Chest Pain

[Anony]

My freind and I did a cold-water night dive last night in a local lake,
we dove to ~60 ft according to his old fashioned depth gauge, and around 43ft according to my dive computer. We did a stop at 15 feet and I dropped my light about a minute and a half into it. I borrowed his light and he ascended.
I grabbed the flashlight off the bottom, came back up slowly, and saw him descending to find me at <15 ft. (We acknowledge this was dumb, and wont be doing it again.) We both ascended then, and then swam back to change out tanks.

One the second dive we werent dont for 20 minutes, never past 35 ft. We slowly ascended and swam back.

A few minutes later he felt nausea and on the drive home he had trouble breathing, with a pain just below his sternum.
He told me later that the pain went from "Very annoying to I-want-to-cry". Macho jerk didnt tell me until the next day. >:[

He went to the family doctor this morning and had a chest X-ray, the doctor found nothing wrong, but cautioned against diving again. The pain persists, though he tells me that moving his body hurts less if his lungs are empty.
He promised to call dan in the morning if the pain persists.

Any idea what is wrong?

 

[bleeb]

Alright. I hesitated quite a bit before replying, and really would have preferred deferring to one of the docs who frequent this part of SB, but from the time of day, it seemed like there was a fair chance no one would reply till tomorrow. (I figured I'd wait a few minutes, first.)

I'm not a medic of any form, and I get a bit uncomfortable with the way "call DAN" seems thrown out almst automatically at times, but this may be one of those times. IMHO, you should call DAN immediately. If he won't until tomorrow (Where are you, anyway?) you should right now. Or get him to the nearest emergency. If you're going to do the latter, preferably do both, just to make sure a set of dive medicine-knowledgeable eyes are looking at the problem. From what I remember of my first aid and dive medicine, 'trouble breathing', 'chest pain', 'increasing' and 'it hurts when he moves' can mean all sorts of really bad things. It could be nothing, but those are at least fairly big yellow flags.

 

[Tenser234]

Im the macho jerk. Eh.

There were no complications after our first dive, we exited the water, changed tanks, went back down. After surfacing the second time I had some stomach issues, was coughing up stuff and my stomach felt like I had indigestion. When I got out of the water I had my fins off, and walked upto my car. By the time I reached my car I had severe pains around my diaphragm. I haven't ever felt anything like that. It was a tightness, like my breath was caught, the pain was unlike anything I have ever felt before. It was brief, probably about 5 to 10 seconds, but it came back randomly while we broke down our gear, on the way home (takes about an hour and 20 minutes). The pain tapered off a little, but it was still to the point that I didnt think I would be able to sleep. I had surgery on my neck end of last month and had codine left over and took one.

At about 3am I woke up in incredible pain. The pain around my diaphragm stopped, but it was now hurting about three inches above my left nipple. On a scale of 1 - 10 the pain is about a constant 2, but it flares up if I move around, or take a deep breathe. The most comfortable position is to keel my arm in as close to my body as possible. Its continued on throughout today about the same amount. Still constant 2, still hurts to move around alot. If I dont move I feel pretty decent.

Doctor took X-rays, and hooked me up to the heart monitor machine with the little tabs. He thinks it is either air leaking into my chest, or I sprained myself. Either way, I am to stay in bed, and if it gets worse, go immediately to the ER.

 

[Anony]

IMHO, you should call DAN immediately.

First: Thanks alot for the reply.
Second: The DAN non-emergency line is closed until morning, and neither he nor I consider this an emergency, since he has already been to a doctor, and been cleared against serious immediate problems.

Any idea how long of an SI is required before a small (not visible on x-ray) pneumothorax is rendered null?

 

[Bubbletrubble]

Did the family doctor rule out mediastinal emphysema (ME)? FWIW, ME presents with substernal pain that increases upon inspiration (although other medical conditions can cause this type of pain, too). The X-ray may or may not show mediastinal widening -- something that a family doctor might be able to recognize. ME can lead to subcutaneous emphysema (SE). It doesn't sound like your friend has SE...or else he'd be complaining of voice changes, neck swelling, painful swallowing, or sore throat.

Patients with a diagnosis of ME should be monitored for signs of coincident arterial gas embolism. More specifically, if he has any neurological or cardiac issues at all, he should see a physician immediately.

Chest pain can be caused by any number of things. It could be as simple as a musculoskeletal issue, e.g., he pulled a muscle lifting a tank. Or it could be something more serious.

If the pain persists, worsens, or he starts to have neurological or cardiac issues, then tell him to seek further medical attention. I'm sure DAN will make similar recommendations.

Good luck with this. I hope your friend feels better soon.

Edited later: The doctor seems like he knows what he is doing. It sounds like he agrees that the chest pain could be caused by ME or uncomplicated musculoskeletal pain.

 

[bleeb]

Edited later: The doctor seems like he knows what he is doing. It sounds like he agrees that the chest pain could be caused by ME or uncomplicated musculoskeletal pain.

Yes, the extra details you supplied are a bit more reassuring. With the original post, it was hard to tell how thoroughly you were looked at, or whether the doc was like many we hear about here or over in Accidents and Incidents with no so much dive medicine-applicable background. Undiagnosed/untreated ME scares me.

Or, things just look rosier in the light of day.

Hope you feel better soon and that it turns out to be nothing serious.

 

[cutlass]

Im the macho jerk. Eh.

There were no complications after our first dive, we exited the water, changed tanks, went back down. After surfacing the second time I had some stomach issues, was coughing up stuff and my stomach felt like I had indigestion. When I got out of the water I had my fins off, and walked upto my car. By the time I reached my car I had severe pains around my diaphragm. I haven't ever felt anything like that. It was a tightness, like my breath was caught, the pain was unlike anything I have ever felt before. It was brief, probably about 5 to 10 seconds, but it came back randomly while we broke down our gear, on the way home (takes about an hour and 20 minutes). The pain tapered off a little, but it was still to the point that I didnt think I would be able to sleep. I had surgery on my neck end of last month and had codine left over and took one.

At about 3am I woke up in incredible pain. The pain around my diaphragm stopped, but it was now hurting about three inches above my left nipple. On a scale of 1 - 10 the pain is about a constant 2, but it flares up if I move around, or take a deep breathe. The most comfortable position is to keel my arm in as close to my body as possible. Its continued on throughout today about the same amount. Still constant 2, still hurts to move around alot. If I dont move I feel pretty decent.

Doctor took X-rays, and hooked me up to the heart monitor machine with the little tabs. He thinks it is either air leaking into my chest, or I sprained myself. Either way, I am to stay in bed, and if it gets worse, go immediately to the ER.

Obviously, the first concern is a cardiac event. Heart attacks do have a tendency to occur during early morning hours. However, the pain tends to be "gripping" or "heavy", quite painful, with sweats, feelings of doom, nausea, and usually independent of changes in position or breathing. Your immediate post-dive and early morning pain patterns seem to be different. While infarcts (heart muscle damage) can show up on EKG/ECG's, that's not garuanteed and might take a specialist's eye to detect. In addition to the "heart machine" exam, did the doctor also draw a blood sample? Damaged heart muscle also typically dumps certain characteristic enzymes into the bloodstream. And while all this may be negative, this still most certainly does not rule out you having had some kind of cardiac event. The suspicion for heart attack is lowered but not excluded and other heart-related problems (e.g. coronary spasm) are not excluded.

You mentioned "coughing up stuff and my stomach felt like I had indigestion". Acid reflux is also somewhat common after exertion and while sleeping or upon wakening because of the recumbent position. Such pain can be spasmotic, burning, and position dependent. I've had it.

Without examination, reviewing your medical history and risk factors, there's no way to say anything definite about your condition. There are many causes for chest pain. You did the right thing to get checked and the plan to go to the ER if it happens again is good.

p.s. I just found this informative link on chest pain issues, apparently extracted from a widely used textbook referred to simply as "Harrison's". The URL hints that it may be from the latest 17th edition.

 

[TSandM]

Chest pain which is increased with inspiration and with movement of the arm is usually related to musculoskeletal problems or irritation of the pleura (lining of the chest cavity). Pleural irritation could be caused by a pneumothorax, and small pneumos are hard to see on chest x-ray, particularly if you are not used to looking for them. Pneumonia, pleurisy, and pulmonary emboli are other things which cause this kind of chest pain.

You can get severe chest pains from esophageal irritation, like acid reflux, and esophageal spasm. You can also get severe pain from cardiac causes, although that does not tend to come in brief spasms, and is not usually changed by breathing or position.

If your pain persists, it would definitely merit a second evaluation, with a repeat chest x-ray, repeat electrocardiogram and cardiac enzyme determination, possibly a d-dimer screening test for blood clots. You do not give your age, but if you are in your 40's or older, you may deserve some type of cardiac imaging as well, like a treadmill or nuclear scan.

The problem with chest pain is that there are a number of very benign causes of it, but quite a few dangerous or lethal ones, and it should never be ignored until a definitive diagnosis has been made.

 

[Tenser234]

Howdy;

Im doing much better. I rested and slept a lot. I don't have any further chest pains except when I lean against something or prop myself up on my arm. Even then its really mild. I can breathe deeply and normally again. I probably strained myself somehow when diving. Thanks for all the advice and concern.

 

[Anony]

Thank you all so much for your advice. See you below.