Dive Medical Questions

Hi, I know there's a lot of wetpixellers who are current or former divemasters. So I have some stream of consciousness questions for you.

1/Inability to autoinflate ear drums is an absolute contraindication to diving, according the SPUMS/Australian standards. I find a lot of people are pretty crap at doing this. Do you find there are some students who can't pop there ears above water who equalise OK whilst diving? (including no reverse block on ascent)

2/Asthma is an absolute contraindication to diving. Anyone know of anyone, ever,anywhere who actually had a lung overexpansion injury as a result of asthma?

BTW, anyone interested in dive safety should have a read of this:

http://www.bsac.org/techserv/increp04/fatalities04.htm

Ouch auto-equainflate ya eardrums ..... OUCH

well from the way you described it afterwards you obviously are talking about popping your ears on the surface by following the equalising techniques.

Yes people can equalise fine underwater when not abloe to on the surface, could even be when on the surface they had a cold, when they dived they didn't. BUT it is very likely that they will have lots of troubles if they can't do it on the surface. I am not saying that they weren't doing it right .. but believe it or not the biggestproblem for equalising ears on surface or in water is that people just don't do it right. There are a million ways to mess it up and I don't want to go into them all just take it from me that even if the person thinks they are doign it right, and could be an experienced diver .. they could still be doing something a little wrong. That is why on the surface it won't work, underwaterthey probably just get lucky and it clears itself.

Asthma is not a contradiction to diving, in fact allergy based asthma is of no consequence underwater as the air you are breathing is clean so no allergies. Exercise enduced asthma is of consequence, but many in the dive world esp medical dive pro's consider exercise related asthma to be a little bit of a joke, I have even been told by doctors it was a brilliant 80's fad where by people made lots of money on prescriptions, i don't know much about it myself, but i do know that if you are in generally good shape it won't matter as long as you are confortable as you won't be over exercising underwater, not if you intended to enjoy your dive anyway.

Lastly, the only reason these have been deemed reasons to not dive is because of the way diving is taught and regulated. I have been a PADI professional for 10 years, i don't agree with their methods and think it is pitiful that they will disregard some people like those with asthma because they think it may be dangerous and haven't investigated the real effects. Yet they will take a 10 year old diving, and they haven't investigated the effects of pressure on their bodies.

And the dive fatality stories, most speak for themselves really, don't do stupid things whilst you are ni the most hostile environment known to man!

Regarding autoinflation of middle ear: (yep, that's the bit where you blow your nose and the ears pop. Shouldn't be an ouch involved, if there is and air comes out your ear you probably blew a bit hard )

Giles, thanks for your reply, I know you've got a lot of bottom time. In Australia, if you can't autoinflate, you supposed to fail your medical. I do wonder if this is a bit harsh and if there's plenty of people who can't do it properly on the surface, but cope OK underwater. Your reply suggests to be the case from your experience, but then you also mention that some of them have a lot of trouble underwater. So maybe it is right after all that they all are prohibited from diving and have to play chess or knit instead.

Asthma is not a contradiction to diving, in fact allergy based asthma is of no consequence underwater as the air you are breathing is clean so no allergies.

Here's the asthma bit from the dive medical standard from Australia:

A4.10 Respiratory System

(a) A full history and examination should be normal. Any abnormal findings should be fully investigated.

Such investigations should include provocation testing if any doubt concerning the possibility of bronchial

hyperreactivity exists.

Particular attention must be paid to any condition that might cause retention and trapping of expanding

gas in any part of the lungs during decompression ( e.g. asthma).

Asthma is probably the most common reason for failing dive medicals. The concern is that you inhale saline underwater, have asthma attack, air is trapped in lungs....and 'pop' as you ascend.

Now, I'm not convinced it actually works like that in the real world - hence my interest in the experiences of people who've actually spent a bit of time underwater. (<edit> - let me rephrase that - my description above is exactly as it occurs in the real world, in those who are sensitive to saline inhalation and have bronchial hyperreactivity ie asthma. It is less clear to me, and of some ineterest, how often these incidents occur, particularly in mild, well controlled asthma 'in the field', so to speak. But anyone reading this thread should be aware that asthma and diving are a potentially lethal combination, and there's a lot of very dangerous advice floating around this thread.)

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Rob the trouble is that these rules are either made up by diving people like SSi or PADI when it comes to certifications, or a local medical board. I worked in Australia for a while in Diving, and I am pretty sure you go by local medical laws. Which is fine, except for the people at the medical board who make up the rules probably don't dive and have made the rules up from what they understand to be the risks from a text book.

When it comes down to it there has not been that much research done into recreational diving, the fact of the matter is that accidents happen. My boss in Australia had one rule, if they want to dive you will take them diving. We had our own doctor on call via telephone so when we were on the barrier reef and found out about a condition a possible diver had we could ask him, asthma was never a reason to stop them from diving .. unless they were on heavy medication and it was exercise enduced. i.e. without meds taken every 10 mins or so an asthma attack would happen. A lot of people have an inhaler and use it when they get out of breath (which could be fixed by getting in better shape).

The rules / laws are set to keep organisations who can be sued safe, not necessarily to keep the individual safe. Just like the courses now adays are set up to make the organisations as much money as possible not to teach the students as much information as possible. It sad, but thats the way it is.

If someone has astma and have been told they can'tdive, find a diving doctor, a doctor who either specialises in it, or is a doctor who happens to dive, they will tell you for sure, and they will also be able to help you out with the ear nose and throat problems. The point i was trying to get across is that a LOT of people just don't equalise right. I can be completely blocked up and still get down because I know how to make it work if i have to, i am normally very lucky.

Two biggest mistakes equalising are not pinching the nose very well (through the mask it can be tricky for various reasons, or two .. believe it or not .. people breath through their mouth while equalising hence they are not equalising.)

If you do have regular problems equalising .. both on land and in water .. i would hazard a guess you have a heavey or loud breathing at night sometime snooring. This can be fixed surgically. Some people just have shallow ducts in their sinuses and air passageways, these need to be kept as clear as possible for diving, so keep hydrated and healthy.

Sudafed can help too to clear out airways for equalisation, but here's what I feel about this. I know they come in 24 hour dosages, but what happens if it works while you are going down .. you equalise fine, but on the way back up .. it wears off and you can't ascend, you have a choice .. ascend and blow your ear drums, or wait while someone ascends gets either another pill for you to take and then wait for that to kick in .. or for them to bring down a hyperdermic needle and pierce your eardrums so you can ascend (which I have seen have to be done).

So i think if i was to pick a key element in all of that, if you need medication, something other than your own helath and physical abilities to be able to do something then maybe you should really consider not doing it, if however you can do these things on your own abilities even if it does mean a change of lifestyle you are probably better doing it that way. People train to go on a ski holiday .. why don't they to go on a dive holiday?

(me saying this makes me such a hypocrit, but I am lucky that my body doesn't have any ailments that make me unfit for diving)

OK guys,

According to the RSTC, Asthma is a Relative Contraindiction to diving. With a proper examination and lung volume testing, it is possible to recieve medical approval to dive in some circumstances. However, Active RAD (reactive airway decease) is an absolute no go and although I have seen numerous examples of doctors in resort areas who will sign a medical clearance, I as an experienced PADI instructor with over 1000 certifications and never a student injured, I would not and will not ever accept an asthmatic as a student, regardless of pressure from a dive shop owner. I have known 2 other good instructors (PADI and NAUI) who have had student fatalities due to asthma attacks and subsequent embolism (both students had doctors medical approval), and it ruined their lives and careers. Dive shops and their instructors should never be allowed to determine whether a student is medically qualified to dive, only a qualified doctor and the proper testing can provide the answers a student and their instructor need.

Hope that helps,

Douglas Kaufman

PADI Course Director CD-31169

Not that I have as much time as the others to post a story, but I have asthma and so does my brother and sister. We are all new divers that have been certified for three years or so and just around 100 dives. FWIW I have never had any asthma problems while diving. In fact when I take my trips to the tropics all my asthma clears up. That and the use of advair I never have problems. Even when I got stuck in a stiff current with my sister and we both had to swim against heavy current back to the boat a few hundred yards and we were fine. I don't think it is a real issue when diving as long as you can mantain it well.

As a physician, diver-photo addict, i feel compelled to respond here. Asthma is a serious condition. People die from asthma, often from not taking sound medical advice, following direction,or not taking there condition seriosly. I would first not take a divemasters recomendation. See a physician quailified in evaluating and treating asthma, for your individual case. Also refer to the dan information on their web site. Diving is an optional activity, not worth dying for.

I am also a physician, photographer/diver for many years. Mr bubbles is correct go see a physician qualified to treat asthma . Every case is unique and cannot be evaluated on a forum like this. FYI this is such a thing as excercise induced asthma and allergic mediated asthma but I am not going to get into it here.

Tony

Australian standards are some of the strictest in the world with regards to medical certification for diving. Here's a copy of the SPUMS recreational standards for anyone who's interested:

http://www.google.com.au/search?q=cache:2m...+%2Bspums&hl=en

Asthma and diving are certainly a risky combination. Anyone with asthma would not pass a dive medical here in the first instance (unless they see Giles' consult-by-phone doc! :roll: ). Further investigation with saline inhalation provocation testing would generally be required. I'd agree with Mrbubbles comments above, and besides the point that asthma itself can be deadly, it's important for divers to note that there are specific problems with asthma and diving (in particular, the risk of potentially fatal lung overexpansion injury and air embolism as Douglas refers to above).

Having said all that, I feel bad for those who fail dive medicals for mild to non existant asthma, or an inability to pop their eardrums properly, and in particular was wondering if those gumbies who just don't seem to be able to perform a simple valsalva manoeuver in the doctor's office actually managed to survive with eardrums intact underwater.

And Giles, I'm not letting you operate on my nose!

I've cannot "auto-inflate" above water, and never could, but now have no trouble equalizing. When I was first learning to dive, it was a bit of an issue. For me, the trick is to perform an initial valsalva (no chin/jaw movements work for me) in the water but while still on the surface. As long as there is a pressure differential between my head and chest, it works. Subsequent equalizations are easy after that.

Being barred from beginning diving because I was unable to perform a valsalva or auto-inflate eustacian tubes on dry land would have really pissed me off. More dive nazi-ism, I'd say.

Those standards are almost 15 years old! Things have advanced in medicine a little bit since then. Quite a few medicines have been approved for usage since that time and now are over the counter.

Tony

The standards I linked to were last revised in 1999, 4-5 years ago, so they're reasonably contemporaneous. Whether the specifics of treatment for any of the conditions mentioned have changed since the standards were published doesn't really alter the question of whether or not having these conditions should preclude someone from diving.

Here's some more interesting reading (if you're interested in this sort of thing - hey, it does make a change from chatting about lenses!)

(from the Medical Journal of Australia):

http://www.google.com.au/search?q=cache:md...%2Bdiving&hl=en

The most interesting part is the sample questions at the bottom of the article which list various scenarios, how many dive doctors would pass each candidate, and what the correct response (according to Australian Standards) should be.

"Diving medicine is an area in which strong opinions are held, but in which evidence is almost totally lacking.", as the article states. Which is one of the reasons it's interesting to hear feedback and opinions from those who spend a lot of time underwater, and in particular those who've spent time training others to dive.

OK guys,

According to the RSTC, Asthma is a Relative Contraindiction to diving. With a proper examination and lung volume testing, it is possible to recieve medical approval to dive in some circumstances. However, Active RAD (reactive airway decease) is an absolute no go and although I have seen numerous examples of doctors in resort areas who will sign a medical clearance, I as an experienced PADI instructor with over 1000 certifications and never a student injured, I would not and will not ever accept an asthmatic as a student, regardless of pressure from a dive shop owner. I have known 2 other good instructors (PADI and NAUI) who have had student fatalities due to asthma attacks and subsequent embolism (both students had doctors medical approval), and it ruined their lives and careers. Dive shops and their instructors should never be allowed to determine whether a student is medically qualified to dive, only a qualified doctor and the proper testing can provide the answers a student and their instructor need.

 

Hope that helps,

 

Douglas Kaufman

PADI Course Director CD-31169

Preface-I am not a doctor. I am a Divemaster.

My wife has Asthma and dives. We actually met diving. Based on her case I certainly see no basis for the argument against her diving. She was a distance swimmer with the University of Oregon and on the US Waterpolo team. She was swimming laps around the dolphins on our last trip together to the point people found it funny.

That said I feel that to broad stroke people out of participating because of having asthma is not fair. Each individual instructor certainly can make his own call on it that is their right. But, there are levels to asthma and if it is allergy or activity induced as far as I know and have seen.

I agree, get checked out by a doctor who understands diving and the effects of diving an ensure you are not putting yourself at great risk.

I get tired of hearing dive staff get all worried when they hear she has asthma before asking relevant questions and observing. Maybe it is the litigious nature of the US that prompts these types of responses. Get the details before assuming someone is guilty. Based on the General dive organization rules a Doctor has already approved the person for diving, myself as a Divemaster am not qualified to medically question their opinion, in my mind.

IMHO

mm

Todd is absolutely correct..I have ok'd some people who have asthma and I have denied some people with asthma. It all depends on the circumstances. It is unfortunate that many people believe in dogma which to me underminds the thinking process of disease states and how they apply to dive medicine.

Two actual cases that I was involved with one asthmatic similar to Todd's wife who has very little trouble with her asthma and is related more to seasonal components and was going to dive in carribean waters who I ok'd for diving. The second case was a young man who was on 3 different inhalers taking oral theophylline (bronchial dilator) and had been hospitalized several times for his asthma. He wanted to dive for the fire department in a nearby town looking for people in murky water that may have drowned. The water temperature being in the 60's with zero viz. I told him with that kind of stress(cold, zero viz, inexperience) and his condition of asthma I could not approve him for diving.

All conditions are individual that is why you need to see a doc....

Tony

It's OK , Dr Critter, my lungs are doing fine (as long as I make my wife mow the lawn )

My interest in the subject is professional rather than personal. We're talking about a subject where there's very little evidence and a great deal of variation between doctors doing the certification.

Standards and attitudes vary also from country to country.

Here's a quote from a French article:

"Asthma, a condition exhibiting increasing prevalence in the general population is currently considered an absolute contraindication for scuba diving by the French Federation for Submarine Sports and Education (FFESSM). There is however no documented evidence demonstrating a higher risk in asthmatic divers. Our English-speaking colleagues have suggested that certain asthmatic subjects could participate in scuba diving sports under certain conditions without any higher risk compared with non-asthmatic divers"

Here's one of the cases from the MJA article I cited previously:

"A 40-year-old female general practitioner with asthma for 25 years, taking inhaled budesonide (800mg/day). She has no symptoms at present and last used her salbutamol inhaler six months ago. Spirometry results, normal."

48 of 52 docs in the study failed this potential diver, which according to local standards is the correct response (the more interesting thing about that article was how much variation there was on some of the other cases) . The question is what's the evidence here on which to make these decisions, and the answer is there's not a great deal.

Well here in the states it is a relative contraindication and that is where the science and the art of medicine have to be balanced out. There is no black and white in medicine like other fields, we as humans aren't put together that way. That's where sound judgement has to take over along with medical knowledge. If it were that easy there would be no need to see a doc. Who wants that? .

I gave a talk on this subject about 4 years ago to a group of physicians we all had an interesting discussion...gotta go on a trip..

Tony

If it were that easy there would be no need to see a doc.  Who wants that? .  

Goodness, no. That would be a terrible state of affairs!

Having said that, I've decided to act on your advice and have got myself an asthma puffer on Ebay to add to my dive kit. Did I choose a good brand?

I was under the impression that asthma was an area where it was up to your personal physician to let you go or not. According to DAN

"For these reasons, physicians trained in diving medicine have traditionally recommended that people with asthma should never dive. However, a consensus of experts at a 1995 workshop held under the auspices of the Undersea and Hyperbaric Medical Society (UHMS) proposed more liberal guidelines. Essentially, the UHMS workshop panel felt that the risk of diving is probably acceptable if, the diving candidate with some asthmatic ‘history’ demonstrates normal pulmonary function at rest (FVC, mid-expiratory flow, FEV1, FEF 25-75) and then again after strenuous exercise. It was also concluded that the degree of competency in making a medical assessment of diving fitness is enhanced if the examining doctor has relevant knowledge or experience of the diving environment and its associated hazards.

This is similar to the diabetes debate, where for many years T1 diabetes was contraindicated and now it is more liberal. We have been looking at some kids with diabetes and last summer there was a small group of T1 kids who learned to dive at dive camp in the Bahamas.

BVA

I was under the impression that asthma was an area where it was up to your personal physician to let you go or not. According to DAN

And what does your personal Physician know about diving !!

it works both ways when you say a divemaster doesn't know medicine.

Doctors prevent a lot of people from doing things they don't know a lot if anything about.

People like Divemasters only prevent people because they are trying to stop themselves from getting sued (in an americanised society).

Wouldn't it be nice if people could just be informed of the inherent risks of activities and then make their ownmind up as to choose to do it or not ?