A funny thing happened on the way to Tubbataha. On May 6, I landed in Manila, Philippines, to join a dozen diving friends for five days of land-based diving at Crystal Blue dive resort; then we were to move on to Puerto Princessa to spend a week on the liveaboard Solitude One, diving one of the more isolated and pristine reef systems left on the planet, Tubbataha.
I hit the ground running. Following a flight from Washington, DC, to Doha, Qatar, then a 9-hour red eye from Doha, Qatar, I was picked up at the airport and transported to Crystal Blue, and within three hours, I was fed and underwater for my first and second dive. It was my third trip to Crystal Blue, and our sharp-eyed guides quickly found all sorts of little critters to photograph.
After the second dive, I noticed my stomach was tender to the touch right above my navel, as if I had taken a punch or something. I assumed I had banged into something on the boat and didn’t give it a second thought. The next morning, following the two morning dives, the tender area expanded until most of my stomach was painful to the touch. Later, I developed a rash in the same area. Now, a few warning bells began to go off. Divers will know where this is headed.
Initially, I didn’t connect the dots, but finally, I realized that I might have skin bends. DCS is not to be trifled with, so I consulted with Mike Bartick, the owner of Crystal Blue, and he suspected the same thing. I was immediately sent to the office and put on oxygen, a standard first aid treatment for DCS, while the staff called and arranged for me to be seen at a hospital in Batangas by a doctor who was a dive injury specialist. There, I was subjected to a battery of medical and neurological tests and diagnosed with DCS.
The standard treatment is to be placed in a recompression chamber and pressurized to take your body to the equivalent of 60 feet underwater and then very gradually (in my case, over five hours) to be brought back to “sea level.” The idea is to compress the bubbles that have formed in your tissue and then ascend so gradually that the bubbles are released through the lungs rather than re-forming in the tissue.
I had already prepared myself for the possibility of a “chamber ride,” but I was not thrilled to be locked in a metal can for five hours. I figured I would take my phone and Kindle and read between naps. Uh uh. No electronics are allowed in the chamber. Oh well, I would just be bored, but I would get in some good napping.
Uh uh. I had to breathe 100% oxygen for four of the five hours inside, but their mask with a demand regulator was ancient equipment that required effort to inhale and exhale. I had to hold the mask on my face with my hands because it is possible for someone under treatment to experience oxygen toxicity and pass out. If the mask is strapped on one’s face, it’s possible no one would notice the patient going unconscious. So, the fail-safe approach is for the patient to hold the mask on; if one passes out, the mask falls off. Simple but effective.
The last surprise was that a hospital employee had to be in the chamber with me in case of an emergency. My male nurse, my companion on this adventure, did not speak English. I felt sure it would be no more fun for him than for me.
The 1960s-vintage chamber was accessed through a short tunnel with about a three-foot round opening. The nurse demonstrated how to enter the tunnel correctly. He went in legs first, crouched, and duck-walked through. He was about 5′ 2″ and in his early 20s. I was not. I had to use stairs to go in head first, crawl to the end, and gracelessly squirm into the chamber.
Inside were two narrow cots, pillows and blankets, headphones for noise reduction, and a small port for passing material into and out of the chamber. I was offered food in the chamber, which I declined, but there were bottles of water. An intercom system reverberated within the metal walls and was nearly useless unless the outside techs spoke very slowly. The nurse asked me to demonstrate my ear equalization technique (the jaw-wiggle technique), offered ear protection, and soon I could hear the loud hissing of air being added to the chamber. I had to equalize my ears efficiently and very often. (I wondered how patients who had difficulty clearing their ears could handle this.) Once we reached a 60-foot depth equivalent, the hissing stopped, and the waiting began.
The nurse helped me properly fit and hold the oxygen mask, and the first oxygen session began. I had no problem with claustrophobia from the tank itself, but holding on the mask required exertion both to inhale and exhale and caused some anxiety, which I had to work to suppress. The five-minute break at the end of the first 20-minute session could not come too soon. Another 20-minute session with a five-minute break followed, and then the sessions and breaks got longer. The final oxygen session was 90 minutes with no break. It was a very long 90 minutes.
Eventually, I became a little careless with the mask fit during exhales because of the push required. I allowed some gas to leak around the mask to make exhaling easier. But while I was on 100% oxygen, the nurse was breathing normal 21% O2 air, and the oxygen level sensors monitored by the technicians outside soon betrayed my cheating. I was told to hold the mask tighter; the air inside the chamber was purged and replaced with regular air. Headphones were required during the purging because of the noise, and the purging took place regularly, I think every hour.
As time passed, the chamber pressure was gradually reduced, moving me up through the virtual water column and allowing the nitrogen in my blood to escape harmlessly. About halfway through the treatment, the nurse operated the door latches on the material port, and soon, he took out a large bag of chips. I regretted turning down the offer of food earlier. During each break, I was encouraged to drink lots of water to help clear the nitrogen but given the hospital method of using the bathroom in the chamber, along with the lack of privacy, I wasn’t too keen on drinking a lot. I managed; we’ll leave it at that.
Toward the end of the treatment, as it approached midnight, I began nodding off and had to be jostled frequently to keep the mask in place. Finally, we hit surface pressure, and it was over. My exit from the chamber was even more awkward than my entry, as I had to crawl out backward. Whatever it takes.
Once I was out of the chamber, they repeated the tests to note my improvement. The rash on my stomach was gone. The pain to the touch remained for a few days but eventually resolved. The treatment was a success, and I stayed the night in the hospital. Although the hospital was pretty much what one would expect in a less-developed country, I must have had a VIP room; it was very large with a dining area and private bathroom. I slept well except for being awakened at 4 A.M. to have my vital signs taken. At 7:00 A.M., I was brought a king’s breakfast: an omelet, bacon, sausage, toast, and OJ. At 9:00 A.M., the doctor arrived with six medical students to examine me one final time. I passed the tests and was told I could be released from the hospital except for one minor thing: the bill.
The chamber ride and overnight stay racked up a $4800 bill. Though I had DAN insurance to cover it, in the past the hospital had to wait a long time for approval and payment, so they were unwilling to release me until I had DAN’s approval. Knowing that might take hours or days, I decided to pay the bill with my credit card and sort out the insurance later.
And then, the elephant in the room: Would I be allowed to resume diving? The answer was yes …. in 30 days. So, my diving trip had ended before it really began. I was discharged and returned to Crystal Blue to sort out what happens when I’m on a group dive trip and can no longer dive. After letting my friends know my situation, I tried to change my return flight to an earlier date, but that was a no-go without a huge fee. I had eight days to kill, and there wasn’t much to do in Manila, so I got out my map. With Tokyo only a 4-hour flight, I decided to visit Japan for a week and make the best of a bad situation.
I wondered what caused me to get DCS. I’m a careful diver, and on the four dives I did, I followed all the same rules I’d been following for 1800+ dives before these. I breathed nitrox, which lowers the risk of DCS. I did not come close to the decompression limits on any dive and followed the same profile as the rest of the group. I made my three-minute safety stops, and I felt like I was sufficiently hydrated. The dives were not cold or difficult.
It was an “undeserved hit” with no apparent cause. However, I am getting older (a risk factor for DCS); I dived after a long flight and a long drive, which is not dangerous in and of itself but tends to dehydrate. I did not keenly watch my ascent rates, as I have always just gone “slowly” to my mind and never had a problem. All of these may have contributed to the cause.
I plan to visit the Caribbean this fall for a test trip and dive where a chamber is nearby to be sure this was a fluke. Going forward, I will be hyper-vigilant about everything that can lead to DCS. I will dive more conservative dive tables and use higher concentration nitrox when possible. I will extend my safety stops to five minutes when possible. I hope this was just my body warning me that I must be ever more careful as I get older (I’m 68), especially when diving in remote locations.
And I must add that the experience was much less stressful knowing that I had a current DAN membership and would not have to foot the medical bill.
Mike Southard
The Shenandoah Valley, VA
Mike thanks for this informative posting. The big decision once this happens to someone with a confirmed PFO is whether to opt for closure. This involves weighting risks of the closure surgery (not only during the procedure but future too, such as increased chance for developing AFib) against the risks of a repeat “unjustified” DCI. That begs the question – if an unjustified DCI happened once, is it nearly certain to happen again unless dive profiles are scaled back appreciably?
A follow-up posting of your experience in Cozumel would be informative.
Hi Mike,
A friend just sent me the account of your DCS injury. My wife and I were with a group in Belize in June and unfortunately had an experience identical to yours.
On the last day of our week of diving after two uneventful dives, my 70 year old wife developed severe abdominal wall pain and intense pruritis (itching) of her abdominal wall. A faint splotchy rash was present over the same area that became much more apparent over the next hour. We started O2 and contacted DAN. I was fortunate to speak to the Chief Medical Officer of DAN who confirmed our suspicions that it was cutaneous DCS and recommended immediate hyperbaric treatment.
Since we were on a remote island my wife was evacuated by helicopter to San Pedro and required three recompression treatments. Fortunately she recovered completely.
My wife’s DCS was also “undeserved” She has none of the known risk factors for DCS and is in excellent health. We have been diving for 44 years and she has never had a problem. Our dive profiles were very conservative and she even sat out a day of diving in the middle of the trip. We dive with Perdix computers, never came close to the no-deco limits, dove with .32 EANx and safety stops were always for 5 minutes.
My wife probably has an unrecognized PFO to explain her injury. I have a documented PFO that was diagnosed many years ago after I developed an “undeserved” case of inner ear DCS after a very routine dive. The fact that these events happened is rather sobering since as many as 10-15% of divers have a PFO that has not been diagnosed. So much for following the rules!
Eric Schroeder, MD
Melanie: At my return-to-diving examination at Duke University, the doctor suggested exactly the same thing. That is slightly complicated because I dive regularly with a group who all use nitrox, so using air dive tables would have me on a very different profile from my friends. I have decided to find a middle ground and dive 32% nitrox on 27% tables, along with extending my safety stops and being more careful about ascent rates. And, of course, not jumping in the water any more right after a 24 hour flight. I hope that will do the trick. I’m headed to Curacao in October (where they have a chamber) to test my theories.
Bob:
I don’t have my profiles in a text form, but they were about 70 feet for 60 minutes, with minimum 60 minute surface intervals. No medicine that would contribute to DCS. Never got within 5 minutes of a deco obligation, my computer will alert me if I get within 5 minutes of NDL. For the record, I have never gone into deco in 30 years of diving. I am VERY careful about that.
Dr. Doster: My very first move was to try to reach out to DAN, but for some reason both of the DAN phone numbers would not connect from my phone. I could dial almost any other US number, but DAN’s would not work, even from the resort phone. Everything progressed very quickly once I accepted the possibility that I might be bent. I was immediately put on O2 at the resort office, and by the time I had received the O2 treatment arrangements had already been made to transport me to the hospital. From realization to the chamber treatment was only about three hours. I did text my travel agent (in the middle of the night) who called DAN for me and had them call me. So, I finally talked to them while I was at the hospital, and by then all the decisions had already been made. I reported to DAN about the connection problem and they had no idea what was wrong. It all worked out in the end.
Dr Preissig: Thank you for your reply and for the helpful information. I will look up the DAN article. And, I was aware of the PFO connection to DCS and as soon as I got back to the states I contacted my cardiologist. I had open heart surgery three years ago for a valve repair and a subsequent heart ablation procedure. My Doc was able to review all of my records and imaging and said he was certain I did not have a PFO. I was actually a little disappointed to hear that because it would have been a relatively easy fix and at the same time solved the mystery.
Hello, this is Mike. I’m going to try to respond to each of you in order.
Clem: The second person, I assume, would not be allowed to sleep, but even so they did not offer me any option to have the mask secured. Regarding DAN, I strongly suspect that if I pushed back they would have let me go, but I was in a hurry and I didn’t mind collecting a nice pile of travel points on my card. FYI, DAN paid the claim quickly and without any hassle.
Thanks for the cautionary tale!
After getting the bends 3 times in 3 months with very reasonable profiles and ascent rates, a DAN physician suggested I dive with nitrox, but set my computer for 21% oxygen. This provides a margin to accommodate both my age, 67, and obvious tendency to get bends. The DAN doctor explained that using nitrox and setting my computer for 32% does little to prevent the bends if you are especially susceptible.
Excellent report, I always read these reports with great interest and concern
A few questions:
1.) What were the exact dive profiles, debth, times.
2.) What were the surface intervals?
3.) Is he taking any medications?
4.) Did he ever get into deco according to his computer on any portion of his dives?
4.) How close did he get to a deco obligation? Time to deco?
Very interesting article. Thanks. As an older diver, I find it very cautionary.
As a neurologist who has seen many cases of DCS (skin and neurological), I second Dr. Preissig’s recommendation to be checked for a patent foramen ovole (PFO). If found, it can be closed by a simple procedure and eliminate that risk factor.
I also recommend contacting DAN immediately when you have DCS. They can communicate with the chamber physician, approve your treatment in advance (vastly simplifies reimbursement), and even change your flights to get home.
I’ve been to the Philippines four times and each tim I arrived exhausted and jet lagged. I always gave myself several days to recover before diving.
As an active Instructor Trainer with 6070 logged dives and being 76 years old I take the possibility of a DCS hit seriously. At around age 60 I started doing 5 min safety stops and diving nitrox when possible. Don’t dive without a good air integrated dive computer, be well hydrated and after very long air flights, take a day to rest at your destination and adjust to the jet lag before that first day of diving. Even with all of that, micro bubbles may still form, we can only do so much but doing it may keep us out of a chamber.
Skin bends is not well recognized, even today. When I saw my first case in the Galapagos 30 years ago, I had never heard of it. I’ve seen several since, and the response is usually “What’s that?” Followed sometimes by “I don’t believe it/I don’t care/some other denial to keep from “ruining” their trip”
I’ll add a few points:
1. Dan had an excellent article on skin bends a few years ago, and you can retrieve it.
2. Anyone who experiences skin bends or any bends should be checked for a patent Foramen Ovale–a hole between the two atrial chambers in your heart.
3. Certain parts of your body are more susceptible to bends. One is your skin, where blood flow can be reduced/slowed due to excess fat, compression by a too tight wet suit, cold/cool water which virtually every dive has. A second more important area is your spinal cord, where the VENOUS blood flow is so slow that bubbles can form and grow even on normal ascents, causing a “cord hit” with paralysis, etc. There’s an old movie showing a dog’s spinal cord and veins with massive bubble formation–AFTER A CHAMBER DIVE AND ASCENT ACCORDING TO THE ORIGINAL NAVY TABLES. Believe me, no one seeing this will ever speed their ascent.
Randy Preissig, MD
Very good read. Thanks for passing on the event.
A couple of questions; if a 2nd person was in the chamber, could they sleep? If not, would a strap on the mask been a possibility?
Regards to DAN, I’ve never had to use the insurance and pray that it stays that way, but, the delay in payment to the facility is a concern. Not everyone would be able to throw down a card for the fee. That is not the point in time where an issue as such should come up.