By Dan Orr
(danorr@danorrconsulting.com)
There are millions of recreational scuba divers in the U.S. and hundreds of thousands of traveling divers from countries around the world making tens of millions of enjoyable recreational dives each year in unique dive locations all over America. In the unlikely event that any of these divers would suffer a pressure-related diving injury, they trust that the U.S. medical system will provide state-of-the-art care for their injuries. As these divers are preparing to enjoy a pleasurable dive in some of the world’s most popular dive locations in this country, little do they know that if an unlikely pressure-related injury were to occur, they may experience a delay in treatment that could adversely impact their chances for a successful outcome.
Unknown to most divers, 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 a much greater risk than any of us have realized.
For example, 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. Divers in that area had been aware that there were five hyperbaric treatment facilities in Pensacola that have been providing hyperbaric oxygen therapy for a variety of non-diving medical conditions but were totally unaware that not one of these facilities would provide the emergency care this severely injured diver badly needed. Instead of being treated at one of these treatment facilities only minutes away, this diver had to be transported to a treatment facility in Mobile, Alabama that was willing to be 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 particular 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 example was fortunately treated successfully with no residual symptoms, despite the treatment delay. As accident data from Divers Alert Network (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.
This 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, the large majority of hyperbaric treatment facilities were available to provide emergency treatment on a 24/7 basis, but today, fewer than 10% of these facilities offer emergency treatment, and some of those facilities do so only intermittently. Non-diving patients being treated for wound healing therapy dominate chamber usage.
As a business enterprise, the scheduled wound healing therapy model is much more profitable than emergency hyperbaric treatment for pressure-related diving injuries. In the past, hospitals and other hyperbaric treatment facilities underwrote the additional costs associated with providing 24/7 access to emergency hyperbaric treatment as a public service for those who required it. Now, because of the negative economic impact, as well as concern for staffing and training considerations and the potential for legal liability, most hyperbaric treatment facilities have ceased to provide 24/7 access to emergency hyperbaric treatment.
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 most. 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 this 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 (www.uhms.org) has been working to address this situation within the U.S. healthcare system by alerting governmental organizations. In a letter they recently crafted and distributed, they identified that this situation will require the identification and implementation of strategies to incentivize hyperbaric treatment facilities to offer emergency hyperbaric treatment. Options for accomplishing this include:
1) direct federal or state grants to hyperbaric treatment facilities that offer emergency hyperbaric treatment;
2) 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;
3) recognition of the public service performed by the hyperbaric treatment facilities that offer emergency hyperbaric treatment when indicated;
4) favorable 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;
5) 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, there should be federal support for non-profit organizations, such as the Divers Alert Network (DAN), that are willing to operate around the clock assisting any patient 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 emergency patient in a specific geographic area is critical to optimal care. It should likewise be a national health care 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.
So, what is a concerned and safety-conscious diver to do? First, it is important to be a member of Divers Alert Network (DAN) to support the emergency medical services they provide. And, always have the DAN Emergency Hotline number in your emergency assistance plan. If a pressure-related emergency were to occur, DAN can assist in getting you 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.
Divers can also determine if treatment facilities at or near their favorite 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 of the U.S., the local diving community has sponsored “Divers 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. We now know that 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.
Very good informative article. I operate one of the few 24/7 chambers in our part of the Caribbean – St. Thomas, VI. I can tell you it is a challenge for facilities to keep open chambers available at any time. Operational costs, maintenance costs, and personnel costs all add up.All this while healthcare in general is more precarious than is has been in a while. But as an industry from tourism to mesophotic (100-300′) research almost all depend on having a chamber available in case of a dive accident. Many researchers will not even go out unless checking that the chamber is operational and available. Some tourists would not otherwise come to an area if there is not a chamber on standby. We are in different times than when chambers were deemed necessary at all costs. Answers are not simple and solutions can be complicated but the diving community knows the importance – especially if one has ever needed it. Thank you Dan Orr for addressing this ever increasing need and ssue.