I was recently asked this question:
“Dear Doc,
I broke my hip. Because of my relatively young age, the doctors decided to pin the femoral head to the neck instead of doing a replacement. My question: Are there treatments which will speed the recovery? (I have access to oxygen.)”
My response was as follows:
“Sorry to hear about the accident. The following reviews suggest that hyperbaric oxygen treatment (HBOT) is of no real benefit in bone healing in humans:
1. Best evidence topic report. Hyperbaric oxygen therapy in acute fracture management. Butler J, Foex B. Emerg Med J. 2006 Jul;23(7):571-2. Review.
2. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union., Bennett MH, Stanford R, Turner R. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004712. Review.”
The inquirer wanted to pursue the subject and wrote me back:
“I did do some research on my own and found some studies using cats where bone graft growth was faster under hyperbaric O2 treatment. I followed up with DAN and they said that while there’s no question that hyperbaric O2 will deliver more oxygen to the affected bone, bone growth under those conditions would be ‘different’. My feeling is I’d better just do ‘normal’ treatment, but I wonder if taking hits off my O2 pony reg will be helpful by itself?”
As is supported by the research reviews I cited earlier, I reiterated:
“There is no compelling reason to believe breathing O2 off one’s pony reg will speed healing following a bone graft.”
Apparently becoming slightly irked at this position, the inquirer wrote back:
“I don’t know why you’d think it not helpful. More O2 means more O2 in the bloodstream, which means more delivered to the injury site.”
Attempting to keep my equanimity, I replied:
“I think it won’t be helpful because in the healthy individual with normal respiratory and hematological function, oxygen saturation is >95% at rest. The empirical evidence indicates that increasing the percentage of circulating 02 by a minuscule amount is not going to significantly speed bone healing. In order to promote a meaningful increase in 02 perfusion, HBOT must be used.
Moreover, hyperbaric oxygen treatment typically involves 100% 02 administered at 1 1/2 – 3 ATA for 90 – 120 minutes per session over multiple sessions. It would be very difficult to reproduce these conditions breathing off a pony bottle.”
The message? The diver is not going to materially affect the speed of healing of bone, or of any other kind of damaged tissue, simply by sitting and breathing 02 from his cylinder.
Just wanted to add that as part of the initial evaluation she had significant fluid in her right lower lobe (just where you’d expect for aspiration). Both tympanic membranes were completely blown out. Her eyes were grossly erythematous. No focal neurologic deficits were noted. Respirations were around 20 while she was combative. She tried to walk around, unaware that she was incontinent of stool and urine. Her lips were cyanotic. Etc, etc. Totally disoriented. No IV antibiotics on board as I recall. But she did indeed fully recover. Note that we did not nearly induce coma. I would call it moderate conscious sedation. Her IV Valium dose was 1mg. No Demerol given as I recall. The single mg of Valium was enough to alleviate her very combative state. Without the oxygen, I fear she would not have made it. There is no question that sedating her was critical in order to have her breathe 100% O2 through a non-rebreather mask (medical mask for oxygen delivery). We did not have a pulse oximeter, but her clinical findings went from pale nail beds, cyanotic finger tips, and cyanotic lips, to nice pink perfusion “everywhere”. The single dose of valium was enough to get her into a natural sleep state of sorts. Her combativeness ended. When she woke up about 24 yours later, she was indeed unaware of what happened, but she knew something was wrong. Fortunately her husband was there to explain everything. There was also an RN present with extensive ER experience, and prior to Valium, we called DAN on the sat phone. They concurred with the oxygen therapy and Valium IV as necessary to reduce the combativeness in order to keep her still in order to treat her.
Cool post! I like your blog, and am a loyal reader. I will return this weekend!
Doc Vikingo takes on a complex topic and ably handles the question. Oxygen therapy at surface pressure has efficacy in certain applications but not what this patient wanted to hear. Even regimens of hyberbaric treatments would probably not produce the results desired. But never underestimate the huge importance and immediate value of O2 administration by 100% demand valve mask in the field for those divers symptomatic of decompression sickness or embolism. While recovery from embolism without recompression is far harder to reliably predict, it may well be the only option in remote areas. In 2005, I treated a massive air embolism to a diver injured at Cocos Island who also had ruptured both ear drums and was blind in both eyes due to collateral damage from the incident. Imagine trying to deal with a patient who was blind and deaf… and completely unable to understand what had happened to her or what we were desperately doing to try to save her life with emergency procedures while 400 miles offshore and nearly 40 hours from the nearest chamber in Panama.
We got underway at once after aggressive CPR and O2 restored breathing and heart function but later the patient became combative in her terror and tore out her IVs that delivered both fluids and sedatives to her while we masked her with O2. Luckily, I had an old friend and M.D. (radiologist) Gregg Gaylord aboard and we decided to, esssentially, induce near coma with IV demerol and valium to knock her out so we could maintain the patent airway for O2. Divemaster Miguel Sanchez of the crew then joined our around-the-clock vigil. After nearly 30 hours of oxygen and fluids, the patient regained vision and we were able to write messages on a clipboard that explained what was happening. When we arrived off Panama after almost 36 hours in transit at sea, the patient had nearly fully recovered and walked off the ship on her own… but with no memory of the accident. She was air-lifted to the U.S. for continued treatment and she fully recovered. But the unprecedented aggressive use of 100% O2 (that was really the only tool we had in the field), was what saved her life. Frankly, most of us thought it was a miracle that she survived at all, much less with no mental deficits.
Oxygen is an extraordinary drug. Always be certain that any liveaboard you go on has plenty and can deliver it via a 100% mask. And never give up on the therapy until you either run completely out or the patient dies.
In my nearly 40 years as a professional diver (that included 25 years running recompression chambers as the supervisor), I have learned that oxygen physiology in diving operations and subsequently in treatments is a subject that few physicians and even fewer lay persons have much familiarity with. There are good reference materials on this esoteric subject including case histories to review. I have gone to great pains over the years to publish a series of articles, formal papers, and as a contributing editor to medical texts on the subject. We need more input from field cases that achieved success so divers can benefit from “real world” patients, not just those in hospital settings. Send any information you may have acquired on your own to Dr. Dick Vann at DAN. He’s one of their primary researchers and a committed professional who would welcome the input. (email: rvann@dan.org)
Bret Gilliam
bretgilliam@gmail.com