Page 71 - JSOM Summer 2025

warm or cold temperatures but is accelerated when a person is concern, as both youth and older people have less ability to
submerged in water and accelerates further the colder the wa- thermoregulate, but these populations are generally not a part
ter becomes. 16,17 Even with warmer waters globally, including of the military population and are less relevant to this man-
temperatures exceeding normothermic body temperatures, ex- uscript. Hypothermia with trauma is associated with double
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posure to air while wet can instigate hypothermia. Hypother- the risk of mortality compared with normothermic trauma pa-
mia has long been a recognized risk for increased mortality in tients. 5,19,23,24 Patient temperature <36°C is an independent risk
trauma patients and combat casualties and was the topic of one factor for mortality in trauma patients and is also correlated
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of the first JTS CPGs, published in 2006. Hypothermia, along to an increase in blood product consumption. In a civilian
with acidosis and coagulopathy, is part of the so called lethal trauma population, 80% of patients who did not survive their
triad to treat and avoid in patients with traumatic injury. Re- traumatic injury were found to have temperatures <34°C, un-
cently, hypocalcemia has also been recognized to be associated derlying the fact that most severe traumas are or rapidly become
with morbidity and mortality in injured patients; added to the hypothermic, and their risk for death increases significantly. 28
lethal triad, these four conditions are often referred to as the
“diamond of death,” and its treatment has become integrated Scenario
into Tactical Combat Casualty Care (TCCC) guidelines. 20–23
Setting
Prevention is a mainstay of both drowning and hypothermia, A U.S. Navy Landing Platform Dock (LPD) underway in the
particularly in high-risk military operational environments. Bering Strait is conducting freedom of navigation operations.
For example, in the 2020 Amphibious Assault Vehicle open The crew includes 386 ship’s company and 800 embarked
ocean training mishap, failure to apply appropriate operational Marines—1,186 total personnel. Medical capabilities include
safety protocols was found to be a contributing factor leading 20 stacked ward beds and 6 intensive care unit (ICU) beds,
to 9 deaths and 1 severe pulmonary injury from drowning in each with cardiac monitoring and ventilator capability (Zoll
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the crew of 15 Marines and Sailors. No matter the opera- EMV+ ventilator). Available laboratory capability includes
tional or training environment, it is vital for all active-duty rapid complete blood count (CBC), using QBC STAR (Drucker
personnel to be well trained in prevention and treatment of Diagnostics, Port Maltilda, PA), an I-STAT (Abbot Point of
drowning and hypothermia and well versed in the operational Care Inc., Abbott Laboratories, Chicago, IL) (capable of pro-
safety protocols and operation risk management procedures viding chemistry, electrolytes and lactate), dipstick urinalysis
specific to their military platforms and occupations. (UA), finger-stick glucose with glucometer, and fecal occult
blood testing. The LPD has basic X-ray capability and an ultra-
Epidemiology sound machine, but none of the caregivers have received formal
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The incidence of drowning worldwide continues to be a signif- ultrasound training. The available medical staff consists of
icant burden of disease, particularly in the developing world, two General Medical Officers (GMOs), the ship’s Senior Medi-
where 91% of unintentional drowning events occur. Drown- cal Officer (SMO) and a Marine Battalion GMO, one Indepen-
ing is a top seven cause of death in all age groups under the dent Duty Corpsman, and 32 Corpsmen from a combination
age of 24 years, a notable figure, as 44% of the entire mili- of ship’s company and embarked U.S. Marine Corps (USMC)
tary population is under that age. 5,24 Alcohol consumption is units. Neither the SMO nor the GMO are residency trained
a frequently related cause of drowning, particularly in young and are relatively new to the operational environment. The
males, which is applicable to the military population but less SMO recently completed a surgical internship and the GMO, a
so in the operational environment. 7 transitional internship 3 months before the current period. Due
to the ship’s location and sea state, it is 48–72 hours before
The incidence of drowning during high-risk training events is medical evacuation (MEDEVAC) is likely to be possible.
unknown, but some epidemiologic data is available describing
the risk to embarked personnel on naval warships. According The ship encounters sea states of 6–8 feet, and two Marines
to data obtained from the Naval Safety Command, between performing chain inspections on the flight deck fall overboard
1970 and 2020 there were 216 drowning incidents involving after the ship sways dramatically from a large wave. Patient
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435 Sailors, 59.7% of which were fatal. While the incidence of 1 falls directly into the water and was not witnessed to strike
“man overboard” events on U.S. Naval vessels has been steadily any objects. Patient 2 slams into the tail rotor of a UH-1Y
decreasing since 1970, they are associated with a significant before falling overboard. Neither were noted to be wearing
mortality rate. Between 1970 and 2020 there were 220 reported life preservers. The episode is witnessed, and man-overboard
man-overboard incidents involving 352 personnel, with an as- procedures are activated immediately. Water temperatures are
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sociated mortality of 71.9%. An analysis of maritime naval 3°C. Due to the sea state, the deployment of the rigid hull in-
mass casualty incidents (MCIs) between 1980 and 2020 found flatable boat (RHIB) and recovery efforts are delayed. The in-
a total of nine noncombatant MCIs with a total of 87 deaths, jured casualties are spotted a short distance from the ship, and
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17 of which were due to drowning. A final study assessed U.S. Patient 1 is seen holding onto Patient 2, who appears uncon-
military deaths between 2013 and 2017, citing a total of 359 scious. Recovery by RHIB takes approximately 50 minutes.
drownings among active-duty personnel, but this figure is a Both patients are evaluated in the well deck before going to the
combination of both operational and recreational causes. 7 ship’s Main Medical department.

Hypothermia alone is a significantly less frequent cause of Patients
death but has been associated with significant mortality. An Patient 1 is a 20-year-old male, awake and oriented to name,
epidemiologic analysis of international civilian hospital admis- place, and date. No past medical history reported. A primary
sions from 1979 through 1985 found that men are three to survey was performed and no abnormal findings or evidence
four times more likely to experience hypothermia and have a of traumatic injury were identified. He is taken to the ship’s
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30% higher associated mortality. Extremes of age are a major medical ward.
Drowning and Hypothermia on an Amphibious Warship | 69