State College, PA is a relatively small college town with relatively few pools but we have had a rash of sudden deaths during laps swims lately. In a little over four years we have had four major cardiac arrests in four different pools during lap swims in our little town with three out of four being fatal.

 

First in 2008, a year before my retirement from Penn State University, a professor died suddenly while swimming his daily mile. Shortly after my retirement from Penn State in 2009, my close friend and colleague at Penn State, Shawn DeRosa, had another male victim die while swimming laps.  In both cases lifeguards recovered the victims and removed them from the water before they could submerge and aspirate any water.  Around the same time, a local State College dentist died while swimming laps at the State College Area YMCA. Again, this was ruled a death rather than a drowning because no water entered the lungs.  Finally, during the past week, Todd Roth's lifeguards rescued and successfully resuscitated a lap swimmer with rescue breathing and AED who experienced a sudden cardiac event at a Centre Region Park and Recreation pool.  Thankfully the victim is doing fine. 

 

With all four major medical emergencies, the lifeguards responded so quickly and professionally that none of the victims aspirated any water.  This is usually NOT the case. There are several important messages to convey to lifeguards about lap swimmers.  NO!  LAP SWIMMING IS NOT DANGEROUS!  In fact the opposite is true.  But too many lifeguards are so fixated on looking for the signs drowning by weak or novice swimmers,  that they tend to relax during lap swimming. Older generations like the Baby Boomers swim to stay young and healthy, but many of these individuals are at risk medically. If lifeguards delay at all when a severe sudden cardiac arrest, stroke or seizure occurs to a lap swimmer, and the swimmer swallows water during his/her distress, there is a good chance this good swimmer will be called a "drownee" by the coroner. As an experienced expert witness I can tell you when water is found in the lungs of the victim, regardless of the primary or initial cause of the medical malady in the pool, it is very difficult to defend, even with the best lifeguards on duty.  This is not fair, but it is true.  So what can we do to prevent negligence when a good swimmer dies of a major medical event during a lap swim?

 

1.  Guard all lap and adult swims carefully; be mindful of all  swimmers.

2.  Teach your guards that medical emergencies might be more likely than traditional drowning events, particularly with older populations.

3.  Be ready by expecting the unexpected.

4.  Respond immediately without delay to distress in the water.

5.  Your goal should be to get to the victim before he/she submerges or aspirates water.

4.  Have an AED and Oxygen close by and be ready to use it.

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Comment by Mario Vittone on June 24, 2013 at 8:55am

Sorry - resuscitation can occur after aspiration.  You are saying that until they aspirate - drowning hasn't occurred yet.  Correct?

Comment by Mario Vittone on June 24, 2013 at 8:54am

Yes - Tom.  I get that part.

As a matter a definition then - drowning only fully happens if you die from it.  Yes?  Again - it's a semantic issue about when we apply the term.  So if a child "struggles on the surface then sinks to the bottom" and the guard pulls him out and he is resuscitated before he actually aspirates water - the you are saying the child did not "drown."  Yes?

Comment by Tom Griffiths on June 24, 2013 at 8:49am

Dr. Jerome Modell is respected as perhaps the leading drowning expert worldwide.  He is the only American to win the International Lifesaving Award. His words describe the “dry drowning” scenario best.

NPR August 16, 2010, Interview of Dr. Jerome Modell on Drowning

CONAN: And here's an email question. And this is from Alicia(ph) in Colorado. Could you talk about the warning signs of dry drowning? Dr. Modell, could you speak to that?

Dr. MODELL: Well, I don't believe dry drowning actually occurs anymore, and yet I believe I'm the individual that introduced that term some 40 years ago. It was based on some studies that were done in France that were perhaps misinterpreted. But about five years ago, Dr. Lunetta and I - he's the professor and chairman of Department of Forensic Science, University of Helsinki - published a paper in (unintelligible) medical literature and a book chapter, and looked at - he had, I think 1,700 cases in his file of people who died from drowning. And we found that in over 98 percent of the time, you could clearly demonstrate that water was aspirated.

If you don't find any evidence of aspiration of water in someone that was thought to have drowned, I believe that they probably died of another cause such as a sudden cardiac arrhythmia resulting in cardiac arrest before they could aspirate water.

CONAN: So dry drowning is, you think, a myth.

Dr. MODELL: Let me just say that I don't think anyone has ever proven it exists. And as a matter of fact, at the world congress on drowning in Amsterdam in 2002, in the final recommendations, it was recommended that the term be drop and not used.

 

 

Comment by Mario Vittone on June 20, 2013 at 11:28am
  • "We [the task force on the epidemiology of drowning] agreed that an acceptable definition meeting these requirements is: 'respiratory impairment induced by submersion/immersion in liquid'"
  • "Massive aspiration during the drowning process is seldom observed in humans."
  • "In general, only small amounts of water are aspirated and sometimes no water at all."

~All from "Handbook on Drowning; Prevention-Rescue-Treatment" released in 2006. (Much of it the identical text from the WHO bulletin of course)  In the same book, the task force on hospital treatment (of drowning victims) uses the word drowning to describe all forms of submersion/immersion accidents that include everything from no water in the lungs to "significant" water in the lungs - whether or not the patient lived or died.

The issue then is (and will remain) semantic I think.  The WHO doc Tom cited goes on to give the three outcomes of drowning as death, morbidity, and non-morbidity.  That means that Drs. Beeck, Branche, Szpilman, Modell and Bierens, think that one outcome of "drowning" is living through it - but perhaps they meant after some aspiration.  I'm a pretty smart guy and the text isn't clear.  But then again, drowning is complex and clarity may be unattainable.  Because here they were, really smart guys still trying to work out what "drowning" means in the 21st century.

My point?  Put experts on a subject together and they will do everything but completely agree.

 

Tom - excellent article.  The idea that lap swimmers should be watched just as close as a pool full of diverse patrons is an excellent notion and one that guards should be aware of.  

Comment by Tom Griffiths on June 19, 2013 at 11:40am

Since the World Drowning Congress of 2002 in Amsterdam, physicians who study the drowning process have carefully redefined the definition of drowning. The consensus of this medical group (Drs. Beeck, Branche, Szpilman, Modell and Bierens) concluded that the terms wet, dry, active, passive, silent and secondary drowning should no longer be used in discussions of drowning (Bulletin of the World Health Organization, Policy and Practice, November 2005, 83 (11). Rather, drowning is a very active process whereby the drowning continuum begins when the victims airway lies below the surface of the liquid, usually water, and after brief breath-holding, the victim actively breathes liquid. In our three swimming pool deaths, none were listed as drowning. Based on the quality work of the World Drowning Congress and the International Lifesaving Society, I do believe, "if there ain't water in the lungs, it ain't drowning."

Comment by Gerald M. Dworkin on June 19, 2013 at 10:06am

Although I agree with the principles advocated in this blog, I disagree with the inference that drowning only occurs when the victim has aspirated water into his/her lungs.

A victim who suffers a medical emergency resulting in sudden cardiac arrest will only aspirate water into the lungs if his/her recognition is delayed and there is a prolonged submersion before the lifeguards recognize the emergency.

Persons who experience a sudden cardiac arrest in the water are typically classified as drowning victims, regardless of whether or not water has been aspirated into the lungs.  It is nearly impossible to determine whether or not the person's cardiac arrest was caused by a medical emergency, or as a result of suffocation caused as a result of a respiratory arrest resulting from being immersed in or submerged in water.

Lap swimming should be supervised, and lifeguards need to be strategically positioned and prepared to respond to incidents in the lap lanes, as much as anywhere else in the swimming pool or at the beach.

All lifeguards need to be knowledgeable about the location of the facility's AED and should be well-trained in the use of this equipment.

And, as for oxygen administration, we advocate that all "guarded" facilities should have oxygen administration equipment available and that lifeguards should be trained and qualified in the administration of oxygen via the use of a bag-valve-mask resuscitator.  Regardless, however, of whether or not that equipment is available, all lifeguards should be trained to effectively provide positive pressure ventilation via the use of a BVM, and all facilities should be equipped with adult, child and infant BVMs.

Also, as I've stated numerous times, we know that victims vomit during the administration of CPR.  Therefore, lifeguards should also be trained in the use of manual hand-held suction devices, and all facilities should also be equipped with this equipment as well.

Gerald M. Dworkin, Consultant

Aquatics Safety & Water Rescue

LIFESAVING RESOURCES

http://www.lifesaving.com

P.O. Box 3006 / 3 Mills Rd.

Kennebunkport, Maine 04046

207/967-8614 • gerald@lifesaving.com

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