Decompression Illness and Denial- Part 1

By Jill Heinerth

The cream of the crop of the diving industry are respected for their work in exploration, science, education, and engineering. They have been bent, A and so have I.
A improved understanding of the psychological issues surrounding decompression illness will help us embrace timely therapy, and allow us all to become safer divers. Photo: Jill Heinerth

Each year, members of Divers Alert Network( DAN) receive a link to review the Annual Diving Report that chronicles diving incidents and accidents that occurred in the U.S. or Canada, or that involved U.S. or Canadian residents anywhere in the world. These incidents are not necessarily presented to DAN directly. Internet news stories, forums, or accounts from affiliated organisations, such as coroners, fish and wildlife officers, medical examiners, law enforcement agencies, or members of the public, offer additional reports. Scrubbed clean from personal details, the lengthy DAN document, carefully compiled by researchers, has a goal ato raise awareness of the risks and hazards associated with diving and to promote safer diving practices.a Vital insight into root causes and outcome of accidents is offered when possible. DAN hopes to raise the consciousness of divers, dive pros, businesses, chamber operators, and medical professionals seeking to mitigate risks and avoid traumata. The report runs far beyond incidents involving DCI. It also covers drowning, boat strikes, or anything else that happens on a bad day of scuba diving. There is no doubt that this report has tremendous value, and yet, most technical divers know that there are many incidents and accidents that donat make the list. DAN can only report on incidents they know about. However, there is a much darker side to decompression illness( DCI) filled with denial and failure to seek treatment.

In this article, I offer anecdotal proof compiled over a one-year period from people who chose to report their accident to me, even if some respondents decided to skip treatment. A few offered their narratives openly without conditions, but the majority of members requested anonymity. For this reason, I have chosen to shield the identities of all the contributors to this story. Examining their first-person accounts, I hope I can provide a deeper understanding of the physical and psychological issues around DCI and some of the growing challenges that we face for getting timely treatment. Finally, I will communicate some essential tips-off to improve safety , not the least of which is to be sure that your DAN insurance is up to date!

Jill diving the wrecks of Bell Island, Newfoundland.Cold water, deep dives, and task orientated objectives can sometimes lead to DCI symptoms

On the Diversa Alert Network website, researchers share an exampleaa tragic tale of the unfortunate diver with 96 dives under her belt. aA female diver surfaced from an 80 fsw dive and experienced back ache and nausea. She was administered oxygen but soon experienced weakness and a apins and needlesa feeling in both legs. She received hyperbaric oxygen( HBO) therapy virtually two days later when she returned home. After three conferences in the chamber, she still has lingering symptoms in her legs[ persisting a year later ]. a They conclude it was a decompression injury of the spinal cord. But what happened? Did she ascend too fast? Skip a safety stop? And why did she wait 48 hours before recompression? Was she in denial or too far from help? We often donat have the answers to those questions. At least we know the mechanics of what happened to this diver.

According to Dr. E.D. Thalmann, DAN Assistant Medical Director, aDecompression illness, or DCI, is a term used to describe an illness that results from a reduction in the ambient pressure surrounding a body, a like when youare surfacing after a dive. aDCI encompass two illness, decompression sickness( DCS) and arterial gas embolism( AGE ). DCS is thought to result from bubbles growing in tissue and causing local damage, while AGE results from bubbles entering the lung circulation, traveling through the arteries and causing tissue injury at a distance by blocking blood flow at the small vessel level.a There is no judgment attached to either definition. Our bodies store inert gases during our dive, and they must be released slowly from our tissues on the ascending. Our ascent plan depends on thoughtfully crafted mathematical algorithms programmed into dive computers that inform us about when it is okay to come up. But the computer can be cold and indifferent. It doesnat know about our physical health, how our dive went, or whether we had three too many beers at the tiki bar last night. The computer doesnat adjust to a bad profile or dehydration. All the computer algorithm knows is the basic math and perhaps a level of conservatism that the diver has selected before the dive. And as you will learn from this article, sometimes DCI is not as obvious as the tingling, back pain, and nausea that diver above experienced. The symptoms can be as insidious and unclear as the foggy, frightened brain of the victim.

1998, Jill finishing her deco obligations from a 21 hour dive. A chamber was used for the last ten hours of deco at Wakulla Springs, part of the Wakulla2 U.S. Deep Caving Team Project. Photo: Richard Nordstrom

HowA doesA itA feel ?

In my case, after several thousands of incident-free dives, I never imagined that I would get bent. The day I did, I had a great dive, so it was like getting hit by a brick wall when I realized that something was wrong. It started with what I call athe impending feeling of dooma. Deep in my soul, I knew that something terrible was happening. The first physical notification came with a creeping sensation in my thighs. At first, it was a tiny niggling, then erupting into the feeling that a colony of ants must be chewing away at my thigh muscles, with each bite erode the likelihood that I could ever dive again. A tidal wave of doubt washed over me. Embarrassment, ego, and athis canat happen to me, a raced through my head.

I was aware that every detail of my dive and life would be played out on Internet forums, with armchair divers hammering away at their keyboards trying to justify why it is possible to never happen to them. aYouare an idiot, out of your league, over your head, beyond your training and experience, use dangerous techniques, a they are likely say. One moment I was an edgy explorer, pushing the limits of technology, the next minute, I was an irresponsible buffoon. So much of the foundation I constructed my career and self-image upon was abruptly washing away, and all I could think about as the physiologic proof emerged is awhatas next? a

The symptoms of DCS can sneak up slowly. It may start its sinister course with an odd jab, tickle, or twinge, and then the signs can march on relentlessly, growing in severity as the minutes progress. Every five minutes, I questioned myself, aIs this worse than it was five minutes ago? a For some people, the twinges go from tingling to numbness, then to ache, and paralysis. One diver reported, aA friend of mine feel a weirdness in his arms, and within minutes, paralysis. We attempted to keep him hydrated on a fast boat rescue, to get him to shore. The whole time heas in convulsions, vomiting, dehydrated, losing consciousness, and brought back from the edge several times.a Iave had friends knocked out of diving for good, slaves to their new physical limitations. Divers can die, gasping for breath, drowning on the surface, or they may lose control of their legs or scream from something that feels like an ice pick stabbing through a joint. Strong people can be reduced to writhing on the ground in pain.

Donat get me wrong; some DCS hits are not all that dramatic. Redness, rash, and itching can all be passed off as inconsequential by a victim. Instances may resolve on their own or be treated successfully during the first chamber ride. Although many people enjoy a full recovery, the moment it happened to me, it was all I could do to fight off the dreaded of all the worst-case narratives Iad heard over the years.A

If, like me, youave been a technological diver for a long time, you have seen numerous emergency situations, in and out of the water. You may have recovered a body, buried friends, or taken somebody to the chamber for recompression. Youave had days where otherwise easy, fun dives have abruptly turned very serious. But the moment when you realize that you are the diver who is bent, you realize you are now in a lottery with little chance of winning. If the symptoms have appeared in the water, you want the nightmare to end, and yet the longer you can stay down, the better chances for a good outcome. When I was bent, it was as if a devil was on my shoulder, saying, aJust surface, it will all be over.a Luckily, I still had a measure of experience and sanity that maintain me down under the water. I believe that DCS bolt up your ability to make a smart, sane decision. To me, that builds sense. We know there is chemical havoc taking place in every part of your body when you are bent. It merely attains sense that it impairs your ability to think straight.

NotA blackA andA white

In reviewing reports, many of the 100+ topics that reached out to me admitted they had been bent more than once. Most reported a range of figures such as, aI have been bent between three and six times.a Numerous topics reported numbers such as a1 6+ a. What I procured shocking was that many of the people who had been bent several times had never sought treatment, even those that carried current DAN insurance. One male diver reported, aAbout 1 in every 25 or 30 decompression dives I was getting bent. I didnat talk much about it except among close friends. I had suffered over a dozen incidents, largely minor, but one incident at[ redacted] cave left me with visual disturbance and severe swelling. I always did my involved decompression on a very conservative setting; sometimes I did more than the computer required. I was still having issuesa | Diving is my livelihood. I was afraid to be told I should quit.a

A female diver was also pointed out that physicians are not always equipped to diagnose and treat DCS if they donat have the background. She experienced vertigo that lasted for one year. aI suspected that I was bent. My husband, a physician and a diver, agreed and brought me to see one of his med school professors( an ENT and a diver) at the University of Miami. The doc didnat believe I was bent( no joint ache) and send me home with Meclazine, and no chamber ride. Vertigo continued for nearly a year. Why didnat I call DAN? I was uninformed and naive. At this time, DAN was taking phone calls but not insuring. But I was an early member and should have called them.a

Should the need develop, Divers Alert Network can help you find a suitable hyperbaric chamber. Not all chambers are set up to treat divers, and they can require extensive prep period. Photo: Maxwel Hohn

Today, DAN receives countless non-emergency medical bellows from divers inquiring about issues ranging from ear problems to swimmeras itch. The emergency hotline connections on-call doctors with divers who have experienced the challenge of a more critical nature. In an emergency, it is essential to get EMS support and screening first, but summarily connecting with DAN can ensure that the attending physician has access to knowledgeable dive medical professionals for consultation. Few general physicians have had more than cursory training in hyperbaric medication. When a DAN member asks for help, the on-call DAN physician will not only speak with the victim or dive buddy, they will also communicate with the emergency room physician to influence the next logical therapy steps.

It can be difficult to confidently diagnose DCI until the main victims receives treatment that provides relief. When immediate relief passes under pressure, then DCI can be easily diagnosed. But the myriad symptoms, from a rash to paralysis and discomfort to joint pain, offers such a variety that they can be ignored or misdiagnosed. If you ever got home after a day of diving and were profoundly depleted, that in itself could be a minor hit. If you ever felt a warm, aching bicep or shoulder after hauling tanks into your vehicle, it could be a pulled muscle or a DCS hit. The mechanism of the illness outcomes in a diversity of signs and symptoms.

Roughly 36% of the respondents to my questionnaire indicated that they discovered they had a medical condition called aPatent Foramen Ovalea( PFO ), after getting bent one or more periods. According to the U.S. National Library of Medicine, a PFO is aa hole between the left and right atria( upper chambers) of the heart.a This hole exists in everyone before birth, but most often closes shortly after being born. A foramen ovale allows blood to bypass the lungs. For divers, this means that the blood( laden with microbubbles) can bypass the very place where off-gassing results, creating a gateway for bubbles to get into the arterial blood system. A male survey respondent indicated that he had likely been bent between twelve and thirty days( treated twice ), suffering from recurred patchy skin rashes, bruising, and itching after his dives. aAfter having the PFO closure[ surgery] three years ago, I havenat had any subcutaneous symptoms.
I am more confident in my diving and what to expect post-dive. An added plus is I have been migraine free for three years, after dealing with debilitating migraines 1-2x per week for 30+ years.a

It is still not advised by physicians to get routine testing for a PFO. A diver can have a PFO yet never get bent. They are also welcome to have a PFO that escapes detecting when tested. For this reason, and the potential risk from the test itself, few doctors subsistence routine testing. The repair of a PFO is relatively straight-forward and done using a coronary catheter. An umbrella-like plug fills the shunt and soon grows over with tissue. Regular diving can often resume soon after.

Talk with openly with your dive buddies to see if they have experienced any DCS symptoms, youall be surprised to learn. Photo: Jill Heinerth

WhyA doA peopleA denyA DCI ?

Retired Navy diver, Commander Joe Dituri gets frustrated when he learns about people who do not get treatment. He was so disturbed by the declining availability of treatment chambers for divers, that he decided to open a hyperbaric facility in Tampa, Florida. Dituri wants the community to consider that, aWe do not know what causes decompression sickness, so please stop badgering people who get it. Please stop keeping secrets in the back room because if you donat tell anybody youare bent, you could hurt yourself later on, and it could lead to more decompression sickness. This is a hobby. Youare supposed to have fun at this. You shouldnat be getting hurt while doing it. If you do get hurt while doing it, tell somebody, and they can help you.a

The lack of timely or affordable treatment options can leave a diver in pain. One person shared, aI called DAN, but they told me to go to the E.R ., and I did not want to go through all the aB.S.a before going to the chamber, so I just waited it out.a This respondent considered their hit to be amajora with asevere shoulder and elbow pain to the point I could barely move for around 24 hours and ran fully away after about a few weeks or two.a

Psycho/ socialA pressures

Some respondents failed to report their symptoms or try treatment due to expense and embarrassment. One person said, aI was worried about what might happen if I told the boat captain how I was feeling. I was imagining him calling the Coast Guard. And/ or being forced to get in an ambulance as soon as we returned to dock. And/ or not being allowed to dive the rest of the week( my hit was on the second day of a week-long trip ). And/ or impacting my buddiesa trip-up, dread of the unknown results of reporting the reach at the time.a Another diver seemed more concerned about what his spouse might say, aI felt some pressure that I would be blamed, or that my spouse would want me to quit technological diving.a

Numerous someones reported very negative feedback after sharing an experience online and in social circles, but a few received positive feedback. One said, aI actually got lots of constructive, helpful feedback and suggestions. People seemed to be genuinely interested and appreciative of the fact that I set it out there for everyone to see. I think thatas more a function of the community of divers I interact with, however. I can easily insure less positive reactions occurring in other forums. I think thereas a propensity to immediately assume that someone got bent because they screwed up, and expectation of criticism is what keeps people from being more open about what happened when they got bent.a

An instructor reported a different reaction, aIt is clear( to me) that telling people I get bent outcomes in some people considering me as a alessera diver in some way. Precisely what alessera entails can differ. One person might suppose Iam foolishly aggressive. Another might suppose I am poorly skilled. Another might discount my thinks on deco hypothesi or my credibility as an instructor.a Another experienced diver felt maligned when he reported his hit to the owner of a dive shop. aHe and I are friends and on excellent terms. But, every time we get into any discussion regarding dive planning or related subjects, he brings up the facts of the case that I have been bent 5 times as evidence that I am too aggressive and too inexperienced.a The tech diver continued, aIn all my cases, and in my buddyas suit, I have reviewed the downloaded dive profile afterward. I have never discovered anything to point at as an aexplanationa for the DCS hit. No rapid ascendings. No omitted deco stops. All my makes have been after NDL divesanever a hit after an actual deco dive.a

In the past, incidents were labeled by both medical professionals and divers as adeserveda or aundeserveda hits. The intent of those labels was meant to indicate whether practitioners knew the root cause of an accident or not. Unfortunately, such incendiary speech has promoted a sense that merely poorly skilled divers get bent. One respondent reported, aI have never heard of a fatal accident involving DCI that did not result from either diver error or an equipment malfunction.a Over half of the people answering the questionnaire indicated that they amade a mistakea or felt they should be ablameda for their accident. However, those same respondents could not have reasonably predicted that a minor oversight or lifestyle issue would have resulted in DCS on a dedicated day or dive. Divers be adapted to my questionnaire were very hard on themselves, accepting blame for lack of sleep, dehydration, or aggressive gradient factors, even when it was tough to determine whether that was indeed the underlying cause of the accident. Retired physician, decompression researcher, and tech diving instructor David Sawatsky adds, aA large percentage of divers who develop DCS after a dive have not done anything awronga, based on our current knowledge. Therefore, sometimes DCS means you made a mistake, but more often than not, there was nothing you could have done to prevent it( other than to not dive ). a

A second dangerous type of denial can be generated by an uneducated boat crew. I once dived on a boat that made it clear during briefings that if they had to deploy oxygen for a diver, there would be a hefty bill for the user. They shamed divers about reporting issues or asking for help. Some crew have even talked their clients out of their symptoms. Whether they fear litigation, disruption of activities, or demands for rebates from missed dives by other passengers, it is unclear. In her article, StraighteningA OutA TheA Bending , Jennifer C. Hunt discusses the mixed messages that are presented in some dive briefings. aIn pre-dive proclamations, divemasters commonly express concern about safety and make clear that injured divers should report problems to the crew. In the same briefings, divers are warned that if they get DCI, it will ruin everyone elseas trip, because the boat will have to go ashore.a One diver explained, aIf this had happened to me in the middle of the journey, I would not have considered telling anyone for a second. They would have had to turn the boat around and go back. You know that people only put down a thousand dollars for this trip, and if they have to turn around and go back because of you, you arenat going to be a real popular person.a She further offered that, aAfter the last dive of the trip-up, this same diver experienced symptoms of DCI. She continued to conceal her fear that she had DCI when they arrived on shore, despite some mild symptoms of paralysis.a

Embarrassment and ridicule can often stop a diver from trying the medical response they require. Photo: Maxwel Hohn

WhenA diversA doA report

When a diver does ask for help, it can create a cascade of different responses. Oxygen first aid is the most important immediate intervention that may help resolve minor hittings. The best overall outcome results from rapid treatment including recompression. That is not always available. On a tech diving boat in a remote place, it may be advisable to treat a minor hit with In-Water Recompression( IWR ), an accepted solution for adequately trained and equipped groups that are far from help. Retired Navy Commander Joe Dituri says, aThe International Association of Nitrox and Technical Divers( IANTD) has spearheaded a course in IWR and is now teaching it. I believe this to be the cornerstone of every technical diver who does expedition form work anywhere further away from a chamber than one hour. IWR is not about obviating the need for a chamber. It is about the immediacy of care to prevent you from a lifelong injury. And then you go to the chamber afterward. This is not a one-step cure like aspirin for a headache. In-water recompression is a prevention methodology for reducing the likelihood of having serious decompression sickness symptoms for the rest of your life.a Dr. David Sawatsky adds a few more caveats, aI supported In-Water Treatment when IANTD decided to teach it. For tech divers who are doing extreme dives in remote warm locatings, I think it is a great idea to have the option available. For most tech divers and all recreational divers, I do not think it is a good notion. Anyone can learn the technique, but one of the biggest problems is not having person like me around to know when and how to use it! a He recognizes that pure oxygen, thermal convenience, ideally a full face mask, and trained buddies are required to pull off successful and safe IWR.

Once you interact with the Emergency Medical System, several different things can happen. Regardless of your condition or certainty of being bent, you will be transported to an emergency room for evaluation. As the triage occurs, a DAN doctor may be looking for available chambers or deciding that you can forego recompression all together. In the U.S ., it is getting increasingly difficult to find the appeals chamber that is readily available for divers. Operating hours, staffing, scheduled hyperbaric treatments, and upkeep might prevent you from gaining access to the nearest chamber. Even in extreme cases of life-threatening emergencies, a chamber may be full, or there may not be staff to offer after-hours care. A standard treatment includes prep, pressurization, and cleanup that spans an entire crew switching. Not all hyperbaric facilities offer therapy for divers in any case. An expert at DAN will not only find an available chamber but can also arrange a medical flight if it is warranted.

There is no dive computer or set of tables I know of that will guarantee safety. I have a pretty good idea that my personal selections on the day I got bent, tip-off me over the edge, resulting in DCS. For me, it was the second day of highly deep diving, with no subsistence and high physical workload. I have completed other dives, one over 22 hours long, and been fine. I have friends who have been bent on simple recreational dives for no apparent reason. In my opinion, DCS is a sports injury. It can be minor, as in a small rash, or major, as in paralysis. And like any other sport, there is a spectrum of traumata that can happen as a result of participation. We shouldnat beat each other up over getting bent. We should learn from each other to create a safer diving environment for all involved.

PartA 2: A Iam going to share some basics on dive physiology that will help you understand how your computer runs, by demystifying conservatism strategies such as gradient factors.

The post Decompression Illness and Denial- Part 1 appeared first on DIVER magazine.

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