“There is a fabulously important role for the hyperbaric nurse to assist with care coordination,” says Nicholas Bird, MD, a physician with Duke Health in Durham, North Carolina, and the former chief medical officer and CEO of Divers Alert Network. “The fact that the patient’s wound exists in the context of underlying chronic disease, diabetes, acute carbon monoxide poisoning, high blood pressure, burns, and other things, necessitates care coordination with the patient’s family. How does that person get the care they need? How do they get transportation to and from? Have they just had a surgical procedure? Have they had an amputation? Have they got a prosthesis? Have they got the ability to ambulate? Have they got home care? Have they got chronic wound care?” asks Bird, who has just described the value and importance of the hyperbaric nurse.
Bird confesses that he’s one of the few people who has made a full-time living as a diving physician consultant in the country. But hyperbaric medicine’s transformation from association with the scuba diving and decompression sickness to oxygen therapy for a range of illnesses has made an appealing opportunity for nurses seeking to work in a very exciting and niche area of health care.
What is Hyperbaric Nursing?
The BNA defines it as “the diagnosis and treatment of human response to actual or potential health problems in the altered environment of the hyperbaric chamber.” The role of hyperbaric nurses is multifunctional, but ultimately, their goal is to provide cost-effective, quality patient care according to established standards. So there is a need for people who are capable of providing dedicated engagement every single day to somebody going through that.
Hyperbarics, as it is often called, is not a mechanism for controlling, for example, diabetes. Rather, it’s the mechanism for minimizing some of the impact of these blood vessel diseases. That is, the downstream effect of long periods (e.g., years) of poor blood sugar control, in the extreme, or just a long-term degree of the disease, which eventually leads to small blood vessel disease. When people get to a certain point where they start having spontaneous tissue breakdown, ulcers, and wounds, those ulcers and wounds won’t heal. Oftentimes, they progress and worsen very rapidly, resulting in people losing toes, feet, even legs. Additionally, Medicare is very specific about the way in which hyperbaric treatment is applied. The patient has to have an ulcer of a certain depth before it is acceptable for hyperbaric treatment.
Initially, many hyperbaric nurses were first experienced in critical care, emergency room, and medical-surgical areas, and they were cross-trained in hyperbaric oxygen therapy. In 1985, the Baromedical Nurses Association (BNA) was founded and hyperbaric nursing became formally recognized. Today, there are over 900 certified hyperbaric nurses and three possible certifications: Certified Hyperbaric Registered Nurse (CHRN), Advanced Certified Hyperbaric Registered Nurse (ACHRN), and Certified Hyperbaric Registered Nurse Clinician (CHRNC). To learn more about becoming certified, visit hyperbaricnurses.org/certification.
Bird believes that the coordination of all of those ancillary services is vital to the success of delivering quality care during or post-hyperbaric care services. “Now, the idea that the care happens magically in this sort of medical bubble here [in the medical facility] and then at home. That home world doesn’t exist and if we’re not successful—because we don’t have adequate care coordination—this is where a nurse comes in to [meet this need] that is so critical,” he comments with much emphasis. What, then, is the role and contribution of the hyperbaric nurse?
Eric Hexdall, RN, ACHRN, the clinical director with Duke Dive Medicine, was a diving officer in the Navy, familiar and competent in dealing with the hyperbaric chamber as applied to diving episodes. He first completed his RN degree and then leveraged his diving experience by obtaining certification as a certified hyperbaric nurse. His entry into hyperbaric medicine followed the typical track. He
worked initially in surgical trauma and the intensive care unit. “So my nursing background is in intensive care, most specifically trauma, but I’ve worked in medical as well,” he explains.
The origins of hyperbaric medicine started with diving medicine. Diving meaning scuba divers and dealing with people with decompression sickness, also known as the bends. Its essence is that of enhancing oxygen delivery to tissues that are compromised. To shed light on how hyperbaric medicine transitioned from diving to oxygen therapy, Bird explains it this way: “You and I are breathing 21% oxygen right here in this room. If I put you on 100% oxygen and then increase the pressure at which you are breathing by two to three fold, I could increase your total dose to the equivalent of about 250 to 300% oxygen. That enables oxygen delivery to tissues that are compromised. Now the tissues that benefit from that are the ones that are the most compromised. So diseased states, like burns or primarily diabetes, and people who have had radiation therapy, are those who have blood vessel or vascular supply problems. The principal issue there is microvascular, so the capillaries—the smallest blood vessels—have poor penetration into those tissues.”
“Diseases like diabetes are really diseases of the small capillaries,” Bird continues. “In a diabetic person, for example, they may have windows of hypovascularity, or decreased blood vessel concentration, so hyperbaric treatment enables oxygen to penetrate deeper into tissues to keep them alive in the early phases of treatment. As treatments go on, day by day, you start to enable the building of new blood vessels, and you facilitate healing of tissues that’s sustained. It’s fascinating. There is no other treatment that does that.”
A little known fact is this: diving medicine constitutes about 1% of any hyperbaric practice and the treatment of decompression illness. The U.S. Navy and Coast Guard are known for having well-trained and up-to-date facilities by the very nature of their service and work, and events at sea brings them hurrying fast to get the diver to the nearest facility within four minutes. However, most clinicians are providing wound care for people, primarily diabetics and those who have had radiation therapy. A crew of health professionals—including registered nurses—are needed to operate the chambers, which can be found in over 750 hospitals nationwide and require sustained follow-up and treatment oversight. Hyperbaric units may also be staffed by certified hyperbaric technicians, respiratory therapists, physical therapists, or emergency medical technicians.
In recent years, hyperbaric oxygen therapy has been explored as a treatment for individuals with autism spectrum disorders. These studies suggest that a number of children who have been treated by physicians using hyperbaric oxygen therapy may work well at low pressures with varying degrees of oxygen concentrations as well as at varying degrees of high pressures with 100% oxygen on carefully selected children. If this proves appropriate and successful, this will open up a new channel for applying the principles of hyperbaric nursing to this population.