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LETTERS: Gary Reah and Ian Sanders Proposed alternatives are incorrect BMJ 1994; 309: 124b [Full text]

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Criticism and Condemnation of Life-Saving Treatment is Incorrect.

Gordon J.G. Ward   (21 August 2007)

Criticism and Condemnation of Life-Saving Treatment is Incorrect. 21 August 2007
Gordon J.G. Ward, Director, Hyperbarics Edmonton General Hospital T5K 0L4 Send response to journal: Re: Criticism and Condemnation of Life-Saving Treatment is Incorrect.	It would appear that Reah and Sanders(1) are incorrect in their condemnation and disregard of Hyperbaric Oxygenation (HBO) as a viable therapeutic alternative for a "patient's refusal of blood products after suffering extensive orthopaedic trauma." (1) Their proposed rationale for such disregard, "hyperbaric oxygen cannot be regarded as a practical alternative to blood transfusion to ensure adequate oxygen delivery for any length of time in such patients" (1), is not consistent with the known and established practice of the highly specialized expertise in hyperbaric medicine and, most specifically, in the field of Military Diving applications. The establishment of modern hyperbaric medicine began with the work and subsequent publication of Prof. I. Boerema indicating the effectiveness of HBO for Exceptional Blood Loss Anemia and the ability of HBO to sustain life in the absence of circulating hemoglobin. (2) Since then, HBO has been an acknowledged treatment and the effective protocols have been well defined. (3) With respect to the commonly held belief that extended durations of oxygen inhalation at increased barometric pressures results in cerebral oxygen toxicity with a manifested seizure and the implied seriousness of such an occurrence, the critical literature typically fails to identify the specific context in which this event occurs and the long-term consequence of such a seizure. On the contrary, such critical literature continues to propagate paranoia against what may be the only life-saving technique available. The United States Navy specifies that qualification for a Treatment Table No. 7 requires a minimum exposure of 12 hours at 60 feet sea water, which is the USN Treatment Table 6. (4,5) Should the patient fail to respond positively to the USN TT 6, then the protocol is followed by or converted to a USN TT 7. In this treatment protocol, there is no minimum duration for the inhalation of oxygen at a barometric pressure of 60 fsw; essentially the protocol is indefinite - either the patient recovers or expires. The capability to maintain a critically ill patient in a hyperbaric chamber under such extreme circumstance is contingent upon the advanced competency of the operating personnel following well established procedures and protocols. In fact: "the training and experience of the physician in managing the patient during treatment is most critical", (6) Such a critical and advanced practice is not for the novice and requires advanced training typically far outside of most publicly offered training programs. For this specific reason, the certification of Hyperbaric Physicians in Canada is specified as three levels, ranging from Basic operations to Advanced levels. (7) Only this Advanced Level III certification qualifies the expertise to complete this level of treatment. Given the known risk of an oxygen-induced-seizure during such a critical treatment, there is an identified response should such an incident occur. "If at 60 feet or shallower and oxygen breathing must be interrupted because of CNS oxygen toxicity, allow 15 minutes after the reaction has entirely subsided and resume schedule at point of interruption". (8,9) "When applying Hyperbaric Oxygen to critical and emergency conditions, injuries with life-threatening results, the concern for or the potential of CNS oxygen toxicity is not necessarily considered to prevail over the treatment procedure or protocol". (10) "Minor signs and symptoms of CNS O2 toxicity can be tolerated for patients, especially if it is necessary to push high partial pressure of oxygen to solve life threatening problems." (11) In weighing the risks verses the benefits in a potentially life- saving protocol, the informed literature places the context of a CNS toxic reaction: "The end result may be an epileptic-like convulsion that is not damaging in itself, but can result in drowning [not applicable in a hyperbaric chamber] or physical injury." (12) "These generalized tonic-clonic seizures are usually self-limited." (13) "Reversal of the symptoms while breathing chamber air is consistent with recovery from oxygen poisoning." (14) "No permanent damage to the nervous system results from the seizures and the seizure threshold is not altered in any way." (15) "On the other hand, no matter how long a person might breathe oxygen, the signs of poisoning disappear soon after he begins breathing air." (16) "The significant concern during any convulsion is the potential for phsycial trauma as a consequence of the uncontrolled movements during the seizure." (10) Given that "there are no residual effects of oxygen convulsions if mechanical trauma can be avoided" (14), and that the "patient's refusal of blood products after suffering extensive orthopaedic trauma" is associated with a high mortality, the risk-benefit would be in favor of the use of hyperbaric oxygenation. The assertion of Reah and Sanders that Hyperbaric Oxygenation is "erroneous" appears to be erroneous itself. The misinformed condemnation of hyperbaric oxygen as a "dubious indication" (1) might possibly deny a patient the reasonable choice of life over death. Gordon JG Ward Director, Hyperbarics Edmonton General Hospital rahbekw@moderndigital.net REFERENCES 1 Reah G, Sanders I. Letters: Proposed alternatives are incorrect. BMJ 1994;309:124. 2 Boerema I, Meyne NG, Brummelkamp WH et al. Life without blood. Arch Chir Neer. 1959; 11: 70-83. 3 Exceptional Blood Loss Anemia. Hampson NB. chairman and editor. Hyperbaric oxygen therapy: 1999 committee report. Kensington, MD: Undersea and Hyperbaric Medical Society, 1999: 35-36. 4 Treatment Table 7. US Navy Diving Manual. Vol. 1: 8-15.3.5. 5 Treatment Table 7. US Navy Diving Manual. Vol. 5: 21; 21-11. 6 Kindwall EP, Goldmann RW. Air Embolism. Hyperbaric Medicine Procedures. St. Luke's Medical Center. Milwaukee, WI. 1995: 206-217. 7 Diving and Hyperbaric Physicians. Competency Standards for Diving Operations. CSA Z275.4-97. Canadian Standards Association. Chapter 24. 8 Treatment Table 7. US Navy Diving Manual. Vol. 5: 21; 21-9. 9 Treatment Table 7. US Navy Diving Manual. Vol. 5: 21-5.5.6.1.1. 10 Ward GJG. Oxygen Toxicity as a Complication and Side Effect of Hyperbaric Oxgyen. Safety and Effectiveness. Application for a New Medical Device Licence. Health Canada Licence No. 60118. July 23, 2002: 51-62. 11 Rutkowski D. Recompression Chamber, Life-Support Manual. Hyperbarics International. 1998. 12 Oxygen Toxicity. Diving Physiology; NOAA Diving Manual; Diving for Science and Technology. Fourth Edition. JT Joiner (Ed.). National Oceanic and Atmospheric Administration. 2001. 13 Delaney JS, Montgomery DL. How can hyperbaric oxygen contribute to treatment? The Physician and Sportsmedicine. Mar. 2001: 29(3). 14 Clark J, Whelan H. Oxygen Toxicity. Hyperbaric Medicine Practice. Second Edition. EP Kindwall, HT Whelan (Eds.). Best Publishing Company. Flagstaff, AZ. 1998: 69-82. 15 Koch GH. Physiological changes of increased atmospheric pressure. Basic Hyperbaric Medicine. J Wilson (Ed.). Hyperbaric Consultants. Toronto General Hospital. 16 Burakovsky VI, Beckeria LA. Hyperbaric oxygenation and its value in cardiovascular surgery. Mir Publishers. 1981. Competing interests: None declared