Skin Bends - Lessons learned

[Duke Dive Medicine]

Getting the bends isn’t a crime or a sin. It’s something that needs to be dealt with to prevent it from getting worse and REALLY becoming problem. And when we tell you, whether it’s a local trip or a foreign trip, that if after a dive you’re feeling SOMETHING UNUSUAL FOR YOU . . . then you need to let us know. In Audrey’s case, she did the exact right thing once she realized there was a problem.

We put Audurey on oxygen and I ordered the boat to pull anchor and head back towards La Paz. Skin bends sometimes resolves with oxygen alone but I needed to get close enough to La Paz to get within cell phone range so we could contact the D.A.N. emergency line and get some advice and perspective on what was going on. And if need be, there was a chamber in La Paz (as well as one in Cabo) so that if Audrey did need to be treated, we could get her in as quickly as possibly. (Unlike in the U.S., you can’t count on a helicopter to come get you so the usual course of action is to head back to port.)

The short version is that we kept Audrey on oxygen, her symptoms resolved, D.A.N. agreed with our skin bends suspicion, and no chamber treatment was required. It was recommended that she stay out of the water for at least 48 hours (which meant no more diving on the trip) and that she’d be OK to fly after that but we should watch for any recurrence of symptoms during the flight.

Ken,

Just seeing this now because I don't frequent this forum. I completely agree with the first paragraph above, i.e. it's not a sin to get DCS.


I do wonder about the advice you received about not needing to treat this diver because her symptoms resolved on O2. DCS symptoms can and do resolve on surface O2. They also can and do reoccur after the O2 is discontinued, and the recurrence can be worse than the initial symptoms. The symptoms you described ("bruised or mottled skin") sound more like cutis marmorata than simple skin bends. Cutis is associated with more severe neurological DCS symptoms. If this diver did indeed have cutis, she should have been evaluated and treated in a hyperbaric chamber, even though the rash resolved.

 

[koyote1111]

Very interesting and important thread...I appreciate the topic!

I did five treatments in the chamber in Cozumel this past June. It all felt quite embaressing as I'd just completed my divemaster certification. I felt as if I had somehow done something wrong...or had somehow failed in understanding the whole concept of DCS. However, where I went wrong was not understanding that I had a symptom that is often not discussed. It is also generally under the heading of "rash" in the literature.

I had the appearance of bruising...and simply wrote it off to doing more diving, potentially tightening in my BCD a bit too much (I was diving in a 3mm for the first time...had always been in a 7mm), etc. I had been watching my profiles carefully...there were a bit aggressive, yet I was staying within all recreational dive limits.

The bruising appeared about 8 hours after the dives and was gone by morning...didn't think much about it. I felt great that morning and had done plenty of diving that was as deep, as long, and more rigorous than the drift dives in Cozumel. Just had never had any problems...and certainly did not associate bruising with DCS.

So, I did two dives the following day... it was then apparent that I was bent. About two hours following the dive, I had the mottled skin appearance on my torso/breast region and by the time I got to the chamber was having joint pain, muscle pain, and some balance problems.

Why did I get bent? Who really knows for sure...my hunch is that my body is definitely not a match with the tables with doing repetitive days of diving. While I had done repetive dives quite often...I had not done the repetive days of multiple dives.

Upon return to CA, I was sent by my dive physician to have an echo to rule out a PFO. Found out...I do have a PFO. How much or if this played a role...again, who knows?

What I do know now is that I am following doctors orders in terms of highly conservative diving. For me...it's a bit of "lets just see how you do with this". Perhaps in time, I will attempt a bit more depth (am currently restricted to 40 ft. as suggested by doctor). It's not that I necessarily want to do deep diving...I would just like to be able to do the local shore dives without constantly watching my depth gauge. I am also restricted to one dive a day and no repetitive days of diving. I now perform extended safety stops and always using Nitrox. Thus far, I've completed six dives without problem...so that's happy news for me. Will be reporting to my doctor after my 10th dive for some follow-up.

While being treated at the chamber in Cozumel...I was told that when women experience being bent, that they will often have breast tenderness and also the sensation of feeling "engorged". If this indeed is the case, it might be something to further educate female divers about. I was also told that about 50% of those who get bent...well, the reason for it happening cannot clearly be identified. In other words..."underserved".

So...yes...very important to pay attention to any symptom...even if it may not exactly match what you've read in the texts. And, yes again to "it's a computer and it does not know YOUR body".

Again...great thread and thanks for posting this information. Perhaps we should do a bit more education regarding the appearance of skin conditions associated with DCS (?). More images of what a rash may look like, what "mottled skin" looks like, what skin bends look like, etc.

 

[heavierthanlead]

Not sure what the origin of this website is, but it does seem to have some useful info (along with pics)...

Skin Bends

Also...

Skin Bends or Cutaneous Decompression Sickness - Skin Bends Information for Scuba Divers

 

[Duke Dive Medicine]

koyote,
Attached is a photo of cutis marmorata. This is from an article in Lancet by Vann and colleagues (Vann R D, Butler F K, Mitchell S J, Moon R E. Decompression Illness. The Lancet. 2011;377:152-164). Sometimes the borders aren't as well-defined as you see in this picture, and sometimes the rash isn't as dark (the photos from heavierthanlead's first link above are good examples), but this is typical of the marbled or mottled appearance.
Best,
DDM

 

[ianr33]

I advised her that she should stay at her safety stop long enough to clear BOTH yellow pixels so she surfaces at the top of the green. (Years ago, Oceanic had that recommendation in their computer manuals but I couldn't find it in any of the current versions.) You can generally clear the top yellow pixel pretty quickly. It's that first yellow pixel that may take a while when you're trying to off-gas some more.

But again, the take-away is that isn't it better to spend ten minutes longer in the water waiting for that second pixel to clear than to spend six hours in a chamber wishing you'd spent ten minutes more in the water????

That's exactly what do. Have had an oceanic computer for many years. Always made it a habit to surface with it in the green. After taking trimix training and learning a little about deco I'm convinced that's a REALLY good idea.

I suspect a lot of DCS cases could have been avoided by 10 minute safety stops.

 

[koyote1111]

Thanks for providing the links and photos...would say that I had cutis marmorata going on, yet not as severe and widespread as what is pictured.
Again...really appreciate this discussion/topic..

 

[redacted]

That's exactly what do. Have had an oceanic computer for many years. Always made it a habit to surface with it in the green. After taking trimix training and learning a little about deco I'm convinced that's a REALLY good idea.

I suspect a lot of DCS cases could have been avoided by 10 minute safety stops.

I dive an older Oceanic with 12 green ticks and 3 yellow ticks. Pretty easy to manage dive to surface after a 3 to 5 minute stop in the green except for the Flower Gardens. By late in the 2nd day and the 3rd day, many dives take me 2 and occasionally 3 ticks into the yellow and even a 10 minute rest stop sometimes leaves me with a yellow tick at the end of the dive. As the days go by doing 4 or 5 deep dives each day, the N2 loading of the slower compartments starts to come into play controlling dives. I suspect that even 10 minute rest stops do not make a big dent in those 60 minute and slower compartments.

I have not yet used DiveNav's newest beta test release that does nitrox and up to 5 dives but I am looking forward to examining FGB profiles on that simulator. Really looking forward to being able to do 12 dives over a 3-day FGB trip to see what is going on with those slower compartments.

 

[Tricia]

First, thanks to Ken (and Audrey) for sharing this with us. And thanks to the Duke dive docs for sharing the photos. I'd never seen that before, but now I know...

TS&M: thanks for that reminder about not shooting up from the bar to the boat. I used to be one of those divers who figured since I had done my safety stop, all was well and I could just pop to the surface. Fortunately, a dive instructor saw me do it a few years ago and set me right. Now, when I see another diver do it, I take them aside on the boat and explain.

An interesting point re the safety stops. In all my years, I had never gone into Deco until the summer of 2010. I was actually looking around at the other divers thinking, "What's that beeping noise?" until I realised it was my computer! After that, I have always done at least 5 minutes at the bar, sometimes longer if I've gone deep. It irritates my buddies, but as Ken says, I'd rather spend a few more minutes down there than hours in a chamber cursing my stupidity.

A very interesting read overall. Thanks!

Trish

 

[kevinbaja]

hey there ken......
there can also be the issue of liposuction as a contributing factor in the possibility of getting skin bends, since liposuction destroys the subcutaneous capillary bed for a period of time. having D.M.'d a trip years ago on that same vessel, one of the clients not only was dehydrated, wore a semi-ill fitting wet-suit, and, i found out afterward, she had gone under the "vacuum" for liposuction, 5-6 months prior the trip. her skin bends hit area was exactly in the areas where the procedure took place. EVEN THOUGH.....on the release form, she stated she had NOT undergone any surgery in the prior year. DAN was called, she went on O2 and was given IV and oral fluids at the navy clinic near the marina, flew 2 days later after the "hit" was resolved....with minor pain in affected areas.

 

[sharksdelight]

I've never been bent that I know of but I have been dehydrated to the point that I couldn't dive for a day in Egypt due to stomach pains, probably a result of pain medications I was taking that was found to be the cause of an ulcer, which was discovered on my return. I am now conscious of drinking more water on any trip than I used to. I also learned from this report regarding altitude and blood pressure meds. I am not on them but my best friend is and will advise him of this. Thanks for an excellent report.
Steve