Near-drowning: improving on deck, deteriorating 30 minutes later
At 0600, in moderate seas and a water temperature of 26 degrees Celsius, a 29-year-old rating falls overboard from the after mooring deck. He is recovered by the rescue boat after about four minutes in the water. He is wearing a lifejacket and is conscious, coughing, retching and bringing up small amounts of seawater, and talking. His breathing is fast at 26 per minute and he says his chest feels tight. After 30 minutes in the ship's hospital he becomes drowsy and difficult to rouse, his breathing rate is 28 with crackles heard at both lung bases, and his oxygen saturation is 89% on room air. He has no external injuries apart from a small scalp graze. The ship has two portable oxygen cylinders with a total of about three hours at 10 L/min, a pulse oximeter and an AED. The master proposes keeping him under observation in his cabin and continuing to the next port 14 hours away.
1. A deckhand suggests pressing on his abdomen to push the swallowed seawater out of his lungs. How do you respond?
Read the worked answer
Refuse, and explain why. Abdominal thrusts and Heimlich-type manoeuvres do not drain the lungs: the water that matters has already passed into the alveoli and is being absorbed into the circulation, and it cannot be tipped back out. What the manoeuvre does do is make him vomit, and that vomit is then inhaled into already injured lungs, adding a chemical pneumonitis to the picture. It also delays oxygen, which is the only treatment that helps, and it carries a risk of injury to the liver and spleen.
What to do instead: 100% oxygen through a non-rebreather mask at 15 L/min, sit him up as far as his breathing allows, continuous pulse oximetry and respiratory monitoring, suction ready because he is already vomiting, keep him warm, and nothing by mouth. Do not make him walk or lie flat. If he becomes unresponsive but is still breathing, recovery position with oxygen applied; if he stops breathing normally, start resuscitation immediately. Document his observations and the time they changed, because the deterioration is the story.
2. The master wants to watch him in his cabin for 14 hours. Set out your case against that plan and what you would do in the meantime.
Read the worked answer
He now has three red flags: saturation 89% on room air, a respiratory rate of 28 with bibasal crackles, and a falling level of consciousness. That is not a patient to observe in a cabin; it is evolving pulmonary oedema or aspiration pneumonitis after immersion, and deterioration can occur many hours after rescue - the risk of cardiac arrest sits in exactly this window.
A cabin on a rolling ship, a single first aider, no suction at the bedside and only about three hours of oxygen is the wrong place for him. Request radio medical advice now, report the saturation, respiratory rate, conscious level, time in the water, water temperature and the trend in his observations, and press for helicopter evacuation or diversion. A 14-hour passage with a deteriorating patient is a decision that may not be recoverable.
Meanwhile: high-flow oxygen continuously, titrated to a saturation of 94-98%, nurse him semi-recumbent, monitor consciousness, respiratory rate, saturation and pulse every 15 minutes, keep him warm, keep him nil by mouth, have suction, bag-valve-mask, AED and a written CPR plan ready at the bedside, and husband the oxygen for the transfer rather than wasting it. Record everything with times for the handover.
3. He becomes unresponsive and stops breathing normally. Walk through your actions, including what is different about drowning.
Read the worked answer
Shout for help, check response, and open the airway with a head tilt and chin lift; his scalp graze suggests possible trauma, but hypoxia kills faster than a cervical injury in this setting, so secure the airway first. Give up to five initial rescue breaths, then start CPR at 30 compressions to 2 ventilations with the bag-valve-mask and high-flow oxygen attached. Drowning is a hypoxic arrest, so effective ventilation matters as much as compressions - do not fall into compression-only CPR.
Attach the AED as soon as it is brought and follow its voice prompts, minimising interruptions. Expect vomit: turn the head to the side or briefly log roll to clear it, suction, and resume compressions immediately. Do not stop to search repeatedly for a pulse, and do not move him to another space unless the scene is unsafe. Continue during a helicopter winching if that is what the winch crew directs, and hand over the arrest time, the number of cycles, shocks delivered and the oxygen used. Keep him warm throughout. At a water temperature of 26 degrees Celsius hypothermia is unlikely, but wet clothing and a rolling deck will still chill him, and a cold patient in arrest is harder to resuscitate.