Weekly Web Roundup: 27 November 2010

We hope our readers in the United States are having a pleasant Thanksgiving holiday and that those elsewhere in the world are enjoying whatever non-stuffed-turkey-involved events are appropriate to their locale. The luxury of few days off has given us the opportunity to relight the boilers and get the weekly roundup moving again.

SCIENCE

Surgeons in the department of thoracic surgery, Ondokuz Mayis University Medical School, Samsun, Turkey, report in the December 2010 issue of The Thoracic and Cardiovascular Surgeon that a week of hyperbaric oxygen therapy helps healing of anastomosis surgery wounds after irradiation and resection of the trachea in an animal study.

Preliminary results from a 24-patient study in China suggest that hyperbaric oxygen therapy may be effective for improving recovery from erectile dysfunction after posterior urethral reconstruction.

Medscape Today provides a case report of a rare necrotizing infection involving an intraperitoneal rupture of an infected urachal cyst. Apparently, HBOT wasn't available in this case.

PRESS/BUSINESS

On December 10th, from noon to 1:00 pm, Dr Thomas Serena, medical director of the Snyder Institute for Vascular Health and Research, will discuss how the Snyder Institute is utilizing hyperbaric oxygen to prevent amputation in diabetics. His presentation is part of a free seminar at the Alle-Kiski Medical Center Hospital in Kittanning, Pennsylvania.

Check out this video tour of McMurdo General Hospital in Antarctica. Conducted by Major Greg Richert, flight surgeon, the tour includes the continent's hyperbaric chamber.

One of the miners who escaped from the Pike River mine in New Zealand after the initial explosion was treated with HBOT for carbon monoxide poisoning according to the New Zealand Herald.

Perry Baromedical has been selected to supply hyperbaric chambers to Restorix Health. Headquartered in Bellevue, Washington, Restorix Health is a community-based center for advanced wound care affiliated with the Restorix Research Institute.

The story in the Pittsburgh Tribune Review on carbon monoxide poisoning reports numerous incidents and insight from Dr. Kevin S. O'Toole, director of the University of Pittsburgh Medical Center's hyperbaric medicine department.

PATIENT STORIES

From the Twin Cities Pioneer Press comes a wonderful success story. The combined efforts of The Hennepin County Medical Center, an Undersea & Hyperbaric Medical Society Accredited Facility, and the renowned Mayo Clinic saved a woman's foot and even seem to have eliminated her migraine headaches. She's published a book and is donating the proceeds to hyperbaric research. Osteomyelitis, or bone infection, is one of the FDA-cleared conditions for hyperbaric oxygen therapy. Migraine and other conditions await more research.

Have news you'd like to share? E-Mail it to us at: press@hyperbariclink.com.

Black Friday

Is the shift from a day dedicated to thanksgiving to a day devoted to voracious acquisitiveness giving you philosophic whiplash? Does the prospect of working off turkey fat by elbowing your way to the best deals on this season's consumer electronics seem rather distonic?

Join us, then, as winter heating season begins, for a brisk walk through the terrain of uncertainty surrounding patients suffering from carbon monoxide poisoning and its long-term effects. Although CO poisoning is an approved indication for hyperbaric oxygen therapy, it is a vastly underutilized treatment for that condition and one for which clinical research is sparse and contradictory.

In studies cited by the Undersea and Hyperbaric Medical Society's Hyperbaric Oxygen Therapy Indications, the 1,500+ patents treated with hyperbaric oxygen during a ten year period from 1992 to 2002 represent only a tiny portion of the 400,000 people estimated to have been seen in emergency rooms for CO poisoning during the same period. Not all incidents of carbon monoxide poisoning are acute, and not all victims seek immediate medical care, so the number of people effected could well be higher.

What accounts for the shortfall? As we previously reported, accurate diagnosis of CO poisoning is an issue. But the state of existing research and a lack of widely accepted protocols undoubtedly has a role in physician acceptance. Uncertainty over efficacy and treatment protocols weighed against potential side effects likely makes physicians reluctant to prescribe the treatment.

Even when detected by a doctor who regards HBOT as an effective treatment and appropriate for the case at hand, access to resources is an issue. Although there are well over 1,000 hyperbaric treatment centers in the United States, many are outpatient wound care facilities, independent hyperbaric clinics, or otherwise not integrated with a hospital's emergency services. For acute cases, access to hyperbaric facilities is likely to require patient transportation in many parts of the country. Traveling a considerable distance for multiple treatments adds to the challenges faced by patients suffering neurologic effects.

Much of the attention focused on carbon monoxide intoxication focuses on acute cases and short-term treatment. Standard protocols and current clinical trials involve 1 to 3 treatments and neuropsychiatric outcomes after 6 weeks. There is, however, research to support more lasting effects of COI. A 2009 review of clinical literature from 1974 through 2006 by the Department of Psychiatry at the University Hospital of Geneva found patients reporting symptoms for more than 30 years after CO poisoning and "affective disorders are observed in almost three-fourths of patients and personality disorders in more than half." The authors speculate that carbon monoxide intoxication may "constitute a risk factor in the waking of long-term neuropsychiatric disorders."

While not all victims of carbon monoxide poisoning have pre-existing risks for psychiatric disorders or suffer severe long-term effects of COI, there are still an array of potential cognitive and affective impairments. What can be done to detect these and measure the efficacy of hyperbaric oxygen therapy in improving patient outcomes? According to a 1995 study by the Center for Prehospital Care at UCLA Hospitals and Clinics, the standard CO Neuropsychological Screening Battery (CONSB) was "ineffective in detecting subtle neurological disturbances in victims of low-level CO poisoning", although the 1991 study by the Maryland Institute for Emergency Medical Services found the test battery to be "effective in evaluating cerebrally impaired CO-poisoned patients" and recommended its use for adequately assessing patients requiring aggressive hyperbaric oxygen therapy. The choice of diagnostic tools may need to be more closely calibrated to the severity and duration of carbon monoxide exposure.

None of the previous studies or current clinical trials evaluate long-term treatment of CO poisoning with HBOT, or speculate as to how neuropsychiatric improvements resulting from HBOT treatment could be measured effectively over time spans exceeding those considered in current studies. While it's possible recent advances in imaging can contribute to the body of evidence, it's likely cognitive testing will continue to be an important resource.

We'd like to suggest exploring a role for the subject-object interview as a diagnostic tool. Based on the understanding that people do not normally regress in their order of consciousness, the test could be used to detect the effects of CO poisoning if it can be shown that regression occurs in individuals effected by forms of brain injury. While the most useful context for comparison would be a relatively recent test prior to injury, severe impairment might be distinguishable relative to normative values for a relevant population group. Speculative, to be sure, but we're generally in favor of the subject-object interview being more widely conducted and understood. If it helps gain greater insight into brain injuries, so much the better.

Good luck with the shopping.

Hyperbaric Oxygen: What Is The Correct Dose?

Ask four experts and you'll get five opinions, as the old joke goes. We were so looking forward to Thursday afternoon's UHMS plenary session but came away even more completely baffled about how your average hyperbaric physician decides what pressure, duration, and number of treatments to prescribe. To say there is wide variation in practice would be a gross understatement.

Only the Navy, the Air Force, and the Divers Alert Network, it seems, stick to some sort of standard dosing tables. Even these standards share a dubious pedigree, which speaker Paul Sheffield traced back to (1) the arbitrary selection of the 90-minute sessions used to treat gas gangrene in 1961 and (2) the strange translation from 45 feet of seawater or FSW to 2.36 atmospheres absolute or ATA. Well, that explains that, anyway.

Practice is one thing. A lack of guidance on dosing also hamstrings the responsible clinical investigator. Dr Neil Hampson, of Virginia Mason Medical Center in Seattle, recounted his quest for "the Holy Grail of HBO2 dosing" when powering his ongoing randomized, controlled trial for carbon monoxide poisoning. He ended the session by suggesting that some measure of cumulative dose, such as ATA-hours, might prove more meaningful than individual doses or numbers of treatments. We seriously doubt it. And we're little comforted by Dr Hampson's claim that "HBOT works, but we still don't know the right dose." Only the right dose works, or are we wrong?

Oxygen is a drug. Pressure is strong medicine. Yet dose ranging studies and so much other basic science has been left undone, for so many decades, we sometimes wonder how hyperbaric physicians expect to gain the respect of the broader medical community.

By holding plenary sessions like this one, is the answer, and sharing a healthy, truthful accounting of the state of affairs. Now to act on the lack of information. Then the applause, applause.

CO Detection: There's An App For That

Soon your cell phone may grow a nose that constantly sniffs the air for carbon monoxide and other dangerous airborne chemicals. Not only would this electronic innovation make your phone a personal CO detector, it could also alert civil defense authorities and emergency first responders to chemical events in real time.

Scientists at UC San Diego and Rhevision developed the tiny detectors, which use supermacro lenses to watch silicon chips that change color when exposed to airborne chemicals. Patterns of color on a single chip can signal a wide variety of toxic hazards.

UCSD's Michael Sailor and team are busy working on prototypes for cell phones and firefighter helmets. The project is funded by the Department of Homeland Security.

Thank you, Medgadget, for alerting us to another amazing new technology.

(Photo: Sailor Lab/UCSD)

CO Poisoning: Is HBOT Still The Gold Standard?

One of our chief missions is to raise awareness and help increase 24/7 access to HBOT chambers at emergency rooms for victims of thermal burns, smoke inhalation, and carbon monoxide poisoning. (Review our past coverage here.) So we were especially pleased to discover a new posting of a 2007 talk by Dr Fred Fiesseler of Morristown (NJ) Memorial Hospital. Drawn from case studies and a review of the medical literature, Fiesseler's presentation reaffirms our commitment to this mission. To listen to the audio file follow this link:

Is Hyperbaric Oxygen Still the Standard for Carbon Monoxide Poisoning?

Going forward we will be identifying ER-accessible chambers in our treatment center directory and partnering with emergency medical associations and innovative companies like Healthagen to spread this lifesaving information far and wide.

Of course some political activism may be in order, too, and count on HyperbaricLink to be there.

HCMC Chamber Reprieved By Senate Earmark

Confirmation arrives late that the US Senate's year-end spending bill, a whopping $1 trillion that barely escaped a filibuster Sunday, includes a $400,000 earmark for replacement of Hennepin County Medical Center's aging hyperbaric chamber. We'd like to think our fall coverage played a small part (but know better). Here's wishing HCMC speedy project funding and completion.

HBOT: Homeland Security Against Cyanide Terrorism

One shudders to think of it, but cyanide poison has become an all-too-imaginable weapon of terror in these troubled times. Maybe we're especially troubled, writing to you from Chicago, home of the 1982 Tylenol murders and the subway scare of 2002.

Hyperbaric oxygen may play a small but critical role in our preparedness for cyanide attacks. According to the chemical terrorism update by Coleman O. Martin, MD, in the July 2002 issue of Emergency Medicine:

Hyperbaric oxygen administration is an adjunctive therapy in patients who do not respond to cyanide antidotes. This may be particularly helpful in cases where methemoglobinemia is excessive and the patient cyanotic. Hyperbaric oxygen should also be considered in patients with cyanide toxicity from smoke inhalation because their high levels of carboxyhemoglobin can hinder safe induction of methemoglobinemia.

Of course O2.0 readers will know that HBOT is approved for treating carbon monoxide (CO) poisoning complicated by cyanide poisoning after smoke inhalation. Better homeland security provides all the more reason every fire rescue squad and trauma center in the US should have 24/7 access to emergency-ready hyperbaric oxygen chambers—plenty enough to handle large-scale disasters, whether tragic accidents or unspeakable acts.

Minnesota: HCMC Fights Back

As the mercury falls in Minnesota, so rises the battle cry to save Hennepin County Medical Center from deep budget cuts. Without swift legislative action, before March 2010, the state's only 24/7 emergency-ready hyperbaric chamber is sure to shut down. (See our October 4 story, "Embattled MN Chamber Faces Ax.")

HCMC is fighting back. Making savvy use of online social media and good old-fashioned grassroots politics, the new Will You Lose? campaign underscores the medical center's proud history and modern role in disaster preparedness and statewide emergency healthcare access, especially for the uninsured. It also offers a great way for the hyperbaric medicine community to get involved. Please join O2.0 in signing up and spreading the word.

(Pictured: Jim Harris, CHT, at the HCMC chamber controls. Photo: Jim Gehrz, Star Tribune)

Carbon Monoxide Poisoning: A Public Health Crisis

We bring you yet more deadly stats for the cold and "flue" season. Carbon monoxide poisoning accounts for some 50,000 emergency room visits annually in the US. Every year about 450 Americans die from accidental exposure alone. Death rates peak in December and January. Almost all survivors experience serious immediate and lasting neuropsychological effects.

Carbon Monoxide Before and After

Rooting through the more recent clinical literature on carbon monoxide poisoning from overseas unearths a few case studies that illuminate some of the difficulties surrounding this condition. In a report from 1993, doctors in Italy described the cases of a husband and wife who had been suffering from headaches, nausea, and neurobehavioral disturbances (which can be involve emotion, learning, or behavior) intermittently for over a year before their diagnosis. It took a careful review of the patient history to determine the source was a mis-functioning heating system. Low level exposure to carbon monoxide can cause symptoms that are overlooked or misdiagnosed.

In another case, a 41-year old woman with no prior history of cognitive or emotional problems developed severe psychiatric problems from carbon monoxide poisoning. Although the patient appeared to make a complete recovery after treatment (hyperbaric oxygen therapy or another therapy), delayed encephalopathy ensued and produced obsessive-compulsive disorder, depression, kelptomania, and psychotic behavior. Brain scans revealed damage in a number of areas. This pattern of symptom, recovery, and re-occurrence is thought to happen in as many as 12 percent of cases.

Together, these examples underscore the need for careful investigation when carbon monoxide poisoning might be suspect, and careful follow-up after an initial series of hyperbaric treatments. Valuable knowledge may be gained if the hyperbaric physician coordinates treatments with assessments by a neurologist.

Postscript: First Response Success With HBOT

Thanksgiving arrived a little early this year in Boston. At a feast two weeks ago today, the Mass Eye & Ear community honored legendary broadcaster Norman Knight, the man who gave the infirmary and the state their first hyperbaric chamber. Even as they were toasting Knight's philanthropy, 14-year-old smoke inhalation victim Shavonne Richards lay recovering at the Norman Knight Hyperbaric Medicine Center. (See also our November 13 post and the November 15 Boston Globe story.)

Not all such young women and not all American cities are so lucky. Reliable access to 24/7 emergency-ready chambers in the US is spotty, at best, and aging equipment and economic woes only compound the problem. Part of the HyperbaricLink mission in 2010 will be to help expose and address this unmet need.

Our thanks this day to all our first responders and to people like Norman Knight, whose quiet generosity and clear vision keep us safer.

First Response Success With HBOT

We note with enthusiasm the prompt application of hyperbaric oxygen therapy in this recent news story out of Boston. Unconscious in a burning building, the victim was rescued by brave, capable Boston firefighters, Massachusetts General Hospital's excellent ER staff, and the Norman Knight Hyperbaric Medicine Center at the Massachusetts Eye and Ear Infirmary. In cases like this, HBOT can provide lifesaving treatment for thermal burns, smoke inhalation, and carbon monoxide poisoning within the golden hour after the traumatic event.

While the trip from Dorchester to the Mass Eye and Ear Infirmary is a short one by ambulance, there are undoubtedly communities without such ready access to an emergency hyperbaric facility. An update to our treatment center directory will provide an index of chambers with 24-hour access and emergency response capabilities.

Carbon Monoxide: Get Your Canary In The Coal Mine

You've got to love a website that touts itself as "the finest public digital expert site available." It's Carbon Monoxide Headquarters and it's a little bit wacky but undeniably chock-full of information. Favorite click-through: The canary button that loads data from a 1912 study comparing birds to mice as an early warning system for coal miners. Another light reminder to purchase and plug in yours.

CO Poisoning: Bad Furnaces Fire Up ERs

We still hear America heating. Recent close calls involving 30 middle-schoolers in North Dakota and a family of four in Michigan should remind us all to get our furnaces tuned up for the season and plug in those carbon monoxide (CO) detectors. You might also want to check if your local emergency room enjoys 24/7 on-call access to a hyperbaric oxygen chamber. And don't forget Canada, where emergency HBOT was already scarce before one major center in St John's, Newfoundland, went offline earlier this year. We worry the sluggish economy is choking off our best chances for the prevention and treatment of CO poisoning.

CO Poisoning: Turning Up The Heat On ERs

We hear America heating. Everywhere the old furnaces are kicking on this weekend, and so the carbon monoxide season begins. Firefighters rushed eight Utahns to the local hyperbaric chamber. They're hanging on by their chattering teeth in the Twin Cities (see below). How's your town set for the right lifesaving equipment?

Embattled MN Chamber Faces Ax

Land of 10,000 Lakes and just one trauma-grade hyperbaric chamber? Things were looking bad enough for Hennepin County Medical Center's 45-year-old chamber, kept in service with great care by the only emergency HBOT facility in Minnesota. Well, forget a replacement anytime soon. Now, after the defeat of state healthcare legislation, the program's very survival hangs in the balance. This is a vital public health issue, and O2.0 urges national leadership from the hyperbaric medical community. Shouldn't every Level 1 trauma center in America have a reliable chamber? Surely we can count on firefighters, EMTs, hospitals, and ERs to join the cause.

Finger Clips, Firefighters, and Hyperbaric Oxygen

Carbon monoxide, "the silent killer," is responsible for more poisonings than any other source in the industrialized world. As reported in the New York Times last year, recent research suggests as many as 11,000 undetected cases of CO poisoning occur annually. At particular risk are firefighters, who work takes them into close proximity with CO and other harmful products of combustion.

Detecting carbon monoxide poisoning in the field or in the emergency room can be difficult, since the symptoms are often flu-like and may be misdiagnosed as being caused by another condition. Early detection is critical. CO leaves the bloodstream quickly, but its effects on heart tissue and the brain can be lasting.

Last year a leading manufacturer of medical devices, Masimo, introduced a pulse oximetry device, the finger clip familiar to hospital patients, that can detect both oxygen and carbon monoxide levels in the blood. With the device, emergency room personnel and first responders have a better chance of identifying high levels of CO in the blood.

Now the company is working with the International Association of Firefighters (IAFF) on a campaign to increase CO poisoning awareness and encourage firefighters to have their CO levels checked at the scene. Because the risks are significant and early detection critical, it's essential firefighters and other first responders understand the symptoms of CO poisoning and have the tools to identify it promptly.

We applaud their efforts. At HyperbaricLink we have a special interest in the issue of carbon monoxide poisoning and its neurologic effects. We also see the potential for increasing use of HBOT in first responder work and willcover both topics with dedication.

Although a multi-center, randomized controlled trial has not been conducted, hyperbaric oxygen therapy is used to treat both acute and chronic CO poisoning and the neurologic effects that result. The HyperbaricLink Evidence Index identifies four clinical trials being conducted to learn more about the treatment of CO poisoning with HBOT. The Undersea and Hyperbaric Medical Society, which approves the use of HBOT for CO poisoning, provides additional information here.

Stay turned for the latest news about HBOT treatment protocols for carbon monoxide poisoning and hyperbaric oxygen in emergency medicine.