As more and more people get into diving , there will inevitably be more diving ‘accidents’. Divers not only will be facing the dangers of the accident, but will be facing a medical system that in most cases will be inadequate to care for the problems they face. Most doctors know little or nothing about diving medicine and sometimes, even the doctor who is on call for a hyperbaric chamber may not know much about diving medical problems.
In this article, we will talk about the various types of diving medical training that are available to physicians. All physicians have to graduate from a recognized medical school and pass various competency examination by state boards and national specialty groups. In addition, they have to complete one to five years of postgraduate training depending on their area of specialization. Some medical schools have limited instruction on diving medicine in the curriculum but most doctors will have received little or no training in this important area (vitally important to an injured diver). Because it is so important for the diver to know, it is entirely possible that most divers actually know more diving medicine than most doctors! The first time physicians might be exposed to diving medicine is when they themselves take a scuba course.
Although a physician’s background medical knowledge a faster learning curve than a normal basic diver, they are still limited by the knowledge of the diving instructor, and some of these doctors (who have only a basic scuba course) feel that they are diving medical specialists! The only way that a doctor can really learn a significant amount about diving medicine is to take a course in diving medicine.
There are many courses available varying in content and length, mostly directed toward doctors who work at hyperbaric chambers. These courses tend to focus on hyperbaric oxygen (HBO) treatment of non-diving problems. This is because most chambers treat hundreds of clinical HBO patients for every diver they see. Therefore, even though the course may be a week long, the doctor may only receive a couple of hours of instruction on diving problems. These courses tend to be held at hospitals with chambers, often located in inland parts of the United States that have few divers. Some courses are aimed at the physician who is also a diver and are therefore held at prime diving destinations (in reality, a tax deductible “working” vacation) and offer CME. They are scheduled so that the doctor can get in a couple of dives a day between lectures; examples are the DAN courses, some university courses and Medical Seminars, Inc. These courses tend to contain much more diving medicine and are taught by people who are expert in the field of diving medicine.
Doctors who are really interested in diving medicine can also attend conferences. The Undersea & Hyperbaric Medical Society has an annual scientific meeting where hundreds of papers are presented on both diving medicine and HBO. The UHMS also has several regional chapters that each hold one weekend meeting per year. Most have one day of scientific sessions and one day aimed at the recreational diver. There are also a number of excellent textbooks available on diving medicine and if the physician reads them they can learn a lot, although they will still be lacking practical experience.
Another way in which doctors can learn diving medicine, and probably the most common way in the US and Canada, is to be trained in the military. These courses are designed to teach military doctors what they need to know to allow them to take care of the many divers in the various branches of the military. Although the courses are not available to civilian physicians, most of these doctors get out after a short stint in the military and therefore many practicing civilian doctors have taken them.
Civilian courses should be long enough to teach a physician everything they need to know to properly conduct a diving physical, to recognize a diving problem when it occurs, and to know where to transfer the injured diver for treatment. They should be exposed to hyperbaric chambers and diving, and should be taught how to treat an injured diver.
In Canada there is an Advanced Diving Medicine Course that is 3 1/2 weeks long. Participants should have at least one year of experience in diving medicine and preferably come certified as a diver (military or civilian) before they take the advanced course. This advanced course focuses on treatment of injured divers and the students spend a lot of time in hyperbaric chambers. In the US, NOAA offers similar courses.
The only way that a physician can advance beyond this course level is to work in the field and to take some form of post-graduate training. There are masters programs leading toward a Master of Science degree in exercise and diving physiology. Other diving medical specialists have spent 6 to 12 months training at one of the US hyperbaric medicine facilities. There are proposed competency standards for hyperbaric physicians (1) which closely follow standards that are used in the United Kingdom, the North Sea, and many other parts of the world. In this scenario, hyperbaric physicians are certified at three levels. Level I roughly equates with one to two weeks of training and are fully qualified to conduct diving medicals and recognize diving medical problems. Level II roughly equates to the Canadian military Advanced Diving Medicine course. These physicians can treat all kinds of diving injuries in hyperbaric chambers using standard treatment tables and have significant practical experience. Level III is reserved for those few physicians who have advanced training and experience. They are able to alter and custom design treatment tables as required and are usually recognized internationally as an expert in diving medicine. Most of the Level II and III diving medical experts in the US and Canada received their training in the military forces.
From an ‘occupational medicine ‘ point of view — another factor of importance in evaluating a physicians’ diving medical expertise is their “diving” experience and training. One of the basic principles of occupational medicine is that the doctor must have a good understanding of the physical and psychological stresses that the worker/patient will be exposed too. In diving, the only way that the doctor can gain the appropriate understanding is to be trained and experienced as a diver.
In the US there is little or no diving medical training for the thousands of local physicians who will be called upon to certify that a candidate is ‘fit for diving’. Although there is now a board examination for hyperbaric and undersea medicine, due to the cost and time involved this will not reach the many doctors who have primary practices of other types and who will eventually be the final arbiters in the certifying process. In addition, there are thousands of doctors who don’t dive and who never take the courses offered by various agencies.
There are many physicians who have attended ‘fitness to dive’ or Diving Medicine seminars, who have read extensively on the subject and who could provide a responsible cadre of professionals to make available examinations at a reasonable charge for new divers. Information about who and where these individuals are
located is not readily available prior to the certification process. Diving candidates don’t usually make contact with DAN or the UHMS until after they are certified – and the medical exam should have been done as the first step in the process.
The relevance of the all this is that as a diver, you must always check out the quality of the advice and information you are given by physicians. Some physicians will tell you that there is no problem for you to dive with a specific medical problem, or, not knowing , refuse to allow you to dive with a condition that doesn’t cause diving problems. They may not know what they are talking about and are just giving you a ‘CYA’* opinion! What if you are sure that you or your buddy is bent and yet the doctor in the local emergency department tells you that you have simply pulled a muscle? Every diver should have the name and number of the closest hyperbaric chamber to call if they have a problem. In addition, it would be a good idea to learn who is the most knowledgeable and experienced diving medical expert in your area ( if there is one ). One way that I’ve found is to call around to offices and ask the nurse/receptionist if the doctor ever takes diving trips. This is not the best way to choose a doctor but at least he/she will know something about diving and may be able to refer you to the proper care.
When you are diving away from the US or Canada you should be a member of the Diver’s Alert Network (DAN). They provide extensive assistance for medical problems, can advise you on whether you should seek out medical treatment, and can tell you where the closest chamber is located (anywhere in the world). Their insurance program is inexpensive and is outstanding and they have a 24 hour service which allows you to contact someone knowledgeable in diving medicine anytime from anywhere in the world. Considering that evacuation and treatment of DCS can easily cost $100,000.00, to dive outside of North America without some form of insurance would be crap shooting and could lead to financial ruin. DAN can be contacted by calling 919-684-9111.
Finally, for their own protection all divers should learn as much about diving medicine as possible. They must understand that very few physicians know anything at all about diving medicine and that even the doctor on call at a hyperbaric chamber might be trained mainly in HBO. If you or your buddy have a diving medical problem and the local emergency physician does not recognize it as such, don’t take this as the last word — go to our Diving Medicine Online page**, call the nearest hyperbaric chamber or call DAN; one of these will usually get you help!
(1) David Sawatsky, MD; Diver Magazine, Feb 96
*CYA=cover your ass