First off, I’m OK. I learned that phrase from my dad. It really means that I am about to tell you something bad that happened, but I don’t want you to worry and have to wait until the end to discover that I OK. We knew, at some point during our journey, things would go very wrong. We almost made it to the 5 month mark before that happened. If you are not already familiar with diving, you may want to see the section at the bottom titled "Nitrogen and Diving" for some background info that might help to better understand the story.
After arriving on the Thai island of Koh Lipe (pronounced 'co lee-pay'), we set out to find a dive charter. We first talked to the place located next to where we were staying. They were doing a deep dive the next day for "advanced" divers. By advanced, they only meant that you needed the advanced certification, which we just got, so we were all set.
{Error in judgement: Jesslyn just started diving, and I hadn't been diving in a long time until recently. We both just got our advanced certification. Now we decide to do an advanced, deep dive with people we don't know, in a remote, unfamiliar place, with rental equipment we are unfamiliar with. We should have gone with a different dive charter which was doing a more moderate dive.}
We had a divemaster to lead Jesslyn, me, and one other diver. Our divemaster also happened to be the owner of the dive shop and charter. We did a quick pre-dive meeting to discuss the plan. There is a bit of a current, so after jumping off the back of the boat, use the rope on the surface to pull yourself to the mooring line which we will use to descend. The mooring is atop an underwater mountain whose peak is at about 18 meters/60 feet. From there, we will descend lower, staying on the side of the mountain protected from the current. When one of us reaches 70 bar of air pressure in our tank (about a third of a tank), we will start our ascent.
{Error in judgement: During our pre-dive meeting, we didn't discuss how deep we would go, nor what we would do if one of us reaches our "no decompression limits". I should have asked and make it known if I wasn't comfortable with the plan.}
That first dive went went well for me, but was difficult for Jesslyn - see her previous blog post for those details. The dive ended when she hit 70 bar as planned. We stayed within our no-decompression limits and did our 3 minute safety stop. The next dive was at the same site and Jesslyn opted to sit this one out. I decided to go. With the three of us more experienced divers, our divemaster was much more aggressive. We descended quickly to where we saw a couple enormous grouper in the 300 lb. range. We followed the grouper even deeper, I noticed we were quite deep and purposely stayed as shallow as I could while still being able to see the divemaster below me. After the dive, my computer registered my deepest as 42.5 meters, or 139.5 feet.
{Error in judgement: I wasn't comfortable going that deep. If I were diving without a guide, I would never even come close to that depth. The PADI advanced certification that I have qualifies me to dive at 100 feet max. I should have communicated to the divemaster that I wasn't comfortable, if I could have gotten his attention without actually chasing him to that depth. Alternatively, I could have just not gone any deeper than I was comfortable, and let him come find me when he realized I was no longer following.}
Not too much time passed before my dive computer was beeping to warn me that I was about to surpass my no-decompression limit. Since I knew I had been shallower than the divemaster, I knew that he was also passing his limits. He wasn't fazed. I thought, "OK, we are going to do mandatory decompression stops, no problem. I am with an experienced diver.". Again, if I were diving on my own, I would never have done this.
{Error in judgement: If I wasn't planning on or comfortable with going past the limits before the dive, I shouldn't change my mind during. I should have communicated that I was going to ascend due to the no-decompression limit.}
There is another phenomena that divers experience at depth called "nitrogen narcosis". You basically can get high from diving deep. I don't recall having this feeling, but maybe I can blame some bad decisions on that? It is another reason why it is so important to have a thorough dive plan that everyone agrees upon and sticks to.
When I reached 70 bar of pressure in my tank, we started our ascent. The divemaster's dive computer told him he needed to stop at 15 meters, so we did. I don't think my dive computer was telling me to stop at 15 meters, but I can't be absolutely sure. I wasn't familiar enough with the computer I was renting to know definitively how it communicates mandatory decompression stops (see the first 'error in judgement' regarding diving with unfamiliar equipment). I stopped at 15 meters with the divemaster anyway, since it is more conservative than what I thought my computer was telling me. We did our second stop at 5 meters where my computer told me I needed to stay for 7 minutes. I stopped for 7 minutes, then to be conservative, I stayed for several more minutes before surfacing.
Back on the boat, I felt fine at first. As I was sitting cross legged on the bow, my leg went numb. It must have just been the way I was sitting since it went away after I stood up. I sat down again and the other leg went numb. Must still just be the way I was sitting.
{Error in judgement: If I had any suspicion on decompression sickness, I should have told the crew. At the very least, they could have administered first aid (oxygen), discussed other possible symptoms, and reviewed the dive profile on my computer.}
Over the course of the next 24 hours, I had a slight tingling sensation in my feet and legs below the knees, but I was sure it would just go away. We then flew to Chiang Mai.
{Error in judgement: Not only did I still not seek treatment, if there is any suspicion of decompression sickness DO NOT FLY! The pressure in an airplane at altitude is even lower than at sea level making the problem even worse. I told myself that I wasn't sick, so therefore flying shouldn't be a problem. To make matters worse, we were flying inland where there are no facilities to treat the problem.}
Once we were in Chiang Mai, the tingling sensation didn't go away. My mood was obviously affected by my anxiety because Jesslyn could sense it. I finally told her what was going on and she made me seek medical help. I first called DAN (Diver Alert Network) which has a free emergency medical advice hotline for divers. The gentleman I spoke with told me that my symptoms were consistent with decompression sickness and I should seek medical care. I did some research for a good English speaking doctor, and called to make an appointment. They could take me that day at 5pm.
{Error in judgement: Don't make an appointment for later in the day, go to the emergency room immediately. Decompression sickness is considered a medical emergency.}
The doctor in Chiang Mai did a neurological test, which I passed with flying colors. She was not familiar with dive medicine at all and suggested I take some vitamin B12 and see if it clears up over the next few days. I told her that I suspected decompression sickness so she called the local branch of the Bangkok hospital to consult. They told her that I needed to go to the hospital and if necessary, they could consult with a specialist in dive medicine in Bangkok. The next morning, I called DAN again. This time I spoke with a woman who asked me a lot more questions, like how many dives I did, how deep they were, how long they were. She told me that she was almost certain that I had decompression sickness and warned of the possible severe outcomes. Even if the symptoms went away on their own, they would likely recur and even do permanent nerve damage. I could even have nitrogen bubbles lodged in other places which could get into my spine or brain, and that is obviously really bad. She asked where I was so she could recommend a treatment facility. She agreed that going to the local hospital and consulting with experts in Bangkok was the best option. I was really impressed with her thoroughness, professionalism, and general care for my wellbeing.
So, we immediately went to the Chiang Mai branch of the Bangkok Hospital. I met with a doctor there who did another neurological test. She wasn’t familiar with dive medicine and told me that I should make an appointment with a neurologist. After firmly stating that we need to speak with a dive medicine specialist in Bangkok, we were able to get one on the phone. They told me to get to Bangkok for treatment (but don’t fly!).
We got on the 14 hour overnight train. It was the first overnight train we had been on and it would have been a pretty cool experience had I not been worried about permanent nerve damage to my legs. We had a first class cabin which meant it was just the two of us. There is a bench seat that folds out into a bunk bed. The employees on the train came and took our dinner and breakfast orders, delivered food, and even made up the beds for us. We ate, watched a movie on the iPad, then went to sleep. We woke up, had breakfast, got cleaned up, and then all of a sudden we were in Bangkok. Not bad for a $35 ticket. We will have to do that more often.
At the Bangkok Hospital in Bangkok, we didn’t have to wait long before meeting with a doctor who very quickly assessed my situation and had me immediately go to the 6th floor for hyperbaric oxygen (HBO) treatment. I remember seeing pictures of hyperbaric chambers about 25 years ago, and I recall these large steel spheres with a small porthole in it. The person is sitting inside wearing a mask feeding them oxygen. They aren’t like that at all anymore (or at least that is not what I experienced). Instead, you lay down on a table, and they slide you into a clear tube. There is no mask to wear since the entire tube is fed with oxygen. Because the air inside is almost pure oxygen, you can’t take anything in with you since it is a highly flammable environment. Only cotton clothes are allowed (they made me change into a hospital outfit). You have to wash off any makeup, lotion, and even deodorant you are wearing. They put a grounding strap on your wrist to prevent static electric sparks. Apart from thinking about dying in a fire inside this tube, the experience was not bad at all. After they seal the chamber, it is slowly pressurized. As the pressure builds, you need to equalize the pressure in your ears just like when diving. Once the pressure levels off, you just lay there. For me, it was actually quite peaceful. It is not claustrophobic since the tube is clear. All you hear is the ssshhhhhh sound of the oxygen entering the chamber. So, I slept a little, but I think all the oxygen made that tough. Mostly I tried to meditate. I could actually feel things happening in my legs. I think I was at peace because I had the feeling that I was being healed. For the first session, a pressure equal to 66 feet underwater was applied for 30 minutes, then 50 feet for one hour. The next session that day was for 3 hours at 33 feet. I continued with 2 sessions per day, each one for 90 minutes at 33 feet, over the next couple days.
There was a dramatic improvement in the tingling sensation I felt after the first and second sessions. There was less improvement with each subsequent session. After 6 sessions and 11 hours total in the chamber, the doctor felt that all the nitrogen should be gone. I still have slight sensations in my legs at times, and the doctor feels that it is due to some of the damage that was done, but it should heal on its own over the next week or two.
I wasn't sure what the medical facilities would be like here in Thailand. There was no need to worry, they were fantastic. The Bangkok Hospital in Chiang Mai and in Bangkok are two of the most modern and clean hospitals I have been in anywhere in the world. We never had to wait long for anything. They speak English extremely well. They helped us to extend our travel visas. The billing and paperwork were all straightforward. The medical costs should be reimbursed by our US health insurance and the travel costs should be covered by our supplemental travel insurance. But if they weren't, it wouldn't break the bank like it would have it we had to pay out of pocket in the US. In fact, the first doctor I saw at the clinic in Chiang Mai didn't charge me anything. During our final consultation with the doctor he asked where we were headed next. After telling him we are going to Laos, he chuckled and said, "don't get sick there". I suspect their medical facilities may not be on par with Thailand. We will be extra careful there, and no diving.
This was a clear reminder that I am the only person responsible for my own health and safety. It has certainly been our experience that there is a lower level of safety standards and regulations here in Thailand (our snorkeling trip in lightning and the ferry with a missing section of railing on the top deck come to mind). However, the dive shop and charter were run by Europeans, not Thai people. Plus, the dive shop we dove with in Koh Lanta couldn't have been more conservative and safe.
I am extremely lucky that things didn't turn out worse. After having decompression sickness and a significant delay before treatment, this was the best outcome that could have happened. Worst case is death. Best case is having our travel plans have been interrupted. We missed out on the Loi Krathong festival in Chiang Mai, when thousands of lanterns are released into the air. Jesslyn was more excited about this than anything else I can think of recently. We missed our cooking class and our visit to the Elephant Nature Park. We had to waste time in Bangkok rebooking things and filing insurance claims.
I am embarrassed that this happened to me. I am supposed to know better. I feel like a jerk for causing all of this inconvenience and worry for my family. Despite my shortcomings, Jesslyn is awesome. She was by my side the entire time, reminding me that our travel plans are not important. What is important is getting healthy. While I was in the chamber, she was there next to me figuring out how to get our travel arrangements back on track. Thank you Jesslyn for your love and support.
Me inside the hyperbaric oxygen chamber.
- Jake
Nitrogen and Diving
Since I am not an expert on the topic, I will keep this explanation high level. The air we all breathe everyday is mostly nitrogen, and that is also true for the air in a scuba tank. When your body is under pressure while underwater, that nitrogen ends up in solution in your blood and tissues. The longer and deeper you go, the more nitrogen gets absorbed. When you ascend, the nitrogen leaves your system. If you do it correctly, it will leave your system slowly with no problem. If you ascend too quickly however, the nitrogen will turn to a gas and create bubbles (Imagine a soda bottle that hasn't been opened, there doesn't appear to be carbonation, but once you open the cap and relieve the pressure, bubbles suddenly appear.). In diving, this is a serious condition is known as decompression sickness. To avoid it, divers typically keep their dives short enough and shallow enough such that very little nitrogen ends up in their blood. This is staying within the "no decompression limits" which means no need to do anything special other than ascend slowly. Even though not absolutely required, it is a standard practice to stop at 15 feet below the surface (called a safety decompression stop) to let excess nitrogen safely dissipate. If you stay too deep for too long, you must do (a) decompression stop(s) for some amount of time. Divers wear a small computer on their wrist that tells them how long they can stay at the current depth without a mandatory decompression stop, and if it is exceeded, it displays what depth(s) and for how long to stop during the ascent. But everyone's bodies are different, and even the same person's body is different from day to day (fatigue, illness, dehydration are factors) so there are no universal limits. That is why it is recommended to stay well within the limits.