The Lifeguard’s Drowning Dirty Dozen:
Fake News and Common Medical Myths Around Drowning
Dr. Gary Payinda
There is no such thing.
In 2005, the World Health Organization got rid of the old jargon and adopted two straightforward terms to describe drowning: ‘non-fatal drowning’ if the patient survived, and ‘fatal drowning’ if the patient died. If you hear a health professional or instructor using the term ‘near-drowning’ you know they are roughly 16 years out of date. Anyone who specialises in drowning uses the terms ‘non-fatal drowning’ or ‘fatal drowning’. Just like electrocution, where a person can be electrocuted and survive, a person can experience a ‘non-fatal drowning’ and survive. A person does not have to be dead to have drowned. They’ve just had a ‘non-fatal drowning’. This highlights the reality that drowning is a process. A process that can be interrupted, and lives saved. Let’s all use the correct terms.
Technically, it is defined as “the process of experiencing respiratory impairment from submersion or immersion in liquid.” A more simple definition could be: experiencing persistent breathing problems due to water entering the airway.
A cough that goes away after an underwater dunking is not ‘drowning’. But a persistent cough after going underwater is a ‘drowning’, and more specifically: a ‘non-fatal drowning’.
“Delayed drowning” or “Secondary drowning”
There is no such thing. These are not medically accepted diagnoses.
There are no patients that drown, recover completely, then suddenly deteriorate or die hours to days later. If you had mild symptoms which completely resolved, you are safe.
However, if you drowned and had ongoing symptoms — even very mild ones like a cough, or faster than normal breathing rate, or mild breathlessness — you need to see a medical professional. They will listen to your lungs and measure your blood oxygen levels. It is quite possible to have seriously low oxygen levels despite feeling only mild symptoms after a drowning.
Likewise anyone who had a moderate or severe drowning event, with symptoms like a loss of consciousness or serious trouble breathing, should have 111 (emergency services) immediately called on their behalf.
There occasionally are cases reported in the media of kids suddenly developing severe breathing problems and dying weeks after a drowning. These events are often sensationally attributed to drowning, but on a later autopsy proven to be due to a completely unrelated (and usually unsuspected) heart condition or heart infection.
‘Dry drowning’ and other myths, David Szpilman, MD, Justin Sempsrott, MD, Jonathon Webber, RN, Seth C. Hawkins, MD, Roberto Barcala-Furelos, PhD, Andrew Schmidt, DO, MPH and Ana Catarina Queiroga, PhD, Cleveland Clinic Journal of Medicine July 2018, 85 (7) 529-535; DOI: https://doi.org/10.3949/ccjm.85a.17070
There is no such thing.
Outdated, poor quality medical studies suggested 15% of fatal drowning autopsies showed dry lungs. Doctors came up with various creative explanations for why this might occur, none proven. Newer post-mortem CT-based studies suggest the actual number is less than 2%. Either way, wet or dry lungs on autopsy are clinically irrelevant. Autopsy findings are increasingly being shown to be unreliable in drowning.
Schneppe, S., Dokter, M. & Bockholdt, B. Macromorphological findings in cases of death in water: a critical view on “drowning signs”. Int J Legal Med 135, 281–291 (2021). https://doi.org/10.1007/s00414-020-02469-9. “Nevertheless, it can be stated that none of the drowning signs we examined guarantees high diagnostic certainty.”
“Saltwater vs freshwater drowning”
The only factor that is important in drowning is the submersion time. The longer a patient is underwater, the more likely they are to die. The less time they are underwater, the greater the chance of survival.
Clinically irrelevant in almost every NZ case of drowning.
It is true that if a patient falls through ice into ice-cold water, and they are a child or very small person, there is an exceedingly small chance they can survive a long immersion (as long as an hour) without brain damage or death. In the vast majority of cases in New Zealand, however, the patient will drown in non-freezing water temperatures, and therefore the body will not cool down rapidly enough to make a difference. It is worth remembering that even in the most ideal circumstances, ie, a young child falling through ice, almost 100% of these patients, once in cardiac arrest, will remain dead despite all resuscitation attempts.
Do not count on water temperature. The thing that matters is the speed you can get a person breathing again. If you can resuscitate a patient within a few minutes of submersion, their chance of survival will be vastly improved.
‘Shock’ is a medical term, it immediately tells a paramedic or doctor that the patient you are treating might imminently die. If you are a lifeguard, you should use the term shock only for a medical condition of low blood flow to the brain and other essential organs. A person may be in shock if they have had an injury or illness and are:
- confused, slow to respond, or unconscious
- have a weak pulse and cold and clammy skin
- have a heart rate that is very slow or very fast
- have other evidence of severe blood loss, internal bleeding or a brain injury
- have an irregular heartbeat or heart condition
Shock, medically speaking, is not emotional upset, fear, an inability to answer questions due to surprise or being overwhelmed, denial, disbelief, or anxiety. A first responder must never confuse emotional upset with a medical condition that will, if untreated, likely result in the patient’s prompt death. Use ‘shock’ to refer to the immediately life-threatening condition, and ‘anxiety’ to refer to the psychological symptoms which are also very important to address through sensitive mental health assistance, but need to be treated differently than ‘shock’.
Hands-only CPR / Compression-only CPR
Largely irrelevant to drowning resuscitation.
Hands-only CPR is optimal for just one thing: a primary cardiac arrest, the sudden collapse of a patient, often a mature adult experiencing a heart attack or dangerously irregular heartbeat (a life-threatening arrhythmia), where chest compressions circulate oxygenated blood to keep the brain alive for a few extra minutes until an AED can be used to deliver a shock to the heart.
In drowning cardiac arrests, and in virtually all other causes of cardiac arrest, the heart stops not because it suddenly went into ventricular fibrillation, but because the critical organs were deprived of oxygen for so long they began dying. In the brain, this manifests as confusion, combativeness, and eventually unresponsiveness. The brain can undergo profound and irreversible damage due to hypoxia (oxygen starvation) in less than 8 minutes. With the much more durable heart hypoxia usually manifests as a fast heartbeat, then eventually a slowed one as the heart gradually succumbs, eventually developing irregular beats, and then stopping. This final stoppage is termed asystole, a non-shockable rhythm that almost every time irreversibly results in death.
Restoring oxygen at some point during this process (the earlier the better) through mouth-to-mouth, mouth-to-pocket-mask, or bag-valve-mask ventilation is absolutely essential in preventing death due to drowning. Roughly ten percent of drownings will have a shockable rhythm when found, so getting an AED and applying it is still important, but for the majority, prompt rescue and prompt ventilation is the key.
Hands-only CPR may be useful if a rescuer is unable or unwilling to do rescue breathing/ventilations, but this is not the recommended practice for a lifeguard or other first responder. Hands-only CPR is acceptable in primary cardiac arrest, ie, for an adult seen to suddenly collapse unconscious on land. But SLSNZ in every case recommends the same response: DRSABCD with head-tilt and chin-lift to open the airway and hold it open, bag-valve-mask ventilation with two rescuers (one holding the face tightly sealed up against the mask, and the second rescuer squeezing the bag), chest compressions for anyone who is unresponsive and not breathing normally, and defibrillation with an AED as promptly as possible.
Concussion does not require the patient to get ‘knocked out’.
A simple headache, ‘seeing stars’, slower than normal thinking, nausea, blurry vision, or mood changes can all be signs of a concussion. Even one of these in the setting of a head injury are enough to suspect a concussion, remove a participant from patrol, competition, or training and place them on an immediate standown, initiating a 21 day graduated return to play scheme, including mandatory medical clearance prior to a return to play/duty.
By contrast, an actual loss of consciousness, vomiting, or trouble standing or walking are all signs of a potentially serious brain injury/brain bleed and need to be assessed by a medical professional immediately. Call 111 in any such case where a critical brain injury is a possibility.
It’s effective. It’s generally very safe. But in extremely rare cases, it can be the cause of malignant hyperthermia, a disorder that is sometimes fatal.
The green whistle, also known as Penthrox or methoxyflurane, is an inhaled anaesthetic that relieves severe pain. It is a prescription-only medicine, prescribed by the SLSNZ Medical Director and used under their medical license. The Ministry of Health allows specially trained and vetted lifeguards to administer methoxyflurane under a “Standing Order”. If administered to the wrong patient, ie someone with a personal or family history of malignant hyperthermia, there is a chance the patient could die despite medical treatment. Make sure you know the contraindications that preclude the use of methoxyflurane before you even consider its use.
Very unreliable in drowning.
The facts are that pulse oximeters are extremely inaccurate in wet patients and cold patients. Wet and cold are how most drowned patients will be found when rescued, meaning pulse oximeters are almost useless in the very patients we are most concerned about. In testing, cold and wet volunteers will have grossly inaccurate blood oxygen readings about 50% of the time. Before you use a pulse oximeter, know the limitations. And never rely on a single test or observation. Assess the patient yourself and see if the test results fit with your findings.
Stop bleeding first.
DRSABCD is a wonderful mnemonic (memory aid). But it is not perfect in every case. One of the few times it falls down is in the management of massive haemorrhage. In major trauma with external bleeding (ie, bleeding that can be seen, and often controlled), time is of the essence. Blood must be kept inside the patient as a priority. It makes no difference if the patient’s airway is opened, and their breathing assisted with ventilations, and an AED placed on the patient if they have lost so much blood that they become unconscious, lose their blood pressure, become unable to fill their heart, exsanguinate, and die. Ambulances do not carry blood, and there is no replacement for critical blood loss immediately available on scene. A patient who has bled beyond a critical amount (around 2-4 litres in an adult) will likely not respond to CPR or survive resuscitation. Therefore, once you have taken steps to protect yourself, place firm, direct pressure directly on the bleeding wound and maintain it until bleeding has stopped. Do not merely pile on more dressings which will soak up more blood, these are wholly ineffective at stopping serious bleeding. Apply firm, direct pressure directly to the bleeding site in the wound.
Hope this helps. Kia rite!
Dr Gary Payinda
Medical Director Surf Life Saving New Zealand
Emergency Medicine Specialist
Lifeguard, Ruakaka Surf Lifesaving Club