Vision: Training the world’s best Hyperbaric Medicine physicians.

Mission: To sustain world-class physician training in Hyperbaric Medicine with special emphasis in military operations (in war and in peacetime).

Course Number: B5OZY48A4-001

Location: USAF School of Aerospace Medicine, Brooks City-Base, Texas

Course Duration: 12 Months

Personnel Trained: Determined by the annual physician specialty forecast board and the yearly Joint Graduate Medical Education Board.

Fellowship Prerequisites: Doctor of Medicine or Osteopathy, unencumbered professional credentials, residency training, and either documented full board eligibility or board certification in a medical specialty acceptable to the Joint GME Selection Board; no particular specialty board certification is given preference over another. AF applicants must have completed the Aerospace Medicine Primary course (initial flight surgeon’s course available to all AF physicians) to be considered.

Class Size: 2 Air Force and up to 2 additional Fellows chosen from sister services or Allied military physicians - - maximum 4 total Fellows per year.

Class Schedule: One class per year - - 1 July - 30 June. RNLT 25 June.

Course Content:

1. The USAF Hyperbaric Medicine Fellowship is a training program designed to prepare physicians for the practice of Clinical Hyperbaric Medicine. It is a broad-based, intense study of Hyperbaric and Hypobaric Physiology, Diving Medicine, and Clinical Hyperbaric Medicine. In addition, there is significant emphasis on military operational problems derived from excursions within the vertical continuum of pressure, extending from the ocean floor to outer space.
2. This course of study provides specialized training to select physicians in the discipline of Clinical and Operational Hyperbaric Medicine. This includes diving and aviation medicine as it relates to decompression sickness and bubble-related diseases, fitness to dive considerations, dive operations, decompression tables, and chamber safety. In depth experience with clinical processes are covered in the fellowship including the emergent care of acute soft tissue infections (i.e., necrotizing infections), acute ischemic conditions (i.e., compromised flaps), carbon monoxide poisoning, chronic radiation-related necrosis, and complicated non-healing wounds, among others. Duties include daily wound care, hyperbaric medicine consultations (i.e., taking call up to every other week in frequency), teaching, and research. While on call, fellows are primary responders with 100% staff back-up and review and consultation immediately available on every case.
3. In-depth knowledge of hyperbarics is provided in a structured environment that includes reading requirements, outside clinic rotations, staff/fellow conferences, and formal courses. Practical patient management skills are obtained through daily patient care, case presentations, new patient evaluations, and on-call duties.
4. Opportunities for research are available in clinical, laboratory, and basic science areas. Primary research, while an excellent learning experience, is not required due to the brief year allotted for the fellowship.  Obtaining fundamental background experience in setting up or implementing a study is required. This includes but is not limited to performing background literature searches, writing protocols, participating in institutional review board meetings, writing and submission of abstracts, and presenting reports of research studies at scientific meetings where possible.
5. Required rotations and formal courses include:  The Jefferson C. Davis Wound Care and Hyperbaric Medicine Center (San Antonio, TX),  NOAA Dive Medical Officer Course (Yorktown, VA or Seattle, WA), (cme: 82 cat I hrs), Primary Training in Hyperbaric Medicine (Columbia, SC), (cme: 40 cat I hrs), Monoplace Chamber Operations, U. Texas HSC (San Antonio, TX), Surgical Burn Management, Brooke Army Medical Center (San Antonio, TX), Recognition and Treatment of Diving Casualties at the Naval Diving and Salvage Training Center (Panama City), (cme: 63 cat I hrs).

Fellowship Specifics and Requirements:

1. Facilities: Davis Hyperbaric Laboratory has three hyperbaric chambers available for patient care. A twelve-place chamber provides primary treatment capabilities for patient care. Our four-place "Panama" chamber is available for overflow or unique, patient specific requirements. A Sechrist monoplace chamber provides additional scheduling flexibility, and provider experience.
2. Patient Population: Patients are beneficiaries of military care. They are referred for care from Wilford Hall Medical Center, Brooke Army Medical Center, the Institute of Surgical Research, and the Audie Murphy VA Hospital. There is a significant population of diabetic wounds, radiation injuries, and osteomyelitis; however, nearly all UHMS approved diagnoses are encountered during the year. Annual patient count averages at least 125; an annual hyperbaric patient treatment count in excess of 2500 and a diverse wound care count of 3000 is our normal load.
3. Duration of Training: The Fellowship is a 1-year block of training. The Fellow is allowed up to 3 weeks leave at the discretion of the Director.
4. Number of Fellows: Up to two (2) USAF Fellows are trained annually. In addition, there are two (2) training positions reserved for US Army/US Navy physicians or military physicians of Allied nations. Thus, a total of four (4) Fellows may be trained annually.
5. Fellow Prerequisites: Fellows are required to be Board Eligible or Board Certified in a Primary Care or Surgical Specialty. The Aerospace Medicine Primary Course (initial Flight Surgeon's course) is required of all AF applicants.  Allied nation physicians are selected after CV and credentials review on a case-by-case, best qualified basis.
6. Daily Responsibilities: Each Fellow will spend the bulk of their training time caring for patients. This includes daily wound care, patient referral evaluations, and worldwide telephone consultations. Throughout these functions, the Fellows are under the direct supervision of USAFSAM Staff Hyperbaricists. During these functions, appropriate charting is expected. The Fellows work with the Staff as a team. There is no tolerance of responsibility shifting. The Fellow will become expert in the use and interpretation of Doppler ankle-arm pressure measurements, laser Doppler skin perfusion pressure measurements and transcutaneous oxygen measurements. The Fellow can expect to "dive" with patients 1-2 times monthly. When on-call as Medical Officer of the Week (MOW), the Fellow ensures all daily charting is complete, completes weekly progress notes, and produces the weekly Formal Patient Progress Report (FPPR). This FPPR is presented during a weekly staff conference at the end of the call week (the MOW report). Once presented, a copy becomes part of the Unit Record, and serves as a 100% QA/peer review of our patient management plans.
7. Reading Responsibilities: The Fellow is expected to complete an intense reading program within his/her initial four months. This includes the textbooks: Diving Medicine, Problem Wounds, Hyperbaric Medicine Safety, and Hyperbaric Medicine Practice. In addition, there is a large collection of articles that address Hyperbaric Medicine issues in the annually updated Primary Reader. Journal Club provides an additional opportunity to review these and other materials amongst the basic science and clinical staff. The Fellow is expected to read such additional literature as is necessary for him/her to perform their duties.
8. Teaching/Research Responsibilities: Each Fellow is required to present lectures for the Hyperbaric Medicine Academic Training Course(s) provided by the staff during the year. In addition, Fellows are expected to present a formal didactic lecture at a Staff/Fellow Conference each semester. A total of two presentations are required during the year. This is an in-depth examination of some aspect of Hyperbaric Medicine. Although not primarily required, Fellows are encouraged to participate in developing protocols in an area of either clinical or basic science research. Research, if completed, could be presented at an academic meeting of UHMS, etc. As a minimum, the Fellow will gain research experience by active participation and/or review of subjects and patients entering into on-going clinical or physiology-based research protocols.
9. Call Responsibilities: Each Fellow takes Primary Call throughout his/her training year. This includes performing clinical patient evaluations & consultations, directing chamber operations, participating as inside chamber observer/tender, administering daily wound care, preparing weekly patient reports, leading the MOW report discussion, and providing worldwide telephone consultations. Generally, the Fellow can expect to be On-Call for a 1-week period, at maximum, every other week.

Training Requirements:

1. Daily Patient Duties: Includes patient wound care, patient evaluations, worldwide consultations, on-call responsibilities, charting and report preparation responsibilities.
2. Patient Case Load: Minimum training standards are set for the purpose of assuring the most basic preparatory experience is obtained to function independently as an efficient and knowledgeable clinical hyperbaricist.
   
   • Required supervised patient evaluations are:
     HBO consultations: 25
     Transcutaneous oximetry: 25
     Peripheral Pulse Exams: 25
     Remote (telephonic/electronic) hyperbaric consults: 25
   • Required supervised patient treatments are:
     HBO patient treatment dives: 100
     Wound care interactions (debridements): 100

   While these are the minimum requirements, a fellow will typically see or perform 200% to 400% or more of these of clinical activities during the term of their fellowship.

3. Newsletter Duties: The USAF Hyperbaric Newsletter has been replaced by the Hyperbaric Medicine Case of the Month presentation, for subsequent publication on the web site. Each Fellow is required to prepare four cases, two per semester.
4. Hyperbaric Training Course (HTC): Each Fellow completes this initial hyperbaric course at Brooks early in the Fellowship. This ensures a common information baseline, and serves as a template for their future teaching responsibilities in the course.
5. NOAA/UHMS Physician’s Diving Medicine Course: Each Fellow attends this two week course in Diving Medicine cosponsored by NOAA and the UHMS. This serves as a foundation for the treatment of operationally acquired DCS and AGE as well as provides formal training in saturation, mixed-gas, commercial and scientific diving.
6. Introductory/Primary Training in Hyperbaric Medicine: Each Fellow attends a one week course. This supplements the foundation in Hyperbaric Medicine that has been formed up to this point, focusing on civilian monoplace chamber protocols, presenting a different approach to the patient. This is invaluable, as it represents the environment commonly found by the field-level flight surgeon in his/her civilian support community.
7. University of Texas Health Science Center-SA: Each Fellow spends up to one week at this busy monoplace unit. Here critically ill patients with severe infective processes can be seen which require in-house hyperbaric support.
8. Jefferson C. Davis Hyperbaric and Wound Care Center: Each Fellow spends up to a week at this busy private multiplace unit---Methodist Hospital and the Nix Hospital. Here, they will meet and interact with some of the gurus of modern Hyperbaric Medicine.
9. Institute of Surgical Research---Brooke Army Burn Unit: Each Fellow spends a one to two week rotation. Here, they will see one of the most devastating injuries that humans can experience. This is both an operational and a wound care experience.
10. Recognition and Treatment of Diving Casualties---NDSTC: Each Fellow attends this intense two week course taught by the US Navy at the Navy Diving and Salvage Training Center. Training is geared towards the care of the operational diver.
11. Travis AFB: Each Fellow will rotate for a week to experience the inpatient milieu of our hospital-based USAF Hyperbaric Medicine Department. Here, he/she can work with DHL Fellowship-trained USAF physicians using an 18-place chamber.
12. UHMS Annual Meeting: Each Fellow may attend this meeting to better appreciate the breadth of Hyperbaric Medicine. Here, they can meet many of the luminaries of modern international Hyperbaric Medicine. They are encouraged, but not required, to prepare data for an abstract or a poster presentation.
13. Miscellaneous: Each year opportunities for specialized courses and clinical experiences appear unexpectedly. The Fellowship remains flexible to those opportunities. This allows maximum promise for exceptional training.

Core Knowledge Competency:

1. History of Undersea and Hyperbaric Medicine
2. Physiology:

1. oxygen physiology in normobaric, hyperbaric, and hypobaric environments
2. oxygen toxicity
3. CO₂ and CO physiology and pathophysiology
4. inert gas physiology and dynamics
5. mixed gas breathing and saturation physiology
6. effects of hyperbaric oxygen on inside observer denitrogenation

2. Physics

1. Gas laws (Boyle, Henry, Dalton, Guy Lussac, Pascal)
2. Partial pressures
3. Effects of compression and decompression
4. Absorption and release of inert gases

3. Hypobaric and Hyperbaric Environments:

1. human performance and adaptation
2. medical standards and exam for working personnel
3. recognition and treatment of related disease entities

4. Decompression Illness:

1. pathophysiology of decompression sickness and arterial gas embolism caused by hypobaric, hyperbaric, or iatrogenic exposures
2. theory and application of decompression tables
3. effect of hyperbaric oxygen on all forms of gas bubble disease

5. Radiation Tissue Damage:

1. pathophysiology of ionizing radiation
2. osteoradionecrosis and soft tissue radionecrosis
3. effect of hyperbaric oxygen on irradiated tissues

6. Toxic Gases:

1. pathophysiology of toxic gases with emphasis on CO and CN
2. effect of hyperbaric oxygen on toxic gas exposure

7. Ischemia-reperfusion Injury:

1. pathophysiology of ischemia-reperfusion injury
2. emphasis is crush injury, compartment syndrome, failing grafts/flaps,
3. thermal burns
4. effect of hyperbaric oxygen on ischemia-reperfusion injury

8. Infection:

1. pathophysiology of infection and infection control
2. emphasis is clostridial gas gangrene, necrotizing soft tissue infections,
3. refractory chronic osteomyelitis, intracranial abscess
4. effect of hyperbaric oxygen on infection

9. Wound Healing:

1. physiology of normal wound healing
2. pathophysiology of abnormal wound healing
3. techniques for managing complicated nonhealing wounds
4. effect of hyperbaric oxygen on wound healing dynamics

10. Exceptional Blood Loss Anemia:

1. pathophysiology of acute blood loss
2. transfusion science and reasons for no transfusion
3. effect of hyperbaric oxygen on exceptional blood loss anemia

11. Patient Care:

1. comprehensive evaluation of the clinical hyperbaric medicine patient
2. management of critically ill and emergent patients in the hyperbaric environment
3. expertise in the performance and interpretation of transcutaneous oxygen
4. measurements and ankle-brachial indices

12. Chamber Operations:

1. multiplace and monoplace chamber operations
2. emergency procedures
3. safety considerations in the hypobaric and hyperbaric environments
4. effects of hypobaric and hyperbaric environments on medical and technical equipment
5. use of drugs in hypobaric and hyperbaric environments

13. Miscellaneous:

1. economic aspects of hyperbaric medicine
2. controversial aspects of hyperbaric medicine
3. research aspects of hyperbaric medicine
4. research & development of operational hyperbaric medicine deployment models

Fellow Evaluations: Upon matriculation, each Fellow will take a test to assess their present Hyperbaric Medical knowledge. This serves as a baseline for future evaluations. More importantly, each quarter there is an in-depth one-on-one evaluation with the director to evaluate progress and give and receive feedback. At the completion of the fellowship, each Fellow receives a formal End-of-Course Training Evaluation which remains on permanent file. The Fellow is expected to complete a formal Course Evaluation to enhance future course curriculum.

Staff/Fellow Conferences: These conferences are formal academic presentations. Lectures are presented on a regular basis, usually monthly. The Fellow will present one lecture per semester on a selected topic. Faculty or guest lecturers will provide the rest of the monthly lectures. There is a wealth of local clinical expertise available, and upon occasion, a visiting professor may be able to speak.

USAF Hyperbaric Newsletter: The Newsletter is a medium through which academic information--both basic science and clinical---is disseminated throughout DoD facilities. Topics may be selected from Basic Science, Clinical Medicine, Diving Medicine, Hyperbaric Operations, Hyperbaric Nursing, and Hyperbaric Technology. It is published once or twice annually with each issue containing an article by each Fellow.

Research and Program Highlights: There is significant opportunity to participate in original research, however, this, per se` is not required by the Fellow. The fellowship requirements are covered above.

1. Basic science facilities include a world class research lab. Equipment includes capabilities for confocal laser microscopy, hi-flow cytometry, high pressure liquid chromatography, and molecular biology capability. Polymerase chain reaction capability, mRNA probes, and cell culture maintenance are also performed. Ph.D. scientists and associated technical lab specialists are actively pursuing the cellular effects of hyperbaric oxygen, looking at biomarkers in disease and healing.
2. Clinical investigations are ongoing, currently examining possible HBO effects in Central Retinal Artery Occlusion, and reversing the effects of radiation exposure. Other avenues of investigation remain open to the enthusiastic researcher. All research must undergo Institutional Review Board approval to meet the necessary accepted standards. Investigators participates in the Good Clinical Practices training course administered by the FDA.
3. Our institution has the distinction of being the point of contact for clinical hyperbaric medicine for the US Department of Defense. We are also consultants to NASA in space operations for questions related to mixed gas breathing, and decompression sickness prevention/treatment. We have teaching and research relationships with The University of Texas Health Science Center in San Antonio; Clinical Investigations Division, Wilford Hall Medical Center, Lackland AFB, TX; Institute of Surgical Research, Ft Sam Houston, TX; The University of Texas, Austin; Wright State University, Dayton, OH; Medical College of Ohio, Toledo; USAF Academy, Colorado Springs, CO; Medical College of Wisconsin, Milwaukee; Southern Illinois University, Springfield; Louisiana State University, Baton Rouge; and The University of South Carolina, Columbia. Our faculty has membership in various professional local, state, and national organizations. Dr Wolf, chairs the Southwest Texas Research Consortium which meets in San Antonio. Dr Bertoldo is a member of the Joint Military GME Selection Board which meets annually in Washington, DC and serves on the UHMS education committee. Dr Zwart is the hyperbaric medicine consultant to the USAF Surgeon General, and to the Lead Agent for the DoD in Clinical Hyperbaric Medicine. Dr Wright is a fellow of the American College of Surgeons, holds an Associate Clinical Professorship in Surgery at the University of Oklahoma Medical School, and heads our clinical investigations program.
4. Our division chief (Col James Dooley, PhD) and all faculty members sit on the DoD's Joint Advisory Committee on Clinical Hyperbaric Medicine. Faculty members regularly advise residents on research projects, publish in peer-reviewed journals, and present at internationally attended scientific meetings.
5. The following is a list of current interest areas:

1. The effect of hyperbaric oxygen on the healing of diabetic ulcers
2. The effect of hyperbaric oxygen on the recovery from central retinal artery occlusion
3. The effect of hyperbaric oxygen on the healing of skin grafts in rats
4. The effect of hyperbaric oxygen on the healing of fractures in rabbits
5. The effect of hyperbaric oxygen on the healing of skin grafts in pigs
6. The effect of hyperbaric oxygen on carpal tunnel syndrome in humans
7. The effect of hyperbaric oxygen on long bone fractures in humans
8. The effect of hyperbaric oxygen on acute peripheral nerve lacerations in humans
9. The effect of hyperbaric oxygen on ischemia-reperfusion injury wounds in the pig latissimus dorsi flap
10. The effect of hyperbaric oxygen on brown recluse spider bites in humans
11. The effect of hyperbaric oxygen on acute blood loss in the rabbit
12. The effect of hyperbaric oxygen on erectile dysfunction in post-radical prostatectomy patients

Rotators: USAFSAM/FEH provides other clinical training opportunities as well:

1. Fellows: Reciprocal training agreements are arranged with Hyperbaric Medicine at UTHSC-SA.
2. Residents: At present, there is time and space available for resident rotations. These have been very well received. Recently the Residents in Aerospace Medicine (RAM) have been reincorporated into a 2-week hyperbaric medicine rotation during their second year of training.  Rotations have been offered to ER and OMS residents at Wilford Hall.
3. Medical Students: Rotations are available. Initial interest has been shown by USUHS students and appropriate letters have been sent. USAFA cadets and UTHSC-SA students have visited.
4. Nursing Students: UTHSC-SA nursing student classes regularly visit.
5. Visiting Physicians: Rotations have been arranged at the visiting physician's request. Thus far, they have been very successful.

Faculty:

Name: Benton P. Zwart, MD, MPH
Rank: Col, USAF, MC, CFS
Title: Chief, Clinical Operations Branch
         Hyperbaric Medicine Consultant to the USAF Surgeon General
Medical Education: University of Connecticut; Farmington, Connecticut
Board Certified: Occupational Medicine
                         Aerospace Medicine
                         Undersea and Hyperbaric Medicine

* * * * * * * * * * *

Name: Robert N. Bertoldo, DO, MPH
Rank: Col, USAF, MC, SFS
Title: Chief, Clinical Education
        Director, Hyperbaric Medicine Fellowship
Medical Education: University of Health Sciences
College of Osteopathic Medicine
Kansas City, Missouri
Board Certified: Family Practice
                         Aerospace Medicine
                         Undersea and Hyperbaric Medicine

* * * * * * * * * * *

Name: James K. Wright, MD, FACS
Rank: Col, USAF, MC, FS
Title: Chief, Clinical Research
Medical Education: University of Chicago; Chicago, IL
Board Certified: General Surgery
                         Plastic Surgery
                         Hand Surgery
                         Undersea and Hyperbaric Medicine (board eligible)


* * * * * * * * * * *

Name: Larry P. Krock, PhD
Rank: PhD (GS-15)
Title: Chief Scientist, USAF School of Aerospace Medicine
Doctorate Training: Texas A&M University, College Station, Texas
Primary Research Interests:
Cellular mechanisms for differentiation and proliferation in an ischemic milieu
Immune response maintaining physiological homeostasis during exposure to stressful environmental conditions
Chronic delayed-healing wound model for hyperbaric medicine
Noninvasive assessment of physiological change during wound healing
General physiological responses to environmental stress

* * * * * * * * * * *

Name: John E. Kalns
Rank: Ph.D.
Title: Research Scientist
Doctorate Training: Oregon State University, Corvallis, Oregon

Primary Research Interests: The focus of current research is in the effect of oxygen on cellular processes involved in tissue repair and remodeling. Areas of interest include studies examining the role of oxygen induced alterations in gene and protein expression in cells obtained from patients treated with HBO, animals exposed to various types of injuries including directed energy exposure (microwave and laser), and in vitro tissue culture models. The goals of these studies are to determine how HBO can be used as primary or adjunctive treatment of disease states characterized by acute ischemia (crush injury, flap failure, burn, stroke, organ transplant) or chronic hypoxia (non-healing dermal wounds). Another major research interest is development of surrogate markers of tissue repair and injury. Surrogate markers may prove useful in wound healing treatment optimization and in definition and evaluation of novel treatment paradigms.

Adjunct Faculty:

Name: E. George Wolf Jr, MD
Rank: Col (retired), USAF, MC, CFS
Title: Past Chief, Hyperbaric Medicine Division
Past Chair, Department of Force Enhancement
Medical School Training: University of Alabama, Birmingham, Alabama
Board Certified: Aerospace Medicine
Hyperbaric Medicine (board eligible)

* * * * * * * * * * *

Name: Andrew Pilmanis
Rank: Ph.D.
Title: Research Scientist, High Altitude Protection Laboratory, Air Force Research Laboratory
Research Interests: NASA-related research focusing on physiologic responses to exposure to artificial atmospheres; various mixed gases, ambient pressures, under various workload factors.

* * * * * * * * * * *

Name: James T. Webb
Rank: Ph.D.
Title: Research Scientist, High Altitude Protection Laboratory, Air Force Research Laboratory
Research Interests: High altitude physiology and decompression sickness; pathophysiology and countermeasures.

* * * * * * * * * * *

Point of Contact: Robert N. Bertoldo, DO, MPH
                            COL, USAF, MC, SFS
                            Director, Hyperbaric Medicine Fellowship

Phones:  DSN:  240-3281
              Comm:   (210) 536-3281 Voice
                                           -2944 Fax

Address:                                                            Website:
USAFSAM/FEH                                   http://www.brooks.af.mil/web/hyper/
2601 LOUIS BAUER DRIVE
BROOKS CITY-BASE, TX 78235-5130

 

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