The Role of the Medical Director in Hyperbaric Safety

I've been asked to address some of the qualities of a hyperbaric medical director with the theme of hyperbaric safety as the core concept. I'm happy to do so. On this blog post we provide a brief overview of this theme, but for more details please refer to the topic "Role of the Medical Director in Hyperbaric Safety", available to PRO+HBO premium subscribers.

As a UHMS facility accreditation surveyor, 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 develop an interactive role with the staff of your facility. You are supposed to be a leader in your facility. It's time to step up to the plate!

The medical director, rather than simply being a figurehead, must take an active role in conjunction with that of the safety officer. Not only is it an organizational role, but it is 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 chamber and equipment maintenance, 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.

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.

Here is a situation that we see all over the country. Many new certified hyperbaric technologists (CHTs) and hyperbaric physicians, 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 with shades of gray and without full knowledge of background details.

Consider some of the following challenges that simply cannot be answered in a black/white decision tree:

• Scenario 1. 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? You have a number of resources, including querying physicians who practice at altitude, but you should know that 4 different facilities may give you 6 or 8 answers ... ahhhh, how to tell the correct one? Now that's the dilemma. Once you have developed a safe inside attendant protocol, are you finished? No, not so. Did you document your decisions in a facility log like, an operations log?
• Scenario 2. 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. 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?
• Scenario 3. What do you do with implantable devices such as pacemakers, infusion ports, cochlear implants, spinal stimulators and the like? This is a shared decision by the medical director and safety officer of your facility. 

Needless to say, these problems can generate a discussion. You have, no doubt, had particularly difficult decisions to make regarding your facility. Have you come to a satisfactory answer? If not, let's discuss the issues. I would be happy to point you toward resources that might benefit resolutions and advancement of your facility's safety environment. 

We can summarize 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.

RESOURCES

The WoundReference Hyperbaric Oxygen Therapy Knowledge Base features guidelines to promote high standards of patient care and operational safety within the hyperbaric program and other important tools (See "Role of the Medical Director in Hyperbaric Safety", "Safety Program Guidelines (free)", "Designation of Safety Director", "Go-No-Go Lists / Prohibited Items", and more). The WoundReference Curbside Consult gives you actionable, specific answers from our advisory panel in a timely manner.