What happened to me?

[Seaweedsteve]

Hey there. I recently had a worrisome experience during and after an intense first week (22 dives in six days) of diving on a liveaboard boat near Roatan, Honduras.

None of the other 10 folks who dived the same profiles that week had a problem and I'm arguably the healthiest. Main difference is: I'm a brand new diver, and I slept poorly. No alchohol, lots of water.

I was just certified a few weeks before that and had only been under the minimum amount for certification. No problems, though, and I took right to diving with ease. I do wonder if I was holding my breath while scuba diving as I free dive a bit and was just learning bouyancy.

Anyway, my story/ symptoms were:

1) Midweek dull, fleeting pains in muscles,tendons or thereabouts in all
limbs - passed after a day. Pains would last a minute or two in a spot then go away to reappear in another spot. Not judged by the captain or experienced divers to be dive-related at the time.

Related note: I went for a rather athletic swim during my surface interval that day. No one had ever told me that was a bad idea, and no one thought it was at the time.

2) End of week those symptoms returned plus fleeting pin/pricks/itching
at skin level in limbs - again occurring now and then for a minute or two at a time..

At the captain's advice, I went to see the dive doc at the Anthony's Key Resort (Roatan) who found no verifiable nervous system damage or loss of strength. Nonetheless, they put me in the tank for two hours two days in a row. The symptoms subsided but remained at very low level for several more days. One peculiar note: When I was compressed, the symptoms increased during the compression. AT compression, they were gone. As I was decompressed, they increased again, but subsided at normal atmospheric pressure. I neglected to mention this to the doc there, but later realized that this was not what I understood to be typical.

After this, I went on to Utila where we were set to dive for another week. Since I was advised not to dive, I did not. Just to be sure, (I did not want to waste my trip for nothing), I went to see a dive doc on the island (Dr. John), who examined me thoroughly and declared that my symptoms resembled "the Niggles" but as far as he could tell, I had a "dive-related injury, but not DCS"

At the same time, I contacted DAN by email and started a dialog with a doc there. She advised me not to dive until six weeks after symptoms went away, and that it was possible that I had DCS.

3) Okay. no more diving. Symptoms are now virtually gone eight days after diving and 6 days after chamber treatment. I get on an island hopper, no problem. Then I get on a full, pressurized jet and head accros central america. As the Jet goes up, the symptoms start again ! But worse. Somewhat scary. I am itching some and rubbing painful spots in my limbs, and even a bit in my trunk this time for the whole short flight. Then, going down, they stay the same and only begin to subside as we get to the ground.

Whew! Must be pressure related. The next day, crossing a mountain pass, we drop down several thousand feet in the bus fairly rapidly. The symptoms are agitated again, then subside.

They then stayed with me, very lightly for three more weeks. Now, they are mostly gone. I would never notice them if I was not a bit sensitive to this by now.

WHAT THE HECK HAPPENED TO ME ?

Pretty weird, huh? Any ideas?

Should I consider myself at increased risk from now on? Should I
increase my safety stops or include half depth safeties as well?


Thanks for any thoughts or advice. I do have a copy of my email dialogue with the DAN doc - if you want, I can paste that in, but hesitate to make this any longer right now.

Steve

 

[Doc Intrepid]

"The most common manifestations of DCS are joint pain and numbness or tingling. ...Severe DCS is easy to identify because the signs and symptoms are obvious. However, most DCS manifests subtly with a minor joint ache or a paresthesia (an abnormal sensation like burning, tingling or ticking) in an extremity."

From this citation:
http://www.diversalertnetwork.org/medical/articles/article.asp?articleid=65

(see paragraph 1 of Section V - Denial and Recognition)(emphasis added)

See also "Skin Bends".

The recurrence of symptoms during aircraft transportation is also suggestive.

(I'm not a medical doctor, and this constitutes nothing more than speculation based on the symptoms you described correllating to defined symptoms.)

I'd keep on talking to DAN. Sounds like you overdid it a bit on your trip. It may be prudent to do some more reading on the topic, so that during your next trip you're tracking things like exertion and fatigue as well as nitrogen loading and SI.

If you're up for a little in-depth reading about what happened to you, here is an excellent place to start:
http://www.immersed.com/Articles/PDFs/hit.pdf

Hope this helps.

Regards,

Doc

 

[Dr Deco]

Hello seaweedsteve :

I certainly not tell you what occurred, since I was not there. However, I can give some ideas based on my research experience.

Dive profile

Thoughts:

• While gas loading is a very important aspect of DCS, if one is within the boundaries of the model, problems should not arise in the vast percentage of divers.
• Gas loading analysis is a historical fact with diving, and virtually all analysis of injury will reflect this type of thinking. It is a poor analytical tool and will not explain most DCS problems.
• The fact that others dived this profile without problems is an indication that gas loads were not at the root of the problem.

Activity Level

I suspect this factor because:

• There are no real NDLs; they are all exercise dependent.
• Physical activity is the best way to generate a free gas phase [= bubbles] when you have a supersaturated condition.
• You do in fact indicate that you went for a surface swim. You are now aware that this is not a good idea.

Arterialization

It sounds to me as though you were experiencing problems associated with gas bubbles coming from the venous side into the arterial side. As a new diver, you were not aware of a potential anatomical problem.

• These bubbles were generated in a large measure during the surface swim.
• Somewhere along the line, gas bubbles passed into the arterial system. This is either through lung capillaries [pulmonary shunts] or a PFO. This could have been assisted by Valsalva-like maneuvers, e.g. during swimming.
• The persistence of effects is, I suspect, partially a result of capillary blockage and partially from secondary biochemical effects of the bubbles themselves.

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm

 

[Seaweedsteve]

"The most common manifestations of DCS are joint pain and numbness or tingling. ...Severe DCS is easy to identify because the signs and symptoms are obvious. However, most DCS manifests subtly with a minor joint ache or a paresthesia (an abnormal sensation like burning, tingling or ticking) in an extremity."

See also "Skin Bends".

The recurrence of symptoms during aircraft transportation is also suggestive.

(I'm not a medical doctor, and this constitutes nothing more than speculation based on the symptoms you described correllating to defined symptoms.)

I'd keep on talking to DAN. Sounds like you overdid it a bit on your trip. It may be prudent to do some more reading on the topic, so that during your next trip you're tracking things like exertion and fatigue as well as nitrogen loading and SI.

Doc

Thanks for the info leads. Just what I needed. Only had time to read the first article so far.

I am still in touch with DAN, although we are at the point where there is not much more they can say, other than advising me to see another Dive Doc. After seeing two experienced ones in Honduras, I'm wondering what more there is to investigate on the physical/symptom/treatment level. Theory and info are about all that's left as far as I can tell. I certainly do plan to be more aware of exercise and stress loading as well as diving more conservativly next time !


Cheers,
Steve

 

[Seaweedsteve]

Hello seaweedsteve :

I certainly not tell you what occurred, since I was not there. However, I can give some ideas based on my research experience.

Dive profile

Thoughts:

• While gas loading is a very important aspect of DCS, if one is within the boundaries of the model, problems should not arise in the vast percentage of divers.
• Gas loading analysis is a historical fact with diving, and virtually all analysis of injury will reflect this type of thinking. It is a poor analytical tool and will not explain most DCS problems.
• The fact that others dived this profile without problems is an indication that gas loads were not at the root of the problem.

Activity Level

I suspect this factor because:

• There are no real NDLs; they are all exercise dependent.
• Physical activity is the best way to generate a free gas phase [= bubbles] when you have a supersaturated condition.
• You do in fact indicate that you went for a surface swim. You are now aware that this is not a good idea.

Arterialization

It sounds to me as though you were experiencing problems associated with gas bubbles coming from the venous side into the arterial side. As a new diver, you were not aware of a potential anatomical problem.

• These bubbles were generated in a large measure during the surface swim.
• Somewhere along the line, gas bubbles passed into the arterial system. This is either through lung capillaries [pulmonary shunts] or a PFO. This could have been assisted by Valsalva-like maneuvers, e.g. during swimming.
• The persistence of effects is, I suspect, partially a result of capillary blockage and partially from secondary biochemical effects of the bubbles themselves.

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm

Thank you so much for your response. It's a learning process and I will go over what you have said very carefully study more and maybe see about the class too?

Um, a couple more things:

Concerning chamber treatment - I understand that DCS is mostly confirmed by improvement of symptoms in response to chamber treatment - this is not exactly what happened for me, rather it got agitated not improved.

Do you feel that the short table treatments might have been inadequate? I understand that it's quite late for long table, but am curious.

Does the fact that compressing seemed to agitate symptoms as much as decompressing tell you anything? And these decompressions were,of course, very slow....
Symptom strength and quantity was correlated with change in pressure, more than decompression. .... any more thoughts on that?


OK. Are you ready for further complications? I hesitate to add this, but it may be critical or more likely, irrelevant. I have a history of Lyme's disease (15 years ago) with mostly neurological symptoms - it did get to my heart a tiny bit, some sound or something - no worries said the doc, I mended very well.... these neurological symptoms (nerve sheath damage) felt similar to the fleeting pain symptoms of my possible DCS.

The tingling symptoms were a totally new experience. My tingling/itching symptoms, by the way, were/ are not area-wide as in "foot's asleep", but more like one to four toothpick pricks in a group. I've been told this is not the way DCI tends to work.

Forgive me for the complicated info and scenario. I hope it's fun detective work for you, more than a PITA !

Steve

 

[Dr Deco]

Hello steve:

Variability

Because decompression bubbles form in many tissues and also can move about to some degree, it is always difficult to predict just what will happen in random situations. In laboratory tests, with very controlled conditions and specific test subjects, many aspects of DCS are quite repeatable. It is not exactly true that it is variable as though it were a roulette game. It does follow the laws of chemistry and physics.

However, that said, it is also true that many conditions control nitrogen uptake, dissolved and free-gas elimination, tissue nuclei number and nuclei characteristics. All of these result in a complicated scenario. We are still held tight by the myth of gas loading as the only cause of DCS.

Hyperbaric Treatment

Your treatment was many hours following the initial appearance of the problem. One would not expect the results of treatment to be as salutary as if instigated within an hour or two.

Strange as it may seem, people do report that problems often increase with compression. The reason for this is not known. It might be reperfusion pain.

Lyme Disease

This is a compilation. Because there are neurological presentations to this disorder, some of which are delayed for years, one can not say what occurred that week. I could well imagine that some aspect of a free-gas phase in the body might have instigated something, but as far as certainty, who knows at this point? :06:

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm

 

[Seaweedsteve]

Wow, thanks for not only answering, but making things as clear as they can be made! Sept 10-13, huh?

I'm still waiting/hoping for the symptoms to completely disappear (what else can I do?) and hoping to do some test dives 6-8 weeks after that. I'm invited for another liveaboard trip next year. I really would like to stay in the game, if it's not too risky...

Cheers,
Steve

 

[DrSteve]

Dr Deco - Part I didn't understand was the physical exercise part. I would have thought (and I'm not a medical guy or a biologist) that the increase in respiration associated with harder physical exercise would allow for more effective off-gassing. Why would this cause bubbles to form?

 

[the_cat_keeper]

• These bubbles were generated in a large measure during the surface swim.
• Somewhere along the line, gas bubbles passed into the arterial system. This is either through lung capillaries [pulmonary shunts] or a PFO. This could have been assisted by Valsalva-like maneuvers, e.g. during swimming.
• The persistence of effects is, I suspect, partially a result of capillary blockage and partially from secondary biochemical effects of the bubbles themselves.

Hi, Dr. Deco,

Does this mean that any form of aerobic exercise would not be advisable after diving/ in between dives? I had instances where during a liveaboard, we'd gone island hopping and I ended up doing some trekking too...

Thank you.

 

[Dr Deco]

Hello DrSteve and Cat Keeper:

Activity

Any form of strenuous activity is to be avoided, I believe, for about four hours post dive. Movement of arms in legs is fine, but lifting, climbing, running are really taboo .

Gas Exchange

Yes, some movement will increase the blood flow to tissues. This is good. However, vigorous activity will promote the growth/enlargement of microbubbles and add to DCS risk.

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology September 10 – 11, 2005 :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm