Diver’s Medical Advice provides you with a broad range of FAQs and real life case studies about general medical advice sought from London Diving Chamber Professionals.

If you cannot find an answer to the questions you have here, please contact us using the form below.


All assessment and treatment for DCI in the UK is free.

The London Diving Chamber will assess you as soon as possible after you have contacted them, and treatment will begin immediately if DCI is suspected.

The first treatment is the longest one, with subsequent shorter treatments on following days. These continue until you have full resolution of your symptoms, or there is a “treatment plateau” (where there is no change in your symptoms from one short treatment to the next). After each recompression, the doctor will assess your symptoms.

When the treatment regime has been completed, the doctor will recommend a certain time away from diving and will book a review appointment before you dive again. If other problems are suspected as the cause for your DCI, e.g. patent foramen ovale (PFO), the doctor will arrange for further investigations before you dive again.

Finally, a letter about your treatment is written to your GP.


General Information on Diving Fitness

Q: Am I fit to dive?

A: Blue skies, hot sun and warm seas with unlimited visibility? It’s easy to see why the dive holiday or even just the “try dive” is so popular. More people get their first experience of diving when on holiday than at home.

With such good conditions, and with the enthusiasm of the holiday break, it is easy to forget that diving has some inherent risks, and that not everyone is ‘fit to dive’. So if you have never dived before, or only done a simple shallow try dive and now want to go the whole way to getting your diving certificate, it is best to read the information below before booking your first dive trip.

Fitness to dive has changed considerably since the start of diving. The sport used to attract the serious ‘macho’ diver. At least 20 lengths of the pool blindfolded with weights and that was just for starters. Thankfully this has changed; but has it changed too far? Some opinions are that everyone should be able to dive, regardless of fitness or medical health. This is not the case, and the aim of this article is to try and give the prospective diver some guidance as to whether they are ‘fit to dive’ before booking a holiday, or at least to encourage them to get some proper medical advice before doing so. It is often too late by the time you arrive abroad: at best you will end up having to splash out on a medical with an unknown doctor, cancelling the course or at worst attempting to carry on and ‘taking a risk’.

And remember, some insurance companies won’t reimburse you for loss of activity since you were still able to go on holiday.

When you arrive at the dive shop at your location they will hand you various forms to fill in. The most important of which is the Medical Form. IF YOU TICK “YES” TO ANY OF THE QUESTIONS THERE MAY BE A PROBLEM IN ALLOWING YOU TO DIVE. So if you do then it is best to see a dive doctor BEFORE you pay for a dive holiday and travel abroad.

Below are lists and explanations of:

Serious Contraindications- conditions usually resulting in a no to diving.

Conditions that a prospective diver MAY be able to dive with if they get appropriate investigation and medical advice.

Those medical issues that are usually ok but may need a chat with a dive doc before going ahead.

Serious Contraindications to Diving
These medical conditions are generally regarded as no-no’s to diving.

Epilepsy: generally regarded as the biggest contraindication. This is because an epileptic fit underwater normally means certain death by drowning. I don’t think any doctor would allow an active epileptic to dive underwater. However, if an epileptic has been fit free for many years and they have not been on medication for 5 years, diving can be considered.

Pregnancy: there are conflicting problems here. Firstly there are numerous reports of women diving in early stages of pregnancy without knowing they were pregnant. No harm seems to have come from this. Secondly, studies in animals have shown that bubbles cross the placenta which might indicate a risk to the foetus. In short, no doctor is going to take the risk of allowing a pregnant woman to dive as the potential risks are too great.

Lung Problems: with the pressure changes causing large changes in the volume of air, especially at shallow depths, the lungs are particularly important in diving medicine. Any lung condition that causes a restriction in air coming out of the lungs or a weakness in the structure of the lung is a no-no. Such conditions may be bullae (large air sacs), severe asthma, chronic obstructive pulmonary disease (emphysema), and certain types of lung surgery. Spontaneous pneumothorax (burst lung) occur in people (usually young men) that have weaknesses in the lung and normally are not fit to dive, although as time goes by and the person gets older a more relaxed view may be taken.

Head Injury: severe head injury, whether it is caused by external trauma or something like a stroke, is often associated with damage to the brain tissue, memory and behavioural problems. It can also increase the risk of epilepsy. In the short term definitely not fit for diving, but in the long term may and should be discussed with a Dive Doc.

Severe heart disease: this includes congenital heart defects, severe valve problems and some ‘holes in the heart’. Severe ischaemic heart disease especially when not fully controlled or residual heart problems after heart attacks may be a problem too.

Neurological Problems: progressive neurological problems such as severe MS, Parkinson’s, and motor neurone disease tend to stop people diving. Milder forms may be OK to start with, but the diving career can be short.

Heart Rhythm problems: any sort of heart rhythm or electrical problem of the heart that causes a person to feel funny, black out or collapse would be a contraindication.

Perforated eardrum, grommets, severe vertigo: diving with perforated eardrums could lead to a nasty middle ear infection and even meningitis. Severe dizziness could be very dangerous underwater.

Blood disorders: this includes severe bleeding disorders (e.g. haemophilia), and blood cancers (leukaemias).

Severe mental health problems: schizophrenia, mixed bipolar disorders, depression (in acute stages), personality disorders etc. are unlikely to be fit to dive due to the stresses and potential dangers of instability in the water (to both the diver and the buddy).

Drug abuse: active drug abusers are definitely not fit to dive. This could include drugs such as cannabis and alcohol.

Relative Contraindications to Diving
The “maybes” with good diving doctor advice – I stress the word “maybe”:

Ischaemic heart disease: well treated ischaemic heart disease may be compatible with diving if the heart is not damaged, exercise tolerance is good and the medication compatible with diving. Several tests may need to be undertaken to assess this. Pacemakers are occasionally ok under pressure but need to be checked with the manufacturer.

Asthma: mild, stable asthma, with little exercise, cold or emotion components are fit to dive, but require careful assessment due to the risk of collapsed lung. Even then, certain countries will not allow you to dive.

Multiple Sclerosis and other progressive neurological problems: stable neurological conditions are often compatible with diving; it is more the more variable ones that can cause confusion with decompression illness. The prospective diver needs to have their condition ‘mapped’ so that they know exactly what problems they may have in the future.

Diabetes: over the last few years, an increasing number of diabetics have taken up diving. It does require careful a work up and a willing and enthusiastic diver before this can happen though, especially for divers on drugs that can cause hypoglycaemia (low blood sugars). Late onset diabetics are also at greatly increased risk of heart disease, which needs to be assessed as well.

Ear/nose problems: most ear problems and equalisation problems can be sorted out with time. Chronic infections, wax, and inflammation can be difficult. Severe deviated septums may need to be corrected.

Blood problems: mild bleeding disorders may be ok. Conditions such as thalassaemia and sickle cell are no longer thought to be a major problem.
Depression, anxiety, claustrophobia: can cause severe problems underwater with panic attacks being a danger to diver and to buddy. The medication can also cause problems but if the condition is stable and well controlled, simple diving may be possible with a sympathetic instructor.

Obesity, unfitness: contrary to popular belief, diving can be a strenuous task. Lifting weights and tanks, swimming against current, climbing in and out of boats etc. means a certain level of fitness is essential. Severe obesity decreases fitness, increases risk of diabetes and heart disease and can affect lung function’ there is also a theory that it may increase a person’s risk of decompression illness.

The usual OKs
Might need some advice and tweaking of medication but normally OK to dive:

Blood pressure: provided it’s stable with no complications and the medication is compatible with diving.

Arthritis: some adaptations to techniques and equipment maybe necessary. Severe back disc issues with nerves problems need careful assessment. Likewise, joint replacements are usually OK when full recovery has occurred.

Abdominal problems: most simple gut problems: reflux, hernias, inflammatory bowel disease are usually fine with a little advice. Some of the stronger medications for inflammatory bowel disease may cause problems.

Colostomies: I have always been amazed as to how well divers cope with ‘ostomies’. The main thing is to make sure the bag can vent gas or surprises can occur.

Dental problems: simple dental, bite and denture problems can be sorted out with a good dentist and a little imagination. Different regulator mouthpieces help.

Breast implants: not a problem. They are all fluid or gel filled and therefore do not compress.

General Information on Medication

Q: What medication can I use safely with underwater activities?

A: Most medication is not tested underwater and therefore we often have very little idea how a person will react under pressure. Experienced dive docs will have come across a wide range of medication and will be able to give you some good advice as to whether it is safe to dive on the tablets or if some adaptations need to be made.

General Information on Medical Advice

Q: Where to go for professional and free medical advice?

A: The above list of diving fitness considerations is by no means exhaustive and there are individual variations. Any doubts should be discussed with a doctor trained in diving medicine.

Doctors giving advice about fitness to dive come in all shapes, sizes, and backgrounds. This can cause considerable variability in both the type and quality of advice given. Most general doctors and specialist consultants poorly understand the physiology and unique problems that occur in diving and they may therefore give ill informed advice based on a person’s general fitness (“but I can run a half marathon!”), without understanding how a problem that has stabilised on land could be potentially dangerous under water. Finally, doctors around the world have different ideas, often based on how their country perceives a particular condition in respect to diving (e.g. asthma in the UK versus Australia).

In the UK, we are lucky to have a few systems in place to help the prospective diver understand whether they can dive or not with their medical condition:

UKDMC (The UK Sport Diving Medical Committee); doctors trained in diving medicine who give advice, examine and treat divers all over the UK.

Various hyperbaric/diving chambers over the UK run their own in-house medicals and advice lines: ours (based in London and Rugby) offer free telephone and e-mail advice. We also do all the relevant dive medicals if needed before you go.

Diving is generally a safe sport, but there are some limitations regarding medical conditions. If you are on medication or have a medical problem, get advice before you splash out on that holiday/training course. You could save yourself a lot of money and keep yourself safe.

Still have questions?

Please read through the other FAQs on the Sunken Dreams’ Answers to Your Questions webpage contact us using the contact form below.


Bilharzia: Case Study 1

Q: Lake Malawi this summer. My son, who is 16, did an intensive 5 day scuba diving course.

After reading the travel books, we decided to take action, even though we have no bilharzia symptoms. Sixweeks after exposure, our GP agreed reluctantly to sendoff stool samples for testing for ‘all egg infestations’. The results have come back ‘normal’.

Should we take any other action?

A: Sadly, Lake Malawi is now known for harbouring bilharzia, and I see your point about getting checked for it now you are back.

Many people who are infected by this nasty parasite do not get any symptoms for a couple of months, but later they may get blood in the urine, a raised fever or blood on the stool. The best test is in fact a blood test for antibodies to the parasite. If this comes back positive then a single dose of a powerful drug called praziquantel is all that is needed.

I don’t know what your doc expects to find with a simple stool parasites and eggs test. This is normally something you do to look for bowel bugs rather than bilharzia.

So I think you need to get your doctor to do the blood test, but if you are still asymptomatic after all this time then the chances are that you probably do not have the disease.

If you ever go back to the lake, avoid contact with the snail that is the parasite-human vector by wearing dive boots in the reeds near the shore, and best to swim or dive off a boat in the open water.

Bilharzia: Case Study 2

Q: I’m planning a trip to Malawi, and obviously want to dive Lake Malawi when I’m there. I’ve read that there is a problem with something called bilharzia there. Should I take any precautions whilst diving there?

A: You’re right there. Lake Malawi always had the reputation of being bilharzia free, but recently more and more cases of this problem have been reported from the Lake. The area most affected is in the Southern part , around a place called Cape Maclear. This may be as it’s the most popular part as it’s the most beautiful and hence has most visitors.

Bilharzia or schistosomiasis as it’s also known, is caused by a nasty little worm that has part of its life-cycle in a freshwater snail, and the rest in the human bladder, liver or blood supply to both. It is contracted when you come into contact with the worm after its come out of the snail. It then burrows through the skin and into the body… the rest you don’t really want to hear!

But don’t worry, if you take precautions, you’ll be fine.

Stay out of the mushy, reedy lakeside areas where the snail lives. Try to dive from a RIB and if you are wading to shore, wear your dive boots.

If you do feel unwell at all, its easily diagnosed with a blood test and then easily treated too.

Bilharzia: Case Study 3

Q: The shores of Lake Malawi have been my home for the last few months. I’ve been seeking inspiration for my latest work and I thought I’d found the perfect location to galvanise my literary brain into sensuous and romantic outpourings. Sadly after an ill-advised snorkelling trip in the lake I’ve contracted a vulgar disease called bilharzia instead. I felt fine initially but a few weeks after my dive I was prostrated by severe abdominal pains, fever and diarrhoea. What’s the prognosis, doctor?

A: I’m quietly confident that the outlook is good, Kenneth. You’ve been the victim of a nasty water-borne illness which is a growing menace to the idyllic shores of Lake Malawi. Bilharzia (or schistosomiasis – careful how you say that) is a disease caused by parasitic flukes that use humans as hosts. The eggs breed in snails that live in the reeds in the stiller areas of the lake, and once they’re released into the water they develop into larvae that are capable of infecting mammals. They cleverly secrete enzymes that break down human skin, allowing them to penetrate it and migrate to the lungs and liver. Once there, they grow and start feeding on red blood cells, and they may end up moving to the kidneys, bladder or intestine. After loitering maliciously for 6 to 8 weeks the mature worms start producing eggs, anywhere between 300 and 3000 a day, many of which are shed in faeces and urine. It’s the eggs that don’t make it out but stay trapped in the body that stimulate a massive immune response, giving rise to the fatigue, fevers, pains, swollen livers/spleens and genital sores that are the hallmarks of the disease. Disconcertingly, the worms survive in the body for an average of 4 and a half years, sometimes much longer. Counting eggs per gram of poo isn’t my idea of a good day out, but this is how the disease is most commonly diagnosed. But happily, it’s easily treated, by a single oral dose of the drug praziquantel. The WHO is promoting efforts to eradicate bilharzia and some countries have managed it, but Malawi isn’t yet one of them. As we all know, prevention is better than cure, so avoid areas known to be infested; don’t swim, wash, paddle, push vehicles or wade through rivers or water, especially if slow-flowing or stagnant; don’t drink potentially infected water without at least boiling it for a minute or more; and wear protective footwear if you are walking through mud or damp areas near rivers or lakes.

Coral: Case Study 1

Q: I have just returned from a diving holiday in the Red Sea. Last Saturday on my final dive I was stung by Fire Coral on the back of my left leg. I have burns within a 12″ by 4″ area, which are red and itchy. I have consulted my GP (who has no experience of this condition), who advisedme to use anti histamine cream, which is not having any significant effect.

Please could you advise if there is a more appropriate treatment and how can I get the prescription asap.

A: The treatment for fire coral stings is fairly straight forward in the acute phase.

The pain and rash is caused in a similar way that a jellyfish will cause the problems too. Lots of stinging nematocysts, full of venom, implant into your skin and pump in the poison.

The can be neutralised by vinegar. But in your situation where you are still itching like crazy you need to get some steroid cream. At this late stage I would also make sure there’s some antibiotic in the cream too as there may well be itching if you have been scratching the area.

Try “fucibet” cream. Its got a good strong steroid and a broad spec antibiotic. It is only prescribable though, so if you need it asap, then either try e-med, or wait patiently at your doctors.

Coral: Case Study 2

Q: I am hoping you can offer advice on a coral sting received 5 months ago. I am a relatively inexperienced diver, becoming Padi Open Water qualified earlier this year, and on a dive in Bora Bora in June tried to get out of the way of another diver who was heading backwards at me. Unfortunately, I brushed against coral which has left what looks like chicken pox marks all up my arm. I do not know what coral I touched but the pain was excruciating and subsided over a few days.

The dive instructor told me to place lemon juice of the sting and a paramedical that was also diving with us, told me to place hydrocortisone on the sting and take an antihistamine, which I did.

On returning to the UK I visited my doctor who thought the sting was shingles but offered no advice other than if anything was going to happen it would have happened by now!! I am now 5 months down the line and whilst the sting has slowly started to heal the marks are still very evident, more so when I am cold. As my daughter is getting married next year and the embarrassment the marks are causing, I am obviously concerned over the timescale involved.

Please could you advise me whether the marks will clear and if I can do anything to assist in the healing process. Please could you also inform me the procedures if anything like this was to happen again – hopefully not as I intend to stay well clear of any other divers and wear a full suit.

Many thanks for your assistance, in anticipation.

A: Here’s the plan. Do nothing. Why? Well if it’s the wedding you are worried about, and there are these interesting marks down your arm, what better way of deflecting the conversation away from “doesn’t she look beautiful, you must be proud”, or “not salmon again” as the buffet looms, than by having ultra cool fire coral scars up your arm and you can then bang on about Bora Bora and which footballer or film star you roomed next to!

These marks can last a long time, years even, so get used to them. And if you want to damage limit the next time, wear a stinger suit, i.e. full 1mm lycra bodysuit if you’re there again. Or use Fucibet cream straight away on the area twice a day for a couple of weeks.

Lastly, how your GP could hear a story of immediate rash after a coral burn, and then tell you it is shingles defeats me. You don’t have to be clever to go to med school, just know the right people I guess.

Coral: Case Study 3

Q: Hi, I wonder if you could help. Whilst diving in the BVI’s 2 weeks ago I received a coral burn on my hand from inadvertently grabbing hold of a rock to steady myself in a swell in a confined space. This was just a minor pins and needles feeling for about an hour after I surfaced. After returning to Blighty the burn seems to have been reactivated by something I must have done – rubber gloves – cat flea spray??? And the whole area has swollen up and is extremely itchy and painful especially in the mornings. As it is my thumb and two first fingers of my right hand I am unable to use them much. I am currently using anti-histamine cream on the area which temporarily helps but it doesn’t seem to be going – any ideas of what I should be doing and why it’s continued so long.

The dive instructor told me to place lemon juice of the sting and a paramedical that was also diving with us, told me to place hydrocortisone on the sting and take an antihistamine, which I did.

On returning to the UK I visited my doctor who thought the sting was shingles but offered no advice other than if anything was going to happen it would have happened by now!! I am now 5 months down the line and whilst the sting has slowly started to heal the marks are still very evident, more so when I am cold. As my daughter is getting married next year and the embarrassment the marks are causing, I am obviously concerned over the timescale involved.

Please could you advise me whether the marks will clear and if I can do anything to assist in the healing process. Please could you also inform me the procedures if anything like this was to happen again – hopefully not as I intend to stay well clear of any other divers and wear a full suit.

Many thanks for your assistance, in anticipation.

A: “You’re full of pizen, honey”, sang poodle haired spandex rockers in the 80’s, that desert decade for decent music. Fire coral can be nasty with pain and itching lasting for weeks, and the chance of secondary infection too. My favourite poultice is called Fucibet, a steroid and antibiotic cream. Apply it twice daily. If there is redness and swelling you may need a tablet called Magnapen too. So go show it to the doc, and it would be good to leave off other skin irritants as well. Avoid rubber gloves and cat flea spray by simply hiring a cleaner and buying a gun.

Coral: Case Study 4

Q: I have just got back from Sharm and was stung by a fire coral last Friday. It first went into a swollen bubble and they put white vinegar and iodine on it. Since then the swelling has gone down but around the wound there is a red/purple patch. I have been given steroid injections, antihistamines and painkillers at Sharm. It is not painful now but is very itchy and irritated. Unfortunately it is beneath my bottom and the allergy has gone toward my inner thigh (not nice) as I have to sit on it. I will try to attach a picture to this email. Could you please help me.

A: Not to worry, even professional snorkellers get stung from time to time. Fire corals are so named because of their similarity in appearance to reef-building coral, but in fact they are carnivorous members of the coelenterates (jellyfish). The thing all coelenterates have in common is the development of stinging capsules called nematocysts, which either cling to victims via sticky mucus or a hook, or inject venom into prey by penetrating like a needle. Either way, the idea of the nematocyst is to immobilise the hapless chump so it can then be eaten.

Fire corals have bright calcified skeletal coverings perforated by millions of tiny pores, through which stinging tentacles project. Hence people can be injured by scraping themselves against the skeleton, or by being stung, or often both. The symptoms vary from a mild, burning itch to severe pain, and what you see is a reddish swelling around the site, often surrounded with blisters or weals. Occasionally the blisters become pus-filled but most dry and flake off within 24 hours or so.

Plenty of local treatments have fallen in and out of favour over the years. Alcohol was once thought to dehydrate the nematocysts and thus prevent further stings, but studies now suggest it may actively stimulate more discharges. Current fashion is to use vinegar, which seems to reduce the number of stings from a live tentacle, although it does nothing for pain. Local anaesthetic ointment will provide relief however, as will antihistamines and steroid creams for the itch. Local heat, in the form of a hot towel or hot water, can help to denature the stinging toxin too. These are the only remedies for which there is evidence, gleaned from trials involving brave (or foolish) guinea pigs who volunteered to be stung. Lime juice, washing powder and mermaid’s milk are unlikely to be of benefit.

Coral: Case Study 5

Q: My buddy and I were recently diving in Mexico, which was excellent until the last day. We were hanging onto the shot line doing our safety stop, I had gloves on and she didn’t. As she pulled herself up to the surface she cut her hand on something. It was bleeding at the surface but looked clean so we just rinsed it with fresh water and plastered it. It stung a lot on rinsing. It’s now 3 days on and she says it’s throbbing horribly, and her other hand is covered in red swollen marks. What’s going on? Any ideas on how we can get this better?

A: Ah, this bears all the hallmarks of a good dose of the fire corals. Quite often anchor or buoy lines are colonised by corals and hydroids, and the unwitting gloveless diver’s hands, softened up nicely after an hour’s submersion, are sliced easily by hard coral fragments. Subsequent discharge of thousands of stinging nematocysts and the injection of foreign particulate matter into the wounds leads to a real humdinger of blistering, infection and chronic inflammation. Yuk. So the aim of initial first aid is to clean the wound as much as possible and neutralise the sting (the hypotonic nature of fresh water will actually cause MORE stings to be released). Plenty of vinegar should be used to flush the wound, and a good scrub with soapy water should rid it of most of the retained dirty bits of coral. If it’s a deep or large cut then it’s probably wise to start some antibiotics, as infection is pretty common. A tetanus shot is a must, and if it’s not obviously healing and improving in 2-3 days, it’s likely there’s some remnants in there which are causing a secondary reaction. This then requires further cleaning, debridement and probably a trip to the doc’s for some strong antibiotics. Beware of delayed reactions too: sometimes victims can suffer itching, burning and pain for months, so get in early with some steroid creams and painkillers if these symptoms start to appear.

Coral: Case Study 6

Q: I have just got back from Sharm and was stung by a fire coral a week ago, on my second dive of a series of ten. Initially it blistered into large fluid-filled bubbles all over my leg. The doctors at the hotel put white vinegar and iodine on it. Since then the swelling has reduced but there is now a purple discolouration developing around the wound. I have been given an iv injection of steroids, and some gel to rub on, but don’t feel any better at the moment. It is not painful but is very itchy and irritated. Is there any other treatment you can suggest as I don’t want to be stuck in the hotel missing all my dives!

A: Fire corals are so named because of their similarity in appearance to reef-building coral, but in fact they are carnivorous members of the coelenterates (jellyfish). So in essence the treatment of these stings is the same. Fire corals differ slightly in that they have bright calcified skeletal coverings perforated by millions of tiny pores, through which their stinging tentacles project. Hence people can be injured by scraping themselves against the skeleton, or by being stung, or often both. The symptoms vary from a mild, burning itch to severe pain, and what you see is a reddish swelling around the site, often surrounded with blisters or weals. Occasionally the blisters become pus-filled but most dry and flake off within 24 hours or so. As well as the usual jellyfish remedies, local heat, in the form of a hot towel or hot water, can help to denature the stinging toxin too.

Freshwater: Case Study 1

Q: I am planning on taken part diving in the Thames & other British fresh water sites both rivers & lakes.
I would like to know of any health risk’s that might be involved in diving such sites & any preventative measures I can take to protect myself. Also if you can advise me of any vaccinations that might be advantagous I would be grateful.

A: I think you should be fine in our joyous clean waters here in the UK. The only real issue is that of an interesting illness called Weil’s disease or leishmanisis. This is a bug transferred into fresh water from rat’s urine. However it’s mostly really found in still water like in wells or small ponds where the only divers are from the supermarkets retrieving their trolleys. If you are diving big lakes or quarries like Stoney then there is little chance of getting this interesting condition. As for rivers, they are pretty clean, even in London as the number of cormorants visible from Chelsea Bridge proves.

What immunisations?

Well, you should always keep up to date with tetanus and polio, which are every 10 years anyway. That’s about all you need look out for but if you are diving near unprocessed sewage get a Hepatitis A shot too, but nowadays most of the Capital’s number 2’s are clean enough to drink after processing by the water authorities. Well that’s what they tell us anyway!

Freshwater: Case Study 2

Q: I’ve been stationed out in Vietnam with work for a year, and whilst here I’ve been enjoying all the natural pursuits the country has to offer – amongst them, diving in inland lakes as well as off the coast, caving, longboating up the river etc. Recently I had what I though was just a cold/cough, with the usual symptoms of fever, shivers, muscle pains and a sore throat. It went after 4 or 5 days, but someone mentioned a condition called Weil’s disease, and that it was common here and I might have picked it up from the water? Is this possible and what should I do to find out if I’ve got it?

A: Adolf Weil first described “an acute infectious disease with enlargement of spleen, jaundice and nephritis” in 1886. This bacterial illness, known as leptospirosis, is usually acquired via water contaminated with animal urine coming into contact with eyes or unhealed breaks in the skin. Surfers, rowers, farmers and sewage workers are examples of your at-risk groups; leptospirosis has even been seen in golfers who have become infected while retrieving balls from stagnant pools. Thankfully it’s rare, as it’s a pig to diagnose. Symptoms vary from none at all to almost anything, but typically an initial flu-like illness resolves before a second phase of meningitis, liver damage and renal failure kicks in. Diagnosis is via blood tests and cultures but can be hit and miss unless there is access to a lab with sophisticated equipment. High doses of antibiotics are required to deal with the bacteria, but handily doxycycline is a good prophylactic (in addition to its similar function as an antimalarial). As usual, the golden rule is to try to stop yourself getting it in the first place, so avoid any rat-infested swimming pools if you can.

Jellyfish: Case Study 1

Q: I am going to Baja California in October and after a nasty sting in the Red Sea by a jellyfish, would like to know more about how to prevent it happening again, and what to do afterwards?

A: Fear not because at least now you are going to a relatively jelly free part of the world. The Sea of Cortez is not as bad as other parts of the Pacific for this problem. What you always need to do when you are swimming or diving in a new area is ask the locals. They should be able to tell you if there are any jellyfish blooms or a sudden influx of these creatures locally. This can commonly happen after a storm or strong onshore wind.

Now if there are local reports of their presence and you still have to go into the water the best thing to do is prevent yourself from being stung. This is best achieved by wearing a full wetsuit or a suit called a stinger suit. This is made from Lycra, fits snugly and will stop the jelly from stinging you, but only on the non exposed parts of your body.

The way jellyfish feed is by enveloping their prey in their tentacles and paralysing them with “nematocysts”. These are tiny bags full of venom that are found on the tentacles, and on contact with a fish or human skin they fire off, releasing the poison into whatever they are in contact with. If this happens to be you or a friend then you need to act quickly.

Get out of the water as soon as you can and have someone help get any tentacles off your skin. They must first of all stop any remaining nematocysts from firing off and the best thing for this is ordinary household vinegar. Pour this over the area affected and on any remaining tentacles. If there is no vinegar handy then there are other fluids you can use, the best of which is urine, which may seem bizarre but has good medical grounding due to its relative warmth and acidity.

Having been doused in whatever liquid try to take off any remaining tentacles with gloved hands so you don’t get stings on your fingers.

Now, depending on what sort of jellyfish it was appropriate action needs to be taken. If you were in Eastern Australia where the deadly Box Jellyfish frequents then you need to get some antivenom as soon as possible and go under medical supervision for a while, but fortunately most stings are not deadly, just really painful.

Take a simple analgesic such as ibuprofen and apply some calamine lotion on the affected area twice a day too.

Finally, when you’re diving remember to always look up when surfacing after a dive, as this is where most problems happen, and going up headfirst into a Portuguese Man’o’War is not the best way to enjoy Baja.

Jellyfish: Case Study 2

Q: I got your email address from the BSAC list of approved diving doctors and wondered if you could offer some advice.

While diving in the Atlantic off the coast of La Gomera in the Canary Islands my daughter suffered a jellyfish sting on her face. We treated it immediately with a sting remedy from the chemist called ‘After bite’. It looked very red and was quite swollen. After it calmed down we started applying vitamin E cream to try and repair the skin, which was still quite red and chafed looking.

Now, nearly five weeks later it still hasn’t disappeared completely and in fact started to hurt again, not only on the site of the sting itself, but also around it and across her chin. It seems very dry and there are darkish marks in a patch where she was stung, which become prominent if she gets a bit cold, e.g after swimming.

I think the jellyfish was called a ‘medusa’ but I don’t know the latin name. Do you think it needs looking at by a doctor? Is it possible that there is something remaining in there that needs to be removed?

I would appreciate any advice you may be able to give.

A: Interesting one, this. 5 weeks after a jelly sting, to be getting pain and deformity. It must be the result of scarring is all I can assume. It is unlikely that there are any nematocysts still there, but certainly infection is a possibility.

I would try a cream with some antibiotic and steroid, e.g fucibet twice a day for a week. If this doesn’t nail it and there’s still a problem then you may be better off seeing a dermatologist for a closer look.

From my own experience with a similar beastie called a hydroid, the pain and itchiness can last for a good few weeks.

Jellyfish: Case Study 3

Q: Yesterday my wife got stung by a jellyfish whilst diving in the waters off Saudi Arabia. We washed the affected area with vinegar and soaked it in hot water. However she still has a lot of pain and no painkiller is working. She took an antihistamine shot. She now has started antibiotics (amoxycillin 875mg, clavulanic acid 125 mg). Please assist us to find the cure and end her pain, as I am suffering too, to see her in such distress. Many thanks for any advice you can offer us.

A: Jellyfish are stunningly versatile creatures, with over 2000 species living in all the world’s oceans from the surface to the deep sea. They’re clearly not fish, they don’t have recognisable organ systems, they’re over 90% water and unfortunately for us, some have a very effective defence mechanism. Contact with a tentacle causes the discharge of millions of specialised stinging cells called nematocysts, which pierce the hapless victim’s skin before injecting poison to immobilise them. Luckily only a few are deadly, some in fact produce no noticeable effect whatsoever, but best not to play with a jelly just in case. And so to treatment: if there are tentacles still clinging to the skin, these should be doused liberally in vinegar and then lifted off as gently as possible, with tweezers or gloved hands. A judicious coating of flour can aid the removal of particularly adherent tentacles with a blunt knife. Rubbing the wound or saturating it with alcohol, ammonia or urine seems to cause further nematocyst discharge, so avoid these “remedies” if they are suggested. Pain is sometimes severe, but can be relieved by ice packs, local anaesthetic sprays, ointments (such as lignocaine 5%); use steroid creams if itching is a problem. Beyond these there is little of proven benefit, although people have tried anything from baking soda to meat tenderiser over the years. Antibiotics are indicated if there’s any sign of infection developing

Other Mean Critters: Case Study 1

Q: I am getting married next month and my fiancee is planning a surprise diving honeymoon.

But my fear is that its going to be to the Barrier Reef of Australia as I found the tickets the other day. This is a problem as I have a total phobia about spiders which he doesn’t know about yet and I know that Australia is full of them.

Am I right in thinking that there are going to be some poisonous spiders out there, even on the coast which could kill me, or should I not worry at all?

A: Well what can I say to reassure you. Not a lot!

To answer your question there are venomous spiders in Australia and they do have the potential to kill you. But as you know Australia is visited by many millions of people and they have a wonderful time without so much as seeing a spider at all, let alone getting bitten by one of the toxic varieties.

The one to look out for in the part you may be visiting on your not such a surprise honeymoon is the Redback spider. This is a close relative of the Black Widow that is found in the Americas. The Redback is not an aggressive spider but contact comes by accident when the unfortunate victim either sits or lays a hand on it. Redbacks are known to live under the seats of lavatories. So it is advisable to always check before you sit down as the consequences can be a trip to the local Hospital for a shot of antivenom.

The really nasty spider out there doesn’t live so much in the outback but more in the suburbs of the bigger towns like Sydney and along the East Coast.

It’s called the Funnel-Web Spider and is an aggressive spider that can bite you without provocation. It usually lives under raised houses in its funnel shaped web.

They have been known to come out from under the house with the sole purpose of biting the foot of any adult or child that may be in the garden.

If this happens death can come as a result and it is important to lay the victim flat, apply a pressure bandage to the affected area, but not a tourniquet, and make sure they are transported to medical back up with as little fuss as possible.

Symptoms that can develop are the local reaction to the bite, with pain and inflammation right through to paralysis of the nervous system with death due to respiratory failure.

So those are the two worst you could encounter, but there are plenty more that can still inflict a nasty bite, or as one Australian arachnophobe once said to me “I don’t care whether they’re poisonous or not Doc, just seeing them will give me a heart attack”. My suggestion is that you would be in a spider free zone if you went on a live aboard around the Whitsunday Islands, and the diving would be a lot better than some of the Cairns shore-based round trips to the inner reef that are done.

However perhaps the best long term option is to get some help with your problem. One therapeutic technique is called “flooding”. Here the phobic is made to face their fear for as long as it takes, so you would have spiders crawl all over you until there was no more screaming. Unsurprisingly this technique has been waning in popularity.

Other Mean Critters: Case Study 2

Q: I am going cave diving in South America and my doc is not sure what shots I need. Can you help me out?

A: This is a fairly straightforward question, however there is a little twist which you may find interesting.

The baseline shots to make sure you are always up to date with, even if you are in the UK are tetanus and polio.

What you then need to top up with before going out to South America are typhoid, which comes as a single shot in the arm, or there is an oral version for those who don’t like the throbbing arm pain that typhoid immunisations always seems to cause.

The next is Hepatitis A, a single injection giving you a years immunity, another shot after 6 months increasing your immunity to 10 years.

You are also advised that South America carries a risk of Yellow Fever, a viral disease spread by forest dwelling mosquitoes, and in many countries it is mandatory that you have a certificate of immunisation against this illness before you enter the country. Yellow fever has recently been spreading into more urban parts of this continent, because human habitation has sadly moved into forested areas, and also the mosquito has been making tracks into areas where it was never found before.

The debate though is whether you need to have a rabies shot.

This will not prevent you from getting the disease if you are bitten, but means that if you are you will not need to find the immunoglobulin, which can be very scarce in many parts of South America. You will still need to have a course of rabies injections if you are bitten by a suspect animal but these are easier to get.

So, what are the risks of getting into contact with a rabies carrying animal?

Well, normally its fairly rare, but one species that does carry the rabies virus is the bat. The virus can also be present in the excreta of the bat, which is found on the floor of the large caves where they roost during the day. It has been stated that there is a theoretical risk of contracting rabies if this excreta is inhaled. So if you are caving there is a fair chance that this may happen to you, so I would also recommend that you have a rabies shot too.

The best way to prevent inhaling rabies laden bat excreta is to wear one of those masks that cyclists wear in polluted cities. Likewise I would always ask any local guides what the current information is on the bat colonies that live in the caves you are about to go deep into as they will be far better informed than most other sources.

Finally, don’t forget your malaria medication and also a good secure mosquito net.

If you are caving in remote areas you are entering Vampire bat and also Cone-nosed bug territory. We all know about the former, and the latter is the vector that spreads Chagas’ disease. So remember a mossie net is not just for keeping off mosquitoes, but all the other biting bugs bats and animals that would cause most travellers sleepless nights as they lie in fear of what will drop onto their heads at night from the ceiling of their hotel room.

Other Mean Critters: Case Study 3

Q: I have recently returned from a diving trip to Zanzibar, where due to the fact that all my money was stolen I had to spend a few nights in a dirt cheap hotel until more was wired out to me.

Since my return I have had the most awful itching on my hands and feet, but what’s odd is that it is mostly at night. Any thoughts on what it could be?

A: I think I can make a diagnosis here with some assurance. You have unfortunately contracted one of those skin infestations that seems to be becoming commoner as more people travel over the world.

It sounds like something called Scabies. This is caused by a tiny mite, Sarcoptes scabeii, which is caught by either being in contact with a person or rarely bed sheets where the mite has previously been.

The mite having got onto your skin normally finds its way to specific areas of your body, notably the wrists and finger webs, also the feet and ankles and finally your genital area.

Having got there, the mite burrows under your skin leaving a tell tale track to its hiding place. The reason the itching occurs is that the next part of its life cycle is that when it is night, it comes out of its burrow and lays its eggs on the surface of your skin. This usually occurs at night as those areas where it lives on your body are now warm and moist which make for a better environment for the eggs.

However the eggs on your skin do cause an intense itching and part of the process is that you reimplant them by scratching your skin and also it helps to spread them over other parts of your body.

The usual signs of this disease are the previously mentioned tracks, and also a rash where you have been scratching your body. I have seen very bad cases of this in the past where the infestation has affected the whole body, and this is what used to happen years ago before any cure was around. In very rare cases it can even lead to death where infection gets into the blood stream from the open scratched sores on the skin.

We are luckier now, though as it is very easy to treat. The basis of the cure is an antiparasitic cream called permethrin which you have to apply to your whole body from neck down to the tip of your toes. Leave the cream on for 24 hours then wash it off and reapply again. One day later wash it off and that should finally get rid of it. As the mite can still live on clothing and sheets for a while then you need to wash anything you have worn or slept on since your return on the hottest wash available to kill off any remaining mites or their eggs.

Finally, this rash and itch usually comes on about 6 weeks after contact, if any diver experiences an itchy rash sooner after diving, then it is wise to make sure it is not a case of “skin bends”. This though is more often found on the shoulders and trunk and associated with an odd marbled looking rash. The only effective treatment for this is recompression in a dive chamber, and if you don’t know where the closest one is to you, then contact e-med and we can direct you to one.

Other Mean Critters: Case Study 4

Q: I have just returned from Mexico (Cozumel) and I have a very strange rash on my leg. While diving on the second to last day I had a sting on my leg while lying on the bottom taking a picture. The sting was not too bad and not the first either, so I ignored it.
The stinging abated after a few hours and I assumed I had rubbed against some fire coral, albeit that I did not see any near where I had settled.

It is now four days later and unlike the other stings has developed into a long rash about six inches long which is very red and lumpy. It looks a bit like 30 mosquitoes all homed in on the same place. Lastly the rash does not itch or sting and merely looks unsightly.

Is this anything to be concerned about and should I do anything about this?

A: And there I was too in Mexico. Smoothly moving over a bare rock to approach the seal pups.when ouch, what the f*** was that. I had gotten stung by something invisible. I went back to look and there were a couple of weird looking fronds. Like tiny sea bracken, it must have been that. All was OK for a few hours then it kicked in and itched like hell for the next two weeks. So I was introduced to the evil hydroid.

That’s what’s got you too. God or Darwin put them on this planet to create good copy for diving medical columns as they don’t seem to do much else.

Use a mixed antibiotic/steroid cream and don’t scratch. I suggest Fucibet applied twice daily, and next time stay mid-water.

Other Mean Critters: Case Study 5

Q: I have just returned from Sharm and I have been attacked yet again by unseen beasts of the deep! I luckily wore a full wetsuit but got stung on my wrists ankles and face and lips (it was sore when it got me and my fellow divers felt the stings but didn’t have the bad reaction.) The next day I had itchy bumps and now they have turned into fluid filled blisters. This has happened to me before (hence the full wetsuit in 28 degree water) in the Maldives and Thailand but not in the Caribbean. I did not see jellyfish nor did I touch any coral. I thought in the past it could have been small jellyfish but the dive outfit I was with says it is plankton. Any idea of what this mysterious beast is and how I can avoid it in the future and get rid of this horrendous rash!! Any help would be appreciated!!!

A: Yup, it’s the plankton, zoophytes or zoon sort of beasties. Not much use to man or toothed mammal, but I guess they make up some part of a food chain somewhere.

If you are covered in an itchy rash, then the best thing to take is some oral antihistamines, like Clarityn, with calamine lotion. If that doesn’t work, use a mild steroid cream over the area, say a 1% hydrocortisone. It may take a while though. I got hit by these critters and it was a good 2 weeks before I stopped rubbing my back against trees and other tube passengers.

Prevention is always the best way, but you have to be practical. A neoprene gimp suit would raise too many concerns on a Carib boat. Mind you so would pulling out a pot of Vaseline and handing it over to the Instructor, with the order to “sort me out so the pricks don’t hurt.” Best you go with a stinger suit, lycra gloves and one of those new face masks as advertised in the back of this mag.

Other Mean Critters: Case Study 6

Q: I was recommended to email you by Kitty Jempson, our group leader for the Maldives trip going this weekend. A lot of the times I have been diving (in tropical waters) I get stung by no-one-seems-to-know-what! (perhaps tiny microscopic jelly fish or plankton, have been suggested)

It feels like very tiny stings, but I don’t react till the next day. Even though I try my best not to itch, the stings become painful, red, swell up and blister!

Someone suggested using a gel called Diprobase? Would this help to protect exposed skin against whatever it is that I seem to react badly to?

Many thanks.

A: No Diprobase is the wrong stuff. That’s what you put on a little babies bottoms when it gets all sore and rashy. The stuff to use if you need to barrier against stings is something thicker that will stay on you in the water. Rather like some buddies we know! Try Vaseline or other forms of petroleum jelly.

Of course, do not dive without a wet suit or stinger suit on. It probably is plankton or some sort of beastie like that. The fact you swell up and itch the next day, is probably due to sensitive skin. To get around this, if you think you have been “gotten” after a dive, then go for an antihistamine like Clarityn, and take one a day. This should stop the swelling up and itching.

Other Mean Critters: Case Study 7

Q: Hi, Every time I go diving I seem to get bites on my toes. First time it happened was after diving at Swanage Pier and there were bites all over the underside of my toes and on the balls of my feet that were so painful I could hardly walk. They are individual red spots that swell up and itch too, so I can only assume they are bites.

However, every time I go diving now I get the same thing, but fewer of them (usually a few bites on each little toe now). It’s really quite frustrating as I don’t know what it is. I have tried disinfecting my boots, but even after that I still got a couple more on one toe.

What do you think it could be and what else can I do to prevent it?

A: Sea lice or other such scummy critters. New boots. At £15.99, the disinfectant will probably cost you more.

From your story things are improving, if you are now down to two bites as opposed to a foot full. I would just buy some new boots and if it did ever happen only at Swanage again then we can point a finger of blame. Allergy, infection or infestation. A forensic water sample could be run and show the people there excrete only ammonia in their urine. That’ll be the inbreeding down there then.

Urchins: Case Study 1

Q: First week of November I was diving in Gulf of Thailand and put my hand on the Sea Urchin. I removed all stings but my finger (just one) until now is still swollen and I am still unable to bend it properly. It does not look like I have anything left in my finger but it also does not look like it is healing itself. What should I do?

A: There is a chance something got left in. A tiny fragment from the tip of the spine is the most likely. But no surgeon is going to plough in there risking further damage. You have an infection, that much is obvious, so the best way forward is to take antibiotics. Magnapen 4 times a day is the best, as long as you are not penicillin allergic. The fragment, being made of keratin, like human hair and nails, will disintegrate in time, and the infection will be fought, and all will be well.

If it happens again, there is a myriad of potential ways of removing spines. See the e-med “Your diving medical questions answered” page for helpful tips. Wax, needles, hot rocks and hammers, that sort of thing. Never urine though.

Urchins: Case Study 2

Q: I put my hand and foot on sea urchins back in early July. I managed to get most of the spikes out but a few remained. one has just exited my finger the opposite side that it went in, two appear to be doing the same in my toe but there are two at the base of my thumb/palm of my hand that I know are in there but cannot feel anymore. Should I be worried about the remaining bits in my hand? (The bit that came out of my finger was about 10mm long.)

A: One of the reference texts on marine dangers includes the following helpful advice on sea urchins: “stay away from these creatures”. Concise, practical, but not exactly useful when spines are nestling happily in your digits. Bad luck on that front, but you needn’t worry too much. First, a bit more info on these bad boys of the ocean;

Sea urchins vary considerably in colour, size and venomous potential. They are animals of the phylum Echinodermata, ‘urchin’ being the Old English name for hedgehog. The spines are attached by ball-and-socket joints to their globular body, and can waft about menacingly, or converge on a point to deter predators. Unfortunately the spines are very sharp, often piercing tissues on contact, and very brittle, tending to break off and embed themselves within those tissues. Unsurprisingly, severe pain ensues, out of proportion to that of the piercing alone, and lasting up to 4 hours. Trying to extract the spines only serves to snap them off deep in the wound. The surrounding area then becomes inflamed and swollen over the next few days, with any luck healing up in a week or two.

Sometimes the spines are absorbed by the tissues, but they can also become encrusted and remain for many months before emerging from sites distant from the original puncture site. This has obviously happened with the spines in your finger and toe. Drawing pastes such as magnesium sulphate will often speed this process up. The other possible complication is infection, which is accompanied by the usual signs of increasing pain, redness and swelling. Occasionally the ache spreads to involve the whole limb, making movement difficult.

Traditional Islander remedies include urinating on the wound (nice) or placing it in thick mud. Bathing the area with hot water or methylated spirits has also been advocated. Embedded spine fragments can be crushed up by vigorous pummelling with a fist, which seems to relieve pain, although whether this is by replacing it with a distracting new pain is unknown. Rarely, if troublesome remnants persist, they can be dealt with surgically with an X ray of the area should pinpoint where they are, and under local anaesthetic the area can be explored and the pesky fragments removed.

So in your case I would hold off as those bits in your hand have probably either been broken down, or will work their own way out. It’s a bit late to start peeing on your hand at this stage.

Still have questions?

Please read through the other FAQs on the Sunken Dreams’ Answers to Your Questions webpage contact us using the contact form below.


Bends: Case Study 1

Q: I have recently returned from a diving expedition to Roatan. On the morning of Friday 2nd March I got decompression sickness.

I was on a 30/14 profile but my max depth was 25m, my buddy had a dive computer and the ascent was fine, with a 3 minute saftey stop at 5 metres. I surfaced, and after a few minutes on the boat my elbow started to tingle, after about 10 mins I started to feel lightheaded and when I got of the boat I felt very dizzy. I was then put on oxygen (about 40 mins after surface time) and taken to see a dive doctor, I was put on oxygen again for another 30 mins. I then had an hour break in which I felt 99%, apart from a slight soreness in the elbow.

I was put in a recompression chamber for 2.15 hrs and felt fine afterwards. Then during Saturday afternoon I started to feel lightheaded again and slightly spaced out, this feeling has stayed with me ever since, in the following week I saw the doctor twice and she told me that it was just as a result of the treatment and it would pass, I haven’t dived since and I still feel the same.

A: Sorry but I think you need assessment quickly. The situation here is that a 2 hour plus recompression is not really adequate if you have been diagnosed as having a bend. The fact that you had these symptoms before treatment and then again after means that you need retreatment.

At our chamber we use a standard Royal Navy Table 62 for the first treatment. This is a minimum of 4 hours and is accepted as the minimum needed for the first recompression. A table this short and with no further treatments when your symptoms returned is what we call a “partially treated bend”.

You need to see a dive doctor for assessment and then start all over again if your symptoms warrant it.

[He was seen immediately and had the proper treatment at Capital Hyperbarics. He has now recovered]

The lesson here is that in various chambers over the world you well may come across different treatment tables, however if you are ever in doubt about what you have had then please e-mail us and we can advise you on what to do next. If you are going into the pot then you may as well go in properly. As if you don’t then you will have to on your return to the UK anyway. And I’ll tell you from experience it can be a bit boring the second time around.

Bends: Case Study 2

Q: I had a Type 1 bend in Scapa Flow in April and was treated with a table 6 recompression. I have since see my diving doctor, who gave me a check up and a HSE Certificate (Recreational Divemaster) without any restrictions on my diving i.e. Depth limits etc.

I plan to go to Scapa again next April, what are the chances that I will get bent again? (I will be doing similar repetitive dives – 2 dives a day for 6 days). Should I do more deco or reduce my bottom time. I plan much slower ascents now (no more then 6-8m/min.) Do I have to dive with Nitrox on Air tables?

I might be answering my own question here…but if the doctor has given me the all clear with no restrictions, what am I worring about?

A: I think a Type 1 that needed only 1 treatment in the chamber is fairly minor on the bends ladder. Is there a chance you could get bend again? Well there is a chance of a hit every time you dive. However I would say that Scapa with it’s depths, bottom times needed and coldness can be more of a risk than say the good old Dredger in Portland with its 10metre max and lovely warmth!

So, to be really safe just use Nitrox and set your computer for air. Keep well hydrated, and if your deco stops are a bit chilly then increase the time by a few minutes to compensate for cold veins constricting and not letting the blood back so easily, which can decrease off gassing.

Or, what about waiting for Hollywood to make the movie of Scapa. They’ll say it was them that won it, shoot it with full size re-creation in Palau, and stick it in 10 feet of water. Historically inaccurate as ever but a safer dive!

Bends: Case Study 3

Q: This is probably a silly question but I will ask it anyway.

I was doing my rescue dive exam day off Sharm in September. I did the required search pattern exercise at 12m (approximately 10-12 minutes) about an hour and a half later I carried out a rescue scenario on an unresponsive diver found at 10m. For reasons I will not go into here I had to descend and ascend three times during this exercise (again I was only under for approximately 12-15 minutes). Later that afternoon I took part in a dive during which the instructors illustrated some novice diver mistakes/antics and during which I was responsible for leading the dive. This dive was very tiring even though it was short. The dive was only 23 minutes, maximum depth 20 metres (but we were only at 20 metres for two minutes and most of the dive was at 17-12 metres).

About half an hour after my dive I began to feel exhausted and faint. I attempted to rehydrate and immediately felt better. An hour or so after returning to the shore I felt extremely dizzy but again, sitting indoors and drinking water helped considerably. The dive instructors (and I) thought I just had heat exhaustion or sunstroke.

The following morning I woke feeling pretty ropey and I had tingling fingers and a dull pain in my elbow. I reported this to the dive operation and went to Sharm. I was treated with O2 and after a positive result was put in the chamber for 2 hours. I was asked to return twice to check that none of my symptoms had reoccured and I received no further treatment because I was fine.

My dive profile was judged to have been safe, however, the 47 degree heat and dehydration were deemed to have contributed to what was described to me as a mild bend.

I am due to book in for a dive medical soon and want to start my DM course in Thailand in April. I have noticed that my elbow (the one which was painful in Sharm) is painful if I press on it. It is a different kind of uncomfortable feeling than I think I remember from Sharm but I just wondered if that is something I should be concerned about.

Sorry for the length of this query.

A: I’ve been in 45 degrees, and its hot. 47 has to be the hottest time ever out there. That and all those up and down shenanigans will easily equal a bend. You got better with the treatment. But now the pain is back. Well in my experience, if you press something hard enough it will hurt later. It doesn’t mean the bend is back. But in these cases always see a dive doc just to make sure.

N.B. I saw this lady and all was fine. Tennis elbow, not an undertreated case of DCI. Better to make sure though.

Bends: Case Study 4

Q: I am just back from 2 weeks diving in St Lucia. Great first week with 8 dives over 4 days but was not well the 2nd week. I moved resorts for week 2 and went on one of those day trips around the island but felt completely worn out by the next day. However, the following day I felt fine to dive so did 2 dives (both about 14m for 40-45 mins). Later that day I felt extremely tired and my neck, shoulders, arms and under my ribcage ached and had some slight tingling in my fingers. So the next morning I spoke to the dive instructor and he immediately put me on oxygen for 1 hour and phoned the DAN. They suggested I go for a check up. The doctor carried out various tests with blood pressure, pulse, temperature, reflexes, breathing and feeling/sensations all ok. He did not think I had DCS (I have to say that Tommy at Frogs Diving, and the hospital staff were fantastic).

So some background.

(1) 3 years ago I had a micro-discectomy on L4/L5. Since the operation I have learnt to dive (just reached my 50th dive) and have had fit to dive medicals etc. One consequence of the back problem is constant pins and needles in my right foot. To help combat this I was taking gabapentin working up from 100mg once a day in June 2006 to 500mg 3 times a day. One side effect of this is tiredness. This was the first time diving whilst on medication. I had seen the specialist just before I went away and he said that there should be no problem diving (his wife dives) but that I should try a different drug because of the tiredness. This meant reducing the dosage over the course of my holiday and my last dose was the day after my sight-seeing trip and before my final 2 dives. I have not started the new drug yet.

(2) I was not feeling 100% before I went away – the doctor thought that my symptoms could be viral.

(3) The doctor also thought that it could be dehydration – from cold London to hot and sticky St Lucia, long day trip, 8 dives in week 1 etc. I had been drinking plenty of water but perhaps not replenishing salts. Very little alcohol was drunk! He prescribed some of those rehydration sachets and told me to rest for the remainder of the holiday.

The tingling soon went but all the aches and tiredness still continue even though I’ve been back in the UK 4 days. I am wondering whether you have any thoughts on what this could all mean. Perhaps a visit to my GP is called for?

A: Hmm, a complex mesh of interwoven symptoms, overlaid with curve balls and red herrings, all making a big slice from the Pie of Confusion and Doubt. Here are some thoughts. The gabapentin decreases the tingling but makes you tired. So by stopping it you’d think your tingling would increase but you would feel less tired. After the diving, and since your return, you still feel tired but the tingling has gone too. And your previous tingling was in your foot, not your hand. Dehydration can predispose to a bend as you have less fluids to take away all that nitrogen.

Yes, viral illnesses can make you tired and mimic any symptoms, but they usually run for 7-10 days, and you have these problems after a 2 weeks holiday and 4 days back. Should you see your GP for something that could be dive related? Probably not. They wouldn’t have a clue and would tell you to come back in a week, so you can catch something off someone else in the waiting room.

Here’s my advice. And remember the mantra. If it wasn’t there before diving, and it is there now, always assume it’s a bend until proved otherwise. So best you see the doc at your local chamber for full assessment for DCI, as that can only be treated by recompression. If it’s not a bend then post viral, change of meds, holiday fatigue, or still just plain miserable that we were so bad in Germany, will get better. Well maybe not the last one.

Bends: Case Study 5

Q: We have just returned from a trip to Tobago. We did a night dive with two inexperienced Germans on their third dive of the day. Having lost his fin, his torch, and after a bit of a panic ran out of air, His buddy gave him his alternate, but they were taken in a down current to 33m. (from 15m) The dive guide and another diver went down and brought them to the surface ASAP due to lack of air reserves. The two Germans were given oxygen at the center, but declined treatment at the decompression chamber, due in part to the dive Doc not being able to find the key. Two days later one told me he had pins and needles and the other had had bleeding from his ears.

What happens if you do not get treatment after a bend? Does it sort its self out if you leave it long enough? Or are you asking for problems next time you dive?

A: I love this. They turned down treatment on account of the doc losing the key to the chamber room. Yeah right. It sounds like someone persuaded them not to get un-bent because of the hassle of going to the locksmith. Ear bleed bloke was OK, but Herr Tingle did need treatment. The consequences of diving again, still symptomatic of DCS, are worsening the problem. Not clever.

On occasions it can just improve in time, but nitrogen bubbles are curious things. If they were totally asymptomatic, without treatment 4 weeks later, they could dive, maybe, but best to see a dive doc for a check up before risking it. In my experience though, on close questioning, there are always some symptoms left, and late treatment can be warranted if they were to dive again.

Bends: Case Study 6

Q: I have recently undergone treatment for a bend for the second time this year. As for the first one, I have been advised not to dive for 6 weeks then that I should be OK. The doctor has said he is not worried about a PFO or other susceptibility, but I would like to clarify.

The first one occurred while using a new drysuit that had a shoulder instead of cuff dump (and which was also adjustable and inadvertently closed). I had dived to about 24m, basically sat on the bottom as it was a deep spec training dive and other group members having problems descending meant we couldn’t proceed and didn’t give me much time at the level to play with my buoyancy. When it came time to ascend, my buddy actually ascended faster than me, though mine was also out of control and only just within the 18m/min limit – part of the problem was that my buddy’s faster ascent stopped me from realising my own situation. I brought it under control 1m from the surface, started to go back down to 5m for a safety stop then changed my mind at about 3m and came up. It wasn’t especially severe, and I safely drove home from Chepstow to Poole, but felt ill that evening and next morning had a pain in my elbow. My buddies with faster ascents had no problems.

The second one occurred on a shallow dive, with a maximum depth at 9m and most of the dive at 5-7m (after going to 9m and coming up I don’t believe I returned, but there was quite a bit of going over rocks and stuff) for about 50min. At the end of my ascent I dropped my SMB reel, which I went in again for believing that, while not ideal, that just to 5m and brief it should be OK, as the dive was within no-stop limits by a long way. I was shocked when the doctor described it as a “Guaranteed” bend, and this statement has provoked the same surprise from a number of very experienced divers and even instructors, who reinforced my original view that, while not recommended, such dives are very common particularly with regard to tying off anchors and stuff. My symptoms in this case occurred straight away and included itching skin and a general unwellness/lack of mental alertness. Stupidly I denied this for 24 hours and was treated the following day.

Should I be concerned about a PFO/is it worth testing for peace of mind, or was my profile on the second dive just more dangerous than I had realised?

Aside from that I am a reasonably young (24) and healthy non-smoker. On another note, I have been referred for a 6 week follow up consultation with an independant doctor in Ringwood (I think he’s involved in some sort of survey). Problem is I am moving to Essex in 3 weeks and they have told me that there is no one I can be referred to in London instead. Surely that’s not right?

A: The last bit first. Utter b*******. Of course there are doctors in London who can assess you post treatment and pre-return to diving. There’s about 5 or 6 including myself. Whoever told you that at the chamber you were treated at should hang their head in shame.

Now, was it a guaranteed bend? Well itching, and feeling dull and drowsy are bends symptoms. You did get this straight after a dive, and I assume you got better in the pot. So it must have been. There are other causes of itching and dullness but it would be freaky if say you suddenly got eczema and Alzeimers straight after a dive. A coincidence to end them all. So we gotta say it was a hit. Now that’s 2 for you, and the last one after a shallow dive with a tiny bounce.

If it were me I would be hammering on the door of the cardiologist already. I think you have to exclude PFO for peace of mind and for the future, as you seem to be more than the once a year on holidays sort of diver. So see a dive doc and get referred for an echocardiogram to look for this hole.

Bends: Case Study 7

Q: I have been experiencing balance, coordination problems, and tremors since my last dive. My last dive was a long time ago, 6 weeks in fact, but to explain: I had an uncontrolled rapid ascent, bottom depth 21 metres, lost control around 14 metres. I emptied my BCD, breathed out, but came up so fast my mask was ripped off my head. The dive operation in Malaysia said I was fine and to stop complaining. That night I had itchy skin. Told me not to worry. I flew after 20 hours from the dive. Next day staggering and pain in my arms. Went to hospital in Korea, where I live. Told me not to worry, not dive related. Now I have neurological problems that I’ve never had before. Could it be related to the rapid ascent? What to do?

A: This may seem like one of those no-brainers but I wanted to point out the sort of advice that is sometimes dished out by those “in the know” when overseas. I’d like to say I made this question up but unfortunately it is genuine, unadulterated, and all too representative of the overseas cases we are seeing at LDC. I hardly need point out the salient features that would have me hollering down the phone but this poor diver has illustrated perfectly the dangers of leaving decompression illness untreated. We have naturally urged her not to dive again until she’s been seen by a competent dive doc, but the salutary lesson is never be fobbed off by a dive school eager to absolve themselves of any blame.

Bends: Case Study 8

Q: Hi, I spoke to someone on the London Diving Chamber 24 hour advice line who recommended I send you a quick email regarding some tingling I’m having in my left arm. I was doing my PADI Open Water course in the swimming pool yesterday and was at a depth of around three metres when I had to make an emergency ascent as I panicked during mask removal. I’m unsure if I held my breath as I ascended as I was panicking, but felt no lung pain or other symptoms on surfacing. On returning to three metres shortly afterwards I had lots of tingling and numbness in the bottom of both hands, but I have had this before when distressed (not diving related) and so disregarded it. This subsided shortly afterwards.

I was in the pool for a number of hours during the day, but this was at various depths (max three metres) and I was in and out of the pool during that time. The symptoms I’m having now are a slight intermittent tingling up my left arm, some minor loss of dexterity on this arm also, and very occasional mild dizziness. I’m a little concerned that I may have held my breath on my three metre ascent, and am worried that I may have done myself some damage because of this.

I’m also aware that I am tired due to the diving, and do not usually do the kind of physical exertion that scuba entails. It is very possible that I may have just strained my arm putting all the gear on. I just wanted to get your opinion before I disregard the symptoms and assume they will get better.

A: This is the $6 million question. The problem that gets all us dive docs hotted up at the bar after a good old conference. Where DAN may disagree with the Aussies. Can you get a bend from a pool dive? A three metre pool is only at 1.3 atmospheres. Not usually enough to bring on a DCI. However, we have seen cases where, with plenty of other extraneous factors, things can go wrong: long bottom times; cold pools; multiple bounce diving; breath-holding ascents; and the dreaded PFO (that little hole that can let microbubbles across the atria, straight into the arterial circulation).

So, I never say never. If the symptoms you have are different from the ones you get when distressed then it’s worth a check up with your local dive doc.

Yes, we have recompressed pool divers in the past, who have gotten better. And yes, we have figured out that some post pool diving problems are due to mental state rather than nitrogen. But either way we will be polite when we tell you our opinion.

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Leukaemia: Case Study 1

Q: I’ve just been diagnosed with chronic lymphocytic leukaemia (CLL). My haemoglobin is 12.1, platelets 86 and white blood cell (WBC) count 91. The consultant has advised me to start chemotherapy shortly but I had planned to try scuba diving before all this. Is diving still a possibility? I am aware my comparatively low platelet count would be a problem if I were to cut myself or worse but are there any other implications. With thanks for any advice you can offer.

A: Very sorry to hear of your diagnosis. The leukaemias are a group of disorders, basically cancers, of the blood or bone marrow. What distinguishes them is the rapid proliferation of abnormal white blood cells. In the acute form, many immature non-functional cells overcrowd the bone marrow, making it unable to produce healthy cells, and so treatment needs to be immediate. The chronic type takes much longer, but still results in the presence of many abnormal cells in the blood. It tends to affect an older age group, and sometimes is monitored for a time to determine when treatment will be most effective.

Despite the fact there are excessive numbers of cells in the blood, the symptoms result from the lack of normal, functioning ones. Platelets are crucial to blood clotting, so the low count can lead to easy bruising, prolonged bleeding from cuts or scrapes, or in the worst case, a spinal DCI. White cells are an important line of immune defense, making a leukaemia sufferer more prone to picking up infections, and to those infections being much worse than usual. Finally, the depletion of red blood cells, so important for carrying oxygen around the body, renders the patient anaemic and often breathless with poor exercise tolerance as a result.

Treatments for all leukaemias have improved vastly over recent years, but as a disease it still shortens lifespan. With CLL, however, some patients may require no treatment if their disease progression is sufficiently slow. As regular readers will know, I’m never one to give a blanket “no” to anyone, as I believe in assessing on a case-by-case basis, and it is possible that you could dive, based on your current condition and symptoms. Once chemotherapy has started, however, your chances would be much slimmer, due to the side effects of the agents used.

Prostate: Case Study 1

Q: I have just been diagnosed with prostrate cancer. Radical surgery advised within 4-6 weeks. Can I dive in the meantime? NO symptoms. Also can I dive in the future and when. Doc’s at hospital NOT very astute re diving etc. Thanks.

A: Poor you. I hope it all works out. If you are asymptomatic, no metastases to the bone, or local invasion to important vessels, and you feel well enough then diving is no problem. Once its been removed, and you have been given the all clear, then give it a few weeks and diving should be fine too.

Point to note here, thank medical science for progress. In the old days one of the cures for prostate cancer was orchidectomy. That’s castration to you and me. Ouch.

Prostate: Case Study 2

Q: Having recently retired my plans have been somewhat derailed by a diagnosis of prostate cancer. I am about to start a course of injections called triptorelin, a month before embarking on my Divemaster qualification. I had intended to complete this in UK waters before jetting off to sunnier climes, but wanted your advice on whether I need to rethink. Will I be ok to dive? My radiotherapy does not start until 6 months later. Thanks for any info as no one can give me an answer.

A: I’ve been in 45 degrees, and its hot. 47 has to be the hottest time ever out there. That and all those up and down shenanigans will easily equal a bend. You got better with the treatment. But now the pain is back. Well in my experience, if you press something hard enough it will hurt later. It doesn’t mean the bend is back. But in these cases always see a dive doc just to make sure.

N.B. I saw this lady and all was fine. Tennis elbow, not an undertreated case of DCI. Better to make sure though.

Radiotherapy: Case Study 1

Q: I am wondering if you can give me an opinion on whether I can dive again please. I had a malignant tumour in my right breast which was removed last year. At the beginning of this year I underwent radiotherapy and additionally I was prescribed Tamoxifen. I am worried whether my lung tissue was damaged by the radiation and if I am able to dive again. I feel healthy now and have started exercising again. I used to be quiet fit and sporty. I never smoked. The only other major health problem I ever had was a prolapsed disc many years ago, which caused no more problems since an operation 4 years ago. I am now 47 years old. I started diving in 2000 and have since performed a little more than 400 dives. I am qualified as an SSI divemaster with nitrox and rebreather specialities, but I am not planning to be involved in teaching. I would like to do a few dives in the English waters every now and then (neither deep nor especially long) and spend a relaxed holiday in Egypt in autumn. I would be grateful for any advice you can give.

A: This is always a tricky one as there is no definitive “yes” or “no” answer. The reason for this is that radiotherapy (and chemotherapy) is highly targeted to the tumour in question, so one patient’s treatment is invariably different to the next; the best recipe changes depending on the tumour type, how advanced it is, whether it has spread etc. Generally speaking, both chemo- and radiotherapy can induce scarring of the lung tissue and render a diver more susceptible to pulmonary barotrauma, embolism and pneumothorax. So you would need to have some investigations to assess these risks, usually involving a CT scan of your lungs together with lung function tests, before diving again. That said, the odd shallow UK dive and some relaxed drifting about in Egypt should be well within achievable realms, and would probably be just the ticket after what sounds like a pretty traumatic year.

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Arteries / Veins: Case Study 1

Q: I am 54 years old and have been diving for some 6 years now. Most of this is in either tropical waters or temperate areas with water temps of 18 deg C or more. Two years ago I underwent varicose vein surgery to both legs and veins were removed from both lower limbs. The ops. were completely successful. The only discomfort I now suffer is occasional cramp, which happens during the night.

My diving activity over the last two years has all been in Tropical waters at 25 deg plus with no cramp effects. I have however just returned from Western Australia and among other dives, we enjoyed the inaugural dive on the HMAS Perth in Albany. Water temp was 18 deg and I was “crippled” during the last 10 minutes of each dive, causing some concern to myself and diving buddies alike. The two layers of 5mm neoprene kept the rest of me quite warm enough in the water.

Is there any drug treatment that I can use to alleviate this inevitable consequence, or any physical treatment to be advised.

A: I assume that “crippled” was with the cramps you experience at other times.

I think there are a few things you can do to make sure it doesn’t happen again.

Cramps result after the build up of lactic acid, a by product of the burning of other elements apart from the glucose that is the normal stuff the tissues need to give them energy.

If you dive dehydrated or do not eat properly before you dive then the chances of getting cramps are greatly increased. As we know as well in diving the muscles we use most are those in the legs when finning, so if you are going to cramp then the legs are probably where you will get it.

Again keeping warm is important as cold legs and arms will result in cramps fairly soon into a dive if you are having to fin a lot.

So the lesson here is plenty of fluids, energy drinks may be the best for you and perhaps a set of ergonomic fins so you use your leg muscles less.

If you do cramp underwater, depending on the situation your buddy could pull the muscle for you by flexing the leg. But if it’s a serious one just come up slowly and try this manoevre during a deco stop, but if it is too painful just get back to the boat.

The varicose vein surgery is a red herring as it doesn’t necessarily contribute to causing cramps, but what you can use for any night cramps is a tablet called quinine sulphate. This is the same compound used as an antimalarial and also found in tonic water. So if you’re stuck for the tablets, a few bottles of this may help. Gin is optional.

Arteries / Veins: Case Study 2

Q: Wondering if there are any problems with diving if I have varicose veins – any risk to worsening the condition, or whether it could impact my ability to dive.

A: I can’t see any real issue here. Sure they’re ugly, sure they may cause a bit of aching and discoloration, but as long as they are not really severe, you can dive. By severe imagine great thick wriggly blue worms, trying to bust out from under the skin on your legs. If these are knocked or pricked on something spiky, the column of blood above them can dump out quicker than a Texan oil strike. The only way of taming this wildcat is to lie on your back and get a passer by to put pressure on the point of the bleed with your leg raised.

But to let the varicosities get to that stage would be criminal, so as you are smart enough to take up diving, I assume the problem is a minor one.

In fact, if you’re wearing a full length nice tight neoprene wettie, then the pressure might even act to improve the condition temporarily. And be a darn site more fashionable than one of those grotty NHS pressure stockings, that seem to slip down to the ankle, especially in the elderly obese Richard and Judy watching care home resident types. An image still burned into my brain from early years working voluntarily in old folks homes. Ever been a bingo caller to people with Alzheimer’s? The longest of all games.

Arteries / Veins: Case Study 3

Q: I have burgess disease. out of the 3 artery running down my calfs i have half remaining in one leg and almost two in the other i get intermittent claudication in feet and hands. does this mean i cant learn to dive

A: Honey, if I don’t tell you, then no one will. The next book you read will not be the PADI Open Water course book. It has to be ‘Ant and Bee Learn Basic Grammar and Spelling’. I get the odd typo from you lot, but this is my finest one yet. So ‘capitalise your I’s and caps after a full stop please. That’s enough pedantry!

It’s called Buerger’s disease, named after some German bloke no doubt, as opposed to the coke fuelled author of A Clockwork Orange. It is also known as thromboangiitis obliterans and is a rare disease characterized by a combination of acute inflammation and thrombosis (clotting) of the arteries and veins in the hands and feet. The obstruction of blood vessels in the hands and feet reduces the availability of blood to the tissues, causes pain and eventually damages or destroys the tissue. It often leads skin ulcerations and gangrene of fingers and toes. And as you do have clogged up arteries in your legs, and you get this ‘claudication’, or angina of the legs then it is a real issue with diving. If you were to fin at all, then you would get searing cramps and pains up your legs, whilst at depth. This would result in the sight of you bend double in agony, desperately pulling the tip of a fin to release a cramp, but with no result as your blood supply would be so bad.

So sad news I am afraid. But you could at least see the inside of a dive chamber, as hyperbaric oxygen is used a lot for the treatment of this condition.

Arteries / Veins: Case Study 4

Q: My family has a history of Hereditary Haemorrhagic Telangiectasia (HHT), with my mother currently suffering from nose bleeds and stomach bleeds, as well as other symptoms such as blood spots on her fingers etc. I have nose bleeds but not to the same degree as my mother. I recently read some info on the condition and about the effects sometimes causing Pulmonary Arteriovenous Malformations (PAVM’s). As far as I am aware my mother has never been tested for this. I am obviously concerned about the effects that this could have on my diving especially as the symptoms of HHT are expected to worsen as I reach 30. Could you tell me any more info on PAVM? Is my diving career over before it has even started?

A: Hereditary Haemorrhagic Telangiectasia: a fine phrase to roll around the tongue, but a hugely inconvenient condition to live with. About 1 in 5000 people do, and almost all are afflicted with recurrent nosebleeds. Telangiectasias are malformations that cause the walls of small blood vessels to become fragile, and hence bleed easily. Arteriovenous malformations (AVM’s) occur if larger vessels are affected; in HHT they can be found in the lungs, liver and brain. Lung (or pulmonary ) AVM’s are a problem for divers as essentially they do the same thing as a PFO – bypass the normal filtering action of the lungs on bubbles, allowing them to cross into the systemic circulation. The big difference is that pulmonary AVM’s are normally multiple, so rather than deploying an umbrella over a hole in the heart, they are treated by embolisation. A catheter is advanced into the heart, similar to the approach used in PFO closure. Dye is then used to highlight the AVM’s, and tiny coils deployed into them, which cause the blood within to clot off and the lesions to regress. It’s a complicated technique but in the right hands, good success rates are achievable. However, AVM’s can recur, so I would counsel anyone with this condition to think very carefully before considering diving, even if they don’t appear initially affected.

Blood: Case Study 1

Q: In Feb 2000 I was hospitalised with Henoch-Schoenlien purpura. It is a rare sometimes recurring condition which causes blood vessels in the skin and kidneys to become inflamed. I have to take 2mg of Perindopril daily for life, to keep my blood pressure under control (because high blood pressure increases the risk of long term kidney damage). I am in other respects a healthy, 42 year old non-smoker. After treatment I was cleared to dive and enjoyed a liveaboard holiday in September. My diving included 4 dives a day without incident, including several dives deeper than 30m and 1 to 60m. A few days ago I was diagnosed with an HSP flare-up and am taking 20mg of Prednisolone and 300mg of Ranitidine daily in addition to the Perindopril. These should halt and reverse the flare up and the quantity of Prednisolone will hopefully be reduced in 2 weeks although reduction to zero must be gradual. I am currently planning a 2 week dive holiday commencing next month. Please can you advise whether I can still dive safely while taking this medication and whether I should follow any precautions.

A: Indeed your problem is a rare one which characteristically starts off with a rash on the buttocks and upper thighs. It is also associated with pain in the joints known as arthralgia, problems with the gastrointestinal system which can lead to bloody diarrohea and most seriously kidney damage which as you say is made worse by having a high blood pressure. Thankfully most people recover in time and do not end up on drugs forever.
The fact that you have had a flare up and need the steroid tablets to control it normally wouldn’t be too much of a problem if you weren’t a diver. But steroids in very high doses can cause a degree of fluid retention in the body which rarely could manifest itself as fluid on the lungs called pulmonary oedema. This would obviously cause you problems with breathing underwater as it affects the amount of oxygen you would absorb through the lungs with each breath.

My suggestion is that you discuss your steroid reduction with your Consultant to see what dose you would be on when you go diving and if it is low enough then you should be fine to dive.

The other situation here is that a flare up of HSP can cause a sudden haemhorrhage of blood from your bowel, and this would be disasterous on a dive, so again your doctor should give you a clear indication of your particular risks and you shouldn’t dive if there is a chance of this.

The medication you take for your blood pressure, perindopril, will not cause any problems with diving but one of it’s side effects can be an irritating dry cough which would be an annoyance to you with a reg in your mouth at 60 metres. So if this side effect ever hits you, consider a medication switch or make sure your mouthpiece fits well with plenty of bite so it doesn’t pop out of your mouth unexpectedly.

Blood: Case Study 2

Q: I have just learned to dive with a local club in London, but I am having difficulty in finding out some information. I have always been a blood donor and still want to carry on giving blood, but I’m not sure and no one can tell me, how long I have to wait before going diving again after giving blood and are there any dangers if I were to go diving too soon.

A: This is a very good question and oddly one that I have never been asked before, though there is an obvious relation between the two. However do rest assured. When you go to give blood the transfusion service always do a haemoglobin test to make sure that your blood is not too thin or anaemic, and also to make sure that when they take the blood it wont leave you in that state either. So whatever happens you wont be left in a state where your blood will be too thin which would certainly increase a chance of a bend or even exhaustion if you had to exert yourself during a dive. But having said that, when the blood is drawn, about 400mls in all, this is about a tenth of your circulating volume. The actual fluid volume in your vessels is replaced fairly quickly by what we call extra-cellular fluid being drawn into your veins and arteries, but the replacement of the red blood cells takes a bit longer. A hormone called “erythropoetin” or EPO, a favourite of Tour de France cyclists, is released which makes the bone marrow step up production of the red cells. It takes from 4 to 7 days to fully replace the missing cells and that governs your ability to dive again.

So despite probably being fine the next day, I would really only recommend you could safely dive after a week after giving blood.

Blood: Case Study 3

Q: I was wondering if you could give me some advice regarding diving and anaemia.

I am a fit 22 year old female. I recently underwent a HSE medical and the results of my blood test showed my haemoglobin level as 11.3g/dl, which is apparently slightly low. I regularly dive in the UK and have some deco diving lined up in the foreseeable future, am I at any higher risk of DCS?

A: This haemoglobin is within the boundaries of normal.

It can be lowered in females after a period. If you are showing signs of anaemia like shortness of breath or looking ghostly pale, do not dive. But if you feel fit and well there is no problem.

Likewise it should not increase your chances of a bend as the nitrogen is not carried by haemoglobin or red cells, so it’s not like it’s going to be left behind in the tissues.

So go eat some liver and spinach and carry on as usual.

Blood: Case Study 4

Q: Doctor, I would like some diving advice. My wife (and my diving buddy) has recently received the results of a blood test, and this has shown that she is quite badly anaemic. Apparently (according to second hand reports), a normal blood iron reading is between 20 (ish) and 200(ish) (I cannot recall the precise ranges) – apparently, she has a reading of 4. Moreover she has been anaemic for at least several months now, having been turned away from donating blood on 2 consecutive occasions, despite us both eating more iron rich foods. She has since refused to accept a prescription for iron tablets on the grounds that they make her uncomfortable.

I am very concerned that this presents a danger vis a vis diving for her and thus for the both of us, and I am reluctant to go diving with her again until I get some reassurance. Am I being unreasonable here? Or do I have grounds for legitimate concern?

We are only at an early stage of our training and are still limited to pool training, but we are aiming to become open water qualified in about 4 weeks time, and aim to go sea diving at the end of May.

Should we delay this until my wife’s blood-iron count normalizes?

A: Grounds for legitimate concern? Grounds for divorce mate.

If your wife is badly anaemic caused by a lack of iron, and then won’t take the iron as it makes her uncomfortable, in which case she risks death, then that is pretty dopey really.

Iron builds haemoglobin. Haemoglobin [Hb] carries oxygen molecules to the tissues. Oxygen is the fuel for the cells in the body. The oxygen also creates diffusion gradients to help get rid of nitrogen. So you can see its importance to the diver. Anaemic people also get short of breath, faint and get excessively tired with the simplest of tasks. And look rather pale and ghostly.

So here’s the plan. If her Hb is that low, ask your GP if he can refer her for a quick transfusion. That’s the quickest way to get better. Otherwise she will have to eat more spinach than 10 Popeye’s. If it is a borderline low then iron tablets will have to do. Sure they can make you uncomfortable, but that’s only really constipation. And the best way to treat that? Traditional Egyptian cooking.

Blood: Case Study 5

Q: I am a regular blood donor and was wondering whether you could see any reasons I can’t dive? I really want to try diving and I asked the staff at my last donation session whether it was OK but they didn’t really know. Is there a recommended time I should leave between giving blood and diving?

A: Blood has been called the “river of life” and has many functions besides being a vampire’s next meal. It transports gases, nutrients, waste products, cells and proteins all over the body, as well as being important to heat regulation. About 45% of blood is composed of cells (mainly red blood cells, which contain the haemoglobin that carries oxygen) and the remaining 55% is fluid (“plasma”, which transports dissolved gases and proteins). Each time they take an armful of your vintage claret, your circulating volume drops by about half a litre (470mls to be precise). The average human has a total blood volume of about 5 litres, so we’re talking less than 10% of that with each donation. The body responds by moving fluid from the tissues into the circulation, so that the volume loss is replaced within 24 hours (quicker if you drink lots of fluid). It takes up to 8 weeks to replace all the cells that have been removed though, so the concentration of red cells takes this long to recover.

The consequences of this on diving are several. In the first 24 hours after a donation, you are more prone to fainting due to the reduction in your circulating volume and hence your blood pressure. (This is why you are force-fed tea, biscuits and preferably Guinness afterwards.) In essence, you are dehydrated. Divers get notoriously dehydrated anyway, through immersion, breathing dry compressed gas, being cold/shivering etc. So I would certainly advise no diving within 24 hours, preferably longer to be on the safe side. There is no evidence that donating blood increases your susceptibility to narcosis or oxygen toxicity. Nitrogen is dissolved in the plasma, and for various reasons the plasma volume and delivery of blood to the tissues increases after a donation. Theoretically then, the risk of DCI might increase slightly, but so many other factors are involved that the effect is probably tiny and not worth worrying about.

Blood Pressure: Case Study 1

Q: My dear wife (49 years of age) uses atenolol for high blood pressure which she hopes to come off from, and as we are going to Egypt soon on a liveaboard. Can you suggest any other alternatives?

We have also been informed that a supplement of B1 will keep the flies away, is this true?

We have had Hepatitis, tetanus and typhoid are there any other jabs needed?

Do you have any other health tips?

A: Dear wife, yes I agree they can be expensive! Atenolol is a beta blocker and as I have pointed out before in previous issues this drug has a risk of causing a build up of fluid in the lungs if she were to exercise more than she was used to. This is called “pulmonary oedema” and results when the heart, which is slowed by the medication, not coping with the amount of blood returning to it, which then oozes out of the capillaries of the lungs into the tissues of the lungs itself. You can recognise someone with this as they are classically short of breath and cough up frothy blood stained sputum rather like the head of a glass of strawberry Cresta if you can remember popular 1970’s soft drinks. Atenolol is the most commonly used of the antihypertensives as its cheap and pretty effective, but I’ve got to advise that she try a non beta blocker, and the best of these for a diver is probably Losartan. So try to get her medication switched afore she goes.

Now the question of what best to keep the flies off. Traditionally one of the Vitamin B subtypes, either B1, B6 or B12 works to keep off mosquitoes rather than flies, but to tell the truth I’m not sure which one it is exactly. But by no means is this to be relied on instead of antimalarials if that occurs where you are. I think the theory is that it makes the skin smell bad to these bugs and wards them off like garlic is also supposed to. But flies are a different matter, bigger and bolder. I guess the key is not to smell like what flies like, or make someone else an attractive proposition. I’ll leave that to you! Your shots seem fine as long as its Hep A you’ve had. As for health tips�plenty.

The most important is to stay well hydrated as this is the biggest contributor to DCS in divers out there. This includes not getting diarrhoea, so watch what you eat there.

Remember the sunscreen and from my experience never be the first to get rigged up before a dive if there’s a real slowcoach, standing in 35 degree heat with a wetsuit on for 20 minutes if someone’s still in the loo can exhaust you to the point of collapse.

Enjoy the trip.

Blood Pressure: Case Study 2

Q: I hope you can advise me on the following ?

During a full and very comprehensive annual medical from my usual G.P. of many years, he finds, at present I have mild hypertension. Under normal everyday conditions he stated “He would monitor my Blood Pressure again in 6 months time” within the PADI “Guidelines for Recreational Scuba Divers Physical Examination” there are no limits for relating to hypertension level which my G.P. can assess if my condition is of any concern and therefore sign my “Medical Statement” document.

Are you able to provide any advice which I can pass to my G.P. to enable my Medical Statement to be completed .

I am 45 years old, have been diving for 18 years, currently a PADI A/I, complete over 100 pleasure dives per year and teach one night per week. Health generally good and a reasonably normal level of fitness.

A: The guidelines are fairly straightforward as regards high blood pressure and diving. In the UK if you are an established diver, with a BP of under 160/100 you are allowed to dive, but if you are new to the sport and you have a BP of over 150/90 then you need to see a medical referee before you are allowed to dive.

Now before you get too worried you need to understand something. The pressure that your doctor checks is a variable thing. It may be high when he or she checks it, but it may be low later when you are at home. So in my practise I never go on a single reading that I take. I always suggest that a patient with borderline high BP either buys a machine to check it themselves at home on a regular basis which I think is a far more accurate way, or even better, has a 24 hour BP monitor. This gives the most accurate reading for your BP and quite often shows that it was normal anyway.

However, if it is raised enough to stop you diving then hypertension is very easy to treat and can be under control within a week or two with a choice of medication that won’t interfere with diving.

So, get it properly checked firstly and then get it controlled and you can be diving sooner than you think.

Blood Pressure: Case Study 3

Q: In October last year I experienced unusual chest pains and was checked out in Hospital. I underwent a range of tests including an exercise ECG on the treadmill. My problems were diagnosed as Stress / Anxiety as all the tests came back clear, no medication was prescribed. The nurse who carried out my exercise ECG said my BP was too high. My own GP checked me out after and said my Blood Pressure was raised 145/95 and prescribed Propanolol as this would help both BP and anxiety. After this I must say I felt awful and eventually in December I managed to persuade him to stop the medication and let me settle down.

My Blood Pressure when checked by the nurse last week was 130/90. He has agreed to let me go diving again but seems insistent that we get the 90 down to 80 and I believe he will be prescribing more drugs next time I see him.

Please could you comment on whether my BP is high and if so what medication is ok to take when diving. Diving is important to me in enabling me to cope with stress.

A: So diving makes you less stressed, and the problem was stress in the first place. Sounds like we need to re-open Mr Cousteau�s Sudanese underwater world for you. Your BP is actually OK to dive with, anything below 150/100 in an existing diver can be considered fine. If you are going to go onto meds, my recommendation is any drug ending in ‘-sartan’.

Blood Pressure: Case Study 4

Q: I am a 51 year male and my LDL cholesterol is a little high. My Doctor has just put me on a daily dose 20 mg of statins to try to get the level down. My blood pressure is normal and I am otherwise healthy. Is there anything he or I should be aware of that would inhibit my taking diving lessons?

A: This is going to get more and more common, as NHS GP’s are paid to put people onto these sort of meds at the soonest instance. 250 G’s a year!! They’re having a laugh, and it’s our taxes. And they whinge about over-work. Try running a proper business, I say.

Anyways, as long as you are not a coronary risk, and it sounds you are not, then you are fine to dive.

Blood Pressure: Case Study 5

Q: My employer is calling me from Hawaii, she wants to scuba dive for the first time but she is being treated for high blood pressure. She is in otherwise good health, only an abnormal eye exam recently related to the blood pressure. There were other references to blood pressure on the dive site, but nothing specifically related to an angiotensin receptor blocker, only beta blockers. Can you advise whether she should dive? She is in her early 40’s.

A: Im trying to get my head round this. Your boss is in Hawaii, needs a medical question answered, and instead of asking the dive shops dive doc, calls you. I hope you don’t have to wipe her; you know what I mean!

Anyways up, she will need to get seen before diving, to check what the hypertension has done to her, but the good news is that the meds she is taking are the best with diving. So she should be ok to learn. Hey, you could even do her PADI exam for her too.

Blood Pressure: Case Study 6

Q: Kitty at Dive Solutions has given me your name. I have been discussing with Kitty the possibility of buying my father some diving lessons for his 70th birthday. He is generally fit and healthy. There are a couple of questions on the health form which I am not sure about (and because it’s a surprise, do not want to ask him what the position is). These are the questions relating to high cholesterol and high blood pressure. I believe that he does or, at least, has in the reasonably recent past, taken Lipitor (or something similar) but I am not aware (nor is my mother) of any problems and his cholesterol is in check.

Kitty thought that you would be able to “sign him off” so that I can purchase the lessons for him. Is this correct? Do you need any further information?

A: I think we can work round this one, before it gets in to ‘Carry On’ proportions of comedy as you try to hide the secret as he walks into a docs office with pictures of divers everywhere. If it was just high cholesterol, then this has never stopped anyone form diving. But he will need a medical. I suggest remotely certing him for the pool and theory, but before the open water dives, where he would have clicked by then, seeing me. Of course there are no guarantees he will pass the medical, but you get a feel for people and he should be OK.

Blood Pressure: Case Study 7

 Q: Please can you advise me on my medication as I am going diving on 15th November in Oban. I started on ramipril 2.5 increasing to 10mg. I have been on the 10mg for just over a week. I take it at bedtime. Last week after taking the first of the 10mg I woke up regurgatating acid and felt very dizzy with strange feelings down the left hand side of my face. Since then at the weekend I felt nausea and dizzy. Will it safe for me to dive or will I have to wait until I have been taking medication a little longer.

A: Whooa, this sounds like quite a side effect, and I hope you have gotten rid of it by now, if not, go see your regular GP for an immediate assessment of your blood pressure. When you up a dose like that there are chances it can drop your BP too much, hence nausea and dizzy. And strange feelings on one side of your face really need a neurological assessment, to make sure there’s no strokey sort of things going on. So, assuming this is still present, do NOT dive.

If it does settle and it’s simply a transient problem with the dose increase and now gone, this is how you dive. High blood pressure does need to be assessed by a dive doc before diving. You need an ECG to make sure there’s no damage to the heart, and a general once over. But these meds are dive friendly, few side effects like the dreaded beta blockers or diuretics. I reckon your chances are good, as long as all this side effect malarky has gone for good.

DVT: Case Study 1

Q: I have been given this email address by a PADI member to ask if you can help me to obtain medical clearance to enable me to take up scuba diving in spite of the fact my doctor will not give me clearance based on contacting one of the PADI consultants.
Basically I have had a DVT in each leg and take a low dosage of warfarin. My INR is maintained at 2-3.

I imagine there must be many people like me who are otherwise very fit and strong and still exercise regularly.

I did attend one session with PADI and this gave me greater incentive to see if somehow I can get my GP to reconsider proving I can give him evidence of other divers together with references who have suffered like I have and happen to take warfarin.

Hope you help – PLEASE!

A: I don’t like stepping on other doctors toes or going against their decisions. However the fact is that you are allowed do dive if you are on warfarin. Your depth will be restricted to 20metres as this lowers the risk of the bends. The risk being that a hit could cause a bleed into the spine and paralysis. A shallow depth should prevent that.

But, and there’s always a but, a DVT in both legs is pretty unlucky. I assume all is well now, but you must have one of those clotting disorders where you are prone to this illness and the warfarin might be a lifetime’s treatment.

I suggest you see a dive doc face to face and make sure they are aware of the recent warfarin guidelines, and look forward to doing your course.

DVT: Case Study 2

Q: I have heard about the sad death of a young girl from a clot in her legs and lungs after the long haul flight from Australia, and as I am flying to and from there next month to dive the Barrier Reef, I would like to know what I can do to prevent this and if diving has any effects of increasing the chances of these clots forming.

A: What happened to this girl was sadly preventable and also becoming more frequent as flights get longer and seats get more cramped. It even has a name now, being called “Economy Class Syndrome”
She suffered a blood clot in the deep venous system of her calf. This is called a deep venous thrombosis or DVT. If part of this clot dislodges, it travels up the venous system back to the heart, through the right side of the heart and to the lungs. This is what happens to cause death , as if a big enough piece of the clot gets to the lungs then it causes the blockage of the blood supply there. This is called a pulmonary embolus and it can be fatal.

Recent research has shown that up to 1 in 4 people that get a DVT have all been in a long haul flight in the last few weeks. You can see that this is an incredible statistic as a lot of the smaller DVTs go undiagnosed as they don’t cause the classic symptoms of swelling of the calf with redness and pain in the same area. The reason that air travel can cause this problem is due to several factors, all which seem to coexist on these flights.

Firstly for a clot to form the blood needs to be very slow moving. This occurs in-flight as passengers sit in a cramped position with their knees bent. This can restrict the flow back of the blood and help a clot form. The next problem is with dehydration. It is said that you should drink a litre of fluid every 3 hours on a flight, but what is normally given out, i.e. alcohol can actually dehydrate you more as it makes you need to urinate more often. As you now have less circulating fluid volume the chances of clot formation are a lot higher.

Finally the swelling in your lower legs due to the position you sit in also causes to constrict the veins too. So these factors can cause a clot, but also being on the contraceptive pill, obesity and smoking too will all increase the risk.

What is recommended to stay alright in-flight is to keep your toes moving by regularly going for a walk up and down the aisle, and also keeping well hydrated. I would also suggest that anyone who is high risk, and by that I mean overweight, Pill taking smokers who have a family history of clots forming, take a dose of 75mg of aspirin before they fly, as this thins the blood enough to stop the DVT forming. However if you suffer from stomach ulceration or allergy to aspirin then there is a shot of a blood thinning agent called heparin available.

If anyone experiences tender calf swelling or chest pain and shortness of breath after a flight, then please seek medical attention immediately.

There is little evidence to suggest that diving would increase the chances of in-flight clot formation on your return home, but again as most divers seem to spend their 24 hours pre flight non-diving time in a state of post alcohol dehydration then it is doubly important to make sure you have enough fluids with you to drink during the flight back.

DVT: Case Study 3

Q: Basically, in summer 2003 my partner suffered a DVT and recovered. He became an instructor in late 2003. He last dived in February this year. We moved to Spain from the UK in April (very long drive) and in July following a few long evening shifts on his feet suffered another bout of thrombosis, this time superficial, with a vein on the outer part of the leg affected. He was treated with Clexane and rest until the end of August and an ultrasound in September showed that the leg is clear of thrombosis. He still has discomfort in the leg (still recovering/healing?) but is desperate to get back in the water in the near future. Is it likely he will be able to dive again as a job? His doctors here do not really understand what scuba is. He is due to have a blood test next week to see if there is an underlying cause as to why a man of 42 should have suffered two bouts of thrombosis. We have already turned down a great job in Africa for fear it was in a too remote location and too soon but would like some idea about how long it might be before he could safely dive again. Any advice would be much appreciated as finding anyone here that understands, is near on impossible!

A: 2 sets of clots in 2 different venous systems of the legs has got to be due to something. There is a chance it is bad luck, or the sheer standy-up-all-dayness of a shift, but before embarking on a career as an Instructor, it is imperative that he has the triple blood test to look for proneness to clotting problems. If it is negative, then cool, all he has to do is make sure he is always hydrated and all should be OK. If it is positive, then he may be put on regular daily aspirin or clopidogrel, its less acidic cousin. If this is the case, then there is a good likelihood he will be allowed to instruct. Abroad definitely, as medical rules are frankly slacker, but there could be issues in the UK. However for his own safety, I suggest that either way, it would be best to dive nitrox, and if doing repetitive dives, then set the comp for air tables. Why? Well in cases of DCI and also with microbubbles, they have been shown to cause a tiny clotting cascade around the surface of the bubble. If you are prone to clotting, then this can be enhanced. So the best way of making sure there’s no darn bubbles, it to 02 it up with the nitrox.

Word. As they say in my part of London.

DVT: Case Study 4

Q: I’ve recently been diagnosed with something called Factor V Leiden after my sister had a blood clot (deep vein thrombosis, or DVT). The doctors told me it makes me more susceptible to DVT myself, but does it increase my risk of getting a bend?

A: Blood clotting is a complicated series of events involving a chain of ‘factors’, imaginatively referred to in Roman numerals from 1 to 12 (I – XII). So when you slice open your unprotected scalp on a sharp bit of wreck (as I have done on several occasions, I REALLY must wear a hood) this cascade is triggered, rather like someone pushing over the first domino in a line, and the end result is that the blood thickens up and stops hosing from the wound. Some people have faulty genes however that make them more (or sometimes less) likely to clot. The commonest is Factor V Leiden, named after the town in the Netherlands where it was discovered in 1994. It is a mutant gene now known to be carried by about 5% of white Europeans.

Now to my knowledge no diving related problem, bend or otherwise, has been directly attributed to Factor V Leiden, but there are a few issues to mention. You are more likely to develop a DVT on one of those long dehydrating plane flights to exotic dive locations, so get up and move around as much as possible and keep glugging the water. If you need to take anticoagulants for a clot then these can increase your risk of bleeding due to barotrauma, so I would be very cautious about diving if you ever get put on warfarin or one of the heparins. Tight-fitting dive gear and weight belts could conceivably reduce the flow of blood and make you more likely to clot at depth. You should plan your diving to try to minimise your risk of bubble formation and injury, as the clotting cascade could be triggered in response to either. So just be aware of all these factors and plan your diving accordingly.

Heart Attacks / Angina: Case Study 1

Q: I’ve just had a qualified SAA-Dive supervisor asking to dive with us. He’s had a bypass, but says he never had a heart attack/angina. His last medical is from January 1999. The operation took place before that date. I know it’s not much info, but in your opinion, is he fit to dive?

A: He probably will be if what he says is true. It’s surprising that he had a bypass though having never had any cardiac symptoms. Something has to lead a man into the cardiologist to have either a coronary angiogram or a thallium scan that would show the necessary poor blood supply from the cardiac arteries to the heart muscles that then ends up as a bypass. So the fact he says he has never had any angina or even the teeniest heart attack makes we wonder.

However if he is symptom free, and by that I mean he is not just sitting at home watching telly beer in one hand, fag in the other saying there’s no chest pain with me doc. He has to prove that on exercise he gets no reduced blood supply to the heart, and this would need an exercise ECG or even better a thallium scan.

He may well have had one of these after the operation and if fine then let him dive with you as long as there hasn’t been any symptom return.

Also note that some patients after this sort of op take beta blockers to decrease the workload on the heart, so if he is then he should not risk diving. Its also in his best interests that he does get certified as fit to dive with a proper diving doctor on a regular basis then he wouldn’t have any problems from insurance companies if anything were to happen.

Heart Attacks / Angina: Case Study 2

Q: I had a heart attack on the 23rd August, apparently mild as it was quickly attended to. It has been reported as a clot in the right artery or in medical terms – acute inferior myocardial infarction. I was discharged from hospital after a 9 minute treadmill test.

I am due to see a cardiologist later this month.

I received strepokinase on admission and am now on Ramipril (5 mg), Simvastatin (20mg), Atenolol (50mg) and Aspirin (75mg).I have suffered no further pain since admission and am currently doing regular one-hour walks. On Saturday, I am meeting a hospital-trained fitness trainer to get a programme for further work.

I am hoping to travel to Hawaii by the end of October and would like to do some diving. I have Padi Open Water 1 and probably about 100 dives behind me. I would not intend diving beyond 20 m at this stage. I am 61 years old.

Is this sensible? Can I/should I have any specific checks or tests to be sure and where can I get this done?

Thank you

A: Sorry to hear about your heart attack, but I guess the silver lining is that our medical advances mean that you can return to normal life a lot quicker than you could a few years ago.

As regards your return to the deep, there are a few criteria you have to satisfy first. There must be no remaining decreased blood supply to your cardiac muscle, this will come across as chest pain on exercise, but as your treadmill seemed to be alright then I assume that’s OK. The reason for this is that we have to make sure you don’t get another one underwater. You are now not allowed to buddy with a novice diver either, but must team up with someone of DM standard at least. Before going back in you need to be passed by a diving doc who will probably impose a depth restriction on you, normally 20-25 metres. One of the reasons for this is that the deeper you go, the more resistance in your peripheral blood vessels due to the pressure, and the harder your heart has to work. You will need an annual medical, and you must never risk a dive where conditions could turn for the worse, resulting in an unexpected increased level of activity.

Sorry to lay it on like that, but that’s the rules. You sound like you should be fine. See you on a one way gentle drift in tropical waters!

Heart Attacks / Angina: Case Study 3

Q: I wonder if you could give me some advice. I have a colleague wanting to take up open water but has angina. He is on beta blockers (METAPROLOL)and carries a GTN spray. He also has a stent.Is he still able to dive.

Thanks for your help as usual.

A: Someone who has had angina, corrected with a stent [a small plastic tube inserted into the coronary artery to keep it open] is often fine to dive. However your colleague’s problem is that he has to have a GTN spray. This is an admission that he still gets the occasional attack of chest pain. He would then spray this under his tongue to help dilate the coronary arteries along with the other blood vessels. It would be hard to do this if he had an attack underwater. The other problem is the beta blockers. These are usually a bar to diving as they affect the heart’s response to exercise and also can worsen breathing underwater.
So, a double whammy here.

His only way out is if the GTN spray is cosmetic and he never needs it, or he does a full on exercise ECG to prove all is well. So off to a cardiologist with diving experience. There’s a good one in Shrewsbury called Dr Wilmshurst. Find him via the web.

Heart Attacks / Angina: Case Study 4

Q: I would like to do my Dive Master course. I understand that I would need to have a HSE medical. Would my previous heart attack in 2000 prevent me doing this course. I have no chest pain, was taken off cardiology consultant list after the first year following my heart attack. My BP is usually around 120/80 pulse resting is 70. No oedema around my ankles or wet cough.

Thanks for any information about the Diver master course / HSE medical.

A: You are caught between a rock and a hard place here, so I hope the following makes sense.

A commercial diver, having had a heart attack, would normally be barred from diving. However, a non-commercial diver if they are controlled and fit, are fine to dive in your situation [as long as they pass the medical]. So is a DM a commercial diver. According to the HSE they are as they all need to have the full HSE medical. Though they did not a year ago. But if you were getting the same level of qualification with BSAC you would not need an HSE and so would be OK.

Confused? Yes, so am I!

For some reason BSAC divers, even the top instructors do not need to do an HSE but can self-cert themselves. Apparently it’s because they are a club, and not a commercial organisation like PADI who do the DM course.

I think your best bet is to contact the HSE and ask for exemption and explain that you want to do the DM solely for yourself and would not be gainfully employed as a diver. If they get arsey about it try BSAC as it seems you would pass the basic medical for them with your condition.

Pacemakers: Case Study 1

Q: Three years ago, I was fitted with a cardiac pacemaker due to a slow heart rate causing dizzy spells and two blackouts. The pacemaker immediately stopped these symptoms. My cardiologist considered that I was safe to dive to 100 feet, and gave me a copy of the manufacturer’s test report detailing the results of hyperbaric tests on the device.

After a week of work as a diving instructor in the Middle East, I was sacked when I mentioned my pacemaker. The dive centre had consulted the Naval hyperbaric specialist, who stated that I should not be diving at all, let alone instructing, despite any medical certification.

I understand that the limitations are purely due to distortion of the titanium casing when subjected to pressure, but he suggested that temperature differences may also be a problem.

The manufacturer has not replied to my emails on the subject, hence my career as an instructor is on hold. Can you help?

A: Yes, don’t instruct, but you can dive. Sadly the rules are, in the UK at least, that an Instructor can’t teach if they have a pacemaker. If there was failure, which can happen, but is very very rare, your poor students would be left hovering around wondering why their man was floating of to the bottom of the ocean. Panic would set in, and as you have responsibility as an Instructor, the lawyers would be after your estate.

As an individual diver, the rules are a bit more accommodating, as the responsibility is on you. The pacemaker maker has Ok-ed the pressure to 100ft, 30 metres, or 4 atm. If that’s what it will stand, then that’s what it will stand, so you can dive to that depth. Temperature is not really an issue, as I assume you will suit up to keep at a reasonable warmth, but for God’s sake don’t go naked ice-diving, or boil yourself in a volcanic geyser as that would be into the realms of daft and then the titanium might bend and affect the pacing.

On a tangent, I used to play cricket against a mate who had one. Fearing my extreme pace, he used to wear bizarre things to protect the machinery from the super-quikkie. Ladies’ sanitary towels were one of the oddest.

PFO: Case Study 1

Q: Please can you give me some advice on where to obtain some expert diagnosis on some possible decompression problems that have occurred to me after diving recently and another incident that happened 3 years ago but was dismissed as diving related at the time.
Recent incident. After 4 dives over 2 days not greater than 20 metres, all at no stop diving times, both dives morning and afternoon respectively I experienced some left shoulder pain, then progressively pins and needles down my forearm and then pain in my wrist joint followed by numbness in my forearm. The onset of this occurred about 1.5 hours after diving and increased up-to about 6 hours later. Gradually subsiding during the next day to

The past incident happened during a flight returning from a diving holiday and was very similar to the latest episode, this has now led me to question whether indeed I do have a problem, maybe PFO???

Please can you help me on my next step to being fully assessed as to any reasons why I should be susceptible
to this sort of problem.

PS Started Diving 1988, no problems up to these incidents.

A: I agree, this is odd, to get what seems an obvious case of DCS after relatively simple shallow diving.

But before you embark on investigations for a PFO, ask yourself this.

Did you do anything to make the dives more DCS prone, ie increase on-gassing or decrease off-gassing. Dehydration, diarrohea, increased exercise before and after diving, a sawtooth profile, or any rapid ascents. All these can affect your ability to get rid of the nitrogen in your body.

If the answer to the above is no, then you ought to get a PFO check. This is a specialist cardiac investigation and needs GP or diving doc referral.
If one is found, and remember that up to 30% of us have one, then you need to weigh up the need to have it closed against your desire to dive again.

Some doctors say if it is small and you don’t want to undergo operative closure, then diving on Nitrox using air tables will increase your safety margin.

PFO: Case Study 2

Q: A few weeks ago I had an unsuccessful op to repair a Patent Foramen Ovale (PFO) following ‘undeserved’ decompression sickness. I had a further bubble study done, and while they are confident I don’t have a PFO, there was still bubble migration between the right and left chambers, at an interval of 7-9 cardiac cycles. The doctor suggested it might be pulmonary, and said I should have an angiogram and/or a CAT scan, but I am no closer to knowing what the solution is than before.

What does ‘it could be pulmonary’ actually mean? Does this have implications for my general long term health? Is it something that can be fixed, and if so, when can I go diving again? It may sound trivial but I’ve been out of the water for 10 months now and am getting desperate!

A: Knowing what an obsessive lot us divers are, I would never label being out of the water for 10 months as trivial! This is a bit of a complicated tale though. It will help to do some explaining, and I apologise in advance as this will be a little technical… let’s start with the blood’s journey through a normal heart. When the heart beats, the left side contracts and squeezes blood through the body’s arteries. The blood then returns to the right side of the heart through veins. When the right side contracts, it pumps the blood to the lungs, where it picks up lots of oxygen so it’s ready for its next journey through the arteries. This cycle is repeated about 100,000 times every day, meaning that the human heart beats around 35 million times in a year, and an incredible 2.5 billion times in an average lifetime. Not bad for an organ the size of two clenched fists.

When dealing with PFO’s and the like, the concept you need to understand is right to left shunting, where some of the blood bypasses the lungs and goes straight from the right side of the heart to the left. This means that those pesky nitrogen microbubbles, rather than being filtered out by the lungs, go straight past and enter the normal circulation, potentially leading to decompression illness. A PFO is the most common form of right to left shunt seen in divers, but there are others, including ASD (atrial septal defect) and pulmonary (lung) arteriovenous malformations (AVM). The latter is what your doctor is suggesting, as it is most likely in the absence of an obvious PFO on echo – this is often the case when the bubbles show up after more than 5 cardiac cycles. A pulmonary AVM is basically an abnormal communication between the pulmonary artery and pulmonary vein, which again allows blood (and bubbles) to bypass the lungs. They can be diagnosed by CT scan or pulmonary angiography. Most are congenital (ie present since birth). They can be treated, either surgically or with embolisation, but this depends very much on the exact type and individual circumstances of each case. Whether diving is possible afterwards again is difficult to say – the cardiologist would have to be sure that there is no residual right to left shunting. So there’s no definite answer here until you’ve been fully investigated I’m afraid. Fingers crossed.

PFO: Case Study 3

Q: I have just been released from 5 hours recompression following a dive on Sunday. The dive was absolutely brilliant and followed a normal profile without any issues and in fact took 5 mins to ascend to 5M and stopped for 6mins for extra precaution. 20mins after surfacing I developed pain in my back and stomach that I couldn’t locate and then quickly followed by a mottled rash covering my back and stomach. When I tried to move my legs they gave out and experienced pins and needle sensation right through my whole body. I took emergency O2 and drank water before ending up in A&E. The first time I had bends I was in hospital for 3 days of recompression following an uncontrolled ascent, however here I am 3 stone lighter with a perfect profile and the bends again – totally unfair. To get to the point the diving doctor who saw me suggest I should give up diving as no reason could be given for this encounter of DCS. I have been following an extreme diet of
600calories and 4 litres of water a day where your body goes into ketosis and wondered if this was the main reason for the getting DCS?

Your opinion would be most appreciated.

A: Hmm, tricky one here. Is a diet that tends you towards ketosis likely to bring on DCS, despite the increased amounts of fluids taken at the same time? I can see it causing cramps, see your body finding it harder to find energy to dive and all that, and see odd osmotic issues causing increased cell fluid retention and so less ability to off-gas but it may well be a red herring. With a second mystery hit, and with skin DCS to boot, I think you need to look up the PFO route for the reason.

If this is confirmed, then closing the hole would allow you to return to diving. So some good news as I think the other doc is being over cautious with a total ban at this stage. If you turn out to be PFO negative, lets have a rethink.

A point to note here, I think its best not to go onto fad diets if you are diving a lot. Eat less, move more. An easy mantra.

PFO: Case Study 4

Q: Doc,

I have a maximum of 2 x migraine with aura and transient sensory loss of right hand and wrist per year. I’ve never needed prophylaxis medication. I do approx 80 dives per year as a BSAC instructor and am trimix qualified. In the past year I have had 2 x DCI events. The first was after 2 x 30m dives in Malta and may have been brought on by post-dive exercise (climbing steep steps with kit at the dive site), involved the shoulder joints and necessitated recompression treatment. The second was to 30m in Ireland, a non-aggressive profile but dehydration may have been a factor in a skin bend on the stomach. I am now concerned about PFO, would appreciate your advice on the issue and how I go about getting an echo check (who to go to etc).

Many thanks.

A: Yes you do need a PFO check, and definitely before you do another dive. The easiest way of doing this is for me to refer you to a cardiologist with experience in these tests. I can do it remotely, if you join e-med, and you can get to London as we have a good man here to do it. But this would be a private referral and it costs about 180 quid for the scan. Or you could ask your NHS GP, and join the queue behind all the “more needy” cases.

PFO: Case Study 5

Q: I am very keen on doing a Divemaster internship but have only dived once in my lifetime! During some travelling a few years ago, I was prevented from diving at the Great Barrier Reef. The reason was that I was born with a hole in my heart (atrial septal defect) but it was corrected when I was 2 years old. I think I still have a murmur (I don’t know much about it really) but I don’t think it is a problem. I am a fit and healthy 32-year-old now, I can exercise and have never had any problems with it. I go to hospital every two years for a check-up, but if I am considering diving would you recommend that I have a diving medical done by a specialist?

A: Not many people realise that we are all born with a hole in the heart. It lies between the top 2 chambers of the heart, called the atria. When we’re curled up in the womb it’s the presence of this hole that allows oxygenated blood to pass from the placenta through the foetal heart and round the body, bypassing the lungs (which are full of amniotic fluid and therefore not much use). At birth, what’s supposed to happen is that the hole closes; the blood then gets directed around the lungs to pick up its oxygen, before being pumped around the body. This hole is called the foramen ovale (because it’s oval-shaped), and sometimes it doesn’t fully seal over, resulting in a ‘patent’ or permanently open hole – the PFO, of which you may have heard. So a PFO is one type of atrial septal defect (ASD); there are others, of all sorts of shapes and sizes, and I suspect yours must have been rather large if it needed to be operated on at 2 years of age.

To understand why ASD is a problem, a little explaining is required. The right and left sides of the heart are normally separate. The left side of the heart pumps blood around the entire body, and so the pressure is much higher than on the right, which just pumps blood to the lungs. If you have a hole between the two sides, then the right side of the heart becomes exposed to the higher pressure of the left, which in time will overload it. This is called a ‘left to right shunt’. Fluid will then accumulate in the lungs causing breathlessness, and ultimately the heart will fail. If the ASD is small, this process may take many years, but a large hole can cause heart failure in childhood.

These days the hole is easily closed with an umbrella-like device which is threaded through a groin vein into the heart, and deployed on either side of the ASD (or PFO for that matter). After a few months enough scar tissue has formed to occlude the defect completely, and separate the two sides of the heart again. So at the ripe old age of 32, if you are able to exercise without any symptoms, the heart should be normal, to all intents and purposes. An echo test to put some numbers on the heart function would be useful, but I anticipate it will show a heart that’s perfectly capable of diving.

PFO: Case Study 6

Q: I’ve had a few episodes of odd visual disturbances after diving that I’d like to discuss with you. They are very intermittent, occurring only once or twice a year (and I’m diving most weekends), but usually involve my vision getting darker, almost like the lights being dimmed. Then I get coloured curves and zig-zags, and sometimes a headache. The eyes themselves are painless and don’t appear red or inflamed at all. On one occasion I mentioned this to the boat crew and was given surface oxygen, which resolved everything in 20 minutes, so I never took it any further. It’s happened twice since, and as I’m going to be doing some marine conservation work in the middle of nowhere for three months in the near future, I’m a little concerned. I would really like some reassurance that what I’m experiencing isn’t serious!

A: Quite a bizarre set of symptoms there, but I’ll throw in my two pennies/cents. I’m presuming from your question that these episodes didn’t cause any problems in other organ systems, ie. they purely involved your vision. In which case, despite the apparent response to surface oxygen, we can put DCS and/or arterial gas embolism lower down on the list, as they tend to present with other manifestations too. We should consider simple things such as contact lens problems, medication side effects or local infections as well, as they can cause all sorts of visual disturbances. Typically though, they will be irritating or painful and involve watering or other surface reactions; not the impression I get from your description. My feeling is that these are probably migraine-like phenomena, which have been reported in the literature after exposure to pressure. These can be triggered by diving, or just happen as a coincidence, but are sometimes very difficult to distinguish from DCS. There is a well-publicised link between visual auras and patent foramen ovale (PFO, the ‘hole in the heart’ that can predispose to DCS), which confuses the picture even further. As this is recurrent and you’re intending to dive for a long period in a remote location, my advice would be to get this fully checked out by a cardiologist with diving medicine experience before your trip.

PFO: Case Study 7

Q: Whilst on a dive last week I experienced visual disturbances akin to those which precede a migraine, ie. flashing lights and shimmering areas of vision. I used to suffer from migraines but haven’t done so for many years. The visual symptoms went shortly after leaving the water. I had a similar experience last year after diving, but the symptoms were more severe. Then I put it down to exertion (I was new to diving and very nervous) and dehydration, but with it happening a second time, and especially with it happening under water, I am concerned it might have been a mild ‘bend’. The dive itself was very relaxed, max depth 25m and I was only below 20m for about 10mins. Do you think this could have been a ‘bend’, should I go and see my GP, what should I do if it happens again, do you think it would be OK for me to dive again? I have been looking medical forums and the nearest I can find to visual disturbances seems to link with PFO. Any advice would be very gratefully received.

A: We’re impaled on the particularly spiky horns of a classic diving doc’s dilemma here: migraine or bend? Difficult to distinguish the two, as both can result in similar visual tomfoolery. The commonest eye-related DCS symptoms include blurring, tunnel vision and loss of parts of the visual field. These can also occur as part of the aura of a migraine, and as we know, headaches can be a presenting symptom of DCS. A tangled web indeed. Your unprovocative dive circumstances don’t ring DCS alarm bells, but we all know that a normal profile doesn’t exclude a bend. Other features unconnected with vision and headache (eg. joint pain) might lead one to suspect DCS, but you don’t mention any other symptoms. So my advice would be to see a neurologist about this before diving again. There are other conditions to consider, eg. TIA (Transient Ischaemic Attack, otherwise known as a ‘mini-stroke’), and as the symptoms have recurred and are worsening, you really need a full work-up to be sure what the cause is. An echocardiogram looking for PFO should be part of this.

PFO: Case Study 8

Q: I’m a fit and healthy 22 year old female. I was diagnosed two years ago with first degree heart block but no other abnormalities. Following a routine check up last week I mentioned that I was planning to dive with a conservation organisation in Fiji. The consultant advised me to have an echocardiogram to ensure maximum safety when diving. As a result of this procedure I was diagnosed with PFO. My doctor advised against dives that would involve a ‘staged ascent’. The position which I hope to take up in Fiji would involve survey dives at 6-8m and 10-12m, although it may be possible to limit my dives to less than 10m. I am quite an experienced diver with over 130 logged dives (several of which were to greater than 30m) and have never experienced any symptoms of DCS. I would very much appreciate your opinion on whether my condition is sufficiently serious to avoid diving altogether, and if not, is there a particular depth limit you would advise me to stay within.

A: Your query is a good one and this issue is the subject of much debate in the diving medicine fraternity. The main problems causing the controversy are poor standardisation of the diagnosis of DCS, and of PFO. Without applying the same criteria to all data, it’s difficult to interpret. Furthermore, measuring the diameter of a PFO is one thing, but grading of the resultant shunt is a tricky task; quantifying its size by counting the number of bubbles crossing is difficult and very operator dependent. This is the reason that studies looking at the relationship between DCS and PFO vary so much in their conclusions, quoting an increased DCS risk with a PFO of anywhere between 2.5 to 4.5. Importantly though, the overall risk for DCS in recreational divers remains very low, something of the order of 0.005% to 0.08%, or 1 in 3500 dives. So even in the worst case scenario, multiplying this by 4.5 still equates to a very small number. What it boils down to is how much risk you are willing to accept. Ultimately what you have to remember is that it is not a PFO that causes a bend, it is nitrogen bubbles. So I humbly suggest your objective should be to minimise your bubble load at all times, using the simple measures I’ve outlined in this article.

PFO: Case Study 9

Q: I am about to complete my Dive Master course and will need an HSE medical to enable me to assist in training and supervision. I would like to ask about PFO. My 2 year old second cousin has just had surgery to repair this condition and I am told that this can be a genetic/hereditary disorder associated with focal migraines. I have been diving for 15 years, since I was 10. I have suffered from full focal migraines with aura (blurred vision, nausea, fuzzy lights, aversion to light, etc.) for most of my life, as have my dad and grandfather. I dive regularly, doing 20-30m dives both in the UK and abroad. I am relatively fit and active but am quite overweight (age 25, 5’5”, 15stone). I have never (touch wood) yet suffered from DCI. Should I get checked out for PFO before going for the medical exam? To what extent is the condition restrictive to diving once repaired?

A: PFO is such a common condition, and the actual number of bends so low, that screening everyone would be unethical – although the test is very safe, there are risks attached, and a large number of divers would end up requiring closure procedures unnecessarily. However, certain groups are thought to be more prone to PFO. Those who suffer migraines with aura are one. Aura is the term given to a neurological disturbance that precedes or accompanies your typical migraine headache. The commonest symptoms are visual disturbances (eg. zigzag lines, blurred or tunnel vision) but pins and needles, tingling, weakness, speech problems and even strange tastes or smells are possible. There is some evidence linking this type of migraine with the presence of PFO, and if you are keen on a career in commercial diving then one could make a case for screening to pre-empt a later episode of avoidable DCS. However, it has to be remembered that not all bends are due to PFO, so fixing the hole doesn’t make one ‘immune’ to future bends. But once repaired, you’re carrying the same risk as a diver without a PFO, so you shouldn’t be discriminated against.

Rhythm and Rate: Case Study 1

Q: During the last 2-3 years I have suffered an increased frequency of irregular heart beat. The frequency was such that I consulted my doctor soon after Christmas about the condition. I have been referred to a consultant who has diagnosed atrial fibrillation from the results of a 24 hour ECG. Initially the irregular heart beats occurred when I was at rest, but latterly came on as well during vigorous exercise. I do not experience any other symptoms like shortage of breath during an attack.

At present I swim 1 km in a local pool most mornings without detrimental effect. A recent unmedicated ECG on a running machine conducted by the consultant did not not bring on an attack even with the heart rate at 156.

In the middle of July I am due to holiday in Cuba when I planned to scuba dive. (I have PADI Advanced Open Water Certification) My current medication is 25 mg of Metoprolol twice daily. With my current situation is it safe to dive or would I be a risk to myself and others?

Your guidance would be appreciated.

A: This is an interesting question. Atrial fibrillation or AF is a condition where the heart beat becomes irregular, but in an irregular sort of way. Unsurprisingly doctors describe the rhythm as “irregularly irregular”. Diagnosing it is easy but what is harder is finding out why this has happened. It can be due to valve problems in the heart or even thyroid disorders too. So it is important that your cardiologist has excluded the causes of this problem.

If no cause is found then it is known as “lone atrial fibrillation” as it can occur with increasing age on its own. If it is this variety then you have to look at how often it occurs and what happens to your heart and lung function when it is happening. It seems that you are able to exercise well without it coming on but your consultant did not, it seems, check your lung function at the same time, as AF can rarely cause fluid build up in the lungs which would be catastrophic underwater.

The other thing that is a problem in your case is that you are taking a medication known as a beta blocker. Metoprolol will slow your heart rate down, however it also affects your response to exercise [I see you were not on it during the ECG] again leading to a fluid build up in the lungs called pulmonary oedema.

So at this stage I would say that you are at risk and should not dive. There are other treatments for AF that are not beta blockers such as digoxin or disopyramide which it would be fine to dive on, but the medication switch is something you need to discuss with your consultant.

Also to be able to dive you need to prove that the exercise test you do will never bring on a run of AF that would then bring on this pulmonary oedema. You also need an echocardigram to exclude all other heart valve problems. So there’s a bit of work to be done before you go, but with non beta blocker well controlled AF you should be fine in the end.

Lastly it has been shown that AF can cause little clots to shoot off around the body called emboli. These are caused by the fact that the blood is not flowing normally around the heart chambers and can clot in the atria. Therefore is a good idea to take an aspirin daily to prevent these clots from forming.

Rhythm and Rate: Case Study 2

Q: On March 9th this year I was admitted to hospital with a severe virus infection and I was kept in for four weeks. The virus was never identified but it caused me to become seriously ill and affected most of my organs.

Blood potassium and sodium were extremely low and my kidneys started to fail. However, with good nursing, I have made a good recovery from the viral infection. While I was in hospital, I developed atrial fibrillation with a pulse rate of 156. This has now been brought back to normal and I am taking Amiodorone. I am told I have hypertrophic cardiomyopathy, HOCUM, which must have been present all my life and only caused problems when the virus struck. I am still on Warfarin but this will be stopped quite soon now. I have never had any previous illness and am a keen diver, diving twice a year for two weeks at a time. I have always been keen on tennis, swimming and walking.

I am seventy. Do you think I could dive again next year? Would I be a bad buddy? Can one dive while taking Amiodorone? I now have no atrial fibrillation and my pulse rate is 70.

Please could you give me your opinion.

A: You sound fit, fun and are obviously active. But sadly I have to be the bearer of sad news. I think diving is going to be beyond your medical capabilities.

Even if you are off the warfarin. Even though your pulse is a normal rate and not fibrillating. [ A kind of irregular irregularity in the pulse, imagine a monkey on a piano for the beat.]

The bottom line is that you have HOCUM, and that can cause the heart to flip into an odd rhythm. This could cause a faint or collapse above the water. Imagine what would happen below.

I know you might think, I’ve been diving all my life, never had a problem, until this darn virus did it’s worst. And I know you are also thinking, the heart is fine without the virus, so why not just carry on especially as the amiodarone has put me in the safe zone. And I know you are thinking, if I went to some dive resort and just said I never had a problem, they would never know and let me dive anyway. But rules is rules.

Rhythm and Rate: Case Study 3

Q: I had an ECG in December 06 which has indicated possible enlargement of the left ventricle. My GP has also detected a heart murmur. I am due to have an ultrasound of the heart in Feb which will give more info about what is wrong. If I do have an enlarged left ventricle in addition to the heart murmur does this mean my diving career is over? I am 44 years old and an open water diver and at the moment I have stopped diving including swimming pool practice sessions. Grateful for your advice!

A: And much to tell you here. Left ventricular enlargement is not a bar to diving per sae. But rather like the fading male porn star, it’s all about the failure of the organ to pump properly. Bring out the fluffers I say.

A few things can cause the left ventricle to get bigger. High blood pressure and floppy or tight heart valves are but three of them. Now if the heart is compromised as it can’t send the blood round the body properly, you can imagine the effects on the body demanding fuel as it dives. Likewise there can be effects on the ability to push out the blood returning from the venous side and the lungs. Pulmonary oedema or wet lungs that be, me hearties. So, it depends on how big the enlargement is, and how much it compromises the heart’s function. As a ball park, 20% loss would be a problem and disqualify you. So get your cardiologist to check something called ejection fraction. A bit like our porn star on the wane. Well just a misplaced consonant.

Rhythm and Rate: Case Study 4

Q: I am a 26 year old female with anorexia nervosa. Been diving since I was 14. Just got an ECG test back that said my heart rate was slower than normal (in the 50’s). Does this put me at increased risk for diving? I am going away for the next two weeks and was hoping to dive – is it safe?

A: Anorexia nervosa is not a new illness. ‘Fasting girls’, a Victorian term for non-eating pre-adolescents, have been around since the Middle Ages, and were often claimed to have miraculous or magical powers, usually by exploitative museums. Sadly, whenever these claims were tested, the girls in question starved. Today the condition is a formal psychiatric diagnosis, an eating disorder that causes low body weight, body image distortion and an obsessive fear of gaining weight. In general terms, the problems that this would cause for diving are several. Reduced strength and exercise tolerance are common, meaning kit-carrying and hard finning may produce early fatigue. Psychological issues might jeopardise safety, with panic and phobic behaviours a prominent feature. Any medication taken for the disorder might have repercussions also.

As far as your specific heart rate query goes, a slow pulse can be a sign of a very fit heart. If the ECG is otherwise normal then the rate itself would not put you at any increased risk of diving problems. Nevertheless, I would suggest you are cleared by a diving doc, for the reasons outlined. The fact that you have been diving for 12 years should be in your favour though.

Rhythm and Rate: Case Study 5

Q: As well as diving, I also fly light aircraft – why do I chose expensive hobbies?! My pilot’s licence requires that I have an annual medical with an ECG. At the last medical it was discovered that I had Right Bundle Branch Block (RBBB). The Civil Aviation Authority then required that I be subjected to additional tests, namely, a stress ECG, an echocardiogram and a 24 hour monitor ECG. The results were deemed satisfactory and I get to keep my flying licence. It was my understanding from this, that the RBBB is of little consequence and shouldn’t affect my health or life expectancy. I didn’t think to ask the consultant if there is any problem diving with a RBBB. Is it safe to continue diving?

A: The heart beats about 35 million times a year, or over 2.5 billion times during an average lifespan, so you’d expect it to have a fairly foolproof control system. In fact the electrical wiring of the heart is quite simple. There are two ‘nodes’ and specialised bundles of conducting tissue (much like normal electrical cable) that pass ‘current’ through the heart muscle to make it contract. Electrical impulses begin at the sino-atrial (SA) node, which under normal conditions generates them roughly 60 to 100 times a minute. Each stimulus then passes to the atrioventricular (AV) node, and after a brief pause it splits and flows down the right and left ‘bundles of His’ (pronounced as in the snake noise). The end result is that the atria (top 2 chambers) of the heart contract first, emptying their blood into the ventricles (bottom 2 chambers), which squeeze the blood all around the body just afterwards. Clear as cocoa? Hopefully the diagram will explain things.

For a variety of reasons, the bundles of His can stop conducting impulses, which is unsurprisingly termed Bundle Branch Block (BBB). This can be left or right-sided, or rarely both (in which case all sorts of bad things happen and you end up with a pacemaker). In general the left bundle does a lot more of the work than the right. Correspondingly, blockage of the left is far worse than the right. Left BBB requires an evaluation of exercise tolerance, such as you’ve just had, so it’s reassuring that the results were all OK. If the right bundle blocks then the left often takes over (with minimal fuss but regular demands for overtime pay). So in your case I have no qualms about your continuing to dive.

Rhythm and Rate: Case Study 6

Q: Recently, I experienced six days of ectopic heart beats. For the first few days they were extremely frequent, up to 10 a minute, gradually decreasing on the sixth day to an infrequent two or three an hour. I have never experienced anything like this before in my life. I have seen a cardiologist and all my blood tests have been normal. A 24 hr ECG monitor showed up a number of ectopics but at a rate low enough to be considered normal. An echocardiogram was also normal, and so no explanation could be given for the “flare up”.

Do these ectopics have any impact on my ability to dive?

A: The 2.5 billion beats a heart generates in an average lifespan are by and large regular as clockwork, thanks to the sino-atrial node, a little clump of cells that act as a natural pacemaker. Occasionally though, another bit of the heart tries to muscle in and fire off its own contraction; an ectopic is the result. Basically they’re extra beats out of sync with the regular heart rate. The vast majority are harmless and seen in many normal hearts, but if they occur too frequently or in long runs, they can indicate a diseased heart. Reassuringly in your case, the blood tests and echocardiogram were normal. Sometimes these ectopics can be due to excessive fatigue, caffeine, alcohol, nicotine or other drugs, so have a think if any of these factors are relevant. But if your cardiologist is happy that your heart is in good shape, then I think you’d be safe to dive again.

Stroke: Case Study 1

Q: I am a recreational diver and would like advice on the resumption of diving following a subarachnoid haemorrhage (SAH). 4 months ago I had an accident on my racing bike (bicycle) which was caused by the chain snapping. As a result, I went over the handle bars and struck the back of my head on the road (I was wearing a helmet at the time). I was unconscious for (I believe) a very short time. I was assisted on the road side by a passing doctor and rushed to A & E. Following a CT scan and assessment, it was considered that I had possibly suffered a SAH and was moved to the high dependency ward.

The following day I was given CT and formal angiography which showed a heavy bleed, although no aneurysm was detected. I did not undergo any surgery, clipping, nor did I require a coil to be inserted.

I remained in hospital for 18 days before a final formal angiogram. This was negative and I was discharged the following day. I was prescribed nimodipine for 21 days, together with pain relief as necessary.

My consultant advised rest for a few months but did not specify any restriction. I have returned to work and have resumed cycling and a normal life. I am an accountant.

A:Accountants do have the worst luck, don�t they? This strikes a bit of a chord with me. Most days I bike into work along the canal and I�ve had several near misses. I memorably terrified a small child recently by rising from the swampy mire like some algae-draped lagoon dweller, having skidded in after a similar chain-snapping mishap. A short anatomy lesson first: the brain is covered by 3 membranes, collectively called the meninges, the middle one being the arachnoid. So a subarachnoid haemorrhage means bleeding under this middle layer. Some bleeds are caused by head injury, others can be spontaneous (the so-called �thunderclap� headache, a sudden “most severe ever” pain developing over seconds to minutes). Most of these spontaneous occurrences are due to aneurysms (weak bulges) in the blood vessels of the brain, and if left they can rebleed at a later date. They are generally treated by clipping them off, or inserting little platinum coils which cause them to clot off and disappear.

But in your case the haemorrhage resulted from a bang on the head, and thorough investigations have not revealed any aneurysms which might potentially bleed again. So after this episode has fully settled (give it 3 months at least), and provided you have no complications, I would be happy for you to dive again.

Stroke: Case Study 2

Q: My father is an ex-military diver, he is now 68 years old, but has kept up recreational diving for many years since he left the Navy. He has always been pretty fit but 6 months ago he had a stroke. He suddenly lost the use of his leg and his speech went. The hospital have been putting him through rehab and he is doing really well – speech is nearly back to normal and he can walk unaided now. I know how much he loves his diving and how good it would be for him to get back in the water, but is it safe?

A: I’m not usually partial to Americanisms but they have a vivid term for what we Limeys call a stroke; a “brain attack”. It does evoke much more succinctly what is going on; a stroke is very similar to a “heart attack” of the brain, where blockage or bleeding of a blood vessel in the brain causes damage and loss of function. It also emphasises the urgency of treatment; again similarly to a heart attack, clot busting drugs can be administered in certain strokes and can massively improve outcome. The precise symptoms of a stroke depend on the portion of the brain that is damaged, but like a phoenix from the ashes it has an amazing ability to recover and circumvent injured areas.

You don’t mention whether your father’s symptoms came on soon after diving, but a cerebral arterial gas embolism (CAGE) can look exactly like a stroke – in this case the cause is an escaped gas bubble blocking a blood vessel. Usually this is apparent during or immediately after surfacing and symptoms are sudden. Resuscitation and recompression are the important emergency treatments here.

It sounds as though your father’s recovery is proceeding well. My concern though is whether he is at risk of a further stroke. Obviously the hospital will try to control his risk factors as much as possible (treating high blood pressure, diabetes, high cholesterol, stopping smoking: note again the parallels with heart attack), but the fact is that having had one stroke he is more likely to get another. Individual assessment is important though: his general fitness and previous diving experience would count very much in his favour. If he regains full use of his leg and is able to hold a regulator comfortably in his mouth, then he might well be able to dive again. Is it safe? There is no yes or no answer to that, but if progress is good then the risks can be reduced to a potentially manageable level.

Stroke: Case Study 3

Q: I am a diver who gave up smoking for 3 months and took to eating jelly beans instead and had to have a blood test which showed my blood sugars ‘off the scale’. I stopped the sweets and went back to smoking (38 year habit) and a blood test a week later showed blood sugars as normal. I have not had a bad reading since then in 4 years so consider myself a ‘developing diabetic’. Last Christmas I awoke to find myself blind in one eye, which lasted for approx 10 mins. Doctors have diagnosed this as a mini stroke (TIA) and given me ECG’s, carotid artery scans etc, all of which came out as ‘normal’ but a check on my eyes last week showed restricted blood vessels in the back of the eye due to 42 years of smoking. The mini stroke clinic consultant likened diving to flying as it involved a change of pressure and advised me not to dive for 6 weeks. However, I would like your opinion before the season starts – I have been diving in the pool all winter – up to 2 metres only without any ill effects.

A: Well I think 6 weeks is about right after your TIA, provided you are fully back to normal, but from what you’ve said you are at quite high risk of a future problem. Smoking for that long (whether it’s 38 or 42 years, it’s still a very long time) will have furred up the pipes, caused significant lung damage and is likely to predispose you to high blood pressure. It’s good to hear your carotids are hunky-dory but the other test you need is an echocardiogram. This looks at the four chambers and valves of the heart. Sometimes little bits of clot form on the valves or in the chambers, which can fly off and cause further TIA’s or full-on strokes. While the pressure changes of diving don’t cause strokes in themselves, vigorous exercise, tank lifting and forceful equalising manoeuvres can all raise arterial pressure in the head and increase the risk of a TIA or stroke. And of course diabetes comes with its own set of dive-related issues. Basically I’d be pretty careful with the type of diving you do – try to keep depths and bottom times minimal and avoid situations where you are pushing your physical endurance. Pool diving is no substitute for the open water.

Stroke: Case Study 4

Q: I’m a character who has suffered a subarachnoid haemorrhage. The treatment was a 6 hour operation where they “cut my skull open” and made the repair. The vessel had popped in 3 places over 5 years but the final pop caused serious headaches which finally led me to hospital in a wrecked condition. Over the years prior to the final episode, I was diving a lot to depths of approx. 30m and had no idea that I was born with a weak vessel in the brain. Last September the vessel exploded and resulted in a major operation a day later. 7 months on and I have returned to work full time and feel good. I get the occasional skull aches but this is down to the “skull repairing”. There are no other symptoms that worry me except the “who knows” theory. In simple terms Doctor, I want to dive again and have been advised to take a 12 month break. My dive club has said that I should seek further advice before diving.

A: Exploding blood vessels are never a good thing, but at least it didn’t happen on a dive – that could easily have been curtains. For the uninitiated, a subarachnoid haemorrhage is a bleed into the space between two of the three membranes that cover the brain. It classically appears as a ‘thunderclap’ headache, sudden and severe, often causing vomiting, seizures or reduced consciousness. Most often the blood vessels are inherently weak and form ‘aneurysms’, thin-walled bulges that can burst without warning. Luckily these aneurysms can be clipped or coiled to prevent re-bleeding. You must have had clipping, as this involves opening the skull (a procedure called a craniotomy) to locate the source of bleeding, then placing clips around this area. Coiling involves the deployment of platinum coils in the aneurysm by feeding a catheter through a groin artery; a clot forms in the aneurysm, obliterating it. So, if we’re sure that your bleed was fixed and that you don’t have any other ‘ready-to-pop’ aneurysms, then the prospects for diving are good. Clearly your skull needs to be devoid of holes, ie. fully healed up, and you need a full neurological check-up to ensure there are no residual deficits from the bleed. 12 months is about right; see your friendly local dive doc soon after for a medical.

Valves and Holes: Case Study 1

Q: I am approaching you as I had a “Hole in the heart” which was patched at about 8 Months old. ( I think it’s known as a VSD?) And I wish to know what steps I need to take (if any!) before embarking on deeper diving. I was under Great Ormond Street hospital until the age of 14, when I was informed that no more check ups are necessary, and I was cleared for a normal/active life.

I am now 28 and have asked for a referral letter from my GP to be sent to a cardiologist that I know who consults from Guy’s Hospital. He has agreed to see me and give me an echocardiogram once he has received the referral letter. Is this necessary after such a long period of time?

A: A VSD is better known as a “ventriculo-septal defect”. This is where a hole between the 2 ventricles still exists after birth and is picked up on listening to the heart sounds when you are a baby.

A quick echocardiogram, a small op and its fixed. Well in your case anyway. The potential problem with holes in the heart is that if they shunt blood from the right to the left side problems can ensue. Nitrogen bubbles from the venous circulation can get into the left side an off into the arterial circulation, so missing being exhaled and causing all manner of bend symptoms. But your luck is in here. Those with a VSD tend to shunt blood the other way, from left to right so the former doesn’t happen. So the understanding is that divers with a small untreated VSD should be fine to dive. However blood shunted from left to right with each beat of the heart can, in periods of exercise, potentially put too much blood back into the heart/lung circulation and block it up causing pressure on both those organs. I would advise a diver with an untreated VSD to see a doc for an exercise test to make sure this doesn’t happen. But back to your case. It was treated at birth, you have been given the all clear too, but with the offer of a free echocardiogram how can you turn that down!

I would have it just to make really sure that all is well. If there is still a tiny fault then you should be OK, bigger hole and get the exercise test one. But I reckon your chances are near enough 100% that you shouldn’t lose any sleep over it.

Valves and Holes: Case Study 2

Q: I have just had a something called Aortic Valve Incompetence diagnosed after a long fever. My doctor doesn’t know if I should continue to dive.

I have been diving for many years now without any problems.

What should I do?

A: This problem is not what we call an ” absolute contraindication ” to diving like Aortic Stenosis where the valve stays tightly shut limiting the flow of blood out of the heart to the body.

It is a “relative contraindication”, which means it depends on how loose and floppy the valve is, as to whether you should continue diving.

At it’s worst, this condition means that blood exiting the heart falls back into the chamber slowing down the new blood filling the chamber up for the next beat.

This can cause a back pressure on new oxygenated blood arriving to the heart from the lungs. What happens then is that your lungs get waterlogged making you short of breath. You can se why this would be incompatible with diving if it were that bad in yourself. However , if the problem is only minor, and the valve stops most of the blood from coming back into the heart then you may well be fit to dive.

The best thing to do is discuss it with a cardiologist, make sure you have regular ultrasounds of the heart, called echocardiograms, and if you get any symptoms of shortness of breath, see your doctor quickly.

Valves and Holes: Case Study 3

Q: I have not been allowed onto any PADI compatible course abroad due to my medical condition. I am hoping that I can get this medical hurdle and then the training cleared in the UK so that this will not be a problem when I visit Sharm in October.
My condition is as follows: –

I was born with a congenital heart condition. This included aortic stenosis,and various other problems. The condition was operated on in 1977 – the stenosis was removed. Although this operation was successful, I have a leaky valve (the left ventricle) and so I have a systolic murmur. The hospital tells me that the heart is 20% overworking.

The consultant that I saw thought that my stenosis would reoccur by the time I was 18, but it has not as yet reoccurred. I have annual check ups at the Royal Brompton National Heart and Lung hospital, which includes a full range of appropriate tests.

The hospital has not objected to any activity that I have discussed with them in the past – I do not undertake super-strenuous exercise such as marathons etc, but I have been to a gym in the past, and I regularly play football. I did ask them about diving, but they said that they did not feel qualified to make a judgement – my GP says the same.

I have swum regularly since I was very young, and am reasonable. I have no problems holding my breath, or swimming underwater.

Please let me know if there is already a good reason why I will fail a diving medical, if not, how and when I can get a medical, and if this is the case, if there are any actions that I need to take such as requesting any details from the Brompton.

A: Bad news I am afraid. Although your stenosis i.e. closure of the main valve that regulates the oxygenated blood going out of the heart is fixed, the other valve will cause you problems. This is the mitral valve and sits between the left atrium and venticle. When the ventricle contracts, whooshing blood out of the heart, this valve tops the blow back of blood into the atrium and lungs. If it is faulty and leaks, you get a back pressure into the lungs. Blood will pool there and affect your ability to oxygenate blood. [hope you are still with me here!]

This is pulmonary oedema and can be fatal for the diver. Frothy sputum on ascent, blood in the spit, the works.

Add the fact that your heart is already overworking anyway and sadly you wont get into a dive docs door, let alone pass the medical.

Valves and Holes: Case Study 4

Q: I am currently completing a UK Sport Diver Medical Form and I answer NO to two questions. For Questions 1: I have a heart murmur – that has been checked by an ECG and is normal. Will that be an issue?
I had recurrent migraines at 14, they stopped after that and then three years ago I had recurrent migraines linked to the pill I was taking – since changing my pill I have had no problems. Will this be a problem for Question 10?

A: You should be fine. Most murmurs are what they call a flow murmur. Just the sound of the blood rushing through the heart. An ECG won’t necessarily show a murmur but it would show signs of heart changes if it were a pathological one.

Migraines are only a problem if you get one underwater. Searing headaches and visual distortion aren’t a good combination with diving. But as you have resolved the problem by switching the pill to another one, you will be fine as well.

Valves and Holes: Case Study 5

Q: My brother in law, aged 28,ex-smoker, has a VSD which he has had since birth and this does not seem to affect him physically in any way, he has an excellent exercise tolerance playing for a semi pro football team. No other PMHx, Dx or FHx.

He has been advised by his GP that diving is a big no! Can you please advise as I do feel very sorry for him?

A: Sorry for a semi-pro footballer. Half the money, half the women but a longer FA Cup run than Leeds. Probably.

The fact that he can do all this, shows his heart is physically up to it. But in diving it’s all about which way the blood shunts across the hole, or the D for defect in a Ventricular Septal Defect. VSD.

It’s most likely from the big pumping left ventricle across to the weedier right one, which is OK. But in this cruel world rarely it can go the other way, which can be disaster for a diver. That brings the fizzing nitrogen-microbubbled blood back into the arterial side, missing the lungs where it would be exhaled normally. Bends city. It is rare but it ought to be checked out by a cardiologist first. If all is OK, then kapooow, he can dive.

Valves and Holes: Case Study 6

Q: Hi, I have recently been for a routine medical for my job. My doctor suspected that there may have been a problem so sent me for an ECG, the results for this came back and now he wants me to go for an ‘echo’ to see if I have an enlarged heart. Have you ever known anyone with an enlarged heart that would be safe to dive? I had a basic dive medical in April 2007 (ie blood pressure, ears, reflexes) and my blood pressure was 120/70 which I understand is OK for a 33 yr old male. My blood pressure was 136/80 on my last test 3 weeks ago.

A: Anyone remember Leonard Rossiter, the lecherous landlord in Rising Damp? Despite being exceedingly fit he died suddenly whilst waiting to go on stage. The cause; undiagnosed thickening of the heart muscle (or HOCM in medical speak). There are different forms of heart enlargement, but the principle can be explained by the old “hot water heating” analogy. Imagine the water as blood, the pump as your heart, the pipes as your arteries and veins, and the water pressure as your blood pressure. If your pipes get furred up, then the pump has to work harder to keep up adequate water pressure, and to cope with this, your heart muscle enlarges. You might think this would make it a more effective pump, but in fact the reverse is true. The heart sits in a stiff sac, so any heart muscle growth occurs inwards, reducing the amount of space within it for blood; so less is pumped with each beat. Exercise capacity therefore drops, and any sudden strain on the heart can push it into failure. This sometimes explains those stories of young people suddenly dropping dead without warning – most recently one lad sprinting to try to set off a speed camera! Heart enlargement produces tell-tale signs on your ECG, which your doc is likely to have spotted, and hence you need a echo test to look closely at the chambers of the heart. It’s this test that will determine your fitness to dive.

Valves and Holes: Case Study 7

Q: I am very keen on doing a Divemaster internship but have only dived once in my lifetime! During some travelling a few years ago, I was prevented from diving at the Great Barrier Reef. The reason was that I was born with a hole in my heart (atrial septal defect) but it was corrected when I was 2 years old. I think I still have a murmur (I don’t know much about it really) but I don’t think it is a problem. I am a fit and healthy 32-year-old now, I can exercise and have never had any problems with it. I go to hospital every two years for a check-up, but if I am considering diving would you recommend that I have a diving medical done by a specialist?

A: Not many people realise that we are all born with a hole in the heart. It lies between the top 2 chambers of the heart, called the atria. When we’re curled up in the womb it’s the presence of this hole that allows oxygenated blood to pass from the placenta through the foetal heart and round the body, bypassing the lungs (which are full of amniotic fluid and therefore not much use). At birth, what’s supposed to happen is that the hole closes; the blood then gets directed around the lungs to pick up its oxygen, before being pumped around the body. This hole is called the foramen ovale (because it’s oval-shaped), and sometimes it doesn’t fully seal over, resulting in a ‘patent’ or permanently open hole; the PFO, of which you may have heard. So a PFO is one type of atrial septal defect (ASD); there are others, of all sorts of shapes and sizes, and I suspect yours must have been rather large if it needed to be operated on at 2 years of age.

To understand why ASD is a problem, a little explaining is required. The right and left sides of the heart are normally separate. The left side of the heart pumps blood around the entire body, and so the pressure is much higher than on the right, which just pumps blood to the lungs. If you have a hole between the two sides, then the right side of the heart becomes exposed to the higher pressure of the left, which in time will overload it. This is called a ‘left to right shunt’. Fluid will then accumulate in the lungs causing breathlessness, and ultimately the heart will fail. If the ASD is small, this process may take many years, but a large hole can cause heart failure in childhood.

These days the hole is easily closed with an umbrella-like device which is threaded through a groin vein into the heart, and deployed on either side of the ASD (or PFO for that matter). After a few months enough scar tissue has formed to occlude the defect completely, and separate the two sides of the heart again. So at the ripe old age of 32, if you are able to exercise without any symptoms, the heart should be normal, to all intents and purposes. An echo test to put some numbers on the heart function would be useful, but I anticipate it will show a heart that’s perfectly capable of diving.

Still have questions?

Please read through the other FAQs on the Sunken Dreams’ Answers to Your Questions webpage contact us using the contact form below.


Glaucoma: Case Study 1

Q: I currently have pressure on my eyes and was prescribed Timolol Maleate by my Eye Doctor to equalize my eye pressure. I read in your FAQ that glaucoma should not pose any problem to scuba diving. Does it apply to me and my condition? Your help is greatly appreciated.

A: Diving does not exert any more pressure on your eyes so diving with a glaucoma is acceptable. The 2 things you should look out for though are mask squeeze where insufficient air is in your mask which could cause problems, and the fact that very rarely the eye drops you are using can have a wider effect on your body. Timolol is a beta blocker and in theory could reduce your heart rate enough that your tolerance to exercise is affected. So if you have noticed this as an effect you should see a local diving doctor to have a fitness check so that you don’t discover that you get short of breath on a dive where a lot of exertion is needed.

Glaucoma: Case Study 2

Q: As somebody keen to learn to dive I wondered if there is any information on the effects of diving on the eyes.

I have a type of glaucoma which caused high pressure in my eye and resulted in an operation which built in a drainage channel to relieve the pressure. There is a permanent stitch in the eye to prevent this from healing but no other signs.

I have noticed pain in my eye when flying, although this could be caused by the dry air.

My specialist was unable to discover any information/research regarding the effects of diving and suggested I contact a Dive expert. I hope you can send me some information regarding this.

A: This is a very difficult one.

The key thing is mask squeeze.

When you descend to depth , the air in your mask contracts, this may cause problems if you’ve had the operation. There is a chance that the negative pressure could affect your eye.

But as your husband will tell you there are ways to prevent this by blowing air into your mask on descent to stop this from happening.

The pressure at depth should not be a problem as you only dive for a short while and if you can equalise the pressure in your mask then it shouldn’t be any different to normal atmospheric pressure on land.

My only other concern is that of infection if you have an open stitch exposed to the elements, but the sea is no more polluted than bath water at times, However if you do experience any redness in the eye after diving then you may need to start antibiotics very quickly.

Glaucoma: Case Study 3

Q: As an older diver I find my bones and joints are cracking and creaking with ever increasing frequency. One of the penalties of advancing years I suppose. However the reason for my email is that I have been diagnosed with glaucoma. As I understand it, for some reason the pressure has increased in my eye but the specialist didn’t know whether my vision would be affected by the additional pressures of diving. Can you please enlighten us both?

A: I’ll do my best. As you correctly say, glaucoma is a condition in which increased pressure in the eye can lead to damage to the optic nerve and consequent visual loss. You would expect, therefore, that the high external pressures of diving might worsen the condition, but this doesn’t appear to be the case. This is because the eye is filled with a gelatinous substance that is essentially incompressible, so the water pressure doesn’t actually affect the internal pressure of the eye. However, some of the medications used to treat glaucoma can have side effects that might endanger underwater safety; beta blockers in particular may cause disturbances of heart rate, blood pressure and breathing, so exercise tolerance and lung function might need assessing. Other drugs such as Diamox (acetazolamide) and related compounds can cause tingling of the extremities and mental fuzziness; leading to potential confusion with symptoms of DCS. So you need to be careful diving if you’re taking any medications for the glaucoma, and I would strongly advocate visiting a dive doc first.

Lenses: Case Study 1

Q: I have been interested in scuba diving for some time now and have taken part in a couple of try-dives with my local diving center (SeaScape Scuba) in Ashford, Kent. I really enjoy diving and wish to attempt the PADI training later on in my life. However, I am short sighted and have asked around for information considering this problem. The main answer has been that I could get a prescription mask but I have also wondered whether wearing contact lenses would be alright. My mother mentioned something about wearing contacts and there being suction in the mask, I personally can’t see there being any suction in a mask but I am however wondering about this! Can you give me any information considering this or even tell me if I can scuba dive when I am short sighted.

A: You should have absolutely no problem.

Obviously don’t dive without any kind of visual help underwater.

Your buddy and the fish will not thank you for crashing into the reef, even if you have seen the boat to get on in the first place.

Getting a prescription lens for a mask is easy to do nowadays and this issue should carry a couple of ads in the back for manufacturers of these masks. They can be pricey and if you got 2 it would be really good. There’s no accounting for who will drop a tank on your kit on the first day of a liveaboard.

Many divers do dive wearing contact lenses and have absolutely no difficulty. There is no issue with the mask pulling them off your eyes as you descend as you should be taught how to correct a mask squeeze, by blowing a bit of air into it with your nose, as you get deeper.

The only thing to watch out for with contacts is that they can leave micro grazes on your eyes. This has been linked to an infection by a bug called acanthamoeba. This little nasty can make your eye flare up red, and even lead to blindness if left untreated.

So get a prescription mask, and if you ever do dive with contacts, see an eye doc if you get any redness within 2 or 3 days of a dive.

Lenses: Case Study 2

Q: I am currently a Divemaster trainee, who wears contact lenses. I went for a contact lens check up recently and was “told off” for wearing my contacts whilst both swimming and diving due to the high levels of bacteria and particularly “flesh eating protozoa”. I was warned that if a protozoa such as this got into contact with my contacts that I could lose my sight overnight. I was so stunned at the time that I didn’t think to ask any further questions.

My concerns fall into two categories:

1. This is not a well advertised fact, and I have noticed when helping with student divers that many of them also wear contacts. Should I warn them not to?

2. Is the bacteria/protozoa problem also valid in the sea? Or is it confined to swimming pools.

I am quite prepared to get a prescription mask if necessary, I just find that whilst kitting up etc. it is far easier to have contacts in. I have never had a problem before.

I would really appreciate your feedback on this issue, as it seems to affect a large proportion of divers.

A: I have spoken to a selection of optometrists and ophthalmic surgeons and the good news is that it should be fine to dive in contacts.

Sure there are situations in swimming pools where there are bacteria that could infect your eyes but this is not as common as you think.

What they suggest is that you use softer lenses and after diving in the pool wash them thoroughly before replacing them. If you develop any redness in your eyes afterwards then go and see your doctor to rule out any conjunctivitis. Don’t worry about flesh eating bacteria, that is alarmist nonsense. The Ebola virus is the flesh eater you are worried about, and at the moment the only way you will get that is to eat some bushmeat in the rainforest of Central Africa, and not by doing a try dive in your local baths.

As for diving in the sea, I don’t think you should worry either with the lenses, again stick to soft and if you get any reaction because of the salt water then perhaps its time to try a prescription lens mask.

You do raise a good point though that if your sight is particularly bad, then kitting up without your lenses can be difficult and that is where mistakes could happen. So in all I suggest you go with contacts in the sea and the pool and if any problems occur they can be easily treated with antibiotics, and then you can think about the mask after that.

Lenses: Case Study 3

Q: Diving is one of my major passions in life, the other being rifle shooting. In competition I am finding it more and more difficult to focus on faraway targets, and my optician has advised me that I need a prescription to correct my distance vision. The options appear to be glasses, contact lenses or laser surgery. I’m most keen on the third option as the thought of never having to wear milk bottles or fiddle about with bits of plastic and solutions really appeals. What I would like to know is, which is the best option from a diving point of view? I suspect there are pros and cons to each, so bearing in mind my shooting hobby, what would you go for?

A: An age old query this, but still relevant with all the newer approaches to refractive surgery these days. No easy answer either, I’m afraid. The least risky option is a prescription mask, as clearly this doesn’t involve any direct interference with the eyeball itself. Problem is, it’s more of a hassle kitting up. Contact lenses are generally very safe, but due to their close adherence to the cornea can cause abrasions and scratches. These then present an easy portal of entry for marine nasties if the eye is exposed to contaminated water. Most authorities advise using soft disposables rather than hard lenses, and they generally don’t wash out even if you do lose your mask underwater. Any signs of soreness or redness after diving should make you run for the nearest optometrist and antibiotic eyedrops though. Finally, the surgery options are many and varied, and the burgeoning amount of data gleaned in the last decade suggests it’s a safe long-term option for the vast majority of people. LASIK, the commonest procedure used nowadays, has not been linked with diving-related complications, but you need to wait a good month or more to allow any bubbles around the incision site to dissipate and the flap to heal. If it was me, I’d probably go for surgery, but it’s all down to individual decision-making in the end. Good luck.

Mask Squeeze: Case Study 1

Q: Aquanaut has asked me to check that my son will be able to scuba dive with a prosthetic left eye on medical grounds?

A: Poor lad. Of course he can. A prosthetic eye is a solid object. As we all know, and he will learn from training, solids and liquids are not compressible with depth. Only air is. So nothing will actually happen to the eye on a dive.

However what he must watch out for is mask squeeze. This is where a tight fitting mask traps its air and the vacuum caused on descent can pull at anything within the mask. Obviously a false eye could be pulled from the socket into the mask if this happened.

He must make sure he has a loose fitting mask, and knows how to equalize it by blowing out through his nose as he goes down deeper.

Mask Squeeze: Case Study 2

Q: Thank you for your last advice, all is well. However, I have made a school boy error and have now got Mask Squeeze!

The white of my eyes have been very red for a week now and are now starting to itch and weep tears. How long does this take to clear up as I am quite concerned? My vision and balance is fine, but my eyes look like a Zombies eyes, not nice!

Should I see a doctor or an Optician?

A: To weep a zombies tears. Poetic in the extreme, I sometimes wish I had been around in the time of Byron and Shelley. Sadly now most wordsmiths are employed writing meaningless jingles for food that kills our kids.

Right, mask squeeze- the negative pressure of the tight fitting mask sucks your eyeballs out and pops the blood vessels. Result- subconjunctival heamhorrage, or red eyes. This normally looks worse than it is, and clears in a week. But if you are now itching and weeping, chances are that you may have some allergy in there now as well. Best try Opticrom eye drops for a day or so. If that nails it then continue for a week longer. If not then see a doc asap to rule out infection.

Mask Squeeze: Case Study 3

Q: Recently had a diving medical with you. Have completed open water dives (max depth 9m). My left eye is very bloodshot and under my eye is a little bruised looking. Searching the internet it appears that this might happen as a result of not equalzing my mask but I thought I was doing this correctly. I am concerned about whether I should see a doctor and also whether I should dive again (in the near future or ever?)

A: Of course you can dive again. This is only a minor set back, caused by a tight mask. The negative pressure as you descend caused the tiny thread capillaries on the surface of your eye to pop. Hence the bloodshot look. All you have to do is loosen your mask strap, say an inch or more. It should be loose enough to sit softly over your face, and not leave a mark when you take it off on the surface. [This is only when you try it on at home]. When you descend, blow a tiny bit of air from your nose into the mask as it tightens, and lo, all will be fine. Panic over, get diving again.

Mask Squeeze: Case Study 4

Q: I have a keratoconus, a thinning of the cornea in my left eye. It hasn’t stopped me from diving so far, but since I’m considering going pro I would like to know if a keratoconus is really a no-no condition which excludes diving. My keratoconus is so far stabilized and does not require surgery.

A: A friend rang me recently in a state of hysteria. She’d been all set to get laser surgery for short-sightedness but was declined on the basis of the same thing: keratoconus. Since the laser basically slices off layers of cornea, if it’s too thin to start with you can’t really go ahead. Apparently she used to rub her eyes constantly which has over time worn the corneas away. In extreme cases, the cornea becomes so thin that it ruptures and fluid-filled swellings form on the surface, and a corneal transplant is required urgently to avoid loss of the eye.

Diving-wise, the condition itself is not affected by pressure or depth changes. The risk is largely down to mask squeeze. If the cornea is sufficiently thin, and a negative pressure builds up in the air-filled mask space, then theoretically this could lead to rupture through the weakest point of the cornea. The current method of dealing with this is to use rigid but gas-permeable contact lenses. Gas-permeable lenses avoid the problem of bubbles becoming trapped between the lens and eye, whilst strengthening the cornea to stop it rupturing. The time course of keratoconus is variable: some are stable indefinitely while others progress rapidly or get unpredictable exacerbations, so if you’re considering turning pro then it will be important for you to keep a close eye on the condition (a pun punishable by sustained flogging; I do apologise).

Mask Squeeze: Case Study 5

Q: I have a question, but first a short narrative. Today I went on my second dive with 2 experienced divers in Indonesia. When we started to descend they went down very fast (faster than I was comfortable with) and my mask was on too tight, putting massive amounts of pressure on my face and forehead. I had to come up, and I came up probably faster than I should have. I stopped when I got dizzy till it went away and then came all the way up. The dive leader came up after me to check on me a few minutes later and we adjusted my mask and tried to descend again but it was still too tight so I had to come up. Over the course of the day the area around my face (only where the mask was and especially around my eyes) looked like a bruise and I have 2 black eyes� like all the blood vessels have popped or something. I have had a headache all day but other than that feel OK. I am just wanting to check with you to see if that has ever happened to anyone. I can’t imagine it’s DCI since I was only down for a few minutes or so and I wasn’t down that far when I came up but I just wanted to double check with you.

A: This is classic mask squeeze, and rest assured it has happened to many people. What happens is that the air in the mask space gets compressed as you descend, sucking the facial tissues in which can make them bleed. It looks very alarming (zombie jokes often fly around) but will settle down by itself given time, just like a bruise. As you say, it doesn’t sound like DCI, in the absence of any other symptoms.

To avoid it in the future, try to exhale some air through your nose into the mask as you descend. This should stop the suction effect. If things get tight then a good mask clearing manoeuvre will sort things out.

And don’t worry if you start to look like a beaten up boxer, the blood may turn all sorts of funny colours as the body breaks it down and reabsorbs it. Take some pictures in fact, as a good mask squeeze photo is hard to come by.

Other: Case Study 1

Q: I am a PADI Advanced diver and about 4 years ago had a brain scan after my ophthalmologist noticed I had nystagmus on a routine eye test. (Nystagmus is a repetitive involuntary oscillation of the eyes, like watching a lengthy Federer-Nadal tennis rally without moving your head.) The scan showed up Arnold Chiari malformation, type 1. I have no other symptoms and was told by a neurologist that I could carry on diving. However, I am concerned about the pressures on the body whilst diving and would greatly appreciate your opinion as I would not like to make the situation worse. I am a nurse, so as you know, a little knowledge is dangerous and I am seeking reassurances. Have you ever come across this or could you find out about it on my behalf? I would really value your comments.

A: To tell you the truth, I have never come across this in a diver before. As always, an anatomy lesson for starters. In those human beings lucky enough to possess one, the brain sits happily in the skull, linked to the spinal cord which traverses the whole length of the vertebral column (backbone). The aperture in the skull through which the spinal cord passes is called the foramen magnum (Latin for ‘ice cream’ ‘big hole’). At this junction there is a chunk of brain called the cerebellum, which deals with co-ordination of various senses and motor control. It’s this portion we’re testing when we do all those ‘standing on one leg with your eyes shut’ manoeuvres in dive medicals. Arnold and Chiari were both German pathologists, who independently noted cases where a part of the cerebellum had protruded (‘herniates’) through the foramen magnum, sometimes with other abnormalities such as spina bifida. This herniation can block the flow of blood and the cerebrospinal fluid that bathes and protects the spinal cord, resulting in a variety of symptoms; dizziness, odd eye movements (such as your nystagmus), muscle weakness, numbness, headache, and problems with co-ordination and balance. Basically a checklist of DCI symptoms. There are several types of Arnold Chiari malformation, with type 1 luckily the most benign.

Despite extensive searching I couldn’t find a similar case in the diving literature, so I can only offer my own musings on the potential issues here. Firstly there is the perennial problem of diagnostic confusion, as the symptoms of the malformation can be so similar to those of DCI. Secondly, and more seriously, if you were to suffer a case of cerebral decompression illness then it is possible that some herniation of the lower parts of the brain could occur through the malformation, which could be fatal. How likely this is is anyone’s guess, but it’s the severity of this consequence that leads me to the conclusion that it is probably too risky for you to dive safely. I would have no problem with you snorkelling, but without any other evidence it’s the only safe recommendation I can make.

Other: Case Study 2

Q: I’m a recreational diver of 10 years’ standing and feel the desire to impart some of my hard-earned diving knowledge to others. I’ve therefore been contemplating becoming a divemaster (and hopefully eventually an instructor) with PADI, but understand that in order to do so I need to pass the HSE medical. The issue is, I only have the use of one eye. My left started to form but stopped when I was very small, so is essentially redundant. Would this stop me from passing the medical? I’ve amassed over 400 dives with no problems so far and my right eye has perfect sight, without the need for contact lenses or glasses.

A: Secondary anophthalmia (the technical term for what you’ve got, or in terms of eyes, not got) is pretty rare, and its cause is unknown, although it appears both hereditary and environmental factors are involved. There’s very little that can be done to treat it, other than try to preserve the vision in the good eye as far as possible. Implants can be used for cosmetic reasons but before puberty these need to be changed regularly to keep pace with the enlarging eye socket. For diving purposes, the HSE guidance advises that ‘visual acuity with or without correction and colour vision must be adequate for the type of diving activity such as the requirement to read a watch, computer, depth gauge, tables, instrumentation etc.’ Practically speaking, you’ll have monocular vision, so depth perception will be diminished, but other than this there should be no problem with achieving these requirements to an adequate degree. Hence I can’t think of a legitimate reason that you should not pass the HSE on these grounds.

Other: Case Study 3

Q: What are the effects of oxygen on the eye? I am asking because my boyfriend is diving on high partial pressures of oxygen (1.4 – 1.6 ATA) on a regular basis and he is complaining of some difficulties with focussing. He says his vision blurs for a few hours after his dives, but because it always returns to normal he has not been to see an eye doctor. I am worried that if he keeps this up he may cause permanent damage to his eyes. Is this possible?

A: There are lots of potential causes of visual blurring after diving. Many are to do with contact lenses; gas bubbles underneath them, dryness, they’ve scooted up under the eyelids or been otherwise misplaced etc. So if your boyfriend is a lens wearer then try some lube first. Other possibilities include corneal scratches, sunburn of the eye, irritation from anti-fogging mask solutions, or anti-seasickness medication side effects. Rarely one sees visual blurring in decompression sickness, but usually with other symptoms as well. However, high partial pressures of oxygen can indeed affect vision, as you allude to in your query. One of the commoner side effects of treating patients with hyperbaric oxygen is a temporary deformation of the lens, that causes a degree of short-sightedness. This is of the order of 0.25 dioptres per week and is progressive, but usually reverses when treatment is stopped. Most cases return to normal within 6 weeks but it can take up to 12 months. It’s extremely unusual in recreational diving, but has been reported. I would expect the same return of vision once exposure to hyperoxic gas mixtures ceases, so I doubt he will cause permanent damage to his eyes, but nevertheless would suggest he stops this type of diving until he is back to normal. With very long hyperbaric oxygen inhalation, visual blurring can progress to field constriction, loss of vision and hallucinations, and eyelid twitching often heralds a full-blown seizure. Luckily removal of the oxygen will stop the fit, but if this occurs underwater, you can imagine the consequences are potentially fatal.

Retina: Case Study 1

Q: My partner has just been diagnosed with a partially detached retina – apparently there are several layers at the back of the eye, and over a small area these have separated and a small bubble of liquid has got in between. The doctor he saw at Moorfields said it should heal up without problem over 6 months or so, but if it did not, then it would be treated by laser. However, the staff on duty in the casualty department on Saturday were not sure whether he would be able to go diving or not as they did not really know what the effects would be. This was not good news, as we are flying out to Sharm el Sheikh for 2 weeks diving in early July – less than a week’s time.

They advised him to go back today to see a specialist, and he has just been told that they cannot envisage any problems as the space is liquid-filled and should therefore on and off-gas as does the rest of the body. This is good news – but I am not sure whether the specialist was a doctor with much experience of diving medicine, so I was wondering whether you had anything further to add to the advice from Moorfields – I am sure this must be something you have come across before and it would be reassuring to know if other people have dived with this problem without ill effect. My partner does not want to risk his eyesight for the sake of one holiday – he is 40, so hopefully has quite a few years diving left! (If he does dive, obviously it would be with additional caution in respect of depths, times and ascent rates – and if he saw any change to his vision would stop immediately).

I appreciate that you may not be able to give a definitive answer if there is not much data on this problem, but even if it’s only an “if it were me….” we would be very grateful to hear from you (whether it’s good news or bad).

A: Well “if it were me” I would be checking out the batfish schools on the Ras and the Camel Bar in Sharm. A liquid filled retinal detachment will not be affected by diving as the eye, its contents and this problem are incompressible during diving, so it won’t worsen. The thing you have to watch out for though is any over exertion that will enlarge it.

An increase in the pressure of the eyeball can be caused by straining when exercising, such as putting on a tanked up BCD or lifting your buddy out of the water in an emergency.

So as diving is always unpredictable, your husband should wait until it is lasered back to normality or do the most basic of dives where a problem could never be encountered. So as four metre diving surrounded by three year old snorkellers on the house reef can be a bit tiring by the second day, I would stop off at the one stop laser shop to get it fixed quickly before you go.

Retina: Case Study 2

Q: I am a novice diver and I have just been diagnosed with central retinal vein occlusion with macular oedema. In short, I can’t see a thing out of my left eye. I have had two injections so far and have to have another one next month. The ophthalmic surgeon I saw (well, half-saw!) advised me not to dive until my condition has improved a lot more. I was hoping you may have a different opinion, as I am due to commence my confined water dives in Stoney Cove shortly. Any advice would be greatly appreciated.

A: If it’s any consolation, the visibility in Stoney isn’t exactly world-shattering at the best of times… The retina is the thin membrane that lines the inner surface of the back of the eye. Its function is similar to that of the film in a camera (for those of us world-weary enough to recall the pre-digital era). Blockage of the central vein draining blood out of the eye causes blood and other fluids to leak into the retina, causing bruising and swelling (“macular oedema”) as well as lack of oxygen. This interferes with the light receptor cells and reduces central vision.

Treatment of central retinal vein occlusion is controversial, as precious little evidence exists for anything. The injections you mention are of a substance called anti-VEGF, which is safe and can sometimes reduce the macular oedema. General advice is to avoid strenuous activity as the risk of bleeding into the eye is increased; in particular to avoid bending and lifting heavy weights, which can raise intraocular pressure.

Obviously diving can involve these aforementioned risk factors, so I would have to agree with your ophthalmic surgeon’s advice, especially if the condition is in its early stages.

Surgery: Case Study 1

Q: I appreciate that you are not an optician, but was wondering whether you could give me any advice at all with my dilemma. I am considering having laser surgery to correct my vision, but as a diving instructor would welcome your opinion on any effect diving may have. Specifically, what duration to remain out of the water, with relation to both fear of infection, and any problems there may be connected to pressure related injuries (if any).

I have been working in the Red Sea over the last couple of years, but am now back in the UK for a few months, and will not be returning to diving until later this summer, at the earliest. So now seems a good idea to go for the surgery.

My prescription is fairly mild (-3.25), which means I can have either type suggested currently.

Lasik – Layer of cornea cut and folded back, laser reshapes cornea and flap is then replaced.

Epi-Lasek – Epithelium parted, laser reshapes (flattens) cornea, epithelium pushed back over flattened cornea.

Is it possible that either is more or less likely to cause problems than the other?

When I mentioned my concerns regarding diving, no-one at Optimax could give me a definitive answer, except I should not go swimming for a month. Obviously swimming and diving are to two different issues. Even just diving and teaching could be separate issues, since unless I am teaching, my mask (hopefully) remains firmly in place.

A: Here’s the deal with diving and eye surgery. It’s not a case of compression or the eye bursting at depth. It’s a solid with some jelly like stuff in the middle. So it wont be affected by pressure. It’s all about the abrasion to your cornea, and the chances of infection getting into the eye. The main nasty is called “acanthamoeba”. Get it and you can lose your sight in a few days. And the main way it is contracted is by swimming or diving and getting into contact with it in the water.

So if your eye docs say you can swim a month post-op, then in theory you are fine to dive as well. I always used to say 6 weeks though, so an extra 2 wont hurt.

When you dive, hang that mask loose and watch any squeeze.

I don’t think it wise to teach before this time, acanthamoeba can lurk
around in pools as well, so stay out of all water for this time.

Surgery: Case Study 2

Q: I had an orbital floor fracture repair about 4 months ago to cover a hole that was around 2cm in diameter, and in excess of 50% of the orbital floor. The material used was titanium mesh.

A complication arising from the initial trauma, however, was that it was not possible to correctly reposition a portion of the eye tissue at the back of the orbit. This tissue remains trapped behind the titanium sheet and in the maxillary sinus. It has been decided that any further operation would be too risky to my sight. Can you please advise as to if there would be any contraindications for my diving.

If you need to see CT, or have me take a medical, just let me know.

A: Blimey that’s a big hole. The orbit is the cavity in the skull which accommodates the eye. Orbital floor fractures commonly result from blunt objects (fists, car dashboards, balls) impacting on the eye socket, which then breaks. Over 80% occur in males (funny that). What actually happens is that the object in question, say a well-aimed punch from the gloved fist of Joe Calzaghe, squishes the incompressible eyeball inwards. The rapid increase in pressure in the socket then causes it to ‘blow out’ at its weakest point, the floor. The fatty tissue around the eye then drops through the hole, often pulling a couple of eye muscles with it, resulting in double vision. And a rapid lie-down.

In a victim without visual disturbances, where the fracture covers less than 50% of the floor, and where there’s no trapped fatty or muscle tissue, one option is to leave the area alone and treat with steroids and antibiotics. In your case however, surgery was undertaken, repositioning the disrupted bony fragments and patching up the fracture with a mesh. One issue with this type of repair and diving is whether there is any possibility of trapped gas within the tissues. I would assume that any gas introduced would by now have diffused safely away, but it would be worth checking with your eye surgeons to guarantee this. A second issue is whether the tissue trapped in the maxillary sinus will obstruct your ability to equalise, or make that area more susceptible to barotrauma. I would imagine that as long as the sinus can drain normally you would be OK on that score.

Otherwise I can’t see (pardon the pun) any reason you shouldn’t dive once you’re fully recovered.

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Diving With Dental Braces: Case Study 1

Q: My 14-year-old son will be making his scuba certification dives to 45 feet/13.7 meters. He is in good health, athletic and has worn braces on his teeth for about nine months. Can scuba diving or the depth of his dives create any safety problems?

A: Scuba diving with dental braces in a young adolescent should pose no problem. Neither teeth nor braces are compressible, so the depth of a dive, or the pressure that is exerted on a body air space, like a sinus, should not present a problem.

That is not to say that a new diver with braces won’t have some soreness or aches after scuba diving. Braces gradually realign the position of an individual’s teeth over the course of many months. At any given time, most of the teeth are still mobile.The act of biting down on the bite block of a scuba regulator mouthpiece for a prolonged period of time may produce a little extra stress or tension on a young diver’s teeth that are still being realigned. This may produce a little soreness or tenderness after a couple of dives and perhaps a little jaw fatigue in a new diver. Any diver should be able to properly grasp a regulator mouthpiece for the duration of a dive or series of dives without difficulty in order to dive safely.

Note: there have been reported incidents of tooth squeeze in divers when an air pocket has developed in a loose filling or through tooth decay; the air expands upon ascent and can cause pain and even break through a filling. For more information on this see “The Rarest Barotrauma” by Laurence A. Stein, D.D.S., in the September/October 1993 issue of Alert Diver.

Broken Teeth: Case Study 1

Q: Hi, I had a bicycle crash last week when I sustained multiple fractures of the cheekbones and lost a few teeth. All seems to be healing well one week on but I’m wondering how this could affect ear clearing and risk of embolism in the face on ascent i.e. should I just give up the week’s diving trip I’ve already paid for 8 weeks after the accident and if so, what about future diving? I didn’t have an operation, just broken teeth removed but have been told I can’t get work done on them until face bones are healed and that could be 1-2 months. I can give more medical details if necessary, I’m wondering really if there’s likely to be a mandatory 3 month exclusion or similar.

A: There is the potential here for gas to have entered the facial tissues, or for abnormal conduits to have been made between the usual gas-containing spaces in the head (sinuses, ears). Gas in the tissues is referred to as “subcutaneous emphysema”. The classic diving-related manifestation is when the lung tears on a rapid or breath-holding ascent, with consequent leaking of the air into the tissues. I can remember the first patient I saw with this; the crackling sensation when I felt his neck was just like popping bubble wrap. Although the commonest symptoms are breathlessness and chest pain, sometimes the only one is a high-pitched or unusually nasal voice, as the free gas reaches the larynx and distorts the vocal cords. Happily the gas is reabsorbed fairly quickly so the treatment is simply supportive; oxygen and bed rest will usually do the trick, but obviously the cause of the escaped gas needs to be corrected (often more difficult).

In your case, the question is whether there is any gas trapping. Hopefully the X rays and imaging you had would have revealed any abnormalities, but it’s difficult to exclude small pockets of gas in the tooth sockets with such tests. But following the same principles, gas will normally dissipate within days, and if the repair work is going to be delayed then it shouldn’t be an issue. I’d suggest you get a check up with a diving doc nearer the time to make sure, but I don’t see any need for a compulsory 3 month lay off. Take care when you next mount your 2 wheeled steed.

Infections: Case Study 1

Q: I have a swelling in my jaw on the left hand side under a molar that has been root filled (about 6 years ago). I went to the dentist yesterday, had an X-ray, and the results proved to be uncertain. The dentist is trying to get me an appointment at the hospital for a second opinion. She thinks I have two areas, one of which is between the molars and the bigger area is underneath the root filled molar. She thinks they might be cysts, but is uncertain and was a bit surprised I think. She has put me on amoxicillin 250mg three times a day, as well as metronidazole 200mg three times a day.

Have you ever heard of this before, and could it be related to diving, i.e. I’m gripping my mouthpiece wrongly with my teeth, or griping too hard? I don’t think I do bite too hard, but the jaw does feel tired at the end of a full days diving.

The swelling is quite dramatic and painful , and I am a little concerned. Could you please tell me if this might be diving orientated?

A: This is unlikely to be diving related. I assume they are fleshy infected cysts, rather than bony hollow cysts that sometimes occur. The antibiotics you are taking are the standard dental ones, so I assume the former. When you grip a mouthpiece you are using the molars and pre-molars, where your problem is. The amount of time in reality you have a mouthpiece in is small compared to other things you do with your mouth. Like chewing. However when you bite the rubber, so to speak, when you dive, it could worsen a pre-existing problem. But there is something you could try where no bite is involved. It’s called the Manta mouthpiece and it has wings that pop out toward the cheeks which pulls the reg up against the mouth so you don’t need to bite. It’s fairly new on the market so ask your local dive shop to get one in for you to try.

Whilst you are waiting, finish the antibiotics and it all may end up with further root canal work. Good luck, I know how much fun that can be.

Infections: Case Study 2

Q: I am going with London Scuba on a diving holiday to Egypt this coming Sunday. However I had to go to the emergency dentists yesterday due to arather bad gum infection. The infection has now been flushed through and I have been given two sets of antibiotics (1 weeks course of each). They are 500mg Amoxicillin and 400mg Metronidazole. The course will finish on the day after I arrive in Sharm. Will I still be ok to dive?

A: You will be fine. Gum infections are a bummer. But these are the only 2 antibiotics that can treat them. The former, a standard penicillin. The latter “the antibiotic you can’t drink alcohol with”. I took metronidazole once, drank a pint of cider and went mental. I had to apologise to Lionel Blair 20 years later. Poor luvvie was doing the summer season in Weymouth as I wandered shouting, alcohol-antibiotic reacting, down the same back street, and called him something when I saw that nice brown quiff approaching me.

Film, book, play. No, it’s an insult. 2 words. First word, 2 syllables. I digress.

Give it 3 days for the metronidazole to clear from your body before the Saqqara. And also watch for any pain from the mouthpiece on your gum. That’s the only problem really. There are softer, longer bites on some, so try one of those if there’s some gob-chafing.

Infections: Case Study 3

Q: I’ve have been advised to take Amoxicillin 3 times a day for a problem with a tooth. Is it safe to dive whilst on it?

A: It is indeed. Amoxicillin is a fairly bog standard antibiotic used from everything from tooth to chest infections. The only thing to watch for is an allergy, but if you haven’t broken out into itchy urticarial wheals, or hives as they are otherwise known yet, then all will be OK.

Whilst on this subject, drugs and diving, I was approached by a couple of Instructors in Sharm recently, as to whether we could build some software for the e-med site that could inform those who need to know which drugs are OK with diving.

Well, we’ve looked at it and it’s a fairly Herculaen task. Seeing as there are thousands of different medications, all with at least twenty different brand names worldwide, my IT people could be programming from now until we next win a World Cup before it is done.

But a rough rule of thumb is that antibiotics are fine, anti-epileptics are not, anti-depressives need a dive doc clearance, as do blood thinners like warfarin.

Anything that can be bought over the counter is OK as the doses are quite low, and most common of all, the blood pressure lowerers do need a consult especially if they are of the beta blocker variety. And if anyone out there is bored enough, or technically minded and can solve the software problem, I’ll be first in the queue to buy it.

Pain: Case Study 1

Q: My daughter (9) has recently taken up scuba diving. She started complaining of toothache on her back molars about a week before her first dive. She seemed to have a few problems equalizing, but has since solved that issue. For the last two weeks her tooth pain got worse and then she started to complain about headaches and earaches. The dentist couldn’t find any cause for her pain and our GP was at a complete loss, since there didn’t seem to be anything wrong with the ears. She prescribed a course of antibiotics anyway which I am reluctant to give to my daughter, since there is no obvious infection. My guess would be a sinus problem, but who do I consult, if the GP can’t give me an answer? Please help!

A: Hmmm, this ain’t anything to do with diving. I know this ‘cos it started before she even dived. And she equalized OK too. And the problem has gotten worse since then. So pain in the back of the molar mouth area? Could it be wisdom teeth, an early eruption? Where there X-rays taken?

I used to get minor inflammation of my gums there and yes it does cause ear pain, and that doesn’t half give you a headache. Sinal pain is mostly associated with colds and green gunk in that area too.

Or stress, was she anxious about the diving? So many questions, but in a 9 year old there’s often only one answer. Buy them more toys, they soon get better. If you do want another opinion though I am happy to see her.

Pain: Case Study 2

Q: The last few times I’ve been diving I start to get headaches during my first dive. After the dive the headaches persist and if I dive a second dive the headaches intensify, on the last occasion quite severely and for several hours afterwards. They are always left-sided. At first I put it down to a number of contributing factors; too much exposure to the Red Sea sun, general dehydration, a bit of sea sickness etc. Unfortunately my last dive was 2 weeks ago at Capenwray, a million miles from Egypt so I can’t really find a link. A friend who dives thought I might be biting too hard on my regulator, and I remember my dentist saying I had a small bite – could this be anything to do with it? Any advice would be gratefully received.

A: Agreed – I would guess this is something to do with your bite. The joint that connects the jaw to the skull is called the temporomandibular joint (TMJ). Like any other joint, it can be affected by dislocation, arthritis and other injuries. Symptoms include all sorts of things; difficulties with biting and chewing, clicking or popping sounds when opening or closing the mouth, pain in the ear or head, migraines, and neck or shoulder pain. Biting the mouthpiece for long periods on dives can cause facial muscle fatigue and bring on the symptoms of TMJ dysfunction. So first step here is to see your dentist again to check you out for any signs of this. It’s a complex disorder and may require some experimentation to fix things, but may I suggest a change of mouthpiece, to a Comfobite or similar; much easier to hold onto throughout a dive without clenching for Britain.

Procedures: Case Study 1

Q: If I have had a root canal work or fillings in the past what are the considerations for diving?

A: Ouch. You think seeing the dentist can be a bad experience, just wait until you have a tooth blow out on an ascent.

Like most things that cause you pain underwater, it’s all about air spaces. We all know that the middle ear and sinuses will traumatise and squeeze if they are not properly equalised or cannot release the air within upon ascent. Well, there is a third potential air space not a lot of divers know about and its right there biting onto your mouthpiece. Normal teeth are a solid mass of dentine, enamel, nerve fibres and pulp and so don’t compress on descent or ascent. But what can go wrong is when these healthy teeth become diseased and begin to get a hole or two in the middle of them. These holes are either due to being forgetful with the toothpaste for a few years or when you have succumbed to your wallet and been to a bad dentist. A poorly fitted filling is perhaps the commonest tooth problem that will bring a tear to ascending divers eyes. What can happen is that the pressurised air breathed at depth can make its way into a tooth cavity underwater. If that air gets trapped in the tooth, it will expand on ascent, press on any nerve in that tooth and cause the sort of pain that can only be described as being hit by Tyson in a debate about a fender bending! What causes air to be trapped, as normally the hole will just release gas through the same entrance as it went in, are things like the filling dislodging during a dive or even biting down on a different part of the mouthpiece later on in the dive. The same goes for badly fitted crowns as well. If you get a tooth squeeze there’s not a whole lot you can do except take the pain, figure out how you are going to take revenge on the dentist later that week and reach for the whisky on surfacing. Sometimes moving your mouthpiece to a different bite may work or sucking on the tooth may remove any detritus that blocks the now air filled hole. Now, root canal work is different and I speak from experience. This is a long, literally boring and expensive procedure and should deaden the nerve in the tooth. If there were a potentially fillable air space then you wouldn’t feel anything as the nerve has been killed. Bad dentistry could still lead to a space, which could blow a tooth, but it would have to be really bad dentistry and on surfacing forget the painkillers just call a lawyer!

So there you have it, teeth and diving, but the key here is that you wont know you have a problem until it happens, and if it does get the tooth fixed before going in again. Just look after them in the first place.

Procedures: Case Study 2

Q: I’m due to have a wisdom tooth out (bottom right) on the 18th September. However, I am going diving on 3rd October.

I have been having trouble equalising due to the tooth interfering with my ear, so thought by having it out I might be able to equalise more easily, however is this date too close to diving and should I postpone the extraction?

Please help.

A: I’m not really convinced that a wisdom tooth, inflammation around it and all, will really affect your ability to equalise. Certainly pain from the tooth can be referred to the ear, but a tooth so far back in the mouth is nowhere any of the relevant tubes.

But if its causing enough aggro to want you to remove it then it’s best you go ahead.

Now, the all important timing.

3 weeks should be ok from the op to a dive. However I have seen tooth extractions go merrily awry. Post op infection, constant bleeding, all that nonsense. So I think the safe thing to do is not book the trip until a week before. If you are fine 2 weeks after the op then you will be fine to dive. But any inflammation and infection will prevent you from biting on your reg mouthpiece, a dangerous problem even in the mildest current.

Procedures: Case Study 3

Q: I’m hoping you could help me with a diving question.

I am having a new orthodontic treatment called Invisalign. If you haven’t heard of it, it basically does the job of braces by using very thin plastic aligners that look kind of like gum shields only a lot more fitted.

My query is whether I am allowed to dive with these in my mouth? They do not cause me excessive pain or discomfort. My only worry is that perhaps if some air got caught in-between my teeth and the aligners it might cause a problem. Would you be able to advise me?

If you are unable to help perhaps you have a contact that might be able to offer some assistance?

A: At last someone has invented something to stop the shame and embarrassment of our nation’s children. And adults for that matter. I can’t see a problem here at all. If it lies outside your teeth, away form the nerves, then even if air got in, it should be able to get out as well as you ascend. The only potential disaster is if air gets in and under at depth, and then you block it in by biting on your reg mouthpiece too closely. Air would expand on ascent and, I suppose could cause pain. But if you got this, then ease off the bite on your reg, and all should be fine.

From the other side of the coin, do ask your dentist fitting it if there would be issues of having a rubber mouthpiece close to it for 2 hours a day. If there is a risk of dislodging it or breaking it, then maybe get it fitted after your dive hols, as from my experience, there’s nothing cheap in the world of teeth, and you don’t want to see a couple of grand settling on a sandy bed in the blue.

Procedures: Case Study 4

Q: I’m due to go to Malta in March, but my 13-year-old daughter has beentold by her orthadontist that she will be having braces fitted on 15 February. Will this prevent her taking her Open Water course and diving? Would the brace prevent her from breathing through the regulator mouthpiece?

A: Braces come in all shapes and sizes but generally aren’t a problem for divers. The (obvious) principle is that your daughter should be able to hold the reg in her mouth and form an adequate seal around the mouthpiece.There are tabs on the mouthpiece of the regulator, just like a snorkel, and there are occasional reports of these snagging on braces.

You can get mouldable mouthpieces which would solve this if it becomes a problem. Ifshe can open her mouth to eat then breathing through it should be fine.

There are some elaborate orthodontic constructions that reduce the bite diameter but I doubt whether these would you allow you to get the mouthpiece in at all.

Procedures: Case Study 5

Q: I know you are a doctor and not a dentist but I hope you can help. If you can inform me of any diving-dentists I’d be very grateful.

The situation is this. I’ve had to undergo the removal of a front tooth which has been the bane of my life since the age of 14 when my brother first kicked me in the mouth and broke it. I now have to wear a palette with a false tooth for 6 months before they can bridge the gap. My worry is this. Although it’s quite a good fit I can still move the palette up and down away from the roof of my mouth. Will this cause me any problems by creating air pockets when I descend which I may have problems equalising? Can I manipulate the palette in my mouth to overcome this or should I remove it before I dive? I don’t want to create problems for myself but it would ruin my smile when I get back on the dive boat!

I can’t be the only person who has had to confront this situation and it may sound stupid to even ask but it so changes the way I appear to myself let alone my fellow divers. Okay – it’s vanity. However I’d rather take it out and enjoy my diving than give myself problems.

A: ‘When my brother FIRST kicked me in the mouth’?! Sounds like a tough upbringing in your household. My sympathies.

I think you should remove the palette before you dive. The reason is not air pockets, which won’t happen by the way, but mainly obstruction. The palettes slide in and out I believe, and there could be a situation where it could get caught up or even prevent quick accurate placement of your buddies occy if you had an out of air situation. It would be mad to be struggling to first place your teeth in line before biting on a reg in an emergency. When the bridge is in, all will be back to normal again. So don’t worry about your smile when you get back on the dive boat. That’s not the first thing blokes look at anyway.

Procedures: Case Study 6

Q: I am off travelling and have done a lot of diving but my girlfriend has a fake tooth which is attached to the teeth either side with metal / glue. Although this is very well fixed she is worried about the pressure – any advice?

A: Firstly, I would suggest a quick dental check up for hidden vials of potassium cyanide or other suicide pills hidden within the fake tooth. Next, blindfold your girlfriend, take her down into the basement, tie her to a chair and administer intensive interrogation with the aid of a feather duster, a riding crop and a sordid imagination. If she still won’t talk, I think we’re okay to go diving. A tooth like this is going to be solid and therefore not susceptible to pressure effects. As long as the glue holds tight there’s nowt to worry about.

There are occasional tales of exploding teeth and ballooning gums that make the scientific dive literature, but I think more as exceptional cases than as common problems. The term ‘aerodontalgia’ has been coined for this, mainly to confuse the layman: it literally means ‘air tooth pain’. You can get gas spaces forming around the roots of infected teeth or where old fillings cause little gaps to appear between the tooth and gum. During a descent the contracting gas spaces can suck in blood or make the gum swell, causing pain, or in the worst case scenario, a particularly fragile tooth can collapse. Naturally, the gas expands again on ascent, again causing pain, or the occasional ‘blow out’, where the tooth literally explodes. Some older divers with lots of fillings can actually gauge their depth quite reliably on the basis of how much pain they’re in. But before anyone with fillings panics, cases like this are unusual. A dental check once a year should show up any problems. Pain in the teeth on a dive can sometimes be referred from a sinus squeeze, but if it persists a trip to the ‘drawer-tooth’ is probably a good idea.

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ADHD: Case Study 1

Q: I am taking my son (16) on his first try dive within the next few weeks and I wanted to ask your advice. He takes Ritalin 10mg and Pimozide (for mild tourettes – pacing) and I was wondering if this was safe to dive with.

My son doesn’t actually need to take the medication whilst diving but I thought it might be wise as his concentration levels will be affected without it. I can stop the pimozide for the dive day, but thought the Ritalin would be wise whilst going through safety briefs etc.

Please advise, I would hate for him to miss out. Sorry, the medication is for ADHD (attention deficit activity disorder).

A: I’ve gotta be Doctor Gloomy here and break the bad news. I think diving on a medication like Ritalin is totally unsafe. It’s basically an amphetamine, speed if you like. It will increase heart rate, cause dry mouth, whack up the metabolic rate etc. Also there is no research as to the drugs affects at depth, the worst place to find your son getting overly fidgety and not remembering his training. And, as you say if he is off it then he lacks concentration, then watch the dive brief. They can be boring enough as it is without certain divers fidgeting and forgetting the information. I suggest have a good close look at his diet. Went out with a lady once who had an ADHD child, and it seemed to me that all the junk foods, like coke and crisps made him worse. I have a theory that this modern disease phenomenon could be rooted in other causes. So forget taking him into the deep for now. Snorkeling should be OK though.

ADHD: Case Study 2

Q: My son is 16 years old and has been taking Ritalin for 8 years. He is perfectly well physically, although following a recent growth spurt is a little on the skinny side. He is a Royal Marine Cadet and takes part in all physical training activities without problems. He currently takes 72mg per day of Methylphenidate, branded as Concerta, which helps him focus and concentrate at school (he is an A grade student). But on seeing the PADI medical questionnaire his Doctor has flown into a tizzy, saying she is not qualified to complete a diving medical and he would have to have a full physical check at probable cost of at least – 200.

I would be grateful if you could give me some more concise advice.

A: And concise I shall be. Sadly he is not going to be allowed to dive.

Right next question:

OK then I shall elucidate a tad more.

The problem with ADHD, and even a well controlled condition is that the poor kid, who has it, is prone to bouts of well, attention deficit. That’s OK in a maths lesson now and again and even if you are Rio Ferdinand at the back for England, but not with diving. Yes he could pass the Open Water course with flying colours, and I bet know more about air tables than the Instructor, but diving is more than that. There is a whole world of hurt down there in the deep. Kit can fail, buddies can fail, and the sheer unexpected can happen as well.

A situation where cool calm logical thinking is needed. You may not believe that looking at some of the divers munching bacon sarnies on the quays, or in the pubs of Portland on a Saturday night. But they are a good crowd of folk who do well in times of hazards. So can an ADHD sufferer be 100% certain to be able to correct their buoyancy, save a buddy, and launch an SMB all at the same time. As we cannot guarantee they can, then they aren’t allowed to dive.

This is not withstanding the lack of evidence of the effects of Ritalin/ other amphetamines underwater, that has yet to be studied.

So concisely- No. But there’s always kite surfing for the Sea Scout in him. That’s pretty cool, if CSI Miami is anything to believe.

ADHD: Case Study 3

Q: Dear Doctor, I am a BSAC sports diver and have been diving for just over 9 years to various depths (up to 52m). In February 2007 I had a hernia operation. My doctor has now pronounced me fit but as advised me to take things easy with anything physical, especially to start with. In 2003 I was rediagnosed (I was originally diagnosed as a child) with Attention Deficit Hyperactivity Disorder (ADHD). Since then I have been taking the following medication daily:

*Two Methylphenidate Hydrochloride 20mg capsules. About 2 hours apart.
*One Methylphenidate Hydrochloride 10mg tablet as required. I usually take 3/4 of a tablet late afternoon or evening.

Since being diagnosed and taking this medication things have improved a great deal for me. My short term memory is far better and I am able to concentrate and focus far more effectively. I have also continued to dive (although not very much) and have dived several times having taken my medication (up to 25 metres) with no ill effects. I have asked my Doctors at the Learning Assessment Centre if it is ok to dive. One of them has said he will ask the tablet makers. He is still awaiting a reply. Now that I have been passed as fit after my hernia is it safe to continue to dive? Many thanks for your time.

A: A classic case of a hidden dilemma nearly slipping under the radar. Hernias we dealt with a couple of issues ago, and the bottom line is that once they are fixed and fully healed there is no problem with diving. The thing that is a worry here though is diving with a diagnosis of ADHD. Unfortunately this particular illness has had an extremely bad press over the years. Although mostly thought of as a recent medicalisation of tartrazine-crazed kids, descriptions of ADHD-like symptoms go back to Ancient Greek times – in one individual, Hippocrates noted “quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression”. His explanation for this was “overbalance of fire over water”. Dearie me. Things have moved on considerably since, and the illness now has a well-defined set of criteria which must be fulfilled for the diagnosis to be made. Some of these involve inattention and, well, hyperactivity and this obviously makes diving with the condition a risk – the last thing you want is your buddy drifting off into a world of their own, or fidgeting hysterically throughout the dive briefing. The effects of pressure and nitrogen on the medication itself is another factor that is very difficult to generalise about; a lot of these medicines will never have been exposed to such conditions and thus evidence is lacking as to their potential side effects. So at the very least you would need to be thoroughly assessed by your local dive doctor before continuing to dive.

Depression: Case Study 1

Q: I am a qualified PADI diver and my fiancee would like to learn to dive, however when she went to a try dive session she was advised that she probably wouldn’t be able to get a medical signed off because of the medication she takes.

She is taking Stelazine 5mg and Procyclidine Hydrochloride 5mg once per day. This is to counteract a dopamine deficiency. She is aged 42, otherwise in good health and does not smoke. The type of diving we would do would be warm water, Red Sea, Caribbean, and possibly some summer UK (when hot!) and not exceeding 18m depth, mostly a lot less as nearly all the pretty stuff can be found in the first 10m. We are both fairly cautious in nature so we would not intend to ‘push the envelope’ in taking any risks or intensive diving, tight surface intervals etc.

I would be very grateful if you could advise me whether it would be safe for her to dive as described above and whether it would be possible to obtain a diving medical certificate when taking this medication.

A: I think its going to be difficult to get her signed off to be fit for diving on this drug combination and also for what it is used to treat.

Stelazine is a powerful tranquillizing drug used for treating severe anxious, psychotic and depressive episodes. It also has side effects similar to Parkinson’s Disease, for which the procyclidine is given to counteract.

Stelazines tranquillizing action will inhibit her ability to respond in critical situations endangering both herself and her buddy, and if this were added to any narcosis then a fatality could happen.

As she is on this treatment for a major psychiatric episode, then this in itself would bar her from diving too.

I suggest she sees her psychiatrist to find out how long they think she needs to take this treatment, and if ever she is off it then a diving doctor would need a clear letter from her psychiatrist that she has fully recovered before passing her as fit to dive.

Depression: Case Study 2

Q: Been diving for 3 years, AOWD, around 60 dives. Basically after a bad year at work, off-shoring, redundancies, pressure at work, I’ve been signed off work since 5th Dec, some 5 weeks ago. From elsewhere on you site probably was in the ‘morbid depression’ as a classification. Was referred to and am seeing a Dr in local hospital mental health unit weekly. Perhaps mid life crises, work-career etc. Currently feeling better than I was, generally less depressed, other wise in good physical health. Due to go diving mid March, how will I fair for diving medical regarding the prescription and ‘depression’, (I may hopefully be off the prescription before March)?

A: I know how you feel mate, bad years and all. But well done for getting through the worst of it, so some good-ish news for you. I assume you are on the newer SSRI style anti-depressives. These are OK for diving but only after an assessment by a dive doctor. One of the things they will look for is how bad your depression is. Morbid depression and weekly visits to the doctor is very significant. You could be a risk to yourself and buddy if things went pear shaped at depth. So you need the problem to lighten a bit, which is often due to the removal of the causative factors. Bad boss/relationship/pay etc. If these are resolved, the depression kind of normal and no side effects from the meds, then you could well be fine to dive.

Oh happy days. C’mon sing. Remember that scene in Con Air.

Depression: Case Study 3

Q: My brother who is a diving instructor is taking me to do the pool work of an open water course on Saturday. He said that as I had intussusceptions (sorry for the spelling which is probably incorrect) when I was a baby that there might be a chance that I would need a medical before I could do the course. I had the operation when I was 6 months old and I am now 28. I have not had any intestinal problems since caused by the operation or otherwise.

I also have suffered from panic attacks after I had glandular fever when I was 18 and also 2 years ago whilst working in a very stressful job which I left. I have not suffered from anxiety or panic attacks for the last 2 years though. Do you think I need to have medical.

A: The PADI medical has a real catch all statement on the form. ‘Do you have or have you ever had’. And one of the questions is about psychological problems. So you will have to answer YES to that. When you present the form to any dive shop after your bro’ has trained you, it may cause concern. So best to get your ‘Get out of jail free’ card, otherwise known as the Fit to Dive cert. As all has been OK for a while, I am sure the anxiety will not be an issue. Unless of course, you are a total bag of nerves, and normal for you is half way between Norman Wisdom and a man about to be electrocuted.

The other issue, intussusceptions is not a problem now, but an interesting medical problem. That’s where your bowel slides into itself, like those odd water filled toys. The bowel then gets its’ blood supply cut off resulting in agonising pain, gangrene and death. Mainly babies get it and the classic sign is redcurrant jelly-like goo from the anus. A Munchausen’s-by-proxy favourite for parents with nothing to do after their lamb roast.

Depression: Case Study 4

Q: I have been diving for around five years. I took Cipramil for depression for two years and continued to dive regularly during that time – I never experienced any problems with this whilst diving. I first took 20mg per day then 10mg and I finished taking it around 9 months ago.

I think it’s probably true to say that the benefit I get from diving feels as though it does me every bit as much good as taking Cipramil did. In fact, the thought of not being able to dive makes me feel really quite down.

At the moment, I feel that the depression is returning (although I’ve never had panic attacks and I’ve never felt suicidal). I think I’d probably benefit from the support of taking medication again for a while, but I do feel a bit reluctant to start up the drugs again.

I’ve heard good reports from a friend of how much better he felt after taking St John’s Wort, so, after reading about it as well, I have been considering trying it myself. I’m in good health generally and I’m not taking any other medication of any sort.

Would it be OK to take St John’s Wort and carry on diving?

A: Sorry to hear you are on a bit of a low, but here’s some good news. The newer SSRI type antidepressives are a whole lot safer than the old ones. So it is accepted, that as long as your condition is stable; no one wants a suicidal buddy after all- and there are no odd side effects then most divers will be OK on cipramil. You will need a dive doctor to sign you off for this though, not your local GP.

As for St Johns wort, this is a fairly active compound, more in line with the old style meds, so I would think it better that if you wanted to dive, to go back to the cipramil, as at least this drug had been researched far better and we know its full side effect profile.

Or how about nature’s own prozac’..dolphins. From what I have heard, a quick dip with Flipper and Mr Gipper [his stunt double, yes really] and your serotonin will be leaking out of your ears.

Depression: Case Study 5

Q: As a latecomer to diving I’ve become pretty obsessed with the sport. Having mastered air diving I feel restricted by the 40m depth limit, and would like to take up technical diving so I can get to 40m+, use Trimix, and try wreck and cave diving. But I’m concerned that my medications will hinder my progress. Currently I’m taking Bupropion, which I read can increase seizure risk. I’m also taking Epilim and have just started Olanzapine. Do you think it’s safe for me to pursue my ambitions whilst taking these? Please say yes!

A: Er, this is going to disappoint you, but the answer is most likely no. We need a little more information here on why you are taking what you’re taking. Bupropion (aka Zyban) is most widely known as a smoking cessation pill, but was actually developed as an antidepressant. It does potentially increase seizure risk, but actually no more than many other antidepressants. The other two drugs you’re on lead me to believe you have bipolar disorder, a condition where moods cycle between manic highs and depressive lows (hence its previous label ‘manic depression’). This puts us in a quandary. Drug companies aren’t really interested in what happens to drugs under pressure, so there is usually precious little evidence of their safety in divers. We do know from animal studies that the blood brain barrier becomes more permeable to drugs with depth, so it’s not a big leap to imagine this might occur in humans too. This mix of medications in unpredictable doses, nitrogen narcosis and the inevitable heightened anxiety of a new diving environment could easily tip a previously stable brain into all sorts of bizarre activity. In my view the risk of a potentially fatal accident is too high here.

Depression: Case Study 6

Q: I have a mild form of Seasonal Affective Disorder (SAD). Basically I get pretty miserable between November and March, which makes me clam up in my shell and interferes with my social life. Diving through this period keeps me going but I prefer solo trips. We were discussing this at my dive club recently and they suggested contacting you for some advice on safety aspects and possible treatments. Any comments?

A: Most people get the winter blues to some extent but SAD takes this to a slightly more intense level. It can be experienced in summer, spring and autumn as well as winter. Sufferers complain of lack of energy, mood swings, poor concentration, unhappiness, and cravings for sweets or starchy foods, accompanied by withdrawal from family, friends and social activities. One interesting theory is that SAD is a mild remnant form of hibernation, and these features basically result from a reduced need for calories. Confusingly there is also a condition called reverse SAD which manifests as insomnia, anxiety, irritability, decreased appetite and increased sex drive. Diagnosis can be difficult! Bright lights, ionised air, cognitive behavioural therapy and timed supplements of melatonin can be effective as treatments. I wouldn’t ever recommend a sufferer diving alone, but with a trusted buddy looking out for you I don’t see why you shouldn’t carry on diving, particularly if you find it an antidote to the dull winter gloom.

Depression: Case Study 7

Q: My doctor has recently put me on some treatment for depression. It’s something I’ve suffered with over the years and normally I can get through it without needing medication. This time round it’s been accompanied by (or perhaps resulted from) stress at work and financial concerns so I’ve caved into pressure from my GP and started taking Venlafaxine. Does this mean I can’t dive?

A: The ‘black dog’ of melancholia is part of the human condition, so much so that depression could be considered as a normal facet of being alive. It is certainly a very common issue that often goes unrecognised. Severity varies enormously, from a general vague feeling of the ‘blues’ to a life-threatening illness. And so each case needs careful individualised assessment from a dive doc. We should remember that diving has plenty of positive benefits on the mind and represents a lifeline for many people, so solid reasons need to be provided for cutting it. However it can also be a very effective method of suicide. Where medications are required to treat depression, we also have to consider side effects and the consequences of pressure on the effective drug dose delivered to the brain. My rules of thumb: only one antidepressant, which should have been taken for a good few months to allow the brain to get used to it, no worrying side effects, and no significant mood swings. I always suggest fairly conservative diving (a maximum depth of 30m), and the diver’s buddy should be fully aware of the condition too.

Depression: Case Study 8

Q: My girlfriend had a recent family bereavement and she’s started to get panic attacks at random times. She starts hyperventilating and gets palpitations. The attacks last a few minutes and she’s getting better at controlling them with breathing exercises (I never believed that old paper bag trick would work but it does!) We’re supposed to be going on a dive trip soon and I’m worried about what might happen if she gets one underwater. Can you enlighten me: is it safe?

A: Overbreathing can occur in a variety of situations; the out of shape diver frantically finning against a current, the malfunctioning regulator causing excessive breaths in a panicked diver, or the hyperventilation provoked by unpredictable anxiety (as in your girlfriend’s case). Rapid breathing blows off carbon dioxide, and makes the blood less acidic and more alkaline. These conditions cause calcium in the blood to bind to a protein called albumin, lowering the free calcium level and causing ‘tetany’ – where muscles start spasming involuntarily. Not surprisingly, this causes further panic, more rapid breathing, and a vicious circle develops. The brown paper bag trick (yes, it does have to be brown) works by making you rebreathe your exhaled air, which is high in carbon dioxide, so raising the calcium level and restoring normal muscle function. Sadly there’s no waterproof equivalent as yet, so a diver has to be able to slow their breathing and keep the panic at bay whilst making a controlled ascent to the surface – easier said than done. And there’s the conundrum: if there’s no obvious cause for the hyperventilation (fatigue, a hangover, equipment failure etc.) then you need to be certain that you could cope with the sudden onset of panic underwater. A bit of honest self-assessment required, and in my view, any uncertainty necessitates a delay to diving until the issue is resolved.

Depression: Case Study 9

Q: As a latecomer to diving I’ve become pretty obsessed with the sport. Having mastered air diving I feel restricted by the 40m depth limit, and would like to take up technical diving so I can get to 40m+, use Trimix, and try wreck and cave diving. But I’m concerned that my medications will hinder my progress. Currently I’m taking Bupropion, which I read can increase seizure risk. I’m also taking Epilim and have just started Olanzapine. Do you think it’s safe for me to pursue my ambitions whilst taking these? Please say yes!

A: Er, this is going to disappoint you, but the answer is most likely no. We need a little more information here on why you are taking what you’re taking. Bupropion (aka Zyban) is most widely known as a smoking cessation pill, but was actually developed as an antidepressant. It does potentially increase seizure risk, but actually no more than many other antidepressants. The other two drugs you’re on lead me to believe you have bipolar disorder, a condition where moods cycle between manic highs and depressive lows (hence its previous label ‘manic depression’). This puts us in a quandary. Drug companies aren’t really interested in what happens to drugs under pressure, so there is usually precious little evidence of their safety in divers. We do know from animal studies that the blood brain barrier becomes more permeable to drugs with depth, so it’s not a big leap to imagine this might occur in humans too. This mix of medications in unpredictable doses, nitrogen narcosis and the inevitable heightened anxiety of a new diving environment could easily tip a previously stable brain into all sorts of bizarre activity. In my view the risk of a potentially fatal accident is too high here.

Depression: Case Study 10

Q: Hi, I had a diving incident with a friend who I was guiding nearly ten months ago. The incident involved him having a buoyant ascent from 15m in a dry suit. Upon reaching the surface he then (having by this time dumped all the air from his suit) dropped back to a depth of 20m. I went after him fearing he was unconscious, on reaching him he gave me the out of air signal. Using my octopus we made an emergency controlled ascent and straight away sought medical attention, and were put on oxygen.

Since the incident we have felt no physical effects and have continued to dive, however for me since the accident I haven’t been able to enjoy my diving. I seem to have built up some sort of mental block about diving deep and can’t bring myself to go beyond 20m. I am a PADI Divemaster and have over two hundred dives, some to 50 plus metres so I am very concerned about what is going on in my head about this? If I can’t be comfortable with myself how can I look after students?

I don’t allow myself to feel completely comfortable anymore. In fact, I seem to ‘spook’ myself out my comfort zone when I’m too relaxed and become ‘super aware’ of everything going on around me. I love diving and it’s really knocked me for six, as I am normally a very confident person. A year ago I was happily sitting on the bottom at 36m playing with reef sharks, talking about tech diving. Now I’m only diving in 10m of water and saying to myself ‘there’s no point in going down there!’

Could you tell me if you think it’s wise to speak to a sports psychologist? If so, is it a service that you offer or could you recommend someone?

A: There’s only one guy I know who can fix this shit. You need a dive doc with a leaning toward psychology. They are few and far between as most dive docs come from GP or anaesthesia-land. Email us here at the magazine for their details.

But in a coneshell ‘here’s the deal. It’s my first rule of diving. ‘They who go with the bolter get the symptoms. They who bolt, don’t.’ So, you are part of this law I’m afraid. You will be fine. You need to take it easy. Five metres at a time down deeper. Distractions work. Take a new camera with you. Turn your depth gauge round so you can’t see it and just look at fish ‘n’ stuff. Not up. Not down. And you will be fine.

Eating Disorders: Case Study 1

Q: I’m writing to ask if I would be allowed to scuba dive with an asthma condition. I have an average peak flow metering of 450 and take Terbutaline sulphate 500 microgram turbohaler and Pulmicolt Turobhaler 200.

I also have an eating disorder which I keep on binge eating at the moment and I have found that my breathing as become a lot shorter than before would this affect me at all?

A: The asthma here is the least of your problems. As discussed many times in the past, a well controlled asthmatic, with no exercise inducement of the problem, is OK to dive. As long as they pass the medical that involves lung testing.

It’s your eating disorder that worries me. These normally fall into 3 categories. Anorexia, where you don’t eat. Bulimia where you do too much. And bulimia nervosa where you eat and throw up.

Yours obviously falls into the latter 2 categories. The problem with over-eating and vomiting, is that there is a risk of inhaling some of the acid in the vomit. This can cause spasm in the lung tubes, and shortness of breath. It could be what is happening to you. And made worse by pre-existing asthma, where these tubes are prone to spasm anyway.

So, where does that leave you? I think you really need to address the eating disorder. It is often caused by subliminal issues, often from childhood, and often centred around “control”. If you are on the edge and bingeing, you may well have psych problems underwater and be a risk to yourself and others.

Get to a psychologist and get control of the problem. When this is sorted, getting the asthma passed, should be a breeze.

Miscellaneous: Case Study 1

Q: Hope you can help me out on a little problem I have with a client.He is a certified diver and dived with us 1 day prior to starting an Advanced course. When filling out the medical questionaire, we were made aware that he is on prescription, which our doctor here is unsure of and has therefore stopped him from diving until the position can be made clear. The prescription is Triflouruperazine and Procyclidine prescribed by a consultant psychiatrist. The client says it is to reduce voices that he hears on occassions.

A: Would be grateful if you could verify the diving situation for this client, as he is obviously very disappointed to come all this way to dive. He will be leaving us in a few days.
Sadly I think that this diver should not really be in the water. The voices that he is hearing are a classic symptom of a psychosis. They are known as auditory hallucinations and are a symptom of schizophrenia. The medication that he is taking is a called a phenothiazine and has a wide side effect profile including seizures and blurred vision. Another side effect is called a “tardive dyskinesia”, where the mouth and lips go into a sort of spasm. So you can see the dangers of diving if these were to occur. The procyclidine part of the treatment is supposed to stop some of the side effects however one of the problems with this condition is that the medication is often forgotten and the symptoms come back under stress or anxiety.

Hence my advice that he would be better off not taking the risk of diving.

This, though does bring up another issue. That of disappointed divers arriving on their holiday only to find that they are unable to dive. I think that its about time that some of the holiday companies double check the client’s medical history before they pay for the holiday. This can so easily be done by simply including the questionnaire from the PADI dive form in the brochure on on their websites, then a “yes” to any of the questions and the potential client knows to get medical clearance before going ahead and booking the trip.

This would have saved this person a 4000 mile trip to find out all he could do was lie on the beach.

Miscellaneous: Case Study 2

Q: I am having a problem getting my doctor to sign my medical form for a PADI Open Water course. This is because I ticked ‘yes’ for having or ever having claustrophobia. I used to occasionally feel claustrophobic on buses and I had trouble when I went caving once. However I do not feel claustrophobic in water and I never have done.

Please could you tell me your opinion.

A: This is where a little common sense is needed. Claustrophobia is on the PADI form as a no-no to diving. But there are many shapes and forms of this psychological phenomenon. In most dives the only enclosed space you will find is your mask and the bogs on board a boat. So you would have to have an extreme version of this problem to find this debilitating.

I think that if you are OK with a mask and don’t do the swim throughs or caves or wreck penetration then all will be fine.

In these circumstances I don’t really need to see a patient but can take their word on it by email. There’s not a lot I can tell from seeing you face to face that would enlighten me about your problem. Unless I put you in a small box.

So send me your forms and I will post them back to you, all signed up. The only cost is a fiver to the RNLI. A fine charity whom once saved me when I was the worlds worst surfer.

Still have questions?

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Asthma: Case Study 1

Q: I have a friend who suffered from asthma when she was young, but she now rarely experiences any relapse. She has taken part in diving on 2 occasions and seemed to be all right. Is diving suitable for her?

A: In the UK we allow asthmatics to dive, but only if they have passed a stringent medical. The main danger is that if a diver suffers bronchconstriction whilst underwater, the expanding gas cannot be exhaled fully as the air passages are inflammed and so are blocked. This means that the tiny alveoli at the end of the lung tubes are ruptured by the expanded air, and so air bubbles pass into the arterial circulation causing the dreaded CAGE , or cerebral artery gas embolus.

This can easily cause death.

But as things have moved on the evidence is now that a well controlled asthmatic has an equal chance of this as a smoker, and we let them dive. So in the UK at least we have relaxed our opinion on asthma and diving.

The medical is to check that the lung function is good enough to dive and also that the trigger for asthma is not exercise. If it is then the diver is failed as if a dive turned nasty an asthma attack would be fatal and also risk the buddies life too.

From my experience of seeing a lot of asthmatics who want to dive is that it amazes me how quite often the diagnosis is questionable, made early in their life on the basis of a few nocturnal coughing fits and then a lifetimes ventolin inhaler usage will follow.

So I suggest your friend sees a Diving Doctor to see if she is fit enough to dive, and if so even go and see an asthma specialist to ask whether the diagnosis still holds.

Asthma: Case Study 2

Q: I have been referred to you by my dive instructor. I am due to start a diving course on Monday night but have been refused certification by a GP. Basically I have mild asthma, mostly brought on by allergies to smoke and artificial fog. However, several years ago (about 7) I did have an attack, which my school nurse put down to over exertion during a football training session. I also have problems equalising on aircraft, possibly due to sinus problems. I’m not sure I am the ideal contender for SCUBA diving but I am hoping you could give your opinion to settle the matter. I would be very grateful for your input.

A: There is hope for you.

I have responded to many asthmatics who want to dive and seen many too. The bottom line is we doctors need to be able to guarantee that you have a zero percent chance of having an attack or onset of wheeziness underwater. The asthmatics who generally fail are those who get it easily on exercise or those in whom control is very poor. The reason the former flunk the test is that any dive can turn from a gentle fin around to heavy work if a strong counter current comes along. Likewise if you have to tow your ailing buddy 300 metres to the boat, if you then get wheezy it’ll be curtains for you both.

So if there is any chance of exercise inducement then the doc will exercise test you and check on your lung function at timed intervals after the test. Pass this and you will be fit to dive. However I have a hunch that you will pass this as I reckon you must have done a bit more exercise than the school nurse saw all those years ago.

Don’t worry about the smoke and weird fog as a trigger as these should be rarely encountered underwater, but bear in mind that diesel fumes can swirl around from a boat engine. So if your diving doctor does pass you as fit then be sensible on the RIB.

The other issue of the equalisation is interesting. It doesn’t bode well for you if you can’t even do this on a plane, so your dive doc should check this as well by looking at your ear drums when you swallow and blow. But from what limited info you have given me I bet you have one of those allergic conditions where you bung up easily which makes your sinuses stuffed and the asthma like condition too.

If you spent a bit of time with an allergist I bet they could sort you out. Failing that I have seen pretty good results from homeopathy so maybe give that a go too.

Good luck, but your first stop should be the diving doctor.

Asthma: Case Study 3

Q: Please can you stop me panicking.

I am a very fit 30-year-old man and I have been diving exclusively in the UK since last August. By ‘fit ‘ I mean cycling 12 miles nearly every day and that is cycling not just riding as I regard my health and fitness as very important. I am also a worrier and recently managed to get myself in a stew about my blood pressure for no good reason, so I went to my GP to get it checked. Of course it was fine but when I mentioned that I was going to go for a diving medical he did a spirometry test on me just out of interest, using a simple spirometer with a sliding scale. You can imagine my surprise when I couldn’t manage more than 575 litres/min peak expiratory flow rate. My GP said it should be 640 litres/min for a man of my age but did not seem greatly concerned and asked if the results of the medical could be copied to him for my notes.

The thing is I am now worrying if I am asthmatic and it’s not going to be off my mind properly until I’ve had this medical but I was just hoping you could type some reassuring words so that I can stop worrying about it for five minutes or at least until I have this medical. I have never had any problems with breathing and can still breathe well on strenuous exercise. I have had a slight wheeze on strenuous exercise in cold air but it did not interfere with me getting air and I certainly wasn’t gasping for breath.

Another worry is that if I’d not panicked about my blood pressure I would never have known anything about my breathing and would have carried on diving on self-certification indefinitely. Am I justified in this or just being a bit of an old woman?

Thanks for any help you can give.

A: Yes you are. So put away your knitting, get that hanky out of your sleeve and calm down. From the top with the blood pressure as that was your first worry. Basically there is no problem with BP as if its normal then you dive, if it’s abnormal we treat with diver friendly antihypertensives such as losartan and you dive.

You didn’t have spirometry from your doctor you had a peak flow. 2 very different things. Spirometry measures lung volume and how much you can exhale as a percentage of that volume in a certain time.

Peak flow [PF] measures the fastest you can exhale. Sure your score may have been a bit low for age and height however the problem with PF is that it is very technique dependant. If you can cycle 12 miles a day then chances are that you do not have asthma that’s exercise triggered. So get proper spirometry to set your mind at ease and take a big deep breath and relaaaaax.

Asthma: Case Study 4

Q: I am about to self-certify for the BSAC medical. I need to get a medical referee to sign regarding asthma. My old GP reckoned that my almost annual bronchitis as a child was due to asthma. I use a puffer now occasionally in the winter, when I get a really bad cold (which would prevent me diving anyway) but at no other times. I don’t ever get close to the stage of not being able to breath, but as told using the puffer will reduce the time the cold hangs around. When I don’t have a cold I never use the thing. I visited another doctor a year back I had a bad cold and she doesn’t think that I have asthma, and I’m currently trying to get it taken of my medical insurance as a pre-existing condition. I have dived before (10 years back, when medicals were required) but the puffer thing has occurred since.

A: Once again these BSAC self certs seem to throw up a lot of confusion. I don’t think you can tick yourself off as fit to dive on an e-mail or a phone call so you will need to see a dive doc. Basically if you are well controlled and do not get wheezy on exercise or cold air then you are likely to be passed as fit, but only after seeing a doctor for the full lung testing and work up. Once passed it is then up to the doctor as to how long you need a revue before carrying on diving. For example I had someone in the back of my surgery the other day who was so well controlled they hadn’t taken an inhaler for years and ran the London Marathon in a sub 4 hours, probably dressed as Orville the Duck with no problems. They can be passed as OK on the first meeting and then self cert if there are no problems after for years. But the key here is that it’s best to be seen in the first place. On top of this no doctor in their right mind would put their signature on a medical form of an asthmatic whom they have never seen as “fit to dive” as behind all the rocks and weeds underwater, what lies in wait by the bottom feeders’ lawyers, that’s who.

Asthma: Case Study 5

Q: I came to you 8th April last year and you gave me a dive medical according to an Australian diving medical form. I did a dive expedition with CCC which started in October last year. I did my PADI divemaster certification and finished in May.

I have since been to Australia and I went to get another dive medical as the liveaboard I was hoping to do required a current medical.

The diving physician examined me and I mentioned that I had a mild asthmatic allergic reaction to cat’s saliva and dust mite faeces. As soon as he heard this he signed me off as being permanently unfit to dive, especially as two of my grandparents developed asthma later in life. He also said that I should never have dived in the first place and that I was lucky to be alive due to the high risk of developing a reverse air embolism.

I have been in the tropics since October and have stopped using my inhalers due to there not being any of my particular allergens in the environment and have not experienced any tightness in my chest since leaving the UK.

When I came to you in April last year, my peak flow was better than average and you gave me a clean bill of health for diving, using the same form that the Australian doctor used. I have since stopped diving until I can find out more about my condition and the risks that are involved with diving.

I wonder if you could give me your opinion on this and the different views held by European and Australian doctors. Is there any literature in this field which I could use to help evaluate the risks of my continuing scuba diving. Is there anyone you could recommend I can go and see to get a more detailed physical examination?

I was intending to get my PADI instructor accreditation in the next year or so and I am not ready to give up on diving just yet.

A: I am surprised that the doctor failed you so here is some good news. Yes there is a difference of opinion between UK and Australian doctors as regards a blanket ban on anyone one with any sort of asthma not diving.

Over here we realise that some forms of asthma contraindicate diving but others do not.

You have what is called allergic asthma, cats and mites being your triggers to wheezing. It would be a pretty weird dive if you came across either of these underwater, so modern medical thinking is that you are at a low risk of getting an asthma attack whilst diving and you should be fine. You still need to go through a full medical with a doctor who will check your lung function before passing you as fit.

However the sorts of asthma that stop you from diving are where the triggers are exercise, cold or emotion. With these there is a risk that an attack of wheezing can occur underwater, and as we know this leads to air trapping in the alveoli, that expands on ascent, ruptures into the bloodstream and causes a gas embolism to the brain.

A diving doctor will always exercise test the asthmatic if there is a risk of this being the trigger and a significant decrease in the flow rate during exhalation after exercise will result in a bar to diving.

So your good old well controlled allergic asthmatic really has no greater risk to lung damage than a smoker who is allowed underwater, so over here we let them dive.

Now in Australia it seems that this is not accepted, and anyone who has the asthma label cannot ever dive. This is probably because it has become one of those group opinions that just become entrenched into the psyches of a body of doctors, and they have never been lobbied by a large group of asthmatics to review their rules.

I suggest that anyone who is going to learn to dive and has asthma gets checked over in the UK first of all because you don’t want to take the risk of being disqualified nonsensically out there, and the Barrier Reef is pretty boring if stared at through a glass bottom boat.

As you are in the Phillipines you need to find a local diving doc, and the best way to do that is to call the nearest Dive Chamber who can point you to a suitable person.

As for research papers, take a look at the BMJ website www.bmj.com and put in the keywords diving and asthma. So don’t be too concerned as to what the other doc said and go for that Instructors Cert.

Good luck!

Asthma: Case Study 6

Q: I have asthma and I am thinking of taking a diving course soon. Will I need to get a medical cert before I will be able to dive. I have done a try dive before and the doctor there said I was OK to a certain depth.

A: If you have asthma then it is necessary to get passed as fit to dive by a certified diving medical referee. Your normal GP probably won’t have the necessary experience to do this but PADI can give you details of a someone in your area or alternatively if you email me again I can give you details as well.

A while ago anyone with even a hint of asthma was told they couldn’t dive, but we are wiser now. In the cases where it is only mild and well controlled your risk of problems under water is the same as a smoker, and as they are not barred from diving there may well be no problem with your condition.

The other point is that you should make sure your diagnosis is correct. I have seen many so-called asthmatics over the years who , when asked, tell me they have always assumed they were, even when there haven’t been any symptoms for years, because the GP diagnosed it after a cough when they were 3 years old!Since then they have run a marathon a month and swim 50 lengths a week without using an inhaler or even wheezing slightly.

So it is worth discussing the complete history of your problem with the diving doc when you see them.

Asthma: Case Study 7

Q: I have had consultation with a dive doctor who thinks that I have a mild form of asthma. He sent me for exercise tests and the results suggest that exercise does not affect my peak flow rate. I wish to undertake a TDI Extended range course before I get the chance to see the dive doc for the second time. Would it be unwise to do this course before I see the dive doctor? I have dived to 20m without problems since the suspected asthma presented itself at the end of last year. I run for 30 minutes three – four times a week without problems.

A: I can’t see a problem there. If the dive doc thought you were fit to dive, with no exercise induced asthma and passed you fit for recreational diving, then you are automatically OK for the deeper stuff. With fitness and asthma, its not really a question about depth but how your lungs are. Remember your training, the first 10 metres is the danger zone when it comes to over-expansion injuries. So if your asthma is OK for that, then it’s OK for the TDI ER course. Just make sure you can handle narking, and a lesson from Dave at DLL, never shine your torch onto your ultra reflective computer in low viz on that course. Temporary blindness at 70m is not a lot of fun.

Asthma: Case Study 8

Q: I have been diving for a couple of years now and I am qualified to Rescue Diver level. I have asthma but this is mild and well controlled and only ever presents a problem if I suffer a chest infection (usually about twice a year Autumn/Spring). I had a chest infection recently which has lingered a bit and upset my asthma quite a bit (I had to use prednisolone tablets). I was feeling a lot better and virtually back to normal and decided to dive this weekend (Sat). I did a wreck dive at an inland quarry to a depth of 18 meters. The descent was fine and conducted slowly. On reaching the max depth and beginning to circle the wreck I began to feel that my breathing was a little laboured and uncomfortable. This did not feel like an asthma attack as my breathing wasn’t fast or panicked, just heavy and uncomfortable. I immediately signalled the problem to my buddy and we ascended slowly to 5 metres, completed a 3 minute safety stop, and then went to the surface. The total dive time was 18 minutes. Since then I have felt an uncomfortable “heaviness” in my chest and have been quite weak and tired all the time. I have used my reliever inhaler which helps the breathing but does not remove the heaviness. It doesn’t feel like regular asthma issues. I am concerned that I may have done some damage to an already weakened chest. Could it just be worsened asthma or could I have done some more lasting damage. I have rested since and obviously not dived again. Please advise as I am really concerned. It seems to be getting better with rest but I want to be sure I can’t have done any lasting damage. I don’t see the point in visiting my own doctor as he has no specialist diving knowledge. Please help!

A: Yup, you need to see a diving doc asap. And one that works near a dive chamber too. There is a theoretical risk that you could have a DCI here. Lets say the infection had not cleared fully, or there was some sort of gunk plugging your bronchioles, then expanding air could pop an alveoli and release bubbles into the system. This could give you the funny chest feeling, and other symptoms to boot.

So you need lung assessment, and you need it fast.

Asthma: Case Study 9

Q: Hi. I’m a lifelong asthmatic but in the last couple of years it seems to have got worse, and my GP can’t work out why. I’m 36 now and have been diving for 2 years, never with any lung problems though. My GP referred me to a specialist and they recommended some breathing exercises called Buteyko. They seem to be helping but I’m a bit concerned about continuing to dive. Do you know about this idea and if it’s safe to dive still?

A: Buteyko was invented by a Russian professor in the 1950’s and in 2008 was the first complementary therapy to be endorsed by the British Thoracic Society in its guideline on asthma. It’s based on the theory that asthmatics are long-standing ‘overbreathers’, and by reducing the breathing rate and volume of each breath, symptoms can be alleviated. One technique taught is to hold your breath until it becomes uncomfortable, simulating the ‘air hunger’ of an asthma attack. Obviously this would not be a good idea whilst diving! Another theme is the emphasis on breathing through the nose, which helps clean and warm the air before it reaches the lungs. This is obviously impossible using SCUBA equipment. But the idea of calm, relaxed breathing has parallels with the yoga techniques used by freedivers, and would definitely be beneficial. It’s important to realise all this is not a substitute for standard inhaler treatment though, more an adjunct to it. You’d still need a dive doctor’s clearance before tackling the wet stuff.

Asthma: Case Study 10

Q: On a recent trip to Australia I went to a locaI diving outfit to book onto a liveaboard. I had asthma as a child but grew out of it years ago so didn’t think it would be a problem. I did mention this to the staff and they took what I thought was a very hard line, saying I had to get it checked out by a doctor and get a “bronchial provocation test” before they’d take me. To cut a long story short I couldn’t find a doctor in time so had to bin the trip. Is this standard practice for someone like me, who hasn’t needed an inhaler for about 10 years?

A: Diving with asthma is still a controversial issue, and the Australians are known for their conservative approach to it. Even so, without wishing to offend our South Pacific cousins, I’d say you were a bit harshly done by here.

Inhaled salt water can cause a sudden tightening of the airways, and the bronchial provocation test involves squirting saline into the airways and then monitoring the lung function to look for signs of the airways tightening up. However, in one study of asthmatics, half of the subjects did not show any evidence of lung constriction in reponse to salt water inhalation. So it’s not a particularly good way of predicting diving-related illness.

Is there anything better? Unfortunately, not really at least, there’s no simple practical test that can 100% exclude the risk of lung damage. In the end it comes down to regional attitudes to risk, and sometimes you have to accept the law of the land in which you dive.

Asthma: Case Study 11

Q: My 10 year old daughter Lucy has asthma, which she’s had since birth. In her first few winters it was quite severe and she ended up in hospital on several occasions. Thankfully this has become less frequent as she’s got older, but she still has to take a daily preventer inhaler and a tablet to keep it under control. My husband is a dive instructor and is keen on Lucy trying out diving, but obviously only when it’s safe enough for her. Do you have any thoughts on this?

A: Childhood asthma was, until relatively recently, considered a psychosomatic disorder. The plaintive wheeze was interpreted as a child’s suppressed cry for its mother, and the treatment of depression in such children was therefore the focus of their management. In these more enlightened days we know that many children with ‘episodic wheezing’ will grow out of it as they get bigger and their airways become larger. I’m not sure Lucy’s quite there yet though. Use of daily preventitive oral medication in a child is indicative of moderate to severe asthma, and there’s also the issue of how she might respond if an attack occurred underwater panic and a rapid breathholding ascent are much more likely in a child. My advice would be to hold off until her teenage years and reassess then. She’ll be older, wiser, hopefully fitter and healthier, and diving will be still be around. Unless we’ve all been swamped by global tsunami’s of course.

Asthma: Case Study 12

Q: I have recently signed up to do a PADI diving course and because I have very mild asthma, have been asked to get a medical form signed by my family GP.

This she has signed to clear me as Fit for Diving; however she has since contacted me regarding this and states that she has read up on the guidelines and discovered that I need to undergo lung function testing and spirometry before her signature can be fully valid. I believe this NOT to be the case as spirometry tests are normally only done on bad asthmatic patients and patients with COPD. Could you please confirm who is correct as I need to sort out what to do ASAP.

A: In this case I thoroughly agree with your GP. Any asthmatic needs to undergo full lung function testing before diving. The reason for this is that symptoms of asthma do not correlate well with objective measurements of lung function; I’ve seen plenty of people who claim their asthma is well-controlled whose spirometry tests are appalling and would make diving very dangerous. That said, there is no consensus on what test results should be deemed acceptable.

For those in the dark, spirometry involves a forced exhalation into a machine which estimates lung capacity, and how much of the total capacity is exhaled in one second. This can be seen as a measure of the ‘elasticity’ of the lung, and most would agree that 70% is a minimum result. The other important point is that asthma is an ‘episodic’ disease; what a doctor sees in a short appointment is not necessarily what will be the case the next day. All this needs to be explained in detail, in person, so I’d suggest getting yourself to a doctor with some diving medicine training.

Asthma: Case Study 13

Q: I’ve had asthma all my life and always thought that meant I could never take up diving. But in the States on holiday recently, I came across a snorkel for asthmatics, with an attachment on the side for an inhaler. I enquired into this and the shop assistant then showed me a similar device for divers, a normal-looking regulator with an extra hole to insert an inhaler. Have you seen these before? What is your opinion of them?

A: I have seen these and I have to say I’m very dubious about the idea of either. I’m not trying to be a killjoy; in fact the basis of my approach to all fitness to dive issues is that I have to have a good reason not to say yes. My major gripes with these types of devices are that they are really sending out a signal that any asthmatic can dive, and that having a dose or two of an inhaler will alleviate all the symptoms of an underwater attack. Granted, the manufacturers do emphasise that they are not condoning the safety of diving for all asthmatics, but this is the impression that will inevitably arise. If an asthmatic feels the need to use a reliever inhaler, should they be in the water in the first place? And a severe attack will sometimes not be alleviated by any inhaler, no matter how many puffs are administered. Such a diver would be at great risk of lung barotrauma, air embolism and, with a panicked, uncontrolled ascent, DCS too. Since the maximum expansion of gas occurs in the uppermost few metres of water, the risk of lung rupture is actually highest here, so I’m afraid the snorkel gets the thumbs-down from me as well as the regulator.

Gas Embolism: Case Study 1

Q: I have been diving for a couple of years now and I am qualified to Rescue Diver level. I have asthma but this is mild and well controlled and only ever presents a problem if I suffer a chest infection (usually about twice a year Autumn/Spring). I had a chest infection recently which has lingered a bit and upset my asthma quite a bit (I had to use prednisolone tablets). I was feeling a lot better and virtually back to normal and decided to dive this weekend (Sat). I did a wreck dive at an inland quarry to a depth of 18 meters. The descent was fine and conducted slowly. On reaching the max depth and beginning to circle the wreck I began to feel that my breathing was a little laboured and uncomfortable. This did not feel like an asthma attack as my breathing wasn’t fast or panicked, just heavy and uncomfortable. I immediately signalled the problem to my buddy and we ascended slowly to 5 metres, completed a 3 minute safety stop, and then went to the surface. The total dive time was 18 minutes. Since then I have felt an uncomfortable “heaviness” in my chest and have been quite weak and tired all the time. I have used my reliever inhaler which helps the breathing but does not remove the heaviness. It doesn’t feel like regular asthma issues. I am concerned that I may have done some damage to an already weakened chest. Could it just be worsened asthma or could I have done some more lasting damage. I have rested since and obviously not dived again. Please advise as I am really concerned. It seems to be getting better with rest but I want to be sure I can’t have done any lasting damage. I don’t see the point in visiting my own doctor as he has no specialist diving knowledge. Please help!

A: Yup, you need to see a diving doc asap. And one that works near a dive chamber too. There is a theoretical risk that you could have a DCI here. Lets say the infection had not cleared fully, or there was some sort of gunk plugging your bronchioles, then expanding air could pop an alveoli and release bubbles into the system. This could give you the funny chest feeling, and other symptoms to boot.

So you need lung assessment, and you need it fast.

Infections: Case Study 1

Q: I would appreciate your advice re an injury I have sustained. After having a cold and cough for approximately a month, I developed a pain to the right side of my ribcage. I visited my GP, when the pain failed to subside after about a week. At this time I was informed that I had cracked one of my ribs and it may take 4-6 weeks to heal itself. This was about 5 weeks ago. The pain has generally gone, but I get discomfort on sneezing, etc. and after vigorous exercise. I am a keen sports diver and concerned as to effects of diving on this injury. Is there a recommended time I should refrain from diving? (I am 31 years old and have no other illnesses or injuries and take no medication.) Thanks in anticipation of your advice.

A: I think that you have waited long enough to get back in the water. If you suffer a rib fracture for whatever reason then it will be pretty much healed in 6 weeks.

The thing to watch out for is the pain and the way it may limit your ability to inhale.

If you find that on inspiration when the chest expands that it catches, and makes you cough, then this is a problem underwater. On top of this is the effect of an inflated BCD pushing onto the painful area. This may compound the problem. So my tip is to put on your BCD at home, orally inflate it and try to breathe in as deeply as you can. If there is no pain and you can inhale fully then you should be fine to dive.

A point though from what your doc told you. There are other reasons for late presentation localised chest pain if you start with a simple cough. Rib fracture is rare, but there could be a chance that you have a pneumonia or pleurisy. This is where the outer lining of the lungs get infected and can cause a similar sort of pain. I think that if you are still getting pain now a chest X-ray would be useful as you shouldn’t dive with the latter two.

Infections: Case Study 2

Q: I am planning to start diving next week but my concern is the illness that I had 9 months ago. It was tuberculosis, and it was in my lungs …I wonder if I could dive. Treatment completed 3 months ago and I don’t use anymore medication…another thing that I would like to ask you is that I have Hepatitis B and I receive treatment for that which is the drug called NIMUVADINE(100MG).

Could you contact my diving centre which is called Triton Diving in Islington, London and my self to advise me on these matters..?

A: Let me be the first to break the bad news. Sorry it’s no diving for you.

It’s not the Hepatitis B though. Divers are not a squeamish lot. The prospect of doing CPR and mouth to mouth on a Hep B positive buddy is not an issue, with protective mouth guards that are used nowadays. And any liver enzyme derangement will not affect diving.

The issue lies with the TB.

Lung TB is not a fatal thing like in the old days of seaside sanatoriums. But it does cause terrible cavitating lesions in the lungs when it is pulmonary or lung TB. So when you dive, the air would enter the lung under pressure of depth. Air trapping would be the inevitable result as it would not be exhaled. On ascent [you can’t stay down there forever remember] the air would expand and. badoom, air bubbles into your lung circulation, left heart and of into your brain and spine.

Sorry to paint such a bad picture but you need to realise how dangerous it would be to dive.

I am glad though that Triton Diving had the foresight to get you to mail me first, they obviously seem to know what they are doing.

Infections: Case Study 3

Q: I grew up in India and had tuberculosis (TB) at a young age. Unfortunately I didn’t improve despite all the drugs that were given to me (for at least a year I think). In those days the only treatment they could offer me was pulmonary resection – cutting out the part of the lung with TB in it. My parents were very worried I would not survive the procedure. I am now in my 60’s and have never had any suggestion of the TB returning. I am fit for my age, and 2 of my sons have qualified as divemasters. Now they want to take me diving, and I would like you to tell me whether this is possible. (is vital capacity the sum of BOTH lungs?)

A: Tuberculosis, aka ‘consumption’ (so-named because of its ability to ‘consume’ genetically-susceptible sufferers), was the scourge of Europe in the 19th century. Its hardcore statistics make grim reading. 1 in 4 deaths in England was due to TB in 1815. Traces of TB have been found in the spines of Egyptian mummies, so it has been around for thousands of years. Although nearly eradicated in the 1980’s, the nasty bacterium is now making a comeback thanks to the emergence of HIV and multi-drug resistant strains.

TB tends to target the lungs but can be found in almost any tissue. It is spread by air (coughing, sneezing, spitting), producing a new infection at the worldwide rate of one every second. One of its scariest aspects is its ability to lay dormant for many years. It is estimated that a third of the world’s current population has been infected, but most cases will luckily remain asymptomatic, with only one in 10 going on to develop active disease.

Treatment consists of a wolf’s liver taken in thin wine, the lard of a sow that has been fed upon grass, or the flesh of a she-ass taken in broth. At least it did in Pliny the Elder’s time. These days antibiotics are the norm, although they are only barely more palatable. But in the pre-antibiotic days of the 1940’s, surgery was the commonest method used to try to cure the disease. You don’t say how old you were at the time the scalpel was wielded on your lung, but I would guess 40 to 50 years have elapsed since. Active TB is a complete no-no for diving, but a past history does not necessarily exclude it. The key question is, are there any cavities or scarred areas in the remaining lung tissue that might predispose you to pulmonary barotrauma? To find out you would need to see a respiratory physician and have some pretty detailed scanning of the lungs, as well as functional testing (blowing into various machines, usually via a suspicious-looking toilet roll tube). If the tests come back clear, then certainly diving is possible.

Lung TB is not a fatal thing like in the old days of seaside sanatoriums. But it does cause terrible cavitating lesions in the lungs when it is pulmonary or lung TB. So when you dive, the air would enter the lung under pressure of depth. Air trapping would be the inevitable result as it would not be exhaled. On ascent [you can’t stay down there forever remember] the air would expand and. badoom, air bubbles into your lung circulation, left heart and of into your brain and spine.

Sorry to paint such a bad picture but you need to realise how dangerous it would be to dive.

I am glad though that Triton Diving had the foresight to get you to mail me first, they obviously seem to know what they are doing.

Lungs: Case Study 1

Q: I read with interest your column in Sport Diver, and have a question for you.

My father, sister and brother all have marked alpha-1-antitrypsin deficiency(genetically predisposed deficiency of a protease inhibitor), predisposing them to emphysema. I have only a mild deficiency, and I have been diving for five years without problems, although I avoid technical diving.

My question regards my younger brother, who is 17 years of age, and is in good general health and does not smoke. Is recreational scuba diving going to be contra-indicated for him, or is it reasonably safe to recommend him to take it up?

Any advice would be greatly appreciated.

A: Alpha-1-antitrypsin deficiency is one of the commoner genetic disorders but is still rarely found. Basically it is a lack of the protein of the same name which has the function of keeping in check another protein called neutrophil elastase. The purpose of this is to digest ageing lung cells or bacteria in the lung. The problem with neutrophil elastase is that once it gets going on these cells it will go on and destroy the healthy lung cells unless the alpha-1-antitrypsin is there to stop it. So people with a deficiency of this will go on and get permanent lung damage, called emphysema.

But the question in your brothers case is how deficient is he, and does this deficiency mean that he will definitely get emphysema, and if so when?

Some research shows that even if he has only 15% of his expected level of alpha-1 then he may well not go on to get emphysema. On top of this there is a replacement treatment called Prolastin that can slow down the lung damage to the same levels as the rest of us.

If he has got any lung damage it would be fatal to dive, as the emphysema results in air pockets in the lungs. This means that air inhaled would not be able to be exhaled and would expand on ascent resulting in pulmonary barotraumas and CAGE as with the asthma question.

So the question is, exactly how bad is your brothers deficiency, has he been on any treatment and are there any signs of emphsema yet, despite his young age?

As you say it is “marked” then I guess that he is a bad case. Lung function testing and X-rays can tell how bad any damage is. But the only hope would be that if a Respiratory Physician were to be able to 100% guarantee that there were no lung effects yet then he may be fine at this stage. However most docs wouldn’t risk this sort of call to sign off a diver, so sadly it may be better if he pursued another sport.

Lungs: Case Study 2

Q: Can you confirm what range or percentages a normal result from a lung function test falls into. I’ve started doing a lot of yoga including breathing exercises and my most recent medical showed I was exhaling 115% of my predicted capacity. My yoga instructor has just done her open water training and her result read 170%. Does a higher than average lung function have any advantages or disadvantages when diving?

A: Big lungs are generally better for diving (less gas consumption, in theory) and you tend to find that people who dive regularly (such as commercial divers) get progressive increases in their FVC (forced vital capacity, which approximates to your total lung capacity). Most divers tend towards an increase in FVC with age but the general conclusion, that divers tend to have larger vital capacities than non-divers, was not confirmed by a study of 126 saturation divers by Thorsem et al (1989). They suggest that the increase is transient and that later there is a greater decline. Any change of vital capacity probably has little effect upon the diver’s general health.

There have been some studies that suggest divers develop a degree of air flow obstruction due to airway narrowing over the long term. However more recent studies have not confirmed this, and actually in a group of military divers there was no evidence of obstruction compared to non-divers. In divers who smoke however there was a much more marked decline in lung function so there’s an obvious message there.

Some swimmers and divers I know use resistive training devices such as the PowerBreathe to improve their lung function and there is good evidence that this helps asthmatics; it helps strengthen the inspiratory muscles and produces similar changes to yoga breathing exercises. So adopt that Wind Relieving pose, stop smoking and watch your lung capacity and bottom times soar!

Lungs: Case Study 3

Q: Hi Doc,

I was first diagnosed with Synovial Sarcoma in ’92, a 2cm lesion on external fascia of right rectus sheath. Broad excision completed Sep ’92 No further treatment, but Scans for 5 years.

In July 2004, noticed a lump in left thigh, CT of thorax showed huge mass in upper lobe of right lung. Resection of thigh lesion 13 Aug 04, Lobectomy Sep 04. Began 6 cycles of high dose Doxorubicin/Ifosfamide in Oct and completed Jan 05.

Have discovered further lesions in right thigh, all those big enough to remove have been (2 weeks ago). No ongoing medication, but potential for further chemo (Gemzar/Taxotere……maybe ET742) as things develop. I was told by my thoracic surgeon that I’d be ok to dive 6 weeks after the lobectomy, although naturally, didn’t dive during chemo (too weak, too much neutropeania!).

However, since chemo finished, I’ve completed 30 dives, (max 38m) as well as my PADI EFR and Rescue Diver courses. My last thorax CT (3 weeks ago) was squeaky clean. I have pristine lungs (what’s left of ’em), no bullae, and excellent lung function.

The reality is that I’m likely to have further mets, and that this disease is going to kill me. But I’ll be damned if I’m going to sit on my arse and watch it happen, so whatever happens, I WILL be diving again.

However, to dive where I want to, with the people I want to, they have implied that I need a medical (purely because of the lobectomy), and I’m a little cautious about that. From what I understand, and my experience to date, I genuinely don’t believe that I should be barred from diving (at this stage…different if I get more lung mets). Could you give me your opinion as to where I stand?

I’m very grateful for your advice!

A: A sad tale. Well done for coping with everything thrown at you so far. A lesson to us all.

In your situation, where you are going to dive anyway, as you say, then we have to be rational. If your surgeon feels you are fit, and there is no risk that an undiagnosed metastasis will affect you. [i.e one that appears before your next scan] then you should approach an empathic dive doc and get some lung and blood tests to make sure you wont be a risk to a buddy.

I think if you are going on a dive holiday, then get a check up, as well as a scan if you can as close to departure as possible. I assume you have enough power in your legs after all that tissue removal, if not consider a DPV.

Finally some chemotherapeutic agents can affect the lung structure, so the lung tests are the real deal here. Get to a doc, and work up a good relationship as you may be better off having 3-6 monthly medicals.

Lungs: Case Study 4

Q: My boyfriend has recently been diagnosed with sarcoidosis, bit of a nightmare as we are divemasters and have flights booked to Thailand to do our instructor course.

He has seen the specialist and his lung function tests are better than average, but he has a small amount of scarring on his lungs. He has never experienced any symptoms and we probably never would have known if it wasn’t for a chest x-ray needed for Aus visa (which apparently we now can’t have, but that’s a different nightmare).

The specialist has told him that it will probably go away and no treatment is needed, but the big question is can he dive?

Your website is most helpful and your comments would be appreciated.

A: This is a funny old illness of unknown cause which is extremely variable in severity and duration. It gives rise to “granulomas” (small nodules of inflammation) in any organ, but most commonly the lungs and lymph nodes. Young adults of both sexes are typically affected, peaking in the 20-29 age range. The symptoms are often vague at first; fatigue, dry eyes, a cough, general aches and pains; the sorts of things young adults dismiss, so the diagnosis is sometimes delayed. As in this case, most sufferers are picked up on chest X rays or breathing tests performed for another reason. You see a classic shadowing on the lungs caused by big lymph nodes in the early stages, but this can evolve into more serious lung disease. And this is why diving might be a problem: our old friend pulmonary barotrauma. Active sarcoid can cause scarring or air trapping, predisposing a diver to burst lung.

Treatment usually involves steroids or other immunosuppressant drugs, but mild cases often remit without therapy. The hope in your boyfriend’s case is that, given time, the lung changes will clear up, but it could take many months. My advice is not to dive until you have a clearer idea of the course of his illness.

Lungs: Case Study 5

Q: I would like to know if you can give me some advice after having pneumonia and a pleural effusion. I went to A&E after breathing difficulties & coughing up blood (only small amounts in a tissue over 12 hours). I was kept in for 4 nights & treated with antibiotics (clinical presentation said pleuritic chest pain & haemoptysis) then sent home with a follow up appointment in 6 weeks. At this appointment I was told that I had a pleural effusion after an episode of pneumonia and had 660 mls of clear fluid drained from my right pleural cavity (ie. not from inside the lung). After a follow up appointment a couple of months later I was told that there was still fluid present but that they would like me to try and get rid of it naturally over time rather than drain or syringe it out.

I was told by the non diving doctor that providing my fitness was OK then there would be no problem diving. Would it be possible for you to confirm this please? I currently only dive in warm water on holiday.

A: A pleural effusion is a potential complication of pneumonia, but one that will often clear up by itself (if the volume of the effusion is not too large). Just to get the anatomy clear (as you know I’m a stickler for these things), the pleurae are membranes that cover the inside of the chest cavity and the surface of the lungs, forming one continuous lining. The space in between the two layers usually contains a small amount of fluid (3-4 teaspoons or so), to lubricate the movement of the lungs against the chest wall with breathing. Normally surface tension holds the two layers close together, allowing the lungs to expand maximally. If 660 mls of fluid accumulates in this space it effectively squashes down the lung tissue, so reducing the surface area over which gas exchange can take place. So less oxygen makes its way into the blood, and if you factor in the increased work of breathing at depth, then it’s easy to become dangerously low on oxygen in this situation.

Before you dive again it would be important to ensure that all of the fluid has been reabsorbed, and there is no significant scarring of the lungs. This is probably going to mean some X rays to ensure the lung fields are clear, and a set of lung function tests. You might be able to organise these via your GP, but you may require a visit to a local dive doc to get your fit to dive certificate.

Lungs: Case Study 6

Q: I’ve been diving for 30-odd years and was a smoker until five years ago (I’m now 48). Unfortunately I think I left giving up a bit too late: I was diagnosed with chronic obstructive pulmonary disease (COPD) six months ago. The docs say it’s mild but because I smoked for 20 years (an average of 40 a day) it’s likely to get worse. I do wake up coughing and have to clear some fairly putrid-looking oysters (sorry) in the morning, but otherwise I’m pretty fit (still run and cycle to work). Can I still dive?

A: Your typical COPD case is picked up in those aged 45 or older, with a smoking history of at least 20 pack-years. (Pack-years is a quick way of estimating long term smoking exposure; one pack year is equivalent to smoking 20 cigarettes a day for one year, so in your case you have a 40 pack-year history.) Early symptoms such as frequent throat clearing, breathless on mild exertion and an irritating cough are often blamed on aging or lack of fitness. Progression to chest tightness and wheezing may take years, but other behavioural signs may appear first; avoiding the stairs in favour of the lift, taking longer to mow the lawn etc.

Lung infections become more common and severe as time wears on. Your major achievement has been to stop smoking, which is the most important treatment. There’s nothing you can to do to reverse the damage, but at least it won’t accelerate now. Medications can help widen the airways and treat infection, and no doubt these have been discussed with you. I’m afraid your diving days are numbered though; poor lung function will reduce exercise tolerance and put you at risk of barotrauma. Borderline cases with very mild symptoms and satisfactory lung function tests might get away with it, but it’s difficult to be certain of safety and personally I wouldn’t risk it. Time to hang up those fins.

Pneumothorax (Spontaneous): Case Study 1

Q: Many years ago, I had on 2 separate occasions a Spontaneous Pneumothorax. If memory serves correctly it was on the same side. That is the left side. I do recall that the doctors told me that this is a common occurrence amongst young tall, thin men. I am not that tall (5’10”), I am now older and heavier (31 next week and just under 11 stone). My last ‘attack’ was in early 1994. As it has been 7 years since I was last affected by this, is it sufficient time to assume that I am now safe to start scuba diving?

Do I need to have any specific tests done?

Will I need a proper medical certificate?

I am going on holiday in July to the Maldives and I think that this would be a wasted opportunity not to have an introduction to scuba in such lush tropical waters, as Scuba is something I have always longed to do.

I appreciate any help and advice that you could offer me in this respect. Many thanks.

A: To answer both your questions in turn. Yes and yes.

A pneumothorax is when you burst the outer lining of your lung. What then happens is that the air you breathe in instead of being exhaled normally can escape out of the newly blown hole into the chest cavity. The more air that escapes, the more this air can then crush down on the lung as it is all enclosed, so eventually collapsing down the lung. So imagine a situation where air under pressure in inhaled when you dive, a pneumothorax occurs and then as you ascend this air expands.
You would be breathless in seconds and in some cases the venous blood flow back to your heart can be cut off too. Nothing in to the heart, nothing out and then death is the sad eventuality.
So you can see the risks of diving if there is any chance of this happening again.

The stats on pneumothorax is that it can occur for no reason in young tall fit men and can reoccur again soon after the first event. However if a period of 4 to 5 years goes by without a recurrence then it is unlikely to come again.

The key fact as a diving doctor is what are the risks of a repeat episode and will that happen when you are diving.

We assess this by both waiting a number of years after the first event and also having a special scan of the lungs to see whether there are any abnormalities that will cause another pneumothorax. This is called a CT scan.

If it is at least 5 years post initial pneumothorax and your CT is normal as well as lung function studies then you should be fine to dive.

This though throws up an interesting issue that I have come across many times with divers in your situation. Because diving is a recreation the good old NHS will not do your CT for free as it is deemed non-essential to your continued wellbeing. This means that you have to fork up for a private CT which comes in at about -300 to -400 before you can dive. I personally think that this is a mad situation as you have been honest about your problem and you now have to foot the bill through no fault of your own. If you had been a smoker and suffered lung problems then all CT scans would be free. Write to your MP on that one.

To your second question, you will need to be signed off by your local diving doctor after seeing the CT results before you can learn to dive.

There are other causes of pneumothorax that can mean a quicker return to diving but we will look at those next month.

Pneumothorax (Spontaneous): Case Study 2

Q: My name is Melany and I’ve recently moved to Dahab to work and to learn how to dive but unfortunately due to an incident that happened more than 21 years ago, I’ve been advised that I can never take up diving. What happened was I suffered a collapsed lung on the right side, just the top part of it went, I had X-rays, was given a course of tablets to take (can’t remember what they were) that went away but some weeks later I had the same problem with my left lung, what it was due too I was never told, again I took tablets and this problem has never re-occurred nor have I ever suffered any discomfort. I don’t smoke and rarely drink alcohol. I live a healthy, clean life-style and would very much like to exhaust every channel of hope before I give up my dream of being able to dive. I won’t attempt it has the advise I’ve received from the club I work for ( dive urge ) are very professional in their approach to my problem and I intend to see a doctor again when I’m back in the UK in April but would very much appreciate any advice you can give me on this.

A: There is a school of thought, not supported by many dive docs, but still expounded at conferences we go to, that a past history of collapsed lung [pneumothorax] is not really a bar to diving in the future. I prefer a more logical approach, and that is as follows. The causes are little blebs or pouches on the lung surface. If they burst, air gets out, and the outside pressure collapses the lung. They often repeat themselves soon after, but then never occur again. It it were to happen underwater, then it could be fatal, so you must make 110% sure that there are no blebs left. This can be done by an operation to stick the lungs to the chest wall. However before you leap into this, there are tests to se if your blebs have gone. A certain sort of CT scan can show the lung structure and resolve the issue for you. So I suggest you arrange for one of these on your UK return. If all is well then you could be allowed to dive. But if there are still abnormalities, and you are commited to Dahab, then you had better go buy a windsurfer.

Pneumothorax (Spontaneous): Case Study 3

Q: Hello, I’m interested in giving diving a go, but I have a history of spontaneous pneumothorax. A friend of a friend who is a diving instructor said you might be able to advise me. I first had a pneumothorax in 1994 at the age of 18 on my right lung. I had a chest drain put in for that at Maidstone hospital. A few months later my left lung collapsed and I had surgery for that at Guy’s hospital in January 1995 (thoroscopy and then pleurodesis). I had no more trouble with my left lung, although my right lung would occasionally suffer small relapses until I got to about 23 years old (1999) – these reccurences were never large enough to require treatment though, and resolved themselves.

As I say, I’m interested in trying scuba diving but I understand that with my medical history I might not be suitable. I feel completely confident in myself that my lungs are fine now, but I was hoping you could advise me on the best way to be certain that I would suffer no ill effects from scuba diving.

A: I’ve got a bad feeling here. You have never dived, and there are loads of things you could do otherwise. And having a pneumothorax underwater could be fatal. I just don’t think you should risk it. Sure you could get CT scans, MRI’s and see the worlds best lung Professor, and get passed with a lot of finger crossing. But mate, if if if, so to speak. Go spelunking or canyoning or whatever. A burst lung there, and you can easily survive. But just don’t risk messing with the physiological laws of expanding gases in confined places, i.e your thorax on ascent.

Pneumothorax (Traumatic): Case Study 1

Q: I am proposing to go on a diving holiday, but wanted to ensure that I am medically fit enough to go, and wondered if you can help? I had a pneumothorax as the result of a fractured rib, two years ago. I am fully recovered now. Do you foresee any problems?

I had a seizure, also at this time, due to a head trauma. This seizure occurred whilst unconscious. I have had none since, and have been declared medically fit to drive. I do not take any medication. Are there any problems with this too?

Finally, I sustained some fractures in my pelvis and upper left arm. Both have healed and I have no problems.

Am I medically fit enough to go diving?????
Thank you very much for your time.

A: There are 3 issues here to deal with. As your punctured lung or pneumothorax was as a result of injury, rather than being spontaneous, it is more likely that you will be fit enough to dive.

You still need to have your chest examined by a qualified diving physician, and our regulations also call for a CT scan of your chest to make sure that all is well now before we can recommend you dive again.

Your seizure is less of a problem. In normal cases of head injury the length of any amnesia or presence of a seizure will decide the lay off from diving time. You have been fine for the last 2 years with no problems , so I think that this shouldn’t be a problem to you.

Finally the fractures you sustained are of relevance only if they stop you from kitting up on a RIB, or mean that you would not be able to look after your buddy if they had a problem. The other thing to have checked by your diving doc is if there is any residual problems left by the injury which could be mistaken for a bend, by this I mean areas of numbness or joint pain in your pelvis or upper left arm .It’s best to have these documented now, so you are not incorrectly diagnosed as bent in the future. So, if the chest CT is fine look forward to getting wet!

Pneumothorax (Traumatic): Case Study 2

Q: Recently my boyfriend and I went an a rescue diver course in Looe. We finished our course on the Friday doing our last dive on the Friday morning. We returned home both feeling fine. On the Monday my boyfriend went for a run and ended up in hospital. The doctors diagnosed him with a pneumothorax (although the lung did not completely collapse it just had a hole in it). Do you think that this could have been diving related? Also do you think that it would be safe to dive again? The doctors at the hospital he was at said he should consult a diving specialist doctor.

A: To answer your question… Yes. There is a chance that it could be diving related.

If for some reason he had had some pulmonary barotraumas i.e. lung damage , mainly due to breath holding during ascent then this may have only gotten worse when he was exercising fully i.e. during his run. But we have to assume that it was a spontaneous pneumothorax which can happen in tall skinny people when they are exercising. They have something called “bullae” which are large blown out lung bubbles. During exercise these can burst spontaneously with a sudden onset shortness of breath and chest pain on the side of the problem. Now the problem with diving is that if these fill with compressed air at depth they then have the air expand on ascent which causes these lung ruptures, which can be fatal.

I actually think your boyfriend was very lucky not to have had this happen to him underwater, which could have happened if he had had a very exhausting dive. But whatever the cause, the fact remains that after such an event he should avoid diving for 5 years, and after that he needs a CT scan of his chest to make sure all is well afterwards If he smokes he should stop immediately as this increases the risk of recurrence dramatically.

Sorry to bring the bad news, but it’s snorkelling for now.

Pneumothorax (Traumatic): Case Study 3

Q: I have been given you name from the London Diving School. I am looking to go diving at Easter but just wanted to check some medical details with you first. I had a car crash 16 years ago and my lungs collapsed and I was on a life support machine for 10 days. Unfortunately the crash happened out in Saudi and so I was not allowed to take any of the medical records out of the country. I was 14 when it happened – now 30 and fighting fit with no conditions at all. Could you advise me if it’s ok to dive this Easter?

A: The chances are good for you. The reason for this is because although you had bilateral pneumothoraces. Punctured lungs in effect, it is more allowable to have had these if they were caused by a traumatic event, than if they were spontaneous and occurred as you were ambling down the street. In such a serious accident as this, often the ribs will break, puncture the lining of the lungs, the pleura, and cause air to enter around the lung on each breath, which then crushes the lungs slowly. Life threatening stuff, and in need of a great big tube in through the chest to decompress the lungs. But once resolved, as your lungs were in good nick before, they should be fine after. So all you need is this checked with a test called spirometry. Contact your local dive doctor for this.

A spontaneous pneumothorax means there is underlying disease, and one which can occur again at any time where there is exertion. These people need to jump through a lot more hoops to be able to dive than you.

Bit odd, though, them not letting you take your medical records with you. They would be useful, so call the British Embassy out there, drag the ambassador away from his Ferrero Rocher and tell him to go get ’em.

Pneumothorax (Traumatic): Case Study 4

Q: I’m hoping you will give me some information over a problem I’ve had for some time. About 15 years ago I was attacked with a baseball bat and a machete, I was on life support and in a coma with multiple injuries. When I eventually got out of hospital I started going to a gym and got myself fit again, a few years ago I started diving, I’m now an AOWD and I love it. The problem is, one of my injuries was a collapsed lung, the hospital drained all the tar which had accumulated over the years being a heavy smoker and cleaned me up I haven’t smoked since, I don’t have any problems healthwise but I do use Seretide 500 once a day for asthma which doesn’t effect me in any way. I’ve had numerous health medicals all proved good but I’ve never told anyone about the lung problem. It is now starting to worry me before each dive as I am ignorant to the fact of what might happen, my wife keeps going on at me to write to you. Please explain to me doctor, what’s the consequences, can I keep diving or am I just being an idiot aged 55 but fit.

A: I don’t think you’re being an idiot at all, but there are some issues here. Firstly, a word or two about collapsed lung, or “pneumothorax”. The lung normally sits happily in the chest cavity, like a balloon, but if the surface is damaged then air leaks out into the chest. As the air accumulates, the increasing pressure crushes the lung down, until eventually it collapses; a pneumothorax. These are generally split into 2 types, spontaneous (out of the blue) and traumatic (due to an injury of some sort). Spontaneous ones can occur in young people, skinny tall smokers being particularly prone, or in older individuals with underlying lung disease (again most common in heavy smokers). Sometimes even a hiccup is enough to rupture a wee portion and allow air to escape. Traumatic ones are due to an injury, which can leave scars on the lung. Both types can predispose you to air trapping, with consequent over-expansion injury when you ascend from a dive. If the incident is 15 years in the past then it is very unlikely to cause a problem, but a CT scan of the lungs may be needed to be 100% certain. You should keep an eye on the lung function too, particularly with the asthma. Yearly spirometry (where you blow into a tube which estimates your lung capacity and elasticity) is a good idea. So I would pop down to your local dive doc and get the tests done for full peace of mind.

Pneumothorax (Traumatic): Case Study 5

Q: Hello. As part of an investigation into abnormal levels of iron in my liver my consultant wishes to perform a liver biopsy. This involves a 1 in 1000 risk of a punctured lung. I am a very active diver and would therefore not like to jeopardise this. What advice would you give? Does an “accidentally” punctured lung heal? Thank you.

A: Hi. As a kid I remember games of Risk that went on for days over Christmas. I realise now that it was a tactic to keep the aunts and uncles from each other throats while they deployed their armies and biscuit crumbs across the globe. But dealing with medical risk is an altogether more interesting concept. What does “1 in 1000” mean to you? If I told you that the chance of needing emergency treatment in the next year after being injured by a bed mattress or pillow is 1 in 2000, would that make you more or less likely to take this 1 in 1000 risk?

Oodles of stuff has been written about “risk perception”; how an individual understands and judges risk (and how that influences behaviour). People are much more willing to accept voluntary risks (such as driving a car, where the lifetime risk of dying in a crash is 1 in 100) than risks where they have no control. The risk of lung cancer from a pack a day habit is about 1 in 125 over a lifetime; for skin cancer from sun exposure it’s a staggering 1 in 3 (although most are non-fatal). 1 in 1000 is about the same probability as a 4-4 draw in a football match. A 5-5 score would be 1 in 10,000 and winning the Lottery about 1 in 3,000,000 so get down to William Hill rather than buying scratchcards. According to the HSE, the average annual risk of death from SCUBA diving is 1 in 200,000 dives. Pretty safe really.

Ultimately then, each individual has their own perception of risk, which is shaped by their personality, previous experiences and probably hundreds of other factors yet to be determined. On this aspect it’s therefore difficult to give black and white answers.

Punctured lungs I’ve covered in some depth in previous articles. The bottom line is that we are talking here about a so-called “traumatic” pneumothorax, where the cause of the lung injury is known (in this case an errant biopsy needle). So there is no reason to suspect that the underlying lung tissue is more susceptible to barotrauma or another puncture. Most of these types of injuries heal up and all that is required is some confirmation that the repair is complete, usually a CT scan and some lung function tests.

Word of advice for the New Year – take care in the bath. There’s a 1 in 685,000 chance you’ll drown in it before 2010.

Pulmonary Embolism: Case Study 1

Q: I recently went into hospital for 3 hernia operations and during the course of recovering developed a PE. I have been put on to Warfarin and I am advised that I will remain on it until August. My question is after I have completed the medication is there any reason why I shouldn’t be able to dive. I am a warm water diver and only dive on holiday!

A: You can dive on warfarin, but with heavy restrictions. However, if you can leave it until August, then that is safer. So, as long as the PE, or pulmonary emboli have not cocked your lungs up big time, then the answer is a resounding affirmative Captain.

3 hernias fixed at once. Awesome. I am just trying to get my head round what it must have been like pre-op for you, and thank the Lord for surgeons, or a triple truss would have made you more wrapped than one of those suitcases on a dodgy airline.

Pulmonary Oedema: Case Study 2

Q: Hello Doctor, can you give me some general advice please. 2 months ago, my brother undertook a trek to Aconcagua, a 7000m peak in Argentina. His trek had to be aborted when he was diagnosed as suffering from high altitude pulmonary oedema (HAPE). Since he returned to the UK he has recovered quickly and appears fit and well. Like all our family he is a keen scuba diver and had scheduled to go diving in Thailand next month. Do you think his lungs will have recovered enough for him to dive?

A: Despite being at the opposite end of the pressure spectrum, the pulmonary oedema that affects mountaineers is very similar to that which affects divers. The mechanisms by which fluid accumulates are different, but one effective treatment is to put the sufferer in a recompression chamber, just as with DCI. Happily, the changes of HAPE also resolve very quickly when the victim descends, and within 2 or 3 weeks the lungs are fully functional again. So after 3 months I would imagine he’d be fine to dive again. A set of lung function tests wouldn’t go amiss though, just to be on the safe side.

Pulmonary Oedema: Case Study 1

Q: I am a fit, healthy 25 year old who plays a lot of sport. I have done 70 dives with 60 being in temperate waters around Britain and Ireland. I have done all my dives in a wetsuit.

I developed what I believe now to be cold water induced pulmonary oedema on my 50th dive. The oedema occurred at the end of the dive. I had a chest injury at the time and I felt that that it was due to this. After a year break from diving and consulting a cardiologist, I returned to diving. I had all manners of medical tests: ECG, PFO test, exercise test, CT scan and all showed that I was in good condition.

I kept on diving in my wetsuit. I am cold on my dives but I tend to grin and bear it. Since my return to diving I have done 25 dives. Recently I was doing some deeper and longer dives and on my 70th dive, it happened again, at above 3m. I recognised it immediately, dekitted, got in the boat and put myself on oxygen. Again it cleared in 15 minutes. I went back to see my cardiologist and he suggested that I refrain from diving.

From what I have read in the literature on immersion/cold water induced pulmonary oedema it seems to me that there is a lack of consensus as to whether someone should refrain from diving or not. A diver I know back in Ireland had two cases 17 years ago but has been diving since. I find the advice to refrain from diving a little conservative. The UKSDMC say that since people have begun using drysuits that the number of cases of pulmonary oedema have dropped. I feel that the cold was a critical factor and that if I was using a drysuit this may well not have happened. I don’t think you will find many people who have done as much diving as myself in a wetsuit in these waters.

I would like to return to diving but I would definitely be more conservative as regards temperature. Any advice is welcome.

A: This seems to be a case of pulmonary oedema associated with cold water immersion. The main mechanism behind this is as follows. On land, quite a lot of blood sits in peripheral veins, but when the body is immersed in water, the peripheral veins shut down, and the blood in them physically shifts to the deeper vessels, moving centrally. If the water is cold, the effect is more pronounced. This increases the amount of blood reaching the heart with each pump, as well as increasing the resistance against which the heart is pumping (as the peripheral vessels are shut down). Sort of like a water pump trying to squeeze water through furred up pipes. There is also a theory that the chest constriction caused by a tight wetsuit might contribute. The net effect of all this is to cause fluid to leak out into the lungs.

Bizarrely, the patchy pattern of lung changes seen in pulmonary oedema in divers is very similar to patients who have overdosed on cocaine. But that’s not important right now. What is, is that the changes resolve very quickly with appropriate treatment. The body somehow cleverly shunts blood away from the fluid-filled (non-functioning) alveoli, towards the ones that are still working, so that the lungs can still do their job while the damaged alveoli heal.

Although it often resolves with no long term complications, to have had it twice at your age does suggest some predisposition to it. Interestingly this is similar to high altitude pulmonary oedema (HAPE), in which there is a definite genetic component. Your investigations sound pretty thorough so I would assume they have found no cardiac or pulmonary cause for it.

Certainly this is a grey area in terms of recommendations for future diving. Obvious measures such as dry suit diving and steering clear of cold water would be mandatory. Other than that, however, one of the issues is that the onset of pulmonary oedema is often acute and unpredictable. Personally I would be reluctant to consider diving again other than in very safe and non-challenging conditions.

Smoking: Case Study 1

Q: Like many divers who enjoy a holiday in the Red Sea, I have partaken in the local custom of smoking on the hubbly bubbly pipe otherwise known as shisha, or hookah. Can you clarify to me whether or not smoking these things can or will damage a person’s health. Some people I have spoken to believe it is the same as smoking cigarettes whilst others say that the tobacco contains no harmful substances. It is quite relaxing after a days’ diving to sit down with a beer and a pipe and enjoy some of the local entertainment but am I being naive to think this pastime is harmless? Your advice is most welcome.

A: There can’t be many visitors to Egyptian shores (or the Edgware Road) that haven’t been tempted by, or at least curious about, these splendidly ornate stemmed water pipes. They do elevate smoking from a squalid habit to what some deem a fine art. The expatriate British lawyer William Hickey, renowned for his thoroughly debauched existence, wrote this about hookahs in 1775, after arriving in India: “The most highly-dressed and splendid hookah was prepared for me. I tried it, but did not like it. As after several trials I still found it disagreeable, I with much gravity requested to know whether it was indispensably necessary that I should become a smoker, which was answered with equal gravity, “Undoubtedly it is, for you might as well be out of the world as out of the fashion. Here everybody uses a hookah, and it is impossible to get on without” [… I] have frequently heard men declare they would much rather be deprived of their nightly sex than their hookah.”

As to the wisdom of a pipe after a days’ diving, the crux of the matter is whether they use tobacco or not. Shisha comes in various lurid and herbaceous guises, but unfortunately most of them are around a third tobacco, with the rest made up of spices and fruit pulps. Thus you are effectively smoking flavoured cigarettes. Many studies have shown that the health risks are similar to cigarette smoking, indeed potentially worse; the average shisha session (try saying that quickly) of 40 or more minutes can deliver considerably more smoke than a pack of cigarettes, and the cooling effect of the water combined with the intoxicating fruity aromas may lull those who indulge into a false sense of security. The water filter does not rid the smoke of any impurities or nicotine (most of the toxic chemicals and nicotine are not water soluble). The pipe sharing aspect does also expose the smoker to gum infections or cancers.

For the hardened hookah hedonist there is hope, however; tobacco-free flavoured herbal blends are available, which are theoretically less harmful, and various attachments can be added to the basic device to filter out the nasties. A number of Smoking Research Institutes (which I envisage are rooms full of white-coated scientists furiously dragging on nefarious nicotine delivery devices) are looking at the long term effects of hookah smoking, but at present the jury is out.

So smoking a shisha with tobacco is most definitely not harmless, it carries the same risks as smoking cigarettes.

Smoking: Case Study 2

Q: I’m in the process of trying to quit smoking (again). I’m 42 now and have given up for a year or two before, but somehow always end up having a cheeky one in the pub and falling off the wagon. This time I’m going to use something to help. Bearing in mind I’m a technical diver, what do you recommend is the best way to go? Patches, gum, Champix, Zyban or anything else?

A: Nicotine replacement therapy, in whatever form, has been shown to help people stop smoking, and for good. It’s not a substitute for willpower but does take away some of the unpleasant physical side effects of withdrawal. Nicotine does cause a short-term increase in blood pressure, heart rate, and the flow of blood from the heart, and it narrows the arteries too. All of these effects do put some extra strain on the heart, but no more than a cigarette would, and without having to contend with a load of carbon monoxide as well. No effect of pressure on the release of nicotine from the patch has been demonstrated (it might easily fall off if it gets wet though). So there’s no real danger in diving whilst using them. Champix and Zyban both have a list of undesirable side effects as long as a Portuguese Man o’ War, some of which could be detrimental to underwater safety, particularly in a technical setting. You’d be best off avoiding these, or at least minimising your inert gas load whilst taking them and seeing your dive doc before you embark on any deep wreck stuff.

Smoking: Case Study 3

Q: Being honest, I’m one of those annoying on-off social smokers who’s always scabbing cigarettes off people at parties and never buys their own. Normally I go out on Thursdays and don’t smoke Friday so it clears my system before I dive on the weekend. This year though, I’ve been getting bunged up on Saturdays and Sundays and had loads of equalising problems and sinus squeeze. But last week we went out Friday, I smoked a pack and was fine diving: it’s almost like it cleared everything out. What’s all that about?

A: Being honest myself, it’s always difficult to give concrete explanations for quirky individual symptoms like this. I suspect though that after a day of withdrawal (your usual Friday off the fags), your lungs are beginning their recovery and consequently your respiratory tract produces more mucus, causing congestion in your ears, nose and sinuses. By smoking that pack last Friday you beat your poor cilia back down into submission, so rendering the system ‘clear’. Sadly this delaying tactic will only postpone inevitable (and bigger) problems. Social smokers run pretty much the same risks as full timers’ they tend to take more drags, and inhale deeper and for longer, so their overall exposure is similar. The same goes for smokers of ‘light’ cigarettes – research suggests they still get as much heart disease and lung cancer. Giving up totally is really the best option.

Smoking: Case Study 4

Q: I’ve been diving for 30-odd years and was a smoker until five years ago (I’m now 48). Unfortunately I think I left giving up a bit too late: I was diagnosed with chronic obstructive pulmonary disease (COPD) six months ago. The docs say it’s mild but because I smoked for 20 years (an average of 40 a day) it’s likely to get worse. I do wake up coughing and have to clear some fairly putrid-looking oysters (sorry) in the morning, but otherwise I’m pretty fit (still run and cycle to work). Can I still dive?

A: Your typical COPD case is picked up in those aged 45 or older, with a smoking history of at least 20 pack-years. (Pack-years is a quick way of estimating long term smoking exposure; one pack year is equivalent to smoking 20 cigarettes a day for one year, so in your case you have a 40 pack-year history.) Early symptoms such as frequent throat clearing, breathless on mild exertion and an irritating cough are often blamed on aging or lack of fitness. Progression to chest tightness and wheezing may take years, but other behavioural signs may appear first; avoiding the stairs in favour of the lift, taking longer to mow the lawn etc.

Lung infections become more common and severe as time wears on. Your major achievement has been to stop smoking, which is the most important treatment. There’s nothing you can to do to reverse the damage, but at least it won’t accelerate now. Medications can help widen the airways and treat infection, and no doubt these have been discussed with you. I’m afraid your diving days are numbered though; poor lung function will reduce exercise tolerance and put you at risk of barotrauma. Borderline cases with very mild symptoms and satisfactory lung function tests might get away with it, but it’s difficult to be certain of safety and personally I wouldn’t risk it. Time to hang up those fins.

Smoking: Case Study 5

Q: Common sense tells me it’s not a good idea to smoke tobacco as a diver, but does that apply to things like shisha pipes and cannabis as well? It’s not that I smoke these things all the time, but I have in the past, and want to know whether this would cause me any harm if I dived afterwards. What is it that’s the problem, the smoking process or what it is that’s smoked? Hope I’ve explained my question clearly enough!

A: You have indeed. Shisha, hookah, hubbly bubbly; all refer to filtering smoke through a pipe, often via a water-filled bowl to cool and humidify it (contrary to popular belief, the water doesn’t filter many of the real nasties out). What is smoked can vary enormously, with a mixture of tobacco, dried fruit, spices and treacle most common. Although the percentage of tobacco is therefore reduced, a typical hookah session lasts way longer than a cigarette, and delivers vastly more smoke, tar and nicotine. So in many ways it’s actually worse for you. Common sense should also tell you it’s not a good idea to smoke cannabis either, for obvious reasons; being stoned and narced at the same time could have pretty dire consequences. In answer to your question, ultimately it’s a combination of the smoking process AND what’s being smoked that leads to problems. Best to avoid it altogether.

Smoking: Case Study 6

Q: At the ripe old age of 50, and after numerous attempts, I have finally managed to give up smoking. I say this every year of course, but in 2016 I seem to have stayed quit for longer than ever – 3 months and counting! This time the difference is my trusty e-cigarette – I got a Vape for Christmas and with it by my side I have no doubt I can ditch the tobacco for good. But I do wonder whether there’s been any research on vaping and diving. Is it actually safe for me to continue? I don’t do anything extravagant, just recreational stuff at 30m max in warm waters generally. What do you think?

A: Herbert Gilbert is the chap credited with the invention of the electronic cigarette, way back in 1965. His original patent application makes interesting reading, describing a “battery powered cigarette (which) uses no tobacco and produces no smoke. A replacement tip, moistened with harmless warmed chemicals, could simulate the flavour of anything from root beer to rum. The smokeless cigarette also has medical potential. For example, asthma patients could be given internal medication through the lungs merely by moistening the tip with the medicine.”

Of course, at the time, big tobacco saw this as a threat to their profits and the device was met polite non- committal interest (for which read scorn and derision). Changing attitudes and a popular Chinese e-cig called Ruyan led to a huge uptake of this nicotine delivery system in the mid-2000s, and now “vaping” is brisk business the world over. The principle is simple enough: a tiny heating element at one end vapourises whatever liquid the user decides to place in the refillable cartridge at the other end, and the resultant flavoured steam can be inhaled or puffed in much the same way as a traditional cigarette. In the case of nicotine, this method can handily deliver the “hit” of a fag without the additional 70-plus carcinogenic chemicals that burning tobacco produces. A review by Public Health England in 2015 concluded that “E-cigarettes are 95% less harmful than tobacco and could be prescribed on the NHS in future to help smokers quit.”

There’s no research on this and diving, so far as I know, but I cannot see any empirical reason that it would be unsafe; and if we are to believe the positive benefits then perhaps we should be encouraging all divers to transfer their allegiance to e-cigs. The only note of caution I would highlight is that nicotine withdrawal can cause a lot of unpleasant symptoms, including dizziness, anxiety, sleep disorders, depression, fatigue and muscle pains; so best not to be diving whilst undergoing a withdrawal programme as such. Congratulations though on kicking the habit so far – keep it up and your lungs will be forever grateful.

Trauma: Case Study 1

Q: Having just done a try dive, I have the bug. My problem is I have been diagnosed with Asbestosis & Pleural Plaques in its early stages, so my question is will this rule me out of doing a Padi open water course or does this put me at a greater risk of lung problems than any one else, or does diving make my condition any worse. I am 48 years old and have a reasonable level of fitness and feel I can cope with diving for a few years at least. Your advise would be greatly appreciated.

A: The situation with lung problems and diving can be summed up in a couple of points. Firstly, is your lung function good enough to ventilate you adequately during a dive and also if that dive were to suddenly become more of an exertion than you had originally planned, e.g. a strong counter current or having to tow your buddy back to a boat a few hundred yards away. This is assessed by lung function studies known as spirometry and should be done by a recognised medical examiner of divers in your area.

Secondly, lung problems that can result in dead air spaces or “bullae” are a definite contraindication as air gets into these spaces under pressure at depth and as you ascend, as the air cannot be expelled it expands and causes bad lung damage called pulmonary barotraumas. Now your problem is not normally associated with these bullae so you should be fine on that count.

However the bad news is that asbestos can lead to rather a nasty piece of medical grief called a “mesothelioma”. So to make sure you never get this, have regular high resolution CT scans of the lungs. Even every year or two to be safe, if these are OK then as diving will not make your condition worse, and if you also pass the spirometry, and the asbestosis doesn’t affect your fitness you should be fine to do the PADI Open Water course.

Trauma: Case Study 2

Q: What is a pulmonary barotrauma? Is it life threatening? Does it mean you can have a heart attack under the water?

A: Burst lung. Yes. No.

I’d better elucidate a bit more than that! Pulmonary barotrauma happens when the air in the lungs expands on ascent faster than a diver can exhale it. This is why we are all taught to exhale on an emergency ascent on our PADI Open Water course. It’s not difficult to imagine what can happen to the lungs if the air inside them expands at a rapid pace. The very tissue and structure will be torn apart. Air bubbles will get into your arterial circulation, go through your heart and off to raise hell in all other parts of your body. But what is life threatening is that without normal functioning lungs there’s no oxygen supply to the rest of the body.

How you tell a diver has this problem when they are back on the boat depends on the extent of the lung burst. A very mild case may not be noticed at all. But as it gets more severe problems associated with the actual lung damage such as shortness of breath, blue lips, a cough, and right up to a severe case where the diver is coughing up blood stained frothy sputum and rapidly becoming shocked.

Its not just a panicked diver on a rapid ascent that can get this problem though, its one of the reasons that asthmatics are so strictly controlled as divers. If someone were to get a constriction in the bronchi or lung tubes through which the inhaled and exhaled air flows, then all that air inhaled under pressure at depth can’t get out properly on ascent. The resulting problem is this pulmonary barotraumas.

Dealing with it is very simple for the dive crew onshore or the boat. Quickly put the diver on their back, give 100% oxygen and call a chopper in asap. We doctors will do the rest but the key is recognising the problem quickly and not being afraid of calling the Emergency Services as fast as possible.

As for a heart attack underwater, it won’t cause this but an indirect effect may be to decrease the amount of oxygenated blood getting to the cardiac muscle so it dies which is by definition a “heart attack”. But by this time the diver is so well and truly screwed that it’s only of interest to the poor old doc doing the autopsy.

So all you asthmatics, get passed as fit by a diving doc, and for the rest of us, remember the words of the Prodigy: EXHALE.

Trauma: Case Study 3

Q: I sometimes have trouble clearing my ears when I start to descend in the water but I get a clear warning in the form of pain and ascend a little and make sure I clear my ears before I try again. My question is this, would I get a similar pain signal in my chest if I were to ascend and not breath out? I have made ascents breathing out on the way up but I was never daft enough to hold my breath to find out if I would feel any warning pain for fear of an embolism.

A: I must say I’ve never been asked that before!

I assume you want to know what it would feel like if you weren’t exhaling quick enough in relation to your speed of ascent.

Well, my first thoughts are that you must always exhale and never breath hold whilst ascending. Pulmonary barotrauma, or lung damage, is always the result.

So long as your throat is open and epiglottis in the right position the expanding air will always come out and you needn’t worry.

As for how it would feel, well, it would be like when you sneeze but stop it just before or similarly letting a full party balloon deflate through your lips when you have just taken a full breath. I don’t suggest you try this though, Nugget, just exhale normally.

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Allergies: Case Study 1

Q: I am looking for help to solve a problem I have everytime I dive. I hope you can help me. I have been diving for 5 years and everytime I dive a I get pimples/ acne in the face (nose and forehead), the longer / deeper / more I dive the worst my face gets. I do not know what can it be, I have been treated against acne for the last year (to avoid this situation when I dive. I do not usually have pimples) but I went diving last week and the same thing happened again. Do you have any idea what can it be to contact the right specialist?

A: I think the only thing this could be is perhaps a reaction to the silicone in your mask. When it happens again see if the distribution of the rash is in the same place as the mask lining and the nose piece. If it is then either find a barrier cream you can rub on the inside of the mask, like Vaseline or try a non silicone mask lining. Sadly hypoallergenic masks have yet to be invented.
If the above doesn’t work then maybe other causes are at work. Stress is a great inducer of acne like rashes. If you find diving stressful, and we all have at times then think long and hard about what brings it on. Bad buddys Diving beyond your limits Or, the fact that you are being cajoled into it against your better judgement. And treat the cause.

Allergies: Case Study 2

Q: Firstly I would like to take this opportunity to thank you for the great advice in your column in Sport Diver each month.

I am a fairly new diver with a mere 20 dives done, this has been one of the things I have dreamt about doing for quite a long time. So I have booked myself this Red Sea trip and got myself some kit and off to the must do RED SEA. Well after the third day of diving I started to get this itchiness on my belly and thighs, and after the eight day this was really painful on arrival back in the UK I was soon off to the Dr and she prescribed some Cortisone cream and tablets. Now as far as I know this is not the kind of tablets you want to take for just anything which means that it can’t be to good for you? Well the Question is what can I do to prevent this rash/itchiness as this must be some kind of allergic reaction to the suit(Neoprene)? Will some kind of undersuit help or is there some kind of medication that one can take to prevent this?

A: This is obviously a suit rash if you are getting it all over the body. There are weird algae blooms and other nasties that lurk in the deep that can cause similar problems, but neoprene rashes are by far the commonest.

You have 2 options here. Either you get a lycra undersuit, as its less likely to cause problems. Or you go the other way and get a drysuit. Under this you can wear whatever you want, even your normal clothes that you know wont cause a rash and itching. It may be a lot of kit to wear in hot countries but you’ll get used to it. Just don’t dehydrate, as you stand in 40 degree heat waiting to get in the water, as some muppet takes an hour to put on their own kit.

Allergies: Case Study 3

Q: I seem to be allergic to certain rubber/latex products, like for instance the brand new Mares Nemo watch I bought this weekend, got massive swelling/blisters where the watch straps actually touched my skin while only wearing the watch for about 4 hours. Do you know of any solution to this problem? Also which type of wetsuit would I need, would I get the same reaction from that? Would appreciate any help!!

A: That’s a pretty swift and severe reaction to a not inexpensive dive comp, how unlucky. I guess you could always go for the nice cheap titanium strap instead! The best solution to latex/rubber allergy is obvious; don’t put these products next to your skin. Most wetsuits are made of neoprene and allergy to some of the compounds used in its manufacture is becoming more common (a lot of neoprene wetsuits do contain small amounts of latex). You can wear a non-allergenic layer under a neoprene wetsuit, eg. a fleece or Lycra lining. Some people I know smother themselves in Vaseline to protect their skin but I’m not sure how effective this is in the long run and it gets pretty messy. If the symptoms are that severe (blistering etc.) it might be worth seeing if your GP can refer you to an allergy specialist for patch testing, to find out exactly what you are allergic to. There are several chemicals used in making neoprene and if you can find out which one you react to, and avoid it, you may be able to find a neoprene wetsuit that you can wear.

Allergies: Case Study 5

Q: In the summer I went diving in Milford Sound in New Zealand. It was amazing, green water, the vis wasn’t great but stacks of critters and strange fish there. Anyway, I dived in a lot of wetsuit – I had 15 mils of neoprene on and could hardly bend my knees or elbows! Despite all the rubber I still felt really cold on the dives, and the dive guide poured flasks of hot water down our backs during the surface interval. When I got back to the campsite I found a strange rash on my arms and legs, lots of little raised bumps, different sizes, which were really itchy. I went straight back to the dive shop and they sent me to a doctor. Thankfully she didn’t think it was DCI (and I couldn’t believe it was either as we only did 2 dives and they were really safe). She thought it was an allergic reaction to the cold, but I’ve never had that before. I didn’t get any other symptoms but the bumps are still there, 4 months later. Was she right, or should I come and see you?

A: I have a feeling she was right, actually. The rash you’re describing sounds very unlike the classic mottled appearance of a skin bend, and I’ve never heard of one lasting 4 months. In the absence of any other symptoms, I think DCI is unlikely; this sounds to me like something called cold urticaria. It is indeed a form of allergy, triggered by exposure to cold, where hives, wheals or bumps form on the skin. They can be incredibly itchy, and last for anywhere from minutes to months. Strangely it can be inherited (when it’s present from birth), or it can develop later in life, most commonly in the early 20’s. The diagnosis is usually made by the aptly named ‘cold test’; an ice cube held against the arm will produce characteristic hives after a few minutes. The treatment is pure rocket science; stay warm. The quicker the skin is warmed, the sooner the reaction will disappear. Antihistamines will sometimes help the itch and possibly reduce the number of hives. Although it sounds trivial, cold urticaria can sometimes result in serious anaphylactic shock, which can be fatal, so more severe sufferers should carry an adrenaline injection around with them. In your case, if the bumps are still present, I would strongly advise you see an allergy specialist to get a concrete diagnosis. Probably best to avoid cold water diving until then too.

Allergies: Case Study 6

Q: I’ve been diving for a few years now, but seem to have developed an allergic reaction to something in my wetsuit. I’m not conscious of anything abnormal whilst I’m wearing it, but after a dive I seem to get red weals, bumps and itchiness over my arms, legs, stomach and back. I’ve been reassured by plenty of experienced divers that it’s not DCS (it’s happened many times so I think I’d know by now!), and the suggestion I’m getting from most of them is that it’s neoprene allergy. Is it common for someone to develop this after diving for some years? What can I do about it, if anything? Please don’t say stop diving!

A: Stop diving. No, don’t panic, there are several potential remedies to trial before you take this most drastic course of action. Neoprene allergy is not that uncommon, but the typical products that seem to provoke skin reactions are the accelerators used to cure and harden the natural rubber in neoprene manufacture. Discovering which one would be tantamount to finding the proverbial needle in a haystack, so rather than embarking on fruitless and arduous skin testing procedures, I’d advise you to try some alternatives. A mild allergy can sometimes be controlled by antihistamines and chemical barriers such as Vaseline, but these don’t tend to last for long. Exposure suits made of Polartec Aquashell or Lycra are a better option; they can be worn in between your skin and the neoprene, which would provide a layer of insulation as well as removing the causative agent from skin contact.

Miscellaneous: Case Study 1

Q: I went to my doctors the day before I flew to Egypt at the end of September. I had painful lumps under both arms and quite a bad head cold at the time. They were diagnosed as abscesses and was told that they would probably come to a head, which luckily they didn’t. I was prescribed antibiotics and they did almost but not fully disappear. I still had small lumps under the skin on one arm. I was told that I could dive once I had finished the course in Sharm. I had a week of fantastic diving then on the last day the lumps reappeared. I rang my doctor as soon as I could when I got home. One arm has cleared up completely, but under the other I have what looks like a tendon or gland that is visable beneath the skin. It is painful if I lift anything too heavy or stretch my arm up too much. I have been referred to the local hospital but am waiting for an appointment. Can I still dive with this as I was told that I cant with any swelling? I look forward to hearing from you.

A: Good news. You can dive if you want.

There is no problem with what you have as regards to all the usual diving medical factors. It’s just a question of how you take the pain. It can be bloody painful, having a throbbing red pussy swelling under your arm. The neoprene will rub. The BCD will too. But diving won’t worsen it and the salt water may even improve it. Armpits are a notoriously good breeding ground for abscesses. Lots of hair follicles, sweat and friction. A bit of shaving if you’re not German and there’s the causes. It would be pertinent to check for diabetes as this can make them frequent after adolescence. If your sugars are fine then dive away and in time they will get better, making the whole experience less painful.

Miscellaneous: Case Study 2

Q: We are on a diving holiday in Sharm and my poor daughter has got suncream lotion in her eyes. She has bathed them in cold water but they are still burning after about 2 hours. The name of the suncream lotion is CALYPSO SPF 35 ULTRA HIGHT PROTECTION LOTION is there anything that you can suggest that I can do. She is 16yrs old.

A: Poor little thing. It takes ages to persuade kids to apply this stuff, and when they finally get the point, this happens. Mind you it’s normally me putting it into my child’s eyes. “Sorry Tom, you moved your head as I was putting it on your nose”, lies Daddy as he was staring at the women’s beach volleyball final, Sweden vs Brazil at the crucial time of application.

In these situations, when the water doesn’t get rid of all the pain, use steroid eye drops. Predsol is one brand I like, but it’s scrip only, so either go prepared, or run like hell to a pharmacy if there’s one close. 2-3 drops 3 hourly will keep the tears at bay.

Miscellaneous: Case Study 3

Q: Early last year I had a case of acute dermatitis, basically, my whole body was covered with the exception of hands, feet and face. After much application of various creams, lotions etc. I healed although it took 2 weeks. I have recently taken up scuba diving (May this year). All my dives to date have been in a semi-dry suit with hood. During my last two week-ends of diving I noticed a rash forming on my neck, underarms and groin area. These were itchy and I consulted my doctor. He said the dermatitis had returned, probably due to the chaffing of the hood combined with salt water. The rash on my neck has subsided, although the other places are still there but not quite as bad as before. I am now in the process of changing from a semi-dry suit to a dry suit. Is there anything on the market today that I can buy to minimise the effect of the chaffing/salt water? My doctor said I could possibly use petroleum jelly as a barrier. Would this work?

A: Ah back to my old friend the tub of Vaseline again. If you are about to switch to a dry suit then your problem is going to solve itself. As you can wear normal clothes underneath, that will spare your groin and armpits. That just leaves your neck and wrists. And if it’s chafing you hate, may I recommend a crushed neoprene suit with neoprene on the cuffs and collars. This is a lot softer on those body parts, and with my joyous O3 brand you use copious amounts of aqueous jelly to slip them over, thus creating a nice barrier to prevent the chafing.

Problem sorted. Sort of, there’s still the hood to think of and that can cause problems on your head area. A good barrier here is maybe some light cotton. So get down your local Puff Daddy franchise and purchase a do- rag, direct from the Crips in Compton, L.A. Put it on, hood over, and babba-ding, the God of Bling, no dermatitis.

Miscellaneous: Case Study 4

Q: My wife is 49 years old and is in general good health although she takes ACE-inhibitors for high blood pressure. She has a dive medical every year and really enjoys her diving, and we have been fortunate enough to travel as far as Australia to dive in quite exotic locations as well as here in the UK. She now has about 130 dives but in the last eighteen months she has suffered terrible dry skin on her feet that cracks and splits, becoming quite painful, when we go on our diving jaunts and she dives for more than a couple of days. This has now started to spread to her fingertips. Although she can be in great pain and hobbles out of the airport arrivals on our return, she loves diving and would physically assault somebody who would suggest giving it up. We have tried all sorts of barrier creams, plastic bags on her feet before putting on dive boots and in case it is a combination of salt water immersion reacting with the dive boot materials/glue she has tried full foot fins. The pharmacist in El Gouna believed the problem to be immersion in salt water – can you suggest any possible remedy to prevent or even delay the problem?

A: A tough one this, as you seem to have tried everything sensible. So we are in the realms of exclusion. To see if it is the salt water, why not spend your next holidays in Leicestershire. Go for several dives at Stoney Cove. If, with the same kit, she has absolutely no problems, then you know it is the salt water. If she gets the same, then if could be the water/boot/fin angle. And so on, you could replace each item with an alternate to find a cause. However, if none of the above work, then I suggest moisturizer. Not a little bit, but shed loads, worked into the skin at the beginning and end of each day. That’s all that can prevent skin drying and cracking. A couple of the better ones are Unguentum Merck or Diprobase. You can get them at certain pharmacies. Good luck. And not being one for uneccessary violence, how could I suggest she not dives.

N.B. if I am being particularly thick and someone has any advice on this that does not involve the words Tea and Tree, please let me know and I will pass it on.

Miscellaneous: Case Study 5

Q: Just wanted some information, could you help please? I am currently half way through a trimix course and I’ve got a tattoo planned on my back. Is it still ok to dive with a tattoo and if not how long would I need to leave it? Thanks so much.

A: Beckham-style wings? “APNOEA” in bold Cyrillic up your spine? A pod of dolphins leaping playfully across your trapezii? I’ve seen plenty of tats in the course of doing daily dive medicals, some pretty cool, others just unfathomable. Freshly tattoed skin is quite raw and susceptible to infection, so you need to wait until it’s fully healed up. How long that is depends on your individual metabolism and immune system; it probably takes at least a week or two though. Submerging the new tattoo too early in water might also cause the colours to fade or leech out completely. Then you’d have to go through all the pain again. Rather you than me!

Miscellaneous: Case Study 6

Q: I’m in my 60’s and over the years have developed deep laughter lines and creases around my brow and eyes. They say laughter keeps you young, but annoyingly it also causes my mask to leak. I’ve tried a couple of different brands but there’s always a trickle that gradually fills up my mask. It probably doesn’t help that I’ve got a fearsome set of whiskers too. Any tips on how to stop this?

A: The single page website of the BLF (Beard Liberation Front) seems to suggest the organization is now sadly defunct. Which is a shame, since previous ‘Beard of the Year’ winners have largely been cricketers who’ve gone on to do great things; Flintoff and Panesar, to name but two. What you need, however, is a prominent and fulsome silicon skirt on your mask. This, coupled with judicious gobs of Vaseline or silicone grease in the areas that typically leak, should halt the ingress of water. If not, then it’s probably worth trying a few other models (change sizes as well as brands) as there’s no one-size-fits-all in the mask world. Over-tightening is a common culprit; get your local dive shop to take you through correct sizing and fitting. While you’re there, you could investigate purge masks, which allow water out through a one-way valve, thus easing the arduous task of constant mask clearing. If all else fails, one solution remains: targeted depilation of the immediate under-nose area, which permits a tight seal and shouldn’t disrupt your hirsute visage to any noticeable degree.

Miscellaneous: Case Study 7

Q: Every time I go diving I seem to pick up a bad dose of Athlete’s foot. At least I think that’s what it is. The skin between my toes flakes off and I get quite painful cracks developing, underneath my toes and on my heels as well. Am I right, and is there anything I can do to stop it happening? It’s almost making me want to stop getting wet!

A: I’m not sure why this condition is called Athlete’s foot, as most people I’ve seen with it are as far from athletic as England are from winning the World Cup (there could be a lot of egg on my face next issue). Tinea pedis or ringworm of the foot is a classic fungal infection of moist skin folds. It’s essentially a trivial condition, but if it goes untreated, the breakdown in skin integrity can lead to secondary bacterial infections which can get really nasty. The fungus that causes it lives on wet towels, swimming pool floors and footwear (including dive boots). I suspect your boots are probably acting as a perfect damp incubator for the fungus, so every time you put them on you’re inoculating yourself with a fresh dose. My suggestions: firstly, get the condition treated. Try over-the-counter antifungal cream initially, and if it persists (it often takes months to clear completely) you can get oral antifungals and antibiotics from your GP. Get your boots thoroughly disinfected and cleaned, let them dry out completely, and see if that helps prevent reinfection. Make sure you always dry between your toes after your feet get wet, but don’t use the same towel for tackling the groin – jock itch is particularly embarrassing. Wear flip-flops or sandals in public showers or swimming pools to stop picking up new bugs. Sometimes antifungal powders help to dry the area and prevent infection, so whack some on if all else fails (be warned though, it tends to cake and leave all sorts of squidgy cheese-smelling deposits in your socks). Ripe!

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The following NHS vaccinations are available for people travelling abroad:

Cholera vaccination

Vaccination against cholera isn’t routinely needed for most travellers. However, in some cases it may be recommended for aid workers and people likely to have limited access to medical services – for example, people working in refugee camps or after natural disasters.

Most cases of cholera are confined to regions of the world with poor sanitation and water hygiene, such as parts of:

  • sub-Saharan Africa
  • south and southeast Asia
  • the Middle East
  • central America and the Caribbean

The vaccine is usually given as a drink in two separate doses, taken one to six weeks apart. Children aged two to six years old should have a third dose taken one to six weeks after the second dose. You should make sure you have the final dose of this vaccine at least a week before you travel.

A single booster dose or full revaccination is usually recommended if you’ve previously been vaccinated against cholera and you’re planning to travel to an area where the infection is common.

Read more about the cholera vaccine.

Diphtheria vaccination

A combined vaccination that protects against diphtheria, polio and tetanus is routinely given to all children in the UK. You should ensure you and your children are up-to-date with your routine vaccinations before travelling.

Further booster doses are usually only recommended if you’re going to visit parts of the world where diphtheria is widespread and your last vaccination dose was more than 10 years ago.

Diphtheria is more common in parts of the world where fewer people are vaccinated, such as:

  • Africa
  • south Asia
  • the former Soviet Union

Additional doses of the vaccination are given in a single 3-in-1 Td/IPV (tetanus, diphtheria and polio) injection.

Read more about the diphtheria travel vaccine.

Hepatitis A vaccination

Vaccination against hepatitis A is recommended if you’re travelling to countries where hepatitis A is widespread, particularly if you’re staying for a long period or somewhere with poor levels of sanitation and hygiene.

Areas with a high risk of hepatitis A include:

  • sub-Saharan and north Africa
  • the Indian subcontinent – particularly Bangladesh, India, Nepal and Pakistan
  • some parts of the Far East – excluding Japan
  • the Middle East
  • south and central America

The vaccination against hepatitis A is usually given as a single initial injection, with an optional booster dose 6 to 12 months later that can protect you for at least 20 years if necessary.

You should preferably have this initial dose at least two weeks before you leave, although it can be given up to the day of your departure if needed.

Jabs that offer combined protection against hepatitis A and hepatitis B or typhoid are also available if you’re likely to also be at risk of these conditions.

Read more about the hepatitis A vaccine.

Hepatitis B vaccination

Hepatitis B vaccination

Vaccination against hepatitis B is recommended if you’re travelling in parts of the world where hepatitis B is common, especially if you’ll be doing activities that increase your risk of developing the infection.

As hepatitis B is spread through blood and body fluids, activities such as having sex, injecting drugs or playing contact sports on your travels can increase your risk. Anyone travelling for long periods or who is likely to need medical care while abroad is also at increased risk.

Hepatitis B is found worldwide, but it’s more common in:

  • sub-Saharan Africa
  • east and southeast Asia
  • the Middle East
  • southern and eastern Europe

The hepatitis B vaccination generally involves a course of three injections. Depending on how quickly you need protection, these may be spread over a period as long as six months or as short as three weeks.

A combined hepatitis A and hepatitis B jab is also available if you’re likely to be at risk of both these conditions while travelling.

Read more about the hepatitis B vaccine.

Japanese encephalitis vaccination

Vaccination against Japanese encephalitis is usually recommended if you’re planning a long stay (usually at least a month) in a country where the condition is widespread. It’s particularly important if:

  • you’re visiting during the rainy season
  • you’re going to visit rural areas – such as rice fields or marshlands
  • you’ll be taking part in any activities that may increase your risk of becoming infected – such as cycling or camping

Japanese encephalitis is found throughout Asia and beyond. The area it’s found in stretches from the western Pacific islands in the east, such as Fiji, across to the borders of Pakistan in the west. It’s found as far north as Korea and as far south as the north coast of Australia.

Despite its name, Japanese encephalitis is now relatively rare in Japan because of mass immunisation programmes.

See the US Centers for Disease Control and Prevention (CDC) website for a map of Japanese encephalitis risk areas.

Vaccination against Japanese encephalitis usually consists of two injections, with the second dose given 28 days after the first. Ideally, you need to have the second dose a month before you leave.

Read more about the Japanese encephalitis vaccine.

Meningococcal meningitis vaccination

Vaccination against meningococcal meningitis is usually recommended if you’re travelling to areas at risk and your planned activities put you at higher risk – for example, if you’re a long-term traveller who has close contact with the local population.

High-risk areas for meningococcal meningitis include parts of Africa and Saudi Arabia. All travellers to Saudi Arabia for the Hajj or Umrah pilgrimages are required to show proof of vaccination.

If travelling to a high-risk area, you should be vaccinated against meningococcal meningitis with an ACWY vaccine, also known as the quadrivalent meningococcal meningitis vaccine. This is a single injection that should be given two to three weeks before you travel.

You should have the ACWY vaccine before travelling to high-risk areas, even if you had the meningitis C vaccine as a child.

Read more about the meningococcal meningitis vaccine.

MMR (measles, mumps and rubella) vaccination

The MMR vaccine that protects against measlesmumps and rubella is routinely given to all children in the UK. You should ensure you and your children are up-to-date with your routine vaccinations before travelling.

If you’ve not been fully vaccinated against these conditions or you’re not already immune, the MMR vaccination is recommended before travelling to areas where these conditions are widespread or where there’s been a recent outbreak.

The MMR vaccine is given as two injections. These are usually given when a child is 12 to 13 months old and when they start school. However, adults can have the two doses one month apart, and children can have them three months apart if necessary.

You should ideally have the final dose at least two weeks before you leave.

Read more about the MMR vaccine.

Polio vaccination

A combined vaccination that protects against diphtheria, polio and tetanus is routinely given to all children in the UK. You should ensure you and your children are up-to-date with your routine vaccinations before travelling.

Further booster doses are usually only recommended if you’re going to visit parts of the world where polio is widespread and your last vaccination dose was more than 10 years ago.

Currently, the condition is most common in Pakistan, Afghanistan and Nigeria, but it’s also a risk in other regions of the world.

Additional doses of the vaccination are given in a single 3-in-1 Td/IPV (tetanus, diphtheria and polio) injection.

Read more about the 3-in-1 Td/IPV vaccine.

Rabies vaccination

Vaccination against rabies is advised if you’re travelling to an area where rabies is common in animals, particularly if:

  • you’re staying for a month or more
  • there’s limited access to medical services
  • you’ll be carrying out activities that could expose you to rabies – such as cycling or running

Rabies can be found in many parts of the world. The GOV.UK website provides a detailed list of countries that have rabies in domestic animals or wildlife.

Vaccination usually requires a course of three injections. The second dose is given seven days after the first, and the third dose is given 14 to 21 days after the second.

Further doses aren’t usually recommended for travellers, unless it’s been more than 10 years since you were first vaccinated and you’re visiting an area with a high risk of rabies.

Read more about the rabies vaccine.

Tetanus vaccination

A combined vaccination that protects against diphtheria, polio and tetanus is routinely given to all children in the UK. You should ensure you and your children are up-to-date with your routine vaccinations before travelling.

Further booster doses are usually only recommended if you’re travelling to areas where access to medical services is likely to be limited or your last vaccination dose was more than 10 years ago.

Additional doses of the vaccination are given in a single 3-in-1 Td/IPV (tetanus, diphtheria and polio) injection.

Read more about the 3-in-1 Td/IPV vaccine.

Tick-borne encephalitis vaccination

Vaccination against tick-borne encephalitis (TBE) is usually recommended for anyone who plans to live or work in a high-risk area, or hike and camp in these areas during late spring or summer.

The ticks that cause TBE are mainly found in forested areas of central, eastern and northern Europe, although at-risk areas also include eastern Russia and some countries in east Asia, particularly forested regions of China and Japan.

The vaccination requires a course of three injections for full protection. The second dose is given one to three months after the first and provides immunity for about one year. A third dose, given 5 to 12 months after the second, provides immunity for up to three years.

The course can sometimes be accelerated if necessary. This involves two doses being given two weeks apart.

Booster doses of the vaccine are recommended every three years if necessary.

Read more about the tick-borne encephalitis vaccine.

Tuberculosis (TB) vaccination

Vaccination against tuberculosis (TB) is given to some children in the UK who are at increased risk from tuberculosis.

For travellers, the BCG vaccination – which protects against TB – is recommended for people under 16 who:

  • will be living or working with local people for three months or more
  • haven’t been previously vaccinated

The BCG vaccine is given as a single injection.

Parts of the world that have high rates of TB include:

  • Africa – particularly sub-Saharan Africa and west Africa
  • southeast Asia – including India, Pakistan, Indonesia and Bangladesh
  • Russia
  • China
  • South America
  • the western Pacific region (to the west of the Pacific Ocean) – including Vietnam and Cambodia

For a world map showing countries with high rates of TB, see the World Health Organization (WHO) website.

Read more about the BCG vaccine.

Typhoid vaccination

Vaccination against typhoid fever is recommended if you’re travelling to parts of the world where the condition is common, particularly if you’ll:

  • be staying or working with local people
  • have frequent or prolonged exposure to conditions where sanitation and food hygiene are likely to be poor

High-risk areas include:

  • the Indian subcontinent
  • Africa
  • south and southeast Asia
  • South America
  • the Middle East
  • Europe
  • Central America

Two main vaccines are available for typhoid fever in the UK. One is given as a single injection, and the other is given as three capsules to take on alternate days. It’s also possible to have a combined hepatitis A and typhoid jab.

Ideally, the typhoid vaccine should be given at least one month before you travel, but it can be given closer to your travel date if necessary.

Booster vaccinations are recommended every three years if you continue to be at risk of infection.

Read more about the typhoid vaccine.

Yellow fever vaccination

Vaccination against yellow fever is advised if you’re travelling to areas where there’s a risk of yellow fever transmission. Some countries require a proof of vaccination certificate before they let you enter the country.

Yellow fever is most common in some areas of tropical Africa and South America. A map and list of countries where yellow fever is foundis available on the NHS fitfortravel website.

A booster dose of the yellow fever vaccine is currently recommended every 10 years if you’re still at risk. However, this is likely to change in the future as recent evidence suggests a single dose offers lifelong protection.

You must have a yellow fever vaccination at least 10 days before you travel.

Read more about the yellow fever vaccine.

Where further advice is required

Speak to your GP before having any vaccinations if:

  • you’re pregnant
  • you’re breastfeeding
  • you have an immune deficiency
  • you have any allergies

Still have questions?

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