DCS type 2 case

[Duke Dive Medicine]

Interesting. Thank you for the additional details.

First, standard of care for suspected decompression sickness is immediate recompression, especially if there are neurological symptoms. I can't imagine why they would leave you on O2 overnight with worsening symptoms unless they were in doubt about the diagnosis.

That said, your improvement with hyperbaric treatment lends some credence to the diagnosis of DCS. If symptoms do not resolve with the first treatment, standard of care is daily serial hyperbaric treatments until symptoms resolve or improve to a plateau. From what you've relayed, the crew there are unaware of this and it is distressing that they would laugh at you. For reference, here's a link to the U.S. Navy Supervisor of Salvage website so you can download the Navy Diving Manual:

Naval Sea Systems Command > Home > SUPSALV > 00C3 Diving > Diving Publications

I'm not sure what to say about the focal facial paresthesia except that it's an unusual symptom of DCS recurrence.

Second, recurrence of DCS symptoms on a flight over a year after the original insult would be so unusual as to be publishable, especially if they didn't recur on your flight home to Europe from Indonesia. I have personally never heard of this and am not aware of any literature that documents it - if anyone is, please share. I doubt that it's related to your injury and it makes me wonder if the original diagnosis was correct.

Of course all of this is speculation. Your best course would be to follow the other posters' recommendations and continue to follow up with your treating physician. If you haven't already, I'd recommend seeing a good neurologist as well.

Re the PFO test, given the information you've provided, the indication for a PFO test would be slim and I would be hesitant to make any diving recommendations based on the results. If you have a PFO it's probably a red herring.

Best regards,
DDM

 

[**pYgmY**]

Thanks for your message!

Unfortunately the hyperbaric chamber there is not available 24h, there is no trained staff for emergencies during night time. I guess they might call them in if they have a very severe case but they obviously didn't think it was necessary for me. That's why I was only put on oxygen..

What you explain about the standard care is something that I only know now since I had the chance to do some research, but is definitely not what they did/do in Bali. After the 2-minute check when I arrived at the hospital I did not see another doctor again until they brought me to the chamber the next day (they did not do a neurological assessment, only checked the strength of my handshake and asked some questions). A nurse came at some point to tell me that they had arranged an appointment for the USN TT6 at 9am, but when I got to the chamber they have already put 5 locals in for a 2h ride (no emergencies). So I had to wait another 3 hours to finally start treatment.

I asked several times but the dive doctor as well as the Australian chamber technician kept telling me that 1 single USN TT6 is their standard treatment and that it will be enough as it removes all residual nitrogen. I only went back because the dive doctor at home said that chamber treatments can be effective up to 14 days after injury, so I thought I'd better give it a try.

Looking back on the whole procedure, I find it quite alarming that on an island like Bali - with tons of nearby divesites and heaps of diving travellers - they have a hyperbaric chamber but don't know the international treatment standards. It could have been worse but I had to take care of many things myself.

Can I ask why you don't think a PFO could be the cause for the DCS?

Just one more thing: The flight which resulted in the recurrence was only 7 weeks after my last dive and 3 weeks after my flight home from Indonesia.

Kind regards

 

[Duke Dive Medicine]

Oof. I got thrown by the European date. Sorry. Still, a DCS recurrence on the airplane that far out, after you'd already had a flight with no symptoms and been asymptomatic after, would be difficult to explain.

PFO is associated with severe, sudden-onset neurological DCS, inner ear DCS and cutis marmorata. Your symptoms don't fit that description IMO. I would of course defer to the diving physician on-site, but given your description of your symptoms and their progression we would probably not test you for PFO.

Best regards,
DDM

 

[**pYgmY**]

Thanks, interesting aspect about the PFO, I did not know this.

Assuming the symptoms are DCS related - what is your experience regarding the prognosis for residual tingling? Does this usually resolve with time?? It's getting less intense, I just never expected symptoms to linger for such a long time.

 

[Diver0001]

So first question: do those dive profiles look terribly wrong to you?
day 1 15:00: 15m / 42min
day 2 10:00: 26m / 62min
day 2 15:00: 22.4m / 37min
day 3 08:15: 28m / 45min
day 3 11:00: 28m / 41min
all dives done with a 3min safety stop at 5m

I can't advise you about the DCS hit and Dr. D already seemed to have answered your questions. Your story does seem unusual to me in some regards, such as the 8 hr delay before initial onset and the recurrence after a year. However, I'm not a doctor, I'm just a diver and I've never been bent so I don't know much beyond what the book says.

I'm actually replying because you asked about these dives. That is something I do know a bit about. Personally I wouldn't have been the least bit concerned about making those profiles provided
a) the computer did not go over the NDL's
b) you maintained a good ascent speed.
c) you were not cold during the ascent phase, working hard on the bottom or fatigued.
d) you did not perform any intensive sports like weight lifting within 6 hours after the dives.

The nearest thing to what you have experienced that I've seen with my own eyes was a buddy of mine who pulled a muscle in her shoulder lifting her set up. The set was full of integrated weights. The morning after our first day of diving her shoulder started aching terribly as we were getting ready for the morning dive so she skipped the dive. By lunch time the pain had gotten bad so we took her to a nearby hospital with a hyperbaric chamber. The doctor diagnosed it (correctly as it turns out) as musculoskeletal and gave her some pain killers. She was sent home (in this case home was a dive camp where we were staying) and he visited her the next day where he once again said that he thought the tenderness was strain related. The pain she had was intense enough that she had to sleep pretty much sitting up for 2 days and she missed the better part of a week of diving.

I thought I would share this story with you because while her symptoms were different the fact that yours started in the shoulder/trapezius area and there was a long onset before you really started having issues with it, sounds to me (and once again, I am NOT a doctor) more typical of muscle injuries than DCS. When I initially read your story I wondered if you didn't have a pinched nerve in your neck that could explain the other symptoms you were having including the initial symptom of pain in the trapezius. A pinched nerve could also result in a tingling/burning sensation and weakness so it also seem to me -- as a complete layman -- to fit the symptoms you were having, save one, which is that it improved after a session in the chamber.

Did you or your doctor consider this option at the time?

R..

 

[Duke Dive Medicine]

Thanks, interesting aspect about the PFO, I did not know this.

Assuming the symptoms are DCS related - what is your experience regarding the prognosis for residual tingling? Does this usually resolve with time?? It's getting less intense, I just never expected symptoms to linger for such a long time.

Hi **pYgmY**, residual symptoms can take weeks to months to years to resolve, so the fact that you've noticed improvement is reassuring. There is no predictable time line since individual cases vary so much, but the majority of symptoms tend to resolve with time.

Best regards,
DDM

 

[KeithG]

I can't advise you about the DCS hit and Dr. D already seemed to have answered your questions. Your story does seem unusual to me in some regards, such as the 8 hr delay before initial onset and the recurrence after a year. However, I'm not a doctor, I'm just a diver and I've never been bent so I don't know much beyond what the book says.

I'm actually replying because you asked about these dives. That is something I do know a bit about. Personally I wouldn't have been the least bit concerned about making those profiles provided
a) the computer did not go over the NDL's
b) you maintained a good ascent speed.
c) you were not cold during the ascent phase, working hard on the bottom or fatigued.
d) you did not perform any intensive sports like weight lifting within 6 hours after the dives.

The nearest thing to what you have experienced that I've seen with my own eyes was a buddy of mine who pulled a muscle in her shoulder lifting her set up. The set was full of integrated weights. The morning after our first day of diving her shoulder started aching terribly as we were getting ready for the morning dive so she skipped the dive. By lunch time the pain had gotten bad so we took her to a nearby hospital with a hyperbaric chamber. The doctor diagnosed it (correctly as it turns out) as musculoskeletal and gave her some pain killers. She was sent home (in this case home was a dive camp where we were staying) and he visited her the next day where he once again said that he thought the tenderness was strain related. The pain she had was intense enough that she had to sleep pretty much sitting up for 2 days and she missed the better part of a week of diving.

I thought I would share this story with you because while her symptoms were different the fact that yours started in the shoulder/trapezius area and there was a long onset before you really started having issues with it, sounds to me (and once again, I am NOT a doctor) more typical of muscle injuries than DCS. When I initially read your story I wondered if you didn't have a pinched nerve in your neck that could explain the other symptoms you were having including the initial symptom of pain in the trapezius. A pinched nerve could also result in a tingling/burning sensation and weakness so it also seem to me -- as a complete layman -- to fit the symptoms you were having, save one, which is that it improved after a session in the chamber.

Did you or your doctor consider this option at the time?

R..

i agree that there may be value in considering other causes. pinched nerves are nasty.

i have bone spurs in my neck which causes pinched nerves. due to the random appearance and disappearance and wide variation of symptoms it took several years to properly diagnose my condition.

trigger events can vary, but episodes most often ocur when there has been a physical change in my routine. and scuba trips are top of the list: being jammed into an airplane seat too long, sleeping on a different mattress, sleeping with a different pillow, lugging heavy gear, cranking my head around to look at things underwater,....

 

[**pYgmY**]

@Diver0001 & giffenk:
Thanks for sharing the stories, definitely something that has to be considered. I agree that the pain in the trapezius area might have just been from carrying the tanks - I have not had it again, it completely disappeared.

I have been to a dive doctor, neurologist, physical therapist and osteopath though, all of them more or less saying that for the rest of my symptoms, with their exact location and history, a pinched nerve as the cause is not on top of the list. Esp. the dive doctor saw the DCS diagnosis confirmed - just like you guys said as well - since I have felt better after every chamber treatment and the symptoms even resolved. The therapists worked on connective tissue, muscles and craniosacral to take away pressure from the nerval system, which helped but didn't eliminate the symptoms yet. I will continue with treatment for a while anyway.

But you're right, I might never know about the cause for sure. Somehow there seems to be no obvious reason why the symptoms returned on that flight. If I had known that I put myself at risk of a recurrence I wouldn't have been on that plane..

For the dives: no NDL exceeded, ascent speed was fine, no cold, no exercise. I really don't have much of an idea what I did wrong.

@DDM: Thanks for explaining, very relieving to hear that from someone experienced!! It's easier to stay patient if there's still a chance of a full recovery.

Best regards,
pYgmY