Future requirements for medical support of diving – IMCA questionnaire

The availability of doctors with experience of the commercial diving industry and its unique medical problems is diminishing. Such cover was provided traditionally by doctors trained in naval diving, but over the years this source of expertise has almost disappeared. Competent civilian medical cover was achieved early in the development of the offshore oil and gas industry, but often this was on an ad hoc basis. Another factor today is that medical training throughout the world is changing towards greater specialisation and even now, when the training objectives for this tiny speciality have been agreed, it is difficult to achieve this training in a hospital environment. Medical input is needed by IMCA members in air and mixed gas diving for:

1. assessments of fitness to dive, and occasionally to resume diving;
2. immediate treatment of all foreseeable diving illnesses and accidents;
3. advice on the physiology, toxicology and the other preventive aspects of diving.

Each of these requires different knowledge and different levels of skill. To ensure the future availability of medical cover, particularly at the second skill level, the attached questionnaire has been developed to review current and future needs for competent medical support in each of the IMCA geographical regions. The information gathered from the questionnaire on current availability of medical support will be treated confidentially and collated by the IMCA secretariat. The data to be reviewed by IMCA’s Diving Division Management Committee will be limited to numbers – details on names and nationalities are only being sought to avoid double-counting where individuals support more than one diving contractor. The collected results should help us quantify the perceived problem and develop action plans for this vital support service for offshore diving. All IMCA diving contractor members are asked to respond to this exercise, by completing and returning the attached questionnaire by 3 September 2007. The following paragraphs provide a bit more background on the subject.

Training

The training objectives for “diving doctors” in Europe were prepared by a task group of the European Committee of Hyperbaric Medicine (ECHM) and European Diving Technology Committee (EDTC) in 2004 and, after a few amendments, have been accepted by the Diving Medical Advisory Committee (DMAC) and EDTC as the basis for assessing training in this field. The training objectives and courses have also been recognised by IMCA (see Training of diving doctors). The training in diving medicine increases in complexity as one progresses through the following three levels: as providing appropriate standards for medical proficiency in this unique industrial environment.

• Medical assessment of divers (Level I) – a course of a few days enables a doctor of any clinical speciality to understand medical, mental and physical fitness for all aspects of diving. The course recognises the mobility of professional divers and so, even for regions with only air-range diving, it includes the relevant aspects of mixed gas diving;
• Competence in diving medicine (Level IIa) – a relatively short course for a Level I doctor who is already fully accredited and competent as a medical specialist (whether hospital based, in occupational medicine or in general practice). The course offers proficiency that, with experience, enables each doctor to cope with any medical aspect of operational commercial diving. This includes not only the management of decompression illness but also other incidents including ear problems, coincidental physical injury, and the medical management of those in lost bells or during hyperbaric evacuation. Even for those associated with only shallow diving, the training must include all aspects of professional diving;
• Internationally-accepted expert in diving medicine (Level III) – this applies to some individuals but no specific EDTC-ECHM recommendations have been agreed for minimum training. Recognition at present is based on having wide experience and appropriate peer-reviewed publications. (Attendance at symposia and lectures is also important but any course that claims to be able to teach this expertise should be regarded with some caution.)

It is important to distinguish the training in diving at Level IIa (for those who are already accredited specialists) from the prolonged period of training (including Level IIb) that leads junior doctors towards a specialist career in hyperbaric oxygen (HBO). Recognised training posts are available in hospitals to gain that status in HBO after which they can treat, among other patients, those divers with decompression illness who arrive at their hospital chambers. This career training is a lengthy procedure that includes the Level IIb course and was formulated by the ECHM on the basis of the joint ECHM-EDTC agreement of 2004. It focuses on hospital treatments and at this time does not A qualification in recreational or professional diving is a useful supplement when being trained to Level IIa but offers no exemptions from the formal training requirements. include all the training necessary to cope with diving medicine and physiology outside a hospital environment. This may change in the next year or so and in the meantime crossovers from HBO to diving medicine are available. A number of specialists are competent in both. The Divers Alert Network (DAN) provides an insurance and triage service primarily for decompression illness among recreational divers. The network advises on transfer to a recompression chamber that is responsible for the treatment and a number of its doctors have Level IIa and/or IIb certification.

IMCA members’ need for medical manpower

The Level I training for medical examiners of divers is not expected to be a future problem. Standards of medical assessment are largely controlled on a national basis and audits of Level I doctors are conducted as needed by national authorities. Reciprocation of diver fitness certificates is a matter of mutual agreement between individual nations. The training standards vary around the world and IMCA members may wish to check that the medical examiners have been trained to national or DMAC-EDTC standards, whichever is the greater. Level IIa training of established specialists in other medical specialities will continue to be needed, especially with the reduced availability of experienced ex-naval doctors. There are several courses around the world that meet the standards needed by the commercial diving industry and/or are applying for DMAC-EDTC recognition. However many hospital managers are no longer ready to authorise study-time for courses that do not relate to hospital medicine. Also, even for those in occupational medicine, proficiency from this additional qualification offers no guarantee of being able to recover the costs of training. The Level IIa on-call duty rotas in any region should include the immediate availability of a second Level IIa doctor to provide cover when the first doctor has to travel offshore for medical intervention. Thus Level IIa doctors also need survival-at-sea and helicopter-escape training. Level III expertise is based upon years of accumulated experience covering a wide range of in-water and offshore accidents and illnesses. Such doctors may offer advice remotely and many effective phone consultations have been made across the world regardless of regions. Some IMCA members have established international consultations within their companies but others use this telephone network informally when it is dependent on individual availability. Level III also needs a wide knowledge of hyperbaric toxicology, respiratory and thermal physiology and the many other foundations of safe diving. This is likely to be acquired on an ad hoc basis especially while associated with military or commercial diving developments.

Originally issued with the following reference(s): IMCA D 07/7