State Referral Centre: Diving and Hyperbaric Medicine
The Department of Diving and Hyperbaric Medicine at Royal Hobart Hospital is the State referral centre and the only facility of its type in Tasmania. The recompression facility enables therapeutic recompression of divers with dysbaric illnesses, and treatment of medical conditions using hyperbaric oxygen. It is a tertiary level service, with ICU capability, and has significant integration with other tertiary services located at RHH including: Endocrinology, Infectious Diseases, Vascular Surgery, High Risk Foot Clinic, ENT and Faciomaxillary Surgery, Critical Care, Cardiothoracic Surgery and Emergency Medicine.
The Department and its specialist staff have a key role in supporting the Tasmanian Professional Diving Industry. Without the facility, Professional and Scientific divers in Tasmania would be unable to comply with Australian Standards and Occupational Health Legislation, because they lack a supporting treatment facility, and they would be forced to stop all diving activity (Reference AS 2299.1 4.1(b)). The facility also provides support, advice and emergency treatment to 20,000 recreational and tourist divers.
There are multiple key relationships with services that are located in Southern Tasmania and the facility provides support to these services. These include the Aquaculture Industry, Royal Australian Navy Dive Team 10, Police Marine Rescue Division, CSIRO, IMAS, University of Tasmania, Australian Antarctic Division and the State Forensic Pathologist.
Diving and Medical conditions treated with hyperbaric oxygen include the following:
- Decompression Illness and Arterial Gas Embolism in divers
- Arterial Gas Embolism (non-diving related) due to accidents, cardiac surgery and invasive lines and medical misadventure
- Diabetic problem wounds, ulcers and gangrene
- Non-healing hypoxic wounds
- Prevention and treatment of osteoradionecrosis
- Soft tissue radiation injury and necrosis
- Necrotizing fasciitis and synergistic gangrene, Fournier's Gangrene
- Gas gangrene and Clostridial Myonecrosis
- Chronic mixed deep infections soft tissue and osteomyelitis
- Severe carbon monoxide poisoning
- Compromised flaps and grafts, and crush injuries
- Adjunctive therapy to enhance effectiveness of radiotherapy for solid tumours
Other specialist roles for the hyperbaric facility staff:
In addition to therapeutic recompression and hyperbaric oxygen treatments, specialist hyperbaric medical, technical and nursing staff provide the following services:
- Assessment, treatment and expert advice regarding diving emergencies that do not require recompression such as pulmonary barotrauma, pneumomediastinum, pneumothorax, ear and sinus barotrauma, marine envenomation and near drowning
- Specialist medical advice to the Tasmanian diving community (tertiary referral centre)
- Provision of expert advice to the investigation of diving fatalities – field and dive site assessments, analysis of diving equipment, and specialist advice to the Coroner
- Health monitoring and advice regarding fitness to dive for professional and recreational divers
- Provision of expert advice to the State and Federal Governments, statutory bodies such as Standards Australia, the scientific community, and Industry on issues relating to Diving and Hyperbaric Medicine
- Input to dive safety committees of CSIRO, marine aquaculture, IMAS, UTas and AAD
- Expert advice to other specialties regarding the role of hyperbaric oxygen in treating unusual or difficult to treat conditions (eg rare fungal infections and refractory osteomyelitis)
- Teaching including training of speciality registrars, medical students, ambulance officers, professional and recreational divers, nurses, technical staff, and other UTas students (Biomedical Science)
- Multidisciplinary Wound Care
- Research and teaching
- Postgraduate training
In the last financial year there were 2051 patient treatments provided at RHH Hyperbaric facility. Patient treatments have been increasing at a compound rate of 3.8% per annum:
Surgical and Medical Patients at RHH
Hyperbaric Medicine provides a key support role for surgical services where there is ischaemic tissue, necrotizing and anaerobic infections, radiation necrosis and where there is host compromise – eg diabetic patients.
Key interdisciplinary speciality relationships with other clinical tertiary services at RHH mandate that the hyperbaric facility continues to be located at RHH, whilst maintaining Statewide service delivery:
- Provision of support for complex general surgery, plastic surgery, ENT and head and neck surgery, vascular surgery, cardiothoracic surgery and where there is high level ICU back up. Patients with complex wounds, necrotizing fasciitis, requirements for extensive plastic surgery including flaps and grafts, and where surgery is conducted through irradiated tissue receive hyperbaric oxygen treatment in support their surgery. The bulk of this complex surgery is undertaken at RHH, and there is only limited access to these services at other hospitals. These patients are frequently very sick and may be ventilated in ICU.
- Support in a time critical manner for cardiac surgery. On rare occasions when a patient on cardiopulmonary bypass surgery sustains gas embolism to the brain, Hyperbaric Oxygen Therapy is the gold standard treatment. Because of this, the hyperbaric facility needs to be co-located with cardiac surgery.
- Support of radiation oncology treatment and its complications. Hyperbaric Oxygen Treatment is an established treatment for radionecrosis, osteoradionecrosis and soft tissue radiation injury. Multiple evidence based reviews by the Australian Federal Government Medical Services Advisory Committee have established its role in treatment of the complications of radiotherapy. This generally falls under the more complex care provided for cancer patients at RHH, and integrated services in this regard are more limited in other centres in Tasmania.
- Treatment of patients with high risk diabetic feet. Hyperbaric treatment of diabetic ulcers and gangrene has Level 1 evidence demonstrating improved wound healing and also preventing major amputations. Services from endocrinology and also vascular surgery are key relationships for Hyperbaric Medicine. RHH Hyperbaric Medicine staff have recently established regular input to the High Risk Foot Clinic at LGH.
- A high percentage of all patients treated at the hyperbaric facility are referred by the above tertiary specialities located within RHH – further demonstrating the key clinical relationships for the service.
Diving Activity in Tasmania
Professional Diving Activity: Tasmania has nearly 2,000 professional divers. The majority of Tasmania's professional diving activity is based in the South and South East of the state. This includes the aquaculture industry (Tassal, Huon Aquaculture, and Marine shellfish leases), Institute of Marine and Antarctic Studies, CSIRO, Abalone diving, University of Tasmania Scientific Divers, Royal Australian Navy Reserves Divers, and Police Marine Rescue Unit. Medical support is also provided to professional and recreational diving training establishments.
Recreational Diving Activity: Tasmania has over 20,000 recreational divers. Because of weather, geography and population distribution, the majority of the diving activity occurs on the East Coast, South East and South of the State.
In the last two financial years (2012-13 and 2013-14), 44 divers were treated for decompression illness (186 treatments). Another 150 divers assessed for non-decompression emergencies.
- 68% of these divers originated from the south of the State.
- 24% came from the north and north west and 8% were from interstate or overseas.
- The RHH facility treats as many diving emergencies as each of the facilities in Brisbane, Adelaide and Perth
Other Key Roles and Relationships of the Hyperbaric Facility
The Hyperbaric facility provides chamber training dives and chamber support to Tasmania Police Marine Rescue Divers, The University Department of Zoology (Southern Campus), Institute of Marine and Antarctic Studies, and also the Australian Antarctic Division (Diving Operations).
In addition to the support provided to these programs there are contributions to the academic and research work done in Southern Tasmania, including the newly developed virtual Centre for Antarctic, Remote and Marine Medicine.
Hyperbaric staff assist forensic pathology investigations, diving accident investigation and provide support for the State Forensic Pathologist based at RHH.
There are multiple established research linkages between hyperbaric facility staff (Nursing, Medical and Technical), the aquaculture industry in southern Tasmania, University of Tasmania, Australian Antarctic Division, and the Diver Alert Network.
The Department of Diving and Hyperbaric Medicine is involved in a number of national and international multicentre randomized controlled trials and international research collaborations, including close research relations with the Defence Research and Development in Toronto, Canada.
Postgraduate Training and Teaching
The RHH Hyperbaric Facility is accredited for postgraduate medical training by the Australian and New Zealand College of Anaesthetists (Special Interest Group Certificate in Diving and Hyperbaric Medicine), the Australasian College for Emergency Medicine (Special Skills Rotation), the Australian College of Rural and Remote Medicine, and the South Pacific Underwater Medicine Society (Diploma of Diving and Hyperbaric Medicine). There is an active post graduate nursing teaching program in Hyperbaric Nursing and Wound Care. Teaching is provided by all staff to undergraduates, post graduate nurses doctors and other students, in the hospital and community. Staff also contribute to teaching at national and international courses.
Labour Force Issues
The skill set of technical, nursing and medical staff at the Hyperbaric Facility is highly specialised, and has taken two decades to evolve.