Have you ever seen an oxygen toxicity seizure? You can see one on this You Tube, produced by the U.S. Navy many years ago.
Here are the verbatim comments of hyperbaric technicians (from the Hyperbaric Oxygen Therapy Registry) who observed oxygen seizures during routine hyperbaric treatments:
- “He flexed his arms across his chest, eyes deviated to the right and he developed a generalized seizure for 4 minutes.”
- “The patient had a tonic/clonic seizure that lasted 15 sec.”
- “The patient had a seizure (sic) lasting approximately two minutes.”
- “During the ascent developed generalized tonic/clonic convulsion.”
- “He noted loss of clear hearing of television and then had a seizure that lasted for approx. 6 minutes.”
- “He noted that the TV voices were breaking up, took his airbreak and had a 10 minute seizure.”
About a decade ago, I did a safety analysis from the Hyperbaric Oxygen Therapy Registry (HBOTR) for a UHMS Gulf Coast meeting. The HBOTR data (10 years ago) had details on 3,757 patients who underwent 94,349 hyperbaric treatments (an average of 25 treatments per patient). There were 30 patients reported to have had an oxygen induced seizure. To determine the validity of those data, I personally read the notes from each of the events. That’s where I got the quotes above. Every one of these events was unquestionably real. Separately, there were 137 episodes of acute onset shortness of breath, and 2 patients had sudden loss of consciousness.
I haven’t looked at HBOT safety data since I did that presentation, which was about 10 years ago. The HBOTR has grown at a logarithmic pace in the past decade. However, there’s never been any real support for what it does or the data in it. I keep it because it seems important. Today I was wondering what would happen to those patients who had seizures if no physician had been in attendance. The patients would have survived of course. We can’t say that with confidence about all the patients Helen Gelly has documented as having cardiac arrests during HBOT. Bad things during HBOT are rare. It’s much more common for patients to have ear clearing problems or a “bathroom emergency.”
It’s possible that hyperbaric oxygen therapy treatments will no longer require the “direct supervision” of an advanced practitioner trained in the field. That’s the language in the proposed rule for the Hospital Based Outpatient Payment System.
If you think that HBOT should NOT be moved to “general supervision” (which does not require a physician immediately available), you can post a comment here, but the deadline is THIS FRIDAY, SEPTEMBER 27TH.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
Hyperbaric oxygen treatment should require direct supervision.
Depends, what exactly do you consider direct supervision. O2 toxicity is real & so are the O2 induced seizure. But this article lack specifics, what depth, how long…what table was followed. I worked 10 years on hyperbaric chamber, we *never had a seizure. The ‘medical attendant’, usually specialy trained RN, (sometimes hyperbaric specialist) was *’locked in chamber’ with a pt. And that is the safest way, and should be the standard in Hyperbaric medicine. You do not need a physician for ‘direct observation’, “hyperbaric physician” needs to be available by phone (don’t ever hire a regular dr. for Hyperbaric medicine)
I feel much better knowing a physician is readily available in case of those rare occasions. Taking supervision away leaves so many at risk. Sometimes for the patients just knowing a doctor is present is reassuring especially since a treatment is every day.
It needs to be a specialist / a physician trained in altitude physiology
Hyperbaric oxygen therapy absolutely requires physician supervision. Think about our patient population. Many of them are in danger of dropping did injure waiting room, let alone should someone give them a physiologic push they cannot tolerate.
As a HBO tech and safety director for the last 15 years, I definitely want to know there is a Physician in the house when we treat. Most of our population of patients are at risk for various reasons, so having a Physician immediately available makes the tech, the patient and the rest of the staff more at ease. It is true, the need for the supervising physician to make an immediate action or treatment decision is rare but always a possibility.
Having been a non clinical administrator at numerous centers that offer HBOT I would suggest that the cost savings of taking a physician away is not worth the risk. I think that its important to keep a physician on site during treatment.
I agree with Brian. Having recently transitioned from an HBO safety director to a non-clinical admin role, I think all of the rigorous pre-screening, checklists, and daily evaluations have been highly effective at limiting these sorts of events. However, even with all those measures in place, I have witnessed two seizures in my 10 years of operating chambers. It’s very easy to get lulled into complacency. My initial reaction is that this would be a slippery slope that may lead centers the way of Ocean Hyperbaric Neurologic Center in Florida.
Excellent analogy
Physicians are our support system and if nothing else, an extra set of hands in a event. .
There definitely should be Direct Supervision. In an emergency, it is important to have fast response from a trained MD
Patient safety and the responds time to any incidents in an HBO chamber should not be compromised. Losing the presents of a provider could lengthen responds time and put patients are more risk of injury
The level of the trained provider must be taken into consideration. Consider an NP who worked ED/Trauma for more than 15 years, has intubated more than 100 pts, placed chest tubes, central line, ran codes and trauma teams. Worse HBO2 pt event was recognizing flash pulmonary edema from a cough. I had a very busy Family Physician as a supervising Dr. at the time. He also told the patients “ if there’s any acute complication, we’ll both be better off if she’s here”. In todays healthcare with hospitalist caring for inpatient treatments, many Dr. covering HBO2 could not do more than rely on 911 or acute care/ rapid response staff in an adverse event. So given this scenario, level of confidence with training has to merit some consideration. Anyone can sit through a training class but to put it in practice is all together different. Just my thoughts. Good day.
The article does not have specifics, at what table the patients were treated. I work 10 years in hyperbaric chamber, we have never had a seizure. RN trained in altitude physiology was *’locked in the chamber’ (or sometimes Hyperbaric specialist). Don’t ever hire regular MD, the ‘Physician that specializes in Hyperbaric Medicine’, should be available someplace on site, or by phone; no need for direct supervision
The potential of physician assistance allows treatment of a larger patient population, with a wider (and often more severe) set of co-morbidities. This is true in both the mono- and multiplace environment. While it is true that many of the “first line” procedures involved in emergencies encountered in the HBO2 enviornment are handled almost exclusively by the chamber operator/technician, it is also true that physicians (or clinicians with similar degrees of autonomy and medical training, whether they be NPs, PAs, etc.) can provide assistance in the latter stages of these emergency events. Whether it be something as simple as that doctor having a working knowledge of where your HBOT unit’s chest tube/intubation kits are stored, to something more complex, such as assisting in emergency extrication during a fire, a hyperbaric physician is not only a trained medical professional, but one who (we assume) has at least a cursory understanding of the types of emergencies that can arise, as well as a knowledge of things like the location of your Main O2 Zone Valve, etc.
The key, to me, is that there is simply too much variability from program to program. There is no mandate for nursing to be present for a treatment, for instance (although I agree this is best practice). There is no mandate for technicians to receive advanced training (such as use of an ACLS Crash Cart). (And, to do so would often break a hospital policy). Therefore, (and especially since the physician is required to prescribe HBOT, and will be billing for it,) it only makes sense that the physician is the “easy” component of your staff to require to be available.
The mandate for “immediate” availbility isn’t complicated. It allows the physician to practice with relative autonomy in various capacities within the hospital (absent scrubbing into surgery). If a physician cannot commit to simply breathing within range of the hyperbaric chambers as they’re treating patients, then the physician should have nothing to do with the administration, prescription, or practice of HBOT.
In closing, I would like to clarify that I consider DPMs to be physicians, and thus fully capable and trained to administer emergent care, including the re-inflation of a lung in a situation of life or death (just like a paramedic.)