Cutaneous Decompression Sickness

[wylerbear]

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About 2 years (and a couple hundred dives) ago I experienced extreme pain after a dive and ended up spending 6 hours in an ER while they poked and prodded me and ran a zillion tests and ended up not knowing what was wrong. A few months later I experienced Sunday it happened again.
After the first incident I posted on another scuba forum and got a lot of theories from too much carbonation from the Pepsi I drank, to too much fat from the cheese sandwich I ate, to a gall bladder attack. I appreciated all the comments but there didn't seem to be a good answer. It was suggested by several people that I contact DAN but since the symptoms were gone I never got around to calling them and I dove many dives without a problem.
After Sunday's problem I contacted DAN and had a long talk with one of their Medics. I found out that what I experienced was Cutaneous Decompression Sickness. This is something that there is not a lot known about at this time but the Medic I talked to is compiling data so she can write a paper to be presented at a conference in a couple of months.
In the interest of helping this study and spreading knowledge I wanted to outline my symptoms. If anyone has had similiar symptoms it would be great if you could contact DAN and talk to Laurie about them.

ME:
50 year old female with a little more body fat than I should have. Post- hysterectomy. (Post-menopausal women and women who have had hysterectomies are more likely to experience this).
Diving for 3 1/2 years averaging 80-100 dives a year.
Generally a pretty conservative diver.

THE DIVES: (Sunday's)
First dive 60 minutes to a maximum depth of 83'. More than half of the dive between 50-60 feet. More than 8 minute safety stop.
Second dive 59 minutes to a maximum depth of 79'. Most of the dive between 50-60 feet again. At least 10 minutes above 30' and perhaps 5 minutes at safety stop depth.

THE SYMPTOMS:
Extreme burning and pain in the abdomen area (apparently this happens in areas which are fatty-abdomen, hips, buttocks)
Skin rash-reddened skin and small bumps. Can also present as purple bruising.
Skin very sore to the touch.
Slight dizziness and brief nausea.
Onset of symptoms: about an hour after second dive ended
Duration of symptoms: about 2 hours for the pain to abate and maybe another hour for the rash to disappear.

CURE:
If you experience this, surface Oxygen is called for if available. The first time I was at a hospital so they administered it but Sunday I didn't get it. I didn't notice any difference between the two times but it is DCS and it is caused by a build up of Nitrogen so Oxygen really is indicated.
Dive conservatively. Shorter dives, longer safety stops, longer, slower ascents. Take off a day if doing mutiple days of diving.
If you experience these symptoms, don't dive for a couple of days-continuing to dive after having this WILL make it worse including neurological problems.
Dive Nitrox instead of air.

So, that's my story. If you experience this or know someone who does or if you are an instructor who has a student who has this problem, I hope this information helps.
__________________

 

[Uncle Pug]

Georgia, where you using nitrox on either of these dives?

 

[MilitantMedic]

Wow....those are some pretty "out there" profiles if you were on air. Also when you walk into an ER (I'm sure you know this part) you'll be talking to a Triage Nurse, makes sure you say "Diving Accident" and request a transfer to the nearest chamber...even if it's just Cutaneous DCS. I'm saying this mostly for anyone else who goes through this. I've found that hospitals usally have very little experience with any form of diving accidents and may not respond as promptly with proper care and procedures (which they really don't have access to).

Side Note: Diving Nitrox isn't "safer," only the diver is safer. Just like computer don't make a dive/plan "safer." Use each gas according to proper principles.

 

[BigJetDriver]

...when you walk into an ER (I'm sure you know this part) you'll be talking to a Triage Nurse, makes sure you say "Diving Accident" and request a transfer to the nearest chamber...even if it's just Cutaneous DCS. I'm saying this mostly for anyone else who goes through this. I've found that hospitals usally have very little experience with any form of diving accidents and may not respond as promptly with proper care and procedures (which they really don't have access to).

MM,

Thank you for re-iterating what for me is a constant message. The folks at the ER just don't know what the Hell they are doing with DCS cases 99.9% of the time! :11:

I am by no means slamming the hard-working folks at the ER. It is not their fault! It is just that the system does not give them the training or the tools.

 

[MilitantMedic]

It's no fault of there own, and it's such a rare occurence (which is a great thing!) that they never see anyone present with it.

Dr. Deco should post a DCS algorithm =).

Mine is (so far):
Oxygen NRB @ 15lpm
Assess symptoms/field neuro exam
IV Bolus NS 1L then 1L @ 10cc/min

Pretty minimal but about as good as I can come up with until I can transfer to the chamber.

 

[wylerbear]

I was NOT diving Nitrox but will be taking the Nitrox course on the 13th (soonest I could arrange it).
When I went into the ER I immediately announced that it could be a dive-related problem and I was immediately ushered into a room ahead of others that were waiting. I did not demand to go to a chamber. What I did do, is after 10 minutes of answering questions, demanded (well, just strenuously suggested) that I be put on Oxygen in case it was DCS. The physician smiled tolerantly at me, told me he had worked in a chamber for years, and reassured me that I would be put on Oxygen as soon as they were finished with the assessment. That happened a few minutes later. The doctor spoke with the nearest chamber a couple of times in the 6 hours that I was there. Initially they thought they would send me but as my syptoms were already abating, they decided to wait awhile. Since I continued to feel better they decided it was NOT dive-related. It was officially diagnosed as "non-specific abdomen pain" or something like that. Until it happened again after diving, I was willing to believe it had nothing to do with diving-just coincidence. But now I know better. If it, or anything even faintly resembling DCS occurs to me again, my first call will be to DAN.

What do you mean my dive profile was pretty "out there". I think I was diving pretty conservatively. Most of both dives were at the 50-60' range, both included long, slow ascents with more than adequate safety stops.

 

[Saturation]

A standard approach to any ill sensation after a dive that worsens or persists in severity is insure that divers:

See a healthcare professional;
mention they were diving;
Get DAN on the loop SOON.

The phones are answered by EMS or equivalent, not MDs. We are involved only on a physician-physician discussion to provide insight into diving specific issues at a high level.

What is described is skin bends, its not a new thing, its very well known established.

Diving related issues are misdiagnosed often because they are rare, and not even all hyperbaric specialists are equally familiar with it ... simply because it does not occur often enough to create familiarity. To insure the treating doc is made aware of its possibilities, a consultation with DAN is helpful. Its is not mandatory on their part so it must be encouraged to the treating physician.

 

[Dr Deco]

Hello wylerbear:

Cutaneous DCS

This is a rather rare occurrence, but certainly not unknown. There is some evidence that it is associated with a patent foramen ovale, but this is not certain. Since you have many dives and see this rash but rarely, I would suspect that a PFO is not a problem for you.

Certainly conservative diving is always a good idea. That means slow ascents and safety stops.

Emergency Rooms

Many things are not covered in medical school. While this may surprise many people, it is a fact. Time is short, and the world is large. Medical students will use Guyton’s “Medical Physiology.” My copy has one chapter on “Physiology of Deep Sea Diving and Other High Pressure Operations.” This is covered in seven pages in my edition. This is only the physiology of the disorder and not the medical treatment.

Most physicians with whom I have had contact that were acquainted with diving medicine were former diving medical officers in the US Navy. If your ER team does not include a SCUBA diver or a former diving medical office, you are amongst individuals who probably do not know what to do. Only in certain cities are SCUBA diving problems somewhat known by medical teams in a hospital (e.g., Florida).

I have heard stories of ER teams drawing arterial blood and determining that DCS was not the problem, since they did not find any gas bubbles. Not correct - - - not even close.

“Diving” Accident

The group should also be made aware that the patient is talking about a scuba diving problem. In some cases, the medical staff might think this was a diving accent where someone hit their head on a diving board and had a neck injury.

Dr Deco :doctor:

 

[Dive-aholic]

I was NOT diving Nitrox but will be taking the Nitrox course on the 13th (soonest I could arrange it).
When I went into the ER I immediately announced that it could be a dive-related problem and I was immediately ushered into a room ahead of others that were waiting. I did not demand to go to a chamber. What I did do, is after 10 minutes of answering questions, demanded (well, just strenuously suggested) that I be put on Oxygen in case it was DCS. The physician smiled tolerantly at me, told me he had worked in a chamber for years, and reassured me that I would be put on Oxygen as soon as they were finished with the assessment. That happened a few minutes later. The doctor spoke with the nearest chamber a couple of times in the 6 hours that I was there. Initially they thought they would send me but as my syptoms were already abating, they decided to wait awhile. Since I continued to feel better they decided it was NOT dive-related. It was officially diagnosed as "non-specific abdomen pain" or something like that. Until it happened again after diving, I was willing to believe it had nothing to do with diving-just coincidence. But now I know better. If it, or anything even faintly resembling DCS occurs to me again, my first call will be to DAN.

What do you mean my dive profile was pretty "out there". I think I was diving pretty conservatively. Most of both dives were at the 50-60' range, both included long, slow ascents with more than adequate safety stops.

First, unless you were planning decompression dives, those profiles do appear to push the table limits.

As for the ER - I work in several different ERs and most ER staff don't know much, if anything, about diving issues. One of the hospitals I've worked at even has a chamber and calling the chamber doc still didn't get any action for a diver who had hit 500' (supposedly) chasing after a student (I'm not sure how this happened, the patient wasn't very clear). Some ER staff can have somewhat of an attitude when someone comes in dictating the care they should receive. It's wrong, but it's the way it is. Even as an RN, I might get the same attitude. My answer to this - I would call DAN on the way and have them contact the hospital or just hand my cellphone to the staff. I might still get the attitude, but my lawyer will have an easier time getting a settlement.

 

[Dive-aholic]

I just pulled out my wheel.

First dive - 83' for 4 minutes puts you in PG B, ascend to 60 feet - NDL is 36', then you bought a deco obligation. Of course, you can ascend to above 40' and buy some more time, but you don't mention that. So 40 minutes, 2 minute ascent, 8 minute stop, you still have 10 minutes unaccounted for in what looks like you were trying to make a NDL dive.

Second dive profile is a little better because of the time at 30'. But how long was your SI?

No offense intended, but the way you present your profile, you did blow the table. And this is further proven by your visit to the ER.

Of course the profile you present is not exact. If your computer is letting you do this type of diving and you're getting skin bends, you might want to consider leaving it set on air even when you're diving nitrox just to be more conservative.