Walking Again

An evacuation and 10 chamber rides later, this diver is back on two feet.

May 2, 2010, was like any other Sunday. I was at my part-time home in Manzanillo, Mexico, and my buddy, Terry, and I were preparing to dive one of our favorite sites. Los Frailes is not an easy dive; it's subject to heavy currents, but it's beautiful, Terry and I are experienced divers, and our planned profile was one we'd completed many times without incident.

That day was no different. We followed our dive plan, swimming across the current without overexerting ourselves. We reached a maximum depth of 100 feet and remained underwater for a total of 30 minutes. The only thing that didn't go exactly according to plan was our safety stop; Terry was having buoyancy issues, and so we cut the stop short rather than risk getting separated in increasingly rough seas.

Once back on board our boat, I struggled to remove my wetsuit. The tight cuffs on the arms and legs had made it a challenge before, but on this day it was particularly possessive of my legs. It took me almost 40 minutes — and a lot of exertion — to remove the suit completely.

Once I triumphed over the wetsuit, I felt very strange. No matter how I sat, turned or stood, I could not get comfortable. I finally found a tolerable spot on the bottom of the boat, and after lying there for 30 minutes my discomfort had been reduced to weak and rubbery legs. I was able to help Terry load the boat onto the trailer and get it to his home for storage, but when I reached my own home, I rinsed my gear and took a nap.

When I awoke at 6:30 p.m., it all started to go downhill. I noticed I was walking oddly; my gait was wobbly, and I couldn't seem to get balanced. I knew there was something more than wetsuit-fatigue going on, so I did what any smart diver should — I called DAN®. After giving an operator my name, location and call-back number, I was transferred to DAN Medicine staff member Dr. Matías Nochetto. After establishing the facts of my case, Matías recommended that I get to the nearest medical facility. It seemed that the symptoms I was experiencing didn't really align with the day's diving (they were more extreme than the dive would warrant), and as a lack of balance and wobbly gait are also indicators of stroke, getting checked out was prudent.

I called Terry and asked him to go with me to the little hospital close to my home. Once there, an English-speaking doctor was called in to examine me; at that point I was still feeling fine overall, but the numbness that had developed in my legs was starting to spread, and I was growing increasingly unsure about my ability to walk. I called my new DAN friend Matías again and put him on the phone with my doctor. After conferring for several minutes, my doctor admitted me for more tests in the morning.

I spent the night in the little five-room hospital; by the time I awoke Monday morning, I could no longer walk at all. Not only was my balance completely gone, but so was the feeling in the lower half of my body.

The doctors performed a CT scan to try and rule out stroke as a reason for my symptoms. They did, but the scan didn't prove to be especially conclusive beyond that. I called Matías again to see if he'd confer with my attending doctor and neurologist, since the working diagnoses under discussion were neurocysticercosis (a parasitic infection that comes from eating ill-prepared pork; the tapeworm larvae can sometimes get in the brain) and Guillain-Barré Syndrome (another neurological disorder that can affect motor function in ways similar to what I was experiencing). Decompression illness was also being considered, but only because DAN recognized the possibility; my local doctor wasn't familiar with diving injuries. Since the initial tests weren't conclusive, Matías suggested that it might be a good idea to evacuate me to a hospital in the United States. Fortunately, my doctors in Mexico agreed, and DAN went to work putting the evacuation wheels in motion. Four hours later, I was loaded onto a pressurized jet and flown to the University of California at San Diego (UCSD) Medical Center.

Now would be a good time to note that at the time of my injury, I was not a DAN Member. My DAN membership and dive accident insurance had expired due to a change of address and my oversight in renewing it, but in terms of the assistance I received, my membership status didn't make a bit of difference. DAN took care of me on every front — Matías stayed in touch with my doctors (and on call for me), DAN got the ball rolling for my evacuation from Mexico to San Diego, and they continued to follow up once I arrived there. The only thing DAN wasn't able to do for me in the end (since I wasn't a member) was cover the $22,000 cost of the evacuation, but thankfully, I was in a position to be able to do so.

When I arrived at the UCSD Medical Center, I was met by an ER doctor who was temporarily covering for the hyperbaric team, and while I was awaiting a bed, I received a call from Juan at DAN TravelAssist®, who wanted to make sure I'd arrived OK and that everything had been satisfactory. By 11 p.m. Monday I was in the hyperbaric chamber; I'd been thoroughly examined by a medical team headed by Dr. Karen Van Hoesen, and they'd determined that my condition was not a parasite but, in fact, decompression illness. That first chamber ride lasted until 6:30 a.m. Tuesday, and Dr. Van Hoesen told me not to expect miracles with only one treatment. She was right; I still had no feeling in my legs, and my balance remained off.

I was placed in the recompression chamber again Tuesday afternoon for my second treatment; two and half hours later, there was still little or no change in my condition. Wednesday brought two more sessions, but by the end of the day, I was able to stand next to my bed without falling over. The physical therapist came to see me with a walker and strict instructions that it was to be used only with a nurse present. I didn't mind the rules; being told I could do any form of walking was music to my ears!

On Thursday I hit the milestone of walking in and out of the chamber for my now twice-daily treatments. Granted, the walking was slow and shaky, but with assistance on each side, I walked. Matías at DAN called to check in and monitor my progress.

After two treatments on Friday, I still had a lot of numbness and tingling in my legs, but I was also a lot steadier on my feet. I used a walker to trek the 8th floor of the hospital, and my day was made when my doctors told me that as of Saturday, I'd be receiving outpatient treatment. Since I was going to be leaving the hospital, I immediately asked about the second-most important topic to me: when I could return to diving. I was afraid they were going to tell me my diving days were done, but once again I was given good news: I would need to modify my dive practices to do only shallow dives, stay out of cold water and to dive Nitrox while on air decompression tables, but if I did so, there was hope I'd be able to return to the water.

Saturday brought two notable events: the first being my initial day as an outpatient. The second was that instead of the daily double, I received only one chamber treatment that day. Unlike my first entry into the hospital, this time I was able to walk through the hospital doors and into the chamber. It felt like a great accomplishment.

As with so many steps forward, Saturday also brought a step backward. After my chamber treatment, I returned to the hotel and decided to relax in the spa. When I sank into the water, I discovered that the sensors in my legs had gotten confused; the hot water felt cold to me. The nerves in my spinal cord had gotten scrambled and were reversing the sensation; it was disorienting to say the least.

Sunday marked the one-week anniversary since the onset of my symptoms. I celebrated it with another chamber treatment, and as with each treatment I completed, I continued to improve. I was still miles from normal, still unsteady on my tingling legs and feet, but I was improving.

On Monday I arrived at UCSD Medical Center for my 10th and final hyperbaric treatment. Before I left, I was given the happy news that I was cleared to return to my home in Tucson, Ariz. Hyperbarics and the UCSD medical staff had done all they could; now time and rest needed to take me the rest of the way.

And they are. As I write this, it's been six weeks since the injury, and while some numbness and temperature reversal remain in my legs, I continue to improve and can now walk without worrying if I'll fall over at any moment.

Sometimes it still seems incredible to me that I went from the prospect of never walking again to being this far along the road to recovery. I may never know why my symptoms came on as severely as they did, but I know one thing for certain: Without the care I received when I called for help, the outcome would likely have been a disaster. But because of the care I received from DAN, the evacuation team, Dr. Van Hoesen, Dr. Kim Buschmann and the rest of the UCSD medical team, I continue to hope for a full recovery.

And, needless to say, I am once again a DAN Member.
Medic's Perspective
Cases like this are always cause for concern. Although it is possible for DCS to appear after less provocative dives, Jim's exposure was a quite common recreational dive. However, his inital description of his symptoms was inconclusive, so we recommended immediate medical evaluation. Though DAN cannot practice medicine over the phone, our approach is technically still the same; we just can't see or examine the patient. On the DAN Emergency Hotline, our only resources are a good case history and our knowledge. Jim's tale of his prolonged struggle to remove his wetsuit followed by the onset of a wobbly gait made a few warning lights start flashing. I could imagine the force of his struggle increasing both his intrathoracic and his intracranial pressure. A cerebrovascular event, such as stroke, was my first thought, but DCI needed to be ruled out as well. It is known that if a patent foramen ovale (PFO) is present (and Jim was later found to have one), sudden post-dive increases in intrathoracic pressures can cause random venous gas emboli (bubbles) to shunt from one side of the heart to the other, thereby bypassing the lungs (missing their chance to be "filtered") and finding their way into systemic circulation. This can cause a paradoxical arterial gas embolism, which presents with many of the same symptoms Jim was experiencing. We didn't know for sure what was behind Jim's symptoms, but it was easy to see that whatever the cause, he needed medical evaluation as soon as possible.

Jim's case is an interesting one simply from a medical perspective, but it's an important one on other fronts as well. Whether or not his PFO had something to do with this case cannot be determined, so it should be noted that its presence must not be seen as a smoking gun. However, it emphasizes why DAN is undertaking research studies in these areas. And while we are really thankful when a caller is a DAN Member (we like knowing you have access to all the benefits that can help you), some simply aren't. But for those of us on the hotline, membership status makes no difference. Our help and advice will be the same. DAN was here for Jim, and so were our collaborative partners, including the crew at DAN TravelAssist and our friends at UCSD Medical Center. We're all here for you if you need us. All you need to do is call.

– Matías Nochetto, M.D., Latin America Medical Coordinator, DAN Medical Department

© Alert Diver — Summer 2010