Lingering DCS Symptoms?

[Jonnyola87]

Recently had my first run-in with DCS, and I'm having what I imagine are lingering symptoms. Wondering if anyone has experienced anything similar, and how it progressed/what was done. Apologies for being long-winded, I'm trying to provide as much information as I can for 1.) posterity's sake, and 2.) so anyone with any expertise can have the full picture.

For background
-All FL Keys dives in May, water temp ~78-81
-Several hundred dives completed, no issues prior
-No pertinent medical history that seems to lend anything to an explanation
-Healthy 37yom in (relatively) good shape
-Lots of fluids and eating well throughout the trip, minimal to no alcohol, typical amount/quality of sleep which is average

I arrived in the Keys on a Thursday.
-Friday AM, 2 recreational dives to Spiegel.
-First dive a lot of current, had some periods of exertion, called the dive a bit short to be conservative, came up ~800 PSI after a relatively short dive (maybe absorbed lots of N2 quickly?).
-Total dive time ~29 minutes
-Max depth 96'
-Within NDL
-EAN 30%, AL80
-Of note, experienced a headache at depth (lingered on surface for a bit), attributed to overexertion getting down the line
-Surface interval 50 minutes, 3-5' seas, felt some seasickness, vomited once (fairly unusual for me) but otherwise uneventful
-Dive #2 improved conditions, EAN 30%, AL 80, max 91', within NDL, run time 38 minutes
-After second dive had some lingering feelings of seasickness, and fatigue most notably.

---After this day, no dives for 4 days (met up with family friends, did Keys stuff)
-Vague lingering fatigue, which improved over the next day
-Back to feeling well

-On day 5, started AN/DP course
-AM shallow dive, 28' for skills and drills, 48 minutes, back-mounted AL80 doubles and AL40 stage bottle (for familiarity), 30%, within NDL
- No issues
-Second AM shallow dive, almost identical except ~52 minutes
-- ~3 hour surface interval
-PM dive to Spiegel grove, recreational (within NDL), AL80 doubles + stage, avg depth 58', max depth 90', 42 min, EAN 25% (topped off cylinders with air), 80% in deco bottle which was used for 5 minute safety stop (practice reg switching)
-- ~56 minute surface interval
-Repeat recreational dive to Spiegel, same gases and equipment, avg depth 60', max 85 ft, run time 40 minutes, 5 minutes on 80% for practice at safety stop

Between and after all this day's dives, no issues. Went back to Airbnb, ate chicken and potatoes, planned following day's dives, went to sleep. Hydrating always.

Following day:
-AM- Spiegel again, AL 80 doubles with 29%, stage AL40 79%, avg depth 93', max 100', 48 minute bottom time, 65 minute run time, switched to deco gas at 30' (I don't remember the minute by minute deco schedule, I BELIEVE it was 2 min at 30', 10 min at 20', and then my Peregrine which was being used as a backup gave me a 5 minute safety stop which I did just for conservatism).
---3 hr surface interval, ate lunch, planned afternoon dive
-Of note, small patch (3-4") on abdomen which was pinkish/reddish and slightly itchy, dissipated after ~10 minutes, assumed irritation from harness or suit (probably my fatal error), no other symptoms
-PM dive- Same equipment, topped up cylinders with air so now on EAN 24%, same deco setup. Avg depth 69', max 121', 35 min bottom time, 56 min run time. Stops at 40-30-20' (1 min, 3 min, 11 min, plus 5 min safety stop at 10')
-At shallowest stop, started feeling some rawness with inspiration, attributed to pulmonary O2, but thought it was odd)
-At surface, fatigued quickly
-By the time I had pulled myself back to the boat I had a few seconds of feeling as though my left leg were asleep
-Able to climb the ladder and get to my seat, then started having significant dyspnea (could only breathe in the middle ~1/3 of my tidal volume, very tachypneic, same "raw" sensation on inspiration)
-Ongoing fatigue, having trouble holding my head up or getting my gear off
-Crew helps me with gear, ~3 minutes later I'm on 100% O2 via NRB
-Back to dock in ~30 minutes, medics on site, on 100% still
-Mottled skin around chest and upper abdomen, bilateral flanks
-Line and fluids started en route, experiencing tingling in left arm, ongoing fatigue, just feeling out of it
-Respiratory symptoms slowly improved
-Tachycardic
-In ER- working dx DCS type II vs PE
-In Chamber (Table VI) ~ 2 hours from incident
-Felt ongoing air hunger, so keeping the mask on in the chamber was a challenge, I'm sure I did not get 100% of the ideal volume
-Somewhat improved on floor, but ongoing nausea, fatigue, mild difficulty with walking (left leg felt asleep, though no neuropathy, just some laxity) same in left arm
-Chest CT shows body wall anasarca, mild interstitial pulmonary edema
-Labs: hemoconcentrated (H&H ~ 18.9/54, WBC 23 with left shift), RP-O2 27%, mildly acidotic (7.28)
-Fitful night of sleep
-Following morning, third spacing everything into chest and abdomen (anasarca)
-Ongoing hemoconcentration with similar labs, also LOW ALBUMIN (explains the anasarca)
-Repeat Table VI, much more able to tolerate
-Improving left side "weakness"
-Still faint raw sensation with breathing
-Did not urinate until well into the second day but now starting to
-Appetite improved
-Improved headache and fatigue, but lingering
-Still overall feeing of unwell, but improved considerably
-Repleted albumin, getting lasix for anasarca, ongoing IVF
-Following morning labs improved (no further hemoconcentration, no leukocytosis, albumin slightly low still but improved)
-Now urinating regularly
-Repeat chest CT clear with ongoing anasarca but improved
-Discharged feeling much improved, with MILD residual left arm "weakness" (weakness isn't the best word, more like laxity or looseness with movements, but full ROM and able to exert strength), mild fatigue, ongoing body wall edema which was uncomfortable (mottling at this point has dissipated)
-On lasix and KCL, baby aspirin
-Could not fly home (New England), so chose to rent a car and drive, picked up some compression socks and took daily ASA 164mg, normal appetite and fluid intake

Fast forward to now, 9 days later.
-Improved from initial incident, ongoing general feeling of mild unwellness, intermittent nausea/headache, daily (afternoon) fatigue, almost post-viral feeling globally, intermittent laxity notably in left arm (very mild) and left leg with ambulation, also faint neuropathy in left hand (C8). Somewhat fitful sleep, though this isn't too far from baseline. Lingering intermittent tachycardia (normal resting HR ~60, now 80+). Mildly fatigued when walking long distances.
PCP follow up this week, will refer to a dive doc in my area for ongoing evaluation/treatment as needed and ultimately bubble study, labs, and clearance. Plan on taking ~8 weeks off diving (or more as needed).

After all that, my questions are
-Has anyone had similar symptoms which lingered beyond a few days-weeks and if so, were any additional HBOT regimens ordered that far out?
-Is there any indication for additional HBOT this far out?
-Aside from repeating bloodwork and having a bubble study, has anyone run into any other diagnostics which shed any light on their DCS situation?
-Does any of this sound to anyone like my diving days are done?

Again sorry for the brain dump, once I had turned a corner and felt much improved I had been hoping I'd be done, though I know objectively symptoms can recur.
Any insight anyone has would be immensely appreciated.

Cheers.

 

[Allen-1]

@Duke Dive Medicine

 

[The Chairman]

Tell me that you're in constant contact with DAN over all this.

 

[Jonnyola87]

Reached out to DAN yesterday, talked to a medic, reported the whole situation, and got a list of docs in the area. Working on an appointment.

 

[uncfnp]

I assume you were admitted? Did you see any specialist? Cardiac workup? BNP?
D-dimer? Ultrasounds? Apologies if in your post and I missed it.

 

[Jonnyola87]

Yes, admitted. Only the dive docs. Negative trop, no dimer or BNP done, no ultrasounds. Sinus tach on tele intermittently, NSR when resting, non-ischemic EKG, no right heart strain.

 

[crofrog]

You should get into another chamber although perhaps too much time has passed. The standards of care is 2 dives in a row without improvement or a return to baseline.

 

[Duke Dive Medicine]

Recently had my first run-in with DCS, and I'm having what I imagine are lingering symptoms. Wondering if anyone has experienced anything similar, and how it progressed/what was done. Apologies for being long-winded, I'm trying to provide as much information as I can for 1.) posterity's sake, and 2.) so anyone with any expertise can have the full picture.

For background
-All FL Keys dives in May, water temp ~78-81
-Several hundred dives completed, no issues prior
-No pertinent medical history that seems to lend anything to an explanation
-Healthy 37yom in (relatively) good shape
-Lots of fluids and eating well throughout the trip, minimal to no alcohol, typical amount/quality of sleep which is average

I arrived in the Keys on a Thursday.
-Friday AM, 2 recreational dives to Spiegel.
-First dive a lot of current, had some periods of exertion, called the dive a bit short to be conservative, came up ~800 PSI after a relatively short dive (maybe absorbed lots of N2 quickly?).
-Total dive time ~29 minutes
-Max depth 96'
-Within NDL
-EAN 30%, AL80
-Of note, experienced a headache at depth (lingered on surface for a bit), attributed to overexertion getting down the line
-Surface interval 50 minutes, 3-5' seas, felt some seasickness, vomited once (fairly unusual for me) but otherwise uneventful
-Dive #2 improved conditions, EAN 30%, AL 80, max 91', within NDL, run time 38 minutes
-After second dive had some lingering feelings of seasickness, and fatigue most notably.

---After this day, no dives for 4 days (met up with family friends, did Keys stuff)
-Vague lingering fatigue, which improved over the next day
-Back to feeling well

-On day 5, started AN/DP course
-AM shallow dive, 28' for skills and drills, 48 minutes, back-mounted AL80 doubles and AL40 stage bottle (for familiarity), 30%, within NDL
- No issues
-Second AM shallow dive, almost identical except ~52 minutes
-- ~3 hour surface interval
-PM dive to Spiegel grove, recreational (within NDL), AL80 doubles + stage, avg depth 58', max depth 90', 42 min, EAN 25% (topped off cylinders with air), 80% in deco bottle which was used for 5 minute safety stop (practice reg switching)
-- ~56 minute surface interval
-Repeat recreational dive to Spiegel, same gases and equipment, avg depth 60', max 85 ft, run time 40 minutes, 5 minutes on 80% for practice at safety stop

Between and after all this day's dives, no issues. Went back to Airbnb, ate chicken and potatoes, planned following day's dives, went to sleep. Hydrating always.

Following day:
-AM- Spiegel again, AL 80 doubles with 29%, stage AL40 79%, avg depth 93', max 100', 48 minute bottom time, 65 minute run time, switched to deco gas at 30' (I don't remember the minute by minute deco schedule, I BELIEVE it was 2 min at 30', 10 min at 20', and then my Peregrine which was being used as a backup gave me a 5 minute safety stop which I did just for conservatism).
---3 hr surface interval, ate lunch, planned afternoon dive
-Of note, small patch (3-4") on abdomen which was pinkish/reddish and slightly itchy, dissipated after ~10 minutes, assumed irritation from harness or suit (probably my fatal error), no other symptoms
-PM dive- Same equipment, topped up cylinders with air so now on EAN 24%, same deco setup. Avg depth 69', max 121', 35 min bottom time, 56 min run time. Stops at 40-30-20' (1 min, 3 min, 11 min, plus 5 min safety stop at 10')
-At shallowest stop, started feeling some rawness with inspiration, attributed to pulmonary O2, but thought it was odd)
-At surface, fatigued quickly
-By the time I had pulled myself back to the boat I had a few seconds of feeling as though my left leg were asleep
-Able to climb the ladder and get to my seat, then started having significant dyspnea (could only breathe in the middle ~1/3 of my tidal volume, very tachypneic, same "raw" sensation on inspiration)
-Ongoing fatigue, having trouble holding my head up or getting my gear off
-Crew helps me with gear, ~3 minutes later I'm on 100% O2 via NRB
-Back to dock in ~30 minutes, medics on site, on 100% still
-Mottled skin around chest and upper abdomen, bilateral flanks
-Line and fluids started en route, experiencing tingling in left arm, ongoing fatigue, just feeling out of it
-Respiratory symptoms slowly improved
-Tachycardic
-In ER- working dx DCS type II vs PE
-In Chamber (Table VI) ~ 2 hours from incident
-Felt ongoing air hunger, so keeping the mask on in the chamber was a challenge, I'm sure I did not get 100% of the ideal volume
-Somewhat improved on floor, but ongoing nausea, fatigue, mild difficulty with walking (left leg felt asleep, though no neuropathy, just some laxity) same in left arm
-Chest CT shows body wall anasarca, mild interstitial pulmonary edema
-Labs: hemoconcentrated (H&H ~ 18.9/54, WBC 23 with left shift), RP-O2 27%, mildly acidotic (7.28)
-Fitful night of sleep
-Following morning, third spacing everything into chest and abdomen (anasarca)
-Ongoing hemoconcentration with similar labs, also LOW ALBUMIN (explains the anasarca)
-Repeat Table VI, much more able to tolerate
-Improving left side "weakness"
-Still faint raw sensation with breathing
-Did not urinate until well into the second day but now starting to
-Appetite improved
-Improved headache and fatigue, but lingering
-Still overall feeing of unwell, but improved considerably
-Repleted albumin, getting lasix for anasarca, ongoing IVF
-Following morning labs improved (no further hemoconcentration, no leukocytosis, albumin slightly low still but improved)
-Now urinating regularly
-Repeat chest CT clear with ongoing anasarca but improved
-Discharged feeling much improved, with MILD residual left arm "weakness" (weakness isn't the best word, more like laxity or looseness with movements, but full ROM and able to exert strength), mild fatigue, ongoing body wall edema which was uncomfortable (mottling at this point has dissipated)
-On lasix and KCL, baby aspirin
-Could not fly home (New England), so chose to rent a car and drive, picked up some compression socks and took daily ASA 164mg, normal appetite and fluid intake

Fast forward to now, 9 days later.
-Improved from initial incident, ongoing general feeling of mild unwellness, intermittent nausea/headache, daily (afternoon) fatigue, almost post-viral feeling globally, intermittent laxity notably in left arm (very mild) and left leg with ambulation, also faint neuropathy in left hand (C8). Somewhat fitful sleep, though this isn't too far from baseline. Lingering intermittent tachycardia (normal resting HR ~60, now 80+). Mildly fatigued when walking long distances.
PCP follow up this week, will refer to a dive doc in my area for ongoing evaluation/treatment as needed and ultimately bubble study, labs, and clearance. Plan on taking ~8 weeks off diving (or more as needed).

After all that, my questions are
-Has anyone had similar symptoms which lingered beyond a few days-weeks and if so, were any additional HBOT regimens ordered that far out?
-Is there any indication for additional HBOT this far out?
-Aside from repeating bloodwork and having a bubble study, has anyone run into any other diagnostics which shed any light on their DCS situation?
-Does any of this sound to anyone like my diving days are done?

Again sorry for the brain dump, once I had turned a corner and felt much improved I had been hoping I'd be done, though I know objectively symptoms can recur.
Any insight anyone has would be immensely appreciated.

Cheers.

I'm glad you're (relatively) ok. It sounds like you got good pre-hospital care and got into the chamber very quickly.

As @crofrog said, the standard of care in hyperbaric treatment for DCS is serial treatments until symptom improvement plateaus, that is, there's no further improvement with treatment. Residual symptoms typically resolve on their own but that can take a while. Serial hyperbaric treatments can accelerate that process, even this far out.

Hemoconcentration is expected in third-spacing. Anasarca from hypoalbuminemia is more a chronic thing. If you didn't have it before, acute anasarca in the setting of pulmonary DCS may also be a manifestation of decompression sickness. In cases of pulmonary DCS, sometimes there is also frank gas in the portal veins that lead to the liver, which can mechanically obstruct blood flow. It looks like you had your chest CT after your first treatment. Did they do any chest/abcominal imaging before you were treated in the chamber?

As far as diving again, that's an in-person conversation with a trained, experienced diving physician. Your dives were provocative, that is, more likely to produce DCS, but this severe a case of DCS after normal decompression is qute rare. If you can't get to the root of why this happened, the recommendation may be for you to either not dive again or to stick with very conservative, shallow dive profiles.

Best regards,
DDM

 

[Landau]

@Jonnyola87 Thanks for the detailed write up. It helps us all to learn from. Glad it appears you are mostly OK and hopefully improving.

Could you add a bit more detail: what was the computer you were using, and at what settings for GF or conservativeness?

 

[Jonnyola87]

I'm glad you're (relatively) ok. It sounds like you got good pre-hospital care and got into the chamber very quickly.

As @crofrog said, the standard of care in hyperbaric treatment for DCS is serial treatments until symptom improvement plateaus, that is, there's no further improvement with treatment. Residual symptoms typically resolve on their own but that can take a while. Serial hyperbaric treatments can accelerate that process, even this far out.

Hemoconcentration is expected in third-spacing. Anasarca from hypoalbuminemia is more a chronic thing. If you didn't have it before, acute anasarca in the setting of pulmonary DCS may also be a manifestation of decompression sickness. In cases of pulmonary DCS, sometimes there is also frank gas in the portal veins that lead to the liver, which can mechanically obstruct blood flow. It looks like you had your chest CT after your first treatment. Did they do any chest/abcominal imaging before you were treated in the chamber?

As far as diving again, that's an in-person conversation with a trained, experienced diving physician. Your dives were provocative, that is, more likely to produce DCS, but this severe a case of DCS after normal decompression is qute rare. If you can't get to the root of why this happened, the recommendation may be for you to either not dive again or to stick with very conservative, shallow dive profiles.

Best regards,
DDM

Very much appreciate the input.
To clarify- I'd say at the time of discharge discussions, I was back to baseline-with the exception of some lingering anasarca and fatigue-which I attributed to the inflammatory cascad. 3-4 days of lasix and no more edema, and my vital capacity is improving. And even now, the amount of deviation from my baseline is very very small, but I notice it. And in fact the periods during each day wherein I really notice symptoms are diminishing.

I'm wondering if during the strenuous recreational dive 4 days prior, I had started to have subclinical DCS without realizing it, and the nitrogen load was just building over time. That's my prevailing theory for now, primarily because I want an explanation and because I don't want to be done with diving, recreational or technical. Though I suppose if I have to stick to recreational limits, so be it.

First chest CT was done prior to the first chamber treatment, and improved post treatment. I'll be looking into the possibility that I'm just chronically hypoalbuminemic, which would be odd (never had abnormal LFTs and I eat pretty well). I'll probably need to end up traveling to meet with a dive doc (I believe we have a few in RI but I'm not sure how many divers they really see.) Boston and NY are easy enough to get to.

@Jonnyola87 Thanks for the detailed write up. It helps us all to learn from. Glad it appears you are mostly OK and hopefully improving.

Could you add a bit more detail: what was the computer you were using, and at what settings for GF or conservativeness?

Thank you for the well-wishes. I wanted to try and be as clear as possible as we are, after all, always learning when it comes to diving and dive related injuries.
For my fun dives (4 days prior) I was using my Peregrine on 45/85 (I believe these are factory settings).
For the remaining dives I was using a Perdix also on 45/85 with a matched Peregrine as backup. The exception being the final dive, wherein I changed both to 45/75.