FITNESS TO DIVE
(Self Contained Underwater Breathing Apparatus)
diving is a safe sport enjoyed by millions with a fatality rate less
than downhill skiing (estimated at 1 in 95000 dives.) The risks of
serious injuries are either from breathing compressed air or by the
other environmental factors exists.
Scuba diving requires that the participant be healthy and be able
to respond to problems under water. In the same way that an individual
should be competent to drive a car, divers should be held to a higher
level of competence since problems could endanger not only themselves
but also other divers and rescue workers.
Not to Dive
Absolute conditions are those diseases or injuries where a person
should not dive under any circumstances. These may be temporary as
some conditions will change but are often permanent. An individual
who was previously cleared to dive may acquire a condition temporary
or permanent that would disqualify them from diving. It is every divers
responsibility to disclose any conditions that may make him or her
endangered, as well as anyone attempting to rescue them. Relative
contradictions are conditions that may or may not prevent someone
from diving, depending on an individual review by a physician who
has knowledge in scuba.
Proper scuba technique and medical screening may help minimize these
hazards. Scuba diving should be learned from a properly organized
course, and not in a compressed afternoon.
Panic has also been a major determinant for disaster in diving. Experience
and training will help minimize this. Avoid diving partners who are
immature, intoxicated or using street drugs. If you don't like your
diving partner(s), break up with them before you agree to go in the
water, otherwise, stick with them until the dive is over.
Any illness should be cleared with a dive physician or by checking
with the Divers Alert Network (D.A.N). If in doubt, don't dive. No
matter how expensive the trip was, remember you always can enjoy a
snorkel, which does not have the risk of dysbarism, since you are
not breathing compressed air.
Divers can be affected in many ways by dive related diseases, as well
as the mundane types. It is often difficult for even experienced physicians
to make a correct diagnosis in an ill diver.
Conditions That May Prevent People From Diving
Because of the varied severity of many conditions, this list is deliberately
vague and incomplete and persons with specific medical problems should
always clear them with a dive physician.
People generally do diving over 16 years of age, but frequently children
wish to dive. Children as young as 12 years may be considered for
diving but this should be very carefully thought out.
Cardiac - Any serious cardiac conditions should not dive unless
screened by a Cardiologist and are able to perform 13 METS on an exercise
Pulmonary - Any asthma or lung disease should be assessed by a
Respirologist, chest x-rays, spirometry and possibly exercise challenge
may be needed.
Neurological - Patients with alterations in consciousness or
uncontrolled seizures should not dive. Prior decompression illness
should be carefully reviewed to evaluate if they should ever dive
Ear/Nose/Throat - Divers with hearing in 1 ear or prior ear
surgery should not dive. Sudden ear or sinus infections should also
not dive till conditions improved (there is a risk of accident and
they will have a painful dive anyways).
Gastrointestinal - Divers with digestive diseases have had
increased incidences of injuries. Diseases should be stabilized before
diving is allowed.
Diabetes - Diabetics with poor control or end organ damage
are not recommended to dive. Other endocrine problems should be well
controlled. Extreme obesity has had a higher incidence of decompression
Pregnancy - Women who are or many become pregnant (during dive
trip) should not dive. The fetus is vulnerable to dive injuries and
the hyperbaric chamber as well.
Blood diseases - Severe anemia and sickle cell diseases should not
Orthopedic - People with severe back pain or recent fractures
should not dive. Prior aseptic necrosis (a disease seen in commercial
divers) should stop diving.
Behavior - Any psychiatric condition that limits an individual's
ability to cooperate with others, solve problems, or react to stress
should not dive. Divers themselves should screen unknown diving buddies
for incompatibilities before the dive begins. There should be no use
of street drugs or alcohol with diving.
Dental - All cavities and closed spaces should be managed prior
Drugs - People on medications that interfere with thinking,
concentration, or cause sedation should not dive.
Any other condition not mentioned above, that may interfere with the
thinking or performance, may also limit diving.
Consider not diving if you are unwell. Definitely do not dive with
an ear or sinus infection or any type of respiratory wheeze. One of
the main concerns about diving injuries is that many divers will minimize
their symptoms or deny them. It is important to have a plan if something
goes wrong, agree with your diving partner(s), and always follow through.
In addition to proper certification, divers should be up to date in
their vaccinations if traveling, be counseled on malaria and traveler's
diarrhea prevention, be knowledgeable in the prevention of parasites
(from swimming in infected water), and seafood poisoning. Divers should
be knowledgeable in the conditions where they are diving as well.
Conditions Related to Breathing Pressurized Gas
Nitrogen Narcoses (Rapture of the Deep)
This usually occurs at depths of 30 feet or 40 meters and is similar
to feeling intoxicated. This may be hard to recognize in beginners,
so they should limit their depths when starting. Symptoms may range
from poor judgment, over confidence, inappropriate behavior and even
stupor or coma. The treatment is ascension, until symptoms clear.
Central nervous system oxygen toxicity occurs when breathing
mixed gas combinations (not regular air) at greater depths. Symptoms
include; nausea, dizziness, ringing ears, altered vision, and even
convulsion. If convulsing at depths, the buddy should either reduce
the oxygen partial pressure by switching tanks or by gentle ascension
will also decrease the oxygen pressure, but managing an underwater
seizure is difficult.
If warning symptoms occur, the diver should alert his buddy and make
a controlled ascent. If a seizure starts, the buddy should:
a) Get behind the diver and release the buddy's weight belt
(if victims wearing dry suit leave on as this affects the balance).
b) Leave the regulator in the victim's mouth. If it is out,
do not replace it.
c) Grasp the victim around the chest, above the underwater breathing
apparatus. If difficult, use the best possible method to gain control.
d) Make controlled ascent to surface, while keeping slight pressure
on victim's chest to help exhalation.
e) If additional buoyancy activates victim's life jacket, do not
drop your own weight belt or use your own life jacket.
f) Inflate the victim's life jacket at the surface if it has not
g) Remove the victim's mouthpiece and switch valve to SURFACE
(for rebreather masks, as this could flood the unit and weigh the
h) Signal for help.
i) Once the convulsions are over, open victim's airway by lifting
j) Mouth to mouth breathing if necessary.
k) Transfer victim to dive medicine facility.
Reference: U.S Navy Dive Manual Volume 2 Revised
This can happen under heavy exertion, by skip breathing (slow breathing),
or equipment failure. Symptoms include shortness of breath, headache,
nausea, dizziness, and confusion. Divers may develop rapid breathing,
muscle twitches, and unconsciousness. If breathlessness occurs, divers
should stop and rest until breathing returns to normal, if not, then
Lung Overpressure Syndrome
These problems can occur independently or with an air embolism. They
all represent that the lung is injured and an embolism should be suspected.
Pneumothorax usually is felt as chest pain or shortness of
breath and occurs when air enters the space between the lung and chest
wall. This problem can worsen with time and treatment in a hospital
to remove this is needed.
Mediastinal Emphysema is when air becomes trapped in the space
between the heart and the lungs, and is felt as chest pain, shortness
of breath and faintness. This must also be followed in a hospital.
Subcutaneus Emphysema is when escaped air from the lungs is
trapped under the skin, usually at the neck. A swelling and crackling
is felt at the neck, with a change of voice and difficulty swallowing.
This is a simple condition and no treatment is required for it alone.
Breathing 100% oxygen will help resolve all types of over- pressure
Motion Sickness should be anticipated and medication should be used
with caution since they all cause some drowsiness. It is advisable
to cancel a dive if sickness is severe. Some will take meclizine 25
mg taken 2 hrs before dive (lasts 6-12h).
Some illnesses require recompression therapy. They can be subtle but
should be acted on promptly if suspected.
DECOMPRESSION ILLNESS - is the broad term to describe both
air gas embolism (AGE) and decompression syndrome (caused by nitrogen
bubbles forming in the body) signs and symptoms of AGE include - any
type of neurological problem, chest pain, personality change, bloody
froth, paralysis, convulsions, and death. Symptoms can occur immediately
after surfacing. Airplane travel can also precipitate nitrogen bubble
formation. DAN recommends not to fly 12 hours after the last non-
stop diver. The U.S Air Force recommends 24hrs. Longer time is needed
if the dive is a complicated one.
Decompression illness symptoms may also include fatigue, itch, pains
in muscles or joints, and a blotchy rash. Even muscular symptoms are
worrisome since bubbles could soon form in the nervous tissue. Once
you suspect Decompression illness the diver may be categorized as
Emergent, Urgent, and Timely.
Emergant cases are obviously very sick. Begin CPR, and arrange
evacuation. Check for foreign bodies and place patient on back (if
vomiting, turn onto side) 100% oxygen should be supplied.
IV fluids using isotonic fluids without glucose should be given (this
corrects dehydration and reduces hemoconcentration) Give 1litre over
30 minutes then 100-175 cc/hr.
If trained, insert urine catheter to monitor urine output. After stabilization,
contact D.A.N for nearest chamber location. Transfer even if the victim
is improving. Take a detailed history, and evaluate neurological status.
If flying, pressurized aircraft is recommended.
In cerebral arterial gas embolisms, having the head slightly down,
theoretically reduces further emboli towards the brain. Some believe
that this can also increase cerebral pressure. A compromise is to
keep the victim level with the body and tilted to the left side. In
Decompression sickness, muscular or other body movements can dislodge
venous emboli so patients should rest. Near-drowning victims movements
may redistribute fluid causing decreased lung compliance. Patients
with hypothermia should not be jostled as this could precipitate a
cardiac arrhythmia a in a chilled heart.
Additional treatments that have some evidence to support them, include
giving ASA (chewable baby aspirin may stops platelets accumulate around
bubbles and lidocaine (dose is the same as for cardiac patients).
Given in 1 or 2 boluses, Lidocaine acts to increase cerebral blood
flow and may prevent leukocyte activation. Corticosteroids like decadron
are sometimes also given but there is less evidence of their usefulness.
Urgent - These patients are those with severe pain that has
unchanged or become worse over hours. Their neurologic status appears
normal. They should be placed on 100% oxygen and given oral fluids.
Contact DAN and arrange a transfer.
Timely - These patients have vague complaints with abnormal
sensations. Phone DAN and go to the nearest medical facility.
This information is very helpful to D.A.N. Find out all dives (dive
logs), symptoms (onset and progressive), all first aid measures, description
of rashes, and any other medical information.
Neurologic history of injured divers should include:
1) Orientation (to name, place, and time)
2) Check movement of eye following a finger, check pupil size
3) Look for symmetry of facial muscles, facial sensation
4) Hearing (check ability to hear rustled hair at each ear)
5) Watch the swallowing reflex 6) Check if tongue is straight
when stuck out
7) Check muscle strength - ask patient to shrug shoulders against
resistance, check the strength of both arms and legs by asking the
patient to bend and extend while you resist movement. Look for symmetry
in all findings.
8) Check sensory perception to light touch along left and right
side of body.
9) Balance and coordinate. Have divers walk heel to toe in
a straight line if able, forward and backward. Then stand with feet
together, eyes closed and palms held straight out. Check for ability
to maintain balance and be prepared to catch the person. Check the
divers ability to touch your finger and their own nose while you move
Divers First Aid Kit (Basic)
1) Vial of rubbing alcohol (to
neutralize jelly fish stings)
2) Package of baking soda
3) Decadron 8mg or Prednisone 50mg (for anaphylaxis)
4) Motion sickness tablets (meclizine, phenergan,
6) Mechanical suction device
7) Resusitube (combi-tube) with training
8) Tourniquet (stop bleeding)
10) Rubber cement (to pull out spines, envenomations)
11) Oxygen and training
12) First aid training
13) Pressure bandage to slow venom from sea snakes and blue
By doing these tests early and regularly at 30-60 min intervals, valuable
information about a neurologic injury is obtained while awaiting evacuation.
(Tests 1,7, and 9 are the most important)
Sinus Squeeze -occurs as acute pain in sinuses
Mask Squeeze- painful pressure buildup around mask
Ear Barotrauma- Otitis media barotraumas acute pain in ear. Should
not dive till healed. Inner ear disturbance should be treated as a
possible urgent referral to D.A.N (it might only be a perilymph problem
in the inner ear but it cannot easily be differentiated from AGE or
Marine animals and envenomations are beyond the scope of this pamphlet
but should be treated by experienced people.
- Method of recompressing when Hyperbaric chamber is >12hours away.
Use only if pre planned and experienced personnel. Pioneered in
1) Dive and Marine Medicine (3rd Conference. March 2000, sponsored
by The Undersea and Hyperbaric Medical Society.
2) Dive and Travel Medical Guide Ed Thalmann, Editor, Revised 1999,
published by D.A.N.
3) Divers Alert Network (D.A.N.) is a non-profit organization that
gives information and advice to the general public. They support
diving research and have a 24-hour emergency phone number (1-919-684-2948)
for dive accidents. Members are eligible for very good travel insurance
packages while on dive-related vacations.
4) Bore, Alfred A and Davis, Jefferson C. (1990) Pub W.B Saunders.
5) Edmonts (1978) Diving and Sub Aquatic Medicine 2nd Edition. 6)
Divers Alert Network. Report on Decompression Illness and Diving
Fatalities 2000 Edition.
7) Undersea and Hyperbaric Medical Society Inc. (July 21, 1995)
Published meeting. Are Asthmatics Fit to Dive?
8) Rose, S (2001) International Travel Health Guide 12th Edition
9) Divers Alert Magazine Published by D.A.N.
10) D.A.N Website link: http://www.diversalertnetwork.org/
For your convenience we have prepared downloadable pamphlets on:
Fitness to Dive Front
Page - Back Page
Scuba First Aid Front
Page - Back Page
We assess prospective scuba diving candidates to determine if they
have any medical conditions that prohibit them from diving. The
charge for signing a clearance form is $50.00. Divers who develop
problems and need to be assessed are covered by Manitoba health
as insured services and there is no charge for these assessments.
We encourage all SCUBA participants to check with us if they feel
they have a problem that will affect them while diving. For more
information on diving medicine please follow this link. Any diver
with an acute problem suggestive of a serious dive accident must
attend the nearest emergency centre for immediate treatment. Our
clinic is listed as a resource through the divers alert network
and can be consulted with for dive injuries, but acute cases must
always go through the emergency department.
Divers Alert Network (DAN at www.diversalertnetwork.com)
is an excellent resource for divers with pre-existing medical problems
as well as for those with suspected Dive injuries. They have a good
travel insurance plan for divers and also provide phone assistance
Canadian Amphibious Search Team (CAST) Our clinic provides
the medical review for members of CAST. CAST is a professional search
and recovery unit dedicated to assisting individuals, justice departments
and government agencies worldwide. CAST is comprised of over fifty
professional men and women from various emergency service backgrounds,
including forensic investigators, coroners and underwater investigators.
The scope of their mission is not limited to evidence and body recovery,
be it on a small or large scale. CAST is also a training agency
offering specialized courses in Capsized Vessel Rescue, Swift Water
Diving, and K9 Handling (specializing in cadaver).
If you require the services of CAST please contact them directly,
Winnipeg Scuba Resources
We are involved with the local Scuba diving community. Besides being
medically fit to dive it is even more important that new scuba divers
receive the proper instruction in technique and equipment and we
stress that travelers should be properly instructed. These resources
are available in Winnipeg at several Dive shops. They will train
and educate divers even in the winter. Through organizations such
as PADI (Professional Association of Divers International), arrangements
can be made so that once a candidate has taken their written exam
and pool work they may do their open dive certification on vacation
also through PADI. This arrangement ensures that they get full instruction.
Our clinic has seen several divers who have had decompression illness
from being improperly trained abroad.
We are also pleased to announce that our Travel Clinic Nurse, Gail,
has successfully completed the Underwater Investigator course and
is now qualified as a consultant to underwater forensic investigations.
Guidelines for Physicians in Scuba Medicine
Dr Podolsky was part of the College of Physicians and Surgeons Committee
to review the Recommendations for physicians examining recreational
scuba divers. Unfortunately funding for all of the colleges guideline
programs was cancelled because of limited funding by Manitoba Health.
It is our plan to attempt to finish the guidelines independently
as a volunteer committee (without any official validation or recognition
by the College). Interested members of the Manitoba Physician and
Scuba community may contact us if they wish to be involved with
Our clinic is familiar with Aviation medicine but at this time we
are not able to certify aircrew. Dr Podolsky has worked for the
Canadian Air force as a civilian physician but is not licensed to
unground pilots. He can give an opinion but Pilots and Aircrew seeking
to be ungrounded must see a designated Health Canada Physician for
Our clinic sees many people with anxieties and questions about flying.
There are also several medical conditions that may limit a person
from flying. In order to evaluate these we need to see each patient
in person by appointment before making any recommendations.
We will try to assess patients with urgent needs (i.e. a possible
ear infection) prior to their departure.
Council - A community for SCUBA divers.