Objectives of Training
Objectives of Training in Diving and Hyperbaric Medicine for the ANZCA Certificate in Diving and Hyperbaric Medicine
Section 1: Patient Assessment
Section 2: Hyperbaric Oxygen Therapy
Section 3: Diving Medicine
Section 4: Wound Management
Section 5: Complications of HBOT
Section 6: Indications and Contraindications for HBOT
Section 7: Research and development
Section 1: Patient Assessment
General Instructional Objective
"The Trainee is meticulous and reliable in assessing and preparing patients for Hyperbaric Oxygen Therapy (HBOT)."
1.1 Initial assessment
| a. | Appreciates those aspects of patients' physical, physiological and mental states which influence the administration of hyperbaric oxygen |
| b. | Assesses patients' status by history taking, physical examination and diagnostic tests |
| c. | Identifies patients as suitable or unsuitable for hyperbaric oxygen therapy on the basis of their physical, mental and emotional status |
1.1.1 Previous history
| a. |
Understands the relevance of previous or surgical events and drug exposure |
| b. | Identifies and evaluates the significant features in the previous history |
1.1.2 Clinical examination and investigation
| a. | Is aware of significant symptoms and signs and can determine what investigations are necessary |
| b. | Evaluates the significance of age, size, nutritional state, gender |
| c. | Elicits relevant history and physical signs |
| d. | Assesses the ease of auto-inflation of the middle ear (including tympanometry) |
| e. | Interprets ventilatory function tests with full understanding of their relevance and impact on Hyperbaric exposure |
| f. | Identifies and interprets relevant laboratory and imaging investigations |
| g. | Identifies relevant medical problems and their implications for hyperbaric oxygen therapy |
| h. |
Is competent at assessing peripheral circulatory status with Doppler ultrasound devices |
| i. |
Understands the principles and interpretation of transcutaneous oximetry mapping of wound |
1.2 Effects of HBOT
| a. | Knows the effects of HBOT on the body systems |
| b. | Understands the effects on the body systems of important medical and surgical diseases and their treatment, and the impact of HBOT and pressurisation on such conditions |
1.2.1 The primary condition
| a. | Describes those aspects of the aetiology, natural history and effects of the important medical conditions which are relevant to hyperbaric medical practice |
| b. | Identifies the effects on the conduct of HBOT |
| c. | Identifies the effects on the patient’s condition and on the incidence of complications |
| d. | Identifies and interprets those investigations which are relevant to each patient’s condition with special reference to HBOT |
| e. | Evaluates the urgency of treatment, placing patients' interests before convenience |
| f. | Ensures patients are properly prepared for treatment |
| g. | Clearly states why treatment should be deferred if indicated |
1.2.2 Intercurrent diseases
| a. | Understands the effects and how these conditions may be modified by appropriate treatment |
| b. | Identifies the local and regional effects of relevant medical diseases and the principles of their management (e.g., diabetes, malignant disease, severe sepsis) |
| c. | States the effects of HBOT on the progress of intercurrent diseases |
| d. | Evaluates their effects and therapy on the conduct of HBOT |
| e. | Evaluates their effects and therapy on the conduct of HBOT |
| f. | Describes appropriate investigations |
| g. | In consultation, adequately prepares patients for treatment |
1.2.3 Drug therapy
| a. | Understands what effects drug therapy may have on physiology and how this may be affected by HBOT |
| b. | Identifies those drugs which may have adverse effects on patient physiology leading to potential complications with HBOT |
| c. | Modifies (where possible) existing drug therapy appropriately prior to HBOT |
| d. | Modifies (where appropriate) hyperbaric oxygen therapy treatment profiles to reduce toxicity or complications from co-existant or previous drug therapy |
1.3 Assessing the risk of HBOT
| a. | Understands the factors involved in judging the risk of HBOT, and able to balance the urgency of treatment against the potential complications |
1.4 Routine preparation of patients for HBOT
| a. | Understands usual preparatory routine |
| b. | Prepares a scheme for routine preparation, including appropriate clinical observations, obtaining of consent, etc. |
| c. | Understands the role of medications which may be used in conjunction with HBOT (topical agents, sedatives, analgesics, insulin, etc.) |
| d. | Balances the need for medication against the risks involved with their use |
| e. | Describes the basic pharmacology of drugs used in HBOT, and understands how the pharmacokinetics and pharmacodynamics may be altered by HBOT |
| f. | Outlines the objective of administration of drugs in conjunction with HBOT |
Section 2: Hyperbaric Oxygen Therapy
General Instructional Objective
"The Trainee understands the physiology and complications of Hyperbaric Oxygen Therapy. He or she has a detailed knowledge of the equipment used in the administration of Hyperbaric Oxygen Therapy, and how it is affected by the hyperbaric environment."
2.1 Physiological effects of HBOT
| a. | Knows and recognises the effects and side-effects of HBOT |
| b. | Describes the effects of HBOT |
| c. | Balances the effects of HBOT against the risk of physiological disturbance |
| d. | Understands the Hyperbaric Oxygen Treatment tables, and how these may be modified to provide optimal therapeutic effect and minimise complications |
| e. | Modifies treatment tables in the presence of complications |
| f. | Indicates personal interest in the welfare of patients by meticulous observation and management |
| g. | Demonstrates a detailed knowledge of the complications of HBOT and the management thereof |
| h. |
Demonstrates ability to act as in-chamber attendant for routine patient treatment |
2.2 Equipment for HBOT
| a. | Knows the range, function, clinical use and hazards of equipment used in HBOT |
| b. | Recognises the need for safety in the use and maintenance of equipment in the hyperbaric environment |
| c. | Shows detailed knowledge of the different types of oxygen delivery apparatus used in HBOT, and their different features. Is able to select appropriate oxygen delivery apparatus for each patient. |
| d. | Understands the effect of the hyperbaric environment on the function of equipment and recognises which pieces of equipment are not suitable for exposure to pressurisation |
| e. | Is familiar with the modifications which may be required before exposure of equipment to the hyperbaric environment |
| f. | Demonstrates ability to use equipment safely in the hyperbaric environment |
| g. | Understands the effects of pressurising items of equipment with air-filled cavities, and can safely modify the usage of such items (e.g., endotracheal tube cuffs, pulmonary artery catheters, underwater seal drains) |
2.3 Hyperbaric therapy for the critically ill patient
| a. | Demonstrates advanced airway skills, including bag-mask ventilation, endotracheal intubation and mechanical ventilation |
| b. | Understands the principles of invasive pressure monitoring and implications of these under hyperbaric conditions |
| c. | Demonstrates ability to act as in-chamber attendant for ventilated critically ill patients |
| d. | Demonstrates proficiency at cardio-pulmonary resuscitation and has a detailed knowledge of all emergency drugs |
Section 3: Diving Medicine
General Instructional Objective
"The Trainee is able to perform detailed medical assessments for prospective divers. He or she has a detailed knowledge of diving related illnesses and their management, including prevention and treatment."
3.1 Diving medical assessments
| a. | Demonstrates a detailed knowledge of the requirements for fitness to dive |
| b. | Has a detailed knowledge of the Australian Standards relating to diving and working under hyperbaric conditions |
| c. | Understands the implications of medical and surgical conditions for divers |
| d. | Demonstrates the ability to perform detailed diving medical assessments for prospective divers according to AS2299 |
| e. | Demonstrates ability to interpret all relevant investigations, including respiratory function tests, tympanometry, audiology, radiological investigations, and pathology tests |
| f. | Understands the physiological changes experienced during diving |
| g. | Demonstrates ability to communicate with prospective divers regarding fitness to dive, especially when candidate is unfit |
| h. |
Understands the influence of age, gender, and medications on fitness to dive |
| i. |
Is familiar with the different types of equipment used in the diving industry |
3.2 Diving accidents
| a. | Demonstrates a sound knowledge of diving related illness and their first aid and definitive management |
| b. | Understands the pathological processes involved in diving related illnesses |
| c. | Demonstrates an ability to gather detailed information regarding a diving accident and give appropriate advice regarding immediate first aid, and subsequent management |
| d. | Has detailed knowledge of the local retrieval services and is able to arrange appropriate retrieval of diving casualties to the nearest Hyperbaric Facility |
| e. | Carries out thorough clinical assessment of diving casualties, orders appropriate investigations, and determines when HBOT is required |
| f. | Has detailed knowledge of the commonly used recompression tables and their application |
| g. | Supervises recompression therapy and is able to modify treatment tables when required to treat refractory cases |
| h. |
Understands the role of adjunctive therapy for decompression illness and gas embolism (e.g., lignocaine, NSAID’s) |
| i. |
Performs detailed clinical assessment after treatment, and arranges further treatments and follow-up as required. Provides detailed advice to divers about future diving and risks involved, and about restrictions relating to decompression stress after diving illness (e.g., flying, ascent to altitude) |
3.3 Commercial diving
| a. | Understands the physiological stresses experienced while working under water or in a hyperbaric environment |
| b. | Is aware of the different gas mixtures used in commercial diving practice and the rationale for their use |
| c. | Is aware of the decompression procedures used in the commercial diving industry, including routine saturation diving practices |
| d. | Is aware of those problems commonly encountered in association with commercial and saturation diving, and understands their prevention and management |
3.4 Marine envenomation
| a. | Has a working knowledge of the venomous marine creatures present in Australian waters, and the effects of their venom |
| b. | Provides appropriate treatment and advice regarding management of envenomation |
| c. | Is aware of the sources of expert advice available within the profession and how to initiate contact with those experts when required |
3.5 Other immersion disorders
| a. | Has detailed knowledge of the physiological and pathological effects of hypothermia, and its management |
| b. | Understands the physiological and pathological effects of near drowning, and its management |
| c. | Understands the physiological and pathological effects, and the clinical manifestations of salt water aspiration syndrome, and its management |
| d. | Understands the effects on the cardiovascular system of immersion in cold water and the implications of this |
3.6 Diving-related disorders
| a. | Understands the pathophysiology and clinical manifestations of inert gas narcosis and high pressure nervous syndrome |
| b. | Understands the pathophysiology and clinical manifestations of aseptic necrosis of bone, and demonstrates ability to detect and initiate treatment for those affected |
| c. | Is familiar with the long term neurological effects of diving and is able to detect and initiate management of those affected |
Section 4: Wound Management
General Instructional Objective
"The Trainee understands the role of Hyperbaric Oxygen Therapy in the management of wounds."
| a. | Understands the pathology of commonly presenting wounds, and is able to make an assessment of their suitability for HBOT, and develop a comprehensive management plan |
| b. | Understands the differing pathological causes of wounds and chronic ulcers |
| c. | Demonstrates skill in Doppler assessment of the circulation of the limbs, and understands the significance of the results |
| d. | Understands the role of transcutaneous oximetry, its use in planning treatment, its role in determining the end point of therapy, and its limitations. He or she demonstrates skill in performing the transcutaneous oximetry procedure |
| e. | Has detailed knowledge of commonly used dressing material, and is able to plan a customised dressing regimen for each patient |
| f. | Understands the role of HBOT in wound management and determines the suitability of each patient for treatment |
| g. | Appreciates the multidisciplinary nature of wound care and demonstrates an ability to liaise with other specialists. He or she understands when further referral is required, and is able to initiate |
Section 5: Complications of HBOT
General Instructional Objective
"The Trainee demonstrates detailed knowledge of potential complications of therapy and ability to prevent complications where possible, and to detect and treat complications as they arise."
5.1 Barotrauma
| a. | Understands the physiological principles leading to the development of barotrauma |
| b. | Provides detailed instruction to patients regarding middle ear autoinflation techniques, prior to pressurisation |
| c. | Demonstrates skill in otoscopic examination of the ear |
| d. | Understands the classification of aural barotrauma |
| e. | Prescribes appropriate treatment for aural barotrauma |
| f. | Has a detailed knowledge of barotrauma in other body parts (e.g., lung, sinus, teeth, GIT) and appropriate management |
5.2 Hyperbaric myopia
| a. | Understands the importance of assessment of visual acuity prior to HBOT |
| b. | Understands the pathological and physiological processes contributing to the development of myopia following HBOT |
| c. | Provides appropriate advice to those affected by hyperbaric myopia |
5.3 Oxygen toxicity
| a. | Has a comprehensive understanding of the toxicity of oxygen, both pulmonary and neurological |
| b. | Understands the aetiology, pathophysiology and predisposing factors for hyperoxic seizures |
| c. | Recognises the symptomatology of hyperoxic seizure aura |
| d. | Is competant in the management of hyperoxic seizures |
| e. | Understands how treatment tables can be modified to reduce the risk of hyperoxic seizures |
| f. | Understands the aetiology, pathophysiology and predisposing factors for pulmonary oxygen toxicity, recognises the symptomatology and recommends appropriate treatment |
Section 6: Indications and Contraindications for HBOT
General Instructional Objective
"The Trainee has a comprehensive knowledge of indications for, and contraindications to Hyperbaric Oxygen Therapy."
6.1 Accepted indications
| a. | Has a comprehensive knowledge of those conditions for which HBOT is used |
| b. | Is familiar with the published lists of approved indications, and understands how these were derived |
| c. | Understands the concept of evidence based medicine and how it applies to the practice of Hyperbaric Medicine |
6.2 Contraindications to HBOT
| a. | Has a comprehensive knowledge of conditions in which HBOT may cause unwanted side-effects |
| b. | Understands those risk factors which may predispose to side-effects from HBOT |
| c. | Knows those conditions which are absolute contra-indications to HBOT, and understands the rationale for this |
| d. | Knows those conditions which are relative contra-indications to HBOT, and understands the rationale for this |
| e. | Is able to make an educated recommendation on the safety and desirability of HBOT in those patients with relative contra-indications, through a risk/benefit analysis |
Section 7: Research and development
General Instructional Objective
"The Trainee understands the principles and practice of medical research. Understands the importance of continuing quality improvement within the Hyperbaric Medicine Unit."
7.1 Research
| a. | Demonstrates a sound knowledge of the principles of medical research and the interpretation of the results of clinical trials |
| b. | Understands the procedures required in carrying out clinical trials and their importance in establishing a base of medical evidence |
| c. | Understands the principles of presentation and publication of research material |
7.2 Administration and Quality Assurance
| a. | Has a comprehensive knowledge of the standards relating to hospital-based hyperbaric patient treatment facilities, and how they have been applied to the local facility |
| b. | Understands the value of keeping accurate records and data for quality assurance and audit purposes |
| c. | Understands the concept of clinical indicators and their role in quality assurance |
