Monday, December 5, 2016

Circum Rescue Collapse - or After Drop Information necessary for Ice Swimmers.


All Organisations/Groups/Teams faced with a probability of treating hypothermia should be prepared to apply the best care available and not that which is merely available or assumed sufficient to prevent death. 

Over the last few years of dealing with acute hypothermia injuries -I am reminded over and over again that no one is immune.  

According to Giesbrecht, there are many examples of people being taken from cold water immersion in an apparently stable and conscious condition only to experience "a rewarming shock" or a "rewarming shock" with symptoms ranging from Ventricular fibrillation and cardiac arrest. 

Golden has noted that deaths can occur either before, during or after rescue-known as "Circum Rescue Collapse" It was long thought that the After drop with a potential drop of 4-5 deg could contribute to the collapse post cold water immersion but Golden discounted this and started to focus on a collapse in arterial pressure BP and inadequate coronary blood flow and the increased sensitivity of a cold heart. 

Getting out of the Ice water after spending 10-20 mins at 0-5 degree and walking to the recovery area to begin the recovery is some of the most challenging moments which exist for a swimmer and the team since 450m/1000m became a bigger event in Ice Swimming. The recovery is also the greatest risk area. 

Going back to 2012 in Ice Swimming and before that with Coast Guard and Rescue training- what I have experienced and loved learning in the last 4 years is not so much about the swimming but about the management of the swimmer and seeing what we can do to protect both the swim and the swimmer. 



When a swimmer exits the Ice water. 
it was not JUST a swim-
1.The swimmer has exposed their body  to extreme freezing water and the physiological make up of the body has changed completely.  
2. The work for the team and the recovery unit is challenging for many reasons of "laws of physical inevitable consequence"   
 
Collapsing and altered consciousness is something that I have seen many times in the last few years in the recovery area of Ice Swims. It has a lot of supporting evidence and I myself have witnessed and managed this area about 10-15 times in the last few seasons at Ice Events. 4 of these circumstances were of a serious nature. I felt we were lucky to have positive outcomes and for this reason i think it is important that we begin to start creating procedures and education in this area. 
Swimmers should not be allowed to assist in their own recovery.

Afterdrop or the area of Circum Rescue Collapse.  Both are vital to understand. In my experience Post Rescue Collapse has a greater role to play with the movement of the swimmer post swim.  

After drop is a process where the sequence of heat flows between an inner and an outer area-the core being warm and the peripheral being cold. it is the physical law of inevitable consequence of having your body immersed in cold water where the heat loss is greater than heat production and then reheating began. 

However the fact that losing consciousness on recovery, rescue and also removal from water can occur before the after drop begins-this then focused leading discussion and rescue services to address this area as a greater risk to life. 

The protocol for Coast Guard- removal and management of cold water extraction is horizontal positioning from Vertical removal. Holding the swimmer in a horizontal position has a greater recovery potential. If a swimmer becomes unconscious on removal it is vital to put them in a horizontal position

Watching the transport of swimmers in 2012 in Siberia when many distance swims were completed was exactly as we now understand. Many extreme swimmers were transferred to the sauna in complete horizontal position including Andrey Stoyev. 
In Murmansk 2013 when I completed my first 1000m at 0 degree, the distance from the poolside to the sauna involved a lot of steps so those who could stay in the heated area by the pool for a few minutes to steady and then transferred with assistance. This also existed in 2015. 

Many swimmers including myself had moments where we drifted in and out of consciousness on the walk to the sauna-but we were managed brilliantly once there. 
The procedures of recovery and removal are vital for sustaining life post an Ice Swim. Understanding the body is crucial. 

To truly understand the sport-you have to be there-you have to see the management of an Ice Swimmer on the edge. You have to understand why each move is calculated and understand the value of knowing this information.

Swimmer or casualty we all have the same physiology. It's the same injury. 
I have spent a lot of time talking to and working with Rescue services and medical personal on the issues around these physiological challenges post removal. I would love to see swims implement procedures. 
Some would say the speed of the swim can increases risks to the physiology of the body and outcome but I would also argue that the expected and managed time outcome, the proximity of the swimmer to the exit and the expectation of the swimmer to survive also acts as a positive for swimmer v casualty. 


The main difference between an Ice Swimmer and a Casualty in Ice water is that the Casualty is hoping for survival and the Swimmer is looking for Performance and survival. 
  • The body now contains a mixture of warm blood and very cold blood. . 
  • The heart has a decreased ability to speed up to meet swimming needs  as time passes 
  • The muscles fail to perform small tasks
  • The veins and nervous system are temporarily altered in such a way that has them on the edge very close to significant hearts malfunction 
  • Risks attached to the speed the swimmer approaching the finish 
I have seen and managed probably over 15 cases in the few events 1000m I have attended. 
Lifeboat services in Germany post war decades ago discovered that if they managed the casualties horizontal post swim and fewer died.

The good news is the best chance of Survival is water temperature under 5 degrees.

Where has the Circum Rescue Collapse thinking come from?
Over 15-20% of people who are taken from the water conscious as casualties, collapse and die post rescue. This is a very significant number.

This area of death post rescue is well documented with reports of entire ship crews picked up after the war and once removed conscious from the water, many died from no apparent injury with the exception of the immersion. 
Cold water  temperature played a significant part. 160 rescued from the water below 10 deg 17% died within 24 hrs of rescue. 
Of the 109 rescued from the water over 10 Deg none died after rescue. 

Matthew describes airman being in the water for a short period of time, once their rescue commenced and they assisted in their own rescue, some fell unconscious and died on removal from the water. 


 similar to standing up to quickly and feeling faint but the same thinking that could cause the swimmer to collapse on exiting the water. 


There is anecdotal evidence that 1985 a sailor who was washed overboard North Cape Sea Temp 5 deg-8 mins in the water, airlifted by helicopter on a vertical strap,(he assisted with the rescue on a few attempts)  he regained consciousness on the helicopter once he was put in a horizontal position in the helicopter. Golden et al-circum rescue collapse

Hypothermia in itself has proven that it is not a major risk at 1000m events-especially as majority of our swims are short and those which are longer as time and distance have a time limit of 25 mins for most events. 
The difference between 300m and 1000m is gargantuan. It was the difference between 6 mins in the ice and 20 minutes.  When the swimmer stands up to climb the ladder-swimming position from Horizontal to Vertical -and a drop in blood to the head. 
 It is now considered that it is a collapse in the Arterial pressure which contributes to collapse also the speed of the swimmer.  



  • Racing to the ladder horizontal at speed then quickly standing up gives a HUGE possibility that climbing up the ladder and the hydrostatic pressure of the body could collapse.
  • This change in body position could also stimulate Hypovolemic shock when the working rate of the heart collapses as the warm blood drops down and the workload of the heart needed to function could cause the swimmer to go unconscious. 
  • The movement of the swimmer’s arms and legs have to be kept to a minimum when moving and could rush and flush the cold blood into an already stressed working heart causing possibility Ventricular Fibrillation. 
  • The release of stress hormones at being removed from and being in a safer environment can cause the swimmer to relax and collapse. 
  • Incorrect rewarming or no treatment -Techniques are important if there is rewarming of the body incorrectly -such as rewarming of the hands and feet can send cold blood back to the core and this cold blood trigger the heart to collapse and arrhythmias. 

    Paradoxical Undressing -where the swimmer states that they are OK.. that the swimmer indicated that they do not need assistance.The swimmer indicates that they do not need any rewarming assistance-we treat everyone equal. 

Particular the post swim 30 minutes 

Recommendations : 

  • Responsibility of the swimmer is explained and understood. 
  • Experience at both temperature and distance is relevant to the temperatures of the event and distances 
  • Medical responses are final. 
  • The removal methods of the swimmer from the water understood by teams and discussed in advance
  • The risks of swimming at 0 degree and also - 40 degree Air temps are understood.  
  • The distances from pool to recovery is managed and challenges like steps etc are taken into consideration for the recovery. 
  • Understanding the risks of swimming Open water and also pool-rules are different. 
  • The steps to distance swimming is slow and organised with building physical understanding. . 
  • The treatment in the recovery area to rewarming is explained to the team and also the swimmer-this is the greatest risk. -do not rub, handle gently, and sow managed recovery. 
  • The understanding of the energy required post event-Blood sugar drop -shivering takes energy and this must be fuelled. 
  • Team training. 
  • The understanding of the physical response from Horizontal to Vertical and the risks attached. 
  • The responsibility of the swimmer to be healthy-and have understanding of the hypothermia impact on the body
  • The responsibility of the swimmer to be emotionally strong to fight the survival. .. such as the return down the mountain-in Murmansk 2015 I feel many swimmers experience 0 degree for the first time and the recovery as not easy. 
  • Maybe having 3 x 450m at 0 degree before 1000m at 0 degree or something like this. 
The future is so bright for Ice Swimming but understanding the best practice for removal and for the safety of events is vital for all. 

For more information I have published a manual 
An insight into the World of Ice Swimming. 
for interest please contact me on nualamooreswim@gmail.com




6 comments:

  1. Great article Nuala and very timely. Thanks for writing this.

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    1. Thanks so much Tiffiny-yep it's all about understanding that the impact of the cold blood requires us to managed very fragile-cold heart is quite Giddy!!! really is... All safety-you've seen the challenges yourself and it's all about information..

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  2. Excellent Nuala ! Thank you very much. It's great to see your commitment to the sport. You're great girl ! Kss from Bue !

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    1. Thanks so much Fabien-I am still working on our document but I got involved in this area and I will use all the information that you sent to me.. What an amazing experience it was sharing the Beagle Channel with you and what a wonderful group of swimming.. Hope to see you sometime again.. to share some more cold water.

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  3. thanks for sharing your valuable information .. you are truly amazing .. keep it up x

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    1. Thanks so much Lisa.. it'a all about learning the best practices.. and hopeful enjoy many years of safe swimming.. !

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