Medical standards for divers the EDTC view

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Medical standards for divers-the EDTC view

• Jürg Wendling, Biel (Suisse)

Diving Medicine 2006, UKSDMC, March 23-24, 2006,
Shrewsbury (UK)
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Medical standards for divers The EDTC view
Contents
I Who is EDTC

• II Why fitness-to-dive standards?
• III Standards EDTC orWhat is good practice?
• IV Different criteria for different types of
  diving
• V Conclusions

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EUROPEAN DIVING TECHNOLOGY COMMITTEE
Who is EDTC?
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NGO of17 Nations, each represented by
Who is EDTC?

• Government representative
• Diving industry representative
• Working divers / Union representative
• Diving medicine representative

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European Diving Technology Committee, EDTC

• Work completed
• Goal-setting principles for harmonised diving
  standards in Europe 1995
• Training standards for diving and hyperbaric
  medicine 1998
• Standards for medical assessment of working
  divers 2001

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Medical standards for divers The EDTC view
Contents

• I Who is EDTC?
• II Why Fitness-to-dive standards?
• III Standards EDTC orWhat is good practice?
• IV Different criteria for different types of
  diving
• V Conclusions

II Why Fitness-to-dive standards?
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Fitness-to-dive assessment costs
Why fitness to dive standards?

• No medical (selfassessment) 0 Euro
• Check by familiy doctor 20 Euro
• FTD check (/guidelines) 100 Euro

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Diving has remarkable risks (recreational and
occupational)
Why fitness to dive standards?

• 140227 DCI/dives (lt30m, no deco)
• 1 6604 DCI/dives (gt30m or deco-dives)
• 1 4346 DCI/dive/h (professional diving
• sat-D, bounce D, Bell (TUP),
  Sur-D,
• umbilical diving with in-water
  deco)
• 1 xxx DCI/dive (technical diving)
• From DAN Europe statistics 1996 and D. Holland
  1996

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Epidemiology prevalence
Why fitness to dive standards?
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Risk analysis severityDCI dysbaric
disorders (decompr injuries)
I
Why fitness to dive standards?

• 40 not disabling, reversible
• 35 not disabling, permanent
• 15 disabling, reversible
• 10 disabling, permanent
• From DAN Europe accident report 1997

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Risk analysis severity
Why fitness to dive standards?

• Mortality 10 of diving accidents
• 800 DCI/year (USA, DAN statistics 97)
• 100 Diving fatalities/y (USA, DAN statistics)
• Same relation for CH (6/50 1999),
• UK (17/125 2000), D

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Why fitness to dive standards?
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Non-dysbaric accidents in professional diving
PERSONAL INJURIES 1997Total 19Serious
1Infections 11
NEAR ACCIDENTS 1997Total 19Serious
6Other 10 (SLS) Semincolsed life saving
system)

• NEAR ACCIDENTS (serious) 1997
• Lifting operations under water (2x)
• Falling object
• 10bar hose pressurized to 20 bar
• Diving Platform-drift off
• Trawl passed 30 metres from the bell

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Risk analysis
Why fitness to dive standards?
prevalence
severity
200 X
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Risk analysis
Why fitness to dive standards?
Fatalities ------------------------ Accident
s -----------------(with medical
treatment) Accidents ------------(no medical
treatment) Incidents ----------(no symptoms
Signs)
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Causes of fatal dive accidents
Why fitness to dive standards?

• Poor medical fitness
• 40 Psychological/panic (behaviour,
  essoufflement, CO2 retention)
• 13 Cardiovascular
• 7 Lung disease evtl. Contributing
• 4 Insufficient exercise capacity
• 2 Asthma eventually contributing
• lt1 Diabetes, epilepsy, aneurysma
• From sticky beak study, spums 98

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Mechanisms of dive accidents
Why fitness to dive standards?

• Multifactorial
• Overconfidence
• Poor physical fitness
• Stress by difficult communication
• Essoufflement / exhaustion
• CO2 retention
• Panic
• Barotrauma
• Medical condition

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Safety of a dive
Why fitness to dive standards?

• Hazards (objective risks, prevalence,
  severity)

medicalphysicalmental
fitness
Safety management
knowledgeskills
training
Equipment Procedures
Residual risk (danger) ? Acceptable risk
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Safety of a dive
Why fitness to dive standards?

• Hazards (objective risks, prevalence,
  severity)

medicalphysicalmental
fitness
Safety management
knowledgeskills
training
Equipment Procedures
Residual risk (danger) ? Acceptable risk
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Health aspects(preventive medicine point of view)
Why fitness to dive standards?

• Water is an unusual and unforgiving medium
• We have no intuitive feeling for the medical
  risks during immersion
• Danger (residual risk) is real! Permanent
  disability or death are possible

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Safety aspects(public responsibility)
Why fitness to dive standards?

• Actions to other team members
• Stressing other divers when in rescue situation
  (indirect risk)

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Legal aspects
Why fitness to dive standards?

• Safety at work regulations
• Health conservation regulations
• Protection of employer against future court
  action
• Occupational insurance wants to reduce risk of
  expensive cases
• Non discrimination act and privacy

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FTD concerns EDTC policy
Why fitness to dive standards?

• Many of the member countries have not appropriate
  standards
• Many professional divers go for work abroad
• British HSE does not further certify foreign
  MED's and diving medical physicians
• IMCA needs a standard to be used as well in other
  continents

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Medical standards for divers The EDTC view
Contents

• I Who is EDTC?
• II Why fitness-to-dive standards?
• III Standards EDTC orWhat is good practice?
• IV Different criteria for different types of
  diving
• V Conclusions

III Standards of EDTC or What is good practice?
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Self-Assessment (Questionnaire)
Standards EDTC or What is good practice?

• ? Are questions easily understandable
• ? Questions should not allow interpretation
• - Assessment of motivation and psychological
  signs and symptoms will not be possible
• - Temptation to deny medical diagnosis
• Avoid extra-costs

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Assessment by diving instructor or supervisor
Standards EDTC or What is good practice?

• Specific functional ass. for the activity
• Business priorities make it difficult to
  beobjective (bias)
• /- May be good for physical and mental fitness,
  but not for medical fitness ass.
• Important for disabled divers programs where
  limited physical fitness is the rule

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Assessment by med. examiner
Standards EDTC or What is good practice?

• History is taken by a knowledgeable examining
  doctor
• List of diagnosis will be more complete
• Allows individual assessment in case of
  borderline signs for contra-indications or if
  disability is present
• Allows the doctor to roughly judge the mental
  fitness and motivation of a candidate
• Possibility to give general advice as to
  safety and physiological limitations to the diver
• Costs
• Needs time and sometimes travel
• ? Quality assurance of medical examiner
  (certified?)

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Standards EDTC or What is good practice?
Selfassessment Questionnaire (pass/fail) Prescrib
ed examination (pass/fail)

• Discretionary assessment (no hard pass/fail
  criteria)

• easily done by any untrained doctor. Nonsensible
  certification
• diver as risk taker is excluded
• audit and arbitration is needed for fairness

• needs a doctor with knowledge and experience in
  the relevant aspects
• diver as risk taker is central to the process.
  Individual restrictions.
• Sensible medical certification advice
  informed consent.

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Modern approach (e.g. NZ occup Med Dir 99)
Standards EDTC or What is good practice?
Excludes those with clear contraindication In
order to find a sensible individual solution To
assess ability for a particular diving activity
Questionnaire selfassessm.
Discretionay medical assessment by trained
medical examiner
Functional assessmentby training agencies,
physical competency tests
Fit for a diving activity
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EDTC good practice is
Standards EDTC or What is good practice?

• Discretional medical assessment of FTD using
• Guidelines based on international consensus
• Medical training of examiners based on
  international standards

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Medical assessmentof fitness to dive
Standards EDTC or What is good practice?

• internat. consensus
• Competence/Training
• europ FTD-standards
• Desktop reference
• Discretional decision and advice
• (Informed consent)

Expertise (Credibility)
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EDTC ftd standardsthree types of assessments
Standards EDTC or What is good practice?

• In-depth assessment- initial medical
  examination- periodical in-depth examinations
• Annual assessments
• Re-assessment after injury or DCI

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Frequency of assessments
Standards EDTC or What is good practice?

• Variable intervalls for periodical in-depth-ass.
• Determined by the medical examiner of divers
• generally 5 years for young healthy divers
• Shorter intervals for aging divers (generally gt
  50 y)
• Annual check (monitoring divers, functional
  self-assessment)

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Standards EDTC or What is good practice?
The rhythm of medical assessments
First in- depth FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Periodical in- depth FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Periodical in- depth FTD assessment
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Standards EDTC or What is good practice?
The rhythm of medical assessments
First in- depth FTD assessment
Annual FTD assessment
Annual FTD assessment
Periodical assessment every 5 years Decreasing
with age above 45 Or at discretion of medical
examiner
Annual FTD assessment
Annual FTD assessment
Periodical in- depth FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Periodical in- depth FTD assessment
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Standards EDTC or What is good practice?
The rhythm of medical assessments
First in- depth FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
?
D C I
Annual FTD assessment
Periodical in- depth FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Annual FTD assessment
Periodical in- depth FTD assessment
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Resume diving assessement
Standards EDTC or What is good practice?

• Searching for lesions and differential diagnosis
• Specialist consultations
• Risk assessment for further job activities
• Further need of monitoring and therapy
• Eventual limitations (incl. interval for periodic
  assessments

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In-depth Assessment - History
Standards EDTC or What is good practice?
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In-depth assessment - Status
Standards EDTC or What is good practice?

• Clinical status incl. heartlung auscult, BP,
  basic lab
• Otoscopy Valsalva simple hearing test
• BMI
• No ECG, but a stress-ECG by cardiologist after
  age 45
• Lungfunction including a flow-volume loop
  specialist consultation if values are lt80 of
  normal values
• Aerobic capacity (submax ergometry, VO2, from
  nomograms) if lt12METs consider restricted diving
• Neurology incl. sharpened Romberg-Test
• Psychological judgement

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In-depth assessment - Status
Standards EDTC or What is good practice?

• Additional examinations
• Initial ass. optional spiral CT-scan of lungs,
  otherwise no further chest x-rays unless special
  indication
• Screening for bone necrosis, if diving gt20h/w
  and gt30m x-rays hips ap, shoulders ap, blood
  test for lipids
• Specialist consultations
• Referral to diving medicine expert
• Audiogram, if for hearing conserv. program

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In-depth assessment Conclusions / Certification
Standards EDTC or What is good practice?

• Informed consent

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Annual medical FTD assessment
Standards EDTC or What is good practice?

• History (face-to-face), general and diving
  activities
• Checking of divers log book (including
  recreational and private working dives)
• Simple clinical examination

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EDTC guide-lines for fitness-to-dive
Standards EDTC or What is good practice?

• Few exclusion criteria
• Many relative contra-indications

Medical should be task oriented based on exposure
since last medical
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Fitness to dive certification
Standards EDTC or What is good practice?

• Respects confidentiality of history and findings
  (patient rights)
• Indicates limitations, if relevant for employer
• Other restrictions (assured) by informed consent
  on physicians protocol

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Medical assessmentof fitness to dive
Standards EDTC or What is good practice?

• internat consensus
• on med training
• internat. FTD-Standards
• Desktop reference
• Discretional decision and advice (Informed
  consent)

Expertise (Credibility)
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Medical training standards
Standards EDTC or What is good practice?
EDTC/ECHM standards for medical training in
hyperbaric medicine 1998 www.edtc.org
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Levels of training needed "jobs"
Standards EDTC or What is good practice?

• I Medical Examiner of Divers
• IIa Diving Medicine Physician
• IIb Hyperbaric Oxygen Physician
• III Hyperbaric Expert or Consultant (hyperbaric
  and diving medicine)
• IV Associated Specialists

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Job I medical examiner of divers
Standards EDTC or What is good practice?

• Competent to perform the "Fitness to dive
  assessment" of working and recreational divers
  and compressed air workers (except the resume
  assessment of divers)

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Guidelines for teaching hours per module
Standards EDTC or What is good practice?
I Med. ex. of divers 25 h lectures 3h
practicalII Diving med. physician the above
30h lectures 10h
pracitcal IIb Hyperbar.med. physician 60h
practical phase (5 clinical cases / different
indications III Div. and hyper. med. need
further review expert
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Medical assessmentof fitness to dive
Standards EDTC or What is good practice?

• internat. consensus
• Competence/Training
• internat. standards
• Desktop reference
• Discretional decision and advice (Informed
  consent)

Expertise (Credibility)
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Standards EDTC or What is good practice?
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Citation from EDTC standards
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From the reference section 2.1 Asthma
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Medical assessment of FTD
Standards EDTC or What is good practice?
Good practice (summary)

• Find the relevant medical risks of a diver
• Medical assessment not too extended (technical
  diagnostic procedures only if efficient, i.e.
  justified from risk analysis)
• Only specific specialist referral on indication
• Reassessments adapted to the time interval/age
  and activities of the diver

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Medical standards for divers the EDTC view

• I Who is EDTC?
• II Why fitness-to-dive standards?
• III Standards EDTC orWhat is good practice?
• IV Different criterias for different types of
  diving
• V Conclusions

IV Different criterias for different types of
diving?
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Criteria of fitness to dive (all divers)
Different criteria for different types of diving

• Unrestricted ability to do the job / diving
  activity (swim, communicate, manage
  responsibility, mental fitness)
• No endangerment of safety of diver or buddy by a
  medical condition during a diving activity (e.g.
  loss of consciousness, orientation, panic
  attack)
• No worsening of a condition by diving/job (e.g.
  conditions leading to barotrauma)
• No predisposition to diving related illness or
  injury (e.g. DCI with PFO)

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Criteria of fitness to dive all divers?
Different criteria for different types of diving

• Equal qualitative criteria for recreational and
  professional divers
• Different activities/jobs are more or less
  demanding and something requires specific
  abilities (pass-fail criteria are not enough)

So not all divers will need the
same assessment
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Types of diving (professional)
Different criteria for recreational and
profressional divers?

• Scuba air diver
• Inshore air diver
• Offshore air commercial diver
• Offshore bell diver Special techniques
  Rebreather, standard dress
• Compressed air workers (tunnel)
• HBOT chamber personal

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Differencies Recr x Prof Diving
Different criteria for different types of diving
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Restricted diving
Different criteria for different types of diving
Restricted fitness certification is needed for
professional and recreational divers

• Examples
• Professional diving restriction to a work site
  or dive technique (e.g. harbour diver)
• Recreational diving time limitation of
  certificate (e.g. asthmatics, some cardiac
  conditions)

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Restricted diving
Different criteria for different types of diving
Restriction by informed consent (certification
without restriction)

• Examples
• Professional diving use of increased safety
  deco-schedules (DCI with PFO)
• Complete dependance from diving instructor, clear
  shallow, calm water, few meters (e.g.
  introductory dive, no med. assessment)

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Restricted diving
Different criteria for different types of diving

• Handicapped diving
• 3 levels of certification
• I Difficult to train, but autonomous diving as
  end point(independent and able to help a buddy)
• II Able to dive without help, but not in all
  waterconditions, unable to help buddy
• III Needs continuous assistnace from helpers

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Medical standards for divers The EDTC view

• I Who is EDTC?
• II Why fitness-to-dive standards?
• III Standards EDTC orWhat is good practice?
• IV Different criteria for different types of
  diving

V Conclusions
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Conclusions

• European Fitness-to-dive standards are useful as
  consensus of all European countries
• For nations lacking own standards (template
  function)
• motivation to adapt regulations in the
  traditional diving nations in order to
  harmonise ass.procedures
• Medical training is essential for good practice
  and update-workshops/seminars are needed.
• EDTC medical subcommittee has published the
  standards as a manual (quick reference
  handbook)with support of IMCA

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thank you
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thank you
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The future
Conclusions

• Searching harmonisation with UHMS and SPUMS/SIG