APPENDIX A: DROWNING PREVENTION FOR MILITARY PROVIDERS

GENERAL PREVENTION

- Respect the power of moving water and debilitating effects of cold water on the body.1-3 The effects of fast-moving water can be devastating for swimmers of all skill levels.
- Wear a personal flotation device (PFD) and have a PFD available for every person.1-2,4
- Huddle – if in a group, everyone faces inward and huddle with arms interlocked.
- Get as much of body out of the water as possible (e.g., climb onto submerged boat) to reduce detrimental hypothermic effects of cold-water exposure.1-2,5
- Learn to swim, tread water, or float (not a substitute for PFD) and always swim with others.
- Have a well-developed safety and rescue plan that is exercised and practiced routinely.1-2
- Be aware of the behavior of submerging vehicles.
- Average vehicle takes 30 seconds to 2 minutes to sink.
- Once even partially submerged, windows and doors can be nearly impossible to open or kick out.
- Vehicle escape procedure SWOC: 6
  - Seatbelts off
  - Windows open
  - Out immediately
  - Children first

COLD WATER IMMERSION/SELF AID

- Sudden immersion in cold water ( < 91.4°F/33 °C) causes panic and reflexive gasp for air and rapid breathing which results in increased risk of aspiration, dysrhythmias.
- Prolonged exposure to cold water rapidly leads to incapacitation with diminished strength and coordination.1,15,7,2,3,5,8,9
- Follow the above instructions for escaping a vehicle (if warranted).
- Limiting time of exposure is critical. A general timeline is provided for guidance below with expected survival times listed in Table 1 at the beginning of CPG.
- Control breathing in order to survive shock of exposure during the initial one minute.
- Within 10 minutes, exposed individuals will become incapacitated and thus must move judiciously during this time. If able to reach and maintain control of the ice, the victim should hold on to the edge of the ice, kick his/her feet to become horizontal and pull. See ice rescue training images (Figure 4).
- Incapacitated individuals will generally become unresponsive due to hypothermia within the first hour.
- Onset of lethal dysrhythmia can occur within the first 2 hours.
- If a flotation device is available, exposed individuals should assume the “HELP” position (heat escape lessening posture) (Figure 5.) by bringing the knees to the chest and crossing the arms over them. Alternatively, in a group, the "huddle” position (Figure 5.) should be used.1-2

Figure 4. Ice rescue training

RESCUE AND IN-WATER RESUSCITATION

**Please note this is placed as an appendix based on standard international recommendations. This does not take the place of standard unit military training.**

- Identify and locate the victim (ask if there are more than one).1-2
- Victims are often seen motionless, sinking slightly below the surface.
- They may submerge into the water and never surface.

GOALS

- Initially the type of water does NOT matter (salt, fresh, clean, dirty).1-2
- Alert advanced life support as soon as possible.
- Accurately record environmental conditions including time of submersion, type and temperature of water and air, scuba diver (depth, time at depth, type of dive rig).
- As a clinical provider, if you find yourself being a rescuer, don’t become a victim. If you are being deployed on a Naval vessel – ensure you have taken all the courses about rescue swimming. Rescuer safety is a priority. Untrained rescuers or weaker swimmers should utilize alternative means of rescue such as the use of flotation devices, ropes, or paddles. Options for rescue include but are not limited to the following: 1-2,10

1. 1. Reach with an object from the safety of the shore or ship.
   2. Throw an object like a rope or flotation devices (this may help the victim stay afloat or the search and rescue team locate the victim.)
   3. Row (or paddle) a smaller craft to the victim if they are too far from shore to reach or have a floatation device thrown. The rescuer should ideally stay out of the water.
   4. Tow them into shore or away from danger in the water (i.e. swift water rescue).
   5. Go into the water (as a last resort) to rescue the victim if this is within the rescuer’s skill set.

- In water rescue, breaths should only be done when rapid extraction is NOT feasible. In water, chest compressions are NOT effective and should not be attempted. 1,11,12,16,
- Cervical spine injury in drowning victims is low (0.009%). Unnecessary cervical spine immobilization can impede delivery of rescue breaths via time of application and reduced airway opening. Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury (diving, boat accident, and fall from height) is not recommended. If suspected, protect cervical spine by assuming neck injury (use jaw thrust to open the airway and utilize C-Collar when feasible).1-3,9,17
- Hypothermic patients rescued from cold water are prone to lethal dysrhythmias (ventricular fibrillation). Patients should be handled as gently as possible to include the performance of life saving procedures (e.g., intubations) as these may precipitate dysrhythmias. Priority remains oxygenation, ventilation, and restoring circulation. 13

Figure 5. HELP and Huddle positions 14

References

1. Auerbach’s Wilderness Medicine, 7th Edition, Paul S. Auerbach, Drowning and submersion injuries (Chapter 69) (2016).
2. NOLS Wilderness Medicine, 6th Edition, 2007. Tod Schimelpfenig, Drowning and cold-water immersion (Chap 14).
3. Wilderness Medical Society practice guidelines for the prevention and treatment of drowning, 2016: 236-251.
4. PFD Selection, Use, Wear & Care, available at https://www.dco.uscg.mil.
5. S. Search and Rescue Task Force, Cold water survival (available at http://ussartf.org).
6. Giesbrecht GG, McDonald GK. My car is sinking: automobile submersion, lessons in vehicle escape. Aviat Space Environ Med. 2010 Aug;81(8):779-84.
7. Global report on drowning: preventing a leading killer, World Health Organization, Nov 17, 2014.
8. Ashley D. GMO Manual: A medical reference for the operational medical officer 4th Edition, Submersion injuries.
9. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 9: Post–Cardiac Arrest Care. Circulation. 2010;122:S768–S786.
10. 2020 American Heart Association Guidelines for CPR and ECC.
11. American Red Cross Life Guarding Manual 2017.
12. Bennett and Elliotts' Physiology and Medicine of Diving, 5th Edition, 2003. Chapter 6: Drowning and Nearly Drowning.
13. European Resuscitation Council. Advanced challenges in resuscitation. Section 3: special challenges in ECC. 3F: cardiac arrest associated with pregnancy. Resuscitation. 2000 Aug 23;46(1-3):293-5.
14. 2014 Videos of the Year: Ice Rescue Training (YouTube).
15. US Navy Diving Manual, Rev 7, Commander Naval Sea Systems Command (2016) Drowning/Near-drowning (Chap 3-5.4).
16. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. N Engl J Med. 2012 May 31;366(22):2102-10.
17. Williams VF, Oh GT, Stahlman S. Update: Accidental drownings and near drownings, active component, U.S. Armed Forces, 2013-2017. MSMR. 2018 Sep;25(9):15-19. PMID: 30272989.