1. Fitness to Dive: The Health Professional’s Role in Evaluation
Joel Silverstein
Scuba Training and Technology Inc. / Tech Diving Limited
Claudette Dorsey, RN, Providence Little Company of Mary Medical Center 1

2. Overview
Divers should have a reasonable level of physical fitness to cope with the environmental stresses of being underwater.
Exertion required for propulsion through the surrounding water
Heat loss to water that is generally colder than body temperature
Breathing gas of compressed density
Changes in the cardio respiratory system from using underwater breathing gear
Changes in the gas volume and pressure within air spaces in the body eg; ears, stomach, etc
Introduction into the body of gases that can have toxic, narcotic, stimulatory or gas solubility effects on bodily functions.
. Even a diver in good health can experience physiological strain from environmental factors that include: 2

3. Dive Medical Requirements
The rules and requirements are slightly different for different classes of divers:
Military
Commercial
Scientific
Technical
Recreational
This presentation will focus on the recreational diver’s needs.
Assumes the medical professional is also a diver. 3

4. Goals for Diver Medical Exam
Exclude people from SCUBA who have medical conditions causing unacceptably high risks.
Illuminate medical conditions present that, while not precluding diving, could increase risks.
Educate to risks of common conditions and simple risk management for diver and his/her dive buddies.
Diving is Dangerous – Most People Should Not Do It 4

5. Chronic Health Conditions Reported by DAN - PDE
Percent of PDE Divers

6. Distribution of Fatalities by Age and Gender
Percent of Fatalities
Age (Years)
DAN

7. Classification of Fatalities by BMI
75% were not healthy
Percent of Fatalities
Overweight
DAN
BMI Classification

8. Certification of Divers Who Died
Percent of Fatalities
DAN
Certification

9. Cause of Death Decided DAN N = 88 (on certificate)
Percent of Fatalities
DAN

10. Disabling Injury
N = 71
Percent of Fatalities
DAN

11. How many of each year’s diving fatalities and injuries would have been avoided had the diver had a proper medical examination ?
Would she have sought treatment or improved health condition and delayed diving ?
Illumination and Education of your patient’s condition is the goal.

12. Typical Scuba Agency Questionnaire

13. And your patient asks you to sign this form !

14. Are you ready to sign on the line ?

16. “Doctor, you are priceless…”
An expert physician with experience in diving.
A diver who understands the “why” behind the anatomy and physiology of diving.
A resource to the diving community.
A reference for your non-diving MD colleagues.
A reality check in a world of often baseless opinions. 16

17. Goals: Exclusion, Illumination, Education.
There are many resources to help you determine what are non-acceptable conditions.
NOAA Diving Medical Standards
Australian Fitness Assessment
British Health and Safety Executive
Recreational Certifying Agencies
Never-Never conditions
Do no harm 17

18. Goals: Exclusion, Illumination, Education.
Challenges of specific diving environments.
“What are your plans in diving?”
Cold water
High current or flow
Caves / Wrecks
No-stop or Decompression
Deep or extended range
Benign, warm, easy, low impact 18

19. Goals: Exclusion, Illumination, Education.
References:
Your personal diving experience.
Research specific diving conditions in which you lack experience:
Specialty instructors
Specialty certifying agencies
Specialty internet forums or discussion boards
Today’s diver expects you to know what she will be doing! 19

20. Goals: Exclusion, Illumination, Education.
Unsure? Find the experts:
Diabetes under tight control and mature behavior.
Mild asthma
Urinary or GI stomas
PTSD
Psychiatric
Is there a way to say, “yes”, safely?
Many things that were once exclusions are now acceptable when understood by physician and patient.
Adaptive diving. (We’ll come back to this…) 20

21. Goals: Exclusion, Illumination, Education.
Dropping the hammer:
The decision to exclude.
Sometimes you have to say NO GO!
Situation
Background
Assessment findings
Recommendation 21

22. Goals: Exclusion, Illumination, Education.
Objective validation for exclusion:
The Australian site
NOAA’s list
Recreational diving is a buddy sport:
Medical risk endangers the buddy as well.
Adaptive diving option (H.S.A. We’ll come back to this…)
Exclusion is a “Crucial Conversation”
“I can’t clear you for diving now and here is why....” 22

23. Goals: Exclusion, Illumination, Education.
The Provisional Exclusion:
Variables that may change.
Future re-evaluation, with date range.
Temporary conditions
Ex. Recent LOC head injury
Medication related exclusions
Long-term VTE medication
Psychoactive medications -
variations in ability to assess and respond to problems in unforgiving underwater environment. 23

24. Goals: Exclusion, Illumination, Education.
Provisional exclusion (con’t)
Obesity
Lack of safe minimal cardio-vascular fitness for the environment in question. 24

25. Goals: Exclusion, Illumination, Education.
Provisional exclusion (con’t)
Be clear and precise.
Offer measurable criteria.
Discuss a timeline. 25

26. Goals: Redirection of the Diver with unique needs
Instead of Exclusion…
…Redirection!
Handicapped Scuba Association. (H.S.A.)
Fully qualified instructors for adaptive diving.
Amputees
PTSD
Brain Injuries 26

27. Goals: Redirection of Divers with unique needs
H.S.A.
Paraplegics
Quadriplegics
Safely certify divers at varied levels of independence
H.S.A. also certifies dive buddies to assist some levels of disabled divers.
Even H.S.A. has medical restrictions such as seizures, heart problems, significant asthma. 27

28. The Medical Exam Obtain a complete history from the PT
Most will not disclose
They will self-filter
Help them disclose
Create a “Diver” Questionnaire

29. The Medical Exam
NOAA Age Requirements
This is a good place to start.

30. What to do.

31. Some results

32. Your results....
Good to Go ?
Not sure ?
Not good to go?

33. Goals:Exclusion,Illumination,Education.
“This person is Fit to Dive. Now what?”“
Clear summary of findings and assessment.
Compare your findings to the known tasks and requirements of diving.
Make your thinking transparent.
Make recommendations. 33

34. Goals:Exclusion,Illumination,Education.
“What are your plans in diving?”
Discuss the types of challenges the diver may encounter.
“Where do you see yourself diving in 3 years?”
Local?
Know your region, features, diving destinations.
Local internet forums / discussion boards are a window into the community
Local instructor specialties
Travel diving?
Caves, Strong Currents, Wrecks, Cold water, Ice 34

35. Goals:Exclusion,Illumination,Education.
Compare your medical findings with the environment and demands of their trip.
Discuss the types of challenges the diver may encounter and contrast those to any physical or medical deficits they have. 35

36. Goals:Exclusion,Illumination,Education.36

37. Goals:Exclusion,Illumination,Education.
Teachable moments.
You likely have better quality information than they could find searching the internet.
An MD who knows diving… you are rare and very valuable. 37

38. Goals:Exclusion,Illumination,Education.
Read and vet online and printed resources for diving medical questions.
Offer a list of best online sources you find with valid medical information.
Scan Wikipedia for common diving related medical topics… because you know divers will.
Offer more reliable alternatives.
Consider contributing to high quality forums. 38

39. Goals:Exclusion,Illumination,Education.
FAQs – They’re going to ask them.
Send them to great resources.
Ear equalization (list best site)
Dental issues
Small joint pains after diving
O2 as ideal response for most DCS and AGE
Using DAN if you go to the ED after diving. 39

40. Goals:Exclusion,Illumination,Education.
FAQs (con’t)
Ear infections
Latex allergies
P-valves for drysuit diving (there are divers every year who get UTIs and pyelonephritis related to P-valves, and the discussions begin again on the internet.) 40

41. Goals:Exclusion,Illumination,Education.
FAQs (con’t)
Diving with head congestion
Prescription masks (If your vision is very bad without one, you need two in case of emergencies.)
Diving after surgery 41

42. Goals for Recreational Diver Medical Exam (review)
Exclude people from SCUBA who have medical conditions causing unacceptably high risks.
Illuminate medical conditions present that, while not precluding diving, could increase risks.
Educate to risks of common conditions and simple risk management for diver and his/her dive buddies. 42

43. Let’s Go Diving!

44. Resources NOAA Medical Standards Procedures Manual
Australian Dive Medical Fitness
British HSE Medical Examination and Assessment for Divers 44

45. Resources: Ears
Ear anatomy and physiology for divers, video by Dr. Edmond Kay:
Preventing Swimmer’s Ear, by Doc Vikingo in Alert Diver,
The Diver’s Complete Guide To the Ear, from DAN
Practical “Ear Clearing”, by Larry Taylor, Ph.D. 45

46. Resources: Eyes
Fitness to Dive: Eye Problems and the Instructor
Diving and the Eye, references from Scuba-Doc.com. (Ernest S. Campbell, MD, FACS)

47. Resources: Stomas
Scuba with a Stoma, by Adrian March
The Website for people with Stomas Scuba Diving experiences in the forum:

48. Resources: Diabetes
DAN and UHMS Guidelines for Recreational Diving with Diabetes,
DAN Summary Guidelines