Cold Water Drowning
“You’re not dead until you’re warm and dead.”
This is another of several Watoga Trail Reports that will shine the spotlight on individuals who have made significant contributions to humanity. These are people who remain relatively unknown to most of us. In our star-struck society, we often overlook the quiet and persistent in favor of the loud and glamorous.
These dispatches pay respect to those who have dedicated their lives to making our world a safer and more interesting place to live.
Today, we shine the light on a doctor whose resolve and uncommon intelligence has saved many lives. He has also made us aware of our body’s remarkable abilities to protect us in extreme environments.
Imagine now that you have pulled your car off the main park road to take a picture of Watoga Lake covered in ice. In this beautiful setting of the frozen lake ringed by snow-draped trees, a lone person in the middle of the lake is fishing through a hole in the ice. A Kodak moment to be sure; you reach for your camera.*
Imagine further that you see this individual suddenly break through the ice and disappear under the water. Your heart races, and your first aid training tells you that this person must be rescued within a few minutes so you run for help. A rescue group arrives some 30 minutes later and pulls a young woman out of the deep cold water.
Conventional wisdom tells you that the victim is unlikely to survive for more than four minutes underwater without brain damage – even in the unlikely event she is successfully resuscitated. You look down at the victim, and she shows no visible signs of life.
What can these emergency responders be expected to do now?
Let’s stop the action in our mind-movie and go back in time to the late 1970s. If this tragic drowning took place before 1977, no attempt would likely be made to resuscitate a victim submerged for 30 minutes with no detectable pulse and respiration. The victim would be pronounced dead and removed from the scene.
After 1977, the outcome may have been entirely different. So start up your mind- movie again and return to the drowning scene at Watoga Lake. This time instead of writing the ice angler off as dead, you watch the EMTs immediately start CPR. Without attempting aggressive rewarming, they transport the victim to the hospital ASAP.
Why the different treatment protocol after 1977?
In 1977, one doctor stepped forward to challenge the long-held assumption that brain damage should be expected if someone is underwater for more than four minutes.
Unless you have attended a wilderness medicine seminar or one of his lectures, you may not know the name, Martin Nemiroff.
Dr. Nemiroff was a professor of pulmonary internal medicine at the University of Michigan Medical School in 1977.
While there, he pursued an idea that would forever change the way drownings would be treated by first responders and hospital emergency staff alike.
Dr. Nemiroff graduated from the University of Michigan Summa Cum Laude and Phi Beta Kappa. He then went on to graduate Alpha Omega Alpha from the University of Michigan Medical School. He was, by all measures, a brilliant man.
It occurred to Dr. Nemiroff that the physiological mechanism permitting air-breathing mammals like dolphins to stay underwater for extended periods may also be active in humans.
And indeed, he was correct.
Although humans may not employ the same physiological responses as diving mammals, we have a similar protective mechanism. Mammalian Diving Reflex in dolphins, otters and seals has been studied and understood since the 1930s.
The term Cold Protective Response is used when referring to the human physiological response to total immersion. This response is more likely when the entire body, including the face, is underwater. As well, the response is much stronger in cold water and in younger humans.
To test his theory, Dr. Nemiroff requested that hospital emergency personnel in the area around the University of Michigan contact him whenever a drowning victim was brought into the emergency room. Particularly if the victim had been recovered from cold water.
Cold water has subsequently been defined as water below 70 degrees Fahrenheit for purposes of medical treatment.
One of his first cases involved an 18-year-old Michigan student who “borrowed” the family car. The highways were icy, and he slid off the road in a curve and out onto a frozen pond. The ice broke, plunging the vehicle and its male occupant to the bottom of the pond.
A nearby resident witnessed the accident and called in the emergency. A dive team arrived within 30 minutes and pulled the young man from the submerged vehicle.
The victim had been underwater for a total of 38 minutes. There was no detectable pulse; the body was blue with no vital signs. He was pronounced dead at the scene.
As the body was carried to a waiting hearse, a rookie emergency technician mistook an “agonal belch” as a sign of life and started CPR. **
Having been notified, Dr. Nemiroff was waiting at the hospital when the victim arrived. A plan for a controlled rewarming and maintenance of vitals was immediately put into action.
Two weeks later, the victim returned to his college classes. As for brain damage, he continued his studies with straight A grades.
What is this treatment that can save the lives of cold water drowning victims?
Before we can understand how the treatment works, we must examine how the body responds to total immersion in cold water.
Here are the basics.
The initial response of the body to being submerged in cold water is to override the normal homeostatic reflexes. A homeostatic state is one that is steady and working at optimal functioning, i.e., blood pressure, heart rate, fluid balance, etc.
Within seconds the metabolism slows down dramatically. The heart rate may drop to just a few beats per minute, making it difficult for a first responder to detect a pulse.
Simultaneous vasoconstriction in the skin and extremities effectively reduces heat loss from the body’s core. This results in the pooling of colder blood in the extremities while at the same time keeping the warmer blood closer to the heart.
Our body orchestrates this complex response as a desperate, but often effective means of extending our viability.
Now, the medical treatment.
Treatment protocols have varied through the years and from hospital to hospital. But slow rewarming was recognized as necessary to a successful recovery early on. A severely hypothermic patient can go into a state called “rewarming shock” if rewarmed too quickly, often resulting in ventricular fibrillation or cardiac arrest.
Methods of slow rewarming, one-degree Celsius per hour on average, range from peritoneal lavage with warm saline solution to the use of a kidney dialysis machine to rewarm the blood.
The key, as Dr. Nemiroff knew, was rewarming at a slow rate so as not to trigger the cold blood returning from the extremities too quickly as well as overwhelming the brain.
Survival is dependent on keeping the brain cool until the heart and vascular system are stabilized.
Educating first responders to initiate CPR in the field is paramount to keeping the victim alive. They should refrain from any aggressive forms of rewarming other than preventing any further heat loss. This is generally accomplished by removing wet clothing and wrapping the victim in a blanket.
As of 2014, victims have survived cold water drowning after being submerged for as long as two hours.
There are many people walking about today thanks to Dr. Martin Nemiroff.
I had the distinct pleasure of cross-country skiing with Dr. Nemiroff in 1978. I found him an affable man with a wonderful sense of humor and exceptionally generous in sharing his cutting-edge knowledge about hypothermia and cold water drowning.
In 1980, Dr. Nemiroff joined the U.S. Public Health Service and was attached to the U.S. Coast Guard where he was a flight surgeon and aircraft crash investigator in Alaska and northern Michigan.
He devoted his entire career to preventing loss of life in cold environments. Dr. Nemiroff received numerous awards and citations for many successful search and rescue cases. He continues to be internationally recognized as an expert in hypothermia and cold water drowning.
Dr. Martin Nemiroff left our world on November 28, 2018.
Postscript: There is always the danger of cold water drowning while ice fishing. Ice is notoriously unpredictable and can become unstable quickly. I urge you to have a personal flotation device (PFD) readily accessible anytime you are out on the ice.
I have witnessed children running around on the ice at Watoga Lake on several occasions. Parents, please, I implore you to make sure those youngsters are wearing a Coast Guard approved lifesaving device at all times when on ice or around water.
* There was a time when a camera and a phone were two separate things – Kodak was a name brand camera.
** “Agonal Belch” is an involuntary release of gas from the stomach, sometimes post mortem.
New York Times, Theory on Drowning 1977
Sonoma Index Tribune 2018