Divers with Asthma

[Crowley]

Good to see an open discussion on this thread. I'm not an asthmatic but I am an IAHD (International Association of Handicapped Divers) instructor (although I'm not disabled myself) and the one medical condition that I fear most in a student diver is asthma.

Here is a simple fact. If a diver has an asthma attack at any depth over 3 or 4 metres he or she runs the risk of serious injury or death. If a section of the lung becomes isolated during an asthma attack then making an ascent will cause a lung over-expansion injury - either a collapsed lung or worse, an embolism. On the other hand, if you cannot recover from your asthma attack, the diver will suffocate. It's a REALLY tough call. I appreciate that allergy induced asthma is not likely to be a problem whilst diving, but excercise induced asthma most certainly is.

This does not of course preclude people from diving, and clearly the number of asthamtics involved in this thread demonstrates that. As an instructor however, I will accept nothing less than a medical certificate from a doctor certified in hypobaric medicine before accepting an asthmatic student. I'm wondering how other instructors feel about this?

For the diving asthmatics - please understand this is not some form of predjudice but the simple fact is that if an asthmatic has a serious attack at 30 metres, they will die. Womble's last post I thought was well stated. I appreciate there's a lot of negativity about diving with asthma in the press but some of it is for a very good reason. It's a difficult topic sometimes... I'm glad to see an open discussion about it!

 

[fisherdvm]

. As an instructor however, I will accept nothing less than a medical certificate from a doctor certified in hypobaric medicine before accepting an asthmatic student. I'm wondering how other instructors feel about this?

I think a certification from a hyperbaric medicine doctor might be an overkill. If they follow current guideline, I think a pre and post exercise pulmonary function test is required. Usually this is done in a pulmonary doctor's office, or an occupational medicine doctors office, and some fp's offices.

I know that SSI has some standard clearance forms which included these guidelines, and pre and post dive spirometry. You might want to google this, as I think it is pretty strict.

With so many triggers in asthma, perhaps the best "test" is a good medical history. Certainly you can not expect a physician to do a hypothermia, exercise, and seasonal test to clear someone who has seasonal asthma, cold induced, and exercise induced asthma. These folks can only be teased out with a good history.

 

[Marek K]

I think a certification from a hyperbaric medicine doctor might be an overkill. If they follow current guideline, I think a pre and post exercise pulmonary function test is required. Usually this is done in a pulmonary doctor's office, or an occupational medicine doctors office, and some fp's offices.

Problem is, doctors who are excellent pulmonologists/allergists may not have any idea about diving/hyperbaric medicine. (Please understand I'm speaking as a layperson.)

Our now-14-year-old daughter has a history of childhood asthma, induced exclusively by upper respiratory infections -- she'd tend to get wheezy a few days after getting sick. She seems to have grown out of it in the last couple of years.

But when we wanted to enroll her in OWD two years ago, her pulmonologist/allergist -- one of the leading ones in the city -- didn't even want to hear of the possibility of her diving. No if's, and's, or but's. No, he wasn't a diver; just seemed like he was one of those who believed an asthmatic shouldn't dive. Punkt.

I know it sounds like we were shopping around, but we wanted a second opinion. We got some recommendations and found another leading pulmonologist, who is also a hyperbaric specialist. (Are all hyperbaric doctors by definition pumonologists?)

He took a careful look at her medical history, spirometry, x-rays, and blood and urine tests. He also put her on a regulator from a scuba tank to see how she took cold dry air. No problems. He cleared her, as long as she didn't have a cold before diving.

Daughter's due for an annual scuba medical clearance. Guess who we're going to?

The other side of the coin is interesting. How much of a potential risk is it for a non-hyperbaric pulmonologist to erroneously clear an asthmamatic for diving? Or do doctors tend to to err on the side of caution?

--Marek

 

[DocVikingo]

Hi Crowly,

There are a number of asthma protocols out there (e.g., BSAC,YMCA) and they share many commonalities.

The SSI protocol referred to by fisherdiver was developed by their Medical Advisor, Dr. Duke Scott. He is Medical Advisor to the YMCA program as well and their YSCUBA program also has adopted the protocol.

To the best of my knowledge that protocol cannot simply be googled up. The first iteration was online at one point, but has been revised and I believe that Dr. Scott needs to be contacted directly to obtain the most recent version.

Last I knew, he was at:

Duke Scott, M.D.
1606 Arrowhead Trail
Neptune Beach, FL 32266
Phone: (904) 246-0750
Fax: (904) 246-4947
Email: dr1313@aol.com

As regards requiring clearance from a certified diving medicine physician, this makes sense as long s/he also has at least some expertise in pulmonology. Sadly, many regular pulmonologists are hopelessly out of date on the current thinking regarding diving with asthma. They'll simply say,"no." The diving medicine doctor can refer the patient for whatever PFT's, imaging studies and other diagnostics may be needed. He'll get the results and then apply his specialized knowledge in making the call.

Regards,

DocVikingo

 

[Ana]

Several good points have been argued on the previous posts.

At the begining who ever wanted to dive, went ahead got some training (or self-learned) and made sure to be responsible for his/her own safety. With asthma or without.

Then came the time of the "Legal releases", self responsibility was not good enough, someone has to protect the divers because they can't be trusted. At that point who ever really wanted to dive and had asthma figured that it was easier to lie about it and be responsible for their own safety.

Recently, a wave of "I can do everything regardless of my impairments, and someone else has to keep me safe" surfaced. I don't know exactly how is the paperwork completed, but I do see people in the water that are just not comfortable and blame asthma, even if thewy aren't really asthmatics. These are the people that spread a terrible image of an asthmatic. I realize it is easier to blame an ailment instead or their own incompetence or the simple fact that diving is not for them.

I just hope that people in contact with this whinners realize that is not the asthma, it is them.

Heavy duty asthmatics tend to be very proud of their accomplishments and keep their asthma to themselves and their doctors. Most of the asthmatics are very aware of their limitations and take responsibility for their actions even if some result on an episode.

 

[DocVikingo]

Good points, Ana.

Be honest with yourself and others, including dive buddies and ops, and take responsibility for your own behavior.

Regards,

DocVikingo

 

[fisherdvm]

It is a sad state in medicine and diving, where both sides are being so defensive. The more studies the diving communitiy do on asthma, diabetes, and other common medical conditions in diving, the higher the public expect the LDS, and the doctors to know about these.

I fear there will be a day, when an LDS will be held accountable, because a family doctor cleared a diver for diving, but the diver might sue the LDS for having not followed the "latest" recommendation and referred so and so diver to a pulmonist who is a hyperbaric physician.

Vice versa, the medical community might also rebound, and refuse to clear any patients for diving, unless they see a diving specialist.

There has to be a fine line somewhere, where personal responsibility is required. My gut feeling is, most LDS are not requiring the more stringent protocol by Dr. Duke Scott, but most are willing to accept a simple clearance from any MD or DO's.

 

[Marek K]

My gut feeling is, most LDS are not requiring the more stringent protocol by Dr. Duke Scott, but most are willing to accept a simple clearance from any MD or DO's.

You mean after a diver declares on a self-clearance form (like the RSTC Medical Statement) that they have or have ever had asthma?

I think that's pretty much correct. Not just LDS's, but destination operations and everybody.

And any kind of protocol. Wonder how many operations are even aware of the one you and DocVikingo reference?

But for that doctor's statement, what's usually accepted is a physician's signature; either on the RSTC form itself, or even a vague one-liner assessment ("I see no contraindications to diving") on a blank piece of paper. As long as there's a valid (-looking) medical signature on the paper.

Even here in Europe, where things tend to be more regulated and stringent, I've never seen anyone require a fully filled-out or standardized protocol. One-liner with a physician's signature? Fine. How would it be controlled any other way? Would the dive operation be qualified to double-check the physician?

Britain and France might be exceptions. (?)

That's not a judgment -- good (assuming the diver's personal responsibility and the doctor's medical knowledge) or bad (assuming the opposite).

 

[mdjh51]

UHMS has periodic programs in conjunction with NOAA that trains phsysicians on evaluating fitness to dive. There are other programs as well that will train the phsyician to evaluate divers for fitness.

I am currently working on a systematic review of literature evaluating the relative risk of diving with asthma when compared to the general population. My intent is to publish the work. I will keep teh board updated as I work through the project

 

[Crowley]

All good points - I liked Ana's comments - people need to assume responsiblity for their own actions. I would like to take everybody diving but sadly in this day and age of litigation it's no longer possible. Clearly any cardiopulmonary / respiratory specialist would be able to give a good diagnosis, but I'd have to take that under very careful consideration if they weren't also trained in hyperbaric medicine.

It's a sad state of affairs that people will - and have successfully - sued organisations even though it's their own fault. People can even sue because they got burned on a hot cup of coffee because it was - er - hot!

I hope everybody understands that it's not because I have some weird prejudice against asthamtics, and more information is always welcome!