Back disease and morphine use

[Romain V.]

Dear fellow divers,

I am a diving instructor working in the Maldives and I came across a tricky situations few days ago. I checked in a diver from Switzerland and he wanted to register his wife for OW course. They informed me that she has a long term back disease that affects the back cords disks. She had since she's 7 years old about 8 back surgeries to fix screws in her back spinal cord as her disks break very easily. She came up with a doctor certificate that doesn't state which disease it is but allows her to dive if she equips herself in the water. After they filled up the medical questionnaire answering no to every question but the back problems one, and provided me with that medical certificate, I felt pretty comfortable taking her for her first confined session.

She's doing ok, not the best student I ever had, but ok. Now she gets tired very easily and since her back is very fragile, there are a few skills she can't complete like BCD removal UW and on the surface. Tell me if I'm wrong but these are skills you need to become Open Water certified. I then thought ok, she might be ok for a Padi scuba diver license instead since these are confined 4&5 skills. Am I right ?

Then after discussing a bit further with her, she told me that she is under low dosage of morphine at all times to cope with the pain. That wasn't mentioned in the medical form neither in the medical certificate from her doctor.

My question is, will I as her certifying instructor be liable for any post certifications injuries ? Moreover, is diving a good idea for such a "patient" ? She's is very I to it and wants to get certified as she told me diving helps her relax. Her husband who is already AOW is also kind of pushing so she gets it. I will get in touch today with her own doctor and get another opinion from the DAN doctors, but I though I could use as well some suggestions from our community.

Thanks a lot for your wise answers.

Romain

 

[GrimSleeper]

Dear fellow divers,

I am a diving instructor working in the Maldives and I came across a tricky situations few days ago. I checked in a diver from Switzerland and he wanted to register his wife for OW course. They informed me that she has a long term back disease that affects the back cords disks. She had since she's 7 years old about 8 back surgeries to fix screws in her back spinal cord as her disks break very easily. She came up with a doctor certificate that doesn't state which disease it is but allows her to dive if she equips herself in the water. After they filled up the medical questionnaire answering no to every question but the back problems one, and provided me with that medical certificate, I felt pretty comfortable taking her for her first confined session.

She's doing ok, not the best student I ever had, but ok. Now she gets tired very easily and since her back is very fragile, there are a few skills she can't complete like BCD removal UW and on the surface. Tell me if I'm wrong but these are skills you need to become Open Water certified. I then thought ok, she might be ok for a Padi scuba diver license instead since these are confined 4&5 skills. Am I right ?

Then after discussing a bit further with her, she told me that she is under low dosage of morphine at all times to cope with the pain. That wasn't mentioned in the medical form neither in the medical certificate from her doctor.

My question is, will I as her certifying instructor be liable for any post certifications injuries ? Moreover, is diving a good idea for such a "patient" ? She's is very I to it and wants to get certified as she told me diving helps her relax. Her husband who is already AOW is also kind of pushing so she gets it. I will get in touch today with her own doctor and get another opinion from the DAN doctors, but I though I could use as well some suggestions from our community.

Thanks a lot for your wise answers.

Romain

Well, the RSTC medical form specifically asks about medication and you now know that your student lied. There's no way I'd certify her for ANYTHING without, at the very least, clearance from a doctor for the morphine use - anything else is a breach of standards. You have no choice.

As to Scuba Diver, well, if she meets the performance requirements, she meets them. But if she can only gear up in the water because her back is so bad, how is it she can't do equipment remove & replace? She's already, presumably, doing the replace bit, and she'll have to do the remove bit if she's ever going to get back onto a boat.

Ask yourself whether this lady is ever going to be truly able to safely conduct a dive, including entering and exiting the water. How badly is her back going to get messed up if someone has to conduct a rescue on her? It's difficult, especially if the husband us pushing you as well, but sometimes you just have to have 'that' conversation. Ask yourself what you're prepared to have on your conscience. If you're happy with it and you're not breaching standards, you can certify her. I can't say without meeting her, but I suspect I'd be suggesting she find another way to relax - one that doesn't, potentially, involve rough seas, being manhandled onto a boat, heavy equipment, and the fact that probably nobody can really tell how that much surgery will affect on- and off-gassing, especially given that it's round her spinal chord.


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[Romain V.]

Thanks for the reply Grim, we are on the same page... I still didn't managed to get the Swiss doctor on the phone but I'm expecting some silly answers since he didn't mentioned the morphine even tho he knew she was using it. But here is what the DAN doctor replied today :

Dear Romain,
the underlying condition, per se, would be enough to prevent a full Fitness To Dive Certification, even if it might be consistent with a limited ability kind of diving, with adequate and specific procedures, such as the ones foreseen by organizations like the HSA.
The fact that the person is also under constant opioid therapy to control pain, on the contrary, is not compatible with safe diving of any kind, unless specifically cleared by a Diving Medicine Specialist (which I personally consider very unlikely to happen).
Furthermore, such a condition and situation may seriously impair the validity of any diving injury insurance regarding this person herself, as well as the validity of any liability cover of her instructors, dive guides or diving centers accepting her as a client / student.
To answer you last question: no, at this stage and with this information, scuba diving is not advisable for this lady.
Kind regards

Dr. Alessandro Marroni, M.D.
Chief Medical Officer, DAN Europe Foundation

I cannot praise enough the efficiency and kind professionalism of the DAN foundation which has always provided me with great advices and support through my diving career.


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[Romain V.]

One more question, if i get clearance for the medications, DSD is not such an issue right ? Just have to pick an easy place and the right weather..


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[Adventure-Ocean]

I would contact the legal department of the dive agency she'd be certified for. If they convince you her documentation is all that's needed to release you from liability you may want to teach her and her husband how to dive safely with her limits. Long term back disease sounds pretty bad. Diving might provide the only physical fun she could do. If you are convinced you are legally protected to instruct her you just might take this opportunity to provide this awesome ability to someone who could really use it. It is a difficult situation. Good luck.... Adventure-Ocean

 

[GrimSleeper]

I certainly wouldn't argue with Dr Marroni - he's a man who knows his stuff when it comes to diving medicine.

In my opinion you'd have the same issue with DSD. While you wouldn't have to worry about future liability, if anything goes badly wrong during the DSD you may find you're not covered by your insurance, and whatever insurance the student has may also refuse to pay out. The doctor in Switzerland clearly isn't a diving medicine specialist, and a good (by which I mean ruthless) lawyer could probably use that to dismantle any defence you offer regarding her having been declared medically fit to dive.

Bear in mind that the legal department of a certification agency exists to protect the agency, not you the instructor. Most agencies have very little provision for teaching less physically able divers, and don't teach their instructors to do so. I'd be very tempted to suggest that, if this particular lady really does want to dive, she finds herself an HSA instructor and learns to dive though an agency and with an instructor specifically focussed on teaching divers who don't share the same physical abilities as most students.

I'd be honest with the lady, show her Alessandro Marroni's email if need be, and move on. It's a shame, especially if it's something she desperately wants to do, but in the end the simple truth is that diving can and does cripple or kill people, and this poor lady is apparently at a significantly greater risk of that than the average person. People with long-term conditions are often determined not to be defined by them, which is admirable, but can sometimes lead to unrealistic expectations as to what is possible. I think it's your duty as a professional, both to yourself and to her, to explain why diving is not for her.

 

[DogDiver]

Hi. NAUI instructor here. Praise her on her ambitions to want to learn to dive. Then politely state she would be safer and really enjoy herself by snorkeling. No way I would allow her in the water with scuba gear.


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[Romain V.]

Thanks a lot guys for your replies, I've never come across this situation before and what you are all saying helps me make a better judgment. By the way, the Swiss doctor replied today. He is as well a sports medical doctor and a surgeon plus a diver and once again gave her the green light to go out for scuba, stating that the back is strong enough and the low dosage of morphine would not be an issue. I have forwarded him Dr. Maronni email, let's see what he says.


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[Romain V.]

Oh I didn't realized who was Alessandro Marroni until I typed his name in google.. Founder and president of DAN Europe, and he replies to my email, I'm chocked and amazed. There is no way I would argue with his recommendations. Let's see now what the Swiss doctor will say haha.


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[TSandM]

The issue of chronic narcotics use is an interesting one, although I for one fall on Dr. Marroni's side on this.

The major side effects of narcotics that would be relevant to diving are sedation and blunting of respiratory drive. Narcotics show a significant degree of tolerance, meaning that with time, the same dose has less effect, both as a pain reliever and in terms of side effects. But I think it is fair to say that, if the medication is working to relieve pain, it is also creating some degree of sedation and blunting of respiratory drive. This may be very mild, and on land, may not be noticeable at all, but if you get someone in the water whose response to CO2 is not normal, it's a setup for increased narcosis, which will add to the sedative effect of the medication.

Add in the fact that the back pain is sufficient to require narcotics, and therefore, if the person reduces or skips her dose, she may be physically unable to do what is necessary to dive -- or, and equally bad, have so much situational awareness sucked away by coping with the pain that she can't respond appropriately to her environment, and you have an unsafe diver.

I don't know what the stand of the HSA is on medications of this type -- I would assume that many of the divers they work with are on medications which have sedating side effects. Given the increased degree of vigilance and responsibility taken by the buddies of HSA divers, that might be reasonable.

I've had friends who have developed pain issues after being certified and have dived on narcotics. I've always looked at it rather dubiously.