Scott Bein - Hyperbaric Oxygen Therapy

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Transcript

Voiceover:
Welcome to Prescribed Listening from the University of Toledo Medical Center, each week UTMC providers sharing insight into their medical specialty. This week, Scott Bein.

Scott Bein:
My name is Scott Bein, I'm the program director for the Hyperbaric Medicine Department here at University of Toledo Medical Center. I've been here for about five years now and have developed this program to what it stands today, and we are treating wonderful, wonderful patients so they can get back on with their life and keep their standard of life to the way it was before they got their ulceration.

Scott Bein:
I became involved in hyperbaric medicine when I went to college in San Diego. I actually started going to school in a trade school for commercial diving. So I was really involved in scuba diving, I have thousands of dives under my belt, and hyperbaric medicine follows the same gas laws, physics, as scuba diving, and I thought commercial diving would have been right up my alley, and it was. I loved it, I'd go back and do it again. After a bit of time I did injure my knee and I was not able to do commercial diving, and followed up with hyperbaric medicine.

Scott Bein:
My first job was all the way across the country in Oregon, and wound up taking a position here as the program director, and never regretted it a moment in my life. It was fantastic. I absolutely loved the science behind it, it's all physics and science, it's all gas laws and equations, to make sure that the patients receive the treatment that they're ordered for, and to make sure they're safe and they go home every single day. That is what my job is, and that's what I love about it.

Scott Bein:
Hyperbaric oxygen therapy is an oxygen treatment under pressure. This has been around since 1667. A clergyman by the name of Henshaw in England discovered that different atmospheric pressures surrounding the body has different tangible healing properties. Back then they were just doing pressurized air, and it wasn't until late 18, early 1900s where they started introducing oxygen, and it actually became a medical modality back in the forties, thirties and forties. Hyperbaric oxygen therapy is a great modality for ulcerations, radiation, and bone infections that will not heal over a 30 day period. So it's a great and fantastic idea that's been around forever, but today with modern science, we've been actually able to precision the treatment per patient to exactly what they need.

Scott Bein:
So the process of hyperbaric oxygen therapy is our patients will sit inside the chamber, the chamber will be pressurized to two atmospheric pressures. So it's the same pressure as you would feel if you're scuba diving to 40 feet of salt water. Now obviously there's no water involved, it's all air pressure. Once we reach the pressure, the patient now wears a oxygen delivery hood, it's a clear vinyl hood, and under pressure we can actually induce, or super saturate the body with oxygen, to an equivalency of 200%. We're doubling the amount of molecules that can saturate the blood plasma within the body itself. Now normally our oxygen is carried through our red blood cell via the hemoglobin, and we can saturate that to 100% right here on surface with just a regular non-rebreather, or a nasal cannular, with 100% oxygen.

Scott Bein:
Inside the chamber we bypass the red blood cell as our oxygen carrier and we diffuse that oxygen molecule into the plasma of the blood, which is the liquid part of the blood. Now the plasma of the blood doesn't get stopped by those damaged vessels in the body that is created by either diabetes, radiation therapy. Because it's a very dense tissue, bone infections are very, very difficult to get enough oxygen to those tissues for them to function properly. Inside the chamber, breathing oxygen under pressure, we can super saturate those areas, get the oxygen to those damaged tissues downstream of those damaged vessels, and we can regrow new tissue, we can also have a huge effect on infections and make sure that the new tissue grows the proper amount of vascularity so when they heal, they stay healed and they don't have to come back, unless whatever caused the issue the first time causes it again.

Scott Bein:
On a daily basis our indicated patients from the wound care center will come in for hyperbaric treatment Monday through Friday, they're here for a two hour treatment, and the treatments are on the average of about 40. So they're here for about two months. Now within that period they get checked in every day, the doctors come down and check them out and make sure that they're good to go, and then our trained staff and team takeover. Inside the chamber is where our patients will sit. This chamber is 10 foot in diameter, 15 feet long. We can sit up to 10 patients at one time. At all times, whether we have one patient or up to 10 patients, we always have a staff member inside the chamber, and this is for safety and comfort, and to ensure that the treatment is exactly what the patient needs, and is ordered.

Scott Bein:
The difference between multiplace chamber and a monoplace chamber, the treatments are exactly the same. So when you're delivering 100% oxygen at the exact same pressure, there is no difference. Here at University of Toledo Medical Center we have the only multiplace chamber associated with a hospital in Northwest Ohio. Our chamber is pressurized with air, which is a safer gas mixture, within the treatment timeframe, and all of our oxygen is delivered by an oxygen hood or an oxygen mask. In a monoplace chamber, they are pressurized with 100% oxygen, the patient is laying on a gurney or a bed, and that's the only position they can be in. It is very, very technical at what goes inside a monoplace chamber because of a risk of fire or an explosion. In our chamber, much safer, we have a lot more relaxed rules because of the safety percentage that is built into it, we have staff members inside the chamber at all times, whereas monoplace the patients in by himself.

Scott Bein:
So on a daily basis here, our majority of indications are chronic non-healing wounds such as diabetic foot ulcers. Diabetic ulcers of any lower limb, as long as the insurance will approve it. Those particular indications, the diabetes, has damaged the blood vessels and we need to rebuild them through angiogenesis and neovascularization, which hyperbarics creates the environment for that new tissue growth, and for those particular [dallies 00:07:02] to occur. Now outside of diabetes, the next indication that we treat most here is radiation, or delayed radiation injuries. So radiation nowadays is becoming very, very pinpoint accurate, highly effective, but no matter how much effectiveness we can get it, there's always going to be what they call a scanner field of radiation outside of the treatment area. Now that scanner field creates damaged tissues. Now this sometimes takes months, sometimes years to develop those tissues to break down, but once you're radiated, that area is always subject to radiation injury from then on out.

Scott Bein:
So the radiation injury itself, or delayed radiation injury itself, is the soft tissue breaking down over time. Now it can happen in bone tissue as well, but usually that is a head or neck type of radiation where we're going to see that the most. So soft tissue radionecrosis is a slow degradation, or necrosis of the skin or soft tissue due to capillary beds and microvessel breakdown over time. Those ulcers develop usually 30 days or greater after the last treatment and will not go away. Hyperbaric oxygen therapy creates an environment for the body to actually recognize that there is an ulceration and start the healing process. Those particular patients are usually the highest success rates within our hyperbaric therapy due to the fact that all they really need is just extra oxygen at higher pressures for their body to react correctly and start that healing process.

Scott Bein:
So the last indication that we normally see within hyperbarics is osteomyelitis, which is an infection of the bone. After standard care and therapy, such as bone debridement, surgical intervention, and six weeks of appropriate antibiotics, a lot of these bone infections are still around, and they will not go away. Hyperbaric oxygen therapy is indicated at this time due to the fact that hyperbaric oxygen is also a bactericide, so meaning the high doses of oxygen can get within that tissue and help alleviate or eliminate the bacteria that's in that bone infection. The nice thing about hyperbarics and osteomyelitis is high doses of oxygen and antibiotics have a huge synergistic effect. By themselves antibiotics work great, but certain antibiotics require a certain amount of oxygen for the antibiotic to work correctly across the cell membrane and take care of the bacteria, as well as some antibiotics synergistically improve and have a higher kill rate with oxygen levels being as high as we can administrate them in hyperbarics.

Scott Bein:
Risks and side effects to hyperbaric medicine, there are some, absolutely, just like any other medical therapy or medical intervention. The risks are minimal, and they're only within the hyperbaric chamber itself, those are the ones that we really, really keep an eye on. It's called oxygen toxicity. At the dosage in which we administer the oxygen, it's considered a drug. Now drugs do have side effects. We have an acronym called [inaudible 00:10:31] that we keep an eye on, it's not all inclusive, but it's something that keeps us on the lookout for an oxygen toxicity event inside the chamber. Now vision changes, ringing in the ears, nausea, twitching, tingling of the fingertips, irritability, dizziness are all small signs that the body's natural reaction to saying, we've had too much, and that's why we have an attendant inside the chamber.

Scott Bein:
The worst case scenario we have what we call an oxygen induced seizure, and that's, again, why we have the inside observer inside the chamber at all times. Lower blood sugars also can be an issue within the chamber. Diabetics have to be a 100 milliliters per deciliter before they go inside the chamber, and that is because they usually drop, on the average, of 20 points while they're in the chamber. Now over time we regulate how much each individual patient needs to have before they go in the chamber, because each one drops at a different rate. Some patients go in and they raise sugar levels, and some go in and drop sugar levels.

Scott Bein:
No matter if it's a low blood sugar or an oxygen toxicity event, we treat it all the same. The first thing we do is take off the hood. This lowers the partial pressure of oxygen within the body itself, and if it's oxygen related, they snap right out of it, usually within a few minutes. If it's a low blood sugar, we're checking sugars anyways, that's always the next step. We have capabilities of checking sugars inside the chamber, and then we also have countermeasures as needed to ensure that the sugar levels go back up. Inside our chamber there are different issues, but that's why we have people inside the chamber, and that's why we are trained all the time on those particular incidences.

Scott Bein:
Now any type of lasting side effect outside the chamber, there is a near-sightedness that could happen, but it is only temporary. We tell all of our patients about near-sightedness prior to starting their very first treatment so if they do have corrective lenses, they don't go out and change their prescription because it's going to go right back to normal, usually within six weeks after their last treatment. Outside of near-sightedness, we do have a consent form that every single patient is informed of, is more than happy to read every single word of it. But I make sure that when I go over the consent form, they understand not only the side effects, such as near-sightedness, but the inherent dangers within the chamber that we want to eliminate, or at least reduce to a very, very low percentage of danger, or eliminate completely.

Scott Bein:
Now these particular types of dangers we eliminate by making sure that nothing goes in the chamber that is not allowed in the chamber. No battery operated equipment, no metallic pieces of metal that can cause sparks inside of our chamber, these particular issues can cause fires because we do have 100% oxygen under pressure within the chamber. Now just in case something outside of our control happens, the chamber is capable of a fire suppression system, it is equipped with a fire suppression system. And this fire suppression system is activated twice a year for annual plan maintenance, and to make sure that it functions properly. Every one of our staff members actually goes inside the chamber at these times and experiences that fire deluge sprinkler system so they know how to act and they know what to experience when that goes off. Our chamber is the safest chamber in Northwest Ohio, it is the safest chamber due to the fact that it is a multiplace, we have fire suppression systems, and we always have an inside trained observer at all times in the chamber.

Scott Bein:
Contraindications, there's only one absolute contraindication, and that is called an untreated pneumothorax. So any type of collapsed lung or air bubble within the lung itself, the lung cavity, that cannot be vented, that's the only absolute contraindication. Outside of that, there are relative contraindications, bleomycin, cisplatin, sulfamylon, these have to be removed or these drugs have to be stopped before treatment can start. There are a list of relative contraindications sent as pregnancy, high fevers, sinus congestion, things like that, that we can alleviate prior to going in, and they're not as severe.

Scott Bein:
So the relative contraindications, we can still treat people if it's an emergency, but long-term chronic daily treatments, we have to make sure that these relative contraindications have been alleviated before they go in the chamber. The reasoning is, is the extra pressure on the body has different effects on particular types of issues, like sinus congestion and things like that, it's called trapped gas in those areas, and the pressure affects those trapped gas pockets in many different ways. But that's why we screen each and every single patient before they go in the chamber, the doctor listens to the lungs, looks in the ears, and clears you for treatment for that day, to make sure that all of these contraindications have been addressed.

Scott Bein:
As for providers, if I were to hope they would take away from this, is hyperbaric medicine has been around for hundreds of years. It's approved by all insurances for the appropriate indication. Diabetic foot ulcers, soft tissue and osteoradionecrosis, radiation cystitis, radiation enteritis, radiation proctitis, osteomyelitis, these are the ones that we find the largest healing rates with. We have a very, very good success rate with hyperbaric medicine and these indications. The sooner that the patient can be seen by the Wound Care Center here at UT, and evaluated for hyperbaric medicine, the faster the heal rate will be for that patient.

Scott Bein:
Unfortunately, some ulcerations, depending on what causes it, they can have these ulcerations for years. I actually had a lady at one time, she had an ulceration for over 12 years before we got her in the chamber, because nobody knew how to take care of it. She was referred to the Wound Care Center at the time, once evaluated she had advanced wound care therapy, she was a soft tissue radionecrosis patient. She was putting the chamber, we did a little over two months with her, and she wound up healing and moving on. So no matter how much we try, and we want for the patients to heal outside of wound care, advanced wound care therapy and hyperbaric therapy are sometimes the only way and the best way to make sure our patients get back to their normal daily lives outside of regular clinic visits.

Voiceover:
Thank you for listening to Prescribed Listening from the University of Toledo Medical Center. To learn more about the provider you heard on today's show, visit UTMC.Utoledo.edu. More Prescribed Listening next week from UTMC.