EN Today: KESMARC explosion follow-up

JER investigates the tragic hyperbaric oxygen chamber explosion that occurred Feb. 10 in Ocala, which claimed the lives of an employee and a horse.

A note from John:

Two months ago the eventing and equestrian community was struck with the tragic loss of life when 28 year old Erica Marshall and the promising young event horse Landmark’s Legendary Affaire passed away in a hyperbaric oxygen chamber explosion in Ocala, FL. Nothing anyone can write or do can fix that tragic loss, but we have an opportunity to learn from what happened and make sure that such a tragedy never happens again. EN guest writer JER has investigated the incident and writes about her findings regarding the application of the therapy at KESMARC Florida below. Before I turn the floor over to JER, I want to stress that I personally believe hyperbaric therapy is an excellent treatment for a variety of medical conditions and that it has produced some truly extraordinary results including aiding the well documented recovery of the True Prospect Farm fire horses last year, especially Neville and Catch a Star. If my vet recommended hyperbaric therapy I wouldn’t hesitate to use it on a horse and the same goes for my doctor recommending the treatment for me. However, after reading JER’s article I would be considerably more careful about who I used to apply the therapy. Thank you for writing this JER and thank you of reading.

Photo from Eisaman Equine

From JER:

An Explosion in Ocala    

On February 10, 2012 at 9:21 am, Marion County emergency personnel responded to a 911 call from KESMARC Florida, an equine rehabilitation facility located in Ocala.   There had been an explosion in the facility’s hyperbaric oxygen treatment unit.  Crews worked quickly to put out the fire and shut off the flow of oxygen.  A Lifeflight helicopter arrived to transport 33 year-old Sorcha Moneley, an Irishwoman who’d been ‘observing’ the treatment of a horse in the hyperbaric chamber, to Shands Hospital with serious blast injuries.  The horse in the unit, a six year-old Thoroughbred owned and bred by prominent eventing owner Jacqueline Mars, was killed instantly.

Arriving on scene at 10:17 am, a police officer noted the ‘total destruction’ of the barn area in which the hyperbaric unit was housed.  Then, he ‘observed the body of a white female buried in the rubble of what was once the control room.’

Erica Marshall, 28, a Kesmarc employee who’d been operating the HBOT unit for two years, was dead.

At 10:39 am, just over an hour after the 911 call, Marion County Sheriffs put up yellow tape and initiated a Crime Scene Log.

KESMARC is an acronym for Kentucky Equine Sports Medicine and Rehabilitation Center.  Kesmarc has operated in Versailles, Kentucky since 1989, under the ownership and management of Kirsten and Harry Johnson.  The Johnsons are also part-owners of Equine Oxygen Therapy, the company that manufactured the unit that exploded in the Ocala facility.  Equine Oxygen Therapy trained the Kesmarc Florida employees, like Erica Marshall, who operated the hyperbaric chamber.

Although Kesmarc Florida continued to use the Kesmarc name, the two facilities were said to have been otherwise unconnected at the time of the accident.  Kesmarc Florida is owned by Main Street Management Services, whose CEO, Robert L. Miller, identifies himself as the ‘owner’ of the clinic.

For the first two years in Ocala, the Johnsons of the Kentucky Kesmarc were listed as managers of KESMARC, LLC in Florida.   In 2010, the company name was revoked and made inactive for failure to file an annual report.  Then in January 2011, Kesmarc South, LLC was formed, and the Johnsons names were no longer listed on the filings.  A July 25, 2011 article titled “Changing the Landscape of Equine Recovery” in the Chronicle of the Horse magazine interviewed Kirsten Johnson about equine rehabilitation and noted ‘KESMARC in Kentucky shares a name with the Florida location but is now a separate entity.’  When contacted by an Ocala newspaper following the blast, Johnson said she had not been ‘affiliated’ with the clinic for ‘quite some time.’

However, Kesmarc Florida’s current Facebook page continues to call the Ocala location the ‘sister facility to Kesmarc KY.’

Kesmarc Florida opened its doors in 2009, promoting its services through its website, by taking out advertisements in equestrian publications, and by sponsoring popular event riders Karen O’Connor and Peter Atkins.  In addition to hyperbaric oxygen therapy (HBOT), services included an Aquatred, a swimming pool, an indoor jogging track, and rehabilitative and post-surgical care.  The facility promised state-of-the-art therapies by experienced staff; the website contained blurbs from satisfied clients and noted that Kesmarc’s treatments played a role in the success of ‘multiple’ Breeder’s Cup and Eclipse Award winners.

The Ocala clinic actively, and, it claimed, successfully, pursued the sport horse market as well.  In the Summer 2011 issue of Florida Sport Horse, a two-page feature on the clinic claimed that ‘Kesmarc tripled its business this past year, partially because sporthorse owners are realizing that the services and treatments are not just a luxury for wealthy equestrians.’    (While no price list is available for Kesmarc’s HBOT services, comparable clinics charge $300-$350 per session.)

Or, as the article put it, ‘When elite equestrians such as Karen O’Connor sing the praises of Kesmarc, people listen.’

However, a public records request to Florida state agencies reveals a darker history, one  to which Kesmarc’s clients and celebrity endorsees most likely were not privy.  In mid-2010, the Florida Department of Business and Professional Regulation opened an investigation into allegations of misleading promotion and unlicensed activity taking place at the clinic.  At the conclusion of the investigation several months later, the DBPR found evidence of ‘unlicensed [veterinary] practice as alleged’ and issued a Notice to Cease and Desist, warning Kesmarc, ‘If you are found continuing to engage in unlicensed activity in spite of our action herein, we will prosecute the matter for the maximum administrative penalty permitted under law ($5,000.00 to $10,000.00 administrative fine per count).’

It does not appear that Kesmarc attempted to comply with that order.  To the contrary, there is compelling evidence that Kesmarc continued to promote its services in the same way, and also of unlicensed activity in the treatment of the horse that died in the hyperbaric chamber explosion.

On  August 31, 2010, following a citizen complaint to the Department of Business and Professional Regulation, authorities began an investigation into Kesmarc’s practices.  The specific concern was that Kesmarc was violating Florida law through its services and website.  According to the DPBR’s report, the alleged violation was Florida Statute 474.213 (1) (A):  To lead the public to believe one is a licensed veterinarian or to perform veterinary functions without being properly licensed.

Florida law states that ‘no person may practice veterinary medicine in this state unless the person holds a valid, active license to practice veterinary medicine.’  At the time of the complaint – and right up until the day of the explosion – Kesmarc did not have a veterinarian on staff or an affiliated supervising veterinarian, despite the Notice to Cease and Desist issued some fourteen months before.

Some of the services touted on Kesmarc’s website would seem to fall under the Florida definition of veterinary practice.  Indeed, the very term ‘equine sports medicine’ implies a veterinary connection.  The DBPR investigators’ report cited phases used on Kesmarc’s website, phrases like ’24-hour postoperative care’, ‘nursing the critically injured’, and ‘comprehensive rehabilitative care.’  One section of the website stated: ‘Kesmarc seeks out the world’s top specialists in all fields of equine medicine, including orthopedics, internal medicine, infectious diseases and general practitioner.  By working with so many of equine medicine’s “best and brightest”, Kesmarc has gained an abundance of knowledge and expertise in equine rehabilitation.’

More disturbing was Kesmarc’s description of its DERBY Internship Program.  The goal of the program was ‘to let students experience the world of equine veterinary medicine, equine rehabilitation and equine veterinary nursing firsthand’:

Duties expected of our interns include (but are not limited to) the following:

  • Daily administration of medications and supplements
  • Assisting veterinarians as required (for radiographs, ultrasound, scoping, etc.).  Although we do not have a veterinarian on staff, we have multiple veterinarians performing different procedures on a daily basis.
  • Supervised operation of Hyperbaric Oxygen Chamber treatments (only available to interns committing more than three months)

Under Florida law, administration of medication to animals requires some level of supervision or direction by a licensed veterinarian.   The administration of ‘anaesthesia or tranquilizers’ requires the immediate supervision’ of a licensed vet.  ‘Immediate supervision’ is defined as ‘a licensed doctor of veterinary medicine is on the premises whenever veterinary services are being provided.’  At Kesmarc, horses were routinely sedated before entering the hyperbaric chamber, yet there was no vet on site, not according to Kesmarc’s website, nor according to owner Miller, who, in an on-premises interview with a DBPR investigator, stated specifically that a vet was not present during HBOT sessions.

But Miller also told investigators that ‘90%’ of the horses receiving treatment at  Kesmarc were ‘owned’ by the facility.  He repeated that claim in a letter to the DBPR dated October 1, 2010:  ‘As I have explained to you, nearly all of the horses at our facility belong to us.  For those not owned by us, they are brought to the facility under the care of their own veterinarian.’  He added, ‘We do have very knowledgeable people on our staff, including interns who are in veterinary school.’

The letter concluded: ‘We want to cooperate, and if there are any further questions, please feel free to contact me.  If you determine our procedures need to be modified, we will do so.’

Yet, even after the DBPR sent a letter to Kesmarc’s attorney, Willa Fearrington, outlining relevant sections of Florida law regarding the practice of veterinary medicine and suggesting a review of her client’s website, there is no indication that Kesmarc made any changes in how they promoted or conducted their services.   As one of the sponsors in October, 2011 of the USDF Region 3 Championships, Kesmarc’s promotional materials used the same language that was cited in the DBPR’s earlier investigation.  Kesmarc’s current Facebook page (cached here) still calls the clinic a ‘world class equine sports medicine facility’ as well as identifying it as the ‘sister facility to Kesmarc KY.’

But once a Notice to Cease and Desist has been issued, the DBPR does not usually do any follow-up, unless they receive a subsequent complaint of unlicensed activity.

The operation of the HBOT chamber by unpaid, uncertified interns is deeply troubling.   While HBOT is an accepted medical treatment for conditions like burn injuries, anemias and decompression sickness, a hyperbaric chamber is a medical device that is not without some very serious risks to the patient, the operator and to anyone in the general vicinity.  The Undersea and Hyperbaric Medical Society (UHMS), the governing body that accredits treatment facilities and certifies practitioners, maintains a database of accidents (PDF) involving HBOT.  During the years 1923-1998, 83 human fatalities occurred in monospace chambers (like the one in Ocala), most of which were caused by fires in the unit.  There have been more recent fatalities as well, including one in Broward, Florida in 2009 in which a four-year old boy and his grandmother were killed when a chamber exploded.  The boy, who had cerebral palsy, was from Italy, where HBOT is strictly controlled due to the risk of fire.

For humans, the UHMS lists fourteen approved uses of HBOT and cautions against any ‘off-label’ applications.  Medicare and most US health insurers will only reimburse for treatments for those fourteen conditions, and HBOT chambers are FDA-approved and licensed and regulated via state agencies.  Health Canada will grant a medical device licence for hyperbaric chambers only for the UHMS-approved conditions.  The Health Canada website states that HBOT is ‘generally safe, as long as the chamber is properly installed according to municipal and provincial regulations; operators and attendants are properly trained; and a certified hyperbaric physician is either on site, or can be reached easily and quickly.’

Unlike in human medicine, the use of HBOT for animals is largely unregulated.  Kesmarc promoted HBOT for a whole host of maladies, not all of which are on the UHMS-sanctioned list.  HBOT, the website said, was ‘useful’ in treating ‘breeding difficulties’, ‘low libido’, ‘low sperm count’, ‘post-colic surgery’ and ‘compromised immune system following disease exposure, traumatic surgical or traveling experiences.’   As Dennis Geisler, DVM and director of hyperbaric services at the University of Tennessee’s Department of Large Animal Clinical Sciences told a reporter for the magazine DVM 360,  “In the animal world, since we don’t have third-party pay, we can treat a lot of different problems.”

Landmark’s Legendary Affaire, or ‘Tux’ as he was known, was a six year-old Thoroughbred who had evented to the Novice level.  That much is known about him. Accounts differ on why he was undergoing HBOT that day.  The United States Eventing Association website quotes Stonehall Farm manager Sue Clark as saying the horse was in for a ‘general wellness treatment in preparation for the upcoming eventing season.’  Sorcha Moneley, the ‘observer’ injured in the blast, told sheriff’s investigators that he was being treated for Equine Protozoal Myeloenchephalitis (EPM).

Both of those things can’t be true, and neither is an approved medical use of HBOT.

The Marion County Sheriff’s report on the explosion, issued on February 16, 2012, is a harrowing read.  It’s the brief, tragic narrative of a doomed, agitated horse trapped in the chamber amid sparks and flames, of Erica Marshall crying as she tried to shut the unit down, of Sorcha Moneley running for help, finding herself thrown to the ground, choked by the hot air that ‘took her breath away.’

This was a situation that no one would ever wanted to find themselves in, and it was a situation that no one present – human or equine – should ever have been in.  In the MCSO report, Sorcha Moneley told investigators that the chamber had been malfunctioning recently.

… she was aware that there were some problems with the valves on the chamber leaking.  She stated that (clinic manager) Leonora Byrne had contacted that facility in Kentucky requesting that they send an engineer to look at the chamber.  Ms. Byrne had contacted the Kentucky facility on more than one occasion and was told that they would send someone when they could and for the time being the chamber could be manually operated to maintain the desired pressure.  Ms. Moneley said she was aware of some heated emails and arguments between Ms. Byrne and the Kentucky facility concerning the hyperbaric chamber.

When interviewed by the sheriff’s investigators, Leonora Byrne did not mention any knowledge of the chamber’s malfunctioning nor did she mention those ‘heated emails and arguments.’  She also stated that the horse had not been sedated prior to entering the chamber that morning which contradicted Moneley’s statement that the horse had been sedated.

This is critical information because, as previously mentioned, Florida law prohibits the administration of tranquilizers without a supervising, licensed veterinarian present.  Furthermore, the Notice to Cease and Desist from 2010 ordered Kesmarc to discontinue and remediate any unlicensed activity.  If what Moneley says is correct, Kesmarc was not complying with that order.

The horse was also allowed into the chamber with four steel shoes on his feet.  Although early reports said the horse’s shoes were covered over with tape or Elastikon, Moneley said the shoes were uncovered because ‘the inside of the chamber is lined with a protective coating making it unnecessary to take (sic) or cover the horse’s shoes.’  Tux, when agitated, kicked out at the wall of the chamber, dislodging a metal lid at the rear of the chamber and striking a spark.  Whether tape would have helped in that situation is unclear but it appears that horses were routinely put in the chamber without any covering on their shoes.  This would never be allowed in a human treatment facility, where metal objects are banned from HBOT chambers.  The risk of fire is just too great.

The MCSO report also gives conflicting information about Moneley’s role at Kesmarc.  Manager Byrne said that Moneley ‘was here to observe the chamber and its inner workings due to the fact that she was from the European theatre and that there were no public hyperbaric chambers situated in Europe.  It was her hope to open her own chamber somewhere in Europe.’  On her Twitter account, Moneley identifies herself as an ‘Equine Physiotherapist’ with a special interest in ‘the use of Hyperbaric Medicine for recovery and rehabilitation of the Equine Athlete.’

When interviewed at Shands Hospital, Moneley told sheriffs that she was staying in a home provided by Kesmarc on the property but denied being paid for her work.  But an OSHA investigator told police that ‘he had spoken with the owner of the property and was advised that she in fact was receiving cash from the facility; however, due to her visa restrictions, she is prohibited from gainful employment in the United States.’

On the website for Veterinary Hyperbaric Oxygen, the company that used to be known as Equine Oxygen Therapy, which manufactured and sold the malfunctioning chamber that exploded in Ocala, there’s no mention at all of the Kesmarc accident at all.

Speaking on behalf of the chamber manufacturer, part-owner Kirsten Johnson, one-time manager of the Ocala facility, told DVM 360: “All of the veterinarians that own hyperbaric chambers have been contacted by the company,” she adds. “They own those chambers … and so are we making recommendations? Is everyone on heightened alert? Of course we are. Have we made any demands? No.  We are being responsible and we are moving forward in a responsible way and all the information we have and we can give, we’re there for them and we’re supporting everyone.”

Hagyard Equine Medical Institute took a different approach.  Hagyard shut down their hyperbaric unit after the Ocala incident in order to to ‘conduct an extensive review of safety protocols and procedures with the chamber’s manufacturer.’  On February 27, the Blood-Horse reported that the unit was back in service, with “additional features” installed in the chamber to enhance “our stringent safety protocols.”  Perhaps this is what should be expected from a renowned veterinary clinic whose hyperbaric medicine director, Dr. Nathan Slovis, DVM, and safety officer, Lynne Hewlett, are both  UHMS-certified as both human and veterinary hyperbaric technologists.

But Hagyard is the exception rather than the rule.  Speaking to DVM 360’s Rachael Whitcomb, Dr. Dennis Geisler acknowledged the lack of standards, and said he was working to set up a veterinary hyperbaric medicine society and also to establish a certification program for technicians.  Meanwhile, he said, veterinary HBOT was on the increase, with small animal veterinarians buying reconditioned human chambers for their practices.  “I don’t even have a handle on how many of those are around.  There are quite a few.”

Warning: Some of the information in the below report is not for the faint of heart.

Sheriff’s Report 1

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