Monday, August 6, 2012

Six Questions with Dr. Jeffrey Niezgoda

President, American College of Hyperbaric Medicine (ACHM) 
Medical Director, The Center for Comprehensive Wound Care and Hyperbaric Oxygen Therapy, St. Luke's Medical Center, Aurora Health Care, Milwaukee, Wisconsin    
President and Chief Medical Officer of   
Associate Professor and Hyperbaric Consultant, Medical College of Wisconsin 
MD from the Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland, 1985    
BS in Biology from the US Air Force Academy, Colorado Springs, Colorado, 1981

Jeffrey A. Niezgoda, MD, FACHM, MAPWCA, is a recognized wound care and hyperbaric medicine expert, educator, and entrepreneur. We know him best as president of the American College of Hyperbaric Medicine (ACHM), a professional organization working to develop an image of hyperbaric oxygen therapy as a distinct medical specialty, often requiring full-time practice. His work uniquely spans the clinical, professional, academic, and business aspects of hyperbaric medicine today. He spoke with us in his Milwaukee offices in March 2012.

HyperbaricLink: Tell us about the first time you ever saw a hyperbaric chamber.
Niezgoda: My first exposure to hyperbaric medicine was many years ago, circa 1976. I grew up here in Milwaukee and had the privilege of touring St. Luke’s and the hyperbaric unit when I was an Explorer Scout. I was 17 or 18 years old at the time, and I joined a medical explorer post, because I wanted to go into medicine. Ironically, the hyperbaric chamber tour was conducted by Dr. Eric Kindwall, who many years later became my colleague and mentor, and a dear friend. I clearly remember him showing us the original multiplace chambers, Bonnie and Clyde. I’m very sad that he’s no longer with us. I often think back to that day that I first met Dr. Kindwall, at the time never dreaming of walking in his footsteps. It is amazing to me that I have been so fortunate to have had the honor and privilege to come back to Milwaukee to practice hyperbaric medicine.

HyperbaricLink: Can you a recall one real breakthrough success or aha! moment in your career?
Niezgoda: Yes, it was when I was doing my fellowship at Travis Air Force Base, in the late 1980s, working with another one of the world renowned hyperbaric physicians, Dr. Ben Slade. I was still learning and questioning certain aspects of hyperbaric medicine, in a way trying to validate it in my own mind. Much of our time was dedicated to treating the standard conditions. But Ben always liked to push the envelope, and use HBO to help patients that presented with problems that theoretically would benefit from hyperbaric. So from time to time we would treat conditions that were considered experimental back then, under IRB [institutional review board] guidance, of course. Sometimes the patients improved, sometimes not. One day Dr. Slade came in to Morning Report and said, “We’re going to start treating a patient with brain abscess.” I was thinking to myself, “You've got to be kidding! Here we go again.” The patient was actually incarcerated at the prison in nearby Vacaville, California. Every day two armed guards brought the prisoner in from the infirmary, by ambulance, on a gurney, dressed in his orange garb. I thought that the handcuffs and guards were somewhat silly as the patient was essentially comatose due to high intracranial pressure and mass effect from several large abscesses. He was obtunded and didn’t know who he was or where he was. He had been on broad-spectrum antibiotics for several days and really wasn't getting any better. The neurosurgeon who referred the patient to us said, “If I open this patient’s cranium to drain the abscess, he will end up herniating and dying.” So this is how it went day after day. The patient would come in for treatment, we would say hello and he would not respond in any way. Well, I’ll never forget it. On hyperbaric day 7 or 8, I was sitting with my back to the door, charting. Klaus, my med tech, came in and said, “Dr. Niezgoda, Mr. XYZ is here for his treatment.” Very facetiously, without looking up, I said, “Great! Let the party begin!” All of a sudden I hear a voice I didn't recognize say, “I’ll bring the women and the beer!” I turned around and see this guy is sitting up in his gurney, fully awake, fully conversant, sharp as can be. It was simply amazing.

HyperbaricLink: How would you characterize the status of hyperbaric oxygen in healthcare today?
Niezgoda: The overall acceptance and validation of hyperbaric medicine as a true medical specialty is probably the biggest change that has happened over the last 5 to 10 years. When I was doing my fellowship we had to really work for patient referrals. There were a lot of naysayers. There was a lot of skepticism. We were criticized for the lack of hyperbaric literature. We worked hard to convince our colleagues that HBO was a valid adjunctive treatment. It often felt like I had to be a cheerleader or salesman for this treatment modality. Fortunately for our patients, much of this has changed. Some really excellent clinical and research studies with supporting publications have appeared in the literature. Based on the literature and excellent clinical outcomes, hyperbaric has truly emerged as a primary advanced treatment modality for wound care patients. Younger doctors appear more ready to accept case studies which highlight some really amazing success stories and refer their patients for care. I think mainstream medicine has finally accepted hyperbaric as a viable treatment. It is rewarding after all these years of hard work, advocating for a treatment that I believe in based on outstanding results and limb salvage, to have physicians who had previously doubted and questioned hyperbaric—the plastic surgeons, the vascular surgeons, the general surgeons—now calling and asking for our help.

HyperbaricLink: What can the hyperbaric community do to better educate the public and referring physicians?
Niezgoda: I don't think that, as hyperbaric physicians, we like to boast or wave our flag. I think we do a great job of providing care. I think we do a great job of taking care of patients. However, we don’t do a very good job of telling our success stories. We have wonderful success stories, great outcomes, and amazing stories to tell about healing. Unfortunately, this information does not get shared very well. We need to tell the world what a huge impact we make in people’s lives. When a young child nearly drowns and is resuscitated and has a great outcome, the media praise the medical community. It makes the news headlines. Limb salvage, necrotizing fasciitis, and carbon monoxide cases, quite frankly, can be just as impressive. Sure, patients go out and talk about it. But if you try to market anything in the US by word-of-mouth, one by one by one by one, it’s an incredibly slow and uphill climb. We don’t have an effective mechanism for selling our success. We need to better educate our colleagues, we need to tell the community our success stories.

HyperbaricLink: Where do you see things going in the next 3-5 years?
Niezgoda: I suspect that we will see several changes in the field of hyperbaric medicine, some good, some not. I would anticipate that within the next few years several new treatment indications will be accepted. This will be due to current and ongoing research, but also because of continued efforts on the part of the lay public, some of whom are strong advocates for use of HBO for conditions that aren’t on that list of approved indications. One of these indications will relate to the use of HBO for acute hypoxic or ischemic periods, such as for acute ischemic injury to the brain, to the heart, to the lower extremities. I am hopeful there will be an improvement in the way we educate hyperbaric physicians. Newer platforms such as online courses and certification pathways will enhance the care provided to our patients. CMS has already accepted online hyperbaric education, now we just need the professional hyperbaric societies to do the same. Unfortunately, I also see that reimbursement for wound care and hyperbaric services will be cut, which will translate to program closure. Without access to this care, patients will ultimately be negatively impacted, they will suffer with nonhealing wounds and amputations.

HyperbaricLink: If you could teach the world one thing about hyperbaric oxygen therapy, what would it be?
Niezgoda: Good question. Hyperbaric oxygen therapy can achieve some impressive results, some amazing outcomes, and it is complementary or adjunctive to standard care plans. In a limb salvage effort, for example, hyperbaric oxygen can augment surgical and medical care, it can be that bridge, that additional treatment that reverses tissue hypoxia, helps healing, and prevents amputation. So if I could help my surgical colleagues to consider hyperbaric oxygen therapy, rather than defaulting to amputation, that would be a huge lesson. If we could communicate the efficacy of hyperbaric in the care of diabetic foot ulcers, I think we would be doing our patients a great service.

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