Tragedy in Michigan Highlights Importance of Hyperbaric Safety Protocols
The hyperbaric medicine community was shaken by the heartbreaking news of a five-year-old child’s death following a hyperbaric chamber fire at a facility in Oxford, Michigan, on February 2, 2025. The Undersea and Hyperbaric Medical Society (UHMS) has extended its deepest condolences to the family and all those impacted by this tragedy.
“A single spark it appears ignited into a fully involved fire that claimed Thomas’s life within seconds,” attorney general Dana Nessel said at a news conference.
This incident underscores the paramount importance of adhering to strict safety protocols in hyperbaric oxygen therapy (HBOT). As providers, we are reminded that every treatment carries the responsibility of ensuring patient and staff safety at all times.
Background
The Importance of Accredited Facilities and Proper Oversight
The UHMS, in collaboration with the U.S. Food and Drug Administration (FDA) and the National Fire Protection Association (NFPA), continues to emphasize that HBOT should be delivered only in accredited facilities under the direct supervision of qualified hyperbaric professionals. UHMS accreditation ensures compliance with rigorous safety standards, including those set by the NFPA.
FDA recommends UHMS-accredited hyperbaric facilities for treatment of specific illnesses
The FDA regulates both the oxygen used in HBOT and the hyperbaric chambers. In a recent release entitled “Hyperbaric Oxygen Therapy: Get the Facts” the U.S. FDA cleared the use of HBOT for the treatment of several conditions. The agency recommends that patients seek treatment at UHMS-accredited facilities, which are subject to inspections and held to high safety and clinical standards:
“If your health care provider recommends HBOT, the FDA advises that you go to a hospital or facility that has been inspected and is properly accredited by the Undersea and Hyperbaric Medical Society.” - U.S. Food and Drug Administration (FDA)
UHMS-Approved Indications for HBOT
The UHMS has delineated specific indications for HBOT use. UHMS emphasizes that treatments should be conducted in accredited facilities under the direct supervision of well-trained hyperbaric medical professionals including a hyperbaric medicine trained physician.
The UHMS has approved HBOT for the following conditions:
- Air or gas embolism
- Avascular Necrosis of the Femur
- Carbon monoxide poisoning
- Central retinal artery occlusion
- Clostridial myositis and myonecrosis (gas gangrene)
- Crush injury, compartment syndrome, and other acute traumatic ischemias
- Decompression sickness
- Enhancement of healing in selected problem wounds
- Exceptional blood loss (anemia)
- Intracranial abscess
- Necrotizing soft tissue infections
- Osteomyelitis (refractory)
- Delayed radiation injury
- Compromised skin grafts and flaps
- Thermal burns
- Sudden sensorineural hearing loss
For details, refer to topic "HBO Treatment Indications With Protocols".
Reflection from the National Board of Diving & Hyperbaric Medical Technology
In its February 2025 briefing, the National Board of Diving & Hyperbaric Medical Technology (NBDHMT) acknowledged that the event should prompt immediate internal reviews of the facility’s hyperbaric safety plan and hyperbaric safety protocols, directed at fire prevention to ensure they reflect current standards.
NBDHMT's president noted the importance of considering emerging safety concerns - including wearable tech such as biometric sensors incorporated into finger rings and smart glasses - that may inadvertently be brought into the chamber environment. Facilities need to ensure comprehensive adherence to the hyperbaric safety plan, including periodic practicing of mandatory hands-on safety drills.
The NBDHMT also addressed discrepancies in initial reporting. Early press coverage and statements from local police and fire departments described the incident as a "chamber explosion"—a term typically defined as a sudden outburst of energy with destructive shattering of a vessel or structure. However, this characterization appears to have been inaccurate.
According to the NBDHMT, the fire was likely contained within the chamber, though hot gases may have escaped through a compromised door seal. This scenario suggests a relatively low "fuel burden", that is, the amount of combustible material (fuel burden) was not significant to cause a chamber explosion.
This 2025 event contrasts with a 1996 monoplace chamber fire that did result in an actual explosion and structural failure. That tragic event claimed the lives of the patient and his wife, who was standing near the chamber door, and injured two hospital staff members. In that case, the heightened fuel burden - several blankets and heavy personal clothing, including a winter jacket - was identified as a contributing factor.
Safety Stops, Checklists… When to Document
Hyperbaric medicine is a procedure-driven specialty, and safety should begin before the chamber door closes. In 2014, the UHMS Safety Committee issued a position statement recommending the use of a Safety Time Out/Pause (STOP) prior to the start of every hyperbaric treatment. For the safety of patients and staff, we strongly encourage documentation of a STOP verifying the “Right Patient, Right Treatment and Right Safety.”
- A STOP should be completed regardless of multiplace or monoplace operations.
- A STOP will be performed in order to be compliant with safety goals, to combat complacency, and document completion of our unique safety practices.
- We recommend that the STOP be modeled after the timeouts performed before surgical procedures.
In addition to verifying two patient identifiers and having the patient sign a procedure consent form, the STOP checklist should include:
- Checking the patient ground (monoplace)
- Ensuring all prohibited items are removed from the chamber (both monoplace and multiplace)
- Confirming the treatment profile and staffing plan
- Completing and signing a STOP checklist by two staff members prior to closing the chamber.
For details refer to blog post "Safety stops, checklists… when to document".
Documentation and the Role of Pre-Checklists
The UHMS Safety Committee position statement provides a structured approach to pre-treatment procedures. This UHMS statement was long overdue and should be taken one step further to include pre-hyperbaric treatment checklists. Pre-treatment checklists have been employed for many years and include inspection and confirmation that Prohibited Items have been removed from the patient’s possession prior to initiation of the treatment. Elements of the Safety Stop should be included in all pre-treatment checklists.
Research published in NEJM Catalyst (“Smart lists for Patients: The Next Frontier for Engagement?”) supports the use of customized checklists to enhance safety, coordination, and patient education. As Latif et al. note, checklists clarify who needs to act, what actions must be taken, and when those actions should occur.
The question becomes, at what point is the inspection and verification of NO Prohibited Items documented? Are you inspecting the patient, verifying, initiating descent and then documenting? If so, then utilizing a “STOP” prior to the initiation of treatment (descent) should be implemented and utilized to ensure all pre-treatment safety checks are appropriately completed.
Moving Forward with Vigilance and Compassion
This tragedy serves as a sobering reminder that safety in hyperbaric medicine must never be assumed - it must be practiced, documented, and regularly reviewed. As a community, we must remain committed to upholding the highest standards of care, for the safety of our patients, our teams, and the families who place their trust in us.
Resources
References
- The UHMS Safety Committee UHMS Blog, accessed 10-26-2018: http://uhmsblog.wordpress.com/2014/07/31
- The Joint Commission, Standards, National Patient Safety Goal, Universal Protocol, accessed 4-12-2014 http://www.jointcommission.org/standards_information/up.aspx
- NEJM Catalyst, Smart lists for Patients: The Next Frontier for Engagement, accessed 10-26-18: https://catalyst.nejm.org/patient-centered-checklists-next-frontier
- FDA.gov: https://www.fda.gov/consumers/consumer-updates/hyperbaric-oxygen-therapy-get-facts?utm_medium=email&utm_source=govdelivery
About the Authors
Jeff Mize, RRT, CHT, UHMSADS
With over four decades of healthcare experience, Jeff currently holds the position of Principal Partner at Midwest Hyperbaric LLC and the Co-founder and Chief Clinical Officer of Wound Reference.
Jeff has excelled in critical care throughout his career, devoting almost a decade as a Flight Respiratory Therapist/Paramedic for the Spirit of Kansas City Life Flight. In 1993, Jeff transitioned into the field of Hyperbaric Medicine and Wound Care, where he committed 21 years of his career to serving as the Program Director for a 24/7 Level 1 UHMS Accredited facility with Distinction. In this role, he continued to provide patient care while overseeing all administrative, clinical, and daily operations within the Wound Care and Hyperbaric Facility.
Jeff is a Registered Respiratory Therapist and a Certified Hyperbaric Technologist (CHT). He has also undergone training as a UHMS Safety Director and a UHMS Facility Accreditation Surveyor.
Jeff currently serves as a member of the UHMS Accreditation Council, the UHMS Accreditation Forum Expert Panel, and the UHMS Safety Committee. Additionally, he is an esteemed member of the NFPA 99 Hyperbaric and Hypobaric Facilities Technical Standards Committee.
Jeff's dedication to the field has earned him numerous prestigious awards. In 2010, he received the Gurnee Award, which honored his outstanding contributions to undersea and hyperbaric medicine. Three years later, in 2013, he was awarded the Paul C. Baker Award for his commitment to Hyperbaric Oxygen Safety Excellence. Most recently, in 2020, Jeff was honored with "The Associates Distinguished Service Award (UHMSADS)," a recognition reserved for exceptional Associate members of the Society who have demonstrated exceptional professionalism and contributions deserving of the highest accolades.
