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Undersea and Hyperbaric Medicine Section Newsletter - September 2009, Vol 16, #3

Hyperbaric Medicine

circle_arrow Undersea and Hyperbaric Medicine Section Meeting at Scientific Assembly
circle_arrow Message from the Chair
circle_arrow Case Report
circle_arrow 2008 Annual Meeting Minutes

Newsletter Index


Hyperbaric Medicine Section

Undersea and Hyperbaric Medicine Section Meeting at Scientific Assembly


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Make plans to attend the Undersea and Hyperbaric Medicine Section Meeting!

Wednesday, October 7, 2009

10:00 am – 12:00 pm

Room 252B, Convention Center

Come join your colleagues to discuss the issues most pertinent to hyperbaric medicine.

Be sure to check the schedule on-site as meeting times and location could change.


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Message from the Chair

Christopher J. Logue, MD

I hope everyone is excited about the upcoming ACEP Scientific Assembly in Boston, October 5th – 8th. There has been a lot of action since the last newsletter….so here are some updates.

The Undersea and Hyperbaric Medicine Board Review Course for Physicians was a huge success!!!!

We had 53 attendees at our first ever Board Review Course for Physicians in Undersea and Hyperbaric Medicine which was held at the University of Pennsylvania from August 21st – 23rd. We received a lot of positive feedback from the attendees (we will see if the feedback remains positive come exam time).

Many thanks go out to the ACEP Undersea and Hyperbaric Medicine Section members who participated as faculty including:

  • Marc A. Hare, MD
  • Sorabh Khandelwal, MD
  • Emi Latham. MD, FACEP
  • Tracy Legros, MD, PhD, FACEP
  • Heather Murphy-Lavoie, MD
  • Alan Wyatt, MD

Since the course was a success, we are making plans for the 2nd Annual version for next year…for those of you who still need to take the exam prior to the closing of the "grandfather" period.

The Formation of the Council of Fellowships in Undersea and Hyperbaric Medicine (CO FUHM’s) is progressing!!!

Thanks to the efforts of our own Ian Grover, we have begun the process of forming the Council of Fellowships in UHM. The council is being formed as an extension of CORD (The Council of Residency Directors in Emergency Medicine) since fellowship programs can become associate members of CORD. CORD will allow us to have our own "SharePoint" website for sharing of academic and administrative information. We will have an email list-serve and an on-line practice "test question" bank that can be used to assess the knowledge of fellows in training in UHM.

Of course, current fellowship programs are encouraged to join, but also programs that are in the process of forming fellowships can become members too! The primary purpose of the council is to facilitate collaboration between fellowship programs and continuously improve the formal training and education process for physicians in the sub-specialty of Undersea and Hyperbaric Medicine. The Council will also be instrumental in helping new fellowship programs come "on line" and to help existing programs navigate the accreditation review process.

In addition, CORD will allow non-emergency medicine fellowship programs (ie, Preventative Medicine Programs) to join the Council as long as they are willing to accept Emergency Medicine Residency Trained candidates.

We are very excited about the progress and will discuss the Council further at the Section Meeting in Boston!!

The ACEP Undersea and Hyperbaric Medicine Section Meeting at the Scientific Assembly

Our section meeting is scheduled for Wednesday, October 7th from 10:00am – 12:00 noon in Room 252B of the Boston Convention and Exhibit Center.

I would like to once again thank Sorabh Khandelwal, MD and the folks at the Ohio State University Comprehensive Wound Care Center for providing box lunches that will be available at the meeting.

In addition, I am excited to announce the speakers and topic for our educational meeting!


Into the Sea for Science:

Research Diving through the Years at Woods Hole Oceanographic Institute

Terry Rioux, Diving Safety Officer
&
Maggie Rioux, Research Diver and Systems Librarian


I look forward to seeing many of you there!!!


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Case Report

Christopher J. Logue, MD

Mr. KM is a 30 year-old right handed male who is a PADI Advanced Openwater Diver who is currently working on his Divemaster certification. He has completed 125-150 dive in his career and was SCUBA diving 14 miles off the Jersey Shore with family members from a personal boat on a shipwreck. The water temperature on the bottom was 55 degrees Fahrenheit, he was using a drysuit with appropriate thermal undergarments, breathing 25% Nitrox and using a Nitrox dive computer during his dives. The first dive was to a depth of 100 FSW for 33 min followed by a surface interval of 93 min prior to his second dive to a depth of 98 FSW for 31 min.

There were no reported problems during either dive. He did not report any difficulty equalizing his middle ear pressures, there were no equipment problems and he and his buddy reported normal ascents including safety stops associated with each dive and there were no reported uncontrolled ascents. His dive computer did, however, register rapid ascent warnings for both dives, but his dive buddy’s computer (different manufacturer) did not register any warnings. A review of his dive computer’s log revealed that it was set appropriately for a Nitrox breathing mix of 25% and although he did not exceed the decompression limits, he was in the "caution zone" very close to requiring decompression stops.

He surfaced from his final dive at 11:06 am and climbed onto the boat with no difficulties. However, about 15 minutes following the dive he began to notice a change in his hearing including muffled hearing and a sensation "like listening to a seashell". This was followed by gradual onset of severe vertigo and a markedly unsteady gait. He also reported gradually worsening profound generalized weakness and dizziness. Family members reported that he looked "pale and weak". Oxygen was administered on the boat with only minimal improvement in symptoms until it ran out. Upon reaching the dock, family members called the Diver’s Alert Network (DAN) who recommended that he be taken to the nearest hospital for evaluation. He was evaluated in the emergency department where he had several bouts of emesis along with weakness and a profoundly unsteady gait. After receiving IV fluids and 100% oxygen by non-rebreather he began to improve, but he still could not ambulate without falling to his left.

He was transferred to our facility and was evaluated by the Hyperbaric Medicine Service. His past medical history was significant for a moderate-severe concussion from an MVC about one year ago with no persistent symptoms. He had an ORIF of the right wrist in the past. He is a social drinker and did have 3-4 beers on the night before the dive. He denies use of tobacco or illicit drugs.

Upon initial evaluation his vitals were 135/67, 52, 22, 97.8 with O2 sat of 100% by NRB. He had no nystagmus and his cranial nerves were intact with the exception of deficits involving CN #8. He had normal bilateral sensation and motor strength. He had difficulty standing with a markedly + Romberg sign with circling and falling to the left. He was unable to walk without assistance, had a wide-based gait and was lurching to the left. He had questionable slight slowing of his finger-to-nose cerebellar testing on the left. He reported "muffled" hearing bilaterally that was more pronounced on the left. His tympanic membranes were normal without evidence of middle ear barotrauma.

He had an elevated WBC count at 16.1 and was hemoconcentrated with an Hct = 44.6% His CXR and CT head were unremarkable. His EKG demonstrated sinus bradycardia with an early repolarization pattern and he reports having a low resting heart rate due to his excellent cardiovascular conditioning.

His differential diagnosis included both inner-ear DCI and inner-ear barotrauma. So, the decision was made to proceed with a trial of hyperbaric oxygen therapy utilizing a USN TT#6 along with continued administration of IVF’s.

During his first treatment he had dramatic but incomplete improvement in his symptoms. Following the treatment he could walk without assistance and his gait was only slightly wide-based and ataxic with some leaning to the left. The muffled hearing was now well localized to the left ear but improved somewhat.

He was admitted to the hospital and completed a total of four hyperbaric oxygen treatments with stepwise gradual improvement to a plateau. During his in-patient stay he had formal evaluations by neurology and ENT. He had an MRI of the brain, a screening echocardiogram for a patent foramen ovale and an audiology exam. His MRI showed possible slight increased flair signal intensity in the left insula, anterior lentiform nucleus and corticospinal tract in the posterior limb of the internal capsule. This was of unknown significance and did not correlate with his deficits on exam. His echocardiogram was negative for a PFO. His audiogram is shown here.

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His presumed diagnosis was inner-ear DCI given the clinical scenario (a provocative decompression stress, no history of difficulty with middle ear equalization or forceful valsalva and no evidence of middle ear barotrauma). His symptoms also improved (and did not worsen) with hyperbaric oxygen therapy. However, inner-ear barotrauma could not be definitively ruled-out without surgical exploration.

By recent phone conversation, he reports that his symptoms have since resolved and he is scheduled for a repeat audiogram and ENT evaluation in the near future. Then he will return to our clinic for a medical assessment of his fitness to return to diving.

What do you think? What are your thoughts on the issue of his returning to diving?


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2008 Annual Meeting Minutes

American College of Emergency Physicians
Scientific Assembly
McCormick Place-Lakeside Center
Tuesday October 28, 2008
Chicago, IL

Minutes

Participants

Section members participating included: Christopher J Logue, MD, chair; Sorabh Khandelwal MD, Immediate past chair; John Alexander, MD, FACEP; David Mark Charash, DO, FACEP; Dennis G Cochrane, MD, FACEP; James H Creel, Jr, MD, FACEP; Sol S Edelstein, MD, FACEP; Frederick W Fiesseler, MD, FACEP; Juliusz Jakubaszko, MD; Eric J. Lavonas, MD, FACEP; Steven D Mehaffey, MD, FACEP; Robert E Rosenthal, MD, FACEP; Harry W Severance, MD, FACEP, Robert Sherwin MD; Christian A Tomaszewski, MD, FACEP; and Keith W Van Meter, MD, FACEP

Others participating included: David C. Seaberg, MD, FACEP, Board Liaison; and Margaret Montgomery, RN, MSN, Staff Liaison.

Agenda

  1. Welcome and Introductions
  2. Educational presentation
  3. Business Meeting
  4. Operational Guidelines
  5. Nomination of New Officers

Major Points Discussed

  1. Dr. Logue welcomed the attendees to the meeting and introductions were made. Dr. Seaberg, Board Liaison briefly addressed those attending. Dr. Logue asked if anyone had heard of additional issues with reimbursement from Blue Cross Blue Shield for hyperbaric treatments for carbon monoxide poisoning. It was mentioned that this had been a problem in Tennessee but this was overturned. Georgia was mentioned as another state that had raised the issue. It was recommended that the section e-list be utilized to solicit information about the scope of the problem.
     
  2. Dr. Van Meter presented the education component of the meeting. The title of the presentation "The Potential for Hyperbaric Oxygen to be an Important Adjunct Therapy for Resuscitation of Select Patients in the Emergency Department." Handouts were provided for the lecture.
     
  3. Dr. Logue then initiated the business portion of the meeting. The minutes from the section meeting last year were reviewed and approved. It was announced that the section now has 128 members.
     
    Dr. Logue discussed efforts to put together a Winter Symposium for those interested in an educational meeting that would include diving. It was suggested that working with others that are also planning a hyperbaric specific CME program may be beneficial.
     
    It was announced that the ACGME Monitoring Committee accepted the request to delay any recommendation regarding the accreditation authority for Undersea and Hyperbaric Medicine until July 1, 2010. The limited number of physicians boarded in hyperbaric medicine, limited slots and training programs were identified as limiting factors. It was also pointed out that there was some talk about preventive medicine no longer supporting certification in hyperbaric medicine. Development of a board review course was mentioned. Many agreed that there is a lack of awareness of the specialty and that it would be beneficial to all to have additional involvement of fellowship programs in the section.
     
    Dr. Logue provided information to the section about a survey he conducted within a three hospital system about the use of hyperbaric and the lack of awareness of the medical staff of the indications for its use. Dr. Logue plans to publish the results of the study.
     
    Dr. Logue proposed that the section sponsor a contest for underwater photography for display at a future Scientific Assembly. Meeting participants were in favor of sponsoring a contest.
     
    Dr. Khandelwal reported that there were no council resolutions that were specific to the Hyperbaric Medicine Section.
     
    Ohio State University Comprehensive Wound Center and Dr. Khandlewal were thanked for providing sponsorship for the luncheon buffet.
     
  4. The draft operational guidelines including the option to vote by email were provided to the section members for review. The operational guidelines were approved by the members present.
     
  5. New officer nominations were made and the following members will serve in the following positions  

  Chair Christopher J Logue, MD
  Chair-elect Tracy L. LeGros MD, PhD, FACEP
  Past Chair Sorabh Khandelwal MD
  Secretary/Newsletter Editor Edward Choi, MD
Matthew S. Partrick, MD
  Councillor Sorabh Khandelwal MD

With no further business the meeting was adjourned.


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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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