A Note to EMS Providers on Hyperbaric Chambers

I don’t know about the rest of the country/world, but in my neck of the woods, EMT students are taught to bring patients involved in a diving incident, no matter how minor, directly to a hyperbaric chamber.

Can someone please put a stop to this nonsense?

First of all, HBOT (Hyperbaric Oxygen Treatment) is a treatment, and needs to be ordered by a physician.  Unless directed by medical control to transport the patient directly to an awaiting chamber, as can be the case with public safety and commercial divers, patients need to be in stable condition before being subjected to the pressures and stress of a hyperbaric chamber.  Literally.  If a patient is unresponsive, can’t maintain a patent airway, or needs immediate surgical intervention, they won’t be ALLOWED in the chamber.  Period.  End of story.

Secondly, most operational chambers are used for a growing number of non-diving related treatments.  Insurance and Medicare consider the following conditions for HBOT to be covered for payment:

  • Air or Gas Embolism (AGE), including cerebral (CAGE)
  • Carbon Monoxide Poisoning
  • Compartment Syndrome/Crush Injury/Other Traumatic Ischemias
  • Decompression Sickness (DCS) / Decompression Illness (DCI)
  • Diabetic and Selected Wounds
  • Exceptional Blood Loss (Anemia)
  • Gas Gangrene
  • Intracranial Abscess
  • Necrotizing Soft Tissue Infection
  • Osteoradionecrosis and Radiation Tissue Damage
  • Osteomyelitis (Refractory)
  • Skin Grafts and (Compromised) Flaps
  • Thermal Burns

The following conditions may or may not be covered by insurance or Medicare, but can also be treated with HBOT:

  • Autism
  • Cerebral Palsy
  • Lyme Disease
  • Migraine
  • Multiple Sclerosis
  • Near Drowning
  • Recovery from Plastic Surgery
  • Sports Injuries
  • Stroke
  • Traumatic Brain Injury

The staff operating a chamber are well versed in treating the above-mentioned ailments/indications, although they have a working knowledge of DCS/DCI/AGE and have been taught the basics.  The physician at a chamber site would sometimes need to call on another specialist for assistance if an ambulance pulled up with a bent diver looking for treatment, if they even let them get past the front door to begin with.

Other reasons you shouldn’t bring a patient with a possible DCS/DCI issue directly to a chamber include:

  • No available chambers (once a patient is under pressure and being treated, you can’t just yank them out for someone “worse”.)
  • Gas supplies on hand (oxygen and compressed “clean” air) are low and won’t last the required length of a table 6 treatment.
  • The facility may not treat diving injuries.
  • An injured diver needs to be “cleared” for hyperbaric treatment by a physician.  Contraindications for HBOT include pneumothorax (collapsed lung), tension pneumothorax, myocardial infarction (heart attack), and/or neurological and musculoskeletal injuries with symptoms similar to DCS/DCI, to name just a few.
  • The facility might be closed after normal operating hours.

If you encounter a patient that you think might be suffering from a diving related injury, the best thing to do is to provide high-flow oxygen via a nonrebreather mask (15lpm or higher) as soon as possible and transport to the nearest ED.  Gather and record as much information as you can pertaining to the patient’s diving profile, including:

  • signs and symptoms, chief complaint
  • deepest dive depth
  • number of dives in the last 48 hours
  • type(s) of gas used (Nitrox, tri-mix, heliox, air, etc.)
  • diving environment (fresh water or salt water)
  • ascent/descent/bottom issues (if any)
  • equalization problems during ascent/descent (if any)
  • equipment malfunction issues (if any)
  • name and phone number of the diver’s divebuddy
  • any pre-existing medical conditions

Provide the information gathered with your handoff report, preferrably on paper, along with any equipment they were using (if you picked them up at the dive site.)

Call Divers Alert Network (919-684-9111) and speak to a Medic, or have the receiving physican call and speak to a DAN Medic or physician for treatment options.  The phones are staffed 24x7x365, and they accept collect calls.

The single-most important treatment for a diver suspected of having DCS/DCI is a BLS adjunct: OXYGENLots of it, as soon as possible, for as long as possible.  Forget a nasal cannula at 4lpm.  Oxygen breaks down the nitrogen bubbles in the blood stream and tissue compartments.  Nitrogen is what causes DCS/DCI, so the faster you can apply SLO2 (surface-level oxygen), the faster you can begin the nitrogen breakdown, and the diver will have a better chance of recovery once they start the chamber treatments.

Whatever you do, DON’T, for the love of whatever you consider Holy, take them directly to a hyperbaric chamber.

 

  • renoun

    Give some serious consideration to transporting the dive buddy[s] to with the patient. They are likely to have experienced similar risks of DCS/DCI if they dove the same profile as the patient, may have omitted decompression or made a faster than otherwise prudent ascent to assist the patient, and are likely to be a good historian about known aspects of the dive. They also may also be distracted enough to not recognize their own subtle symptoms of DCS/DCI or be asymptomatic do to variations in individual physiology. Offering the buddy high flow oxygen while the main patient is evaluated/packaged or awaiting an additional unit may be very therapeutic and is unlikely to be harmful.

    Many recreational divers, nearly all professionals, and most dive boats carry oxygen kits. Don’t be surprised to find to arrive and find the patient on high flow oxygen. Many will be using an oxygen conserving demand valve and ora-nasal mask that may appear unfamiliar but will deliver a higher concentration of inspired 02 at lower flow rate than a typical non-rebreather. It may be beneficial to the patient to transfer this equipment to your own oxygen supply or carry it as a backup in case you need to switch to portable oxygen tanks. Also when you do get to the hospital be a good advocate for your patient and ensure that they remain on high flow 02 until their situation is completely understood.

    I recently heard of several cases of divers diagnosed with immersion pulmonary edema. These are patients that may benefit from CPAP if it is available.

    DAN Medic/Physican can also coordinate hyperbaric chamber access if appropriate and may be able to help you with suggestions of transport destination. Finally if you operate under restrictive protocols consider having a conference call with the DAN Medic/Physican and your online medical control, they can probably set up the call for you.

  • http://www.netwrx1.com George R. Kasica

    DiverMedic:

    GREAT post, I happen to be an EMT here in WI and also was a PADI cert. Dive Master up until a dive accident on 2/15/03 ended my diving. WIthout peoper handling by DAN and the local medical resourced it might have ended far more seriously.

    THe story to illustrate how its supposed to work with DAN – I was on an under ice training dive for the Ice Diving Cert. in Lannon, WI about 35 miles NW of Milwaukee, WI at the time and ended up head down with a dry suit on 50′ below water. Long story short I lost the regulator behind me and took a mouth of ice cold water. After that next memory was waking up on the ice above with an NRB O2 mask on my face without dive gear – I had been recovered with the safety rope when I went unconcious under water. My diving buddies happened to all be FF/EMTs from local depts and they knew to call DAN ASAP even though at the moment I felt fine – this was going to change rapidly.

    DAN reacted immediately and told them where to take me and alerted the receiving facility – St. Luke’s Medical Center in Milwaukee- and when we arrived they were waiting for me and had started the process of prepping a Chamber (Clyde fpr anyone who knows what that one is) and getting the needed RN staff etc. paged and called in, etc. – in the event I needed to dive.

    They are 24/7/365 service but not necessarily have the folks just sitting waiting for a case to come in to dive – most have other hospital duties as well. It’s handled similar to a “Code-4″ event where a pager is activated and staff responds to the ED area etc.

    I was immediately placed on CPAP and evaluated for dive related issues by an MD that was a specialist in Dive Medicine (turns out I worked with the guy as an IT specialist during my real job several years earlier- Hi Dr. Otto & Simanonok, MD) and they rapidly assessed me annd decided to run a Table 6A for AGE since my symptoms included shortness of breath, chest pain and a pulse ox in the 70′s on room air, among the std. DCS/DCI injuries type symptoms.

    Long story short within the hour of the accident I was rolling into the Chamber with an ICU RN (Hi Mary Jo – a co worker of my wife’s – who both happened to be working at the time) and spent the next 6.5 hours approx, in there beuing taken to depth and resurfaced properly.

    Once released I was reevaluated and a week long 4 hour daily re-dive protocol was set up for me to mop up any remaining issues.

    All ended well here and I had no lasting issues but MDs felt that given some other health issues that it would be best after this that I quit diving as reoccurance of AGE apparently goes up after the initial problem.

    SO there’s the story of how it’s SUPPOSED to work – without DAN I likely would have ended up at a local hospital about 10 minutes away with NO Dive Medicine ability but a mono-place chamber used for wound care and not staffed on a late Saturday afternoon in February.

    Oh and a final note for Divers – If you’re unsure about buying that DAN Premium Dive Medicine Insurance which at the time was I think $60 a year for top tier coverage, BUY IT. My total bill for this little oops was between $50-60K all totaled up with follow up and such. My Medical Insurance paid portions of that – yes they picked up most of it, but with deductibles and co-pays I would still have been out about $2-3K – with DAN I paid absolutely ZERO after they covered what Medical Insurance didn’t or wouldn’t. It allowed me to get the best care possible as its NOT health system or doctor specific like most traditional medical plans.

    That’s my story and comments, Thanks DiverMedic for a great post, hope that my followup helps at least 1 person out there.

    George

  • http://Www.Jonemtp.com Jon Blatman

    DiverMedic,

    I have added DAN to my phone. Not sure why I never thought about it before.

    In my neck of the woods, I’ve got a University Hosptial within 45-60 minutes drive time that has a fantastic hyperbaric program (with dive medicine contacts). My gut would be to call their Command Doc first, and probably consider risk vs. benefits of immediate transport there.

    My bigger concern with your initial post is that, as George said, there are some facilities that may have “hyperbaric therapy”… But it’s a single coffin-esque chamber in the wound care clinic open Monday-Friday daytime. There are competitively VERY few facilities that are capable of medically managing a dive.

  • http://10-9.blogspot.com Mr. Police Man

    I’ve called DAN once after my set of dives in Hawaii where I could barely walk my foot hurt so bad. I only purchase DAN, just an avail. $$$ issue, when I’m diving and I’m less than regular.

    They walked me through my problem and I am forever grateful.

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