breast/lymphatic pain after an easy shallow dive

[Duke Dive Medicine]

Hi Doc,
This one is from an abstract that Dr. Moon presented at UHMS in 1991. This one is a study by Wilmshurst in 1989. Both show correlation between DCS and severe neurological symptoms but not mild DCS symptoms. Dr. Moon uses these in his presentations on the relationship between PFO and DCS.
On a less scientific note, the physiology doesn't really fit - a PFO is going to cause bubbles to arterialize and become emboli, but there hasn't been a mechanism identified that would allow arterialized bubbles to pass into the lymphatic system.
Best,
DDM

 

[munkfish]

I'm guessing they decided not to treat you in the chamber.

Well that one went back and forth a few times over the course of my stay, since the symptoms were progressively getting worse. Infection was considered but eventually ruled out (no fever, nausea, discharge, itching).

There is only one chamber in the city, and it had closed several hours earlier. They couldn't get hold of anyone to man it. They were set to transport me to the nearest open-for-business chamber several hours away in Montreal, but given the pain wasn't unbearable (7/10) the decision was eventually made to let it resolve itself, with pain meds.

I don't know much about dive medicine, but I found the experience discomforting. I sure as hell shouldn't know more about it than the attending medical teams. Left me with a feeling of still not being 100% sure what happened. The good news is the symptoms seem to be improving on their own. On day 3, red marks are subsiding and pain is down to a 4.

 

[TSandM]

Munkfish, just to defend my profession . . . there is a LOT to know in medicine. There are not many divers, and DCS is rare even among active ones; I would guess the majority of emergency physicians go their entire professional careers without ever seeing a case. In addition, diagnosis of DCS is at best imprecise; the person who has heavy nitrogen loading, an uncontrolled ascent, and severe joint pain is not the the most common presentation that someone is going to see. It's more likely to be a diver with a marginal or even totally acceptable profile and some more vague symptoms, and there is no blood test or x-ray that will allow the doctor to say with certainty that this IS or is not DCS. When you get to more unusual presentations like yours, I can't imagine any ordinary ER physician feeling comfortable or confident with deciding whether this was decompression-related or not. At least your docs were honest about not knowing; we have seen stories here of ERs that even refused to put people who KNEW they were bent on OXYGEN! (Shoot, we just about put hangnails on oxygen in my ER.)

Anyway, this is an interesting story, but I'm not sure we are ever going to know what the answer is, unless your symptoms are recurrent with resumption of diving.

 

[DocVikingo]

Hi Doc, ... Both show correlation between DCS and severe neurological symptoms but not mild DCS symptoms. ... On a less scientific note, the physiology doesn't really fit - a PFO is going to cause bubbles to arterialize and become emboli, but there hasn't been a mechanism identified that would allow arterialized bubbles to pass into the lymphatic system. Best, DDM

Morning DDM,

Leaving aside for a moment the issue of a mechanism for PFO-related arterialized bubbles to pass into the lymphatic system, there is relatively recent research suggesting a possible relationship between breast pain and DCI in women with PFO. E.g., see my earlier comment, "If you wish to read still more, I suggest this short and understandable read --> Decompression illness presenting as breast pain http://archive.rubicon-foundation.org/dspace/bitstream/123456789/5024/1/16716055.pdf ," and this really is the focus of the thread.

OTOH, while I'm not convinced the 1989 Wilmshurst et al piece is the complete and final word on the subject, I tend to agree that the majority of mild DCS signs/symptoms, and the gas phase abnormalities that precipitate them, very likely have an extravascular (i.e., not PFO-related) etiology.

Now leaving aside the issue of PFO in mild DCS symptoms and addressing a possible mechanism for PFO-related arterialized bubbles to pass into the lymphatic system, I would note that the lymphatic and cardiovascular systems share a vast and intimate relationship, not the least of which is a capillary relationship. I can think of a couple of theoretical mechanisms by which passage could occur, although they are long shots, well beyond the scope of this inquiry and audience, and, in any event, I’m too dumb to cogently argue them ; )

Thanks for the input.

Regards,

Doc

 

[munkfish]

just to defend my profession . . . there is a LOT to know in medicine

I just wanted to say first, thanks for this and everyone's thoughtful, helpful responses

...and second, despite my frustration, no defense of the profession is necessary, really. I owe my own life to medical professionals several times over - I don't envy them their stress or weighty responsibilities/expectations.

The ER team who treated me was excellent, doing everything in their power to provide quality care AND learn what they could in a short timeframe. Doctors are human, and like all people, some are awful while others are exemplary. Everyone I saw this time around fell into the latter category. Professional, caring, thorough, competent, and without ego. Care continued even after I left - they called once I got home with more information they had discovered (along with the PFO test order) and my own doctor called today to follow up.

I guess it was just a sobering realization that dive incidents represent such a generalized gap in medical knowledge. And the fact that it took several hours of concerted effort to access anyone who had anything to do with the local chamber is a scary thing indeed.

 

[DocVikingo]

And the fact that it took several hours of concerted effort to access anyone who had anything to do with the local chamber is a scary thing indeed.

I detect an opportunity for some positive community medical action.

Regards,

DocVikingo

 

[bleeb]

I guess it was just a sobering realization that dive incidents represent such a generalized gap in medical knowledge. And the fact that it took several hours of concerted effort to access anyone who had anything to do with the local chamber is a scary thing indeed.

With all due respect to the individual medics involved, I'm a bit surprised the system as a whole had as much trouble as it did finding someone with more knowledge, since I thought the local hospital was one of the four centers in the province handling hyperbaric emergencies, covering the entire eastern part and much of the north of the province. I think I saw something in the news a couple of years ago that due to provincial health budget cutbacks, only Toronto's chamber was going to be staffed for emergencies 24-hours a day, while the others would just be on call. But I would have thought the ER docs should still have known which specialists to get a hold of, or some way to reach the if that was where the breakdown was happening.

 

[Duke Dive Medicine]

Morning DDM,
Leaving aside for a moment the issue of a mechanism for PFO-related arterialized bubbles to pass into the lymphatic system, there is relatively recent research suggesting a possible relationship between breast pain and DCI in women with PFO. E.g., see my earlier comment, "If you wish to read still more, I suggest this short and understandable read --> Decompression illness presenting as breast pain http://archive.rubicon-foundation.org/dspace/bitstream/123456789/5024/1/16716055.pdf ," and this really is the focus of the thread.

Hi Doc,
I read the case report (is this the research you're referring to?). It references the Wilmhurst paper I linked, along with another by the same principle author: "Both women were subsequently shown to have significant patent foramen ovale, known to be associated with an increased risk of some presentations (italics mine) of decompression illness (3, 4)." Those "some presentations" are severe neurologic symptoms and cutaneous symptoms, respectively. While it's intriguing that both divers had a PFO, the authors of the case report don't make any association between the breast pain and the PFO in either woman. Also, the dives the two women made were far more aggressive than the OP's and thus more likely to produce clinically significant venous gas emboli. Putting aside the location of the OP's symptoms for a second, if her reporting of her dive profile was accurate, it's virtually impossible for her to have had enough of a bubble load to cause symptoms IF she had a PFO and IF she shunted bubbles through it, which is indeed the focus of the thread.

Now leaving aside the issue of PFO in mild DCS symptoms and addressing a possible mechanism for PFO-related arterialized bubbles to pass into the lymphatic system, I would note that the lymphatic and cardiovascular systems share a vast and intimate relationship, not the least of which is a capillary relationship. I can think of a couple of theoretical mechanisms by which passage could occur, although they are long shots, well beyond the scope of this inquiry and audience, and, in any event, I’m too dumb to cogently argue them ; )

Come on now, give yourself and the audience a little credit. What's your theory?

 

[DocVikingo]

Hi Doc, I read the case report (is this the research you're referring to?). ... While it's intriguing that both divers had a PFO, the authors of the case report don't make any association between the breast pain and the PFO in either woman./QUOTE]

Hi DDM,

I think we have a communication issue here. I entirely agree that the authors of the case report didn't make any association between the breast pain and the PFO in either woman. And neither have I. I merely quoted a case study entitled "Decompression illness presenting as breast pain", which I thought the OP might find interesting as DCI and breast pain most indubitably is the core topic of this thread. The link to my earlier coverage of lymphatic DCI also was informational only.

Not only did I not suggest that she may lymphatic DCI and not only did I not suggest that she may have a PFO, above all I agreed with you and TSandM that she likely didn’t have DCI of any sort to begin with.

What am I leaving unclear?

Regards,

Doc

 

[Duke Dive Medicine]

What am I leaving unclear?

Hi Doc,
Maybe we're hound dogs barking up the same tree. It sounded like you were offering a counterpoint to the suggestion that lymphatic DCS is not associated with PFO. I think what it comes down to is that given the OP's stated history, available evidence suggests that there's no indication for a PFO test, and a positive result could cause her unnecessary distress. What are your thoughts?
Best,
DDM