Medical Advisories
Yes, Asthmatics Can Dive
In 2001, I introduced my Protocol For Asthmatic Divers, which has been embraced by the YSCUBA. Since its introduction, over 300 previously certified “closet asthmatic” divers have used the Protocol to increase their degree of safety. Over 150 students with asthma have utilized the Protocol and my guidance to achieve their dream of participating in SCUBA. I have cleared many other asthmatics as either being stable without medication or actually being free of active asthma. During this period no adverse events have been reported by the asthmatics who followed the Protocol’s guidelines and my guidance.
The purpose of this article is to dismiss the myth that no asthmatics are fit to participate in SCUBA and to encourage our instructors to take on the challenge of teaching them. Why teach asthmatics? The answer is simple. 17 million individuals in the USA alone have asthma. At least half of these are potential SCUBA students. Why is it safe? Better management and medications. First, there was the realization that asthma is a chronic inflammatory disease involving the lungs’ bronchial tree. This changed the focus of treatment from symptomatic therapy to preventative therapy by using medications that inhibit or reduce bronchial inflammation. Secondly, a class of long acting anti-bronchial spasm drugs were developed. These drugs are taken daily and constantly guard against the occurrence of bronchial spasms. Their action is more predictable than the short acting Albuterol. This allows asthmatics that are stabilized on these medications to dive safely.
How does the Protocol work? When a potential student marks the “yes” box for asthma, contact me immediately. Include the student’s name, your name, the agency and contact information. After the student reads the Protocol have them contact me. They should include their name, contact information, age, type of asthma, degree of severity, general health, exercise history, “triggers” (such as exercise and cold), and any medications (including Albuterol inhalers). Then leave it in my hands. First, I will determine if they have active asthma and secondly, their fitness to dive. Unfortunately, not all asthmatics are stable enough to dive safely. Most just need to have their medications adjusted. This is accomplished by working with the asthmatic and their physician. Pulmonary function tests will be performed, if indicated. Once stabilized, the asthmatic is turned over to you for training. At that point, I will e-mail you a detailed statement certifying that the asthmatic may participate in SCUBA and what he/she has agreed to. The instructor should have the student sign the statement, keep a copy of the signed statement and fax a copy to me. If the asthmatic does not stabilize, does not agree to the recommended changes in therapy (if any) or to following the Protocol’s guidelines, then they may not participate in SCUBA. I do not charge for my services.
The Asthmatic Protocol is user friendly, but complete. It explains the proper use and importance of a Peak Flow Meter (PFM). The monitoring of PFM readings is critical for the safety of asthmatic divers. The Protocol includes a discussion of asthma, instructor instructions, student instructions, student assumption of risk form, asthma medical form, and training forms. I urge each instructor to request a copy of the Protocol, read it thoroughly, and contact me with any questions or concerns, before deciding whether or not to teach asthmatics. Most asthmatics are motivated and easy to work with. But, I caution you not to take on any individual who may be asthmatic without putting them through the process outlined in this article. Not all physicians are equally aware of the potential danger of air trapping and/or frank bronchospasm when breathing compressed air (gas). Inadequately controlled asthmatic divers represent an Air Gas Embolism waiting to happen. Adequate control for strenuous activity on terra firma does not compare with the control needed for participation in SCUBA. However, with stabilization of their asthma and your excellent training they can now share our underwater world. Remember, that when I first advocated in 1995 that stable diabetics could participate in SCUBA (Protocol for Diabetic Divers) it was considered provocative, but is now widely accepted. In my opinion, it is safer and easier to teach stable asthmatics.
Duke H. Scott, M.D.
YSCUBA Medical Director
SSI Medical Consultant
Email: dr1313@aol.com
Phone: (904) 246-0750
Cell: (904) 655-6745
Fax: (904) 246-4947
Diabetic Protocol
In 1995 the YMCA Scuba Program introduced the YSCUBA Protocol for Divers With Diabetes (The Protocol). The goal of the Protocol was to guide instructors in the safe scuba training of qualified diabetics. This goal was in keeping with the YMCA of the USA's mission of enabling individuals with disabilities to achieve their fullest potential. Until that time diabetes mellitus had been considered a contraindication for participating in scuba. However, it was well known in the diving community that many "closet" diabetics were safely diving. During the twelve years since its conception the Protocol has exceeded our expectations. Its use had enhanced the lives of many diabetics, allowing them to experience our planet's wondrous underwater world. YSCUBA instructors have embraced the Protocol and many consider the training of qualified diabetics as routine. The Protocol has also been adopted by many existing diabetic divers as a standard for safe diving. We are please to report that during this period no adverse events have been reported.
The YSCUBA Medical Advisor developed the Protocol after consulting with many instructors, diving diabetics, diabetic athletes, and experts on diabetes. Once formalized, the Protocol was reviewed by these same experts and deemed workable. Developing hypoglycemia (low blood sugar) while submerged is the primary hazard unique to the diabetic diver. Therefore, the focus of the Protocol is preventing the diabetic from experiencing a hypoglycemic episode during a dive. However, the danger of developing excessive hyperglycemia (high blood sugar) and subsequent ketoacidosis is also recognized and addressed.The Protocol is conservative and only targets diabetics with stable, well controlled disease. The potential diver must be in good physical condition and willing to follow the Protocol.
In June of 2005, the Undersea and Hyberbaric Medical Society (UHMS) and Divers Alert Network (DAN) co-sponsored an international workshop to develop guidelines for diving with diabetes. I was privileged to be a presenter as well as a participant in that workshop. The workshop resulted in a comprehensive set of guidelines for diabetics participation in SCUBA. These guidelines were jointly published by the UHMS and DAN. The title of this publication is “Diabetes And Recreational Diving: Guidelines For The Future.” My Diabetic Protocol includes a summary of and is in concert with those recommendations. The Protocol may be utilized for implementing these guidelines by instructors and their diabetic students.
Every person with diabetes is unique and minor adjustments in the Protocol may be necessary to fit the needs of the individual diabetic scuba diver. However, such changes should be undertaken only with the advice and consent of the diabetic's personal physician. The diver's physician should have knowledge of scuba diving. If the Protocol is followed accurately a diver with diabetes reduces the risk of becoming hypoglycemic during the prescribed scuba dives. As data is gathered, the Protocol will be reviewed and/or revised as necessary, depending on the feedback received from diabetic divers and experts in diabetes.
Over the last twelve years many advances in the management of Type I and Type 2 diabetes have occurred and/or become the standard of care. The most significant of these is the improvements in, and the increased utilization of, the insulin pump. In young, physically fit Type I diabetics it has been found to provide tighter and more effective blood glucose control. However, at this time the effects of water submergence and increased atmospheric pressure on the pump function have not been determined. But the diabetic may participate in scuba by disconnecting the pump during a dive. Generally, the pump should not be disconnected for longer than one to two hours. The details of this should be worked out with the diabetic diver’s physician. In addition, several new oral medications and forms of insulin have been developed. Although they provide for effective blood glucose control, some of them may enhance the diabetic’s potential for developing hypoglycemia during physical exertion. Therefore, the diabetic diver must have a thorough understanding of how their particular diabetic regimen works, particularly with regard to the danger of developing hypoglycemia or hyperglycemia during physical activity. It is also critical that the diabetic's physician counsel the diver to check for and prevent delayed hypoglycemia, which may develop even hours after the diving activity. After reviewing the advantages and disadvantages of various insulin regimens, the diabetic's physician should be able to tailor the diabetic's regimen to allow for safe participation in scuba diving.
Diabetics with any of the following problems are excluded from YSCUBA training unless approved by the YSCUBA Medical Director:
- History of recent or recurring episodes of hypoglycemia during exercise or while at rest.
- History of hypoglycemia unawareness, such as nocturnal or asymptomatic hypoglycemia.
- History of recent or recurring episodes of excessive hyperglycemia and/or ketoacidosis.
- Significant systemic diabetes: retinopathy, peripheral neuropathy, nephropathy, microvascular disease, macrovascular disease, or diabetic foot.
- Lack of good metabolic balance.
- Diabetic being treated with a sulfoxyline due to increased incidence of hypoglycemia.
The YSCUBA program is still the only training agency with a specific plan for training diabetics. In order to make this training even safer, I developed the Simulated Open Water Pool Dive for Diabetic Divers. This pool exercise is performed at the completion of the diabetic’s scuba training and before his open water dives. This allows the diabetic diver to test his diabetic dive management plan for potential flaws. It also allows the diabetic diver and his informed buddy to practice responding to an underwater hypoglycemic event. The Simulated Dive Protocol is now an integral part of the Protocol.
Three new forms have been added to the Diabetic Protocol. These forms were developed to facilitate safe training of diabetic scuba students. They are: (1) The Diabetic Profile for Pool Activity; (2) The Dive Profile for Diabetic Divers; and (3) The Diabetic Diver Medical Form Supplement. The use of these forms is required by all scuba instructors who elect to use the YSCUBA Diabetic Protocol for teaching diabetics to scuba dive. It is also requested that copies of these forms be submitted to the YSCUBA Medical Advisor when the diabetic student completes the course. Any adverse events should be reported to the Advisor immediately; this will allow YSCUBA to monitor the use of the Protocol and collect data concerning its use.
YSCUBA instructors who teach qualified diabetics to dive are covered by their YSCUBA liability insurance, but only if their student follows the Protocol and fills out the required forms. The forms must be submitted to the YSCUBA Medical Advisor in a timely manner. These forms may be obtained from the YSCUBA Medical Advisor.
Physicians, SCUBA Instructors and diabetics who desire a copy of the Protocol should contact the YSCUBA Medical Advisor, Dr. Duke Scott, if they have any questions or problems concerning the use of the Protocol. The best contact method is email.
Duke Scott, M.D.
YSCUBA Medical Advisor
1606 Arrowhead Trail
Neptune Beach, FL 32266
Email: dr1313@aol.com
Phone: (904) 246-0750
Cell: (904) 655-6745
Fax: (904) 246-4947
September 2007