Recompression And Medical Ethics

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The in-water recompression in Ginnie last week was due to DAN not being willing to send the diver to a chamber. Well, that's what I heard from two of the divers involved. I wasn't on the phone with DAN at all, so this surprised me.
I have reported probably 25 DCS incidents to DAN as the boat captain. How DAN responds is often dependent on how the report is made. It is very rare, in my experience, that when I say "this diver is bent and needs to be medivacced", that the diver isn't medivacced. Now, I have had the Coast Guard refuse to fly, but never had DAN refuse to treat someone that we thought needed to be treated. I have had them tell me to use O2 and monitor a case of skin bends. Never had them refuse to treat a real type I or II.

It's no skin off of DANs ass to treat a diver. It doesn't cost DAN a penny to get someone treated. If they refused to recommend treatment, than the tech obviously thought the victim wasn't bent. For the tech to say that, the report was obviously not made with proper urgency.
 
The in-water recompression in Ginnie last week was due to DAN not being willing to send the diver to a chamber. Well, that's what I heard from two of the divers involved. I wasn't on the phone with DAN at all, so this surprised me.

That surprises me too, and I suspect it's not the whole story.

Best regards,
DDM

There was an in-water recompression in Ginnie?
 
Man I am learning so much about DCS and chambers and the logic of the almighty DAN (never had to call them up ... yet...*knocks on wood*). And uh ... Florida chamber politics? ... I don't know what to call it.

Anyway ... interesting thread - I will keep an eye on this.
 
Frank, Pete & DDM -- you've pretty much justified how 'effed-up things are in all of Florida.
I have reported probably 25 DCS incidents to DAN as the boat captain. How DAN responds is often dependent on how the report is made. It is very rare, in my experience, that when I say "this diver is bent and needs to be medivacced", that the diver isn't medivacced. Now, I have had the Coast Guard refuse to fly, but never had DAN refuse to treat someone that we thought needed to be treated. I have had them tell me to use O2 and monitor a case of skin bends. Never had them refuse to treat a real type I or II.

It's no skin off of DANs ass to treat a diver. It doesn't cost DAN a penny to get someone treated. If they refused to recommend treatment, than the tech obviously thought the victim wasn't bent. For the tech to say that, the report was obviously not made with proper urgency.
Here in offshore/nearshore Southern California:

Simple straightforward triage as a Layperson First Responder (i.e. DiveBoat Captain, Dive Master, Rescue Diver etc on the scene), based on initial reported symptoms and worst case scenario of a just surfaced conscious diver onboard in post-dive distress . . .Rule Out DCS and/or AGE, and start victim breathing on O2. Once the chain of care is started, only the Patient can refuse further treatment AMA (Against Medical Advice).

Radio-in, rendezvous & evacuate patient by Baywatch Paramedic Boat or US Coast Guard Helicopter to Big Fisherman Cove West End Catalina Island while underway at sea. Evaluate and begin Hyperbaric Oxygen Therapy at Catalina Recompression Chamber as necessary with attending Emergency Medicine/Hyperbaric Specialist Physician on-call & enroute by Helicopter, and then post-treatment assessment & stabilize for transport. Helicopter patient back to mainland LA/USC County General Hospital for further diagnostic work-up/treatment as needed for secondary conditions or comorbid pathologies.

IMO, this is the preferred beginning of the standard chain of care for all dive accidents here in SoCal with suspected DCS/AGE --whether victim is conscious or unconscious; alert & oriented or in full cardiorespiratory arrest: the initial response and call for immediate aid should always be the same. Even with late onset of DCS symptoms and presentation at a private mainland Southern California Emergency Dept/Hospital, I would still recommend insisting on consultation with an LA County ER/Hyperbaric Physician, with possible evacuation by chopper to the Catalina Island Recompression Chamber if a mainland private hyperbaric facility is closed-after-business-hours. . .

(Y'all are totally 'effed-up there in Florida. . .)
 
(Y'all are totally 'effed-up there in Florida. . .)
Like I said, we don't do ratio deco, so we don't have the same needs as you. Rail against us all you like.
 


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Dial it down, or I'll start removing posting privileges in this thread.
 
Can I buy a chamber and put it in the back of a semitruck and drive around N/mid Florida - I'll meet the helicopter halfway!

How feasible would it be to put a filling station and a chamber in a semitrailer?


This is a serious question - even though it sounds insane.


This seems relevant: gas embolism at vortex springs. 7 days ago.

Scuba diver almost dies; turned away from E.R.

It doesn't sound insane at all. The Navy does just that with its Flyaway Recompression Chambers. The hard part would be getting the funding, and physicians and staff willing to run it 24/7.

The news report, thought a bit sensationalistic, does speak to John's original question in that Florida Hospital in Orlando is no longer treating divers, and as I understand from their transfer center they're business hours only now. It's not just the divers who will suffer; what about the 6-month-old baby with carbon monoxide poisoning at 2 am? Another one down. It's a bloody shame.

Best regards,
DDM
 
It doesn't sound insane at all. The Navy does just that with its Flyaway Recompression Chambers. The hard part would be getting the funding, and physicians and staff willing to run it 24/7.

The news report, thought a bit sensationalistic, does speak to John's original question in that Florida Hospital in Orlando is no longer treating divers, and as I understand from their transfer center they're business hours only now. It's not just the divers who will suffer; what about the 6-month-old baby with carbon monoxide poisoning at 2 am? Another one down. It's a bloody shame.

Best regards,
DDM

Yea finding staff would be the problem. The news report is something I just ran across today and it seemed to fit somewhat. It's going to be unfortunate when someone needs that chamber at a time that's not 9-5 or whatever the hours were.
 
In this day and age, it's not just getting a piece of equipment, it's maintaining it, having people not only trained/able to with whatever licenses/certifications are needed to provide the services, volunteer = 'Someone who works for free under no obligation' so finding plenty of dependable ones for consistent, full-time staffing can be a problem, and what happens when someone has another serious medical event mistaken for DCS, gets diverted to a recompression chamber instead of a standard E.R., dies & the family sues, claiming whoever made that call was in the wrong and had the diver gone to the E.R., he'd be alive. Who pays the malpractice insurance? And what all support is needed or regulations must be met for a room of facility to house a recompression chamber?

And what would all this cost? Does Florida have a big budget deficit like some other states? How's funding the pension plan for state workers going? What's the vaccination rate amongst poor kids? These days, if you want a pile of money for something, there are likely competing interests after that same pile.

Richard.
 
It might be a good time to circle back to John's original question, which is, what are the ethics of not treating an injured diver when a facility has the staff and training to do so?

First, I think that there are some misconceptions about hyperbaric facilities, in that some believe that any hyperbaric facility has the capability and equipment to treat injured divers. This is definitely not the case. The overwhelming majority of hyperbaric chambers in this country are monoplaces (i.e. only one patient at a time can be treated in the chamber) associated with wound care clinics, and are used as an adjunct to wound healing. The medical professionals who staff these clinics are by and large excellent at what they do, which is, heal wounds. However, many of the physicians are not fellowship-trained in hyperbaric medicine; rather, they attend a week-long introductory course. This course does not prepare them to diagnose and treat diving injuries. Also, monoplace chambers are pressurized with 100% oxygen and many do not have the ability to provide a patient with air breaks as required by the U.S. Navy treatment tables. Would it be ethical for one of these facilities to agree to treat a diver? Arguably not.

The second, more fuzzy situation is the one mentioned in the article that Reku linked, in which a hyperbaric facility that used to operate 24/7 and treat emergencies stops doing so. There are a few reasons that this could happen: first, I can tell you from years of first-hand experience that it's difficult to staff this. I wish I had a dime for every minute I spent on the phone trying to get a PRN critical care nurse to come in and dive with an intubated patient. Often I'd end up going in myself, relying on my hyperbaric fellow and attending physician for outside chamber support, and catching up on the charting when the treatment was finished. Some facilities have staffing challenges that force them to give up treating 24/7 emergencies.

Another consideration that's already been mentioned is financial. Divers make up a vanishingly small fraction of the income for most hyperbaric facilities, and DCS isn't the most common emergent indication treated. It also costs money to pay staff to be on call 24/7, and the overtime adds up quickly in 24/7 facilities, our own included. The present environment of diminishing reimbursement from Medicare and private insurance carriers makes it increasingly difficult for hospitals to operate, and quite frankly, every health care facility in the U.S. is looking for ways to streamline care, operate more efficiently, and yes, cut costs. It's only going to get worse in the years to come. Reimbursement decisions are algorithm-based and are made by people with very limited knowledge of hyperbaric medicine. Here's an example (with back story): hyperbaric patients being treated for chronic conditions may require up to 60 treatments in order for the therapy to be effective. At Duke, we offer patients two treatments per day because we have the physical capacity to do so. This allows them to complete their treatment course much more quickly. Medicare refuses to reimburse for twice-daily treatments. It doesn't cost them any more, but some under-informed bureaucrat decided that only one treatment per day is reimbursable. Who's on Medicare? Retired people, many of whom are on a fixed income, and many of whom (in our case) come from a long distance away. Getting their treatments twice daily would let them go back to their daily routines faster, maximize their quality of life and minimize their expenses (many of them stay in hotels). This case has been made to Medicare numerous times, without success.

Here's another example: if we treat an emergency, some private insurers require us to inform them within 24 hours. If you've ever tried to navigate a phone menu for a health insurance company, you know what we're up against. We have to punch the same buttons that patients do and wade through endless automatic phone menus that don't have what we need. However, if we don't call within 24 hours the patient gets stuck with the entire bill. Our administrative coordinator fights this every day.

Here's another example: many state subsidiaries of a certain well-known private payor now operate under the Milliman Care Guidelines (MCG) for reimbursement. The MCG for hyperbaric oxygen therapy include only three of the fourteen UHMS-approved indications, and these state subsidiaries will not reimburse for things like late effects of radiation (the best-studied indication for hyperbaric oxygen) or carbon monoxide poisoning. MCG is a private company that ostensibly looks at all the available evidence on which treatments are effective and then sells the results of that research to insurance companies. What kind of research do you think insurance companies are going to lean toward: that which requires them to reimburse more, or reimburse less? In the interest of fairness, the North Carolina branch of this payor has been very reasonable and, upon our request, agreed to change its policy to reflect all of the current UHMS-approved indications.

In other words, another reason that emergency hyperbaric facilities are closing is that hospitals are being forced to significantly alter the way they do business as a result of tighter and tighter reimbursement criteria from both government and private payors. Some health care administrators come to the conclusion that the return on investment of keeping a chamber crew on call 24/7 is insufficient because the volume (and therefore the reimbursement) is relatively low. The case could be made that it is neither ethical nor in the best interest of patient care to further limit access to a treatment modality that can preserve life or function.

Best regards,
DDM
 
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