Incident on the Spiegel
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TommyTutone
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Some other information that might help: I am 40, somewhat of a runner, that is, I run in 5k and 10k races fairly often, but I am not that great at them, a bit overweight, which leads to my not-so-great times (but I have sexy runner's legs, LOL), quit smoking three years ago after 18 years of smoking, drink occasionally, although I had only two beers over the course of my week in Key Largo and neither were on the night before the dive. I had a bagel with cream cheese and turkey for breakfast along with a large cup of water, drinking more water on the boat on the way out. I had never been hospitalized before and my check up six months ago came back with a clean bill of health save for needing to lose some weight (6' 2", 235 pounds).
As for the dive, the things I remember fairly well is that I was apprehensive about the dive, as it was only my 17th dive or so, and my first one deep. We did a swim through part of the ship and when we went through a door, the tank hit the top of the doorway which scared the poop out of me, but once I reset, got to the right height, there were no more issues at all. I remember holding onto the rope the incorrect way up (though I held it correctly on the way down), but at no point did I separate from the other six, so we all ascended at the same rate.
Regarding the current at 15 feet, it might not have been bad to others, but between my inexperience and quickly tunneling vision, the plankton or whatever was in the water was flying by my face at a rate I was not accustomed to. The flow was horizontal as best as I could tell though and I do not recall going up or down once at 15 feet. It is possible that I held my breath at some point, I honestly do not remember, but it is not something that I had ever done before. The current at depth was pretty much non-existent as I recall it.
I spoke again with DAN today who would like me to send my dive computer report which I will do tonight. In the meantime, Atlanta apparently has no dive-specializing neurologist so I am working to schedule a time with a 'normal' neurologist and DAN has mentioned that I can give both him and my gp their number so that they can consult on any issues that might be dive specific. What an amazing resource they are and the community is really lucky to have them!
As for the dive, the things I remember fairly well is that I was apprehensive about the dive, as it was only my 17th dive or so, and my first one deep. We did a swim through part of the ship and when we went through a door, the tank hit the top of the doorway which scared the poop out of me, but once I reset, got to the right height, there were no more issues at all. I remember holding onto the rope the incorrect way up (though I held it correctly on the way down), but at no point did I separate from the other six, so we all ascended at the same rate.
Regarding the current at 15 feet, it might not have been bad to others, but between my inexperience and quickly tunneling vision, the plankton or whatever was in the water was flying by my face at a rate I was not accustomed to. The flow was horizontal as best as I could tell though and I do not recall going up or down once at 15 feet. It is possible that I held my breath at some point, I honestly do not remember, but it is not something that I had ever done before. The current at depth was pretty much non-existent as I recall it.
I spoke again with DAN today who would like me to send my dive computer report which I will do tonight. In the meantime, Atlanta apparently has no dive-specializing neurologist so I am working to schedule a time with a 'normal' neurologist and DAN has mentioned that I can give both him and my gp their number so that they can consult on any issues that might be dive specific. What an amazing resource they are and the community is really lucky to have them!
Tommy, have you ever been assessed for COPD? A friend, a very active mountain and road bicyclist, was diagnosed to his shock and horror. He had smoked for 20 years. A compromised respiratory system is not good for gas exchange.
Rileybri
Contributor
Was the tank ever checked for gas contamination?
Yes, DAN is truly amazing and we keep saying that. But until a person has used DAN, they can't fully appreciate what a resource DAN is. I had an incident a couple summers ago and had just purchased the high tier insurance the previous January. DAN went above and beyond my expectations in handling my situation. They didn't have to go the lengths they did for me and I still would have felt they were worth the yearly membership. I'm a life-long fan of DAN and recommend them whenever I can.
As a technical diving/rebreather instructor who is also an interventional cardiologist who closes PFOs for a living and is the principal investigator for the DAN PFO study, I feel the need to chime in here.
First of all, I agree with a great deal of what has already been said. You have shown great insight in assessing your role in this terrible event. A deep dive with current like is frequently found on the Spiegel Grove after only 17 dives was a poor decision on your part -- but I'm sure a large number of us here on Scubaboard have made dives that, in retrospect, we probably should not have made. This was definitely a learning experience for you and the fact that you showed such good insight in a post-dive analysis and were willing to speak about it here in an open forum should be applauded.
While a DCI (DCS and/or AGE) event can occur on any dive, this was not an overly aggressive dive from a DCS (decompression sickness) standpoint and the timing of symptom onset sounds much more likely to be an AGE (air gas embolism) than DCS. You do mention that there was a lot of current making your ascent difficult and you "may" have held your breath. That could definitely have led to an AGE event. However, the dive was deep enough for significant nitrogen loading despite nitrox and DCS events from a PFO (patent foramen ovale) often behave like an AGE as they result from bubbles that have formed in the venous system crossing the atrial septum and becoming bubbles in the arterial system that then often embolize to the central nervous system (brain or spinal cord). For completeness, another source of right to left shunt, not from a PFO, would be an intrapulmonary shunt.
For the above reasons, I would recommend being evaluated for a possible shunt. While a transcranial doppler (TCD) test (mentioned in one of the posts above) is a reasonable choice, I feel the best test would be a transesophageal echo with a "bubble study" (injection of agitated saline from an IV). This would allow thorough evaluation of the atrial septum to look for PFO, a true atrial septal defect, an atrial septal aneurysm (which are often associated with a fenestrated atrial septal defect) and would also, by the timing of bubbles appearing on the left side of the heart, give your doctor a feeling about the likelihood of an intrapulmonary shunt. A TCD only tells you "yes or no" about a shunt but does nothing to localize where it may be located.
You will notice I said I would recommend being evaluated for this. I did not say I would automatically close a PFO if one was found. While a recreational diver with a PFO has a five fold higher risk of DCS than a diver without a PFO, the ABSOLUTE risk is quite small. The risk would go from 2 in 10,000 dives to about 1 in 1000 dives which is still a very small absolute risk of having a DCS event. While percutaneous closure is a low risk procedure (I am speaking from experience of closing them for the past 10 years) it is not NO risk. And the risk of a complication is definitely higher than 1 in 1000.
A diver who has had a DCI event and is found to have a PFO has several options:
1. Give up diving -- if you don't breathe compressed gas, you will not get DCS
2. Dive more conservatively -- shallower/shorter dives, long safety stops, using the richest nitrox mix allowed by the dive and your training, and possibly breathing a rich nitrox mix or even pure oxygen on your safety stop (if you have the training for this). You can also dive nitrox but using air tables or an air computer.
3. Percutaneous closure of the PFO -- this is almost always reserved for multiple neurologic unexpected ("undeserved") DCS events.
Finally, as I mentioned I am the principal investigator on a DAN-sponsored study of divers with PFO. If you happen to elect to be tested for and be found to have a PFO we would love to have you in our study -- regardless of whether you decide to simply make more conservative dives or if you elect to close the defect. It is a prospective study where we will be following divers and annually ask them about any recurrent events they may have had. The information is at DAN: Divers Alert Network - Scuba Diving and Dive Safety Association.
Thanks! If you have any questions or concerns that I can help you with, feel free to PM me.
Doug
First of all, I agree with a great deal of what has already been said. You have shown great insight in assessing your role in this terrible event. A deep dive with current like is frequently found on the Spiegel Grove after only 17 dives was a poor decision on your part -- but I'm sure a large number of us here on Scubaboard have made dives that, in retrospect, we probably should not have made. This was definitely a learning experience for you and the fact that you showed such good insight in a post-dive analysis and were willing to speak about it here in an open forum should be applauded.
While a DCI (DCS and/or AGE) event can occur on any dive, this was not an overly aggressive dive from a DCS (decompression sickness) standpoint and the timing of symptom onset sounds much more likely to be an AGE (air gas embolism) than DCS. You do mention that there was a lot of current making your ascent difficult and you "may" have held your breath. That could definitely have led to an AGE event. However, the dive was deep enough for significant nitrogen loading despite nitrox and DCS events from a PFO (patent foramen ovale) often behave like an AGE as they result from bubbles that have formed in the venous system crossing the atrial septum and becoming bubbles in the arterial system that then often embolize to the central nervous system (brain or spinal cord). For completeness, another source of right to left shunt, not from a PFO, would be an intrapulmonary shunt.
For the above reasons, I would recommend being evaluated for a possible shunt. While a transcranial doppler (TCD) test (mentioned in one of the posts above) is a reasonable choice, I feel the best test would be a transesophageal echo with a "bubble study" (injection of agitated saline from an IV). This would allow thorough evaluation of the atrial septum to look for PFO, a true atrial septal defect, an atrial septal aneurysm (which are often associated with a fenestrated atrial septal defect) and would also, by the timing of bubbles appearing on the left side of the heart, give your doctor a feeling about the likelihood of an intrapulmonary shunt. A TCD only tells you "yes or no" about a shunt but does nothing to localize where it may be located.
You will notice I said I would recommend being evaluated for this. I did not say I would automatically close a PFO if one was found. While a recreational diver with a PFO has a five fold higher risk of DCS than a diver without a PFO, the ABSOLUTE risk is quite small. The risk would go from 2 in 10,000 dives to about 1 in 1000 dives which is still a very small absolute risk of having a DCS event. While percutaneous closure is a low risk procedure (I am speaking from experience of closing them for the past 10 years) it is not NO risk. And the risk of a complication is definitely higher than 1 in 1000.
A diver who has had a DCI event and is found to have a PFO has several options:
1. Give up diving -- if you don't breathe compressed gas, you will not get DCS
2. Dive more conservatively -- shallower/shorter dives, long safety stops, using the richest nitrox mix allowed by the dive and your training, and possibly breathing a rich nitrox mix or even pure oxygen on your safety stop (if you have the training for this). You can also dive nitrox but using air tables or an air computer.
3. Percutaneous closure of the PFO -- this is almost always reserved for multiple neurologic unexpected ("undeserved") DCS events.
Finally, as I mentioned I am the principal investigator on a DAN-sponsored study of divers with PFO. If you happen to elect to be tested for and be found to have a PFO we would love to have you in our study -- regardless of whether you decide to simply make more conservative dives or if you elect to close the defect. It is a prospective study where we will be following divers and annually ask them about any recurrent events they may have had. The information is at DAN: Divers Alert Network - Scuba Diving and Dive Safety Association.
Thanks! If you have any questions or concerns that I can help you with, feel free to PM me.
Doug
Ayisha
Contributor
Dr Ebersole, thank you for your insight. If someone who has a PFO stops diving and doesn't attempt to close the PFO (or doesn't have a successful closure), they could still have migraines or a stroke, right? It could be worth the risk of the complications for many divers facing that choice, I imagine.
vladimir
The Voice of Reason
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I'd be largely in agreement with you, Dan, if we were talking about, say, research into the efficacy of a billion-dollar drug like Vioxx. Where is the big diving industry money and which researchers do you suspect have been corrupted by it? Of course this calls for speculation on your part, but a plausible theory would be better than vague accusations, wouldn't it?
There is an "association" between migraine headaches (with aura) and PFOs, the mechanism of which is unclear. Also, in the largest randomized study to date looking at closure of PFOs to eliminate migraines the result was negative -- in other words, they were unable to prove that hypothesis. Other trials are underway. Until those results are known, there is NOT an indication to close a PFO simply because someone suffers from migraines.
The stroke association with PFO is similar to that with DCS in divers and percutaneous closure of PFO after stroke is just as controversial. There is a very heated debate among experts in the field but no one would recommend closing a PFO beause of a "potential" risk of stroke. Now, if a young person has multiple recurrent strokes with no other source found despite being on "blood thinners", that is a different story and some physicians, myself included, would consider closing the PFO in that case.
Hope that helps.
Doug
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Out of curiosity, does anyone have any idea why he may have had the second
Siezure after the hyperbaric treatment? Is this unusual?
Siezure after the hyperbaric treatment? Is this unusual?
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