Physician’s Duties in Hyperbaric Medicine
Prepared by: The American College of Hyperbaric Medicine (ACHM), 1993
During discussions with the Health Care Financing Administration and the American Medical Association’s Current Procedural Terminology Editorial Committee, the American College of Hyperbaric Medicine (ACHM) was asked to produce a source document describing the physician’s duties in hyperbaric medicine. The document below was used to create CPT code 99183, the only code used for hyperbaric services. This information is included for the use of hyperbaric physicians in determining what services are an intrinsic part of their regular duties, and what services are extrinsic to 99183. The secondary use is by directors of hyperbaric training programs to assure that they are educating their students to meet their expected duties.
Physician Work Performed Before Seeing the Patient
1. Review the pertinent medical records of each patient.
2. Schedule hyperbaric treatments. Because the patient will be involved for two hours or more, the treatment must be scheduled around the patient’s other activities, including other therapies, diagnostic testing, surgery, physician rounds, and other timed activities.
3. Determine the depth, duration, breathing gas mixture, and frequency of treatment for that patient for that particular treatment.
4. Take necessary special precautions with the patient, derived from any changes that have occurred since his or her last treatment, i.e. isolation measures, seizure precautions, etc.
5. Evaluate for new contraindications to treatment from a therapeutic change, such as a new medication (which may increase a patient’s susceptibility to such adverse effects as lowering the seizure threshold and facilitating oxygen seizures), or a recent surgical procedure (such as the inadvertent creation of a pneumothorax during the placement of a CVP line, which could result in a deadly tension pneumothorax at depth).
6. Evaluate for the interaction of any new medications or medical devices with the hyperbaric environment. While they may not prevent treatment as would a contraindication, these changes may alter the care of the patient at depth.
7. Evaluate the relevancy to the hyperbaric environment of any changes of the patient’s current chest x-ray or pulmonary function test.
8. Discuss with the hyperbaric nursing staff any specialized nursing needed by the patient during the pre-, intra-, or post-treatment phases.
9. Calculation of Unit Pulmonary Toxic Dosage (UPTD) of oxygen for patients receiving high FIO2s while on ventilatory assistance, PEEP, or CPAP, to determine potential injury. These high inspired oxygen concentrations for prolonged periods can cause lung damage due to their synergy with the high oxygen tensions in the chamber, and the production of increased alveolar free radical concentrations, with attendant alveolar damage.
10. Determine the required method of transportation of the patient for that day. As an example, often a patient with a new skin graft to the leg can no longer be moved into the chamber by wheelchair, and requires a hyperbaric stretcher.
11. Consult, by phone or in person, with other physicians participating in the patient’s care, particularly concerning any changes, such as a high fever, that might complicate the patient’s hyperbaric oxygen therapy.
12. Order and schedule laboratory, imaging, and other diagnostic or therapeutic modalities; and interpret their results.
13. Calculate the duration from last ionizing radiation treatment to current HBOT, to evaluate possible potentiation of radiotherapy. This is particularly important in cases where surgical wound dehiscence occurs in an irradiated field, necessitating HBOT for healing of the surgical wound, but hyperbaric oxygen is known to potentiate superficial tissue activity from recent radiotherapy administration, which is dose related.
Physician Work Performed Before or After Hyperbaric Treatment
1. Evaluate the patient’s general medical condition from answers to historical questions and findings from a physical examination. Special attention is paid to possible adverse effects of HBOT to tympanic membranes, eyes, lungs, and central nervous system. Any deleterious effects of previous hyperbaric treatments on potentially closed spaces is evaluated and treated.
2. Examine and evaluate all material that will enter into the chamber with, on, or in the patient. These specific items vary from patient to patient, and from day to day. This list includes, but is not limited to the following:
(1) Evaluate the patient’s clothing, make-up and hair products for fire risks.
(2) Determine whether intravenous fluid pumps or patient controlled analgesia pumps can be safely sent into the chamber without inducing unit malfunction or fire.
(3) Decide if the patient’s specific model of cardiac pacemaker is known to tolerate without failure the high pressures to which it will be exposed.
(4) Determine if monitoring equipment, such as EKGs and arterial lines, are correctly routed for chamber use, vented, and grounded, to prevent forcing a gas bubble into the patient’s arterial system, or starting a fire.
(5) Examine any balloon-tipped catheters, drains, or tubes, to insure that they have not been improperly filled with air instead of saline, causing a lack of sealing at depth,
and compromised function or tube loss. It would be catastrophic for a ventilator-dependent patient to lose his endotracheal tube.
(6) Ascertain whether the patient’s ventilator is approved for chamber use from a pressure resistance and fire safety standpoint, and if the ventilator settings are compatible with the increased air density that occurs during HBOT, which alters both flow and measurement characteristics.
(7) Modification of orthopedic or surgical devices and materials may be required; that modification, such as the bivalving of casts or the padding of the ends of external fixation devices to prevent sparking or chamber tube damage, may have to be performed by the hyperbaric physician, and is always done under his authority. The hyperbaric physician is ultimately responsible for everything that enters the chamber with, on, or, in the patient.
3. Evaluate the wound, with respect to changes, either beneficial or adverse, in perimeter size or area, depth, presence or absence of necrotic material or drainage, development of granulation tissue (particularly over exposed tendinous structures or bone), odor, capillary refilling, swelling, presence of arterial pulses, security of suture or staple lines, development of lines of demarcation of ischemic areas, viability of affected areas, successful take of skin grafts or flaps, development of new lesions, and the proper use of dressing materials, as ordered.
4. Sample wound drainage for possible infections/colonization. This may also involve the actual biopsy of wound margins or readily accessible bone.
5. Perform topical wound care, to include dressing changes, often with specialized materials, topical antibiotic use, wound debridement as indicated, probing of wound channels, cavities, or fistulae, packing of abscess cavities and fistulae, and placement (or removal) of sutures or staples in the subcutaneous tissues and skin.
6. Determine if specialized testing modalities, such as in-chamber transcutaneous oxygen monitoring, will be employed during the dive, and what site(s) will be monitored.
7. Evaluate the development of any psychological stress, such as anxiety or depression, from previous or upcoming treatments, and prescribe appropriate therapy for these problems which may include anxiolytics, antidepressants, or antipsychotics.
8. Evaluate the patient’s need for any specialized monitoring during the treatment, such as additional guidance in pressure equalization via the Eustachian tubes, fluid restriction during the mid-dive air break, special body position requirements to prevent movement that would geometrically stress a fresh graft or flap, or continuous electrocardiographic or arterial blood pressure surveillance.
9. Determine the need for adjunctive agents such as Heparin, Vitamin E, Trental, or antibiotics.
10. Evaluate the patient’s current nutritional status. This is critical for wound healing.
11. Discuss with the patient information he has been told by other treating physicians which is not in the medical record.
12. Work with the patient (specifically outpatients) to establish what treatment schedule they will be able to meet based upon their work schedule, transportation availability, physician appointments, additional scheduled studies (x-ray, CT, MRI, or Doppler vascular), and other activities.
Intra-Hyperbaric Treatment Physician Work
The physician evaluates the patient during the treatment, either from outside the chamber, or, when necessary, inside the chamber. (This is possible only with multiplace chambers and some monoplace chambers.)
Management of Specific Problems That Can Occur
1. Diagnose and treat alternobaroic vertigo of ascent or descent.
2. Manage difficulties with pressure equalization of any air spaces such as the middle ears, sinuses, dental pockets underlying recent fillings, tight orthopedic casts, and the like. These can occur at either ascent or descent, and require immediate skilled management, particularly on ascent, or the patient cannot return to surface pressure.
3. Prevent or manage difficulties with pressure equalization of gas-containing patient appliances, such as colostomy and ileostomy bags, closed drainage systems, and continuous irrigation systems, that are not designed for the hyperbaric environment, but may be required by the patient. The barometric changes can result in unplanned insufflation of air or liquids into the patient, with potentially serious results.
4. Solve problems of gas contamination, which can require either a change of gas mixture, or immediate dive termination.
5. Manage oxygen toxicity effects, such as seizures, either grand mal or focal motor.
6. Treat complications of improper gas mixture use. Oxygen at two atmospheres of pressure is a therapeutic drug; but at four atmospheres of pressure it is a deadly poison.
7. Treat acute confinement anxiety, break-through of schizophrenia, or drug-related psychodynamic phenomena during treatment.
8. Manage the potentiation in the hyperbaric environment of respiratory depressant medications such as sedatives or the lingering effects of recent anesthesia, which could result in respiratory failure.
9. Control the amount of fluid intake during descent for patients on fluid restricted diets. Many patients equalize the pressure in their middle ears by drinking water to open the
Eustachian tubes, and their fluid intake varies depending upon the ease with which they clear their ears during that particular dive.
10. Control the effects of the latent heat of compression, and adiabatic cooling of decompression, on patients with temperature control mechanisms that are compromised by such injuries as spinal cord damage, which prevents sweating below the level of injury.
11. Alter the treatment profile due to patient or technical problems; patients may require unplanned ascents due to equipment failure or due to medical problems. Only the hyperbaric physician can alter the decompression schedule, and this may require the calculation of specific controlling surfacing nitrogen compartment partial pressures to expedite ascent. Gas mixture changes may be required, with the potential for incurring additional decompression obligations, particularly if another inert gas, such as Helium, is used in addition to the Nitrogen in air or if Nitrox breathing mixes.
12. Manage the medical complications of intrachamber emergencies, such as explosive decompression or omitted decompression from door seal failure, burns and smoke inhalation from a chamber fire, or similar problems.
13. Immediately treat such life-threatening problems as acute myocardial infarction, stroke, or pneumothorax. Because many patients are elderly, often have multiple major medical problems, and spend up to six hours per day in the hyperbaric facility, their chance of a medical problem that occurs that day happening in the hyperbaric department is 1:4, due to the amount of time they spend with us.
14. Evaluate in-chamber blood glucose levels in diabetics, and the appropriate management of abnormalities, whether from hyperglycemia or hypoglycemia.
15. Alter ventilator settings, including flowmeter corrections due to non-standard conditions, based upon arterial blood gas results.
16. Change intra-treatment oxygen duration due to changes in the patient’s condition such as nausea or vomiting. Patients in multiplace chambers and some monoplace chambers wear a hood or mask for the delivery of oxygen, and could aspirate vomitus.
17. In those chambers where it is possible for the physician to enter the chamber while it is pressurized ("entry capable"), the physician actually joins the patient in the hyperbaric environment, and performs emergency care under extremely difficult and stressful conditions.
18. Treat any medical problem in the chamber such as diarrhea, pain, or bleeding. No orders from any other physician are accepted by the hyperbaric staff due to non-hyperbaric physicians being unfamiliar with the specific problems of high pressure and high oxygen concentrations.
Post-Hyperbaric Treatment Physician Work
1. Management and treatment of any problems that occurred during the treatment but were not sufficiently severe to require that the physician enter the chamber on an emergency basis (such as muscle strain). If a patient is unable to adequately ventilate his or middle ear spaces, and suffers barotitis media, the hyperbaric physician evaluates the problem immediately after the treatment, diagnoses the condition, initiates treatment, and determines if the patient’s barotitis will require alteration of their next treatment protocol, in frequency or descent rate. If the patient has had ear clearing problems during previous treatments, the hyperbaric physician arranges for an otorhinolaryngologist to place pressure equalizing tubes in the person’s tympanic membrane(s).
2. Evaluation of any post-dive change in the patient’s condition, such as new onset of pain, shortness of breath, or a change in mentation, to determine if that symptom or sign might be due to decompression sickness or arterial gas embolism incurred during the hyperbaric treatment. If either is the cause, immediate recompression of that patient on an emergency basis is required.
3. Re-evaluation of the condition of reimplanted digits or limbs, or skin grafts or flaps that are being treated on an emergency basis for salvage, and then communication with the attending surgeon to relate these findings so an updated treatment plan can be followed.
4. If a patient has undergone inadequate or omitted decompression, the hyperbaric physician determines if the patient needs immediate recompression, and if so, under what treatment protocol and breathing gas mixture. This procedure must be carried out immediately, because the decision is extremely time urgent and there are multiple options for this treatment, depending upon the presence or absence of symptoms and physical findings.
5. Contact is made with the attending physician if any unexpected event occurs during the treatment. Appropriate referrals for the management of any new problems, such as seizures, are made by direct contact with the appropriate specialist, by telephone or in person.
6. Prescription of any ancillary treatment needed by the patient such as whirlpool, physical therapy, occupational therapy, or diabetes training.
7. Preparation of the medical records of that patient, and the documentation of those findings that would need to be known by any other physicians caring for that patient.
8. Coordination with other physicians concerning the other aspects of the patient’s care, such as the scheduling of surgery, based upon any new findings.
9. Determination of whether the patient may be converted to outpatient or skilled nursing facility status, and the facilitation of that change.
10. Evaluation of the patient’s response to treatment, and determination if additional treatments are indicated.