A Note to EMS Providers on Hyperbaric Chambers

I don’t know about the rest of the country/world, but in my neck of the woods, EMT students are taught to bring patients involved in a diving incident, no matter how minor, directly to a hyperbaric chamber.

Can someone please put a stop to this nonsense?

First of all, HBOT (Hyperbaric Oxygen Treatment) is a treatment, and needs to be ordered by a physician.  Unless directed by medical control to transport the patient directly to an awaiting chamber, as can be the case with public safety and commercial divers, patients need to be in stable condition before being subjected to the pressures and stress of a hyperbaric chamber.  Literally.  If a patient is unresponsive, can’t maintain a patent airway, or needs immediate surgical intervention, they won’t be ALLOWED in the chamber.  Period.  End of story.

Secondly, most operational chambers are used for a growing number of non-diving related treatments.  Insurance and Medicare consider the following conditions for HBOT to be covered for payment:

  • Air or Gas Embolism (AGE), including cerebral (CAGE)
  • Carbon Monoxide Poisoning
  • Compartment Syndrome/Crush Injury/Other Traumatic Ischemias
  • Decompression Sickness (DCS) / Decompression Illness (DCI)
  • Diabetic and Selected Wounds
  • Exceptional Blood Loss (Anemia)
  • Gas Gangrene
  • Intracranial Abscess
  • Necrotizing Soft Tissue Infection
  • Osteoradionecrosis and Radiation Tissue Damage
  • Osteomyelitis (Refractory)
  • Skin Grafts and (Compromised) Flaps
  • Thermal Burns

The following conditions may or may not be covered by insurance or Medicare, but can also be treated with HBOT:

  • Autism
  • Cerebral Palsy
  • Lyme Disease
  • Migraine
  • Multiple Sclerosis
  • Near Drowning
  • Recovery from Plastic Surgery
  • Sports Injuries
  • Stroke
  • Traumatic Brain Injury

The staff operating a chamber are well versed in treating the above-mentioned ailments/indications, but usually not trained to treat diving-specific injuries, although they have a working knowledge of DCS/DCI/AGE and have been taught the basics.  The physician at a chamber site is not required to have a specialty in diving medicine.  Hyperbarics and diving medicine are not the same specialty, so in all likelyhood, the attending physician would need to call on another specialist for assistance if an ambulance pulled up with a bent diver looking for treatment, if they even let them get past the front door to begin with.

Other reasons you shouldn’t bring a patient with a possible DCS/DCI issue directly to a chamber include:

  • No available chambers (once a patient is under pressure and being treated, you can’t just yank them out for someone “worse”.)
  • Gas supplies on hand (oxygen and compressed “clean” air) are low and won’t last the required length of a table 6 treatment.
  • The facility may not treat diving injuries.
  • An injured diver needs to be “cleared” for hyperbaric treatment by a physician.  Contraindications for HBOT include pneumothorax (collapsed lung), tension pneumothorax, myocardial infarction (heart attack), and/or neurological and musculoskeletal injuries with symptoms similar to DCS/DCI, to name just a few.
  • The facility might be closed after normal operating hours.

If you encounter a patient that you think might be suffering from a diving related injury, the best thing to do is to provide high-flow oxygen via a nonrebreather mask (15lpm or higher) as soon as possible and transport to the nearest ED.  Gather and record as much information as you can pertaining to the patient’s diving profile, including:

  • signs and symptoms, chief complaint
  • deepest dive depth
  • number of dives in the last 48 hours
  • type(s) of gas used (Nitrox, tri-mix, heliox, air, etc.)
  • diving environment (fresh water or salt water)
  • ascent/descent/bottom issues (if any)
  • equalization problems during ascent/descent (if any)
  • equipment malfunction issues (if any)
  • name and phone number of the diver’s divebuddy
  • any pre-existing medical conditions

Provide the information gathered with your handoff report, preferrably on paper, along with any equipment they were using (if you picked them up at the dive site.)

Call Divers Alert Network (919-684-9111) and speak to a Medic, or have the receiving physican call and speak to a DAN Medic or physician for treatment options.  The phones are staffed 24x7x365, and they accept collect calls.

The single-most important treatment for a diver suspected of having DCS/DCI is a BLS adjunct: OXYGENLots of it, as soon as possible, for as long as possible.  Forget a nasal cannula at 4lpm.  Oxygen breaks down the nitrogen bubbles in the blood stream and tissue compartments.  Nitrogen is what causes DCS/DCI, so the faster you can apply SLO2 (surface-level oxygen), the faster you can begin the nitrogen breakdown, and the diver will have a better chance of recovery once they start the chamber treatments.

Whatever you do, DON’T, for the love of whatever you consider Holy, take them directly to a hyperbaric chamber.