Physical Examinations for Divers

Major U.S. training agencies mandate diving physicals and medical clearances for divemasters, assistant instructors, and instructors. Entry-level divers only need to fill out a medical questionnaire.

In Australia, however, the Queensland Territory has a legislative requirement for medical clearance for trainees, and nationally major training agencies encourage such medical clearance. Dr. Michael Bennett of the University of New South Wales Department of Diving and Hyperbaric Medicine acknowledges, “To their credit, the major dive training organizations have accepted such examinations as desirable throughout the country. It is standard practice that diving candidates are not accepted without medical clearance.” The South Pacific Underwater Medicine Society has published a standard medical form to guide physicians through examinations.

In 1969, the British Sub-Aqua Club made medical examinations for divers mandatory. They required physicals of all applicants and members, and these became progressively more frequent with age. A diver’s general practitioner (GP) could conduct these. In 1994, the Sub-Aqua Association and Scottish Sub- Aqua Club joined with BSAC to form the UK Sport Diving Medical Committee (UKSDMC), which sets common standards for all three diving organizations. The UKSDMC found that examination by a GP was largely unhelpful in identifying divers with significant medical conditions, so last year it replaced the routine examination with a health questionnaire the diver completed. If a diver answers “yes” to any question, he or she must contact a medical referee who may pass the diver or, if necessary, refer him or her to a specialist. Dr. Stephen Glen, UKSDMC Chairman, told Undercurrent that the organization will publish three-year safety statistics next year. (PADI UK follows the same guidelines as PADI America, the selfreport medical questionnaire with medical clearance required for “yes” answers. It’s similar to what UKSDMC members do.)

Since 1990 in the United States, applicants for all levels of dive training are required to complete and sign a standard “Diver’s Medical Questionnaire.” Developed by the Undersea and Hyperbaric Medical Society (UHMS) and DAN; the form canvasses medical conditions that may affect safe scuba diving. A “yes” answer to any item means that the applicant must obtain written medical clearance to dive. Even then, not all students are accepted. However, as demonstrated in the case of the intoxicated 58--year-old woman completing the familiarization class, not all trainees are forthright about their health.

PADI’s director of training and quality management, Brad Smith, told Undercurrent that, ultimately, the scuba instructor decides whom they will permit to take a scuba course. He or she may require anyone to secure medical approval from a physician, even if the student has marked “no” on all questions on the medical form.

However, once certified, divers may dive forever with no further medical prohibitions unless they indicate problems on predive questionnaires. Should routine medical clearance be required?

Ernest Campbell, M.D., (a.k.a. “Scubadoc”) told Undercurrent that he feels strongly that “medical aspects of the sport should be more closely regulated by some central, nongovernmental entity possibly similar to the UK Sport Diving Medical Committee. However, this would require the total support of the training agencies and our quasi-official societies, as well as UHMS, DAN, and the recently formulated national boards. Getting physicians trained would be the easy part. Draconian rules would make it difficult by placing monetary, liability, and certification roadblocks.”

UKSDMC medical officer John Betts is not so sure that getting trained physicians would be easy. He told Undercurrent that even if it is tempting to envisage mandatory medical examinations, it would be impossible to provide enough experienced diving doctors to cope with the numbers involved.

While these are real issues, the overriding question is, “Would mandatory diving physicals for all recreational scuba significantly decrease morbidity and mortality?” They may not.

A study in the British Journal of Sports Medicine (2000; 34:375-378) suggests that self-certification may be sufficient to keep medically related dive accidents to a minimum. It analyzed the routine physical examinations and self-certification questionnaire findings of 2,962 Scottish divers. No examination finding alone caused a subject to be classified unfit to dive. One hundred and seventy-four subjects reported abnormalities and were referred to physicians. The most common reasons were assessment of asthma, hypertension, and obesity. Upon expert evaluation, they allowed most of the subjects to dive, with only 25 percent not receiving immediate clearance.

Even physicians trained in dive medicine may not be able to determine fitness to dive. A study reported in the Medical Journal of Australia (1999; 171:595-598) sent fifteen hypothetical clinical scenarios to a group of physicians who had completed approved training in underwater medicine and asked them to declare the prospective scuba diver fit, unfit, fit after investigation, or to offer specialist referral. Seventy percent agreed about unfitness in four cases, and fitness in only two cases. For each case where the guidelines firmly indicated an unfitness to dive, at least one physician passed the hypothetical prospective diver. The study concluded, “There is no consensus among doctors who perform diving medical examinations about what constitutes fitness to dive; current guidelines need to be improved.”

Joel Dovenbarger, vice president of medical services for DAN, says that few young persons entering scuba have worrisome health problems. The older population with longstanding health issues is by far the most problematic. In fact, more than half the diving deaths occur in the 40-to-50--year-old groups. Cardiovascular disease, which is strongly age related, is the most common medical condition among those who die. Dovenberger maintains, “The responsibility for maintaining personal health remains with the individual, as well as the reassessment of fitness after illness, injury, or the effects of aging.”

Major U.S. training agencies do promote medical prudence in their students and professionals. Without compelling evidence that diving physicals substantially reduce the risk of injuries and death, it is unlikely that the U.S. dive industry, a self-regulating and peer-reviewed entity, will mandate standards that increase the external costs of diving and reduce the pool of potential or active divers.

— Doc Vikingo