Editor’s Note: This commentary reflects, in part, on a panel discussion of the Gulf Coast Chapter of the Undersea and Hyperbaric Medical Society to address the issue of available HBOT facilities being equipped to provide emergent treatment 24/7.
Conditions that may require urgent hyperbaric oxygen treatment (HBOT) are well known to include decompression sickness, air or other gas embolism, carbon monoxide (CO) poisoning, and necrotizing and gas-forming bacterial infections. Less commonly encountered conditions such as acute ischemic limb salvage and crush injuries, central retinal artery obstruction (CRAO), sudden sensorineural hearing loss (SNHL), and blood-loss anemia when transfusion is delayed or not possible can also occur. Many of today’s outpatient wound clinics and HBOT facilities have adopted business plans that do not allow the flexibility required to treat patients urgently. Their limited types of hyperbarically treated indications undermine the position of our small specialty of clinicians for these unique services and shifts the burden of care to fewer facilities, which are likely more distant for patients and result in more travel time/challenges.
With this commentary, I’ll be sharing my experiences regarding these matters from the perspective of my wound clinic and what I’ve observed in my community and surrounding region as a means of reminding key industry decision-makers and the general population of wound care providers that a dangerous situation that currently exists can be modified to improve patient care and relieve the burden on the remaining centers that are still available to handle HBOT emergencies.
A Loss That Spells Urgency
Not that long ago, our hospital-based multiplace facility in Tallahassee, FL, was one of several locations in the north Florida and surrounding region (including hospital-based units in Jacksonville, Gainesville, Panama City, and Pensacola) that accepted and cared for emergency HBOT referrals. Over several years, seemingly one by one, facilities have been closed to this patient population, leaving them treating primarily those living with difficult-to-heal chronic wounds related to diabetes, osteoradionecrosis, soft-tissue radiation necrosis, and preparation/preservation of compromised flaps. Facilities that remain open to urgent/emergent treatments are severely overburdened from a clinical perspective, are similarly inconvenienced by staffing challenges (eg, clinicians subject to inadequate sleep between shifts, considering that many hyperbaric emergencies happen after hours and on weekends), and risk potential loss of income associated with being able to manage a chamber facility without interruption of care to routine wound and HBOT patients. Other issues, such as immediate appropriate evaluation and management of recent diving injuries, CO poisoning, CRAO, and SNHL (including delays in transport from the initial acute care facility to the eventual treating facility), have been occurring frequently with the potential to affect care and outcomes.
Our facility in particular experienced a rather dramatic surge in HBOT emergency care preceded by a steep decline. In 2008, we recorded 11 emergency treatments, followed by four in 2009, 28 in 2010, 24 in 2011, 15 in 2012, and six through the first half of 2013 before we decided to cease taking emergency referrals from other healthcare facilities. Some key personnel who were trained in managing patients in an acute or critical setting within the hyperbaric chamber had left the locale and we experienced a drop in the number of regular wound care and radiation necrosis patients, which made paying staff to be on-call and/or to go to training programs difficult. A few years prior to this, the major community hospital in town had contracted with a national wound care company and placed two monoplace chambers in its outpatient facility. The peripheral vascular service medical group signed an exclusive contract with the community hospital, making revascularization procedures more difficult in our facility because we had to seek other contracted providers for this service.
In a 2012 article, Dick Clarke, CHT, president of the National Board of Diving & Hyperbaric Medical Technology, exposed the concerns and risks to this patient population and the industry.1 It’s easy to acknowledge there is special clinical knowledge as well as certain equipment and training procedures necessary in order to be able to care for this patient population — education that can be attained as a component of practice scope for nurses, therapists, and technicians. What is astounding, however, is a seemingly inadequate level of physician support for full-service HBOT facilities to be available to care for those patients in need of this care. Managers of most facilities will have difficulty finding resources to pay additional chamber personnel to be on-call, yet many physicians are also going to be reluctant to devote extra time to be on-call for patients they have not already committed to. Unfortunately, the satisfaction of seeing a neurologically injured patient from diving, CO poisoning, or with an anaerobic necrotizing infection recover function to near or absolute normal capacity does not seem to be worth the effort if there is not adequate compensation for many individuals who could be involved.
Where Do We Turn?
As far as finding a solution that will get previously capable and functioning hyperbaric programs back in the business of taking care of the sickest patients, adequate funding is obviously imperative. Finding the will for that is the challenge. The best solution may be to improve the capacity for care at enough centers offering monoplace and/or multiplace chambers to avoid the “last man standing” scenario, which represents a dangerous form of musical chairs. Consider a letter to the editor2 recently written by Julio R. Garcia, BSN, RN, CHT, ACHRN, program director of the HBOT facility at Springhill Medical Center, Mobile, AL, who has been busy caring for diving emergencies among patients living in the Gulf Coast of Florida. Some of these accidents involve victims of complex diving profiles with mixed gases, including trimix and nitrox, with long exposures in the fresh water of cave systems or deep-sea water wrecks offshore. Currently, there are no other facilities north of Florida’s Orlando Regional Medical Center to manage the recompression and treatment of these patients due to the closure of other facilities in the state.
Imagining what could be done if that will is realized and all hyperbaric providers could expand the value of their care for their communities is the fuel needed to generate a return to proper care for these patients. “Kicking the can down the road” should no longer be tolerated by us or our patients. Board certification in hyperbaric medicine is helpful in knowing the needed skills to engage in the care of a patient who is restored with as few as 1-4 treatments. No clinician is an island in this endeavor. Staffs of trained, certified personnel who are motivated by the best medical outcomes for patients, in or out of their chambers and who collaborate on decisions related to patient care can bring a force stronger than the limitations imposed by delay in treatment, allowing all clinicians the pleasure of knowing that we are all living up to the goals we set when we entered the world of hyperbaric medicine.
William T. Kepper is medical director of the hyperbaric department at Capital Regional Medical Center, Tallahassee, FL.
1. Clarke D. Divers losing access to emergency care. Alert Diver. 2012. Accessed online at www.alertdiver.com/emergency_care.
2. Garcia J. State of emergency in hyperbaric medicine: A clear and present danger. Wound Care & Hyperbaric Medicine. 2011; 2(3)9-12.