Bad Luck

[deepsix]

I am new to the sport, I did my OW and AOW back to back. I have only got 11 dives under my belt, and I'm affaird that is all I'm going to get. :upset: On my 11th dive I got bent. The whole dive was bad from the start. Now that I think about it I know that I did a few things wrong on that dive, but I did stay with in the dive table limits plus I did have a dive computer. Lets blame the whole thing on inexperience.
Any way I'm not here to dwell on the past I'm more concerned about my future. I wish I knew then what I know now about DCS.
It has been about a month now and both of my legs are still numb. I have been to the hyperbaric chamber. 7 hours worth five one day two the next. No help, probably because it was 2 days after the dive. The kicker is the doctor is the one that told me I was border line go home and he would call me the next day.
I have been told that I have nerve damage and I'm still waiting to have tests done to find out how much nerve damage there is.
I would like to know how long this is going to last. Some people say I'm looking at six months others say weeks others say never.
Any way this is what I would like to know, and I have been told different things already.
1) If or when this all clears up can I dive again?
2) If this does not clear up and my legs stay numb can I dive at shallow depths 60 feet or less?
3) Whats the risk if I do?
4) Can I get bent easier now?
5) Does water temp play a factor I was in 43 degrees F
If so that bites because I was in a wet suite but my dry suite was supose to be in.
6) I know that you should not fly after diving but is it safe for me to fly now?
I know there is alot more for me to learn finding this web site has helpped. It may not always be the case but in the different stories I have read about DCS one thing amoung others that I have noticed is that the simtoms come then they go so people think they are fine or it was no big deal and next thing you know there back again. That is what happened to me with in five minitues of being on the boat I got hit hard my legs and arms and one side of my neck went totaly numb. I could barel stand up. By the time I got to shore and all my gear off I was normal again as if nothing I ever happened. So I went home, took a hot shower at that time I did not know that was a no no. Went to bed and the next moring was numbess was back no wears as bad as the night before. It has been the same ever sence. Any way any help that any one can give it would be nice thank you.

 

[art.chick]

I have a diving aquaintance who has been bent. He dives every weekend now. He is not supposed to go below about 35'. I don't know how long he had to wait, or what may make his case different than yours. Just thought I'd let you know that others have lived to dive another day even after the pain of DCS. Sorry to hear about your suffering.

 

[mtdivegirl]

Deepsix,
Sorry to hear about getting Bent. I don't want to ask you to dwell in the past but I am curious (since I am a new diver) what you think you did wrong?
Any information you can provide about the dive would be appreciated.
Hopefully one of the great MD's on this board can provide you with some of the information you are looking for.

 

[Spectre]

I'm not a doctor either, but I know a few answers...

Originally posted by deepsix

1) If or when this all clears up can I dive again?
2) If this does not clear up and my legs stay numb can I dive at shallow depths 60 feet or less?

Yes... your doctor won't like it, and it's a risk, but yea, if your careful you can continue diving.

3) Whats the risk if I do?
4) Can I get bent easier now?

That's the catch. you are going to have to be _extremely_ conservative because you will be much more suceptable to getting bent. I dove with a guy in NC that had been bent a couple times, and then a few more after that staying well within limits. He now is the first one in the water, and the last one out... he now hangs for at least as long as the dive

5) Does water temp play a factor I was in 43 degrees F

Yes. I don't remember which part of it [circulation, shivering, etc...] is the reason, but yes, cold water increases your risk of DCS.

6) I know that you should not fly after diving but is it safe for me to fly now?

What's done is done... flying is fine. However if/when you start diving again, I would be overly conservative on that end as well.

My recommendations [remember, you get what you pay for, and this is free advice!]... Take it slow getting back in the water when you feel your ready. When your ready, I would recommend you get nitrox certified [if you aren't already], and dive on mix with air tables. Plan your gas supply and dive so you can hang for extended periods [e.g. minimum of a 10 minute safety stop].
Good planning would be start your ascent with half your supply, and then just hang until your down to 500 psi.

Best of luck... you have a difficult road ahead if you choose to continue diving...

 

[Dr Deco]

Dear deepsix:

Ouch!

That was certainly a lot for a new diver. One is probably wondering if there was something that I could have changed. Very possibly there was not (other than not going to pressure in the first place). Concerning your questions, I am not speaking here as a clinician (since I am not one) but rather as a research scientist. Remember that there is a certain risk even if everything has been done right. In our lab tests, some test subjects will get the bends - - and no one did something wrong.

Can I dive again?

There simply are some individuals who are more susceptible to DCS than others. This may be the result of some factors such as fitness (which seems to govern blood flow through tissues) and hence nitrogen off gassing. Or it might result from biochemical factors that control micronuclei size and stability. Additionally one could have an anatomical problem (a hole) in the heart (a PFO) and be prone to arterialize bubbles (bubbles move from the veins to the arteries)

If you have encountered a problem, it indicates that you might be more susceptible and thus should minimize inert gas loads. The small loads result from an outright avoidance of diving altogether. Harsh - - but some have chosen this path.

If my legs stay numb, can I dive at shallow depths?

If you legs remain numb, it indicates that you have a neurological problem that has not resolved. If this were the case, you have developed nerve damage and probably could not sustain more. That is, another diving injury (in a possibly “prone” individual) would result in a total loss of all nerve fibers. There are no longer any more nerve fibers to carry the necessary signals. Since some diving injuries can occur at very shallow depths, this is unadvisable on the basis of physiology and mechanisms.

What’s the risk if I do?

Let us assume that all was done correctly. Then this case might indicate that you are a sensitive individual with respect to acquiring DCS. I would look for another sport. If something were done incorrectly (you climbed a ladder with you gear on and then performed a Valsalva-like maneuver) then I certainly would not do that again. Not having been there, I cannot say. Even if I were there at the time, I doubt I would have seen some egregiously wrong. You have sustained a neurological injury, and that is very serious, especially for a recreational diver. Furthermore, that injury has NOT resolved after several weeks.

Can I get bent easier now?

This is a question that cannot be answered with the available data. However, if everything has been done correctly, then you may be a bends-prone individual. If that is true, then you can get “bent” again. Even if you are a resistant individual, you can get DCS again.

Get DCS once does not mean, however, that you are now more “sensitive” to nitrogen or bubbles.

Does water temp play a factor?

Water temperature does play a role. It is more important, it seems, if the diver is moving a lot to maintain body temperature. Simply being cold is actually “protective” since blood flow is reduced to the extremities. Being warm in the water and cold on the surface is the condition that is the most problematic.

Is it safe for me to fly now?

At several weeks post incident, it would really not be possible that a gas phase still remains. Therefore the situation of reduced pressure in an airplane cabin should not present a problem with respect to exacerbation of DCS.

Please note

Please remember that I am speaking to this situation as if it were a condition brought on by a free gas phase in the body. The possibility exists that you have some other nerve problem that occurred when you were diving. This is always a possibility. It is not indicated whether you have numbness (and weakness) is BOTH arms or just one side. Do you have numbness in both legs or just one leg (is it the same side as the arm?)?

Your local physicians will need to make a medical assessment.

Dr Deco :doctor:

 

[zelevin]

Originally posted by Dr Deco
If something were done incorrectly (you climbed a ladder with you gear on and then performed a Valsalva-like maneuver) then I certainly would not do that again.

Huh? I don't think I'd ever do what you describe above, but what is wrong with it?

 

[The Iceni]

Originally posted by zelevin


Huh? I don't think I'd ever do what you describe above, but what is wrong with it?

Hi zelevin. You could have a patent foramen ovale.

If the moderators will forgive me I will attach an edited copy of an article on this very subject wrote for my own dive club's magazine;-

"A patent foramen ovale (PFO) increases the risks of DCI which is caused by bubbles produced when nitrogen and/or helium come out of solution and these bubbles are more likely to form where the pressure gradient is greatest and micronuclei present. As the pressure in the arteries is much greater than in the veins the pressure gradient across nascent bubble nuclei is greatest in the capilliaries and veins so this is where bubbles are more likely to form. It is now believed that small bubbles always form in the veins during the ascent from any dive. Thankfully blood from the veins must first pass through the right side of the heart and then to lungs, where even the smallest in size are mopped up by lodging in the pulmonary capillaries, where they do little damage.

Although bubbles can form in the tissues, causing localised damage (usually type I DCI) a significant cause of DCI is when bubbles find their way into the body's arterial circulation. When in the arterial circulation the bubbles subsequently lodge (embolise) in the small vessels of the vital organs such as brain, spinal cord and even the heart (the coronary circulation) where they can cause a heart attack in an otherwise healthy heart. Obstruction of the arterial supply to these organs stops the supply of life-giving oxygen, causing the damage frequently recognised as DCI type II.

In an adult there are two circulations left and right, which act in series. The left ventricle pumps blood around the body at high pressure, which is then returned to the right side of the heart where the right ventricle pumps exactly the same amount of blood to the lungs, but at a significantly lower pressure.

A PFO is a persistent, usually flap-like opening between the two atria of the heart. It is essential to intrauterine life where the lungs cannot function and very little blood passes through the pulmonary vessels. In the foetus both sides of the heart act in parallel. This means that the right ventricle receives some of the venous return from the body and most the blood that is normally pumped through the lungs by the right ventricle finds its way directly to the aorta (a part of the left side of the circulation),via the ductus arteriosus another intentional right to left shunt.

After birth the lungs expand, the pulmonary vessels open up and the pulmonary circulation becomes established. The increased left atrial blood flow and pressure results in functional closure of the foramen ovale simply because of this pressure change. In the majority, the flap valve is subsequently permanently sealed. However, closure is incomplete in up to 25-35% of adults in which case a small percentage of high pressure blood from the left atrium finds its way into the right atrium depending on the size of the defect; a left to right shunt.

By itself a left to right shunt is not problematic for divers, since as we know this blood goes to the lung filter. There are circumstances, however, when the shunt is reversed. This occurs when the right atrial pressure is greater than the left. Examples include coughing and sneezing and the end phase of the Valsalva manoeuvre, when the pressure within the rib cage is temporarily increased and then released. This is also a feature of pulmonary barotrauma. If bubbles are present in the venous blood they can find their way into the arterial circulation by the means this right to left shunt and cause an "unexpected" DCI, particularly the more serious type II.

Echocardiography can demonstrate the presence of a PFO, which can be found in up to 20% of healthy adults and is now routinely performed after any type II DCI hit. In the general population there is a strong association between the presence of a PFO and the risk of stroke which is four times normal. Most strokes are caused by embolisation of small clots that are frequently seen in the venous circulation. Like strokes, the risk of DCI is increased by the size of the defect.

At present echocardiography is not useful for the screening of diver recruits. It is expensive, at over £600 a time, and it is not always accurate. However, when detected, a PFO can be closed by an umbrella device, which is inserted via a peripheral vein and thence into the heart."

So, zelevin. This is "what is wrong with it".

I hope you understood the article and found it useful.

The attached schematic of a foetal heart shows the functional PFO together with the great veins. The trunk of the aorta and the origins of the pulmonary arteries (and the ductus arteriosus) are hidden from view but are at about the level of the (mitral and tricuspid) valve cusps.

 

[DocVikingo]

Hi Zelevin,

In response to DrDeco's remark, "If something were done incorrectly (you climbed a ladder with your gear on and then performed a Valsalva-like maneuver) then I certainly would not do that again," you inquired, "what is wrong with it?"

From my view, there are two issues that need to be addressed:

1. The caution about climbing the ladder with your gear on relates to the production of tiny bubbles, sometimes referred to as microbubbles, micronuclei or seed bubbles, that are believed to be one of the components necessary in the cause of decompression sickness (DCS).

Heavy strain on joints, such as might occur to the knees in the above example, may produce such bubbles. As the knees are stressed while climbing, the rapid tearing, or moving apart, of tissue interfaces can result in the generation of seed bubbles.

Composed mostly of water vapor, these seed bubbles serve as ready receptacles for nitrogen passing from the dissolved stage to the gas-phase. As pressure drops with ascent during the dive, dissolved nitrogen molecules can move into these seeds, and can cause them to grow to a size where they have the potential to result in DCS.

For this reason, it seems wise to avoid heavy exertion & stresses on the joints shortly following a dive.

2. The caution about Valsalva-like maneuvers relates to problems that can result if you are among the 25%-30% of adults who have an abnormality of the heart known as patent foramen ovale (PFO).

Dr. Thomas' excellent coverage of this condition well describes the anatomy of PFO and why it is worrisome in divers. I wrote a similar piece for my "Ask RSD" column in the Apr '00 issue of "Rodale's Scuba Diving." I'm going to reprint a modified version here to make it easier (hopefully) to understand:

"PFO is an abnormal opening between the right and left upper chambers of the heart.

It is normal for blood to flow through a small opening between these two chambers during fetal development when the lungs are inoperative and blood is oxygenated by the mother. At the moment of birth, however, changes in chamber pressures cause this opening to close, shunting blood to the now functioning lungs.

While usually permanently sealed by the 3rd month of life, this does not always occur; about 25%-30% of people have an incomplete closure of varying size. Without complete closure, blood can flow from the right to the left side of the heart without passing through the lungs. The majority of otherwise healthy persons with PFO, many with only small openings, are entirely unaware they have the condition. It typically requires no treatment in the adult.

Of significance to divers with PFO is the increase in right chamber pressure that occurs with common equalization techniques like the Valsalva maneuver. Under this condition, nitrogen bubbles that can form in the veins during ascent may pass directly into the arteries without the filtering action of the lungs.

Studies have shown that a high percentage of divers who had otherwise unexplained incidents of DCS, especially Type II DCS (signs & symptoms caused by bubbles interfering with nerve function, such as numbness & loss of strength or muscle control), turned out to have PFO. In addition, the risk of severe decompression sickness appears to be about three to five times greater in those with PFO as compared to the general diving population.

PFO is often diagnosed by routine echocardiography, a simple procedure where sound is passed through the chest wall to the heart and the echo measured. If abnormalities are detected or suspected, this may be followed up with a more complicated echocardiogram where the sound transducer is passed down the throat to the region of the heart.

Despite the finding of increased risk of DCS in divers with PFO, the risk is still quite low. Most dive medicine experts do not recommend echocardiogram as a routine procedure in healthy divers. However, a history of unexpected DCS, especially Type II, or multiple episodes of any type, are reasons to further evaluate for the possibility of this cardiac defect."

Hope you found this informative.

DocVikingo

 

[zelevin]

Paul & DocVikingo -

Originally posted by Dr Paul Thomas

By itself a left to right shunt is not problematic for divers, since as we know this blood goes to the lung filter. There are circumstances, however, when the shunt is reversed. This occurs when the right atrial pressure is greater than the left. Examples include coughing and sneezing and the end phase of the Valsalva manoeuvre, when the pressure within the rib cage is temporarily increased and then released.
[...]
So, zelevin. This is "what is wrong with it".

I hope you understood the article and found it useful.

Thanks; yes, I understood the article (I got a couple of degrees in nuclear physics); and it is quite illuminating.

So - let me see - is sneezing when getting out of water potentially dangerous as well for people with PFO? Ouch.

Curious -

- Vladimir

 

[DocVikingo]

Hi Vladimir,

Yes, any event that increases right atrial pressure, like sneezing when exiting the water, is potentially dangerous to the diver with PFO.

Best regards.

DocVikingo