Basic Training

  • Darren Mazza, EMT, CHT
  • Volume 06 - Issue 4

Although National Fire Protection Association (NFPA) code 20.3.1.3 explains the role of hyperbaric safety directors and their responsibilities, an individual's job description may vary from one facility to the next. As the safety director for Swedish Edmonds Center for Wound Healing and Hyperbarics in Edmonds, Washington, I have a great deal of responsibility. I take pride that the hospital I work for is committed to supporting me in my role to ensure the safety of both the patients and staff during day-to-day hyperbaric operations. As the safety director, I am responsible for providing training to all staff in our facility, as it pertains to hyperbaric operations, monthly staff emergency training, or just hyperbaric orientation for all new employees hired in our facility.

It’s absolutely crucial to provide hyperbaric therapy department orientation to every new employee from the secretary to the wound-care provider. This orientation time is what I call “basic training.” Everyone receives one-hour orientation/education pertaining to the operation and safety guidelines of the hyperbaric department. In the event an emergency evacuation is needed and the certified hyperbaric technologist (CHT) needs assistance, everyone receives both basic chamber door operation and gurney operation training and is signed off after orientation time.

Staff training never ends. All staff in our facility participates in monthly hyperbaric emergency procedure training on one of the following topics:

  • Otic barotrauma
  • Sinus barotrauma
  • Anxiety
  • Nausea/vomiting/diarrhea
  • Hypoglycemia/hyperglycemia patient
  • Unresponsive patient oxygen toxicity/seizure
  • Pneumothorax
  • Gas embolism
  • Loss of oxygen pressure/contaminated air
  • Power loss
  • Severe weather
  • Fire in the chamber room
  • Fire in the building
  • Fire in the chamber

These emergencies and the emergency-response procedures are in plain sight, laminated, and attached to the railings of each chamber.

Every month, I select an emergency topic, and the staff is taught the appropriate emergency response for the specified emergency according to the clinic’s hyperbaric emergency procedures policies.

Example: Unresponsive patient

CHT immediate actions:

  • Note time and depth.
  • Notify MD.
  • Abort treatment.
  • Start ascent to surface @ 5 psi/min.
  • Check vital signs.
  • Start basic lifesaving (BLS ) protocols as appropriate.
  • Check blood glucose.
  • Call for assistance as appropriate.

All staff members are in-serviced on three critical components:

  1. Type of emergency
  2. The CHT appropriate response
  3. The appropriate response of all first responders to the chamber room

Constant and adequate communication between the CHT and wound-care staff is a must at all times. Every shift, I communicate my needs for staff assistance for patient change-outs/ prepping to the charge nurse in wound care so she can coordinate with the backup CHT who works in wound care primarily through the day. I then provide a hand radio to the charge nurse, hyperbaric nurse, and backup CHT so I can maintain constant direct communication with everyone in the event that I may need them for any reason, especially an emergency.

Another responsibility of mine as a safety director is to educate the medical community on both the benefits and risks of hyperbaric therapy. Occasionally I have the opportunity to present to medical providers and other medical professionals. I enjoy this because this enables me to be part of the hospital outreach program, educating the medical community on the evidence-based science and benefits hyperbaric therapy and the conditions we treat in our facility.

Without a doubt, a hyperbaric program with a good safety program in place is also a successful one. The more we educate the staff, the better the outcome in the event of an emergency. One important message for other wound care and hyperbaric facilities is to offer every clinical and nonclinical staff member a UHMS-approved forty-hour introductory to hyperbaric medicine course. I have found that this not only improves hyperbaric safety awareness among staff but also greatly improves staff knowledge in the science and benefits of hyperbaric therapy.

Final note: When it comes to hyperbaric safety, establishing a “basic training” process for the entire staff in your facility will not only better prepare the staff for an emergency but also will improve the day-to-day operation of the hyperbaric program. The entire wound-care staff is more inclined to be vigilant in coordinating care with the CHT as they will have a better sense of time constraints in the hyperbaric environment.

 

About the Author

Darren-M

DARREN MAZZA is the CHT and safety director at the Center for Wound Healing and Hyperbarics at Swedish/ Edmonds, located in the greater Seattle area. He has twenty years of experience in health care, which includes eight years as an EMT in the greater Sacramento region. Mazza also worked as a preceptor trauma tech in a Sacramento hospital for several years. After leaving California and moving to Idaho in 2005, his hyperbaric career began after becoming the department head of an outpatient wound care and hyperbaric center.

 

CLINIC IN FOCUS

  • Edward Hospital Wound Healing and Hyperbaric Center
  • Volume 06 - Issue 4

clinic-in-focus-6-4

 

Continuing our series of interviews featuring outstanding hyperbaric and wound care centers around the world, we spotlight in this issue the Edward Hospital Wound Healing and Hyperbaric Center at Edward Hospital in Naperville, Illinois.

 

How has seeking UHMS accreditation affected your clinic?

It has demonstrated our passion to provide the highest quality care and outcomes. It united the clinic to work for a common goal and to continue to treat our patients with best- practice medicine. Having hyperbaric oxygen therapy in the wound clinic itself allows all the staff to coordinate care for the patients. It provides streamlined and efficient care.

CLINIC DETAILS
Clinic Name: Edward Hospital Wound Healing and Hyperbaric Center
Location: Edward Hospital, Naperville, Illinois
Website: www.edward.org
Phone: 630-527-3002
How long in business: 8 years
How many chambers: 3
Chamber types: Perry Sigma 36 and Perry Sigma 40
How many physicians/nurses/CHTs5 physicians, 2 APNs, 5 RNs, 4 CHTs
Medical director: Dr. Najjar (wound care), Dr. Villanueva (hyperbaric)
Date of UHMS accreditation: October 2014

 

What are the most common indications treated at your clinic?

Wounds and ulcerations of various etiologies are treated at the Edward Hospital Wound Healing and Hyperbaric Center. Wound care indications such as diabetic foot ulcers, venous leg ulcers, peripheral arterial ulcers, and pressure ulcers are the main four, with diabetic foot ulcers as the most common. Evidenced-based practice guidelines are utilized to develop comprehensive treatment plans to assist with the healing of the patient.

The most common indications treated in the hyperbaric oxygen (HBO) therapy program include diabetic foot ulcers, compromised flap/graft, osteomyelitis, and soft tissue radio necrosis. After appropriate patients go through a screening process and it has been determined that HBO therapy may assist with healing, treatment is started in conjunction with standard wound care. Treatments consist of two hours a day, five days a week, for an average of thirty treatments.

6-4-image2

 

What is the most memorable treatment success story that has come out of your clinic?

A 40-year-old female with a history of neurofibromatosis injured her left lateral leg in March 2014 after it was hit by a car door. She was treated for a staph and fungal infection. In August 2014, the wound was surgically debrided and started on negative pressure wound therapy. Due to complications of infection and comorbidities, the wound deteriorated, and the threat of loss of limb was pending. With collaboration of a vascular surgeon and infectious disease and wound care team, the patient was followed very diligently. She was seen in the wound care center three times a week for close visualization of wound. Infection was managed, and she improved to the point of accepting a biosynthetic skin graft.

Currently she is 99% healed and should have total resolution of the wound within the next few visits.

If you had to pick one thing to attribute your clinic’s success to, what would it be?

Collaboration between all the staff is the main reason for our success. Everyone works together on the patients’ care. Physicians, RNs, APNs, medical assistants, and hyperbaric techs all give their input. Everyone’s treatment is individualized based on best-practice guidelines

What is one marketing recommendation that you can make to help clinics increase their patient load?

Communicating with the community’s physicians is an important marketing tool. Wound care and hyperbaric medicine are specialized services to help patients heal. Reports are sent to primary physicians to update them on their patient’s progress, and referrals to other specialties (diabetes education, physical therapy, weight-loss clinics) can be coordinated. Also, it is helpful to communicate the benefits of hyperbaric medicine to oral surgeons and cancer physicians who may not be aware of some treatment options that hyperbaric medicine can provide.

Is there are any additional question you’d like to answer, or any other information about your clinic you’d like to showcase?

All of our hyperbaric techs are CHT. We also have two nurses who are CHRN and four nurses who are certified in wound and ostomy. All the staff has taken a forty-hour hyperbaric training course — even the director of the program has taken it. It shows how invested the staff and hospital are to providing the best care and outcomes for their patients.

 

Scuba Diving and Coronary Artery Disease

  • Douglas Ebersole, MD, FACC, FACP
  • Volume 06 - Issue 4

It is estimated that there are about 3 million certified scuba divers in the United States. A large number of these individuals are middle-aged or older and at risk for coronary artery disease. Cardiovascular disease is the third most common cause of death while diving and remains the principal cause of death in the general population. The development of symptoms of angina, pulmonary edema, or sudden cardiac death underwater carries with it a much higher mortality than would the same event on land. This article will review the workloads related to scuba diving, ways to assess risk in those with or at risk of developing coronary artery disease, and make recommendations to make scuba diving safer.

Scope of the Problem

In 2008, Dr. Petar Denoble published a paper showing the annual death rate for scuba divers was 16.4 per 100,000 persons.1 This was similar to the rate of 13 jogger deaths per 100,000 participants each year2 or the risk of driving where motor-vehicle accidents result in 16 deaths per 100,000 persons per year.3 Thus, while the likelihood of dying when scuba diving is quite small, understanding how and why these deaths occur is imperative.

Unfortunately, the ultimate cause of death while scuba diving is drowning. This does not give us great insight into what led to the drowning. Denoble reported on the causative process of 947 fatalities in an attempt to better define scuba diving fatalities.4 He divided this into sequential components: trigger, disabling agent, disabling injury, and cause of death. Cardiac events constituted 26% of disabling injuries, and these events were frequently associated with a history of cardiovascular disease and age greater than 40 years. Thus, it looks like underlying cardiovascular disease is a major component in scuba diving deaths.

Workloads Associated with Scuba Diving

It is clear exercise itself is a cardiovascular stress, and the majority of nontraumatic deaths during exercise are cardiac in origin. In most situations, diving is not particularly physically stressful. However, there are times due to current, waves, wind, and other environmental stressors that demands during diving can reach 20 ml/kg/min (6-7 METS). Exercise capacity is reported in terms of estimated metabolic equivalents of task (METs). The MET unit reflects the resting volume of oxygen consumption per minute (VO2) for a 70-kg, 40-year-old man, with 1 MET equivalent to 3.5 mL/min/kg of body weight.

In the standard Bruce protocol, the starting point (i.e., Stage 1) is 1.7 mph at a 10% grade (5 METs). Stage 2 is 2.5mph at a 12% grade (7 METs). Stage 3 is 3.4 mph at a 14% grade (9 METs), and Stage 4 is 4.2 mph at 16% grade (12 METs). This protocol includes three-minute periods to allow achievement of a steady state before workload is increased.

Thus, a diver with a steady-state exercise capacity of 6-7 METS can expect to manage most diving contingencies without concern for cardiovascular complications. In most occupational exposures requiring increased physical activity, guidelines recommend maintaining workloads below 50% of maximal oxygen consumption. Based on this relationship, a diver who is expected to minimize safety concerns related to environmental contingencies should have a maximum oxygen consumption of 12-13 METS or about 12 minutes on a standard Bruce protocol exercise test. Divers with peak exercise capacity below that level could expect to dive safely in low-stress conditions such as warm water, minimal currents, and calm seas but could develop cardiovascular limitations under stressful diving conditions.

Who Is at Risk?

For divers older than 35 years, the dominant risk for sudden death is from coronary artery disease. Although the incidence of coronary artery disease death is falling, the rising incidence with age makes this diagnosis the most important consideration when clearing divers who are middle-aged or above.

One strategy to lower the risk of cardiovascular deaths would be to screen all adult participants prior to certification, as most exercise-related cardiac events in adults are due to atherosclerotic cardiovascular disease.

author-diving

The Framingham Risk Score is one of a number of scoring systems used to determine an individual’s chances of developing cardiovascular disease. A number of these scoring systems are available online.5,6 Cardiovascular risk scoring systems give an estimate of the probability that a person will develop cardiovascular disease within a specified amount of time, usually ten to thirty years. Because they give an  indication of  the risk of developing cardiovascular disease, they also indicate who is most likely to benefit from prevention. For this reason, cardiovascular risk scores are used to determine who should be offered preventive medications such as drugs to lower blood pressure and drugs to lower cholesterol levels.

The population risk for divers could be predicted by using tools such as the Framingham Risk Score, and potential participants with a specific score could be identified and excluded. The problem with this approach is that atherosclerotic cardiovascular disease is prevalent among lower-risk subjects. Also, extremely high-risk subjects are only a small part of the total population. Consequently, the largest absolute number of acute events occurs not in the highest-risk subjects but in the moderate- and lower-risk groups. Excluding the highest-risk group likely has little effect on the total number of deaths.

A Framingham Risk Score lower than 10% ( less than 1% per year risk) is considered a low score. If a subject is assessed to be at low risk in general, that individual is not likely to have an acute coronary event while diving. On the other hand, high-risk individuals (Framingham score greater than 20%) could be at considerable risk and should have further evaluation to evaluate whether diving will be safe. Intermediate-risk individuals with a Framingham score between 10% and 20% should have further risk stratification to assess their risk for an acute coronary event while diving.

In all individuals, regardless of risk, we should practice primary prevention of coronary artery disease. The recommended performance measures for primary prevention are:

  1. Lifestyle/risk-factor screening
  2. Dietary-intake counseling
  3. Diabetes screening and management
  4. Physical-activity counseling
  5. Smoking/tobacco cessation
  6. Weight management
  7. Blood-pressure control
  8. Blood-lipid measurement and control
  9. Global risk estimation with tools such as Framingham Risk Score
  10. Aspirin use in selected individuals

Implementation of these measures requires performance of a careful history and physical examination, laboratory testing for lipids, and formal assessment of cardiovascular risk.

Performing stress testing in selected individuals, such as those with intermediate- or high-risk Framingham scores, is also an approach. In comparison to younger individuals, far less attention has been paid to designing screening programs for older, usually recreational, athletes. Few detailed preparticipation guidelines exist, and there is little reported experience in this age group. Instead, most authorities focus on strategies used in clinical medicine for the early detection of atherosclerotic diseases, as these are the most common cause of death in this age group.

diverquoteSince most individuals are asymptomatic, the history is often more helpful in identifying risk factors rather than symptoms.Similarly, there may be few detectable abnormalities at rest or even with exercise, as events are often due to spontaneous rupture of nonobstructive plaque.

The American Heart Association issued recommendations for preparticipation screens in older athletes in 2007.7 This document recommends that older competitive athletes (over 35 to 40 years old) be “knowledgeable” regarding their personal history of coronary artery disease risk factors and family history of premature coronary artery disease. Further, stress testing should be performed selectively for individuals engaging in vigorous training and competitive sports and who meet the following criteria: men over 40 years or women over 55 years with diabetes mellitus, or at least two risk factors or one severe risk factor other than age. Finally, the document recommends education regarding prodromal cardiac symptoms, such as exertional chest pain.

What about Patients with Established Coronary Artery Disease?

Patients with known coronary disease often have been subject to revascularization either by coronary-artery bypass surgery or by percutaneous coronary intervention, usually with implantation of one or more coronary artery stents. The degree of revascularization can determine safety in diving. With complete revascularization, low-stress diving can be accomplished successfully, but diving in rough seas, fast currents, or cold water could be risky. Many divers have returned to diving after either coronary-artery bypass surgery or stenting. Success in return to diving is based on restored exercise capacity without ischemia after revascularization and choosing diving environments that do not produce excess stress on the cardiovascular system.

Patients with significant reduction in left ventricular systolic function (LVEF under 35%) are at risk for exacerbation of congestive heart failure while diving. Water immersion itself results in approximately 700 cc of fluid shift into the central circulation. This could provoke congestive heart failure in patients with impaired left ventricular systolic function. Additionally, most patients with LVEF under 30-35% will have impaired exercise tolerance when diving as outlined above. For these reasons, patients with significant left- ventricular systolic dysfunction should be advised against scuba diving.

Recommendations

1. All adults should be evaluated for their risk of coronary artery disease prior to scuba diving.

2. Selected individuals with intermediate to high-risk Framingham scores should be referred for additional evaluation, such as treadmill testing prior to scuba diving.

3. All individuals should practice primary prevention strategies to decrease their risk for the development of coronary artery disease.

   a. Smoking cessation

   b. Blood-pressure screening and management

   c. Weight control

   d. Physical-activity counseling

   e. Cholesterol screening and management

4. Patients with coronary artery disease may begin (or return to) diving as long as they have beenre-vascularized with no ischemia on treadmill stress testing, have good exercise tolerance (defined as a maximum exercise capacity of 13 or an ability to sustain a workload of 6 METs), and have relatively preserved left ventricular systolic function.

References

  1.  Denoble.PJ, Pollock NW, Vaithiyanathan P, Caruso JL, Dovenbarger JA, Vann RD. Scuba injury death rate among insured DAN members. Diving Hyperbaric Medicine 2008; 38:182-188.
  2. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode Island from 1975 through 1980. JAMA 1982; 247:2535-2538.
  3. Denoble  P, Marroni A, Vann R. Annual fatality rates and associated risk factors for recreational scuba diving. In: Vann R, Lang M, eds. Recreational Diving Fatality Workshop. Durham, NC: Divers Alert Network; 2011.
  4. Denoble PJ, Caruso JL, Dear G de L, Pieper CF, Vann RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyper Med 2008; 35:393-406.
  5. University of Edinburgh. Cardiovascular Risk Calculator and Chart. Cvrisk.mvm.ed.ac.uk. Last modified May 28, 2010. Accessed September 14, 2013.
  6. National Heart, Lung and Blood Institute. Framingham Risk Functions. https://www.framinghamheartstudy.org/risk-functions/index.php. Accessed May 7, 2013.
  7. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on nutrition, physical activity, and metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007; 115:1643-1655.

 

About the Author

DR-DOUGLAS-EBERSOLE

DR. DOUGLAS EBERSOLE is a cardiologist specializing in coronary and structural heart interventions at the Watson Clinic LLP in Lakeland, Florida. He is also an avid technical, cave, and rebreather diver and instructor.

Contact Ebersole at This email address is being protected from spambots. You need JavaScript enabled to view it..