Oxygenation

The National Fire Protection Association (NFPA) defines hyperbaric as a “facility, building, or structure used to house chambers and all auxiliary service equipment for medical applications and procedures at pressures above normal atmospheric pressures.”1 Additionally, they define hyperbaric oxygenation as “the application of pure oxygen or an oxygenenriched gaseous mixture to a subject at an elevated pressure.”2 Hyperbaric oxygen therapy (HBOT) “can actually signal the DNA in our cells to perform healing tasks that the body normally can’t do.”3

While most of us may be familiar with the use of a hyperbaric chamber with diving accidents and the treatment of the divers for decompression sickness (the bends), HBOT can be used to enhance the treatments of other illnesses and conditions also. The Undersea and Hyperbaric Medical Society (UHMS) lists approved indications for hyperbaric oxygen therapy.4 The following indicators are listed:5

Air or gas embolism

Carbon monoxide poisoning

Carbon monoxide poisoning complicated by cyanide poisoning

Clostridal myositis and myonecrosis (gas gangrene)

Crush injury, compartment syndrome and other acute ischemias [restriction of blood supply to tissues] Decompression sickness

Arterial insufficiencies such as central retinal artery occlusion [blockage of a blood vessel]

Enhancement of healing in selected problem wounds6

Severe anemia

Intracranial abscess

Necrotizing [death of cells in living tissue] soft tissue infections

Osteomyelitis [infection and inflammation of the bone or bone marrow]

Delayed radiation injury (soft tissue and boney necrosis)

Compromised grafts and flaps

Acute thermal burn injury

Idiaopathic [disease or condition the cause of which is not known or that arises spontaneously] sudden sensorineural7 hearing loss

Some of the other areas where HBOT is being tested are autism, cancer, diabetes, multiple sclerosis, asthma, cerebral palsy, and heart disease, but these are not on the approved list of indicators of the UHMS.

 Health care workers such as paramedics are familiar with some of the most basic technology that goes into oxygen therapy - pulse oximetry, said Dr. High Tadlock of the College Station (TX) Medical Center’s Wound Healing and Hyperbaric Center.

“Hospitals check your blood pressure, temperature and pulse with a little clip on the end of your finger,” Tadlock said. “Well we use an oximeter that is more sophisticated. It measure the oxygen around wound. If that oxygen is low, it only makes sense to get more oxygen to the wound and improve its capacity to heal.”

But adding oxygen at normal pressure does not push it deep into the damaged tissue where it is needed. By using a hyperbaric chamber, oxygen can be introduced at 2.4 times normal atmospheric pressure. That is the equivalent of driving 66 feet under water.

 Hyperbaric chambers can be either hard-shell chambers made of steel and acrylic or soft-shell chambers considered portable chambers. Hard shell chambers may be small one-person devices or larger ones that accommodate multiple patients. Soft-shell chambers, inflate to a lower atmosphere (1.3 atmospheres) as compared with hard-shell chambers which are rated for three atmospheres or greater.8 Soft-shell chambers may consist of a urethane coated, nylon-bonded flexible acrylic pressure vessel with steel-weld technology.

Chambers may be monoplace and multiplace. Monoplace chambers hold one patient at a time. During treatment the chamber is pressurized and filled with 100 percent oxygen. Patients in monoplace chambers are grounded, and the chamber itself is grounded, to prevent sparks from static electricity. New advancements in design is the pressure-safe acrylic tube. This chamber has clear walls to allow the clinical staff to have a clear view of the patient, while reducing the closed-in feeling that the patient may have.9 Multiplace hyperbaric chambers hold many patients at a time. Patients receive 100 percent oxygen through a hood, mask, or endotracheal tube. Periodic air breaks are necessary to prevent oxygen toxicity.10

NFPA 99 Health Care Facilities Code classifies hyperbaric chambers as follows:11

Class A- Human, multiple occupancy

Class B- Human, single occupancy

Class C- Animal, no human occupancy12

These classifications affect the fire resistive ratings for surrounding enclosures and openings as well as finishes, ventilation, depressurization in emergencies, and other fire protection measures.

Fires involving hyperbaric chambers are rare, in comparison to the number of chambers in use and the number of treatments. Prior to 1970 there were no national fire safety standards for clinical hyperbaric chambers in the United States. Fire prevention at that time was left to the common sense of the operators.13 Oxygen enriched atmospheres “usually facilitate the initiation of the combustion process, and once ignition has occurred, the flame reaction proceed with greater rapidity.”14 Additionally, “in confined spaces, the combustion of a relatively small quantity of combustibles can result in the rapid generation of extremely high temperatures and increased pressure. The high temperature can result in the ignition of other combustibles some distance from the initial reaction zone, thereby contributing to the rapid spread of the fire. The high temperatures and toxic combustion products that are generated are in themselves potentially lethal to personnel in the environment, even if they are not engulfed in flames. The increased pressure produced in association with the flame process can also result in the explosive rupture of the chamber.15 As a result, fire prevention is especially important. A review of fires in hyperbaric and hypobaric chamber fires over a 73 year period globally reinforced that “fatal hyperbaric chamber fires were caused by a combination of factors: abundance of burnables [sic], elevated oxygen concentration, faulty electrical components, inadequate extinguishment, and lack of vigilance to exlude ignition sources from being carried into the chamber.

NFPA 99 Health Care Facilities Code requires strict fire protection measures for hyperbaric chambers and facilities. This fire protection includes but not limited to:17

Class A chambers must contain a fire suppression system consisting of independently supplied and operating handline and deluge type water spray systems.

Failure of the components of either the handline or deluge system will not render the other system inoperable.

Intrinsically safe circuits, including sound powered communications, shall be permitted to remain connected when either the handline or deluge system is activated.

Manual activation and deactivation of deluge controls shall be located at the operator’s console and in each chamber compartment containing a deluge system.

An automatic wet pipe sprinkler system shall be installed in the room housing a Class A, Class B, or class C chamber, and in any ancillary equipment rooms. These chambers when not contiguous to a health care facility and located in a mobile vehicle-mounted facility shall not be required to be protected with a wet pipe sprinkler system.

Surveillance fire detectors responsive to the radiation from flame shall be employed. These detectors may be used to activate the deluge system in addition to the manual controls.

Hyperbaric facilities shall designate an on-site hyperbaric safety director to be in charge of all hyperbaric equipment and the operational safety requirements of NFPA 99.

Emergency procedures specific to each facility must be developed and all personnel trained in emergency procedures.

Emergency procedures and fire training drills shall be conducted at least annually and documented by the safety director.

Ensure that potential ignition sources are eliminated.

The following are prohibited from inside the chamber and the immediate vicinity outside the chamber: smoking, open flames, and hot objects. The following are prohibited from inside the chamber: personal warming devices (hand warmers, etc.), cell phones and pagers, sparking toys, and personal entertainment devices. Electronic devices are placed outside the chamber on top of a rubber mat so the patient can watch a DVD, TV or listen to music. .

Antistatic procedures employed whenever atmospheres containing more than 23.5% oxygen by volume are used. (see photos 1 & 2 showing grounding wires from chamber to grounding nut)

Silk, wool, or synthetic textile materials, or any combination thereof shall be prohibited in Class A or Class B chambers.

Garments fabricated of 100 percent cotton or a blend of cotton and polyester fabric shall be permitted in Class A chambers with handlines and deluge systems as well as Class B chambers.

Petroleum based products e,g., oil based cosmetics, lotion and bath oils, Vaseline, fingernail polish, perfume, and aftershave are generally prohibited inside the chamber.

On a personal level, several years ago Chief Tarantino spent some time at a HBOT facility as a technician in training. The facility was owned and operated by a fellow firefighter and his family. The firefighter had an autistic child and through a network of parents with autistic children, learned about the possible advantages of HBOT for autism. There were no known facilities in their state and they subsequently went to San Diego for their daughter’s treatments. At the time, their daughter was 2 years old and was not crawling or even beginning to talk. She could only sit up by herself for about 15 seconds. After 3 weeks and 4 days of treatment, which was twice a day 6 days a week, for 90 minute sessions, she could sit up on her own and was more mobile. Overall, she had more movement and was more aware of her surroundings. Their daughter’s treatments continued over the years and she is now 12. The parent’s believe that the HBOT treatments have helped their daughter tremendously, even though the use of HBOT for autism is still under evaluation. They now operate a facility as a non-profit organization to help improve the lives of veterans by relieving the symptoms of Traumatic Brain Injury disorder (TBI) and Post Traumatic Stress Disorder (PTSD) through the use of HBOT. This in addition to the approved indications for HBOT therapy.

A more comprehensive view of fire protection and prevention measures are contained in NFPA 99. It is recommended that fire departments with HBOT facilities in their jurisdictions make visits to these facilities and learn more on what they do, the hazards contained, and the emergency procedures employed. Emergency procedures of the facility should be contained or referenced in the fire department’s pre-plans. Many times, fire prevention inspectors are the only interaction a facility has with the fire department. Fire department operations units should be familiar with the facilities and have interaction with facility staff as well. Remember, the time to know the hazard and operation is prior to the incident, not during.

Authors Chief (ret) Sue Tarantino Chief Tarantino is a retired 28-year veteran of the Charlotte (NC) Fire Department (CFD). She currently is a senior fire protection specialist with World Safe International (WSI), LLC teaching flammable liquids firefighting and performing consulting work in storage tank facilities and other industrial complexes. Additionally, she assists in managing major clients for WSI including Industrial Emergency Services and Svitzer Salvage Americas. As a member of the CFD Sue had served as a Battalion Chief for 12 years, during which time she supervised the operations of the hazardous materials company. In her previous capacity she oversaw the preincident response planning and response to numerous petroleum storage tank facilities within the battalion’s response district. She has also served as the Chairperson for the department’s Health and Wellness Committee and drafted the CFD’s respiratory protection program. Chief Tarantino is an instructor in Advanced Strategy and Tactics at Piedmont Community College as well as Command and Control with the Office of the State Fire Marshal. She has been published in national trade publications. Sue holds an Associate degree in Fire Protection Technology, a Bachelor of Science degree in Industrial Psychology and a Master of Business Administration. Assistant Chief Craig H. Shelley Chief Shelley is a 40-year veteran of the fire service. He served with the FDNY for 26 years retiring as the Chief of Marine Operations. Craig was also the Chief of the City of Rutland (VT) Fire Department as well as serving as a Fire Protection Advisor for Saudi Aramco. Chief Shelley served for eight years on the NFPA’s Technical Committee on Training. Craig has performed petroleum industry and marine consulting throughout the world, most recently for major oil companies in Libya and Brazil where comprehensive analysis of process, storage and marine facilities were conducted. Currently, Craig is an Assistant Chief with Industrial Emergency Services, managing their marine operations program in conjunction with Svitzer Salvage. He holds a Bachelor of Science degree in Fire Service Administration and a Master of Science degree in Executive Fire Service Leadership. www.usfirepump.com | 215-429-1423 MAX WATER FLOW FOR ANY SITUATION Be prepared for the unexpected with the most powerful fire pump in the industry! Rated NFPA 1901 at 6000 GPM, the High Velocity Fire Pump is the largest single stage fire pump in the world. Designed for NFPA industrial fire pump applications and high volume water supply, thie High Velocity pump is available as a direct engine mount or a midship mount utilizing 600+ HP engines. HIGH VELOCITY FIRE PUMP Fire Boats 6000 GPM Trailer/Skid 5500 GPM Fire Apparatus 5000 GPM NFPA RATED 4000 GPM SKID PACKAGES STARTING AT $183,000...CALL FOR MORE DETAILS

1 National Fire Protection Association (NFPA), NFPA 99, Health Care Facilities Code (Quincy, MA: NFPA, 2012) 3.3.76

2 NFPA 99, 3.3.77

3 K. Paul Stoller, A Primer of Hyperbaric Therapy for Parents, (2013) Retrieved from the World Wide Web http://www.tacanow.org/family-resources/hyperbaricoxygen-treatment-for-autism-spectrum-disorders/

4 Approved by the Hyperbaric Oxygen Therapy Committee of the UHMS 5 Undersea and Hyperbaric Medical Society, Definition of Hyperbaric Oxygen Therapy, Retrieved from the World Wide Web http://membership.uhms. org/?page=indications

 6 Hyperbaric oxygen therapy has proven beneficial in burn care as well as diabetic foot wounds

7 Sensorineural hearing loss (SNHL) occurs when there is damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain. Most of the time, SNHL cannot be medically or surgically corrected. This is the most common type of permanent hearing loss.

8 K. Paul Stoller

9 Hyperbaric link, About Hyperbaric Oxygen Therapy, Retrieved from the World Wide Web http://www.hyperbariclink.com/hyperbaric-oxygen-therapy/ hyperbaric-chamber-types.aspx#.UvaCZHcQT2N 10 Hyperbaric link

11 NFPA 99, 14.1.2.2 12 Chambers designed for animal experimentation but equipped for access of personnel to care for the animals are classified as Class A.

13 P. J. Sheffield & D. A. Desautels, Hyperbaric and Hypobaric Chamber Fires, (1997) Undersea and Hyperbaric Medical Society

14 National Fire Protection Association (NFPA), NFPA 53, Recommended Practice on Materials, Equipment, and Systems Used in Oxygen-Enriched Atmospheres (Quincy, MA: NFPA, 2011) E.5.1 15 NFPA 53 E.5.2 16 Sheffield & Desautels

17 More detailed information regarding fire protection is contained in NFPA 99, Chapter 14