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Multiple cases of skin bends - what now?

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

  1. Germie

    Germie Cave Instructor

    # of Dives: 1,000 - 2,499
    Location: Netherlands
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    Read the article in German in Wetnotes october 2018. They advice, even if you have a pfo, NOT to quit technical diving, but to breathe oxygen at surface. And they tested it and almost all divers with a skinbend history can go on doing technical diving. That doctors are in Murnau I believe.
    Giving up diving or technical diving would never ever a discussion with me if I was in your case. I know from divers who got skinbends several times, started diving more conservative and no problems anymore. So I would go on with technical diving, but more conservative and use oxygen.

    BMI is the biggest ******** there is. It is developed for the white people, man, of a maximum length of 1.80. And then they use it now also for women over 1.80, that does not work. There is also a new and better calculation made for 'bmi'. But it still does not work for all people.
     
    FindingMenno likes this.
  2. hroark2112

    hroark2112 Tech Instructor

    # of Dives: 0 - 24
    Location: Raleigh, NC
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    Menno,

    I'm in a very similar condition. I have had one serious case of skin & pulmonary bends that required 2 chamber rides. Since then I have definitely had a few minor cases of skin bends that have been treated with O2 and rest.

    You and I have a common friend who you should definitely speak to. Doug Ebersole spoke at InnerSpace about PFO and technical diving. He gave us some great advice to consider. Some of what he recommended:

    Adjust your gradient factors to a more conservative profile.
    Extend your decompression stops.
    Spend extra time after your last stop and allow your body to continue to off-gas.
    Consider changing your diving habits.

    Doug & I have talked at length about my specific issues. In addition to the extra time off-gassing at depth, consider staying on the loop even after you surface for a while. Keep O2 handy and don't hesitate to use it if needed. None of these are as a substitute for proper treatment, but the sooner you're on O2 if you think you're bent, the better change for recovery you'll have.

    Doug can tell you how to properly diagnose a PFO and what your options are. If I were you, he'd probably be my first call!

    Best of luck and don't hesitate to reach out if I can help you in any way!

    Anthony
     
    FindingMenno likes this.
  3. Dr Simon Mitchell

    Dr Simon Mitchell Medical Moderator Staff Member

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    Hello Menno,

    In respect to your TTE, are you SURE this was done with bubble contrast AND provocative maneuvers like valsalva and sniffing at the point of maximum opacification of the right heart?

    Thanks,

    Simon M
     
    FindingMenno likes this.
  4. Dr. Doug Ebersole

    Dr. Doug Ebersole Instructor, Scuba Staff Member

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    Anthony -- I've spoken with Menno about his episodes and reviewed his dive profiles

    Simon -- I agree. A transthoracic echo with "bubbles" AND with provocative maneuvers are needed to look for PFO.

    Menno -- If a good quality transthoracic echo study is truly NORMAL, it is unlikely that you are missing a significant PFO that would be picked up on TEE. However, if the images are of poor quality, a TEE with bubble study and provocative maneuvers would be the next step. If bubbles are seen "late" on the left side of the heart (defined as later than 3-5 heart beats), you would need to consider an intrapulmonary shunt from a pulmonary AVM (arteriovenous malformation). These can be confirmed on a CT angiogram of the chest and are often able to be closed percutaneously (non-surgically) by an interventional radiologist.

    Just my 2 cents.

    Douglas Ebersole, MD
    Interventional Cardiology, Watson Clinic LLP
    Director, Structural Heart Program Lakeland Regional Health
    Cardiology Consultant, Divers Alert Network
    IANTD and TDI CCR Trimix Instructor
     
  5. FindingMenno

    FindingMenno PADI Pro

    # of Dives: 1,000 - 2,499
    Location: Grand Cayman, Cayman Islands
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    Hi all, thanks for the many responses. And sorry for the delayed response, I'm in the process of relocating out of the Cayman Islands, so last days have been a bit busy.

    Anthony, first of all sorry to hear of your DCS episodes. Being through the same it really knocks your confidence quite a bit.
    I'm doing exactly that. My GF is set to a conservative 40/70 and looking at setting the GF low higher. I'm doing a 6 min safety stop after any deeper/longer dives. If on CCR, or even OC recreational Nitrox, I take 5 min on the surface after the dive to breath down some higher O2 gas available to me.
    I have not done any decompression diving since my last bend.

    As @Dr. Doug Ebersole already mentioned, Doug has been extremely helpful and kind in discussing my case.

    And sorry to have not been able to meet you at Innerspace this year, I was on Grand helping in running the shop there.

    Hi @Dr Simon Mitchell thanks for your comments. I was asked the question about the valsava, and I really can not recall if it was done yes or no during the procedure. There was a lot going on of course during the test, and I just can't recall. I assume so, they have had more divers in so should be experienced. They showed me the film of a diver with PFO they have had and I could clearly see the bubbles coming through.

    I have the bubble study report attached to this post. I also have the video images, but it requires to install some proprietary GE Healthcare software to be installed, which in turn requires a (almost antique) Windows 7 computer that I haven't found yet.

    Hi Doug, thanks for pitching in, next to all your help you have already provided me in our e-mail conversations as well over a beverage on Grand Cayman.
    Also I hope you do not regard me posting my case here as not trusting your view, or me trying to find a different answer. I just want to soak up as much insights and knowledge as there is on this subject, so I can figure out the best way forward for me.

    I am considering doing a TEE. As you have explained, the chance of any large PFO being picked up there is very small. My main reasoning for doing it would be as sort of an 'insurance' in case the TTE was not done correctly.
     

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