Author Question: Drowning

Sally joins Redwood's Medical Edge again with an author question. She had visited previously with a question about food allergies that you can find here.

Sally asks:

I have a character that someone is trying to drown. They hold her under water, and she runs out of air, but someone else pulls her up. I don't want a scenario where she needs CPR or mouth-to-mouth, maybe just some coughing and choking, spitting out water. Does that work for her to be under water only a couple seconds and suck in water?

Jordyn says:

Yes, it works.

I like these types of injuries when writing medical scenarios because it offers you a wide range of things you could do to your character-- from nothing at all to significant injury.

Not all people react the same when their head is pushed under water. There is what's called a diver's reflex where you will instinctively hold your breath and drop your HR when your face hits cooler water-- which most bodies of water are less than your body temperature.

That being said, what a person does after those first few seconds is up in the air which is good because it gives you writing leeway. So the amount of water they inhale and at what point they would do that is for you as the writer to decide.

Possible patient outcomes for this particular scenario:


1. She is just fine (once she gets over her initial coughing and spitting up of water) and doesn't need any medical intervention.

2. She inhales a little water where it might be good for her to be medically observed for a while but she suffers no ill effects and doesn't need any medical intervention-- just observation on a monitor. This may be only a few hours to twelve hours depending on the physician.

3. She inhales some water and she is symptomatic (low blood oxygen levels, increased respiratory rate, increased work of breathing like using accessory muscles) but doesn't need any dramatic intervention-- maybe just some oxygen to tide her over and medical observation until this clears up. Her shortest observation time would likely be 12-16 hours to watch for further developing lung injury.

4. She inhales a lot of water and develops respiratory distress to the point she would need to be intubated-- or go on a breathing machine.

Every patient is different. Sometimes we in the medical field feel that the mechanism isn't that impressive but the patient does suffer ill effects-- so again, a lot of room for the author.

And remember-- drowning doesn't always look like what television portrays it as.

If interested in further medical posts are drowning they can be found here and here.

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Sally Bradley has worked for two publishers, writing sales and marketing materials, sorting through the slush pile, and proofreading and editing fiction. She has a BA in English and a love for perfecting novels, whether it's her work or the work of others. A judge in fiction contests, Sally is a member of ACFW, The Christian PEN, and the Christian Editor Network. She runs Bradley Writing and Editing Services from her home outside Kansas City. A mother of three, Sally is married to a pastor who moonlights as a small-town cop.

Summer Safety

Okay-- 4th of July is tomorrow and I JUST can't help myself. In real life, I am a pediatric ER nurse and summer always brings a unique set of injures. Drownings increase. This is a completely preventable injury.

It's not unusual to have a child who suffered a drowning (you die) or near-drowning (got resuscitated) on a holiday. Adults get together and there are lots of above ground pools around. Adults are drinking. Adults assume their child is an adequate swimmer after passing swimming lessons (this is not necessarily true.) Adults assume the older kids will watch for the younger ones.

Lesson One: Don't assume.

I'll share a personal story. We were with friends in Kansas for a 4th of July BBQ many years ago. They had fashioned a plastic slide to a large above ground pool and all the children were having a blast. My oldest at the time was two.

Knowing what I know-- I parked myself right next to the pool with a soda. Responsible watching people. Sure enough, my daughter goes down the slide and when she hits the pool, she can't gain traction and goes under.

There are several older kids with her in the pool (middle school age) and they happily splash as she is drowning right next to them.

I shudder to think what would have happened had I not been right there.

Remember, above ground pools should be treated like regular swimming pools. They should be fenced off. The fence should not include access from the home.

Lesson Two: Learn the facts. 

Everyone: Please READ this article: Drowning Doesn't Look Like Drowning.

Lesson Three: Know it CAN happen to you or your child. 

Have a SAFE and responsible holiday.

Please-- I don't want to see you in my ER.

Author Question: How Long to Drown to Death?

Kara asks:

I'm a fan of your blog and was hoping you could help me. My current work in progress has a seven-year-old girl die from drowning. After the rest of her family goes inside, she returns back to the pool to retrieve something and then is found minutes later.

My question is two-fold:

1. What is the minimum amount of time a girl that age and of average weight and height would succumb to drowning (assuming she fell & hit her head, then fell into the water.)

2. Physically, what exactly happens when a person drowns? I'm assuming there is a lot more to it than just the lungs filling with water. For example, what would an autopsy show to prove that it was a drowning?

Jordyn says:

I had prepared this post to run long before I got a phone call from a good friend who also happens to be an ER nurse and mother of seven. I don't know what it is about kids and water-- but it draws them like a moth to a flame.

I think personal accounts of situations are good for us to read through as writers because it gives us a glimpse of what it's like to have a moment in another person's shoes. My friend's young son drowned and was subsequently revived with no neurological deficits. This is a MIRACLE and you can read her first hand account of this event here.

Part one of your question-- first thing you need to determine is does she fall into the water unconscious? If so-- she will drown quicker. Versus, if she falls into the water conscious-- she will struggle in the water (you can determine this) before succumbing to the water based upon her ability to swim. Maybe this struggling lasts for 2-3 minutes, then she goes unconscious.

When she goes unconscious, the water will flow into her lungs. When water is in the lungs-- there can no longer be gas exchange. When there is no longer gas exchange, the organs begin to die from lack of oxygen. The most common time frame you'll hear for "brain death" to occur is four minutes.

Now, it would not be all that unusual to revive her at some point after four minutes. We may get a return of her pulse but her brain likely will be past the point of return. So, upon finding her down in the pool, say after 10 minutes of someone last seeing her, you could just have them be unable to revive her at all. That would probably be the easiest way to deal with it. She would likely still be transported to the hospital and worked on because she is a child and pronounced dead at the hospital.

If she is revived-- that's a whole other can of worms you may not want to go into.

As far as what the autopsy would show-- this is an excellent resource I think you should read through. I think it has a lot of what you're looking for.

http://forensicpathologyonline.com/index.php?option=com_content&view=article&id=101&Itemid=125

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Kara Hunt is an inspirational speaker and writer who throughout the years has mentored women on the various aspects of living daily and triumphantly as women of God, despite their past and regardless of their circumstances. Kara’s transparent testimony touches hearts and has helped many women reconnect and refocus on what’s truly important during their spiritual journeys. As Kara ministers out of her own personal experiences, she desires to communicate God’s truth as He reveals it, and wants other women to know that they too can experience God’s merciful and unspeakable joy.

Kara also created the Christian Fiction blog "Fiction With Faith." See her upcoming reviews and news at http://www.kararhunt.com/

Hypothermia or Death by Drowning? The Titanic.

I'm so pleased to host Paula Moldenhauer today at Redwood's Medical Edge. It was 100 years ago that the Titanic sunk and there is still speculation on many fronts. Cause of death of the victims in the water reamains one of them.

What do you think--did those victims die from hypothermia or did they drown?

Welcome Paula!

“For forty-five minutes the eerie, distressed cries reached across the frosty depths, tugging at our very souls. Their words were unintelligible at this distance but not their agony. They cried with decreasing volume as the mass of dying humanity became a crowd, a cluster, and finally a solitary whimper.

The quiet that followed, may the gods help me, brought great relief. At first my tortured ears strained without permission, listening for that one more sound of life, but I knew it would not come. Not from those frozen corpses shrouded in darkness. Not from that bitter grave.

It was finally—mercifully—silent.”

                                                                        Excerpt from Titanic: Legacy of Betrayal

In the historical research for Titanic: Legacy of Betrayal, most first-hand accounts of survivors talked about the horrible sound of the victim's screams that started as a roar and tapered off as those in the water were rendered unconscious or dead. 

Now, one-hundred years later, there is still some dispute over whether the majority of the RMS Titanic’s victims drowned or died from hypothermia.

Paula Moldenhauer

According to the Pacific Yachting Magazine, "Cold water carries heat away from the body 25 times faster than air of the same temperature and as a result, the body core immediately begins to lose heat to the outside environment. At first, the body tries to generate more heat by shivering, but this is not enough to offset the loss of heat to the water. Within 20 to 30 minutes, depending on water temperature, body core temperature drops to below 35° C (95° F) cognitive functioning and judgment become affected. This cooling, if not checked, leads to disorientation, unconsciousness and eventually death."*

Still, most statistics tell us that most people die of drowning, not hypothermia. 

Maybe "Cold Shock," the initial minute or two of exposure to cold water, provides an explanation. It signals a "gasp" reflex, which can cause serious problems if your head is under water. Next, you hyperventilate, your heart races, and blood pressure spikes. It's hard to breathe and panic increases. In some people these symptoms cause cardiac arrest. Even healthy individuals can have difficulty keeping their head above water in such stressful situations!

Kathy Kovach

Cold Shock is followed by Cold Incapacity. During this time, "neuromuscular activity slows and body fluids literally congeal in the muscles."* It becomes increasingly difficult to do anything that requires manual dexterity. Your hands and fingers stop working first, then the deeper tissues of the arms and legs cease operating properly. After ten minutes, they no longer respond to your will. Even experienced swimmers find short swims difficult or impossible. Without proper flotation equipment it is hard to keep your face out of the water and prevent inhalation.

If victims survive the first two stages, hypothermia sets in after 20-30 minutes of exposure. The body's core temperature drops to 95 degrees F. Once hypothermia begins the victim's clothing, body fat, and other factors come into play. On average, there is about another 30 minutes of "useful consciousness" left. 

According to PYC, "During this last period, it is still likely victims will die from drowning, unable to keep their airways above water as they slip into disorientation and unconsciousness. The only victims who actually die of hypothermia are those who have managed to keep their airways above water, even after unconsciousness, by securing themselves to floating wreckage or through the use of self-righting lifejackets."*

Which brings us back to the RMS Titanic. Experts say Titanic’s life jackets kept victims afloat, but were not-self-righting. (You can learn more about this here.) Since survivors report hearing cries for help for 40 minutes to an hour despite the frigid 31 degree water, this seems to indicate that at least some of the victims were able to avoid drowning and succumbed to hypothermia.

Still, despite the obvious fact that that the RMS Titanic victims were in freezing water, the technical cause of death could still be drowning in most cases, as people lost the ability to keep their head above water.

Either way even now, 100 years later, I'm haunted by the thought of almost 1,500 people left in the water, crying for help.

(BTW, Here's what to do to prevent hypothermia according to the Red Cross.)

*The direct quotes were taken from The Chilling Truth About Water. You can also find a chart there that breaks down survival times in cold water.

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Paula Moldenhauer co-authored, Titanic: Legacy of Betrayal, with Kathleen E. Kovach. Author, speaker, and mom of four, Paula has published over 300 times. Her first two novels released in 2012. She serves as the Colorado Coordinator for the American Christian Fiction Writers and homeschools. Paula loves peppermint ice cream and walking barefoot. Her greatest desire is to be close enough to Jesus to breathe His fragrance. Her website offers homeschooling and parenting articles, devotionals, and information about her books. www.paulamoldenhauer.com Visit her on facebook at: http://www.facebook.com/PaulaMoldenhauerAuthor

Remember Me: Use of Amnesia in Fiction

Heidi asks:

My question is, if I have a character that drowns but is revived, could they have temporary amnesia, especially if they hit their head? If so, how long might it last?  A few days? I know Goldie Hawn's character in Overboard gets amnesia after falling off a boat into the water, but I'm not sure how accurate that really is.

Dianna says:

The definition of drowning: A submersion event where a patient is pronounced dead within 24 hours of the event.

 If a patient dies 24 hours post the event, it's called a drowning-related death.

That said, your character did not drown and was then resuscitated. Instead, your character suffered a near-drowning event. In order for it to be referred to as a near-drowning event, the patient must be treated for at least one submersion-related complication. You say your character was resuscitated, so I'm assuming the patient was in cardiac arrest, which would definitely be considered a submersion-related complication.

Detail to consider: How long was the patient in cardiac arrest? In cold water, the mammalian diving reflex can prevent death, even after prolonged submersion (a patient in cardiac arrest can be resuscitated after 30 minutes or even longer).

I'd definitely write in that the character hit their head somehow and then suffered a prolonged cardiac arrest due to the submersion post hitting their head. (Basic background information: If the human body loses its oxygen supply, the heart stops. Since we can't breathe under water, we're unable to in-take oxygen.) If cold water isn't fitting for your story, then lower the cardiac arrest time to 5-10 minutes, which is still long. The amnesia could occur simply from the trauma to the head only. The near-drowning event and long cardiac arrest time could worsen the amnesia.         

Anterograde amnesia: Memory disorder only affecting the retention of new information and events. Example: Patient Jim can only identify his friends, recall their names, retell stories about them ONLY if he knew them BEFORE the amnesia. So, when Patient Jim meets anyone after suffering with amnesia, it doesn't matter how much time he spends with them, next time he sees that person he won't remember them at all.   

Retrograde amnesia -- Memory loss of the past or segments of the past.

Some patients can suffer with both anterograde and retrograde.

Some patients fully recover from amnesia, some don't.

Every patient is truly unique with every medical situation -- how one patient's body responds medically, another patient responds completely different. So, you could write whatever you want (within reason) with amnesia and it would be realistic. Again, every patient is very different.

In Overboard, that character's memory returned in a very realistic manner. What happened was she had a strong visual (her husband) of her past, which triggered her brain to remember her past, and pop her memory returned. Sometimes memory return is gradual, other times it comes all at once. However, the situation with her simply falling into the water and losing consciousness then coming to in the hospital with amnesia is over the top Hollywood. If I remember correctly, the storyline was that the cold water and the experience itself (floating in the ocean for hours), was the cause of amnesia.

Sure, it's possible (again, everyone is different) but not a solid storyline. To me, what that storyline says is the amnesia is an emotional issue (the floating experience, plus not being happy in her life), not a medical issue, which is definitely possible, but they should've highlighted that point. Or, adding in head trauma would've made it an even better story.   

The tricky thing about amnesia (but it's good for writers) is it deals with the brain, an organ us humans will never be able to truly understand like we do all other organs and systems, so we have little knowledge on how or why some things occur or don't occur with: memory, personality, personality disorders, mental illness, etc.     

Medical Question: Submerged Vehicle Part 2/2

We're concluding Mart's question today about treatment of victims that submerged their vehicle into the water. Last post, Dianna covered the EMS response. Today, I'm going to cover emergency department management.

Jordyn (ED Evaluation):

I'm going to start from the point that EMS brings them to the hospital. You say that one patient, Ruby, is conscious. I'm going to assume she had some period of time in the water and assume she was submerged. Yes, we will treat her. We'll be concerned about how much water she inhaled into her lungs. She'll be placed on a monitor that watches the electrical activity of her heart, her respirations, her oxygen level and checks her blood pressure every so often.

PhotoBucket/tomcat12161

If she has a fairly normal respiratory assessment: she's breathing at a normal rate, her breath sounds when listened to with a stethoscope are clear, and she has a good oxygen level we will likely watch her for several hours to make sure these things stay normal. However, if her breathing rate is elevated, her breath sounds indicate fluid might be building up, and/or her oxygen level are low we will escalate her care.

 We would obtain a chest x-ray to look at her lungs. Supplemental oxygen. A blood gas which is a lab test to see how well her lungs are exchanging oxygen. If she is not breathing well on her own then she will be placed on a ventilator. This is a good medical overview: http://emedicine.medscape.com/article/908677-overview

Patients that are brought in unconscious and without pulse or breathing are essentially dead. It depends a lot on what we get from the EMS crew as to whether or not we will "work" the patient... meaning try to save their life by doing CPR, etc. If EMS says, “we saw the kid go in the water and we got him out quickly”-- we'll probably work that patient for awhile. A patient that is submerged when found with an unknown downtime, no pulse, no breathing, and has a normal body temperature may not be worked at all.

If the patient comes in with no pulse, no breathing and is hypothermic or has a low body temperature, it will be up to the physician whether or not to try and save them. There's this saying in medicine: “you have to be warm and dead”. Many times, we'll try and correct hypothermia to see if this will bring the patient back to life, particularly in cold water drowning.

If the patient is brought to the hospital but dies, the presiding ED doctor will declare death. However, if an autopsy is going to be done, then law enforcement/coroner's office will take possession of the body.

It is possible to come in and be in a coma. This means that you have a pulse but may or may not be breathing. If you have a pulse and are not breathing, we will do that for you by putting you on a ventilator. Whether or not a person comes out of a coma depends on a myriad of factors and writers have a lot of latitude here. The person could wake up. The person could be in a persistent vegetative state on life support for the writer's determined amount of time. The person could progress to brain death and be legally declared dead while still on a ventilator. Or, they could simply die from complications. The sister in the coma will be admitted to the ICU on life support until one of these four things plays out.

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Martha Ramirez has enjoyed writing stories, poetry, and drawing since childhood. Her first children's book entitled The Fabulous Adventures of Fred the Frog was created and inspired by the curiosity and fascination her toddler has with books. Writing continues to be her passion as she strives to create stories children will love as well as learn from.

She is a reviewer for Bookpleasures and a member of YALITCHAT, ACFW (American Christian Fiction Writers), the Muse Conference Board, CataNetwork Writers, American Author's Association, and CWGI (Christian Writers Group International).  She has written articles for Hot Moms Club, Vision, and For Her Information (FHI) magazine. Martha is looking forward to starting new projects and is excited to write in a new genre. She resides with her husband and son in Northern California where she is currently at work on a new series to a YA novel.

Visit her website/blog at: http://www.blogger.com/www.martzbookz.com, http://www.blogger.com/www.martzbookz.blogspot.com%20.

Medical Question: Submerged Vehicle Part 1/2

Mart asks a fairly detailed medical question so I'm going to split this post up over two days. Today, our resident EMS expert, Dianna Benson, will offer the EMS response. Next post, I'll cover the emergency department treatment.

Mart asks:

This is the scenario:

Ruby, Gio and their parents are in a car that submerges in the river.

 Some of the things I need to know:

1.      What happens when paramedics get to them?

2.      Do they do CPR and if so for how long (with no pulse of a drowning victim and one that has a pulse but ends up being in a coma)

3.      Who declares them dead?

I've read that it depends on the state. Sometimes the doctor does. This takes place in NY. Ruby is the only one conscious. Do they treat her in any way? What happens to her sister if she is in a coma? Is that possible? What happens to her dead parents?

Dianna(EMS Response):

Clinical Definitions:

Drowning: An incident in which a victim has been submerged in water and dies within 24 hours of submersion.

 

Photobucket/Moonstruck1977

 Near-drowning: An incident in which a victim has suffered a submersion but has not died or dies more than 24 hours after the incident. A near-drowning patient must be treated for at least one submersion-related complication or it’s not considered a near-drowning.

Submersion: An incident where a victim is submerged in water and requires some type of emergency care due to the submersion.

When we (EMS) are dispatched to a water-related emergency, we often suspect a possible spinal injury. In the case of a car landing in water somehow, we’d definitely take spinal precautions, and thus apply a neck collar and strap the patient onto a backboard while the patient is still in the water.

Cold water and warm water emergencies are different. If a victim goes into cardiac arrest in cold water (68 degrees or colder), the mammalian diving reflex may prevent death even after prolonged submersion (even 30 minutes)  – a body could be frozen in cold water temperatures to the point all the systems go into a hibernation-like state.

 Firefighters do not extricate victims from submerged vehicles unless they are trained in water extrication. I’m a scuba diver and trained in water extrication, so when I arrive on scene of a water-related incident, I’d be one of the emergency crew members extricating. Emergency crews include: firefighters, EMS, law enforcement, forest ranger, etc. However, if no one on the scene is trained in water extrication, then whoever is there improvises until someone with training arrives, but risking your own life in ways you’re not trained for causes more chaos to the situation.

PhotoBucket/firefighter8069

A dry team works on shore and a wet team is in the water extricating (removing from vehicle) and immobilizing (collar and backboarding) the patient. The wet team doesn’t just jump in the water (unless it’s safe for us to do so) – we throw the victim a floating device and pull them to the boat we’re in, or dock, or shore (or whatever).

For EMS – we first focus on a patient’s airway, breathing, circulation, and any hemorrhaging issues (bleeding). If Ruby is breathing efficiently, if she has a solid pulse, if she's A&O X 4 (alert and oriented times four), and if she’s not hemorrhaging anywhere, then she’s a stable patient. Submersion patients can develop complications that lead to death even after 72 hours post incident, so EMS transports ALL submersion patients, so Ruby would be transported as a stable patient.      

On-scene the sister would be considered unconscious (not in a comma). As a writer, you can make the situation be whatever you want, so if you want the sister to be in serious condition, have her respiratory system either be failing or have her be in respiratory arrest with a rapid pulse when EMS arrives. I’ve seen a MVC – motor vehicle collision – where in the same car four people died and one person didn’t. I’ve seen an airline crash where two dozen people survived the crash, hundreds of people died on impact, and of the two dozen who survived the impact most died within an hour or so of the crash. So, whatever you write is believable if you make the details of the “after the incident” believable.  

EMS can “call it” – meaning, we can determine if a patient is dead and we can either stop resuscitation attempts or not initiate them. Every county within each state has different protocols (and criteria to follow) on calling death, but they’re all similar. So, you can certainly have EMS “call it”, and that would increase your tension, especially for Ruby, instead of waiting for the ME to arrive on scene. For fiction, there’s no reason to wait for the ME; just have EMS do it. 

For Ruby: We’d insert an IV line and place her on oxygen at 2 liters per minute via a nasal cannula and we’d monitor her. If she’s stable, we’d retake vital signs every 15 minutes en route to the hospital. If she’s not stable, we’d retake vital signs every 5 minutes en route. We’d place a 12-lead on her (cardiac monitor/defibrillator) to obtain her heart rhythm and to monitor her cardiac functions. We’d inject meds depending on her situation and needs.

 For the sister: We’d insert an IV line and inject meds as needed. We’d place her on O2 via a NRB at 15 lmp. We’d place 12-leads on her as well to do the same as I stated above. We’d retake vital signs every 5 minutes and transport her to a trauma center, possibly via a flight for life helicopter.

Any other thoughts for Mart?

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