Lingering DCS issues or ??

[jklassy]

I was treated for DCS 3 weeks ago. I have some weird lingering symptoms and am curious if they are likely related to the DCS, or perhaps nerve compression, or simple paranoia. I saw my doctor, but she's not a DCS specialist and doesn't think there is one in our area.

The details: Somewhat experienced diver (330 dives, AOW, Nitrox), 56, female. In mid April I did two dives in the Galapagos. The first dive was 20m, lots of current (up, down, sideways). Unfortunately I was underweight (I told the dive master before we descended, but he said "you'll be fine" and didn't give me more weight). Not surprisingly, I was too light on the safety stop. I thought the DM would hand me a weight, but no such luck. He did try to pull me down, but couldn't and waved for me to just go up. So, no safety stop on dive 1, though I felt fine after. I told the DM I'd skip the 2nd dive since I didn't do a safety stop. He convinced me I'd "be fine, it'll be much shallower." I stupidly ignored my instincts and did the dive. He actually took us deeper, 22-24m, but due to currents and horrible visibility, I felt like I had to stay with the group. This time I did a safety stop, but we were exerting a lot to stay down due to the currents and I was actually overweighted, so I sucked more air on this one.

After the diving I felt ok, just tired. I took a nap, and woke up itching with a rash on my hip. I thought maybe it was skin DCS, but my partner (instructor) said it didn't look what he'd seen before, so I waited. A couple hours later I got a very weird, random pain in my abdomen (like after doing a hundred sit ups, but only along a very thin line). Fortunately, there was a chamber a few blocks away. Came up from dive at 2:30pm, went to the medical center at 8pm, in the chamber around 9pm.

My symptoms were all neurological, no joint pain. No reflexes on the right side, balance issues, failed the eye tests. I did Table 6 that night, went back for table 5 the next day, and then did table 2 I think (approx 2 hours) the morning after that. I was released and told not to dive for 8 weeks, and never to dive without nitrox again. The doctor said it was unusual to get DCS after just two relatively shallow dives (end of Nov I did a 7day liveaboard in the Red Sea, 3-4 dives per day, without issue), but attributed it to dehydration, missing the safety stop, cold water, and possible overexertion due to current.

The night after my last chamber session, I started to have numbness and tingling in the back of my right leg. Sometimes stretching down to my calf. Sometimes it's really noticeable, sometimes it goes away. The chamber doc speculated it was caused by a compressed nerve due to weird sitting position in the chamber. In the early days after the chamber, I occasionally had numbness and tingling in my right arm and going across my upper back, but that has stopped.

Is there any reason to think I need to follow up with a DCS specialist? The chamber doctor told me that after 10 hours in the chamber, I wouldn't have any nitrogen left in my system, so I shouldn't have any lingering issues. Just wondering what other people's real world experiences have been.

TIA

 

[Capt Jim Wyatt]

Is there any reason to think I need to follow up with a DCS specialist?

I think you should

@Duke Dive Medicine *** @rsingler

 

[scubadada]

Did you discuss your case with DAN, at the time of the initial episode or since, regarding your residual complaints? If not, that would be a good idea.

Your dives were not particularly deep, I assume they were on air, is that correct? Out of interest, what computer do you use and what were your NDLs at the end of the two dives?

 

[rsingler]

I'd defer to @Duke Dive Medicine, but true neurological DCS after what may have been a modest nitrogen load might make me more inclined to see a cardiologist than anyone else.
As @scubadada suggested, it would be interesting to gauge your actual loading. Tank size? How close to NDL? Pop-up ascent after the safety stop was completed?
We all bubble, so I'm trying to get a feel for how much bubbling you might have had compared with your symptoms.
I don't know that neurological symptoms that are intermittent would be amenable to further hyperbaric treatment, but again, @Duke Dive Medicine would be better able to advise us there. But the possibility that modest bubbling was shunted to the arterial side via a pulmonary shunt or PFO might be worth following up with a cardiologist.

 

[jklassy]

Did you discuss your case with DAN, at the time of the initial episode or since, regarding your residual complaints? If not, that would be a good idea.

Your dives were not particularly deep, I assume they were on air, is that correct? Out of interest, what computer do you use and what were your NDLs at the end of the two dives?

Unfortunately, I was using rental equipment which didn't include a computer. Because I was only planning a couple of dives, I thought that would be ok. Sigh, so many mistakes. Tank was standard size (12L?), regular air. The first dive was 54 minutes, 20m, and I came up with almost half a tank remaining. I didn't rocket to the surface, more of a gentle float up. Surface interval between 90 and 120 minutes. Second dive was 52 mins, 22m, and I was under 500 psi when I surfaced.

 

[Duke Dive Medicine]

I was treated for DCS 3 weeks ago. I have some weird lingering symptoms and am curious if they are likely related to the DCS, or perhaps nerve compression, or simple paranoia. I saw my doctor, but she's not a DCS specialist and doesn't think there is one in our area.

The details: Somewhat experienced diver (330 dives, AOW, Nitrox), 56, female. In mid April I did two dives in the Galapagos. The first dive was 20m, lots of current (up, down, sideways). Unfortunately I was underweight (I told the dive master before we descended, but he said "you'll be fine" and didn't give me more weight). Not surprisingly, I was too light on the safety stop. I thought the DM would hand me a weight, but no such luck. He did try to pull me down, but couldn't and waved for me to just go up. So, no safety stop on dive 1, though I felt fine after. I told the DM I'd skip the 2nd dive since I didn't do a safety stop. He convinced me I'd "be fine, it'll be much shallower." I stupidly ignored my instincts and did the dive. He actually took us deeper, 22-24m, but due to currents and horrible visibility, I felt like I had to stay with the group. This time I did a safety stop, but we were exerting a lot to stay down due to the currents and I was actually overweighted, so I sucked more air on this one.

After the diving I felt ok, just tired. I took a nap, and woke up itching with a rash on my hip. I thought maybe it was skin DCS, but my partner (instructor) said it didn't look what he'd seen before, so I waited. A couple hours later I got a very weird, random pain in my abdomen (like after doing a hundred sit ups, but only along a very thin line). Fortunately, there was a chamber a few blocks away. Came up from dive at 2:30pm, went to the medical center at 8pm, in the chamber around 9pm.

My symptoms were all neurological, no joint pain. No reflexes on the right side, balance issues, failed the eye tests. I did Table 6 that night, went back for table 5 the next day, and then did table 2 I think (approx 2 hours) the morning after that. I was released and told not to dive for 8 weeks, and never to dive without nitrox again. The doctor said it was unusual to get DCS after just two relatively shallow dives (end of Nov I did a 7day liveaboard in the Red Sea, 3-4 dives per day, without issue), but attributed it to dehydration, missing the safety stop, cold water, and possible overexertion due to current.

The night after my last chamber session, I started to have numbness and tingling in the back of my right leg. Sometimes stretching down to my calf. Sometimes it's really noticeable, sometimes it goes away. The chamber doc speculated it was caused by a compressed nerve due to weird sitting position in the chamber. In the early days after the chamber, I occasionally had numbness and tingling in my right arm and going across my upper back, but that has stopped.

Is there any reason to think I need to follow up with a DCS specialist? The chamber doctor told me that after 10 hours in the chamber, I wouldn't have any nitrogen left in my system, so I shouldn't have any lingering issues. Just wondering what other people's real world experiences have been.

TIA

I am hesitant to Monday-morning QB a provider who evaluated you in person. That said, there is such a thing as recurrence of DCS symptoms after treatment, and going by your description of numbness and tingling in multiple areas, I don't think it can be ruled out. If you're concerned, it would be reasonable to follow up with someone. DM to follow.

Best regards,
DDM

 

[Duke Dive Medicine]

I'd defer to @Duke Dive Medicine, but true neurological DCS after what may have been a modest nitrogen load might make me more inclined to see a cardiologist than anyone else.
As @scubadada suggested, it would be interesting to gauge your actual loading. Tank size? How close to NDL? Pop-up ascent after the safety stop was completed?
We all bubble, so I'm trying to get a feel for how much bubbling you might have had compared with your symptoms.
I don't know that neurological symptoms that are intermittent would be amenable to further hyperbaric treatment, but again, @Duke Dive Medicine would be better able to advise us there. But the possibility that modest bubbling was shunted to the arterial side via a pulmonary shunt or PFO might be worth following up with a cardiologist.

I'd be interested to hear about the OP's symptom progression. PFO is associated with sudden-onset severe neurological DCS, inner ear DCS, and cutis marmorata. @jklassy ? Can you describe the rash that you had and exactly how your symptoms progressed to the point at which you were examined at the chamber?

She described some significant neurological symptoms, but those can exist without PFO and she had a couple of risk factors for DCS (cold water and heavy work on the bottom). Dive profiles alone wouldn't be an accurate enough predictor of individual bubble load to use that as a go/no-go determinant for PFO testing.

Best regards,
DDM

 

[jklassy]

I'd be interested to hear about the OP's symptom progression. PFO is associated with sudden-onset severe neurological DCS, inner ear DCS, and cutis marmorata. @jklassy ? Can you describe the rash that you had and exactly how your symptoms progressed to the point at which you were examined at the chamber?

She described some significant neurological symptoms, but those can exist without PFO and she had a couple of risk factors for DCS (cold water and heavy work on the bottom). Dive profiles alone wouldn't be an accurate enough predictor of individual bubble load to use that as a go/no-go determinant for PFO testing.

Best regards,
DDM

I came up from the water at 2:30pm. 45 min car ride to the hotel, took a hot shower and a nap. Around 4:30 or so I woke up itching. The rash is hard to describe - it almost looked like it could have been red marks from the scratching or a scrape from brushing against something, which is why we thought maybe it wasn't DCS. I also had a very small red rash mark, size of a thumbprint, in the middle of my chest.

During dinner, around 6:30 or so, I got a pain in my abdomen. It felt like I'd done a hundred sit ups, but only along a very small line from my belly button down, about the width of a toothpick, but very noticeable. After that I went to the center - 8pm. I don't really remember any other major symptoms, but the doctor noted the following: weakness/fatigue, skin pressure, dehydration, marbled skin rash on hip, red skin rash on chest, nystagmus, reduced muscle power (both arms), impaired reflexes, positive rhomberg, and decreased skin sensation. I do believe the decreased sensations and impaired reflexes were predominantly (maybe only) on the right side. He also noted left ear with signs of barotrauma.

He noted that cardiac sounds had normal rhythm and frequency, heart rate 90, with elevated BP of 135/85 (I typically run about 117/72), and pulmonary fields clear and ventilating.

After Navy table VI (9pm to 2am), several of the markers were better. Additional improvement after Navy table V 11:30am, and then all symptoms seemed to disappear after Navy table IX (8am next day). I do recall the nystagmus didn't resolve until after the 3rd treatment.

Late on the evening (around 11pm) of the last treatment, I noticed tingling in the back of my right thigh. That persisted over the next few days, occasionally traveling down my leg and wrapping to the front of my right calf. I don't recall exactly when the random tingling and numbness occurred in my right arm, traveling across my back to the left side, but it was a few days later. It was brief, maybe 20 or 30 minutes. Since then, I've occasionally (rarely) felt a bit of tingling in my right arm. The tingling in my right leg continues. It's not constant and not as intense as it was the first week, but it is noticeable and occurs daily.

Is it common with DCS to have symptoms predominantly on one side of the body? Are there other long term symptoms or effects I should be mindful of?

I do appreciate all the advice and insight!

 

[Duke Dive Medicine]

I came up from the water at 2:30pm. 45 min car ride to the hotel, took a hot shower and a nap. Around 4:30 or so I woke up itching. The rash is hard to describe - it almost looked like it could have been red marks from the scratching or a scrape from brushing against something, which is why we thought maybe it wasn't DCS. I also had a very small red rash mark, size of a thumbprint, in the middle of my chest.

During dinner, around 6:30 or so, I got a pain in my abdomen. It felt like I'd done a hundred sit ups, but only along a very small line from my belly button down, about the width of a toothpick, but very noticeable. After that I went to the center - 8pm. I don't really remember any other major symptoms, but the doctor noted the following: weakness/fatigue, skin pressure, dehydration, marbled skin rash on hip, red skin rash on chest, nystagmus, reduced muscle power (both arms), impaired reflexes, positive rhomberg, and decreased skin sensation. I do believe the decreased sensations and impaired reflexes were predominantly (maybe only) on the right side. He also noted left ear with signs of barotrauma.

He noted that cardiac sounds had normal rhythm and frequency, heart rate 90, with elevated BP of 135/85 (I typically run about 117/72), and pulmonary fields clear and ventilating.

After Navy table VI (9pm to 2am), several of the markers were better. Additional improvement after Navy table V 11:30am, and then all symptoms seemed to disappear after Navy table IX (8am next day). I do recall the nystagmus didn't resolve until after the 3rd treatment.

Late on the evening (around 11pm) of the last treatment, I noticed tingling in the back of my right thigh. That persisted over the next few days, occasionally traveling down my leg and wrapping to the front of my right calf. I don't recall exactly when the random tingling and numbness occurred in my right arm, traveling across my back to the left side, but it was a few days later. It was brief, maybe 20 or 30 minutes. Since then, I've occasionally (rarely) felt a bit of tingling in my right arm. The tingling in my right leg continues. It's not constant and not as intense as it was the first week, but it is noticeable and occurs daily.

Is it common with DCS to have symptoms predominantly on one side of the body? Are there other long term symptoms or effects I should be mindful of?

I do appreciate all the advice and insight!

Thanks for those details! Given this information, and with the strong caveat that I'm across the continent from you and haven't evaluated you in person, it doesn't sound like a PFO test would be indicated.

What you're experiencing now might be a mild recurrence of DCS symptoms but I'm not sure we would treat you in the chamber if you presented with only this. The sensation in your leg will probably continue to improve and then resolve over time. DM sent as well.

Best regards,
DDM