Diving Medical Specialists
The last issue of "Dive Ontario" (the newsletter of the Ontario Underwater Council) contained an article by Dr. Ron Linden in which he talked about the problems divers can run into with the medical system when they have suffered a diving accident. He emphasized the point that most doctors know little or nothing about diving medicine and that sometimes, even the doctor who is on call for a hyperbaric chamber may not know much about diving medical problems. In addition, last week I was given a draft copy of the "Competency Standards For Physicians Engaged In Hyperbaric Medicine". These standards will most likely be adopted by the Canadian Standards Association and will be used to categorize doctors who work in hyperbaric medicine. In this column, I will review the types of diving medical training that are available to physicians in Canada so that you will be able to evaluate your doctorsÕ expertise in this area.
All doctors in Canada have to graduate from a recognized medical school and pass a national competency examination. In addition, they have to complete one to two years of postgraduate training with the exact requirements varying from province to province. Some medical schools have one hour of instruction on diving medicine in the curriculum but most doctors will have received NO training in this important area (vitally important to an injured diver). Therefore, in Canada, most divers actually know more diving medicine than most doctors!
The first time physicians might be exposed to diving medicine is when they take a scuba course. Although a physicianÕs background knowledge of anatomy and physiology allows them to learn diving medicine much faster than a normal basic diver, they are still limited by the knowledge of the instructor. Some of these doctors (who have only a basic scuba course) call themselves diving medical specialists! Although these physicians may take several additional diving courses and do a bit of reading, they still seldom know more than a good advanced instructor.
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 and they vary in their content and length. Most are aimed at doctors who work at hyperbaric chambers and therefore their content tends 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. Examples of these types of courses are "Introduction to Hyperbaric Medicine" (five days), "Clinical Hyperbaric Medicine" (four or five days), "Clinical Applications of Hyperbaric Oxygen Therapy/Wound Care Management", and "Primary Training in Hyperbaric Medicine" (five days). These courses tend to be held at chambers, often located in parts of the United States that are not known for good diving and where diving medicine is not locally important.
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). They are scheduled so that the doctor can get in a couple of dives a day, between lectures; for example, "Temple University Underwater Medicine" (eight days, Little Cayman) and "DAN Diving Accident and HBO Medicine Course" (eight days, Bonaire). These courses tend to contain much more diving medicine although much of the course time is taken up by recreational diving. 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 several 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 Canada, is to take one of the Canadian Forces (CF) Diving Medicine Courses. These courses are designed to teach military doctors what they need to know to allow them to take care of the 1000+ military divers. Although the courses are not available to civilian physicians, most doctors get out after a short stint in the military and therefore many practising civilian doctors have taken them. In the past, the CF had only one course on diving medicine. It was taught at the Defence and Civil Institute of Environmental Medicine (DCIEM) in Toronto with part of the course taking place at one of the CF Diving Units (Halifax and Victoria). The course took the doctor from their first exposure to diving medicine to a level qualified to deal with all types of diving medical problems, including commercial and saturation diving. At first, it also included certification as a diver but for several reasons the course was shortened so that when I took the last one (1982) we did not receive a C card.
The course I took contained three solid weeks of lectures on diving medicine from experts flown in from all over the world and two weeks of diving in which we were exposed to and dived all of the different types of diving equipment in use in the CF. We started with a pool session, progressed to "plodding equipment" (lead boots and a heavy weight vest in which you walk around on the bottom) and then free swimming scuba. We did underwater tasks such as sawing a 4 x 4 piece of wood in half, "plumbers nightmare" (a complex pipe construction that you have to take completely apart and then reassemble) and underwater searches. The second week we dived in surface supplied diving equipment and even did a dive in a rebreather. We of course did many dives in various hyperbaric chambers. I was a certified civilian diver at the time but most of the other doctors were not and found it challenging to say the least!
After my course, it was decided that most military doctors did not need such extensive training in diving medicine and therefore the course was divided into two. The Basic Diving Medicine Course is two weeks long and is designed to teach a physician everything they need to know to properly conduct a diving medical, to recognize a diving problem when it occurs, and to know where to transfer the injured diver for treatment. They are not exposed to hyperbaric chambers or diving, nor are they taught how to treat an injured diver. The course is conducted entirely at DCIEM.
The Advanced Diving Medicine Course is 3 1/2 weeks long and it is recommended that the physician has at least one year of experience in diving medicine and preferably becomes certified as a diver (military or civilian) before they take the advanced course. The advanced course focuses on treatment of injured divers and the students spend a lot of time in hyperbaric chambers. They also have some opportunity to actually dive the various kinds of diving equipment in use in the CF and they are introduced to submarine medicine. The course is aimed at physicians who will be working at a hyperbaric chamber. The basic lectures are given by CF physicians (I did a lot of lecturing during my seven years as the diving medical specialist at DCIEM and still do some) but internationally recognized experts are still flown in to lecture, especially for the advanced course. As in the past, the diving part of the course is held on one of the coasts.
The only way that a physician can advance beyond this level is to work in the field and to take some form of post-graduate training. I did a two year 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. Earlier I mentioned the proposed competency standards for hyperbaric physicians. They closely follow standards that are used in the United Kingdom, the North Sea, and many other parts of the world. Hyperbaric physicians are certified at three levels. Level I roughly equates with the CF Diving Medicine Basic course. These physicians have 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 CF 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 can 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 Canada received their training in the CF.
Another factor that I believe is important in evaluating a physiciansÕ 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 a factory, the doctor can be given a tour, see the worker at their job, and thereby gain the required understanding. In diving, the only way that the doctor can gain equivalent understanding is to be trained and experienced as a diver. Some diving medical experts do not agree with me on this point but then, most of them are not divers or have not dived for many years!
By now you might be asking, so what? The relevance of the above discussion is that as a diver, you must always evaluate the reliability 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. Do they know what they are talking about? Many times different doctors will tell you conflicting things. Which one is most likely to be correct? 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). This is the person you should call when all else has failed.
When you are diving away from home, there is really only one option, you should be a member of the DiverÕs Alert Network (DAN). They provide extensive assistance for medical problems, can advise you on whether you should seek out medical treatment, can tell you where the closest chamber is located (anywhere in the world) and for a small additional fee, provide insurance to pay for evacuation and treatment of diving injuries. 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 $50,000.00, to dive outside of Canada without some form of insurance could be financial ruin. In Canada, the provincial health plans will pay for evacuation and treatment. DAN also provides a very useful service in education and I strongly recommend all divers join. They can be contacted by calling 919-684-2984 or sending a fax to 919-684-8111.
In conclusion, for their own protection all divers should learn as much diving medicine as possible. They must understand that most physicians know next to nothing 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, do not despair. Call the nearest hyperbaric chamber or call DAN, they will be only too happy to help. After all, I know of many bent divers who have been sent home from emergency departments on aspirin, and even one diver who was told she was not bent by two physicians who worked at a chamber (she was, and recovered after treatment) but thatÕs what this column is designed to prevent, isnÕt it?