CPR in water when close to shore / boat what to do first?

[ArcticDiver]

I am with medic diver on this. While I would certainly not fault anyone for trying what they think is the right thing to do in an impossible situation far from help the reality is that the science of CPR is now almost overwhelming towards maintaining the circulation of the existing oxygenated blood. The only real way to do this is to get the victim to a hard surface ASAP. Many other variables also come into play so a couple of quick breaths may be effective in situations such as a near drowning or respitory issue but the reality is that most will not be able to detect this in an emergency (notice I said most, not all - so put down the axes). Traditionally the survival rate for full arrest victims has been poor at best and I have participated in many over the years that did not end well, however, with the focus shift that has taken place and the emphasis placed on effective compressions the survival rates for those patients found in either ventricular fibrillation or ventricular tachycardia who receive high performance CPR and early defibrillation has dramatically improved. Some agencies are reporting 30% save rates with the agency I work for approaching the 20% range. These are real and documented saves. For those patients found in a asystole (flatline) the numbers are about the same as they have always been. BTW, I will take issue with the comment of"just do 5 min of CPR and stop, no first responder I know does this or would even consider it, however, once a set criteria has been met such as ALS care for a defined period (usually 20-25 min with drugs and airway in place) we do terminate efforts in the field. I have also done this numerous times and it is not an easy thing to do. It should also be mentioned that it is often situation dependent. No one would leave a child or a physically fit diver as opposed to a known hospice patient or a patient with an unknown down time and an extensive medical
history. Policies across the country vary on this but no physician "on scene" is needed, just contact via medical control. It should also be mentioned that some agencies do not allow this at all. In 27 years as a medic, medic instructor
and FF I have seen many not make it, but the last 3-4 years have been different. Good compression work for those who are savable. Give them the best chance and get them to a place where you can do it. I'll get off my soap box now.

What is your definition of a "save"? Getting the patient to the hospital with life signs? Discharge from the hospital as an independent functioning person? Lasting two or three days in the hospital before officially dying from organ failure? Discharge with neurological deficits?

Over the years I've seen lots of numbers bandied about. To understand them a person needs to know just what they mean.

 

[k ellis]

Rescue 911 - Episode 218 - "Florida Keys Scuba"(Part 1 of 2) - YouTube

Rescue 911 - Episode 218 - "Florida Keys Scuba"(Part 2 of 2) - YouTube


Maybe this will help with questions of CPR in the water. True story FYI

 

[AFD362]

Arctic Diver,

Let me clarify the point to answer your question. Their many different definitions of a "save" and as any statastician will tell you that numbers can be tweaked to mean anything, just look at what politicians do with numbers to make them mean what they want. My definition of a "save" is discharge with intact neurological functions and return to a similar life as the victim had prior to the cardiac arrest. The heart muscle, when deprived of 02 via delivery by circulating red blood cells, will become ischemic and progress to infarction. The deprivation may be caused by several different factors such as blockage, blood loss, trauma, etc. During this process the heart muscle will begin to act erratically (ventricular fibrillation) and no effective cardiac output will occur. As this process continues it will eventually end in flatline (asystole - no heartbeat and no pulse). This process in its early stages is clinical death or the absence of a heartbeat and breathing. The process then progresses to biological death or death of the brain cells due to lack of oxygen. At this point it is rare to "reverse" biological death. Experience has shown me that many patients found in flatline may have a return of circulation when the body is stimulated with cardiac medications and full advanced life support, however the vast majority of these patients have still suffered biological death of the brain cells and thus do not have positive outcomes. I DO NOT CONSIDER these a "save".

A long established belief (and medical evidence of the same) is that biological death occurs in 4-6 minutes following clinical death, with this known the opportune time for intervention (compressions to circulate blood) is early as possible within this time frame. The current philosophy of CPR is changing from "this will absolutely save your life" to more of a "compressions and circulating blood with available oxygen are really preserving brain cells until the patient can be defibrillated and advanced life support medications delivered". Thus it should be pointed out that CPR with a focus on high quality compressions is truly a life saving measure and can extend the period between clinical and biological death. Studies have shown that good quality effective compressions only deliver approximately 30% of the cardiac output that a healthy heart delivers on its own, and this is by well trained clinicians. To further complicate the process the first 10 or so compressions of a 30 compression cycle really serve to prime (or build up pressure within the circulatory system) the pump with the last 18 or 20 delivering effective blood flow, then we stop to give 2 ventilations. While stopped the pressure built up drops and the whole process must be started over. All of these numbers are in controlled settings, in the water the numbers (I have not seen any studies) would probably be far less (my opinion).

When response times of professional rescuers are factored in, which average 5 min from 911 call to arrival in an urban/suburban area to 30-45+ minutes in rural settings and who knows what in a tropical dive setting, it is easy to see why their are so few patients are found in ventricular fibrillation (still savable in the clinical death period). The survival rates I quoted earlier are only for those patients found in this state (V-fib or V-Tach). As before, those patients found in asystole, continue to have poor outcomes (the vast majority).

The OP asked the question whether CPR in the water is effective. My education and training say no, get them to a hard surface ASAP. However, as I stated before, I would never fault any one for trying. Many different situations have been presented in this thread and each would require a different response based on the situation presented. As a professional responder I would try whatever I thought would work in a given situation and I encourage everyone to due the same. Even the subordinates the work for me would also do whatever it took to get the job done, giving up is not an option but our response is based on training and education of the latest available medical science.

I just returned from a dive trip to Cozumel and the thought crossed my mind more than once what course of action we would take if the unthinkable happened. Of the 10 on the trip, 9 were coworkers, we did discuss this and decided the best course of action would be to get the person back on the boat ASAP and begin care. To my surprise the boat was never more than a 100 or so yards away from us when we surfaced.

I apologize for the lengthy response but hope I have answered your question.

Sincerely,
Captain Gerald Randall
Arlington Fire Rescue
Dive/SWR Team, Program Coordinator
NREMT-P




---------- Post Merged at 02:48 PM ---------- Previous Post was at 02:34 PM ----------

Good story and more proof that early intervention with good CPR can make the difference between life and death. (above videos)

 

[ArcticDiver]

Yes, you did and your definition of a "save" is the same as mine. So often in discussions such as this it cuts off at getting the patient to the hospital with some kind of life signs. It took a long time but more and more the definition has changed to our's where it is not a save unless the patient walks out of the hospital with the ability to live essentially the same life as before the event.

I have seen CPR save a diver's life. When we were diving on a wreck off Key Largo an unfit diver could not hang on to any of the lines in the water and drowned. When that happened there were many divers right there and several dive boats. He was out of the water and having good quality CPR including oxygen within 5 minutes. From the debriefing I gather he regained life signs before reaching shore. He was transferred to local EMS and then to a hospital where he was observed per near drowning protocols and ultimately discharged to normal life.

But, that is definitely a rarity. I'm not as charitable as you about attempting fruitless efforts that pose a significant risk to themselves or others. Too often I've seen such scenarios devolve into multiple casualty events where they didn't need to. So, in the situation we have been discussing here the wise thing is to tow the person to the boat at a speed that does not drain the rescuer. In more graphic terms, as you said, the person is clinically dead. Any potential rescuer needs to ask themselves how much danger to themselves they are willing to endure for a dead person.

Me? If there is a reasonable chance I can save a person's life I will pull out all the stops even to the point of significant risk to my own. But, as I've posted that does not extend to fruitless efforts for people who are most likely already dead.

 

[AFD362]

We're way closer in our thoughts than you realize. My never give up response was intended to address an earlier comment about "a new generation of responders who do 5 min of CPR then quit when they know the patient is toast". That's not how we operate and it is obvious you don't either. Your right about the situation that has been presented, it could easily result in two victims instead of one. It all boils down to "risk a lot to save a lot, risk little to save little to save a little and risk nothing to save nothing". Of course this refers to my own safety and especially the safety of my personnel.

 

[Kevrumbo]

Yes, you did and your definition of a "save" is the same as mine. So often in discussions such as this it cuts off at getting the patient to the hospital with some kind of life signs. It took a long time but more and more the definition has changed to our's where it is not a save unless the patient walks out of the hospital with the ability to live essentially the same life as before the event.

I have seen CPR save a diver's life. When we were diving on a wreck off Key Largo an unfit diver could not hang on to any of the lines in the water and drowned. When that happened there were many divers right there and several dive boats. He was out of the water and having good quality CPR including oxygen within 5 minutes. From the debriefing I gather he regained life signs before reaching shore. He was transferred to local EMS and then to a hospital where he was observed per near drowning protocols and ultimately discharged to normal life.

But, that is definitely a rarity. I'm not as charitable as you about attempting fruitless efforts that pose a significant risk to themselves or others. Too often I've seen such scenarios devolve into multiple casualty events where they didn't need to. So, in the situation we have been discussing here the wise thing is to tow the person to the boat at a speed that does not drain the rescuer. In more graphic terms, as you said, the person is clinically dead. Any potential rescuer needs to ask themselves how much danger to themselves they are willing to endure for a dead person.

Me? If there is a reasonable chance I can save a person's life I will pull out all the stops even to the point of significant risk to my own. But, as I've posted that does not extend to fruitless efforts for people who are most likely already dead.

Elaborate on the "danger to self" of the potential rescuer . . .what's your risk: physical exhaustion? What are these "devolving scenarios" you allude to or allege to have seen??

And if the victim "crashes" (goes full arrest) right in front of you on the surface --you actually witness it. . . you throw your hands in the air, "Oops most likely already dead --rescuing efforts fruitless" --as the dive boat in the distance comes for recovery???

Objectively, how many compression/breath cycles are you able to do if trying a modified Heimlich maneuver for in water CPR? One maybe two continuous cycles before fatigue sets in? If other divers are on the surface, couldn't they team up and try as well?

Or just declare all of it "fruitless" and give-up?

 

[AFD362]

Kevrumbo,

No one is suggesting that we just throw our hands up and say "oh well, too bad". In the situation you present of course I would try your modified method but never to the detriment of my own safety and a risk vs benefit analysis would be done in the back of my own mind. Knowing what I know about the effectiveness of CPR the best course of action would be to get to help. The decision to do CPR, modified in the water, verses towing to help would be a decision made based on the situation at the time.

 

[Kevrumbo]

Alright & fair enough. . .

As a former volunteer member of the Catalina Island Hyperbaric Chamber Crew, we were told that if a dive accident victim arrives for treatment without a pulse --chances are they will leave the facility without a pulse on a chopper back to the LA County Morgue, despite the heroic efforts of divemasters, boat captains, LA County Lifeguard Baywatch Paramedics, and US Coast Guard Personnel.

That said, we were still expected to perform CPR inside the Chamber on the victim, in the heat of compression of well over 100deg F to a pressure of 6 ATA/165', for a modified Table 6 Treatment Arterial Gas Embolism (Imagine being inside of a scuba tank during a fast fill --it gets very hot in there!). Together as a team with the Baywatch Paramedics, we were to continue CPR for as long as it takes to helicopter in the Attending ER/Hyperbaric Physician from the mainland to in all probability, declare the patient dead . . .and that could take as long as 20 minutes.

I'm a naive layperson in the EMS Chain of Care and I'll do the best I can until hopefully relieved, or collapse in exhaustion, or a Doctor officially orders me to stop. . .