I posted this on another forum originally and the consensus was that I should post over here for broader dissemination. Since my report is long, I'll be splitting it into two sections. Hope that's acceptable to do here.
This is a tale of many acronyms: PFO, ASA, ASD, DCS, TEE, TTE and last but not least, DAN. Over the last several years I began to realize that I experienced [usually mild] DCS symptoms on diving profiles that other divers have experienced no problems. As I learned more about Patent Foramen Ovale (PFO) and its increasingly accepted association with migraines associated with aura and DCS, I began to suspect the presence of a PFO in my own heart. A PFO is a type of defect in the atrial wall that can allow blood to pass from one side of the heart to the other without it first going through the lungs, and is commonly referred to as a "hole" in the heart. It was difficult finding a cardiologist who knew anything about DCS or about scuba diving in general, so I kept hitting dead ends when it came to actually being tested for a PFO. This past summer I had a consultation with a cardiologist who agreed to order a transesophageal echocardiogram (TEE) if I insisted but dissuaded me by suggesting that there was no point unless I planned to stop diving if it were positive or if I planned to pay for the closure of the PFO myself as insurance would be unlikely to cover the cost. A previous transthoracic echocardiogram (TTE) had shown everything as normal. A TEE is considered the definitive test for a PFO since the ultrasound probe is inserted down the esophagus and can get a clear picture of the heart and the atriums due to the probe's proximity to the heart. A TTE on the other hand is done via a probe against the outside of the chest, and has to go through muscles and bone for the view of the heart.
Heart interior view:
Fast forward to November 2008 ...
The Dives and the Diver:
We were diving in Jupiter, Florida and did three dives in the 87 to 98 foot range, surface intervals were 45 minutes to an hour, and water temps were in the 77-78 degree range. The first two dives were the deepest, within a few feet of each other. Visibility was excellent and the currents were relatively mild. We were hunting lobsters and I was swimming hard through all three dives, something I am not normally accustomed to as I'm usually seen carrying a camera vs. a looper and often pausing to take photos. That said, I exercise regularly and am in good shape physically and in good health. I had gotten 8 hours of sleep the night before, was well hydrated and had eaten well the night before and at breakfast. I had a couple of glasses of wine the night before at dinner (about 15 hours prior to the first dive.) Although I was swimming hard through all 3 dives, I felt very good and the dives were enjoyable. I've logged well over 1000 dives all over the world in all kinds of conditions, and was comfortable on these particular dives. In the past year, I had been diving aboard liveaboards in Raja Ampat and the Galapagos without incident, so had no reason to think that 3 dives in Jupiter (all within the limits of my computers) would be an issue.
The only thing unusual about the third dive was that I was feeling extremely over weighted although my buoyancy had seemed okay on the first two dives. However, I was heavier than I prefer to be as I was diving with a heavy steel tank and a pony bottle along with 2 pounds of lead I didn't really need, but which helped to balance things out. As soon as I hit the water, I sank fast and had to add a lot more air in my BC than I had on the earlier dives.
I also was diving with two air-integrated Nitrox computers (Oceanic VT3 and Oceanic Pro Plus 2). Until recently, I had dived for years on Nitrox using air profiles, but had recently gotten the new computers. The bottom line was that I was diving less conservative profiles than I would have in the past. Although I was in the 'yellow' on all dives, no limits were exceeded and I came up slowly, doing both deep stops and full 3-minute 15-foot safety stops. Detailed dive profiles were downloaded from my dive computers.
Post-Dive:
Following the third dive, everything seemed normal at first. I got out of my wetsuit and chatted with other divers, even commenting how good I felt although we had done a lot of diving and had been swimming hard all day. Within about 20 minutes or so of exiting the water, though, I had a migraine with aura (no pain) come on and had wavy lines and bright lights across my field of vision. I also felt a tightening across my chest. It became very difficult to focus my eyes and I had a severe case of vertigo. I had no tingling in my fingers, joint pains, or red blotches. I soon found it hard to hold my head up due to the dizziness and before long I was flat out on a bench with my eyes closed and stayed there until the boat got back to the dock. I could not sit or stand up due to the vertigo. Every time I tried to sit up or open my eyes I felt like I was going to pass out. I was concerned about getting other people worried and just said that I had a migraine which is what I really thought. I thought the visual disturbances from the migraine were causing the vertigo and that I just needed to go lie down for a while.
I needed help to get off the boat and was literally lifted from the boat onto the dock. Through the night, I felt okay as long as I stayed horizontal with my eyes closed. If I stood up the vertigo came on and I had to stumble to the toilet to throw up. By the next morning I was a bit better, but noticed that I had developed pain in my shoulders and upper arms and I'm not certain when that came on. Somewhere along the line I also wondered if the scopolamine patch I had been wearing was causing the vertigo, and took that off. Finally, at some point during the night I started to accept the fact that I was bent and wished I had asked for oxygen on the boat (or someone had overruled me and insisted on it).
DCS Treatment:
I was able to eat some breakfast the morning after the dives sorely needed since my stomach was beyond empty after all the vomiting and called DAN. After hearing my symptoms, Marty at DAN suggested I head to Orlando since that was the closest chamber to where I was in Jupiter. (The chamber in West Palm Beach is not staffed on the weekends. Go figure.) Arriving in Orlando by mid-afternoon the day after the dives, the emergency room staff checked me out and took a chest x-ray and then the hyperbaric team was called in. Although I had an IV, it was never connected so I could be rehydrated. Again, in hindsight I realized that no one offered oxygen. Since it was a Sunday evening, the hyperbaric doc was obviously not happy about having his team called in and reexamined me to make sure I truly did need a chamber ride.
I was in the chamber from about 5 p.m. to about 10 p.m. (Table 6). I was significantly improved when I got out but still had some pain and dizziness. The doctor told me that I had Type II DCS and might have some permanent damage and that I should check with a neurologist when I got home. He also told me I could fly on Tuesday afternoon to return home (it was now Sunday night.) I also was told that I could return the next day to join the group scheduled in the chamber the next morning, but the doctor stressed that he thought this was unnecessary and I would only need to come back if I started getting worse again.
The multi-person chamber at Florida Hospital in Orlando:
When Marty called me afterward to follow up, he told me he wanted me to check with a doctor he recommended at Mount Vernon Hospital once I got back to Northern Virginia. I called and made an appointment for Friday, explaining that I had received a Table 6 treatment in Orlando and had been advised to follow up with them. I still had symptoms at this point although they were decreased.
The approach at Mount Vernon was much different than in Orlando. I really can't say enough good things about the staff at Mount Vernon Hospital. I was thoroughly examined and listened to. It was obvious that the Mount Vernon staff felt I should have been treated until I either had no symptoms or until I stopped improving and that's exactly what they set out to do although it certainly would have been preferable if so much time had not already elapsed. I ended up with 4 more Table 5 chamber rides at about 2 hours each over the next 4 days. I was told not to fly for a week, and that I should not have flown home two days after the first treatment. In the end, I had no further arm pain and no vertigo. The brain 'fuzziness' that I had been feeling for days since the incident finally cleared.
One of the single-person chambers at Mount Vernon Hospital:
Follow Up: The Root Cause:
The doctor at Mount Vernon and I talked a lot about my previous experience diving and my history of migraines with aura. I also had some arm pain in the past that I chalked up as skin bends (now I realize it was more than that), and have gotten migraines with aura after dives. I would sometimes get them when not diving, but not often. We talked about PFO and the fact that I had looked into getting tested this past summer, but was dissuaded after a consultation with a cardiologist not familiar with dive physiology or medicine. To find the cause for my 'undeserved' hit, I was given a referral for a TEE and asked me to return for a follow up checkup prior to returning to diving.
As I somewhat expected, having done a fair amount of research already, the TEE showed that I have a PFO. At the same time, several people to whom I had expressed concerns regarding the possibility of a PFO had sent me contact information for a cardiologist who is also a technical diver and dive instructor, Dr. Doug Ebersole. I began emailing him as he is located in Lakeland, FL and I'm in Virginia and he was extremely forthcoming in answering my questions and providing information. He also offered to review the CD of my TEE and give his opinion and a recommendation for an interventional cardiologist closer to my home. As it turned out, I had planned to visit family in Florida before Christmas and decided to schedule a consultation with Dr. Ebersole at the same time. When he reviewed the CD, he pointed out that I also had an atrial septal aneurysm (ASA), which is basically a "floppy" atrial wall. Taken together, the two significantly increase the risk of stroke, and likely DCS as well. I was advised that a singular medical procedure could fix both problems and that I should not dive until my PFO was closed. I decided to go ahead with the procedure, so it was scheduled for January 2. I was told that if all went well I could be back in the water in 3 months. That said, my decision to opt for closure as recommended was not solely due to the fact that I wished to continue to dive but also because of the increased risk of stroke the PFO/ASA combination posed.
In the meantime, migraines continued. I'll be very interested to see whether my migraines disappear permanently with the PFO closure.
Here is the device used for closure:
As described by the manufacturer, the closure device is a self-expandable, double disc device made from a Nitinol wire mesh. The two discs are linked together by a short connecting waist allowing free motion of each disc. In order to increase its closing ability, the discs contain thin polyester fabric. The polyester fabric is securely sewn to each disc by a polyester thread. It is inserted through the PFO (hole) in the wall dividing the right and left atriums.
The cardiologist planned to go in through the femoral veins (on one side with an ultrasound device and on the other with the closure device via catheter). ). For more info and a simulated demo visit ASD Septal Occluder Placement Video. You also can view a video of my TEE here: YouTube - TEE of PFO & ASA. On the TEE video, the cursor points to the area with the PFO and ASA. Look very closely for the cursor in the left corner of the screen.
(to be continued)
TRIP REPORT: My Dry Dives and Other Adventures
This is a tale of many acronyms: PFO, ASA, ASD, DCS, TEE, TTE and last but not least, DAN. Over the last several years I began to realize that I experienced [usually mild] DCS symptoms on diving profiles that other divers have experienced no problems. As I learned more about Patent Foramen Ovale (PFO) and its increasingly accepted association with migraines associated with aura and DCS, I began to suspect the presence of a PFO in my own heart. A PFO is a type of defect in the atrial wall that can allow blood to pass from one side of the heart to the other without it first going through the lungs, and is commonly referred to as a "hole" in the heart. It was difficult finding a cardiologist who knew anything about DCS or about scuba diving in general, so I kept hitting dead ends when it came to actually being tested for a PFO. This past summer I had a consultation with a cardiologist who agreed to order a transesophageal echocardiogram (TEE) if I insisted but dissuaded me by suggesting that there was no point unless I planned to stop diving if it were positive or if I planned to pay for the closure of the PFO myself as insurance would be unlikely to cover the cost. A previous transthoracic echocardiogram (TTE) had shown everything as normal. A TEE is considered the definitive test for a PFO since the ultrasound probe is inserted down the esophagus and can get a clear picture of the heart and the atriums due to the probe's proximity to the heart. A TTE on the other hand is done via a probe against the outside of the chest, and has to go through muscles and bone for the view of the heart.
Heart interior view:
Fast forward to November 2008 ...
The Dives and the Diver:
We were diving in Jupiter, Florida and did three dives in the 87 to 98 foot range, surface intervals were 45 minutes to an hour, and water temps were in the 77-78 degree range. The first two dives were the deepest, within a few feet of each other. Visibility was excellent and the currents were relatively mild. We were hunting lobsters and I was swimming hard through all three dives, something I am not normally accustomed to as I'm usually seen carrying a camera vs. a looper and often pausing to take photos. That said, I exercise regularly and am in good shape physically and in good health. I had gotten 8 hours of sleep the night before, was well hydrated and had eaten well the night before and at breakfast. I had a couple of glasses of wine the night before at dinner (about 15 hours prior to the first dive.) Although I was swimming hard through all 3 dives, I felt very good and the dives were enjoyable. I've logged well over 1000 dives all over the world in all kinds of conditions, and was comfortable on these particular dives. In the past year, I had been diving aboard liveaboards in Raja Ampat and the Galapagos without incident, so had no reason to think that 3 dives in Jupiter (all within the limits of my computers) would be an issue.
The only thing unusual about the third dive was that I was feeling extremely over weighted although my buoyancy had seemed okay on the first two dives. However, I was heavier than I prefer to be as I was diving with a heavy steel tank and a pony bottle along with 2 pounds of lead I didn't really need, but which helped to balance things out. As soon as I hit the water, I sank fast and had to add a lot more air in my BC than I had on the earlier dives.
I also was diving with two air-integrated Nitrox computers (Oceanic VT3 and Oceanic Pro Plus 2). Until recently, I had dived for years on Nitrox using air profiles, but had recently gotten the new computers. The bottom line was that I was diving less conservative profiles than I would have in the past. Although I was in the 'yellow' on all dives, no limits were exceeded and I came up slowly, doing both deep stops and full 3-minute 15-foot safety stops. Detailed dive profiles were downloaded from my dive computers.
Post-Dive:
Following the third dive, everything seemed normal at first. I got out of my wetsuit and chatted with other divers, even commenting how good I felt although we had done a lot of diving and had been swimming hard all day. Within about 20 minutes or so of exiting the water, though, I had a migraine with aura (no pain) come on and had wavy lines and bright lights across my field of vision. I also felt a tightening across my chest. It became very difficult to focus my eyes and I had a severe case of vertigo. I had no tingling in my fingers, joint pains, or red blotches. I soon found it hard to hold my head up due to the dizziness and before long I was flat out on a bench with my eyes closed and stayed there until the boat got back to the dock. I could not sit or stand up due to the vertigo. Every time I tried to sit up or open my eyes I felt like I was going to pass out. I was concerned about getting other people worried and just said that I had a migraine which is what I really thought. I thought the visual disturbances from the migraine were causing the vertigo and that I just needed to go lie down for a while.
I needed help to get off the boat and was literally lifted from the boat onto the dock. Through the night, I felt okay as long as I stayed horizontal with my eyes closed. If I stood up the vertigo came on and I had to stumble to the toilet to throw up. By the next morning I was a bit better, but noticed that I had developed pain in my shoulders and upper arms and I'm not certain when that came on. Somewhere along the line I also wondered if the scopolamine patch I had been wearing was causing the vertigo, and took that off. Finally, at some point during the night I started to accept the fact that I was bent and wished I had asked for oxygen on the boat (or someone had overruled me and insisted on it).
DCS Treatment:
I was able to eat some breakfast the morning after the dives sorely needed since my stomach was beyond empty after all the vomiting and called DAN. After hearing my symptoms, Marty at DAN suggested I head to Orlando since that was the closest chamber to where I was in Jupiter. (The chamber in West Palm Beach is not staffed on the weekends. Go figure.) Arriving in Orlando by mid-afternoon the day after the dives, the emergency room staff checked me out and took a chest x-ray and then the hyperbaric team was called in. Although I had an IV, it was never connected so I could be rehydrated. Again, in hindsight I realized that no one offered oxygen. Since it was a Sunday evening, the hyperbaric doc was obviously not happy about having his team called in and reexamined me to make sure I truly did need a chamber ride.
I was in the chamber from about 5 p.m. to about 10 p.m. (Table 6). I was significantly improved when I got out but still had some pain and dizziness. The doctor told me that I had Type II DCS and might have some permanent damage and that I should check with a neurologist when I got home. He also told me I could fly on Tuesday afternoon to return home (it was now Sunday night.) I also was told that I could return the next day to join the group scheduled in the chamber the next morning, but the doctor stressed that he thought this was unnecessary and I would only need to come back if I started getting worse again.
The multi-person chamber at Florida Hospital in Orlando:
When Marty called me afterward to follow up, he told me he wanted me to check with a doctor he recommended at Mount Vernon Hospital once I got back to Northern Virginia. I called and made an appointment for Friday, explaining that I had received a Table 6 treatment in Orlando and had been advised to follow up with them. I still had symptoms at this point although they were decreased.
The approach at Mount Vernon was much different than in Orlando. I really can't say enough good things about the staff at Mount Vernon Hospital. I was thoroughly examined and listened to. It was obvious that the Mount Vernon staff felt I should have been treated until I either had no symptoms or until I stopped improving and that's exactly what they set out to do although it certainly would have been preferable if so much time had not already elapsed. I ended up with 4 more Table 5 chamber rides at about 2 hours each over the next 4 days. I was told not to fly for a week, and that I should not have flown home two days after the first treatment. In the end, I had no further arm pain and no vertigo. The brain 'fuzziness' that I had been feeling for days since the incident finally cleared.
One of the single-person chambers at Mount Vernon Hospital:
Follow Up: The Root Cause:
The doctor at Mount Vernon and I talked a lot about my previous experience diving and my history of migraines with aura. I also had some arm pain in the past that I chalked up as skin bends (now I realize it was more than that), and have gotten migraines with aura after dives. I would sometimes get them when not diving, but not often. We talked about PFO and the fact that I had looked into getting tested this past summer, but was dissuaded after a consultation with a cardiologist not familiar with dive physiology or medicine. To find the cause for my 'undeserved' hit, I was given a referral for a TEE and asked me to return for a follow up checkup prior to returning to diving.
As I somewhat expected, having done a fair amount of research already, the TEE showed that I have a PFO. At the same time, several people to whom I had expressed concerns regarding the possibility of a PFO had sent me contact information for a cardiologist who is also a technical diver and dive instructor, Dr. Doug Ebersole. I began emailing him as he is located in Lakeland, FL and I'm in Virginia and he was extremely forthcoming in answering my questions and providing information. He also offered to review the CD of my TEE and give his opinion and a recommendation for an interventional cardiologist closer to my home. As it turned out, I had planned to visit family in Florida before Christmas and decided to schedule a consultation with Dr. Ebersole at the same time. When he reviewed the CD, he pointed out that I also had an atrial septal aneurysm (ASA), which is basically a "floppy" atrial wall. Taken together, the two significantly increase the risk of stroke, and likely DCS as well. I was advised that a singular medical procedure could fix both problems and that I should not dive until my PFO was closed. I decided to go ahead with the procedure, so it was scheduled for January 2. I was told that if all went well I could be back in the water in 3 months. That said, my decision to opt for closure as recommended was not solely due to the fact that I wished to continue to dive but also because of the increased risk of stroke the PFO/ASA combination posed.
In the meantime, migraines continued. I'll be very interested to see whether my migraines disappear permanently with the PFO closure.
Here is the device used for closure:
As described by the manufacturer, the closure device is a self-expandable, double disc device made from a Nitinol wire mesh. The two discs are linked together by a short connecting waist allowing free motion of each disc. In order to increase its closing ability, the discs contain thin polyester fabric. The polyester fabric is securely sewn to each disc by a polyester thread. It is inserted through the PFO (hole) in the wall dividing the right and left atriums.
The cardiologist planned to go in through the femoral veins (on one side with an ultrasound device and on the other with the closure device via catheter). ). For more info and a simulated demo visit ASD Septal Occluder Placement Video. You also can view a video of my TEE here: YouTube - TEE of PFO & ASA. On the TEE video, the cursor points to the area with the PFO and ASA. Look very closely for the cursor in the left corner of the screen.
(to be continued)
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