Developing an Undersea and Hyperbaric Medicine (UHM) Fellowship that integrates hyperbaric medicine, aerospace medicine, hypobaric physiology, decompression science, and operational medicine is a substantial but worthwhile undertaking. The strongest programs (military and civilian) are built as competency-based fellowships that satisfy accreditation requirements while also preparing physicians for operational environments where pressure physiology, environmental extremes, and mission readiness intersect.

While most HBO training programs tend to focus on the specialty around the delivery of hyperbaric oxygen as a therapeutic tool, and touch upon aerospace almost as an after thought. Operational medicine, I suspect would be just as tangential and would be a novel addition to a fellowship program in Hyperbaric and Aerospace Medicine. I suspect most programs do not integrate Hyperbaric, Aerospace, and Operational Medicine. I think a modern fellowship program should be more inclusive. This is how I would plan a modern fellowship.

Phase I: Strategic Planning

A modern fellowship should not simply train hyperbaric physicians. It should develop specialists capable of managing human performance and injury across the entire pressure spectrum:

• Hyperbaric medicine
• Diving medicine
• Aerospace medicine
• High-altitude physiology
• Hypobaric medicine
• Decompression science
• Occupational medicine
• Operational medicine
• Disaster and austere medicine
• Marine medicine
• Military medicine
• Environmental physiology
• Human performance optimization

The fellowship should answer one central question:

How do pressure, oxygen, environmental stressors, and operational demands affect human physiology and clinical outcomes?

Phase II: Accreditation Requirements

In the United States, the fellowship should align with the standards of:

• Accreditation Council for Graduate Medical Education (if pursuing accredited fellowship status)
• American Board of Preventive Medicine
• Undersea and Hyperbaric Medical Society

Core accreditation components include:

• Program Director qualifications
• Faculty qualifications
• Hyperbaric facility
• Clinical volume
• Scholarly activity
• Research opportunities
• Quality Improvement
• Didactic curriculum
• Evaluation methods
• Case logs
• Procedural competency

Phase III: Curriculum Design

I would divide the curriculum into major educational domains.

Domain 1 – Basic Pressure Science

Topics include:

• Gas laws
• Pressure physiology
• Oxygen physiology
• Carbon dioxide physiology
• Nitrogen kinetics
• Helium physiology
• Diffusion
• Bubble mechanics
• Tissue perfusion
• Microcirculation

Domain 2 – Hyperbaric Medicine

Core diseases:

• Carbon monoxide poisoning
• Air embolism
• Decompression illness
• Necrotizing infections
• Radiation injury
• Osteoradionecrosis
• Diabetic wounds
• Crush injury
• Burns
• Compartment syndrome

Skills:

• Chamber operation
• Emergency procedures
• Critical care in chambers
• Hyperbaric emergencies

Domain 3 – Diving Medicine

Including:

• Commercial diving
• Military diving
• Scientific diving
• Public safety diving
• Recreational diving

Medical issues:

• Barotrauma
• Decompression sickness
• Arterial gas embolism
• Oxygen toxicity
• Carbon dioxide toxicity
• Nitrogen narcosis
• High-pressure nervous syndrome

Domain 4 – Aerospace Medicine

Subjects include:

• High altitude physiology
• Cabin pressure
• Rapid decompression
• G-forces
• Spatial disorientation
• Human factors
• Pilot physiology
• Aviation toxicology
• Fatigue
• Circadian disruption

Domain 5 – Hypobaric Medicine

Including:

• Acute Mountain Sickness
• High-altitude cerebral edema
• High-altitude pulmonary edema
• Acclimatization
• Expedition medicine
• Mountain rescue medicine

Domain 6 – Operational Medicine

Topics:

• Combat casualty care
• Austere medicine
• Tactical medicine
• Maritime medicine
• Special operations medicine
• Remote medicine
• Human performance
• Environmental medicine

Domain 7 – Research

Each fellow should complete:

• Original research
• Systematic review
• Quality improvement project
• Chamber protocol development
• Clinical guideline

Phase IV: Clinical Rotations

Recommended rotations include:

Electives:

• Burn Center
• Plastic Surgery
• Infectious Disease
• Occupational Medicine
• Vascular Surgery
• Rehabilitation Medicine
• Tropical Medicine in an austere location

Fellowship-driven 24-hour coverage Marine and Maritime telemedicine program with Satellite comms

Phase V: Simulation Training

Simulation is essential.

Examples include:

• Massive air embolism
• Chamber fire
• Oxygen toxicity seizure
• Diver evacuation
• Aircraft decompression
• Altitude illness
• Helicopter transport
• Hyperbaric code blue
• Saturation diving emergency

Simulation should progress from individual skills to full interdisciplinary exercises.

Phase VI: Laboratory Experience

The fellowship should include laboratory exposure in:

• Hypobaric chamber
• Hyperbaric chamber
• Pulmonary function testing
• Exercise physiology
• Cardiopulmonary testing
• Gas analysis
• Ultrasound bubble detection
• Doppler studies
• Transcutaneous oxygen monitoring
• Near-infrared spectroscopy

Phase VII: Research Infrastructure

Research themes might include:

• Oxygen toxicity
• Stem cell response to hyperbaric oxygen
• Wound healing
• Radiation injury
• Brain injury
• Diving physiology
• Altitude adaptation
• Human performance
• Artificial intelligence in chamber monitoring
• Predictive decompression modeling

Phase VIII: Competency Assessment

Assessment should include:

• Direct observation
• Procedure logs
• Objective Structured Clinical Examinations (OSCEs)
• Oral examinations
• Written examinations
• Simulation performance
• Multisource (360-degree) evaluations
• Milestone-based reviews
• Portfolio review

Phase IX: Operational Partnerships

Collaborations strengthen both education and research. Potential partners include:

• United States Navy Diving programs
• National Aeronautics and Space Administration
• National Oceanic and Atmospheric Administration
• Federal Aviation Administration
• Civilian trauma centers
• Commercial diving organizations
• Air medical transport services
• Offshore energy operators
• Academic medical centers

These partnerships can provide exposure to operational scenarios not available in a single institution.

Phase X: Continuous Quality Improvement

Continuous improvement should use measurable outcomes and formal review cycles.

Track metrics such as:

• Board certification pass rates
• Procedural competency
• Fellow scholarly output
• Patient outcomes
• Hyperbaric safety events
• Research productivity
• Graduate career placement
• Faculty evaluations
• Fellow satisfaction
• Referral growth

Review these data quarterly with a program evaluation committee, revise the curriculum based on gaps or emerging evidence, and incorporate new technologies and operational lessons learned.

A Vision for an Integrated Fellowship

Rather than treating hyperbaric medicine, diving medicine, aerospace medicine, and operational medicine as separate disciplines, an innovative fellowship can organize them around the unifying science of environmental and pressure physiology. Fellows would learn how altered atmospheric pressure, oxygen availability, and operational stress affect human performance and disease across settings ranging from hospital hyperbaric chambers to aircraft, submarines, offshore platforms, expeditionary environments, and spaceflight analogs.

This integrated model prepares graduates not only for excellence in clinical hyperbaric practice but also for leadership in research, military and civilian operational medicine, disaster response, occupational health, and emerging fields such as commercial spaceflight and advanced human performance medicine. It positions the fellowship as a multidisciplinary center of excellence capable of adapting to future advances in environmental physiology and mission-critical healthcare.

Evert Randall Bentley, DO, MS, FACOI

First draft July 20, 2022