Getting Bent Four Hours from a Chamber

Patent Foramen Ovale is a hole between the upper chambers of the heart. Everyone is born with it, but for 70-80 percent of people, it closes naturally after birth. It's diagnosed by a cardiologist conducting an echocardiogram bubble test. Divers with a PFO are at a much higher risk for DCS than others, as the sidebar discusses.

One of our correspondents, a 60-year-old woman diver, had a bends hit, after which she discovered her PFO. We want to share her story with you. It's a case that demonstrates too much diving upon arrival at a destination, dehydration, not catching early symptoms, the difficulty of getting to a recompression chamber, the ordeal of a chamber, and dealing with the cost, even though she had DAN insurance. Thankfully, she has no lingering problems, but she tells a cautionary tale.

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In November 2020, I went with friends to a liveaboard in the Maldives, my 60th birthday trip! We went directly to the boat after traveling for 24 hours and started diving right away - no time off to rehydrate or catch up with jet lag. Two dives the first day, three the next, all on computer, no deco limits, no issues. I was the only woman and the least experienced diver, with about 150 dives compared to 600 to 1000- plus, so perhaps the desire to keep up with the other kids drove me to dive more than I would have. My guide was not helpful when I wanted to surface earlier than others. I have to take personal responsibility for my DCS, but I will never let it go again if a divemaster ignores me.

On the third day, after the second dive (92 feet max, 59 minutes) I had a rash on my abdomen. That dive involved a negative entry and much exertion against the current to reach a pinnacle. I thought the rash was my dermatitis acting up, so I applied hydrocortisone cream and didn't tell anyone about the rash. On the third dive, I exceeded the max depth of 100 feet (105 feet max, 64 minutes). I honestly don't know what I was thinking or if I was thinking! My computer did not indicate deco, but of course, it did not account for the exertion. I was not drinking enough water, and I don't pee in my wetsuit.

Following that dive, the rash was much worse. I was exhausted, and my abdominal muscles were stiff, which I attributed to being out of shape. I did not have joint pain or skin tingles, so I woke up at 5.00 a.m., and when I tried to stand, I passed out and collapsed with my legs bent under me. I screamed from the pain. I was immediately put on oxygen while our group leader contacted DAN and tried to figure out how to get me to the only open hyperbaric chamber (of three in the Maldives) at Kuredu Resort in the north.

Getting to a Chamber

Since it was a Friday in this Muslim country, arranging a speedboat from Male was difficult, but the captain arranged for one to meet us as we motored north. It was $1700 cash (all I had) for the four-plus hour speedboat ride to Kuredu. At 4.00 p.m., I was taken to the chamber, where an excellent Turkish dive physician discovered I had skin marbling indicative of neuro involvement. Conferring with DAN, he diagnosed me with DCS type 2 with neurological involvement, and I spent a grueling six hours in the chamber with an attendant. I could not lie down (sleep is prohibited), not talk (to reduce needed gas replacement rates), and I couldn't sit up completely due to the chamber size.

Over the next few days, I had two more treatments. I was told to follow up with a specialist to determine whether I had a PFO and was given a three-month dive prohibition. I felt so great I stayed in the Maldives for a couple more weeks (snorkeling, not diving!)

I owe the expertise and quick action of my dive shop leader and boat captain to my total recovery and to DAN physicians, who said no to the protocol to first send me to the emergency room in Male for evaluation before evacuating to the chamber.

Paying the Bills

I was surprised to learn that my DAN dive insurance would not pay my bills! At least not at first. For Europeans with national health insurance, DAN pays first and gets reimbursed by the government health service. For U.S. citizens, you must pay yourself, then seek reimbursement from your primary insurance. Only then does DAN step in to pay unreimbursed medical and travel expenses. In my case, this was $1700 cash for the speedboat, $17,000 for the chamber, and a couple thousand more for lodging and meals, etc., during my treatment.

I had a lower credit card limit, so I had to charge the max, go online to pay my bill, and when it cleared, pay the balance! Now I know to take two credit cards to ensure I have enough capacity to pay for emergencies upfront. The DAN adjustor arranged an interestfree loan for the expenses pending reimbursement and helped ensure I had all the documentation needed for the claim. It took four months to get reimbursed from my primary insurer, which paid 100 percent of the medical expenses since it was emergency care. DAN covered the lodging and meals. And I got $100 a day reimbursement for my missed days of diving (which cost about $500 a day.) I think paying secondary is why DAN insurance premiums are so reasonable.

PFO Diagnosis

Back home, I was diagnosed with a large PFO, about a 40 percent shunt, which was repaired in same-day surgery via catheterization. I probably had this since birth without knowing. I only found out after the repair that when I was born, my parents were told I had a heart murmur but not to worry; I would grow out of it. Apparently not. Maybe I am lucky that it took such extreme measures (exceeding depth limits etc.) before getting DCS for the first time since certification in 1990. Unfortunately for divers, cardiac imaging for PFOs or other defects is not routinely offered without symptoms (TIA, fainting, etc.) because PFOs are so common. But if there is any reason to suspect one, I would urge pushing to be evaluated.

I am much more mindful and conservative of limits in my diving now, although I have always dived within no-deco limits before. I have added margins like arriving a day or two before diving. The scariest thing was being mentally impaired without any self-perception of the impairment, even though it was evident to everyone else.

DAN insurance is underwritten by a large insurance company, with steely-eyed adjusters whose primary concern is limiting their loss. Be sure to find out all required documentation and get it before you leave the facility/country, all receipts, medical reports, liveaboard, divemaster statements, etc.

Do not be embarrassed to tell your leader or the dive boat captain about any symptoms, even if you do not suspect DCS and have not exceeded your computer limits. And weigh the proximity and accessibility of the nearest chamber when making dive travel plans. Chamber treatment is grueling, loud, cold, long, uncomfortable, and expensive, even if it saves your sorry fanny from long-term disability, so think of it as a last resort, not a backup to your dive plans.