INTRODUCTION

Background

At the onset of this discussion, we recommend that you review the topics “HBO Medical Director Guidelines” and “Medical Director Job Description.” These responsibilities are at the core of the medical director role in a hyperbaric medicine facility. We have listed the UHMS facility accreditation expectations of the medical director and hyperbaric staff physicians here.

ROLE OF THE MEDICAL DIRECTOR IN HYPERBARIC SAFETY

When we visit facilities for accreditation surveys, it is readily apparent from the outset of the accreditation whether the medical director takes a “hands-on” role or not. We encourage you to consider the following and develop an interactive role with the staff of your facility.

The medical director, rather than simply a figurehead, must take an active role in conjunction with that of the hyperbaric safety officer. Not only is it an organizational role, but it is also a public safety role. The medical director and safety officer have joint responsibilities, such as assuring proper maintenance of the hyperbaric chamber(s) in the facility, proper ancillary equipment maintenance, obtaining proper clothing and attire for patients and staff, reviewing and implementing an environment of safety, and knowledge of hyperbaric chamber operation. Failure to fulfill these roles can lead to criminal prosecution in event of a fire or other catastrophic failure at a facility.

Real world scenarios

For instance, we have reviewed the 2009 facility fire in Florida. Both the medical director and safety officer were charged with criminal negligence, found guilty, and served time for the negligence. Bluntly spoken, failure to take an active role in department safety creates a situation where the result is likely to be piles of scrap metal with dead bodies inside.

We have found that many new certified hyperbaric technologists (CHTs), nurses, and medical directors, having attended a 40-hour introductory course, view hyperbaric medicine challenges in a strict black/white decision tree. Daily practice and experience shows that this is rarely the case, and there are many decisions that must be made in shades of gray and without full knowledge of background details. We give you a challenge. Are you ready?

Scenario 1. Safety at 4500 feet above sea level

Scenario: You are the new medical director for a hyperbaric chamber at 4500 feet above sea level. It is a multiplace chamber and you need to plan appropriate treatment protocols in order to keep your inside attendants safe. There is a potentially higher risk than at sea level for inside attendants to develop decompression illness. How will you proceed?

Analysis: There is no black/white answer for this question. Many facilities at higher elevations are monoplace facilities only. There are multiplace facilities that have chosen never to treat at pressures higher than 2.0 ATM in order to avoid this situation. But, what are you going to do? Is the black/white solution the best for your population of patients? What do we do for a gas gangrene patient, where the standard of care treatment table prescribed is 3.0 ATM (and we have only a multiplace chamber)?

The Bühlmann altitude diving tables are a help, but those do not specifically answer the question, since they were designed to correct for an excursion to altitude then diving after arriving at altitude. There is a program developed by a United States Air Force hyperbaric and altitude physician. This program sought to take traditional diving tables and add an altitude component in order to predict nitrogen elimination at altitude, with/without a hyperbaric exposure. The program is called NoBendEm and can still be found on a Google search today. We encourage you to at least look at the program and become familiar with what information it can tell you about hyperbaric stress in your inside attendants. We do not expect that you need to become an adept user of the program.

Even with this software spreadsheet, the medical director and safety officer need to plan appropriate air breaks and inside attendant oxygen breathing so that the attendant comes out of the chamber with minimal decompression stress. This requires decisions in the gray zone. Once you have developed a safe inside attendant protocol, are you finished? No, not so.

In addition to developing protocols, changes to the “standard” hyperbaric treatment tables require that both the medical director and safety officer detail the protocol changes in the facility exception or operations log. These decisions must be codified so that others can review the details at any time. Hence, the medical director and safety officer are both responsible parties and must document and sign those decisions in a contemporaneous manner.

Scenario 2. Medication patches in hyperbaric chambers

Scenario: Patient with a fentanyl patch needs to undergo hyperbaric oxygen therapy. A frequent conundrum is whether or not to allow medication patches in your hyperbaric chambers. Many physicians and safety officers have taken a simplistic approach to the problem by burying their heads and denying any medication patch in the chamber environment. What you should recognize is that there is no published medical literature that answers this question. Hence, your approach to this will always be in the gray zone.

Analysis: We encourage you to perform a PubMed search and have a look at the undersea and hyperbaric medicine literature on Rubicon-Foundation (hyperbaric medicine articles can be found faster if search is conducted on WoundReference data aggregator). After a diligent search of the diving and hyperbaric medicine papers/abstracts, we find 3 references on this subject. First, there is no evidence of enhanced fire risk for medication patches in the hyperbaric environment. Second, it is safe to remove a fentanyl patch from a patient, then replace with a new patch after every single treatment. (Safety officers and nurses may argue that they do not have the authority to remove the patches then dispose of them in such a way as to please the DEA and the state Bureau of Narcotic and Dependent Drugs. I suggest that this is not an appropriate manner to approach these patients.) Finally, we come across one diving medicine paper that stated scopolamine patches were safe to remain on during diving trips. There appeared to be no excess drug absorption due to elevated hyperbaric pressures found in SCUBA. See more information in topic "Go-no-Go Lists/ Prohibited Items", and in the blog post "Prohibited Items, Risk Assessment And Authorization".

Well, here we are again! Very little scientific information, but we need to make a decision based on the safety of our staff and the well-being of our patients. What are you going to do? Regardless of your choice, I highly recommend Medical Directors to instruct the staff hyperbaric physicians to follow whatever decision the team agrees upon. It is much better to be consistent among all hyperbaric physicians. For customized answers from WoundReference's Advisory Panel, please refer to "Curbside Consult".

Scenario 3. Implantable devices in hyperbaric chambers

Scenario: A patient with an implanted defibrillator needs to undergo hyperbaric oxygen therapy. Another frequent conundrum is what to do with implantable devices such as pacemakers, infusion ports, cochlear implants, spinal stimulators and the like?

Analysis: This is a shared decision by the medical director and safety officer of your facility. Your decision and a reference copy of the manufacturer's hyperbaric pressure approval letter must be codified in your exceptions log for that particular patient. We suggest that you include a copy in the patient chart for completeness. See more information in topic "Go-no-Go Lists/ Prohibited Items", and in the blog post "Prohibited Items, Risk Assessment And Authorization".

We can summarize this topic by stating the following:

1. A successful hyperbaric facility functions based on teamwork. The better team you build, the better your safety program. 
2. The medical director sets the tone for the department. We encourage each medical director to build a tone of quality by encouraging lifelong learning and your stamp of interaction with staff and patients on a daily basis.
3. Every department comes to some sort of conflict from time to time. The medical director and safety officer must resolve the conflict in an expeditious manner and for the good of the department, clinic, and patients. I encourage you to listen carefully to your staff, nurses, and safety officer. They are looking at long-term perspectives that you may not yet have seen. 
4. Finally, no job is finished until the paperwork is done. We encourage you to be active in documenting medical decision making and hyperbaric safety. This can be in a patient’s medical record, the hyperbaric maintenance log, operations log, and/or the hyperbaric exceptions log. Document what you do … and do what you’ve documented.