Primum Non Nocere and the 5 Rights.

Overutilization of hyperbaric oxygen therapy (HBOT) is commonplace and primarily associated with outpatient wound care. While the number of hospitals providing HBOT is at an all-time high, the number of those willing to treat patients in immediate need is at an all-time low. Huge areas of the country, including major population areas, are now completely devoid of 24/7 HBOT availability and inpatient access. Purchasers of healthcare, including the Centers for Medicare and Medicaid Services, have become increasingly concerned to the point that several strategies have been introduced to constructively deal with this issue. This commentary serves as a counterpoint to concerns that one such approach, prior authorization of elective indications, adversely delays medically necessary care. The historical evolution of HBOT practice will be described to underscore how this problem has become so widespread and, to date, largely unchecked. It will also address the paradoxical national crisis of access for emergencies.

USN Treatment Table 9.

The United States Navy (USN) introduced Treatment Table 9 (USN TT9) in 1999. Its purpose is to provide a dosing protocol for cases of incomplete resolution of decompression sickness (DCS) and arterial gas embolism following initial provision of USN Treatment Table 6 (USN TT6). It also can be used for several non-diving-related acute toxicities. Prior to USN TT9, it was and remains common to use USN Treatment Table 5 (USN TT5) for 'follow-up' therapy. An exception might be cases of severe residual neurologic injury, where some prefer to repeat USN TT6. The primary role of USN TT5, however, is for treatment of 'pain only' (Type 1) DCS that has fully resolved within 10 minutes of the first oxygen breathing period at 60 feet of seawater (fsw) (284 kPa). It is thought helpful here to point out that USN TT9 offers certain safety and operational advantages over USN TT5. As USN TT9 employs a maximum pressure of 243 kPa, a marked risk reduction exists for the injured diver in terms of CNS oxygen toxicity. Seizures are reported during treatment of divers using US Navy protocols, some as early as the second and in one case during the first oxygen breathing period at 284 kPa (Mitchell SJ, personal communication, 2016). The inside attendant likewise enjoys an iatrogenic DCS risk reduction. While air breathing exposure time at 60 fsw on USN TT5 appears modest at first blush, the table can be extended at 30 fsw (203 kPa) for two additional oxygen/air cycles. Such extensions result in a not inconsiderable total exposure time of three hours. DCS risk is also increased if the treatment represents a repetitive dive for the attendant, a not uncommon event. Given the ongoing occurrence of inside attendant DCS, in some cases career ending and twice with fatal outcome, its mitigation should be aggressively pursued (author's personal files). From an operational perspective, both treatment pressure and sequencing of oxygen/air breathing cycles during delivery of USN TT9 are essentially identical to that commonly employed during multiplace chamber delivery of hyperbaric oxygen treatment. Accordingly, it is straightforward enough to incorporate follow-up decompression illness cases into daily clinical practice. Not having this dosing 'match', i.e., using USN TT5, might otherwise disrupt regularly scheduled cases. In my capacity as a medical claims adjudicator and clinical resource, I am involved, to varying degrees, in more than 300 cases of decompression illness each year. In those involving more than a single treatment, it is very much the exception, even after 17 years since its introduction, that USN TT9 is employed. The primary purpose of this correspondence, then, is to make mention of the advantages of USN TT9 and remind providers that it is indeed a standard of care in cases of incomplete relief for those who choose to base decompression injury management decisions on USN treatment procedures.

Pyoderma gangrenosum: dermatologic application of hyperbaric oxygen therapy.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of skin and subcutaneous tissue. The current accepted theory is that PG is an immunologic-based phenomenon. Several therapies have been used to control this disease, including corticosteroids, antibiotics, immunotherapy, dapsone, and hyperbaric oxygen therapy. This article will review the application of hyperbaric oxygen (HBO) therapy in patients with PG. Information for this manuscript was derived from multiple searches of MEDLINE and the National Baromedical Service literature collection. HBO therapy has been shown to effectively treat PG ulcers and reduce pain associated with PG in several case studies. Evidence from the studies cited herein help to establish a foundation for further research to investigate the role of HBO therapy as an adjuvant therapy in the treatment of PG.

Brown recluse spider envenomation: dermatologic application of hyperbaric oxygen therapy.

Envenomation from the brown recluse (Loxosceles recluse) spider commonly proceed on one of three clinical pathways. The majority of bites (90%) result in nothing more than a local reaction. They are essentially self-limiting, require little if any attention, and resolve spontaneously. A great majority of the remaining bites will produce necrotic ulcerations of various sizes and dimensions, with systemic sequela ranging from fever to hemolysis and kidney failure. Finally, and in the most rare cases, the patient will succumb a fatal systemic reaction. Current therapeutic options for these wounds remain controversial and include the following: local care, corticosteroids, dapsone, and hyperbaric oxygen (HBO) therapy. This article will review the application of HBO therapy for patients who are envenomated by brown recluse spiders. Information for this manuscript was derived from multiple MEDLINE searches as well as searches of the National Baromedical Service's hyperbaric specialty literature collection.