UHM 2014, Vol. 41, No.

3 – DCS CaSeS in TURKEY 1963-1998

Decompression sickness cases treated with recompression therapy

between 1963 and 1998 in Turkey: Review of 179 cases
Akin Savas Toklu 1, Maide Cimsit 1, Senol Yildiz 2, Gunalp Uzun 2, Sefika Korpinar 1, Hakan Sezer 3, Samil Aktas 1
1 Department of Underwater and Hyperbaric Medicine, Istanbul University, Istanbul Faculty of Medicine,
Istanbul, Turkey
2 Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Teaching

Hospital, Istanbul, Turkey

2 Turkish Naval Forces, Underwater and Salvage Command, Beykoz, Istanbul, Turkey

CORRESPONDING AUTHOR: Akin Savas Toklu, M.D. – akin@toklu.net

_______________________________________________________________________________________________
ABSTRACT

The purpose of this study was to review the cases
diagnosed as decompression sickness (DCS) with
recompression therapy treament between 1963 and
1998 in Turkey. The records of 179 cases were
analyzed for age, gender, type of DCS, presenting
signs and symptoms, time to onset of symptoms,
time to recompression therapy, recompression table
used, total number of treatments and outcomes.
The diving depth on the day of injury ranged between
60 and 215 fsw (18 and 65 msw). The symptoms
developed during ascent or within 10 minutes after
surfacing in 47% of divers and within the first hour
in 87% of the divers. The most frequent symptom
_____________________________________________________________________________________________
was sensory loss in the extremities. The dive before
the symptoms was a repetitive dive in 50% of the
cases and the diagnosis was Type II DCS in 79%
of these divers. Most of the divers (84%) received
recompression therapy after a delay of more than 12
hours. Healing rate was 68% with the air recompres-
sion tables and 86% with the oxygen tables. Repeti-
tive dives were associated with a higher incidence
of Type II DCS than single dives (79% and 66%,
respectively). The results using recompression
tables with oxygen were more successful than the
treatment with air tables.

INTRODUCTION Commercial diving in Turkey began with sponge

Decompression sickness (DCS) occurs when there is a
rapid decrease in environmental pressure, such as during
ascent from a dive, exit from a caisson (compressed
tunnel) or fast ascent to altitude. The bubbles formed
by the previously dissolved inert gases in blood vessels
or tissues play a critical role in the pathophysiology
of the disease [1]. DCS can cause a wide variety of
symptoms such as pain, skin problems like itching
and rashes, neurological symptoms as numbness and
tingling, muscular weakness or paralysis, loss of bowel
or bladder function, loss of coordination and even col-
lapse or unconsciousness [2]. DCS cases should receive
prompt recompression therapy in a hyperbaric chamber
after diagnosis is established. The time interval between
the onset of DCS and recompression therapy will affect
the result of the recompression therapy and the course
of the disease [3].
diving in the 1930s [4,5]. The sponge divers used to
learn diving by apprenticeship. They utilized in-water
recompression on air in the event of DCS until the
Turkish Naval Forces established a recompression unit
in the 1960s. At that time, the only land-based recom-
pression chamber that was used for the treatment of
DCS was in the Turkish Naval Forces Underwater &
Salvage Command. The facility was located in Istan-
bul, and all DCS cases who required recompression
treatment were referred to this facility until the new
hyperbaric unit was established in 1984 in Bodrum,
where the majority of sponge divers used to live. In
1989, another hyperbaric chamber was established in
the Istanbul Faculty of Medicine, Department of
Underwater and Hyperbaric Medicine for the treatment
of DCS and other indications that require hyperbaric
treatment. This study includes DCS cases treated in

Copyright © 2014 Undersea & Hyperbaric Medical Society, Inc. 217

 UHM 2014, Vol. 41, No. 3 – DCS CaSeS in TURKEY 1963-1998
these three recompression chambers between 1963 and
1998. The number of hyperbaric centers in Turkey has
increased due to private companies opening centers
since 1998 [6].
We retrospectively evaluated 179 DCS cases treated
at the three hyperbaric facilities listed below between
1963 and 1998 to see the distribution and onset time of
the symptoms, the delay in recompression therapy, and
types and outcomes of the recompression treatments.
Since this study spans a considerable period before
the introduction of recent descriptive terminology on
decompression disorders, classical terminology for the
categorization of decompression sickness will be used
throughout.
METHODS
The source of the data used in this study were records
of the patients treated at three hyperbaric facilities in:
1. Turkish Naval Forces Underwater & Salvage
Command in Istanbul;
2. Fishery Institute in Bodrum; and
3. Istanbul Faculty of Medicine, Department of
Underwater and Hyperbaric Medicine in Istanbul.
All facilities had a multiplace double-lock recom-
pression chamber. Usually quick transfer was not
possible from the diving site to the recompression
chamber because of limited transportation facilities.
We evaluated the medical records of 232 DCS cases.
Of these, 53 (22%) cases were excluded due to incom-
plete data. The records of 179 cases who were treated
between 1963 and 1998 in the three centers were ana-
lyzed for age, gender, type of DCS, presenting signs
and symptoms, time to onset of symptoms after sur-
facing, time to recompression therapy, recompression
table used, total number of recompression treatments,
and outcomes. Although all the charts included the
symptoms, onset time of the symptoms, type of recom-
pression tables, delay in the treatments, some did not
contain the details of the neurological examinations.
Long-term follow up was not available in any patient.
The denominator was 179 while calculating per-
centages for presence or absence of a condition. The
continuous data were presented as mean, median,
minimum, maximum and standard deviation (SD).
RESULTS
The data from 179 DCS cases were analyzed. All of
the divers were male, the mean age was 29.6 years
(16-57 years). There were 168 (94%) commercial
divers and 11 (6%) recreational divers. The diving
218
__________________________________________________
Table 1. Symptoms observed in divers
n percentage
__________________________________________________
sensory loss in the extremities 88 49.2
__________________________________________________
weakness in the extremities 80 44.7
pain in the extremities 73 40.8
__________________________________________________
__________________________________________________
urinary incontinence 42 23.5
__________________________________________________
chest pain 22 12.3
__________________________________________________
paraplegia 17 9.5
nausea and vomiting 15 8.4
__________________________________________________
__________________________________________________
back pain 14 7.8
__________________________________________________
dispnea 12 6.7
__________________________________________________
rectal incontinence 9 5.0
dizziness 9 5.0
__________________________________________________
__________________________________________________
stomach ache 8 4.5
__________________________________________________
skin rash 8 4.5
__________________________________________________
numbness in trunk 8 4.5
hemiplegia 7 3.9
__________________________________________________
__________________________________________________
fainting 7 3.9
__________________________________________________
headache 6 3.4
__________________________________________________
speech disorders 4 2.2
subcutaneus emphysema 4 2.2
__________________________________________________
__________________________________________________
visual disturbance 3 1.7
__________________________________________________
imbalance 2 1.1
__________________________________________________
hearing loss 2 1.1
tinnitus 2 1.1
__________________________________________________
__________________________________________________
blackout 2 1.1
__________________________________________________
convulsion 1 0.6
depth on the day of injury ranged between 60 fsw
(18 msw) to 215 fsw (65 msw).
Fifty divers (28%) had Type I DCS, and 129 (72%)
divers had Type II DCS. Type II DCS occurred in
70 of 89 divers (79%) who performed repetitive dives
on the day of injury compared with 59 of 80 divers
(66%) who had made only a single dive. The mean
duration between surfacing and the onset of symptoms
was 41 minutes with a range of 0-300 minutes. The
symptoms developed during ascent or within 10
minutes after surfacing in 47% of divers and within
the first hour in 87% of the divers. The symptoms
observed in the divers are listed in Table 1.
After recompression treatment, 41 (23%) divers
made a complete recovery. Significant improvements
were achieved in 104 cases (%58). There were minimal
residual symptoms such as slight weakness, numbness
A.S. Toklu, M. Cimsit, S. Yildiz, G. Uzun, et al.
 UHM 2014, Vol. 41, No. 3 – DCS CaSeS in TURKEY 1963-1998
and pain in these cases when recompression treat-
ments were stopped. Fourteen (8%) divers had re-
sidual symptoms that affected their quality of life,
and two divers died. Information about final out-
comes could not be reached in 18 cases since they
had been referred to hospitals for additional care.
number of divers
The mean delay from initial symptoms to recom-
pression therapy was 47 hours (median: 24 hours),
with a range of 4-720 hours (Figure 1). The healing
rate reduced with increased delay to recompression
therapy. The complete or partial healing rate was
96% in divers treated in the first 10 hours after
the onset of the disease. 74% of cases were treated
within 24 hours of the onset of DCS. Of these,
83% had a complete or partial recovery.
In divers who were treated more than 24 hours
after the onset of DCS the full or partial recovery
rate was 80%. In six divers the delay to treatment was
greater than seven days. Four of these (57%) experi-
enced significant improvement, with only mild residual
symptoms.
Divers received a variety of recompression treat-
ments, including U.S. Navy Treatment Table (USNTT)
1A, 2A, 3, 4, 5, 6 and 6A and standard hyperbaric
oxygen treatment table (Table 2). The oxygen treat-
ment tables as USNTT 5, 6 and 6A were used after
1980 in 125 cases. Fifty-nine (33%) divers received
more than one treatment. While the complete or partial
healing rate was 68% after treatment using air tables, it
was 86% after the oxygen tables. The information
about the use of adjunctive medical treatments such
as steroids or intravenous fluids was not sufficient in
the charts for evaluation.
Nearly one third (n=57, 32%) of the divers had tried
in-water recompression on air after injury. Complete
and partial healing was observed in 40 of 57 (70%)
divers, while this rate was higher (81%) in divers who
did not attempt in-water recompression. A few divers
were urged to run after injury by other divers. Methods
like massaging with olive oil, burying the divers in
sand and keeping divers awake were other empirical
procedures for managing the symptoms of DCS among
sponge divers.
Two divers (1.1%) died. Both were commercial
divers with type II DCS. There was gross omitted
decompression stops in their dive profiles. One diver
went to 120 fsw (36 msw) depth four times, with about
40 minutes of bottom time for each dive and surface
intervals of less than an hour. The other diver made
A.S. Toklu, M. Cimsit, S. Yildiz, G. Uzun, et al.
___________________________________________________
Figure 1
120 ________________________________________________________________________
100 ________________________________________________________________________
80 ________________________________________________________________________
60 ________________________________________________________________________
40 ________________________________________________________________________
20 ________________________________________________________________________
0 < 6 hr |
7-12 hr
| |
13-24 hr 25-48 hr
|
2-7 d
|
>7d
|
The time interval between initiation of symptoms
and recompression therapy.
__________________________________________________
Table 1. Recompression tables used in the treament
of decompression sickness
n % complete or
partial recovery
__________________________________________________
__________________________________________________
USNTT 1A 1 0.6 100.0
__________________________________________________
USNTT 2A 6 3.4 83.3
__________________________________________________
USNTT 3 10 5.6 90.0
USNTT 4 37 20.7 59.5
__________________________________________________
__________________________________________________
USNTT 5 40 22.3 100.0
__________________________________________________
USNTT 6 42 23.4 88.9
__________________________________________________
USNTT 6A 35 19.5 34.2
Clinical HBO2 therapy 8 4.5 100.0
__________________________________________________
his last dive as a second dive to a depth of 215 fsw
(65 msw) with a bottom time around 20 minutes. The
deaths occurred during recompression treatment with
USNTT 4.
DISCUSSION
In this retrospective study, we evaluated 179 divers who
received recompression treatment between 1963 and
1998 in Turkey. The vast majority of the divers were
commercial divers (94%). Two factors may have affect-
ed this distribution. First, the number of recreational
divers was not significant until the mid-1970s. Second,
sponge divers made up the majority of the diving
population in Turkey during the study period, and the
DCS rate was very high in these divers due to unsafe
diving practices (4). The main purpose for diving
219
 UHM 2014, Vol. 41, No. 3 – DCS CaSeS in TURKEY 1963-1998
between these two diving groups was different. While the
commercial divers were compelled to dive for a living,
recreational divers did because they had enough money
to do so. This may in part explain why the dive pro-
files of two groups differed and why commercial divers
violated the safe diving limits more frequently.
In this study we have classified cases as Type I, Type
II and arterial gas embolism. Arterial gas embolism
refers to neurologic symptoms which manifest short-
ly after diving and results from introduction of air
into the circulation by pulmonary barotrauma. Divers
with musculoskeletal, skin or lymphatic symptoms
were classified as Type I DCS and divers with neuro-
logic, cardiorespiratory, audiovestibular symptoms or
shock were classified as Type II DCS.
Recently, a modification of this terminology, which
combines arterial gas embolism and DCS as “decom-
pression illness,” has been proposed [7]. This new
terminology has removed the need to distinguish be-
tween cases with arterial gas embolism and Type
II DCS. In this study most of the divers had Type II
DCS (72%). The most frequent symptom (49.2%) was
sensory loss in the extremities. In fact, pain in the
extremities has been reported to be the most frequent
symptom in DCS [8,9]. In our case series, pain was
recorded in 40.8% of the cases. Most probably the
majority of divers with complaints of pain alone
(Type I DCS) did not seek recompression therapy.
Subcutaneous emphysema was reported in four cases.
It is possible that some of the cases who received
recompression therapy had pulmonary barotrauma.
Unless an accompanying pneumothorax presents, pul-
monary barotrauma is not a contraindication for
recompression therapy.
In our study, we found that a significant number of
divers (32%) tried in-water recompression on air after
injury. All of these divers had serious decompression
sickness, except one case, who had Type I DCS. In-
water recompression is the practice of diving back to
the previous depth in order to eliminate the gas bubbles
that are causing symptoms. It is used if DCS occurs
in remote locations, where a recompression chamber
is not available for treatment. Since divers’ symptoms
can worsen underwater, they can become unconscious
and drown. Because of this, in-water recompression
should be attempted only if adequate equipment and
educated personal are available. We found that com-
plete or partial healing was lower in divers who at-
tempted in-water recompression compared to divers
220
who did not attempt in-water recompression (70% vs.
81%, respectively). In contrast to general recommen-
dations, our cases used air rather than oxygen for in-
water recompression. This may explain the unfavor-
able outcome of divers who attempted in-water recom-
pression.
Repetitive diving is a common practice in com-
mercial divers in Turkey [5]. Turkish sponge divers
frequently omit surface intervals between repetitive
dives, which increases the risk of DCS. The rate of
Type II DCS was higher in the divers who performed
repetitive dives on the day of incident. Although we
do not know the number of single and repetitive dives
that were conducted during the period of this study, we
believe that repetitive dives increase the risk of DCS.
This study also demonstrated the change from air
tables to oxygen tables in recompression treatments.
The role of oxygen in the treatment of DCS either at
atmospheric or hyperbaric conditions is well estab-
lished. In our cases the results with recompression
tables with oxygen were more successful than the
treatment with air tables. Eighteen cases were referred
to hospitals probably because they required intensive
care or rehabilitation. The hyperbaric units were not
hospital-based except the one in the Istanbul Faculty of
Medicine. Ideally, it is better to treat severe DCS cases
in a recompression chamber located at a hospital, or a
hyperbaric unit with continuous hospital support.
Most of the cases presented with delay for re-
compression therapy since the importance of quick
transport was not fully understood. For the majority
of the cases the time intervals between the onset of
symptoms and recompression therapy was more than
10 hours. Those cases were delayed because of geo-
graphical factors. The location of dive sites and dif-
ficulties encountered during transport indicated the
necessity of recompression chambers in remote areas.
Currently hyperbaric units are available in those areas.
LIMITATIONS
There are limitations to our study. Due to the retro-
spective design of our study, we were unable to obtain
all the necessary information from the medical records
of all divers, and 22% of cases were excluded due to
incomplete data. Secondly, outcome data were not
available in 18 divers who were transferred to hospitals.
In addition, long-term outcomes of the divers were
not available.
A.S. Toklu, M. Cimsit, S. Yildiz, G. Uzun, et al.
 UHM 2014, Vol. 41, No. 3 – DCS CaSeS in TURKEY 1963-1998
CONCLUSION
Divers who attempt in-water recompression on air
may have unfavorable outcomes. DCS cases that occur
after repetitive dives are more severe. Oxygen recom-
pression tables are more successful than air tables.
Delays in the recompression treatment clearly affect
prognosis, but recompression treatment should be
applied to DCS cases even after long delays.
_____________________________________________________________________________________________________
REFERENCES
1. Francis TJR, Mitchell SJ. Pathophysiology of
decompression sickness. In: Brubakk AO, Neuman TS, eds.
Bennett and Elliott’s Physiology and Medicine of Diving,
5th edition. W. B. Saunders Co Ltd; 2003, p.530-56.
2. Eliott D, Kindwall E. Decompression Sickness. In:
Kindwall E, Whelan TW, eds. Hyperbaric Medicine
Practice 1st edition. Best Publishing Co. ; 2002, p.433-488
3. Ball R. Effect of severity, time to recompression with
oxygen, and re-treatment on outcome in forty-nine cases of
spinal cord decompression sickness. Undersea Hyperb Med.
1993;20:133-45.
4. Toklu AS, Cimsit M. Dysbaric osteonecrosis in Turkish
sponge divers. Undersea Hyperb Med. 2001;28:83-8.
5. Toklu AS, Cimsit M. Sponge divers of the Aegean and
medical consequences of risky compressed-air dive profiles.
Aviat Space Environ Med. 2009;80:414-7.
A.S. Toklu, M. Cimsit, S. Yildiz, G. Uzun, et al.
Acknowledgment
This paper was supported by the Research Fund of The Uni-
versity of Istanbul, Project Number: 6364.
Conflict of interest
The authors have declared that no conflict of interest exists
with this submission.
n
6. Aktaş S, Toklu AS, Yildiz S, Uzun G. Development of
underwater and hyperbaric medicine as a medical specialty
in Turkey. Undersea Hyperb Med. 2013;40:63-7.
7. Francis TJR, Mitchell SJ. Manifestations of decompres-
sion disorders. In: Brubakk AO, Neuman TS, eds. Bennett
and Elliott’s Physiology and Medicine of Diving, 5th edition.
W. B. Saunders Co Ltd; 2003, p.578-99.
8. Lam TH, Yau KP. Manifestations and treatment of
793 cases of decompression sickness in a compressed air
tunneling project in Hong Kong. Undersea Biomed Res.
1998;15:377-88.
9. How JH, West D and Edmonds C. Decompression sick-
ness in diving. Singapore Medical Journal. 1976;17:92-7.
✦
221