Thouhgt I'd reply since I just did all this, and more.  Had a severe hit (7
chamber rides) on a recretional no-deco dive, dry suit, nitrox, 15 min
ascent from 90 feet, including safety stops at 30 and 15......hit in right
arm within 5 mins, right legs within 30 mins and numbness and tingling in
right hand one hour later.  Multiple dive physicians could find no cause,
after lengthy risk discussions.

So...it was off to the diagnostic world -
Trans-thoracic echo (through the chest wall - the regular kind)with color
doppler/aerated saline bubble contrast.  Loks for PFO's AND Pulmonary AVM"s
(places where the artery and venous system directly mix without passing
through the capillary system - hence Atrerio-Venous Malformation) - $800.00

Trans-esophageal echo (down the troat, looking through the side wall of the
heart) with bubble contrast -$1000
General anesthesia to go with the thing being shoved down your throat -
$1250.

A hint - Pediatric Cardiology is often the way to go - they are the ones who
deal with PFO's ALL THE TIME - it's the babies that have most of the
problems.   They are VERY good at echos.  And...if you aren't willing to pay
for GOOD (which does NOT necessarily mean expensive - just very competent) -
don't bother.  You'll get cruddy pictures, no real info, and a false sense
of confidence.

A second hint - your Cardiologist should already know that they should be
looking for Pulmonary AVM's as well as PFO while doing the Doppler bubble
contrast echo.  Otherwise, they don't REALLY understand why you are doing
this....

These were normal, so we went for the MRI of the head ($1250), and MRA (an
MRI that follows the blood vessels to look for an AVM in the brain), also
$1250.  Both also normal.

My insurance paid for 80% of all, including the $14,000 in hyperbaric
charges.  PADI dive insurance picked up the rest - and will pay for any
testing/consultations, etc. for A WHOLE YEAR after the accident, up to the
limits of the policy.  (It's cheap and worth it for any recreational dives -
no hassle on paying out, either!)

I was lucky - medically and insurance-wise.  I hope you don't go through a
similar experience, but if you do, I hope this is helpful.  Unfortunately,
no more trimix caving for me.  :-(

Questions may be sent privately.

Susan
-----Original Message-----
From: Dr. Chris. Edge <cjedge@di*.de*.co*.uk*>
To: Bill Wolk <billwolk@ea*.ne*>
Cc: wwm@sa*.ne* <wwm@sa*.ne*>; Cavers List <cavers@ca*.co*>;
Techdiver List <techdiver@aquanaut.com>
Date: Sunday, May 03, 1998 4:26 PM
Subject: Re: New Requirements


>I'd like to comment on this:
>>On 5/1/98 1:36 PM, wwm@sa*.ne* wrote:
>>
>>>In speaking to a friend of mine who advises insurance carriers I learned
>>>that some new requirements may be coming down on the tech diving
>>>industry.
>>>
>>>It seems that given the shocking record of accidents and fatalities of
>>>late one means of diminishing some of the risk may be to require Stess
>>>testing in conjunction with PFO and oxygen tolerance testing.
>One must ask the question, if screening for a particular condition:
>Is it relevant?  For an answer re PFO, see below.  However, one thing
>that is certain is that oxygen tolerance testing will give no indication
>as to the susceptibility of an individual to get hit.  The
>susceptibility varies between individuals and between measurements on a
>given individual on different days (as is commented below; see also
>McDonald's book on Oxygen and the Diver).
>>>
>>>In my opinion it is very wise to perform these tests regardless of
>>>whether they are a requirement or not.  The commercial diving industry
>>>considers this form of testing to be a mandatory prerequisite. Tell me
>>>why we shouldn't follow suit?
>Because you are giving all sorts of ill-informed persons (the assessors
>in the insurance industry) a very big stick with which to beat you.
>>>
>>>Bill
>>
>>Bill -
>>
>>I was going to respond to this when Dan Volker first posted the idea of
>>mandatory PFO screenings.  In principal, it's a very good idea --
>>especially for any kind of decompression diving -- but lets put a
>>practical framework on the PFO issue:
>>
>>First, based on DAN statistics, PFOs are present in an estimated 10%-15%
>>of the population
>No, in fact a paper in the Am.J.Cardiol. puts the figure at 27% at
>autopsy.  Other papers do likewise.  I can give all the references if
>you want them.
>>
>>Second, diagnosing one requires -- at a minimum -- an echocardiogram with
>>contrast (aka a bubble echo) which costs approximately $1,000.00.  (I
>>know -- I just had one done.)
>Well, if you must get an expensive cardiologist, you deserve all you
>get.  Many cardiologists use aerated saline solution, which is cheap and
>gives very good contrast.
>>
>>Third, even bubble echoes will not diagnose small PFO shunts because of
>>interference from the rib cage. (This was surprise info from my
>>cardiologist while the bubble echo was being performed.) To truly rule
>>out a PFO, you have to get an endotrachial bubble echocardiogram in which
>>a miniturized echo device is actually lowered down your throat to produce
>>an internal picture of blood flow through the heart.  I didn't look into
>>the cost of this procedure, but since it involves intubation and
>>anesthesia, I think it's safe to say that it won't be simple or cheap. Do
>>you know of anyone who's taken it this far?
>Transcranial Doppler is as good.  There are several papers which
>indicate this fact.  You don't require anaesthetic or anything down the
>throat.  The test is simple and straightforward and detects all shunts,
>not just those which are intracardiac.  Which brings me to the question
>as to why detect a PFO?  If you look at the paper by Knauth et al. in
>the British Medical Journal, you will find that they detected 11 divers
>in whom the PFO was "haemodynamically significant".  In only 3 of the
>divers did they find that there were any significant MRI lesions.  Now,
>I quite accept that they didn't look in the spinal cord, but nonetheless
>it is true to say that, if roughly 27% of divers have PFOs, the diving
>community is going to shrink quite unnecessarily if all those who have
>PFOs are ruled out of diving.  27% of divers do not have problems.
>>
>>That said -- it you can afford it or have medical insurance that will
>>pick up the tab, it's not a bad idea. I though it was important to do
>>before starting mix dives and squeeked mine through my PPO insurance, but
>>it wasn't easy.  As for Ox tolerance testing -- not sure it would show us
>>much since the ox tox threshold varies so much from day to day and dive
>>to dive even in the same individual.
>>
>>Perhaps rather than make it mandatory, a bubble echo should be strongly
>>recommended by the tech certification agencies and this recommendation
>>should be backed up with a full and medically graphic description of what
>>can happen to a diver with an undiagnosed PFO on a deco dive.
>Most of the time, in the vast majority of divers, nothing.
>> Think of it
>>as an informed consent -- "we're recommending this procedure; it's your
>>choice not to get it; but this is what can happen if you don't" -- with
>>that, some divers will have the procedure done and those who don't will
>>at least have made a decision based on a clear sense of the risks and
>>benefits.  (Personally, I think the risks of most diving are underplayed
>>in order to increase the market, but that's another issue.)
>Difficult to see what you base this comment on.  The facts are there,
>and must be interpreted correctly as they are at present known.
>>
>>Based on the info you've posted in the past and the DAN accident reports
>>I've read, it seems like the vast majority of scuba accidents and
>>injuries are earned -- from improper training, poor equipment
>>configuration, bad gas planning, diving beyond limits, etc. -- and not
>>from unearned causes like undiagnosed PFOs. Certainly that much is
>>obvious about West Palm. It seems to me that we'd save lives and reduce
>>risks more by setting higher training and equipment standards -- as you
>>and George have been doing all along -- than by requiring expensive
>>medical testing.
>This I totally agree with.  Very few of the accidents in the UK are due
>to PFO problems.  However, none of the agencies does any kind of audit
>of the quality of their training, because none of them seem capable of
>collecting denominator data i.e. the number of dives their certified
>divers are undertaking.  It's no good trumpeting one year that the
>number of accidents has decreased because of good equipment and training
>unless one can show that the number of dives performed has not decreased
>drastically.
>>
>>Just my $.04 -- Sorry about the length of the response -- it was a good
>>question!
>>
>>
>>
>>Best Regards --
>>
>>Bill
>>
>>--
>>Send mail for the `techdiver' mailing list to `techdiver@aquanaut.com'.
>>Send subscribe/unsubscribe requests to `techdiver-request@aquanaut.com'.
>Well, undoubtedly I have echoed some comments.  Doubtless it will set
>the cat amongst the proverbials...
>--
>Dr. Chris. Edge


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