CO: It’s Not Just About the Gas

  • Joseph C. White, MD
  • Volume 08 - Issue 1

The Hyperbaric Oxygen Therapy Unit at John T. Mather Memorial Hospital in Port Jefferson, NY, is one of the few units still providing 24/7 care. It has effectively dealt with many dramatic situations. To illustrate the ongoing issues surrounding carbon monoxide (CO) as well as the global issues it raises, I present here a case of CO poisoning the unit encountered.

Six people with potential CO poisoning were transported to the Mather Hospital emergency room (ER) and its 24/7 hyperbaric unit. A power outage had been reported secondary to weather conditions, so the victims had borrowed a generator from a friend. They were aware of the potential dangers of CO, so to mitigate the issue, they left open the windows in the house but made the mistake of putting the generator in the basement.

Despite their precautions, one victim was awoken when she heard her husband moaning in his sleep. Immediately upon waking, she had a tremendous headache and  realized the problem could be CO. She had difficulty arousing her husband but was finally able to get him up. He also had a tremendous headache as well as dizziness and confusion. She was also able to wake her two children, two other family members in different areas of the house, and call 911.

The victims were transported on 100% oxygen to the ER, where three adults had levels between 20 and 28, the children (ages 5 and 10) had levels of 9 and 12, while the fourth adult had a level of 11.

After evaluation, three of the four adults were offered hyperbaric oxygen (HBO) treatment on Dr. Lindell Weaver’s protocol. The fourth adult, who had the level of 11, had a significant heart issue with an ejection fraction of 20% and had been on a life vest. Our hyperbaric cardiologist’s evaluation recommended he not be put into the chamber but to remain on 100% oxygen. One child refused to stay in the chamber.

All patients were doing better after treatment, but they declined completion of the Weaver protocol.

I will discuss a few of the issues this case of CO highlights.

First, no matter how you try to mitigate it, machinery that can produce CO, a generator in this case, should not operate in an inhabited space. It is difficult to track the path of air currents throughout the space, and the locations of the victims during the intoxication can cause a significant variation in both CO levels as well as resultant symptoms.

These patients actually knew CO could cause harm and left all the windows open, believing it would prevent the problem. Consider what the results might have been if they had closed the fresh-air source.

A second point is the need for CO detectors. Despite all the information about CO, there are still many homes and other inhabited spaces, including work areas, that go without detectors. Our patients had detectors but had removed them and placed them in the moving van on the driveway since they were relocating in a few days. Continued education and legal requirements remain the mainstays of evoking the change needed for CO monitoring.

An issue we have experienced is the resistance of patients to accept a three-course HBO treatment protocol despite a maximal educational effort by the HBO staff, focusing on the possible long-term sequelae CO may cause.

Those reading this magazine are probably already woefully aware of the issue regarding the availability of acute hyperbaric access as discussed in this case and raised in the article “Emergency and Critical Care Hyperbaric Medicine in the United States” by Enoch Huang, MD, in the Fall 2016 issue of WCHM. Thankfully, 22 years ago our hospital agreed to establish a hyperbaric program, which has served our community with 24/7 coverage since its inception.


There has been a massive exodus of 24/7 hyperbaric units in the country for various reasons, but I would postulate a lot of it is directly related to the cost of maintaining a unit, staffing and lack of appropriate insurance reimbursement. There is, in my opinion, an absolute need for access to immediate HBOT for certain medical issues such as dive injuries, gas gangrene, certain CO accidents, some necrotizing infections and some acute ischemic perfusions cases. If the exodus continues, there will be even less opportunity to treat these patients.

If indeed there is a difference between levels of hyperbaric unit care (levels 1–3), cost is probably the overwhelming factor leading to closure of 24/7 units, and then the payers should reimburse on standards based on these levels. Perhaps if this occurred, it would encourage centers to remain available, and others who are considering initiating a program may opt into a more encompassing level of service.

The constant battle that occurs between providers and payers continually grows. Part of the responsibility, in my opinion, belongs to the hyperbaric community. There have been many hyperbaric treatments and reports of units that will treat disease processes not amenable to hyperbaric treatments and bill erroneous codes. This can lead to such scrutiny that it becomes very difficult to get payment for appropriate HBO care.

I am sorry to say that after 22 years and more than 35,000 treatments, even our unit is struggling with the concept of changing to a 9-to-5 outpatient radiation and wound-care only facility. That will leave our county without any HBO 24/7 unit, and any acute HBO case will now have to travel about 20-50 miles to get to one. In other areas of the country, patients need to travel hundreds of miles, which in many cases can lead to no access to HBO treatments.

The hyperbaric medical communities have been championing the need to keep these important centers and chambers viable, but it is a relatively small community of providers. Until there is a strong medical, patient and politically supported movement to halt the loss, we will soon cease to exist in any meaningful quantity. Some will argue we are there already.

I strongly encourage everyone to bring this issue to the forefront to those who can help ensure the viability of hyperbaric medicine in our country.

About the Author


JOSEPH C. WHITE, MD, is director and cofounder of the Hyperbaric Medicine Unit at John T. Mather Memorial Hospital in Port Jefferson, NY. A graduate of the Georgetown School of Medicine, he has been practicing hyperbaric medicine since 1994. He is UHMS board certified and is board certified and a Fellow in the American Academy of Family Physicians (AAFP), practicing family practice for more than 30 years. He oversees a three-chamber monoplace unit at Mather Memorial and was involved in assisting with dive and identification operations during the 1996 TWA Flight 800 incident in New York. He coauthored an article related to thermal decompression stresses in heated dive suits from that operation.


Protecting Patient Privacy

  • Darren Mazza EMT, CHT
  • Volume 08 - Issue 1

While trying to provide good patient care, the clinical environment can be chaotic at times due to time constraints. Many patients treated in the hyperbaric department are also treated in the wound center, requiring collaborative efforts between both departments.

With the Health Insurance Portability and Accountability Act of 1996 (HIPAA), providing patient privacy is not only the law but is also sometimes difficult to ensure in the monoplace environment. Although my department has two patient-changing rooms and several privacy curtains, including a curtain between both chambers, patients occasionally pass each other when either coming from the changing room, to and from the bathroom, or entering or leaving the department. Occasionally, patients will speak to each other in passing and will share both their medical and treatment information with one another.

Hyperbaric patients receive daily treatments, and because  of this we, as certified hyperbaric technologists (CHTs), spend a great deal of time with them. We develop a comfort zone and a friendship with each patient. This is good because sometimes patients seek comfort from those they trust. We value and respect each patient’s right to privacy. I want patients to have trust and confidence not only in my competencies relating to the job but also that they can depend on me to protect their privacy during their treatments.

On one occasion, the biomedical tech came into the chamber room to speak with me regarding a problem with one of the chambers, but I was prepping a patient for treatment. The biomed tech attempted to come through the privacy curtain, but I quickly stopped him. Although a patient seems amiable with other staff members coming in, it’s not OK.

On another occasion, an employee from another department in the hospital came in to speak with me, and the patient was clearly uncomfortable. So I now make every effort to obtain patient permission before introducing them to another staff member. I myself have been hospitalized and can recall how compromised I felt. As a patient, you tend to feel at the mercy of those around you. Having to wear a hospital gown makes one feel compromised and vulnerable. It’s absolutely crucial for the CHT to recognize when this occurs and to do everything possible to prevent it through protecting the patient’s privacy.

Take home message: Stay vigilant in your efforts to ensure patient privacy at all times. A good CHT first needs to be a good patient-care provider, one who makes it a priority to protect and maintain patient privacy.

About the Author

DARREN MAZZA has been the CHT and safety director at the Center for Wound Healing and Hyperbarics at Swedish Edmonds in Washington since 2008. He began his health-care career working as both an EMT and an emergency room preceptor in Sacramento, California. In 2005, he moved his family to Idaho, where he was department head of the hospital’s outpatient wound-care and hyperbaric center. With more than 28 years in health care, he has been able to apply his past to his current role in the hyperbaric industry, making him a more responsible CHT and safety director.




Textbook of Chronic Wound Care: Chapter 1

  • Herbert B. Slade MD, FAAAAI, and Jamie M. Slade, MD.
  • Volume 08 - Issue 1

Textbook of Chronic Wound Care: An Evidence-Based Approach to Diagnosis and Treatment by Drs. Jayesh Shah, Paul Sheffield, and Caroline Fife, editors, is a companion reference book for the Wound Care Certification Study Guide, 2nd edition. Due for publication by Best Publishing Company in the first quarter of 2017, this textbook provides the best diagnostic and management information for chronic wound care in conjunction with evidence-based clinical pathways illustrated by case studies and more than 350 pictures. The textbook provides up-to-date information for the challenging chronic wound care problems in an easy-to-understand format. What follows is a reprinted excerpt from Chapter 1, Anatomy of the Skin, written by Herbert B. Slade MD, FAAAAI, and Jamie M. Slade, MD.



Skin is an integumentary system at the interface between the human organism and its environment (Table 1). The boundary limits of skin are found at its transition to mucosal surfaces of the respiratory, alimentary, and urogenital systems; at the conjunctival epithelium of the eye; at the ductal epithelium of the lacrimal and mammary ducts; and at the tympanic membrane of the ear.

Anatomically, skin is organized into an outer layer of epidermis covering a deeper layer of dermis, which is further subdivided into papillary dermis and reticular dermis. The epidermal epithelium gives rise during fetal development to the skin appendages, namely the hair follicles and associated sebaceous glands (pilosebaceous units), eccrine and apocrine sweat glands, and nails. Beneath the dermis is the hypodermis or subcutaneous fat layer (the panniculus adiposus). Connections between skin and its underlying hypodermis include ligaments, nerves, blood vessels, and lymphatic vessels.

The gross appearance of skin varies between individuals, within an individual by anatomic location at any point in time, and within an individual over a lifetime. Variation is found with respect to texture, tone, distribution and amount of pigmentation, and expression of hair. For example, scrotal skin is very thin, with readily visible hair roots, specialized sebaceous glands, and few or no elastic fibers but consider- ably greater laxity compared with skin covering the trunk. By contrast, the glabrous skin of the palms and soles is tightly fixed to the underlying fascia, lacks hair follicles and sebaceous glands, and contains sweat pores opening into ostia located along prominent friction ridges. The epidermis is considerably thicker.

The overall thickness of skin across the body is determined by the thickness of the several layers of epidermis and the thickness of the underlying dermis. Typical thickness in a young adult ranges from the eyelids (epidermis ~50 µm, dermis ~1,000 µm) to the back (epidermis~40 µm, dermis ~5,000 µm), to the palms of the hands (epidermis ~600 µm).(1-2) The thickness of the outermost cornified layer (the stratum corneum) is greatest in areas of callous but also varies among flexor forearm, thigh, back and abdomen across a range of ~13µm (flexor forearm) to ~8µm (abdomen).(3) Published values for these measurements differ considerably, likely as a result of differences in location of sampling, methods of visualization, and methods of preservation in the case of biopsy material. (4-5) 

The structure of the skin (Figure 1) is established through the orchestrated arrival, arrangement, and differentiation of a broad array of cell lineages during embryogenesis and fetal development.(6) When it is fully developed, approximately 20 different types of cells are found in association with a complex extracellular matrix that provides both strength and flexibility(7) (Table 2). 

I. Epidermis

Full keratinization of the outermost keratinocytes is achieved prior to birth, by gestational weeks 26-28. The epidermis at birth is still relatively thin with only 2-3 cell layers in the stratum spinosum and 5-6 layers in the stratum corneum.(8) The thick whitish “vernix caseosa” covering the epidermis at birth is a product of the sebaceous glands combined with shed periderm and squames. A mixture of water, proteins, antimicrobial enzymes and lipids, the vernix is thought to provide a degree of protection against maceration while the skin is exposed to amniotic fluid, while allowing the skin to hydrate itself more rapidly following birth.(9) Removal of the vernix at birth leaves the stratum corneum drier than adult skin for some time.

Four distinct epidermal layers persist into adult life, with a basal germinative layer resting upon a basement membrane elaborated through cooperative effort between the basal keratinocytes and the underlying mesodermal fibroblasts. A fifth layer of cells can be found beneath friction ridges on the palms of the hand and soles of the feet, between the granular and horny layers. Fully developed epidermis is thus a stratified squamous arrangement consisting of a basal layer of stem and transit-amplifying cells,(10-11) above which are the spinous, granular, clear, and horny layers. The corresponding Latin descriptive terms – stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum – remain in use. The integrity of epidermis is maintained by various connections between cells and at the basal layer, with the basement membrane. Basal cells use hemidesmosomes, integrins, and anchoring fibrils to maintain contact with the basement membrane, while desmosomes, gap junctions, and adherens junctions keep them connected with each other and with cells of the spinous layer. Desmosome, gap junctions, and adherens junctions persist in the spinous layer, while in the granular layer the gap junctions give way to tight junctions. Adherens junctions and desmosomes persist in the granular layer, while in the stratum corneum the predominant connections are corneodesmosomes and tight junctions. Although epidermis is commonly thought of in terms of a “bricks and mortar” organization, cells other than keratinocytes make their way into the epidermis, some of them sending dendritic extensions between the keratinocytes (melanocytes, Langerhans cells) or crawling into and through the epidermis to perform immunologic surveillance.

TABLE 1. Functions of the integumentary system
Function Major structure(s) or cells
Waterproofing Stratum corneum
Protection against minor trauma Stratum corneum
Prevent entry of toxins Stratum corneum
Moisture balance Epidermis
Vitamin D, hormone production Keratinocytes
Prevention of invasion by pathogens Epidermis, dermis, lymphatics
Regeneration Basal epithelium, hair follicles, blood vessels
UV radiation protection Melanocytes
Physical cushioning Dermis, subcutaneous fat
Insulation Hair, subcutaneous fat, arrector pili muscles
Temperature regulation Vasculature, sweat glands, motor nerves
Sensation Sensory nerves
Immunity Dendritic cells, lymphocytes, lymphatic channels

Melanocytes have a remarkably different shape compared with resting keratinocytes, with long extensions termed “dendrites” passing between and around their keratinocyte neighbors. These cells take up residence in the stratum basale and in the hair bulb. Within the stratum basale, the ratio of melanocytes to basal keratinocytes is approximately 1:10, with each melanocyte associating with 30-40 keratinocytes above the basal layer through dendritic extensions.(12) An essential role of melanocytes is to protect the basal cells from ultraviolet radiation, accomplished through the production and transfer of melanin via melanosomes. The darkness of skin pigmentation does not depend on the number of melanocytes, which is constant across all skin tones, but rather on the extent to which melanin is produced and the size of the melanosomes, which serve as transport vehicles from the melanocytes to the keratinocytes.

Epidermal Langerhans cells are found in the epidermis, replicating there to replace dying cells and cells which have migrated to the draining lymph nodes. There does not appear to be any need for replenishment from the circulation, although circulating monocytes can enter the skin and differentiate into scavenging and antigen presenting dendritic cells.

II. Dermis

Development of the dermis is largely controlled by fibroblasts. Each of the embryonic fibroblast precursor lines is thought to split into distinct lineages, giving rise to “upper lineage” fibroblasts, which include fibroblasts of the papillary dermis, the hair follicle dermal papilla, dermal sheath cells surrounding hair shafts, and the arrector pili muscle. It also includes “lower lineage” reticular fibroblasts, pre-adipocytes, and adipocytes. Cells of the lower lineage are primarily involved in replacement of extracellular matrix following wounding, while cells of the upper lineage sup- port repithelialization.(13) The depth of injury determines the types of cells, which become engaged in repair, with lacerations extending into the middle depth of reticular dermis leading to a scarring response. Lacerations of the superficial dermis can repair themselves without visible scarring.(14) In addition to depth of injury, the amount of tension experienced by fibroblasts and the duration of inflammation also affect scarring. Primary closure of lacerations reduces tension, while control of infection limits inflammation, resulting in reduced scarring.

Hair follicles are widely distributed in skin. Epidermal cells form the primitive hair germ, penetrating as a column into the underlying dermis. An invagination or papilla is formed at the column tip into which mesodermal blood vessels and nerve endings develop. Fibroblasts within this dermal papilla seem to induce the follicular epithelial cells in the center of the follicle to undergo differentiation into central cortex cells, which generate the keratinized hair shafts. The dermal papilla and surrounding epithelial matrix cells constitute the bulb of the hair follicle. The hair shaft itself eventually consists of a medullary core, surrounded by the cortex and hair shaft cuticle.(15)

Along the upper portion of the hair follicle, superficial to what will become the upper cutaneous plexus of blood and lymphatic vessels, one or more small out buddings of the epithelial follicular sheath develop into the dermal sebaceous glands. These glands generate a lipid-rich material (sebum) that rises to the skin surface alongside the hair shaft, lubricating the skin and occluding the shaft. Deeper along the hair follicle below the forming vascular plexus, mesodermal cells give rise to smooth muscle fibers which develop into the arrector pili muscles.(16) These muscle fibers are anchored to the follicle at the “bulge region” of the outer root sheath and superficially to connective tissue beneath the basement membrane, such that a sebaceous gland is often located between the muscle and the hair follicle. Activation of these muscles results in the hairs becoming more vertical and a small amount of sebum being expressed from the glands between the shaft and muscle.


TABLE 2. Cells found in healthy adult skin
Name Location Function Subsets
Keratinocyte Epidermis Regeneration of the stratum corneum, re-epithelialization of denuded skin, acidification of the skin surface, antimicrobial peptide production, inflammatory signaling. Terminally differentiated keratinocyte providing a physical and chemical barrier Basal, transit amplifying granular, corneocyte
Fibroblast Dermis Generation of extracellular matrix, repair Papillary, reticular, myofibroblast
Melanocyte Basal layer of epidermis, hair follicle bulb Protection against ultraviolet radiation, hair coloration ---
Merkel cell Epidermis at dermal-epidermal boundary, upper portion of hair follicle Touch sensation through connection with nerve endings in Touch Domes ---
Endothelial cell Blood vessel lining, lymphatic vessel lining Vascular channels Blood vascular, lymphatic vascular
Pericyte Abluminal basement membrane of endothelial cells Support endothelial cells, participate in angiogenesis ---
Neuronal axons Nerves Sensory and motor nervous functions Based on neurotransmitters, end structures, efferent or afferent function
Schwann cell Surrounding neuronal axons Create myelin sheaths to insulate nerves ---
Endoneural cell Surrounding Schwann cells Protect and support Schwann cells ---
Perineurial cell Surrounding endoneural cells Create nerve fascicles ---
Myocytes Smooth muscles Express the contents of glands, cause "goosebumps" and hair erection, modulate blood flow Arrector pili, vascular smooth muscle, glandular smooth muscle
Mast cell Near blood vessels Innate immune defense, immune modulation, wound healing, angiogenesis ---
Macrophage Near blood vessels Immune surveillance, cell killing, phagocytosis of cell debris M1, M2
Dendritic cell Epidermis and dermis Immune surveillance Langerhans cells, conventional dendritic cells, plasmacytoid dendritic cells
Lymphocyte Epidermis and dermis Immune survieillance, cell killing, regulation of adaptive immune responses Memory CD4+, memory CD8+, γδ-T cell, invariant αβ-NKT, variant αβ-NKT, anergic CD4+, Tr1 T-regulatory, Th3 T-regulatory 
Adipocyte Hypodermis Energy storage (triglycerides), thermal insulation, modulation of inflammation (adipokines) Pre-adipocytes, adipocytes
Stem cell Hypodermis, basal epithelium, hair follicle "bulge region" Regeneration of various cell lines Keratinocyte stem cells, mesenchymal stem cells, skin-derived precursor cells


Along the upper portion of the hair follicle, superficial to what will become the upper cutaneous plexus of blood and lymphatic vessels, one or more small out buddings of the epithelial follicular sheath develop into the dermal sebaceous glands. These glands generate a lipid-rich material (sebum) that rises to the skin surface alongside the hair shaft, lubricating the skin and occluding the shaft. Deeper along the hair follicle below the forming vascular plexus, mesodermal cells give rise to smooth muscle fibers which develop into the arrector pili muscles.(16) These muscle fibers are anchored to the follicle at the “bulge region” of the outer root sheath and superficially to connective tissue beneath the basement membrane, such that a sebaceous gland is often located between the muscle and the hair follicle. Activation of these muscles results in the hairs becoming more vertical and a small amount of sebum being expressed from the glands between the shaft and muscle.

A single hair follicle with its associated sebaceous gland(s), arrector pili muscle, and papilla is termed a pilosebaceous unit. Arrector pili muscles may attach to several adjacent fol- licles within a follicular unit consisting of 2-6 follicles. Pilosebaceous units serve as reservoirs of Langerhans cells. They are normally absent from the glabrous skin of the palms and soles. Pilosebaceous units differ between the scalp and beard region (terminal units), the axilla and groin (apopilosebaceous units), the face, back, and chest (sebaceous units), and the remainder of the skin (vellus units). Vellus hair follicles extend to the upper or middle reticular dermis, while terminal hair follicles and surrounding dermis protrude down through the interface with the hypodermis.

Eccrine sweat glands (“true” sweat glands) develop over most parts of the skin, beginning in a similar manner to hair follicles with an extension of germinative epidermal cells down into the developing dermis. The coiled secre- tory gland is located at or below the level of the hair follicle bulb, with a relatively straight dermal portion of duct becoming a spiraled duct as it passes through the epidermis (the acrocyringium).

Apocrine sweat glands develop normally as a third bud from hair follicles, superficial to the sebaceous glands. These are notably present in the axilla and pubic regions, areola and nipple of the breast, eyelids, and circumanal region. With the exception of the modified apocrine glands forming the ciliary glands in the eye- lids and the ceruminous glands in the auditory canal, these specialized structures do not begin development until puberty. Other distinguishing features are that the secreted product of apocrine glands normally exit the skin from the hair follicle and includes remnants of the secretory vesicles which are released from the glandular cells. The milk-producing mammary glands are modified apocrine glands. Myoepithelial cells arising from the basal layer of the glands provide a smooth muscle shroud that can squeeze the contents of the gland out through the duct.(17)

Multipotential hematopoietic stem cells arising from the fetal liver and bone marrow give rise to mast cell committed progenitors, which interact with fibroblasts in their environment to determine their differentiation into connective tissue mast cells which are found associated with blood vessels, nerves, and skin appendages of the subpapillary dermis.(18)

III. Dermal-epidermal junction

The boundary separating the epidermis from the dermis is marked by a basement membrane, occupied along its superior border by basal keratinocytes, which bind to basement membrane anchoring filaments. On the inferior aspect of the basement membrane are anchoring fibrils attaching into the extracellular matrix of the papillary dermis. Including the anchoring elements, the “basement membrane zone” is typically described as having four layers:

  • A basal keratinocyte hemidesmosome layer
  • The lamina lucida
  • The lamina densa
  • A lamina reticularis (or fibroreticularis)

The epidermis extends into the papillary dermis at regular intervals to form rete pegs, thus increasing the amount of contact between epidermis and dermis. The rete pegs deepen following term birth. On the palms and soles, the dermal-epidermal boundary forms extended ridges and troughs termed friction ridges, most prominently visible at the fingertips (fingerprints).(19)

IV. Hypodermis and Dermal

The loose connective tissue beneath the dermis is termed the hypodermis or subcutaneous layer. A prominent feature of this layer is adipocytes (fat cells) organized into prominent lobules separated by fibrous septa containing the blood and lymphatic vessels. Fibroblasts, macrophages, mast cells, and mesenchymal stem cells are also found in the hypodermis. A thin layer of smooth muscle termed the tunica dartos scroti (male) and tunica dartos labia majora (female) is found within the subcutaneous fascia of the genital region, where it will contract in response to cold temperatures to tighten and wrinkle the skin. Muscle fibers are also found in reticular dermis adjacent to the nipple, in the penis, and perineum. Immediately beneath the hypodermis is a more densely fibrous deep fascia. Human skin attaches to underlying skeletal muscle groups indirectly via small fibrous bands termed skin ligaments (retinacular ligaments), extending through the hypodermis to connect the deep reticular dermis with the underlying fascia.(20) Although widely distributed, the skin ligaments are not uniform across the body. In the upper trunk, limbs, head, and neck, the ligaments provide a close association with underlying muscles. Elsewhere, such as the abdominal region and buttocks, attachments are less dense. In particular regions these ligamentous structures are prominent, as with Cooper’s suspensory ligaments in the breast. Various degrees of tethering create greater or lesser limits to the movement of skin over the underlying fascial planes.

The depth of sharp debridement can be gauged by key differences in the appearance of these distinctive layers. Bleeding occurs at the papillary dermis and deeper, white collagen bundles are prominent in the reticular dermis, yellow bundles of adipocytes mark the hypodermis, while fascial planes, ligaments, and muscle fibers indicate the lower boundary of the skin.

V. Vascularization

The epidermis contains no blood vessels (Figure 2). Nutrients arrive by diffusion from capillaries in the papillary dermis, while oxygen arrives both by diffusion through tissue and by direct uptake from the atmosphere. It is currently estimated that atmospheric oxygen penetrates to a depth of 250 – 400 mm, which includes the full epidermis and much of the papillary dermis.(21) Atmospheric oxygen flux through skin decreases when more skin capillaries open up, but shutting off capillary flow results in only a small increase in oxygen flux directly from the atmosphere.(22) Thus a lack of vascular perfusion cannot be overcome by direct diffusion except under hyperbaric conditions.


Protective Footwear

  • Anna M. Tan, Michael B. Strauss, Lientra Q. Lu
  • Volume 08 - Issue 1

Protective footwear is the second line of defense after skin and toenail care for prevention of new and recurrent wounds (Figure 1).1,2 Any patient who has one or more of the conditions recognized as risk factors for wound development — such as deformity, peripheral vascular disease, history of a previous wound, previous amputation and/or neuropathy — and is ambulatory requires intelligent decision-making for the selection of protective footwear. This line of defense is so important that in 1993, Medicare (Center for Medicare/ Medicaid Services) under the direction of Congress, initiated the “Therapeutic Shoe Bill” benefit for diabetic Medicare beneficiaries with risk factors for wounds. Undoubtedly this decision was based on the assumption that the potential benefits to prevent diabetic foot problems outweighed the costs to provide protective footwear.3,4 Essentially, it is less expensive to prevent a diabetic foot problem from arising by providing therapeutic footwear than it is to treat the complications that arise from not using appropriate footwear. In recognition of this, benefits for protective footwear for diabetic patients were established and will be delineated later in this article.

FIGURE 1. Appropriate footwear selection is the second line of defense against developing new or recurrent foot wounds.


Legend: Selection of appropriate footwear depends on findings from the evaluation. Footwear selection choices lie on a continuum from least expensive/less complex to most expensive/most complex. Medicare provides benefits for diabetic patients who require prescription footwear.

Footwear Selection

Selection of protective footwear is not a matter of fashion. It requires knowledge, insight and experience. There are a large number of options to consider when recommending and prescribing protective footwear including individual adjustments such as casts, orthotics, wedges, fillers, lifts, cut outs, relief areas, bars or other modifications. To simplify matters, the selection of protective footwear can logically be placed in a hierarchy from least to most complex (Figure 2). Factors that determine complexity include availability ranging from off-the-shelf to custom-molded and modifications from simple inserts to specifically placed reliefs and pads. As the complexity increases, the costs increase proportionately. The hierarchy has five levels: 1) quality walking or athletic shoes, 2) off-the-shelf diabetic shoes with cushioned plantar inserts, 3) custom prescriptions added to off-the- shelf diabetic shoes, 4) custom-molded diabetic shoes and 5) Charcot restraint orthotic walkers (CROW boots).


Shoe Components

To appropriately prescribe protective footwear, it is helpful to be aware of the various components of a shoe, its functions, what alternatives exist for each component and what complications may arise from them. Surprisingly, many options also exist for sock choices. The following is a summary of major shoe components and sock compositions:

1.Covering materials (outer portions) are what the outer component of the shoe is made of, give the shoe above the sole portion its shape, and often give the shoe its common name such as leather,  house, tennis, athletic, boot, etc. Common components include leather, cloth, netting comprised of various materials, canvas, rubber, synthetic fibers (rigid or flexible) or plastic. Multiple combinations may be used, as is often found in tennis shoes. Leather is desirable for its durability, breathability and malleability to accommodate deformities. Flexible synthetic fibers are desirable because they accommodate changes in foot size due to swelling and are pliable enough to avoid pressure concentrations. Rigid plastic coverings, such as those used in the Charcot restraint orthotic walkers (CROW boot), require padded inner linings.

2. Fasteners are the devices that help to keep the shoe on the foot. There are three basic choices: 1) string ties, 2) elastic bands and 3) Velcro® straps. String ties tend to be more secure but require agility and good proprioception to tension properly and tie. If the knot becomes untied, the shoe may loosen, subjecting the patient’s skin to shear stresses and the foot and ankle ligaments to sprains. Another hazard of string ties is they can become untied and can cause the patient to trip over a shoelace. Elastic bands or Velcro® straps are more user-friendly and the preferred choice for many patients with comorbidities such as arthritis, obesity and hemiparesis, etc. In patients who retain fluid, the elastic bands may indent the edematous skin and interfere with venous return.

3.  Heels are elevations that may be are elevations that may be added to the back thirds of the shoe sole (discussed below). They may be thick, thin, wedged on either side, extend medially (Thomas heels) or absent, depending on the perceived needs of the hindfoot. Whereas some of the heel modifications are of dubious value, those used to counteract equinus deformities and position the ankle during Achilles tendon healing are of value

4. Heel counters are the parts of the shoe that come in contact with the back of the shoe heels. They may be low profile, barely covering the back of the heel, or enough to extend proximal along the back of the Achilles tendon. The higher the heel the greater is the control of the hindfoot. The inside portion of the heel counter may be padded with foam or soft cloth or merely lined with cloth or leather to provide a cosmetic appearance for the shoe covering material. Semirigid plastic inserts may be placed between the layers to add increased rigidity to the heel counter and control of the hindfoot.

5. Inner lining may or may not be present. They may increase the cushioning properties of the shoe, absorb moisture or help with the fit of the shoe. In stylish shoes, most are thin leather and added only for their cosmetic effect. In addition to lining materials may be cloth or various types of foam.

6. Lasts refer to the shape of the sole portion of the shoe. Usually the last is slightly concave along its medial aspect. For angular deformities (especially metatarsus adductus in children), the lasts may be straight or reversed, that is convex along their medial border.

7. Shanks are devices inserted into the sole portion of the shoe to control flexibility. Most often they are rigid steel bars and used for specific occupational needs rather than as modifications for protective footwear.

8. Shoe heights (upper portion) designate the portion of the shoe that is attached to the sole and extends over the foot, ankle or leg. Low-cut shoes such as moccasins and flats may cover only the bottom half of the foot. Consequently, they provide minimal support and stability. Intermediate cut shoes, the most frequently prescribed protective footwear, enclose the feet and extend to just below the level of the ankle malleoli. High-top shoes extend above the malleoli, with boots being a good example of this type of footwear. With increasing height of the upper portion of the footwear, protection, support and stability increase. Conversely, the greater the height of the upper portion of footwear, the more difficult it is to don, fasten and remove the shoe. Velcro® straps help to mediate the difficulties of tying the shoes. Specially designed footwear such as CROW boots help to mitigate the difficulty of donning and removing the shoe.

9. Shoe soles are the part of the shoe that makes contact with the ground or floor. They may be rigid or flexible. Typically, they may be flat, with or without the addition of a heel portion. Materials used for the soles of shoes include leather, plastic composite materials, wood and rubber. The rocker-bottom sole is a modification that facilitates walking in the presence of severe deformities or joint mobility problems.

10. Shoe tongues may or may not be present in protective footwear. Tongues, when present, are usually a separate component that attaches to the toe box (described next). Tongues serve several purposes, including providing protection between the laces and the top of the foot, and improved fit and comfort. Tongues may or may not be padded. Shoes that do not have tongues usually have overlapping flaps secured with Velcro® straps. These make the shoe easier to don and remove.

11. Toe boxes are the portions of the shoe top that cover the forefoot.  For most protective footwear, the toe boxes are spacious enough to prevent pressure sores developing from clawed toes and other forefoot abnormalities. Of course, the antithesis of the large toe box is the pointed-toe shoe. In comparison to protective footwear, pointed-toe shoes have many undesirable features that contribute to bunion deformities, hallux valgus, hyperpronation of the great toe, varus plus supination deformities of the little toes and cross-over toes. In conjunction with high heels, pointed-toe shoes contribute to clawed toe deformities, hyperextension contractures of the toes at the metatarsal-phalangeal joint levels, proximal migration of the forefoot fat pads, as well as calluses, bone spurs and ulcerations under the metatarsal heads. When toes or a distal portion of the foot are absent, a filler (or spacer) is usually inserted in the toe box to help with shoe fit and prevent shearing stresses on the skin with movements of the foot.

12. Sock options should not be overlooked in conjunction with footwear selection. Knee-length compression stockings with 20- to 30 mmHg tensions are recommended for all patients who have had foot surgeries, lower-extremity edema, mobility problems, venous stasis disease or spend extended periods of time with their feet immobile in the dependent position. Sock fiber choices include cotton, wool, acrylic, polyester, polypropylene or combinations of these fibers. Cotton socks are the least expensive, do not provide very good padding and manage moisture poorly. Wool socks provide good insulation and manage moisture fairly well. Acrylic socks fit well, reduce shear, cushion well and handle moisture well. The other synthetic fibers manage moisture well but do not provide good padding. Blends of these fibers can combine the desirable features of several fiber types. White stockings are especially desirable for those patients with risk factors for wound development because a stain on a white sock will not likely be ignored, as it might be if the patient was wearing dark-colored socks. Finally, stocking cleanliness is desirable, preferably with changes being made daily. Socks from synthetic fibers tend to retain odors and pile with repeated wear.


Footwear Choices
Although nearly a dozen components, as just described, may be considered when prescribing protective footwear, choices can be reduced to five principle types in a hierarchy that ranges from off-the- shelf, least expensive to custom-molded, most expensive (Figure 2). Knowledge of the footwear options and what protective footwear. Considerations include the following:

  • patient’s functional capacity

  • characteristics of the foot problem

  • modifications available for the five principle protective footwear choices

  • patient goals

In most circumstances this information, except for knowledge of the available modifications, is already available from the patient’s initial evaluation or becomes readily obvious with the reevaluation preceding the footwear prescription. The actual protective footwear selection, addition of modifications and fitting should be done by the pedorthotist or orthotist, who is the health-care professional most knowledgeable in this aspect of protective footwear. The following information describes the five principle choices for protective footwear in the hierarchy of complexity and costs. For each upward step in the hierarchy, the costs increase two- to threefold.

FIGURE 2. Hierarchy of prescription footwear

FIGURE-2Legend: As the foot problems become more complex, the protective footwear options move up the hierarchy and correspondingly become more expensive. CROW = Charcot Restraint Orthotic Walkers.

Level 1 — Quality walking or athletic shoes:

Theses shoes can be purchased without a prescription and usually do not qualify for Medicare Therapeutic Shoe Bill benefits. They are the least expensive and the best looking of the footwear options (Figure 3). Not only is the construction of the highest quality, but they are also usually available in a variety of lengths and widths to accommodate a wide range of foot sizes. The insides of these shoes are typically well-padded and the soles fairly rigid. The shoes are generally secured by lace-up ties or Velcro® straps. Many choices have large toe boxes that provide room for clawed or hyperextended toe deformities. This footwear choice is ideal for patients without foot deformities and/or who have only minimal, if any, risk factors for wound development. Prices of quality walking or athletic shoes range from $100 to $200.

FIGURE 3. Quality walking and athletic shoes vs. a high-fashion


Legend: Quality walking and athletic shoes can be stylish as well as functional, but contrast markedly with the shoe in the right hand figure, which has pointed toes, a thin side, compressed toe box, and slip-on (moccasin style) fixation to the foot.

Level 2 — Off-the-shelf diabetic shoes with cushioned plantar inserts:

As the name implies, these are production model (i.e., mass-produced) shoes that generally are available in most well- stocked specialty footwear and orthotic- prosthetic providers. The shoes are similar to the descriptions given above for quality walking or athletic shoes with the major difference being that there is enough room to accommodate extra- depth inserts (Figure 4). Although these shoes with the prescribed orthotics can be purchased without a prescription, a prescription by a physician is necessary for patients with diabetes to receive Medicare Therapeutic Shoe Bill benefits. There are advantages in obtaining these shoes from sales people trained in the fitting of protective footwear, including 1) improved likelihood of  proper size selection, 2) experience with the choices available to comply with the footwear prescription, 3) recognition and management of special needs such as different sized shoes for each foot, 4) preparation and fitting of multidensity inserts (Table 1), 5) ability to stretch and relieve pressure areas that are noted after using the shoes and 6) recourse such as exchanges or refunds if the patient is not satisfied with the footwear that was selected.5 In general, patients who enter the footwear selection hierarchy at this level have minimal deformities, although they have risk factors for the development of foot wounds.

FIGURE 4. Off-the-shelf shoes with cushioned plantar inserts for diabetics


Legend: These shoes have the desirable features of the quality walking and athletic shoes (Figure 3) in addition to providing additional room for inserts.

Note the relief areas in the orthotic under the first metatarsal head and lateral side of the midfoot (⇔) in the left half of the figure.


TABLE 1. Materials commonly used for shoe inserts and/or orthotics


Durability of Level 2 protective footwear: For household and limited community ambulation needs, off- the-shelf diabetic shoes should remain effective for approximately a year. The Medicare Therapeutic Shoe Bill allows for shoe replacement yearly. With use and time the shoes stretch, become easier to don and remove and, according to the patients, feel more comfortable. Unfortunately, these may be clues that it is time to replace the shoes. Other signs of shoe deterioration include wearing down of the heels or soles so they no longer keep the foot plantigrade, shifting of the upper portion of the shoe on the sole, wearing away of the inner linings especially over bony prominences, separation of seams, and excessive wear and tear of the upper portions. Consequently, if the shoe fits, it does not always mean it should be worn. Multidensity inserts quickly lose their cushioning ability with use. The Medicare Therapeutic Shoe Bill provides for replacement inserts as frequently as every four months if they are no longer effective. Prescription footwear with inserts usually costs about two to three times as much as quality walking or athletic shoes or in the $300–$500 range.

Level 3 — Custom prescriptions added to off-the shelf diabetic shoes:

This is the third level in the footwear selection hierarchy (Figure 5). This step of the hierarchy is typically associated with a single fixed (static) or dynamic deformity of the foot or ankle. Generally, shoes from the previous level are used as the foundation for the prescription modifications. A large number of options exist; essentially every shoe component previously discussed can be modified in one way or another (Table 2). When shoe modifications are prescribed, several requirements need to be met. First, the modification should address the structural deformity. The deformity can be as simple as mildly depressed metatarsal heads that require placement of a simple metatarsal pad to associated with Charcot neuroarthropathy.6 Second, the modification needs to provide a stable, plantigrade platform for the bottom of the foot to transfer the patient’s body weight to the underlying walking surface. Third, the modification needs to reduce focal areas of pressure as typically found over deformities. Fourth, the modification needs to eliminate shear stresses. For example, the indication for prescribing a filler or spacer for the forefoot after a transmetatarsal amputation (Figure 6).

FIGURE 5. Custom prescriptions added to off-the-shelf diabetic shoes

FIGURE-5Legend: Major customized modifications to control severe lateral instability of the foot and ankle. These modifications made to an off-the-shelf athletic shoe. Note normal height of the medial side of the athletic shoe heel in the photo inset in the upper right side of the figure.

FIGURE 6. Custom prescription for a transmetatarsal amputation

FIGURE-6Legend: Extra-depth plastizote insert plus filter for missing forefoot added to an off-the-shelf diabetic shoe that has a large toe box. The filter prevents the shortened foot from sliding forward in the shoe when walking.

Note the slight ridge at the heel portion (long black arrow) of the insert. This helps stabilize the heel. Also, note the darkened spot on the heel portion of the insert. This "dirty" area confirms that the patient has been an active ambulator with the prescription protective footwear.

TABLE 2. Foot problems manageable by footwear modifications


Bracing for protective footwear

Another prescription addition that may be required at this level of protective footwear is the use of the metal double upright brace (Klenzak). Whereas plastic ankle foot orthoses (AFOs) have many desirable features such as lightness and ease of application, they do not control angular and rotation deformities very well. They are most suitable for drop foot (peroneal nerve palsy) problems where a single (i.e., lack of foot dorsiflexion), nonangular deformity is present. In addition, AFOs may cause ulcerations not initially perceived by the patient due to their sensory deficits. The Klenzak brace with its distal insertion into a high- quality shoe (frequently with prescribed adjustments) can control angular, rotation, static and dynamic deformities simultaneously. In this respect,  despite its weight and unattractiveness, it is a valuable asset in the armamentarium of protective footwear alterations.

Successful use of protective footwear: Although prescription modifications may be the logical choice for the problem observed in the foot and ankle, they are not always successful. Maintaining the ability to walk and the prevention of new wound problems confirm successful use of the footwear. This is achieved only in conjunction with patient education and proper skin and toenail care. Often revisions and adjustments are needed to make the protective footwear function optimally. Even then, they may be able to only maintain the status quo — that is, prevent the wound from worsening while maintaining the patient’s mobility such as in a chronic, stable wound. A second corollary of successful protective footwear modifications is that they may require ongoing adjustments. Frequently, the shape of the foot changes with time. This is especially noted with Charcot neuroarthropathies, posterior tibial tendon insufficiencies and motor neuropathies. The third corollary is to establish whether or not the deformity is static, that is present even when not weight bearing or dynamic, that is it is present only with weight bearing.  In general, static deformities are harder than dynamic deformities to control with prescription adjustments. Prescription adjustments for dynamic deformities, however, have a propensity to generate shear stresses when walking and thus are more prone to cause skin ulcers. Shoe modifications/adjustments are another provision of the Medicare Therapeutic Shoe bill for diabetic patients. In general, adding prescription modifications to off-the-shelf shoes triples the costs of the unmodified shoes.

Level 4 — Customized molded protective footwear: This is the fourth level in the hierarchy of footwear options and is especially suited for patients with multiple deformities that have dynamic as well as static components (Figure 7). These shoes, as the title implies, are custom molded to accommodate unique foot and ankle deformities. Common features of these shoes are their unattractive appearance, their high- topped lengths and their asymmetry  with the opposite shoe. Typically, the deformities are unilateral and so severe that the footwear selections from the first three levels of the selection hierarchy are not able to protect (from new ulcerations) and maximize function of the foot and/or ankle. Examples include Boyd amputations (all the foot bones are removed except for the talus and calcaneus), rigid foot deformities in which the majority of the foot bones have fused into a solid mass, and the splayed forefoot in which the medial and lateral toes and rays are widely divergent. The costs of custom-fabricated shoes and/or double upright braces attached to prescription shoes is in the $1,000 to $1,500 range or two to three times the costs of shoes with prescription adjustments.

FIGURE 7. Custom molded protective footwear

FIGURE-7Legend: Custom molded shoes to manage major deformities of the feet and ankles. Note the asymmetry of the shoe lasts and upper portions. Regardless of the appearances of the shoes, the patients were thankful that these protective footwear devices allowed them to remain ambulatory and gainfully employed while not developing new wounds.


Charcot restraint orthotic walker (CROW) boots: The CROW boot represents the ultimate in the hierarchy of prescription footwear (Figure 8). When multiple fixed and dynamic deformities are present in the foot and ankle, uncontrollable by other means and the leg is at risk of a below-knee amputation because of them, a CROW boot is indicated. The CROW boot consists of a rigid posterior foot and leg shell that is filled with an injection molded rubberized foam material that conforms to the foot and ankle deformities. The patient steps into the posterior shell with the rubberized lining conforming exactly to the shape of the foot and leg. A padded anterior splint is placed over the front aspect of the foot and leg to close the boot and completely encircle the extremity. The anterior portion of the boot is held securely to the posterior shell with three Velcro® straps. With the uniform contact of the foam lining material, dynamic rotational problems between the foot and leg are controlled. With the elasticity of the lining material and the leeway the Velcro® straps provide in closing the CROW boot, leg swelling from fluid retention can be accommodated. The sole of the CROW boot has a rocker- bottom shape to facilitate walking with its rigid construction.7 Typically it is 3-4 cm thick, so a thick-soled shoe may be needed on the other foot to equalize lower-extremity lengths.

FIGURE 8. Charcot restraint orthotic walker (CROW) boot

FIGURE-8Legend: The CROW boot is at the apex of the protective footwear hierarchy. Features include a thick rocker bottom sole, a rigid posterior-plantar shell, an injected molded rubberized foam lining that conforms to the patient's foot/ankle deformity, a padded anterior splint that make with the posterior shell and Velcro® straps.

Usually the deformities that are found in conjunction with the Charcot arthropathy shorten the foot and ankle so much that the thick sole of the CROW boot equalizes the lower-extremity lengths with regular-thickness shoe soles on the other foot.

Indications for a CROW boot: A CROW boot is usually not prescribed until other levels of the footwear hierarchy have been tried and found to be unsuccessful. With the most severe foot and ankle deformities such as those associated with severe deformities from Charcot neuroarthropathy, however, a CROW boot becomes a first line defense to prevent new and recurrent foot wounds and to maximize the patient’s walking ability. Clinical judgment is required to make the decision. If the patient has little or no potential for ambulation, there is little indication to order a CROW boot. In this situation, the ambulation goal would be mobility with a wheelchair. If the deformity is controllable by cast wear and the cast makes it possible for the patient to do limited walking, a CROW boot is indicated. As with the other levels of the protective footwear hierarchy, the CROW boot may require adjustments and replacements with time and use as the foot shape changes and the device wears.

Considerations regarding CROW boots: As desirable as the CROW boot is as a functional device for ambulation in patients with the severest of foot and ankle deformities, it has undesirable features. These include its appearance, weight and contraindication for wear when any but the smallest wounds are present. CROW boots cost $1,500 to $2,000. Even when CROW boots are prescribed with the indications given in the previous paragraph, about one-fourth of the patients do not use them. Reasons, in addition to those mentioned above, include worsening infirmities that negate walking and development of new wounds. When sizable wounds are present and/or new wounds develop, surgical options such as complex foot reconstruction or lower-limb amputation must be considered.



1. Cavanagh PR, Owings TM. Nonsurgical strategies for healing and preventing recurrence of diabetic foot ulcers. Foot Ankle Clin. 2006; 11(4):735-743.

2. Strauss MB, Miller SS. Diabetic Foot Problems: Keys to effective, Aggressive Prevention. Consultant. 2007; March:245-25.

3. Sugarman JR, Reiber GE, Baumgardner G, et al. Use of the therapeutic footwear benefit among diabetic Medicare beneficiaries in three states. Diabetes Care. 1998; 21:777-781.

4. Wooldridge J, Moreno L. Evaluation of the costs to Medicare of covering therapeutic shoes for diabetic patients. DiabetesCare. 1994; 17:541-547.

5. Paton J, Jones RB, Stenhouse E, Bruce G. The physical characteristics of materials used in the manufacture of orthoses for patients with diabetes. Foot Ankle Int. 2007; 28(10):1057-1063.

6. Hastings MK, Mueller MJ, Pilgram TK, et al. Effect of metatarsal pad placement on plantar pressure in people with diabetes mellitus and peripheral neuropathy. Foot Ankle Int. 2007; 28(1):84-88.

7. Brown D, Wertsch JJ, Harris GF, et al. Effect of rocker soles on plantar pressures. Arch Phys Med Rehabil. 2004;85(1):81-86.

8. Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of and ankle pathology. J Am Acad Orthop Surg. 2008;16(3):152-158.

9. Groner C. Orthosis Symbiosis: Clinicians are finding a middle ground in the debate over custom versus prefab foot orthoses. BioMechanics, 2005, 12(5):22-23.

10. Frigg A, Pagenstert G, Schafer D, et al. Recurrence and prevention of diabetic foot ulcers and total contact casting. Foot Ankle Int. 2007 Jan; 28(1):64-69.

11. Janissee DJ. The Therapeutic Shoe Bill: Medicare coverage for prescription footwear for diabetic patients. Foot Ankle Int. 2005; 26(1):42-45.

About the Authors


MICHAEL STRAUSS, M.D., an orthopaedic surgeon, is the retired medical director of the Hyperbaric Medicine Program at Long Beach Memorial Medical Center in Long Beach, California. He continues to be clinically active in the program and focuses his orthopaedic surgical practice on evaluation, management and prevention of challenging wounds. Dr. Strauss is a clinical professor of orthopaedic surgery at the University of California, Irvine, and the orthopaedic consultant for the Prevention- Amputation Veterans Everywhere (PAVE) Problem Wound Clinic at the VA Medical Center in Long Beach. He is well known to readers of WCHM from his multiple articles related to wounds and diving medicine published in previous editions of the journal. In addition, he has authored two highly acclaimed texts, Diving Science and MasterMinding Wounds. Dr. Strauss is actively studying the reliability and validity of the innovative, user-friendly Long Beach Wound Score, for which he already has authored a number of publications.



ANNA M. TAN, DPM, is the chief resident of podiatric medicine and surgery at Long Beach Memorial Medical Center. She graduated cum laude from the University of Southern California in 2006 and received the Dean’s Award for her undergraduate research on netrin-1, a protein involved in axonal guidance. Subsequently, she attended the California School of Podiatric Medicine at Samuel Merritt University in Oakland, California, receiving her doctor of podiatric medicine degree in 2014. Dr. Tan has special interests in surgical management of problem wounds and limb salvage. In her spare time, she enjoys Bikram yoga, cooking and traveling.


LIENTRA LU is a research coordinator at the VA Medical Center in Long Beach, California, under the guidance of Dr. Ian Gordon, a vascular surgeon, and Dr. Michael Strauss. She is also an administrative assistant in the accounting department of the Southern California Institute for Research and Education (SCIRE). She received a bachelor of science degree in chemical biology at the University of California, Berkeley, in 2015 and subsequently has taken medically related courses at the University of California, Los Angeles. Miss Lu is helping with diabetic foot and venous leg ulcer studies at the VA Medical Center while also serving as an assistant in patient care at the PAVE Clinic there. She also works with the American Red Cross in her other interest, disaster preparedness.





The Advantage to Having Registered Nurses in Hyperbaric Facilities

  • Janet Bello, RN, ACHRN, and Laura Josefsen, RN, ACHRN
  • Volume 08 - Issue 1

The clinical world of hyperbaric medicine is truly team concept with each member (physicians, nurses, and technicians) bringing the best of each respective scope of practice. The Undersea and Hyperbaric Medical Society (UHMS) accreditation process utilizes physicians, registered nurses (CHRNs) and technicians (CHTs) to evaluate hyperbaric facilities as each professional brings his or her own perspective to the comprehensive care that patients receive.

The specialty of nursing is a multifunctional part in the medical model. Nursing is the profession representing patient rights. According to the American Nurses Association, “Nurses use theoretical and evidence- based knowledge of human experiences and responses to collaborate with health-care consumers to assess, diagnose, and identify outcomes, and plan, implement, and evaluate care.” 1

“Nurses provide management for quality improvement, documentation, infection control, patient education, and intervention as well as initial and ongoing nursing assessment of patient care,” notes HG Vincent in Hyperbaric Nursing.2,3

The perception is that the quality of documentation equates to the quality of care. Documentation is an essential aspect of the nursing process, which includes chart reviews for accurate, comprehensive charting to meet regulatory and reimbursement guidelines for patient care, patient safety, and billing/reimbursement.4
Patients receiving hyperbaric oxygen treatments benefit from having the hyperbaric-trained RNs as part of their initial and ongoing nursing evaluations. The trained hyperbaric nurse uses critical thinking skills in the areas of quality improvement by gathering, assessing and evaluating data for patients going into the altered environment of 100% oxygen under increased atmospheric pressure. This data includes the following:

  • physical and psychosocial assessments, patient attitude

  • education, how patients learn, barriers to learning

  • patient compliance, ability to deal with health-care issues

  • baseline functional status, social environment,cultural environment, emotional states, and safety issues to identify initial and ongoing nursing interventions and revisions 2,3

To further assess the potential for patient issues going into the hyperbaric chamber, including the goal/rationale and actions for each issue, the Baromedical Nurses Association (BNA) Guidelines for Standard of Care for the Patient Receiving Oxygen Therapy (HBO2) are available on the BNA website at


  1. American Nurses Association. Nursing: Scope and Standards of Practice, 2nd ed. Silver Spring, MD:;2010.

  2. Vincent HG. Documentation. In: Larson-Lohr V, Norvell H, eds. Hyperbaric Nursing. Flagstaff, AZ: Best Publishing Company; 2002. p. 5-78.

  3. Vincent HG. Documentation of the Nursing Process as it Relates to Hyperbaric Oxygen Therapy, In: Larson-Lohr V, Norvell H, eds. Hyperbaric Nursing. Flagstaff, AZ: Best Publishing Company; 2002. p. 79-119.

  4. Larson-Lohr ed. Hyperbaric Nursing and Care. Flagstaff, AZ: Best Publishing Company;2010.


About the Authors


JANET H. BELLO, RN, BSN, ACHRN, is an independent consultant for hyperbaric medicine. As an Associate member of the Undersea and Hyperbaric Medical Society (UHMS), she serves as secretary for the Associates Council, is a nursing representative on the UHMS Accreditation Council, a nurse surveyor for the UHMS Accreditation Team and on the Membership Committee. Janet has also served as an officer and board member for the UHMS NE Chapter and the Baromedical Nurses Association. Her past experience includes hyperbaric programs supervisor for the Wound Recovery and Hyperbaric Medicine Center at Kent Hospital in Warwick, RI, and program manager for Praxis Clinical Services at Our Lady of Fatima Hospital, Hyperbaric Medicine Unit, in North Providence, RI. Both facilities provide hyperbaric emergency and critical care 24/7 for patients in monoplace chambers. Other nursing experience includes critical care and cardiovascular services, critical care educator and clinical manager for cardiovascular stepdown units at Piedmont Hospital in Atlanta, GA. She is licensed in the Commonwealth of Massachusetts. She received her bachelor of science degree in nursing at the University of Virginia.



LAURA JOSEFSEN, RN, ACHRN, has been involved in hyperbaric nursing since 1982. A founding member of the Baromedical Nurses Association (BNA) in 1985, she served as BNA president from 1996 to 1998 and as a board member in several positions throughout the years. She served on the Undersea and Hyperbaric Medical Society (UHMS) Associates Council for six years, with two of those years as Nurse Representative on the UHMS Board of Directors. She has been a member of the UHMS Accreditation Team as a nurse surveyor, served for many years as an executive board member of the National Board of Diving and Hyperbaric Medical Technology and is a previous chairman of the BNA Certification Board. She is a member of the UHMS Associates, former member of Divers Alert Network, and former member of the Hyperbaric Technologists and Nurses Association (HTNA) of Australia. She has numerous publications and is an internationally recognized speaker in the field of hyperbaric medicine. Her passions are quality improvement and education to promote hyperbaric nursing, safety, and optimal standards of care and practice for patients and the community.


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