Three doctors - Christopher Edge, David Lindsay and Peter Wilmshurst - review the status of diabetics who dive, and report that the BS-AC has lifted its ban and cleared some sufferers for diving
DURING the last 18 months, the BS-AC medical committee has taken time off from diving to consider whether certain diabetics should be allowed to dive or not.
Strong rumours had been heard that some diabetics were in fact diving, but were doing so without letting on hat they were diabetic. It was therefore decided to review the evidence that led to diabetics being banned from diving with the BS-AC in the first place and to see whether modern medical technology might have a role to play in letting certain diabetics get their feet wet again.
The ban on diabetics came about in the mid-1970s, when a diver who was diving on the Persier ascended normally within the no-stop time according to the BS-AC/ RNPL 1972 tables, but had difficulties in swimming to the boat, and had to be dragged on board, where he collapsed. Unfortunately, his problems were put down entirely to his being diabetic and he was not recompressed for a few hours, by which time he had become permanently paralysed from the waist down. He later committed suicide as a result of his depression at being confined to a wheelchair. The BS-AC medical committee of the time then banned all newly diagnosed diabetics from diving with the BS-AC, a ban that was later extended to most of the existing diabetics already diving with the club.
Since that time, three relevant things have happened: microelectronics have come along; Dr. Claire Eno has conducted a survey into diving diabetics; and Peter Wilmshurst has been hard at work looking at PFOs, or "holes-inthe- heart". Peter's research has showed, amongst many other things, that divers with PFOs stand a much greater chance of suffering from a gas embolus as a result of gas bubbling out from the tissues
during the ascent from a dive.
If a diver does suffer such an embolus, then it is quite likely that the effects of that embolus will show themselves within the first 30 minutes after the ascent, and may even show themselves within the first five minutes. Given the Persier diver's problem, which occurred within a few minutes of his ascent, Peter decided to have the dead man's heart examined again, and on close inspection it proved to have the hole that he was looking for. It therefore seemed likely that the diabetic diver's problem may have been entirely due to the hole in his heart, rather than the diabetes.
There are two forms of diabetes, one called diabetes insipidus and the other called diabetes mellitus. It is the latter form that is the main concern to divers, as it is much more common than the diabetes insipidus form.
So what exactly is diabetes mellitus? Put simply, it is an imbalance between the levels of insulin (a molecule called a hormone made by cells in the pancreas) and the level of sugar, which comes from food in the form of glucose, present in the blood. If there is too much glucose in the blood (a situation called hyperglycaemia) then this may cause problems for the diabetic but only over a relatively long period of time, typically a few hours.
Of much more cause for concern is the situation where there is too much insulin compared to the level of glucose in the blood (hypoglycaemia). This can arise in two ways. First, the diabetic may have injected him/herself with too much insulin, or, in the case of diabetics taking tablets, have taken too many tablets. Second, thediabetic may have forgotten or been unable to eat a meal for a few hours.
When either of these situations occurs, the blood levels of glucose drop very quickly and brain cells start to die. In most diabetics, there is some warning that this situation is happening, and symptoms such as sweating, rapid pulse, a feeling of hunger, persistent yawning and headache occur. If the diabetic does not act quickly and take some glucose, then the symptoms and signs become more severe, taking the form of irritability, neurological problems and unconsciousness.
Death can result. Clearly, such problems should not be allowed to occur in the diabetic diver.
In May 1987, DIVER magazine published the results of a survey into diving diabetics by Dr. Claire Eno. One of the questions that was asked of the diabetics surveyed at the time was: "Have you had any problems diving with your diabetes?" and the answer by all the respondents was "No".
Unfortunately, the survey was biased, because it could be argued that any diabetic diver who had had problems with his/her diabetes might well have given up diving and would not have read DIVER.
Therefore, they would not have responded to the survey with their adverse comments about diabetes and diving. But the most important fact to come out of this survey was that there were diabetics diving, some of whom had carried out several hundred dives, and that these diabetics were managing to control their diabetes so that they could dive safely and enjoyably.
The advent of microelectronics has revolutionised most of our lives, and none more so than those of diabetics. It is now possible to buy a small, portable computer called a glucometer that can measure a person's blood glucose within a few minutes, a feat that was not possible some years ago. This means that the diabetic can measure and then take steps to correct if necessary his/her blood glucose as soon as they come back from a dive. If the diabetic is not able to do this for him/herself, then a suitably trained person can do this for them. Thus the confusion as to whether a diabetic who has had problems on a dive is suffering from low blood glucose or some other condition has been avoided.
The BS-AC medical committee has come to the conclusion that certain diabetics can be allowed to dive with the club, provided that they meet some rather strict medical criteria. These criteria are assessed during the annual medical which potential diving diabetics must pass, and in essence consist of saying that the diabetic must have no evidence of the long-term complications that can occur in diabetes.
In addition, three forms, obtainable from your friendly BS-AC medical referee or from BS-AC headquarters, must be filled in on an annual basis, one by the diving diabetic, another by his/her consultant diabetologist and the third by a medical referee. It may be thought by some that this is excessive bureaucracy, but we wish to be as certain as possible that we have made the correct decision.
How then can you and your diabetic buddy dive together safely and enjoyably? We have listed the precautions that you both should take.
• Both you and your buddy should be fit and mentally alert before the dive. Only one of the divers should be diabetic.
• You should be familiar with your buddy's diabetic problems and have been taught to measure his/her blood glucose and how to administer emergency glucose in the event that he/she cannot do it for him/herself.
• Both you and your diabetic buddy should agree on the dive plan before the dive, let the dive marshal and, if on a boat dive, the boatperson know of your dive plan, and then stick to that plan ("plan the dive and dive the plan").
• Both divers should be well hydrated before the dive (with water and not alcohol!).
• The diabetic buddy should inform the dive marshal and boatperson that he/she is diabetic.
• The diabetic buddy should be slightly sugar-loaded {hyperglycaemic) before the start of the dive.
• There should be an emergency supply of glucose on board the boat and on the shore. Some diabetics have found ways to carry emergency glucose on their persons whilst diving without getting it wet. This is to be recommended, providing that it can be got at by the nondiabetic buddy in an emergency. An example of such an emergency would be the "lost diver" situation, in which the diabetic diver, having taken some insulin earlier in the day, now finds him/herself swept out to sea for some time. We recommend also that the diabetic diver should always carry a flag, flares or other method of attracting attention in case such a problem arises.
• The diabetic buddy should ensure that at least one other in the diving party is able to measure his/her blood glucose level and to administer glucose in the case of an emergency.
During the dive, you and your buddy should be on the lookout for any signs or symptoms that could be due to a falling level of glucose in the blood. In most cases this will manifest itself as strange behaviour or behaviour "out of context" on the dive. If such problems do occur, then the dive should be aborted. At present, the BS-AC medical committee is advising diabetic divers that they should not dive below 30m.
during the ascent from a dive.
If a diver does suffer such an embolus, then it is quite likely that the effects of that embolus will show themselves within the first 30 minutes after the ascent, and may even show themselves within the first five minutes. Given the Persier diver's problem, which occurred within a few minutes of his ascent, Peter decided to have the dead man's heart examined again, and on close inspection it proved to have the hole that he was looking for. It therefore seemed likely that the diabetic diver's problem may have been entirely due to the hole in his heart, rather than the diabetes.
There are two forms of diabetes, one called diabetes insipidus and the other called diabetes mellitus. It is the latter form that is the main concern to divers, as it is much more common than the diabetes insipidus form.
So what exactly is diabetes mellitus? Put simply, it is an imbalance between the levels of insulin (a molecule called a hormone made by cells in the pancreas) and the level of sugar, which comes from food in the form of glucose, present in the blood. If there is too much glucose in the blood (a situation called hyperglycaemia) then this may cause problems for the diabetic but only over a relatively long period of time, typically a few hours.
Of much more cause for concern is the situation where there is too much insulin compared to the level of glucose in the blood (hypoglycaemia). This can arise in two ways. First, the diabetic may have injected him/herself with too much insulin, or, in the case of diabetics taking tablets, have taken too many tablets. Second, thediabetic may have forgotten or been unable to eat a meal for a few hours.
When either of these situations occurs, the blood levels of glucose drop very quickly and brain cells start to die. In most diabetics, there is some warning that this situation is happening, and symptoms such as sweating, rapid pulse, a feeling of hunger, persistent yawning and headache occur. If the diabetic does not act quickly and take some glucose, then the symptoms and signs become more severe, taking the form of irritability, neurological problems and unconsciousness.
Death can result. Clearly, such problems should not be allowed to occur in the diabetic diver.
In May 1987, DIVER magazine published the results of a survey into diving diabetics by Dr. Claire Eno. One of the questions that was asked of the diabetics surveyed at the time was: "Have you had any problems diving with your diabetes?" and the answer by all the respondents was "No".
Unfortunately, the survey was biased, because it could be argued that any diabetic diver who had had problems with his/her diabetes might well have given up diving and would not have read DIVER.
Therefore, they would not have responded to the survey with their adverse comments about diabetes and diving. But the most important fact to come out of this survey was that there were diabetics diving, some of whom had carried out several hundred dives, and that these diabetics were managing to control their diabetes so that they could dive safely and enjoyably.
The advent of microelectronics has revolutionised most of our lives, and none more so than those of diabetics. It is now possible to buy a small, portable computer called a glucometer that can measure a person's blood glucose within a few minutes, a feat that was not possible some years ago. This means that the diabetic can measure and then take steps to correct if necessary his/her blood glucose as soon as they come back from a dive. If the diabetic is not able to do this for him/herself, then a suitably trained person can do this for them. Thus the confusion as to whether a diabetic who has had problems on a dive is suffering from low blood glucose or some other condition has been avoided.
The BS-AC medical committee has come to the conclusion that certain diabetics can be allowed to dive with the club, provided that they meet some rather strict medical criteria. These criteria are assessed during the annual medical which potential diving diabetics must pass, and in essence consist of saying that the diabetic must have no evidence of the long-term complications that can occur in diabetes.
In addition, three forms, obtainable from your friendly BS-AC medical referee or from BS-AC headquarters, must be filled in on an annual basis, one by the diving diabetic, another by his/her consultant diabetologist and the third by a medical referee. It may be thought by some that this is excessive bureaucracy, but we wish to be as certain as possible that we have made the correct decision.
How then can you and your diabetic buddy dive together safely and enjoyably? We have listed the precautions that you both should take.
• Both you and your buddy should be fit and mentally alert before the dive. Only one of the divers should be diabetic.
• You should be familiar with your buddy's diabetic problems and have been taught to measure his/her blood glucose and how to administer emergency glucose in the event that he/she cannot do it for him/herself.
• Both you and your diabetic buddy should agree on the dive plan before the dive, let the dive marshal and, if on a boat dive, the boatperson know of your dive plan, and then stick to that plan ("plan the dive and dive the plan").
• Both divers should be well hydrated before the dive (with water and not alcohol!).
• The diabetic buddy should inform the dive marshal and boatperson that he/she is diabetic.
• The diabetic buddy should be slightly sugar-loaded {hyperglycaemic) before the start of the dive.
• There should be an emergency supply of glucose on board the boat and on the shore. Some diabetics have found ways to carry emergency glucose on their persons whilst diving without getting it wet. This is to be recommended, providing that it can be got at by the nondiabetic buddy in an emergency. An example of such an emergency would be the "lost diver" situation, in which the diabetic diver, having taken some insulin earlier in the day, now finds him/herself swept out to sea for some time. We recommend also that the diabetic diver should always carry a flag, flares or other method of attracting attention in case such a problem arises.
• The diabetic buddy should ensure that at least one other in the diving party is able to measure his/her blood glucose level and to administer glucose in the case of an emergency.
During the dive, you and your buddy should be on the lookout for any signs or symptoms that could be due to a falling level of glucose in the blood. In most cases this will manifest itself as strange behaviour or behaviour "out of context" on the dive. If such problems do occur, then the dive should be aborted. At present, the BS-AC medical committee is advising diabetic divers that they should not dive below 30m.
This seems a reasonable limit given that the BS-AC regards any dive below this as being a "deep dive", requiring of itself other special precautions to be taken.
Once the dive is completed, the diabetic diver should measure his/her blood glucose level as soon as possible. This should be possible by carrying the glucometer out in the boat, well protected against seawater and sun. The blood glucose level should be raised if necessary. There should then be the usual enquiries as to whether you are feeling well or whether there are any problems as a result of the dive. Remember, any abnormal signs or symptoms should be reported to the dive marshal immediately and should not be passed off as merely "part of diving"!
If a diabetic diver does have abnormal signs or symbols, do not ignore them with the fond hope that they will disappear with time, as the only thing to disappear will be the general level of consciousness!
The blood sugar level should be measured, and if the level is found to be too low, glucose should be given. Oxygen should be administered.
Transport to the nearest recompression facility should be arranged by contacting HMS Nelson. If the diver is conscious then clear fluids may be administered by mouth, but a careful watch should be kept on the victim in case of vomiting.
Provided that simple precautions are taken, it is possible that over the next few years more diabetic divers will be seen around our coasts. It is in everybody's interests that this is so because sport diving should be seen to be not just for the superfit macho person, but for everyone who is reasonably fit. Unfortunately, for various reasons, not every diabetic who wishes to dive will be allowed to do so, but we hope that a few more people will be able to experience the wonders of diving and to assist with the preservation of the coastal and underwater environment.
Once the dive is completed, the diabetic diver should measure his/her blood glucose level as soon as possible. This should be possible by carrying the glucometer out in the boat, well protected against seawater and sun. The blood glucose level should be raised if necessary. There should then be the usual enquiries as to whether you are feeling well or whether there are any problems as a result of the dive. Remember, any abnormal signs or symptoms should be reported to the dive marshal immediately and should not be passed off as merely "part of diving"!
If a diabetic diver does have abnormal signs or symbols, do not ignore them with the fond hope that they will disappear with time, as the only thing to disappear will be the general level of consciousness!
The blood sugar level should be measured, and if the level is found to be too low, glucose should be given. Oxygen should be administered.
Transport to the nearest recompression facility should be arranged by contacting HMS Nelson. If the diver is conscious then clear fluids may be administered by mouth, but a careful watch should be kept on the victim in case of vomiting.
Provided that simple precautions are taken, it is possible that over the next few years more diabetic divers will be seen around our coasts. It is in everybody's interests that this is so because sport diving should be seen to be not just for the superfit macho person, but for everyone who is reasonably fit. Unfortunately, for various reasons, not every diabetic who wishes to dive will be allowed to do so, but we hope that a few more people will be able to experience the wonders of diving and to assist with the preservation of the coastal and underwater environment.
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