Would you know what to do if you were in a vehicle that was rapidly sinking in water? What if you or an EMS unit working under your supervision were responding to this situation? Numerous popular media and supposed experts have promoted strategies that, unfortunately, may be more likely to kill occupants than save them. Quality evidence-based analyses are as rare as Hollywood depictions of the situation are common. Happily, as in so many areas of medicine and EMS, evidence is now being collected to address this question. Reviewing the work done in this area can lead to safer procedures when a vehicle is submerging, whether you are a rescuer or an occupant.
Submersion in vehicles as a cause of death by drowning is not routinely classified as a drowning death. (Wilderness Medicine, 6th ed., Philadelphia: Elsevier, 2012; p. 1496.) The incidence of drowning in motor vehicle deaths during disaster was as high as 10 percent in one series, however. (Traffic Inj Prev 2003;4:279.) As our climate changes and we face more extreme weather events, flooding and its impact on motor vehicle operations become increasingly important considerations. Conversely, some series suggest motor vehicle submersions are responsible for approximately 10 percent of all drownings. (Wilderness Medicine, p. 142; Am J Public Health 1990;80:1068.)
Popular Wisdom Wrong
Significant public health efforts are directed at primary prevention, such as the National Oceanic and Atmospheric Administration's “Turn Around, Don't Drown” campaign, and this certainly represents a situation where prevention may be possible and deserves widespread promotion. Whether by ignoring preventive actions or by unavoidable circumstance, death in a submerging vehicle clearly represents a statistically significant source of fatal drowning and motor vehicle-associated death. The fact that it is a common problem and that popular wisdom about how to manage it is wrong makes a more successful intervention all the more important for everyone in emergency medicine. (Aviat Space Environ Med 2013;84:498.)
It wasn't until Karla Gutierrez of Miami drowned in 2001 that drowning in a submerged vehicle become a national discussion. Amazingly and tragically, she was on the phone with a 911 dispatcher for more than three minutes as her car sank. (Sun-Sentinel Feb. 20, 2001; http://bit.ly/1AHmK84.) She became a drowning fatality once the vehicle was fully submerged. Sadly, these incidents persist on an almost annual basis, where callers die of drowning while on the phone with 911 in a submerging vehicle, often for three minutes or more. (Naples News Dec. 11, 2010; http://bit.ly/1HudYQN.) One particular tragedy occurred in 2013 when two hikers were rescued after they got lost in the dark; one was pregnant. Because it was so dark after they were rescued, they made a wrong turn in their car, drove off a dock, and their vehicle became submerged in a lake. They had time to call 911, and were getting instructions when their line went dead. Both drowned. (Fox News July 25, 2013; http://fxn.ws/1GjMnTB.)
Recently, I became state certified as an emergency medical dispatcher (EMD), and continue to maintain dual physician-EMD credentialing. I am able in this role to explore in detail some of the dispatch protocols for handling submerged vehicle drownings. The Medical Priority Dispatch System is one of the most commonly used dispatch protocols by formally certified EMDs. Following these many incidents, this protocol system developed an extremely rare pull-out card (only a couple exist in the entire card-based protocol system) instructing EMDs not to get a location for a submerging vehicle, and instead to have a caller get out of the vehicle if it is submerging.
A dispatcher in other situations must persevere in getting a location before moving further through a patient's queries because rescue and medical resources cannot be dispatched without a specific address. This compulsion, however, led to deaths while callers remained on the phone trying to describe their location. Meanwhile, their vehicle rapidly submerged, and they should have gotten off the phone and escaped the vehicle. A significant amount of space in the very limited card-based protocols are dedicated to this intervention, which I think recognizes the relatively high fatality rate and the available lifesaving intervention, as well as that the time spent determining location by an EMD can result in the patient's unnecessary death. (Aviat Space Environ Med 2013;84:498.) We now believe this is one of those EMD interventions that can save a life, which otherwise could have been lost minutes later.
There is a small but existing body of peer-reviewed literature addressing submersions. (Inj Prev 2002;8:342; Am J Public Health 1990;8:1068.) A formal review of educational and public service information, including a public survey, identified “three probable significant contributors to [the] high fatality rate [of drowning in submerged vehicles]: ‘authorities’ provide an inadequate description of vehicle sinking characteristics, contradictory and inadequate advice is often provided, and a poor public perception of how to escape.” (Aviat Space Environ Med 2013;84:498.)
Specifically, several sources recommend questionable practices that expert analysis suggests can increase rather than decrease risk of fatality. These include letting the passenger compartment fill with water so that it will be easier to open the doors, waiting until the vehicle hits the bottom to maintain orientation, relying on kicking out the windshield or opening the door to exit, and assuming trapped air will be available in the passenger compartment. (Worst-Case Scenario Survival Handbook, 1st ed., San Francisco: Chronicle Books, 1999; p. 36; “Escape from a Sinking Car,” Smart Driving 2004; http://bit.ly/1EcowPY.) A formal survey found that half or more of the general public believes staying in a vehicle while it sinks to the bottom is the safest option when trapped in a submerging vehicle. (Aviat Space Environ Med 2013;84:498.)
Get Out Fast
Gordon Giesbrecht, PhD, a professor of kinesiology and recreation management at the University of Manitoba, has conducted well-designed research that includes 35 vehicle submersions in multiple locations and seasons. His research suggests that these perceptions of submerging vehicle characteristics, along with their associated survival strategies, are erroneous. He proposes alternate strategies and education to reduce fatality. (Aviat Space Environ Med 2013;84:498.)
His data demonstrate that a vehicle floats for 30 seconds to two minutes prior to sinking. In this phase, windows can be easily opened and used for exit, assuming the risk outside the vehicle is not greater than the risk inside the vehicle (e.g., swift water or a non-swimmer exiting into deep water). Three adults in one trial were able to exit a single vehicle, which included releasing a child manikin from a rear child seat, in 51 seconds. During the sinking phase (after two minutes), occupants can breathe as water rises inside the vehicle, but he noted that chances for escape and survival decrease considerably during this phase because doors and windows became less available due to rising water pressure. In the third, submerged phase, the vehicle is full of water and no air pockets exist, and the chance of survival is negligible.
“It is important to inform and train the public of these factors so that they become second nature. This will greatly increase the probability of persons initiating the proper exit strategies when faced with an emergency situation with little time to think rationally of a course of action,” Dr. Giesbrecht wrote. “Clearly the best time to escape from a vehicle is immediately during the initial floating phase. The following escape procedure should be followed:
- Seatbelts: unfastened
- Windows: open
- Children: if present, released from restraints and brought close to an adult who can assist in their escape
- Out: children should be pushed out of the window first, and followed immediately.” (Aviat Space Environ Med 2013;84:498.)
Those of you who are visual learners might enjoy an entertaining yet instructive episode of the Canadian television show, the Rick Mercer Report, where Mr. Mercer and Dr. Giesbrecht participate in actual submerged vehicle demonstrations on YouTube while describing his proposed interventions. (http://bit.ly/1Dj2t9U.)
Dr. Giesbrecht has convinced me and other national bodies like the Medical Priority Dispatch System. I'm sharing it with you in the expectation that it may be, despite flying in the face of popular media opinion, equally convincing and equally important to share more widely via our role as public health agents and experts in evidence-based emergency medical interventions.Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.