Pulmonary emboli, coumadin and diving

[ChrisM]

I know there have been a few threads on diving on thinners, and I've read through them, just looking for other input.

My short history, DM with 900 or so dives over the last 10 years, no DCI or DCS incidents. 43 year old male, relatively decent health.

In July 2009 suffered an idiopathic PE, minor lung infarction. Never found a DVT (likely because the docs - GP, cardiologist and pulmonologist -couldn't diagnose my shortness of breath for 5 weeks), full hematological workup at UCLA, negative results or explanation. Full negative cancer screening.

Warfarin July - December 2009. CT in Nov 2009 showed clots had dissolved, no lung injury.

Second PE episode March 2010. CT showed no lung injury. Second cancer screening negative. I will be seeing another hematologist to see if any other tests can be done, but frankly am not in a hurry to do so

Warfarin for life at 2.0-3.0, currently controlled by clinic, and fairly regular at 2-2.4. In the next month moving to home monitoring so I will be testing it weekly. Primarily because I am very active, still ride my bike, run trails, etc. I honestly don't bleed much more than I did in the past nor do I get many bruises unless I've really whacked myself, in which case it appears a bit darker and bigger than it may have before.

Haven't dived since pre PE, but question is: I have a trip to Coz scheduled for November, which will be 8 months after second PE episode. I've read up on the danger of trauma, bleeding, and theoretical DCI increased risk, but I guess the question is whether having 2 PEs there are any issues in the lungs to potentially be worried about. I'd like to avoid another CT if possible, having had 5 in the last 2 years or so.

I've got no problems limiting depth to 80-90 feet, I am happier shallow anyway. I dive conservatively, on EANx, slow ascents, mid stops, etc.

Any and all input welcome. Thanks

Chris

 

[TSandM]

I'm quite sure there's no literature on diving after pulmonary embolism. Diving on anticoagulants is not contraindicated, if the dose is stable and the INR is therapeutic.

There is undoubtedly some small, theoretical risk of a pulmonary infarction creating an abnormality that could cause gas trapping. But, in general, in an infarction, the tissue distal to the obstructing object dies and fibrosis -- it therefore should no longer be transmitting or containing air.

I can't give you a reference at all, but I, myself, would be willing to dive in the situation you describe. The risks aren't known, but my analysis of the pathophysiology of PE suggests you're at more risk from a recurrent clot than from gas embolism.

 

[HBO MD]

Agree with TS and M.
I think the risk relates more to the trauma you encounter while diving, which is often inevitable.
I would hope that the hematology workup would bare some fruit in terms of any potential coagulation disorder which has predisposed you to embolic events.
Good luck.

 

[NC Wreck Diver]

Call DAN and review everything with them. I wouldn't call the emergency number, or maybe e-mail them and follow up with a phone call. They are very good. Good luck with your situation.

 

[ChrisM]

thanks for the posts. Just a follow up. Decided to go to the local DAN referral doc. He's a board certified internist, pulmonologist and internist. He worked up my case, and even asked me to delay his opinion until he could present my case at the recent conference of the Pacific Hyperbaric Doctors Association (or something like that).

Basically, would like me to have a PFO test (which I am having Monday) due to clotting issues, although I can't say I am 100% sure why. I understand the relationship to diving, but never having had a TIA or stroke (or "undeserved" hit) not sure it's all that relevant to the clotting, but I suppose my insurance will cover it and as a diver it's nice to know I don't have one (or, if I do....).

Other than that, the real risk is coumadin and bleeding, so he recommends avoiding very remote/exotic locations. I guess this means no Irian Jaya for me, but at least I got Galapagos and Cocos out of my system.

Chris

 

[Duke Dive Medicine]

Chris,
The PFO study would be to ensure that you don't have one. You seem to be pretty well educated as to the risks of a thrombus passing through to the arterial circulation... I imagine the physician is just being thorough and wants to reassure you (and himself) that that's not going to happen.
You also seem to have a good grasp of the risks of diving on an anticoagulant. You are at increased risk of bleeding, either spontaneously or due to trauma. If you're being tossed around on a boat (or in the water in heavy surf) and you hit your head, the larger bruise you mentioned may not be so superficial or benign. If you choose to continue diving, please use extreme caution.
Finally, we'd echo what HBO MD said about getting to the bottom of your clotting disorder. Be your own best advocate, and keep plugging until you get an answer.
Kindest regards,
DDM

 

[ChrisM]

Chris,
The PFO study would be to ensure that you don't have one. You seem to be pretty well educated as to the risks of a thrombus passing through to the arterial circulation... I imagine the physician is just being thorough and wants to reassure you (and himself) that that's not going to happen.
You also seem to have a good grasp of the risks of diving on an anticoagulant. You are at increased risk of bleeding, either spontaneously or due to trauma. If you're being tossed around on a boat (or in the water in heavy surf) and you hit your head, the larger bruise you mentioned may not be so superficial or benign. If you choose to continue diving, please use extreme caution.
Finally, we'd echo what HBO MD said about getting to the bottom of your clotting disorder. Be your own best advocate, and keep plugging until you get an answer.
Kindest regards,
DDM

Thanks. I am fine with having the test, I think it's good information to have as a diver. The more info, the better, I feel.

Yes, I am an active person so I've educated myself well. I have returned to doing triathlons and cycling, I just do things differently now. Lots of indoor training, choose my riding partners carefully, choose races carefully, etc. I also home test for INR on a weekly basis so I am very on top of my levels, vs. the 1x/month the clinic would recommend. A spontaneous bleed given my level of monitoring is highly unlikely. That said, even being as safe as I can be, I understand that there are certain risks that may not be within my control, and I am prepared to live with those. Sort of like solo diving

I am determined to live as "normal" a life as possible. I would hate to give up all of my activities for fear of falling, only to fall getting out of the tub, what a waste that would be

After the first round of PEs, I consulted with a UCLA hematologist, who ran a number of tests, and at the time I could reel them all off and discuss the results (aTTP, diluted russell's vyper, factor VIII, etc etc), although at the moment the only thing I recall is an elevated Factor VIII, which by itself was not enough to warrant continued anticoagulation in his opinion (of course, the second round changed all of that).

Much as I prefer UCLA over USC, I have found a thrombophilia specialist at USC from whom I am going to seek a second opinion, see what additional tests he moght recommend, etc. There is nothing in my physical history (no surgeries or immobility, long airplane flights, etc) or bloodwork (except the F VIII) that would suggest I am susceptible to clotting, other than the clots themselves, so the whole thing is currently a mystery.

I had originally thought the first ones arose after a half ironman race I did in May 2009, fairly hot, got dehydrated, foolishly drank a little too much that night (more dehyd), then drove home 5+ hours the next day only stopping once. First PE symptom showed up 4-5 weeks later (a google search of endurance athletics and blood clots is revealing). But that doesn't explain the second round.

Chris

 

[ChrisM]

Just to wrap up the thread, negative for PFO