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Thread: DCI: What could have triggered it?

  1. #41
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    Re: DCI: What could have triggered it?

    Quote Originally Posted by Jim  View Original Post
    You are hiding behind stats .... the vast majority of tech diver's I know are experienced guys and girls with a good deal of common sense, ignore your NNT, NNH - if you have suffered a bend or like most that go on to be diagnosed, multiple bends, for what appears to be no known reason on conservative dives, an educated person would look to get themselves tested or give up diving (as discussed an unfixed PFO still carries risks). That's it, as simple as I can make it - You don't need stats to tell you it's a wise move.

    I'm not talking widespread testing as I've already suggested which blows out most of your stats because you are working with a bunch of already bent divers - you can statersize (is there such a word - I'm sure you will correct me) & theorise all you like. I'm talking common sense from experienced, educated, knowledgable tech divers.

    Jim. You are basing your opinions on what has happened to you and applying it to all divers. Thing is, you're not a typical diver, and you're doing different diving to the majority of divers in the world, including probably / possibly the original post here.

    Also you need to be careful about extrapolating your experiences. Last year I was on a boat with someone who missed all of his stops after a trimix dive to 45 metres. He got away with no symptoms. It 'worked' for him on that occasion but I'm still going to do deco! That's why we need stats and not anecdotes.

    Just because your operation was successful and your PFO was picked up it doesn't mean that everyone else's is. I know of someone who had an allergic reaction the the implant (not nice) and it is not without risk.

    That said, because I am a similar sort of diver to you, if I had multiple bends then yes I would get tested and if I had a large PFO like yours then I would probably get it fixed. But you and I (and the rest of the board) aren't typical divers.

    If Missus Janos (a recreational diver) had a single bend then I'm not sure whether it's sensible for her to have the PFO test or not. TEE might be worth it but I'm don't know about a TOE. Fingers crossed we won't have to make that decision :)

    Janos

  2. #42
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    Re: DCI: What could have triggered it?

    This thread is just following the same path that so many previous ones on PFOs have done. Personal experience seems so much more convincing than science. Neither side convinces the other.

    To the other doctors here I would just like to point out that our job is to make difficult decisions on the basis of limited and often contradictory information. That is what we are trained to do and we learn to be comfortable with uncertainty. The patient however wants a clear recommendation and often feels unhappy if there appears to be any doubt. Our job is to bridge the gap between the uncertain medical literature and the patient's individual requirement. That is one major reason why these arguments occur in a forum like this.

    As far as vested interests are concerned, I can't believe that chamber operators want divers to get bent and would therefore dissuade a diver from being investigated for a PFO. Cardiologists, of course, have a different viewpoint.

    Lastly:

    TOE = transOesophageal echocardiography (British/Oz/NZ)
    TEE = transEsophageal echocardiography (same thing, only American, therefore probably more expensive; also doesn't trip off the tongue quite as well)
    TTE = transthoracic echocardiography (the one that doesn't involve having a black 1/2 inch thick probe shoved down your throat, just a load of jelly smeared on your chest)

    Andy

    (Trained in cardiology, hyperbaric medicine and TEE/TOE)

  3. #43
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    Re: DCI: What could have triggered it?

    Quote Originally Posted by Janos  View Original Post
    Jim. You are basing your opinions on what has happened to you and applying it to all divers. Thing is, you're not a typical diver, and you're doing different diving to the majority of divers in the world, including probably / possibly the original post here.

    Also you need to be careful about extrapolating your experiences. Last year I was on a boat with someone who missed all of his stops after a trimix dive to 45 metres. He got away with no symptoms. It 'worked' for him on that occasion but I'm still going to do deco! That's why we need stats and not anecdotes.

    Just because your operation was successful and your PFO was picked up it doesn't mean that everyone else's is. I know of someone who had an allergic reaction the the implant (not nice) and it is not without risk.

    That said, because I am a similar sort of diver to you, if I had multiple bends then yes I would get tested and if I had a large PFO like yours then I would probably get it fixed. But you and I (and the rest of the board) aren't typical divers.

    If Missus Janos (a recreational diver) had a single bend then I'm not sure whether it's sensible for her to have the PFO test or not. TEE might be worth it but I'm don't know about a TOE. Fingers crossed we won't have to make that decision :)

    Janos
    I trust Missus Janos doesn't require the experience either for both your sakes.

    Just got back from my run and chilled out nicely - FU&*ed !!

    I fully appreciate all divers are not the same, not too sure the deco story adds much to the argument (wasn't Duncan was it?), but I did mention 'Tech' divers several times and being a rebreather forum most reading and posting are effectively tekkies? You are correct the original post possibly wasn't a Tech diver (although given his possible bottom times he may be and just doesn't know it !!!!).

    APitkin sounds like a man in the know !! Even if you do hale from cloud cukoo land !! I take back my comment re Chamber Operators and apologise ...... uncalled for.

    Janos, I note you are a lot closer for that beer - will catch up at some point diving out of Brighton / Eastbourne ??

    All the best.
    Last edited by Jim; 1st January 2007 at 15:21. Reason: Spelling and post thought!

  4. #44
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    Re: DCI: What could have triggered it?

    Quote Originally Posted by Yann A.  View Original Post

    PFO seems vrey unlikely though, as the diver get complete medical check every 6 months for work.
    After a friend of mine got bent due to a PFO, I decided to get checked. A normal medical check would not cover this. The first test they did on my was an ultrasound done through my chest wall (while injecting a bubble solution), but that doesn't give a very good picture. I actually had to go back to get a transesophageal echocardiogram which showed that I didn't have a PFO.

    Most people with a PFO don't realize it, and it doesn't cause health problems except in the worst cases (with the exception of divers).

    Your friend's case seems very similar to my friend's, and if I bet, I'd say PFO was a contributing factor.

    Aloha,
    Charlie

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    Re: DCI: What could have triggered it?

    It is quite difficult to make a thorough analysis without the graph of the dive profile, not the description. Suffice to say, lets assume the dive was done properly: ascent rates, multi-level dives under NSL, air.

    Given the risk of NSL dive as ~ 1/10,000 dives, most folks should not get bent in their lifetimes of NSL diving. Therefore, this unexpected DCS, which reads as DCS 2 plus skin bends, is a trigger for a workup, as Genesis suggested. This is because the only reason for considering PFO evaluation and closure, as Jim describes, is prior history of DCI and a wish to continue to dive. DCS 2 plus skin bends is commonly associated with PFOs.

    However, PFO do grow with age, and a negative test can become positive as the walls weaken and the PFO widens.

    Repairs are not permanent either, and what little data available shows that non-open heart closures, like the Amplatz occluder, sometimes move out of position, leak, and form clots. One may be able to dive again after closure, if DCI is indeed PFO related, but the closure would have to be followed for the life of the diver to catch complications. So far, there have been rare needs for full open heart surgery to correct the occluder's mal-position, a situation that would not happen if alternative measures to reduce DCS risk were done in lieu of surgical closure.

    While it reads Jim's need for closure is likely needed, I do not agree with his reasoning, analysis of his data nor projecting it to all divers at large. I agree fully with Genesis and Teubner and those who subscribe to their logic.

    Most of the diving literature alludes but ignores that the body is fully of shunts other than PFOs, more commonly lung shunts. These shunts can be physical and permanent anomalies or physiological, meaning they allow large bubbles to pass with normal lung function under specific conditions. Shunts are present in nearly all organs and tissues ... and is increasingly more noticed because of transcranial doppler studies ... that reveal unexplained bubbles in the arterial circulation in the absence of bubbles in the pulmonary circulation.

    Given that body shunts are unfixable, the wiser alternative is to optimize bubble reduction strategies fully, before repairing a PFO. A PFO workup, if positive, will provide the diver with 3 options and any one, or combos of all are possible:

    bubble reduction strategies
    PFO closure
    stop diving

    Bubble reduction strategies included nitrox on air tables, 02 on safety stops, reduced bottom times, improve fitness, fat reduction etc.,









    Quote Originally Posted by Yann A.  View Original Post
    Dear All,

    This is a non-rebreather diving incident but as a member of this forum I thought I ask the question here on RBW as it has the highest concentration of knowledgeable people on the net. Here is what happened:
    No excessive drinking (only 2 beers during dinner the previous day) or drug usage before the dives or days prior to the dives, no previous condition, healthy diver 36 years old The dives went without ay incident, the profiles were smooth (no ups and downs) and well within the No-deco limits. 1st dive 26.5m for 46minutes, surface interval of 1h14, 2nd dive 26.7m for 55minutes, surface interval 1h35, 3rd dive 21m for 57minutes. Theses dive times all include a minimum 3minutes safety stop and at no time during the dive did the diver went into deco.
    15h00, 30 minutes after the last dive of the day, the diver started to feel very tired and weak. No oxygen was available so he’s been given some water and asked to rest. 15h45, the diver complained of feeling loss in the fingers and some “blue-black” marble patches started to be seen on his upper body (chest, back and shoulders) so we started the 4h drive to the chamber. During the trip the diver developed severe pain in the legs that increased as we were driving up to a maximum of 600 to 800m above sea level (no choice as it was the shortest road to the hyperbaric facility.
    By the time we reached the chamber at 19h (4h after the last dive) the pain had gone and the skin patches were no longer as blue-black but disappearing slowly. Although we did call the hyperbaric physician on call and she told us the chamber was ready, nothing had been done and we were up to a 2h wait going thru ER process of general examination and chest X rays, till she finally arrived at the hospital. At 22h, the doctor decided not to treat the diver who was said to have a body temperature too high (37 degrees C) and she decided to place him under observation for the night and run a USN table 6 treatment the next morning. No oxygen was given to the diver (except for 30min in the ER when we requested for it). The diver felt only a bit dizzy the next morning but was treated (one run under USN Table 6) and asked not to fly for the next 72h nor dive for 1 month. The diver is now fine.

    The purpose of this mail is to try to understand what may have gone wrong to justify this DCI only and not on the way the emergency has been handled we know what the loop holes were and will use a different dive operator the next time.

    Thanks for your help to understand what can have triggered this DCI.

    Yann.

  6. #46
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    Re: DCI: What could have triggered it?

    I’d like to thank every members who participated to this thread constructively. I knew that with so little info it would be difficult to get a straight answer but some of the posts have been informative.
    The diver just had a proper check with a diving physician who is also a cardiologist in Paris. No PFO or any other heart problems, only overweight, fatigue from frequent traveling and bad luck. The doc suggested to dive nitrox with longer surface intervals and loose weight.

    Thank you All.

    Yann.

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    Re: DCI: What could have triggered it?

    I've OC dived in a number of warm water locations including Manado in Indonesia.

    In humid hot locations dehydration is easy so I'd suggest that maybe your friend didn't quite drink enough water?

    Also, I'd agree with several others who have said that the SI's were too short regardless of what PADI or other dive tables say.

    On this programme of dives, two hours would be my minimum SI.

    Charlie

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    Re: DCI: What could have triggered it?

    Quote Originally Posted by Yann A.  View Original Post
    I’d like to thank every members who participated to this thread constructively. I knew that with so little info it would be difficult to get a straight answer but some of the posts have been informative.
    The diver just had a proper check with a diving physician who is also a cardiologist in Paris. No PFO or any other heart problems, only overweight, fatigue from frequent traveling and bad luck. The doc suggested to dive nitrox with longer surface intervals and loose weight.

    Thank you All.

    Yann.
    your welcome

    http://www.rebreatherworld.com/showthread.php?t=9040

    http://www.rebreatherworld.com/showthread.php?t=9040

  9. #49
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    Re: DCI: What could have triggered it?

    Interesting....

    The risk of DCI is very low, a PFO will essentially double your risk, but again it is still very low. The best way to detect a PFO is with contrast echocardiography while the patient valsalva's. If I had a truly "undeserved" hit, I would get the echo to know my true risk.

    Agree with everyone elses comments about the dive profile and that the tables are based on statistics and all decompression theory is based on tissue models.

    I am sure that I have made those types of dives many times. There are several things that can change your risk, as I am sure you all know. The fever is interesting, febrile people are usually dehydrated, at least to some degree.

    Put it all together you have a moderately aggressive series of dives, a couple beers the night before, possible illness (fever), and possible dehydration. And a 1 in 3 chance of a PFO which would double your risk. Also, what was the water temperature and what was the workload during the dive?

    You are unlikely to really know why they took the hit with this information. But for the future, you need to do everything to decrease that risk. In my humble opinion, air is perferct at sea level, but in the water between 0 and 100' Nitrox and deeper Helium mixes. Stay hydrated, when you hit the water, the body releases BNP and that causes the diuresis which we all experiance once at depth. Hence a little dramatic, but "hydrate or die".

    I am a beer drinker myself, 2 beers may worsen the dehydration, so I again stress the stay hydrated point (with water)

    Realize this is late, but maybe someone will find it helpful... CJG

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