Chapter 12 - Standards for Diving and Hyperbaric Exposure/media/royal navy responsive... · CHAPTER...

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BRd 1750A 12-1 March 2013 CHAPTER 12 STANDARDS FOR DIVING AND HYPERBARIC EXPOSURE CONTENTS Para 1201. Authority to Conduct Medical Assessments of Fitness to Dive 1202. Assessment of Fitness 1203. General Medical Standards 1204. Conditions Influencing Fitness for Diving 1205. Dermatological Conditions 1206. Ears, Nose and Throat Conditions 1207. Respiratory Disorders 1208. Cardiovascular Conditions 1209. Alimentary System Conditions 1210. Musculoskeletal Conditions 1211. Nervous System Conditions 1212. Mental Health 1213. Genito-Urinary Conditions 1214. Infection and Impaired Immunity 1215. Female Reproductive System 1216. Endocrine Disorders 1217. Haematological Conditions 1218. Dental Standards 1219. Visual Standards 1220. Additional Investigations for all Service Occupational and Service Sports Divers 1221. Fitness and Fatness 1222. Medication and Divers 1223. Service Occupational Divers - Procedures 1224. Service Occupational Divers - Additional Investigations 1225. Service Occupational Divers - Delay of 'Additional Investigations' 1226. Service Sports Divers - Procedures 1227. Service Sports Divers - Additional Investigations 1228. Procedures for Occupational Acquaint Dive or Acquaint Recompression Chamber Exposure 1229. Recompression Chamber Workers 1230. Submarine Escape Training Tank Instructors LEAFLETS Leaflet 12-01 Guidelines for Performing Simple Spirometry Leaflet 12-02 Medical Certificate of Fitness to Undertake Service Occupational Diving Leaflet 12-03 Medical Certificate of Fitness to Undertake Service Sports Diving Under Joint Services Sub Aqua Club and British Sub Aqua Club Regulations Leaflet 12-04 Medical Certificate of Fitness to Undertake Occupational Acquaint Dive Training or Compression Chamber Exposure Leaflet 12-05 Assessment of Medical Fitness for (STASS) Training Leaflet 12-06 Medical Certificate of Fitness to Undertake Recompression Chamber Work.

Transcript of Chapter 12 - Standards for Diving and Hyperbaric Exposure/media/royal navy responsive... · CHAPTER...

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CHAPTER 12

STANDARDS FOR DIVING AND HYPERBARIC EXPOSURE

CONTENTS

Para1201. Authority to Conduct Medical Assessments of Fitness to Dive1202. Assessment of Fitness1203. General Medical Standards1204. Conditions Influencing Fitness for Diving1205. Dermatological Conditions1206. Ears, Nose and Throat Conditions1207. Respiratory Disorders1208. Cardiovascular Conditions1209. Alimentary System Conditions1210. Musculoskeletal Conditions1211. Nervous System Conditions1212. Mental Health1213. Genito-Urinary Conditions1214. Infection and Impaired Immunity1215. Female Reproductive System1216. Endocrine Disorders1217. Haematological Conditions1218. Dental Standards1219. Visual Standards1220. Additional Investigations for all Service Occupational and Service Sports Divers1221. Fitness and Fatness1222. Medication and Divers1223. Service Occupational Divers - Procedures1224. Service Occupational Divers - Additional Investigations1225. Service Occupational Divers - Delay of 'Additional Investigations'1226. Service Sports Divers - Procedures1227. Service Sports Divers - Additional Investigations1228. Procedures for Occupational Acquaint Dive or Acquaint Recompression

Chamber Exposure1229. Recompression Chamber Workers1230. Submarine Escape Training Tank Instructors

LEAFLETS

Leaflet 12-01 Guidelines for Performing Simple SpirometryLeaflet 12-02 Medical Certificate of Fitness to Undertake Service Occupational DivingLeaflet 12-03 Medical Certificate of Fitness to Undertake Service Sports Diving Under

Joint Services Sub Aqua Club and British Sub Aqua Club RegulationsLeaflet 12-04 Medical Certificate of Fitness to Undertake Occupational Acquaint Dive

Training or Compression Chamber ExposureLeaflet 12-05 Assessment of Medical Fitness for (STASS) TrainingLeaflet 12-06 Medical Certificate of Fitness to Undertake Recompression Chamber Work.

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CHAPTER 12

STANDARDS FOR DIVING AND HYPERBARIC EXPOSURE

1201. Authority to Conduct Medical Assessments of Fitness to Dive

a. Different types of diving have different risks and different types of legislativecontrol. The medical assessment procedures and fitness requirements therefore differfor different categories of diver. This chapter describes the requirements for Servicepersonnel. Reference is also made to the requirements for civilians who may also beinvolved in MOD diving projects.

b. The Diving at Work Regulations 1997 apply to many aspects of Serviceoccupational diving, Service sports diving and other military hyperbaric exposures.For this reason Service personnel undertaking any diving or hyperbaric exposure musthave a valid certificate of medical fitness to dive. Service Medical Officers and MODcivilian medical practitioners are recognised as an approved class of medicalpractitioners under regulation 15(6) of the Diving at Work Regulations 1997 andauthorised to conduct and record diving medicals on Service personnel in accordancewith this BRd.

c. The certificate of medical fitness to dive issued in accordance with this BRd isautomatically recognised as a certificate of medical fitness to dive under the Diving atWork Regulations 1997 whilst the person holding the certificate is employed by theMinistry of Defence as a member of the armed forces of the Crown. When at work butnot being employed by the Ministry of Defence, a certificate of medical fitness to diveissued by an HSE approved medical examiner of divers is required.

d. Medical examinations of Service personnel for occupational diving, hyperbaricexposures and submarine escape training are to be performed by Service MedicalOfficers and MOD civilian medical practitioners who have successfully completed theStandard Underwater Medicine Course (SUMC) at the Institute of Naval Medicine(INM). This qualification is valid for 5 years. In order to remain eligible to perform thesemedicals, Service Medical Officers and MOD civilian medical practitioners must attendan Underwater Medicine Refresher course at INM within 5 years of completion of theSUMC, and subsequently at intervals of no more than 5 years..

e. Medical examinations of Service personnel for Service sports diving (ie sub-aquadiving under the Joint Services Adventure Training Scheme or sub-aqua divingauthorised by single service adventure training authorities), may be performed by anyService Medical Officer or MOD civilian medical practitioner using this document andconsultant support from INM. However, whenever practicable, it is preferable thatsuch examinations and surveillance should be performed by a medical practitionerwho is authorised to conduct medical examinations of Service personnel foroccupational diving.

f. Adaptive Training Programme is a programme for disabled Service personnel toparticipate in Adventurous Training subject to being medically fit for the activity. It isonly available to personnel injured on duty and undergoing rehabilitation programmessuch as 'Battle Back'. A functional assessment must be made by a Diving Instructorcertified to work with disabled divers. Eligible Service personnel should attend for aService AT Diving medical at their medical centre. The medical must be performed bya Standard Underwater Medicine Course qualified doctor, who refers the case toSMO(DM) at INM for final approval. Restricted Medical Certificates of Fitness toUndertake Service AT adaptive diving may be issued with this approval fromSMO(DM) and are only valid for 12 months. (See Adventurous Training Vocationaland Recreational Diving Manual, JSP 917, for more details).

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g. Medical examinations of Service personnel for Short Term Air Supply System(STASS) training may be performed by the following categories of Medical Officers:

(1) Service Medical Officers and MOD civilian practitioners authorised toconduct Annual Aircrew Medicals in accordance with Para 1106.

(2) Service Medical Officers and MOD civilian practitioners authorised toconduct medical examinations of regular and reserve Service personnel foroccupational diving, hyperbaric exposures and submarine escape training inaccordance with Para 1201.

h. Medical examinations of MOD civilian 'commercial' divers may only be performedby an HSE approved medical examiner of divers. Medical Officers who are requiredto perform such examinations should apply to the HSE, having first completed theStandard Underwater Medicine Course at INM or an HSE recognised alternative. Themedical standards in this BRd apply to Service personnel only. The medical standardsfor MOD civilian divers are outlined in the HSE document 'The Medical Examinationand Assessment of Divers (MA1)'.

i. Civilian personnel who participate in Service sports diving and who are 'at work'are to be assessed in line with the Diving at Work Regulations 1997 and theRecreational Diving Projects ACoP. These personnel must have a valid certificate ofmedical fitness to dive issued by an HSE Approved Medical Examiner of Divers (seeJSP 917 for further details). An exception to this is authorised when these personnelare serving in a Permanent Joint Overseas Base and an HSE Approved MedicalExaminer of Divers is not available. In these cases, personnel identified in Para 1201sub para d are authorised to conduct a medical using the standards for ServiceOccupational Divers and issue Leaflet 12-02 if appropriate. Individuals shouldproduce details of their previous medical examination (such as HSE form MA2) unlessreturning to the medical centre that conducted the previous medical. If this is notpossible or if the medical is an initial diving medical, Annex 1 of Appendix 1 containedin the HSE document (http://www.hse.gov.uk/diving/ma1.pdf MA1) should becompleted by the individual's GP prior to the medical.

j. Civilian personnel who participate in Service sports diving and who are not 'atwork' are to be assessed in line with standard BSAC policy. This requires use of the'UK Sport Diver Medical Form' for annual self declaration and (when required), furtherassessment and certification by a UK Sports Diver Medical Referee.

1202. Assessment of Fitness

a. The requirements for the medical examination of various categories of Servicediver are given in Table 12-1. There are different requirements for initial and thensubsequent medicals after divers have qualified from training.

b. The fitness standards for RN Clearance Divers, Army Divers, Swimmer Canoeistsand Search and Rescue (SAR) Divers are given using the group name 'ServiceOccupational Divers'.

c. The investigation of candidates with conditions which might make them unfit is tobe initiated by the examining physician, with specialist opinions sought as appropriate.The candidate is to be considered temporarily medically unfit until a definitive decisionis made.

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d. If investigation fails to resolve the issue of fitness, Service candidates should bereferred to:

Senior Medical Officer (Diving Medicine)Undersea Medicine DivisionInstitute of Naval Medicine (INM)Crescent RoadAlverstokeHampshirePO12 2DLTel: 02392 768213 (Mil: 9380 68213)Fax: 02392 768241

e. Referrals to SMO(DM) should be on an FMed 7. Referrals will normally bereceived on DMICP, but SMO(DM) may request the FMed 4 be forwarded if it becomesclear that the latter contains information relevant to the referral that has not beenplaced on DMICP. SMO(DM) should be notified that a referral has been sent by e-mailing the DMICP number and the date of the referral to INM-OMS (MULTIUSER).

f. Referrals do not normally trigger a face to face consultation, therefore it is vitallyimportant that the referral contains as much relevant information as possible so thatSMO(DM) is able to reach an opinion on the facts of the case. Incomplete referralsresult in the need to seek further information and thus introduce unnecessary delays.

g. On completion of the referral SMO(DM) will make any necessary JMES changeson DMICP and the referring medical centre will be informed by e-mail that a reply isavailable to view.

h. A decision of Permanent Medical Unfitness for Diving in a trained ServiceOccupational Diver may only be made by SMO(DM). Any trained ServiceOccupational Diver presenting with a condition likely to result in long term unfitnessmust be referred to SMO(DM).

i. Certificates of medical fitness to dive become invalid if a diver develops a newmedical condition that may affect their safety. During the risk assessment before eachdive, supervisors must check that each diver has retained their medical fitness sincethe certificate was issued. Divers have a legal responsibility to take care of the healthand safety of themselves and others. This includes declaring when their fitness mayhave fallen into doubt.

j. It is important to consider fitness for immersion and pressure exposure whenevera diver attends for any medical consultation, whether in a primary or secondary caresetting. A relevant medical condition will have an immediate effect on the fitness of adiver and prompt investigation and referral should be instigated as appropriate.

k. Fitness to dive may be certified for a maximum period of 12 months. Where anannual medical examination or health surveillance is conducted within 1 month priorto the expiry of current certification, the starting date of the new certification maycommence from the expiry date of the current certification, with a maximum validity of12 months.

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Table 12-1. Requirements for the Medical Examination of Divers

Service Occupational Diver Initial

Service Occupational

Diver Qualified

Service Sports Diver Initial

Service Sports Diver Qualified

Occupational Acquaint Dives including Acquaint Recompression Chamber

Exposure

Recompression Chamber Worker

STASS

Primary Care Records Available

Yes Yes Yes Yes Yes Yes Yes

Physical Examination

Yes Annual Yes Every 5 years to age 40, every 3 years to age 50 and annually thereafter.Annual Health Surveillance required if no physical examination that year:see Para 1226 sub para c.

Yes Yes/Annual Yes

Blood Pressure

<140/80 mmHg <150/90 mmHg <150/90 mmHg <150/90 mmHg <150/90mmHg <140/90mmHg <140/90mmHg

Dental Examination

Yes Annual Yes Yes Yes Yes/Annual Yes

Visual Acuity uncorrected

6/36, 6/36 and 6/24 with both

eyes.

6/36, 6/36 - - -

Visual Acuity corrected

6/6, 6/9 6/6, 6/9 6/12 with both eyes

6/12 with both eyes 6/12 with both eyes (Note 3) 6/12 with both eyes -

Colour Perception

CP3(See Note 2)

CP3(See Note 2)

CP4 CP4 - CP4 -

Exercise Tolerance Test

Yes Annual Yes At each physical examination

No Yes No

Urine Test Yes Annual Yes At each physical examination

Yes Yes No

Vitalograph Yes Annual Yes At each physical examination

Yes Yes/Annual Yes

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Notes:

1. Dental examinations may be undertaken by the Medical Officer but, where doubt as to dental fitness exists, the candidate should bereferred to a Dental Officer.

2. Swimmer-canoeist with a colour vision standard of CP4 are to be given a restricted certification of fitness to dive; 'Unfit Mixed Gas Diving,Navigation and Watch keeping Duties'.

3. Occupational Acquaint Divers should meet Service Occupational Diver initial standards.

4. Audiogram within three months of exam is acceptable.

Service Occupational Diver Initial

Service Occupational

Diver Qualified

Service Sports Diver Initial

Service Sports Diver Qualified

Occupational Acquaint Dives including Acquaint Recompression Chamber

Exposure.

Recompression Chamber Worker

STASS.

Full Blood Count

Yes As clinically indicated

No No No No No

ECG Yes Annually after age 35

Yes At each examination from age > = 40 years

No At initial medical then at 5 yearly intervals

from age 40

No

Audiometry Yes Annually(Note 4)

Yes As clinically indicated As clinically indicated Annually No

Chest X-ray In 12 months prior to

certification

As clinically indicated

As clinically indicated

As clinically indicated No As clinically indicated No

Diver Bone Survey

As clinically indicated

As clinically indicated

As clinically indicated

As clinically indicated No No No

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1203. General Medical Standards

a. Candidates must be physically and mentally fit and be without evidence ofemotional instability. There is no upper age limit, but the discretion of the examiningphysician should be exercised when assessing the level of general fitness and,specifically, the reserves of pulmonary and cardiovascular function in individual cases.All candidates must be in JMES category MFD with a PULHHEEMS assessment ofP2 U2 L2 M2 and S2. Those in a temporarily downgraded medical category must beconsidered unfit for diving until recovered. In exceptional circumstances somepersonnel who are MLD (P3P) may be considered for fitness for diving but all suchcases must be referred to SMO(DM).

b. The underwater environment is, by its nature, hostile to air-breathing humans andmakes no distinction between those who dive for pleasure and those who dive foremployment. Because of this, the medical standards for Service personnel whoparticipate in sports diving are, with limited exceptions, the same as those applied toService Occupational Divers. Any deviation from the medical standards outlined inthis chapter must be discussed with SMO(DM) prior to being cleared as fit to dive.

c. Standards for males apply equally to females but pregnant women must not diveor undergo any other pressure exposures.

d. Para 1204 to Para 1222 give guidance on medical conditions and other factorswhich can affect fitness to dive. Investigations and procedures for different groups ofdivers are covered in Para 1223 to Para 1230.

1204. Conditions Influencing Fitness for Diving

a. It is not possible to provide a comprehensive list of conditions, which permanentlyexclude a candidate. Frequently, a decision is based on the extent of the abnormalityor the severity of disease and the individual response to treatment. Conditions, whichhave a bearing on fitness for diving, are listed in the following paragraphs. By scrutinyof medical documents, direct questioning and physical examination, these conditionsmust be excluded. Where positively elicited or identified, these conditions arenormally grounds for rejection, however, in cases of doubt, the candidate should bereferred to SMO(DM) (see Para 1202 sub para d).

b. Service personnel who suffer a diving-related injury requiring recompressiontherapy may return to diving if all the following have been satisfied:

(1) All symptoms have resolved after recompression treatment,

(2) Diver has remained in a “no-dive” status for the mandated period of time

(3) Diver has been cleared to return to diving by a medical officer trained indiving medicine and the case reviewed by SMO(DM).

c. Service divers have the right to appeal the decision of the examining medicalofficer to SMO(DM).

1205. Dermatological ConditionsA functionally intact integument is required. Any untreated chronic or acute skin

disorder, including the cutaneous manifestations of systemic disease, other than mild,localised conditions, will disqualify a candidate from diving.

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1206. Ears, Nose and Throat ConditionsA functionally competent larynx and nasopharynx together with the ability to equalise

pressure in the middle ear and sinuses are required.

a. The following conditions render a candidate unfit for pressure exposures:

(1) Chronic or recurrent sinusitis.

(2) Chronic or recurrent outer or middle ear inflammation or infection.

(3) Severe allergic conditions of the upper respiratory tract.

(4) Meniere's Disease or previous stapedectomy.

(5) Perforation of the tympanic membrane, unless adequately healed orsurgically corrected.

(6) Obstruction of the nasal passages.

(7) History of inner ear barotrauma.

b. The following conditions render a candidate or qualified diver, temporarily unfit forpressure exposures and should be referred to an ENT specialist:

(1) Viral labyrinthitis.

(2) A history of ENT surgery.

c. Hearing should be of H2 standard on initial medical for Service OccupationalDivers. Subsequently a reduced category may be acceptable on the advice ofSMO(DM). Service Sports divers/candidates may be H3, but must have adequateability to communicate in the diving environment documented on the diving medicaland subject to ENT review. The tympanic membrane should be clearly seen onexamination with evidence of satisfactory Eustachian tube function and adequate earclearing by observing the eardrum to be mobile while a Valsalva manoeuvre isperformed. When inadequate ear clearing is the only reason a candidate's fitness maybe in doubt and the cause is not considered to be due to a short term condition suchas an upper respiratory infection or catarrh, a cautious exposure to pressure shouldbe carried out in a compression chamber. The chamber depth should not exceed 9metres. Continued failure to clear ears should be cause for referral to an ENTconsultant for formal assessment of Eustachian tube function.

d. Exostoses are acceptable provided they do not completely occlude the externalauditory canal.

1207. Respiratory DisordersNormal respiratory function is a requirement.

a. The following conditions will render a candidate permanently medically unfit forpressure exposures:

(1) Symptomatic asthma or other forms of recurring bronchospasm.

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(2) Chronic obstructive airways disease; areas of potential air trapping (eg lungcysts, bullae and blebs); pleural effusion; lung fistula; bronchiectasis; pulmonaryfibrosis; neoplasm and unresolved pneumothorax.

(3) Pulmonary tuberculosis unless limited to an isolated healed and calcifiedperipheral primary focus (Ghon focus). Such lesions are not necessarily anautomatic bar to pressure exposures. However, personnel in whom they arediscovered should be referred to the SMO(DM).

(4) Sarcoidosis or other restrictive pulmonary condition.

(5) Any lung disease, abnormality or penetrating chest injury likely to result inareas of altered lung compliance and/or pleural adhesions. Candidates with ahistory of complicated or severe pneumonia, e.g. requiring hospitalization, shouldbe referred to SMO(DM).

b. Candidates with a past history of reversible, obstructive airways disease arejudged on an individual basis. Isolated attacks of bronchospasm in association withfrank chest infections must be discussed with SMO(DM). It is of extreme importanceto identify any tendency to recurring obstructive airways disease. A current historyconsistent with bronchoconstriction on exercise or in a cold environment is an absolutecontra-indication to pressure exposure; the candidate should be made unfit forpressure exposures and SMO(DM) should be informed of this finding.

c. Candidates with current or past history consistent with reversible or allergen-mediated bronchoconstriction should be asked to keep a Peak Expiratory Flow (PEF)diary and referred to INM for further evaluation. The PEF diary should be kept for atleast 28 days; recording best of 3 efforts, additional blows should be done if the largesttwo PEF are not within 40 I/min:

(1) On waking and at 1800 each day.

(2) Pre- and post-exercise, making a note of this in the diary.

(3) If the candidate feels wheezy or short of breath, making a note of this in thediary.

(4) If an occupational exposure is suspected then readings should be takenevery 4 hours while awake and every 2 hours while at work, with careful notes ofcircumstances at each reading.

d. A history of perforating chest injury or open chest surgery may disqualify if thereis evidence of residual pulmonary or pleural scarring. The underlying reason for thesurgery may be disqualifying and should be established. All such cases are to bereferred to SMO(DM) (see Para 1202 sub para d).

e. A history of spontaneous pneumothorax usually precludes pressure exposures.Individuals who have been recurrence-free for at least 5 years and in whom it hasbeen determined by detailed pulmonary function assessment and high resolution CTscanning that no residual impairment remains may, in exceptional circumstances, bepermitted to undergo pressure exposures. All such cases must be referred toSMO(DM) (see Para 1202 sub para d).

f. History of non-spontaneous pneumothorax may be found suitable for pressureexposure providing at least 3 months have elapsed since resolution and it has beendetermined by high resolution CT scanning and detailed pulmonary functionassessment that no residual impairment remains. All such cases are to be referred toSMO(DM) (see Para 1202 sub para d).

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1208. Cardiovascular Conditions

a. The following conditions will render a candidate permanently medically unfit:

(1) Any organic heart disease. That includes all types of cardiomyopathy,ischemic heart disease, haemodynamically important valvular disease, cyanoticheart disease and other shunts.

(2) Coarctation of the aorta.

(3) Any history or evidence of coronary insufficiency or myocardial ischemia,even if treated by angioplasty or coronary bypass grafting.

(4) Cardiomegaly unless it is established by specialist investigation to be theconsequence of athletic training.

(5) Peripheral vascular insufficiency.

b. The following conditions must be referred for specialist cardiological opinion priorto referral to SMO(DM) (see Para 1202 sub para d).

(1) Significant atrial or ventricular septal defects, other potential right to leftshunts. These conditions are usually incompatible with pressure exposure unlesssurgically corrected. Primary screening for right to left shunts, however, is notcurrently considered justifiable. An incidental finding of asymptomatic PatentForamen Ovale is not automatically disqualifying, but all cases should be referredto SMO(DM).

(2) Cases of valvular stenosis or regurgitation.

(3) All arrhythmias except sinus arrhythmias and ventricular extra systoleswhich disappear with increasing heart rate.

(4) Conduction defects. Right bundle branch block may be acceptable providedit is determined by specialist opinion that it is an isolated finding. Asymptomatic1st degree heart block, as evidenced by an isolated finding on ECG of aprolonged PR interval, is not disqualifying if thought to be secondary to athleticheart syndrome.

c. Abnormalities found on cardiovascular examination, such as murmurs or ECGfindings, must be investigated to an appropriate extent before a decision on fitness ismade.

d. Blood pressure is to be recorded with the candidate in the supine position andusing the 5th Korotkoff sound. It should not exceed 140/80 mmHg at initial medicalexamination of Service Occupational Divers or 140/90 at subsequent annualmedicals, Stage 1 (see Note) hypertension is acceptable in both qualified ServiceOccupational Divers and Service Sports divers provided that:

(1) No medication is required or the medication taken has no adverse effect onthe diver's cardiovascular performance or exercise tolerance.

(2) There is no evidence of end organ damage.

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Service Occupational Divers and Service Sports Divers requiring more than two anti-hypertensive medications to control their blood pressure must be referred toSMO(DM).

e. Symptomatic haemorrhoids and severe varicose veins are relative contra-indications to diving.

Note. Stage 1 hypertension Clinic systolic blood pressure 140-180 mmHg, diastolicblood pressure 90-110 mmHg and subsequent ambulatory blood pressure monitoring(ABPM) daytime average or home blood pressure monitoring (HBPM) averagesystolic blood pressure 135-155 mmHg, diastolic blood pressure 85-96 mmHg NICEclinical guideline 127, Aug 2011.

1209. Alimentary System ConditionsThe alimentary system should be functionally normal with no increased tendency to

vomiting, dyspepsia, reflux, bleeding, perforation, diarrhoea or pain. Hepatic and pancreaticfunction should also be normal.

a. The following conditions will render the candidate permanently medically unfit:

(1) Chronic inflammatory bowel disease.

(2) Acute or chronic active hepatic disease.

(3) Gall stones, unless adequately treated.

(4) History of pancreatitis.

(5) Abdominal wall herniation unless adequately repaired.

(6) Hiatus hernia.

(7) Individuals who have undergone fundoplication or bariatric surgery remainunfit to dive as there is a small, but definite increased risk of gastric rupure onascent.

b. Peptic ulceration also disqualifies a candidate unless there is evidence of healingand the candidate has been asymptomatic for at least 1 year. Divers who continue tobe prescribed medication after healing is complete should be referred to SMO(DM) forconsideration of fitness on a case-by-case basis (see Para 1202 sub para d). In thosecases due to Helicobacter pylori infection an individual will be considered fit if they aresymptom free and there is evidence of successful eradication.

1210. Musculoskeletal Conditions

a. Candidates must have unimpeded mobility and dexterity. Any limitation should beassessed on the basis of the candidate's ability to perform their work or undertaketraining and, particularly, its possible impact on safety.

b. The presence of juxta-articular ('A') lesions of dysbaric osteonecrosis maydisqualify from further pressure exposures and all cases should be referred toSMO(DM) for consideration of fitness on a case-by-case basis (see Para 1202 subpara d). A shaft ('B') lesion only disqualifies from participation in experimentalpressure exposures.

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c. Successful surgery for prolapsed intervertebral disc may be acceptable providedneurological examination is normal and there is no functional impairment. Prolapsedintervertebral disc managed non-surgically which responds to therapy, is not recurrent,and causes no neurologic deficits may be considered acceptable as long as it doesnot impact on mobility and the candidate is able to carry out all the functions requiredof a diver at their level of training.

d. Musculoskeletal, or referred, pain that might mimic decompression illness mustbe assessed carefully. If any doubt exists, the case should be discussed withSMO(DM).

1211. Nervous System Conditions

a. The initial neurological examination must be particularly rigorous with attentionpaid to documenting variations from normal. Similar care should be taken atsubsequent examinations to confirm that no hitherto unrecognised neurologicalchange has taken place. This is particularly important if there has been an episode ofdysbaric illness since the last routine assessment.

b. Significant neurological abnormalities may merit specialist referral. To avoidpossible confusion over a subsequent diagnosis of a dysbaric disorder, it is importantthat any abnormal findings are reported to the diver and clearly recorded in the Diver'sLogbook.

c. Conditions that may render a candidate permanently medically unfit for pressureexposure are as follows:

(1) Epilepsy, including petit mal and partial seizures, and irrespective of anytreatment renders the candidate permanently medically unfit. Febrile convulsionsup to the age of 5 years should not be considered a bar to pressure exposure.Individuals who have suffered an isolated seizure but who are not considered tobe suffering from epilepsy, should be referred to SMO(DM) (see Para 1202 subpara d) after evaluation by neurology consultant with positive recommendations.

(2) Intracranial surgery.

(3) Severe motion sickness.

(4) Migraine unless mild and unaccompanied by visual, speech, motor orsensory disturbance.

(5) A history of bacterial or viral meningitis or encephalitis is compatible withpressure exposure provided that the candidate has been asymptomatic for 12months and there is no evidence of neurological sequelae.

(6) Recurrent, unprovoked loss of consciousness of unknown aetiology orrecurrent episodes of fainting.

(7) Neurological diseases such as stroke, multiple sclerosis or Parkinson'sdisease.

d. Head injury accompanied by skull fracture or resulting in loss of consciousness orpost-traumatic amnesia may result in increased risk of convulsion. This may be furtherincreased by high inspired partial pressures of oxygen. Head injuries may be gradedby severity and guidelines on fitness are given by grade as follows:

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(1) Severe head injuries have one or more of the following features:

• Brain contusion (diagnosed on the basis of observation during surgeryor focal neurological symptoms).

• Intracranial haematoma.• Loss of consciousness or post-traumatic amnesia for more than 24

hours.

Candidates with a history of severe head injury are permanently disqualified fromdiving. In exceptional circumstances candidates whose severe head injuryoccurred more than 10 years prior to the medical and in whom there is noevidence of neurological sequelae may be permitted to dive, but all such casesmust be referred to SMO(DM) (see Para 1202 sub para d).

(2) Moderate head injuries have one or more of the following features:

• Loss of consciousness or post-traumatic amnesia lasting 30 minutes to24 hours.

• Skull fracture.

Candidates with a history of a moderate head injury may be considered fit to diveafter a period of 1 year without sequelae but will require referral to SMO(DM) andwill be assessed on an individual basis.

(3) Mild head injuries have:

• Loss of consciousness or post-traumatic amnesia for less than 30minutes.

Candidates with a history of a mild head injury may be considered fit to dive aftera period of 1 month without sequelae but will require referral to SMO(DM) and willbe assessed on an individual basis.

1212. Mental HealthPsychiatric illness, other than minor reactive or transient non-recurring conditions are

incompatible with diving. A history of past or present psychiatric or psychological disordershould be considered a contra-indication to pressure exposures unless the examiningphysician is content, having taken specialist advice if indicated, that it is of a minor nature andunlikely to recur. An asymptomatic period without requirement for psychotropic medication ofat least 6 months in a normally stressful environment is required before fitness for diving canbe considered. A history of alcohol or drug abuse disqualifies unless a consultant psychiatricopinion is favourable. Present evidence of alcohol or drug abuse disqualifies from pressureexposure. These cases must be referred to SMO(DM) for a final opinion.

1213. Genito-Urinary ConditionsRenal calculi and malformations of the urinary system will be cause for rejection

unless adequately treated. Divers and candidates must be stone-free prior to return to diving.

1214. Infection and Impaired Immunity

a. A positive HIV test need not preclude diving, potential fitness to dive beingdependant upon disease stage. All divers identified as being HIV positive should bereferred to SMO(DM) for assessment as to their continued fitness to dive.

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b. A diver with impaired immunity for other reasons, such as splenectomy or aregular requirement to take medication known to impair immunity will, as they are atincreased risk of infection, have been graded MLD or MND by their Single servicemedical board. All such divers should be referred to SMO(DM) for assessment of theircontinued fitness to dive.

1215. Female Reproductive System

a. Pregnancy makes a diver temporarily medically unfit (TMU) for diving andpressure exposure.

b. Post-partum, female divers are to be considered temporarily unfit for diving for aperiod of 3 months, i.a.w. JSP 346 Chapter 4.

1216. Endocrine Disorders

a. Endocrine conditions that are stable (following successful treatment if necessary)and have no significant effect on mental or physical performance may be compatiblewith pressure exposure, but all such cases must be referred to SMO(DM). Detailedscreening for endocrine conditions is not normally required. However, whereabnormalities are detected clinically, these should be investigated and referred toSMO(DM) (see Para 1202 sub para d).

b. Qualified divers who develop diabetes mellitus must be referred to SMO(DM).Divers with DM controlled by diet alone may be permitted to dive; DM requiring insulinand/or oral hypoglycaemic agents is an absolute contra-indication.

1217. Haematological Conditions

a. Requirements for screening tests are given in Table 12-1. Abnormalities revealedshould be referred for specialist assessment.

b. Asymptomatic sickle cell trait or thalassaemia trait is not a contra-indication topressure exposure. Individuals with frank sickle cell disease or thalassaemia major willbe unfit for entry into military service. Routine testing for sickle cell disease is thus notrequired.

1218. Dental Standards

a. Candidates require a high standard of dental fitness. Whereas examination by aDental Officer is not required routinely, candidates are to be dentally in-date. Teethshould be sound or adequately restored and the gum and supporting bones should behealthy. Malformations or missing dentition should be assessed in the light of thecandidate's ability to retain a mouthpiece and affect an adequate seal, bearing in mindthat dentures should be removed when diving.

b. Crowns and fixed bridgework must be scrutinised annually. If in doubt as to acandidate's dental fitness, the examining physician should seek the opinion of a DentalOfficer.

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1219. Visual Standards

a. For Service Occupational Divers other than Swimmer Canoeists, the followingvisual standards apply:

(1) Initial uncorrected visual acuity is not less than R 6/36, L 6/36 and 6/24 usingboth eyes. R 6/36, L 6/36 may be accepted at subsequent examinations.

(2) Corrected visual acuity is not to be less than R 6/6, L 6/9.

(3) Near vision should be at least N5.

(4) Colour perception is to be at least CP3.

b. For Swimmer Canoeists, visual standards are in accordance with therequirements of Leaflet 6-03. Swimmer Canoeists with a colour vision standard ofCP4 are to be given a restricted certification of fitness to dive; 'Unfit Mixed Gas Diving,Navigation and Watch keeping Duties'.

c. For Service Sports Divers, the following visual standards apply:

(1) Corrected visual acuity is not to be less than 6/12 using both eyes.

(2) Near vision should be sufficient to be able to read instruments underwater.

(3) Colour perception is not a significant safety factor in sports diving and astandard of CP4 is acceptable.

d. For Service Occupational Recompression Chamber workers the following visualstandards apply:

(1) Corrected visual acuity is to be not less than 6/12 using both eyes.

(2) Near vision corrected should be at least N5

(3) Colour perception is not a significant safety factor in recompression chamberoperation and a standard of CP4 is acceptable.

e. For all Service Divers:

(1) Visual fields should be normal using the confrontation test.

(2) Fundi should be normal.

(3) A history of detached retina normally precludes diving, all such cases mustbe referred to SMO(DM).

(4) Contact lenses may be worn in accordance with the guidance in BR 2806,Vol 1, Chap 2, Para 0219.

(5) Successful corneal refractive surgery, other than radial keratotomy, isunlikely to affect long term medical fitness for diving. A minimum period oftemporary unfitness of 6 months is required after surgery. In cases where thereis a doubt or concern, advice should be sought from SMO(DM).

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1220. Additional Investigations for all Service Occupational and Service Sports Divers

a. Urinalysis. Dipstick examination of the urine for protein and glucose is requiredannually.

b. Spirometry.

(1) Lung function tests are required as part of both initial and subsequentexaminations. These tests are carried out on Vitalograph wedge-bellowsspirometers, which are available at establishment sick bays. Instructions on thecorrect use of a Vitalograph spirometer are given at Leaflet 12-01. If it is notpossible to access a Vitalograph spirometer, a mass flow spirometer may beutilised for service sports divers only, provided that the examining medical officeris fully aware of the limitations of such devices. Further detailed advice isavailable from SMO(DM). The ratio of FEV1/FVC should not be less than 70%and the FVC should not be abnormally low compared to that predicted by age,gender and height. FVC should be compared to established norms, an exampleof which can be found at the John’s Hopkins Medical Centre website: http://www.hopkinsmedicine.org/pftlab/predicted.html.

Minimum FVC can be considered 85% of the lowest predicted value calculated bythe website calculation tool. It should be remembered that predicted values forpersons of African or Asian are around 10% lower than those of Caucasian origin.

(2) Cases where there has been a significant fall in spirometric values should bereferred to SMO(DM). Spirometry is a simple lung function test and should beregarded as a screening procedure only and failure to achieve the standardsdescribed above should not, on its own, be automatically regarded as a cause forrejection. Leaflet 12-01 Para 3 gives instructions regarding candidates who fail toachieve the stated standards. Candidates whose FVC is in excess of that capableof being measured by the standard Vitalograph spirometer should be referred tothe Institute of Naval Medicine, to permit accurate measurement of their lungfunction.

(3) Spirometry is required as part of the medical examination for OccupationalAcquaint Dives and in the initial medical examination for Compression ChamberExposure.

1221. Fitness and Fatness

a. Divers are to be aerobically fit as gauged by the Harvard Step Test, 1.5 mile (2.4km) timed run or multi-stage (bleep) test.

b. The Harvard Step Test is to be performed as follows:

(1) The candidate is required to take steps of height 43 cm at a rate of 30 stepsper minute for 5 minutes.

(2) After 1, 2 and 3 minutes post exercise a 30 second pulse count is taken.These are added together and a score of 190 or less is regarded as an acceptablelevel of fitness.

(3) Candidates who fail to achieve this standard should be re-examinedfollowing a suitable period of fitness training.

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c. If the diver possesses official certification of having completed a 1.5 mile runwithin 10 minutes and 30 seconds, or achieving a score of 11.01 on the multi-stage(bleep) test in the last 28 days, then the Harvard Step Test may be waived.

d. The height and weight of the diver measured in underwear and bare feet shouldbe measured and recorded at every medical examination and the Body Mass Index(BMI or kg/m2) calculated. Dietary and fitness advice at BMIs >27 is recommendedin the hope of pre-empting restriction when a BMI of >30 is reached.

e. Individuals with a BMI of more than 30 are generally unfit to dive unless it isconsidered that, in view of the person's morphology and muscular development, theexcess is not due to fat.

f. Where doubt about the possible obesity of a candidate exists, the case is to bereferred to the Head of the Environmental Medicine Unit at the Institute of NavalMedicine who will arrange for an anthropometric assessment. Individuals with a bodyfat content in excess of 25% for males and 30% for females may be considered unfituntil weight has been satisfactorily reduced, particularly if associated with a lack ofoverall physical fitness.

1222. Medication and Divers

a. Before a diver can be cleared as fit to dive whilst taking medication it is importantto consider the following issues:

(1) Is the condition requiring medication compatible with diving?

(2) Will the medication or sudden withdrawal of it affect the safety of the diver?

(3) Will the pharmacokinetics of the medication be affected by diving?

b. If a diver is to be commenced on medication, a period of evaluation while notdiving is necessary to enable any adverse effects to be manifested. This shouldnormally be a minimum of 2 weeks.

c. Due to its increased seizure risk and potential side effects, divers prescribedMefloquine are unfit to dive for a period of 12 weeks following completion of thecourse.

d. Drugs required for chronic pain usually disqualify divers (eg opiates, tramadol,amitriptyline, gabapentin and similar medication).

e. Psychotropic drugs, including those used for smoking cessation, usuallydisqualify divers.

f. If there is any doubt about the fitness of a diver requiring medication, the caseshould be referred to SMO(DM) (see Para 1202 sub para d)

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1223. Service Occupational Divers - Procedures

a. The results of the medical examination of Service divers are to be recorded on FMed 143 (Special Medical Examination Record) ensuring that the record includes adescription of the type of diving for which the diver was assessed (ie ServiceOccupational Diving). When completed this must be included in the candidate's F Med4 and DMICP record.

b. In addition, the results and date of annual medical examinations and periodic X-rays are to be recorded in the Diver's Logbook (S1627) and signed by the MedicalOfficer or MOD Civilian Medical Practitioner.

c. Service occupational diver candidates who are due to undertake selectioncourses or initial diving training courses may not have been issued with a Diver'sLogbook (S1627). If this is the case the certificate at Leaflet 12-02 should becompleted. It is to be signed and dated by the examining Medical Officer or MODCivilian Medical Practitioner and is to bear an official stamp. The certificate, which canbe valid for no more than 12 months, should be given to the candidate for presentationat the selection or training course.

d. The F Med 4, including the completed F Med 143, of all diver candidates forselection courses and professional diver training courses at the Defence DivingSchool must be forwarded to the training establishment to arrive before the course isdue to start. Exceptionally, in order to avoid delay, documentation may be handed tothe candidate for delivery to the training establishment. The establishment should beadvised by telephone that this is being done.

e. A diver may decide that they are fit to resume diving after a minor illness providedthat it lasted not more than 5 days, was not diving-related and did not require medicaladvice or treatment. In all other cases, a suitably qualified Medical Officer (see Para1201) should be consulted for advice. Any service person whose fitness for divingremains in doubt or whose fitness has changed such that they may need restrictionsplaced on their diving activity or be graded Permanently Medically Unfit for ServiceOccupational Diving must be referred to SMO(DM) (see Para 1202 sub para d). TheDiver's Logbook should always be annotated if a temporary or permanent 'unfit to dive'decision is made.

1224. Service Occupational Divers - Additional Investigations

a. Audiometry. Audiometry is to be performed at the initial medical, then annuallyor more frequently if clinically indicated. Audiometry should always be performed afterany significant middle ear barotrauma.

b. ECG. All divers are to have a standard resting 12 lead ECG at initial examinationand annually after the age of 35. This should precede the exercise tolerance test. Inthe event of deviations from normal being detected, the advice of a specialist shouldbe sought before proceeding with the exercise tolerance test.

c. Radiology. X-rays should be performed as follows:

(1) Chest X-ray requirements:

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(a) All service occupational divers at initial medical will require screeningprior to undertaking training; inspiratory PA chest X-ray to have been takenno more than 12 months prior to initial medical. The X-ray must bespecifically reported for fitness for diving purposes.

(b) Qualified divers require chest X-ray only if clinically indicated.

(2) Long bone X-ray requirements. Long bone x-ray surveys for dysbaricosteonecrosis are no longer routinely required, and should be performed asclinically indicated. Questions related to clinical indications for long bone surveysshould be referred to SMO(DM).

1225. Service Occupational Divers - Delay of 'Additional Investigations'If, owing to sea or detached service, the 'additional investigations' listed cannot be

performed, a diver may, at the examining physician's discretion and subject to the rest of themedical examination being normal, continue to dive after the date of expiry of his/her lastmedical. However, this should not normally be permitted for more than 4 weeks withoutendorsement by SMO(DM).

1226. Service Sports Divers - Procedures

a. Any Service Medical Officers or Civilian Medical Practitioners may performmedical examinations of Service Sports divers and conduct annual health surveillanceof Service Sports divers using this document and consultant support from INM.However, whenever practicable, it is preferable that such examinations andsurveillance should be performed by a medical practitioner who iaw Para 1201, isauthorised to conduct medical examinations of regular and reserve Service personnelfor occupational diving.

b. Service Sports divers must have medical examinations prior to undertaking anyform of dive training (see Note). Subsequent examinations are to be performed at 5yearly intervals to age 40, 3 yearly to age 50 and annually thereafter. More frequentexaminations may be required, i.e. after dysbaric disease, inter-current illness orinjury, or at the instigation of the SMO(DM).

Note. There is however the ability for Service Sports Divers who are fully fit with nopast history of relevant medical conditions to 'self declare' their fitness for a JointServices Sub-Aqua Scheme compliant British Sub-Aqua Club 'Try Dive' undercontrolled conditions within a swimming pool or registered sheltered water trainingarea. The relevant questionnaire is included in the 'Joint Service Sub-AquaRegulations' issued by the Superintendent of Diving.

c. In the years between medical examinations, Service Sports divers are to haveannual health surveillance. This health surveillance is to be performed by a ServiceMedical Officer or Civilian Medical Practitioner who has access to the Primary Caremedical records of the diver. This surveillance is to check that the diver:

• Remains MFD.• Has had no significant illness or injury since the last medical examination.• Has had no change in their medical condition.• Is not taking any medication contraindicated for divers.

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d. At each examination and annual health surveillance the diver is also to bereminded of their legal responsibility to report any change in their health that mayaffect their fitness to dive before any subsequent diving takes place.

e. A diver may decide that they are fit to resume diving after a minor illness providedthat it lasted not more than 5 days, was not diving-related and did not require medicaladvice or treatment. In all other cases a Medical Officer should be consulted foradvice. Any Service person whose fitness for diving remains in doubt or whose fitnesshas changed such that they may need restrictions placed on their diving must bereferred to SMO(DM) (see Para 1202 sub para d).

f. The result of both the medical examinations and the annual health surveillanceare to be recorded on F Med 143 (Special Medical Examination Record) ensuring thatthe record includes a description of the type of diving for which the diver was assessed(ie Service Sports Diving). When completed this must be included in the candidate'sF Med 4 and DMICP record.

g. Candidates certified as fit to dive are to have the certificate at Leaflet 12-03completed and signed for presentation at a training course or inclusion in a divinglogbook. It is to be signed and dated by the examining Medical Officer or MOD CivilianMedical Practitioner and to include details of when the divers next full medical examis required. The certificate can be valid for no more than 12 months.

1227. Service Sports Divers - Additional Investigations

a. Radiology. Chest X-ray is only required as clinically indicated.

b. Audiometry. This must be performed at the initial medical and following anyepisode of ear barotrauma. Audiometry only needs to be performed at subsequentexaminations if clinically indicated.

c. ECG. An ECG must be performed at the initial examination, at age 40 and atsubsequent examinations. An ECG may also be recorded on other occasions whenclinically indicated or at the discretion of the examining physician. The ECG is to beperformed before the exercise tolerance test (see Para 1221 sub para b).

1228. Procedures for Occupational Acquaint Dive or Acquaint Recompression Chamber Exposure

a. This group comprises persons who are undertaking a single shallow, shortduration, acquaint dive - usually for educational purposes - in a safe and controlledenvironment. The requirements for this group are given at Table 12-1 and in Para1204 to Para 1219.

b. The above medical examinations may only be conducted by Service MedicalOfficers and MOD Civilian Medical Practitioners authorised to conduct medicalexaminations of regular and reserve Service personnel for occupational diving,hyperbaric exposures and submarine escape training in accordance with Para 1201sub para d. The results of the medical examination are to be recorded on F Med 143(Special Medical Examination Record) ensuring that the record includes a descriptionof the type of diving for which the diver was assessed (ie Occupational Acquaint Diveor Recompression Chamber Exposure). When completed this must be included in thecandidate's F Med 4 and DMICP.

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c. Candidates certified as fit to dive are then to have the certificate at Leaflet 12-04completed and signed.

1229. Recompression Chamber Workers

a. A small number of non divers are required to work routinely within recompressionchambers. This includes medical, nursing and technical staff. The requirements forthis group, who may be required to perform demanding physical activity (patienthandling, cardio pulmonary resuscitation etc) within the confines of a recompressionchamber whilst at depth, are given at Table 12-1 and in Para 1204 to Para 1222. Theresults of the medical examination are to be recorded on F Med 143 (Special MedicalExamination Record) ensuring that the record includes a description of the type ofdiving for which the diver was assessed (ie Recompression Chamber Worker). Whencompleted this must be included in the candidate's F Med 4 and DMICP record.

b. The certificate at Leaflet 12-06 should be issued and kept within their divinglogbook. It is to be signed and dated by the examining Medical Officer or MOD CivilianPractitioner and is to bear an official stamp. The certificate can be valid for no morethan 12 months.

1230. Submarine Escape Training Tank (SETT) Instructors

a. SETT instructors undertake specialist breath-hold diving and pressurised ascentsfrom the escape system, both in the training tank and in open water during trials. Theyare required to achieve the fitness standards for occupational divers listed above. Ifthey are submariners they are also required to achieve the standards required inChapter 13.

b. SETT instructors are to have their initial medical completed by the Medical Officerattached to SETT and, in cases of doubt, their fitness discussed with SMO(DM) beforethey commence training. Annual medicals are to be conducted by the MO attached toSETT and a full medical is to be completed and, in cases of doubt, discussed withSMO(DM) on completion of work at SETT.

c. SETT Instructors require an inspiratory PA CXR for their initial medical.Subsequent CXRs are only needed when clinically indicated. They do not requirelong-bone studies unless clinically indicated and then only after discussion withSMO(DM).

d. Table 12-2 outlines their medical requirements:

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Table 12-2. Requirements for the Medical Examination of SETT Instructors

Note. Dental examinations may be undertaken by the Medical Officer but, where doubt as todental fitness exists, the candidate should be referred to a Dental Officer.

SETT Instructor

Initial Qualified

Physical Examination Yes, examination by SETT MO and approved by SMO(DM) if required

Annual examination by SETT MO

On completion of appointment, a sign-off examination by SETT MO

Dental Examination (see Note) Yes Annual

Exercise tolerance test Yes Annual

Fitness Pass RNFT by run or bleep test iaw local SETT policy

Urine test Yes Annual

Spirometry Yes Annual

Full blood count Yes If clinically indicated

ECG At each medical if over 35 years old

Audiometry Yes A minimum of 3 yearly or iaw local hearing conservation policy, and on completion of career as instructor

Chest x-ray In 12 months prior to attending SETT

If returning to pressurised work and 12 months elapsed since last pressure exposure or if clinically indicated