The Doctor Will See You Now: Diving Fitness and Medical Examinations

I’m sure that there are places where I’m more ill at ease than in a doctor’s office, but I can’t really think of one. This isn’t to say that I don’t take my health care seriously. My doc is an affable and competent person whom, like it or not, I visit on a fairly regular basis. Over the past several years I’ve been poked, probed, palpated, stuck, irradiated and imaged in every way imaginable, and some that aren’t so. Heck, I even get my teeth cleaned twice a year. However, I’m not one who runs out to the doctor for a hangnail or at the first sign of a cold. In fact, as testament to my abhorrence to anything medical, there have only been two occasions in my entire adult life when I visited a doctor for something other than preventive care.

My fear and loathing of medicos goes back to my childhood. I had had two operations by the time I was 6 years old, and that much hospital experience for one so young definitely has an effect. Even as a teenager, as much as I dreamed of becoming a diver, I was initially reluctant to get certified when I learned that it would require a medical examination.

Of course, knowing one’s level of fitness is essential to safe diving because, regardless of how easy it has become, surviving underwater subjects our bodies to some pretty stressful and unforgiving situations. But what exactly constitutes “fitness to dive,” and how can we assess that? Does determining our fitness always require the insight of a trained medical professional? These questions have been debated since the beginning of recreational diving and, as in most fields, opinions and practices have changed over the years. Even today, polices on prequalification medical exams and diving fitness are not universal.

The What and Why of ‘Fitness’

In scuba diving, when it comes to assessing fitness, times have certainly changed. Years ago, many were reluctant to even consider diving because they thought it was deep, dark and dangerous. Today, it’s just the opposite. Many are lulled into diving because they view it as simple, safe and easy. Indeed, diving takes place in a relatively weightless environment, which may make it seem effortless, but it does require a degree of both health and stamina.

In determining what fitness means to you, understand that there’s no single answer; it means different things to different people. The first issue to consider in evaluating your fitness level is where and what type of diving you plan to do. Obviously, enjoying a shallow reef in the Florida Keys on a still summer morning is far less demanding than braving 8-foot seas to dive the wrecks off the New Jersey coast. Although this may seem obvious, it’s amazing how many folks will assume that their Florida Keys fitness is all they need when they one day decide to dive New Jersey or California. Your well-being demands that you be honest about what you want from the diving experience, and make sure that you don’t exceed the conditions on which you’ve based your fitness decision.

Still, even if you do decide that you’re only interested in relatively “easy” conditions and environments, things don’t always go as planned. Even the best conditions can change rapidly, and it’s these unforeseen circumstances that cause a lot of accidents. So, whatever you expect, assume that once in a while, at least, conditions will be worse; perhaps much worse. This means that you must possess not only the level of fitness required for what you normally encounter, but a “reserve,” just in case. Granted, assessing, acquiring and maintaining an appropriate level of fitness may not be easy, but never forget that Murphy’s Law is always right around the corner ready to bite you on the backside when you least expect it.

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Whether you expect it or not, on any dive you may encounter long surface swimming, have to contend with strong, changing currents or just deal with being at the surface in conditions akin to a washing machine during the rinse cycle. All require more fitness than walking from your easy chair to the fridge. Unanticipated and strenuous physical tasks are part of the diving experience in any environment; therefore you must not have any health conditions, or take any medications, that may impede your performance.

Assessing your fitness also isn’t a one-time event. When I started diving as a young teenager, there were few physical tasks a diver might encounter that I couldn’t handle. But to assume that’s still the case more than three decades later is a recipe for disaster. So, the next time you’re filling out your logbook, take a few minutes to ask yourself a few simple questions: Did I encounter conditions that were close to or beyond my physical capabilities? How likely is it that these conditions may occur again? Do I need to reconsider my “comfort envelope” or try to improve my fitness? The answers require a great deal of self-honesty, but the exercise may be the best thing you’ll ever do for your health and well-being.

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Finding a clear method to assess and quantify your level of fitness isn’t always easy, but there are some basics you can keep in mind. First, if you can’t walk around the block without a rest, or if you’ve never even tried, diving at any level probably isn’t something you should try (or continue). At least, not until you’ve improved your conditioning. A very minimal guideline for fitness is the ability to walk a mile (1.6 km) within 12 minutes. If you can’t do this, you should plan to exercise for at least 20 minutes four or five time per week, but only after you’ve gotten the approval of your doctor. And if possible, add swimming with fins to your routine. A useful measure that I’ve always given my own students, based on years of teaching experience, is this: No one should consider themselves prepared for a certification course who cannot swim at their own pace, using a mask and fins, at least 200 yards (182 m) without stopping and/or becoming exhausted.

Restrictions and Red Flags

Aside from physical fitness, divers and would-be divers must also consider how any existing medical conditions can affect their health and safety. Surviving in an environment that’s 800 times denser than the atmosphere can present problems that might never arise while sitting in your living room, or even engaging in moderate physical activity on terra firma.

First, let’s consider temporary conditions such as colds, flu, injury or even pregnancy. All should be considered reasons to curtail diving until the effects have passed. Colds, flu or allergy attacks cause swelling or blockage in the sinuses and eustachian tubes, which means pressure equalization will be difficult or impossible. Injuries can leave you with restricted strength, stamina or mobility, and can even put you at a greater risk of decompression sickness due to alterations or restrictions in blood flow. Furthermore, when diving with an injury, the accompanying pain could mask symptoms of decompression sickness. So it’s best to postpone diving until you’re fully healed. Lastly, diving while you are or could be pregnant is considered a no-no for one simple reason: We just don’t know enough about its effect on the developing fetus, so why take the chance? Can any hour spent underwater be worth the risk to a child’s life or quality of life?

It should be obvious that you must take into account the effect of any medications. This goes for both prescribed and over-the-counter (OTC) meds. Frankly, most medications have no effect on diving, but some definitely do. They may cause drowsiness or fatigue, which may make you more susceptible to nitrogen narcosis, or impede your thinking at just the time thinking is most critical. Other medications, as well as illicit drugs, can affect heart rate even in those without heart problems. Clearly, if you plan to dive, it’s especially important to read the warning labels before using any drugs. And it’s just downright stupid to dive while taking any recreational drugs.

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Another concern that’s foreign to any landlubber taking meds is whether and how the increased pressure at depth can affect any drug. There is always a possibility of such an unexpected reaction to medications, and some drugs are noted particularly for pressure-induced side effects. But the problem is that these reactions can vary from diver to diver, and even from day to day. So, the first step in preventing a dangerous situation is knowing well in advance what side effects any medication has on you before using it while diving. It isn’t smart to pop a pill for the first time just as you’re about to enter the water. This is true even of common OTC drugs like cold and allergy or seasickness medications.

The effect of diving on prescription medication can be a very complex issue, and requires a knowledgeable doctor’s advice. Regardless, always remind your doctor that you’re a diver when he or she prescribes a med. And, if your doc isn’t up on how diving can affect your condition or medications, you should be prepared to provide some resources. (See the sidebar “Educating Your Doctor” on Page 34.)

Some medical conditions aren’t temporary, and these can have major consequences for divers. Two of the more common concerns are asthma and diabetes. Both are becoming epidemic in many regions of the world, including North America, the Caribbean, and the islands of the South Pacific; and many believe that this is the result of lifestyle and the degrading quality of our environment. This is a serious problem for all segments of society, but it poses additional problems for the diving community. For decades there has been much debate about whether to allow those with either condition to dive; and at one time the answer was quite simple: no. But many have questioned such a ban on diving, and today, after careful medication evaluation, some asthmatics are permitted to dive.

Diabetes, as well, is a chronic condition that’s been recently reconsidered by diving medical experts. Today, rather than a blanket disqualification, divers and diving candidates with diabetes are evaluated on a case-by-case basis with an appropriate medical specialist. A similar situation exists for one of the most common disorders in almost every developed society: cardiovascular disease. (For more information, see “The Heart of the Matter,” Dive Training, April 2006.) Research and debate continue regarding both asthma and diabetes, and it’s likely more issues and findings will appear.

This Will Only Hurt a Little

Whether you’re a diver or not, the cornerstone of good health is a regular physical exam. Opinions on how often this should happen seem to vary; and to be perfectly honest, after graduating from college I didn’t set foot in a doctor’s office for almost 20 years. But that all changed when I hit the big 4-0, a milestone no one should ignore. Since then I’ve had regular annual checkups, along with the associated diagnostic, age-appropriate tests involving treadmills, CAT scans, endoscopes, rubber gloves and assorted other accouterments of medical technology.

The issue of physical examinations for divers has undergone quite an evolution. Even today, policy varies from country to country. As I mentioned, when I got certified, everyone was required to first secure medical approval from a physician before being accepted into a class. But in North America, that hasn’t been the case for a long time. As many of you no doubt know from your experience, some of you had to have physical exams, while others didn’t.

North American-based diver training organizations require that all candidates for instruction complete the Recreational Scuba Training Council’s “Medical History Statement and Questionnaire.” (A copy of the form can be downloaded from many sources; just type in the search term “RSTC medical form.”) As the form explains, its purpose is to find out if a perspective diving student should be examined by a doctor before participating in training. A “yes” response to any question doesn’t necessarily disqualify someone from diving, but it does indicate that there could be a pre-existing condition that may affect safety. Therefore, the candidate must seek the advice of a physician before engaging in diving activities.

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Some believe that this approach is inadequate, contending that everyone new to diving should first have medical clearance from a physician. In fact, some countries such as Australia require this. But is this additional expense and inconvenience really warranted? Some who have studied the matter don’t think so. For instance, the UK Sport Diving Medical Committee found that examination by a physician was largely unhelpful in identifying divers with significant medical conditions, and concluded that a health questionnaire, like the current medical history form, is perfectly sufficient. A similar result came from a study six years ago published in the British Journal of Sports Medicine.

However, this selective nature of medical exams does not apply to some divers. All commercial divers, including professionals such as divemasters, dive control specialists, assistant instructors and instructors, are required to have full medical clearance before they’re accepted into training. Scientific divers, including most divers in university programs and those working under the guidelines of the American Academy of Underwater Sciences (AAUS), also require full medical evaluation before training, and while active in such programs.

For recreational divers, the current medical standard has been in effect for almost two decades. The questionnaire was developed by the Undersea and Hyperbaric Medical Society (UHMS) and Divers Alert Network (DAN). (More information about the form is contained in “Assessing Your Medical Fitness to Dive” on Page 36.)

In the end, however, the final arbiter of who can enter a diving course, for medical reasons or otherwise, is that of the instructor. In fact, based solely on his or her judgment, an instructor may require anyone to secure medical approval from a physician, even if the candidate has indicated no affirmative answers on the questionnaire.

We all like to think the best of ourselves. And often our image doesn’t reflect reality. Usually, this has little potential to do harm to anything but our ego. But fitness for diving is a different matter. When it comes to fitness, lying to yourself or others can put both you and your buddy at serious risk. Remember, no diver ever thought that they weren’t coming back from their dive.

Educating Your Doctor

As we all know doctors are very busy people. Their medical school training is intense, and with continuing advances in medical research, they have to know more and more. So, it’s no surprise that a subject like diving medicine doesn’t receive much, if any attention, in either medical school or afterward. In fact, if a doctor doesn’t take up diving personally, he may know less about diving medicine than a knowledgeable scuba instructor. This isn’t intended as a slam. It’s just that, in the scheme of things, scuba diving isn’t a very common activity. So, most doctors only rarely deal with divers and would-be divers. As a result, when it comes time for a diving medical exam, you may find yourself in the delicate situation of having to educate your doctor.

But the situation isn’t as daunting as it may sound. The RSTC “Diving Medical Statement and Questionnaire” contains a section designed just for this purpose: “Guidelines for Recreational Scuba Diver’s Physical Examination.” It includes three pages of detailed instructions with 16 medical references. So, when you show up to your doc’s office, be sure that you take a copy of the entire six-page form, not just the part he or she has to sign.

The guidelines discuss areas of concern for divers, and what to look for in a medical assessment. Temporary, relative and severe risk conditions are listed for the neurological, pulmonary, gastrointestinal, orthopedic, hematological, metabolic/endocrinological and otolaryngological systems. There’s also a segment on behavioral health. At a minimum, the examination should include these points. The list of conditions is not all-inclusive, but contains the most commonly encountered medical problems.

The guidelines define “temporary risks” as those that are responsive to treatment, allowing the student to dive safely after they have been resolved. “Relative risks” refer to conditions that exist but, in the judgment of the physician, are not contraindicated for diving. Finally, “severe risk” implies that an individual is believed to be at substantially elevated risk of decompression sickness, pulmonary or otic (ear) barotrauma or altered consciousness with subsequent drowning, compared with the general population. In these cases, as the guidelines state, “The consultants involved in drafting this document would generally discourage a student with such medical problems from diving.”

The guidelines conclude by informing physicians that medical professionals of the Divers Alert Network (DAN) associated with Duke University Health System are available for consultation. If you find that your doc would like even more insights, here are some additional references:

“Medical Examination of Sport Scuba Divers,” 3rd Edition, A.A. Bove, M.D., Ph.D (ed.), Best Publishing Company, P.O. Box 30100, Flagstaff, AZ 86003-0100.

“The Physician’s Guide to Diving Medicine,” C.W. Shilling, C.B. Carlston and R.A. Mathias, Plenum Press, New York, New York (Available through the Undersea and Hyperbaric Medical Association, Bethesda, Maryland)

Assessing Your Medical Fitness to Dive

The “Diving Medical Statement and Questionnaire” has been produced under the auspices of the Recreational Scuba Training Council and endorsed by the Undersea and Hyperbaric Medical Society (UHMS), Divers Alert Network (DAN) and more than two dozen of North America’s top diving medical specialists. To assess whether an individual should have medical clearance to enroll in a scuba course, here are the areas it addresses:

First, the questionnaire addresses those over 45 years of age. For this group, a positive response to smoking, high cholesterol, family history of heart attack or stroke, high blood pressure, diabetes (even if controlled by diet alone), or if you are receiving medical care means a trip to the doctor’s office.

It then goes on to ask all applicants if they have or have ever had any of several medical conditions, listed below; and if they take any prescribed medications for anything other than malaria prophylaxis or birth control. Female diving candidates are asked whether they are, could be or are attempting to become pregnant.

Again, an affirmative response to any of these questions or conditions, and a doctor’s approval is required for continuing with your wishes to become a certified diver.

• Asthma, or wheezing with breathing, or wheezing with exercise.
• Frequent or severe attacks of hay fever or allergy.
• Frequent colds, sinusitis or bronchitis.
• Any form of lung disease.
• Pneumothorax (collapsed lung).
• Other chest disease or chest surgery.
• Behavioral health, mental or psychological problems (panic attack, fear of closed or open spaces).
• Epilepsy, seizures, convulsions or take medications to prevent them.
• Recurring complicated migraine headaches or take medications to prevent them.
• Blackouts or fainting (full/partial loss of consciousness).
• Frequent or severe suffering from motion sickness (seasick, carsick, etc.).
• Dysentery or dehydration requiring medical intervention.
• Any dive accidents or decompression sickness.
• Inability to perform moderate exercise (i.e., walk 1 mile [1.6 km] within 12 minutes).
• Head injury with loss of consciousness in the past five years.
• Recurrent back problems.
• Back or spinal surgery.
• Diabetes.
• Back, arm or leg problems following surgery, injury or fracture.
• High blood pressure or take medicine to control blood pressure.
• Heart disease.
• Heart attack.
• Angina, heart surgery or blood vessel surgery.
• Sinus surgery.
• Ear disease or surgery, hearing loss or problems with balance.
• Recurrent ear problems.
• Bleeding or other blood disorders.
• Hernia.
• Ulcers or ulcer surgery.
• A colostomy or ileostomy.
• Recreational drug use or treatment for, or alcoholism in the past five years.

By Alex Brylske