August 2000

By Ernest Campbell

Will the joint pain resulting from untreated decompression sickness disappear after time or will it just get worse?
via e-mail

Joint pain that is due to a decompression accident is caused by several things:

• The pressure caused by the actual presence of bubbles in the tissues around the joint

• the production of chemicals called kinins that cause an inflammatory response similar to arthritis

• tissue that is damaged when clotting and other protective systems are triggered, resulting in pain, increased blood flow and swelling.

Compression, such as a blood pressure cuff or a tightly wound Ace bandage, usually causes an immediate decrease in pain. However, if left untreated, the pain has a greater chance of being caused by the effect of kinins, swelling and loss of blood flow. In this case, the pain might last for an indeterminate period--sometimes for weeks or longer. This untreated damage might also tend to make the diver more susceptible to subsequent episodes of decompression illness.

Bubbles have been found in divers even after what was thought to have been successful treatment of DCS. Consequently, it would be wise to recompress every case of DCS using oxygen alternated with air (the oxygen replaces the nitrogen and is metabolized rapidly, reducing bubble size even more).

I got a fire coral burn about a week ago. I treated it with vinegar, meat tenderizer and cortisone. It seemed OK, but now the rash is back, with welts. I used vinegar again and Neosporin in case of infection. I also took an antihistamine pill. What are the long-term effects? Should I see a doctor?
via e-mail

Coral can cause rashes from four sources:

• Nematocysts

• Abrasion

• Allergic reaction

• Marine infection

You seem to have a combination of the first three. The first-aid measures you took are appropriate for this injury. The vinegar is for deactivation of the nematocysts, but will not be effective after the first day or so. Good cleansing and re-moval of foreign bodies is very important and the cortisone cream is excellent for any ensuing inflammation. However, infected scrapes should have appropriate antibiotic coverage and tetanus antitoxin.

Persistent difficulty usually is caused by foreign body particles related to the abrasion. A visit to a dermatologist might be the wisest (and eventually least expensive) course to take.

I own a dive facility in Canada. Now that there are courses designed for kids as young as 10, how do we keep them warm enough in 60- to 65-degree water when they can't get themselves into a custom-fitted suit appropriate for our climate?
via e-mail

You pose a very good question--and one that has other ramifications. There is no way possible for a 10-year-old child to dive in cold water without having a custom-fitted suit. The dangers of hypothermia are already high in children, not to mention the difficulties with buoyancy and the wetsuit near the surface. Add these challenges to the other difficulties faced by a 10-year-old and you have a setting for disaster.

Physically, the young diver should weigh a minimum of 108 pounds (50 kg) and be at least 60 inches (1.52 m) tall. Equipment must fit properly. He or she should be able to handle the bulky diving equipment and should be able to enter and exit the water without difficulty. Gear size can be reduced and smaller tanks utilized.

Cold stress and buoyancy control pose special problems for a person of smaller stature, particularly on the surface in a suit. In addition, the child should be physically, mentally and emotionally mature enough to rescue a buddy in distress.

**Two years ago, my 20-year-old son broke his elbow in a skiing accident. He had surgery, and a small metal bar and screws were used to repair the broken bone. The bone has healed and he has no problems with his arm. The metal appliances are still in place.

He is now interested in pursuing a career in commercial diving and has been asked to provide an X-ray of his arm before acceptance into the training facility. Could there be a problem with this injury and his choice of career?**
via e-mail

Whether the site of a fracture is a starting point for bubble formation because of changes in blood flow has been the subject of medical debate. There are no consistent studies that show that this assertion is valid. There is no good evidence that surgery, fractures or other injury increases the incidence of DCS in the injured area. Your son's elbow, even with a metal plate and screws, should not be affected disproportionately by the diving environment.

The agency may be requiring an X-ray to have a baseline for comparison later, should the need arise. They may be using some guidelines that they have set up for the protection of the diver (and the agency itself).

If his fracture has completely healed to the satisfaction of his doctor and he has rehabilitated his elbow adequately, your son should be able to dive without difficulty.

I recently started taking Coumadin for a deep vein thrombosis (DVT) in my leg. Will this medication affect my diving?
via e-mail

Diving with DVT could be hazardous because of the constricting effect of dive equipment, belts and wetsuits on the superficial veins. The effect of weightlessness on peripheral blood flow is another unknown, with possible increased flow due to lack of gravity. Unfortunately, I know of no studies on this question. Immersion does cause a central migration of body fluid, thereby possibly lessening swelling of the tissues and the amount of blood returning to the veins.

Secondly, the drug Coumadin is quite difficult to control and dangerous because it makes it possible for significant bleeding to be caused by very minor trauma. Barotrauma of the ears, sinuses and lungs can cause bleeding, which is not usually severe in the average diver. However, when taking Coumadin, this minor trauma can become life-endangering or at the least cause significant ear damage with possible hearing loss.

For more information: www.scuba-doc.com/antcoag.htm.

If you didn't have decompression sickness and entered a recompression chamber for treatment, is it possible to have any medical problems due to entering the chamber when it was not needed?
via e-mail

Treating decompression illness (decompression sickness and arterial gas embolism) is just one of the uses for recompression chambers. They are now being used to treat quite a few other illnesses. In the United States, chamber treatment is approved by Medicare for some 13 conditions.

Being compressed in a chamber is in essence a "dry dive" without the dangers of being in a watery, alien environment. You would, however, be subjected to the same risks of barotrauma to air-containing body spaces and the possibility of ear, lung and sinus problems. If 100 percent oxygen were being used, you would also be at risk of oxygen toxicity if the oxygen intervals and pressure were not properly controlled.

Some side effects of hyperbaric oxygenation treatment include seizures and lung damage from oxygen toxicity, finger numbness, inflamed middle ear and refractive changes in the lens of the eye. For more information, go to: www.scuba-doc.com/hbocont.htm.

I apparently have an ongoing sinus infection that is only evident when I dive. I take the prescription drug Augmentin with me now when I go on vacation because without it I sometimes get pressure in my sinuses when I descend. Both my regular doctor and a specialist say that the infection is something that is most likely ongoing and will never be completely eradicated, only diminished with antibiotics. It causes me absolutely no problems topside. No allergies, no itchy, watery eyes, nothing. It only shows up when I dive. What is going on?
via e-mail

You probably have something obstructing the outlet of the affected sinus--such as a deviated septum, polyp, scarring or other growth.

This is apparently not a problem when you're not diving, but causes blockage due to pressure changes on descent and ascent. The lining of the blocked sinus is damaged by the pressure changes, resulting in swelling and hemorrhage and allowing a flare-up of any bacteria that might be lurking around in the sinus.

The appropriate antibiotic depends entirely upon the type and kind of bacteria present--as determined by nasal cultures and sensitivities. Augmentin is a broad-spectrum antibiotic and should handle most bacteria of the kind living in the nasal cavity. However, some germs are resistant and this might cause your doctor to change to a more specific drug.

This problem will continue until you find the cause and get it managed properly, possibly surgically.

Ernest S. Campbell, M.D., FACS, makes his home in Orange Beach, Ala. He is a retired surgeon, avid diver and webmaster of "Diving Medicine Online" (www.scuba-doc.com).

Please send your dive medicine questions to RSD, 6600 Abercorn St., Suite 208, Savannah, GA 31405. Fax: (912) 351-0735. E-mail: edit@scubadiving.com.