DCS Question

[jules]

On May 22, I was diagnosed as having a minor case of type 1 DCS. I was on vacation and had completed my first two dives of the trip. Nothing unusual about any of the dives - everything was within limits, and I felt fine after both dives. About one and a half hours after surfacing I had severe pain in my breast and was starting to become fatigued. I called DAN and after 2 hours a doctor was found who could see me. By the time of the examination the fatigue was increasing, but the pain was resolving. After consulting with DAN, the doctor decided not to treat the DCS and let the symptoms resolve on their own. It took about 24 hours for the pain to resolve and 2 days for the fatigue. Naturally, I did not dive the rest of the trip.

I flew home on May 29. After the two flights, I experienced all of my symptoms over again. This time they did not resolve. After being referred to several doctors, I finally saw one on June 9 who did a full evaluation and decided on chamber treatments. By that time I was extremely fatigued, had pain in my breast, and weakness in my right arm. I had dramatic improvement after the first two chamber treatments. I am having my 5th (probably the last one) tomorrow.

I have two questions:

1) Could the flights home have generated a second, more severe case of DCS? Or might this be a result of not getting treated immediately after the initial diagnosis? Maybe a bit of both?

2) I have a list of questions I plan to ask the doctor. I would appreciate any advice on things it would be important to ask or follow up on.

 

[ScubaDadMiami]

I am not a diving physician (or any other kind of physician). I do read a fair amount about this though. I have also attended physician level training in this area just because I find it so fascinating. So, don't listen to my lay guesses here, contact an expert.

From what I have learned, seven days after is too long for the problem to still be the nitrogen in your tissues from your prior dives. However, there has been damage to those areas from the prior dives. Depending on the severity of the injury, it can take up to a number of weeks for these areas to heal, if they are not permanently damaged (which could be the case).

When you get onto a plane, it is like doing another decompression from the 1 ata of the earth's surface to the pressure of the cabin while in flight. The already damaged areas can often take less trauma than the initial insult to renew or even worsen problems that you experienced after your dives. This is especially the case before sufficient treatment or time to heal has passed.

This is my guess for what likely happened to you on your flights back. If the plane landed and took off a number of times after the initial departure, this caused even further trauma.

This is your body. Besides discussing in depth with your doctor, you should read and learn all you can about DCS. You can get a lot of information from DAN, Divers Alert Network. They can even hook you up with phycian level materials, so that you can learn about this to a very high level.

Hope you end up 100 percent.

 

[jules]

Thanks for your response. I knew the flights contributed to my increased symptoms. I was just surprised at how much worse they were. I've started reading more about DCS. I plan to find out as much as I can so that I can feel comfortable diving again, and monitoring myself when I get back in the water.

 

[Dr Deco]

Hello jules:

It is difficult to imagine that a gas phase could persist for several days and expand on airplane seven days later. Nonetheless, it appears to respond to hyperbaric oxygen treatment.

It is possible that the problem is responding to increased oxygen (during the treatment) rather than the pressure increase per se. That still provids little in the way of an answer.

I do not really have much of an answer for this question. :280:

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology is September 10 – 11, 2005 :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm

 

[RTodd]

On May 22, I was diagnosed as having a minor case of type 1 DCS. I was on vacation and had completed my first two dives of the trip. Nothing unusual about any of the dives - everything was within limits, and I felt fine after both dives. About one and a half hours after surfacing I had severe pain in my breast and was starting to become fatigued. I called DAN and after 2 hours a doctor was found who could see me. By the time of the examination the fatigue was increasing, but the pain was resolving. After consulting with DAN, the doctor decided not to treat the DCS and let the symptoms resolve on their own. It took about 24 hours for the pain to resolve and 2 days for the fatigue. Naturally, I did not dive the rest of the trip.

I flew home on May 29. After the two flights, I experienced all of my symptoms over again. This time they did not resolve. After being referred to several doctors, I finally saw one on June 9 who did a full evaluation and decided on chamber treatments. By that time I was extremely fatigued, had pain in my breast, and weakness in my right arm. I had dramatic improvement after the first two chamber treatments. I am having my 5th (probably the last one) tomorrow.

I have two questions:

1) Could the flights home have generated a second, more severe case of DCS? Or might this be a result of not getting treated immediately after the initial diagnosis? Maybe a bit of both?

2) I have a list of questions I plan to ask the doctor. I would appreciate any advice on things it would be important to ask or follow up on.

I can't give you anything of medical value since I am not too good at listening to doctors. This is all just personal experience and the sample is way to small to extrapolate. But, having flown within 12 hours of a minor Type 1 hit I can say that the plane ride definately makes it worse. However, I have also flown 48 hours after a minor Type I hit and the plane had no effect. (You really should be bubble free by then) If it is truly just a type I hit it does generally take a few weeks to heal and pain will come and go, just like a really bad sprained ankle or other sports injury. But, the manifestations of discomfort can be sort of weird.

I would also encourage you to look really closely at what caused this and to get tested for a PFO (although not very likely a cause for a type 1 hit). In my experience, how far outside of the no-decompression or how much omitted decompression you have (within reason) has far less effect on whether you get hit than other factors such as hydration, exertion or cutting off circulation inadvertently during or post dive, etc. If you didn't have these factors you may want to count this as a not-too painful hint to discontinue diving.

 

[Saturation]

On May 22, I was diagnosed as having a minor case of type 1 DCS... About one and a half hours after surfacing I had severe pain in my breast and was starting to become fatigued.... It took about 24 hours for the pain to resolve and 2 days for the fatigue. Naturally, I did not dive the rest of the trip.

I flew home on May 29. After the two flights, I experienced all of my symptoms over again. This time they did not resolve. After being referred to several doctors, I finally saw one on June 9 who did a full evaluation and decided on chamber treatments. By that time I was extremely fatigued, had pain in my breast, and weakness in my right arm. I had dramatic improvement after the first two chamber treatments. I am having my 5th (probably the last one) tomorrow.

I have two questions:

1) Could the flights home have generated a second, more severe case of DCS? Or might this be a result of not getting treated immediately after the initial diagnosis? Maybe a bit of both?

2) I have a list of questions I plan to ask the doctor. I would appreciate any advice on things it would be important to ask or follow up on.

I concur with Dr.D's assessment and here's another 2c worth.

#1: Flights can aggravate or induce DCS, after diving or after treatment, but in the case described its unlikely to happen since its been 7 days since the last dive. DCS 1 symptoms will often resolve spontaneously in this time.

#2: No specifics but I question the diagnosis.

Weakness on an arm is concerning.

DCS 1 as joint bends is pain only and more achy, deep and gnawing, there is no true weakness or numbness. Often the pain maybe great that the arms 'seems' weak but this will not be corroborated by a neuro exam. Fatigue is common with many DCS, including symptom preceding DCS of any sort. Breast pain can only occur as some musculoskeletal issue or minor barotrauma.

Neurologic findings have to be ascertain by good physical examination and followed up for progression. Often omitted in most reports are the blood examination studies, while non-specific, any abnormalities support symptoms as real disease.

If weakness did exists and resolve with recompression, then the lingering discomforts felt were likely a type of 'false sensation' i.e., paresthesia, caused by a DCS II hit, and these types of bends leave lingering 'sensations' for much time after the accident. Most symptoms improve with recompression, can reoccur or in a minority, linger for months afterwards.

DCS II would better explain the persistence after the initial event, the worsening with flight, persistent 'breast' pain, and arm weakness. The symptoms suggests possibly spinal segment pain rather than minor cerebral gas embolism, although both can coexists.

Nevertheless, in conclusion DCS II is more likely, and whether it has cerebral or spinal manifestations the treatment is the same.

If diving is still desired and DCS II is a consideration then risk reduction interventions must be considered to avoid unexpected hits from recurring. Finding a PFO will be meaningless unless the patient desires surgical closure because you can initiate the 'treatment' for a PFO, i.e., nitrox diving, reduced bottom times, etc., without testing for a PFO because shunts can also occur that are not PFO related that cause the same symptoms.

As the options become complicated, at this point its best to see the dive doc nearest you for a personalized solution.

 

[jules]

Thank you all for your responses. It's been helpful in figuring out what questions to ask.

I had my last hyperbaric treatment this morning. The good news is that the chamber doctor has taken dive medicine courses and is contacting one of her instructors to get a referral to a dive medicine physician here. I also have more tests scheduled to make sure there are no underlying issues I should be worrying about.

I appreciate you taking the time to post your thoughts.