The difficulty in determining DCS – Anatomy of a Dive Accident

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This is an exact reprint of what I put on my Facebook page, detailing a Dive Incident I had in November. My husband, Dan Volker posted this on my page because we think this should be known by divers - it is very counterintuitive to much diver discussion on DCS.... (I have about 5000 FB friends that follow my exploits and antics pretty closely as you can see if you visit www.facebook.com/sandra.sfdj.edwards )

This story began on a Sunday in November. We were diving on Splashdown Divers in Boynton Beach, Florida, on a day with 3 to 4 foot seas, and we had just finished a 60 foot dive that lasted about 60 minutes. We were diving 33% Nitrox, and after countless thousands of dives that were radically more extreme in depth and duration, Sandra began feeling pains between her shoulder blades about 10 minutes after getting back on the boat.

Sandra told me she was perhaps getting a cramp I could massage out, so we went down into the cabin where we would have room for me to try massaging it out. A few minutes of some trigger point type work did nothing to alleviate the pain, which was growing more intense and now was spreading to her stomach, which was starting to feel both hot and numb.

Now about 15 minutes after surfacing, Sandra said her legs were tingling also along with her stomach. Bells went off in my head, and while I was certain she could not possibly have DCS from such a baby profile, tingling and spreading pain etc. suggested I would need to get her on Oxygen immediately.

I popped up to the top of the boat in an instant, and told the captain what I was doing, then went back to pulling out the Oxygen kit. At about 17 minutes or so Sandra was sitting on the berth in the lower cabin, and now feeling numbness in her legs. By 19 minutes we had her on Oxygen, and I helped lie her down on the floor, breathing it, and believe me, Sandra was scared.

And now she said her legs were paralyzed, she could not feel them. And we relayed to the coast guard that the diver was paralyzed.

Our friend and dive buddy Robert Starling was right there also, and he attended to getting her comfortable, while I headed up to tell the captain what we were doing, and that she would need to be calling the coast guard and heading in. I still did not believe this could be DCS, no way, no how, but we know when these symptoms present, this is what you are supposed to do.

I went over the dive and the events the day before with the captain, and how unlikely this event was, though maybe made possible due to a very intense 3 hour bike ride the day before. There is a “Particle Theory” concept in DCS, where enough inflammation from muscle traumas or lymphatic flow from micro tears, might form bubble nuclei that could turn what should have been an impossibly easy dive into an episode with DCS. This is just theory, it is hard to tie it to the cycling, but we were struggling to make sense of the impossible.

About 20 minutes later we were at the dock, the Ambulance was waiting for us, and the EMT’s came running up to help the diver they heard was paralyzed.

To most, this meant a spinal hit. A huge big deal. But stranger things began to unfold. Sandra Sat up, and told us about 15 minutes after I put her on Oxygen, she suddenly felt blood gushing in her legs, and the feeling came back to them. And now with the EMT’s here, she stood up and walked easily, and said she actually felt great. No pain, no weakness.

Some of the divers were saying how amazing Oxygen is, when you put a diver with DCS on it quickly enough.

The EMT’s took Sandra in the Ambulance, and put her back on their Oxygen. She rode to St Mary’s where she stayed on Oxygen for another hour and a half, until the Hyperbaric Doctor that runs the chamber there arrived, and ran her through a battery of tests. She had no pains, no strength deficits, no reflex issues, and none of the NORMAL symptoms of DCS. Maybe the rapid deployment of O2 resolved the bubbles in her spinal area in 15 minutes. Hard to imagine, but this was the immediate conclusion.

The Hyperbaric Doc then decided since she was presenting no symptoms any longer, she had no reason to go into the chamber…and Sandra did not really want to go in their anyway…she is not the best patient It was hard enough to get her to agree to ride in the ambulance

When we got home we called Divers Alert Network. We were devastated with the news that Sandra had had an episode of DCS, and specifically a spinal hit. We needed to see the best Diving Medicine Specialist we could reach in the State of Florida, and DAN was very helpful in going over the top ten doctors, and in finding the best one for Sandra. We ended up choosing Dr Daniel Grobman in Westin, at Cleveland Clinic. He was both a top Diving Medicine Dr and a diver, AND, he is a top Sports Medicine Doc as well, which we felt was crucially important with Sandra’s cycling issues and potential for micro particle theory discussion. He was on Vacation, but was so committed to divers that his office said he called back right away and would be returning early from his vacation, so Sandra could see him in about 3 days.





We now know an amazing Diving Medicine Doctor we would recommend to all of our friends should they ever need one, and had this not happened, Sandra would not have known she had neck issues that needed to be dealt immediately. Without this episode, they could have gotten to be so bad that she may have needed surgery. If you ever get a dive medicine scare, you can reach Dr. Grobman at 954-659-5930...it is a number to keep with your DAN card and other emergency material.

We now have a program where she should be able to get her cervical spine health to be equivalent to an average 40 year old or better. Who would have ever thought figuring out how you got DCS could go like this?
< continued in following post>
 
I read everything on DCS I had already read for years, and much more again. I chatted with the Duke Diving Medicine guys I know from Scubaboard, and chatted extensively with top tech diving and deco theory friends, Bill Mee and George Irvine. I wrote a paper on everything that seemed relevant, and sent it to Grobman. I was sure of one thing, there is no such thing as an “undeserved hit”, and I would not except this nonsense I had read in so many articles.

And yes, Grobman actually read my word doc, and enjoyed the discussion of the micro particles and bubble nuclei on our first visit.

In this first visit, Grobman was being a detective, and he realized key information was still needed. He scheduled Sandra for 3 MRI’s, Cervical, Thoracic and Lumbar. After this, he wanted a Consult with a top Neurologist in Jupiter.

To make a long story shorter….we go to the Neurologist with the MRI’s, and her biggest most telling question to Sandra was : “ Are you sure you were paralyzed, or could it be that your legs were just numb and weak?” And…..”Did you try wiggling your toes or your feet?”

And of course, Sandra was too freaked, I was too freaked, no one thought of this. And then the neurologist explains that Sandra’s spine has some Stenosis in the neck/cervical area. There is a narrowing of the canal, and there is the possibility of the nerve being irritated or bumped by the canal. Still there was no real change in the assessment, it was still being looked at as a “how did Sandra get DCS?”

In the next week, we spoke at length to Robert Starling again, the friend that had been helping Sandra right after I put her on O2, when I went up on top of the boat with the Captain. In a bombshell revelation, Robert tells us that it was NOT 15 minutes before Sandra felt the paralysis end and the blood gushing into her legs again…it was in fact 10 to 15 BREATHS of Oxygen. Big Wow!

So while I was having difficulty imagining a spinal DCS hit totally resolving in 15 minutes….I was 100% certain that it would be impossible for bubbles to resolve by 15 breaths of oxygen.

Now I knew Sandra had not been bent, but we would still need to get the doctors to see it this way, and to clear her for diving.

This last Wednesday Sandra had her follow up visit to Dr Daniel Grobman. He was very nice when we came in, and while other patients at the Cleveland Clinic were waiting over an hour, we sat in the waiting room for about 3 minutes, and then Dr Grobman walked up to us and invited us to come with him.

I led with the revelation that it was 15 breaths not 15 minutes, and also that Robert had pulled Sandra’s wetsuit off of her soon after she went on the O2, when she though she was paralyzed, and she actually did feel it being pulled off of her legs. And Robert said her legs were showing constant spasms.

Dr. Grobman listened carefully, and without missing a beat, said that he was certain that this had not been a DCS incident, and instead was most likely caused by 3 different things together causing a “perfect storm”…

The day before, Sandra had done an intense bike ride on a race bike which has the seat high up, handle bars quite down hill for aerodynamics, and this means to see where she is going, her neck is massively hyper-extended to look up. Her neck was likely quite inflamed when she woke up that morning.

< continued on following post>
 
Then on the one hour dive, Sandra and I dive with the GUE flat horizontal dive trim…a superman position. This causes a serious hyper extension of the neck if you want to see where you are going. And lifting her heavy camera up to the boat crew on getting back aboard is also a big stress on the cervical area.

The 3rd potential stressor would be the hydrostatic pressure that will occur in rapid descending as we do, where the spine gets compress temporarily by the pressure as we descend. Normally no big deal, but now things were already bad.

As she began presenting in the lower cabin with pain between the shoulder blades, then tingling and numbness in the stomach and then down into the legs, these are all easily connected to the underlying issues of her spinal nerves getting “bumped” by the canal, given the inflammations, pressures, etc. When we laid her flat on her back, to give her the oxygen, it was the flat horizontal positional change, removing pressure from the spine that caused the symptoms to disappear, it was NOT the Oxygen!

Going forward, Sandra has had an entirely new bike fitting by one of the best in South Florida, and now the handlebars are close to the same height as the seat, she is not reaching nearly as much, and the rides are very comfortable…no sore neck after riding. She might not even bike ride on days before diving. She will no longer try to look “GUE-pretty” during a dive….if she is near a muddy bottom, she will do GUE trim as needed. The rest of the time she will consider this to be ill advised and bad for her neck.

I get to lift the heavy camera and heavy gear for her, even more so than before. Now she has a perfect excuse

We now know an amazing Diving Medicine Doctor we would recommend to all of our friends should they ever need one, and had this not happened, Sandra would not have known she had neck issues that needed to be dealt immediately. Without this episode, they could have gotten to be so bad that she may have needed surgery. If you ever get a dive medicine scare, you can reach Dr. Grobman at 954-659-5930...it is a number to keep with your DAN card and other emergency material.

We now have a program where she should be able to get her cervical spine health to be equivalent to an average 40 year old or better. Who would have ever thought figuring out how you got DCS could go like this?
 
Wow what a scary incident. Very glad things worked out ok. One big takeaway is the need to have ALL the facts available when trying to figure out what is going on. Your friend remembering how quickly feeling returned after laying down was a game changer. Sounds like everyone did a good job with the situation. Thanks for posting.
 
What a scare for you all, I was getting scared myself reading it expecting it to get worse until I reached the part concluding that it wasn't a DCS hit after all. I am glad that it wasn't a DCS hit and it was something else you can manage. I wish you all good health and safe enjoyable diving for many decades to come.

I am wondering however if the "GUE posture" is a cause for stress on the neck and other body parts that make it not a healthy posture for the neck/spine in diving.
 
Hi Dan and Sandra,

I'm glad that this episode turned out OK, must have been frightening. It points out the complexity of interpreting an event like this.

I met you both briefly in August 2016, when you loaned me your Excellerating Force Fins to try out.

Very best and good diving,

Craig
 
What a scare for you all, I was getting scared myself reading it expecting it to get worse until I reached the part concluding that it wasn't a DCS hit after all. I am glad that it wasn't a DCS hit and it was something else you can manage. I wish you all good health and safe enjoyable diving for many decades to come.

I am wondering however if the "GUE posture" is a cause for stress on the neck and other body parts that make it not a healthy posture for the neck/spine in diving.
Dan thinks that the GUE posture is quite unhealthy for many people because it causes the diver to hyper-extend the neck to be able to see in front of them. Clearly there are people that have so much neck mobility that it is a non-issue for their neck health..but in looking at populations of people on most dive boats we have been on, I am guessing a large percentage would be a lot healthier doing the GUE superman position ONLY when they need to swim close to the bottom to avoid silting or damaging corals. Dan likes his freedive fins and propulsive efficiency, so he feel compelled to swim flat vertical and to hyperextend his neck to see, much of the time...of course he is usually using dolphin kick or flutter kick with the freediving fins, and not the slow propulsive choice of the frog kick that is practically synonymous with the GUE posture :) ASo now with this new knowledge, he is looking into all possible exercises and stretches that can increase neck mobility so that there would be less hyper extension inflammation...and in chiropractic and other treatments that might mitigate the less beneficial aspects of the GUE trim he still insists on :)
 
That must have been a truly frightening experience but glad that it will ultimately lead to better spinal health! I too have fairly significant neck and low back issues and for much of my diving, especially drift diving, I use what you might playfully call a “modified GUE”


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