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Late Presentation of Decompression Sickness

As the season hits full swing I thought it might be timely to highlight a particularly relevant aspect of decompression sickness (DCS), that of late presentation, or so-called “diver denial”. There is no doubt that the earlier recompression and hyperbaric oxygen can be administered to a diver with DCS, the better their outcome is. Late recognition and treatment leaves divers more vulnerable to serious long-term consequences. However there is often a substantial gap in the time from the event to getting treatment, and denial plays a major role in this – so much so, that the well-known but curious phenomenon of denial has been termed one of the first symptoms of DCS. It has many contributory facets, and is a topic of concern that we at the London Diving Chamber encounter all too regularly. So what factors are involved, and what can be done to tackle them?

The term denial implies an active suppression of a problem, which is too uncomfortable to accept and is therefore rejected, despite what may be overwhelming evidence. There are two broad reasons this occurs in diving: fear and lack of knowledge.

1. Fear can take many forms. Divers may be:

• Afraid of admitting that they have symptoms as somehow this would mark them out as a “failure” or a bad diver;
• Afraid of inconveniencing their buddies, instructors or boat crew, eg. through having to abandon further dives or divert to a chamber;
• Afraid of the treatment – what’s going to happen in the chamber?
• Afraid of the consequences – will I ever be able to dive again?

• “Normal profiles and no alarms on the computer mean that a bend is impossible.” Up to 50% of bends occur in divers who have adhered to tables or dived within their computers’ limits, and who have no other obvious provocative factors in their dive profiles.
• “If ignored or left alone the symptoms will just go away by themselves.” It is possible that mild cases will resolve, but many will persist or deteriorate, as the consequences of bubble damage become apparent.
• “The symptoms are so mild that they’re not worth treating.” What may appear to be inconsequential at the time could become a much more serious problem if left. Consider the pianist or graphic designer with finger tingling, whose careers are jeopardised as the symptoms become permanent through lack of treatment.
• “The symptoms must be due to something else.” Typically heavy lifting, cold temperatures, an old injury or another pre-existing diagnosis. Many other conditions can cause similar symptoms to DCS, but anything that comes on soon after diving shouldn’t be blamed on another problem without very good evidence.

• Education: Despite the lack of evidence of effect, it makes sense that the more one knows about an illness, the better equipped one is to deal with it. We and other organisations host regular courses and workshops to raise awareness of the problem, talk about ways to dive more safely, blow away DCS myths and demystify the whole chamber experience.
• Plan of action: One commonly identified barrier is the absence of a plan of action if symptoms occur, so it’s useful to think through and document responses to a suspected diving incident – when to administer oxygen, where the nearest chamber is, who is going with the patient and how are they going to get there. That way, lengthy discussions and subsequent delay to treatment can be avoided.
• High index of suspicion: Most importantly, it’s vital that the possibility of DCS is considered should anything abnormal occur after a dive. Indeed it’s not too strong to say that any symptom that wasn’t present before the dive should be assumed to be DCS until proven otherwise. Although you might feel that you’re wasting a doctor’s valuable time, I’d much rather speak to and see someone who’s concerned than have them sit at home, worrying about possible DCS on their own.

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