Deep Impact
Rapidly gaining ground as a treatment option for wounds and diabetic ulcers, hyperbaric nursing is a new specialty with research opportunities for nurses

By Melissa Gaskill
August 20, 2003

Sometimes Claude Wreford-Brown, RN, gets a little giddy at work-laughing, joking and feeling euphoric. That's because he's nurse manager at the Virginia Mason Center for Hyperbaric Medicine in Seattle, and goes in and out of a decompression chamber where patients are being treated.

"The patients are breathing 100 percent oxygen, so they're fine," said Wreford-Brown, an advanced certified hyperbaric nurse, "but in the chamber, in effect, you go as deep as 165 feet, and the effect is nitrogen narcosis, the equivalent of about six martinis."

Hyperbaric chambers, first used in the 1600s, treat a variety of ailments, including carbon monoxide poisoning, air or gas embolism, decompression sickness, acute ischemia, hypoxic wounds, blood loss anemia, necrotizing soft tissue infections, radiation tissue injury, osteomyelitis and thermal burns. The treatment also is used as adjunctive therapy for blood loss anemia when patients refuse blood or cross-matching is difficult.

Recently, Medicare approved hyperbaric treatment of diabetic ulcers, bringing the number of conditions approved for compressed oxygen therapy to 14. Wound care patients are now the largest group of patients at most hyperbaric centers.

"The high-pressure oxygen stimulates angiogenesis," Wreford-Brown said. "Radiation damages the small blood vessels, and the high oxygen stimulates the growth of new blood vessels. This stops patients from getting wounds that before were typical."

In cases where angiogenesis is the primary goal, 20 to 40 treatments are needed.

Virginia Mason treats emergencies, like decompression sickness and carbon monoxide poisoning. The chamber also can be used to treat gas gangrene. The high pressure doesn't actually kill the bacteria, Wreford-Brown said, but can put them into stasis mode so they don't progress, giving antibiotics a chance to work.

"We stay very busy," he said. "The facility has been here about 30 years, and was originally a research facility developing saturation tables for North Sea oil operations."

Managing patients

Kathy Furnas, RN, is a clinical coordinator at the Hyperbaric Medicine Center at Presbyterian/St. Luke's Medical Center in Denver, one of the busiest hyperbaric centers in the country, with a 24-patient multiplace chamber.

"By the time folks get to us, they've usually been the rounds," Furnas said. "Everyone else has thrown up their hands and said, 'There's nothing else we can do. Try hyperbaric treatment.' So our cases are very complex."

One of the primary jobs of nurses who work in hyperbarics is managing patients, said Harry Vincent, MHA, RN, director of professional development at Total Wound Care Treatment Center in San Antonio and a certified hyperbaric technologist.

"We assess to see what the individual needs are, applying the nursing process to manage the patient as a whole," Vincent said. "Many times in outpatient therapies, patients get tied up going to this person for this therapy and that person for that therapy, and we are the ones tying it all together-nutrition, lifestyle, help at home-to get them to the point of being well."

Patient education is a big part of the job, said Bobbi Hall, RN, a certified hyperbaric nurse and nurse manager at the University of South Carolina's medical school hospital in Columbia.

"People are nervous. In our chambers, they aren't allowed to wear their clothes or watches or have books. We have to teach them to clear their ears," Hall said. "It's like diving, and one of the main problems we have is with ears popping.

"Depending on the condition they're being treated for, they are in there for up to six hours, and at a minimum two hours. We do have TVs they can see."

Patients are monitored while they are in the chamber, Hall said, with no more than two patients inside per staff member.

Hall's unit does an international training course for hyperbarics and has an advanced hyperbaric symposium for health care professionals annually. "About 30 people attend each course, and probably half are nurses or techs."

Room with a view

The two types of hyperbaric chambers are monoplace units and multiplace chambers.

Monoplace units treat one patient at a time and are made of acrylic with a pressure capability of three atmospheres compressed with 100 percent oxygen.

Multiplace chambers can treat from two to 18 patients, with a pressure capability of six atmospheres. These chambers are on compressed air, and patients are provided with oxygen through an individual delivery system.

Staff members enter and exit the chamber through an access compartment. In this compressed air environment, nurses face the same risk of getting the bends as scuba divers. Compressed air is an oxygen and nitrogen mix, and under pressure, the body absorbs nitrogen.

As the body decompresses-by a diver ascending, or a nurse exiting a hyperbaric chamber-the nitrogen is released. If decompression is too fast, it can form bubbles. Nurses keep track of the time they are in the chamber, keeping dive tables just like scuba divers. Those at high altitudes, like Furnas in Denver, have to take that into account as well. Flying in an airplane is not advised for several days after spending time in the chamber.

"It's a manageable risk," Vincent said, "but there have been some cases of decompression sickness in the industry."

How much nurses actually work the equipment varies from unit to unit. At monoplace chamber facilities, nurses are more likely to be involved in running the chambers.

In multiplace facilities, specialized techs run the chambers while nurses manage overall patient care, attending inside with the patient-and watching that martini effect.

Area of influence

Demand is growing, Vincent said, and so is supply.

More than 500 facilities provide hyperbaric treatment in the country (a list is available at www.scuba-doc.com/listchambr.htm), and the addition of the new Medicare diagnosis likely will spur substantial growth.

Better reimbursement makes it more cost-effective for hospitals and companies. Because staff members at multiplace chambers have to decompress between shifts, these facilities have to employ a large staff.

"The field is always growing and changing," Hall said. "There is a lot of research, so it is a great opportunity for nurses who want to get into research.

"This is a very interesting specialty because there's a lot of stuff that hasn't been substantiated. A lot of what we get comes from Navy and Air Force practice, and clinical applications provide a lot of opportunities to look at different equipment and profiles."

Nurses attracted to the field tend to be those with a "firehouse mentality," Wreford-Brown said. It also helps to be a team player.

"I think it is the best of several worlds," Furnas said. "I like critical care, but not as a steady diet. You get ambulatory patients and pediatrics. There's a nice variety, which keeps things fresh."

Not to mention six martinis with no hangover.

Contact Melissa Gaskill at gaskill@dbcity.com