Craniotomy
Hi,
7 years ago I was hit by a bus and required two craniotomies. This put me at risk of developing epilepsy, but I have never had a fit and am not on medication. I have no driving restrictions.
I recently failed my dive medical because of the risk of epilepsy from the operations. I received some advice that perhaps a letter from my neurosurgeon may help my case to appeal the failed medical. Unfortunately though I had the operations in Scotland, so getting an all-clear from my neurosurgeon may prove near-impossible.
Would there be any other avenues to appeal the failed medical within Australia?
Thanks,
Anna
The logic of this position escapes me entirely. It seems to me that if you are deemed fit to drive a motor vehicle (presumably, including commercial transport, busses, trains and whatnot), where the potential consequences of a seizure might include the deaths of many innocent and non-consenting people, then logically you shoould be deemed fit to dive, where the consequence of such a seizure would likely only be your own death, a possibility you have been informed of and a risk which you implicitly consent to.
But what is that risk? The data is on which to make a decision is fairly haphazard and not terribly organised, and that most pertinent is old data ofen written before new investigational modalities and therapies devloped. The information about LATE epilepsy in someone with no prior seizures is especially lacking. You obviously had a severe brain injury to warrant two craniotomies and would be in an extremely high risk category for devlopment of epilepsy IMMEDIATELY following the trauma. The fact you haven't in 7 years doesn't mean you won't ever (and factors such as intercurrent illness, tiredness, alcohol excess, some medications or use of other drugs may certainly still precipitate an event), however, your risk is presumably NOW very small and probably lessening with further time.
As far as I can tell the best defined longtitudinal work relating to your issue comes from studies of people with stroke (especially haemorrgahic) and those undergoing neurosurgical procedures. The risk is highest in those undergoing clipping of aneurysms (about 10% per year—{Hoh, et al 2011 Neurosurgery pp 644-50; discussion 650, Vol 69, Issue 3} an lowest for those suffering a non-haemorrhagic stroke in big studies from Scandinavia (about 3.2% over a ~ 7 year period {Kammersgaard, 2005 #351;Lossius, 2002 #374}. Assuming the absolute worst case, your probability of a seizure would be about 10% over 8760 hours while for best case (and I suspect this is still a much greater rate than your ACTUAL risk about 3.2 per ~60,000 hours. Assuming you dive for about an hour each time your rsk of a seizure would be between 1:876 and 1:20,000. In other words, given your current seizure free status, I'd guess your risk of dying from epilepsy while diving is substantially less than the general risks most people run while diving.
However, it would be possible to further define and stratify your risk. Personally, I'd see a neurologist and get a standard and a sleep deprived EEG. If they were normal I'd suggest your risk was even lower than 3.2 per 7 years. I hope this helps. A bit.
The logic of this position escapes me entirely. It seems to me that if you are deemed fit to drive a motor vehicle (presumably, including commercial transport, busses, trains and whatnot), where the potential consequences of a seizure might include the deaths of many innocent and non-consenting people, then logically you shoould be deemed fit to dive, where the consequence of such a seizure would likely only be your own death, a possibility you have been informed of and a risk which you implicitly consent to.
The two cannot be compared. With diivng there is 1) more eleptogenic stimuli around (high Po2, increase CO2 sensitivity, light strobe effect of moving water) than with routine driving and 2) if you take the position that the person is only harming themselves then there is really an obligation not to risk diving as it is not a requirement of life (ie risks > benefits). Not being able to drive has a lot more implications for the person in their daily life so the balance moves back and the reality is that the liekly hood of a major issue while driving and having a seizure is location dependant and therefore has a survivability, a seizure underwater is almost universally fatal.
There is current some consesnsus work being done by the Europeans (mainly BSAC from memory) regarding head injuries and diving and the consequences of this and the position papers with the evidence will be out soon (hopefully). Might have a bit more of a platform to work from after that.
Regards Glen
"The two cannot be compared. With diivng there is 1) more eleptogenic stimuli around (high Po2, increase CO2 sensitivity, light strobe effect of moving water) than with routine driving and 2)
I wonder what evidence you have to support that assertion? My guess (and, like your statement, its only a guess) that the "strobe effect of moving water" would be significantly less then the PROVEN eleptogenic effects of flashing lights (indicators/ headlights/variable lumen densities with nocturnal driving etc). There is NO data on this one way or the other. There is certainly no work or hard dateto conclusivelty demonstrate the gast pressures of diving increase the risk of epileplsy in patients with head injury. Unless you have some?
"if you take the position that the person is only harming themselves then there is really an obligation not to risk diving as it is not a requirement of life (ie risks > benefits). Not being able to drive has a lot more implications for the person in their daily life so the balance moves back and the reality is that the liekly hood of a major issue while driving and having a seizure is location dependant and therefore has a survivability, a seizure underwater is almost universally fatal."
No question, as I stated. My position is a civil liberties one. However, by certifying someone as safe to drive one where that may NOY absolutely be the case one is also exposing others on the road and otherwise who have not explicitly consented to that risk. At least the diving individual does implicitly and explicitly consent to what is likely to be an exceptionally low risk of death due to epilepsy underwater, and the death is only ever likely to be their own.
I wonder what evidence you have to support that assertion? My guess (and, like your statement, its only a guess) that the "strobe effect of moving water" would be significantly less then the PROVEN eleptogenic effects of flashing lights (indicators/ headlights/variable lumen densities with nocturnal driving etc).
The problem with this is that photosensitive elpleptics are not going to be allowed to dive but certainly, there is significant storboscopic light effects underwater caused by variable refraction of light with moving surface water. Its a bain (or feature) that underwater videographers (like myself) either love or hate.
There is certainly no work or hard dateto conclusivelty demonstrate the gast pressures of diving increase the risk of epileplsy in patients with head injury. Unless you have some?
No BUT elevated gas pressures by themselves in healthy brains can cause seizures (well documented in hyperbaric medicine) and working on the principal that people with head injuries are more likely to have seizures in the first two years than non-head injured people due to a reduced seizure threshold, there is an easy link betwene the two for increased risk. Are we ever going to find definitive evidence. Unlikely due to the fact that seizure prone persons are not being allowed to dive.
Regarding civil liberties, it is not a right that you should dive and medical advice should be based on the best evidence available. There is hopefully a document looking at all the evidence coming through the process regarding head injuries and diving so that will make for interesting reading.
Regards Glen
Well, I'd say its not a right you should drive either. And the correct libertarian standpoint would be "do whatever you want so long as you don't harm others". You are MUCH more likely to harm others driving vehcles on the road with medical issues than you ever will diving, so all things being equal someone in Annas position should be certified fit to dive before she was to drive, at least from a societal perspective. But, whatever, as I said in my original post the evidence that Anna has any SIGNIFICANT risk of epilepsy now is non existent, and the SCIENTIFIC evidence she is at increased risk of epilepsy from DIVING is similarly non-existent. I wasn't arguing the toss about the theoretical epiletogenic risks of hypercapnia or high ppO2—everyone knows this to be true—but the statement that the variable refractive issues of light through water (as if this is a proven fact) is eleptogenic is just bu@#sh#t. Wheres the evidence for that? One of my best mates studies photic epilespy—particularly amongst video gamers— at the Queens Square in London and she's never warned me of it. I will ask her, though.
As to paying for the tests Anna [might] need I'd have no problem getting medicare to pay for an EEG to determine someones risk of epilepsy in Anna's particular circumstance, especially if there is genuine concern—some might say patient anxiety—about her seizure risk. Having had other imaging procedures that were, apparently, normal I wouldn't see an MRI as important, assuming the previous studies were, actually, normal.
Well, I'd say its not a right you should drive either. And the correct libertarian standpoint would be "do whatever you want so long as you don't harm others". You are MUCH more likely to harm others driving vehcles on the road with medical issues than you ever will diving, so all things being equal someone in Annas position should be certified fit to dive before she was to drive, at least from a societal perspective.
Fair enough. Then why do dive medicals at all? To be honest 7 years without a seizure then she should be fit to dive as the documented limit for having the same risk as a non-head injured person is 2 years. Which in itself is interesting because you can drive at 1 year which means that they allow you to drive at a higher risk than the general population for epilepsy. Go figure.
I wasn't arguing the toss about the theoretical epiletogenic risks of hypercapnia or high ppO2—everyone knows this to be true—but the statement that the variable refractive issues of light through water (as if this is a proven fact) is eleptogenic is just bu@#sh#t. Wheres the evidence for that?
You can't argue either way as their is no evidence that it doesn't cause seizures and because the group that you'd have to test is not allowed to dive (due to their epilepsy) then there is no way you can make the statement that the photostrobic effect is not an issue. I was raising it as a possible point of issue in head injuries.
I would be interested to see what your friend has to say as I know that the light filtering effect does give some of my friends that dive headaches and I wouldn't be surprised that the potential for a photosensitive epileptic to have a seizure under these circumstances is possible. In this particular case it is not an issue.
As to paying for the tests Anna [might] need I'd have no problem getting medicare to pay for an EEG to determine someones risk of epilepsy in Anna's particular circumstance, especially if there is genuine concern—some might say patient anxiety—about her seizure risk.
How will that help? Her risk at 7 years post injury is as per a normal person so whats the point of an EEG and what is the predictive value of a one off EEG in these cases? The only investigation I would think might be useful is to make sure she does not have any trapped air spaces (which is unlikely) with regards risk of barotrauma. Otherwise I can't see why she cannot go back to diving.
Regards Glen
"The two cannot be compared. With diivng there is 1) more eleptogenic stimuli around (high Po2, increase CO2 sensitivity, light strobe effect of moving water) than with routine driving and 2)
I wonder what evidence you have to support that assertion? My guess (and, like your statement, its only a guess) that the "strobe effect of moving water" would be significantly less then the PROVEN eleptogenic effects of flashing lights (indicators/ headlights/variable lumen densities with nocturnal driving etc). There is NO data on this one way or the other. There is certainly no work or hard dateto conclusivelty demonstrate the gast pressures of diving increase the risk of epileplsy in patients with head injury. Unless you have some?
"if you take the position that the person is only harming themselves then there is really an obligation not to risk diving as it is not a requirement of life (ie risks > benefits). Not being able to drive has a lot more implications for the person in their daily life so the balance moves back and the reality is that the liekly hood of a major issue while driving and having a seizure is location dependant and therefore has a survivability, a seizure underwater is almost universally fatal."
No question, as I stated. My position is a civil liberties one. However, by certifying someone as safe to drive one where that may NOY absolutely be the case one is also exposing others on the road and otherwise who have not explicitly consented to that risk. At least the diving individual does implicitly and explicitly consent to what is likely to be an exceptionally low risk of death due to epilepsy underwater, and the death is only ever likely to be their own.
Thinking about this further, it seems to me you could make a case for an "EEG Oxygen stress test", or at least formulate an interesting hypothesis worthy of a decent research projest. Obviously, one of the "stressors" for seizure activity would be high ppO2, and it MAY be that folk with significant head injury such as discussed above may be at increased risk of seizures induced by high ppO2 (and possibly lower than the classic 2ATM we all avoid). There isn't any literature that address this question, (and the old literature that does exist is well out of date) but it seems to me doing EEGs in a hyperbaric chamber with oncreasing ppO2s to establish the threshold at which different people develop eleptiform activity would be a useful excercise.
We all know of or have read of divers (especially, apparently, CCR divers who seem to hit the diving press for these type of events) who have had "Oxygen hits" at apparently non-dangerous ppO2. Maybe it would be a useful exercise these thresholds in "act risk" divers in a hyperbaric chamber. I think it would make an interesting research project anyhow, and I'll ask one of my Neurology mates (an EEGist-eleptologist) what she thinks of the practicalities.
Hello Anna,
Interesting question.
As you may well know there is often no clear answers with respect to some of these cases. There is no formal appeal process per se but you are fully entitled to a second opinion.
I would be looking at a specialist centre for the second opinion based on the capability of getting access to neurosurgeons/neurologists that are familiar with diving and hyperbaric medicine.
Also you may need to have further testing that could include expensive MRI scans or EEGs which would not be available under Medicare so the cost would have to be accepted by yourself.
If you want to talk to someone regarding this further you can reing your local Hyperbaric Unit and they should be able to help you.
Regards Glen