Training standards for diving and hyperbaric medicine

Prepared by the Joint Medical Subcommittee of ECHM and EDTC

1. Introduction:

These training standards are the result of some years of international discussion which began prior the 1st European Consensus Conference on Hyperbaric Medicine, Lille, in September 1994 where one session was devoted to "Personnel education and training policies". A comprehensive paper by J. Desola MD and the subsequent debate defined the 5 different personnel categories ideally involved in the staff of a Centre of Hyperbaric Medicine:

the medical doctors,( including the Medical Director),
the nurses,
the attendants,
the chamber operators, and
the technicians.

The definition, functions, background, academic requirements, dedication, and the continuous education, of each category were agreed. (This full document is reproduced in the Appendix 1). A working group being formed to define the requirements for medical doctors in the fields of diving and hyperbaric medicine. An important feature of this project was the collaboration between the European Committee for Hyperbaric Medicine (ECHM), which is primarily a medical committee, and the European Diving Technology Committee (EDTC) which is a 15-nation committee with not only government, industry and trades union representatives but also with a doctor nominated from each member country. The Goal-setting Principles for Harmonised diving Standards in Europe was published by the EDTC in 1997 and includes a section on the "Qualifications, education and training of medical doctors"(appendix 2).

The work presented here has been done by the Joint Medical Subcommittee of these two main committees and, from time to time, reports by this Subcommittee have been submitted to and approved by each of the two parent bodies.

It is the purpose of this paper to summarise what has been accomplished and to look at the future tasks of a Joint Medical Subcommittee of the ECHM & EDTC.

 

2. Definition of jobs:

Before any consideration of a training programme, the training objectives of each job need to be defined in relation to the competencies that are expected from the incumbent. A number of the jobs in diving and hyperbaric medicine have tasks and objectives in common and so it is possible to optimise the efficiency of the educational program and avoid too much overlap by adopting a modular structure. Thus the first task was to prepare the job definitions which are compatible with EDTC and ECHM:

I. "Medical examiner of divers"

- Competent to perform the periodic "Fitness to dive assessments" of working and recreational divers and compressed air workers, except the initial assessment of novice professional divers.

IIa. "Diving medicine physician"

- Competent to perform the initial and all other assessments of working and recreational divers or compressed air workers.
- Can manage diving accidents and advise diving contractors and others on diving medicine and physiology* (with the back-up of a hyperbaric expert or consultant).
- Should have knowledge in relevant aspects of occupational health. (He or she does not need to be certified specialist in occupational medicine to be in accordance with the standards).

IIb. "Hyperbaric oxygen physician"

- Responsible for HBO sessions at the treatment site (with backup of a hyperbaric expert or consultant)
- Should have appropriate experience in anaesthesia and intensive care in order to manage the HBO patients (he or she does not need to be certified specialist in anaesthesia to be in accordance with the standards)
- Competent to assess and manage clinical patients for HBO treatment

III "Hyperbaric expert or consultant (hyperbaric and diving medicine)"

- Competent as chief of a hyperbaric facility (HBO centre) and/or to manage the medical and physiological aspects of complex diving activities* .
- Competent to manage research programs.
- Competent to supervise his team (HBO doctors and personnel, health professionals and others).
- Competent to teach relevant aspects of hyperbaric medicine and physiology to all members of staff.

IV. "Associated specialists"

This title is not a job qualification, but rather a function. It covers experts, consultants and specialists of other clinical specialities who can be nominated as competent to advise within their own speciality upon specific problems in the diving and hyperbaric field.

 

3. Contents of Modules
  Levels of competence:
  a - basic
  b - need to know
  c - must be expert
Modules of formation and subjects

Jobs:

I

IIa

IIb

III
1 Physiology & pathology of diving and hyperbaric exposure:        
1 Hyperbaric physics

b

c

c

c
2 Diving related physiology I (functional anatomy, respiration, hearing and equilibrium control, thermoregulation)

b

c

b

c
3 Hyperbaric pathophysiology (Immersioneffect, blackout mechanism incl apnea, psychology, working performance/endurance under water)

b

c

a

c
4 Hyperbaric pathophysiology (decompression theories, bubbles)

b

c

b

c
5 acute Dysbaric disorders, DCI (Barotrauma, DCS)

b

c

b

c
6 chronical Dysbaric disorders (Long term effects)

b

c

a

b/c
7 HBO-Basics (effects of hyperbaric oxygen)

-

b

c

c
8 O2 Intoxication

a

c

c

c
9 Inertgas-effects (Narcosis/HPNS)

a

c

a

c
10 medicaments under pressure

b

c

c

c
11 non-dysbaric diving pathologies (Hypothermia, near drowning, fauna&flora effects, injuries and accidents in water, the sick diver)

a

c

-

c
12 diving fatalities

a

a

-

b/c
2 Diving technology and safety:        
1 diving procedures (Bell diving)

b1

b

-

a /c
2 Diving procedures (SCUBA, surface supplied, bell, TUP, SURD, 02-Deco, mixed gas diving

b

c

a

a/ c
3 Divers (Recreational SCUBAdiving, technical and deep diving, Apnea-diving, professional diving: offshore, inshore, scientific, media, recreational divinginstructor, Caissonwork, astronauts)

b

b

a

a/c
4 Diving gear (SCUBA, SSUBA, mixed gas, rebreathers, monitoring equipment, working tools, suits)

b

b

a

a/c
5 Diving tables and computers (incl altitude and interval)

b

b

b

a/c
6 Regulations and standards for diving

b

b

-

a/c
7 Safety planning / management (monitoring)

b

b

-

a/c
3 Fitness to dive        
1 Fitness to dive criteria and contrindications (for divers, tunnel workers and HBOT patients and chamber personel)

c

c

c

c
2 Fitness to dive assessment (diagnostics)

c

c

c

c
3 Fitness to dive standards and regulations (prof and recreational d.)

c

c

b

c
4 Diving accidents:        
1 Diving accidents / incidents (assessment and preclinical treatment incl. ORL, barotraumas, CPR)

a

c

a

c
2 Diving accident management clinical (Diagnostics, patient care, followup)

-

c

c

c
3 Diving accident management: Differential diagnosis a c c c
4 HBO-T for diving accidents (Tables and strategies) a c c c
5 Rehabilitation of disabled divers - a a b/c
5 Clinical HBO:        
1 Chamber technique (multiplace, monoplace, transportchambers, wet recompression) - b c c
2 HBO: Mandatory Indications - a c c
3 HBO: Recommended Indications - - c c
4 HBO: experimental and anectotal Indications - - b c
5 Data collection / statistics / evaluation - b b c
6 general basic treatment (nursing) - b c c
7 Diagnostic, monitoring and therapeutical divices in Chambers - c c c
8 Risk assessment, incidents monitoring and safety plan in HBO-Chambers - b c c
9 Saftey regulations - c c c  
6 Diverse:        
1 Research standards - a a c
2 Paramedics teaching program - b a c
3 Management /Organisation of HBO facility - a a c
7 Practical training:        
1 Fitness for chamber-dive test (of the course participants) - + + +
2 CPR - + + +
3 Practice in field first aid (diving accidents) - + - +
4 practical training FTD exam (skills) + + + +
5 Demo : professional diving + + - +
6 Demo : HBO-T - + + +
7 Introduction to (wet)-Diving (+)2 +4 - +
8 Practice in HBO-T (including pressure test) - + + +
9 Practice in paramedics teaching - +3 - +

1 As required
2 Recommended
3 Exceptions possible, if important reasons of unfitness to dive
4 As required

4. Standards for course organisation and certification

- Teaching courses

In order to comply with this EDTC/ECHM standard the person responsible for the professional contents of the course must be a hyperbaric medical expert or consultant (job type III)

1. The course curriculum should be declared as being "in conformity with the ECHM/EDTC standards" and the educational objective (jobs I and IIa, IIb) stated.

2. The course organisers are invited to send a copy of the curriculum to the joint medical subcommittee of ECHM/EDTC (through the national co-ordinator).

3.The final tests for individual evaluation are mandatory, and should cover all the taught subjects (see list) at the level of competence required for each subject.

The standards do not prescribe the status of the teaching institution but it is strongly recommended that courses are university based, are approved for such training courses by national health authorities, speciality training boards or are under the auspices of the national scientific society for diving medicine and/or hyperbaric medicine.

How a course is to be organised is not prescribed in these standards. Evenings, week-ends or full weeks are possible. For clinical teaching, an internship or residency may be appropriate. The acknowledgement of a high teaching standard is based on a credible final test of the candidates.

- Modules and course organisation

The actual organisation and conduct of the modules will be influenced by local factors and so it is proposed that these details can be decided on a national basis and probably left to the individual course directors. The following proposal indicates the total teaching hours considered necessary to achieve appropriate competencies in the following jobs.
I Medical examiner of divers 25 lecture hours + 3 hours practical
IIa Diving medicine physician The above + 30 additional lectures + 10 hours practical
IIb Hyperbaric medicine physician 60 hours + a practical phase (5 different types of clinical cases with different indications for treatment)
III Diving and hyperbaric medicine expert or consultant This needs further review (see below)

The proposal serves as a guideline and is not mandatory. When one of these teaching programmes includes topics covered elsewhere a reduction in the number of lecture hours may be justifiable.

- Recognition of an expert

The experience needed to become an expert cannot be learned from a course. The essentials have already been described in general terms. The candidate should already be an accredited specialist or equivalent.

Except in those countries where some equivalent or higher standards already exist, those who wish to be acknowledged as experts or consultants in the fields of diving and hyperbaric medicine should send their curriculum to their national co-ordinator (representing the Joint Medical Subcommittee or to that subcommittee itself if that nation has no co-ordinator) who may decide on the basis of the agreed standards. The Joint Medical Subcommittee will be informed by the national co-ordinator and can issue a list of experts if required. In the future the verification of achieved

qualifications will be done by a national helath authority or a scientific body (EU legislation). The aim is to achieve a recognition of the standards by those so that they automatically could take over the role of the national co-ordinator.

 
5. Continuous Education (Quality Control and Competency)

In most countries, the conditions for maintaining the active status of an individual are defined by some system of continuous medical education credit points (CME, as introduced in the USA some time ago). The ECHM & EDTC need to define the minimum requirement for this in a flexible way that provides enough freedom for the national bodies to establish a more detailed system. It is expected that these national requirements will be compatible with our guidance.

Our proposals are the following:

Job I:

A minimal activity of 10 medical assessments of divers fitness per year is needed plus attendance at one refresher course (usually 2-days) in two years. Reactivation after a lapse needs participation in two 2-day refresher courses or a repeat of the full basic course.

Job IIa:

Continuing experience in the field of professional diving (e.g. advising a professional diving contractor or some equivalent activity) and participation in a course or congress previously approved by the national co-ordinator. Reactivation after a lapse should be on the basis of a specifically approved course. Where this cannot be achieved, the candidate should submit an alternative training programme to the national co-ordinator for approval.

Job IIb:

Active employment in an HBO facility (or equivalent activity) and attendance at one national and/or international congress on hyperbaric medicine per year. Reactivation after a lapse needs a 10 working days in a HBO facility and attendance at two congresses in two years.

Job III:

Will rely on the decision of the national co-ordinator

The refresher seminars can serve to update the participants in order to confirm their active status and to reactivate those who temporarily have not maintained their required activity. They can also serve as an introduction to doctors of other specialities who may also gain CME credits in their own specialities. This not only can help the financing of a course but can be a chance for promoting HBO to those who would not attend the HBO scientific congresses.

 

6. The Joint Medical Subcommittee of ECHM and EDTC

This committee will operate on the basis of the tasks outlined above.

The members are the two chairmen of the education and training subcommittee of the ECHM and of the medical subcommittee of the EDTC respectively. Further two to three members are nominated by the chairmen on the basis of their special competence and experience in one of the relevant topics. As the chairmen each represent a specific subcommittee, any major changes or decisions must be discussed within these subcommittees before going to the meetings of the EDTC or ECHM respectively.

Each country interested in educational courses recognised by EDTC/ECHM should be represented by a member who has been acknowledged by the national hyperbaric medicine authority (or of all such authorities if there are more than one such authority in a country). Normally this would be either the national member of ECHM or the national medical representative on the EDTC. If not the same individual, both could attend if appropriate.

The EDTC and ECHM representatives of each country should nominate a national co-ordinator of teaching programmes, who could be the joint subcommittee member himself or who could delegate for that purpose (for instance to the national health and safety authority or any representative scientific body covering all aspects of hyperbaric medicine). The national co-ordinator will have the duty to supervise the national programs, the certification procedures and the status of the course directors.

In order to enhance credibility of certification and to help those who do not yet have the experience necessary to establish a good validation system, the Joint Medical Subcommittee will create a pool of multiple choice questions with an evaluation grid, in the main European languages. This will be available for all members. Evaluation of the answers should be done by an international group nominated by the Joint Medical Subcommittee. This Subcommittee may also certify a national teaching syllabus or educational course if desired by its organisers, thus helping the national societies or other authorities in getting accepted by their governmental health and safety department or by their speciality boards.

 

 

For the Joint Medical Subcommittee of ECHM and EDTC :

J. Desola, D.Elliott, P. Longobardi/ P. Pelaia, F. Wattel, J. Wendling