Suffered DCS for the first time and terrified to dive again

[scubadiver888]

vladimir, medical is covered by the province of Ontario. There is no money out of pocket and no need for reimbursement. If you are a citizen of Canada, live in the province of Ontario and have a dive emergency, call CritiCall and it is covered.

My advice was for jbird71 as his profile indicates he is a resident of Toronto.

 

[vladimir]

vladimir, medical is covered by the province of Ontario. There is no money out of pocket and no need for reimbursement. If you are a citizen of Canada, live in the province of Ontario and have a dive emergency, call CritiCall and it is covered.

My advice was for jbird71 as his profile indicates he is a resident of Toronto.

Thanks, I understood that, but others might extrapolate your advice--no doubt sound in this case--to the general case, so I sought to clarify.

 

[Mr Carcharodon]

One other thing to note when you get back in the water is that nitrox would have really helped on these dives. Using EAN32 would have decreased your air equivalent depth by ~4 msw on average during the first dive, and ~3 msw on the second. That would given you at least an extra 10 minutes of margin on NDL. On the second dive you likely would have not exceeded limits on nitrox. EAN36 would knock another meter or so off your equivalent depths relative to EAN32 and given you an extra couple minutes of NDL time.

Anyway it is easy to second guess after the fact. I am glad you appear to have escaped with little more than a wake up call.

 

[DocVikingo]

@DocVikingo: Thank you for your well-written post. The topic of dehydration comes up quite often in DCS discussions. Any idea how type 2 diabetes (+/- kidney damage) might affect the ability of the human body to "tolerate a very large quantity of water without adverse affect provided it is imbibed at anything approaching a sensible rate"? The reason I ask is that I really don't know if it should be recommended that the OP err on the side of over-drinking.

Hi Bubbletrubble,

Thanks for the kind words.

Frequent urination caused by elevated glucose levels in the blood can predispose the individual with diabetes to dehydration.

Based on ADA guidelines it appears that, unless a treating physician specifies differently, an otherwise healthy and controlled diabetic's daily water intake requirement generally is at least the same as that of a healthy non-diabetic person. Given the dehydrating effects of SCUBA touched upon in my post above, drinking more water than the minimum recommendations seems quite unlikely to put the diver at risk for pernicious over-hydration.

You mention "(+/- kidney damage)". Diabetes indeed can cause kidney damage, and kidney damage can lead to impairment in normal water excretion. This in turn can predispose to over-hydration. In the diver with demonstrated and significant kidney damage (and therefore not "otherwise healthy"), a combination of adjustments in the intake of water and in the amount of salt in the diet may be appropriate. Of course this should be done only under physician direction. BTW, I see nothing in the admittedly incomplete medical history provided by the OP to date that raises the suspicion of meaningful kidney damage.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such.

 

[Quero]

Originally Posted by Quero
You might consider getting checked for a PFO. Simply getting checked doesn't imply getting a PFO repaired, even if it is discovered that you have one.

I know that you are much more experienced at diving than I, as are several others here, but have you read the latest DAN article on that? Alert Diver Online Maybe I could appreciate the idea of exploring that more if it was a totally unexplained hit, but especially looking at that second dive...

Yes, DD, I've read that report. I suggest that you take the time to re-read it as well. The conclusions of the report are not nearly as black and white as you seem to believe. In essence, as I understand the report to say, there's no reason for Joe-diver to do a routine test for a PFO, but on the other hand, when a diver has been diagnosed as having suffered a DCS event all aspects of the dive as well as certain aspects of the diver's medical condition, including the possible presence of a PFO, should be investigated. It goes on to say that if a PFO is discovered, the decision of whether to surgically repair the defect should weigh the potential benefits of closure against the potential risks presented by the surgical procedure. In other words, just getting the test doesn't mean that should a PFO be found to be present it absolutely must be repaired.

The OP has demonstrated by posting the dive profiles generated by his dive computer that he was not in violation of the limits set by the algorithm of that particular computer. I'm not a medical professional and as such am not in a position to say one way or the other whether that the profile of the second dive was without doubt enough in and of itself to provoke the bend--perhaps it was, but it's also possible that there were other contributing factors, and it may be enlightening to find out whether PFO was or was not among those factors. This knowledge could help determine what mitigation strategies the OP might be advised to incorporate into the execution of his dives in the future.

I have myself been tested for PFO, on the recommended of a hyperbaric physician, and I can tell you that the procedure is relatively simple. I can't see any harm in the suggestion that the OP ask a hyperbaric physician about the possibility of getting tested. Keep in mind that it wouldn't be a routine test, but rather one aspect in the investigation of a documented case of DCS, if, in the judgment of the attending physician there is a chance that a PFO could have been a contributing factor.

 

[Duke Dive Medicine]

One concern I have: for reasons I cannot get into, I did not get any follow-up medical checkup. Would this be prudent at this stage?

Hi jbird,
I think a followup with a diving physician would be more than prudent. Our Canadian fellow at the clinic is in the process of locating a diving physician in the Toronto area. I'll try to grease the skids with him/her and I'll PM you with info as soon as I have it.
Cheers,
DDM

 

[Bubbletrubble]

You mention "(+/- kidney damage)". Diabetes indeed can cause kidney damage, and kidney damage can lead to impairment in normal water excretion. This in turn can predispose to over-hydration. In the diver with demonstrated and significant kidney damage (and therefore not "otherwise healthy"), a combination of adjustments in the intake of water and in the amount of salt in the diet may be appropriate. Of course this should be done only under physician direction. BTW, I see nothing in the admittedly incomplete medical history provided by the OP to date that raises the suspicion of meaningful kidney damage.

@DocVikingo: I didn't "connect the dots" in my previous post but the bold-faced text above explicitly states my reasoning. I paid attention to the "otherwise healthy" phrase in your post, but I'm not sure that everyone else might have. Although the OP didn't reveal any significant kidney problems in this thread, I just wanted to make the point that a diabetic (even with currently well-controlled blood glucose levels) might have other associated conditions which could predispose to water intoxication in the context of over-hydration. Moreover, a possible connection between diabetes and DCS is not well-studied. All things considered, it's probably best for the OP to be very conservative with his diving practices from now on.

I always appreciate your posts here on SB. Thanks for your participation.

 

[DandyDon]

Yes, DD, I've read that report. I suggest that you take the time to re-read it as well.

I thot I thanked that post? Now the button is MIA again. Ok, well - thanks.

 

[Duke Dive Medicine]

Although the OP didn't reveal any significant kidney problems in this thread, I just wanted to make the point that a diabetic (even with currently well-controlled blood glucose levels) might have other associated conditions which could predispose to water intoxication in the context of over-hydration.

Bubbletrubble and Doc,

Thanks to both of you for the discussion. Your posts are some of the most literate and easily readable on SB. You've probably already seen this but I'll post the UHMS recommendations for diabetics on insulin or oral antihyperglycemics here for the benefit of the other readers (note that much of this doesn't apply to the OP, whose diabetes is controlled with diet and exercise):

Rubicon Research Repository: Item 123456789/5538

I'd hope that a diabetic whose disease has progressed to the point where nephropathy and the associated fluid retention issues are present would have already been screened as unfit for diving.

 

[Dr Deco]

Hello jbird71 and Readers:

I am sorry to respond so late to this. I am behind – with many things! Christmas was very busy with my three children and three families together – plus I had the stomach flu [or something] and have not be all that well.

Nitrogen Gas Loads

As most responders noted, this was not exactly a horrible gas loading situation. All are trying to analyze this on the basis of tables and nitrogen loading. Readers of “Ask Dr Deco” for the past decade will note that I do not analyze dives and DCS on the basis of gas loading [unless they are obviously horrible]. Gas loading [and tables] will tell you what gas loads will NOT result in DCS, but they will not tell you what loads WILL result in DCS.

What does this mean [in a few sentences]? Obviously, a dive with a small nitrogen load [e.g., from a few breaths] is so small that nothing will happen that is bad. Tables are designed such that the loads [on the basis of data from hundreds of past dives] will result in reasonable bottom times and yet be safe for virtually every diver.

The “margin of safety” between safe and DCS in a table is VERY large in practice. Divers ask, “How much longer can I be down and still be safe?” This is really not possible to answer, since there are many variables in addition to bottom time/depth [leading to nitrogen loads] that lead to DCS. On the basis of nitrogen loading alone [bottom time/depth], you cannot predict that DCS will occur on a dive [unless the gas loads are very excessive, of course]. Having a wide safety margin is the table designer’s best friend!

Musculoskeletal Activity

When someone gets DCS with reasonable nitrogen loads, I look for some other event. My favorite [based on my NASA research] is musculoskeletal stress and strain that results in tissue nuclei formation/ growth. In this category I place activities such as moving bulky dive gear, climbing boat ladders with full gear, surface swims, etc. It is easy to demonstrate in the laboratory that physical activity [during the decompression phase of the dive] will produce bubbles that are Doppler-detectable in the active limb.

P F O

Physical activity can also provoke the passage of bubbles from the venous return though a patent PFO. [In the general population, it is blood clots that arterialize.] These are short episodes of breath hold and release are termed in medicine “Valsalva-like events.” People have reported strokes following activities such as moving furniture, pulling on bushes, lifting boxes, and the like. We all know of this sequence where we hold our breath, pull something, and then release the air. This is what is done in a test for a PFO where Valsalva’s maneuver is employed. During the decompression phase of the dive, this sequence can lead to trouble. People do not think of this as Valsalva's maneuver - but it is. I have written about this over the past ten years in “Ask Dr Deco.”

What Else?

Hydration is not a big factor in most cases for the general diving public.

Temperature can be a factor if one “dives warm and decompresses cold.” This latter situation gave the US Navy a bad spate of the bends a few years ago in Long Island Sound. That does not appear to be the case here.

Dr Deco