Multiple cases of skin bends - what now?

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The first skin bend was classic, alcohol lowers the body’s core temperature and blood leaves the extremities to protect the vital organs, jump into a hot shower and the skin which is the largest organ in the body suddenly heats up resulting in a skin bend, I could be wrong but we were told never have a hot bath or shower after a deco dive, especially if you feel cold. My advice stay away from the booze if you plan on diving and you’ll be fine.

I guess it's no coincidence that the liveaboard I went on in Komodo apologized for not having hot showers as advertised... (not that it mattered anyway, as the weather was so hot that cold showers were a welcome, even after diving)
 
Hi,

first of all thanks for all the support and nice words. As anyone who has encountered something like this, is does kind of throw your world upside down. Your faith in your own body disappears and suddenly every dive feels like playing russian roulette (albeit with better odds!). You feel you might be losing one of the things in life you love, and in my case also might end a career you have been working to create.

So thanks for all your comments, truly appreciated. In response to the various issues raised.

Are you using O2 for decompression starting at 20'?
For the first bend (Apr 2017) I was only Tec40 certified, so up to 50% O2. Since that dive I have done around 10 or so OC dives, several with multiple deco gasses including O2. The majority are 'lighter' deco dives using 50%.

Were these DCS dives done in isolation with no other diving done prior to them, either the same day or day before?
The Apr 2017 dive was my one and only dive in a 3 day period leading up to the dive.
The November 2018 dive was my one and only dive in a 21 day period leading up to the dive. No dives were conducted between this dive and the occurrence of the DCS symptoms 77 hours later.
Looking at my dive and run logs: The dive finished 13 Nov 3.20 PM. My run finished 16 Nov 6.20 PM. I estimate between getting home, showering etc I noticed the marbling around 2 hours later.

I am not a doctor but if I were in your position, I would try a couple of to:
- Change the physiology by reducing the amount of slow tissue. I’d say drop about 40 lbs.
- Change the gradient factor away from deep stops. Perhaps 60/70? I personally dive 70/70 or 75/75 for recreational.

Dropping weight is certainly something that I must do. Being in a more dry role on the island, and with a lot of greasy food, I estimate the last 2 years alone I have gained 15 pounds. When I was in the water more, I was a lot lighter. I have also lost around 35 pound a few years back with a diet when I was around the same weight range as I was now, so that should be possible. It was actually quite easy but does require a certain positive mindset to do that, which to be honest I'm struggling to find at the moment.

I'm reading up on the latest on (deep) stop theory GF, and am most likely going to switch to 50/70 or 60/70.

Allergic reaction to wetsuit?
That is something I considered, but it would surprise me if that came that long after wearing it.

The first skin bend was classic, alcohol lowers the body’s core temperature and blood leaves the extremities to protect the vital organs, jump into a hot shower and the skin which is the largest organ in the body suddenly heats up resulting in a skin bend, I could be wrong but we were told never have a hot bath or shower after a deco dive, especially if you feel cold. My advice stay away from the booze if you plan on diving and you’ll be fine.

Agree. I am fully taking responsibility for that first bend, it was 'earned'. Just to be clear, the boozy lunch was the day before, and I estimate I took my last drink about 24 hours before the dive. Although I've seen other get away with it, for me certainly it doesn't work. So I'm trying to rest and no alcohol in advance of any diving.

The hot shower I sort of knew about, but it never seemed an issue in all my diving, so you become complacent there. For now only lukewarm showers at best after diving.

Are you not going to be satisfied with being a recreational diver rather than proceeding on your tech journey?

My understanding is that your career is entirely in the dive business, though as much or more in management. Please correct me if I'm wrong.

In your case, you may only be calling any future technical diving.

I'm sure that's personally disappointing but nothing that's worth dying or being crippled for.

As for your second bend, 77 hours later? I've never heard/read of such a thing. Are you positive that it was indeed a bend?

And did you ever have any deep tissue pain along with the mottling and itch on either occurrence?

You are correct, I'm a full-time dive professional and currently in a sales/marketing management position at a dive shop in the Caribbean.

In any career, you want to advance, develop and challenge yourself. A goal to strive for. That is not different in a diving career, at least for me. My goal is not to teach DSD/OW's and hang in the bar every evening on a tropical island for the next 20 years, no offence intended.
Of the many career paths that I saw once I started in the business, tech was the one that grabbed me the most. Being an engineer and self-confessed geek, the equipment, planning, skills, it all appeals to me. More than becoming for example a Course Director, UW photo/videographer, fish nerd.
If that career path would become unachievable due to medical reasons, right now I would be struggling to define a new goal to pursue.

With regards to your question, with the first bend I had some irritation in the tissue in the groin area. On the second incident I can't recall any physical sensations (itch, pain).

Hi Menno,

The first case *may* be explained, but I'm at a loss to explain the second. As you probably know, it would be highly unusual for DCS to manifest that far out, and it is almost certainly not due to dissolved gas. You could have had a subclinical DCS with some inflammation that was exacerbated by the physical exercise, but that's about all I can come up with. Your case may be deserving of a writeup in the literature, especially since the details are so well-documented. Tagging @Dr Simon Mitchell here - Simon, have you ever seen anything like this?

As to what that says about your future technical diving, if you're otherwise healthy, I don't see why you couldn't continue and dive more conservatively, but that's a recommendation best made by a physician who can examine you in person. Do you live on Grand Cayman?
Thanks. As mentioned earlier, the first one was certainly 'earned'.

And thanks for the insights in the second DCS incident. I noted I forgot to mention one detail (that I did share with DAN and doctors at the time). The morning after the dive I has what I would call a bit of a very light reddish glow on that side of my body. I usually sleep on that side on my body, and it disappeared quickly after getting out of bed, including taking a warm morning shower. There was no itching or anything, or any other sensations/pain in my body. It was certainly not a well defined discolouration as I saw on my first skin bend, and seeing that the dive was an easy recreational dive, at the time I discarded it as just have slept at a strange angle, or crease in the sheets. The thought of DCS didn't occur at all at the time.
After the marbling occurred later this might have been an earlier sign of DCS. Your hypotheses of subclinical DCS with inflammation might fit this history.
But even then, if DCS had occurred, I'm at a loss how this dive profile, on a CCR, so high % O2 gasses breathed in the shallows, well within NDL, could lead to a case of DCS.

I do live on Grand Cayman and have visited Dr. Osterloh, who is highly regarded by the dive staff on island. Her take on it was that skin bends could be (not 'are') a precursor of a future spinal hit. She recommended to dive conservatively, and only when well rested and feeling fit.

Since the last DCS incident I have done around 50 recreational dives with no issues.
 
In the photograph of the second incident, away from the purple mottling and above it, I think I can see a subtle lacy pink pattern to the skin. Is this the reddish glow that you are referring to? If so, then maybe the DCS was already there and the mottling just an exacerbation?
 
As I recall, it was a lot 'softer' and evenly spread out. I couldn't discern any clear demarkation where the 'glow' started on my body.
 
Hi,

to be honest, this is one of the more difficult posts I have made as I feel my career and one of the big loves of my life is on the line. Also being a dive pro that got bent twice, it seems that my career has stopped in it's tracks, and that I'm seen as a 'lesser' diver by my peers.

But inspired by a recent article by Gareth Lock I also feel that as true professionals we should openly discuss the not so great stories about our development as diver. For myself to learn, but also for my fellow divers.

About me
I'm a male, 45 years old. I'm 187 cm / 6'2" tall, and weigh about 110 kg / 220 lbs. I would certainly consider myself overweight, but not obese.
I'm in decent shape, do run the occasional 5K about twice a week.
In terms of medical history, there are no serious issues. There is a history of Cavernous hemangioma in my family passed down my mothers side. My brother and sister have been diagnosed with it. I haven't tested it but would assume I most likely have it too.

My diving history
Haven been diving since 1990, and as pro (recreational instructor) since 2013. In total I have done about 1,300 dives up to 50 mt / 165 ft. A relative small number for a dive pro as I have never worked for a 'dive factory' and often combined with 'dry' roles as manager and boat crew.
Since 2016 I have been pursuing technical diving and am currently certified at Tec50 diver open circuit, and CCR Mod 1 / air dil. I have done about 50 hours on CCR and around 15 OC tech/deco dives.
My goal is to pursue further technical diving development, using Trimix and potential a tech instructor.

DCS case 1
My first case was after a 'mild' OC tech dive in April 2017. This was up to 40 mt / 130 ft, with just over 15 min at depth. The dive was planned using GF 30/85 and executed as planned, including deco on 50%.
About an hour or two after the dive I noted an itching and skin rash. Initially thinking this was due to the nice hot shower I just had, I quickly realized it was a skin bend. I went to the hospital, went on O2, and was released after a few hours. The rash started subduing after being on the O2.

This bend I feel might be earned. It was a bit more agressive GF setting and resulting dive profile. More importantly, I had a a boozy lunch the day before, so was certainly dehydrated and not in the best shape.

Attached are the dive profile and picture of the skin bend.
View attachment 525639
View attachment 525640

DCS case 2
My second case was in November 2018. This was a recreational / non-deco CCR dive up to 30 mt / 100 ft, total dive time just over 100 minutes. I have checked the computer log, at no time were any deco obligations occurred during the dive. The GF used was 40/70, the more conservative I use nowadays.
The DCS symptoms manifested itself about 77 (!) hours after completion of the dive. This was following a 8K run and hot shower. In this case it was no rash, but more a marbling. There was no itching or any other sensation.
I drove myself to the hospital, went on O2, and took a Table 5 chamber ride. I noticed no difference in how I felt, neither did the marbling subdue much in the treatment.

View attachment 525641
Dive profile (ignore the ceilings, these are calculated by the Subsurface logging software and do not reflect actual ceilings taking into account gas used / pPO2)

View attachment 525642
Marbling before treatment

View attachment 525643
Marbling after Table 5 chamber treatment

Follow-up
After the second DCS incident, I did a TTE bubble study for PFO. That came back negative. However, my technical diving development been stagnated with my current instructor not feeling comfortable pursuing Trimix certification with me.

Therefore I have been talking to some well-regarded experts in this field, including the amazing @Dr. Doug Ebersole to form an opinion if to continue (technical) diving. The feedback I receive can be roughly divided into 2 camps.
a) Your history is the best indicator of your susceptibility - do not pursue technical diving, and consider giving up diving all together.
b) You most likely have no PFO but might be more susceptible to DCS - dive conservatively and it is reasonable to pursue Trimix diving.

I have also questioned doing further tests, such as a TEE bubble study or a CTA. The feedback I get if a PFO can't be detected with a TTE and it requires a TEE, it most likely is so small that that the benefits of closing it are debatable.

What next...
Currently I feel I'm standing at somewhat of a dead end. I feel there is no clarity whether I can pursue (technical) diving, or whether any additional tests would be beneficial. Or if the results of further tests would change anything in my decision - either no PFO detected so no explanation for my DCS incidents - or very small PFO detected so no use in closing.

So my post is here for several reasons:
a) To tap in the collective (medical) wisdom here what might be going on with me.
b) Anybody been in the same situation? What did you do?

Thanks in advance for your contributions!

Menno
Definitely loose weight , your BMI is over 31 and all of this extra weight is so harmful for you. At 45 you will find it harder and harder to loose weight as you get older. Quitting alcohol altogether while you are trying to drop weight will help a lot.
 
High protein, low carbs, fats but not the fried kind. I mean a little oil dressing on your salad. :p

Lord knows it's not easy and I've still got a ways to go.
 
Definitely loose weight , your BMI is over 31 and all of this extra weight is so harmful for you. At 45 you will find it harder and harder to loose weight as you get older. Quitting alcohol altogether while you are trying to drop weight will help a lot.
His BMI is 28. Maybe he’s a bit overweight, if he has no muscle. If he is decently athletic he’s normal. OP, do you lift at all? Can you bench your weight, or deadlift 2x your weight? These things all play a role.

Last time I went to the doctor, he looked at my file and told me I need to lost 35 kg. I could stand to lose 5, but 35 is absurd. I can bench 10 kilo over my weight and deadlift 190 kg. BMI doesn’t care about that tho.
 
Hi, I certainly consider myself overweight. I'm not a massive athletic figure so a part of that is fat.

I do some mild exercises (push-up, squat, sit-up etc), as well as 5K runs regularly. I'd say on average 2 times a week. I not a gym fan so wouldn't know about what would be able to bench or deadlift.

I weighed myself again this morning, it was 220 lbs. I'd say I should be able to drop that by 35 lbs and still be in form.
 
His BMI is 28. Maybe he’s a bit overweight, if he has no muscle. If he is decently athletic he’s normal. OP, do you lift at all? Can you bench your weight, or deadlift 2x your weight? These things all play a role.

Last time I went to the doctor, he looked at my file and told me I need to lost 35 kg. I could stand to lose 5, but 35 is absurd. I can bench 10 kilo over my weight and deadlift 190 kg. BMI doesn’t care about that tho.

BMI penalizes people who have a lot of muscle mass. Athletes do poorly on BMI.

Athletes and muscular sport stars demonstrate the shortcomings of BMI
 

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