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TEKDiveUSA

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What are your thoughts on in water recompression? At TEKDiveUSA.2018 David Doolette will be presenting the process and evidence behind a committee of diving medicine experts who recently revised guidelines for the prehospital management of decompression illness. This committee reached a cautious, qualified endorsement of in-water recompression in some circumstances. Is this a topic you are following?
DavidDoolette2018-1024x621.jpg
 
our opinions be damned, they're closing chambers left and right. If you get bent in Hawaii, you have to FLY to California to get into a chamber... Even in cave country it's getting harder to get into a chamber. We have to come to the reality as an industry that the chambers are closing and we have to be prepared for the reality that IWR is quickly becoming the safest option to treat DCS because of proximity and availability of chambers.
I've purchased my FFM, switch block, and carry extra O2 bottles because of it. IWR plans are printed and laminated with several copies attached to different parts of the equipment. Cheap insurance
 
I think tbone1004 made the point--you HAVE to be following this topic if you are a tech diver, whether you are in remote areas as I am often, or next to a major city with a major hospital. Medical services have made it so that we are on our own. Whether you live or die is up to the resources you bring with you on your dive, because in too many cases, the hospitals and doctors aren't going to lift a finger to help.
 
I was a member of a consulting group doing a feasibility study for a fairly large hospital investigating HBOT (HyperBaric Oxygen Treatment) facilities. Unfortunately, chambers that support unscheduled 24/7 emergency treatment is an awful business plan. Conventional mono or multiplace scheduled treatment centers that operate 8/5 (8 hours/day, 5 days/week) are hard enough to break even with -- even before the bizarre hospital billable markups are applied. Utilization of facilities and staff has to be pretty high and accepting an emergency patient screws up a fairly full schedule of patients. It really doesn't matter if the emergency is a diver with DCI or a CO poisoning case.

Multiplace HBOT facilities suitable for DCI treatments also require a relatively large footprint once you include support machinery (compressors and larger LOX storage) plus staff support. Hospitals make a lot more money on a diagnostic machine they can wheel up to a bedside on a per dollar invested basis; including the initial investment, trainings, certification, and maintenance.

Why Are Fewer Chambers Available for Emergencies? By Marty McCafferty, EMT-P, DMT
 
"Recompression in the water should be considered an option of last resort, to be used only when no recompression facility is on site and there is no prospect of reaching a recompression facility within 12 hours.... in divers with severe type II symptoms or symptoms of arterial gas embolism (e.g., unconsciousness, paralysis, vertigo, respiratory distress, shock, etc.), the risk of increased harm to the diver from in-water recompression probably outweighs any anticipated benefit. . ." (US Navy Dive Manual).

In addition to the presentation on IWR, perhaps there should be another discussion on how to set up a non-profit, local municipal government run Recompression Chamber EMS operation in the United States (i.e. North Florida) as well. . .
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I was a member of a consulting group doing a feasibility study for a fairly large hospital investigating HBOT (HyperBaric Oxygen Treatment) facilities. Unfortunately, chambers that support unscheduled 24/7 emergency treatment is an awful business plan. Conventional mono or multiplace scheduled treatment centers that operate 8/5 (8 hours/day, 5 days/week) are hard enough to break even with -- even before the bizarre hospital billable markups are applied. Utilization of facilities and staff has to be pretty high and accepting an emergency patient screws up a fairly full schedule of patients. It really doesn't matter if the emergency is a diver with DCI or a CO poisoning case.

Multiplace HBOT facilities suitable for DCI treatments also require a relatively large footprint once you include support machinery (compressors and larger LOX storage) plus staff support. Hospitals make a lot more money on a diagnostic machine they can wheel up to a bedside on a per dollar invested basis; including the initial investment, trainings, certification, and maintenance.

Why Are Fewer Chambers Available for Emergencies? By Marty McCafferty, EMT-P, DMT
A misleading and inadequate assessment in the Alert Diver/DAN article, of the standard of care to treat the full range of morbidity in DCI Cases:
. . .Compounding the problem is that some injured divers are turned away because of a misconception that divers need a level of care beyond what a facility can provide. In fact, divers are generally healthier and more stable than the average wound-care patient. Nor do injured divers need a chamber that can be pressurized to more than 2.8 ATA (60 feet of seawater), as is mistakenly believed by some health-care providers. The standard of care for the overwhelming majority of dive injuries is a U.S. Navy Treatment Table 6 (USN TT6). This treatment protocol does not exceed 2.8 ATA. Monoplace (single-occupant) chambers are capable of providing a USN TT6. . .
Alert Diver | Why Are Fewer Chambers Available for Emergencies?
This is what the DAN article above fails to consider:' A worst case emergent scenario of a dive casualty with AGE near drowning in full arrest, will need a 6 ATA capable Multiplace Chamber (multiple occupants including the patient, Chamber Patient Tender and an assisting Paramedic EMT) with an Auxiliary Lock to provide accessibility for an Emergency Medicine Physician with Hyperbaric sub-specialty to examine the patient at treatment pressure, as well as to return the Physician to surface atmospheric pressure in order to prescribe additional Advanced Cardiac Life Support (ACLS) treatment as needed.

There is a difference between a standard level of care mentioned in the article above, and a "Gold or Trauma Level Standard of Care":
. . .Most chambers in the U.S. are used primarily for hyperbaric oxygen treatment for wounds or diabetes and secondarily if at all for diving accidents. They are smaller one or two person chambers meant to pressurize only to the equivalent of a 66-foot depth (3 ATA) in order to improve oxygen saturation to damaged tissues. The Catalina Hyperbaric Chamber has bunks to treat two divers and has been pressed into service to treat as many as four with attendant doctors, EMT’s, and tenders. It can pressurize to 165 feet (6 ATA) in order to squeeze bubbles to their smallest diameter to treat embolisms. It is, therefore, ideally suited to treatment of [all] diving injuries. . .
USC Dornsife Scientific Diving: The Catalina Hyperbaric Chamber

-->The best local resident divers in the world along with welcoming visitors to the best diving here in SoCal, deserve the best emergency support 365 24/7 --all provided by the only civilian joint private university-municipal government run, 6 ATA Recompression Chamber in the United States solely for the treatment of Diving Accidents, as an integral part of Los Angeles County EMS/Fire & Lifeguard/Paramedic and US Coast Guard offshore rescue operations.
Obviously @Akimbo , you can't run a large multiplace 6ATA Recompression Chamber as an independent private business and medical clinic operation treating diving casualties only -there's no way it can financially sustain itself. And @boulderjohn , the reason why you have private "UHMS accredited" hospital facilities refusing to take dive accident casualties is because of the high malpractice insurance for such a low volume of infrequent DCI cases, and also the expense to staff on-call personnel to cover after hours and weekends on 24hr stand-by for emergency DCI cases, plus they most likely do not have a Recompression Chamber rated to 6 ATA for worst case scenarios such as AGE. Unfortunately the bottom line for private facilities comes down to liability and profitability.

Again, the concept to apply in running a Dive Casualty Only Recompression Chamber is similar to running a volunteer fire department -the call volume is not as great or frequent as a major metropolitan city or county, but the Emergency Service is still there on stand-by ready to respond.

One unique solution in operation since 1974 is the Catalina Hyperbaric Chamber Model: a strategic hybrid combination of tax-supported county/state dept of health, hospital & EMS services, volunteer chamber crew, and annual monetary donations & organized charity drives from the regional diving community, and major business corporate sponsorship for example to initially install a 6ATA Multiplace Recompression Chamber -in order to make this urgently needed service to work. (The legal protection comes from being administered as part of a municipal government EMS operation, under a statute of Sovereign Immunity). Again, the cost of stand-by 24/7 operations for treating dive accidents only using volunteers and an on-call ER/hyperbaric physician is not as expensive as running a for-profit full service weekday 9-to-5 Diabetic Wound Care Hyperbaric Clinic facility.
 
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@Kevrumbo

The biggest problem with a private chamber is getting paid for services. Most private and government insurance will not reimburse treatment from a facility unless it has either associated themselves with medical facility or jumped through more expensive bureaucratic hoops than the cost of a small double lock chamber. Even a volunteer operations have a lot of expenses to stay operational.

Something is way out of whack when the US Navy won't treat US citizens anymore.
 
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@Kevrumbo

The biggest problem with a private chamber is getting reimbursed for services. Most private and government insurance will not reimburse treatment from a facility unless it has either associated themselves with medical facility or jumped through more expensive bureaucratic hoops than the cost of a small double lock chamber. Even a volunteer operations have a lot of expenses to stay operational.

Something is way out of whack when the US Navy won't treat US citizens anymore.
Which is why a volunteer Dive Casualty Only Recompression Chamber based on the Catalina Model works @Akimbo : it doesn't rely on expensive annual UHMS accreditation requirements for Medicare reimbursement coverage of high volume treatment cases like Wound Care for example. Again, because of the low frequency of DCI cases, the cost of stand-by 24/7 operations for treating dive accidents only using volunteers and an on-call ER/hyperbaric physician is not as expensive as running a full service weekday 9-to-5 Diabetic Wound Care Clinic.

Here's another and better solution for North Florida that they should be addressing at this TekDive USA conference in Orlando:

Shands/University of Florida Medical Center in Gainesville deserves establishment of a dedicated Hyperbaric Medicine Department -or at least a sub-specialty within Emergency Medicine or Anesthesiology- along with a large 6 ATA Multiplace Recompression Chamber with Auxiliary Lock Entrance to treat all routine inpatient/outpatient cases, as well as 24/7 emergency support of acute to critical DCI/near drowning dive accidents & casualties. There is a clear medical need, and perhaps DAN can be an ombudsman for the resident diving community to alert state dept of health and gov't officials of the problem (and maybe @Duke Dive Medicine can offer advice and opinion on this too), as well as helping to secure federal Dept of Health & Human Services Grant Funds to purchase and install a campus hospital based 6ATA capable Chamber.

This is the most viable solution you have right there in nearby Florida cave diving country, with a large pool of 24/7 available on-call Resident, Teaching Fellow, and Staff Attending Physicians specializing in Emergency Medicine and perhaps later with subsequent additional Hyperbaric training. It's the best permanent and sustainable model, because of the state's tax supported and publicly funded University of Florida Medical School, regional Level 1 Trauma Center designation, and better legal protection and immunity.
 
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https://www.shearwater.com/products/peregrine/
http://cavediveflorida.com/Rum_House.htm

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