Long term effects of Type II DCI

[madmarty]

I am an Orthopedic surgeon and have some questions I hope you can help with.

I have a patient who was a military hard hat diver for 8 years. In about 1978 he sustained a "Type II hit" according to the Navy Medical Diving Officer who treated him on the submarine tender at the time.

The event occurred during the 3rd chamber dive of the day to 112'. He was the inside tender for pressure and O2 tolerance testing. Because of symptoms at the end of the 3rd dive he recompressed to 165' by the DM at which time he had resolution of his symptoms. It was decided, however, to send him for medical treatment so he was surfaced from 165' and taken to the local military hospital where the orthopedic surgeon was unclear as to what was going on, and arranged for transport to the submarine tender where a Navy Medical Diving Officer and a chamber were available. It took approx 4 hours to get to the chamber from the time he surfaced.

His symptoms again resolved with recompression. Following this episode he continued to dive for about a year however had symptoms of low back and neck pain, neuritis and tendinitis in several areas which were the ones that were symptomatic during the DCI. He was taken off of dive status due to these.

The patient continues to have symptoms in the same areas that were affected during this incident and they are gradually worsening as he ages.

In my research I have found reference to DCI being "like a stroke" and therefore I wonder if the longterm problems of my patient are similar to a post stroke syndrome? That is, could the tendinitis and neuritis be due to inflammation and scarring of peritenon and epineurium caused by the initial barotrauma and similar micro-trauma to structures like annulus fibrosus.

In trying to put this all together I have reviewed his complete military medical record and have noted his consistent complaints during the years since the episode in his biciptal grooves, low back, lateral epicondylar regions, peroneal nerves (with release of R peroneal N), cervical spine, and R great toe.

Any thoughts would be appreciated. Are there any other places I might find info on the long term effects of DCI?

Thanks

Martin C Nation

 

[chantana]

Have you tried speaking to someone at DAN www.diversalertnetwork.org?

 

[rmediver2002]

Hello Marty.

The Undersea Hyperbaric and medical Society has some reference material you may find useful:
http://www.uhms.org/

The Navy dive manual also has some information specific to your example, check indirect and direct effects of bubbles.

 

[Saturation]

In my research I have found reference to DCI being "like a stroke" and therefore I wonder if the longterm problems of my patient are similar to a post stroke syndrome? That is, could the tendinitis and neuritis be due to inflammation and scarring of peritenon and epineurium caused by the initial barotrauma and similar micro-trauma to structures like annulus fibrosus.

In trying to put this all together I have reviewed his complete military medical record and have noted his consistent complaints during the years since the episode in his biciptal grooves, low back, lateral epicondylar regions, peroneal nerves (with release of R peroneal N), cervical spine, and R great toe.

Martin C Nation

Yes, DCI most certainly can mimic such changes. However, conjecture on my part, Navy diving is hard work, and these could also be due to the stresses of his entire career.

Inflammation as a result of bony injury needs to be subclassified.

Some suggestions:

Any imaging to suggest bone infarction in affected areas? Any imaging to suggest CNS or spinal cord infarcts?

DJD compatible findings [spurs, space narrowings etc.,] are not consistent with DCI but more with the chronic effects of heavy labor.

 

[Duane S.]

I agree with the previous posts. Dan is a good resource if you or your patient is a member. Your best bet would however be to consult with a reputable dive physician, one who is board certified in hyperbaric medicine. Dan should be able to make a physician referal. I recently had the pleasure of a tour of the HBOT facility at St. John Pleasant Valley Hospital in Camarillo, CA. The doc over there really knows his stuff. If you get stuck, let me know and I'll get his contact info for you.

 

[madmarty]

Wow,

These replies are a great start. Thank you all for your time. I certainly may join DAN and ask them some of these questions. I appreciate the ideas and will follow all the suggestions.

At present we have no evidence of Brain or bone infarcts. His joint troubles seem more like tendinitis, bicipital tendinitis and lateral epicondylitis. Certainly trying to postulate DCI as an etiology of these requires more than just the fact that they are there. Too many other causes. My only current reason to consider this is the obvious thread in his military medical record of onset of these symptoms way back then and repeated visits for the same things over the years.

One of his problems was that he was not a Navy diver. He was an Army Hard Hat diver and you can guess what experience the army doctors had in dive medicine. Other than being sent to the sub tender late after the episode his follow up was with the Army.

Well, I'll get started on the leads you all have provided. I'll try and post back and let you know what I find as in looking at this it seems easy to find advice or opinions about acute events but the long term info is a little harder to come by.

Thanks

Marty

 

[Saturation]

At present we have no evidence of Brain or bone infarcts. His joint troubles seem more like tendinitis, bicipital tendinitis and lateral epicondylitis. Certainly trying to postulate DCI as an etiology of these requires more than just the fact that they are there. Too many other causes. My only current reason to consider this is the obvious thread in his military medical record of onset of these symptoms way back then and repeated visits for the same things over the years.

One of his problems was that he was not a Navy diver. He was an Army Hard Hat diver and you can guess what experience the army doctors had in dive medicine. Other than being sent to the sub tender late after the episode his follow up was with the Army.

Welcome, Marty. The Army uses the USN Manual too, but there can be operational differences. As I'm not an armed forces affiliate, it maybe helpful to contact DAN to speak to someone who'se dealt with hard hat divers ... as they have not been used for over 20 years. FYI, a hard hat rig weights over 200 lbs, the venerable Mark V rig. One expert is in San Diego, Tom Newman, M.D., is very knowledgable, practicing dive doc and has personal experience in this domain. In Southern Florida, see Dick Rutkowski in Key Largo. Both served USN divers while Dick continues to teach USN divers hyperbaric medicine.

A type 2 hit is in the CNS, the complaints registered are localized to joints and tendons. Joints and tendons could have suffered repeated Type 1 hits instead, and these could lead to fibrosis and chronic injury complaints. In addition, degenerate changes from repeated weight bearing could have either been accelerated or made said diver prone to DCS 1 hits. At the time he was hit in the chamber, the symptoms, if localized to these areas, are more DCS 1. DCS 2 residua are typically various neuropathic issues like paresthesias, hype or hyposthesia ... but to be purely sensory would be rare.

Anyway, to answer your question specifically, DCS 2 as the causal agent of these issues is unlikely but possible. DCS 1, more likely. Was the injury possibly due to his stint as a hard hard diver, regardless of whether he was bent or not, yes.