As Summer Approaches Beware of (Dry Drowning)

On June 1, 2008 10-year old Johnny Jackson got water in his lungs while swimming in the pool. He walked home, took a bath, and went to bed; he died in his sleep during a nap an hour later. The county coroner reported water in the boy's lungs.

On June 5, 2008 todayshow.com reported the following:

"According to the Centers for Disease Control, some 3,600 people drowned in 2005, the most recent year for which there are statistics. Some 10 to 15 percent of those deaths was classified as “dry drowning,” which can occur up to 24 hours after a small amount of water gets into the lungs. In children, that can happen during a bath."

While the 3,600 number is fairly accurate (3,582 to be exact), the 10-15% statistic is erroneous and the CDC enterprise communication officer Sandy Bonzo has since issued a statement as such. There are no statistics on the percentage of "dry drownings."

Soon after Johnny's unfortunate drowning, there was a full-on media blitz with the Today Show spearheading the charge. The media did what the media does best: it struck the "Moms you had better take note for your chid's sake or else suffer the consequences" nerve. What followed was a slew of stories on multiple websites, newspapers and local news channels on "dry drowning". . . the story at 10 and you had better not miss it if you care about your child. . .

Although the phrase "dry drowning" is an ideal term for a newscaster hoping to invoke fear in the heart of the average mother, it is a somewhat misleading phrase. In fact, there are so many different phrases used to describe drowning (such as wet drowning, dry drowning, near drowning, secondary drowning, passive drowning) that it leads to ambiguity in what physiologically has actually occurred in each individual case. In an attempt to simplify matters, the 2002 World Congress on Drowning held in Amsterdam defined drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.

So what do people mean by "dry drowning" then? 

It's hard to pinpoint exactly as there is no set definition, but it seems to be any situation where a person cannot breathe and water does NOT enter the lungs. In this sense "dry drowning" could conceivably apply to laryngospasms (spasms of your windpipe) and such external causes such as a lung puncture or a heavier-than-air gas filling the lungs. Even in an underwater drowning, it is conceivable that a person could suffer laryngospasms and die from oxygen deprivation without water entering the lungs, and hence be classified as a dry drowning when in fact the person was fully submerged underwater. You can see how there is ambiguity and confusion in using these terms, which is why the 2002 Congress uses one universal definition.

So exactly what happened in Johnny's case then? 

Most likely Johnny did swallow some water while he played in the pool and some of the water made it into his lungs (which then technically is not a "dry drowning" even though the death occured out-of-water). This water then led to a loss of pulmonary function after the "loss or inactivation of surfactant" of the alveoli in the lungs. Surfactant is an amphiphilic compound which reduces the surface tension of your lungs allowing you to breathe. Basically, it helps your lungs to expand easily allowing oxygen to enter. The water that made it into Johnny's lung disrupted the ability of his natural surfactant and therefore as he napped, he was unable to breathe properly leading to his unfortunate demise.

This type of situation is uncommon, however there are no exact statistics on it. And although it can be a scary concept to every mother whose child goes swimming during the summertime and then on occasion takes a nap, things must be put into perspective. 

First, most drownings do not occur this insidiously. Rather, the majority of drownings happen where it is clear that the child has been submerged under water. In this sense, things can be done to avoid the obvious drowning: close supervision, fences/covers/alarms around unused pools, CPR training, etc.

Second, even in a case such as Johnny's, there will be some warning signs: accidental ingestion of water, forceful coughing >1 minute right after coming out of the water, difficulty breathing, extreme fatigue and changes in behavior. If your child clearly is having an excessive amount of coughing and difficulty breathing right after swimming, it would be evident to the observant mother.

Finally, there is more risk in driving your child to the local movie theater than there is in monitored water play.

The bottom line is that like many other risks that the media has over-hyped, "dry drowning" is a real risk but a very unlikely one if you follow safe water practices. One good thing about this media blitz has been an increased awareness about general water safety, which only benefits summer activities. In this sense, hopefully Johnny's life will serve as a beacon to every mother and child swimming this summer.

Movie Review (Darius Goes West )

So why review a movie on a pediatrician’s blog?

A couple of months ago I received an email from a blog reader who was a participant in a movie project that ultimately produced a unique documentary titled Darius Goes West.

Their ultimate quest: raise awareness and money for Duchenne Muscular Dystrophy research.

For those unfamiliar with Duchenne Muscular Dystrophy (DMD), it is a heartbreaking disease that cripples otherwise healthy children by deteriorating their muscles, eventually leading to loss in ambulation, paralysis and death. The average life expectancy for a child afflicted with DMD varies from the early teen years to the mid-30s.

As a pediatric fellow, I witnessed, up close and personal, several brave patients who battled doggedly against the recessive X-linked killer. Inevitably and unfortunately, the genetic defect always prevailed.

However, there is light at the end of the tunnel; promising new therapies including stem cell replacement, DNA repair techniques, new uses for old medications and completely new medications set an auspicious foundation for the future.

For Daruis Weems, the future may not be soon enough. But rather than succumbing to Muscular Dystrophy, Darius has tackled the disease head-on, creating a documentary film to assist in the fight. The documentary begins in the summer of 2005, with then 15-year-old Darius setting off on a road trip across the United States with the ultimate goal of reaching Los Angeles in the hopes of having his wheelchair souped up on MTV's show "Pimp My Ride".

Eleven of his friends (one of whom emailed me about the cause) join him on this crusade, and what ensues is a remarkable story about courage, friendship and love of life, regardless of the cards life deals you. And while the storyline revolves around the quest to "pimp" Darius' ride, the real story that is ultimately revealed is that life is only as precious and fulfilling as you are willing to make it. And Darius lives life large.

It was neither the best movie nor even the best documentary that I've watched, but I thoroughly enjoyed the film and its authenticity. And for certain, it is the best money I have ever spent in purchasing a movie (10 DVDs to be exact... I wanted to share). I cried, I laughed, and I especially enjoyed the rap numbers Darius performs throughout the documentary. The boy has skillz (I doubt I'll ever use that word in another blog again), and so too does the documentary, winner of over 25 separate film awards.

Ultimately, it is an excellent way to spend an evening. And even if you do not thoroughly enjoy the film, you can walk away knowing your money went to a good cause. One day in the not-so-distant future, Duchenne Muscular Dystrophy will meet its match. Until that day comes, Darius and his team will help lead the charge in his pimped-out wheelchair.

More information (and how to purchase the DVD) can be found at http://www.dariusgoeswest.org/, but to simplify things I have inserted a snippet from the website.

The Million DVD fundraiser has begun! The goal of the DGW Foundation is to sell one million copies of Darius's Award winning film, in roughly one year. The "year" began Sept. 1st '08 and will end on Darius's birthday, Sept. 27th 09.

The best way you can help with our "One million DVD in one year" campaign is to purchase a DVD or a set of DARIUS GOES WEST DVDs. By set we mean multiple DVDs for a group of friends or family...for your entire church, synagogue, or Sunday school class...for everyone who works in your company...or for an entire classroom (or school) of students in middle or high school. Your generosity, at any level, will not only help spread awareness for Duchenne Muscular Dystrophy, but it will also help fund promising research intended to treat or cure this fatal disease.

Because we are a non-profit Foundation, any time you buy a DVD, or a set of DVDs, a portion of the purchase is a tax-deductible donation. The fair market value of each DARIUS GOES WEST DVD is $3. When you make a purchase (of $250 or more), we will send you an official thank-you letter that you can use for tax filing purposes.

Book Review (Super freakonomics)

For the past few years I have been intrigued by the field of behavioral economics and economics in general; the works of Daniel Kahneman, Richard Thaler, Dan Ariely, Steven Levitt (writing with Stephen Dubner), Thomas Sowell, Paul Krugman have influenced my outlook on all aspects of life including healthcare.  With medicine increasingly consuming a larger part of our nation's resources, economic analysis of the efficiency and efficacy of doctors, hospitals, and healthcare policies has and hopefully will continue to produce better theory that will in turn yield tangible results in improving outcome per dollar spent.

Superfreakonomics written by Levitt and Dubner, mentioned above, contains an interesting data-crunching-analysis section regarding the outcome of emergency room visits covering 620,000 visits over eight years, and more than 300 doctors involved in patient care.  In their chapter they discuss various topics including which common complaints are linked to higher death rates (clot, fever, infection, and shortness of breath) and which are linked to lower death rates (chest pain, dizziness, numbness, and psychiatric).

"So a patient with chest pains is no more likely than the average ER patient to die within a year, whereas shortness of breath more than doubles the death risk.  Similarly, roughly 1 in 10 patients who show up with a clot, a fever, or infection will be dead within a year; but if a patient is dizzy, numb, or has a psychiatric condition, the risk of dying is only one-third as high."

Other findings note that you want a doctor who attended a prestigious medical school and residency program, an extra ten years on the job yields the same result as having served a residency at a top hospital, and women in general do a better job at keeping people alive.

The part I found most fascinating was the analysis on what constitutes a good ER doctor.  Essentially, the authors looked at the survival rates of patients after randomizing situations to get a fair comparison of each doctor's ability.  Additionally, they asked the doctors to rank their colleagues to gauge the strength of each physician's reputation.  Surprisingly, the reputation of a doctor had little correlation with the survival rate of his/her patients with overall parity between all physicians analyzed.

What they did find however, was that the best doctors - based on collegial ranking - achieved the same outcomes as weaker ranked physicians with less healthcare dollars spent.  Which means that the best doctors ordered less tests, less medications, and less intervention and still produced the same results as weaker colleagues.  This makes sense: if you have a better fund of knowledge and your deductive skills are stronger, you do not need as many tests to confirm what you can glean from a good history and physical.

No doubt this translates into the primary care setting as well, as insurance companies with their treasure troves of data could easily confirm.  The best doctors do no need as many x-rays, blood tests, and specialist referrals to treat their patients appropriately - of course, in the right situation all of these need to be ordered, but in judicious fashion.
Additionally, the best doctors will utilize less medications and prescribe the cheapest ones available where efficacy is synonymous; this requires a deeper understanding of the psychopathology of disease and the pharmcokinetics of drugs available.  And, of course, in many instances the astute physician will prescribe no medications at all where nature will run its course and healing will occur regardless of intervention.

Judicious use of resources will not only ensure the most economically sound outcome for the patient, but it will limit their exposure to radiation, reduce overall pain from needle sticks and procedures, and circumvent untoward side effects of unnecessary medications.  Less money, less pain, less side effects - it is a win, win, win situation.  As economists devote more attention to healthcare, I hope the ensuing data analysis will assist the medical field as a whole in becoming more efficient and efficacious.