Fiona Garlich MD Mel Herbert MD and Stuart Swadron MD
Print editor: Whitney Johnson MD MS
Take Home Points
- Performing CPR in the field has a variety of challenges compared to resuscitations in the emergency department.
- Crowd control and scene management are important.
- Most people have never seen a cardiac arrest and the aftermath.
- Dry off drowning patients prior to defibrillation as water will attenuate the current.
- Garlich is an attending physician in emergency medicine at LAC+USC. She was at the pool with her two children aged 3 and 5, who were taking swim classes at the local community center. This was a busy pool with multiple lifeguards on different chairs. She heard a loud whistle and saw the lifeguard jump into the water. An adult male was pulled to the surface and onto the edge of the pool. It was instantly apparent that this was not a good situation. She dropped her bags, ran to the side of the pool and met them at the edge.
- She introduced herself as a physician and helped pull him out. He was cyanotic and apneic. He was not moving spontaneously. There were no pulses. She started compressions within 2 seconds of him being pulled out of the pool. With the first compression, water and white foam started pouring from his nose and open mouth. With every compression, more and more water came out.
- Garlich realized that she had never been in a situation like this before. She wasn’t exactly sure what to do. She did not have suction. Another lifeguard arrived with a one-way valve mask and started ventilation. After a period of time, they stopped, did a pulse check, found nothing and resumed CPR. Then after another period of time, the victim seemed like he was moving and was trying to breath. They stopped compressions but it was not clear if there was a pulse present. Compressions were resumed. A few minutes later, the victim regained spontaneous respirations and a pulse.
- They rolled him on his side because there was an incredible amount of liquid, foam and emesis coming out. Garlich was sweeping his mouth with her ungloved hand. An oxygen tank arrived. They placed an oxygen mask over his face and continued to intermittently clear secretions.
- The victim started to wake up. He was moaning and moving his extremities non-purposefully. He was not responding to commands. He remained that way for the next few minutes until paramedics arrived. A rescuer was bitten as they attempted to clear his secretions.
- Garlich gave a report to EMS and they transported him away on a gurney.
- It was chaos. His children (ages 7 and 9) were screaming. He was at the pool with his children for their swim lessons and was doing free swim with them. He was the only parent with them. Hearing the screams of his children was the most intense aspect. “Daddy, wake up! Daddy, wake up!” was really hard to hear.
- Garlich realized that her own children were watching her. She was doing compressions, looked back and saw her three year old standing there watching her with her mouth agape.
- Was anyone doing crowd control? Next time, Garlich would do more active scene management. At the time, she was not confident that there was anyone else there who could do compressions. There was another doctor there as well as a nurse so she probably could have taken a step back. However, it all happened so quickly. She was not fatigued and wanted to stay involved. She assumed that the pool managers and lifeguards were managing the crowd. After the patient was transported, she realized that the children at the pool had been moved to a different area and there were a few adults looking on.
- The other physician was a psychiatrist. Although he was not participating in the resuscitation, he helped retrieve the oxygen and control the crowd. However, he was instrumental in debriefing the children afterwards. He was amazing. This was one of the most important parts of the event. When the wife of the victim arrived, Garlich checked in with her. This was such a traumatic event for everyone; the children, the wife, the lifeguards (who likely had never been involved in an actual drowning) and people at the pool. Garlich realized that she was probably the only person in the pool complex who had previously seen a patient in cardiac arrest and the aftermath.
- This was an incredibly intense experience. Garlich processed it a lot over the next few days. She did a lot of reading and reflection. It is an incredible reminder of how easily drowning can happen. This man drowned in 3 feet of water in a kiddie pool surrounded by people with a lifeguard 15 feet away. It happened fast. He essentially died with people right there monitoring for drowning.
- The patient liked to see how long he could hold his breath underwater. He may have passed out or taken an involuntary breath.
- What could have gone better?
- In drowning victims, oxygenate first. Most of these arrests occur due to hypoxia.
- Perform CPR with breaks to give respirations. Do 30 compressions followed by 2 rescue breaths.
- There was a tremendous amount of secretions coming from the mouth. You could consider briefly turning the patient onto their side.
- It is rare to have a C-spine injury (less than 1%) but it is a good idea to keep potential C-spine injuries in mind.
- Should you use an AED or defibrillation? There is not much evidence, but it makes sense to move the patient to a dry place and dry them off. The problem with water is not that you are going to get zapped but rather that it diffuses the current rapidly and the current is less efficient. Try to dry the chest area. It is probably okay if they are lying in a small amount of water.
- Depending on how long the patient is down, they may be cold. You should do your resuscitation and rewarm them and not call the code until they are warmed up. In most cases, this will be the paramedics unless you are in a rural remote setting. Sometimes if they are truly dead, you will never warm them up and you will need to stop.
- There is a big difference between running a code in a hospital versus outside of your comfort zone and in front of your children. This was a very intense emotionally draining event. We are used to seeing crazy things happen and people die and we move on to the next patient. Garlich tried to move on. Her kids did not understand why they could not get back in the pool. The pool was reopened so she got back in with the kids. It took her several days to process the event emotionally. She processed it intellectually by reading and thinking about what she could have done differently. Processing it emotionally was a different story. It is important to recognize the emotional impact. Give yourself space to have some feelings. We are human. This is emotionally devastating and you need to acknowledge it.
- What happened? On the way home, Garlich called the local hospital and spoke to the physician. The man was awake and talking with his family. However, he was hypoxic, had significant pulmonary injury and was on high-flow O2. He was going to be admitted to the ICU.
Edward W. - May 18, 2020 10:06 AM
If he had hyperventilated prior to breath-holding that would increase his risk of hypoxia and passing out underwater.