Fire drills in Hyperbaric Medicine

Alvim, Helena

Universidade do Porto / CIGAR Centro de Investigação em Geo-Ambiente e Recursos / FEUP Faculdade de Engenharia da Universidade do Porto / Rua Dr. Roberto Frias, s/n 4200- 465/ Porto/ Portugal+351 917 713 482 / helenalvim@fe.up.pt

Tato Diogo, Miguel

Universidade do Porto / CIGAR Centro de Investigação em Geo-Ambiente e Recursos / FEUP Faculdade de Engenharia da Universidade do Porto / Rua Dr. Roberto Frias, s/n 4200- 465/ Porto/ Portugal+351 225 081 997 / tatodiogo@fe.up.pt

Ponce Leão, Rui

Escola Superior de Saúde / Instituto Piaget-Gaia / Hospital de Santa Maria / Rua de Camões, 906 4049-025 / Porto / Portugal+351 965 058 863 / rmplo@yahoo.com

Camacho, Óscar

Unidade de Medicina Hiperbárica / Hospital Pedro Hispano / Unidade Local de Saúde de Matosinhos / Rua Dr. EduardoTorres, s/n 4454-509/ Matosinhos/ Portugal+351 229 391 000 / oscar.camacho@ulsm.min-saude.pt

Santos Baptista, João

Universidade do Porto / CIGAR Centro de Investigação em Geo-Ambiente e Recursos / FEUP Faculdade de Engenhariada Universidade do Porto / Rua Dr. Roberto Frias, s/n 4200-465/ Porto/ Portugal+351 225 081 429 / jsbap@fe.up.pt

Nóbrega, Júlio

Coordenador do Centro de Medicina Hiperbárica (CMH) do Hospital Central do Funchal, Portugal+351 91 993 33 63 / jjpnobrega@gmail.com

ABSTRACT

Hyperbaric Oxygen Therapy (HBOT) is internationally widespread. The hyperbaric team, according to levels of responsibility, should be trained to react appropriately to emergency scenarios. Designing safety protocols in case of fire is an objective. Safety during the HBOT treatment is critical. The oxygen rich atmosphere and pressure enhance the risk of fire. The impossibility of the immediate opening of the chamber door and the prompt evacuation of its occupants are aggravating circumstances. Adequate training of HBOT professional in emergency (e.g. fire drills) procedures can minimize consequences in case of an accident. As a conclusion fire drills should be thoroughly planned and regularly scheduled involving the whole HBOT team.

Keywords

Risk, HBOT, Emergency, Fire

The Hyperbaric Oxygen Therapy (HBOT) is widespread internationally. The element that accompanies the patient (doctor, nurse or camera operator) within the hyperbaric chamber during therapy sessions (designated Assistant or Attendant), and patients are exposed to various risks. The most paradigmatic and documented serious consequence is the potential fire hazard in hyperbaric chambers. During HBOT sessions, both the chamber functioning requirements and the prevention measures to be taken by users have to be thoroughly respected. [2]

Accident situations in hyperbaric chambers, due to fire or explosion were reported since 1923 with serious consequences, mostly fatal for the occupants [22]. After the tragic occurrence at the Istituto Galeazzi in Milan, where 11 people died during the HBOT [8] [23], the hyperbaric chamber technology had an enormous development both within structure and safety equipment and fire fighting [3]. The development of standards and technical regulations at international level, the control in application and adherence of the various Units of Hyperbaric Medicine (UMH) the certification programs make this medical therapy, a method with increasing worldwide implementation. [1] In parallel the procedures and practices implemented in the UMH, increase safety, both to patients and to professionals themselves. Yet, fatal accidents continue to occur, such as:

• • On 6 February 2006. Explosion in a hyperbaric chamber hyperbaric medicine clinic in Lima, Peru;
• • In May, 2009 a fire in a chamber in the U.S. singleseater (single

seater cameras are widely used in this country), which resulted in the death of a child and grandmother1

Hyperbaric Chambers are subject to strict regulations and standards, particularly in the European Community and the United States [1] [2]. Fire Safetyof UMH is defined in EN14931 [12], as well as the Clinical Hyperbaric Facility Accreditation Manual, referring both to the NFPA 99 with regard to measures of reference "Fire on HBO" [1].

The requirement for Fire Safety at international level, including the National

Fire Protection Association (NFPA) is high. Chapters No. 19 and No. 20 of NFPA 99 contain guidelines on prevention of fire and its suppression in hyperbaric environment. With regard to tests and reports (although not applicable to the single seater hyperbaric chambers because they generally do not have a deluge system internal), it is assumed that all facilities, regardless of the existing type of camera, should routinely perform simulation exercises. [24]

The European Committee for Standardization (CEN) has promoted and adopted (at CEN TC 359 Hipertech workgroup project on 09.25.2010) a European

Project Hyperbaric Chambers - Specific Requirements for fire extinguishingsystems, developed with Hipertech CEN engineers and experts, waiting for the publication of EN 16081:2011 soon. [7]

The management of fire prevention within the hyperbaric chambers implies aset of actions and preventive measures [3] and the hyperbaric team should be trained to react appropriately to emergency situations according to their level ofresponsibility.

OBJECTIVES

Optimization of fire safety management through preventive procedures and measures in fire safety and practical training, by management of incident/accident situations in a hyperbaric chamber.

1 [America Oggi, 2009]. Italo American muore per un incendio in camera iperbarica, Florida [Citation: 3 May 2009]. Accessed February 5, 2010. Available in www.americaoggi.info/node/11903.

Methodologically the research was developed in two ways: Case studies, including a visit "in loco" to a Hyperbaric Medicine Unit and analysis of fire drills carried out (fire inside and outside the chamber), bibliographic research developed in the following ways:

• Integrated  search  in  major  databases,  namely  Rubicon  Foundation. Keywords Research (in Portuguese and English) were: simulation; HBOT, emergency, fire;
• Search Legislation on international safety, fire in hyperbaric medicine, intending to investigate the existence of Standards, Guidelines  and Codes of Good Practice,
• Research  news  and  information  regarding  the  fire  safety  in  HBOT,

including available sites of international hyperbaric medicine and underwater: Europe Foundation Divers Alert Network (DAN) Committee for Hyperbaric Medicine (ECHM) Scubadoc's Diving Medicine Online(SCUBA); Undersea & Hyperbaric Medical Society (UHMS) Baromedical European Association for Nurses, Operators and Technicians (EBAss).

RESULTS AND DISCUSSION

The study of incidents inside the hyperbaric chamber, allows to ascertain the causes related to their occurrence, "the suspects" are grouped in the following items: problems related to malfunctioning of the system chamber and/or equipment, because the alias was a higher percentage reported [20], the disregard for safety regulations such as the incident in Milan [8] [23] and in descending order of events [22] the following causes of fire, electrical, electrostatic, entry and use of prohibited items substances not in compliance with the hyperbaric environment. Given that the recent events involving single-seater chambers, as multiplace chambers are also subject to strict scrutiny [14] in which the cause of ignition is closely related to electrical equipment [6] and enriched environment enhanced by 100% O2 [25] there is an urgent risk mitigation with implementation of new procedures and/or containment system and fire control. While safeguarding the safety procedures related observation is restricting the entry of prohibited equipment, materials and/or objects [3] [4] [25] requires to verify the use of cleaning and disinfection products used in the chamber [5] as well as enhanced electrostatic discharge (ESD) protection [15].

A key aspect in UMH safety is to centralize all aspects of prevention in one person appointed by the Director hyperbaric "Medical Director", dedicatedexclusively to the hyperbaric facility. This responsibility is assigned to the

Hyperbaric Safety Director would be consistent with the responsibilities specified in NFPA 99 [16], which according to the National Board of Diving & Hyperbaric Medical

Technology (NBDHMT) should undergo comprehensive training in safety aspects ofhyperbaric medicine and related technologies to the operation thereof, elaboration of the internal emergency planning, including related to Fire in the UMH. Thepreparation of written procedures for appropriate emergency rules in force, the hyperbaric team training and running drills are both described the roles andresponsibilities contained in the proposal EBAss in NFPA99 and the Manual for Accreditation of Units Hyperbaric Clinic. [14]

The self-protection and management of fire safety, particularly in the UMH [3] should be based on the following [9]:

• Preventive measures: prevention plans;
• Intervention measures in case of fire: internal emergency plans;
• Record where safety must include the inspection or survey reports, the list of all maintenance actions and occurrences directly or indirectly related to fire safety;
• Training in fire safety: in the form of actions to all employees and specific training for those responsible for safety and all the elements that deal with situations of increased risk of fire (doctors, nurses and operators involved in HBOT);
• Drills: to test the internal emergency plan and training of occupants and operating the camera, with a view to the creation of behavioral routines and improvement of procedures.

The Emergency Plan should be based on international reference documentsrelating to UMH safety, and should provide protection against fire, explosion and other hazards, without constraining the activities of the HBOT professionals involved in patients caring and rescue. [17]

Once this requirement is assured and if the team is aware of the risksinvolved in HBOT, in the Emergency Plan every aspect concerning safety procedures should be clearly defined. Thus, no member of the team should be exposed to increased risk situations in patient rescue and help in the course of emergency procedures.

Each UMH should initiate a continuous process of optimization of procedures related to fire safety, promoting in a concerted way the specialized training ofprofessionals and fire drills.

Training of attendants

The European Committee for Hyperbaric Medicine [11] established the standards of training of Hyperbaric Medicine. In "The European Code of Good Practice for HBO Therapy" [4] are defined the professional qualifications, functions of jobs, as well as a description of the learning modules to train the necessary personnel.

The European Association for Baromedical nurses, technicians and operators (EBAss), provides training / certification for specialized: Attendant Attendant does not nurse and nurse. [10] NBDHMT provides training / certification for specialized:

nurses "Certified Hyperbaric Registered Nurse Training and Certification" and cameramen "Certified Hyperbaric Technologist Training and Certification."

Fire fighting specific training

Specific training for the fire situation in the hyperbaric environment should be ensure. Several international agencies provide in addition to specific training, training in mock real fire in hyperbaric environment. Examples: The Advisory Committee HBOT Belgium (ACHOBEL - Advisory Committee for Hyperbaric Oxygen Therapy in Belgium) since 2002 which organizes the course "The Fire Fighting Course in the Hyperbaric Environment." In May 2011, training "Hyperbaric Fire Training" (ACHOBEL) was conducted in hyperbaric chambers construction company "Hipertech" in Istanbul in Turkey, where he was tested for the first time the "Fire deluge Europe standard" EN 16081:2011.

Simulators

The use of human simulators in the therapy team training was developed especially for attendants in a study seeking to determine the feasibility of simulation exercise training, development and improvement of skills of the team in hyperbaric environment. It was considered a clear and effective method to transmit and to assess knowledge and techniques necessary for safe and effective care of patients during therapy HBOT. The discussions on the simulation exercises can be more useful than traditional teaching. This method can also be used for the introduction of new equipment, optimizing techniques and understanding of human error. [13]

Fire Drills

It was introduced as a source of information and work experience scenario the Unit of Hyperbaric Medicine, Pedro Hispano Hospital, Local Health Unit, Matosinhos, Portugal (UMH ULS) in fire drills and NFPA 99 for fire fighting in the UMH. [16] [17] [18] [19]

Design of the Simulation exercise• Constitution of the Team "Fire drill"

The head of the UMH Safety [14] [19] should initiate regular fire drills, established in the UMH Internal Emergency Plan. Together with the Director of UMH will be selected / proposed a scenario, the means of rescue and evacuation, involving the safety structure of the 2nd line if the UMH is inserted in a hospital, firefighters, civil protection and public safety.

The structuring of the plan for a simulation exercise implies a detailed description of the scenario testing, and highlighted the objectives to be achieved. According to these, the elements will be selected from each professional group involved in the plan, as well as elements of the hyperbaric team and role for each element.

A first meeting with all the elements of the UMH should be held. Discussed and defined to be tested (the team procedures, answers to events directly relatedto fire); answers to the events planned in the plan, but that may be unknown to their stakeholders.

In the selection of elements and functions that will integrate and represent the group of patients within the chamber, various aspects should be addressed. Theelimination or reduction of the risk factor related to the lack of suitability for the hyperbaric environment, as well as other scenarios reaction of O2 poisoning, panic or other unexpected and uncontrolled situations is important in thesecircumstances. Likewise these situations can be simulated by element "patient" identified for such. The elements (Figure 1a) may be invited within the universe of those exposed and adapted to the hyperbaric environment (hospital staff with recreational scuba diving and/or professional divers).

• Planning

Depending on the scenario chosen, the means of rescue and relief outside entities involved should be set a schedule of meetings preparatory to the simulation exercise. A comprehensive plan, covering all aspects involved and contributes decisively to the success of the exercise and allow its implementation in safety.

The design / build script simulation exercise should consider the participation of the group involved in the simulation exercise. So it must be held a second meeting with stakeholders in the 2nd line to be included if their intervention in the simulation exercise.

The planning should be equated to the risks that will expose all the elements of the plan during the execution of the simulation exercise. The benefits found in this type of exercise for future protection of everyone in the HBOT therapy isenormous, but it should not be overlooked that the increased risk to the entire team is exposed to hyperbaric particularly in the case of real fire simulationexercises.

Given the safety implications involved in this type of simulation exercise should be considered stages of pressure (from one ATA2 to three ATA) in which the predetermined standard procedures should be implemented.

Experience has shown that fire blankets, fire extinguishers carbon dioxide, water, and a methodology for to "extinguish" the fire (Figure 1b) by excluding air

2 ATA - acronym for atmospheres absolute and is defined to be one standard atmosphere of pressure at sea level.

are not effective in controlling fires in oxygen-enriched atmospheres, [17] [25] and It is considered that valuable time can be lost in attempting to use such devices, since the time of onset of irreversible damage is too short. [25]

The monitoring and control during the operation inside the HBOT chamber including a fire is also performed by the Attendant (Figure 1c), can activate thedeluge system hyperbaric chamber (simulated) be activated inside or outside thechamber (Figure 1d), which will cause the release of water from the sprinkler heads in the space of 3 seconds. [14] [16] Theoretically beginning a period of 30 secondsof flood water across the chamber and occupiers, with scattered jets from the ceiling, sides and floor of the chamber completely extinguish the fire cause (these periods may be repeated as long as water outside the tank) the water available in the deluge system must maintain the specified stream [16] simultaneously in eachcompartment of the chamber for one minute.

Should be performed to cut the supply chamber 02 and will be UMH, as well as the immediate exchange of oxygen supply to air for the masks of the occupantsof the chamber. The oxygen concentration inside the chambers Multiplace not exceed 23.5% [17], after giving the operator the fire alarm, having passed itsmanual mode, the camera control begins his despressurizaçã0 and realizes its systematic, whilst safeguarding possible situations of hypoxia (O2 poor).

The control of all operations and/or modification of a procedure is the responsibility of the Medical UMH (Figure 1e), given the circumstances, to decide what is the time of depressurization in an emergency situation. It will take intoaccount the need to rescue the victims inside the chamber vs. exposing all occupants in disbaric accidents to rapid decompression. The emergency depressurization time of the chamber under these circumstances, should be less than 6 minutes [16] and can be faster if the system allows the hyperbaric chamber,being 3min to UMH in the specific case of Portugal.

Procedures for such specific situations should be designed including efficient evacuation management to another UMH (helicopter flying at low altitude) and intra-hospital protocols that assure in-time rescue to an emergency occurrence.

After emergency decompression chamber and help the direct victims of the fire, alert the team of medical emergency (Figure 1f), is made an initial health screening and pathology disbáricas. Ponder will be the evacuation andrecompression filed for UMH (prevention and control of decompression sickness)

When planning fire drills outside the chamber within the UMH, the training must include elements that are in control of the chamber, with the Commissioning of the autonomous system of breathing (Figure 2) during the depressurization ofthe chamber and the evacuation of occupants of the UMH.

Execution of the simulation exercise

Procedures suggested as a guide in case of fire, multiplace chambers are described in NFPA99 [16] and are adopted the procedures employed by the U.S. Air Force. Table 1, standard procedures are named Monday to the experience of UMH ULSM Portugal, which can be adapted for any hyperbaric facility.

• Documentation

After selecting the “observing elements”, that may be chosen from hospital staff without any prior knowledge in hyperbaric medicine but holders of the Emergency Plan in the course of the second meeting, where roles and functions for the simulation exercise were assigned. These elements will record (videos or photographs), fill out the simulation exercise form registering the “time line”, achieved tasks and unforeseen events. Data from every type of registered should be recorded in digital resources.

Figure 1a - "Patients" during the simulation exercise

Figure 1b - Extinguishing agents into the chamber Figure 1c - Inside the chamber control Figure 1d - Activation of the fire system Figure 1e - Control of the hyperbaricchamber Figure 1f – Victims assistance Figure 1 – Fire simulation exercise Hyperbaric Chamber (UMH ULSM) Source: Fire simulation exercise UMH ULSM

Table 1 – Procedures in case of Fire

• Discussion

At the end of the simulation exercise, a meeting will be held with the following participants (Table 2).

Table 2 - Simulation exercise participants

A video acquired during the execution of the simulation exercise, will be viewed and the testimony of all participants registered, regarding the difficulties encountered and possible amendments to the procedures or means provided for that purpose. Discussion on the conclusions should to be drawn, concerning measures to implement the plan and improvement opportunities.

Final remarks

After detailed analysis of the registration records and the documentary evidence of the simulation exercise, the Head of Safety should write a report, considering all improvements proposals presented at the final meeting, as well as the conclusions of all the teams involved.

The final evaluation will be carried out jointly with the Director of UMH, where decisions are taken such as: promotion of training for hyperbaric teamand/or specific training in certain hyperbaric system operations, if gaps have beendetected in the analysis of the results of the simulation exercise; acquisition of equipment or safety technology, change or implementation of safety procedures.

A retrospective analysis of simulation exercises carried out at the UMH, willassess the route taken in the optimization of processes related to safety. It is an important tool to model the decision to conduct future simulation exercises.

Periodicity

The time period for fire simulation exercises (fire drills), according to the category of the risks involved, should not exceed a year. [16] [21]

CONCLUSION

Fire prevention is universally considered the primary measure of safety to take place regardless of where the fire may begin. However in Hyperbaric Medicine, it is important to compare the characteristics and the severity of the fire [25], to reinforce the idea of safety and take actions to be sure that standards and codes are put into practice.

The effective enforcement of the rules on Hyperbaric Medicine, in general, particularly in countries where it is implemented using monoplace HBO chambers(widely reported in the USA and South America), is of utmost importance (in thecase of monoplace HBO chambers used outside of hospitals and clinics) where,perhaps, no criteria related to the formation and training of specific staff hyperbaric are followed [24] or observed and enforced safety rules-

Emergency planning in the internal UMH, the Hyperbaric Safety Director in conjunction with the "Medical Director" should consider various simulationsscenarios exercises, combining several possibilities of fire: Fire in the Chamber, inside the fire Chamber with concomitant emergency (patient and/or attendant); fire out of the chamber with the chamber in operation and fire within the premises of UMH, the chamber itself.

The no panic reaction to an emergency situation can only be expected if the entire team is familiar with the safety recommendations and procedures and if these are routines for all elements tested.

Ideally it’s important that all elements of the hyperbaric team couldconfront, in a controlled environment, a “areal fire inside the chamber”, alias available in the form of training, endorsed by the European Baromedical Association (EBAss) and the Advisory Committee for Hyperbaric Oxygen Therapy in Belgium (ACHOBEL) in partnership with manufacturers of hyperbaric chambers in Europe.

The interest of the fire simulation (real) at 1ATA compared with the test at a higher pressure, is that the team members raise awareness to the exponentiallyfast spread of fire as progressively increases the chamber pressure with anenriched oxygen environment.

The unique features of "fire in hyperbaric environment" are evident in tests of extinction chamber pressure of 1.5-2 bar carried out by Haux [25]. The testswere performed on mannequins, and the fire was triggered at various pressures and with different percentages of oxygen in the chamber (Table 3). The temperature on the mannequin after ignition tests was measured at 10 seconds, and doubled when the contents of the chamber rose from 21 to 23% of oxygen.

Table 3 - Fire tests with dummies in hyperbaric environment

The training program must include: specific aspects for the Hyperbaric Medicine Unit, Specific Training for all elements of Unit (doctors, nurses, cameramen, support staff and members of the secretariat) with special responsibilities for action in emergencies, in particular:

• The responsibility for issuing the alert;
• The evacuation;
• The use of the commands and means of action in case of fire and the second  intervention  serving  the  spaces  of  UMH  (treatment  rooms, offices, support rooms, warehouses, offices, secretarial etc.).
• Reception and forwarding of firefighters;
• The management of emergency operations;
• Activities  planned  in  the  internal  emergency  plan,  referring  to  the hyperbaric chamber, where it is operating in case of fire in the spaces of UMH;
• Activities planned in the internal emergency plan related to the fire inside the chamber, special measures of selfprotection favoring the

maintenance of safety conditions for operators of the hyperbaric chamber, in case of fire, given the unpredictability of their evacuation.

Considering that the formation and training of the hyperbaric team is veryimportant it makes sense that may appear a European Consensus on standardization of training on Hyperbaric Medicine; these are mandatory requirements for the safety of the UHM. [20]. In the future it will be important ro define the skills and requirements [2] in order to establish Standardization and to regulate the profession of attendants.

ACKNOWLEDGMENTS

We thank the entire team of the UMH Local Health Unit in Matosinhos, Portugal.

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