Position Statement: Physician’s Duties in Hyperbaric Medicine - 99183 New!
UHMS Position Statement + Physician’s Duties in Hyperbaric Medicine - 99183
Date created: January 4, 2024 Edited: April 22, 2024
Date of the following review: 2029 Authorship: Dr. Matthew Kelly, Dr. Helen Gelly,
Dr Owen O’Neill, Dr. Dag Shapshak
Reviewed/Approved by: UHMS Board of Directors, January 27, 2024
INTRODUCTION
The Undersea and Hyperbaric Medical Society (UHMS) is at the forefront of advancing medical knowledge and promoting patient safety in the field of hyperbaric medicine. In the dynamic landscape of healthcare, physicians' critical role in overseeing hy- perbaric oxygen treatment (HBO2) cannot be over- stated. This position statement aims to underscore the significance of physician involvement in deliv- ering HBO2 and articulate UHMS’s commitment to maintaining the highest standards of care and safety for patients undergoing hyperbaric treatments.
ABSTRACT
Hyperbaric oxygen treatment demands a meticu- lous approach to patient management. As the com- plexity of hyperbaric patients continues to evolve, the direct oversight of qualified physicians becomes paramount to ensuring optimal patient outcomes and safeguarding against potential risks. In this statement, we outline the key reasons physician involvement is essential in every facet of HBO2, ad- dressing the technical intricacies of the treatment and the broader spectrum of patient care.
RATIONALE
Physician oversight for hyperbaric oxygen treat- ment is rooted in the technical complexities of the treatment and the broader responsibilities associ-
ated with clinical patient care. The responsibilities outlined below delineate services intrinsic to the physician's duties for treating patients undergoing hyperbaric oxygen treatments.
CONCLUSIONS/RECOMMENDATIONS
The UHMS affirms that the duties of a physician su- pervising HBO2 include:
Physician Work Performed Pre-Hyperbaric Treatment
1. Review the pertinent medical records of each patient.
2. Determine the treatment pressure, duration, and frequency of treatment for each patient for a particular disease.
3. Assess the patient’s clinical parameters that may impact hyperbaric clinical response and safety. When appropriate, adjust the therapeutic dose, duration, and frequency of treatments based on any changes that have occurred since the previous treatment, i.e., isolation measures, sei- zure precautions, upper respiratory infection (URI), barotrauma, pain, etc.
4. Evaluate for new contraindications to treatment related to a clinical change, including recent sur- gical procedures (such as the accidental creation of a pneumothorax during the placement of a central venous catheter) or a new medication. Certain pharmacologic therapeutics such as an- tineoplastics, stimulants, and psychiatric medica- tions may lower the seizure threshold, increasing susceptibility to oxygen toxicity seizures.[1-3]
5. Evaluate any new medications or medical devices for their interaction with the hyperbaric environment. The physician may have to verify with device manufacturers if their devices are
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HBO2 compatible (pacemakers, ventriculoperito- neal shunts, and implantable medication delivery systems).
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Evaluate the relevancy to the hyperbaric environment of any changes to the patient’s current chest imaging or pulmonary function test or any underlying pulmonary conditions the pa- tient may have that require special consideration.
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Discuss with the hyperbaric medicine team members any specialized nursing needed by the patient during the pre-, intra-, or post-treatment phases.
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Calculate unit pulmonary toxic dosage (UPTD) of oxygen for patients receiving high FiO2s during prolonged treatments ( Table 6, or multiple treatments in one day). These high inspired oxygen concentrations for prolonged periods can cause pulmonary oxygen toxicity.
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Consult with other physicians participating in the patient’s care, particularly concerning any changes such as high fever, catheter insertions or revisions, or the addition of new medications that might complicate the patient’s hyperbaric oxygen treatment.
10.Order and schedule laboratory, imaging, and other diagnostic or therapeutic modalities and interpret their results.
11. Evaluate the development of any psychological stress, such as anxiety or depression, from previous or upcoming treatments and prescribe appropriate treatment for these problems, which may include proper use of anxiolytics and antidepressants.
12.Evaluate the patient’s general medical condition from answers to historical questions and findings from a physical examination. Special attention is paid to possible adverse effects of HBO2 on tympanic membranes, eyes, lungs, and central nervous system. Any harmful effects of previous hyperbaric treatments on potentially closed spaces are evaluated and treated.
13. Oversee clinical safety questions and concerns, including approved material to enter the cham-
ber with, on, or in the patient. These specific items vary from patient to patient and from day to day. The hyperbaric physician is ultimately responsi- ble for everything that enters the chamber. This list includes, but is not limited to, the following:
a. The patient’s clothing, make-up, and hair products for fire risks.
b.Intravenous fluid pumps or patient-controlled analgesia.
c. Cardiac pacemaker or other implantable devices.
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Pre-treat patients with appropriate pain medications and anxiolytics.
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Examine any material injected into any balloon- tipped catheters, drains, or tubes to ensure they have not been improperly filled with air instead of saline, causing a lack of sealing at depth and compromised function or tube loss. Orthopedic or other surgical devices or materials. Modifications, such as the beveling of casts or the padding of the ends of external fixation devices to prevent sparking or chamber tube damage, may have to be performed by the hyperbaric physician and are always done under their authority.
14.Determine whether dressings placed over open wounds are safe and appropriate. Only certain wound care dressings are suitable for patients undergoing hyperbaric medicine, and the provider may need to discuss dressing options with referring providers. Wounds should be closely monitored during the hyperbaric medicine treatment course to assess clinical improvement and for utilization review for the ongoing need for continued hyperbaric therapies.
15. Determine if specialized testing modalities, such as in-chamber transcutaneous oxygen monitoring, will be employed during the treatment and what site(s) will be monitored.
16.Evaluate the patient’s need for any specialized monitoring during the treatment, such as additional guidance in pressure equalization via the Eustachian tubes, fluid restriction, special body position requirements to prevent
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movement that would stress a fresh graft or flap, or continuous electrocardiographic or blood pressure surveillance.
17.Determine the need for adjunctive agents such as vitamin E, pentoxifylline, or antibiotics.[4]
18.Work with the patient (specifically outpatients) to establish what treatment schedule they can meet based on their work schedule, transportation availability, physician appointments, additional scheduled studies (x-ray, CT, MRI, or Doppler vascular), and other activities.
Intra-Hyperbaric Treatment Physician Work
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Diagnose and treat alternobaric vertigo of ascent or descent.
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Manage difficulties with pressure equalization of air spaces, such as the middle ears, sinuses, dental pockets, tight orthopedic casts, etc. These can occur either during pressurization or depres- surization and require immediate management.
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Prevent or manage difficulties with pressure equalization of gas-containing patient appliances, such as colostomy and ileostomy bags, closed drainage systems, and continuous irrigation systems that are not designed for the hyperbaric environment but may be required by the patient. The barometric changes can result in unplanned insufflation of air or liquids into the patient, with potentially serious results.
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Manage oxygen toxicity effects, such as seizures, either grand mal or focal motor.
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Treat acute confinement anxiety and alterations in behavior.
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Manage the potentiation of respiratory depressant medications for patients directly from surgery or post-operative. This includes sedatives or the lingering effects of recent anesthesia, which can result in respiratory or central nervous system depression in the chamber.
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Control the amount of fluid intake during pres- surization for patients on fluid-restricted diets. Many patients equalize pressure in the middle ears by drinking water to open the Eustachian
tubes and fluid intake may vary depending on how easily they clear their ears during treatment.
8. Control the effects of the latent heat of compression and adiabatic decompression cooling to help maintain patient comfort.
9. Alter the treatment profile due to patient or technical problems, as patients may require unplanned depressurization due to equipment failure, medical issues, or emergencies. Since hyperbaric oxygen is a drug delivered in a therapeutic device under pressure, only the hyperbaric physician supervising the treatment can modify the treatment schedule.
10.Manage the medical complications of in-chamber emergencies, such as seizures, hypoglycemia, explosive decompression from chamber failure, or door seal failure.
11.Many patients treated with hyperbaric medicine are chronically ill and have many co-morbid conditions. Patients are treated daily for several hours for a prolonged period, and their chance of having complications during the treatment course is relatively high. The hyperbaric medicine physician should be available to immediately treat life-threatening problems such as acute cardiac compensation, respiratory distress, metabolic derangements, hypo/hyperglycemia, confusion, stroke, pneumothorax, or a myriad of other medical complaints.
12. Patients undergoing treatment may develop acute bleeding, severe pain, claustrophobia, or other complications necessitating evaluation by the physician to potentially stop the treatment and remove the patient from the chamber early for re-evaluation.
Post-Hyperbaric Treatment Physician Work
1. Management and treatment of any problems that occurred during the treatment. Suppose a patient cannot adequately ventilate middle ear spaces and suffers from barotrauma. In that case, the hyperbaric physician evaluates the problem immediately after the treatment, diagnoses the condition, initiates treatment, and determines if
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the patient’s barotrauma will require alteration of their subsequent treatment protocol. Suppose the patient has had ear-clearing problems during previous treatments. In that case, the hyperbaric physician arranges an otolaryngology consultation, and the otorhinolaryngologist places pressure equalizing tubes in the person’s tympanic membrane(s).
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Evaluation of any post-treatment change in the patient’s clinical condition, such as the new onset of pain, shortness of breath, or a change in mentation.
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Re-evaluate the condition of reimplanted digits, limbs, or skin grafts or flaps being treated on an emergency basis for salvage and then communicate with the referring provider to relay these findings so an updated treatment plan can be followed.
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Contact the referring provider for any unexpected event during the treatment. Appropriate referrals for managing new problems, such as seizures, are made by direct contact with the proper specialist by telephone or in person.
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Prescription of any ancillary treatment needed by the patient, such as wound care, physical therapy, occupational therapy, or diabetes training.
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Preparation of the patient's medical records and documentation of findings that would need to be known by other physicians caring for that patient.
7. Based on new findings, coordinate with other physicians concerning other aspects of the patient’s care, such as scheduling surgery.
8. Determine whether the patient may be converted to outpatient or skilled nursing facility status and assist in facilitating that change.
9. The physician should be available to assess staff working inside multiplace hyperbaric chambers as patient attendants. The physician should assess any hyperbaric medicine tender with complaints during or after treatment, such as barotrauma, oxygen toxicity, decompression sickness, or any other clinical issue.
10. Document every procedure note, including a description of time-out, treatment time, treatment number, treatment protocol, diagnosis, vital signs before and after treatment, glucose readings for diabetic patients, complications during treatment, appropriate hyperbaric medicine ICD codes, treatment course, and improvement or lack thereof.
11. Customize treatment based on changes in the patient’s medical condition or acquisition of new diagnoses during their hyperbaric treatment course.
The attending hyperbaric medicine physician providing oversight of the daily hyperbaric oxygen treatment shall be immediately available during the entire treatment session. The physician should be able to respond promptly chamber-side for patient assessment as soon as requested.
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1. Sutter R, Rüegg S, Tschudin-Sutter S. Seizures as adverse events of antibiotic drugs: A systematic review. Neurology. 2015;85(15):1332-1341.
2. Kanner AM. Most antidepressant drugs are safe for patients with epilepsy at therapeutic doses: A review of the evidence. Epilepsy Behav. 2016;61:282-286.
3. Johannessen Landmark C, Henning O, Johannessen SI. Proconvulsant effects of antidepressants - What is the cur- rent evidence? Epilepsy Behav. 2016;61:287-291.
4. Pareek P, Sharma A, Thipparampalli JR, Nag P, Gupta N, Shekhar S, Kirubakaran R. Pentoxifylline and vitamin E alone or in combination for preventing and treating side effects of radiation therapy and concomitant chemoradiotherapy. Cochrane Database Syst Rev. 2016 Mar 10;2016(3):
DOI:10.22462/06.2024.1