Chokes, skin marbling and unconsciousness occur after repetitive diving and a hot shower (2012, Honduras)
Reported Story
After the third dive on the third day of our trip last year, I was alarmed when I noticed my dive computer’s nitrogen-level indicator was near the red but still in the yellow zone. I saw the same on my buddies’ dive computers, so I was not too concerned. I did three dives that day, all on air. The second dive was to 100 fsw (30.6 msw) and the third to 75 fsw (23 msw) for 20 minutes, with the proper surface interval in between.
After returning to my room, I showered while washing my suit with warm water. While waiting for supper, I was very thirsty and drank several glasses of icy water. I had trouble taking a deep breath without coughing, and I felt very tired. Before the food arrived, I got sick and went to my room. My dive partners came in to check on me. I remember them asking me if I was OK, and then I passed out. They opened my shirt and noticed a rash on my chest. They began to administer oxygen from the resort and demanded that I go to the hospital immediately.
After a complete check at the hospital, the medical staff determined I was not having heart issues and sent me to the recompression chamber 20 minutes away. The doctors there examined me and determined that I probably had some decompression sickness but that it wasn’t severe enough to need any time in the chamber.
The hospital then called and informed me that I was very dehydrated based on the blood test they had done. I returned to the hospital for more observation overnight and intravenous saline infusion.
I passed out again later in the night. The remainder of the stay was fine, and I was discharged the next day mid-morning. I did not dive the remainder of the trip.
Comment
This diver’s symptoms are consistent with skin manifestations of decompression sickness (DCS). With the additional coughing (the chokes) and an episode of loss of consciousness, it is very likely that a neurological component was present. His companions acted appropriately by seeking aid, providing surface-level oxygen and transporting him for a medical evaluation. The surface oxygen helped prevent the worsening of symptoms and may have contributed to their resolution. The hospital staff was prudent to rule out any potential cardiac component, because some of the symptoms he presented can be associated with cardiac issues.
There are data that indicate that a warm shower soon after diving can propagate skin symptoms. The main causative factor is the inert gas tissue load; the greater the load, the greater the likelihood of developing symptoms. It is not definite the shower contributed to the development of symptoms in this case. It is reasonable to believe there is some connection.
The diver mentions that the laboratory tests of his blood indicated that he was dehydrated. What was most likely observed was an increase in a marker known as hematocrit, which is a ratio of the solid components of blood in relation to the fluid content (plasma). The test was taken after the diver already had developed symptoms; the diver’s hydration state prior to the dive is not known. Most recreational divers on a normal dietary regimen before a dive do not get dehydrated to the degree that would affect the outcome of their dive.
However, if a diver gets DCS, his blood vessels will leak plasma into surrounding tissues, which is detectible as changes in the hematocrit level. This most likely accounts for a diver with DCS symptoms appearing dehydrated. An important part of treatment for DCS is fluid resuscitation, ideally achieved with intravenous infusion.
The clinical decision whether to treat a diver in the chamber ultimately rests with the evaluating physician. He will rely on the condition of the patient as well as his own previous experience and expertise. Typically, skin manifestations alone may not require hyperbaric treatment. In this case, there was suspicion of a neurological component. At the time of the diver’s evaluation by the hyperbaric physician, no evidence of neurological symptoms may have been evident. His treatment was not inappropriate; most important, he had a positive outcome. The diver prudently chose not to resume diving on this trip, which is the best prevention of a recurrence of symptoms.
Marty McCafferty, EMT-P, DAN