Dive Medicals

[Germie]

Yep. BMI is only useful when comparing populations. It should never be applied to individuals. Body fat percentage of an individual can be determined directly if that is what you are looking for.

But even then, a lot of fat does not mean unfit or no muscles. Some have both. So also this is not a way to measure I think.
I know people with some 'fat', BMI around 30, but can run over 10km. So they are really fit.

The BMI was developped for the western white man of 1.80m. This means for woman it already does not fit. And I am a woman for example of 1.82m.

 

[dmaziuk]

...

• 50% died on the surface.
• ...
• 10% had been advised that they were medically unfit to dive.

Gotta wonder how many of those unfit to dive died on the surface before their fitness to dive became a factor. Also whether one's chance to die on a dive is 90% greater if one is medically fit to dive.

Ain't statistics fun?

 

[ontdiver]

As popularized by Mark Twain: “There are 3 kinds of lies: lies, damned lies, and statistics."

 

[boulderjohn]

Gotta wonder how many of those unfit to dive died on the surface before their fitness to dive became a factor. Also whether one's chance to die on a dive is 90% greater if one is medically fit to dive.

For this discussion, "fitness" needs better definition.

Jim Fixx wrote The Complete Book of Running, and he was extremely fit. He died at age 52 of a heart attack he suffered while running.

I used to study the annual DAN descriptions of fatalities every year for threads like this one. A lot of the people who died on the surface did so because they suffered a heart attack either before or during the dive. An example is my nephew's mother-in-law, who went to the surface when she felt she was not getting any air from her regulator. She died there. An autopsy showed she had had a heart attack both during the dive and at least a day before the dive.

Heart issues are a major cause of dive fatalities. I am sure that many of the people who suffer them are unfit. I am sure some are as fit as Jim Fixx was when he died.

BTW, for those who assume (as others have in the past) that a heart attack during a dive must have been caused by something that happened on the dive, you should know that the most common time of the day for heart attacks on land is around breakfast time. The second most common is at night, while the victim is sleeping. It does not take a triggering event to cause a heart attack.

 

[Duke Dive Medicine]

Has it been established what kind of dive medicals are being discussed? In my mind such a thing could range from an attestation of health to a complete dive physical with pulmonary function testing, ECG and a prostate exam.

There is precedent for requiring medical exams for certain activities. Kids have to get them before participating in sports in school. @Germie has mentioned the requirements for dive medicals in the Netherlands. I'd be interested to learn more about how that works for recreational divers; the information I found on that was about commercial/professional diving.

There's also precedent for regulating safety in certain activities - motorcycle helmets and seat belts come to mind. If a requirement for a medical for recreational divers was somehow enacted, divers would be understandably upset, and then most of them would comply because they'd want to keep diving, just like motorcyclists in places where helmets are required. The wide variety (and levels of protection) of motorcycle helmets might be a good analogy for the variety of diving evaluations that would probably be seen if something like this happened.

The challenges as I see them would be regulatory and compliance-related. Recreational diving is largely unregulated beyond training and certification, for better or for worse. Who would enact the requirement? The training agencies? I can't imagine all of them agreeing to something like this. What type of dive medical would be required? If it's a complete dive physical by a provider trained in evaluating divers, what about those divers without access to one of those? If it's to be done by a primary care physician, again the question of access comes up along with the wide variation in knowledge about diving physiology that was previously mentioned.

I'm with @kinoons w/r to the statistics. In order to even think about making a dent in recreational diving deaths related to a medical condition you'd probably need a requirement for a complete cardiac workup, ideally with an immersed stress echocardiogram. Regarding the specific diver mentioned by the OP, if he and I are thinking of the same individual, medical clearance would have been predicated not on a provider's exam but on a truthful answer to a screening question about a history of seizures. Would that have happened in this case? I don't know the answer to that but there are quite a few threads on SB where divers discuss fudging answers to screening questionnaires when they gauge themselves fit to dive and think that a medical exam would be an unnecessary barrier.

Best regards,
DDM

 

[Germie]

Has it been established what kind of dive medicals are being discussed? In my mind such a thing could range from an attestation of health to a complete dive physical with pulmonary function testing, ECG and a prostate exam.

There is precedent for requiring medical exams for certain activities. Kids have to get them before participating in sports in school. @Germie has mentioned the requirements for dive medicals in the Netherlands. I'd be interested to learn more about how that works for recreational divers; the information I found on that was about commercial/professional diving.

There's also precedent for regulating safety in certain activities - motorcycle helmets and seat belts come to mind. If a requirement for a medical for recreational divers was somehow enacted, divers would be understandably upset, and then most of them would comply because they'd want to keep diving, just like motorcyclists in places where helmets are required. The wide variety (and levels of protection) of motorcycle helmets might be a good analogy for the variety of diving evaluations that would probably be seen if something like this happened.

The challenges as I see them would be regulatory and compliance-related. Recreational diving is largely unregulated beyond training and certification, for better or for worse. Who would enact the requirement? The training agencies? I can't imagine all of them agreeing to something like this. What type of dive medical would be required? If it's a complete dive physical by a provider trained in evaluating divers, what about those divers without access to one of those? If it's to be done by a primary care physician, again the question of access comes up along with the wide variation in knowledge about diving physiology that was previously mentioned.

I'm with @kinoons w/r to the statistics. In order to even think about making a dent in recreational diving deaths related to a medical condition you'd probably need a requirement for a complete cardiac workup, ideally with an immersed stress echocardiogram. Regarding the specific diver mentioned by the OP, medical clearance would be predicated not on a provider's exam but on a truthful answer to a screening question about a history of seizures. Would that have happened in this case? I don't know the answer to that but there are quite a few threads on SB where divers discuss fudging answers to screening questionnaires when they gauge themselves fit to dive and think that a medical exam would be an unnecessary barrier.

Best regards,
DDM

In my country, diving has no laws. Everybody can go diving on their own, even everybody can start their own agency and everybody is instructor if they want. There are no rules.
For diving, there are no rules and no medicals needed. Also not if you want to do a commercial course from padi, ssi, iantd, or whatever. Then you have to fill in the 'no no no list' and it is ok. Some divecenters require a medical.

There is a national CMAS agency here. Till a few years ago, every member of this agency needed to have medical to participate in club dives or courses from this agency. The rules where quite easy: every doctor can sign of, but it is/was adviced not to let it do by your own housedoctor. There are some 'dive doctors' in my country which just have followed an extra course. For example from S.C.A.S. The basic level for doctors is a 4 day course. So they can earn their points that they need every year to stay 'confident'.
This is all for recreational diving, also the recreational instuctors. The guidelines say it is till 50 years old every 3 years and over 50 years every year.
Now the CMAS here said it is only needed for instructors, and then even the 3 and 1 year apply.
As I am CMAS instructor I have done several of these medicals and even if there are guidelines, I cannot say doctors follow them. In all medicals I had to blow the pipe for spirometry, they tested blood pressure and I had to fill in a list of questions like the 'no no no list'. Some asked me to stand on 1 leg (why? Even people in a wheelchair can dive), some did an eyetest like you do at the opticien when you buy glasses (the answer on my why was that they wanted to know if you can find the boat back. Yes, for sure never heard of optical masks? ) From others I heard that they check sometimes your pee, but none did it were I went. In 20 minutes you are outside again and it costs nowadays about 150 euro, no insurance pays it for me. From my experience, some doctors don't save/file any result, others save/file it too long. I came back after more than the 3 years to the same doctor and he took his old files about me. I said: what are you doing? He said, check if something has been changed. I said you are not allowed, you only can file/save things about me as long as this preventical medical is valid. So after 3 years and 1 day it must have been deleted. I am very strict with checking such things as my medical data have been already 3 times in dataleaks or hacking, happely no serious things, as I am healthy. But I will tell them if they don't follow the law correctly.
The reason why CMAS said it is only for instructors is that there is no single evidence that even 1 dead have been prevented. So now the normal dives only need a medical before starting to dive for a CMAS club and then only need to do a self check.

Germany is champion with dive medicals and rules I believe, and that is the reason I sometimes need a new one before the 3 years are due. There it is 2 years validation till you are 40 years old and over 40 it is 1 year.
When entering some divesites in Germany you need to show a medical.
Also France can be quite strict, but there it is more if you dive a non-CE CCR. But in 2010 they asked me for a medical. In Malta you need to bring one if you are teaching courses there as an instructor from abroad. The divecenter where you rent tanks from has to check it and has to fill in something that you are allowed to teach. On the worldchampionships underwaterphotography for CMAS they state you need to have a valid medical (not written duration of 1,2,3 years validity), but they did not check it last year.
On 1 competion day all competitors had to go to a doctor to let your bloodpressure checked and if it was too high, they had a pill for you. That gave some discussions and at the end everybody could compete. It gave a big delay in the diving schedule.

But for example, can a kid with tubes in the ears dive? I know a doctor that signs a medical off. They say: use a pro ear mask.
Can a person with diabetis type 2 do technical diving? I know several who do it without any problem. The guidelines state no deco, maximum 60 minutes, so only the recreational diving in my country. But all the research has been done on people with type 1 and only a very very small group (less than 20 people). So from what I see around me is that type 2 is no problem for doing technical dives. Some doctors sign a medical off without problem. Others will state only recreational diving. But what if your heart lies in technical diving? Do you quit or do you ignore the advice? Remember a medical is only an advice, never a real law.

I think the most important thing is that you have to look in your own eyes, are you really fit or not? Self overestimating can be a real problem.
The 'no no no list' can give handles to check if you are probably not fit. But if you area diving every week, you know what works for you in my eyes.

But nobody, even no doctor, can say that I will not get bent during my next decompressiondive, or that I don't have to worry about a heartattack before I am 96.

Also the trend in some diving groups to get tested for a PFO. Does this knowledge make you happier? What if it is found and you have been diving for decades without problems? Are you now worried for you next technical dive?

I think, if you are unsure about things, ask a doctor, don't lie to yourself about things and try to live as healthy as possible.

 

[dmaziuk]

... there are quite a few threads on SB where divers discuss fudging answers to screening questionnaires when they gauge themselves fit to dive and think that a medical exam would be an unnecessary barrier.

I think there are several problems with it: one is that the WRSTC form usually used (often incorrectly) for this pretty much guarantees that anyone over, say, 45, will have to tick at least one checkbox. That's most of us and if we stick to the rules we can just skip the form and proceed directly to the doctor's.

OP is in Australia that, last I looked, had the 2nd or 3rd (I forget) best healthcare system in the world, and I believe they have a nation-wide register of diving doctors too. That is very much not the case in e.g. these United States.

Then as DDM says: what kind of medical? A full cardio workout on a threadmill? How many potential cold-water-immersion heart attacks will that catch?

And so on.

We had our local high-profile death a year ago: pre-season check-up dive, hot day, lakes are still cold (maybe mid-60s), happened very early in the dive. I've no idea what Jim's fitness level was, he certainly didn't look "unfit", and I'm sure our Marine Archaeologist with all her creds and experience would not have let him in the water if she had any doubts.

 

[boulderjohn]

An earlier reference to a specific recent incident is sparking this comment, but I want people to know I am not referring directly to that incident, about which I know nothing that has not been made public. My comments are generic and point to what I think is a very common human psychological trait. I wrote about this a couple years ago, calling it something like the Bob Marley Syndrome.

Many people will be surprised to learn that reggae pioneer and open marijuana user Bob Marley was also a fitness nut obsessed with playing soccer. When he had a strange medical condition on a big toe, he went to a doctor, who said he had a very rare form of melanoma. He wanted to amputate the toe immediately. Consultations with other doctors came up with even more drastic prescriptions, including amputating the leg.

Horrified at losing any of his ability to play soccer, he kept looking until he found a doctor who prescribed a treatment that did not require amputation and which allowed him to continue playing soccer as before. He followed that doctor's advice, and when the treatments were over, he stopped going to doctors altogether. Within a couple of years, the melanoma had killed him.

When we humans love an activity and develop a physical malady that threatens our ability to perform that activity, we may have a very difficult time accepting that. That can lead us to do the same sort of thing that led to Bob Marley's death. Many people will indeed stop going to doctors because they are afraid of what the doctor will tell them.

I know someone like that with scuba. Scuba and scuba instruction was the focus of his life, but a medical condition (not really life threatening) means that he logically should move on to something else, but he can't, and he is struggling with it.

 

[Nedster]

What does "lack of disclosure" actually mean, to you, in practical terms? E.g. if I disclosed to you I have allergies, what are you going to actually do?

Do you have a medical professional on staff capable of assessing said disclosures? Do you employ a records officer to properly safeguard the customers' protected medical information as required by their respective laws? Do you carry cyber-insurance for when someone steals your office PC and you have a "data breach" on your hand? Do you want to pay for all that without passing the cost on to the customers and losing your business to the cheaper operation next door?

Be careful with what you wish for...

I am just saying what is happening in reality. I for one, do not believe it is necessary to complete a medical form before fun diving. If that was the case then we would probably have to send away 60% of our customers for a medical check.

 

[Germie]

@Damiazuk, I am over 45 and have no 'yes' on the form and I am not lying. I don't use any medicines, can run 10km (but am quite slow, but this is because of some achillestendon problems that came due to sideeffects of the ciproflaxine I had to take due to a serious dogattack a couple of years ago and never went away sadly completely. But I do running 2-3 times a week from 4 to 13km), I do horseriding, I do swimming (1km in less than 18 minutes), I do hiking/walking 2 times a week (10km). So I think I am quite fit. Only if you look at the bmi, which is wrong for woman, a little bit too heavy.

And I know more over 45 that don't have any 'yes' on the form.

Then the question is, do you think you can avoid heartattacks or other medical problems? One of the doctors I went to for a medical said to me: I sign you off for being fit to dive for 3 years, but do me one favor: don't get a heartattack directly here outside, because this is the real truth about a medical, now you are fit, in 3 seconds maybe not anymore.

You hear fit sportpeople in all kind of sports collapse, falling down, dead. A diver I know which was younger than me died 2 weeks ago. He got unwell under water, was able to walk to his car without problems, got there a heartattack and died.
I had to do CPR to my dad when he was only 66. Because I was sitting directly next to him when it happened, there were less than 15 seconds when I started CPR, so he survived without problems. But there was never a sign that he could get a heartattack. He had some things a lot of older people have, so he was checked by a doctor every 3 months, but in fact he was fit and healthy. He would have got a dive medical if he wanted (but got some several panics when he tried to dive, so he never went further than 1.5m depth).

I think the 'no no no list' will make that some people will ask a doctor first before starting to dive. Especially for people who want to start with diving. They don't realise that asthma or high bloodpressure or heartproblems can be a problem.
But if you are an avid diver, dives every week and then you get a heartproblem, or high bloodpressure, quitting is not that easy. Also, the week before the checkup with a doctor you were diving and all went well. And then the doctor find a condition that maybe it is better to quit? So then there is no risk anymore in your eyes, but you have already done it with that condition.

Also some guidelines for doctors don't work for everybody. Do you want to follow this strict as a doctor or not? For example, I have met a ccr trimix diver who has diabetics type 1. He still did dives over 3 hours, but the 'general rule' for people with diabetics is: no longer than 60 minutes, no deeper than 30m, no decompression diving. If you have to stick with this and you like deep wrecks, you life is over. Not everybody wants to find another hobby or sport. And you must accept this too.

Another guideline here is that if you use 1 bloodthinner you can go diving, with 2 not. But what is the risk you get injured during a dive and the bleeding will not stop? In my eyes there is no risk if I ever have to take bloodthiners. Or I simply will refuse the bloodthinners to go on with diving. So I know people who dive with more than 1 bloodthinner and don't have problems and say there is no risk.

People get aneurismas, and if you get them under water, probably you will die. But you don't want to check all people for aneurismas. Also, you will get a medical if you don't know you have one probably.
Same with a pfo. Do you want to know if you have one? Do you think every diver needs to do a check before starting to do diving or technical diving? It is not said that a very big pfo means that you will get bent. Or that no pfo means you never get bent. I know a diver who got bent 4 times in 4000 dives. He had done a pfo check, and nothing was found. After the 4th time in a chamber, they did again a pfo test and found one. So he got it closed. After he was cleared to dive again, he got bent after a dive within NDL on nitrox in less than 3 months after he was cleared to dive again.

I am in the horseworld too. A lot of people want horses that are perfect on xrays. But there are horses with imperfections that jump in international competitions, and then you want as a hobby rider a horse that has no imperfections? Take xrays of all people over 45 and you will find some artroses or imperfections. But this does not mean that all people have problems or pains.

Further remember doctors can only advice, so a no does not mean you cannot. Some doctors think in no's and others try to think in solutions that fit the diver. In Bali I met a woman of 83 with cancer. Her doctor signed her fit to dive. His reaction was: your cancer is uncurable, so enjoy what you want to do in your life. This diver rented her own porter to help her in the water without equipment, then bring the equipment in the water and put it on and then after the dive the porter brought everything out of the water again and helped the diver out. She and her husband were enjoying easy shoredives. A good way of retirement in the last years of your life in my eyes. 83 and 86 and still diving.
Other doctors would advice to quit, risk of broken bones when you fall, too heavy equipment, etc. But mental aspects are as important as physical aspects in my eyes. Enjoying life is a good thing.

And the most important thing in diving in my eyes cannot be tested, and can change from day to day: To panic or not to panic in a stressfull situation. Stress and panic causes more accidents than just bad luck with your health. Sometimes it is cause and effect.

The medicals or 'no no no lists' are there for divecenters and instructors and as a quick selfcheck. At least you are aware of risks and you signed that you are healthy.

And happely I am no doctor as fit or unfit is no rigid border in my eyes.