13 minute read
Children and Diving: What Are the Real Concerns?
but women might consider reducing their diving exposure during the follicular stage by incorporating additional conservatism into their dive plan. Completely refraining from diving while menstruating is not necessary, but women should be aware of how PMS and menstruation affects them and whether emotional stress, irritability, cramping, headaches or associated symptoms might compromise dive safety.
ORAL CONTRACEPTIVES
Use of oral contraceptives (as well as a sedentary lifestyle and long-distance travel) may contribute to possible clot formation such as deep vein thrombosis. Research indicates that oral contraceptive pill (OCP) use can increase the risk of a thromboembolic event such as a pulmonary embolism, heart attack or stroke. A 1985 report showed that women who use OCPs and smoke more than 25 cigarettes per day have a 23-fold increased risk for a thromboembolic event compared with those who do not smoke.5 While a thromboembolic event may be at least somewhat manageable on dry land, it would be unmanageable in the water. Quitting smoking, exercising regularly and moving frequently during long trips can help minimize the risk of an emergency due to clot formation.
PREGNANCY
Not only should pregnant women refrain from diving, women who think they may be pregnant or are trying to become pregnant should likewise avoid it. For ethical reasons there has never been experimental research investigating the effects of diving on a fetus. The retrospective anecdotal data regarding pregnancy and diving shows there may be a risk to the fetus should a mother continue diving during pregnancy. A survey of 208 mothers who dived during pregnancy showed higher rates of low birth weight, birth defects, neonatal respiratory difficulties and other problems.2
Decompression studies conducted on sheep demonstrated that a fetus may develop bubbles before the mother displays clinical symptoms of decompression sickness.3,4 (Sheep studies are relevant because the placentas of sheep and humans are similar.) The fetus runs the potential risk of death because the fetal cardiovascular system has no effective filter. Therefore, any bubbles formed are likely to go directly to the brain and coronary arteries. All sheep studies showed very high rates of fetal loss. Although it is limited, the available data seem to suggest strongly that women should refrain from diving while pregnant or trying to conceive.
As with scuba diving, the data on freediving and pregnancy are limited, with most data coming from Japanese ama divers and Korean haenyo divers. Freediving for pearls and abalone is a way of life for these divers, most of whom are women. Many ama divers continue to freedive well into pregnancy without many adverse effects, although profiles are modified based on gestation. Conservative freediving during pregnancy may be considered a safe activity for enjoyment or relaxation (provided good maternal and fetal health), but it should not be considered an ideal form of exercise. DAN recommends that pregnant women consult their doctor before beginning any new exercise activity. The recommendations regarding a return to diving after childbirth vary based on the type of delivery. After a normal vaginal delivery without complications, a woman can resume diving in about 21 days. This allows time for the cervix to close, which limits the risk of infection. An uncomplicated cesarean section generally means eight to 12 weeks of not diving to allow the mother to regain stamina and cardiovascular fitness. If a woman is put on bed rest due to complications, waiting more than 12 weeks is prudent because of deconditioning and loss of aerobic capacity and muscle mass. Following a miscarriage, a woman can return to diving when the physician releases her for full, unrestricted activity.
BREASTFEEDING
Diving is considered safe for mothers who are breastfeeding. Nitrogen does not accumulate in breast milk, so there is no risk of the baby absorbing dissolved nitrogen through breastfeeding. But diving can be dehydrating and may thus interfere with milk production, so appropriate hydration is important.
COSMETIC AND RECONSTRUCTIVE PROCEDURES
Fitness to dive following plastic surgery depends on the procedure. For instance, Botox injections, which relax facial muscles to reduce the appearance of wrinkles, typically require very little down time. Diving can be considered as soon as the treating physician feels there is no risk of infection. Dermal fillers warrant more consideration since they are designed to add volume to reduce the appearance of wrinkles. The concern is not the ambient pressure in the diving environment but rather displacement of the filler caused by pressure from the diver’s mask. The treating physician can offer advice on the time required for the displacement of fillers to no longer be a risk.
COURTESY ABI SMIGEL MULLENS
Diving after major plastic surgery such as abdominoplasty (a “tummy tuck”) or breast implants is deemed safe once the treating physician has released the patient for full and unrestricted activity — six to eight weeks is typical for these types of procedures. Caution should be taken when diving with breast implants. Avoid constricting buoyancy compensator straps to prevent undue stress on the implants. Keep in mind that saline implants are neutrally buoyant, but silicone is negatively buoyant and may alter a diver’s trim in the water.
AGING AND MENOPAUSE
The average age of the diving population is increasing. According to DAN membership data from 2000 to 2006, the average age of male members was 44, the average age of female members was 42, and the average age of both sexes increased significantly over the four-year period.1 With aging comes special considerations for female divers. The symptoms of menopause can be both physical and emotional, including anxiety, decreased energy, hot flashes, sleep disruption and mood changes. Nonetheless, menopause is not a contraindication to diving, assuming symptoms do not compromise dive safety, nor is it the greatest risk for aging female divers. Medical concerns associated with aging — such as hypertension, heart disease and diabetes — require greater attention, as they are more likely to affect diving.
Postmenopausal women are at increased risk of certain medical conditions such as cardiovascular disease, stroke and osteoporosis. Hormone replacement therapy, which can be used to relieve some symptoms of menopause, may provide cardiovascular protection in younger menopausal women (age 50-54) but may increase the risk of plaque rupture in older menopausal women.
CARDIOVASCULAR HEALTH
According to the American Heart Association, cardiovascular disease kills more women than all forms of cancer. DAN fatality reports show that cardiac incidents are among the top three disabling injuries in diving fatalities, regardless of sex.1,6 Signs and symptoms of a cardiac event can differ between women and men. Women are less likely to report chest pain during a heart attack, which may result in incorrect diagnoses and treatment delays. Cardiovascular disease can be misdiagnosed as dive-related illnesses, especially in women because of the increased incidence of ambiguous symptoms such as fatigue, malaise and/or flulike symptoms. In any emergency situation, timely first aid is critical, but quick and appropriate intervention in a diving context can be challenging.
OSTEOPOROSIS
Preventative health for women as they age includes awareness of the increased risk of osteoporosis, which can be determined by a bone density test. The National Osteoporosis Foundation recommends that women receive a bone density test if they meet any of the following criteria: they have broken a bone after age 50, they are of menopausal age with risk factors, they are under 65 years of age and postmenopausal with risk factors, or are 65 years of age or older. Compromised bone health is not a contraindication for diving, but women who have been diagnosed with osteoporosis or severe bone loss should consider avoiding wearing heavy dive gear such as tanks and weights while out of the water. Divers with osteoporosis should adapt their diving to reduce the risk of fractures and falls by putting on tanks in the water, avoiding carrying tanks on land and avoiding hazardous shore entries such as rocky beaches.
RELATIVE RISK
A comparison of fatality rates by age and sex of DAN members determined that men were 2.8 times more likely than women to die while diving.1 Some people might conclude this means men are more likely to engage in risky behaviors than women, but that would be speculation.
SUMMARY
Male and female divers have more similarities than differences. To dive safely, both must be physically fit, competent and properly trained for the environment they dive in. But understanding health considerations of particular relevance to women, such as pregnancy, thermal regulation and the differences in symptoms of cardiovascular problems, is useful to all women who dive — and those who dive with them. AD
STEPHEN FRINK
REFERENCES 1. Denoble PJ, Pollock NW, Vaithiyanathan P, Caruso JL, Dovenbarger JA, Vann RD. Scuba injury death rate among insured DAN members. Diving and Hyperb Med. 2008; 38(4):182-188. • 2. Bolton ME. Scuba diving and fetal well-being: A survey of 208 women. Undersea Biomed Res. 1980; 7(3):183-189. • 3. Fife WP, Simmang C, Kitzman JV. Susceptibility of fetal sheep to acute decompression sickness. Undersea Biomed Res. 1978; 5(3):287-292. • 4. Powell MR, Smith MT. Fetal and maternal bubbles detected noninvasively in sheep and goats following hyperbaric decompression. Undersea Biomed Res. 1985; 12(1):59-67. • 5. Rosenberg L, Kaufman DW, Helmrich SP, et al. Myocardial infarction and cigarette smoking in women younger than 50 years of age. JAMA 1985; 253(20):2965-2969. • 6. Denoble PJ, Caruso JL, Dear GdL, Pieper CF, Vann RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyperb Med. 2008; 35(6):393-406.
Clockwise from left: Portuguese man-of-war, fire coral, box jellyfish. Opposite: Encounters with free-floating jellyfish larvae can cause itchy bumps. • Vinegar can neutralize nematocysts to prevent further envenomation.
STEPHEN FRINK STEPHEN FRINK
KELVIN AITKEN/VWPICS/ALAMY
BY JOSEPH BECKER, M.D., AND PAUL AUERBACH, M.D., M.S.
SOME OF THE MOST BEAUTIFUL and seemingly harmless marine invertebrates are among the most hazardous. Snorkelers and divers may unintentionally come into contact with free-swimming jellyfish or touch hydrozoans such as fire coral while exploring reefs or wrecks. Occasionally, people may be stung while handling or stepping on jellyfish that have washed ashore. Although many envenomations are mild, some marine invertebrates produce incredibly potent toxins that can cause serious medical complications and even death.
GENERAL TREATMENT PRINCIPLES
The four main classes considered in this article are (1) hydrozoans, such as Portuguese man-of-war and fire coral; (2) scyphozoans, the true jellyfish; (3) anthozoans, including stony corals, soft corals and anemones; and (4) cubozoans, the box jellyfish, including Chironex fleckeri. Each of these classes is armed with stinging cells generally known as nematocysts. Symptoms of envenomation depend on the species, venom dose and body location. Immediately after a suspected jellyfish or hydroid sting, rinse the affected area with household vinegar (acetic acid 5 percent solution). If vinegar is not available, use seawater or a paste of baking soda. Hot water (to the victim’s and caregiver’s tolerance), heat packs, cold packs or ice may provide some pain relief, but do not place ice or unheated freshwater directly on affected skin. Remove any tentacle fragments, but take care to avoid contact with fingers or hands (wear thick gloves if possible). Rinse again with any remaining vinegar.
Hydrocortisone (0.5 percent to 1 percent) cream or ointment may be applied twice daily to the affected area until signs and symptoms of envenomation disappear. In some cases, a doctor may need to prescribe a stronger steroid regimen. If the area appears infected or the victim develops a fever, discontinue the use of any steroid and seek medical care. Complex or significant envenomations (any producing systemic symptoms such as nausea, vomiting, shortness of breath or confusion) require immediate evaluation by a physician.
After an envenomation it is possible for individuals to develop an allergic reaction, which may be severe. Anaphylaxis is a potentially deadly allergic reaction that can involve respiratory distress, airway compromise and other unstable vital signs. If anaphylaxis occurs, immediately administer epinephrine with an EpiPen or Twinject auto injector, if available. Provide oxygen and the antihistamine diphenhydramine (Benadryl). All patients suspected of having a serious allergic reaction should be treated immediately by a physician, who may administer prednisone or other medications.
Safe Sea, a topical jellyfish-sting inhibitor, has been shown to effectively diminish or prevent certain jellyfish stings. Care should be taken when swimming or diving into jellyfish-infested waters. Protective clothing should be worn, and a wide berth should be given to all jellyfish because tentacles may trail for several meters behind the bell and main body of the organism. Gloves may help protect against hydroid and anemone stings.
BOX JELLYFISH STINGS
The most well-known box jellyfish, Chironex fleckeri, is perhaps the most venomous creature in the sea and can cause death within minutes of envenomation. Although box jellyfish are most often found in quiet, protected and shallow areas — chiefly in the waters off northern Queensland, Australia — they may also be found in the open ocean. Death is attributed to shock, respiratory paralysis and subsequent cardiac arrest and may occur in 15-20 percent of cases. With any suspected box-jellyfish sting, the victim must be assessed rapidly for adequate breathing and supported as needed with artificial breathing and oxygen. The person should be moved as little as possible. The affected area should be immediately flooded with vinegar for at least 30 seconds and preferably a few minutes before any attempt is made to remove adherent tentacles; this can neutralize nematocysts somewhat and helps lessen the ultimate degree of envenomation. Severe pain and rapid development of wheals, blisters and reddishpurple tentacle markings are likely. In certain areas, such as Queensland, Australia, antivenin is available in hospitals and at some beaches, where lifeguards may be trained to administer it by intramuscular injection.
PORTUGUESE MAN-OF-WAR
The Portuguese man-of-war (Physalia physalis), known in the Pacific as the bluebottle, is not a true jellyfish but a colony of organisms. The man-of-war floats in the open ocean, typically in warm waters without any means of propulsion, relying solely on currents and winds. Man-ofwar stings usually cause severe pain, leaving whiplike red welts on the skin. Other reactions include fever, shock, cardiac and pulmonary failure and, in rare cases, death.
Although painful, man-of-war stings often resolve on their own. Affected areas should be rinsed with seawater (avoid freshwater). If symptoms persist, worsen or show no sign of improvement after several hours, or if there are any systemic symptoms such as fever, confusion, nausea or vomiting, seek care from a physician.
FIRE CORAL STING
Fire corals are hydrozoans rather than true corals, although like corals, they are immobile. Fire corals have nematocysts but also have sharp edges that may cause lacerations or abrasions. Symptoms of fire-coral envenomation include immediate stinging and burning. A skin reaction, involving red wheals and blisters, may develop along with considerable itching. Fire-coral envenomations should be treated according to the general treatment principles described at the beginning of this article.
SEABATHER’S ERUPTION
Seabather’s eruption is a skin irritation, mostly of covered areas of the body, caused by larval forms of certain sea anemones. Skin manifestations of seabather’s eruption may occur minutes to hours after swimming. The reaction typically involves red, burning, itchy bumps and/or hives that may persist for up to two weeks. Treatment consists of washing the affected areas with soap and water followed by a vigorous rinse. An initial brief soak with vinegar may help reduce symptoms.
Jellyfish and hydroid envenomations are frequently painful and may occasionally cause severe illness. Careful employment of the techniques above, as well as an effective evacuation plan and knowledge of local medical facilities and resources (including the availability of antivenin) can reduce pain and may be lifesaving. AD
