Diving and diabetes, where is it at?

4 years 11 months ago #26372 by leannec
leannec created the topic: Diving and diabetes, where is it at?
I completed my PADI open water diver cert (c-card) in 1993 - 7yrs before developing type 1 (insulin dependant) diabetes. I stopped diving around the time I was diagnosed largely because I had enough to deal with learning to live with D.
A recent trip to Forster reminded me why I wanted to dive in the first place... So began the journey of discovery in terms of what is accepted now, 10yrs since diagnosis (and 20yrs since my original cert, OMG [^(=)^] )

Lo and behold its seems that around 2005 the shift in thinking re diabetes was being documented and by 2010 our own SPUMS had established a quite comprehensive set of assessment/dive management protocols to consider people with diabetes wishing to dive...

However, due to the need for someone to stump up the $$ to fund a revision of AS4005.1, the Australian Standard for rec diving (including medicals) remains stuck in its 2000 version and continues to list diabetes requiring insulin (and asthma FWIW) as absolute contraindications, yet refers to SPUMS as the peak medical body for diving in Australia.

It seems that in 2011, Workcover QLD issued advice indicating that the SPUMS Medical could be considered an appropriate substitute for AS4005.1 (see: http://www.deir.qld.gov.au/workplace/resources/pdfs/alert-advice-cert-divers.pdf ). However, most dive operators I've looked at online to date, still utilise medical assessment forms based on AS4005.1. And yet DAN requires a SPUMS medical for pre-existing conditions for its insurance policies

Can anyone clarify if this is just an administrative issue? I.e. would you accept a clearance for non-occupational dive courses and/or dive trips based on the SPUMS medical over AS4005.1

Has the been anything issued more recently from PADI, SSI or other authorities in relate to the preferred medical clearance approach?

Please understand, I' m not trying to 'get around' anything - I understand dive operators need to protect their businesses as much, if not more than their customers. It just seems that there is as much confusion for them as there is for me. Hopefully the questions above will help as a start.

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4 years 11 months ago #295968 by dteubner
dteubner replied the topic: Diving and diabetes, where is it at?
Hi Leanne,

SPUMS statement on diabetes is at spums.org.au/page/spums-statements-diabetes and it basically says that diabetic people on insulin should not dive.

BSAC have a rather less conservative approach - www.bsac.com/page.asp?section=1537§i...=Diabetes+and+diving

Some people interpret the fact that BSAC have guidelines to mean that there is a carte blanche for diabetics to be declared medically fit to dive, but this is not the case. Although the BSAC guidelines are much less restrictive, there are still quite a lot of hoops to jump through (no hypoglycaemic episodes, no hospitalisations no proteinuria, good HbA1C etc).

There is also the fact that even if you find a doctor who is prepared to say that you are fit to dive according to the BSAC guidelines (and this is usually possible though not necessarily easy), there is no obligation on a dive operator to accept this - they might well have their own procedures.

So in summary, it's not impossible but it's certainly not easy.

Dave T

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4 years 11 months ago #295970 by leannec
leannec replied the topic: Diving and diabetes, where is it at?
Thx Dave - to be honest, I haven't considered the BSAC statement. SPUMS own dive medical (appendix B particularly) seemed comprehensive enough and applicable within the Australian context.

The SPUMS statement on diabetes kind of adds to the confusion - as you say, it clearly states that with regards to diving quote:

A diabetic whose blood sugar is controlled either with insulin or other oral agents would be incapable of maintaining such an exercise level and should be guided into less exacting pursuits.
The insulin dependent diabetic is prone to hypothermia, hypoglycaemia resulting in loss of consciousness and decompression illness and consequently should be advised against diving.
Diabetics controlled by oral hypoglycaemics are usually obsese, unfit and are unable to maintain an acceptable exercise level.

.

I'm not sure when it was released, but given its most recent reference listed is from 1990 - it seems somewhat out of step with their dive medical 4th edition (2010) which now suggests: quote:

Some individuals with either insulin-requiring or non-insulin requiring diabetes may be able to dive with an acceptable level of risk.



If the intent is to indicate that diabetes requiring insulin remains an absolute contraindication, why make it more ambiguous? Instead of continuing the theme that diabetes and diving don't mix as the earlier statement indicated, the 2010 medical seems to open the door somewhat to a 'on a case-by-case' basis.

I take it from your advice that SPUMS statement over-rides their own medical guidelines in practice? (I understand you are not speaking on SPUMS behalf in this respect, but from your own experience which I appreciate - it helps me to understand)

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4 years 11 months ago #295978 by dteubner
dteubner replied the topic: Diving and diabetes, where is it at?
The problem goes to the heart of what a recreational dive medical is for. There are really two quite distinct opinions. One group of people think that the medical serves some sort of gatekeeping role, and that anyone with a condition which increases the risks of diving is not 'fit to dive' and should not undertake the activity.

The other group prefers to see the medical as some sort of risk assessment, so the diver and the doctor can have a conversation about what the risks of diving might be in that person's particular circumstances and the person can make a decision about whether or not to accept those risks and how best to minimise them if they do accept them.

The problem, IMHO, with the first position is that the whole concept of 'fitness to dive' is stupid and it sets the doctor up as some sort of diving policeman/woman which I personally don't like.

The problem with the second approach is that it is not possible to put good numbers on the increase in risks and one can only talk about "a little bit", "some" or "a lot". This problem is compounded by the liability issues, where there is little appreciation of assessment of probability when a bad outcome has occurred. The observation that 'low risk is not the same as no risk" is not one that coroners (particularly) seem to like.

So if you have IDDM, I think that there is little reasonable doubt that the risks of diving are higher than for an identical person who doesn't have IDDM. The two biggest issues are unexpected hypoglycaemia (exacerbated by exercise, seasickness, hyperbaric exposure and whatever) and silent cardiac disease. You can minimise the risk of the former by following the BSAC guidelines and decrease the chance of the latter by appropriate testing, but the risks are still higher.

A doctor who takes the first approach will not certify someone with IDDM as fit to dive as the risks ARE higher. A doctor who takes the second approach might still not be prepared to sign the form if she/he does not personally want to take on the risk of coroners court appearances or litigation. The fact that SPUMS has a position reduces this risk for the doctor but certainly does not eliminate it.

Dave T

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4 years 11 months ago #295988 by leannec
leannec replied the topic: Diving and diabetes, where is it at?
It actually seems rather unfair that the Dr is placed in that position (in either context) given that the acknowledged risk arising from diabetes cannot be quantified on an individual basis.
The low/no risk issue is somewhat perplexing given that no-one dives with no risk... Though I can appreciate coroners courts become frustrated with potentially avoidable deaths in ludicrous situations.
I wonder if there has been any review of morbidity/mortality rates for BSAC divers following their protocols yet?

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4 years 11 months ago #296006 by Sas
Sas replied the topic: Diving and diabetes, where is it at?
quote:

Originally posted by leannec

It actually seems rather unfair that the Dr is placed in that position (in either context) given that the acknowledged risk arising from diabetes cannot be quantified on an individual basis.
The low/no risk issue is somewhat perplexing given that no-one dives with no risk... Though I can appreciate coroners courts become frustrated with potentially avoidable deaths in ludicrous situations.
I wonder if there has been any review of morbidity/mortality rates for BSAC divers following their protocols yet?




Every year BSAC does an Incident Report: www.bsac.com/page.asp?section=1038§i...ving+Incident+Report .

In 2012 there was at least one incident involving a diabetic (though not fatal). I didn't check the other years but if you are interested they have quite detailed reports each year.

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4 years 11 months ago #296012 by TwoDogs1969
TwoDogs1969 replied the topic: Diving and diabetes, where is it at?
Hi Leanne

I Have type 2 but I am insulin dependent if you want to contact me off list I'll explain how control my sugar levels when diving.

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4 years 11 months ago #296056 by leannec
leannec replied the topic: Diving and diabetes, where is it at?
quote:

Originally posted by Saspotato

Every year BSAC does an Incident Report: www.bsac.com/page.asp?section=1038ionTit...ving+Incident+Report .

In 2012 there was at least one incident involving a diabetic (though not fatal). I didn't check the other years but if you are interested they have quite detailed reports each year.




Thanks, makes for interesting reading.

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