REPORT #2: REALITY CHECK
By Doug Forbes
Orchard Beach, New York. (Photo source and date unknown)
Dr. Francesco “Frank” Pia was only 16 years old when he became a lifeguard stationed at Orchard Beach in the Bronx, New York, a bay-side borough where tricky tides ruled the day. Pia said he helped rescue more than 2,000 people that year - 1959.
More than 60 years later, he remains in New York, he continues to work in drowning prevention and he implores adults to consider a simple proposition.
“There is a difference between a lack of supervision and a lapse in supervision,” Pia said. “At some point in time, an adult is going to make an error. It’s about setting up [drowning prevention] systems to cover for that lapse in supervision.”
Pia said that lifeguards are not babysitters nor substitute family members. A lifeguard’s fundamental duty is to prevent drowning. Parents and caregivers are ultimately responsible for close and constant care of the children in their charge.
Pia’s legacy is formidable. In addition to contributing to a multitude of drowning-related research, developing lifeguard rescue techniques and producing a 1970 game-changing educational film titled The Reasons People Drown, Pia also devised the Instinctive Drowning Response (IDR), a widely adopted definition of the phased manner by which drowning victims fight for their lives.
BELOW
LEFT: The 77-year-old Dr. Frank Pia describes the event more than five decades ago that affected him so deeply as a very young man that it altered the course of his life. RIGHT: Trailer for THE REASONS PEOPLE DROWN, a groundbreaking educational film.
Drowning is QUIET.
Drowning is QUICK.
Drowning is sadly CONVENTIONAL.
And drowning is an EPIDEMIC.
Countless worldwide aquatics experts like Pia deploy the same messages to civic gatekeepers and corporate chiefs, lifeguards and legislators, mothers and fathers:
Ignore the theatrical splash-and-scream drowning depicted on television or in movies. It simply isn’t accurate.
From Orchard Beach in the 1960’s to Long Beach, California, today, drowning has not changed.
Victims either live or die. Some escape unharmed, except for the memories that shadow them ad infinitum.
Others survive with maladies ranging from slight, reversible motor skill or cognitive delays to catastrophic impairments requiring round-the-clock care at a price that few can afford.
Conversations about drowning causation and consequence often lurk in murky waters.
Adults whose children drown commonly disappear into grief or deflect accountability were they present at the time of death or injury. Unfortunately, these responses limit critical epidemiological assessment.
“It’s enormously difficult,” said Dr. Chris Thurber, a Harvard and UCLA-trained psychologist and water safety expert.
“How would we get people to have those conversations? By seeing that they’re not the first ones and seeing the courage that it takes to engage in those conversations is paid forward in the form of many more lives saved or accidents averted.”
According to a Safe Kids Worldwide study, more than 80% of children drown in the presence of nearby adults. Yet, only one percent of parents consider drowning a home safety concern.
The quandary is how to augment drowning research and transform it into candid awareness efforts that impel communities to adopt lifesaving habits.
Thurber said, “How do we get people there if they don’t have a clear understanding of the magnitude of responsibility? If properly contextualized in a professional course, seeing footage of real people in drowning situations isn’t gratuitous at all – no more than it would be gratuitous for someone training to be a cardiothoracic surgeon to watch someone being defibrillated.”
And while candid assessments of deadly outcomes are complex, if not grim, they nonetheless build critical steps toward elimination.
The first step is to understand what drowning is.
According to Healthline, 200 million people visit their site monthly, despite the fact that they use improper terminology such as “near drowning” and incorrectly describe oxygen deprivation in children.
According to their 2016 research study on prevention and treatment of drowning, doctors Timothy Mott and Kelly Latimer said, “Despite this significant health burden, public health initiatives have lagged because of a lack of standardization in definitions and reporting.”
Mott and Latimer said that 33 different definitions of drowning existed before the World Congress on Drowning was first convened.
Fervent prevention advocates eager to slay this preventable injury giant must realize that drowning did not even have an official definition until The World Health Organization finally etched one in stone in 2002:
Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity and no morbidity.
Fatal and non-fatal submersions or drownings are also commonly accepted terms. However, private and public sectors continue to propound specious terms, including “near drowning” and “dry drowning.”
For example, the internationally renowned Mt. Sinai Health System dedicates a web page to near drowning. Popular health information site Healthline does the same for dry drowning and secondary drowning. And the broadly circulated magazine Parents, offers a confusing hybrid of this incorrect terminology, known as “secondary drowning.”
Channel 11 News in Wichita, Kansas, erroneously reported that a 1-year-old at a Disney water park in 2019 suffered serious effects of dry drowning. Dr. Amy Seery, a Witchita pediatrician, failed to correct the record, She said the girl’s symptoms were a “secondary effect.”
Full disclosure: The coroner who evaluated my 6-year-old daughter Roxie – following her 2019 drowning at a Los Angeles County summer camp – improperly cited her cause of death as “near drowning.” This classification was used solely to convey that doctors artificially restored Roxie’s heartbeat after a 40-minute cardiac arrest and irreversible brain death.
Los Angeles County is the most populous county in the nation. Since this region fails to correctly define drownings, data aggregation and assessment efforts are thereby compromised. It is nearly impossible to determine the extent of that compromise nationwide.
This is far from the only roadblock, however. The medical community is also stifled by a dearth of drowning-related research. Limited understanding of the physiological effects of drowning impacts medical interventions and muddies the ways by which we generally perceive and discuss the drowning process.
In 2016, drowning researcher and professor in emergency and disaster medicine, Dr. Joost Bierens, co-authored a report titled “Physiology of Drowning: A Review.” He said, “Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival.”
According to the report, even triathletes experience submersion panic in the swimming section of the race, to a degree that it either disables them or forces them back ashore. Recreational swimmers experience the same panic phenomena as “frightening thoughts” trigger sensory deprivation and irrational cognition.
Victims subsequently endure phased physiological events.
Panic activates desperate downward pressing arm motions, otherwise known by lifeguards as climbing the invisible ladder.
Reduced buoyancy and an inability to speak settle in. Breath-holding commences once the face bobbles under and over the water line.
Some victims choose to dive under water, as if there were no other option but to seek another way out of the chaos. This is known as the diving response.
Oxygen starvation, or apnea, commences within seconds of submersion. A minute or so later, the body’s tissue and organs begin to suffer the effects of such starvation – a condition known as hypoxia, which can manifest as shriveled, bluish skin but also affects both the brain and heart.
Full cardiac arrest ordinarily occurs with the onset of brain hypoxia or low levels of oxygen in the blood, known as hypoxemia. However, drowning victims who resort to extended breath-holding can first experience accelerated hear rate, or tachycardia, followed by excessively slow heart rate known as bradycardia.
According to Bierens’ report, other breathing impairments can take effect, including laryngospasm. “Although there is ongoing discussion about the existence of laryngospasm during drowning, it will only be protective in those few patients where the spasm has been activated and is still active at the moment of rescue from the water,” he said.
Laryngospasm is a reflexive closure of the larynx that, for a brief period, mutes the vocal chords and impedes breathing. In drowning, the spasm attempts to act as a safeguard that prevents lungs from aspirating water.
As submersion time increases, organs are further pressured to a point at which safeguards become unsustainable. And although Bierens said there is “little high-quality data” on water swallowing, drowning does lead to liquid penetration into the circulation system at levels that vary based on fatal or non-fatal outcomes.
Drowning victims who suffer death or morbidity are commonly referred to as brain dead or damaged. However, according to the Bierens research, “The cerebral physiological response to drowning is poorly understood” and “derived from experimental models simulating cardiac arrest.” That said, loss of consciousness is a “critical event” attributed to brain energy failure.
Bierens said, “Awareness has been growing that drowning constitutes a neglected epidemic.” Despite his assertion, awareness has not necessarily moved the needle in a positive direction.
The first report in this series referred to the fact that numerous health agencies cite drowning as the leading injury-related killer of U.S. children 1-4 and third leading cause for those 5-14.
The National Safety Council ranks drowning as the fifth leading cause of preventable injuries overall.
The Consumer Products Safety Commission (CPSC) issues an annual report titled Pool or Spa Submersion: Estimated Nonfatal Drowning Injuries and Reported Drownings. Childhood injuries and fatalities increased from 2017-2019. Overall hospital treatment of children for nonfatal submersions occurred at a rate 17 times that of fatal submersions.
Patty Davis is Deputy Director of Communications and Press Secretary for CPSC. She said that drowning in pools and spas is a leading cause of death for children associated with products under the organization’s jurisdiction and merits continued efforts and attention.
“We often consider what the CDC is observing to contextualize our findings. If we see a rise or fall in pool deaths, are they seeing a similar directional change in all drowning deaths? That can be helpful to us in considering whether a directional change in drowning deaths is reflective of a real world change vs. just a change in how well they are reported to CPSC.”
According to the CDC’s Wonder database, the same age groups suffer the same consequences at roughly the same rates state-by-state. Florida, Texas and California suffer the most submersions overall.
Taking a closer look at California, approximately 10,000 of the state’s children received care for drowning, according to the last available decade’s worth of data from the California Department of Public Health.
According to the California Health and Human Services Agency, nonfatal submersions with catastrophic injuries occur at a rate at least five times greater than fatal submersions. These catastrophic injuries include severe brain damage and an inability to walk and talk or breathe on one’s own.
The California Department of Developmental Services provides publicly-funded care for nearly 800 such victims month-over-month. The majority are children who drown at home.
However, poisoning (primarily drugs), motor vehicle accidents and falls represent 83% of the catastrophic injury category overall. Therefore, while state and federal anti-drug and safe driving mitigation efforts are top of mind, drowning interventions are generally limited to brief, localized seasonal awareness campaigns.
“In order to move any issue in public health, you need to get political buy-in and capital,” said Dr. David Meddings at the 2017 World Congress on Drowning Prevention. Meddings is an official at the World Health Organization where he specializes in childhood injury prevention.
Meddings said public officials and health agencies should be reminded that they invest an array of services in children by the time they are only a year old. Continuing to ignore the prevalence of fatal and nonfatal childhood drowning – a preventable outcome – otherwise continues to squander such investments.
“There isn’t any one single strategy that is important,” Meddings said. “There needs to be a multi-pronged approach. Community awareness-raising and sensitization are very important, because this is an under-recognized health problem, with 50% of global drowning morbidity occurring in those under age 25.”
According to a survey by the American Red Cross, 80% of Americans have water activities in their summer plans. The same percentage said they can swim. Yet, only 56% can actually perform five basic water safety skills in succession:
Entering the water safely and coming back to the surface
Treading water for one minute
Turning and orienting oneself toward the exit of the pool
Orienting oneself into a swim position and proceeding about 25 yards
Exiting the water safely
According to research by USA Swimming Foundation and the University of Memphis, nearly 70% of Black people overall do not know how to swim compared to 40% of white people.
A study on racial/ethnic disparities in fatal unintentional drownings revealed that only 33% of Black children can swim effectively. Black children drown at rates five times greater than white children.
While tens of thousands of Americans suffer from fatal or non-fatal submersions year-over-year, drowning prevention curriculum, drowning research and state and federal initiatives remain scarce, at best.
Yet, other than the rare anomaly, childhood drowning – if not drowning overall – is preventable.
“Parents and lifeguards have an enormous responsibility,” Dr. Pia said. “And they don’t get a second chance.”
NEXT UP
Read Report #3. Includes why adults struggle to hold themselves accountable for preventable drowning outcomes, how social sciences might foster prevention habit-forming and the community of organizations working to foster greater awareness.