten bubble formation (DCS). But VERY unusual to have it so far after the dive unless it was subclinical. Is it possible you had DCS but did not realize it?

And as mentioned about intense physical activity which you describe could be a contributing factor.

I don't think one has to be a technical diver to be a happy diver. You've accomplished a lot and can/should be happy.

 

[Marie13]

I like to remember the adage that “all dives are deco dives,” and weigh how aggressive the diving may be along with possible contributory factors such as dehydration. I have on occasion dived the day after a boozy dinner, or after arriving on a long international flight, but limited myself to baby dives—nowhere near NDL. If I were doing a planned deco dive, I would avoid alcohol entirely. Not to mention hot tubs/showers.

To echo another reply, the second instance, which occurred 77 hours after the dive, is really intriguing. I have been under the impression that DCS appearing after about 48 hours is almost unheard of. Still, it has been said that the mechanism underlying skin bends may be different than other types of DCS, so who knows.

I should have specified NDL dives. Is that better?

 

[Compressor]

For new divers: ALL dives are decompression dives. Some have mandatory decompression stops; some don't.

ALL dives are decompression dives because there is ingassing with increase depth (thus pressure) and upon ascending, the pressure is reduced as one approaches the surface. If dive profile allows ascent to the surface without a stop, decompression is still occurring.

 

[Lorenzoid]

I should have specified NDL dives. Is that better?

I understood. I just wanted to elaborate. The more aggressive the diving, the more careful we need to be about how we take care of our bodies before and after diving.