Dive Accident on Belize Aggressor

[Bubbletrubble]

Many people that have MI, especially NSTEMI, will not have any noticable heart damage. Their EF will remain normal and for all intents and purposes the heart returns to the baseline it was at before the insult. Also, the saltwater aspiration and MI probably were not a cause and effect situation. I would guess that probably the MI was a result of the strenuous swim against current and THEN came the aspiration secondary to exhaustion from the swim. Just a guess.

@ScubaNurse758: Would you describe the heart of a patient who experienced MI as "healthy"? Ejection fraction (EF) may not be different from baseline, but diagnosis of non-ST-segment elevation MI (NSTEMI) implies an incomplete blockage of a coronary artery and that a small portion of the heart muscle is damaged. Perhaps my ignorance here is showing since my experience with cardiac patients, thus far, is somewhat limited.

Even in instances of NSTEMI, one might see any number of EKG abnormalities: ST wave depression, T wave abnormalities, poor R-wave progression, afib, PVCs, etc. Assuming NSTEMI, an EKG might still reveal conditions which may have precipitated the coronary event -- valvular disease, arrhythmia, LVH.
The OP mentioned that she was cathed. I would think that coronary angiography would have been performed, which may have revealed evidence of CAD. (The OP's follow-up post seems to indicate that she has no CAD.)

Even if we assume the OP is saying that her heart function remains at/near 100%, evidence of any of the above conditions would be inconsistent with the label of a "healthy heart."

In a later post, the OP states that her heart condition was diagnosed by "EKG and cardiac enzymes and confirmed with echo and cath tests." Whether the incident was STEMI or NSTEMI, the confirmation by "echo and cath" implies that abnormal heart function persists. In my mind, that's not consistent at all with the label of a "healthy heart." Perhaps I'm misunderstanding something or maybe the OP misunderstood what she was told by her treatment team.

Your explanation of the MI and saltwater aspiration being two separate insults is certainly possible. The OP makes it sound like the MI was a consequence of the saltwater aspiration. In a follow-up post she states: "The aspiration of sea water reduced the oygen [sic] to my heart. The lack of oxygen to the heart cause the heart attack."
Her explanation still sounds rather curious to me without a diagnosis of saltwater aspiration syndrome (SAS) followed by progression to ARDS (which is uncommon in SAS).

I'm going to guess that in the absence of any clear cause of the heart attack, the treatment team was speculating on precipitating factors and settled on "aspiration of saltwater" based entirely on the patient history. Perhaps the team is classifying the incident as a "near drowning." Hypoxia secondary to saltwater aspiration can certainly occur but I would think it very, very, very unlikely to contribute to MI in the absence of any previous heart disease (as indicated by the OP in a subsequent post).

 

[Hatul]

Hi Bubble,

If I may chime in on the physiology of the MI here: Usually hypoxia affects the brain before it affects the heart, but here we have a combination of decreased oxygen supply to the heart due to hypoxia and high heart rate PLUS increased demand due to stress and the strenuous swim. It's a double whammy hitting the heart from both sides. So I think it's quite conceivable to have an MI in spite of a healthy heart.

 

[TSandM]

I think we're arguing over the definition of MI. Elevated enzymes means enough damage to heart muscle cells to cause troponin to leak out of them; but if it's demand ischemia and the peak troponin is something like 2, and the cath doesn't show any significant coronary disease, I guess I'd be tempted to tell the victim that she had healthy arteries and a healthy heart (especially if her EF was normal post-event).

I read the original post with enormous empathy, right up until to the end. I have been in rough water with heavy gear, trying to get back on a rigid inflatable boat. It can be very frightening. I have been bashed in the head with the hull, and I've had the awful feeling of, "I'm not sure I can do this." I was lucky, or perhaps a bit fitter or a bit more determined -- or maybe the ankle weights really did make that much of a difference, although it's hard for me to imagine the usual pound or pound and a half weights doing that much damage.

One of the very human reactions to having been severely frightened is to get angry. If you have come close to death, it's very tempting to try to find someone who is responsible for it. But very much as Wookie says, the boat was not responsible for your equipment configuration or the issues it could cause you. It was not responsible for your decision that you could deal with the problems of getting back to or on the boat in the heavy seas. (I have sat out more than one dive for exactly this reason -- getting in is easy. Any idiot can fall off a boat, and I know because I HAVE. It's getting back on that's the problem.) It was not responsible for your decision to try to fight the current to get back to the boat. It was not responsible for your failure to remove your weights before trying to reboard. And honestly, even if you had -- it's really easy to end up under the boat in rough water, and get hit or pushed underwater. Boats are heavy and ponderous and very, very dangerous to people on the surface -- I think those of us who dive off them regularly get a little too relaxed about this sometimes.

I am very glad to hear you made it through this event, and your story will make me even more conservative about the kind of water conditions I am willing to brave.

 

[Wookie]

I read the original post with enormous empathy, right up until to the end. I have been in rough water with heavy gear, trying to get back on a rigid inflatable boat. It can be very frightening. I have been bashed in the head with the hull, and I've had the awful feeling of, "I'm not sure I can do this." I was lucky, or perhaps a bit fitter or a bit more determined -- or maybe the ankle weights really did make that much of a difference, although it's hard for me to imagine the usual pound or pound and a half weights doing that much damage.

One of the very human reactions to having been severely frightened is to get angry. If you have come close to death, it's very tempting to try to find someone who is responsible for it. But very much as Wookie says, the boat was not responsible for your equipment configuration or the issues it could cause you. It was not responsible for your decision that you could deal with the problems of getting back to or on the boat in the heavy seas. (I have sat out more than one dive for exactly this reason -- getting in is easy. Any idiot can fall off a boat, and I know because I HAVE. It's getting back on that's the problem.) It was not responsible for your decision to try to fight the current to get back to the boat. It was not responsible for your failure to remove your weights before trying to reboard. And honestly, even if you had -- it's really easy to end up under the boat in rough water, and get hit or pushed underwater. Boats are heavy and ponderous and very, very dangerous to people on the surface -- I think those of us who dive off them regularly get a little too relaxed about this sometimes.

Any idiot can fall off a boat. It's actually a line I use in my briefings, and especially for those rough trips. Yes, I will tell you that when it's very rough. How do I know? Well, I've never suffered a MI that I know of (yet, still waiting for the first one), but I've been too exhausted to climb the ladder. Even in no gear and just a wetsuit providing plenty of buoyancy, I've been too exhausted to get on the boat. The same boat I'm captain of. I was able to take off my gear and have the DM haul it up, but there was just no way I was going to make it up the ladder. I had the DM come get me in the chase boat as I rested bobbing in 6 foot seas, and by the time the chase boat got to me, I was in pretty good shape, although 100 yards or more from the big boat. I was able to get in the chase boat and rest some more before I got to the big boat, and I was able to get on the big boat. That's some scary stuff when you're the captain too.

 

[Bubbletrubble]

If I may chime in on the physiology of the MI here: Usually hypoxia affects the brain before it affects the heart, but here we have a combination of decreased oxygen supply to the heart due to hypoxia and high heart rate PLUS increased demand due to stress and the strenuous swim. It's a double whammy hitting the heart from both sides. So I think it's quite conceivable to have an MI in spite of a healthy heart.

I'm not an expert on this, but I would think that healthy heart tissue (in the absence of CAD) usually doesn't die due to increased demand alone. Perhaps the patient had a heretofore "silent" predisposing condition, e.g., Prinzmetal's angina, hypercoagulable state, etc. FWIW, I'm aware that enhanced sympathetic activity (caused by emotional stress) can be a precipitating factor in coronary vasospasm. I suppose that this in combination with increased oxygen demand during physical exertion may have been enough to cause the event.

I was curious about the cause of the hypoxia as well. Did the saltwater aspiration lead to pulmonary edema which resulted in hypoxia? If that's the case I would have expected the OP to have described herself in respiratory distress. I didn't get that impression from her description of the incident.

I think we're arguing over the definition of MI. Elevated enzymes means enough damage to heart muscle cells to cause troponin to leak out of them; but if it's demand ischemia and the peak troponin is something like 2, and the cath doesn't show any significant coronary disease, I guess I'd be tempted to tell the victim that she had healthy arteries and a healthy heart (especially if her EF was normal post-event).

I'm rather surprised by this. Wouldn't demand ischemia imply, at a minimum, the existence of some sort of chronic stable angina (or other cardiovascular disease)?

While it's good news that a patient has clear coronary arteries and normal EF post-NSTEMI, telling a patient that she has a "healthy" heart sort of implies that the patient can return to her normal activities (pre-event) without any increased risk of experiencing another MI. From what I know about NSTEMI, patients are at an increased risk of recurrent heart attack in the 2-month period following the event. By 3 months out, the risk drops back down to baseline.

I would think that the "healthy heart" label would be something that a physician would reserve for follow-up a few months post-event.
Maybe the patient is far enough out from the incident now that the label should apply.
Perhaps I'm reading too much into the "healthy heart" term.

 

[cruiser]

Regarding the OP (or anyone) not being able to pull herself up into the dingy, could she have stayed in the water and been towed by the dingy to the liveaboard?

 

[Wookie]

Regarding the OP (or anyone) not being able to pull herself up into the dingy, could she have stayed in the water and been towed by the dingy to the liveaboard?

Doesn't work and is most uncomfortable. Many ask, none succeed.

 

[DandyDon]

Regarding the OP (or anyone) not being able to pull herself up into the dingy, could she have stayed in the water and been towed by the dingy to the liveaboard?

I did that once diving from Capt Wookie's boat. My bud & I screwed up, got far enough out that he said he was not up to the swim, so we signaled and waited for the dingy. I couldn't get onto it with my pony so rather than remove it or more, I got halfway on and road to the boat like that. BIG DIFFERENCE tho, I was in easy seas and daylight.

 

[Bratface]

Thank you Jan for replying. Sometimes you have to be very brave to post anything in this forum. Your reply was written with grace. Glad you survived your ordeal and I hope you will continue to dive again when you are ready.

 

[Hatul]

Any idiot can fall off a boat. It's actually a line I use in my briefings, and especially for those rough trips. Yes, I will tell you that when it's very rough. How do I know? Well, I've never suffered a MI that I know of (yet, still waiting for the first one), but I've been too exhausted to climb the ladder. Even in no gear and just a wetsuit providing plenty of buoyancy, I've been too exhausted to get on the boat. The same boat I'm captain of. I was able to take off my gear and have the DM haul it up, but there was just no way I was going to make it up the ladder. I had the DM come get me in the chase boat as I rested bobbing in 6 foot seas, and by the time the chase boat got to me, I was in pretty good shape, although 100 yards or more from the big boat. I was able to get in the chase boat and rest some more before I got to the big boat, and I was able to get on the big boat. That's some scary stuff when you're the captain too.

This is why I actually prefer shore diving. My close calls have been in diving off boats and I consider shore diving, at least here in So Calif, safer. You also get a better workout with the swim, but it's a healthy, controlled effort and you can slow down almost any time. If you get lost or run out of air, just surface take your bearing and swim in on your back.