Dirk Jan Bakker

President of the European Committee for Hyperbaric Medicine.

Department of Surgery/Hyperbaric Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands

On the second day of my surgical residency in the end of 1968, under professor Boerema in the "Wilhelmina Gasthuis" in Amsterdam, I found myself in the hyperbaric chamber, supervising the treatment of a patient with gas gangrene.

When I witnessed the sudden awakening of a very serious victim of carbon monoxide poisoning, in the middle of the night two nights later, I was definitively won over to the side of Hyperbaric Medicine.

These, together with palliative surgical procedures in small children (until 1972), were practically the only indications we had at that time.

The role of hyperbaric oxygen was investigated in many different diseases, and also experimentally; but these three were the most successful clinical indications (besides decompression illness and gas emboli).

A lot has changed since then. Many supposed indications have come and disappeared again; a few have stayed and proved to be successful, and new indications have been found. The situation in Europe was that every physician with a chamber at his or her disposal treated the indications he or she believed in and had experience with. Every four, and subsequently three, years we gathered at the hospital or university of one of our colleagues and discussed what we had done in the previous years. This was established as the International Congress on Hyperbaric Medicine (ICHM) in 1963. A great deal of scientific and clinical work was done; and the Proceedings of these Congresses are witness thereof. If you take the opportunity to read these books carefully, you will be surprised by the good scientific work that was done in those days. It is a pity that much of it has been forgotten or duplicated in later years.

An example of the thoroughness of the work is that in almost every animal experiment a control group was included; this, unfortunately, was lacking in most clinical series. The reason was that "experience-based" and

"consensus-based" medicine were the rule rather than the exception. Many of the young investigators who presented their work later became giants in their respective medical fields.

This is the reason that the International Congress on Hyperbaric Medicine is looking for funds to reprint these old Proceedings.

The Undersea Medical Society (UMS later the UHMS, Undersea and Hyperbaric Medical Society, established in 1967) was the first society that selected a Hyperbaric Oxygen Therapy Committee, to identify and classify the various clinical indications on the basis of the scientific evidence that existed. The first Committee Report was published in 1977 and many followed in later years. Gradually, over the years, the insurance companies took these reports as a guide for payment for the treatment of patients with the recommended indications.

The situation in Europe at that time was that we followed more or less the indications from the UHMS Committee Report. The contacts between the different hyperbaric centres were rare and restricted to the occasional symposium or congress.

Contacts with the Soviet Union and the far east were, if they existed, extremely rare. Also the different languages were a big problem (Russian and Chinese for example).

An example of this is the Proceedings of the Vllth International Congress on Hyperbaric Medicine, held in Moscow in 1981, which were published in 1983 completely in Russian without any translation.

This situation changed in 1989 when the necessity of founding a committee, with the goal of raising the quality and profile of Hyperbaric Medicine, emerged during an informal discussion in Milan. The three editors of this new book were all present on that occasion, as was the author of this Preface.

The first informal meeting took place in November 1989; and this date can be considered the initiation of the European Committee for Hyperbaric Medicine (ECHM).

The first Plenary Meeting with all diving and hyperbaric representatives from the different European countries took place in Amsterdam in August 1990, during the Joint Meeting on Diving and Hyperbaric Medicine (of the International Congress, the Undersea and Hyperbaric Medical Society, and the European Undersea and Biomedical Society, EUBS).

The official founding of the ECHM took place again in Milan, in 1991.

The goals for the Committee were defined as: 1). Studying and defining common indications for hyperbaric therapy; research and therapy protocols; common standards for therapeutic and technical procedures; equipment and personnel; cost-benefit and cost-effectiveness criteria.

2). Acting as a representative body for the European Health Authorities of the European Union (EU) in Brussels (Belgium).

3). Promoting further cooperation among existing scientific organisations involved in the field of Diving and Hyperbaric Medicine (for instance the European Undersea Biomedical, later Baromedical, Society, which was originally established in 1965).

The most important mission of the ECHM was to define European Standards for Hyperbaric Medicine practice regarding indications, patient care and quality assurance, equipment and quality control, personnel and training policies and research.

This all was very much in line and at the same time as the rise of the Evidence-Based Medicine (EBM) movement (in Canada) and the Cochrane Library for meta-analyses of randomised trials, and the weighing and determining of the evidence.

This was not an easy task for many of us, as experienced clinicians with many years of clinical practice behind us. We had to get used to another way of looking at our results and a different way of planning of our clinical scientific work. This no longer included retrospective studies or retrospectively studied large cohorts of treated patients, but rather inclined towards prospective, randomised, placebo-controlled and blinded trials, the so-called randomised controlled trials (RCT's), which were considered the 'gold standard'.

In some indications, where we already had large clinical experience and we had already treated many patients, trials were considered unethical; and gradually it became clear that extensive experience was also evidence, but less convincing than the RCT 's.

I think we struggled and succeeded well with these changes; and we showed that Hyperbaric Medicine is a modern and effective therapeutic modality, judged by the standards of 2005. Of course things can always be done better; and we must strive continuously to determine the best evidence. We have that in common with many other medical specialists, some of whom have not made as much progress as us.

We started our work on indications (among many other matters) in 1991; and we organised the "First European Consensus Conference on Hyperbaric Medicine" in Lille (France) in September 1994.

A list of indications, accepted in most countries in Europe, was judged by an independent Jury, applying the rules of evidence-based medicine.

This list proved to be very important because the practitioners of Hyperbaric Medicine in Europe now had a European list of approved indications for their own clarity and to discuss with the various insurance companies for treatment reimbursement. Moreover we had decided together for which indications more evidence was needed before we could accept them (indicating more study); and, not the least important, we had defined what were not indications for hyperbaric oxygen treatment.

This work on indications is still going on with regular Symposia, Workshops and Consensus Conferences (the latest in Lille again, in December 2004).

As a result of this work, a Handbook on Hyperbaric Medicine was published by Springer in 1996 under the editorial supervision of Giorgio Oriani from Milan (Italy), Alessandro Marroni from Roseto degli Abruzzi (Italy) and Francis Wattel from Lille (France). This was the first comprehensive book that appeared in Europe on hyperbaric medicine, a major achievement. Besides the physiology and patho-physiology of oxygen and hyperbaric oxygen, the various clinical indications were described. Also, organisational aspects of hyperbaric therapy, and the treatment of diving accidents, were reviewed. A view to the future, and possible future indications, were given in the stimulating section 'New Frontiers'. One of the innovations which made us proud was that so many different doctors and scientific investigators from so many European countries worked together so harmoniously. Naturally, this book sold out rather quickly. The plans for a new and updated European Handbook were quickly made, but the execution of this plan took some time. Fortunately, about five years ago, the COST B14 action was started. Sponsored by the European Union, many hyperbaric specialists were able to meet in various cities of Europe, discussing and developing protocols for treatment and for scientific investigations in the field of Hyperbaric Medicine. In presenting and discussing the results of this action with the authorities, it became soon clear that we were offered the possibility of writing and publishing a book on Hyperbaric Medicine.

It is the great merit of Daniel Mathieu (President-elect of the ECHM) and Francis Wattel (past President) that they realized immediately the possibilities that were offered here.

In the framework of the COST action, however, it was necessary to publish the book in August/September of this year, 2005. The authors of the various chapters had to be colleagues who had taken part in the COST action's work.

Without any hesitation, the editors of this book started working; selecting authors, encouraging them, setting deadlines for contributions and doing all the work necessary for the writing of the manuscript.

Looking at the content of the book nothing has been done in haste. We find well considered contributions in a logical order to set out and explain the whole field of Hyperbaric Medicine.

Part One starts with the physical and patho-physiological bases of hyperbaric oxygen therapy under the trusted editorial guidance of Martin Hamilton-Farell, Beatrice Ratzenhofer-Komenda and Juha Niinikoski from Finland. Contributions on the physics of increased pressure and on the influence of hyperbaric oxygen on DNA and DNA-repair are present.

Part Two describes the various recommended, optional and controversial indications. This is mainly the result of all the work done for the Lille Consensus Meeting. Editors are Daniel Mathieu, together with Jorg Schmutz from Switzerland and Frans Cronje from South Africa, all experienced clinicians and investigators from the outset of the era of modern hyperbaric medicine.

The 50 pages devoted to controversial and non-indications do not represent so much the importance of these indications, but more the thoroughness with which the authors have studied and weighed the evidence and drawn their conclusions.

It is extremely important to know what not to treat and on what basis of evidence. The lack of this in the past has caused us a lot of trouble and problems with fellow scientists and clinicians, and also the health authorities in some countries.

Part Three is devoted to the practice of hyperbaric oxygen (HBO) therapy. Jacek Kot from Poland, Armin Kemmer from Germany and Peter Germonpre from Belgium write and edit contributions on chamber building and equipment, the organisation of a centre, selection of patients for treatment and monitoring them in the hyperbaric chamber, training of personnel, safety in the hyperbaric environment and the economic aspects of HBO, aspects which are often misunderstood or underestimated, complications, research in HBO and the organisation of Hyperbaric Medicine in Europe at this moment.

The publication of this new Handbook on Hyperbaric Medicine is indeed again a major achievement and another highlight in the history of the European Committee for Hyperbaric Medicine. The editors and the contributors can be congratulated with all their work in writing this book.

I sincerely hope that this book will be disseminated initially all over Europe, but also that it reaches colleagues in other parts of the world. I trust that it will be carefully studied and followed in the directions that it offers.

If anything changes (science is always moving ahead), the European Committee will address it in a future Symposium, Workshop or Consensus Conference and in cooperation with our sister organisations.

Let this first edition be sold out very quickly.

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