Pulmonary barotrauma and AGE hit

[sinduda]

Did your treatment team specifically report findings of pulmonary edema? The reason I ask is that it's possible for a lung over-expansion injury to give rise directly to AGE.

FYI, I would not be so quick to attribute the incident to a diet containing gluten. Celiac disease (CD) is a real condition, but it's getting over-hyped in media/tabloids nowadays. Diagnosis of CD often entails assaying the blood for specific antibodies. However, the most accurate test involves a biopsy of the small intestine. Be aware that it's easy to mistake acute viral gastroenteritis for CD.

Hi Bubbletrubble...The pulmonary edema diagnosis seemed to have been primarily based on the severe bronchial spasm that presented when I surfaced in addition to diminished lung capacity once I could be examined. One of the other divers was a pneumonologist in the past, though a GP now. She was next to me when I surfaced and 'kicked' into doctor mode. Re IPE, she said no pink frothy foam was present when I was coughing. Plus, my symptoms only presented either during final ascent (I think I recall shortness of breath in final ascent from safety stop) or at surface. Seems the other cases presented at depth. I also 'seemed' to be relatively okay within an hour or so after accident. So I'm not quite sure this follows the IPE profile.

It was 36 hours before I was examined and as I was in Galapagos, lucky 1 of the 2 xray machines were functioning (and that they allowed me an xray though it was against the rules due to it being ordered by a doctor outside the clinic), so to say advanced equipment for testing was not available is an understatement. We could only rule out pneumothorax with the xray so I could go into the chamber to treat the neurological symptoms. All other tests were 15 days after the accident at a very modern facility on the mainland.

As for gluten, we figured this out the old fashioned way, before the world was intolerant or celiac way back in the mid 90's and after several doctor visits in NYC could not find a cause of my intestinal pain. Someone from California was describing her symptoms which sounded all too familiar. She suggested I go without gluten for a couple of weeks and then have a meal of pasta and garlic bread. The difference was telling. I don't attribute the accident to gluten alone, but have had problems around congestion I wasn't even aware I had. And I did see several specialists, all of whom could find no problem. They ordered tonal tests, MRIs, etc. Nothing. Was not aware I had congestion on this trip, but took the med prophylactically due to the problems I previously had. Just saying it could have been a factor and am now pretty convinced it is the basis of the congestion issues I've had.

 

[DandyDon]

Sinduda, about the Pseudoephedrine: did you take an antihistamine too, or just the red pills? I'm just an amateur and a decades long user but I am convinced that anyone who take decongestants should also take antihistamines, and I think I have observed a someone common lack of understanding there.

 

[Bubbletrubble]

Based on what you're saying and assuming that the X-ray 36 hours post-incident did not show evidence of pulmonary edema, I don't find the diagnosis of pulmonary edema particularly convincing. This is not meant to be a criticism of the GP who was administering first aid on the boat or the treatment team in the Galapagos.

So you're certain that the mild congestion you experienced on the trip could not be attributed to some sort of respiratory-related infection?

To be clear, your celiac disease diagnosis has not been substantiated by blood tests or small intestine biopsy, correct?

 

[sinduda]

Maybe the question to be asked is, "What would look like a gas embolism in a cat scan?"

I would recommend you report your first post and have this moved to Diving Medicine. With that ongoing study At Duke (did you see the post on that?), they can bring some hellacious resources to bear.

Hi Jax. Apparently, a gas embolism shows black/dark. She explained it to me at length, the difference in what blood would look like and that it's best to do a cat scan with no dye when that's suspected as well as what could maybe cause a fat embolism, which did not seem to apply in my case. I could only truly tune in to what did apply to my reading and she was pretty definite it wasn't blood. Also ruled out an artifact due to being visible in multiple slices. And I am going to try to make a scan or send the original cat scan to Duke. Apparently, if their radiologists read it as a gas embolism still visible 2 weeks post accident and post 6 chamber treatments, that would make me an anomaly. Me? I would just like to truly know what happened as it's almost impossible to see how it could have been caused by the dive profile. I need to know what I need to adjust to feel comfortable getting back in the water.

 

[sinduda]

Based on what you're saying and assuming that the X-ray 36 hours post-incident did not show evidence of pulmonary edema, I don't find the diagnosis of pulmonary edema particularly convincing. This is not meant to be a criticism of the GP who was administering first aid on the boat or the treatment team in the Galapagos.

So you're certain that the mild congestion you experienced on the trip could not be attributed to some sort of respiratory-related infection?

To be clear, your celiac disease diagnosis has not been substantiated by blood tests or small intestine biopsy, correct?

Tried reaching attending and hospital on the mainland today to no avail. So I cannot answer the question about the pulmonary edema diagnosis. The initial medical report simply says "x-ray was taken showing signs of left lung congestion". Later xrays read by multiple doctors followed by specifically a pneumologist did not reveal any respiratory related infection. And the whole point was to determine whether or not there was an underlying physical cause, so....

You are correct I have never had a real test for gluten intolerance, just many years of very uncomfortable results when I binged.

 

[Bubbletrubble]

What was the location of the gas embolism on the CT scan? (roughly speaking)
Did any neurological symptoms persist post-incident and after the chamber treatments?
I'm curious whether neurological symptoms correlated with the brain region affected by the embolism.

 

[sinduda]

Sinduda, about the Pseudoephedrine: did you take an antihistamine too, or just the red pills? I'm just an amateur and a decades long user but I am convinced that anyone who take decongestants should also take antihistamines, and I think I have observed a someone common lack of understanding there.

Just the red pills. Claritin D, Alegra, etc I had tried, but did not like the speedy way they made me feel.

 

[sinduda]

What was the location of the gas embolism on the CT scan? (roughly speaking)
Did any neurological symptoms persist post-incident and after the chamber treatments?
I'm curious whether neurological symptoms correlated with the brain region affected by the embolism.

It was above and behind my ear on the left side. But yes, the affected area was where it would correlate to the issues, thus the entire right side of my body going completely numb in the chamber. Though it is interesting that attending could only guess what happened to affect balance as that did not correlate to the spot that affected the sensory part, as opposed to motor function, of my arms and legs. Then again, doesn't everyone have their balance affected when on a boat for several days? Can say improvement was pretty obvious day to day after chamber treatments in terms of areas no longer feeling numb and beginning to feel pain. Haven't used a needle to stick myself in weeks. Don't have the spur type tool he used. Should see if any symptoms remain.

 

[Bubbletrubble]

Thanks for the info.

The location of the embolism would suggest involvement of the middle cerebral artery (or some offshoot thereof).

Considering the location of the embolism, did you have any problems with speech production or reception?
The location you described is pretty close to Wernicke's area, associated with speech reception.

Yes, spending time on a boat and then returning to land often results in dysequilibrium issues. That's to be expected even in normal, healthy individuals. Still, certain parts of the parietal lobe of the brain are important for integrating position-sensing information from different parts of the body. If bloodflow to the parietal lobe were affected by the embolism, then that could easily explain your balance issues.

Toothpicks are cheap, disposable, fairly sharp, and easy to obtain. They work for testing fine two-point discrimination and pain sensation.

 

[DandyDon]

Just the red pills. Claritin D, Alegra, etc I had tried, but did not like the speedy way they made me feel.

I don't want to interfere with your more important discussion with Bubbletruble, but if you are going to take those meds, it might be helpful to learn what they are and what they do. Brand names are misleading, but then generic names are often difficult to pronounce and/or spell as well as remember well and keep straight. As an introduction only...

The little red pills are generally Pseudoephedrine/PSE, from which Sudafed originally got its name - a popular decongestant that can overly stimulate some. I can't find them in 60 mg anymore so take two 30 mg pills at a time when I do.

Claritin got its name from Loratadine I guess, and original Claritin D is a combination pill of the antihistamine Loratadine and Pseudoephedrine. Strengths vary. Good to know what you're taking and to try it on land first.

Allegra alone is fexofenadine, an antihistamine, and sometime sold as Allergra D with PSE in combination.

Original Actifed is my personal favorite, with triprolidine hydrochloride as the antihistamine plus PSE - really difficult to find nowadays with all PSE products being behind the counter and not profitable for mass marketing, and all of the brand names are trying to get customers to buy a different decongestant called Phenylephrine with the same brand name on the box - with resistance. Original Actifed was used on a couple of Apollo missions and promoted by astronauts when it went OTC. Walgreens has in it their Wal-act, but that's a 70 mile drive for me and I am limited to buying one box of 45/day. I get a box anytime I visit my daughter's family but pay more to order from Canada sometimes - being careful to not go over my 150/month purchasing as I don't want to raise a red flag with the DEA or Texas Rangers. :shocked2:

My daughter and granddaughter both take PSE and antihistamines, but she doesn't pay a lot of attention to those details, then I get confused trying to help her shop. We like to take a 24 hour antihistamine every day each, and some stores charge 10 times as much as other for such common, generic meds. But I am rambling... :silly:

Anyway, you might want to learn a little more about antihistamines, try different ones or ask your doc to see which work for you best, and give some more attention to details there, whether for diving, allergies, or colds. If PSE bothers you, you might try Phenylephrine which is being sold as the PE replacement for PSE, with limited polarities.