detroit diver
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About right now, about 80 percent of you are saying to yourself Whats a PFO and who is George, 10 percent are saying, Oh, someone else trying to kiss GIs butt, and the rest saying This should be interesting. Or at least thats my perception.
So why am I writing this letter? Im writing this because it is my impression that most of you have never heard of a PFO and what can happen to you as a diver if you do have one. Id like to explain by separating this into 3 parts. 1. What is a PFO? 2. Why does it matter to diving and 3.My experience in repairing the PFO.
What is a PFO?
A little story about how I became aware of the whole PFO issue. When I began diving about 4 years ago, I was introduced to the DIR concepts by my open water instructor, Brandon Schwartz (www.scubaguys.com). I assure you that this is not going to become a DIR rant. I am just filling in some holes in the story. Anyway, Brandons emails to me included some interesting (if not colorful!) issues that George Irvine of the WKPP said about diving in general. Some of it was way over my head as I was just certified. Nevertheless, as a student of diving, I found great information among the noise. One of the things I picked up on was this thing called a PFO. George forcefully suggested that any diver should find out if he had this PFO. I believe, in fact, that it was required of all WKPP divers (of which he was director www.wkpp.org). It was mentioned numerous times in his writing. I later came to find out that it stood for Patent Foramen Ovale.
When you are a fetus in your Mothers womb, your mothers body does the job of filtering out all of the harmful pieces of material that float around in the blood supply. The BIG reason for the flap is so the blood purposely bypasses the lungs because the fetus's use of the mother's oxygenated blood is how the baby (in effect ) breaths. Your heart has a hole (actually a flap) between the left and right side chamber so that this filtered blood can supply your (the fetuss) brain. Immediately after birth, this flap is supposed to close. The newborns body is now filtering the dirty blood. I say supposed because about 30 percent of the population still has this flap or hole. That means that of yourself and your 2 other dive buddies, odds are that 1 of you has this PFO (okay, Im rounding the numbers).
Why does it matter to a diver?
Remember all those things you learned about safety stops and slow ascents? Well folks, this is where things get tricky if you have a PFO. Lets say youve been down diving for about a half hour or 45 minutes on a pretty reef in the Caribbean. Im taking strictly recreational diving. After you are done with your bottom time, you have accumulated a fair bit of nitrogen, as Im sure you remember from your OW class. So youre told to ascend slowly and do a 3-5 minute safety stop to allow the nitrogen to filter out of your system via the lungs. This nitrogen-laden blood flows thru the left chamber of your heart. There is a wall separating the left and right chambers, and the wall keeps the unfiltered nitrogenous blood from traveling to the right side, which supplies your brain. The problem arises when you have a PFO. The flap I previously spoke about is in this separating wall and is normally kept closed by your blood pressure, but during periods of exertion- like coughing, strenuous movement, or climbing the ladder of a boat- this blood pressure reduces on the right side for a brief moment and can open the flap that was supposed to close naturally. This can allow small nitrogen bubbles to pass to the right chamber of the heart and be fed to the brain. As you can remember from OW class, Boyles Law takes over here. So as you ascend, those bubble grow in size due to the reduce pressure. Large bubbles in the brain material are not good for anyone, and can cause strokes and paralysis. For some this means death.
My experience in repairing the PFO
You might ask-how did I find out that I had a PFO? During a routine cardiology exam, I asked my cardiologist to check for a PFO because of what I had read from George Irvines writings. My cardiologist looked at me really funny and asked how I knew what a PFO was, and why it mattered to me. I explained to him what I had learned, and that I did a lot of scuba diving. Then he smiled and began to speak about the implications of the PFO in diving and other sports. He related some stories about previous patients that were not divers, but weight lifters. Some are paraplegics now because of PFOs. It seems that during the lifting phase, the exertion caused the flap to open, and its presumed that a piece of plaque or cholesterol passed thru the opening and into the brain. Were talking a kid in his mid-twenties. Really sad. Getting back to my story, I asked him what it would take to test for this anomaly, thinking there was no way that I would have one of these things. It only happens to other people of course. He suggested an echocardiogram with bubble study. This is a fairly benign test. You lay down and an IV is inserted into your arm. A wand is run across your chest that creates ultrasound waves. These are then seen on a monitor by a trained technician. Dyes are injected into the IV and the technician follows the dye into the heart. They then ask you to cough, and try to find out whether the dye went across the wall. Then they inject very small bubbles into your bloodstream and repeat the coughing process. In my case, they could see a few bubbles, but not until after they reviewed the tape later on.
I had left the next day to attend the DEMA show and get in a little diving. Well, I spent about an hour at DEMA and dove the rest of the time, but that is another story! During a surface interval at lunch the next day, I received a phone call from my cardiologist and he told me that upon review of the video, they had seen some bubble pass thru the chamber. In other words, I had a PFO. He believed it was a small one, but told me that I shouldnt be diving deep. In fact, he suggested that I not dive at all unless I wanted to get it fixed. I was a bit shocked to say the least.
So now what? I had a decision to make, and it involved a lot of variables. How important was diving to me? What are the risks involved with closing this flap? How do you close the flap? Is the surgery worth the risk? I wont go thru all of the issues that confronted me, but I decided to go ahead with the procedure. It reduced my risk of stoke, regardless of the diving issue. Would I have done this if I were not a diver? Probably not.
My cardiologist recommended a heart surgeon that had done numerous PFO repairs. I wanted someone who was experienced in this. Probing something into your heart is no simple matter. I interviewed the doctor and chose him to repair my PFO. I entered the hospital yesterday at 6am for a 7am surgery. A nurse shaved parts of my chest for the EKG leads, and the upper part of my groin area where they would insert the catheter for the procedure. An IV was started. And I waited. And waited. Turns out there were a couple of emergencies that they pushed in front of me, and I was finally taken into the Cath Lab at 10:30am. I was moved onto the surgery table, and thats the last thing I remember until I awoke in recovery. Here is what they used to fix the problem: http://www.spencervascular.com/pfoclosure.htm Mine is the device on the right.
For me, there was absolutely no pain involved, other than a slight sore throat from the tubes they inserted during surgery. After you awake and they take you to your room, you are required to lie flat on your back for around 6-8 hours. After they remove the shunt from your leg (around 2 hours), a heavy sandbag is placed over the insertion area. Their biggest concern is that you dont bleed from the artery in the groin that they used. I was allowed to get up after 8 pm that nite. Today I feel wonderful. No pain, no soreness. Just some funny looking shaved body parts!
Epilog
I wrote this because I believe that the PFO issue is ignored or glossed over by the dive industry. If 30 percent of the population has this anomaly, and the potential for serious injury or death is high in the diving world, then it would be my conclusion that it should be more in the forefront than it currently is. I cant speak of every agency, but I know that most agencies do not even mention it in their classes. One can speculate why, but it is my impression that were back to a numbers game. Imagine scaring 3 out of every 10 people that come into your class? Worse yet, scaring those that dont even have the PFO? Unless you test for it, there is no way to know youve got it. Youd have people running from this industry. Not good for business. My guess is that the industries response would be that there is no proof that PFOs cause diving accidents. Not surprising, because there is really no way to pinpoint the problem after it happens. How many of the heart attacks or undeserved hits do we hear about during the year? My guess is that a good portion of these is PFO related. There are just too many of us PFOers within the dive population. And ascent rates and buoyancy control are not often highlighted in the industry. There are a lot of potential victims amongst us.
So George, although Ive never met you, and probably never will, I want to thank you for your teachings and for your insight. I love this sport, but I love my family much more. You have allowed me to enjoy both of them for however long Im supposed to be around. I may have been okay otherwise, but Ive now removed one potential obstacle. Maybe thru this long report of mine, someone else who has not heard about this can benefit also.
Thank you,
Jack
PS. If medical doctors would care to add to the description of the anomaly, or to correct anything Ive written, it would be most appreciated.
So why am I writing this letter? Im writing this because it is my impression that most of you have never heard of a PFO and what can happen to you as a diver if you do have one. Id like to explain by separating this into 3 parts. 1. What is a PFO? 2. Why does it matter to diving and 3.My experience in repairing the PFO.
What is a PFO?
A little story about how I became aware of the whole PFO issue. When I began diving about 4 years ago, I was introduced to the DIR concepts by my open water instructor, Brandon Schwartz (www.scubaguys.com). I assure you that this is not going to become a DIR rant. I am just filling in some holes in the story. Anyway, Brandons emails to me included some interesting (if not colorful!) issues that George Irvine of the WKPP said about diving in general. Some of it was way over my head as I was just certified. Nevertheless, as a student of diving, I found great information among the noise. One of the things I picked up on was this thing called a PFO. George forcefully suggested that any diver should find out if he had this PFO. I believe, in fact, that it was required of all WKPP divers (of which he was director www.wkpp.org). It was mentioned numerous times in his writing. I later came to find out that it stood for Patent Foramen Ovale.
When you are a fetus in your Mothers womb, your mothers body does the job of filtering out all of the harmful pieces of material that float around in the blood supply. The BIG reason for the flap is so the blood purposely bypasses the lungs because the fetus's use of the mother's oxygenated blood is how the baby (in effect ) breaths. Your heart has a hole (actually a flap) between the left and right side chamber so that this filtered blood can supply your (the fetuss) brain. Immediately after birth, this flap is supposed to close. The newborns body is now filtering the dirty blood. I say supposed because about 30 percent of the population still has this flap or hole. That means that of yourself and your 2 other dive buddies, odds are that 1 of you has this PFO (okay, Im rounding the numbers).
Why does it matter to a diver?
Remember all those things you learned about safety stops and slow ascents? Well folks, this is where things get tricky if you have a PFO. Lets say youve been down diving for about a half hour or 45 minutes on a pretty reef in the Caribbean. Im taking strictly recreational diving. After you are done with your bottom time, you have accumulated a fair bit of nitrogen, as Im sure you remember from your OW class. So youre told to ascend slowly and do a 3-5 minute safety stop to allow the nitrogen to filter out of your system via the lungs. This nitrogen-laden blood flows thru the left chamber of your heart. There is a wall separating the left and right chambers, and the wall keeps the unfiltered nitrogenous blood from traveling to the right side, which supplies your brain. The problem arises when you have a PFO. The flap I previously spoke about is in this separating wall and is normally kept closed by your blood pressure, but during periods of exertion- like coughing, strenuous movement, or climbing the ladder of a boat- this blood pressure reduces on the right side for a brief moment and can open the flap that was supposed to close naturally. This can allow small nitrogen bubbles to pass to the right chamber of the heart and be fed to the brain. As you can remember from OW class, Boyles Law takes over here. So as you ascend, those bubble grow in size due to the reduce pressure. Large bubbles in the brain material are not good for anyone, and can cause strokes and paralysis. For some this means death.
My experience in repairing the PFO
You might ask-how did I find out that I had a PFO? During a routine cardiology exam, I asked my cardiologist to check for a PFO because of what I had read from George Irvines writings. My cardiologist looked at me really funny and asked how I knew what a PFO was, and why it mattered to me. I explained to him what I had learned, and that I did a lot of scuba diving. Then he smiled and began to speak about the implications of the PFO in diving and other sports. He related some stories about previous patients that were not divers, but weight lifters. Some are paraplegics now because of PFOs. It seems that during the lifting phase, the exertion caused the flap to open, and its presumed that a piece of plaque or cholesterol passed thru the opening and into the brain. Were talking a kid in his mid-twenties. Really sad. Getting back to my story, I asked him what it would take to test for this anomaly, thinking there was no way that I would have one of these things. It only happens to other people of course. He suggested an echocardiogram with bubble study. This is a fairly benign test. You lay down and an IV is inserted into your arm. A wand is run across your chest that creates ultrasound waves. These are then seen on a monitor by a trained technician. Dyes are injected into the IV and the technician follows the dye into the heart. They then ask you to cough, and try to find out whether the dye went across the wall. Then they inject very small bubbles into your bloodstream and repeat the coughing process. In my case, they could see a few bubbles, but not until after they reviewed the tape later on.
I had left the next day to attend the DEMA show and get in a little diving. Well, I spent about an hour at DEMA and dove the rest of the time, but that is another story! During a surface interval at lunch the next day, I received a phone call from my cardiologist and he told me that upon review of the video, they had seen some bubble pass thru the chamber. In other words, I had a PFO. He believed it was a small one, but told me that I shouldnt be diving deep. In fact, he suggested that I not dive at all unless I wanted to get it fixed. I was a bit shocked to say the least.
So now what? I had a decision to make, and it involved a lot of variables. How important was diving to me? What are the risks involved with closing this flap? How do you close the flap? Is the surgery worth the risk? I wont go thru all of the issues that confronted me, but I decided to go ahead with the procedure. It reduced my risk of stoke, regardless of the diving issue. Would I have done this if I were not a diver? Probably not.
My cardiologist recommended a heart surgeon that had done numerous PFO repairs. I wanted someone who was experienced in this. Probing something into your heart is no simple matter. I interviewed the doctor and chose him to repair my PFO. I entered the hospital yesterday at 6am for a 7am surgery. A nurse shaved parts of my chest for the EKG leads, and the upper part of my groin area where they would insert the catheter for the procedure. An IV was started. And I waited. And waited. Turns out there were a couple of emergencies that they pushed in front of me, and I was finally taken into the Cath Lab at 10:30am. I was moved onto the surgery table, and thats the last thing I remember until I awoke in recovery. Here is what they used to fix the problem: http://www.spencervascular.com/pfoclosure.htm Mine is the device on the right.
For me, there was absolutely no pain involved, other than a slight sore throat from the tubes they inserted during surgery. After you awake and they take you to your room, you are required to lie flat on your back for around 6-8 hours. After they remove the shunt from your leg (around 2 hours), a heavy sandbag is placed over the insertion area. Their biggest concern is that you dont bleed from the artery in the groin that they used. I was allowed to get up after 8 pm that nite. Today I feel wonderful. No pain, no soreness. Just some funny looking shaved body parts!
Epilog
I wrote this because I believe that the PFO issue is ignored or glossed over by the dive industry. If 30 percent of the population has this anomaly, and the potential for serious injury or death is high in the diving world, then it would be my conclusion that it should be more in the forefront than it currently is. I cant speak of every agency, but I know that most agencies do not even mention it in their classes. One can speculate why, but it is my impression that were back to a numbers game. Imagine scaring 3 out of every 10 people that come into your class? Worse yet, scaring those that dont even have the PFO? Unless you test for it, there is no way to know youve got it. Youd have people running from this industry. Not good for business. My guess is that the industries response would be that there is no proof that PFOs cause diving accidents. Not surprising, because there is really no way to pinpoint the problem after it happens. How many of the heart attacks or undeserved hits do we hear about during the year? My guess is that a good portion of these is PFO related. There are just too many of us PFOers within the dive population. And ascent rates and buoyancy control are not often highlighted in the industry. There are a lot of potential victims amongst us.
So George, although Ive never met you, and probably never will, I want to thank you for your teachings and for your insight. I love this sport, but I love my family much more. You have allowed me to enjoy both of them for however long Im supposed to be around. I may have been okay otherwise, but Ive now removed one potential obstacle. Maybe thru this long report of mine, someone else who has not heard about this can benefit also.
Thank you,
Jack
PS. If medical doctors would care to add to the description of the anomaly, or to correct anything Ive written, it would be most appreciated.
