Near Drowning??

[medic403]

I have one for all of you. Please give me your opinion. I work in a very rural area. Nearest hospital (from the time of pt. contact) is approx. 1 hour away by land. I was called to an area approx 20 mins. away for a MVC that sounds serious. Unknown how many PI. Dispatch tones out vol. fire/rescue that would be there much sooner than our rig would be. Vol. Rescue put life flight on stand by and headed for the scene. Once off at the scene rescue found no mvc. rescue went and talked to the business the call came from. The business did not know much except for a gentlemen with a life vest ran in and said to call for an ambulance there has been an accident. So now the accident may be a boating accident. Still nothing further to go on. Life flight is still on stand-by. Well before we have any pt contact or knowledge of what is going on life flight chooses to head to a designated LZ. They have an ETA of 28 min. Once I show up on scene pt still has not came off the river and no one has any idea what or if we have a pt. The guy with the life jacket left before any one was on scene. So now lets reflect. We have an officer (MVA?), game warden (poss. boating acc.), vol. rescue crew (extrication and 2nd pair of hands), ambulance (transport and treatment), and now a life flight helicopter (transport to a trauma center) and still no patient. No one could stand down because we still did not have no idea what we were dealing with. Soon some rafters come off the river and can not tell us anything except we are looking for a blue rafting boat. Still no pt update. after of sitting on scene for approx. 45 minutes a doctor comes off the river and says "the pt may have a broken jaw or neck, but other wise is stable. Pt will be walking off." I shook my head and said, "I don't think he'll be walking off the raft." Then I walked away. OK, so now we have a pt condition maybe. So I relay what i know to life flight. They continue to the LZ. Now approx. 10 mins out. Pt finally arrives lying on bottom of raft. Obvious injuries: Hypothermic and a 1" lac on chin.

Pt AxOx4.

While cutting wet gear off I am receiving report. This pt. raft flipped on one of the whirl pools and was pinned under water for approx 2 mins. Another raft came through pulled him out and did 15 secs. CPR. and rescue breathing. Then pt just started breathing. Pt color was reported as very blue. Pt remained unresponsive for approx 15 mins.

I asked if he had no pulse. Answer was: that was never assesed.

Pt was wearing a full helmet w/ face shield.

Placed pt on 10L of O2 via NRB.

Skin: Pink-cold

Vitals: B/P 140/78, HR 72, RR18, B/G 97

Examination of systems:

HEENT: pt complains of vision disturbances, unable to see.

Pupils: sluggish but react with light, lac on chin, bleeding controlled, other wise clear.

Neck: no JVD, no trachea deviation, no pain on palp, placed collar on pt

Chest: lung sounds clear, no crepitus felt, symmetrical, no pain on palpation

Ab: soft and non tender, no bruising or discoloration, ab slightly distended, pt complains he needs to relieve himself, have male help him with that. 500cc's of slightly yellow urine, no blood presant.

Plevis/hips: clear

Ex: clear, good csm in all ex.

Back: clear, no pain on palp. Boarded the pt.

Iniated rapid rewarming, wrapped pt with blankets, placed hot packs on back of neck, arm pits, and on ab, started 2 large bore IV running w warm normal saline solution.

Placed pt on life flight and was taken to trauma hospital.

I felt the hospital I would of taken pt to would of been sufficient. TIME is the only reason why I felt it was necessary to go with life flight plus they were already there.

How ever couple things bothered me. Waste of valuable resources had taken place and I question the pt was not breathing. I believe CPR was contraindicated in this situation. I believe pt was alive but had water in his airway at first. I believe some one was anxious because we have had 2 deaths on the river in the past two years.

The reason I believe this is because pt had to urinate.

So what do the critics think? Any advice on doing anything different?

Pt outcome: Pt was observed for two days with a concussion and released without complications. Do not have any more information than that.

[Ridryder 911]

Sounds like a bad deal... nothing can be done. Finding the patient appears to always be difficult. I would had obtained the physicians name and as well wonder why he did not stay with the patient? If the patient really did "go under" this could had lead into complications. I ask if there was any ETOH involved as well?

I agree, I doubt CPR was indicated and as well if he really went under that duration without any aspiration occurring. Like zealous rescuers, performing CPR, time is greatly exaggerated.

Personally, I would not have done anything differently as well, from your clinical presentation and history.

R/r 911

[paramedicmike]

A couple of questions for you...

Where are you? What river? Commercial raft trip? Private raft trip? Private kayaker? Class of river (I-VI)? Description of area in which this particular boater was pinned? Was the pin completely underwater? Who were the providers of CPR? Professional guides? Other boaters on the water? Random commercial raft customers?

These may sound like stupid questions. But the answers will potentially affect the answers and reasoning you're looking for.

First, you never know if it was a waste of resources before hand. You, and it sounds like others, went with gut feeling and called for the helicopter. If you had called to stand down the flight team and then decided you really needed them you'd have been so far behind you never would have caught up. It is much too easy to Monday morning quarterback a call like this. Don't let your 20/20 hindsight affect your interpretation of the events as they were unfolding.

Second, don't ever hesitate to call for an aircraft if you think you'll need it. We love to fly. If we get canceled en route we're just as happy...if not happier because now we don't have any paperwork to fill out!

For this part, I don't know your experience so please forgive me if I say things you already know. I don't know if you're a paddler, either. It doesn't sound like it from your post. Again, please bear with me if you know this.

Third, white water rescues (which is what this sounds like) are crazy, hectic affairs. They're even more so in a wilderness setting (which, again, is what this sounds like). There is little time to think, act or do. Things need to be done and they need to be done now! What's worse is that while you're busy trying to affect a rescue you're panicked, your adrenaline is working overtime, and, this is probably the biggest part, for the rescuer (and the pinned boater if still awake) time flies by. They probably thought it only took two minutes to get this boater out of the water when in reality it took 5, 7 or 8 minutes.

Now, you know he hit his head. Helmet or not, if he's got a facial laceration you've got something to worry about. Plus, you don't know what or how he hit or the forces involved. If there was a recipe for a head injury this was it.

If they said he was blue, he was blue. If they said he wasn't breathing, he wasn't breathing. If they said they didn't check a pulse then chances are pretty good you didn't talk to the right person...especially if this was a commercial trip. Commercial raft guides, especially those on big water rivers are pretty good with this sort of thing. They get routine training in rescue, CPR and first aid. Many are EMTs or paramedics with extensive experience. They know what they're doing and how to do it well. What's more, regular boaters (I'm thinking more kayakers) are just as knowledgeable and experienced as commercial guides, if not more so. This is simply because kayakers tend to travel in smaller groups. They have to rely on themselves and their paddling partners to save them should something bad happen.

With a patient like this I'd have preferred to send them by air to a trauma center, too. I would not have trusted something like this to a local community hospital. Again, it comes down to clarity in your reflection on events. It's easy to say after the fact that "they only kept him over night". It would be much harder to say "if we had sent him to the trauma center he might not have died".

River rescues, especially in wilderness situations get really hairy, really quick. The more resources you have the better. The soonest you can have them there is never soon enough. Call for help early, call often.

How, you ask, do I know all this? Glad you asked!

I have worked as a commercial whitewater raft guide for more than 10 years. I have been a whitewater kayaker for about that same length of time. I have been involved in both rescue situations and have been rescued myself. Some of my comments above about guides/boaters are generalizations...many are good, many are not. The same can be said for anything. The ones who are good tend to be the ones who take charge but the ones who aren't tend to be the ones you always manage to talk to (because they like to look/feel important...a form of a whitewater "whacker", if you will).

To give an example of how quickly time can seem to move I'll relate a story about a pin I had. I got stuck upside down, in my kayak, with the edge of my boat under the lip of an exposed undercut right on the eddy line in the middle of a class III/IV rapid. I couldn't reach the rock underwater to push off (not that I could push against the current anyway). Because I was on the eddy I couldn't get enough purchase with my paddle to try and roll up and off or even paddle forward or backwards. I couldn't get out of my boat because if I did the current would push me under the undercut rock and I didn't know where the current would take me (and I really had no inclination to find out). I tried all sorts of things to get myself unstuck (save getting out of the boat because, as we discussed, I didn't know where I'd end up). Nothing was working.

Now, my buddies were scrambling out of their boats trying to figure out a way to get to the rock against which I was pinned. I was rapidly running out of air and in desperate need of a breath. Somehow, and to this day I still don't know how, I washed off the rock and was able to roll up and breathe.

I swore I was only stuck for 30 seconds or so. One of my buddies on shore was watching the time so they'd have an idea of just how long I was with out air when my limp lifeless body finally came out. He said it was almost two full minutes. (I don't know how I held my breath that long. But stranger things have happened I guess.) Every one else thought it was only 30 seconds to a minutes worth of time that I was stuck. Just an example of how their reported "2 minutes" could've been much longer.

Sorry for the long post. I think you were right to summon all the resources possible. I think you were right to fly the patient out. I don't think you should've done anything differently.

If you have any other questions (but don't want another long post), let me know. I'll be happy to discuss the finer details of the joys of whitewater!

edit: I can't believe I forgot this part...

-be safe

[medic403]

Hello paramedic mike. thanks for your opinions and questions. Here is some answers to your questions. This was a trip on the Dead River (no phun intended) located in Northern Maine. This was the end of the season for rafting so many came from far and away to raft. I am not as familiar with the Dead River as I am with the Kennebec River. I pick up to many people to raft or white water kayak. I do flat water or minimal moving water for kayaking. There was some where around 500 rafters on this particular river this day. This rafter was in a private raft with friends and a professional guide from another rafting company. In Maine you need a licensed guide on any rafting trips. The dams were open so the river was higher than normal. Not sure of the flow that day. The one thing i am sure of is the reason it had taken the rafters so long to get the pt to the ambulance was because the accident happened early in the trip. There were many whirl pools do to the water being higher. The rescue was done by a rafting company that saw the accident. Yes you are very right. Time flies by and no one person will be the same as another. But he did receive immediate care, because they were there. Otherwise who knows what would of happened. The pt color tells me he was under water for a time. The CPR and rescue breathing was done by the rafting guides that pulled him from the river and was the one to tell me that pulse was not assessed. The gentlemen told me it was two rescue breaths and approx. 30 chest compressions and pt started breathing. (2 person CPR). End result the pt made a 100% recovery. Physically any way. Unknown mentally, he may be scared of the river now. I know I would be a little nervous.

On a separate note I had Life flight training this past weekend and the same crew that was on this call was doing our training. So I asked about more info on this pt. The flight nurse stated pt had some kidney problems at first from being hypoxic and poss from being hypothermic. But after a couple days and plenty of fluids he showed no signs of failure. thank goodness. Pt was very appreciable that he was still alive. Went home to Ma. 2 days later. Lucky man.

I do appreciate your input. It helps me get another medic perspective on the situation. Anything else I can answer please ask or any comments please add I do read them. Thanks once again.

[FormerEMSLT297]

So, I think you are correct that CPR probably was not necessary. However, you have to go with what you are reported. If someone told you CPR and basically that the person was a post cardiac arrest.. you have treat it as such... so, the helicopter is not necessariry wrong.... Also if the patient isnt able to be located the Helo can be used to search the area with the nitesun and or FLIR.. if so equipped....

all in all i would have done it the same way....

[Stretchermonkey]

I wish I'd picked this up earlier; but here's my thoughts...for what they're worth.

Firstly, I think I good job done by you all round. Secondly, I really hope I am not about to state the obvious and insult you. These are just my thoughts and observations. As has been already said, you have to go on what you are told by the persons on scene, unless you can categorically say something is not true. That would be very difficult.

The alarm bell that rang for me was that chest compressions were done without a pulse check first. In any event they were, so accept that and treat accordingly. I have no doubt that the patient was hypoxic, hence the cyanosis. Unless the water was incredibly cold, I don't think that preipheral vasoconstriction would have been that extreme to have shown as cyanosis in the timescale given.

If one considers the pathophyisiology of drowning...the first thing to happen is laryngospasm when a concious person is submerged. This causes the glottis to shut, and water to enter the stomach (that could well be the reason the patient needed to urinate). When this happens the lungs remain 'dry', but although water doesn't enter the lungs, neither does air. The patient becomes hypoxic and cyanosed. It would be very easy for a rescuer to see a patient in this condition and assume they were dead, and start full CPR without doing all the checks first.

Considering that, this appears to be what occured as the patients lungs were clear, and abdo was slightly distended. I have a feeling you already know this, but you asked if the critics would do anything different. From what I've read you appear to have done a good job. The only thing I would have done is to have put on cardiac monitoring, in case of any dysrhymias present due to the chest compressions.

Just thoughts from accross the pond.

Cheers,

Stretchermoney.

[medic_ruth]

The alarm bell that rang for me was that chest compressions were done without a pulse check first. In any event they were, so accept that and treat accordingly.

-- stretchermonkey

lest we forget that lay-people are taught to look for "signs of circulation" and no longer do pulse checks.

If one considers the pathophyisiology of drowning...the first thing to happen is laryngospasm when a concious person is submerged. This causes the glottis to shut, and water to enter the stomach

-- stretchermonkey

This does not happen to all people, hence the terms "dry drowning" and "wet drowing"

First, you never know if it was a waste of resources before hand. You, and it sounds like others, went with gut feeling and called for the helicopter. If you had called to stand down the flight team and then decided you really needed them you'd have been so far behind you never would have caught up.

--mike

I agree 100%. I am also in a rural area. Though we don't have helicopters available to us (I am in the U.P. of Michigan and they can't fly across the straits) We do sometimes have a considerable amount of time to wait if we need more resources. We also tell neighboring townships the same thing. If you think you need us, call! We don't mind turning around and going back home!!

[Stretchermonkey]

"lest we forget that lay-people are taught to look for "signs of circulation" and no longer do pulse checks."

Wasn't aware of that. In the UK lay responders are still taught to do a pulse check.

"This does not happen to all people, hence the terms "dry drowning" and "wet drowing"

I am aware of this, thank you. However, in this instance I would suggest that this is what happend.

Regards.

[Leen C]

"lest we forget that lay-people are taught to look for "signs of circulation" and no longer do pulse checks."

Wasn't aware of that. In the UK lay responders are still taught to do a pulse check.

Strange, because in Belgium, they aren't, so the USA isn't an exception in that perspective... Here, people are even told to start full CPR in case of respiratory arrest! They develop protocol on the basis of the most likely scenario. Experience has taught them that lay people lost too much time looking for a pulse that most of the victims didn't have...