Can I Ever Dive Again?

The doctor is in, answering this crucial question for four readers.

-By Sam Shelanski, M.D.

Is There Life After the Bends?

Question: Having recently experienced an undeserved hit, I have a question: Is there life after the bends? And what is involved in making the decision whether or not to dive? I have called DAN, consulted with many different doctors and gotten many different answers.

My injury took place in October 1995 and, not believing that I was bent, I didn't get treatment until three days after the dive. I received four treatments in a hyperbaric chamber, and still had some residual pain which has continued to decrease with time. I have had no decrease in strength or sensation, just pain in my left arm and leg.

Patti
via e-mail

Answer: I'm not surprised that you have received several different answers to your questions, as opinions vary greatly concerning diving after getting bent. In general, if a diver sustains a Type I (pain only) DCS hit, he or she can return to diving. If the hit was attributable to diver error, such as exceeding depth or time limits, then the diver can return to diving three weeks after complete resolution of symptoms.

If, as in your case, the hit was unexpected, then the picture is a little more complicated. First, it is necessary to eliminate any possible contributing factors - such as impaired blood flow to a limb resulting from previous trauma or atherosclerosis, obesity or poor physical fitness - that might predispose a diver to the bends. If a contributing factor is found, then that situation should be rectified through surgery, exercise or diet prior to considering a return to the water.

Assuming that no predisposing factors are found, the diver could return to diving four weeks after complete resolution of symptoms. However, in this case the diver should work on the assumption that he or she has a greater than normal susceptibility to getting decompression sickness and should incorporate a larger safety margin into dives accordingly.

Remember that if you've suffered a DCS hit, you should not resume diving until all symptoms have completely resolved. If you are still having residual pain, you should not consider diving again until you have been examined by a doctor and a cause for the persistent pain is identified. In addition, it has been noted that people who suffer a DCS hit are susceptible to a subsequent hit at the same site. This is thought to be due to local muscle damage, scar formation and disruption of blood flow to the area.

Type II or neurological DCS hits are a different issue entirely. With very few exceptions, I would advise that anyone who experienced a neurological deficit as a consequence of a DCS hit not dive again. There will be those who disagree with me on this issue, but I feel that it is important to keep things in perspective.

No matter what, if you decide to dive again, make sure to get completely checked out by your personal physician prior to entering the water.

Diving With Breast Implants

Question: I am a 45-year-old woman who recently took up scuba diving. Three years ago I had a breast removed due to cancer and subsequently had reconstructive surgery with a saline implant. A friend told me that she had heard of implants bursting while diving. Is this possible?

Lori Daniels
Boston, Mass.

Answer: You can relax. Assuming that you have recovered fully from your surgery, there is no reason a breast implant should keep you from diving. The implants are constructed of a tough, flexible shell filled with saline. They are very durable and can easily withstand the pressures associated with even the deepest recreational dives.

Although the outer layer of most implants is gas-permeable and will absorb small amounts of extra gas from the surrounding tissues while diving, this amount is too small to cause any noticeable increase in the size of the implant on ascent, let alone enough stress on the shell to cause rupture on ascent. This is true of the older silicone implants as well. Any rupture while diving would be due to a defect in the implant itself.

Pneumothorax - An Absolute Contraindication?

Question: I am a 32-year-old male with a history of spontaneous pneumothorax. I was told that the lung was 90 percent collapsed. The incident occurred nine years ago, when I smoked a pack of cigarettes a day and did not take care of myself. I haven't smoked in four years now and am in excellent physical shape. My exercise regimen includes aerobic exercise, usually running two miles. I have been denied enrollment in a certification course due to my medical history. I was told that a pneumothorax was a "direct contraindication" to scuba diving. Period. Is there a way to get around this?

Chris Goane
via e-mail

Answer: It is true that under most circumstances a pneumothorax, or collapsed lung, is a contraindication to diving. However, this is not always the case. A pneumothorax is caused by a hole that allows air into the area of the chest cavity surrounding the lung. This air prevents full expansion of the lung on that side and compromises a person's ability to breathe.

There are two types of pneumothorax. The first is a traumatic pneumothorax and is caused by some sort of trauma (stab wound, broken ribs, a complication of medical procedures) allowing air to leak in from outside the body into the chest cavity. This type of pneumothorax is not indicative of any intrinsic defect in the lung. Most people can return to diving after they have completely healed from this type of injury.

The second type of pneumothorax involves a rupture, or tear, of the lung tissue itself, allowing air to leak out of the lung into the surrounding cavity. While the results are the same, the mechanism is different. This type of pneumothorax is the result of either an overpressure accident, such as pulmonary barotrauma from a rapid ascent or a mechanical ventilator, or is indicative of an underlying structural defect of the lung, such as you indicated.

Spontaneous pneumothorax is one of the few clear contraindications to scuba diving due to a dramatically increased risk of pulmonary barotrauma with recurrent pneumothorax and arterial gas embolism. So while I commend you on quitting smoking and striving to be more physically fit, I regret that I must strongly advise that you do not pursue diving as a sport.

A Stroke Victim Asks

Question: Last year I had a stroke and lost the peripheral vision in my right eye. It has taken me a year to get over that, pneumonia and high blood pressure. I am now taking medication for my blood pressure and am finally feeling healthy. Can I resume diving?

Dave Marinsik
Santa Rosa, Calif.

Answer: It sounds as though you had not been treating your high blood pressure prior to your stroke. I am also assuming that the hypertension was responsible for your stroke and that the pneumonia was a complication of your recovery. If this was the case, then you may indeed be able to return to diving, but with several caveats.

The first, and most important, is that you control your blood pressure. There are several different medications and each can affect you in different ways (see "Dive Medicine," RSD, Aug. '96). You must control your blood pressure for two reasons. The first is that hypertension is the leading cause of stroke in the United States, and while your first stroke left you without any truly debilitating neurological deficits, the next time could be much worse. The second reason is that high blood pressure dramatically increases your risk for heart disease.

It is for this reason that you must undergo an exercise stress test prior to returning to diving or any other potentially strenuous exercise. This test should be conducted while you are taking your blood pressure medications.

Finally, to answer your question: Yes, theoretically you can return to diving, provided that your doctor feels that you have recovered sufficiently from your stroke and that you are in good enough physical shape. It may take some time before you have regained the strength and conditioning necessary to dive safely, and even then I would not recommend that you push the limits of the tables or your dive computer.

Questions for Dr. Shelanski should be addressed to RSD, Dive Medicine, 6600 Abercorn St., Suite 208, Savannah, GA 31405; e-mail: RSDmgzn@aol.com.