The Disappearing Recompression Chamber

Undercurrent reader Michael Marmesh (Miami, FL) was aghast to hear that there's no recompression chamber for divers in Miami any longer. That doesn't mean it has closed down. It just means that the chamber, located at Mercy Hospital, just isn't available to injured divers any more.

"As a lifelong scuba diver, I am disturbed," he wrote (and cc'ed us) in a letter to Miami Herald reporter Susan Cocking. "I had reason to consult with them three years ago after a 90-foot night dive. My right leg had been completely numb for half an hour, but the doctor was very helpful and reassuring. Turned out to be a pinched nerve and not a bends hit. Still, the resource needs to be available locally."

Unfortunately, that probably won't happen in the near future. Diver-friendly recompression chambers are closing down in the U.S. on a regular basis. The hardest-hit area is Florida. The Divers Alert Network (DAN) says seven facilities in the last three years have become unavailable for the treatment of decompression sickness (DCS). Cocking tells us that she only found out about the Miami chamber shutdown when a friend of hers got bent and had to be evacuated to the Florida Keys for recompression. "The doctors told us at the time that the only recompression chambers in Florida are in the Keys, Orlando and West Palm Beach."

Ironically, there has been a huge increase in the number of recompression chambers in the U.S. over the past decade, both in hospitals and as stand-alone clinics. Dick Clarke, president of the National Board of Diving and Hyperbaric Medical Technology, says the number of chambers has risen from 200 ten years ago to more than 1,400 today. "The problem for divers is most of that increase is related to a business model designed to maximize profits and minimize expenses." Treating divers for DCS is not part of that model.

Besides treating DCS, recompression chambers are also used for wound healing and treating chronic diseases. Most of those treatments are classified as hyperbaric oxygen therapy (HBOT). "The difference is most HBOT treatments can be run like an industrial factory line," says Mauricio Moreno, founder of SSS Recompression Networks, which runs a dozen chambers in dive destinations worldwide. "You can schedule them easily, and run the treatments either with nurses or physician assistants. DCS treatments are different. Patients come in on an emergency basis, and treatments require a board-certified doctor and internist. The cost of having them on standby for a chamber that is not regularly used for DCS is huge." What's more, those costs are not reimbursed easily. Insurance and Medicare reimbursements for HBOT treatments are low, and DCS treatments are placed in that category. "The payout fis low so the chambers lose a lot of money," says Moreno. That's why chamber operators see that service as red ink."

In the past, most U.S. chambers were available on a 24/7 basis. But because they were losing money, many operators decided to limit hours or just shut down. These days, the majority of chambers are available only to outpatients, typically those needing wound therapy, and operate weekdays during normal business hours. "Most dive accidents occur on the weekends," says Clarke. "Chambers have no interest in treating divers, because divers simply get bent at the wrong time of day and night. That has become a national crisis. An increasing number of divers go without HBOT and suffer the long-term medical consequences."

Clarke also runs National Baromedical Services, a hyperbaric medicine consulting firm for hospitals, in Columbia, SC. It's affiliated with the University of South Carolina's medical center, which has a 24/7 recompression chamber. Now it's the go-to chamber for Charlotte, NC, which lost its sole 24/7 chamber. "Atlanta has four million people, and it used to have two 24/7 recompression chambers in hospitals. Today, there are 14 HBOT programs in hospitals but none are available 24/7."

The situation is better overseas. As with much of healthcare, Americans can find it cheaper and more efficiently overseas than they can in the U.S. Same goes for recompression chambers, says Clarke. "The international ones run 24/7, and they're in places where most divers go to dive, because they were put there to treat divers. But in some cases, these chambers struggle to maintain high levels of clinical and operational capabilities."

Still, it's not uncommon for overseas chambers to have disputes with the insurance companies about reimbursement. Ten of them, led by Moreno's SSS Recompression Networks, got into it with DAN America back in March 2006. They issued a press release stating they would not take DAN America's insurance at their chambers, most in popular dive sites like the Bahamas, Belize, Cozumel and the Galapagos, and the policyholders would have to pay their costs out of pocket. The reason was due to unpaid medical claims, some dating back two years, causing some chambers to consider closing down. Moreno led a lawsuit against DAN America in U.S. federal court. DAN's response was, "It is [our] view that reasonable and customary means the usual charges of similar chambers. It is the view of Mr. Moreno that reasonable and customary means what the chamber charges, even if the charges are significantly higher than charges of other similar chambers." Yet a month later, the two parties reached a confidential settlement over the billing practices, and SSS's chambers announced they would accept DAN America insurance again.

But today, Moreno is still critical of DAN and what it's doing in the wake of constant shutdowns of DCS treatments at U.S. chambers. "DAN is supposed to be monitoring and leading the charge. What are they doing to convince local hospitals not to close their chambers to divers? What are they doing with their money? This issue is right on their doorstep, but DAN is not doing much about it."

We asked DAN for its take. "DAN does everything possible to ensure U.S. chambers are available to divers," DAN spokeswoman Rachelle Deal wrote in an e-mail. "We also maintain a database of all chambers available to treat injured divers, and have programs which allow chambers to become part of DAN's preferred provider network. As part of DAN's mission, we regularly review and consider new programs as circumstances change. Our goal is to make sure injured divers have access to: 1) quality medical care which allows for evaluation of a diving injury; 2) appropriate medical facilities which are operated in a safe, efficient and cost-effective way; and 3) the best treatment available in a given region or territory."

In the meantime, what can divers do? Always buy policies for travel medical insurance and emergency assistance when you're diving abroad. If you are on Medicare, you must have a supplemental policy that provides foreign medical coverage. "It's imperative that you're covered for medical accidents when you travel internationally," says Clarke. "From time to time, some insurance-lacking divers treated in remote areas who can't pay the bill are prevented from leaving the country until someone can pay up. Sometimes passports are removed until they can pay. So have some form of insurance that covers dive-related accidents, and always read the policy to see how you're covered.

As for keeping U.S. chambers open to divers, Clarke doesn't have any good advice. "There have been some initiatives by local diving groups and local chambers to try and stem the tide of disappearing 24/7 programs, but I don't know of any that have been successful. It's a huge financial barrier for chambers. But for divers and others who need this type of emergency treatment, it is a national crisis."

-- Vanessa Richardson