Notes
Slide
1
Slide
2
Slide
3
What’s New in Diving Medicine
Eric Johnson, MD
NAUI #22649
D rector Emergency Services, Teton Val ey Hosp tal, Dr ggs, ID
Past President, WMS
Notes
Slide 4
Sources of Info:
• Divers Alert Network
– www.diversalertnetwork.org
• UHMS
Dive Agencies: PADI, NAUI
– www.uhms.org
• Other Web Site:
•
•
•
•
Slide 5
What’s New ?
•
•
•
•
•
•
•
Slide 6
http://scuba-doc.com
http://faculty.washington.edu/ekay/
http://www.scubamed.com/divmed.htm
www.wms.org
Let’s review some data…
Never forget the basics.
Medical updates.
Diving techniques.
Equipment
Targeted populations
Travel.
UHMS Website
Notes
Slide 7
Slide 8
Slide 9
Notes
Slide 10
Slide 11
Slide 12
Notes
Slide 13
Slide 14
Spontaneous Pneumothorax
Slide 15
Notes
Slide 16
Slide 17
Slide 18
Notes
Slide
19
Slide
20
Slide
21
Notes
Slide
22
Slide
23
Slide
24
Notes
Slide 25
Slide 26
Slide 27
Notes
Slide 28
Slide 29
Medical updates
• Asthma
– Good publication by UHMS & DAN
• Seizures…unchanged, but being challenged
• Diabetes:
– Used to be always a “NO”
– New guidelines and data.
Slide 30
Epilepsy and recreational scuba diving : an absolute
contraindication or can there be exceptions? A call for discussion.
Epilepsia. 2007 May;48(5):851-8
We suggest that people with epilepsy who wish to
engage in diving, and the physicians who certify
fitness to dive, should be provided with all the
available evidence. Those who have been entirely
seizure-free on stable antiepileptic drug therapy for at
least 4 years, who are not taking sedative antiepileptic
drugs and who are able to understand the risks, should
then be able to consider diving to shallow depths,
provided both they and their diving buddy have fully
understood the risks.
Notes
Slide
31
Pollock NW, Uguccioni DM, Dear
GdeL, eds. Diabetes and recreational
diving: guidelines for the future.
Proceedings of UHMS/DAN 2005
June 19 Workshop. Durham,
NC:Divers Alert Network; 2005.
Slide
32
Guidelines for Recreational Diving with
Diabetes • Selection and Surveillance
• Age ≥18 years (≥16 years if in special training
program)
• Delay diving after start/change in medication
– - 3 months with oral hypoglycemic agents (OHA)
- 1 year after initiation of insulin therapy
• No episodes of hypoglycemia or hyperglycemia
requiring intervention from a third party for at
least one year
• No history of hypoglycemia unawareness
• HbA1c ≤9% no more than one month prior to
initial assessment and at each annual review
– - values >9% indicate the need for further evaluation
and possible modification of therapy
Slide
33
New Diabetes & Diving
Guidelines
• No significant secondary complications from diabetes
• Physician/Diabetologist should carry out annual review and
determine that diver has good understanding of disease and
effect of exercise
– - in consultation with an expert in diving medicine, as required
• Evaluation for silent ischemia for candidates >40 years of
age
– - after initial evaluation, periodic surveillance for silent ischemia can
be in accordance with accepted local/national guidelines for the
evaluation of diabetics
• Candidate documents intent to follow protocol for divers with
diabetes and to cease diving and seek medical review for any
adverse events during diving possibly related to diabetes
Notes
Slide 34
Diabetes & Diving
Scope of Diving
• Diving should be planned to avoid
- depths >100 fsw (30 msw)
- durations >60 minutes
- compulsory decompression stops
overhead environments (e.g., cave,
wreck penetration)
situations that may exacerbate hypoglycemia
(e.g., prolonged cold and arduous dives)
• Dive buddy/leader informed of diver’s condition and steps
to follow in case of problem
• Dive buddy should not have diabetes
Slide 35
Diabetes & Diving
Glucose Management on the Day of Diving
• General self-assessment of fitness to dive
• Blood glucose (BG) ≥150 mg·dL-1 (8.3 mmol·L-1),
stable or rising, before entering the water
- complete a minimum of three pre-dive BG
tests to evaluate trends 60 minutes, 30 minutes
and immediately prior to diving
- alterations in dosage of OHA or insulin on
evening prior or day of diving may help
• Delay dive if BG
- <150 mg·dL-1 (8.3 mmol·L-1)
- >300 mg·dL-1 (16.7 mmol·L-1)
Slide 36
Diabetes & Diving
• Rescue medications
- carry readily accessible oral glucose during
all dives
- have parenteral glucagon available at the
surface
• If hypoglycemia noticed underwater, the diver
should surface (with buddy), establish positive
buoyancy, ingest glucose and leave the water
• Check blood sugar frequently for 12-15 hours
after diving
• Ensure adequate hydration on days of diving
• Log all dives (include BG test results and all
information pertinent to diabetes management)
Notes
Slide 37
Plasma glucose response to recreational
diving in novice teenage divers with insulin requiring
diabetes mellitus.
N.W . POLLOCK1, D.M. UGUCCIONI2, G.DeL. DEAR1,2, S. BATES3, T.M. ALBUSHIES4, S.A.
PROSTERMAN5.
1Center for Hyperbaric Medicine and Environmental Physiology, Department of Anesthesiology, Duke University Medical Center,
Durham, NC 27710; 2Divers Alert Network, Durham, NC, 27710; 3Golisano Children’s Hospital, Rochester, NY; 4Concord Pediatrics,
CPPA, Concord, NH; 5University of the Virgin Islands, St. Thomas.
•
Pollock NW , Uguccioni DM, Dear GdeL, Bates S, Albushies TM, Prosterman SA. Plasma glucose response
•
to recreational diving in novice teenage divers with insulin-requiring diabetes mellitus.
•
Med 2006; 33(2):125-133.
Undersea Hyperb
•
•
•
•
•
•
•
A growing number of individuals with insulin-requiring diabetes mellitus
(IRDM) dive, but data on plasma glucose (PG) response to diving are limited, particularly for adolescents. W e
report on seven 16-17 year old novice divers with IRDM participating in a tropical diving camp who had recent
at least moderate PG control (HbA1c 7.3±1.1%) (mean ± SD). PG was measured at 60, 30 and 10 min predive
and immediately following 42 dives. Maximum depth (17±6 msw) and total underwater times (44±14
min) were not extreme. Pre-dive PG exceeded 16.7 mmol⋅L-1 (300 mg⋅dL-1) in 22% of dives. Males had
significantly higher pre-dive levels (15.4±5.6 mmol⋅L-1 [277±100 mg⋅dL-1] vs. 12.8±2.9 mmol⋅L-1 [230±52
mg⋅dL-1], respectively) and greater pre-post-dive changes (-4.3±4.4 mmol⋅L-1 [-78±79 mg⋅dL-1] vs. -0.5±4.3
mmol⋅L-1 [-9±77 mg⋅dL-1], respectively). Post-dive PG was <4.4 mmol⋅L-1 [<80 mg⋅dL-1] in two dives by two
different males (3.4 and 3.9 mmol⋅L-1 [61 and 70 mg⋅dL-1]).
•
The impact of purposeful elevation of PG to protect against hypoglycemia during diving remains to be determined.
• No symptoms or complications of hypoglycemia were
reported. These data show that in a closely monitored
situation, and with benign diving conditions, some
diabetic adolescents with good control and no
secondary complications may be able to dive safely.
Slide 38
Medical
Issues:
Remote DCS TX
Slide 39
New Text on
Medical
Fitness to
Dive…from Best
Publishing
Notes
Slide 40
Flying After Diving
• Single NO-DECO Dive = 12 hour preflight
surface interval recommended.
• Multiple dives in a day or Multiple Days of
Diving = preflight SI of 18 hours.
• I use the 24 hour rule!!!
Slide 41
Slide 42
Diving Techniques & Equipment
• Equipment:
– Improved design
– Better safety gear
• Redundent air sources
• Communication
• Navigation
– Improved “algorithms” for dive computers.
Notes
Slide 43
Dive Techniques
• Buoyancy…always important!
• Reverse Dive profiles:
– The workshop finds no reason for the diving communities to prohibit
reverse dive profiles for no-decompression dives less than 40 msw (130
fsw) and depth differentials less than 12 msw (40 fsw).
• Ascent Rate:
• Slower appears better, but being
tested.
• -30 fpm or slower
• Rule of Halves:
Slide 44
The National Association of
Underwater Instructors (NAUI)
recently recommended the “rule of halves:”
NAUI now recommends for table-based norequired decompression dives in excess of
40 fsw, divers should halve the distance to
the surface from the dive’s deepest depth
and make a 1- minute safety stop, followed
by a 2-minute safety stop in the 15 fsw
zone. For dives shallower than 40 fsw, the
standard 3-minute safety stop should be
completed. Emphasis in the diving
community is still to slowly ascend, 30 feet
per minute (fpm) or slower.
Divers should halve the
distance to the surface from
the dive’s deepest depth and
make a 1- minute safety
stop, followed by a 2-minute
safety stop in the 15 fsw
zone
Slide 45
Targeted Groups:
-Kids
-Technical Divers
Notes
Slide 46
Don’t forget getting there?
• Travel Med concerns
– Immunizations
– Malaria and other “bugs”
– Safety
– TSA
• Dive accidents
– How to get yourself out?
• Most common cause of dive trip injury?
Slide 47
Slide 48
THANK YOU!!!
Notes
Slide 49
If needed, Please
resuscitate the person next
to you!!!