Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
Q - I have read about the epilepsy rules, I am not sure mine was epilepsy but
assume so as my sister had it. I had a couple of attacks over twenty five
years ago but still take very very low dosage meds, am I still unable to
dive as I still take a low form of medication?
A - Aah, that old rascal of a medical problem again. All too common sadly and once more the answer is no. Repeat after me, “You have to be fit free and OFF all medication for 5 big old years”.
This is due to risks of fitting at depth, which equal death basically, as well as the effect of those meds on you at depth. Shallow narcosis in theory.
So whaddya do. Well snorkel and become an active campaigner for Bite Back is a good way of whittling off the years. But you could approach your neurologist now and ask if you really do need those daily tablets. It sounds like you could well be taken of them after a quarter of a century fit free, then after saving the fish you would hope to see you could be diving well before any Tory Government ever got elected.
Q - I took up diving in the late 1970's and between then and 1988 I clocked
up over 500 dives to depths down to 50m, both as part of a research
project and eventually as an instructor and founder member of a club. In
February 1989 (I had not dived for about 9 months prior to this) I had a
sub-arachnoid haemorrhage due to a berry aneurysm which burst. Following
a scan, I was found to have three such berry aneurysms. I had the one
which burst clipped in March 1989, the next one clipped around August
1989, and the final one clipped around January 1992. After each
craniotomy, I was prescribed anti-epileptics as a precaution, but never
had a fit. After the final op in 1992, I was given my driving license
back after 6 months as I was symptom free.
During my divorce between 2002 - 2003 I developed slightly high blood
pressure, and was prescribed Atenolol, but following a return to normal,
I stopped taking this in April 2005.
I took up diving again in September 2005 when my children and partner
were all keen to take the sport up, and obtained a medical from my GP in
October 2005. On the form, she ticked that see could find no medical
conditions that she considered incompatible with diving, but next to
this she wrote "but see below", and in the comments section she wrote
"History of subarachnoid haeorrhage but no neurological sequalae.
Aneurysms clipped so should not recur, but there must be some increased
risk. Patient aware of this. Blood pressure normal - off treatment for 6
months". This was accepted by my local PADI club, and I have since
completed over thirty dives with depths down to 36m (Deep Diver
Speciality, and an Enriched Air speciality amongst others.
I went to Malta over the Easter break, and they presented me with a
medical form to fill in. I completed this truthfully, and made them
aware of my past medical history, and they immediately called in a
specialist hyperbaric doctor for his opinion. He was provided with the
form from my GP, and he would not underwrite my fitness to dive. In his
opinion, anyone who has had a craniotomy has an increased risk of having
a fit, and is more susceptible to Oxygen poisoning. He initially said
he would advise me to limit my dives to 20m, but then said he could not
take responsibility for saying I could dive at all.
I am now very confused and concerned as I was aiming to cross-qualify as
a divng instructor for PADI in September. I was also hoping to dive with
my family and help them to further train themselves. Please could you
give me your opinion on this. I am not on any medication at all, and
A - Ah poor you, not a lot to do in Malta if you don’t dive. Unless you like falcons. I think you have been given the bum’s rush here. To be passed as fit, then see an expert, who says yes to 20metres, then changes his mind later.
I think the deal with you, is that if all the berries have been clipped, so there are none left. You have not had a fit at all, and now it is 16 years later, then it is unlikely that you will have a fit this late. And as for previous craniotomy making you susceptible to an oxygen fit, well show me the evidence I say. So in all I think you could have been passed as OK. These sort of haemorrhages are rare and are caused by a bleed into the brain from tiny defects in the inner brain circulation. The docs did the right thing, and found others, which they have now fixed, so it could be said you are safer to dive now then when you were merrily diving undiagnosed before the bleed.
I think for the future, it’s best to see a dive doctor, proper and get the paperwork before you go to these sort of destinations, or at least have a doc in the UK who can talk to the Malta doc, as you always have to be honest on the medical forms.
Q - I am hoping that you can help me. I am epileptic. I was diagnosed when I was 15yrs old. I am now 29. I have been fit free for 5 years although I continue to take anti-convulsants. (Epilim chrono). I have been scuba diving for the past 4 years.
Is there a convenient time when I could call and speak to you with regards to a dive medical?
I have many questions, as I am sure do you.
A - Yup, plenty of questions from this end. Who said you could dive on those meds for starters?
You have slipped through the net. The rules are that you have to be fit free and OFF the meds for 5 years before diving. You seem to be lucky as there have not been any accidents. The risks are that you nark at very shallow depths, and the bioavailability of the drug could be affected by depth and pressure leading to a fit underwater. The research is foggy here, but that’s the theory anyway.
So whaddya do? I suggest you see your specialist and consider whether you could come off the meds at some point. If they agree, in 5 years time, assuming no wobbles, then you could be back in the blue. It’ll still be there then, unless Ebola sharks have ruined it all. You know the Zambezi’s off the Limpopo are spreading the virus to all the world’s sharks. Wouldn’t eat them if I were you.
See it works!
Q - In your opinion would a single seizure 2 years ago preclude, in itself, an HSE medical for scuba diving? It was a one off seizure. MRI scan showed nothing unusual, no medication was prescribed & was told by the neurologist that it was not epilepsy and has had no recurrence since.
A - Then what was it? The HSE medical does need us docs to be very accurate about past medical history. A seizure is a serious thing, and yes the rules for sport divers are that you have to be fit free and off all meds for 5 whole long years before diving again. The HSE are tighter. Any history of epilepsy will bar you from being a commercial diver. Now as it is not epilepsy in your case, there may be some flexibility, but we do need to know what they thought it was.
So this means a chat with the neuro team, and a clear cut diagnosis. Stress, hypertension, coming off illicit drugs. That sort of thing. Then we can go from there.
Q - I read your Medical Solutions pages in Sport Diver and hope you can help me. At the ripe age of 50, in 2002 whilst living in the USA, I took up diving and in 2 years racked up 88 dives and am now a PADI rescue diver. In February 2004 I went to work in Baghdad and was generally working 14 -16 hours a day, 7 days a week, with a one week break, every 6 weeks. After 7 months of this I suffered four "complex partial" seizures over the space of about 4 hours. I was medivaced to the UK and the Consultant thinks the seizures were caused by the stress of working in Baghdad, through long hours and the fears from incoming rockets and mortars, exacerbated by alcohol (I was drinking well above my 21 units a week, mainly beer). MRI, EEG and CAT scans were all OK and no signs of tumours. The neurological report says "the clinical picture is consistent with focal epilepsy on a background of chronic excess alcohol intake". I am now on Phenytoin 300mg a day and the Consultant thinks I may be able to come off these later this year. My alcohol intake is now less that 8 units a week. The Consulant thinks I will be able to dive again and my understanding of the US PADI advice is it is OK after 12 months seizure free. I believe the UK position is different. Can you advise please?
A - It is a different thing in the UK. Here you have to be fit free and of all medication for 5 years before you can dive again. But yours is a different situation, as you are to be on short term anti-epileptic medication, and you never really had "epilepsy". Only this alcohol-stress-Iraq-thing. However if the neuro report does say focal epilepsy, then that is a tricky one. It sounds like your life being in fear of a bearded nutter strapped with C4 paying you greetings in the name of Allah, has probably caused this. So my thoughts are that a second opinion may be warranted, to avoid the 5 year wait, from another neurologist. But if the Americans allow you to dive a year after a fit, then that is way too shorter time for a condition that will kill you and endanger your buddy, to get back in the water. So a bit of confusion all round.
Hence the second opinion when you are in a less stressed place.
Q - I am currently a PADI Open Water Diver, and have had no medical problemswhile diving. However, on a recent diving holiday I fainted one evening, and had what looked like convulsions. As I had not been in the water for two days, I don't think it was caused by diving. I had CT scans at the hospital in Egypt, and epilepsy was ruled out. The diagnosis was convulsions brought on by hyperventilation, although low potassium levels may have also contributed to the initial fainting.
My diving instructor has requested that I have a diving medical before going on the next dive holiday, but from your website I am not sure if I would need the "fit to dive" medical, or if the "open water medical" would suffice.
Please could you advise.
A - You will need the "fit to dive" medical. The "open water" medical is really for those divers, utterly fit and well who just need a cert for countries like Malta, where they demand a medical irrespective of your health.
We need to look into this more closely with you. Firstly as epilepsy is a massive diagnosis to give a diver, as it's an automatic ban on diving. Yes the CT was normal, but CT scans can't always rule out epilepsy. An EEG [electroencephalogram] would be useful too, along with your previous history of fits or faints.
Secondly, untrained eyes looking at a "convulsion", can get it wrong. A tonic-clonic epileptic fit is a specific thing. An occasional twitch in a fainter can look bad, but not be epilepsy. We need to explore this.
Your Instructor is right, you do need to see a doc before diving again.
[I saw this lady later. It turned out she had not eaten for 2 days before the episode, and had had diarrohea, hence the low potassium. These factors caused the event, and I felt she was OK to dive again]
Q - I am a student just starting my 2nd year in a Marine Biology/Zoology course in North Wales. Although diving is not an essential part of my course it would be very helpful to learn, and I could then join in various excursions and activities with the sub-aqua club.
The problem is that in July 2000, I was diagnosed with having epilepsy. The fits have been occurring since I was 5 but there was long break of about 12 years in between. I am now on medication (lamotrigine 150mg/day). The fits are described as "petit-mal", so are not violent and only last about 1 minute.
The question is am I allowed to learn to dive? My last fit was on the 27th August (due to an operation on my knee) and is there any certain time period of being "fit-free" that I have to wait as with driving?
Please could you give me some info on this.
A - I'm surprised that diving is not essential to being a Marine Biologist, it's rather like a doctor never seeing a patient in their normal environment. Hang on, that's the District Nurse's job isn't it. Maybe you have a point!
I must also say that I envy you your course, if I hadn't managed to get into Med School then Marine Biology at Bangor was my calling and sometimes when faced with a case of anal itching first thing in the morning I dream and regret not being able to study dolphins in the Bahamas and calling it a job. So, good call on the course.
And now for the bad news I'm afraid. As mentioned in previous issues diving is a non starter for you. Epilepsy, whether petit mal, grand mal or any other of the varieties that can occur is absolutely forbidden for anyone who wants to dive and there are no exceptions. The reason is obvious, as a fit underwater will be fatal and not just endanger your life but also your buddies as well.
Petit mal is an odd sort of epilepsy as it is characterised by so called "absence seizures". These appear unannounced and the sufferer will suddenly go blank, stop moving and not be responsive to any stimuli for a short while. You say yours are only for a minute but a minute is long enough for the regulator to drift out of your mouth, you to lose buoyancy and your buddy. Missing diver, that would be the result.
On top of this is the fact that anti-epileptic medication can bring on narcosis at a very shallow depth too and is banned for a diver. But there may be hope there on the horizon, but nothing that can get you underwater before you finish your course. If you stay fit free and off medication for 5 years it is deemed that you are a low enough risk of another fit that you are then allowed to learn to dive. As to when you come off the medication is a decision only your neurologist can make for you. So its no go for now but maybe in the future when you have finally paid off your student loans you may well be in a position to get back into debt by taking up diving!
Q - I would Like to take up scuba-diving but I suffer from epilepsy, my last attack was 8 years ago. I am on medication to prevent these attacks, Epilim and Lamotrigine. So am I permitted to dive? I did a 4m intro dive in Lanzarote with no problems.
A - Sadly as you are still on your current medication, the regulations state that you cannot dive. You have to be fit free and off your medication for 5 years. As you haven't had a fit for a long time now I suggest you go back to your neurologist to see whether you should come off your tablets, and if they agree then its still a long wait before you are allowed to dive.
Q - My son suffers from petit mal epilepsy. He does not suffer from fits, though. He is 12 years old and wants to do his open water course. He is taking 450mg lamotrigine & 800mg tegretol retard. I read in your column that this may cause nitrogen narcosis at as little as 5 metres, is there any way round this such as nitrox diving ?
A - An interesting point and one I have brought up with other neurologists. Yes the problem with these tablets is that they can cause narcosis at very shallow depths, so in theory nitrox may prevent this or lessen it a little. Having said that I cannot advocate that anyone tries this as there are other reasons for not diving whilst taking this medication.
This is the fact that no one knows how the drugs metabolism is affected by depth and pressure. Metabolism of medication is normally a consequence of either kidney, liver function or blood flow to these organs. These organs will break the drug down and excrete it at a normal rate giving a drug what we call "half life". This is different for different drugs, hence you take some drugs 2 times a day and some 4 times a day. Now, when you go diving as you know, blood flow is affected to different organs, and the metabolism of certain drugs can be increased. If this were to happen with antiepileptic medication the consequences would be disastrous as the medication may wear off underwater with a fit ensuing. Again, this has not been researched because of ethical issues and because there is little point as a diver wouldn't be allowed to dive on these tablets anyway, as by taking them it is an admission that there is still a risk of fitting.
However once your son has been taken off medication and cleared by the neurologists, and then remained fit free for at least 5 years then he is considered at low enough risk to start to learn to dive.
He should tell his dive buddy of his past condition though, just to be on the safe side.