A Crisis in Emergency Chamber Availability

When a hyperbaric emergency happens, divers want to know that a chamber is always available nearby. Problem is, it isn’t.

Words by Dan Orr

In the Winter 2012 edition of Alert Diver Online, Divers Alert Network (DAN) published an article authored by Dick Clarke of National Baromedical Services entitled, “Divers Losing Access To Emergency Care”. This article exposed a serious issue in the availability of hyperbaric treatment—specifically in the U.S.—for pressure-related diving injuries on a 24/7 emergency basis. Since that time, the number of hyperbaric care facilities in the U.S. that will treat an injured diver on a 24/7 basis has continued to decrease to a point where the diving community must take action.  

There are millions of recreational scuba divers in North America and hundreds of thousands of visiting divers from countries around the world, making tens of millions of enjoyable recreational dives each year in unique dive locations all over the North American continent. In the unlikely event that any of these divers suffered a pressure-related diving injury, they trust that the local healthcare system would provide state-of-the-art care for their injuries. Little do they know that if an unlikely pressure-related injury were to occur, they might experience a delay in treatment that could adversely impact their chances for a successful outcome.

Most divers are unaware there is a steadily decreasing number of hyperbaric treatment facilities in the U.S. willing to treat them, even in a life-threatening emergency, for decompression sickness or arterial gas embolism. This situation places all divers at risk.

In May of 2020, a recreational diver made a dive off the coast of Pensacola, Florida. After surfacing, he experienced serious neurological symptoms that were indicative of a pressure-related diving injury. There were five hyperbaric treatment facilities in Pensacola that provided hyperbaric oxygen therapy for a variety of non-diving medical conditions, but not one of these facilities would provide the emergency care that this severely injured diver badly needed. Instead of being treated at one of these treatment facilities only minutes away, the diver had to be transported to a treatment facility in Mobile, Alabama that was available to treat injured divers 24/7. 

This facility in Mobile, Alabama is one of the very few treatment facilities in the U.S. that continues to offer emergency care for injured divers 24/7, despite the fact that it may not be financially advantageous to do so. This hyperbaric facility, owned by the Wallace family, continues to provide this as a public service for the Gulf Coast diving community. 

The injured diver in this case was fortunately treated successfully with no residual symptoms, despite the treatment delay. As accident data from DAN has shown, treatment delay—such as occurred during this diver’s care—is one of the most significant risk factors for a negative outcome when treating divers with decompression sickness or arterial gas embolism.

Changing business model

The reduced capability to provide emergency treatment for diving accidents also impacts local fire and police forces, many of which have diving rescue teams; federal law enforcement agencies; fish and wildlife services; park services and other state and federal agencies with dive teams; as well as military divers conducting training operations in areas away from the location of their unit chamber.

There are approximately 1,300 hyperbaric treatment facilities (each of which has one or more hyperbaric chambers) that currently provide hyperbaric oxygen therapy in the United States. As recently as two decades ago, most hyperbaric treatment facilities were available to provide emergency treatment on a 24/7 basis. Today, fewer than 10% of facilities offer emergency treatment, and some do so only intermittently. Non-diving patients being treated for wound-healing therapy dominate chamber usage.

As the normal-business-hours-only hyperbaric treatment model expanded, facilities that had been providing 24/7 hyperbaric care sought out more stable, less clinically-challenging (and typically better-insured) patients. Costs required to maintain 24/7 capabilities continue to increase, as do concerns of potential legal liability, while revenues from this stream maintain a downward trend. As a business enterprise, the scheduled wound healing therapy model is much more profitable than emergency hyperbaric treatment for pressure-related diving injuries. As a result, an increasing number of treatment facilities have reconsidered their 24/7 coverage position. 

Sadly, and all too frequently, the financial argument wins out over the best-medical practice argument. Consequently, a growing number of treatment facilities have elected to discontinue on-call 24/7 availability. Unfortunately, many others have decided to close their hyperbaric treatment service altogether. The result of this shift away from the best medical practice model is a significant national decline in providing and maintaining this vital standard of care for injured divers. While some new treatment facilities have announced their 24/7 availability to treat injured divers, some long-established treatment facilities have continued to opt out. Divers and others for whom the immediate availability of emergency care for their injuries can make the difference between a good outcome and a bad one are increasingly being denied necessary and timely access. 

Strategies to incentivize

For the recreational diving community, this is a critical safety issue. Recreational divers are regularly diving in locations where they believe emergency hyperbaric treatment will be available at nearby treatment facilities that have, in the past, been available to treat injured divers when they needed it. Unfortunately, this may not be the case at all and, if injured, they may have to endure long delays in treatment as they must be transported to a distant treatment facility willing and able to provide the emergency care they need. 

From a diver safety perspective, there is an urgent need to correct the decreasing availability in the U.S. health care system and make emergency hyperbaric treatment available to those who require it. The Undersea and Hyperbaric Medical Society (UHMS) has been working to address this situation within the U.S. healthcare system by alerting governmental organizations. In a recently circulated letter, the UHMS urged the identification and implementation of strategies to incentivize hyperbaric treatment facilities to offer emergency hyperbaric treatment. Options for accomplishing this include:

•  Direct federal or state grants to hyperbaric treatment facilities that offer emergency hyperbaric treatment; 
•  Indemnification from legal liability for hyperbaric treatment facilities and medical providers who provide emergency hyperbaric treatment to divers and other non-diving patients who require it;
•  Recognition of the public service performed by the hyperbaric treatment facilities that offer emergency hyperbaric treatment when indicated;
•  Favourable consideration with respect to Medicare, Medicaid, and private insurance reimbursements to hyperbaric treatment facilities and medical providers that offer emergency hyperbaric treatment when indicated, including carve-outs to inpatient DRG (diagnosis-related group) payments;
•  Incentives for military hyperbaric facilities to provide emergency hyperbaric treatment to civilian patients through emphasis on the training benefit to military providers that this accomplishes; third-party reimbursement for emergency hyperbaric treatment provided to civilian patients by military hyperbaric facilities; and indemnification of the military facility from lawsuits resulting from this public service activity.

In addition, the UHMS has suggested governmental support for non-profit organizations, such as DAN, that are willing to operate around-the-clock, assisting any diver who needs emergency hyperbaric treatment by identifying the nearest hyperbaric treatment facility that is capable of providing this treatment and helping to arrange transportation to it. Since chamber availability may vary based on ongoing hyperbaric oxygen treatments, staffing issues, and chamber maintenance operations, the ability to quickly determine which hyperbaric treatment facility is the most appropriate for a particular injured diver in a specific geographic area is critical to optimal care. It should likewise be a health care system priority to ensure that there is adequate funding for fellowship education in Hyperbaric Medicine so that appropriately-trained physicians will be reliably available to oversee the hyperbaric treatment provided by these hyperbaric treatment facilities.

At the time of writing there is no similar information available regarding chamber availability in Canada (though it is a situation we are monitoring – Ed). It is incumbent upon safety-conscious divers to be knowledgeable regarding the availability of specific medical care for a pressure-related diving injury. 

So what can concerned and safety-conscious divers do? 

First, it is important to be a member of Divers Alert Network to support the emergency medical services they provide. And, always have the DAN Emergency Hotline number (919-684-9111) in your emergency assistance plan. If an emergency were to occur, DAN can assist in getting divers to the most appropriate, available treatment facility with as little delay as possible. Remember that the treatment facility you may be referred to may not be local to your dive location, but DAN is aware of the locations of all treatment facilities available to treat injured divers 24/7, including Canada. 

Divers can also determine if treatment facilities at or near their favourite dive location are, indeed, available on a 24/7 basis and, if not, encourage the local diving community to put pressure on that facility to be available when needed. This may require the local community to reach out to the treatment facility to express their concern and, possibly, offer support in the form of fundraisers or other activities that could help. In some areas, the local diving community has sponsored ‘Diver’s Days” to raise awareness and funds to support local treatment facilities. There are organizations, such as DAN, and individuals who will gladly volunteer their time and resources
to help such a worthy cause. 

Like any other risk in diver safety, we must identify and find ways to mitigate that risk. The decreasing availability of treatment facilities willing to provide emergency hyperbaric treatment when we need it most increases our risk as divers. We must mobilize and mitigate that risk by working with local, state, and national officials to let once-available treatment facilities know of our concern and work with them to find ways to reduce that risk through cooperative and supportive measures. 

For more info: www.uhms.org and www.diversalertnetwork.org