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Multiple cases of skin bends - what now?

Discussion in 'Ask Dr. Decompression' started by FindingMenno, Jun 22, 2019.

  1. FindingMenno

    FindingMenno PADI Pro

    # of Dives: 1,000 - 2,499
    Location: Grand Cayman, Cayman Islands
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    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.
    dSrZrol.jpg
    Uu6JEPW.jpg

    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.

    2PUoKCB.jpg
    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)

    Z0ZwNM5.jpg
    Marbling before treatment

    gyqefn0.jpg
    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
     
    drrich2 likes this.
  2. drk5036

    drk5036 Nassau Grouper

    # of Dives: 50 - 99
    Location: Sapporo, Japan
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    (Not a Doctor...well, I am but not a medical doctor)

    The second case of DCS is especially interesting to me, because it occurred so late, and didn’t go away after treatment...are you and the doctors sure it was truly the skin bends and not something else? Nothing else could have caused the bruising?

    Really sorry you have to go through this, I can understand how tough it must be.
     
    Lorenzoid likes this.
  3. michael-fisch

    michael-fisch Manta Ray

    # of Dives: 2,500 - 4,999
    Location: Germany
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    Can't say anything about the 2nd dive, but you screwed up on the 1st dive!
    After a Deco Dive don't ever dream about exercise or a hot shower for many hours! If you wash your hands, do so with lukewarm water.
    Let others pull the anchor rope up
    Let others arrange the tanks on the boat after a dive
    let others unload your gear from the boat, the heaviest object you should carry is your car keys
    Exercise is like murder, doing exercise with others is like mass murder. If you have to exercise, do so before the dive - after the dive no erercise untill your dive computer says it's OK to fly.

    Michael
     
  4. michael-fisch

    michael-fisch Manta Ray

    # of Dives: 2,500 - 4,999
    Location: Germany
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    Are you using O2 for decompression starting at 20'?
    If not give it a try, and remember no real advantage untill the O2 has a chance to go through your body twice - so go on O2 and the advantages start no less than 5 minutes later. Staying on O2 for 20 minutes is perfectly OK, over 20 minutes you shoud start adding air breaks like 15O2/5Air or for really long exposures the old WKPP schedule of 12O2/6Air worked well.
    Breathing O2 all the way back to the boat, while climbing the ladder, and while sitting on the boat for the 1st 15 minutes is also often done.

    Michael
     
  5. Dan

    Dan Orca

    # of Dives: 500 - 999
    Location: Lake Jackson, Texas
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  6. Jcp2

    Jcp2 Barracuda

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    Were these DCS dives done in isolation with no other diving done prior to them, either the same day or day before?
     
  7. Dsix36

    Dsix36 Solo Diver

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    First off, any of your peers that are worth a damn will not look at you as any less of a man or diver than your were before this began. Some things are out of our control and until we learn much more about decompression and the triggers you may never get the answers that you need.

    A good friend, mentor, and dive buddy of mine had similar issues. We have been diving together for a long time and have done some rather biggish dives with loooong deco over the years. He began to develop skin bends and began running his GF more conservative in an attempt to stop it. No luck was apparent with this experiment. It steadily progressed until he was getting skin bends about 75% of the time we did 45 minutes at 150' and 45 minutes of deco. Then we tried shorter dives of 30 minutes at 150' and 30 minutes of deco. Still no luck. He finally decided it was his body telling him something and hung up his fins for good.

    I am not a doctor and have absolutely no experience with skin bends. I certainly can not tell you if you should or should not keep diving. I merely want you to pay serious attention to what your body and doctors are trying to tell you.
     
  8. CWK

    CWK Manta Ray

    # of Dives: 1,000 - 2,499
    Location: Malaysia
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    I am not a doctor but if I were in your position, I would try a couple of to:
    - Change the physiology by reducing the amount of slow tissue. I’d say drop about 40 lbs.
    - Change the gradient factor away from deep stops. Perhaps 60/70? I personally dive 70/70 or 75/75 for recreational.

    I’m 6’ 2” as well. I used to be a tad over 220 lbs and had a 40 inch waist. I’m now a little under 180 lbs with a 32 inch waist and have less health issues. Anyway... dropping the weight is possible.

    Good luck, whatever you do.
     
    Frank Dieber likes this.
  9. Jcp2

    Jcp2 Barracuda

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    Thinking about it a bit more, maybe what you have is true, true, and unrelated. The second incident that you describe occurred a relatively long time after the dive and did not seem to change with hyperbaric treatment. Maybe it is not skin bends. Just looking at the photograph without the prior history, what you have could be described generically as livedo reticularis (of which skin bends is a very uncommon cause of in general). Has there been an investigation into that possibility as well?
     
  10. caydiver

    caydiver Manta Ray

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    I am in no position to add anything relative to your situation but just want to say I am so sorry to hear about your predicament and truly hope you get satisfactory answers!!
     

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