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Undersea and Hyperbaric Medicine Section Newsletter - March 2009, Vol 16, #1

Undersea and Hyperbaric Medicine

circle_arrow Message from the Chair
circle_arrow Editorial - Carbon Monoxide Poisoning Treatment Protocols: 1 vs. 3?
circle_arrow Case Report—An Interesting Episode of Decompression Illness
circle_arrow Lack of Awareness of Hyperbaric Medicine in the Medical Community
circle_arrow Journal Watch – March 2009


Newsletter Index


Hyperbaric Medicine Section

Message from the Chair

Christopher J. Logue, MD

Finally, we have our first newsletter of the year for you to peruse. The section leadership has been very active behind the scenes despite the tardiness of our first on-line publication. 

As an update, the section meeting at the Scientific Assembly last fall in Chicago was well attended, productive and exciting. Margaret Montgomery (our section liaison) has included the minutes from the meeting in this edition of the newsletter. We would like to send out a special thanks to Dr. Sorabh Khandelwal (our immediate past-chair and councilor) and the folks at the Ohio State University Comprehensive Wound Care Center for providing the wonderful lunch buffet. We were also privileged to have Dr. Keith Van Meter from LSU present recent research findings relating to the use of adjunctive hyperbaric oxygen in the resuscitation of selected critical care patients in the emergency department. 

We are moving forward with some very exciting projects that will be organized and run by ACEP Undersea and Hyperbaric Medicine Section Members. 

Introducing the 1st Annual Comprehensive Board Review Course for Physicians in Undersea and Hyperbaric Medicine.

Save the date: Friday, August 21st – Sunday, August 23rd, at The University of Pennsylvania School of Medicine in Philadelphia, PA 

The course staff is set and will include faculty members (all ACEP Section Members) from three of the ACGME accredited fellowship training programs from around the country. Faculty members will be coming from the Undersea and Hyperbaric Medicine Programs at the University of Pennsylvania, Louisiana State University, the University of California at San Diego and the Ohio State University. 

The course will be an intense, high yield 2.5 day "immersion" in Diving and Hyperbaric Medicine Topics that will appear on the board exam. A mock exam will be given on the final day along with a tour of the multiplace hyperbaric chamber facilities at the University of Pennsylvania. 

Registration will begin within the next several weeks, however, anyone interested in getting on the short-list now should email me at cjologue@yahoo.com

Also, those of you who would like more information about registering to take the board exam (especially through the training plus practice pathway) go to the following ABEM website: 

http://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-US/tabID__3408/DesktopDefault.aspx

Do not hesitate to contact me if you have any other questions about the application process for board certification. 

ACEP Undersea and Hyperbaric Section Members to have an "unofficial" meeting at the UHMS 2009 Annual Scientific Meeting in Cabo, Mexico (June 25th-27th).

At the section meeting in Chicago, we discussed the idea of having a "Winter Symposium" for our members. Since several of our colleagues already run similar programs to desirable diving locations around the globe, we decided that it would be more beneficial to incorporate a meeting of our members with the annual scientific meeting of the UHMS instead. Many of our members will be attending this meeting anyway and it would also be a great way to increase awareness of the section and recruit new members. 

The meeting is tentatively scheduled for Friday, June 26th from 6:30-7:30pm. Mark it on your calendar!! Here is the website for the UHMS Annual Scientific Meeting: 

http://www.uhms.org/MeetingsEvents/2009AnnualScientificMeeting/tabid/217/Default.aspx

By the way, here are the links to Dive Medicine Education Programs in exotic locations!!! 

Underwater Medicine Associates (Fred Bove)

65th DAN Diving and Hyperbaric Medicine Course (DAN)

Medicine of Diving (Paul Sheffield)

Winter Symposium on Hyperbaric Medicine and Wound Management (James Holm and Takkin Lo)

If any section members know of other "educational" opportunities that involve exotic dive destinations let us know!!

Council of Fellowships in Undersea and Hyperbaric Medicine (CO FUHM’s)

Recently, fellowship directors from several of the ACGME accredited programs held a conference call to discuss the future of formal fellowship training in Undersea and Hyperbaric Medicine. The decision was made to form a Council of Fellowships that would function similar to CORD (the Council of Residency Directors in Emergency Medicine). 

The council would function to promote continuous improvements in the education and training of fellows in the subspecialty and promote basic science and clinical research in Diving and hyperbaric medicine. Also, the council would function as a support system for active fellowships as they navigate the periodic RRC review process. 

Another important task that the council will take-on is encouraging and supporting the formation of new fellowship programs across the country. We have already targeted several programs that are on the cusp of forming formal ACGME accredited fellowships. 

If you are interested in learning more about the CO FUHM’s please do not hesitate to contact me at cjologue@yahoo.com or Tracy Legros (Chair elect) at tlegros1@cox.net

More information will follow in the next newsletter. 

I hope this edition of the Undersea and Hyperbaric Medicine Section newsletter finds you in good health and spirits. 

Safe Diving Always!! 


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Editorial - Carbon Monoxide Poisoning Treatment Protocols: 1 vs. 3?

Matthew S. Partrick, MD

When this time of year comes around, the hyperbaric physicians of the world begin to lose sleep (literally and figuratively) over one thing: CO poisoning. Something that has always been a question in my mind: Is there a difference in outcome between one versus three hyperbaric oxygen treatments for these patients? I suspect Dr. Weaver’s paper in New Engl J Med 2002 had a lot to do with legitimizing treatment of carbon monoxide exposure in the rest of the medical community’s eyes, and yet even within our own group there does not appear to be a consensus in how exactly to interpret treatment protocol (or who exactly meets treatment guidelines, but I will save that discussion for another newsletter.) 

It seems obvious from a logistic standpoint why we may all be interested in only one treatment, but what are the pros and cons of the options? Are there clinical or biochemical benefits that we may not realize to performing three treatments? One benefit for three treatments is the ability to follow the patient’s clinical status over a 24-30 hour period. One may be able to see an improvement in neurologic examination if any deficit were present prior to treatment. In addition, if the patient were placed in outpatient observation status in the emergency department, one would be able to follow serial cardiac biomarkers over that period. This of course wouldn’t be available in a "one and done" situation. The logistic hassle involved in three treatments is a negative on choosing this treatment protocol; however, as it stands right now there is very limited data on benefits of one versus three treatments. 

Different treatment centers across the country appear to be interpreting the Weaver protocol in significantly different ways; some make a concerted effort to complete three dives while other centers are shooting for "one and done." I performed an informal poll of some of the larger centers across the country treating CO patients: Penn, Duke, Hennepin County, UCSD, LSU, Utah/Intermountain, Virginia Mason, Jacobi, and Baltimore Shock Trauma. The results were 6 to 3 in favor of one treatment, with some caveats. The most common reason given for not completing three dives was problems with logistics, i.e. getting the patient to the chamber. After speaking with several experts across the country it was evident that this issue is even muddier than it was five or six years ago; thankfully Dr. Weaver is currently undertaking a randomized control trial of one versus three treatments, with one arm getting one treatment followed by two sham treatments and the other arm getting three normal treatments. I look forward to the results of this trial in the near future as I am sure you all are as well. Questions, comments, rants and raves are welcome to this column which will be posted in the next newsletter. 


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Case Report—An Interesting Episode of Decompression Illness

Matthew S. Partrick, MD

This is a 38 year old male with a past medical history of mitral valve prolapse who presented to the hyperbaric medicine service after an episode of pain and rash after commercial diving. He has been diving commercially for the past 11 years around the Southeastern Pennsylvania area and works to repair and inspect various structures in the surrounding rivers. He has a history of experiencing DCI 6 years ago in which he had symptoms of left shoulder and elbow pain as well as left arm numbness acutely after resurfacing. At that time he was treated with HBO2 at the Hospital of the University of Pennsylvania and underwent a US Navy Treatment Table 6 with one extension at 2.8 ATA, during which his symptoms resolved. He denied any side effects from HBO2 therapy. 

He had been working to salvage a sunken barge in the Delaware River near the Walt Whitman Bridge for the past 4 weeks. His duties have included cutting up the barge with a torch, inspecting the underlying structures, and moving heavy equipment and machinery which he states has been more strenuous than normal, especially on the day prior to presentation when he was moving an anchor chain. He has been diving once a day Monday through Friday in hard hat and suit with surface supplied air by umbilical line in water of maximum depth of 38 feet of fresh water for up to 200 minutes, as planned by (pre 2008 revision) US Navy Diving Manual. All dives have been accompanied by a colleague. 

One week prior to presentation after surfacing he initially noticed an itchy rash developing on his torso and back, and also transient blurry vision. A few hours later he experienced bilateral shoulder pain which was 2/10 on the pain scale. His symptoms gradually improved and resolved a few days later. One day prior to presentation after resurfacing at 1550 hours he began to develop symptoms similar to the episode one week prior. The rash appeared duskier in appearance and occurred within an hour of surfacing. His bilateral shoulder pain began within approximately 2 hours of surfacing and progressed to a maximum pain level of 3/10. His blurry vision resolved with a few minutes. He did not take any analgesic or other medication overnight and on the day of presentation he still experienced mild bilateral shoulder pain which was 2/10. The rash was still present however upon presentation. His physical exam including vital signs was otherwise unremarkable. Of note, the patient’s chest roentgenogram, electrocardiogram, basic metabolic profile and complete blood count were normal. Attached is a photograph demonstrating the rash. 

0309decompressionrash

Based on history and physical examination, the patient was diagnosed with decompression illness as manifested by bilateral shoulder girdle pain and pruritic rash consistent with cutis marmorata. The patient was again treated with USN TT6 protocol and noted improvement in shoulder girdle discomfort and appearance of rash after compression was achieved. He was placed on high dose NSAIDS and discharged home following an uneventful treatment. He returned the next day for further evaluation. At that time, his rash had almost totally resolved and his joint pain was almost nonexistent. 

Prior to discharge from our care, a further evaluation of the event was undertaken to determine whether or not it was expected versus unexpected. The patient did not exceed no decompression limits based on pre-2008 USN Diving Manual shallow tables however did exceed the newly revised tables. He also endorsed greater than usual physical exertion during the dive in question. Therefore the current incident is technically an expected event. Based on the history of an unevaluated similar incident one week prior to presentation and previously diagnosed and treated DCI event in 2001we considered anomalous pathophysiologic conditions predisposing this patient to DCI. Furthermore, although the transient visual blurring was likely coincidental and unrelated, it may represent ocular "migraine" that in turn raises concern for previously undiagnosed patent foramen ovale (PFO) or other cardiac septal defect. Therefore, we ordered exercise pulmonary function testing and transthoracic echocardiogram with bubble study to evaluate for presence of PFO. The PFTs were normal; however TTE demonstrated presence of bubbles crossing the atrial septum during Valsalva maneuver consistent with PFO. 

Was the presence of PFO placing this patient at risk of decompression illness? The literature does demonstrate an increased risk of decompression illness in patients with PFO, however the prevalence of recreational divers with PFO can never be known; does this create a serious problem for recreational divers in general? It became much more of a serious issue in this patient due to his livelihood being tied to commercial diving. After discussion with Dr. Fredrick Bove at Temple University, it was his professional opinion that the symptoms consistent with ocular migraine were probably unrelated and that this patient’s symptoms of decompression illness represented strictly right-sided circulation manifestations. The risk of catheter-based closure of PFO in his opinion outweighed the benefits of reducing risk of left-sided circulation DCI. The risk of closure device dislodgement and embolism are as high as 20% in some reported case series, and in Dr. Bove’s opinion do not warrant closure in this patient. Whether or not his diving company will accept this as a reasonable evaluation remains to be seen. In any case, the patient will be referred for transesophageal echocardiogram to confirm the diagnosis of PFO and further delineate the anatomy.  


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Lack of Awareness of Hyperbaric Medicine in the Medical Community

Christopher J. Logue, MD

In 2006, we performed an on-line survey of medical professionals at the Hospital of the University of Pennsylvania in Philadelphia, PA. This also happens to be the location of the regions largest referral center for Hyperbaric Oxygen Therapy. 

The survey was designed to be educational with two parts. Part one included demographic questions about the person taking the survey including; specialty and subspecialty of medicine practiced, year of completion of medical training. We also asked if the respondent was aware of whom they should contact if they wanted to refer a patient for hyperbaric oxygen therapy, whether or not the person has ever referred a patient for hyperbaric oxygen treatment, and whether or not the person is aware that board certification through ABMS is available and recommended in the US. In addition, part one included a list of 26 medical conditions of which the respondents were asked to identify the approved indications for hyperbaric oxygen therapy as described by the Undersea and Hyperbaric Medicine Society (UHMS). Included in this list were the 13 approved indications. 

Once the respondent completed part one, they were taken to part two of the survey by their web browser. Part two provided the correct answers to the survey along with brief descriptions of the rationale and medical literature supporting the use of hyperbaric oxygen therapy for the approved indications. In addition, part two included three final questions: 

  1. Do you have/see any patients that have indications for the use of hyperbaric oxygen therapy in your practice?
  2. Would you consider the use of hyperbaric oxygen therapy as part of your practice in the future?
  3. Would you be interested in learning more about hyperbaric oxygen therapy? 

Respondents could then contact our facility by phone or email for more information or to set up an in-service or grand rounds. 

Here is the link to the survey instrument so you can see it yourself. It is not set up at this time to collect data.  

http://www.uphs.upenn.edu/ifem/ins/page1.html

The results were fascinating. There were 262 respondents. 69% of respondents did not know who to contact if they wanted to refer a patient for hyperbaric oxygen therapy. 34% correctly identified that board certification was available, 62% did not know and 4% did not agree.  

Here is the breakdown of respondents by specialty.  

0309specialtychart

All other specialties and subspecialties had less than 5 respondents.

The following represents the percentage of respondents that correctly identified the 13 approved indications for hyperbaric oxygen therapy.

0309-appr-ox-therapies

The following is the percentage of respondents who incorrectly identified other indications for hyperbaric oxygen therapy that are not approved by the UHMS.

0309-unapp-ox-therapies

Of the 232 respondents that completed part two of the survey, 59% say they see patients that have indications for the use of hyperbaric oxygen therapy. 81% said they would consider the use of hyperbaric oxygen therapy in the future and 68% stated they wound be interested in learning more about hyperbaric oxygen therapy.

After implementing the survey, we saw an increase in referrals to our center and were asked to give more educational talks to other departments at our large hospital.

It is clear that there exists a dramatic lack of awareness of our subspecialty in the medical community as a whole. Improved awareness along with continued excellence in education and research should remain primary goals of the leaders and members of our subspecialty.


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Journal Watch – March 2009

Journal Watch – March 2009

Reviewer: Christopher J. Logue, MD

Bell GS, Gaitatzis A, Bell CL, et al. Drowning in people with epilepsy: how great is the risk? Neurology. 2008;71(8):578-82.

So, this is a large meta-analysis of 51 cohorts of people with epilepsy taken from the WHO statistical databases and from the UK Office for National Statistics. Using these databases, estimates of number of deaths by drowning and person-years at risk for drowning were estimated. The combined data provided 206,596 patient-years of follow-up. There were 88 deaths by drowning in people with epilepsy as compared to an expected 4.70 deaths in a normal general population. This gives an SMR (standardized mortality ratio) of 18.7. The SMR for people with epilepsy in England and Wales was 15.3.

The final conclusion is that the risk of drowning in people with epilepsy is 15-19 fold higher than the general population.

This is useful data to solidify the notion that folks with epilepsy should never be medically cleared for SCUBA diving as the risks for drowning are not acceptable. The question remains open, however, for someone who has had a history of seizure disorder but has been seizure free without medications for 5 or more years.

______________

Reviewer: Matthew S. Partrick, MD

Chong KT, Hampson NB, Corman JM. Early hyperbaric oxygen therapy improves outcome for radiation-induced hemorrhagic cystitis. Urology. 2005;65(4):649-653.

This is a paper from the departments of Urology and Hyperbaric Medicine at Virginia Mason Medical Center in Seattle, Washington. Their objective was to "assess the clinical factors that affect the efficacy of hyperbaric oxygen therapy in treatment of radiation-induced hemorrhagic cystitis." Methods included a retrospective review of all radiation cystitis patients presenting to their service from May 1988 to December 2001. All patients received HBO2 therapy of 100% 02 at 2.36 ATA for 90 minutes per treatment. Follow up was assessed after at least 12 months. The group evaluated patient demographics, types of pelvic malignancy, radiation dose, type of radiation, onset and severity of symptoms such as hematuria and presence or absence of prior invasive treatment such as intravesical management. Clinical improvement was a priori defined as absence of or reduction in clinically significant hematuria.

A total of sixty patients were found in their database, 55 men and 5 women, with a mean age of 70. This group received an average number of 33 HBO2 treatments. 48 of these patients (80%) had either partial or total resolution of hematuria. Of note, the authors found that when hyperbaric oxygen treatment began within six months of the onset of hematuria, 96% of the patient have complete or partial improvement in hematuria with a p value of <0.003%. 100% of patients with history of previous clot retention (11 total) improved or resolved if treated within six months (p <0.007). Also of note, history of intravesical instillation of alum or formalin did not affect outcome measures. In their study population, 14 patients had a history of clot retention and were treated after six months of onset of symptoms. Only 50% of these patients responded similarly well (p<0.007). In addition, their study population showed a trend toward better outcomes in younger patients. Lastly, the modality of pelvic radiation did not affect response rates.

The authors state that limitations of their study include "lack of data on the frequency and severity of every hematuria episode that occurred both before and after hyperbaric oxygen therapy." In addition there was no objective evaluation of affectation of quality of life for these patients before and after treatment. The most interesting finding of this paper seems to be the positive correlation between patients having significantly better outcomes if hyperbaric oxygen therapy is initiated within six months of onset of clinically significant hematuria. This is important for us as hyperbaric physicians because we now have evidence to present to our urologic colleagues that early referral is crucial in these situations to give the most likely odds for improvement in these typically difficult cases.

 


 

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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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