You are part of a wilderness medicine class staying at a small eco-resort on Costa Rica’s Southern Pacific coast.  Your super nice and cool instructor gives you an afternoon off.  You and three buddies decide to head down to the beach, about a quarter mile down a gravel road from the lodge.   It is about 3 pm, very hot on the beach; the very comfortable temperatures of the water feel great.  After a brief dip you and your best buddy retreat to the shade of a palm tree (to study of course!) while your two more energetic friends continue to swim.

All of sudden you hear Jack yelling and you look out to see Elaine waving for help, another 30 or so meters deeper than Jack.   She looks panicked when you get your bird nerd binoculars on her face.  And then she disappears from sight.

1.) What do you do and why?

You re-spot Elaine and she appears to be drifting further away, but it’s tough to tell.  In the waves and surf you lose sight of her for five or ten minutes.  When she reappears she thankfully is closer in to shore, maybe only 50 meters out, and another 100 meters down along the beach.  Her face bobs in and out of sight and she looks totally panicked.  Your friend yells she is going in to save Elaine

2.) What do you do and why?

Elaine is no longer looking panicked, in fact she looks unconscious or dead, the top of her head only occasionally bobbing to the surface.  She is now about 30 meters out.

3.) What do you do and why?

Elaine is now back on shore, but she is U on the AVPU scale.  You do not detect respirations, nor a pulse.

4.) Write out a patient assessment and anticipated problem list. What are you really worried about? What do you do and why? 


What do you do and why?

1.) You don’t rush in to the water to save her.  It is likely a rip current and you put yourself at risk by getting in the water to try to help.  You yell to Jack that there is likely a rip current to get out of the water – you don’t need a second victim.  You use your binos to try to keep an eye on her and look around for anything that floats, a boogie board, surf board, boat, rope, etc.  You wish you would have listened to your professor and pre-positioned some emergency flotation such as a rolled up sleeping pad.  You think hard about whether to send your friend next to you for help.  How far away is it, what resources might there be?

2.) Tell your friend NO!  If s/he wants to help the friend can go back to the lodge to get help, s/he can help keep an eye on Elaine, or s/he can look for emergency flotation.  Most likely, going for additional help, even though it might be limited to just a vehicle (to transport Elaine to definitive care if needed), is best bet.

3.) Depending on your (or your friends’) swimming ability you might consider going out to bring her in.  It doesn’t look like she could be a threat to your safety as she appears unresponsive and you assume there is no longer a rip current to be concerned about since she is actually now closer to shore.  Send out one (or two) of the strongest swimmers to bring her in???

4.) Write out a patient assessment and anticipated problem list.  What are you really worried about?  

Patient Assessment: Elaine, a __ year old female.  Drowned, no respirations, no pulse, CPR initiated.

Anticipated Problems: Breathing and/or heart do not re-start.  Secondary cardiac arrest.  Brain/neurological deficits. Hypothermia.

What Are You Really Worried About: Fatal drowning; definitive care is a long way away.

What do you do and why:  You get Elaine on her back on firm sand and begin CPR.  You need to make an ethical decision on whether you go with just chest compressions or you administer rescue breathing. In drowning, rescue breaths are important but you likely don’t have any kind of mask.  Keep the patient warm (not likely a problem due to hot sun and sand.  Even if she regains consciousness and seems okay she should be transported to a local hospital for observation (for up to six hours).