Eugene R. Worth, M.D.

Dr. Worth is the medical director of hyperbaric medicine at Utah Valley Regional Medical Center. He is subspecialty board certified in Undersea and Hyperbaric Medicine. He is also a NOAA certified Diving Medical Officer.

When I took SCUBA lessons, the talk I got from my instructor was simple, “Here’s the medical statement. You need to write ‘No’ on each line. If you write ‘Yes’ then you get to see your doctor for an examination.” I suspect that many instructors approach this statement in exactly the same way. Why? Could it be that instructors look at physicians as denying the student opportunity to start into this hobby/sport? Or, maybe the instructor has really never known that the objective of the diving physician is to ensure that the student is safe in the water and that health issues can be managed so that the student can SCUBA dive.

While I will be discussing a multitude of medical issues related to SCUBA in future articles, this one will focus on why divers of any ability should have a diving-specific physical examination on a regular basis. Why should you care?

According to the 2008 DAN Annual Report, the average age of divers is increasing and the average age of diving deaths is now 48 years. In the latest survey, there were 75 deaths in the US and Canada, with the majority of deaths occurring in Florida and California. Forty-eight autopsies were conducted and the most commonly reported medical conditions were known heart disease and high blood pressure. Of these deaths, 38% had a body mass index (BMI) greater than 30, which is defined as obese. In 87%, the dive of death was the first dive of the day. Finally, the age distribution ranges from 20 to 79 years and no particular age group is exempt.

Now that we have your attention, let’s talk more about dive medicine physical examinations. We should agree on this point, SCUBA is an extreme sport but not necessarily a dangerous sport. Attention to our health, given the fact that the average age of SCUBA divers is increasing, is important to enjoying the activity and being safe.

Can my family doctor, who may/may not be a diver, do my physical examination? The short answer is, “Yes.” Then why should I choose a diving physician? The doctor, the nurse practitioner, or the physician assistant in your family doctor’s office may perform the typical physical examination. Knowledge of specific diving injuries and diving physiology for this provider may be no better than the training he/she received in their own SCUBA certification course. This is a topic not taught in medical schools or residency programs outside of aerospace medicine. Performance of some (or all) of the detailed neurological examination subparts may not have been practiced since medical school.

What I am frequently told as the basis of a SCUBA examination in a primary care clinic consists of vital signs, heart and lung examination, press on the belly, knee reflexes, and “Good to go.” This is painting with a broad brush, to be sure, but nonetheless a common occurrence.

A diving-specific physical examination starts at the top of the head and ends at the bottom of the feet. A large proportion of the examination is focused on specific tests relating to muscle strength, mobility, and nerve function in various parts of the body. We test reflexes at the elbows (front and back), wrists, knees, and ankles. We examine multiple muscles groups from head to toe. We check skin-spinal cord-muscle reflexes in several places, as well as mapping skin sensation throughout the body. Why so detailed? Decompression illness knows no boundaries as to the parts of the body affected. Without a detailed baseline physical examination, the treating physician is at a loss as to whether this particular abnormality existed prior to the injury or not.

For example, I have recently seen two individuals who have had neck/arm pain after diving. Both were tech divers; not that this couldn’t occur in recreational divers. Patient A told me that (s)he had pain in the elbow after completing a tech dive of moderate risk. (S)He has had hundreds of dives and is a divemaster and instructor. (S)He had never had a problem like this before. Careful examination showed a point of tenderness over the outer part of the elbow and forearm. Diagnosis? Tennis elbow. But there was an issue of numbness not associated with tennis elbow. On further examination, positioning the head and neck in certain positions could mimic and aggravate the typical pain. Likely diagnosis? Degenerative disc disease of the neck. “Now that I think about it, high school soccer caused an injury like this in the past.”

Patient B told me that (s)he had a serious neck injury that resulted in a neck fusion at several levels, “but everything is OK now.” On physical examination, neck mobility was limited in several directions and the grip strength in the little finger was weaker on one side than the other. This could be normal … but … examination of skin sensation with a pinwheel showed definite skin changes in the area of 3 nerve roots from the neck with distribution in the forearm and hand. This was not recognized by the diver and could be significant should this diver have additional arm pain or other symptoms after a dive.

For both patients, we now have detailed baseline physical examinations that show specific physical findings that were not known before nor recorded. These are just 2 examples of why each diver should have a detailed examination on a regular basis by a diving medicine physician. In addition, now each diver has the detailed record that can be laminated and carried in a dive bag. One never knows when that could come in handy when a diving accident or injury occurs.

I also view this time as an opportunity to educate divers about their general health and the importance of health maintenance in order to be safe and enjoy the sport. It is a chance to counsel about weight management and the vital importance of picking a wetsuit of correct size. Too tight, too small, and one reduces the ability of the lungs to expand appropriately with each breath at pressure. Without physical endurance, one runs the risk of not being able to rescue self or others in a mishap.

This is a time to talk about management of high blood pressure, heart disease, diabetes, asthma, and other medical and surgical issues. Women have questions related to particular female issues and diving. Frequently, their OB/GYN or family physician cannot answer diving specific questions. Sometimes patients are fearful of asking potentially embarrassing questions or taking up the doctor’s time with these questions.

Will I need laboratory tests? To be complete, the answer is, “Yes.” Under age 40, we recommend that each diver have a pulmonary function test, hearing exam, eye exam, complete blood count with differential, basic metabolic panel, and urinalysis. While your health insurance will not cover these tests for a SCUBA examination, the tests are usually covered if you ask your primary care physician to get the tests with your annual physical examination. These tests and a SCUBA specific physical examination should be repeated once every 3 years.

If you are over the age of 40, in addition to the above, a 12-lead EKG and a 2-view chest x-ray are recommended. The tests and physical examination should be repeated every 2 years.

In future articles, I will address specific medical issues for divers. We will talk about female issues, high blood pressure, heart disease, diabetes, asthma, and others. We will also talk about some physiology issues such as the different diving clocks: nitrogen time, carbon dioxide, low and high inspired oxygen, and various toxicities. I look forward to your input for topics and questions. Feel free to contact Deann at the shop and she will forward your interests to me.

Until next time, many safe trips … and keep the bubbles on top …