The Denial that Damaged my Brain

Even though DCS might seem subtle, it could be serious. DAN AP Member Alice Grainger shares her experience of denying her decompression sickness due to the lack of the usual physical symptoms, until she decided her brain clearly wasn’t working, and went to seek medical help. With comments by DAN AP Founder, John Lippmann.

Alice’s Experience

We were in the Maldives for a 7-day liveaboard. Almost all the divers we did were deep, the currents were running, and often we found ourselves finning into them as we followed the guides, on the look-out for the sharks and rays this remarkable atoll is famous for. The trip was taking place during the rainy season, and we had already surfaced a few times in heavy downpours, with visibility on the surface reduced to a few metres.

Swimming for safety

On the fifth day, we did two dives, and by about 4pm we were ready to jump in for number three. The water was soupy, green. Bottoming out at around 38 metres, we swam along the outer reef towards the entrance to the channel, which we approached from below the lip that marks the passage into the lagoon.

We ascended slowly up the lip to about 26 metres, feeling the strength of the current increasing as we climbed. But it was going the wrong way, not into the lagoon where the boat would meet us, but out to the open ocean. And it was very strong. Our regulators were rattling in our mouths, and as we cleared the top of the lip, we had to hold onto the rocky substrate to keep ourselves from being pulled off the reef.

The guide called the dive, instructing everyone to start the ascent. We let go and the reef disappeared from view in a matter of seconds. It took us at least eight minutes to reach the surface, all of us making conservative safety stops on the way.

By the time we hit the surface, the current had pulled us a long way from the atoll. The boat, waiting for us in the pre-arranged spot, and was now just a speck on the horizon. It was about 4.45pm, and we had about an hour and half of daylight left. Looking to the west, a squall was fast approaching. We calculated that we had about 20 minutes for the boat to pick us up before the rain hit, closing out the visibility and making it impossible for us to be seen.

With every second we were drifting further out into the Indian Ocean. All of us had our SMBs up, but the boat was too far away to spot them. We were finning in an attempt to remain where we had surfaced, but despite our best efforts, the group was failing to stay together (the best course of action). The squall getting ever closer, I decided to try to swim for the nearest island which was around half a kilometre away, across the current.

I had been swimming for about 10 minutes when a speedboat came past, spotted me in the water and radioed the liveaboard. They dispatched the dhoni immediately, which picked us up just as the rain hit. We had been very lucky.

A sickness so subtle…

That night I didn’t sleep well. I was a little bit nauseous, but put it down to stress. I thought I could feel mild tingling in my feet, tiny, feathery pin pricks, incredibly subtle. I wondered if I was imagining it. Just in case, I decided to sit out the next morning’s dive and see how I felt.

So, on Friday morning I skipped the first dive. I was quite tired, but otherwise had no symptoms. In the early afternoon I was feeling fine so decided to do the last dive of the trip, a relatively shallow and gentle dive to round things off.

That night everyone was enjoying the last evening together and chance to cut loose. I wasn’t feeling it – I was tired and felt a little bit nauseous and went to bed early. The next day, Saturday, everyone was packing and napping – we were all shattered after an intense week. My exhaustion seemed entirely normal.

We flew back to Singapore that night, and I was home by about 10am on Sunday morning. I was extremely tired and went to bed for a “nap”. I slept all the way through to Monday morning, waking to my alarm at 7am. At the office I was still tired, and was having trouble focussing. I put it down to post-holiday blues, and the fact that I hadn’t done so much diving in years. I got home at about 7pm and went straight to bed.

I slept until Tuesday next morning. Getting off the bus I noticed that I was veering to the right as I walked. At work things were not great; I was very tired, and I couldn’t focus on the words on my screen. I was a little dizzy. I was glad to get home and go back to bed.

Still in denial

I woke up on Wednesday having slept for another 12 hours, and still felt tired. I was still veering to the right when walking and it was becoming even harder to work – I couldn’t figure out if the sentences I was writing made any sense, and when I went to paste text, I’d forget the content of the words I had copied. My brain clearly wasn’t working. I decided to go to the doctor.

They gave me the name and number of a hyperbaric doctor, Dr Ted Wong. I was still unconvinced I had DCS; I had none of the “classic” symptoms I’d been taught to expect, the tingling (that I could have imagined) hadn’t returned, I had no pain in my joints, no rash. I also rationalised that even if I was bent, it had now been almost a week since my last dive and so it was probably too late to be treated (how wrong I was!). I went home and again went straight to bed.

By the next day, Thursday, things were even worse. Now my head and neck were also starting to feel strange, slightly numb. That was when I decided to call DAN for some advice.

The DAN doctor told me to see the hyperbaric specialist. DAN Asia Pacific’s John Lippmann then called me personally to make sure I did so. He would prove to be a constant support over the next few weeks.

I was reluctant to go to the chamber, but called Dr Wong anyway. I was still unconvinced that I had DCS, and sure that by now, a week after my last dive, nothing could be done about it even if it was DCS.

But Dr Wong wasn’t buying my denial. He wanted me to be at the chamber in 30 minutes, explaining that my symptoms indicated cerebellar DCS, and that, untreated, they could be permanent, and could even lead to early-onset Alzheimer’s and other neurological disorders. That did it.

Evidence of brain damage

At the chamber I had to write down some personal data. It was the first time I had written anything by hand since the trip and I found it extremely hard to form the letters. Dr Wong administered a Sharpened Romberg test, checking my balance. With one foot in front of the other, heel to toe, eyes closed and arms stretched out to the sides, I had to balance for as long as I could. In that position, my body shook uncontrollably, spasmodic, jerky motions that let me balance for all of 10 seconds. The serial seven test was next, counting down from 100 in sevens. I was allowed to use my fingers, but even then I couldn’t count backwards.

It was frightening to see evidence of how impaired my cerebral functions really were. There were no more objections. Dr Wong gave me a sedative and put me in the chamber.

After a USN Table 6 treatment, Dr Wong administered the tests again; the results were incredible, a massive improvement.

DAN Asia Pacific’s John Lippmann called me that night to see how I was, and was on conference call with me and Dr Wong for my next few sessions. I had another treatment in the chamber the next day, a UNS Table 5, two hours 15 minutes, and a final one two days later. John was calling to check up on me every day, sometimes several times, constantly reassuring. I was prescribed pharmaceutical grade Ginko biloba and Co-enzyme Q-10 to help speed the healing (JL – although there is little evidence to support this it is sometimes used).

For the next few months, I was tired a lot. I would have regular spells of extreme vertigo, and a sensation that I can only describe as having a head full of damp, electric bees – an unpleasant buzzing sensation. I would have to lie down with no stimuli for 15 minutes until it passed. Gradually these episodes became less frequent and less severe. John Lippmann recommended I get tested for PFO, which I did. Unfortunately the test was inconclusive, but I plan on being re-tested.

Lasting lessons

It is now almost two and half years on, and my long-term memory is not what it once was. I forget how to spell words, tasks I have completed, things people have told me. Thank God for spell check, calendars, and understanding bosses!

I could never have imagined that something so subtle could end up being something so serious. The whole episode taught me a number of valuable lessons:

  • Denial is the most common symptom of DCS (thanks, John!);
  • Even if hyperbaric treatment is delayed, it can still be effective;
  • DCS can be A-typical and even if it seems minor, you should always seek medical attention and advice.

But perhaps the biggest lesson for me was the value of DAN Asia-Pacific. My DAN Asia-Pacific coverage meant that they covered the costs of my treatment immediately; I didn’t have to pay for it and then claim it back. But more importantly, they were with me every step of the way, providing support at a time when I needed it most.

Analysis and Comments by DAN AP’s John Lippmann

There are several interesting insights to be gained from this incident; initially from the dive planning aspect. In almost any situation where there is current, or likely to be a current, it is wise for the divers to use a line and float so that the boat can track them throughout the dive. SMBs are often deployed at the end of a dive, but, if the current is strong and/or the weather turns sour, by the time these are used they may not be visible to the boat. I know of many such situations arising, sometimes with fatal consequences.  

Another planning problem was doing a 40 m dive as the third dive of the day. Deep dives carry an increased risk of DCI, as do repetitive dives, so the combination can be a recipe for a decompression problem. This dive, together with exertion likely created the problem.

When symptoms arise after diving (in this case, the nausea and tingling in the feet) it is too easy to put them down to something other than DCI and miss the opportunity to get prompt and necessary first aid. Nausea and tingling are common symptoms of DCI and it is important for a diver to accept this and call a DAN hotline as soon as possible and let a dive medical expert assess the situation and provide advice.  DAN AP recommends that any symptoms that arise within 24 hours of diving (or longer with altitude exposure) should be considered diving-related and diving medical advice should be sought. 

In this case, the advice would likely have included the breathing of high concentration oxygen, for at least 4 hours, and then a re-assessment. Had this been done, Alice might have avoided some of the subsequent problems. Flying with symptoms likely exacerbated the problem, as did the 7-day delay before seeking treatment after arriving back home. This very likely contributed to Alice’s slow recovery and on-going issues. 

Alice’s PFO test was inconclusive but I have encouraged her to have another as some aspects of her circumstances are consistent with a likely PFO. Unless a PFO test is done optimally, it can be easy to get a negative result.

It is common for a diver with DCI symptoms to be ‘in denial’, and this played a big part in this case. Alice is highly experienced and intelligent but still fell into the ‘denial’ trap. I’ve even dealt with a very experienced diving doctor who fell for the same thing!  Don’t leave it to yourself or your dive operator to decide whether or not you have DCI, call a DAN hotline and let an expert make an unemotional and experienced judgement.

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