Dr. Rob Steele (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy, Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and then click the Claim CME button.

Today, we are joined by Dr. Leslie Hueschen to talk about pediatric drowning. Dr. Hueschen is a board-certified Pediatric Emergency Medicine physician with concurrent board certification in General Pediatrics. I love that, by the way, both General Peds and Emergency Medicine. You're a rock star. That's awesome. She has worked at Children's Mercy in Pediatric Emergency Department for almost 11 years after completing her Pediatric residency with the University of Washington and a Pediatric Emergency Medicine Fellowship at the University of Utah.

In the emergency department, she was the ED Trauma Director for five years with a focus on improving the care of our injured children. Nationally, she has worked with the Children's Hospital Association to develop learning modules around the care of drowning in children and previously had an EMS Timely Tips podcast on drowning. She is known for her clinical work and quality improvement and has won two Faculty Awards and Clinical Care Achievement Awards for her sepsis improvement work. Dr. Hueschen, thank you for joining us today.

Dr. Leslie Hueschen: Thank you for having me, Dr. Steele.

Host: So, it's interesting. So, you grew up in Michigan, so you're a Michigander. We're going to talk about pediatric drowning. Michigan, of course, has a bazillion inland lakes. So, this'll test your knowledge of being a Michigander here, do you know how many inland lakes Michigan actually has?

Dr. Leslie Hueschen: Oh, geez, that's a really great question. Well, you know, Minnesota is the state with 10, 000 lakes. So, I think we have to have less than that because we are not putting that on our bumper stickers or our license plates. So, less than that, but I would have to say, oh, gosh, I would say maybe 8500.

Host: So, that's exactly what I would have thought. So, I looked it up, it's actually 64,980 inland lakes. Can you believe that?

Dr. Leslie Hueschen: Oh, wow.

Host: Yeah, I would never have guessed. And in fact, there is no place in Michigan that is more than six miles from one of those lakes.

Dr. Leslie Hueschen: That's what I remember growing up. Yep.

Host: So, what a great segue into talking about water safety and pediatric drowning.

Dr. Leslie Hueschen: Yes. My whole life I grew up in the water, outside of the water, next to the water. And then, I also took up rowing and rowed in high school and then for the University of Michigan in college too. So, there's a special place in my heart about, being in the water, but also being safe around the water.

Host: That's awesome. So, we'll have both personal and professional expertise as we talk about safety around the water as well as pediatric drowning. Let's just jump right on into it. So, for providers who are parents or caregivers of children, what are the most common drowning prevention strategies that you would typically give to those parents and caregivers?

Dr. Leslie Hueschen: Well, I'm also a parent of a five and seven-year-old, so I take water safety very seriously. It's estimated that about 80% of drownings actually remain preventable. And so, it's really important that we have this discussion about the different parts of preventing drowning and what all of us can do, whether we're a provider or whether we're a patient and what we can also counsel our families on.

So, some of it starts with kind of the basic stuff, let's stay within arm's reach of our children when we're in or near water and actually making sure that we're having a dedicated water watcher. Basically, this water watcher needs to be an adult who's not on their phone, not distracted with conversations and friends, but really has the main goal of making sure that the kids are safe in what they're doing in the water.

We at Children's Mercy also have water watcher badges that a lot of times we give away in the summers, but you can also get them online. And a water watcher badge is basically a physical lanyard necklace that you can transfer from adult to adult that really designates that this person is in charge of the children that are in the water. I like to make sure that we have somebody that's a water watcher, even if you're in an area that has lifeguards, because the lifeguards may miss your children. And it's always good to have somebody also watching them.

That brings me to the next point. You know, swimming in water safe areas where there are lifeguards also puts that second layer of support so that if somebody was in an emergency that there are lifeguards that are trained in water safety and water rescue.

Next thing is like we talked about all this time around the lakes when you're using watercrafts, making sure that we're wearing a lifejacket. So, this means not just the speedboat where you're going really fast on the water, but also boats, kayaks, stand up paddle boards. I'm trying to think of all the other water sports.

Host: I mean virtually anything if you're on the water, right? Yeah.

Dr. Leslie Hueschen: Yeah, if you're on the water. And there are different laws, depending on what state you're in, about how old do you have to be to be out of the lifejacket. So, there's also regulations for that too.

Host: So, as we're talking about, I mean, there's summertime, whether you're up in Michigan or you're in the Southern part of the U.S. where I grew up. I mean, lakes and water is such a huge part of summer activities. How common are these drowning injuries?

Dr. Leslie Hueschen: Unfortunately, too common, which is why it's so nice to be invited to have a podcast about decreasing pediatric drowning, because we actually did see an improvement of this between 1999 and 2019. There was actually a decrease in the drowning rates from 1.6 per 100,000 children to one per 100,000. But unfortunately, in the last couple of years, we've seen the number of deaths increased back up, which are actually even higher in boys, higher in Black adults, in Hispanic adults. And unfortunately, Black children who are 10 to 14 years old have a 7.6 higher time risk of drowning, specifically in a pool compared to other children. So, there's a large disparity in where we're seeing people at risk for drownding.

You know, one of the things that prevents drowning is also getting kids into swim lessons. But unfortunately, only about a third of Black adults have ever had a swim lesson and a quarter of Hispanic adults have ever taken a swim lesson. And so, trying to increase the rates of swim lessons universally would really also help protect kids from pediatric drowning.

Host: You know, access to that kind of education for swimming lessons and whatnot is going to be disparate, depending on where you are. And so, I think that's a really important point that you bring out. You know, just as an interesting fact, I think back on my childhood, I remember I graduated from the University of North Carolina. I don't know if they still have this, but it was required for me to pass a swim test before I could graduate. I don't know if they still do that or not, but having it part of the educational system seems like that may be helpful.

Let me pivot just second. There's certain terms that get thrown around both in the medical field as well as in the lay press. And I remember, when I was covering the Pediatric Intensive Care Unit, there was drowning, there was near-drowning, that term, dry drowning, secondary drowning. Can you kind of go through some of those terms for our listeners as to what those would typically mean?

Dr. Leslie Hueschen: I think we were seeing so much out there in the press of all of these different terminologies and not people using them in a unified way. So in 2003, we really made sure that we were very systematic in how we use these terms. So, the terms we usually use are either non-fatal drowning or fatal drowning. And those describe episodes where the patient experiences respiratory impairment from submersion or immersion in a liquid. And from that, you can then also classify that as whether it was a partial submersion or a full submersion. We don't use these terms like wet or dry drowning or secondary drowning because really what they're describing is actually this progression of illness where they don't have immediate respiratory symptoms at the beginning, but within eight hours, they actually develop those symptoms.

And that is actually what we know of as a normal pathophysiology that happens after the non-fatal drowning episode. And so, that same kind of dry drowning or secondary drowning is actually a non-fatal drowning symptoms, but we're just using a different terminology for it. And so, I think it can spread fear in the lay public. And so, you have to be very cautious with it, and I think we need to make sure that we're using that same terminology because those symptoms may actually develop within those eight hours. And so if your child ends up having those symptoms, any kind of respiratory symptoms after a non-fatal drowning episode, they need to come to the ER because they may be developing signs of respiratory compromise or respiratory symptoms secondary to that drowning episode. Because it can actually take sometimes up to seven or eight hours to develop.

Host: Yeah. So, let me pull on that string just a little bit. So, I think what you're referencing is just the inhalation of the liquid that they were submerged in having sort of these late effects or later effects. Can you kind of go through a little bit in more depth of what to look for if this occurs? And certainly, for the primary care physician, if they happen to be seeing a patient a couple hours later that otherwise seemed to survive the episode, but might be having trouble later on.

Dr. Leslie Hueschen: So overall, kind of drowning begins with this period of panic. You get a loss of the normal breathing pattern, breath holding, air hunger, that then leads to a reflex inspiratory effort. These cause hypoxia secondary to aspiration of liquids as they're submersed and reflex laryngospasm when the liquid contacts that lower respiratory tract, so that can result into low oxygen, hypercarbia, acidosis, which all can also impact your heart and your myocardial myocardial contractility, so how your heartbeats, elevated pulmonary artery and systemic vascular resistance and can produce cardiac arrhythmias, which can also lead to cardiac arrest. So, that's how it affects the heart.

How it affects the lungs is the fluid comes down into the lungs, kind of flushes out some of the surfactant, leading to a ventilation-perfusion mismatch, atelectasis, and increased vascular permeability, which then leads to this pulmonary edema, leading to acute respiratory distress syndrome, or ARDS. And we know that probably the type of liquid doesn't really matter because in non-fatal drowning victims, we know that they don't aspirate more than three to four milliliters per kilo, but that's enough to really cause all these secondary effects. And so, you would watch somebody after a drowning injury for eight hours. And if they started having respiratory symptoms, cough, increased respiratory rate, or abnormalities on that chest x-ray, then those patients would need to get admitted to the hospital because they have a risk of progressing with that respiratory injury that has happened from the non-fatal drowning injury.

Host: Great advice. And not to be lulled into, "Hey, you survived the episode. There's still time in which there can still be injury that needs to be monitored." So, very, very, very helpful advice. Let me back up just a little bit and look for the acute episode of a drowning injury. What should providers think about if they happen to be on the scene for performing sort of a rapid assessment of a patient?

Dr. Leslie Hueschen: So if you're there and you're on the scene, then the biggest thing is kind of recovery from the water with a constant attention to the rescuer's own safety. Once you get them out of the water, really your first treatment is ventilation with prompt initiation of the rescue breathing, which will also increase the victim's chance of survival.

After out of the water, really check breathing, give rescue breaths if there's no spontaneous respirations, and then also assess for the pulse. If they're pulseless, after the two rescue breaths, then you're going to begin chest compressions. This is different than the compression only CPR that is taught in PALS and ATLS. There's also a higher risk of arrhythmias in these patients with submersion injuries. So if you do have somebody, have them go and get the AED, and attach the defibrillation pads to really assess for the shockable rhythm and making sure that you're obviously contacting to call for 911 to get them transmitted to the closest hospital.

Host: One thing that you mentioned is the difference between say the ACLS protocol for the patient that may have had a significant drowning injury. Are there different guidelines? And if so, where would the physicians access those?

Dr. Leslie Hueschen: The guidelines for triaging patients post drowning, you know, I think the biggest thing is to reverse hypoxia and restore normal oxygenation and circulation as quickly as possible. This will really help you avoid further injuries to the patient. So, patients can arrive in a variety of clinical states from really being asymptomatic to full cardiac arrest.

And so, in the full cardiac arrest, you need to continue with your PALS ATLS management and managing them. If patients are coming in, and they are awake and alert, breathing spontaneously with really normal oxygen saturation greater than 90% and normal mental status, you can basically observe them with oxygen and continuous pulse ox monitoring for that eight hours to be watching for any kind of symptoms.

If they've got symptoms, cough, hypoxia, you do a chest x-ray and they show any abnormalities there, then those are the ones that you're wanting to kind of get admitted. In the patients with cardiac arrest with drowning, you're focusing on return of circulation, stabilization, respiratory support, correction of hypothermia, and other electrolyte abnormalities with close ICU monitoring.

Host: As I hear you explain to that always, it just comes down to ABCs as it always does. And particularly true on the airway and breathing for these patients. Is that a fair assessment?

Dr. Leslie Hueschen: it is. And I think, you know, one of the things that I didn't fully touch upon is that, all these kids you've just pulled out of the water or some sort of liquid. And so, focusing also on rewarming is going to be really key too, especially in somebody who has a cardiac arrest. We really want you to kind of continue the PALS algorithm until they're back to a normal temperature of 33 to 36 degrees Celsius, because we know that our epinephrine and the medicines we use to restart the heart aren't as effective if the patient's temperature is below 30 degrees Celsius. So, really kind of focusing on that re warming effort along with the management of your ABCs.

Host: Very good. Well, Dr. Hueschen, thank you so much for joining us today and giving us your insight, both personal and professional, about water safety and the acute and post-acute care of the child that had a drowning injury. Before I let you go, and this is almost a love letter to Michigan, because knowing that you're, from Michigan, I couldn't help, particular, as we're talking about water, one thing I'll throw out, that the only state that has more coastline than Michigan is Alaska. Don't know if you knew that or not, but as we talk about water, water safety, for those of you who have not been able to visit Michigan, you should. It's a fantastic state, and I'll throw that out to our primary care physicians listening up there in Michigan.

Dr. Leslie Hueschen: Yes, thank you so much, Rob. Thank you for having me. I was actually just up there on the west side and celebrating Little Point Sable's 150th year anniversary just this last Saturday. One of the tallest lighthouses right there on the coast of Lake Michigan, that's close to where my family stays. And it really is such a gem when you guys go up there. Jump in a lake, eat some Superman ice cream, and try to see all the beautiful lighthouses and all the history they have.

Host: Yeah. And don't forget your Water Watcher badge.

Dr. Leslie Hueschen: Exactly.

Host: There you go. As a reminder, claim your CME credit for listening to our show today. Visit cmkc.link/cmepodcast and click the claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. I'm Dr. Rob Steele. See you next time.