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Dive Safety Diving Medicine Opinion

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, and so have I.
A better understanding of the psychological issues surrounding decompression illness will help us embrace timely treatment, 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 organizations, such as coroners, fish and wildlife officers, medical examiners, law enforcement agencies, or members of the public, provide additional reports. Scrubbed clean from personal details, the lengthy DAN document, carefully compiled by researchers, has a goal “to raise awareness of the risks and hazards associated with diving and to promote safer diving practices.” 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 prevent injuries. The report goes 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 don’t 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 evidence 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 stories openly without conditions, but the majority 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 convey some essential tips 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 goals can sometimes lead to DCI symptoms

On the Divers’ Alert Network website, researchers share an example—a tragic tale of the unfortunate diver with 96 dives under her belt. “A female diver surfaced from an 80 fsw dive and experienced back pain and nausea. She was administered oxygen but soon experienced weakness and a ‘pins and needles’ feeling in both legs. She received hyperbaric oxygen (HBO) treatment almost two days later when she returned home. After three sessions in the chamber, she still has lingering symptoms in her legs [persisting a year later].” 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 don’t 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, “Decompression illness, or DCI, is a term used to describe an illness that results from a reduction in the ambient pressure surrounding a body,” like when you’re surfacing after a dive. “DCI encompasses two diseases, 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 damage at a distance by blocking blood flow at the small vessel level.” 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 ascent. 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 doesn’t 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 doesn’t 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

How does it 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 “the impending feeling of doom”. Deep in my soul, I knew that something terrible was happening. The first physical notification came with a crawling 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 eroding the likelihood that I could ever dive again. A tidal wave of doubt washed over me. Embarrassment, ego, and “this can’t happen to me,” 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 could never happen to them. “You’re an idiot, out of your league, over your head, beyond your training and experience, using dangerous techniques,” they might say. One moment I was an edgy explorer, pushing the limits of technology, the next minute, I was an irresponsible fool. So much of the foundation I built my career and self-image upon was suddenly washing away, and all I could think about as the physiologic evidence emerged is “what’s next?”

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, “Is this worse than it was five minutes ago?” For some people, the twinges go from tingling to numbness, then to pain, and paralysis. One diver reported, “A friend of mine felt 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 he’s in convulsions, vomiting, dehydrated, losing consciousness, and brought back from the edge several times.” I’ve 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.

Don’t 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. Cases 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 dread of all the worst-case stories I’d heard over the years. 

If, like me, you’ve been a technical 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. You’ve had days where otherwise easy, fun dives have suddenly 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 arise 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, “Just surface, it will all be over.” Luckily, I still had a measure of experience and sanity that kept me down under the water. I believe that DCS screws up your ability to make a smart, sane decision. To me, that makes sense. We know there is chemical havoc taking place in every part of your body when you are bent. It only makes sense that it impairs your ability to think straight.

Not black and white

In reviewing reports, many of the 100+ subjects that reached out to me admitted they had been bent more than once. Most reported a range of figures such as, “I have been bent between three and six times.” Numerous subjects reported numbers such as “16+”. What I found 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, “About 1 in every 25 or 30 decompression dives I was getting bent. I didn’t talk much about it except among close friends. I had suffered over a dozen incidents, mostly minor, but one incident at [redacted] cave left me with visual disturbance and severe swelling. I always did my required decompression on a very conservative setting; sometimes I did more than the computer required. I was still having issues… Diving is my livelihood. I was afraid to be told I should quit.”

A female diver added that physicians are not always equipped to diagnose and treat DCS if they don’t have the background. She experienced vertigo that lasted for one year. “I 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 didn’t think I was bent (no joint pain) and sent me home with Meclazine, and no chamber ride. Vertigo continued for nearly a year. Why didn’t 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.”

Should the need arise, 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 time. Photo: Maxwel Hohn

Today, DAN receives countless non-emergency medical calls from divers inquiring about issues ranging from ear problems to swimmer’s itch. The emergency hotline links on-call doctors with divers who have experienced problems 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 medicine. 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 treatment steps.

It can be difficult to confidently diagnose DCI until the victim receives treatment that provides relief. When immediate relief occurs 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 exhausted, that in itself could be a minor hit. If you ever felt a warm, aching bicep or shoulder after hauling tanks into your car, it could be a pulled muscle or a DCS hit. The mechanism of the illness results 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 “Patent Foramen Ovale” (PFO), after getting bent one or more times. According to the U.S. National Library of Medicine, a PFO is “a hole between the left and right atria (upper chambers) of the heart.” 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 occurs, 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 times (treated twice), suffering from repeated patchy skin rashes, bruising, and itching after his dives. “After having the PFO closure [surgery] three years ago, I haven’t 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.”

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 may also have a PFO that escapes detection when tested. For this reason, and the potential risk from the test itself, few doctors support 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, you’ll be surprised. Photo: Jill Heinerth

Why do people deny 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, “We 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 don’t tell anybody you’re bent, you could hurt yourself later on, and it could lead to more decompression sickness. This is a hobby. You’re supposed to have fun at this. You shouldn’t be getting hurt while doing it. If you do get hurt while doing it, tell somebody, and they can help you.”

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

Psycho/social pressures

Some respondents failed to report their symptoms or seek treatment due to expense and embarrassment. One person said, “I 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 buddies’ trip, fear of the unknown results of reporting the hit at the time.” Another diver seemed more concerned about what his spouse might say, “I felt some pressure that I would be blamed, or that my wife would want me to quit technical diving.”

Numerous individuals reported very negative feedback after sharing an experience online and in social circles, but a few received positive feedback. One said, “I actually got lots of constructive, helpful feedback and suggestions. People seemed to be genuinely interested and appreciative of the fact that I put it out there for everyone to see. I think that’s more a function of the community of divers I interact with, however. I can easily see less positive reactions occurring in other forums. I think there’s a tendency 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.”

An instructor reported a different reaction, “It is clear (to me) that telling people I got bent results in some people regarding me as a ‘lesser’ diver in some way. Precisely what ‘lesser’ means can vary. One person might think I’m foolishly aggressive. Another might think I am poorly skilled. Another might discount my thoughts on deco theory or my credibility as an instructor.” Another experienced diver felt maligned when he reported his hit to the owner of a dive shop. “He 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 fact that I have been bent 5 times as evidence that I am too aggressive and too inexperienced.” The tech diver continued, “In all my cases, and in my buddy’s case, I have reviewed the downloaded dive profile afterward. I have never found anything to point at as an ‘explanation’ for the DCS hit. No rapid ascents. No omitted deco stops. All my hits have been after NDL dives—never a hit after an actual deco dive.”

In the past, incidents were labeled by both medical professionals and divers as “deserved” or “undeserved” hits. The intent of those labels was meant to indicate whether practitioners knew the root cause of an accident or not. Unfortunately, such incendiary language has promoted a sense that only poorly skilled divers get bent. One respondent reported, “I have never heard of a fatal accident involving DCI that did not result from either diver error or an equipment malfunction.” Over half of the people answering the questionnaire indicated that they “made a mistake” or felt they should be “blamed” 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 given day or dive. Divers responding 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, “A large percentage of divers who develop DCS after a dive have not done anything ‘wrong’, 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 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 refunds from missed dives by other passengers, it is unclear. In her article, Straightening Out The Bends, Jennifer C. Hunt discusses the mixed messages that are presented in some dive briefings. “In pre-dive announcements, 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 else’s trip, because the boat will have to go ashore.” One diver explained, “If this had happened to me in the middle of the trip, 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 just put down a thousand dollars for this trip, and if they have to turn around and go back because of you, you aren’t going to be a real popular person.” She further offered that, “After the last dive of the trip, 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.”

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

When divers do 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 hits. The best overall outcome results from rapid treatment including recompression. That is not always available. On a tech diving boat in a remote location, 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, “The 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 type 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.” Dr. David Sawatsky adds a few more caveats, “I supported In-Water Treatment when IANTD decided to teach it. For tech divers who are doing extreme dives in remote warm locations, 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 idea. Anyone can learn the technique, but one of the biggest problems is not having someone like me around to know when and how to use it!” He recognizes that pure oxygen, thermal comfort, 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 a chamber that is readily available for divers. Operating hours, staffing, scheduled hyperbaric treatments, and maintenance 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 shift. Not all hyperbaric facilities offer treatment 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 choices on the day I got bent, tipped me over the edge, resulting in DCS. For me, it was the second day of extremely deep diving, with no support 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 injuries that can happen as a result of participation. We shouldn’t beat each other up over getting bent. We should learn from each other to create a safer diving environment for all involved.

Part 2: I’m going to share some basics on dive physiology that will help you understand how your computer works, by demystifying conservatism strategies such as gradient factors.

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