Diving Fitness — Is it just YOUR life?

A reflection on medical honesty, physical readiness, training, experience, and the people who live with our decisions by Brent Webb, Owner Scuba Adventures, Plano. TX.

There is a question we (Scuba Adventures) ask divers all the time: Are you fit to dive?

Most people hear that question and think about whether they can physically make the dive. Can I carry my gear? Can I swim? Can I breathe comfortably? Can I get into the water, complete the dive and get back out? But lately I have been thinking a lot about what that question actually means. Being fit to dive isn't simply about whether you believe you can get through today's dive, and the medical questionnaire you complete before training isn't an administrative obstacle standing between you and the water. It is one part of a safety system designed to identify risks before those risks follow us underwater.

That distinction has been weighing on me more than usual lately.

A few days from now will mark one year since 12-year-old Dylan Harrison died while participating in scuba training at a North Texas dive facility. I wasn't at the lake that day. I wasn't involved in Dylan's training, and the circumstances surrounding her death are not the subject of this article. Her death was not about a diver failing to disclose a medical condition, and I don't want to suggest that it was.

But as the anniversary approaches, I have realized that her death affected me more deeply than I understood at the time. Maybe it is because I am a dive professional. Maybe it is because I understand what it means when someone places their safety, or the safety of their child, in the hands of an instructor. Maybe it is because there is a very different feeling that comes with knowing an accident happened in the same diving community in which I work and teach. Or maybe it is simply because the longer I do this, the more clearly I understand that decisions made around diving rarely affect only the person making them.

Lately, I have repeatedly found myself dealing with something that seems minor by comparison: medical questionnaires that raise questions, answers that change, or situations where it appears someone is more interested in getting the 'right' answer on the form than giving the truthful one. And I keep coming back to the same thought: diving has consequences, and those consequences don't stop with you.

The Medical Form Isn't a Test You Need to Pass

Anyone who has taken a scuba course has probably completed a diver medical questionnaire. It asks about medications, heart and lung conditions, neurological issues, previous surgeries and other circumstances that could potentially affect someone's safety underwater. Occasionally, however, people treat that questionnaire like a test they need to pass.

They answer 'yes' to something, discover that their response requires an evaluation by a physician, and suddenly the objective changes. Instead of asking,

Is this something I should have evaluated before I dive?

the question becomes,

What do I need to put on this form so I can get in the water?

That is a dangerous misunderstanding of what the questionnaire is there to accomplish.

The purpose of medical screening isn't to keep people from diving. It is to identify circumstances where somebody with considerably more medical knowledge than a scuba instructor should determine whether diving presents an unacceptable risk. Your instructor is not your physician. Your divemaster is not your cardiologist. The employee behind the counter at your local dive shop should not be expected to determine whether your prescription medication, cardiac history, respiratory condition or recent surgery is compatible with immersion, exertion, pressure and breathing compressed gas.

Sometimes the appropriate answer is simply, 'We need a doctor to make that decision.' That isn't punishment. It isn't discrimination. It isn't the dive shop making your life difficult. It is the safety system working exactly as intended.

Feeling Fine Isn't the Same as Being Fit to Dive

One of the most common responses to concerns about fitness is, 'But I feel fine' or even ‘Everyone is on medication these days.’ That may be somewhat true. That still isn't the entire question. Diving creates physiological demands that aren't present while sitting at a desk or walking around the grocery store. Immersion shifts blood centrally within the body. Cold, exertion, stress and breathing dense gas all add workload. A person's cardiovascular capacity also changes with age and disease. Divers Alert Network notes that cardiovascular events cause approximately 20 to 30 percent of deaths occurring while scuba diving.[1]

More importantly, we don't train for the dive where everything goes perfectly. Fitness to dive doesn't mean looking like an athlete, and it certainly doesn't mean everyone needs to run marathons. We need enough physical and mental reserve for the dive where something doesn't. A current picks up. The exit becomes more difficult than expected. You surface farther from the boat. Your equipment develops a problem. Your buddy panics. Someone becomes negatively buoyant. Suddenly you aren't merely swimming back to the boat; you are towing another diver while wearing a full set of equipment.

DAN encourages regular exercise, appropriate medical evaluation, and lifelong attention to health and fitness for divers.[1][2] That is why 'I feel fine' cannot always be the end of the conversation.

Your Buddy Is Counting on You

There is another part of fitness to dive that I don't think we discuss enough. When you agree to dive with another person, you aren't only accepting responsibility for yourself. Your buddy is accepting some responsibility for you, and you are accepting some responsibility for them. We teach that from the beginning: stay together, monitor one another, recognize problems, share gas if necessary, assist a distressed diver, and get your buddy safely to the surface when something goes wrong.

But there is an uncomfortable question hiding inside the buddy system: Are you actually capable of doing those things? Could you swim to your buddy, establish buoyancy, control an ascent and tow that person to safety while managing your own breathing, equipment and stress?

Now reverse the situation. If you knowingly enter the water with a significant medical issue you haven't disclosed, or in physical condition that makes you incapable of dealing with foreseeable demands, somebody else may suddenly be required to save you. Your buddy may have to make an emergency ascent. An instructor may have to perform a rescue. Someone may have to provide CPR. EMS may be called. A helicopter may launch. Other divers may participate in a search or recovery. Someone who expected to spend Saturday enjoying a dive may instead go home carrying memories that will remain with them for the rest of their life.

That doesn't mean we should be afraid of scuba diving. It means we should respect it.

The 'If Only' We Never Want Someone to Say

There is a documentary from The Human Diver called If Only... about a tragic and avoidable accident during a diver training course in May 2018. The Human Diver emphasizes that, as with many adverse events, there were multiple contributory and causal factors. In hindsight they can look obvious; in real time they often do not, particularly when similar circumstances have happened before without an adverse outcome.[3]

That is one of the central lessons of human factors. We normalize things. We make exceptions. We have done something before and nothing happened, so doing it again begins to feel safe. We allow the absence of a previous bad outcome to become evidence that the behavior itself isn't dangerous. Medical fitness can fall into exactly that trap:

• 'I've been diving on this medication for years.'

• 'My doctor doesn't know anything about scuba.'

• 'I've never had a problem before.'

• 'I only take it occasionally.'

• 'I know my own body.'

Maybe every one of those statements is true. None of them changes the underlying risk assessment.

Getting away with something is not the same as establishing that it is safe. The point of studying accidents such as the one examined in If Only... is not merely to identify what somebody did wrong after the fact. It is to recognize the same patterns in ourselves before an accident supplies the lesson. Because afterward there will always be opportunities to say:

• if only I had told them;

• if only I had gotten checked;

• if only I had been in better shape;

• if only I hadn't assumed that because nothing happened last time, nothing would happen this time.

The objective of good diving practice is to have those conversations before somebody's family is left having them afterward.

Certification Is Not the Same Thing as Competence

There is another trend in diving that concerns me for much the same reason: the desire to compress competence into the shortest possible path. We increasingly see training marketed around efficiency; how quickly someone can complete training, remove 'unnecessary transitions,' or reach certification. There are even programs marketed around how much diver development can be packed into a single weekend, as though time itself were an inefficiency we finally figured out how to eliminate. I understand the appeal. Everyone is busy, and nobody wants training to take longer than necessary. Nor am I suggesting that a course is unsafe simply because it is scheduled over a weekend. My concern is the broader idea that efficiency in completing training requirements is the same thing as accelerating diver development. It isn't.

I am not suggesting that meeting a certification agency's standards in a weekend automatically makes a course unsafe, nor that taking two weekends automatically produces a better diver. That would be an argument I cannot support. My concern is the larger idea that efficiency and competence are interchangeable. Completing every required performance requirement is not the same thing as acquiring experience. Time underwater matters. Repetition matters. Sleeping on what you learned and returning to it matters. Diving in different conditions matters. Making small mistakes, thinking about them, and learning from them matters. Judgment develops through exposure and reflection, not simply through completing a checklist.

A weekend can teach someone a great deal, and a good instructor can accomplish excellent training in an intensive format with the right student. What no instructor can do is give a student experience that the student has not actually lived. That is why the certification card should be understood for what it is: evidence that a diver met a defined training standard at a particular point in time, not proof that the diver is prepared for every environment or problem that may come afterward.

This connects directly to fitness because fitness to dive is more than medical fitness. It includes physical fitness, mental fitness, skill fitness and judgment. You can have a physician's signature and still not be prepared for the dive in front of you. You can possess certification cards and still lack the experience to recognize a problem developing. There are very few shortcuts in diving that don't borrow something from your safety margin. Sometimes we don't discover what was borrowed until we need that margin back.

The People on Shore Are Part of Every Dive

That brings me to the part of diving safety that I think we forget most easily: the people who aren't diving with us at all. Your spouse. Your parents. Your children. Your friends. They aren't wearing scuba equipment. They may not even be at the dive site. But they are part of every dive you make because they are the people who live with the consequences if you don't come home.

When someone dies diving, the accident ends for the diver. It doesn't end for everyone else. There are families who receive phone calls. There are buddies who replay the dive in their heads and wonder whether they missed something. There are instructors who question decisions they made and signs they might have overlooked. There are first responders and recovery divers who carry images most people will never see. Eventually, someone packs away equipment that its owner will never use again. Then there are birthdays, holidays and anniversaries; dates on calendars that were once ordinary and never will be again.

I think that is part of why Dylan has been on my mind. Her death isn't an example of the medical issue I'm talking about here, and I don't want to turn her into one. What her death has forced me to think about is something much broader: the permanence of consequences in a sport where many of our safety decisions can feel routine right up until the moment they aren't. CBS Texas has reported on the criminal case arising from her death; whatever the eventual legal outcome, the simple human reality remains that a child went diving and did not come home.[4]

A year later, people are still living with what happened that day. That matters to me more now than I realized it did.

Fitness to Dive Is a Continuing Responsibility

One unusual aspect of recreational scuba is that certification generally doesn't expire. Your certification card may remain valid for your entire life. Your body does not remain unchanged for your entire life. The person who earned a certification at 25 isn't physiologically identical at 45, 55 or 65. We gain and lose weight. Our conditioning changes. We develop hypertension. We begin taking medications. We have surgeries. We recover from illnesses and injuries. We develop conditions we didn't have when we learned to dive.

DAN specifically addresses this in its Guidelines for Lifelong Medical Fitness to Dive. DAN notes that scuba certifications are generally lifelong while health status changes over time, and its guidance establishes recurring medical questionnaires and, for certain age and risk groups, periodic medical evaluations.[2] A certification card tells us that at some point we demonstrated particular knowledge and skills. It isn't a lifetime certification of our cardiovascular system, lungs, physical conditioning or judgment.

Certification Is Not Currency

Aviation has understood this distinction for a long time. A pilot can earn a certificate and keep that certificate, but that does not automatically mean the pilot remains current, proficient or medically fit to exercise all of its privileges. Depending on the type of flying, pilots have recurring currency and proficiency requirements, and many must maintain an appropriate medical certificate. The FAA generally requires a flight review within the preceding 24 calendar months to act as pilot in command, subject to specified alternatives, and aviation medical certificates have defined periods of validity. The certificate earned years ago and the fitness to use it today are two different things.

There is an important lesson for diving in that distinction. A scuba certification card may say that twenty years ago you demonstrated the knowledge and skills required to become an Open Water Diver. It doesn't tell me whether you have made two hundred dives since then or two. It doesn't tell me whether you have been underwater in the last month or the last decade. It doesn't tell me whether you can still remove and replace a mask without panicking, control your buoyancy when something goes wrong, assist another diver, or manage an unexpected situation without becoming another casualty. And it certainly doesn't tell me whether the body carrying that certification card today has the same medical fitness it had when the card was issued.

Aviation separates those concepts because the consequences of getting them wrong can be enormous. Certification establishes that you once met a standard. Currency demonstrates that you have remained engaged. Proficiency demonstrates that you can still perform. Medical fitness establishes that your body remains capable of safely doing the job. Diving should take those distinctions just as seriously.

We already understand the principle when it comes to our equipment. We service regulators, inspect cylinders, replace aging components and check batteries because we do not assume that something which worked years ago is automatically ready for use today. Yet we can be remarkably reluctant to apply the same reasoning to ourselves. Our skills deteriorate. Our conditioning changes. Our health changes. Medications change. Judgment can become rusty, and comfort underwater disappears when it is not exercised.

The answer is not that every recreational diver needs an aviation-style regulatory system. It is that the philosophy behind aviation currency makes sense: earning the privilege once does not relieve you of the responsibility to remain capable of exercising it. That responsibility belongs to the diver.

Fitness to dive is something we have to continue earning.

Answer the Question Honestly

So when somebody hands you a medical questionnaire, don't try to figure out which answer gets you into the water fastest. Read the question and answer it honestly.

• If the truthful answer means you need to talk to a physician, talk to one.

• If your health has changed, acknowledge it.

• If carrying your gear across the parking lot leaves you struggling to breathe, consider whether getting back into the water should start with rebuilding some physical conditioning.

• If your skills are rusty, take a refresher.

• If you or your physician has questions about diving medicine, resources such as DAN exist specifically to help address them.

None of that makes you less of a diver. Quite the opposite. Taking responsibility for yourself, and for the people who may someday have to depend on you, is part of becoming a better one.

It's Not Just Your Life You're Taking

Scuba diving can be an extraordinarily safe activity when we respect the systems that make it safe. Training matters. Equipment matters. Planning matters. Supervision matters. Judgment matters. Medical and physical fitness matter. We spend enormous amounts of time checking regulators, analyzing cylinders, planning gas, monitoring depth and calculating exposure. We maintain our equipment because we understand that our lives depend on it. We should be willing to inspect the most important piece of life-support equipment we take underwater: ourselves.

Before your next dive, ask yourself something harder than whether you can make the dive. Ask whether you are prepared for the dive that doesn't go according to plan. Ask whether you could help the person beside you if they needed you. Ask whether you've been honest about your health, your fitness and your limitations.

And remember that when you decide to enter the water, the consequences of that decision don't belong only to you. Your buddy is counting on you. Your instructor is counting on you. Your family expects you to come home. If you knowingly hide something that could affect your safety underwater, you aren't simply accepting a risk for yourself. You may be making that decision for every person who will have to respond if something goes wrong — and every person who will have to live with what happens afterward.

Dive like their lives are connected to yours. Because they are.

References

1. Divers Alert Network, “Cardiovascular Fitness and Diving.” https://dan.org/health-medicine/health-resources/diseases-conditions/cardiovascular-fitness-and-diving/

2. Divers Alert Network, “Guidelines for Lifelong Medical Fitness to Dive.” https://dan.org/dan-publishes-guidelines-for-lifelong-medical-fitness-to-dive/

3. The Human Diver, “If Only...” https://www.thehumandiver.com/ifonly

4. CBS Texas, reporting on the death of Dylan Harrison and subsequent criminal case. https://www.cbsnews.com/texas/news/scuba-instructor-arrested-death-12-year-old-north-texas-dive-facility/

Federal Aviation Administration (FAA), Flight Review guidance (14 CFR 61.56 / AC 61-98): https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_61-98E.pdf

Federal Aviation Administration (FAA), Medical Certificate overview: https://www.faa.gov/faq/what-medical-certificate