With urban and rural swiftwater rescues from flooding or other misadventures; backyard pools of all shapes, sizes and depths; inebriated persons in roadside puddles; and even toddlers upending themselves in buckets, the chances of a rescue team having to deal with a wet victim are very high. While the 'time immersed' does impact survival, the initial treatment of an immersion incident will have a significant impact on the eventual recovery of the survivor.
If the mechanism of injury involves alcohol or other intoxicants, high-powered personal watercraft (PWC), a diving accident or a fall of more than 10 meters, complications should be expected from significant trauma to the head, face, spine or other portions of the anatomy. Another source of secondary trauma is from whitewater incidents, where the victim may be ejected from a canoe, raft or kayak.
THE DROWNING PROCESS
In the mid 1990s, the World Health Organization and World Bank sponsored a study on the Global Burden of Disease, which found that drowning was a much underappreciated cause of death worldwide.1 The first World Conference on Drowning, held in Amsterdam in 2002, developed a new definition of drowning to simplify reporting of injuries and deaths due to immersion. The expectation is that, by replacing many of the other terms and definitions currently associated with drowning, a more comprehensive and useful Utstein-type database can be developed.2 Public health organizations can then use the data to improve prevention efforts. While most injury reporting will be the province of hospital emergency departments, Utstein-style data reporting may be required for EMS divisions of public service districts. A number of primary and supplemental criteria have been identified, including:
- Precipitating event
- Degree and duration of immersion/submersion
- Time to first resuscitation efforts (duration of untreated cardiac arrest)
- Initial response to treatment
- Adequacy and type of ventilation
- Measurement and production of blood flow during chest compressions (demonstrated by palpable pulses in the field), and the definition of return of spontaneous circulation
- Patient condition on arrival at the emergency department.
Other criteria are also included.3 It is hoped that improved reporting of standardized information will help improve the prevention and treatment of immersion victims in the future.
Overall, the U.S. reported 1.93 drowning deaths per 100,000 people for all age groups in 1995, with almost 3,600 unintentional deaths in 2005.4,5 Additionally, there were 14 ED visits and four hospitalizations per death, with the concomitant burden on EMS and ED services. Of these, 25% of victims were under age 15. However, an important point to consider is that the majority of victims suffer no significant injury and often do not seek treatment, leading to significant underreporting of the problem. Improved standards of living and education can make marked improvements in the rates of death, as demonstrated by the Netherlands. The Dutch went from 14.4 deaths per 100,000 person-years in 1900 to only 0.6 deaths per 100,000 in 2000 with a combination of improved swimming instruction and general education. This compares to the current 14.2 deaths per 100,000 person-years in Africa.6 EMS agencies, in conjunction with local swimming pools and the Coast Guard Auxiliary, can improve the survival rate by helping sponsor swimming lessons, especially for lower-income families.
Like so many other causes of death or disability, extremes of age make a significant difference. When considering infants and young toddlers (age birth to 30 months), the major risk areas are bathtubs, toilets and water buckets where the infant is not supervised. Most of us are familiar with the warnings that have been printed on five-gallon buckets for years, because, like toilets, a toddler can upend into a bucket and not be able to get out without assistance. Another consideration in toddlers is the suspicion of child abuse, including Munchausen's by proxy,7 even with an apparently clear-cut explanation for the lack of supervision.8