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Undersea and Hyperbaric Medicine Section Newsletter - June 2009, Vol. 16 #2

Hyperbaric Medicine

circle_arrow Message From The Chair
circle_arrow Nuts and Bolts of ACGME Application for UHM Fellowship Accreditation
circle_arrow How to Apply for Board Certification in Undersea and Hyperbaric Medicine
circle_arrow Journal Watch
circle_arrow Case Report

Newsletter Index

Hyperbaric Medicine Section

 

 

Message From The Chair

Christopher J. Logue, MD 

Greetings from your section officers and administrative staff at the ACEP Undersea and Hyperbaric Medicine Section! We have a lot of activity to report so we will go ahead and "Dive" right in. 

"Unofficial" ACEP Undersea and Hyperbaric Section Meeting at the Annual UHMS Scientific Meeting:

The UHMS has graciously provided an official location and meeting time for us at the Annual Scientific Meeting in Las Vegas, June 25-27th. We will be meeting in the Sapphire 1 room of the Planet Hollywood Resort and Casino on Friday, June 26th from 6:30pm-7:30pm. We have opened the meeting to anyone interested in an effort to promote awareness of our section (encourage new members) and supplement discussions. Topics will include (but are not limited to):

  1. Improving collaboration between ACEP and UHMS
  2. The establishment of a Council of Fellowships in Undersea and Hyperbaric Medicine
  3. Surveillance for problems with insurance denials of reimbursement for hyperbaric oxygen treatments among members

You can still register for the meeting and we encourage your attendance. The Annual Scientific Meeting offers you a chance to meet and mingle with professionals interested in Undersea and Hyperbaric Medicine from across the globe. Here is the link to more information about the meeting. You can register from the website. http://www.regonline.com/builder/site/Default.aspx?eventid=637984

July 1st:  Post-mark Deadline for Applying to take the Sub-Specialty Board Exam in Undersea and Hyperbaric Medicine:

Have you been practicing Hyperbaric Medicine (at least part-time) for two years or more? Not Board Certified in Undersea and Hyperbaric Medicine yet? Well, now is your chance! The deadline (post-marked) for applications to take the board exam through ABPM or ABEM is July 1. Here is the link to information about the UHM exam through ABPM:

https://www.theabpm.org/uhm.cfm

And here is the link for information about the UHM exam through ABEM: 

http://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-US/tabID__3359/DesktopDefault.aspx 

We know the exam is tough!  That is why we have gone to the trouble of organizing…. 

A Comprehensive Undersea and Hyperbaric Medicine Board Review Course for Physicians August 21-23rd 

This comprehensive 2.5 day course will be held at the University of Pennsylvania in Philadelphia. We have seven instructors coming from across the country and representing three of the Emergency Medicine ACGME accredited fellowship training programs. All of the instructors are members of the ACEP Undersea and Hyperbaric Medicine Section and all are board certified. 

The course will include a mock exam on the final day and faculty "office hours" each night to provide individualized help on difficult topics. 

Thanks to the section members participating as instructors in the course!!! 

Marc Hare, MD
Assistant Clinical Professor
University of California – San Diego
Medical Director
Center for Wound Healing and Hyperbaric Medicine
San Diego, CA

Emi Latham, MD
Assistant Clinical Professor of Medicine
University of California – San Diego
San Diego, CA 

Tracy Legros, MD
Assistant Professor
Section of Emergency Medicine
Assistant Professor
Department of Surgery
Tulane Medical Center
Associate Program Director
Undersea and Hyperbaric Medicine Fellowship
Attending Hyperbaric Medicine Physician
West Jefferson Medical Center
New Orleans, LA  

Christopher Logue, MD
Clinical Instructor/Health Systems Clinician
University of Pennsylvania School of Medicine
Emergency Department Attending Physician/Hyperbaric
Medicine Attending Physician
Emergency Department at Penn Presbyterian Medical
Institute for Environmental Medicine
Hospital of the University of Pennsylvania
Philadelphia, PA 

Sorabh Khandelwal, MD
Clinical Associate Professor
Ohio State University
Director Hyperbaric Medicine
Columbus, Oh

Heather Murphy-Lavoie, MD
Assistant Professor
LSU School of Medicine
New Orleans, LA 

H. Alan Wyatt, MD
Clinical Instructor of Medicine
Louisiana State University Health Sciences Center
Associate Medical Director
Department of Hyperbaric Medicine
West Jefferson Medical Center
Marrero, LA 

16.0 hours of AMA PRA category 1 CME credit will be offered. The course is jointly sponsored by the Diver’s Alert Network (DAN) with co-sponsorship by UHMS. Application has been made to the American College of Emergency Physicians for ACEP Category I credit. The fee will be $995 for physicians and $695 for fellows. Here is the link for the course and you can register right from the website! https://cme.med.upenn.edu/eventinfo_3191.html

Please, do not hesitate to contact me with any questions and we look forward to seeing you either at the Annual UHMS Meeting later this month, the Board Review Course in August and/or at the ACEP SA Meeting in Boston this fall!!  

Safe Diving!! 


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Nuts and Bolts of ACGME Application for UHM Fellowship Accreditation

Heather Murphy-Lavoie, MD

In October 2008, the ACGME indicated they may cease to accredit fellowships in Undersea and Hyperbaric Medicine if we fail to show growth and interest in this relatively new specialty. The future of our specialty depends on getting as many centers as possible to apply for ACGME accreditation before 2010. Even if all of the new programs are not approved, it will show we have the potential for growth and interest. As most of you are aware, the practice track for board certification is closing soon and if we don't have fellowship accreditation, this could be the beginning of the end of our specialty. Please help us to stimulate growth in our specialty by establishing a fellowship program and applying for ACGME accreditation. 

The first step to applying for ACGME application is to review the program requirements for undersea and hyperbaric medicine fellowships at: 

www.acgme.org/acWebsite/downloads/RRC_progReq/398pr202_u704.pdf

Step two is to determine whether you should apply under preventive medicine or emergency medicine. Those programs associated with an emergency medicine residency should apply through the RRC for Emergency Medicine. All other programs should apply through the RRC for Preventive Medicine. 

Download New Programs PIF(program information file) under preventive medicine: www.acgme.org/acWebsite/RRC_380/380_pifIndex.asp

Download New Program PIF under emergency medicine: www.acgme.org/acWebsite/RRC_110/110_pifIndex.asp

Fill out the PIF and meet with the Graduate Medical Education coordinator for your institution to review and fine tune the application with you. 

Review the seven steps to accreditation at: www.acgme.org/acWebsite/home/accreditation_application_process.asp

Best of luck and please feel free to contact me if I can be of any assistance in this process!

Heather Murphy-Lavoie, MD
Assistant Residency Director
Emergency Medicine Residency
Associate Program Director
Hyperbaric Medicine Fellowship
LSU School of Medicine/MCLNO
New Orleans, LA
hmurph@lsuhsc.edu  


 

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How to Apply for Board Certification in Undersea and Hyperbaric Medicine

Edward Choi, MD 

The medical specialty board certification overseen by the American Board of Medical Specialties (ABMS) allows the physician to demonstrate his dedication in providing exceptional patient care and maintaining the highest possible standards for healthcare. Since the American Board of Preventive Medicine (ABPM) received certification approval from ABMS in 1989, physicians who specialized in Undersea and Hyperbaric Medicine (UHM) have used this certification to exhibit their commitment to such standards to the patient and the medical community. As of this year, 126 physicians were certified through American Board of Emergency Medicine (ABEM) while 267 physicians were certified through ABPM. 

UHM certification may be applied either through ABEM (www.abem.org) or ABPM (www.theabpm.org). Physicians must submit an application to the board through which they obtained their primary certification.  Physicians certified by an ABMS member board other than ABEM or ABPM and who fulfill the eligibility criteria must apply to ABPM.  There are three pathways for the certification examination in UHM: two fellowship pathways (Accredited and non-accredited) and the training plus practice pathway. Eligibility criteria, application and additional specific documents required for each board can be found at either aforementioned board websites. 

In order to take the UHM certification examination this year, the application must be postmarked by June 30, 2009 and be sent to either ABEM or ABPM. The examination for this year will be administered in Pearson VUE computer testing centers in the United States and Canada from October 5 through 16, 2009. Currently all three pathways are eligible to take the certification examination. However, the non-accredited fellowship pathway and the training plus practice pathway applications will close on July 1, 2010. 

There are two review courses offered this year to prepare the physician for the UHM certification examination and provide CME credits. International ATMO offers a one day 9 hour review course on August 27, 2009 held at TradeWinds Island Grande Resort in St. Pete Beach, Florida as a pre-course meeting to the UHMS Gulf Coast Chapter Meeting. (www.regonline.com/custImages/243791/2009/2009%20UHM%20Review%20Brochure.pdf 

The Division of Hyperbaric Medicine of the Institute for Environmental Medicine from the Hospital of the University of Pennsylvania offers a more comprehensive two-and-one-half day review course from August 21 to August 23, 2009 held at the University of Pennsylvania in Philadelphia, Pennsylvania. (cme.med.upenn.edu/eventinfo_3191.html 


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Journal Watch

Reviewer: Edward Choi, MD

Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005219 

This is a review from the Cochrane Collaboration which tries to assess the safety and effectiveness of hyperbaric oxygen therapy (HBOT) and normobaric oxygen therapy (NBOT) in treating and preventing migraine and cluster headaches. The selection criteria included randomized trials comparing HBOT or NBOT with one another, other active therapies, placebo (sham) interventions or no treatment in patients with migraine or cluster headache. The authors attempted to collect both published and unpublished trials by using several databases such as CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM and the reference lists from relevant articles. Relevant journals were hand searched and researchers contacted to identify the relevant trials. In addition three reviewers independently evaluated the study quality and extracted data.  

The authors were able to identify nine small trials involving 201 participants were included. Five trials compared HBOT versus sham therapy for acute migraine, two compared HBOT to sham therapy for cluster headache and two evaluated NBOT for cluster headache. Pooling of data from three trials suggested that HBOT was effective in relieving migraine headaches compared to sham therapy (relative risk (RR) 5.97, 95% confidence interval (CI) 1.46 to 24.38, P = 0.01). There was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting or reduce the requirement for rescue medication. There was a trend to better outcome in a single trial evaluating HBOT for the termination of cluster headache (RR 11.38, 95% CI 0.77 to 167.85, P = 0.08), but this trial had low power. NBOT was effective in terminating cluster headache compared to sham in a single small study (RR 7.88, 95% CI 1.13 to 54.66, P = 0.04), but not superior to ergotamine administration in another small trial (RR 1.17, 95% CI 0.94 to 1.46, P = 0.16). Seventy-six percent of patients responded to NBOT in these two trials. No serious adverse effects of HBOT or NBOT were reported. 

The authors make several conclusions. Although there is some evidence that HBOT may effectively terminate migraine headache in a general population who suffer from migraines, the practicality involved in delivery of therapy suggest that HBOT should be reserved for those patient resistant to standard pharmacological therapies. They do not recommend HBOT as a routine or prophylactic therapy. In addition, there is weak evidence from randomized trials to establish the effects of HBOT on cluster headache as a treatment for an acute episode or as a prophylaxis against future clusters. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. 

_______________________

Reviewer: Christopher Logue, MD 

Denoble PJ, Caruso JL, Dear G, et al. Common causes of open-circuit recreational diving fatalities.  Undersea Hyperb Med. 2008;35(6):393-406. 

This is an extensive and comprehensive review of 947 recreational diving fatalities in the US and Canada between 1992 and 2003.  The data (each diving fatality) was analyzed using a sequential analysis paradigm.  Each case was analyzed according to the following sequence of events; a trigger (the earliest identifiable event indicating a problem on the dive) followed by a disabling agent (an untoward behavior or circumstance associated with the trigger) which lead to a disabling injury which may or may not be the final cause of death. The Pareto Principle was used which states that the majority of poor outcomes are associated with a few common causes. 

The results demonstrated the most frequent triggers were (in order); running out of gas (41%), entrapment (20%), equipment problems (15%), rough water (10%), followed by buoyancy trouble and inappropriate gas.  The most frequent disabling agents were; emergency ascent (55%), running out of gas (27%), buoyancy trouble (13%), followed by inappropriate gas, equipment problems and entrapment.  The most frequent disabling injuries were; asphyxia (33%), AGE (29%), cardiac incidents (26%), followed by trauma, DCS, unexplained LOC and inappropriate gas.  

A regression analysis was performed to attempt to correlate triggers and disabling agents with the most common disabling injuries by odds ratio.  The following events or factors were associated with elevated odds ratios for asphyxia; entrapment (OR>30), insufficient gas (15.9), buoyancy and equipment trouble (4.5), using a drysuit (4.1) and female diver (2.1).  Emergency ascent was associated with an OR>30 for the development of an AGE.  The presence of CVD (OR>10.5) or age > 40 years (OR=5.9) were associated with cardiac incidents as a disabling injury.  Rough water (OR=2.6) was associated with traumatic injuries.  Diving deeper than 180 FSW (OR>30), diving alone (OR=17.2) and emergency ascent with omitted decompression (OR=16) were associated with DCS as a disabling injury.  Diabetes (OR=12) was associated with unexplained LOC. 

The authors conclude that the Pareto Principle is applicable to diving fatalities.  Using this principle, training agencies could focus efforts on improving the training of divers in specific areas to reduce incidents caused by the most frequent triggers and disabling agents like running out of gas, emergency ascents to the surface and buoyancy trouble.  Interestingly, negative buoyancy was far more frequent of a trigger/disabling agent than positive buoyancy.  Also, it was interesting to see cardiac incidents as the 3rd most common of the disabling injuries and causes of death in diving fatalities.  In many of those fatalities, the diver was experiencing worrisome symptoms prior to the dive including SOB, chest pain and not feeling well.  The results of the article have implications on diver training and issues related to fitness for diving. 


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Case Report

Edward Choi, MD

A 52 year old female with a past medical history of asthma presents to the emergency department with loss of consciousness upon surfacing from a SCUBA dive. She was diving 30 miles off the coast of New Jersey where the conditions of the dive site included strong currents and a water temperature of 48 degrees Fahrenheit at the bottom. She was breathing Nitrox (28% O2) and equipped herself with a dive computer and drysuit. The first dive started at 9:06 am and consisted of max depth 121 feet below sea level with average dive depth of 72 feet for 35 minutes. She was able to make her safety stop during the first ascent and had a surface interval time of 165 min between dives. The second dive started at 12:18 pm and consisted of a maximum depth of 119 feet below sea level with an average dive depth of 89 feet for 25 min. During the ascent from her second dive, the patient felt tired and had difficulty in the strong current which prevented her from safely reaching the surface through a slow controlled ascent. She became inverted and pockets of expanding air developed in the feet of her drysuit which caused her to float feet-first towards the surface. Following her sudden ascent she passed out and was found in the water in front of the boat. Her diving partners brought the patient back onto the boat and administered oxygen which helped the patient regain consciousness. She states that her regulator was dislodged from her mouth during her period of time at the surface.  The coast guard was called for medical assistance and she was flown by helicopter from the scene to Atlantic City where she was once again air-transported to the nearest hospital with a hyperbaric chamber capable of treating emergencies. Prior to this incident, she has been diving for the past 14 years and denied any previous diving incidents or complications. She last dived one year ago.  

In the emergency department, she was alert, oriented and denied any complaints. Patient was mildly tachypenic with mild bilateral basilar rales and rhonchi on physical examination and had pulse oximetry (POx) of 90% on room air. Subsequently she was placed on Venturi mask with 100% oxygen which improved her POx. Otherwise her physical exam was unremarkable. Her electrocardiogram, basic metabolic profile and complete blood count were normal. Her CT head which showed sinus changes consistent with mild sinus barotrauma. In addition, her CT chest without contrast was abnormal showing bilateral moderate to severe patchy groundglass airspace opacities which suggested aspiration pneumonitis with no evidence of pulmonary barotrauma (no pneumothorax or mediastinal emphysema). Attached is an image from her CT chest.

 

pic_1.jpg   pic_2.jpg
  

Based on her history of syncope during her uncontrolled ascent she underwent U.S. Navy Treatment Table 6 for presumed arterial gas embolism. She tolerated the hyperbaric treatment well however her respiratory symptoms did not improve. She was subsequently admitted to the medical service for observation. Throughout her hospital course she only received supplemental oxygen and noted gradual mild improvement in her respiratory symptoms. She was discharged from the hospital on day number 3 with pulmonary follow up within one week.

The pulmonary symptoms and subsequent CT findings in this case may be explained from two distinct pathophysiologic mechanisms. From the history, she noted that her regulator was dislodged upon surfacing raising the possibility of sea water aspiration either during ascent or at the surface. Aspiration of fluid into the lung disrupts the alveolar-capillary membranes and washes out the surfactant lining the alveoli. Exudation of protein –rich fluid into the alveoli then occurs leading to alveolar collapse and atelectasis. Decreased lung compliance leads to ventilation/perfusion mismatching leading to hypoxia. In addition, since she had a past medical history of asthma, introduction of an irritant, in this case seawater into her lung may have triggered an inflammatory response contributing to her respiratory distress. 

Pulmonary barotrauma (PBT) also may cause alveolar exudate formation. PBT results from the inability of the diver to allow expanding gas within the lungs to escape during ascent. From Boyle’s law, the greatest change in volume occurs at shallow depth which the patient has experienced through her rapid uncontrolled ascent. Distention of the alveoli disrupts the alveolar-capillary membrane leading to exudates to escape into the alveoli. Overdistention leads to alveolar rupture which may introduce extra-alveolar air resulting in pneumothorax, mediastinum or arterial gas embolism.  Since, she did not have any notable extra-alveolar gas on CT imaging studies, this could have been a mild episode of PBT with alveolar exudate formation without alveolar rupture. 

What is your assessment? 

Can she return to diving? If so, when? 


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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