The Value of Medical Examinations? Being Honest with Yourself…

I will start this by saying I am not a medical doctor and therefore am not making a formal statement over the efficacy of diving medicals for the recreational (or technical) diver but rather providing links to work already carried out in this area.

Ultimately, you are responsible for your own actions in this recreational activity, if you don’t feel well or fit enough to go diving, don’t go.

For those ‘At Work’ under the Recreational ACoPs for diving in the UK, the HSE have stated that you are to have a medical signed off each year, but such a rule does not exist for ‘fun’ divers.  Notwithstanding this, the majority of diving clubs (e.g. BSAC, ScotSAC) require you to make a self-declaration each year as to your fitness to dive, and if you are undertaking a training course delivered by a formal training organisation recognised by the HSE, you are also required to make such a declaration.

So why make a declaration and not a formal physical each year considering the environment in which we undertake diving?  Didn’t it used to be the case that diving medicals were required, why not now?  This link provides guidance on the current medical forms and standards and why medicals are no longer routinely required; the two articles below are those referenced in the link.  Full copies can be downloaded from the links (some of the stats data was removed from below to make it easier to read).

Medical supervision of sport diving in Scotland: reassessing the need for routine medical examinations – http://bjsm.bmj.com/content/34/5/375.short

Objective—To examine the need for routine diving medical examinations in the Scottish Sub-Aqua Club (SSAC) between 1991 and 1998.

Methods—A medical examination of all SSAC divers is performed at entry and then every one to five years based on their age and medical condition This information was analysed in terms of questionnaire findings and examination abnormalities.

Results—There were 2962 medical forms available for analysis. Examination abnormalities were found in 174 subjects (5.9% of the population), with obesity affecting 75 subjects (2.5%). There was a linear increase in mean body mass index, and a significant difference between 1991 and 1998 (mean (SD) of 24.1 (3.07) and 25.02 (3.4) respectively) which was not related to age or sex distribution. There was also a significant increase in the prevalence of smokers. The most common specialist referral was for evaluation of asthma, with hypertension and obesity as the next most common reasons. Most subjects were allowed to dive, with only 43 (25%) being failed outright. Overall, no examination abnormality alone caused a subject to be classified unfit to dive, and referrals were prompted by the answers in the questionnaire.

Conclusions—No significant unexpected abnormalities were found on clinical examination in this population of sport divers. Conditions that prevented subjects from diving were detected by the questionnaire, and this prompted referral for further assessment by the medical advisors. Routine medical examinations were of little value.

A follow-up study was carried out 3 years later to determine if the suspension of medicals was a good idea.  The results are available here – http://bjsm.bmj.com/content/38/6/754.abstract – Three year follow up of a self certification system for the assessment of fitness to dive in Scotland.

Background: The need for routine medical examinations of sport divers in the Scottish Sub-Aqua Club (Scot-SAC) was revised in March 2000, and a new system using a self administered screening questionnaire was developed to allow divers to be assessed when necessary by doctors with diving medicine experience.

Objective: To assess the effect of the new medical system on medical referee workload, diver exclusion rates, and diving incident frequency.

Methods: All divers were required to complete a questionnaire to screen for conditions that might affect fitness to dive. Divers answering “Yes” to any of the questions had their medical background assessed by a diving doctor, and, if necessary, received a clinical examination or investigation. The rate of diver exclusions based on the questionnaire response was recorded in conjunction with analysis of the incident reports.

Results: The number of forms requiring review by diving doctors increased from 1.2% to 5.7% in the year after the introduction of the new medical system and gradually increased in subsequent years to 7.7%. The number of divers failing to be certified fit to dive increased slightly from 0.7% to 1.0% after one year and subsequently to 2.0% after three years. Most divers were certified fit to dive on the basis of the questionnaire alone, and only 0.9% required objective investigation (such as exercise testing or echocardiography). Analysis of the incidents during three years of follow up confirmed that no incident occurred because of an undetected pre-existing medical condition. Two incidents involved divers with hypertension, but both had received medical examinations and investigation based on their responses to the questionnaire.

Conclusion: The new self administered questionnaire system appears to be an effective screening tool for the detection of divers requiring detailed assessment by doctors with diving medicine experience.

The 2011 DAN Fatalities workshop also examined this subject, with Dr Simon Mitchell & Dr Alfred Bove writing this paper on the subject.  A key point was that whilst cardiac screening is a good idea, “there was considerable discussion over the use of medical screening questionnaires prior to embarkation on charter vessels. Some commentators were adamant that this did not occur and would introduce too many difficulties for dive operators trying to interpret the answers. others were equally adamant that many charter boats included medical questions in their waiver documentation, and this is known to be true in Queensland, Australia. There was no consensus on the desirability of this practice, but it did become clear that there is no standardized questionnaire for use in this con-text. It was acknowledged that comprehensive screening questionnaires such as the RSTC form were not suitable for dive charter use, and that a shorter and highly discriminatory tool needs to be developed for that situation.” 

Ultimately the immediate best judge of health is the diver themselves but for this to be effective, divers have to be honest with themselves about their health. Unfortunately there have been a number of fatalities where divers have lied on their self-declaration medical forms and this has been found out during the fatality investigations; warfarin and diving are not good dive buddies, neither are known significant cardiac issues.  

Your life and your risk, but bear in mind that if you do have a major issue, someone will have to rescue you, and if you subsequently die, you will leave a bunch of family and friends mourning your demise, and considerable stress caused to those involved in the rescue and/or recovery. If you are at all worried about your health, speak to a diving/hyperbaric trained doctor and see what they say. You can find a list of them at here. We aren’t getting any younger…!

Safe diving…

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