Doc Wong Getting Bent in Monterey!

[jumsted65]

Dang, Harry. Glad you're OK and already diving again.

I vaguely remember your reporting getting checked for a PFO some time ago. I also vaguely remember you got the TTE rather than the more conclusive (plus more invasive and more expensive) TEE? If so, might you consider going back for the trans-esophageal test? Just curious.

 

[shakeybrainsurgeon]

That was my question too: if somoene presents himself with DCS symptoms that are as clear as his was, do you just administer oxygen and send them home, or be more prudent and give them a chamber session, or two, along with oxygen? What could be the reason for not doing a chamber session? Cost? Diver had no ins? Puzzling.

Cost would not be an issue, regardless of insurance. In the US, emergency care is rendered (or should be) as dictated by the situation. Elective care is another issue.

It seems here that the symptoms were mild, the limits did not seem to be exceeded and the response to oxygen alone seemed good.

My question, again to people who are DCS experts if any are reading this thread, would be: what role does the profile have in determining use of a chamber in this situation? In extreme cases, the profile will help determining the actual treatment to be rendered in the chamber. But what about the person with DCS who comes in and says "I was within limits"...do you ask to see the profile? Does the decision to treat and/or the manner of chamber treatment depend on knowing the profile in this setting? Or is response to oxygen enough?

The best patient is an informed patient, so we should all know, expert or not, when to question a doc's decision to NOT use a chamber when the symptoms are neurological and clearly DCS. Especially in other countries where a) cost may be on the doctor's mind and b) the liability of the doctor is less clear and c) the expertise of the personnel may be unknown. What if this had happened somewhere in Mexico or Africa and the local doc says no chamber is needed?

When should a diver demand a chamber? How much dive medicine should someone know, particularly when doing repetitive deep dives?

 

[DocWong]

Dang, Harry. Glad you're OK and already diving again.

I vaguely remember your reporting getting checked for a PFO some time ago. I also vaguely remember you got the TTE rather than the more conclusive (plus more invasive and more expensive) TEE? If so, might you consider going back for the trans-esophageal test? Just curious.

For those of who have no idea what this is about. A PFO (Patient Foramen Ovale) or "Open Hole" in the heart between the 2 top chambers, the Atria. This would allow for unoxygenated blood to enter into the oxygenated blood supply incresing the likelyhood of getting bent.

TTE is a Trans Thoracic Echocardiogram, meaning an ultrasoud device is inserted on your chest and you can see the Atria and the blood flowing. Then the cardiologist shoots bubbles into your arm and then you can see it on the ultrasound, almost immediately. You can even take a breath and push (Valsalva Manuver) to further push the bubbles against the Atrial wall to see if there's a hole.

TEE is a Trans Esophageal Echocardiogram, where an ultrasound probe is inserte into your mouth, eshophagus to do the same imaging. It's reported that the TEE is more conclusive than the TTE. It's more invasive and there's anastesia involved.

I went over this with my cardio last year and since we could see so clearly into my heart with his ultrasound machine, we opted for the TTE. It was amazing to watch the bubbles shoot into my heart. I was expecting to experience DCS symptoms right there and then.....freaky.

Also, I'm on a program to improve my vascular elasticity which is going quite well. Last evaluation showed that the blood vessels in my body had the elasticity of a 35 year old.

 

[DocWong]

Also, in this whole experience, it never occured to me to judge this as a "deserved" or "undeserved" hit. But if asked the question, I'd pick "deserved" not that anyone deserves a hit.

I knew better than to lift so much post dive. It was significant. That in addition to stage bottles, deco bottles and doubles and lifting those every dive.

Now for awhile, I'm going to be extra conservative and do my recreational stops on either 50% oxygen or 100% oxygen as a precautionary measure for a couple of months or so.

If I get even a hint of trouble, it's back to the cardio for another PFO check.

 

[DocWong]

Wow, being in the medical field, it never occured to me, but good question.

First besides getting more medical training, when there's a DCS seminar being offered by your local chamber or other event. We have one coming up in May here in Monterey. Then use of common sense would be your best bet. That or knowing a prefessional.

In my case, I like to think I'm relatively current on DCS and the latest recommendations, reading and having attended seminars on the subject. Also I had Alan Studley, a very expereinced diver and medical professional who worked for years at the hospital I was at. Talk about lucky! Then Dr. Hattori did my evaluation, who's one of the best in the area and Alan knew him!

Since my neurological symptoms dissappeared within 5 minutes of being on oxygen and the dizziness reduced 90% and there were no findings on his extensive examination, I could see why he chose to release me.

But if I still had the arm symptoms (heavy, numb) and visual disturbances, I would not have let him release me and would have requested a visit to the chamber.

So common sense and your best educated guess would be the answer.

Doc Wong

Cost would not be an issue, regardless of insurance. In the US, emergency care is rendered (or should be) as dictated by the situation. Elective care is another issue.

It seems here that the symptoms were mild, the limits did not seem to be exceeded and the response to oxygen alone seemed good.

My question, again to people who are DCS experts if any are reading this thread, would be: what role does the profile have in determining use of a chamber in this situation? In extreme cases, the profile will help determining the actual treatment to be rendered in the chamber. But what about the person with DCS who comes in and says "I was within limits"...do you ask to see the profile? Does the decision to treat and/or the manner of chamber treatment depend on knowing the profile in this setting? Or is response to oxygen enough?

The best patient is an informed patient, so we should all know, expert or not, when to question a doc's decision to NOT use a chamber when the symptoms are neurological and clearly DCS. Especially in other countries where a) cost may be on the doctor's mind and b) the liability of the doctor is less clear and c) the expertise of the personnel may be unknown. What if this had happened somewhere in Mexico or Africa and the local doc says no chamber is needed?

When should a diver demand a chamber? How much dive medicine should someone know, particularly when doing repetitive deep dives?

 

[shakeybrainsurgeon]

From what I can elicit from internet searches, DCS I (skin and joint symptoms) can be managed by oxygen. DCS II (vertigo, numbness, confusion) usually needs a chamber, regardless of profile.

 

[dumpsterDiver]

I was bent once with severe skin numbness covering one thigh completely. Immediate 100% oxygen on the surface completely resolved it in 20 minutes and had no other symprtoms or problems. I know a number of commercial lobster divers that self-treat with 100% oxygen at 20 feet (or so) when they experience joint pain due to decompression sickness after climbing on the boat.

I think to say that numbness requires recompression and joint pain does not, would be a gross over-simplification.

 

[shakeybrainsurgeon]

I was bent once with severe skin numbness covering one thigh completely. Immediate 100% oxygen on the surface completely resolved it in 20 minutes and had no other symprtoms or problems. I know a number of commercial lobster divers that self-treat with 100% oxygen at 20 feet (or so) when they experience joint pain due to decompression sickness after climbing on the boat.

I think to say that numbness requires recompression and joint pain does not, would be a gross over-simplification.

Skin and joint symptoms are one thing...vertigo or an entire extremity going dead means either the brain or spinal cord is becoming ischemic. Skin and muscle tolerate embolic processes well because of redundant collateral blood supply (that's why we can sit on our butts for hours without the gluteal muscles and skin infarcting). Brain and spinal cord have very poor collateral circulation. I guess a better way to phrase it is if muscle and skin are involved, maybe oxygen is okay. But if bubble formation is causing symptoms that can be traced to central nervous system ischemia, achamber may be needed. That's what I get from what I read, but I am no expert, except to say there is one valid oversimplification: don't mess with the CNS.:shakehead

 

[shakeybrainsurgeon]

In addition, I have read everything the DAN website has on the subject, and it seems they recommend a chamber in apparently all cases strongly suspected of DCS, at least that's what I'm getting. (Technically they say use oxygen then call DAN, but their treatment algorithm doesn't make chambering seem optional). The site cautions against being lulled into a sense of false security by a response to oxygen since oxygen can make people feel normal only to get bent again hours or even days later --- when it is too late to chamber the person.

 

[pilot fish]

I'm with you on this. It seems so simple, and prudent, since you have the patient there already, to play it safe and add a chamber session to the treatment. I have heard/read of cases of DCS that go away after administering oxygen but come back later that night. I'd think the doctor would want to order a chamber just to protect himself, even if he THOUGHT it MIGHT not be necessary?

In addition, I have read everything the DAN website has on the subject, and it seems they recommend a chamber in apparently all cases strongly suspected of DCS, at least that's what I'm getting. (Technically they say use oxygen then call DAN, but their treatment algorithm doesn't make chambering seem optional). The site cautions against being lulled into a sense of false security by a response to oxygen since oxygen can make people feel normal only to get bent again hours or even days later --- when it is too late to chamber the person.