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Bends - Skin Bends

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - My question concerns the skin symptoms of decompression sickness. On a liveaboard in Papua New Guinea recently one of the group got severe itching after a deepish dive (42m for about 35 minutes). There were no problems on the dive at all. The itching was mainly over the chest, head and hands, but we couldn't find a rash or any other symptoms. The diver had a full-length wetsuit on, so we couldn't understand when the dive guide said it was all due to plankton and tiny organisms in the water, and that she didn't need oxygen. To be fair the symptoms did resolve themselves after a few hours, but was the advice correct?

A - Controversial. One school of thought is that this itching is due to the release of small bubbles from gas dissolved in the skin, and it is sometimes seen in chamber dives. Generally it is intermittent, felt typically around the ears, wrists and hands, entirely benign, and resolves spontaneously. However, an associated rash or altered sensations such as burning or stinging can denote a heftier hit of bubbles, so the minimum treatment here would be 100% surface oxygen, with a view to recompression if complete resolution did not occur quickly. The classic purple mottling of cutis marmorata (“marbled skin”) is more significant as it denotes involvement of the blood vessels in the dermis, and is often found together with other affected organ systems. As well as receiving 100% surface oxygen immediately, these cases should have recompression treatment as soon as possible, and if it’s recurrent or unprovoked, a search for patent foramen ovale (PFO) is recommended as they’re frequently associated. There’s one other unusual skin manifestation of DCS, that of lymphatic obstruction, which results in a swollen area of pitted skin, looking much like orange peel (hence its French pseudonym, “peau d’orange”). Again this signifies more serious disease and should prompt immediate transfer to a chamber.

Q - About an hour after the second dive of the day I started to itch (below breasts and tummy), which I first thought was an allergic reaction (sun....) but I could not see any rash and the following day I was ok so I went diving again, which again resulted in itchy body parts but also muscle/tissue ache as if I'd overdone a work-out, again beneath breasts, on tummy and along the sides/armpits. On both days I\'d been within decompression limits according to my Computer (Suunto) and not been below 30m, and had done my safety stop as usual and not violated any ascend rates. After a day without diving I resumed diving staying within 20m depth and did not experience any problems for the remaining holiday until the last diving day when I had again the itch and aching muscles, but this time I experienced also sporadic muscle fatigue in arms/legs/neck which always only lasted 1/2 - 1 minute. After 3 days of non-diving and the flight back home, I still have some itch/slight ache, but so far no noticeable joint-aches. What would you recommend to do and which medical should I book to see whether I'll be fit for diving in the future.

A - Hmmm. Which medical should you have to dive in the future when you still have symptoms of the bends?! I think we should discuss this after you have treatment in a chamber. Seriously, from what you say, this does sound like skin DCS after your dives, this is allied to a condition called a patent foramen ovale. And the speed you get this after dives, and the way you are getting joint and muscle aches points towards this PFO condition. So the key here is to see a dive doctor who works alongside a recompression chamber asap. After that there will be a lay off from diving, but you can use this time to have the PFO check. If this turns out to be positive you have 2 options. Closure of the hole before diving again. Or never diving again, unless you go for the ultra-cautious approach. By this I mean nitrox only, computer set to air tables, 18 metres max, 1 dive a day. I suggest the former.

[This diver was seen at our facility, treated, improved dramatically and we now await the results of the PFO test]

Q - Recently I returned from a live aboard trip to Red Sea. After my second dive, I experienced quite bad bruising and blotchiness to the stomach area, and pain and redness on the fatty areas of my thighs, it was also very painful, after a few hours this went down, I did another dive, and the same thing happened, this time I also experienced some glassiness in my eyes. I was diving well within my dive limits, had no fast ascents etc, did all my recommended stops and more, was diving to a depth of approx 28 metres. I was OK diving the next day, although I did switch to diving on nitrox, later on in the week the same thing happened. I have had these symptoms before on previous live aboard trips, but it has never happened so quickly. I have always put it down to general tiredness as I never sleep well on these trips, and not drinking enough water. Each time it has happened my dive
profile has been fine. I was diving a couple of weekends before I went on holiday in the UK all weekend and never had a problem. In all my diving career I have never experienced a fast ascent or missed any deco stops, I always ascend very slowly. I consider myself to be fit and very active. I appreciate any advice.

A - The thinking hat doesn't have to be on that long to figure this one out. An obvious skin bend, normal profiles, and even getting it when diving on nitrox. And getting it often too. We have to consider that little 'ole hole in the heart called the PFO here. A patent foramen ovale, the remnant of us being a baby in our mother's womb, where blood circulates in a different fashion. A PFO in divers means that nitrogen returning towards the lungs in
the venous blood misses exhalation and ends up back in the arterial circulation. Skin bends with that classic mottled marbled look is a common consequence. So you need a transthoracic ultrasound to rule this out, and if it's a positive result, you should have it closed before diving.

N.B. We have put the picture of the rash on www.londondivingchamber.co.uk if you want to see a classic skin bend.

Q - My wife and myself went to Stoney Cove last weekend to do a dry suit course. My wife had a membrane suit, hood and 2m gloves, skiing underwear and thinsulate undersuit. The first dive, maximum 20m (average 10m) for 31 mins. Water Temp 13c. After this dive she realised that her drysuit leaked at both the neck and wrist seals. She was cold on surfacing. During the surface interval she was shivering and complained of being wet. She did not warm herself up or change her undergarments. She had also lost dexterity in her hands. The second dive, after 49 min surface interval was for 20 mins - max depth of 7m.

After this dive she showered, dried and got into warm clothes. She complained that her hands had some numbness but also hurt. She also said that she felt a little "strange", a bit "spaced out." During the dive home (2 hours) the pain did not ease off in her hands. The pain in her hands began to wear off after about 4 hours but she noticed that she had some red blotches/rash coming up on her cheeks and chin. These disappeared by the next morning.

I was concerned, at the time, about the pain in her fingers/knuckles, the "strange" feeling - could this be a sign of DCS? She said "No - Just the cold". When I saw the red rash this just made me more concerned - another DCS symptom? She said "No the hood must have rubbed etc."

A little knowledge can lead to a danger of panicking and over reacting. The Course Instructor gave it no thought. Should I have gone to Hospital? Would there even be a doctor who would know about DCS? Level1 DCS? Is it to late to seek treatment?

I'm sure that I'm not the only diver to have pondered these questions and faced this dilemma. I would appreciate your advice and guidance on this issue.

A - Well the answer to your question is something we say a lot to divers. I feel you must always seek advice about any feeling of unwellness after a dive, and the best people to seek this advice from are the Hyperbaric experts. You know where they are, for example at Haslar, DDRC or at our chamber in London, with 24 hour cover all you have to do is call us on +44(0) 20 7806 4028.

The problem with going to your local casualty is that there probably wont be a doctor with a good understanding of DCS and in my experience most people walk out with a diagnosis of middle ear infection and a handful of penicillin.

Your wife could easily have a Type 1 DCS as this is associated with a rash as you describe and the fatigue over and above what is expected from a weekend at Stoney. The biggest problem with DCS is denial, and in the UK I think this is crazy as the treatment is free, and there are plenty of well run chambers where you can get treatment. Being recompressed insures that the problem wont worsen to any permanent damage and also doesn't mean you can never dive again. Again it is never too late to seek advice, and I have treated divers some time after the problem has occurred and had very good results. So call your local unit first, get some good hyperbaric advice and don't just assume you will be fine and it'll pass.

(other dive medical questions)



   


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