Diving Medicine for the Disabled Diver
Dear Esteemed Colleagues,
SCUBA Diving is becoming an increasingly popular sport among pople with disabilities, including patients with Spinal Cord Injuries (SCI). The Handicapped SCUBA Association has been teaching adaptive SCUBA since 1981 and several certifying organizations have developed training protocols for teaching paraplegic, tetraplegic, amputee and other disabled divers.
While the protocols seem to be prudent and many such divers are enjoying diving, the protocols, almost without exception, have been developed without the input of Dive Medicine physicians.
There are several areas where the altered physiology pose concerns. The literature is essentially silent on the problm set posed by the diver with SCI.
At the University of Texas Health Science Center at San Antonio, I am leading a small group of interested physicians in exploring the problems we believe need attention. We will b presenting some early results at the American Academy of PM&R in November. We have some striking data relating to impaired thermoregulation in divers with tetraplegia and paraplegia. If we can secure funding, we hope to look at fluid shifts and immersion diuresis in these divers; aware already that immersion diuresis can complicate managent of neurogenic bladder dysfunction and elicit potentially lethal autonomic dysfunction (Autonomic Dysreflexia).
I also have some vague, ill defined concerns about pulmonary function, especially in the tetraplegic diver.
Many divers with SCI, who I believe are good candidates for adaptive SCUBA report their difficulty finding a physician who will provide medical clearance. Most of my PM&R colleagues are unfamiliar with diving medicine and will not clear them. Many Dive Medicine professionals, far more skilled in this area, have little or no experience with prospective paraplegic and tetraplegic divers.
It occurs to me that the physicians from the UHMS are in a unique position to help explore this area, and collaborate with us in writing improved guidelines for the diver with SCI and related conditions,. This would also be valuable for those dive buddies and instructors who teach or work with this special population.
A brief introdunction is in order. I am a physician and currently Assistant Professor in the Department of Rehabilitation Medicine at the University of Texas Health Science Center at San Antonio. I am board certified in PM&R and carry a subspecialty certification in Spinal Cord Injury Medicine. I have a C7 ASIA A (complete) spinal cord injury since age 17, and am an enthusiastic adaptive diver. I am, in fact, one of those tetraplegic patients who may have approached you for medical clearance!
Given the sophistication of this group, may I propose a forum for presentation of the special problems posed by the potential adaptive diver. There may be professionals who are already working in this area, and I suspect that once I present some of the potential problems, many of you might offer helpful solutions. A quick search of the database will reveal the virtual absence of any serious dive medicine in this area.
If there is interest, the forum could expand into a working group at one of our meetings.
As a start, let me pose some questions.
# Patients with SCI have profoundly impaired thermoregulation. Their potential for early and profound hypothermia will surprise you. (i can present our current data). What does this impairment mean to these divers and what should dive professionals know about the problem?
# Immersion Diuresis is well known to the normal diver. We are observing the same phenomenon in our divers with SCI. I suspect the diuresis is more exuberent in SCI patients. However, the consequences are far different. Distention of the urinary bladder in patients whose injuries are at or above T6 can elicit a massive unopposed sympathetic nervous system storm with hypertension, bradycardia, arrythmias, headache, nausea, vomiting, and seizures among the sequelae. ("Autonomic Dysreflexia"). What can be done to eliminate the risk for AD and what should professionals, instructors and buddies know about this phenomenon?
# There is a body of literature with respect to marine infections in the normal diver. My Urologist here in San Antonio reported to me a patient with SCI whose bladder was managed with a suprapubic catheter. A fishing trip to the Texas coast where he was exposed to waves over his lap resulted in a subsequent bladder infection with Vibrio! This has never been reported in the literature and was a surprise to this experienced Urologist. I need not remind readers of how nasty Vibrio infection can be. Are there marine infections to which these patients with neurogenic bladder are especially at risk?
# Autonomic Dysreflexia with its acute presentation of HTN, headache, vision changes, nausea, cardiovascular instability could be mistaken for decompression illness. It might be treated inappropriately. If occuring at depth, it would force an abrupt ascent with attendant risks. Would the hyperdynamic circulation after a dive (AD while on a dive boat or back on shore) put a diver at risk for DCI or AGE?
How does Immersion Diuresis present and affect these divers? Can it be moderated? How should one advise patients, instructors and dive buddies with respect to managing the neurogenic bladder?
# I am deficient in my understanding of pulmonary medicine, but patients with SCI have restrictive lung disease, with their level of injury defining the muscles of respiration that are paralyzed. The tetraplegic diver may be at risk of fatigue in his remaining intact muscles, predisposing to respiratory failure. This has not been reported. Is there a risk to the pulmonary status of these divers?
# The mobility impairment of divers with SCI and limb amputations affect their efficiency in the water Can we develop simple inexpensive adaptions that could improve their mobility?
# Many patients with SCI as well as the amputee diver suffer with neuropathic pain. I am seeing frequent and persistent reports that this difficult to manage neuropathic pain vanishes when diving. Some report that the pain relief correlates with depth. I have wondered if this is a manifestation of Nitrogen Narcosis. (a single article in normal divers from our journal this year proposes the same.) Is there pain relief from diving and if so, what is the mechanism and could it be exploited clinically?
Please let me know if there are members with interest or advice in this area, or whose interest may have been trigged by these and related questions. Is an online forum or another venue of interest to you?
Mark D Fredrickson, MD, FAAPMR
Department of Rehabilitation Medicine
University of Texas Health Science Center at San Antonio.
P.S. For a glimpse of what adaptive diving looks like, please visit divepirates.org. Dive Pirates is a non-profit 501(c) based in Houston. Their mission is to equip and teach SCUBA to interested divers with disabilities and their buddies. They can offer instruction to those interested in becoming adaptive instructors as well. While not exclusive, most divers have been injured veterans returning from our current conflict. A quick look at the photos will give you a sense of why we are enthusiastic