Diving & Epilepsy

[masterof0]

The problem is that you would have to get people with seizures to consent to dive and monitor whether or not a seizure occurs.

This is the challenge in itself. We have presented a catch 22. I know a number of individuals who do have epilepsy. Some have been cleared due to their absence of seizures (and control through meds) for a minimum of 5 years, while other who don't meet the criteria have not. So if we are going to make a blanket statement that says epilepsy=no diving then how do we prove otherwise?

For those that have been cleared, I don't see why they would not allow it to be monitored or at least report back their status to a governing agency.

The bigger part of this is the idea that if we make the blanket statement that says epilepsy=no diving, then I will bet you there are a number of divers that have knowingly put no to their status (or any other high risk issue) so they could dive. This poses an even bigger risk because now we have no idea what the circumstances are. At least with my buddy, I know his condition and he and I have both accepted the risk of diving with epilepsy. (Also keep in mind that the same rules apply to driving where I think an increased risk occurs due to the number of drivers that are impacted if a driver seizes on the road...but as long an individual goes seizure free for 3 years, they can be released with a doctor's consent.)

 

[ScubaDocER]

I agree that is is a difficult challenge. Most physicians I know still wont allow patients with seizures to drive. Most neurologist I have spoken to will not release a seizure patient to drive. The issue surrounds many things including liability, and the lack o predictability regarding seizures. The concept of being "cleared" by a doctor is not always as cut and dry as it seems. The most a physician can say is that you have been seizure free for 5 years, for example, but that says nothing about your risks for having another seizure. While I respect the faith that has been placed in us by the general public, sometimes our opinion is just that, an opinion or an educated guess. Clearing someone to dive means that the chances of them having a serious medical condition that places them at risk appears minimal. It is never an absolute. We rely on people to make good personal judgments and to be honest so that we may help them calculate their risks. The issue with seizures and diving is drowning, not really seizures. Seizures on the surface can often be treated quickly and without much difficulty. Most seizures resolve themselves before treatment is even begun. They last for 15-30 seconds on average, and stop spontaneously. The patients are turned on their side to prevent aspiration. They usually go through a brief post-ictal phase (minor confusion) and the seizure is over. I cannot imagine trying to do all of this underwater without professional assistance. The blanket statement about seizure patients is not a condemnation of seizure patients, but a concern for their risks of drowning, which is quite probable if a seizure occurs underwater. Because there are no studies that have been able to show a safety record to date, the decision is left to the diver and I suppose the training agency. It's similar to the concept of pregnancy and diving. While no studies prove that you cannot dive while pregnant, people have erred on the side of caution and made a blanket statement that you cannot dive while pregnant because no one wants to assume the risk if there is problem with the baby. If divers chose to lie on their application then I am not sure what more you can do about that. You could require divers to have a note from their doctor stating that they don't have any of the medical conditions that would bar them from diving. But not every one can afford to go to a doctor to have them say that. The honesty of the diver rests with the diver. They assume the risks if they choose otherwise. You and your dive buddy seem to have an honest diving relationship and that's a great thing. As long as you and he know and are comfortable with the risks then the choice is yours.

 

[mikes351]

You have very clearly summarized all of my concerns regarding diving and epilepsy, as an Instructor I certainly can't certify someone as a scuba diver. While this may seem insensitive until such time as there are sufficient studies to recommend the safe certification of epileptics I can't and won't do it. I will keep my ears open for any changes.

 

[masterof0]

I totally understand everyone's concern/fear about diving with an individual with epilepsy. This hold true in other aspects of life as well such as driving. (How many times have you been underwater or passed a car on the road without the slightest clue that the individual was epileptic?...you have no idea, and I can tell you from experience, it is more frequent than you think...especially on the road!). I think the concern from me is that we lump all epileptics together without understanding or knowing that individual situation. Having said that, I totally agree that there should be requirements associated with diving. As with driving, I agree with a window of being seizure free, yearly evaluations and potentially a C-Card that expires on a yearly basis. I am sure there are other things that can be done to mitigate the risk,

I think the other side is the frustration that everyone just throws up their hands and says "too bad." without further studies we cant do anything for your. (and this is true of more than just epilepsy.) This is easy to do when you are not directly impacted by it. To me, this kind of attitude is what leads people to be closed lipped and forge docs and say they are not...more importantly, it encourages individuals to not say anything to their buddy/instructor which creates a further risk. The reality of it all is that whether we like it or not, there are people out there that are diving with epilepsy. They are being signed off on by a doctor and the agencies are certifying them.

Why not use this is an opportunity instead of shunning those that are choosing to dive with epilepsy? If this is what it is going to take, then who do we work with, or how do we facilitate something like this to either validate or disprove everyone's concerns. Is this a DAN concern since they report statistics? Having a buddy with epilepsy, I can tell you from his perspective, if there is proof that there is an impact from diving on epilepsy, he would quit. But until someone can prove it, why should he stop? The other thing to keep in mind, as with every other condition, including heart, diabetes, etc...If an individual lives up to his/her part of taking their meds, they are doing their part to mitigate the risk. Why should they be penalized. What you are going to find out is that the people who we hear about having seizures behind the wheel, or elsewhere, are the people who don't take their meds on a regular basis, or drink alcohol, etc...these are also the people who would NOT get cleared on by any competent doc. (Ironically, this holds true for people who have heart conditions, have had strokes, etc, and are susceptible to repeats, but we chose to look past)

I am passionate about this because I watch someone do the right think and try to be open an honest about his condition, not because he wants to tell the world, but because he wants to make sure he is diving with someone who is aware and comfortable with him as a buddy. As he does that, he has been turned away as a buddy, which he understands, but it is also breaking him down to the point where he is ready to adopt a "don't ask/don't tell attitude" which is not good for anyone.

 

[ScubaDocER]

I can genuinely and sincerely appreciate your concern for your friend. It is obvious that you care for him and his passion for diving, My hope is that that passion does not prevent you from taking note of the risk that that may pose to others. As an Emergency Medicine Physician I treat people with a number of medical ailments on a daily basis. As an Instructor, I am made even more aware as to how these conditions may have genuine consequences. I have no desire to shun anyone with any medical condition. My desire is to participate in the educational process and I would love for any other medical professionals to weigh in on this topic, including any neurologists. I agree that more dialogue about the subject should be encouraged and promoted. More studies should be done and more extensive evaluations should be done regarding the safety of divers with a seizure history to dive. I do want to clear up a few points however. To my knowledge, seizure patients are not allowed to drive. No matter how long they have been medicated. No matter when their last seizure occurred. This is the first question that the neurologist will ask me about a patient in the ER. After that, they make sure that I inform the patient that they are not allowed to drive anymore. It is not to punish the patient, but an issue of safety to other drivers. There is no window of being seizure free. There are just moments between seizures. If a seizure occurs while driving then anyone around that person is at immediate and serious risk for harm and injury, including the driver. Having treated hundreds of seizure patients in my career, I can understand why that is the case. Again, it is not a punishment for one person, but a desire to protect many others.

I would not want you to feel that people are giving up. It must be frustrating for him and obviously for you as well. You are correct in that it is true for conditions other than seizures, i.e., asthma, pregnancy, etc. All I can do is share a medical perspective in hopes that people can make educated decisions about the diving they chose to do. I would state that diving is and always will be a personal decision for the individual diver. If someone chooses to be dishonest about their medical history then they must be willing to assume the consequences of that decision. People can lie about being pregnant, having asthma, or any medical condition. There is no excuse nor any justification to be deceptive with regards to ones medical history as it relates to diving. I would rather your friend be on the surface and alive than be seizing underwater and drowning. That is a genuine, not a theoretical possibility. Just because someone wants to do something that an agency doesn't allow, that does not mean they should do it dishonestly. That sets a worse precedent. You and your dive buddy seem to have an excellent diving relationship. I would imagine that that is due in part because of his honesty with you. He is doing the right thing in being so. I have no problem with you two diving together given the honesty that exists. Did his Instructor know he had seizures when he was certified?

As it stands, there isn't enough information to justify combining a seizure history with diving. But that kind of combination exists in other areas of life. People with poor eye sight, no matter how correctable, cannot be pilots I believe. Instructors are required to look at all aspects of a persons medical history to determine if they are safe to dive. That's our responsibility. They are bound by the rules of their training agency, the law, and common sense. Until the medical community guides them otherwise, their hands are tied.

Diving is associated with risks. Always has been. Each diver determines their own risks and acts accordingly. As long as the two of you accepts those risks then I wish you a lifetime of safe diving.

 

[masterof0]

To my knowledge, seizure patients are not allowed to drive. No matter how long they have been medicated. No matter when their last seizure occurred.

This is not the case. As of right now, we have had correspondence with most of the certifying agencies and if the individual has been release by a doctor, then they can be certified. (This is definitely the case for PADI, as my dive buddy is certified by them). Now the reality ofit is that I don't know of anyone who has recently had a seizure and is being released to dive. I will bet that those who have been release have been seizure free for a period of time...So for those that have active seizures, this is true.

Again, it is not a punishment for one person, but a desire to protect many others.

I agree with this to a point. As you know, there are people that are at high risk for having seizures and have routine seizures even with the assitance of meds. Where I have the problem is for those that have their seizures under control and continue to take their meds. As time passes for an individual who has been seizure free, the risk of seizures drop...Never to zero, but the risk does drop. So to lump everyone in the same boat and say they are all at the same risk is a falacy. This is why the gov has allowed individuals with epilepsy to drive. But as part of the "agreement" between the driver and the gov is that the epileptic individual has to have a physician approval on a yearly basis. Even with that said, after X number of years being seizure free, the gov does not require any further evaluation. Now the other step that the gov has taken to mitigate the risk is to put a limitation on the type of license they can get...Class A only..No commecial license under any circumstance!

So, if there is a greater risk, I would definitely put the greater risk on the road than underwater. If for no other reason than the number of people at risk.

Did his Instructor know he had seizures when he was certified?

YES. It was discussed in great detail. Ironically, one of the instructors at the shop was an EMT, and another one of our current dive buddies is an EMT and we actaully discuss it on a regular basis to ensure we are doing everything we can to mitigate risks.

As it stands, there isn't enough information to justify combining a seizure history with diving. But that kind of combination exists in other areas of life. People with poor eye sight, no matter how correctable, cannot be pilots I believe.

This applies to the military only. There are a large number of commercial pilots that have corrected vision. (Although there may be a limit to "poor vision")

Instructors are required to look at all aspects of a persons medical history to determine if they are safe to dive. That's our responsibility. They are bound by the rules of their training agency, the law, and common sense. Until the medical community guides them otherwise, their hands are tied.

Diving is associated with risks. Always has been. Each diver determines their own risks and acts accordingly. As long as the two of you accepts those risks then I wish you a lifetime of safe diving.

This is where I have the problem, if a properly licensed doctor has approved of the activity, why turn him away just because of what you THINK you know about his condition. Do you evaluate every student that signs up for a class. Do you turn away someone who is overweight with high cholesterol who is at high risk for a heart attack? Probably not. Do you turn away someone who has had a stroke and is at risk for another? Do you turn away someone who is drinking while diving? These are all situations that increase risk while diving, but we seem to look past them. So why turn away someone who has gone through all of hte proper channels who has been approved by a doctor who specializes in neurology and knows the patients condition better than you or I?

When it comes down to it, this really is a catch 22. My goal is not to be combative, but to raise awareness to a reality that most are oblivious too. We both have thoughs/ideas that we can present from both sides of the fence, each equally valid. I really do appreciate hearing from those who agree and disagree. The ultimate reality still comes back to the fact that agencies are certifying divers (although specific instructors may choose not to). The question is whether we want a "don't ask don't tell" mentality or whether we want to open the doors and learn from our experiences.

The funny part of this is that I am actually a much "better" buddy diver when I am with him than with others. Because of perceived risk, we do a much better job of communicating, planning, watching our guages and depths, and most importantly, watching each other when we dive.

 

[ScubaDocER]

I really don't want to belabor the point because I am not sure we are covering new ground. The agencies will allow someone who has been released to dive, but no one has been released to dive. This is done for a reason. No physician wants to be on the wrong end of a law suit if a diver seizes that he "cleared" to dive. Please remember that clearance is a matter of calculating the odds that an event wont happen. When the odds involve someone drowning unnecessarily, it's not a chance the average physician will take.

The concept of "active" seizures is not been applied appropriately. Someone with an active seizure is seizing in front of you. If the seizure is not active, it means they have not seized as of yet. It still comes down to who wants to take responsibility when the diver does seize underwater. Medications for seizures patients, even the ones that are non sedating, cannot tell you when a patient with seizures will seize again. "Well controlled" seizure patients will still seize on appropriate medications. Without warning. I still don't think you will find a physician willing to assume that liability. The issue not that the patient has seizures, but is diving with seizures. There is tremendous ambiguity with regards to being under control. If you seize in your own home, you can fall and hit your head, or just seize in your bed with no damage done. Seizing underwater is unacceptable. On any level. The risk of drowning is overwhelming. I don't want you to tie the concept of people being unfair to seizure patients with the concept of seizing and diving.

The risk of seizures does not drop over time. Time has nothing to do with the risk. Multiple factors come into play, including the underlying cause, response to medication, tolerance to medication, and compliance. Time has no bearing on when or how often a person seizes.

You are correct in that people with seizures may drive if they have met certain criteria, but this varies from state to state. There is still not a consensus on what is considered well controlled enough to drive.

Did your friend receive clearance from a physician to participate in a scuba diving course?

To address your last point, the discretion remains with the Instructor as to who they will train. I would turn away someone who is drinking while driving. If they are over weight to the point where it impairs their ability to perform the necessary skills, then I wont accept them. The reason an Instructor might turn away a seizure patient is because they are aware of the liability they assume. If the medical community cannot come to a consensus, then that gives them reason to pause.

The points you have raised are valid ones. My hope was to discuss more about seizures as it relates to diving an why Instructors as well as the medical community may have concerns regarding the issue. I am not sure Instructors have a blanket policy on issues like this, I think they are looking to the medical community as well as their own training agencies for guidance. To date, there just isn't a consensus to make (most of) them feel comfortable with the decision. I can respect that.

 

[masterof0]

The points you have raised are valid ones. My hope was to discuss more about seizures as it relates to diving an why Instructors as well as the medical community may have concerns regarding the issue. I am not sure Instructors have a blanket policy on issues like this, I think they are looking to the medical community as well as their own training agencies for guidance. To date, there just isn't a consensus to make (most of) them feel comfortable with the decision. I can respect that.

I am open to any discussion. Like you, I was hoping to that some of the agencies would interject so we could get some insight. One thing I will tell you is that I have letters/emails from agencies that state if a doctor will release you, then you are free to be certified. My buddy carries a release at all times in case he is ever questioned or needs to provide proof from his doc to dive. So if you are looking for guidance wouldn't that give you a general idea that things may be changing? We need hard facts, but if we don't allow them to dive, how do you get your facts...You don't.

More importantly, if the reality of it all is that divers with epilepsy are going to dive, how do we engage the agencies, DAN, etc, to use them to either prove or disprove the notion that the two are/are not directly related. Regardless of the outcome, at least there will be proof, not just speculation.

 

[masterof0]

Multiple factors come into play, including the underlying cause, response to medication, tolerance to medication, and compliance.

We agree here. So why not take the time to find out about an individual's specific condition before blanketly saying no?

You are correct in that people with seizures may drive if they have met certain criteria, but this varies from state to state. There is still not a consensus on what is considered well controlled enough to drive.

But there obviously is a consensus that at some point, epileptics are well enough to drive...If a doctor is willing to sign off, why not use that as criteria to say that the person is well enough to dive....Seems to me if they are well enough to drive, they are well enough to dive.

About the only consistency I hear from the agencies is "never hold your breath."

 

[ScubaDocER]

I wish you and your dive buddy safe diving.