In 1995 the YMCA introduced the YSCUBA Protocol for Divers With Diabetes. Every person with diabetes is unique and minor adjustments in the protocol may …
SSI PROTOCOL FOR DIVERS WITH DIABETES
PREFACE
Duke H Scott, MD SSI Medical Advisor
In 1995 the YMCA introduced the YSCUBA Protocol for Divers With Diabetes The goal of the Protocol was to guide instructors in the safe scuba training of qualified diabetics Until that time diabetes mellitus had been considered a contraindication for participating in scuba It was well known in the diving community that many closet diabetics were safely diving During the five years since its conception the Protocol has exceeded our expectations Its use had enhanced the lives of many diabetics, allowing them to experience our planets wondrous underwater world YSCUBA instructors have embraced the Protocol and many consider the training of qualified diabetics as routine The Protocol has also been adopted by many existing diabetic divers as a standard for safe diving We are please to report that during this period no adverse events have been reported Scuba Schools International SSI has adopted this protocol and will be working in conjunction with Dr Duke Scott to implement the protocol Dr Scott developed the protocol after consulting with many instructors, diving diabetics, diabetic athletes, and experts
on diabetes Once formalized, the protocol was reviewed by these same experts and deemed workable Developing hypoglycemia low blood sugar while submerged is the primary hazard unique to the diabetic diver Therefore, the focus of the protocol is preventing the diabetic from experiencing a hypoglycemic episode during a dive The protocol is conservative and only targets diabetics with stable, well controlled disease The potential diver must be in good physical condition and willing to follow the protocol Every person with diabetes is unique and minor adjustments in the protocol may be necessary to fit the needs of the individual diabetic scuba diver However, such changes should be undertaken only with the advice and consent of the diabetics personal physician The divers physician should have knowledge of scuba diving If the protocol is followed accurately a diver with diabetes reduces the risk of becoming hypoglycemic during the prescribed scuba dives As data is gathered, the protocol will be reviewed and/or revised as necessary, depending on the feedback received from scuba divers with diabetes Over the last five years several advances in the management of diabetes have been developed
and/or become the standard of care One of these is the insulin pump which, in selected individuals, has been found to provide tighter and more effective blood-sugar control However, at this time the effect of water submergence and increased atmospheric pressure on the pumps function have not been determined But the diabetic may participate in scuba by disconnecting the pump during a dive The details of this should be worked out with the diabetic divers physician In addition, several new oral medications and forms of insulin have been developed Although they may provide for tighter and more effective blood sugar control, they may actually enhance the diabetics potential for developing hypoglycemia low blood sugar during physical exertion Therefore, the diabetic diver must have a thorough understanding of how their particular diabetic regimen works, particularly with regard to the danger of developing hypoglycemia or hyperglycemia high blood sugar during physical activity It is also critical that the diabetics physician counsel the diver to check for and prevent delayed hypoglycemia, which may develop even hours after the diving activity After reviewing the advantages and
disadvantages of various insulin regimens, the diabetics physician should be able to tailor the diabetics regimen to allow for safe participation in scuba diving Three new forms have been added to the Diabetic Protocol These forms were developed to facilitate safe training of diabetic scuba students They are: 1 The Diabetic Profile for Pool Activity; 2 The Dive Profile for Diabetic Divers; and 3 The Diabetic Diver Medical Form Supplement The use of these forms is required by all scuba instructors who elect to use the SSI Diabetic Protocol for teaching diabetics to scuba dive It is also requested that copies of these forms be submitted to the SSI Medical Advisor when the diabetic student completes the course Any adverse events should be reported to the Advisor immediately; this will allow SSI to monitor the use of the protocol and collect data concerning its use SSI instructors who teach qualified diabetics to dive are covered by their SSI liability insurance, but only if their student follows the protocol and fills out the required forms The forms must be submitted to the SSI Medical Advisor in a timely manner These forms may be obtained from the SSI Medical Advisor
1
SSI
PROTOCOL FOR DIVERS WITH DIABETES
Duke H Scott, MD SSI Medical Advisor
The SSI instructor and/or the diabetic students physician should contact the SSI Medical Advisor, Dr Duke Scott, if they have any questions or problems concerning the use of the Protocol Duke Scott, MD SSI Medical Advisor 1606 Arrowhead Trail Neptune Beach, FL 32266 Phone: 904 246-0750 Fax: 904 246-4947 Email: dr1313@aolcom January 2001
2
SSI PROTOCOL FOR DIVERS WITH DIABETES
PROTOCOL
Duke H Scott, MD SSI Medical Advisor
The SSI Scuba Program does not assure the safety of scuba diving for all people with diabetes or any particular individual with diabetes Diabetes mellitus is a diagnosis that includes a range from the person with a minimum abnormality of glucose metabolism to the person with frequent episodes of hypo-or hyperglycemia low or high blood sugar or ketoacidosis There is a wide range between these two extremes and little published guidance about diabetes and scuba diving This guideline for recreational scuba divers with diabetes the Protocol has been approved by the Advisory Committee of the SSI scuba Program based on the research by and the recommendation of its Medical Advisor and promulgated
by the Director of the SSI scuba Program Scuba diving is a semi-strenuous activity that is carried out in an underwater environment and under certain conditions may increase a diabetics risk of injury The occurrence of a hypoglycemic episode underwater could lead to drowning or other medical problems unique to scuba diving Therefore, a person with diabetes must consult with, and obtain a physical exam and subsequent approval from, his or her personal physician prior to participating in any scuba diving activities The physical exam should be diabetic, comprehensive, and follow the guidelines of the SSI Scuba Program Diabetic Medical Form Since people with diabetes are at increased risk for cardiovascular disease, a heart stress test should be considered To be approved for scuba diving, a person with diabetes should be in good physical condition and his or her diabetes should be stable and under good control People with diabetes with severe or progressive micro- or macro-vascular disease, retinopathy eye disease, nephropathy kidney disease , and/or neuropathy sensory and/or motor nerve disease should not participate in scuba diving This protocol is represented as a guideline only A
currently certified diver or student diver with diabetes who chooses to follow this protocol must first review it with their personal physician who should be familiar with the treatment of diabetes and with the medical aspects of scuba diving The physician may suggest changes in the protocol in order to meet the specific needs of the individual diver Only students or graduates of nationally recognized scuba certification agencies have permission to use this protocol SUMMARY 1 Non-insulin Dependent Diabetic Diver Type II on diet control only: a Should perform self-monitoring of blood glucose SMBG as outlined in the protocol b Should follow other recommendations respecting activities, meals, dive plan, and appropriate responses to any signs of hypoglycemia c Should scuba dive with dive partner the Informed Buddy who is aware if the diabetic divers condition, the protocol, dangers of hypoglycemic reaction, and signs of hypoglycemia This dive buddy must agree to follow the dive plan as outlined in the protocol; be able to perform SMBG, be familiar with the diabetic dive kit, and be able and willing to respond to a hypoglycemic reaction The dive buddy should be a certified scuba diver,
experienced, physically able, and not diabetic 2 Non-insulin Dependent Diabetic Diver Type II on diet and oral medication for control of hyperglycemia: a Should perform SMBG as outlined in the Protocol b Should not take oral medication the night before or day of the planned scuba dive unless directed to do so by the divers personal physician c Should follow other recommendations respecting activities, meals, dive plan, and responses to any signs of hypoglycemia d Dive with an informed Dive Buddy, as described in Section 1c 3 Non-insulin Dependent Diabetic Diver Type II on diet and oral medication plus insulin for control of hyperglycemia:
3
SSI PROTOCOL FOR DIVERS WITH DIABETES
Duke H Scott, MD SSI Medical Advisor
a Should perform SMBG, as outlined in the protocol b Should not take oral medication the night before or day of the planned scuba dive unless directed to do so by the divers personal physician c Should follow other recommendations respecting insulin administration, activities, meals, dive plan, and responses to any signs of hypoglycemia d Dive with an Informed Dive Buddy, as described in Section 1c 4 Insulin-Dependent Diver Type I on insulin for control of
insulin-deficient diabetes mellitus: a Should perform SMBG as outlined in the Protocol b Should follow other recommendations respecting insulin administration, activities, meals, dive plan, and responses to any signs of hypoglycemia c Dive with an Informed Dive Buddy, as described in Section 1c DIVE PROTOCOL 1 Pre-Dive Plan a General 1 Drugs: Absolutely no alcohol or recreational drugs on the day before or the day of the dive Diabetic divers should not be on blood sugar reducing drugs such as Inderal or other beta blockers 2 Insulin Administration: Errors must be avoided, such as reversal of AM and PM doses of insulin, reversal of regular and NPH insulin units, excessive insulin dose, improper timing of insulin administration with regard to meals 3 Insulin Injection: Insulin injections of the pre-dive day should be performed in the abdominal area Insulin absorption from an exercising limb is faster and more erratic than normal The injection site should be an area of the skin that is not scarred or thickened hypertrophic fatty tissue from previous injections 4 Food: Do not alter meal and snack schedule unless directed to do so by the protocol Do not skip any meals or decrease daily
calories; avoid fatty foods; avoid foods or fluids containing caffeine, such as coffee, tea, chocolate, and soft drinks Multiple small snacks are recommended over a single larger one 5 Exercise: Avoid strenuous activity or strenuous exercise during day or evening prior to the scheduled scuba diving activity If the diabetic diver has a daily aerobic exercise program in place, he/she should reduce the amount of exercise by at least one-third 6 Fluids: Increase normal fluid intake significantly for 24 hours prior to scheduled dive A minimum of 8 ounces of fluid should be consumed by the diabetic diver during the pre-dive period 7 Rest: Adequate rest the night before the scheduled dive trip is essential Eight hours of sleep are recommended 2 Evening of pre-dive day a Insulin: Reduce evening dose of intermediate or long-acting insulin by 10, if under loose control or 20, if under tight control The diabetic diver should seek the advice of his/her physici 
an in determining the degree of his/her diabetic control b Meal: Normal evening meal avoid fatty foods and caffeine 3 Morning of Dive Day a Self-Monitoring of Blood Glucose SMBG: Perform fasting blood sugar FBS just before normal
breakfast time 1 If the FBS value is between 75 mg/dl and 160 mg/dl, administer AM insulin according to the following schedule: a Reduce usual AM dosage or regular insulin by 50, if under tight control, or 25, if under loose control b Reduce usual AM daily dosages of intermediate or long-acting NPH insulin by 20 4
SSI PROTOCOL FOR DIVERS WITH DIABETES
Duke H Scott, MD SSI Medical Advisor
2 If FBS is below 75 mg/dl or above 240 mg/dl, the diabetic diver must seek physician approval prior to scuba diving The physician should be knowledgeable with regard to diabetes mellitus and scuba diving b Breakfast: The diabetic diver should increase his/her normal breakfast by 200 calories The increase should consist of a mixture of complex carbohydrates and proteins c Fluids: Between arising and the diabetic divers first dive of the day, he/she should drink at least the equivalent of two to four 8-ounce glasses of non-caloric fluid 4 First dive of the day a SMBG: Perform random blood sugar RBS just before normal breakfast time 1 If the RBS value is between 75 mg/dl and 240 mg/dl, the diabetic diver may proceed with the first dive of the day in there are no other contraindication 2 If RBS
value is below 75 mg/dl or above 240 mg/dl, the planned dive activity should be aborted The diabetic diver should seek medical advice b Food: A small snack should be eaten just prior to the dive, consisting of approximately 100 calories of a mixture of proteins and complex carbohydrates such as 1 bread exchange and _ meat exchange c Dive Plan: The dive should comply with the standards of the SSI scuba program for nondecompression recreational scuba diving The SSI dive Tables should be followed, except that the bottom time for any dive independent of depth should not exceed 25 to 30 minutes Under adverse conditions such as strong current, cold waters, or increased work, or if unexpected physical exertion is required, then the bottom time should not exceed 20 to 24 minutes 5 Post-Dive Plan a SMBG: Perform random blood sugar RBS immediately upon completing the dive 1 If the RBS value is below 80 mg/dl a carbohydrate snack should be eaten immediately Repeat RBS every 30 minutes and take carbohydrate snacks until TBS is 80 mg/dl or above See section on hypoglycemia below 2 If RBS value is 80 mg/dl or above a small protein and/or complex carbohydrate snack is appropriate b Fluids: drink
at least two eight-ounce glasses of a non-caloric fluid c Other: Remove tight-fitting wet suit If cold, get warm If hot, attempt to cool down 6 Surface Interval Time Time between the first and second dive of the day a Rest for the first 30 minutes of surface interval time b Perform no strenuous activity during the entire surface interval time c An SMBG should be performed if any symptoms of hypoglycemia develop and appropriate action should be taken See section on hypoglycemia below d Appropriate meals and snacks should be taken e Omit any scheduled insulin administration between the first and second dive unless otherwise directed by personal physician 7 Pre-Dive and Dive Plan for Second Dive of the Day a Repeat steps outlined in Sections 4 and 5 of Protocol b The diabetic diver should limit his/her scuba diving to two dives per day HYPOGLYCEMIA 1 Signs and Symptoms of Hypoglycemia a Early warning signs: unusual hunger, headache, alteration of mood, nervousness, and/or unusual fatigue
5
SSI PROTOCOL FOR DIVERS WITH DIABETES
Duke H Scott, MD SSI Medical Advisor
b Mild reaction: tremors, pounding and/or rapid heart rate, sweating, clamminess of skin, and/or extreme fatigue c
Moderate Reaction: Severe head and/or neck pain, extreme alterations of mood, irritability and/or extreme fatigue d Severe Reaction: Decreased awareness or responsiveness, unconsciousness and/or convulsions 2 Response to Symptoms of Hypoglycemia a If only early warning signs of hypoglycemia and the SMBG is 80 mg/dl or above, look for other causes of diabetic divers symptoms, including anxiety, sea sickness, dehydration, heat exhaustion, and/or early signs of decompression sickness DCS 1 Eat an appropriate complex carbohydrate protein snack, 2 Repeat SMBG in about _ hour 3 If symptoms clear and SMBG is 80 mg/dl or above, and no other contraindications are determined, then the diabetic diver may continue with his/her scuba diving activity in accordance with the Protocol b If only early warning signs of hypoglycemia but the SMBG is below 80 mg/dl, the diabetic diver should: 1 Take 10 to 15 grams of sugar, such as 4 to 6 ounces of fruit juice, 6 lifesavers, or 4 teaspoonfuls of sugar 2 Repeat SMBG in about _ hour 3 Continue this process until blood sugar value is 80 mg/dl or above and symptoms have cleared 4 Eat a complex carbohydrate-protein snack Cease all scuba diving activity and
seek medical advice 5 Hydration is a priority c If mild signs of hypoglycemia develop and SMBG is below 80 mg/dl, the diabetic diver should: 1 Initiate same treatment as for early warning signs Section 2b above 2 4 glucose tablets may be substituted for sugar snack easier to carry d If moderate hypoglycemia develops and SMBG is below 60 mg/dl, the diabetic diver should: 1 Immediately take 4 to 6 glucose tablets or large sugar snack, or spoonfuls of sugar 2 Repeat SMBG in about _ hour 3 Continue treatment with glucose tablets and interval monitoring until symptoms clear and SMBG value is 80 mg/dl or above 4 Watch carefully for signs of relapse Recovery is usually longer 5 Cease all scuba diving activity and seek medical advice 6 If the diabetic diver becomes confused, disoriented, or combative, he/she may require assistance from their informed dive partner 7 If the diabetic diver is unable to take sugar snack or glucose tablets, then Glucagon 1 mg should be given subcutaneously or intramuscularly in the shoulder or anterior thigh A positive response should be noted in 10 to 15 minutes Proceed with sugar snack, etc 8 Observe SMBG carefully for rebound hyperglycemia high blood sugar 9
Do not give the diabetic diver food or fluids by mouth until he/she is alert enough to swallow, in order to avoid possible aspiration into the lung and/or choking e If severe hypoglycemia develops the SMBG value will generally be below 60 mg/dl, the diabetic divers informed dive partner should: 1 Immediately administer Glucagon 1 mg subcutaneously or intramuscularly to the diabetic diver, as described above 2 If available, and a trained medical person is present, then intravenous glucose and fluid should be given 3 Seek emergency medical service and advice 4 Cease all scuba diving activity f The diabetic diver should cease all scuba diving activity if any signs or symptoms of hypoglycemia develop He/she should not be left alone while others continue to dive Appropriate medical advice and/or treatment should be obtained for him/her 6
SSI PROTOCOL FOR DIVERS WITH DIABETES
Duke H Scott, MD SSI Medical Advisor
g Other problems associated with scuba diving should always be considered They could mimic hypoglycemia or occur simultaneously with hypoglycemia in the diabetic diver OTHER MATTERS 1 Dive Kit for the Diabetic scuba Diver a Watertight container to hold the kit, clearly marked
b The Protocol c Personal medical history d Personal physician name and phone number e SMBG monitor and glucose oxidose sticks, with instructions f Glucose tablets or substitute g Glucagon for subcutaneous or intramuscular injection h Instructions and supplies for administering Glucagon 2 Dive Log for the Diabetic scuba Diver a Log all dives b Keep details of insulin administration, SMBG, environmental conditions, and any adverse reaction Please send copies of your log to the SSI Medical Advisor after every scuba diving activity By collecting and analyzing this data we will be able to review and, if necessary, revise the Protocol Address: Duke H Scott, MD SSI Medical Advisor 1606 Arrowhead Trail Neptune Beach, FL 32266 Phone: 904 246-0750 Fax: 904 246-4947 Email: dr1313@aolcom
Any questions concerning the protocol may be directed to the SSI Medical Advisor by calling 904 2460750 or writing to the above address
7
SSI PROTOCOL FOR DIVERS WITH DIABETES
Duke H Scott, MD SSI Medical Advisor
SSI DIABETIC PROFILE FOR POOL ACTIVITY Name Age Sex Pool Activity SSN
Informed Buddy Diabetic Dive Kit Diabetic History: SMBG: Yes I Diet Med/Insulin type/dosage No Method/Device Type of DM:
Type 1 Type 2
Pre-Activity 1 Random Blood Sugar 2 Med/Insulin type/dosage Omitted 3 Snack 4 Description of Activity calories
II
Post-Activity 1 Random Blood Sugar 2 Snack Hypoglycemia 1 Present: Yes 2 Blood Sugar Level 3 Symptoms 4 Response 5 Result
calories No
III
6 Post-Hypoglycemia Blood Sugar IV Additional Comments
Signature of Participant
Date
Signature of Instructor
8
Date
SSI PROTOCOL FOR DIVERS WITH DIABETES
SSI DIVE PROFILE FOR DIABETIC DIVERS Name Age Sex Informed Buddy Type of DM: Type I Diabetic History: SSN Certification Type II SMBG: Yes Diet Med/Insulin include frequency and dosage PROFILE I Evening of Pre-Dive Day 1 Meal: calories 2 Evening Snack: calories 3 Med/Insulin type and dosage: II Morning of Dive Day 1 FBS: 2 Breakfast: calories 3 Med/Insulin type and dosage: III First Dive 1 Random Blood Sugar: 2 Snack: calories Time: IV Dive Profile 1 Dive: First Second 2 SSI Tables: Computer: 3 Maximum Depth 4 Bottom Time 5 Dive Description V Post-Dive 1 Random Blood Sugar 2 Post Dive Snack 3 Med/Insulin Type and Dosage 4 Hypoglycemia: Yes No Description of Response: a Blood Sugar: b Symptoms: c Response d Result: VI Surface Interval 1 Rest Period time: 2
Meal: calories 3 Snack: calories 4 Med/Insulin Type and Dosage 5 Time on Surface: Diver Signature Instructor Signature
9
Duke H Scott, MD SSS Medical Advisor
Years diving Diabetic Dive Kit No Device
Omitted
Omitted
calories Omitted
Omitted Date Date
SSI PROTOCOL FOR DIVERS WITH DIABETES
DIABETIC DIVER MEDICAL FORM SUPPLEMENT This history and physical form is to be completed by the potential diabetic students personal physician Patients Name: Diabetic History 1 Type of Diabetes Mellitus: Type 1 Type 2 2 Age of Onset: 3 Method of Control: 1 Diet: calories 2 Medication type, dosage, frequency 3 Insulin type, dosage, frequency 4 Present Diabetic Control: Stable Unstable 5 SMBG: Yes No Method 6 Hypoglycemic Episodes: Yes No If yes, explain Systemic Diabetes 1 Diabetic Retinopathy 3 Microvascular Disease 5 Renal Disease Discuss any yes answers: Associated Medical Problems 1 Hypertension 3 Cigarette Abuse Discuss any yes answers: Date:
Duke H Scott, MD SSS Medical Advisor
Yes Yes Yes
No No No
2 4 6
Macrovascular Disease Yes Peripheral Neuropathy Yes Diabetic Foot Yes
No No No
Yes Yes
No No
2
Dyslipidemia
Yes
No
Diabetic Lab Enter values and dates 1 Last FBS 2 Last
HbA1C Cardiovascular Evaluation if indicated 1 Treadmill results and date:
3 Last Urinary Albumin:Creatinine Ratio: Screening for microalbuminuria 4 Urine Albumin
Diabetic Physical 1 Complete the SSI National SCUBA Program Medical Form 2 Additional Examinations: a Elevated BP Yes No b Diabetic Retinopathy c Peripheral Vascular Disease Yes No d Peripheral Neuropathy e Diabetic Foot Yes No f Cardiovascular Disease Discuss any positive findings: Diabetic Protocol Able to follow Diabetic Protocol
Yes Yes Yes
No No No
Able to follow with the following modifications:
MD/DO Physicians Signature Address, City, State, ZIP 10 Printed Name
Source:in.gov
