BRITISH SUB-AQUA CLUB DIVING INSTRUCTORS WITH DIABETES MELLITUS
A DRAFT PROPOSALBob Boler, Chris. Edge, Pat. Farrell
EXECUTIVE SUMMARY
• Between 1975 and 1991, the British Sub-Aqua Club (BSAC) did not allow any persons with either tablet-controlled or insulin-controlled diabetes mellitus (DM) to dive. In 1991 a proposal was submitted to BSAC by the Medical Committee to allow people with well-controlled DM to dive. The National Diving Committee (NDC) adopted the proposal.
• Since 1991, a number of divers with DM have either started to dive or recommenced diving within the BSAC. At the same time, the Diving Diseases Research Committee (DDRC) and Dr. Chris Edge (CE) have maintained a database of all those divers within the BSAC who have registered as being diabetic.
• DDRC and CE have carried out research on a small number of individual diabetic divers, which shows that well-controlled diabetic divers have only a very small risk of developing hypoglycaemia underwater. These results are confirmed from studies on the diabetic diver database, which now has data extending over a period of 7 years.
• A few of the diabetic divers who have registered with the database have progressed with their diving training to the stage where they wish to become diving instructors. The current policy within BSAC is to allow only a very few very highly trained individuals who have become diabetic subsequent to the completion of their diving training to maintain their instructor status.
• This proposal addresses the problem of the diabetic diver who has trained with the BSAC and who now wishes to become a diving instructor. Two new standards are introduced. The training and legal consequences of this step are discussed.
INTRODUCTION
For many years, certification of divers with DM by a recognised scuba diver training agency was onl ypossible if the diabetic diver was diet-controlled (1). This policy was based on the theory that if a diver were to become hypoglycaemic underwater, with the possibility of a seizure or unconsciousness, then death of the diver would be the likely outcome. Furthermore, such a situation would put the diving buddy at considerable risk. In 1991, the BSAC decided that such a policy was too restrictive (2), because at the time several scuba divers with insulin-dependent DM (IDDM) were diving without experiencing episodes of hypoglycaemia underwater. Both IDDM and non-insulin dependent DM (NIDDM) diabetic divers have therefore been permitted to dive by the BSAC provided that they fulfil certain strict criteria (reviewed in (3) and (4)). Other training agencies, particularly in the United States and Australia, have been debating whether to allow divers with diabetes to scuba dive (5-7).
Research (8) carried out at the DDRC on individual IDDM divers in a hyperbaric chamber has shown that, provided the diabetic divers are well-controlled and render themselves slightly hyperglycaemic prior to going diving, more than 4 hours can elapse before the blood glucose levels reach a point at which the diver would have to consume a further quantity of glucose to avoid becoming hypoglycaemic. However, it has been found (9) that the standard blood glucose meters, when used in a hyperbaric chamber, tend to over-estimate the blood glucose levels in the hypoglycaemic diver. This may prove to be a problem when it comes to the treatment of a diabetic diver with possible decompression illness (DCI).
With the help of funding from the BSAC, the BSAC Jubilee Trust and DDRC, a database of diabetic divers who are diving with the BSAC, the Sub-Aqua Association (SAA) and the Scottish Sub-Aqua Club (SSAC) has been established. Preliminary data from this database have been reported at a recent meeting (10). These data showed that a total of 155 diabetic divers (20% female, 80% male) had logged a total of 2478 dives over the period analysed (6 years). 87% of these diabetic divers were classified as IDDM. A small nucleus of respondents had consistently logged more than 40 dives per year, and many of these dives were to depths of 30m or deeper, with decompression stops as required.
The question may be asked as to why a diabetic database should be maintained. The answer to this is simple: currently, most diving physicians and many diver training agencies will not allow IDDM or NIDDM persons to take up scuba diving, due to the risk of a hypoglycaemic attack underwater and the chronic complications of diabetes (11). The maintenance of a database fulfils three functions:
1. It enables data to be collected over a period of years that will (hopefully) convince the diving medical fraternity that well-controlled diabetic people can be allowed to dive and that the increased risk is very small.
2. It allows the diver training agencies who support the diabetic database to be seen as responsible bodies, taking the medical problems of their divers seriously and working towards allowing diabetic persons to learn to dive within their programme.
3. Within the wider context of disabled persons, the diver training agencies who support the diabetic database can state that they are carrying out some of their obligations to the disabled community to allow them to be integrated into the wider community.
As divers who were diabetic when they started their recreational scuba diving training progress through the personal training levels, it is inevitable that a few will wish to develop their instructional skills.
Currently, the position of all diver-training agencies throughout the world is that no diabetic diver can become an instructor. The few instructors within the BSAC who are diabetic divers had trained as instructors to the highest levels prior to them becoming diabetic. This position paper sets out the problems that must be addressed by the BSAC if diabetic divers are to be considered fit to take up instructional positions within the organisation.
CAN DIABETIC DIVERS BE ALLOWED TO BECOME INSTRUCTORS?
There are three broad issues to be considered when attempting to resolve this question:
1. Medical considerations;
2. Diving training considerations;
3. Legal considerations.
These will be considered in turn.
MEDICAL CONSIDERATIONS
These may be divided into three components:
1. Medical fitness to dive as applicable to all divers;
2. Medical fitness to dive when considering:
i. The chronic complications of diabetes e.g. retinopathy, neuropathy, renal disease, cardiac disease etc. some or all of which may be present in diabetic persons whether they be dietcontrolled, or are NIDDM or IDDM;
ii. The acute complications of diabetes which, in relation to diving, are principally focussed on hypoglycaemic attacks. Hyperglycaemia may occur but the occurrence is over a period of hours rather than minutes and therefore represents less of a risk in diving terms.
Current policy for all diabetic divers is that an annual diving medical with the GP/diving physician is mandatory. Additionally the diver must fill out form A (see appendix 1) and his/her diabetic consultant must fill out form B (see appendix 1). These forms are then returned to Chris. Edge who fills out an approval form (form C, see Appendix 2) provided that the diabetic diver is able to fulfil the published criteria (4). Briefly, these criteria state that the diabetic diver must be fit to dive in respect of all physiological systems apart from the glucose control system. In terms of the acute complications of diabetes, the diver must not have experienced any episodes of hypoglycaemia that require hospitalisation during the last 12 months, nor must he/she have experienced any episodes of hypoglycaemia underwater requiring rescue.
Chronic complications of DM are of concern and the diabetic diver’s consultant must be sure that no chronic complications of DM are present, apart from a mild background retinopathy. Of particular concern is the possible presence of covert ischaemic heart disease. The system tries to avoid allowing diabetic divers to dive with this condition by ensuring that no diabetic diver has microalbuminuria, the presence of which has a predictive value for the future onset of ischaemic heart disease. In addition for those diabetic divers over the age of 50, there is a mandatory annual exercise ECG test. However, it must be noted that a small percentage of non-diabetic divers who dive with the BSAC will have covert ischaemic heart disease. This is not tested for in the current BSAC medical.
Future medical policy for diabetic diving instructors must be as strict as it is for the ordinary diabetic diver. In terms of the chronic complications, there is no evidence from the database that diabetic divers who conform to the published standards are at any greater risk of sudden death in the water than is the normal diver (but it should always be borne in mind that “absence of evidence is not evidence of absence”).
When considering the acute complications of DM in the diabetic diver, it is imperative that the diabetic diver does not go hypoglycaemic underwater, thereby imperilling the life of his/her novice, who may be undertaking the first open water dive. Therefore, the following additional standard is suggested for diabetic diving instructors:
The potential diabetic diving instructor must show evidence that he/she has been able to avoid disabling episodes of hypoglycaemia, both on-shore and in the water for a continuous period of not less than 2 years.
The potential diabetic diving instructor must expect to set an example to other divers in the same way that is expected of their non-diabetic colleagues. Some diabetic divers are known to be avoiding registering with the database for reasons best understood by themselves. Such misguided persons should not be permitted to become or to maintain instructor status. It is suggested that the following
standard should be adopted for diabetic diving instructors:
Any diabetic diving instructor must show annual evidence of registration with the diabetic database for as long as the database is in operation.
DIVING TRAINING CONSIDERATIONS
The diving instructor has a general duty of care to the person or persons he/she is instructing. The BSAC takes this duty of care seriously, with compulsory courses and examinations for the various levels of instructor grading that it offers. The teaching situation within the branches is now moving rapidly to the ideal state where only divers who have attended at least a course in instructional diving techniques are carrying out diver training.
The potential diabetic diving instructor also has a duty of care as mentioned above. However, in this case there is clearly an added complication with the potential for the instructor to become hypoglycaemic, this necessitating rescue either by the diver under instruction or by another diver or member of the surface cover. For a novice diver under instruction this responsibility may be too great, depending upon the skill of the novice and the level at which they have competence to deal with the situation. It is unlikely that cold or depth will affect the chance of the instructor becoming hypoglycaemic but the chance will be increased by the level of inexperience of the instructor and by increasing the duration of the dive.
It is helpful to consider the situation of diabetic persons in relation to other sports and activities and to examine whether they can become instructors. In the case of professional driving instructors, it is recommended that they conform to the medical standards of the Group 2 entitlement. These standards disbar all applicants on insulin from 1/4/91. However, those applicants who were licensed to drive and who were on insulin prior to 1/4/91 are dealt with on an individual basis subject to a satisfactory annual consultant certification. Those diabetic persons controlled by tablets and/or diet can be licensed unless they develop the long-term complications of diabetes in which case the license is revoked.
However, it is worth noting that at least three National Instructors and one Advanced Instructor within the BSAC have been teaching diving and continue to teach diving on a regular basis. No complaints have been received about the quality of teaching that these individuals offer; indeed, the teaching that they give is recognised as being of a very high standard. No reports of hypoglycaemic attacks requiring rescue or putting their buddy(ies) at risk have been received.
In light of the above comments, it is recommended that the situation with regard to whether or not a diabetic person can be considered for instructor status be a combination of the medical standards as published together with input from that individual’s diving officer (DO). It is unlikely that there will be very many diabetic persons who wish to become diving instructors and therefore it would be possible for the DO to have an annual consultation with Dr. Chris. Edge and to discuss the situation.
The DO should have assessed on a continual basis (as is presumably done with other normal diving instructors) the safety and competence of that individual in the water and when undertaking instruction in the pool. It would seem sensible that when the diabetic diver is starting to instruct in open water, they be put in charge of individuals who are competent in rescue. As the diabetic instructor gains further experience, then that individual would be progressively put in charge of less able divers.
Clearly, the rate of progression would depend upon the individual and the DO.
LEGAL CONSIDERATIONS
It would appear that there are three issues to consider:
1. The legal framework within BSAC that would allow diabetic divers to become instructors.
2. The legal position of diabetic divers with regard to the Health and Safety Executive (HSE).
3. The legal position of diabetic diving instructors if they did not inform their pupils that they were diabetic.
The authors of this draft position paper are not in a position to comment upon item 1. The NDC and the legal team of the BSAC must resolve this.
With regard to item 2, the current position of the HSE is that diabetic persons are not allowed to become diving instructors if they undertake diving instruction for remuneration. It is an open question (despite reassurances from certain members of NDC; one of the authors of this paper has been informed informally by a member of HSE that it would be an interesting court case) as to whether the payment of expenses is undertaking diving instruction is equivalent to remuneration. If it were possible to document the safety of diabetic diving instructors, then a strong case could be made to HSE that exemptions from the ban could be made for certain named individuals. A parallel may be drawn here between the case of diabetic diving instructors and persons who have suffered spontaneous pneumothorax. One of the authors has personal experience of gaining exemptions for two individuals who had suffered spontaneous pneumothoraces and who are now diving with HSE certificates; one of the individuals is diving in the commercial sector of the North Sea.
The third point may not be a problem. The diabetic diver is already required to make him/herself known as a diabetic person to the club DO; the club DO has to sign form B (see appendix 1) to say that the individual may dive with the club. It is therefore a step that is for the “good of the diving club community” that an individual should declare him/herself to the pupil as being diabetic. This moral obligation probably outweighs the right to privacy for that individual. It is felt that most individuals who are diabetic diving instructors would accept this as being reasonable.
REFERENCES
1. Davies D. “SPUMS statement on diabetes” SPUMS J. 1992;22:31.
2. Edge CJ, Lindsay D, Wilmshurst PT. “The diving diabetic” Diver 1992;37:35-6.
3. Bryson P, Edge C, Lindsay D, Wilmshurst P. “The case for diving diabetics” SPUMS J. 1994;24:49-51.
4. Edge C. “Diabetic diver assessment” In: Elliott DH, ed. Medical assessment of fitness to dive. Ewell, Surrey: Biomedical Seminars, 1995:59-61.
5. Dear GdeL, Dovenbarger JA, Corson KS, Stolp BW, Moon RE. “Diabetes among recreational divers” Undersea Hyper.Med. 1994;21:94.
6. Seckl J. “Endocrine disorders” In: Elliott DH, ed. Medical assessment of fitness to dive. Ewell, Surrey: Biomedical Seminars, 1995:172-4.
7. Cali-Corleo R. “Special medical problems in recreational divers: diabetes” In: Elliott DH, ed. Medical assessment of fitness to dive. Ewell, Surrey: Biomedical Seminars, 1995:44.
8. Edge CJ, Grieve AP, Gibbons N, O’Sullivan F, Bryson P. “Control of blood glucose in a group of diabetic scuba divers” Undersea Hyper.Med. 1997; 24:201-7.
9. Edge CJ, Grieve AP, Gibbons N, O’Sullivan F, Bryson P. “Effects of pressure on whole blood glucose measurements using the Bayer Glucometer 4 blood glucose meter” Undersea Hyper.Med. 1996;23:221-4.
10. Bryson P, Edge C, Gunby A, St. Leger Dowse M. “Scuba diving and diabetes; collecting definitive data from a covert population of recreational divers. Interim observations from a long term ongoing prospective study” Undersea Hyper.Med. 1998;25(Suppl):51-2.
11. Davis JC, Bove AA. “Medical evaluation for sport diving” In: Bove AA, ed. Diving Medicine. 3rd ed. Philadelphia: W.B. Saunders Co., 1997:355-6.
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