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It has certainly been an exciting past few weeks in the drowning community. In addition to the release of the 2015 International Liaison Committee on Resuscitation (ILCOR) guidelines, the 2015 World Conference on Drowning Prevention (WCDP) has just concluded in Penang Malaysia. I will discuss both of these and provide the highlights.

The American Heart Association (AHA), European Resuscitation Council (ERC), and other like agencies adapt the ILCOR recommendations in their own national guidelines. The biggest update to the AHA guidelines with regard to drowning was the issue of Search and Rescue (SAR) versus Search and Recovery. If we had unlimited resources, hope, and safety, we would like to think that our professional and volunteer rescuers could search for drowning patients for an unlimited amount of time. The reality is that weather conditions, rescuer fatigue, water conditions, likelihood of patient survival, and financial resources are all factors that must be considered in determining whether or not to commit rescuers to a SAR operation instead of downscaling resources and transitioning to recovery.

The evidence-based guidelines put forth by ILCOR and adopted by the AHA recommend that submersion time alone predicts survival. Because of the difficulty in bystanders accurately recalling time, submersion time starts when the first professional rescuers arrive. For patients with submersion times less than five minutes, 86 percent have a good outcome; for those with less than 10 minutes submersion, 77 percent have a good outcome. In patients with a known submersion time of greater than 10 minutes, only 4 percent have a good outcome. Patients with submersion times of 15-25 minutes show widely varied survival, and times greater than 25 minutes show nearly universal poor outcomes. There was no prediction of survival based on age, water temperature, salinity, EMS response time, or whether bystanders witnessed the drowning incident. The guidelines specifically note that they did not include the case reports of prolonged survival in very cold water. One such model that includes these case reports is the United Kingdom Fire and Rescue Services National Operational Guidance Programme. The model is designed to give casualties every reasonable chance of rescue and resuscitation and is balanced against the risk of harm to responders when carrying out rescues.


Fig. 1– Water Rescue and flooding Dynamic Risk Assessment (DRA) model for responding agencies. Source – https://fireandrescue-public.sharepoint.com/Pages/Guidance-Catalogue.aspx?guidanceid=65

These evidence-based guidelines highlight the complex technical, emotional, and human challenges facing search and rescue agencies. Every SAR operation is unique, and the guidelines should serve as a starting point for those tasked with planning and executing these complex events.

While I usually wouldn't mention the European Resuscitation Council (ERC) Guidelines, I am very impressed with their aggressive stance on drowning resuscitation and emphasis on the importance of giving rescue breaths early. For responders with a duty to act, the first step is to give five rescue breaths, chest compressions if no signs of life, then apply the AED. (Figure 2) The AHA Guidelines for professional rescuers start with two rescue breaths, followed by checking for a pulse, then chest compressions. This may seem like a small difference, but the rationale for giving five breaths is to interrupt the drowning process by getting more oxygen to the brain as quickly as possible. The drowning patient may have vomit, foam, or other obstructions in the airway, so it may take more than two breaths to effectively deliver oxygen. Giving five initial breaths may also help the rescuer focus on the importance of reversing hypoxia before going right into chest compressions. The ERC guidelines reinforce that drowning resuscitation must be approached differently from other causes of cardiac arrest.

Fig 2 - Drowning treatment algorithm for rescuers with a duty to respond from 2015 ERC Guidelines.

The overarching theme of the WCDP 2015 was one bridging communities to prevent drowning. Based on the World Health Organization's (WHO)  "Global Report on Drowning: Preventing a Leading Killer," we know that 91 percent of drowning deaths occur in low and middle-income countries. The report outlines strategies for what can be done to address these preventable deaths. One of the items included in the "Ten Actions to Prevent Drowning" is to "coordinate drowning prevention efforts with those of other sectors and agendas." This may seem simple at the surface, but it is clear that we must work together with new and ever-evolving partners if we truly want to achieve our goal of zero fatal and non fatal drowning incidents worldwide. We must acknowledge that the traditional approach that we have taken to drowning prevention can be improved upon if we allow collaboration outside of our traditional circles. This means that lifeguards, EMS and rescue agencies, and national and regional lifesaving agencies must look beyond their own walls and collaborate with new partners. These include public health, disaster, healthcare, emergency management, tourism, risk management, climate change, refugee, tourism, human rights, maritime, agricultural, and many others.

Many of those in the wilderness medicine community have ties to these and other sectors that can provide ideas, financing, and other resources to stop drowning. I invite you all to take a fresh look and think outside the box as you interact with these sectors. The report concludes, "Time to act on a preventable killer. Drowning is a leading global killer, particularly among children and young adults. It is preventable but neglected relative to its impact on families, communities, and livelihoods." If you are interested in reading more about the "Ten Actions to Prevent Drowning," the report can be found here.

Though the available evidence on our practices in the drowning community is limited, it is starting to grow. It is an exciting time to be involved in drowning research, prevention, rescue, and treatment. Whether it is in the SAR, lifeguarding, public health, industrial, or other sectors, we must break down barriers to collaboration and commit ourselves to a world free from drowning. Stay safe out there!