Blood in my face mask

[Liquid]

This is beginnng to seem nice. Don't worry about "needling", through arguments one can only get smarter.

As for my remark about our profesions- It was said regarding the issue of medicines used when diving. Your profesion, as a doctor alows you to perscribe medicines, and naturaly you understand about them more than other people. What I ment was that from PRACTICAL experiance, as instructor, using sinus "drying" medicals before diving may couse some grave results, due to several reasons.

Now-since you brought it up lets get a little quote here from the original message that started this thread:

"Went diving this morning with the last remnants of a mild cold. Took some decongestants. A little tight in the sinuses, but was able to equalize ok.
At the end of the dive, there was a little bit of blood in my face mask, from my nose, etc.
Should I be concerned about this? How about diving again tomorrow?
PS - I take aspirin every day, so I tend to bleed a tiny bit more than average on a cut, etc.

Now let's see tha facts:
-The guy had the remanents of a cold,but was more or less ok.
-Had no equalizing problems.
-had a LITTLE BIT of blood in his mask at the end of his dive (a bloody bogey?!)
-He also takes aspirin.

All he actualy says, is that at the end of a dive, in which nothing was wrong, he had a little bit of blood in it. The following 3 messages were ones, that if I read was I in his place, I would have become frightened. I just wanted to notify him, that what he has is probobly nothing seriouse. I did use a bad phrase there, I can see now, becouse I said "The bleeding itself", in a way that sounded general, while I ment the "little bit of blood" he had in his mask after the dive.

Now let's be honest about it- How many of us, including me and you (Doc Billp) have came out with a little bit of blood in our masks, and not only were we not afraid to dive again the day after, but even dive again an hour or two later?
How many time, did we just pick our nose, and found that bogey was a little red?

What we do is take our calculated risk, as in anything in life. Now- what I would do, with a student or a diver in a group, with a little bit of blood in his maks, is explaining the situation, and let him choose what to do.

As for your quotes-two things-
1-would you mind giving me the links (if there are) to them, as I would like to read a bit more about it?
2-I dont really think that they deal in a case of "a little bit of blood in my mask", but I would really like to read more. What I saw was description of extreme cases of barotrauma, and what couses it.

BTW-An interesting issue is the way diving doctors will treat these cases-I know several doctors that I used to work and dive with, and each of them will have a different solution for similar cases-
We had a doctor we worked with, that worked in the HBO in the hospital near us, and he was the most "Strict" doctor- if someone he checked had the smallest of problems, he would tell him not to dive at all. Another doctor, that worked for the navy seals (here they are caled differently, but it means the same), would ususaly be more leniant, and alow them to dive, while advising coution.

I still hold the opinion that one should not be frightened if he finds some blood in his mask after a dive, and had no problem during the dive. Dives that end in seriouse Barotrauma, will usualy start with equalizing problems in either the ears, sinuses or both. When dives end with seriouse barotrauma, though they started quite well, and with no problem, it usualy involves use of a sinus drying medicine. In times, that one is to congested to dive without medications- I will recomend him not to dive at all.

P.S-
I am not native to english, so please understand that it is a little dificult for me to understand completly the exact meaning of what I write. I do, however, try to write things in the way that will best express what I have to say, but alas-I can have mistakes.

 

[ScubaJorgen]

I've experienced my sight getting red :sneeze: during the dive a few times (say 3 out of 150 dives). Thought it was just a bleeding nose....

Flushing my mask a few times resolved the problem....

Jorgen

 

[BillP]

Hi Liquid:

To the best of my knowledge, the contents of the dive medicine texts that I quoted are not available on-line. Your hyperbaric medicine friends or local chamber will likely have them on their shelves, or if the Interuniversity Institute for Marine Sciences there in Eilat has a library, they might have them. I would guess that they'd be found in most dive medicine libraries with texts in English. (Sorry, I don't know if they've been translated into other languages.) I have them in my own personal book collection, and I refer to them frequently. You can order copies of the books for yourself from places like Best Publishing (http://www.bestpub.com/) or even amazon.com. If fact I recommend that you do get your own copies of the books if you're going to continue to advise people on dive medicine topics. I think that you'll find them very informative.

Don't worry about your English, I think it is excellent for a non-native. It is certainly better than my Hebrew, Arabic, or Yiddish. (And your spelling is better than many native English speakers.) But I have to admit that I do think we have something of a communication problem. I don't think that I have yet been able to make clear to you what I'm saying (sorry), I'm not sure you understand what weight some of your phraseology might carry with a native English speaker (ie what they might infer from your choice of words), and I'm concerned that you might have misunderstood a point in rickc's original post.

Let's look at rickc's post again. He did not say, "nothing was wrong" in the dive. He says he had a cold. It was a "mild" cold and he felt he was at its "last remnants", but he still had a cold and enough symptoms that he felt he still needed a decongestant. To use your words, he was "less OK" and not yet well. A prime set-up for barotrauma, wouldn't you say? In fact I think you did seem to say he was a prime candidate for barotrauma when you expressed concern about a diver in his condition diving with a decongestant. You have stressed the importance of not having symptoms with sinus barotrauma, claiming a possible sinus squeeze barotrauma injury is "nothing to worry about, if it isn't accompanied by pain". Did you notice where he described feeling "tight in the sinuses"? Someone else who is a native English speaker might have used the word "squeeze" to describe the sensation. Many might find the sensation decidedly unpleasant if not frankly painful. So we have a diver with a cold and congestion, on the decongestants that you think are so dangerous for causing barotrauma, who experiences a sensation of a sinus squeeze on a dive, and who finds blood in his mask after the dive (not on his finger after picking his nose on the surface). That is a description of a sinus barotrauma injury until proven otherwise, and yet you seem to keep looking for excuses as to why it's not barotrauma, and you told him he had no reason to stop diving.

I have to admit that I have some concern that an experienced dive professional would read that account and attribute it to diving in the hot dry desert, breathing compressed gas (through his nose?), or picking his nose rather than thinking of barotrauma first and then including the other possibilities further down the list in the differential diagnosis. But as you have so adroitly pointed out, I am not a dive instructor. I assume that most dive agencies have standards for their instructors to follow. Are there certification agency guidelines for advising divers under your supervision on when they can continue to dive with a barotrauma injury? I would be interested to know the guidelines of your agency, and other dive certification agencies too if other board members wish to chime in.

I'm also concerned that you put such a strong emphasis on it only being "a little bit of blood". Obviously a massive hemorrhage would be a bad thing, but having only "a little bit of blood" isn't particularly comforting. If the opening to the sinus is occluded (which it is when the diver suffers barotrauma- that's how they get the injury) you may see only "a little bit of blood", but the sinus behind the blockage could be full of blood. The "little bit of blood" is a sign of an injury, but in this situation (as in many others) the amount of blood seen doesn't necessarily correlate with the severity of the injury.

Your concerns about allaying rickc's fears are very commendable, but I think misplaced. I am frequently put in the position of having to give people very frightening news, but I would never put them at additional risk by distorting the truth of that news just to make them happy, to keep them as a paying customer, or so they'll have a better day. That would be irresponsible. Neither would I tell a fellow diver that they have NO risk of continuing to dive after sustaining a barotrauma injury just so I wouldn't scare them. Read my response to rickc again. It wasn't unnecessarily frightening, it was just honest. Would you really have me hide the truth from him about the possible risk of diving after barotrauma just to make him happy?

You said, "I still hold the opinion that one should not be frightened if he finds some blood in his mask after a dive, and had no problem during the dive. Dives that end in serious barotrauma, will usually start with equalizing problems in either the ears, sinuses or both.". I would agree with those statements completely, but unfortunately that is not what you have been saying in this discussion, it is what I have been saying. It represents a turnabout if not an epiphany on your part. Let's look at your sentences. "I still hold the opinion that one should not be frightened if he finds some blood in his mask after a dive, and had no problem during the dive." You are correct. As I believe I've said several times in this thread, the diver is unlikely to suffer any ill effects from that particular dive. But you, my friend, have maintained that the diver has no risk of further injury on subsequent dives after they've already sustained a barotrauma injury. Not true. As you said, "Dives that end in serious barotrauma, will usually start with equalizing problems in either the ears, sinuses or both.". Also correct. That is why you should not recommend to divers with sinus barotrauma that they continue diving. When a diver surfaces with signs of sinus barotrauma- such as blood in their mask after diving with a cold- they have shown you that they have the "equalizing problems in either the ears, sinuses or both" that you mentioned. (Remember the 48% incidence of ear barotrauma associated with instances of sinus barotrauma?) They already have barotrauma and further diving could cause the "serious barotrauma" that you now say can occur.

IMHO, while you shouldn't recommend that a diver with a minor barotrauma injury continue diving, you don't have to refuse to let them dive if you haven't concealed the risks from them and they understand well enough to make an informed choice. I would agree with your statement that, "What we do is take our calculated risk, as in anything in life." But you can't calculate the risk if you don't know the risk. I wasn't trying to scare rickc, I was just informing him of the risk. I have to say that I'm gratified by your statement that, "Now-what I would do, with a student or a diver in a group, with a little bit of blood in his mask, is explaining the situation, and let him choose what to do." I am very glad that you would do that now because I do not believe that is what you did at the start of this thread. I hope that I played some small part in helping you come around to that conclusion.

HTH,

Bill

BTW, I continue to marvel at your logic too, when you ask if we all haven't dived after seeing blood. If you do something foolish and survive unscathed, the foolish act becomes wise? With reasoning like that, you should publish a book. You'd probably become a best selling pop philosophy guru. I know that I'd buy your book! ;-)

 

[Liquid]

Hi doc BillP.

I do not live in Eilat any longer, but it dosen't really matter, I can get a hold of these books anyhow. Just hoped you might save me the trouble by pointing on links , As I am at the end of a term now, and short of time becouse of the exams.

Anyway- I'll make it short this time, so here are 2 things-

One-you said something about agencys's standards regarding this situation-Actualy, when I did the instructor evaluation, one of the questions in the "decivesiveness" (or whatever english name it had) exam was about such a case. A diver that finds out after a dive that he has some blood in his mask and asks the instructor what to do. The more or less correct answer (in this kind of exam there aren't right or wrong answers) should have been- Tell him it's probobly a sinus squees or a little nose bleed, and that probobly nothing is worng, but it is the diver's final decision about what he should do next.

two-as you pointed out I might have misunderstood the sentance: "A little tight in the sinuses, but was able to equalize ok. ". I took it as he had absolutly no problem, where I may have been mistaken.

One last thing-
I still dont think a diver should make a fuss about some blood in his mask after a dive. It does happen to everyone. Knowing the probable couses, ofcourse, is an important thing.

oh-and really last thing-Even in cases of more seriouse synus barotrauma: usualy even these are not dangerouse, and the only problem is the pain that arises when ascending. It usualy ends up in a diver that mast break a "pain barier" in order to surface (otherwise the air will run out), once the "barrier" is passed, the pain usualy stops, and when getting to the surface you get one icky mask filled with blood and foam. Most people I know that are profesianls, and becouse of that may have to dive even if congested (otherwise they won;t be able to pay the rent )had it once or twice. I am lucky to be a man that rarely have any problems with it, and never had a problem with my ears. All of that said, there still are, like you pointed out, more severe cases that ended up with permanent damage.

ok, as I write I think of new things so here's another last one- Can you put your hand on any kid of statistic relating to what this discussion is about?
like-the numbers of incidents that ended with permanent damage, death, etc. etc and what were the conditions in the dive (including how congested the diver started the dive). I'm saying it, becouse I find it hard to belive, that a diver with mild congestion will end up with-"(snip) Occasionally the air may rupture into the cranial cavity and cause pneumocephalus." .

as for the last remark of your message-I happen to know, belive it or not, that people get killed sometime while crossing the road, but I am brave enough to cross the road myself every day!
Guess you keep it safe by living on a lonely mountain with no cars around, eh?
just keep in mind that when my book gets published you'r gone have to buy it! (at least one copy will be sold :innocent: )

 

[BillP]

Ya know Liquid? I think we're almost in complete agreement now. You're really coming around!

You are correct that sinus barotrauma is fairly common, serious health threatening sinus barotrauma is uncommon, and severe problems (like pneumocephalus) from sinus barotrauma are quite rare. But even rare things happen sometimes. I still stand by my original statement that sinus barotrauma injuries are "usually mild and self-limiting, but can on occasion become quite serious". That statement is true. Maybe scary, but true. Now, if you had come back and clarified my statement to read, "but can on 'rare' occasion become quite serious" I would have had no problem. But unfortunately you seemed to be stating, "but on NO occasion can it become quite serious" and that there are "no worries" for a diver with a cold and barotrauma to continue diving. I had to take issue with that, and I'm glad you've clarified your position. No, I don't have statistics on how often serious problems from sinus barotrauma occur, but I can tell you that if a rare serious problem happens to you the incidence in your personal history is 100%.

Having never personally experienced such a rare event yourself, I'm not surprised that you didn't believe it could happen. That's just human nature. I hope that you know better now. I've included a page from Edmonds, Lowry, and Pennefather's Diving and Subaquatic Medicine in the upload link below that illustrates a case of pneumocephalus after sinus barotrauma. I hope that it is enlightening (and that the upload works!)

Originally posted by Liquid


One-you said something about agencys's standards regarding this situation-Actualy, when I did the instructor evaluation, one of the questions in the "decivesiveness" (or whatever english name it had) exam was about such a case. A diver that finds out after a dive that he has some blood in his mask and asks the instructor what to do. The more or less correct answer (in this kind of exam there aren't right or wrong answers) should have been- Tell him it's probobly a sinus squees or a little nose bleed, and that probobly nothing is worng, but it is the diver's final decision about what he should do next.

Excellent! IMO, rationally discussing the potential risks of diving with barotrauma with divers and helping them make an informed choice is much more responsible than just telling them there are no worries and they should continue diving. I'm glad to see that SSI is taking the high road in this matter. I don't suppose that SSI has a specific guideline on advising a diver with an active cold (even if in the "last remnants") already on decongestants who suffers a barotrauma injury whether they should continue diving or not, do they?

Now about those decongestants. I've discussed medicines and diving in quite a few other threads on this board, and have addressed decongestants in particular. You're right, as I've said elsewhere on numerous occasions, there can be untoward side effects from medications when diving. A diver should indeed understand the effects and potential side effects of a medicine before taking it (or rely on the advice of their medical professional). While I would agree with you that as a non-medical professional it is not your place to recommend to divers that they take medicine, I still think that heavy-handed statements like, "Diving with medicine is a bad thing" are unnecessarily harsh. If you lack the knowledge to tell a diver when they can dive on a medicine, you also lack the knowledge to tell them when they can't. If you want to inform yourself on the risks and benefits of particular medicines while diving and then pass that information on to other divers so they can make their own informed choice, that's great. But I hope that you will avoid blanket statements like "Diving with medicine is a bad thing" in the future.

I've found some research studies on equalization, pseudoephedrine, and diving that you might find enlightening. They're a little off topic as they discuss ear barotrauma (rather than sinus- ear problems are more common and easier for researches to look at), but they're still relevant to the general concepts we've been discussing.

You've heard the guideline that if you can't clear your ears or sinuses at the surface you should not dive. And that's a good guideline. But this first study shows that unfortunately the reverse doesn't necessarily hold true. If you can clear at the surface you still might not be able to equalize at depth. Look at:

http://www.ncbi.nlm.nih.gov:80/entr...eve&db=PubMed&list_uids=1872517&dopt=Abstract

The second study suggests that routine use of pseudoephedrine in normal novice divers will decrease (not increase) the incidence of of ear barotrauma in those divers from 32% to 8%. Hey, maybe you should recommend that all your students take pseudoephedrine! (Just kidding.) See:

http://www.ncbi.nlm.nih.gov:80/entr...eve&db=PubMed&list_uids=1610044&dopt=Abstract

You brought up the point that medicines' safe use in diving hasn't been reseached thoroughly, and that's a good point. But that doesn't mean that they haven't been researched at all. The study below suggests that pseudoephedrine is safe in divers from a psychometric and cardiac standpoint. You can find an abstract of the study at:

http://www.ncbi.nlm.nih.gov:80/entr...ve&db=PubMed&list_uids=10999495&dopt=Abstract

But after reading that study, don't miss my comments on DAN and pseudoephedrine below so you can make an informed choice:

http://www.scubaboard.com/showthread.php?s=&threadid=570&highlight=pseudoephedrine+AND+dan

HTH, and good luck with your exams!

Bill

Oh, and yes I do live in the city and cross the street. But I would never tell my children that crossing the street is "no worry" unless they have sudden severe pain in the middle of the road, especially after they've already noticed significant traffic. I would (and do) rationally discuss the risks of crossing a road with them and teach them about potential dangers when crossing the road so they can eventually make the informed choice about when to do it safely. Yes, people cross the road all the time without looking and don't get severly injured, but an estimated 63,000 pedestrians were killed in the US over the last decade. So while crossing the road is statistically safe and problems are quite rare when you take proper precautions, I would never tell someone under my charge that there were "no worries" crossing the road. That would be irresponsible.

 

[Liquid]

Hiya.

I think we'v both more or less finished here, and anything further will be like chewing stones, with no aperant reason. We both actualy say the same thing in a different way.

to finish off-I did know about the complications regarding sinus barotauma. Read my former message, I think I wrote about it there.

Thank you for the good luck wiching, though I hope luck wouldn't be the thing to make the difference

P.S-
Living in the city is danegerouse. Try the desert, just avoid those crazy cammels roaming all over.