Question Fizzy/bubbly tissues in limbs after dives

[femmma]

Hi all,
I’ve had a strange symptom a few times recently after dives, and am hoping someone here might have thoughts on this or heard of something similar before. After four dives within a month, after surfacing from a dive, the tissues of my arms feel bubbly/fizzy to touch, like my muscles had Coca-Cola in them.

For background, I’m a fresh dive master in Thailand, first certified as OWD 4 years ago and now recently as DM. I have 98 dives, of which around 75 are within the last two months. I was about to start my IDC to become an instructor. These symptoms have however now put me out of the water for at least a month, and doctors do not know what it could be.

About the symptom: I do not have any sensation of the bubbles, only when I press on my arms or legs, and it feels fizzy/bubbly like soda. Others can feel this fizzing under my skin as well, if they press my limbs. The symptom does not cause any discomfort or pain, and goes away by itself within 10-15 minutes after the dive. I have no other symptoms than the fizzy feeling under my skin, no joint pain, no rash, nothing. Only once I had a strong headache start during one of these dives.
The fizzy symptom feels harmless, but as we know, bubbles are trouble and therefore my instructors and employers wanted me to get checked to be sure this is not decompression related. I know some of you will be thinking about subcutaneous emphysema, but it doesn’t make sense for it to go away 10 minutes after a dive, and being in the limbs?

About the dives: The symptoms do not occur every time I dive. This has happened on four dives within forty dives in a period of one month. I have gathered the information of the dives this happened on at the end of this message. If you have a look at them, you’ll notice they happened at rather shallow depths: 6m/12m/12m/16m. I cannot find any common denominator for these dives.

About doctors: I was sent to Bangkok Royal Navy hospital to get checked up. I passed all the fit to dive tests: blood, urine, chest x ray, pulmonary power, neurological, vision, hearing, dental, no problems whatsoever. The doctors examined my dive log and same as me, could not find many similarities between the dives the symptoms had occurred on. They did seem to believe it could be decompression-related, but were not sure. Therefore I was sent to get tested for PFO and told to be out of the water for a month. I tested negative for PFO in Koh Samui.

This now puts me in a position where nobody knows what I have or whether it is dangerous. I have no idea if I will able to continue diving professionally.

A few things I already know you might ask about
- my equipment or wetsuits have not been too tight.
- I haven’t drank alcohol before these dives and I don’t smoke.
- I consider my diving pretty conservative/safe, not pushing limits.

Has anyone heard of anything like this before? Your help is much appreciated.

Thanks in advance,
Emma

Dive log:

26.6. Long shallow dive, reef survey
Max depth: 6,7m
Average depth: 5,2m
Time: 13:54
Duration: 83min
Surf: 45h
Previous day: no dive

19.7. AOW assist dive 4
Max depth: 16,4m
Average depth: 13,4m
Time: 16:21
Duration: 46min
Surf: 1h16 (Previous dive: 46min at 10m)
Previous day: 2 dives, 15m, 45min & 47 min
-> on this dive, one of the students had the similar symptom as me.

28.7. OW assist dive 1
Max depth: 12,3m
Average depth: 7,6m
Time: 13:34
Duration: 47min
Surf: 21h
Previous day: all day pool (OW assist)
-> headache started on this dive

OW assist dive 2
Max depth: 12,9m
Average depth: 9,8
Time: 15:44
Duration: 45min
Surf: 1h21

 

[davehicks]

Everyone is going to suggest Skin Bends. I assume you have discussed this with your docs? Have you called DAN to get more info?

Skin Bends

Skin bends can prevent unfamiliar symptoms and may go unnoticed or underreported. If you're experiencing skin bends or unknown symptoms, call a doctor.

dan.org

 

[Wibble]

PFO?

Often the culprit for undeserved bends. Your dives seem to be quite trivial with no decompression obligations.

Challenge is PFOs are difficult to detect. There’s a procedure to detect a PFO. Did they do that?

 

[arbby]

If DCS/PFO has been checked, what were you wearing and was this on areas of exposed skin?

Possibly a reaction to stinging by bits of cnidaria - but then its not uncommon so would think that's already been suggested and ruled out

Good luck anyway

 

[BoundForElsewhere]

Did you just reference an Adam Sandler movie? You Don't Mess with Zohan, to be exact.

 

[chillyinCanada]

I've never before heard that others could feel the same thing! That's impressive but not in a good way.

I've had skin bends but didn't check to see if i could feel it from the outside of my skin. The pain was great! The mottling was evident. I didn't feel fizziness nor bubbling.

 

[Duke Dive Medicine]

Hi all,
I’ve had a strange symptom a few times recently after dives, and am hoping someone here might have thoughts on this or heard of something similar before. After four dives within a month, after surfacing from a dive, the tissues of my arms feel bubbly/fizzy to touch, like my muscles had Coca-Cola in them.

For background, I’m a fresh dive master in Thailand, first certified as OWD 4 years ago and now recently as DM. I have 98 dives, of which around 75 are within the last two months. I was about to start my IDC to become an instructor. These symptoms have however now put me out of the water for at least a month, and doctors do not know what it could be.

About the symptom: I do not have any sensation of the bubbles, only when I press on my arms or legs, and it feels fizzy/bubbly like soda. Others can feel this fizzing under my skin as well, if they press my limbs. The symptom does not cause any discomfort or pain, and goes away by itself within 10-15 minutes after the dive. I have no other symptoms than the fizzy feeling under my skin, no joint pain, no rash, nothing. Only once I had a strong headache start during one of these dives.
The fizzy symptom feels harmless, but as we know, bubbles are trouble and therefore my instructors and employers wanted me to get checked to be sure this is not decompression related. I know some of you will be thinking about subcutaneous emphysema, but it doesn’t make sense for it to go away 10 minutes after a dive, and being in the limbs?

About the dives: The symptoms do not occur every time I dive. This has happened on four dives within forty dives in a period of one month. I have gathered the information of the dives this happened on at the end of this message. If you have a look at them, you’ll notice they happened at rather shallow depths: 6m/12m/12m/16m. I cannot find any common denominator for these dives.

About doctors: I was sent to Bangkok Royal Navy hospital to get checked up. I passed all the fit to dive tests: blood, urine, chest x ray, pulmonary power, neurological, vision, hearing, dental, no problems whatsoever. The doctors examined my dive log and same as me, could not find many similarities between the dives the symptoms had occurred on. They did seem to believe it could be decompression-related, but were not sure. Therefore I was sent to get tested for PFO and told to be out of the water for a month. I tested negative for PFO in Koh Samui.

This now puts me in a position where nobody knows what I have or whether it is dangerous. I have no idea if I will able to continue diving professionally.

A few things I already know you might ask about
- my equipment or wetsuits have not been too tight.
- I haven’t drank alcohol before these dives and I don’t smoke.
- I consider my diving pretty conservative/safe, not pushing limits.

Has anyone heard of anything like this before? Your help is much appreciated.

Thanks in advance,
Emma

Dive log:

26.6. Long shallow dive, reef survey
Max depth: 6,7m
Average depth: 5,2m
Time: 13:54
Duration: 83min
Surf: 45h
Previous day: no dive

19.7. AOW assist dive 4
Max depth: 16,4m
Average depth: 13,4m
Time: 16:21
Duration: 46min
Surf: 1h16 (Previous dive: 46min at 10m)
Previous day: 2 dives, 15m, 45min & 47 min
-> on this dive, one of the students had the similar symptom as me.

28.7. OW assist dive 1
Max depth: 12,3m
Average depth: 7,6m
Time: 13:34
Duration: 47min
Surf: 21h
Previous day: all day pool (OW assist)
-> headache started on this dive

OW assist dive 2
Max depth: 12,9m
Average depth: 9,8
Time: 15:44
Duration: 45min
Surf: 1h21

@femmma , what you're describing does sound like subcutaneous emphysema, which, if true, is suggestive of pulmonary overinflation as you probably know. There's nothing else I can think of that would cause symptoms like this. I've seen it in far more unusual places than the arms. You may need more sensitive imaging than a simple chest x-ray.

Best regards,
DDM

 

[femmma]

Everyone is going to suggest Skin Bends. I assume you have discussed this with your docs? Have you called DAN to get more info?

Skin Bends

Skin bends can prevent unfamiliar symptoms and may go unnoticed or underreported. If you're experiencing skin bends or unknown symptoms, call a doctor.

dan.org

I've discussed it with doctors but this is not a symptom of skin bends. The doctor I consulted works with DAN.

PFO?

Often the culprit for undeserved bends. Your dives seem to be quite trivial with no decompression obligations.

Challenge is PFOs are difficult to detect. There’s a procedure to detect a PFO. Did they do that?

I've been tested for PFO and the result was negative.

If DCS/PFO has been checked, what were you wearing and was this on areas of exposed skin?

Possibly a reaction to stinging by bits of cnidaria - but then its not uncommon so would think that's already been suggested and ruled out

Good luck anyway

It's been mostly on areas uncovered, but also on my thighs that are under my shorty wetsuit.

@femmma , what you're describing does sound like subcutaneous emphysema, which, if true, is suggestive of pulmonary overinflation as you probably know. There's nothing else I can think of that would cause symptoms like this. I've seen it in far more unusual places than the arms. You may need more sensitive imaging than a simple chest x-ray.

Best regards,
DDM

Have you ever witnessed subcutaneous emphysema disappearing by itself in 10 minutes?

Update: I've had a call with a doctor working with DAN and they hadn't heard of this either. According to them what I have is neither skin bends nor subcutaneous emphysema, as it doesn't tick any known symptom boxes. They see no reason for me not to dive, but want me to monitor the symptoms.

All I can say is, WEIRD. How can it be that not a single instructor or dive doctor has ever heard of this?

 

[lowwall]

I do not have any sensation of the bubbles, only when I press on my arms or legs, and it feels fizzy/bubbly like soda. Others can feel this fizzing under my skin as well, if they press my limbs.

This seems the key to me. If you are still alive, there is no way this could be actual bubbles that someone else could feel.

So what are they (and you) feeling? If it's movement, it pretty much has to be muscular. Perhaps some sort of disorganized muscular contractions or a very mild tremor?

Have you ever had issues with muscle spasms or tremors before? Exercise fatigue can induce this kind of thing, especially when coupled with dehydration. It looks like all of these dives were either long or working dives.

CO2 retention can also cause muscle twitches although that's rare, but it can certainly cause headaches. The fact that the symptoms go away so quickly after surfacing could be a clue that CO2 retention is at least exacerbating things, even if it's not the entire explanation.

If any of this is correct, then staying fit, not overworking yourself on a dive, staying hydrated, and making sure you exhale fully should prevent it from coming back.

If not, I'd talk to a neurologist again. Make it clear that this is not a DCS issue so the doctor doesn't have the opportunity to dismiss this without really working through the possibilities.

 

[Duke Dive Medicine]

I've discussed it with doctors but this is not a symptom of skin bends. The doctor I consulted works with DAN.



I've been tested for PFO and the result was negative.



It's been mostly on areas uncovered, but also on my thighs that are under my shorty wetsuit.

Have you ever witnessed subcutaneous emphysema disappearing by itself in 10 minutes?

Update: I've had a call with a doctor working with DAN and they hadn't heard of this either. According to them what I have is neither skin bends nor subcutaneous emphysema, as it doesn't tick any known symptom boxes. They see no reason for me not to dive, but want me to monitor the symptoms.

All I can say is, WEIRD. How can it be that not a single instructor or dive doctor has ever heard of this?

For the record, a PFO in this case would be a red herring. The symptoms you described are not associated with PFO.

Re the symptom resolution, I don't know that it would disappear quickly, but it could theoretically dissipate to the point that it's much less noticeable. And to bring it back around, absent the ability to examine you in person during the event, this is all theoretical. Typically, the first place subcutaneous air would appear is in the shoulders and neck area, so to have it only in the arms and thighs would be an anomaly. But, if your shorty is particularly tight, it could (again theoretically) express the air to the extremities.

The classic description of subcutaneous emphysema is that it feels like "Rice Krispies" under the skin, and the fizzy Coca-Cola description seems analogous to me. Given the information you've provided, IMO it remains on the list of potential diagnoses. Given that, an underlying lung condition can't be ruled out, and the recommendation would still be a thorough pulmonary workup. Chest x-ray is not sensitive enough to detect small lung defects.

Best regards,
DDM