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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at The Nebraska Medical Center. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Fall | Winter 2009

Reviving History

Lon Keim, MD, is a forward-thinking physician, teacher and researcher who is deeply fascinated by the past.

Dr. Keim's 1987 Book

As a pulmonologist and medical director of the Hyperbaric Medicine Center at The Nebraska Medical Center, he specializes in a treatment whose origin dates back to the 1600s and yet each day it is finding increased value in an array of new medical applications.

A way from the hospital, Dr. Keim is an avid Civil War buff whose nearly 400-page book “Confederate General Service Accoutrement Plates” is a reference work prized by fellow historians and collectors.

And as owner of an active ranch near O’Neill, he is dedicated to the restoration of Nebraska’s natural prairie.

“I love Civil War history, and I love Nebraska history, too,” he says. “It’s my golf.”

Though a native of Washington, D.C., Dr. Keim’s Nebraska roots run deeper than the grass in the Sandhills.

His great uncle, Frank, was chairman of the Department of Agronomy at the University of Nebraska-Lincoln for two decades. Credited with building one of the most outstanding agronomy departments in the world, the university’s agronomy and horticulture building, Keim Hall, is named in Frank's honor.

It was that great uncle who persuaded Dr. Keim’s father, Myron, to abandon farming and become an agronomist. His interest and expertise in potash, a key ingredient in gunpowder, led the family to Washington, D.C., to aid in the World War II effort.

Dr. Keim’s interest in the Civil War was sparked while growing up in Richmond, Va., “From 1961 to 1965, every day was the 100th anniversary of something connected to the Civil War.”

The Keim Ranch
located in O'Neill, Neb.

He became a collector of Civil War memorabilia, and over the years Dr. Keim amassed a substantial collection of battlefield and campsite artifacts. Among his prized items are several Confederate flags, one of which is believed to be the Confederate’s first battle flag. His 1987 book, which details more than 600 plates and buckles from the Confederacy, is noted on the Internet as “a must” for collectors.

After receiving degrees in pharmacy and medicine in Virginia, Dr. Keim completed subspecialty training in pulmonary disease and critical care at the University of Iowa Hospitals and Clinics. That was where he met James Armitage, MD, now a professor of internal medicine at the University of Nebraska Medical Center (UNMC).

“We were a couple of Husker fans in Hawkeye territory,” Dr. Keim says.

Dr. Armitage convinced Dr. Keim to move to Omaha, where in 1976 he joined Dr. Louis Burgher and helped develop the pulmonary section of Internal Medicine Associates at Clarkson Hospital.

While attending an annual medical meeting two years later, Dr. Keim took in a session on hyperbaric oxygen (HBO) therapy. And though some of the material and the presenters were “roasted by many of the physicians present … something about it intrigued me.”

HBO involves the breathing of pure oxygen while enclosed in a sealed chamber that has been pressurized at one-and-one-half to three times normal atmospheric pressure. The name for the treatment combines hyper, or increased, with baric, the pressure of the atmosphere as indicated by a barometer. HBO essentially allows a patient to be treated with 200 percent to 300 percent oxygen, Dr. Keim says.

“I love Civil War history, and I love Nebraska history, too. It’s my golf.”
Lon Keim, MD

HBO historically has been met with a great deal of skepticism due to a lack of controlled studies and supportive data to indicate its success. “Unfortunately, the people most unfamiliar with it,” he says, “have also been its biggest critics.”

As knowledge and evidence of its potential grew, in 1986 Dr. Keim began development of the hyperbaric oxygen therapy program at Clarkson Hospital, now The Nebraska Medical Center. In addition to his duties as a private clinician, he also serves as assistant professor of internal medicine, in the section of pulmonary medicine at UNMC.

“At the 17th treatment, she said it was as though she had walked out of a fog."
Lon Keim, MD

The HBO unit has since increased from one chamber to four, and it has moved to the ninth floor of the hospital to be adjacent to the burn unit. “That allows for horizontal transport from the ICU,” Dr. Keim says, “which is greatly preferred over transporting patients from floor to floor.
It also allows us to cross staff the unit with nurses from the burn unit when necessary.”

The use of HBO continues to expand. The U.S. Department of Health and Human Services has approved HBO to treat 12 conditions, including carbon monoxide intoxication, decompression sickness, air emboli and life-threatening processes including gas gangrene and other necrotizing infectious wounds.

According to the Undersea & Hyperbaric Medical Society, one-half of the estimated 1.2 million new cases of invasive cancer will receive radiation therapy as a part of the treatment. An unfortunate consequence of radiation therapy, especially at high doses, is an effect on the blood vessels within the field of radiation.

“It simply wipes out the micro pipes, the smallest of blood vessels, thereby limiting the access of ingredients necessary for healing such as oxygen, antibiotics, nutrition, vitamins, growth factors, etc.,” Dr. Keim says.

Hyperbaric Oxygen Chamber
The Nebraska Medical Center has increased
from one chamber to four

While HBO does not cure cancer, the American Cancer Society points to research that indicates it may be an effective tool in reversing this vascular injury as well as osteoradionecrosis, the bone damage caused by the delayed effects of radiation therapy. Some head and neck surgeons, oral and maxillofacial, and plastic surgeons at The Nebraska Medical Center have begun to include HBO to assist in various soft tissue and bone restorative and reconstruction procedures.

The number one reason for the use of hyperbaric oxygen therapy in Omaha is its ability to reverse this delayed radiation injury vascular effect, Dr. Keim says. He has coined the acronym Radiation Injury Delayed Effect (RIDE) to describe this condition.

“The higher the pressure, the more oxygen is dissolved; and, the higher the pressure in the blood, the greater the opportunity for oxygen to diffuse out into poorly vascularized spaces,” he explains. “This somehow turns on the growth of new blood vessels and, over a course of therapy, a remarkable reversal of the vascular injury can occur.
“With HBO, we can restore 85 percent to 92 percent of the blood vessels damaged by radiation injury.”

Because wounds heal from the inside out, he says, the application of HBO can increase blood flow and improve the performance of infection-fighting antibiotics. “It’s not that HBO can heal a normal wound super fast,” he explains. “But a compromised wound would heal with HBO when it otherwise would not.”

His research currently includes being a collaborator in a national carbon monoxide treatment study co-sponsored by the Centers for Disease Control. Since 1986, the Omaha HBO program has treated more than 600 patients for carbon-monoxide poisoning.

Annually, between 60 and 80 patients undergo a total of 1,600 to 2,000 HBO “dives” in The Nebraska Medical Center’s chambers. The treatments are called “dives” because, Dr. Keim explains, “In essence, we’re taking the patients 33 to 66 feet under water.”

Saundra Keim underwent HBO
therapy to treat chronic carbon
monoxide poisoning.

Dr. Keim’s wife, Saundra, can personally attest to the value of HBO therapy in treating chronic carbon monoxide poisoning. Prior to their marriage, Dr. Keim recommended HBO therapy after she suffered protracted exposure to carbon monoxide from a cracked heat exchanger in a water heater at her home in Lubbock, Texas.

“At the 17th treatment, she said it was as though she had walked out of a fog,” Dr. Keim says. “I’ve heard it described that way by other patients.”

Five years later, they were married. The couple has three sons and three grandchildren.

Honored in 2007 as a Physician of Distinction by his peers at The Nebraska Medical Center, Dr. Keim’s charitable interests include participation in the Cattlemen’s Ball of Nebraska, which benefits the UNMC Eppley Cancer Center and other healthcare programs.

“Aside from my work, the Civil War and my family, my other passion is a piece of ranch property northwest of O’Neill, Neb. Back when everyone was buying Berkshire Hathaway stock,” he says, chuckling, “I was buying sand.”

It’s a working ranch employing the concept of high stock density, time-controlled, management-intensive rotational grazing. “I’m very interested in the restoration of the whole ecosystem of the range grasslands through the use of managed, controlled grazing systems,” says Dr. Keim.

Dr. Keim says his work with HBO “has caused me as an internist to think of respiration more on a cellular level and tissue level.”

Continued study of HBO will place a greater focus on the science of cellular biology. “We’re now looking at oxygenation at the tissue level — the cellular, intracellular level — even the mitochondrial level,” he says.

This appears to ensure the expanding use of HBO therapy. “It has continued to prove its value through the years,” he says. “I believe HBO is here to stay.”

That’s a thoughtful prediction from a man whose opinions bear a profound historical perspective.

Not Just for ‘The Bends’ Anymore

Once used chiefly as a treatment for decompression (the ‘bends”), carbon-monoxide poisoning or an air embolism (bubble) in the bloodstream, hyperbaric oxygen (HBO) therapy has found several recent applications, including the treatment of non-healing wounds and infections, and repairing the damage caused by the use of radiation to treat cancers.

Among its benefits, HBO:

  • increases the oxygen content and oxygen pressure in blood, and it may thereby increase oxygen levels in tissues with compromised tissue oxygen levels and/or decreased blood flow;
  • stimulates the growth of new blood vessels (angiogenesis);
  • neutralizes or minimizes the so-called reperfusion injury associated with compromised grafts or flaps, thus increasing salvage and survival;
  • enhances white blood phagocytosis (destruction of bacteria), thereby improving the effectiveness of antibiotics; and
  • may support tissue oxygenation in the absence of blood products as a result of severe anemia, blood incompatibility or religious preference.

Each treatment (dive) typically lasts two hours. This entails 10 to 15 minutes to descend to maximum pressure, 90 minutes at maximum pressure and 10 to 15 minutes to return to normal atmospheric pressure. Usually 30 to 40 daily treatments are needed for healing radiation damage. Most insurance companies, including Medicare, will provide coverage to pay for HBO treatments for chronic radiation injuries.

The Nebraska Medical Center is the only medical facility that provides HBO therapy in Nebraska.

Next article in the Fall | Winter 2009 issue of One Thousand And One:
Amazingly Ordinary