Santa Claus Gets Bent

Highlighting the severity and commonality of skin bends
Text by Dennis Guichard

I still remember the night in late December. It was a full moon, and the wind was blowing all over the place as it often does when the moon is full. The moon, which is always exciting to stand and gaze at, was shining a deep crimson red just as it broke the horizon out over the sea in the late-night sky.

The hospital was quiet after Christmas with many of the consultants, bar those working in emergency and tending to the wards, still being on their Christmas weekend leave. It was a lovely night to stand outside in the fresh air, marvelling at the view of sparkling lights over the Durban harbour and out to sea.

The peaceful silence was shattered as the red phone on our reception desk rang urgently. Leaves chased me with the wind into the reception as I opened the door to answer the call. What a bizarre night it was about to be.

Turns out the call was from the Netcare 911 paramedical team, who were currently up at Sodwana Bay attending to a diver who had felt unwell in the early evening after a few repetitive deep dives. The diver was pale in complexion and struggling to stand without falling over: that, combined with bouts of emesis (which is a more polite medical term defining the act of vomiting). It certainly sounded like a serious neurological or inner ear bend.

We were asked to get our chamber ready for the patient and that the ‘HEMS Netcare 7 (NC7)’ helicopter was just about to start up for its low-altitude flight back to St Augustine’s hyperbaric facility in Durban (I’ve always imagined that must be the best job in the world doing low altitude flights along the stunning KwaZulu Natal coastline and getting paid for it).
 
I always get excited when any diver presents at the chamber with suspected decompression sickness. Deco science is what brings us alive. It’s what we live for. It’s more exciting than a new packet of biscuits, although I’m certainly partial to those too as my waistline will attest. But that’s got nothing to do with the story.

All the patients’ stats we were given were that the diver was in his late 70s, somewhat overweight, had an extensive white beard, and was jovial despite the circumstances. His blood pressure was reduced (hypotension),  he was struggling to urinate (oliguria), had cold clammy skin (hyperhidrosis), a racing pulse (tachycardia), and a large blotchy blue-purple rash around his substantial abdomen (Livedo Racemosa).

Embroiled in excitement and anticipation myself, I put the phone down and put a call out to our stand-by chamber operator and double-checked that our doctor was activated and en route too. Our Xmas tree was sparkling away in the corner with a packet of mince pies still resting on the branches that a kind patient had left for the chamber staff to enjoy. I proceeded to get the chamber ready for use, checking the air banks were at full pressure and all our necessary medical supplies were on hand for the patient's arrival.

A long drawn-out 2-hours later, ‘NC7’ landed on the roof of the hospital, and the patient was wheeled into our facility after a brief visit to the Emergency Room. It’s always the most exciting time, getting to see what it is that we might have to deal with. Getting the necessary paperwork in order, we asked the diver what his name was. And like out of a suspenseful 007 Bond movie, he told us in poor English, tainted with a heavy hint of Scandinavian accent, that his name was ‘Claus’... ‘Santa Claus’.
 
For a moment, my mind raced in panic. I was glad I’d kept the Christmas tree lights on, but I wondered quite how much he might’ve known about me being either good or bad that year. It was also clear that a few of the mince pies had gone ‘missing’ in the time I was left waiting for his arrival.  

I also had a few questions in mind, like why I never quite seemed to get the presents I asked for, but now didn’t seem like the time to either ask difficult questions or panic.

The term Decompression Illness covers both Decompression Sickness (DCS) and Arterial Gas Embolism (AGE). DCS may be caused by local bubble formation from excessively supersaturated tissues after dives. AGE, on the other hand, can be caused by ruptured alveoli in the lungs or by paradoxical embolism of venous gas bubbles bridging through into the arterial vascular system through a hole in the heart called a PFO (Patent Foreman Ovale).
 
These tiny bubbles can then grow further as they come into contact with supersaturated tissues and/or elevated dissolved gas tensions within the blood. These bubbles can cause vascular inflammation, soliciting an immune system response, and/or can grow large enough to cause a myriad of tiny vascular blockages. One of the telltale signs of this malady is a mottled patterned rash which we refer to as Livedo Racemosa (LR), more commonly known as a skin bend.
Skin bends have long been regarded as a mild form of DCS. They should however be treated as a serious condition because of the severe potential of an underlying neurological complication. Some have postulated that skin bends may be caused by bubbles affecting the brain stem, resulting in the release of neuropeptides, which control vasodilation and vasoconstriction of blood vessels in the skin. Although this remains a controversial hypothesis. Skin bends, regardless, is a potentially severe manifestation of DCS that can, at times, be life-threatening if not managed appropriately.

The condition can result in a significant loss of circulating blood volume, similar to what occurs in extensive burns or severe allergic reactions, potentially leading to life-threatening hypovolaemic shock. Some patients with skin bends may require the administration of substantial intravenous fluids to counteract this shock during hyperbaric chamber treatment.
It’s impossible to predict whether a skin rash will develop into a harmless, self-limiting ailment or a dangerous shock-inducing condition. Therefore, it’s crucial not ever to take one lightly if you experience one after a dive.

There is a strong correlation between skin bends and the presence of a PFO in any diver. As many as 30% of us can have one, although only about 6% of divers are considered to have a PFO large enough to be problematic in diving. PFOs are central to many forms of DCS, and the challenge is we won’t know we’ve got one until we do bend.
Santa’s dive profile wasn’t at all provocative. He followed a good slow ascent rate, did a 5-minute safety stop at 6m depth, and his peak surfacing gradient factor was only at 82%. Santa, however, had been working hard in previous evenings delivering presents to all the good children. He was exhausted and had certainly eaten too many mince pies stopping off at everyone’s home. Too many beers, left by desperate Dad’s, hoping not to get any more socks, had also exasperated his level of dehydration. And then just bad luck that it turned out he’d had this PFO since birth.
In truth, DCS is rare, postulated to only occur in 2 in every 10,000 dives in warm water. But it can often be quite serious when it does occur. If you have a PFO and you align many of the predisposing risk factors, then you’re certainly inviting one to occur.

Alcohol and diving don’t mix. Alcohol can lead to dehydration, and we know that it also interferes with blood serum surface tension. It also reduces surface tension in bubbles trying to make their way to the lungs to be expelled.

Being overweight is also a predisposing risk for DCS. Some would argue that fat is a slow tissue and thus irrelevant in sports diving. Still, it does seem that skin bends (Livedo Racemosa) has a prevalence for subcutaneous fatty areas like the abdomen, chest, thighs, buttocks, breasts (man boobs), and upper arms.

And Santa was a recipe in the making for all of these predisposing risk factors. All he wanted was to enjoy a few dives and some peace and quiet in the idyllic warm waters at Sodwana Bay. It was a good choice to make, and his rampant Ho Ho Ho’s certainly livened up life on the beach. But it just wasn’t his day, and despite doing everything seemingly right, he got the bend regardless. DCS is like that.

Many questions remain. Why Santa had to take the ‘Netcare 7’ helicopter back to Durban instead of just catching a lift on his sleigh? I can only suppose that his reindeer, too, were off sauntering through the iSimangaliso Wetland Park, fraternising with our local zebra and blesbok. Whether he gifted himself his own full set of scuba gear or whether he just rented locally. You’d hope that anyone would always rather have their own kit to use, but I suppose he might not have had space in the boot of the sleigh for all of it.

Santa responded well to a US Navy Treatment Table 6 session in the chamber and 6 litres of IV fluids. After annoyingly finishing off my pack of mince pies, he was released to make his way back north. All’s well that ends well.

From me, I wish you all a very Merry Christmas and all of the very best for a very exciting New Year and all that 2024 might bring. I’m hoping I might get a better present from Santa this year, but I won’t hold my breath.
Enjoy your diving. Stay safe out there.