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The RSTC Medical Statement

“The multiple failures revealed in this court case must send a message to those in the diver training industry that they have peoples’ lives in their hands. Companies responsible for teaching people to dive must follow the regulations which are there for very good reasons. We do not want more people to die in avoidable circumstances” This statement followed the completion of the prosecution of Subaquaholics and its director / instructor Ian Johnson following the death of Mr Jan Karon whilst on a club dive in October 2008.

The following will not be a thorough analysis of all the events that led to this tragic death but will look at the medical aspects. However this would make an excellent case analysis for all dive school professional team meetings. The failings identified at Subaquaholics are not isolated incidents and are prevalent within the industry with less professional dive organisations.

On 15th October 2012 the HSE published a press release that Mr Karon was 54 years old and suffered with medical conditions. Although the fatal dive was a club dive he had one dive remaining to complete his PADI Advanced Open Water course with Johnson of Subaquaholics, with whom he was buddied on this dive. Tragically he surfaced unresponsive and resuscitation was unsuccessful. A subsequent inquest found that Mr Karon died from drowning with coronary artery disease a contributing factor. Following this death the HSE investigated the diving practices of Subaquaholics and this prosecution followed. The presiding judge was reported to say that as the offences occurred before a change in the law, a financial penalty – not custody – was the only option open to him. I understand that a considerable fine and costs have caused Subaquaholics to close, but before they did so PADI had expelled both Johnson and Subaquaholics.

PADI standards require all course students to complete the Recreational Scuba Training Council (RSTC) medical statement. This is used as a screening tool to identify students who may need a medical assessment and clearance prior to diving. It requires the student to answer a series of health questions with a “yes” or “no” (not a tick or cross as this can cause confusion!) Any student that answers a “yes” to any question is required to have written clearance from a doctor before any in-water activities.

Mr Karon suffered with hypertension, high cholesterol and was obese. His 10 year old daughter also suffered with asthma and required treatment. Both had apparently declared these on the RSTC medical statement but neither were directed to a doctor for assessment and written clearance prior to being allowed to dive with Subaquaholics. I understand that neither of these documents nor others required by PADI standards were subsequently available for review in court. So it is probably accurate to state that neither were these medical statements read and acted upon as required, nor were they kept securely after the event as required by Law.

From a medical perspective these 2 dive students would probably have appeared reasonably healthy to a lay person. There are many obese divers and perhaps the 10 year old was only doing a pool dive? So I wonder how many instructors would have been happy to proceed on this basis? They would of course be violating PADI standards. The PADI instructor manual clearly states that completing medical statements and action them if necessary with a signed statement from a doctor is mandatory before any in-water activities.

 

A review of the BSAC annual diving incident reports show that there is an increasing number of UK diving deaths in those over 50 years of age, often from heart attacks. High blood pressure, high cholesterol and obesity are all significant risk factors for heart disease. No doubt as the average age of divers increases these figures will rise.

Asthma is reportedly on the increase so more people are being diagnosed with it. Whilst excellent treatment is available and many lead a completely normal life there are increased risks for scuba diving. These include air trapping in the lungs and increased risk of ruptured lungs, so barotraumas to the lungs needs to be considered. We all “know” that you should never hold your breath when diving, but what we really mean is don’t hold your breath on ascent. The shallowest recorded incident of barotrauma from breath holding occurred in a pool from 1.2m depth. Air trapping in a sub-optimally treated asthmatic could have the same effect. So even a try dive in a swimming pool could be an issue.

These are examples of why using the RSTC medical screening form and any “yes” responses taken seriously is mandatory before any in-water activity. Failure to do so will expose you to prosecution and expulsion from your Training Agency.

The RSTC medical statement does not clarify what sort of doctor can certify a student as fit to dive – any medical doctor can do this. There is little or no medical training in underwater medicine in UK medical schools, and the same is probably true for the rest of the world. Recognising this, a large proportion of UK GPs will not complete diving medicals.

 

The HSE will only recognise doctors who have been trained in underwater medicine to perform commercial diving medicals in the UK, whilst all GPs are allowed to perform many other occupational medicals eg HGV or Taxi medicals. The British Sub Aqua Club (BSAC) uses a similar self declaration medical form, but any club member who admits a problem must contact a “medical referee” on the UKSDMC website ie a doctor who has been trained in underwater medicine.

So whilst it is not a PADI standard, nor legal requirement, dive school instructors would be advised to consider what sort of doctor is signing off these medical statements. These medical statements will not, of course, guarantee that the student will stay alive, but they will help produce a paper trail that you have “as far as reasonably practicable” ensured that the student is medically fit to dive.

Some other issues to consider:

  • What sort of diving is the student doing? The RSTC statement seems to suggest that you are either fit to dive or not. This is far from the truth. Some less fit students may be for shallow, warm and good visibility diving, but not for tech diving. Was this considered by the doctor signing the form? Should you accept the same medical certificate (normally valid for 1 year) for both the PADI OW course and the Tech course commenced 11 months later?
  • The student who completes the RSTC form with all “no” answers yet is seen taking a pill or inhaler prior to diving. Unpublished surveys suggest that in excess of 50% of students make inaccurate declarations! I am not aware, yet, of any legal case where an instructor has been taken to court with an allegation that they were “aware” that the form had been inaccurately completed but still allowed the student to dive, perhaps with a bad outcome – but as society gets more litigious I suspect that it is only a matter of time
  • The student who arrives on the day of the course and has a “yes” answer but has not got a doctors certificate. Some students may even ask the instructor’s advice on how to answer. There is clearly a pressure on the form being answered with all “no” answers otherwise the student will not be doing any in-water activities, but is the instructor medically qualified to advise the student? If something goes wrong afterwards how will the instructor justify in court why they gave advice to put a “no” answer? The accusation that money was more important than the student’s life will be an unpleasant one.
  • If the student is recovered from the water unconscious what information will you be able to give the emergency medical services (EMS)? An assumption that they must be entirely “fit and healthy” or they wouldn’t be diving is far from the truth these days. What will your surface cover (who will probably be the one liaising with the EMS) know about your students? This surface cover is a legal entity in the Diving at Work Regulations 1997 and should know about any medical issues that the students have so that the EMS can be briefed accurately and appropriately. How often do you include your surface cover in the dive team briefing and adequately brief them? (This will be the subject of a further newsletter.) Do you ask your students to complete a form which includes a medical information section to pass on to the EMS if needed? Interestingly PADI do have a “Emergency Treatment Consent Form” for minors which has this information on.

Out of gas

I went along to the first social after Sue and Martin took over Divecrew, to offer my congratulations and show support.  The moment I walked in, Continue reading