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Capita Selecta Duikgeneeskunde: Medication and Diving, PROGRAMME
An advanced course for dive physicians and other care professionals. Venue: Academic Medical Centre, Amsterdam
Subjects
Medication in ENT medicine, neurology, psychiatry, ophthalmology, cardiology and internal diseases.

Aim
This course aims to give insight into the intended effects of the application of drugs and their side effects in
relation to diving. This includes safety aspects, both medical as well as general. A preliminary consideration is
that if a particular drug affects the ability to drive a car safely, diving safety is possibly threatened as well.
Several questions may be distinguished.
1. What is the condition/disorder/illness for which the medication is being prescribed and what are the
relationships between the drug, the patient, his/her diet and the interactions with other (prescribed) medicines? 2. To what extent does the application of the drug for a specific disorder influence an organ or the entire system so adversely as to preclude safe diving? 3. Medications are mainly used by middle aged and elderly people. From the age of 40 to 70 years the physical reserve, and consequently self-reliance is reduced, by at least a factor of two. What are the effects of the drugs on the physical reserve? 4. Also the mental reserve of the aged (that is the drive to preserve ones life) is reduced. Therefore the same question as asked for the physical reserve may also be raised for the mental reserve. 5. Attention, concentration, (situational) awareness, vigilance and decision making ability, all crucial for diving safety, can also be greatly diminished. Moreover, reduced attention and concentration results in reduced perception. To what extend does this all reduces dive safety? Knowledge of the above matter is crucial for the medical examiner. For professional divers the use of drugs would
mostly imply rejection. In recreational diving the criteria for passing a physical are much less clear-cut. In fact,
during the past decennia, the ‘grey zone’ has expanded like an oil-stain.
Another application is the investigation of the relationship between medication and a dive incident.
After this seminar, the physician will have the knowledge to decide whether a professional diver who is using
prescription drugs or has just finished medication, should be passed for his physical and whether a recreational
diver when using specific medicines should be allowed to dive and under what conditions.
This seminar should be regarded as an advanced course. An elementary course on diving medicine (in the
Netherlands e.g. SHF or VSG) is a prerequisite for physicians.
Teachers
Dr. Rob van der Hulst, ENT physician, Dr. Gerhard Visser, neurologist, Dr. Rienk Rienks, cardiologist, Dr. Peter
Westerweel, physician for internal diseases.

Recommendation
The course is recommended by the expert group of dive medicine of the Vereniging voor Sportgeneeskunde (Soc
Sports Med) and by the Nederlandse Vereniging voor Duikgeneeskunde (NVD, Dutch Soc Dive Med).

Accreditation
The program comprises 6 oral contact hours and is assumed to give 6 accreditation points for the Dutch NVD,
NVAB and VSG. The course members obtain a certificate after completion of the whole course.
Course members from outside the Netherlands should apply personally with their own accreditation office. We will
support them administratively. The level of the course is accordance with that of EDTC and ECHM for Medical
Examiner, 2010.
Capita Selecta Duikgeneeskunde: Medication and Diving,
General: mission of the “AMC Capita Selecta Duikgeneeskunde”.
The Capita Selecta Duikgeneeskunde (CSD), refresher courses dive medicine, are given by the Academic
Medical Centre (AMC), a one-board-cooperation of the medical faculty of the University of Amsterdam (UvA) and
the academic hospital with the UvA. This hospital has a special position within the Dutch academic hospitals; it is
the cradle, also in Europe of a related discipline, hyperbaric medicine, performed in the “Boerema Tank”. This
new type of refresher courses, offered to dive physicians, has a typical ‘Alma Mater’ character.
In the first place, the AMC Capita Selecta present extensively and discipline-wise education in dive and caisson
medicine. In addition, they also give education in new developments as they occur in the academic hospitals and
medical faculties. This implies that, within the lessons, the characteristics of disorders are discussed, including
their diagnostics and treatment, form the point of view of the present academic state of the art.
In short, the Capita Selecta are marked by a mix of education in the dive medicine of the respective discipline and
up-to-date education in the discipline itself, for instance in cardiology, ophthalmology, otology etc. Also, the Capita
will pay attention to the requirements of the medical examination.
The Capita are aimed for non-specialized physicians, first line physicians, sport and occupational physicians,
professional dive physicians, clinical doctors and paramedical academics and technicians.
In general, the teachers have their affiliation with academic hospitals and medical faculties, and have an
international reputation in patient care, academic education and/or medical research as becomes clear from their
curriculum vitae.
To have lower thresholds for the courses given in the Netherlands, the venue is easy to reach and centrally
located, and moreover the course is low-budget.
Programme committee
Nico Schellart (chair, diving physiologist), Marga Schweigmann (hyperbaric & diving physician), Erik van der
Sande (family and sport physician).
Executive committee
Nico Schellart (course director), Eduard van Riet Paap (administrative manager) and Hans van Dam
Responsibility
The Capita Selecta Duikgeneeskunde are given under the responsibility of the Academic Medical Centre, Univ. of
Amsterdam (course leader Nico Schellart). The organization is by the Stichting Duik Research (SDR)1) and
Biomed. Eng & Physics, AMC (Prof. Dr. A.G.J.M. van Leeuwen, chair).

Announcements
Ongoing announcements about future courses can be found at www.duikresearch.org, www.diveresearch.org or
are communicated by E-mail.
1) SDR is a non-profit organisation aimed to promote dive safety. Work for SDR is done voluntarily.
Copyright 2013. All rights reserved. Material of this document may not be reproduced in any form without
permission of AMC and the course manager.
Copyright bij het AMC te Amsterdam en de cursusleider (NS). Alle rechten voorbehouden. Materiaal van dit document mag
niet gereproduceerd worden, in welke vorm dan ook, tenzij vooraf toestemming is verkregen van de kopijrechthouders (info
[email protected]).
Capita Selecta Duikgeneeskunde: Medication and Diving, Programme
9:00-9:05 Introduction, Nico Schellart, coarse leader 9:05-10:05 Dr. Rob van der Hulst, ENT physician, Amstelland Hospital, Amstelveen: ENT-medication and Diving 10:05-11:05 Dr. Gerhard Visser, neurologist, Stichting Epilepsie Instellingen Nederland, Heemstede: Neurological medication and Diving. 11:25-12:25 Dr. Rienk Rienks, cardiologist, Utrecht Medical Center, Utrecht: Cardiologic and vascular medication and Diving 13:40-14:40 Dr. Peter Westerweel, physician for internal diseases, Albert Schweitzer Hospital, Dordrecht: Medication of Internal diseases and diving, 14:40-15:15 Cases of Cardiology and Internal Medicine 15:15-15:45 Round Table. Miscellaneous subjects (e.g. dermatology, gynaecology, orthopaedics, rheumatology) Disclaimer: Capita Selecta Duikgeneeskunde (i.e. AMC and SDR) is bound to execute the educational program, but small program changes are under reserve. Capita Selecta Duikgeneeskunde: Medication and Diving, Rob van der Hulst Rienk Rienks Gerhard Visser Peter Westerweel
The lecturers
Rob van der Hulst studied medicine at the Vrije Universiteit in Amsterdam and specialized as an ear- nose-throat
specialist at the Amsterdam Medical Center, AMC. He received his doctorate on the thesis: “Ototoxiciteit door
geneesmiddelen”, i.e. drug induced ototoxicicity.
After some years as staff lecturer at AMC and four years general practice in the otolaryngology department in
CWZ Nijmegen, he is now working in the Amstelland Hospital in Amstelveen.
As otolaryngologist he holds a number of super-specialties. Closely involved with hearing aid revalidation
nationwide he has seats in numerous boards concerned with quality and efficiency in the adaptation of hearing
aids to the user. Besides he is consultant in pressure related ENT cases. A member of the Dutch society for aero-
medicine, NVvL, he advises several Dutch airlines, seeing a large number of flying personnel on a daily basis.
Since 1991, he is also member of the Dutch society for diving medicine, NVD, advising and treating both sports -
and professional divers, among the latter also firemen. Frequently he collaborates with the Royal Dutch Navy
diving centre, DMC, in Den Helder. He lectures and gives workshops and seminars in the aforementioned
specialties of otolaryngology on a regular basis. Also he is a keen sport diver.

Rienk Rienks graduated in medicine in 1981 and was confirmed as cardiologist in 1986. He has been trained at
the Utrecht University Hospital. Since 1983 working at the Utrecht Medical Center, UMC, he obtained his
doctorate in 1991 on a dissertation on the applications of lasers in cardiology. Detached to the Centraal Militair
Hospitaal in Utrecht since 1995, he cares for military personnel.
His main interests lies in diving, aeromedical and sports cardiology. Considered a national authority on hypo- and
hyperbaric cardiology he fills several consultancies and was member of the board of the Dutch Society for Sports
Medicine, VSG, and participates in several committees of the Dutch Society for Cardiology (NVvC) and VSG. He
is member of the UHMS. He started to dive in 1982 during his tenure as a resident in Curacao. He is PADI and
NAUI certified, advanced open water, rescue, Nitrox.
Peter Westerweel is an internist-hematologist working at the Albert Schweitzer Hospital in Dordrecht. He has
authored several international publications in diving medicine, although the majority if his scientific work has been
focused on the role of bone marrow derived progenitor cells in renal and cardiovascular disease. He has obtained
his PhD at the University Medical Centre in Utrecht, where he was subsequently employed as a postdoctoral
researcher. He worked at the Weill Cornell Medical Centre in New York, USA, as a visiting fellow. He is a diving
physician with the Dutch Society for Diving Medicine and member of the board of the society. He is a consultant
for the Diving Medical Center of the Dutch Navy. He has participated in the development of several national
guidelines in diving medicine, including those on diving with diabetes and diving with antiplatelet and
anticoagulant drugs. He is the principle investigator of the DIDIH (Diving with Disorders in Hemostasis) study,
obtaining a large database of comorbidity and medication use amongst Dutch and Belgian divers. He is an
enthusiastic scuba diver and active PADI Open Water and Specialty Instructor, diving in the Netherlands year-
round, but enjoys a tropical underwater excursion also when the opportunity arises.
Gerhard Visser is a neurologist and since 2011 medical head of the Clinical Neurophysiology department and
Epilepsy Monitoring Unit in the Stichting Epilepsie Instellingen Nederland (SEIN), location Heemstede. His former
position was head of Clinical Neurophysiology in the Erasmus University Hospital in Rotterdam. His PdD degree
(1998) was about Non-invasive (EEG and TCD) detection of compromised cerebral circulation in the context of
carotid endarterectomy. His main scientific interests has been motor unit physiology, continuous neonatal EEG
monitoring, and more recently Cortical Excitability.
Capita Selecta Duikgeneeskunde: Medication and Diving, In the diving medical field, he’s been involved in research projects with the Diving Medical Center of the Royal
Dutch Navy with respect to oxygen toxicity and the hyperbaric treatment of cerebral embolism. He has been
member (since 1988) and president (1997-2012) of the medical committee of the Dutch Underwater Association.
He’s member of Expert Committees of the Nederlandse Vereniging voor Duikgeneeskunde (NVD) and the
Vereniging Sportgeneeskunde (VSG), and member of a committee involved in the certification of Sports Diving
Medics (SCAS). In the past years he’s been involved as teacher in many diving medical related courses and the
medical training of divers and diving instructors. He’s a sports diver since 1982 and still enjoys the underwater
world as 4* CMAS diver, 2* Instructor Trainer and Nitrox Instructor.


Capita Selecta Duikgeneeskunde: Medication and Diving, Rob van der Hulst, ENT-medication and Diving Probably the ENT-medication – mainly OTC (over the counter) - has the largest volume in diving medicine pharmacy. Every diver, and not at the least every dive instructor, has his/her own arsenal of personal tricks and tips. Divers of all ages are confronted with problems of the aeration of the cavities of the head. Therefore a professional classification of commonly used medication (like in aviation medicine) is required. Most commonly used are anti-allergic drugs like antihistamines( e.g. Levocetetirizine, Desloratadine) and steroid containing nose-sprays(Fluticasone and Mometasone). Even oral corticosteroids are used “to keep them diving”. The battle around decongestive nose-sprays, like Xylometazoline, is an ever lasting battle. OTC medication like “Sudafed” is in various forms a kind of recue medication for “blocked” divers. Drugs for motion-sickness (oral such as Primatour, Cinnarezine and plasters, such as Scopolamine (scopoderm), as well as the sweet tasting Ginger tablets are commonly used in diving. The prevention and treatment of external otitis is a real topic for every diving doctor, and gives them an enormous amount of alternatives, from topic eardrops, oral medication to irrigation and air-drying devices. Finally drugs to clear all cavities and/or tubes at the same time will be discussed. We will point out to what extend drug may be used while diving and which ones actually do not facilitate safe diving. Evidence should be searched and found to provide a reliable arsenal of diving medication! Most important however is a good knowledge of the physiology of the ENT-mucosa, and an awareness of the external factors(air-condition in airplanes, jet lags, smoking, alcohol, physical condition, ENT medical history), because they determine most of the physical (ENT) diving hazards. Gehard Visser Neurological medication and Diving Changes in the operation of medicaments by use in a hyperbaric environment are usually not well researched. In my presentation I therefore will provide and explain general guidelines that can be used in assessing whether diving with a certain drug can be safely accepted. If relevant drug-specific knowledge is available related to diving this will be given. As the title may suggest, focus will be on drugs that have potential influence on operational diving safety by influencing proper function of the nervous system (either cognitive or functional), or that may give an increased risk for a specific nervous system related diving disorder, including loss of consciousness. For this, the following considerations are important: (1) is the underlying condition for which the drug is given a problem for diving (such epilepsy or depression), (2) are the aimed effects of the given drug a problem (such as anticoagulation and the additional damage that may result in the occurrence of decompression sickness), (3) are the known side effects of the drug a problem (i.e. dizziness, drowsiness, nausea), (4) does the diving environment has an undesirable effect on pharmacokinetics or dynamics, and (5) does the drug gives an increased risk of a specific diving associated condition, in particular decompression sickness, nitrogen narcosis, carbon dioxide or oxygen toxicity. Rienk Rienks, Cardiologic and vascular medication and Diving Important questions for the medical examination are: Cardiovascular Drugs Does the patient have the cardiovascular health and exercise capacity to safely dive? Is a stress EKG needed to confirm good cardiac fitness? The following classes of cardiovascular drugs will be discussed in relation to medical dive safety and dive safety in general: Lipid-lowering drugs, Bèta-blockers, ACE inhibitors, Central antihypertensives, Calciumblckers, antiarrhythmics, and diuretics. Peter Westerweel, Medication of internal diseases and diving The lecture will start by giving a broad perspective on medication use reported by Dutch and Belgian divers in a survey study including more than 1000 Dutch and Belgian divers. This database collected from the DIDIH study (Diving with Disorders in Hemostasis) provides an overview of comorbid diseases and the use of prescription and over-the-counter medication as reported by divers themselves. From this broad perspective, the controversies and changing attitudes regarding the use of antiplatelet and anticoagulant drugs by divers will be highlighted. This will include a discussion of pathophysiology of the hemostatic system in the hyperbaric environment and unique Capita Selecta Duikgeneeskunde: Medication and Diving, real-life safety data on this topic. The Dutch national guideline on the assessment of divers using such drugs will
be summarized. Another controversial topic in diving medicine, diving with diabetes, will be presented including a
presentation of the Dutch guideline on diving with diabetes. Finally, the diving medical considerations will be
discussed regarding some prevalent medications used in general internal medicine that are not covered by the
other speakers, including drugs used for inflammatory, infectious (including tropical medicine), gastrointestinal,
endocrinological (especially diabetes) and pulmonary disease. Examples will include rarities (Can I dive with
Infliximab for my Crohn's disease?) as well as common drugs with notable adverse outcomes (e.g. Diclofenac-
induced pulmonary immersion edema).


Capita Selecta Duikgeneeskunde: Medication and Diving, From € 60 to €,205 dependent on profession and requested accreditation (see subscription form). The fee includes reader, test, certificate, lunch and drinks. Suggestions for nearby hotels are: Hotel Abcoude Kerkplein 7, 1391 GJ Abcoude +31 294 281 271, [email protected] Rooms from ca. 85 €/day Bus connection with AMC: no. 120 and no. 126, 2 times per hour (ca. 20 min in total). Verl. Van Marwijk Kooystraat 30, 1096 BX Amsterdam +31 (0)20-6634567, http://www.bastionhotels.nl/nl/onzehotels/amsterdam Rooms from ca. 85 €/day Metro connection with AMC: many times per hour (ca. 20 min in total).

Source: http://www.diveresearch.org/download/Capita/Capita%20Medication%20and%20Diving%20(2).pdf