Had a disturbing incident yesterday...

[Dr Deco]

Hi Dan:

As others have said, this does not appear to be DCS. Also, "a bubble" does not cause CNS DCS. It takes more air than that. The concusion hypothesis seems much more plausable.

You really did temporize in getting this looked at. Brains often do not tolerate time delays very well.

 

[Duke Dive Medicine]

Dan,

Neurological symptoms immediately following a dive, even one with a "nothing" profile and even if they appear to resolve spontaneously, need to be worked up immediately. It can be difficult to discern subtle neurological symptoms in yourself, so we discourage self-diagnosis. I'm loathe to disagree with TSandM because emergency medicine is what she does (and after I posted this Dr. Powell weighed in) but I'll stick my neck out - I think you need to be seen ASAP. St. Mary's Medical Center in West Palm Beach has a 24-hour hyperbaric unit with staff that can evaluate divers.

Best regards,
DDM

 

[danvolker]

Hi Dan:

As others have said, this does not appear to be DCS. Also, "a bubble" does not cause CNS DCS. It takes more air than that. The concusion hypothesis seems much more plausable.

You really did temporize in getting this looked at. Brains often do not tolerate time delays very well.

In any event, I am dealing with it now. I appreciate the insights I am gaining from you and the others here. Thanks.

---------- Post added September 1st, 2013 at 06:24 PM ----------

Dan,

Neurological symptoms immediately following a dive, even one with a "nothing" profile and even if they appear to resolve spontaneously, need to be worked up immediately. It can be difficult to discern subtle neurological symptoms in yourself, so we discourage self-diagnosis. I'm loathe to disagree with TSandM because emergency medicine is what she does (and after I posted this Dr. Powell weighed in) but I'll stick my neck out - I think you need to be seen ASAP. St. Mary's Medical Center in West Palm Beach has a 24-hour hyperbaric unit with staff that can evaluate divers.

Best regards,
DDM

Thanks for your advise.....I will try and get to the bottom of this now.

 

[danvolker]

After the CT scan showed nothing, I saw a the hyperbaric Doc an hour ago......His take is that the only thing that makes sense is a temporal lobe seizure --brought on by Oxygen toxicity --even though it was only a 100 to 110 foot dive, and I was on 33% nitrox, his experience with car accident victims they put in the chamber ( for burns, healing, whatever) are that sometimes the brain injuries will cause an ox tox event that triggers this temporal lobe seizure...and the memory lapse issue is a typical result of these.

He said if I had done the wreck on air, I probably would not have had any problems.....which is not to say he is giving me the green light to a 100 foot air dive ....now I need to see a neurologist, after I call DAN and chat with them over this....

So some of the idle thoughts bouncing around my in my head now....We know that high oxygen mixes ( Nitrox) will create super oxide free radicals in higher percentages than are ideal for our body/brains.....and that perhaps very high levels could precipitate an ox tox event... It would be my assumption that this is a chemical imbalance/poor equilibrium, as a result of the physical trauma of the crash 2 months ago....While the CT Scan shows no damage, it is not showing chemical equilibriums.....The blood work ups the Del Ray Trauma Ctr did showed nothing, but I am pretty sure this was just ;ooking for clotting issues, and nothing that would relate to the chemistry that would precede a temporal lobe seizure.

I would expect I will be "better", sooner, if I start supplementing more heavily with astaxanthin, with High Gamma Vitamin E, and maybe some High DHA Omega 3's...hoping this would help restore the proper equilibriums in my brain. I have also hear super oxide dismutase is effective for this, but it is one supplement I have never tried.

Any suggestions?

 

[Duke Dive Medicine]

After the CT scn showed nothing, I saw a the hyperbaric Doc an hour ago......His take is that the only thing that makes sense is a temporal lobe seizure --brought on by Oxygen toxicity --even though it was only a 100 to 110 foot dive, and I was on 33% nitrox, his experience with car accident victims they put in the chamber ( for burns, healing, whatever) are that sometimes the brain injuries will cause an ox tox event that triggers this temporal lobe seizure...and the memory lapse issue is a typical result of these.

He said if I had done the wreck on air, I probably would not have had any problems.....which is not to say he is giving me the green light to a 100 foot air dive ....now I need to see a neurologist, after I call DAN and chat with them over this....

Interesting. I'm curious about the knock to the head you took in the bike accident. Did you ever have any neurological symptoms from it? Loss of consciousness, altered level of consciousness, anything at all? The only thing you mentioned in your initial post was your otoliths.

Best regards,
DDM

 

[danvolker]

Interesting. I'm curious about the knock to the head you took in the bike accident. Did you ever have any neurological symptoms from it? Loss of consciousness, altered level of consciousness, anything at all? The only thing you mentioned in your initial post was your otoliths.

Best regards,
DDM

Hi Doc,
The bike crash was a 30mph crash, but I am built more like a powerlifter than a typical cyclist, and the crash was mostly bad for brush burns/road rash....also a cracked rib ( long since healed with K laser treatments)...

My helmet cracked--bike helmets are supposed to on impact.....I should have had an inner liner to further cushion the impact, but it had come detached and I had not replaced it yet...so there was maybe a half inch of head travel possible inside the helmet..... I remember the falling motion in the crash, and the impact to the left side of the helmet did not hurt....there was no pain in my head afterward, and there was no headache at any time after this....However, when I did go to lie down after getting cleaned up, there was major vertigo on getting my head flat--for about a minute. This was treated by the therapy for restoring the correct placement of the crystals in the middle ear, and just prior to the dive, I would have said this vertigo issue was 98% eliminated..now I would put it at maybe 94% eliminated....I do feel a little mild vertigo for about 3 seconds when I lie flat now....this as a result of the dive or the seizure.

But again, there was no loss of consciousness....and I was on my feet within about 10 seconds after the crash...the reason it was not 1 second was that the rib issue did not feel good....and I sat there a few more seconds to make sure that it was only the rib(s) that appeared to have been broken. A lifeguard from the beach we were next to ran over and was cleaning the road rash within about 45 seconds....he had been about 50 feet away when my sprint was interrupted by the chain ripping off the cluster, and my resultant acrobatics. I have been a cyclist since the 80's, and have been in plenty of pack crashes that were worse..felt worse...though never with a helmet so foolishly compromised. Still, the impact seemed minimal.....Sandra could hit me harder

---------- Post added September 3rd, 2013 at 06:03 PM ----------

So after looking up temporal lobe seizures...This does NOT seem to me to be a useful description of what occurred.... I can see Oxygen toxicity with the Nitrox as being involved, with some chemistry changes from a bike crash...but the symptoms shown for Temporal Lobe Seizures fit me about as well as "Athlete's Foot" would fit a guy with no legs.

The issue was caused by Nitrox and depth....Ox tox is going to happen to 100% of the diving population at some depth, on 33% nitrox....on some higher than others....and there are factors that will predispose a person to being more likely to experience the Toxing event on some days over others.....Probably heavy alcohol consumption would be likely to bring this on at shallower depths, and potentially kick boxing or other sports -- where a head impact could change the brain chemistry for the oxygen tolerance at depth, would suggest that in ALL people with this behavior, a memory loss event could be triggered.

I need to pursue this direction, because I think it is foolish of me to allow a mis-labeling of what happened ---if I accept a mis-diagnosis, or an incorrect explanation of what occurred, I could end up disqualifying myself from diving( by medical release forms).... I am more concerned about this right now, than anything else. Ox tox I will accept as an answer.........How the rest of this is described, how I can determine the way to correct the chemistry issues to the point of Ox tox no longer being a possibility, this is where I need a different classification or explanation.

I just heard from one doc that any seizure will disqualify a person from all future diving...... However, I also know that 100% of divers will tox...will have a seizure if you put them too deep on a high oxygen mix. How I get pidgin holed by broad brush approach, is something I need to FIX right now. For the purposes of this issue, the Hyperbaric Doc asked me some questions, did no tests, did not look at the CT scan....He just decided what this sounded like to him....this does NOT suggest to me that I need to accept this as a category of chronic injury....I think it needs to be specified as being a high oxygen injury..like someone breathing 40% at 150 feet and toxing.

 

[chrpai]

Dan, I read what you wrote and I'm not medically qualified to challenge your conclusions but I caution you to please be safe. You may or may not have some short term / long term / chronic predisposition to ox tox.... but how can you know for sure? I know diving is your life and your love... but do you want to take that chance? I assume at some point the answer will be yes so please be as informed as possible about the level of risk.

 

[uncfnp]

Dan, just a few thoughts:

It is a common misconception that you need a loss of consciousness to have a concussion or TBI. But it is true that there should be some symptoms post injury and I wonder if your vertigo was a symptom of concussion rather than simple inner ear. Dizziness is a common symptom in post concussion syndrome and the fact that you hit hard enough "that the crystals in my middle ear dislodged" tells me that you may be underplaying the impact.

I only deal with the more immediate evaluation of TBI but I know the most important initial treatment is rest, both physical and the more often overlooked brain rest. As for the role of supplements in restoring brain health, I'm skeptical but admit I am woefully uninformed in this area. As you may know, I am a huge proponent of health, physical fitness and nutrition (I should follow more of my own advice) but look at supplements much as I do drugs. They are drugs and the ingredients are poorly controlled and I worry about what may actually be in them. Yes, if you have a disease or health issue, medications or suppliments are often needed but I am skeptical that pills of any type will make us healthy. Fitness and nutrition are the keys to Heath and I know you do both in abundance, that is a factor heavily in your favor.

As for future diving, you are getting way ahead of yourself but I can certainly understand your concern. Relax, take it easy, see the neurologist then revisit the oxtox/seizure concern.

 

[tracydr]

You bought a new helmet, right?

Better yet, you bought TWO, so the next time you crash and crack your helmet (as we all know they are designed to do) you can throw it away and use the other one.

Don't bike helmet suppliers replace helmets after you've fallen for free? Horse helmet manufacturers do. You send it in and they send you a brand new helmet. Every time you fall. Many hunter/jumper and foxhunters that I know have two helmets at all times, just for this reason. If you have any sort of fall at all you're supposed to send it back.
I was told the helmet companies want you to do this because they conduct tests on every helmet that takes a fall.

 

[danvolker]

Dan, I read what you wrote and I'm not medically qualified to challenge your conclusions but I caution you to please be safe. You may or may not have some short term / long term / chronic predisposition to ox tox.... but how can you know for sure? I know diving is your life and your love... but do you want to take that chance? I assume at some point the answer will be yes so please be as informed as possible about the level of risk.

Hi Chrpai,
I appreciate you responding here...As to the question on my predisposition to Ox tox, it is the right question, but the answer is not as simple as I would like...
In the 90's, I did many hundreds if not well over 1000 deep air dives between 225 and 280 feet....this is a very high PO2...as you know
I even had one 240 foot deep spearfishing incident, where I shot a 60 pound grey grouper, and on trying to brain it, it was beating the heck out of me in a fight --at depth on air...and I hit very high breathing rates, and suddenly felt very strange and not right--and deduced this was ox-tox coming on, so I puched my inflator, blasted from 230 or so to about 100 feet, then chilled and felt much better in a few minutes...no complications beyond that....from then on I used powerheads on deep dive spearfishing

So here is my issue--and I help some of the medical minds on this forum will help me with this....

I do not accept a snap judgement of a hyperbaric doc, after about 3 minutes of Q& A. There are just too many possibilities not even considered by him...

For instance....

• [FONT=&amp]And this begins with the "IF" of whether this was a seizure....Sometimes a seizure is related to a temporary condition, such as exposure to drugs,withdrawal from certain drugs, a high fever, or abnormal levels of sodium or glucose in the blood. If the seizure or seizures do not happen again once the underlying problem is corrected, the person does NOT have epilepsy. [/FONT][FONT=&amp]Pasted from<[/FONT][FONT=&amp]http://adam.about.net/encyclopedia/infectiousdiseases/Epilepsy.htm[/FONT][FONT=&amp]>
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• A concussion involves changes in the chemistry of the brain, although you do not need to lose consciousness to have a concussion. The chemical changes in the brain last longer than the symptoms, so your doctor will typically recommend that you rest and avoid contact sports for at least a week. Pasted from <[FONT=&amp]http://www.urmc.rochester.edu/concussion/what-is-concussion.cfm[/FONT]>
• ... there are chemical changes that occur with a jolt or blow to the head. Immediate signs and symptoms of chemical changes may include:
  · Amnesia &#8211; especially to details before and/or after the event Pasted from <About Concussions>
• [FONT=&amp]Simply stated, a concussion causes chemical imbalances in the brain to occur. The brain has to then regulate itself to bring the chemical imbalance back to normal.These imbalances cause the brain [/FONT]to work overtime to return itself back to normal. To do this the brain needs blood. However, when the brain is concussed there is a decrease in blood flow to the brain. This inability for the brain to get energy from the blood creates an energy crisis. With all the systems in the brain working over time and a decrease in blood flow the neurons in the brain malfunction which cause the signs and symptoms that people feel when they have a concussion. These concussion symptoms can last briefly or last for a long period of time, while the brain tries to recover.
• Similarities exist between Alzheimer&#8217;s patient brains and post concussion brains&#8230;.the similarity I would investigate, relates to the new theory of Alzheimer's actually being brain wastage from insulin resistance in the brain and inability to use sugar for brain fuel&#8230;.{ Extra virgin Coconut oil CURES this...I have largely CURED my mother's Alzheimer's with this, and 3 other family friends...So maybe in my supposed Post Concussive State, I should be consuming Extra virgin Coconut oil several times per day for brain fuel/nutrition}. We know that in a post concussed state, there is a lowered ability for the brain to get energy&#8230;.
  &#8230;&#8230;&#8230;.With this in mind, my issue may not have been with O2 Toxicity, but rather with an "eggs only" breakfast 4 hours prior to diving, as well as my having had some issues with insulin insensitivity in the recent past...and then after some high aerobic demand activities before and during diving, a combination of low blood sugar in the brain, and Post Concussion effect reduced energy available to the brain--led to a memory loss more like a diabetic episode...
  The brain has a high metabolic rate and requirement for constant sugar. This fuels neurotransmission, which affects learning and memory.
  A lapse in the system causes a reduction in the ability to remember things.
  In cases of uncontrolled diabetes, prolonged high or low blood glucose levels make the hippocampus malfunction, which may influence concentration, attention, memory and information processing.
  Pasted from <Diabetes and Memory Loss>
• Cortisol, an essential hormone in the body that is strongly linked with diabetes, may also affect memory function. Higher and prolonged levels of cortisol in the bloodstream may affect the brain and cause memory loss. My thinking on this is that Post Concussion effects could easily include high cortisol levels&#8230;Pasted from <Diabetes and Memory Loss>
  High levels of Cortisol, in a post brain injury individual, could further interfere with the memory storage of a diver running on insufficient blood sugar for normal brain function&#8230;.Whether or not High PO2 would further disrupt this energetic balance, or the electrical potentials...is yet one more issue to consider&#8230;.we know that high PO2 is going to cause more Oxidation&#8230; Pasted from <Concussion and Alzheimer?s Patients Show Similar Brain Changes | TIME.com>
• Additional Blood chemistry issues at pressure&#8230;.potential for CO2 buildup to cause acidosis and or histotoxic hypoxia. Potential decreased functioning of Carbonic Anhydrases which would result in poor buffering and higher levels of acidity in the blood/brain area.
  Metabolic acidosis is caused by an increase in the level of acids due to increased acid production or ingestion of acids&#8230;.High exertion at 110 feet on a dive, would create high levels of CO2 buildup, high blood acidity...and a chain reaction, including lower thresholds for high PO2 tolerance. I did have sore leg and gluteal muscles for 2 days after the dive&#8230;.if you watch the video, I move around more like a jewfish in speed and distances covered, than like a diver. Pasted from <Metabolic Acidosis: Symptoms, Causes and Treatment>
  
  Accumulation of lactic acid is another contributory factor. It usually takes place due to insufficient availability of oxygen in carbohydrate metabolism...We know high CO2 levels would have existed in me on this dive, relative to most divers....see the video and how I am moving at the speed and distance ranging of the jewfish....Paradise in Boynton Beach - YouTube

[FONT=&amp]Metabolic abnormalities can lead to acidosis. Use of fat instead of carbohydrates, for deriving energy, as in the case of diabetes mellitus, can lead to an excessive production of acids. Breakdown of fats produces ketones and raises the level of acids in the body. This condition is termed as diabetic ketoacidosis.
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• And finally...When there is a sufficient blow to the brain, the membranes of the affected nerve cells in the brain are stretched or twisted, allowing potassium to exit those cells, which triggers those cells to depolarize, thus the phenomenon of seeing stars if the affected area is involved with sight or ringing in the ears if the affected area is involved with hearing. The exit of potassium (K+)peaks approximately two minutes after the incident but continues for another 3-4 minutes.Then, until the chemical balance is somewhat restored, those neurons (nerve cells) are unable to fire again. Furthermore, in a protective reflex of sorts, surrounding cells begin to shut down, a process Hovda calls&#8220;spreading depression.&#8221;
  If enough cells become depressed, confusion, amnesia, and even loss of consciousness result.
  Meanwhile, in an attempt to recover, the brain starts using up massive amounts of blood sugar and will continue to do so for as long as 30 minutes.This overuse of this glucose results in the production of lactic acid which, in excess amounts, inhibits brain function.

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