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SCUBA Diving and Decompression Sickness

Stefan Thiesen, (c) Hawaii, 1994Now: Werner Str. 203D-59379 Selm / Germanyemail:thiesen@uni-muenster.deSCUBA diving nowadays allows easy access to the underwater realmfor almost everybody who can afford to buy or rent the equipment, andthe theory behind the underlying principles of recreational diving isrelatively well understood. Diving is a safe sport if divers are properlytrained and stay within safe limits. The problems already begin with thedefinition of these limits. One of the main dangers is the possibility of amedical condition called decompression sickness or "caisson disease" afterthe French word for box. It was first observed in 19th century France whenunderwater constructions were carried out by workers in boxes on theground of rivers.As implied by the name, decompression sickness is a pressurerelated condition caused by the rapid lowering of ambient pressure, in thecase of SCUBA diving during a fast ascent, usually after a deep dive. The behavior of liquids and gaseous substances with changingpressure and temperature are very well understood, while ourunderstandings of the physiological effects are still incomplete.Under surface norm pressure of one bar only about 4% of theOxygen of each inhalation are metabolized and exhaled as Carbon Dioxidewhile the atmospheric Nitrogen does not contribute to any physiologicalfunction since it is an inert gas. Under water the situation changes. In awater depth of 20m for example we find a surrounding pressure of threebars, that means although the air still consists out of 78% Nitrogen, theNitrogen partial pressure tripled to 0.78 bar * 3 = 2.34 bar, so that there isa higher partial pressure of Nitrogen in the Lungs than in the bodies'tissues which according to the normal human environment are onlysaturated with Nitrogen at a partial pressure of approximately 0.78 bar.While diving, an equalization of the lung and the tissue partialpressures progresses during which Nitrogen continually flows from theLungs into the bloodstream and is distributed to all cells and tissuecompartments. The Nitrogen Molecules are transported from the region of higher partial pressure to the region of lower pressure until a state of equilibrium is reached and the pressure gradient disappears. The reasonwhy only the Nitrogen has to be taken into consideration is because theOxygen does not accumulate in tissues since it is metabolizedcontinuously. The amount of Nitrogen saturated in the blood and tissuesdepend on the surrounding pressure, that means the depth of the dive and1

is based on Henry's law stating that, "The amount of gas that will dissolveinto a liquid at a given temperature is proportional to the partial pressureof that gas."During the ascent this situation is reversed so that after ending thedive the Nitrogen partial pressure in the human tissue is higher than in thebreathed surrounding air. While the ongoing saturation of body tissuesduring descents and deep diving does not have any known negativeeffects, the harmless desaturation goes hand in hand with a maximumpressure reduction rate per time. In other words: it is not dangerous at allin terms of decompression problems, to immediately descent to forexample 40m, but it will surely result in severe problems to directly shootup to the surface from the same depth at the end of the dive. The samephenomenon can be observed as seen when a can of soda is suddenlyopened after it has been shaken. The gas molecules follow Henry's lawand "pearl out" from the surrounding liquid due to the sudden drop of pressure. In the case of the soda the gas is Carbon Dioxide, in the case of the human body it is Nitrogen that is in physical solution up to thesaturation limit under surface pressure and although the saturation limitusually is not reached at the maximum diving depth during a dive, it iseasily exceeded when ascending again even from moderate depths. Thismeans that a fast ascent leads to the formation of bubbles in the humanbody liquids, that is the blood in the major blood vessels as well ascapillaries, tissues, joints and bones. The single most important factor forthe probability of developing decompression sickness is the time, is howlong the diver has been breathing air under increased pressure, since thedifferent tissue compartments have different saturation coefficients andcharacteristic saturation/desaturation times (from only minutes to severalhours at a given pressure). The time needed for saturation on the otherhand depends on the circulation and blood supply to the tissue area inquestion, so a distinction can be made between "fast" and "slow" tissues.In the terminology used blood, muscles and the neural system areconsidered as fast "tissues" and bones, cartilage, sinews, joints andarticular capsules are slow tissues. The next important factor is the "solubility coefficient". Nitrogen ishighly soluble in fat tissues -- five times as high as in diluted tissues. Onthe basis of empirical and experimental data the first decompressiontables were developed by J. Haldane and all later developments are basedon this fundamental research. Although observed as early as 1854,decompression sickness wasn't systematically explained before theFrench researcher P. Bert figured out that the "caisson disease" or "TheBends" called medical condition has its origin in the bubbles formed inhuman tissue by nitrogen during de pressurization. Bert did major researchwork and his work "La Pression Barometrique" as well as his practicalrecommendation concerning slow ascents and treatment of decompression sickness remained valid for a long time, although it didnot yet include a systematic understanding of the behavior and connectionof different tissue types and parts of the human body. Haldane later usedgoats for pressurizing experiments to determine how much nitrogen canbe dissolved in tissues and where the limits for decompression times and2

pressures/depths are. His experiments were successful, the results verifiedby human divers and concluded in the first usable dive tables and largelyincreased diving safety. [PADI 1988: The Encyclopedia Of RecreationalDiving] The tables estimate the minimum time needed for the differenttissues to de-saturate safely, and there are different models used forachieving these goals. These models mainly differ in their complexity andtheir field of application. Tables used for recreational diving are moreconservative, that is "on the safe side", than tables used by professionaldivers in the fields of technical or military diving. On the other handprofessional divers work under water what has effects on the behavior of their tissues that need to be taken into account. The development of modern diagnostical methods, namely theultrasound Doppler detector allowed to prove that the amount of Nitrogenbubbles forming after every dive differs every time, so more accuratemodels for tables and later dive computers could be derived.Diving within the conservative limits of decompression sickness isnormally safe. However: Statistical uncertainties are involved. In somecases one diver shows symptoms after a dive, while all other divers in hisgroup are free of symptoms although they all ascended at the same rateand followed a similar dive profile. This is because it cannot be clearlypredicted where and when small bubbles of Nitrogen clot, form a largerbubble and block a passage to an important body compartment, such asparts of the heart or nervous system. This circumstance makes it evenmore important to stay on the conservative side and properly plan eachdive - especially for recreational diving.

The Two Types Of Decompression Sickness:

Decompression Sickness can be divided into two categories due totheir signs and symptoms. Type one is characterized by the fact that pain is the only symptom. This pain can be felt in different parts of the body and results from localdamage to body tissue. In about 75% of all cases the joints are the mostaffected areas, due to the pain forcing the patient to bend the joints (thisis where the name "The Bends" comes from). In ca. 20% of the cases, skinsymptoms can be found and 5% of the cases suffer from blocked lymphchannels. The later can result in edemas and severe pain. SupplyingOxygen is mandatory and treatment in a recompression chamber shouldbe considered in severe cases. Type two is defined by severe conditions affecting the nervoussystem (brain, spinal cord) and the respiratory system. In most cases(approx. 2/3) decompression sickness of type two also shows thesymptoms of type one. The symptoms are as in type one plus choking andcoughing, shallow breathing, burning chest pain and shock due to lack of Oxygen. Damage to the nervous system can result in many different3

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