CLINICAL INTERNSHIP IN HYPERBARIC TECHNOLOGY

Introduction

In order to facilitate entry for certification in hyperbaric technology, the National Board of Diving and Hyperbaric Medical Technology has established a set of clinical internship guidelines. Graduates of approved introductory training programs in hyperbaric technology and/or medicine are required to undergo a minimum clinical internship of 480 hours. Sixty (60) hours of the requirement should be a supervised clinical internship to complete eligibility requirements for certification examination.

The supervised clinical internship guidelines that follow are general in nature. They are divided into five categories, with specific topics listed for each category. The objectives of each topic are described under the heading “Internship Objectives”. Some of the topics have been expanded to include “Additional Objectives”. Interns should be encouraged to achieve each of the additional objectives in whichever topics are of particular interest, or most applicable to his/her situation. This approach allows individuals with varied skills and backgrounds to utilize a common program of clinical training,

The supervised clinical internship guidelines are not specific to a particular facility or method of delivery of hyperbaric oxygen therapy. Rather, they provide the broadest possible subject matter so that each center can tailor these guidelines to best fit their respective resources and areas of expertise. It should be kept in mind that the objective of this program is to provide the intern with a broad-based general knowledge. Each center is encouraged to develop specific training material with regard to precise objectives, subject matter and teaching methods.

The supervised clinical internship should be preceptor based. As a minimum requirement, each designated facility preceptor(s) should be a Certified Hyperbaric Technologist with a minimum of two (2) years of undersea/clinical hyperbaric/aviation medicine experience. In order to initiate an internship, each facility should inform the NBDHMT, in writing, of the intern’s name, and the name of the preceptor.

I.    CHAMBER EQUIPMENT

1. CHAMBER COMPRESSION GAS

Internship Objectives:  Know and demonstrate knowledge of the routing of the compression gas supply and the Quality Assurance procedure to ensure gas purity.

Additional Objectives:   Inspect the entire gas supply pathway. This will vary, depending upon the chamber type. High pressure or cryogenic storage, or low pressure compressor intake, to pressure reducing or compression mechanisms, to accumulators, zone shut-off -valve to chamber control valving and flow lines should be identified, respectively.

2. BREATHING GAS SUPPLY

Internship Objectives:   Know and demonstrate knowledge of the source of the breathing gas supply and the Quality Assurance procedure to ensure gas purity. Practice proper connection and operation of breathing gas supply.

Additional Objectives:   Inspect the entire breathing gas supply pathway(s). This will likely involve multiple gas mixtures and oxygen in multiplace chambers, and both oxygen and compressed air in monoplace chambers. Special attention should be directed to pressure reduction, isolation and emergency shut-off procedures. Conduct troubleshooting and maintenance of the breathing gas system(s): i.e. regulator, flow meter, humidifier, overboard dump and patient delivery system.

3. FIRE EXTINGUISHING SYSTEM

Internship Objectives: Be familiar with the fire extinguishing system activation procedures for the chamber (where fitted) and the surrounding hyperbaric facility. Operate handheld hose(s), where fitted, and be familiar with the operation of portable handheld devices. Recognize the fire alarm(s).

Additional objectives:   Inspect the water tanks, water delivery, fire director sensors and alarm panel (where fitted). Review maintenance and troubleshooting procedures.

4. COMMUNICATIONS

Internship Objectives:    Be familiar with all applicable forms of voice and visual communications. Recognize factors that may influence operator/inside attendant/patient communications.

1. CHAMBER STANDARD OPERATING PROCEDURES

Internship Objectives:     Know and be able to perform the chamber(s) standard operating procedures.

Additional Objectives:     Inspect chamber console/panel layout. Locate and operate manual and automatic controls.

2. CHAMBER EMERGENCY OPERATING PROCEDURES

Internship Objectives:     Know, and be able to perform, the chamber operating procedures that become necessary under various emergency situations.

Additional Objectives:     Inspect chamber console/panel layout, as it pertains to emergency and override controls.

3. CHECKLISTS, DIVE TABLES AND TREATMENT PROTOCOLS

Internship Objectives:     Be familiar with all chamber checklists (equipment and patient). Have a working knowledge of dive/decompression protocols. Have a working knowledge of all patient treatment protocols.

Additional Objectives:     Demonstrate a working knowledge of decompression table computations.

4. PATIENT TREATMENT AND STAFF DIVE RECORDS

Internship Objectives:     Be familiar with all of the procedural and operational aspects necessary to institute hyperbaric oxygen therapy protocols.

Additional Objectives:     Compile a record of typical patient treatments in accordance with local operating procedures.

5. SUPPORT EQUIPMENT AND SUPPLIES

Internship Objectives:     Be familiar with all chamber and patient ancillary equipment (ECG and pressure monitor; infusion pump; suction apparatus; transcutaneous oxygen monitor; mechanical ventilator; blood pressure and vital signs monitors; Ambu bag etc.). Know all of the supplies necessary to support the elective and emergent patient referral. Be able to identify the effects of pressure on ancillary equipment and supplies. Recognize any associated safety hazards.

Additional Objectives:    Practice set-up, operation and troubleshooting of all ancillary equipment.

6. PATIENT PREPARATION, LOADING AND UNLOADING

Internship Objectives:     Know and demonstrate knowledge of patient preparation for hyperbaric oxygen therapy.  Know the correct procedure for transferring patient into and removing from the chamber.

Additional Objectives:     Practice patient preparation procedures with particular attention to physical, physiological and equipment risk factors. Practice chamber loading and unloading of patients.

1. FIRE SAFETY

Internship Objectives:     Know and demonstrate knowledge of how to prevent/minimize electro-static spark discharge and control/minimize static electricity accumulation and other potential ignition sources. Appreciate the effect of hyperbaric oxygen environments and the burning rate of materials that are allowed, and those not allowed, in the chamber.

Know how to control oxygen levels in multiplace chambers to within operational limits.

2. PRESSURE SAFETY

Internship Objectives:     Know and demonstrate knowledge of the correct procedure for operating/securing all doors, hatches and other pressure boundary accesses. Know the proper set-up and connection of all pass-throughs. Know all of the potential pressure hazards in and around the chamber.

Additional Objectives:     Practice operation of all pressure boundary doors and hatches. Practice set-up, operation and maintenance of all pass-throughs.

1. INITIAL CONSULTATION

Internship Objectives:     Know and demonstrate knowledge of the appropriate referable conditions for hyperbaric medicine evaluation and the related beneficial mechanism(s). Know the currently accepted hyperbaric treatment protocols. Know the treatment plan and appreciate the duties of each of the hyperbaric staff members involved in the patient’s care.

Additional Objectives:     Observe an initial consultation. Review patient’s reason for referral, previous medical management, physical, neurological and vascular examinations. Assist in transcutaneous oxygen testing, review results and interpretation. Formulate and rationalize a treatment plan.

2. ONGOING ASSESSMENT

Internship Objectives:     Appreciate the various clinical and laboratory indicators necessary to evaluate therapeutic response during the treatment course.

Additional Objectives:     Undertake patient evaluation during the treatment course. Determine patient compliance and cooperation. Evaluate for side-effects, including, but not limited to, middle ear/tympanic membrane changes and blood glucose control.

3. FOLLOW-UP ASSESSMENT

Internship Objectives:     Appreciate periodic patient follow-up parameters. Appreciate clinical and laboratory responses, need for other therapy and prognosis.

Additional Objectives:     Attend periodic patient follow-up visits. Determine degree of outcome complications and side-effects to hyperbaric oxygen therapy.

1. PATIENT PRE-TREATMENT BRIEFING

Internship Objectives:     Know and demonstrate knowledge of the risks and potential side-effects of exposure to hyperbaric doses of oxygen.

Additional Objectives:     Brief patient concerning the physical effects of changes in environmental pressure. Brief patient on the correct procedures to limit/reduce the likelihood of barotrauma to the lungs, sinus spaces, ear, teeth and gastrointestinal tract. Brief the patient concerning known risk factors for exposure to hyperbaric doses of oxygen.

2. BAROTRAUMA MANAGEMENT

Internship Objectives:     Know and demonstrate knowledge of the signs and symptoms of barotrauma. Know and demonstrate knowledge of the immediate management of barotrauma.

Additional Objectives:     Instruct and assist patients during compression and decompression phases.

3. OXYGEN TOXICITY MANAGEMENT

Internship Objectives:     Know and demonstrate knowledge of the signs and symptoms of central nervous system intolerance to hyperbaric doses of oxygen. Know and demonstrate knowledge of the signs and symptoms of pulmonary oxygen toxicity. Know and demonstrate knowledge of the various methods that serve to reduce the likelihood of oxygen toxicity. Know and demonstrate knowledge of   the immediate management of CNS oxygen toxicity.

Additional Objectives:     Appreciate the complicating factors associated with the development of pulmonary oxygen toxicity.

4. HYPOGLYCEMIA MANAGEMENT

 Internship Objectives:     Know and demonstrate knowledge of the differential diagnosis of hypoglycemia vs. CNS oxygen toxicity. Appreciate the methods of determining blood glucose. Appreciate methods of correcting hypoglycemia.

Additional Objectives:     Witness blood glucose assessment. Determine prophylaxis or correctional requirements for diabetic patients pre-HBO, where indicated.

5. DECOMPRESSION SICKNESS  MANAGEMENT

Internship Objectives:     Know and demonstrate knowledge of the procedures necessary to prevent/reduce the incidence of iatrogenic decompression sickness. Recognize the common manifestation of decompression sickness.

Additional Objectives:     Appreciate the differential diagnosis of decompression sickness vs. cerebral arterial gas embolism.

6. PULMONARY BAROTRAUMA

Internship Objectives:     Know and demonstrate the knowledge of the risk factors for pulmonary barotraumas of ascent. Appreciate the differential diagnosis of cerebral arterial gas embolism vs. pneumothorax vs. tension pneumothorax vs. mediastinal emphysema vs. subcutaneous emphysema. Know and demonstrate knowledge of the various risk factors that increase and decrease the risk of pulmonary barotraumas. Know and demonstrate knowledge of immediate management of suspected pulmonary barotraumas of ascent.

Additional Objectives:     Appreciate the definitive management of the various forms of pulmonary barotraumas of ascent.

7. CARDIOPULMONARY COMPLICATIONS

Internship Objectives:     Demonstrate proficiency in obtaining vital signs. Know and demonstrate knowledge of the common clinical signs of severe, acute onset, cardiovascular distress. Demonstrate proficiency in basic CPR.

Additional Objectives:     Appreciate normal vs. abnormal ECG wave forms. Appreciate basic methods of airway control.

8. INFECTION CONTROL 

Internship Objectives:     Know and demonstrate knowledge of standard universal precautions and supplemental local infection control policies. Practice universal and local specific infection control precautions.

Additional Objectives:     Recognize patient and equipment risk factors for cross-contamination.

9. PATIENT COMFORT

Internship Objectives:     Know and demonstrate knowledge of the various procedures necessary to ensure patient comfort and thermal control. Know and demonstrate knowledge of the signs and symptoms of claustrophobia and confinement anxiety.

Additional Objectives:     Appreciate the various methods helpful in overcoming confinement anxiety.

10. WOUND CARE

Internship Objectives:     Appreciate the general principles of wound homeostasis; infection control and treatment and wound healing and non-surgical wound care.

Additional Objectives:     Assist in the evaluation of wounds. Assist in the limited debridement of wounds and appreciate the different types of wound dressings and their respective applications.

11. DOCUMENTATION

Internship Objectives:     Know and demonstrate knowledge of all forms and paperwork used to document patient treatment.

Additional Objectives:     Complete pre-treatment patient assessment and treatment protocol forms. Complete ancillary patient chart notes and post-treatment documentation.