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SCUBA Diving With A Disability

Charles James Shaffer (U.S. Navy) learning to SCUBA | Charles James Shaffer (U.S. Navy) learning to SCUBAOutdoor recreation is intended for everyone, and can be enormously beneficial for persons with disabilities. I am in awe of disabled skiers, climbers, divers, and others who have learned to coordinate their bodies and take great enjoyment and a sense of accomplishment from their wilderness activities.

It behooves everyone in the healthcare profession to be aware of certain special medical concerns for persons who are disabled physically or emotionally. Additionally, family members and friends are often well aware of what they can do to help in providing a joint effort to support the disabled.

At the 2010 Wilderness Medical Society annual meeting in Snowmass, Colorado, JenFu Cheng, MD (a pediatric rehabilitation specialist from NJ), gave a wonderful presentation on the medical aspects of (scuba) diving with a disability. He pointed out that there may be up to nine million certified recreational scuba divers in the United States alone. His presentation, rather than focusing on persons who are fully capable physically and emotionally, examined the lesser-known benefits of being in the water for individuals in need of additional support. For instance, aqua therapy (largely enacted in swimming pools) takes advantage of the buoyancy of water to allow a range of mobility that is not possible on land. For example, aquatic exercise has been shown to improve lung capacity and mobility skills in children with cerebral palsy.

Scuba (self-contained underwater breathing apparatus) diving takes aqua therapy to another level. Imagine being a person previously restricted to a wheelchair, who can now freely explore the undersea environment! Although there are few guidelines for selection and training of disabled persons when scuba diving, there are unwritten rules, like advising against diving beyond “no decompression limits.” As Dr. Cheng remarked, John Williams (a professional diver and author of a number of diving guides) observed in 1984 that progress in all aspects of selection of disabled persons for diving, their training, and any applicable “rules” will come from the combined experience of people who are trained in rehabilitation, psychology, and diving medicine. Of course, progress also relies on the divers themselves and their instructors.

The literature, both medical and non-medical, supports the psychosocial aspects of scuba diving for persons with disabilities. Benefits include:

  • ability to explore a new environment
  • abandoning a mindset of disability
  • realizing new physical freedoms
  • being equal to others in their achievements
  • enjoying a spectacular marine environment
  • socializing and relaxing
  • gaining confidence, even to the point of assisting others in distress

Assistance and certain adaptations may be necessary. These include webbed gloves (for greater propulsion or to substitute for amputations), motorized underwater scooters, low-platform dive boats or boats with lift (for easier entry into and exit from the water), different diving techniques that emphasize overcoming physical limitations, and so forth. The Handicapped SCUBA Association includes a certification structure for disabled divers and facilitation of dive buddies.

Special medical concerns for disabled divers include many aspects of diving. Examples are decompression illness in persons with spinal cord dysfunction (such as spina bifida (myelominingocele), where it is important to have the participant’s pre-dive neurologic status available for comparison if there is any question later of decompression illness. Autonomic dysreflexia is a significant problem for spinal cord-injured persons, when there is a complete injury above the sixth thoracic vertebral bone. In this situation, a noxious stimulus below the level of the spinal cord lesion may trigger and maintain a dangerous increase in blood pressure, low heart rate, headache, sweating, and anxiety. Is this a contraindication for diving? Authorities differ on their recommendations. What if someone has a seizure disorder? Some dive certification agencies allow diving if the diver has been seizure-free without medications for at least five years. But what if someone is seizure-free on appropriate anticonvulsant medications? Again, opinion is divided. Other medical situations related to disabilities that should be taken into consideration include ventriculoperitoneal shunts (placed in individuals with elevated intracranial pressure), inner ear (cochlear) implants, implanted pain medication pumps, and gastrostomy tubes. Individuals who must be catheterized in order to empty their bladders should not dehydrate themselves to avoid this necessity. Indeed, they must emphasize hydration to avoid becoming dehydrated, and may therefore need to enjoy shorter duration dives.

Custom-fit wetsuits are available to accommodate deformities and absent limbs. Depending on balance underwater, additional weights may need to be placed to achieve proper neutral buoyancy.

One particular concern is for stasis of blood flow in the veins in limbs that are immobile or have poor vascular tone for many different reasons. This could lead to blood clot formation. If the skin is fragile or in poor condition due to a disability, it should be specially padded and protected from rough handling. Latex allergy appears to be more prevalent in persons with spina bifida, so it should be avoided in dive equipment and the seals in dry suits.

With regard to the heart, exercise testing can be performed to determine if a person meets reasonable requirements to sustain exertion underwater and dive safely. Any lung disorder that creates a residual situation of air trapping that could lead to an overpressurization accident and acute air embolism clearly excludes the afflicted from diving.

This post, SCUBA Diving With A Disability, was originally published on by Paul Auerbach, M.D..

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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