CHAPTER 5: Dr. Julie Stapleton – In Her Own Words
Born in Detroit, Michigan, and growing up in a family of five children, Dr. Julie became interested in healthcare when her dear mother went back to school to become a nurse, which was motivated by the need to pay for Julie’s older brother’s medical school tuition. As Dr. Stapleton describes the beginning of her life’s journey, “I went off to school to become an occupational therapist, but because I enjoyed and excelled in my first years of college, and combined with my mother’s influence, I instead opted to pursue the practice of medicine.”
Nearing the end of medical school, Dr. Julie discovered physical medicine and rehabilitation (PM&R) as a specialty. This brought her full circle back to her original interest in occupational therapy, since PM&R is a specialty whose philosophy is based on providing patients the opportunity to recover from injuries and regain their maximal functional capacity. PM&R physicians are also known as physiatrists and treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons, focusing on the entire body in hard-to-diagnose problems.
“When I got further into rehabilitation as a specialty, I became intrigued by the opportunity to rehabilitate individuals with TBIs, especially those injured combat veterans I now interview and prescribe treatment for at the Rocky Mountain Hyperbaric clinic in Louisville, Colorado. Rehabilitation of such a devastating injury allows me, as the physician, to work closely with my patients and their families over an extended period of time, watching their initial survival from a catastrophic injury, through recovery, through the process of regaining functions, and eventually to the capacity to get back their life … that is what I find most rewarding.”
Hyperbaric Oxygen Treatment
Dr. Julie Stapleton’s introduction to hyperbaric oxygen treatment came through her established medical practice in Boulder, Colorado. About ten years ago, through her patient Charlie Hansen, she became intimately involved with HBOT treatment. When Charlie asked her about HBOT treatments, Dr. Julie told him what she often told others, “I think it is safe, since it is dealing with oxygen under pressure, yet there is no concrete evidence that it works. But there is no harm in trying.”
After some research on chambers, Charlie bought his own chamber and installed it in the back of his Boulder business. His intent was to train some of his family members and key employees to administer the treatments. Once he got the chamber, he became quickly overwhelmed, realizing he needed more help. That’s when he began to look for a trained individual to properly operate the chamber, and that trained technician turned out to be Ryan Fullmer.
As Ryan set up the chamber to treat Charlie, the two of them began conversing about a mutual dream, that of starting a hyperbaric oxygen clinic. They discussed plans to offer oxygen treatment to other patients, but soon realized, per the FDA regulations, that they would need a medical doctor to screen each patient and write a prescription for the HBOT technician to operate the chamber. Quickly, they approached Dr. Julie. The beginning of the “miracle team” had begun.
As Dr. Julie recalls, “Since I was the one who wrote the prescriptions for Charlie, I also referred a couple of my other patients to them so that I could learn a little more about the treatment and witness the results firsthand.” Agreeing to do so for Charlie and bringing in a few of her other patients, Dr. Julie told Ryan, “Okay, fine. I am in as medical director on one condition … it must work! If it doesn’t work, I am out of here!”
As Dr. Julie now confirms, “It has worked and has continued to be an amazingly rewarding experience.”
Admittance – The Screening Process
Dr. Julie has become quite familiar with the technology and politics of hyperbaric oxygen treatment. She tells us that the FDA has determined HBOT to be safe and effective but has limited their approval to fifteen specific diagnoses, including decompression sickness, radiation tissue damage, diabetic wound healing, and carbon monoxide poisoning.
HBOT is not approved for TBIs or spinal cord injuries, yet amazingly, the drug employed in HBOT is one of the most common in nature . . . oxygen. As Dr. Julie explains it, “There is no single drug in the United States that is FDA approved to treat TBI. Every single drug I use in my patient population is borrowed from another diagnosis, which is perfectly legitimate, legal, ethical, and considered safe. It is done all the time across the board in multiple specialties. I write a prescription for oxygen under pressure, then I give the criteria for how much oxygen, how deep the pressure, how frequent the treatments, and the total number of treatments that should ideally be aimed for. The only thing that the FDA controls in this situation is the oxygen.” She further elaborates, “While it is safe and ethical to use drugs off-label, it is not required that insurance companies pay for things off-label, and so they most often do not.”
Dr. Julie first screens patients for indications or conditions that might make hyperbaric unsafe. Longtime smokers, who have emphysema or potential lung cancer, or anyone who has had recent chest surgery, are considered patients who may not handle the pressure that is administered in the hyperbaric chamber. The pressure depth administered in the treatment of TBI and/or PTSD is 1.5 ATA, which is the same as 1.5 times the amount of pressure at sea level, which is roughly the equivalent of going 17 feet below sea level here in mile-high Colorado.
Dr. Julie’s screening approach is simple. “My first goal is to make sure the patient doesn’t have any contraindications, my second is to provide them with education and reassurance that it is safe, my third is to start the process of educating them on how to manage their ears in the chamber while undergoing compression. Finally, my goal is to answer all of their questions and again reassure them that the treatments are safe and comfortable.”
Dr. Julie observes that the veterans who come to her are somewhat different in presentation compared to her civilian population—the traumatic events that have led to their concussive injuries (likely caused by either a blast injury or motor vehicle accident, which in turn may have been caused by the IED blast) are also very likely to be associated with significant combat experience with a possible associated secondary diagnosis of PTSD. Also, it is possible that these individuals have had multiple prior concussive events, which makes their recovery even more challenging.
In describing the phenomenon of treating both post-concussion syndrome (PCS), a minor form of TBI, and PTSD, Dr. Julie explains that “fear is a big part of the traumatic event.” She takes it a step further and adds, “I believe that the fear component that these individuals are experiencing at the time of their injury has a direct impact on their symptoms and recovery. For example, we know for a fact that people who have had past traumatic histories are at greater risk for having more severe and prolonged consequences of a mild brain injury. It is possible these individuals are at a heightened fear response because of PTSD in the field. These veterans may be more likely to have exaggerated and/or prolonged sequelae [after effect or secondary result] of their injury. It is a true neurologic predisposition that makes them more vulnerable to these injuries.”
According to Dr. Julie, a component of that PTSD can be seen “in the hyper-vigilance these individuals experience that manifests as anxiety, insomnia, and irritability—also noticeable after a brain injury. It is the association of TBI and PTSD that is very difficult to tease apart in the military patient population. It presents as a decreased capacity to manage and respond to anxiety, or to anxiety-provoking situations, compared to their pre-injury or pre-combat, or pre-post-traumatic state. Significant effort is being made in both the military and civilian medical communities to help sort out and optimally treat both these coexisting conditions.”
When asked if there is a connection between individuals’ physical and psychological wounds, she responds, “I don’t like it when people try to make that distinction between neurological versus psychological, or organic versus psychological. Do they think that emotions and psychological well-being come from the heart? No, these can be manifestations of changes in the normal functioning of the brain.”
While some experts claim that TBI is a physical injury and HBOT provides the physical healing therapy for TBI, yet PTSD is a psychological injury and requires a much different therapy, she quickly responds, “Not true! They can both be organic brain injuries!” Dr. Julie believes PTSD can respond to HBOT in the chamber, and the results are optimal if supported by complimentary trauma counseling during the weeks of hyperbaric therapy.
Dr. Julie honestly believes that she doesn’t have all the answers for HBOT and whether it works for PTSD as well as it does for TBI. However, she bases her opinion of treating PTSD on the experience of having treated a civilian patient who came to her with disabling PTSD symptoms without ever receiving any physical injuries.
Her patient had witnessed a horrific motor vehicle accident, which had only narrowly missed her own vehicle when she and her young children were stopped at a red light. Dr. Stapleton explains, “That woman experienced a singular moment in time, which I describe as the ‘oh shit’ moment, where an individual experience the fear of death or of serious injury to themselves or their loved one, and they are completely hopeless or helpless to do anything about it. That moment triggered in this patient the fight or flight reaction, which then persisted, manifesting as post-traumatic stress symptomatology for well over a year. She couldn’t sleep, was hyper-vigilant, depressed, extremely anxious, couldn’t handle stress, couldn’t focus her attention, couldn’t problem solve, or make decisions … classic textbook symptoms of PTSD. I prescribed forty sessions of HBOT and her symptoms resolved.”
As justification, Dr. Julie reminds us that, “This story is an example of the definition of what is required to have PTSD and how it changes one’s psyche. Traumatic experience can change how the brain operates, and there is neuro-scientific evidence of that. It is not simply psychological, it is neuro-physiological.”
She makes another important distinction about the coexistence of PTSD and concussion. PTSD doesn’t occur in other events, such as sporting events where the individual has chosen to participate in a risky activity, is aware of and assumes that risk. These individuals may well sustain concussions and are vulnerable to multiple concussive injuries, for example, the types of head injuries that are now being recognized in the NFL, but without the coexisting condition of PTSD. “You make that choice and you know you are going to be in a violent, potentially risky sport. You do not experience that overwhelming fear and are not at risk for triggering the fight or flight reaction. That outcome is different than somebody who gets in a car accident or, worse yet, is the victim of an assault or sustains an injury under combat conditions.”
The Healing Timeline
Dr. Julie points out that when a patient is in the chamber for the prescribed treatments, there often comes an obvious point when their energy, memory, and cognitive faculties start to come back and a new sense of wellness comes into play. At that critical point, the veteran may experience a tremendous psychological boost or a big emotional letdown. It is different for each person. “And so it does help to have a counselor on the team, like Pepe Ramirez, a combat veteran who has been there. These vets, if they do not have good coping skills or good communication skills, and if alcohol and drugs are a factor, may go back down a path of regression. Without the right kind of support system when they leave our clinic, it will look like HBOT didn’t help the PTSD.”
Dr. Julie also continues to learn from past experience and her patients. She further emphasizes, “You have to look at the prior history of the patient. How did they function pre-injury? What challenges did they endure? Do they have good coping skills? Do they have good family support?” She contends that if these skills are not there to begin with, then it really makes the rehabilitation process all that much harder for the patient who is dealing with the dual complexity of PTSD and TBI. At the Rocky Mountain Hyperbaric Institute, veterans benefit from the integration of both kinds of treatment.
Dr. Julie further stresses that HBOT doesn’t work for everybody with TBI and/or PTSD, and forty hours in a chamber is not the magic number of treatments for everyone. It may be just the minimal starting point. Experiences with severely injured veterans who suffer TBI and PTSD confirm this.
Past, Present and Future
When asked why hyperbaric oxygen treatment is not an accepted practice in the medical community, Dr. Julie thoughtfully replies, “Because nobody knows about it yet … they look at old literature, which does not show the success and strides we have made more recently, or become understandably confused and discouraged by the research carried out by the Department of Defense. However, due to the pioneering work of Dr. Richard Neubauer and Dr. Paul Harch, there have been numerous articles, books, and well-designed studies that have demonstrated the benefit of HBOT in the treatment of mild TBIs.
Dr. Harch has been involved in educating and documenting these benefits for several decades. Despite that, the benefits of hyperbaric therapy are often considered as anecdotal, which implies favorable human-interest stories suggesting good outcome rather than solid scientific research. It has been extremely challenging to perform controlled studies in HBOT like you can with medication. It is hard to design a placebo, since it is hard to fake a hyperbaric oxygen treatment. Despite that challenge, progress is being made, and evidence is mounting that HBOT is a safe and effective addition to a comprehensive multi-disciplinary treatment approach.”
What Keeps Dr. Julie Stapleton in the HBOT arena?
“Hyperbaric therapy actually treats the problem rather than just putting on a Band-Aid. In my treatment of patients with TBI, I first treat sleep and pain, and then I compensate for cognitive and emotional issues, mostly through medication, education, and therapy. But hyperbaric oxygen treatment really does heal the brain! Long ago, I used to say that acupuncture likely works but has no good evidence-based science to back it up. Now I am an acupuncturist and I have no doubt that it works. I also have no doubt that hyperbaric therapy will soon be readily recognized as a mainstream treatment option, as acupuncture has become.”
Dr. Julie is still very much in the game because of all the success she witnesses. She revels in the stories about veterans who tell their buddies that they should come to the clinic and try it out. One of the first questions she asks a new veteran who is checking in is, “How did you hear about us?” Their response is often, “Through a friend … another veteran who you helped!”
What the Veterans Think about Dr. Julie and HBOT
What is most obvious about Dr. Julie’s practice is reflected in the comments of the many veterans she has treated at the clinic (and the civilian clientele as well). She is held in very high regard, and that respect is reflected in their comments about her.
One veteran responded, “Dr. Julie. She really cares for us. You can tell by the way she talks to you and the nice way she gets your medical information that she really likes us. She puts us at ease when we first meet her, and her smile and demeanor give you a sense of confidence that she will really help heal us and make our lives so much better.”
Dr. Julie Stapleton of Boulder, Colorado, joined the Rocky Mountain Hyperbaric team in 2007. She commits time and energy from her established practice of physiatry to function as the medical director for the Rocky Mountain Hyperbaric Institute. Dr. Stapleton graduated from University of Michigan Medical School in 1985 and has been in practice for thirty-one years. She completed a residency in the University of Michigan Health System in Ann Arbor, Michigan. As a clinical professor while at University of Michigan, she administered the TBI Day Treatment Program as its medical director. She currently practices at Julie A. Stapleton, M.D., and is affiliated with Boulder Community Health. Dr. Stapleton is board certified in Physical Medicine and Rehabilitation.