Letter To The Editor
From Henry Oakeley, M.R.C.P.
Dear David,
Thank you for passing on Dr. Lloyds comments. Some of his smaller points echo my
sentiments exactly; certainly his main point, that reading about the management
of such emergencies is no substitute for practical experience, cannot be
controverted. In my article, I may have
been unduly dogmatic in places, hoping thereby to avoid clouding the main issue
with all the arguments (and their references too!). Olivers first comment is an example of
something which has arguments both for and against, and I would bow to his
personal, practical knowledge in this aspect of management of drowning. I must thank him also for bringing to our
attention that I have neither stressed the danger of cold exposure
sufficiently, nor made any mention of the hot bath in its treatment. I can say no more than that cold exposure
can kill you, quickly, un-dramatically, and irrevocably. The hot bath treatment is probably the best
thing for reversing cold exposure. Victims of this will scald easily so do not make the bath hotter than
you yourself can tolerate. Death can
occur during the re-warming process so the presence of a doctor is an
advantage, but do not delay because of the absence of one. At a certain stage in the progression of cold
exposure the body will stop producing heat so effective insulation will not
stop you from getting colder and only external heat will reverse the process.
There are two points which perhaps he misunderstood, which I
would like to clarify.
Firstly, concerning the time before starting cardiac
massage. Following drowning most healthy
young hearts will restart readily following the initiation of artificial
respiration, without recourse to cardiac massage. In inexperienced hands cardiac massage is
quite dangerous, in experienced hands most of the victims suffer fractured ribs
at least which may be so severe as to require continuous artificial ventilation
until they heal up (i.e. days). Cardiac
massage performed on a beating heart may stop it. A cold wet caver with no experience in
feeling for a pulse may have the utmost difficulty in assessing whether a heart
is beating when the pulse is very weak, so because of this and because of the
dangers of cardiac massage, I would advise that massage should not be attempted
until you have felt unsuccessfully for a pulse for a good half minute. A one minute delay in starting cardiac
massage is, in these particular circumstances, of less harm than performing it
unnecessarily, but if you are experienced in assessing whether the heart is
beating or not, then I would agree with Oliver that the earlier that you start
the better.
Secondly, concerning the use of amphetamines. I agree that there is good evidence that amphetamines
are of benefit in improving endurance and performance in normal people and in
people suffering from exhaustion due to lack of sleep. Amphetamine taken by mouth takes two hours to
act fully so it may, by its ability to improve feeling of well being and of
raising morale, prevent the onset of cold exposure if taken in good time during
a prolonged and arduous expedition. However, there is absolutely no evidence that it has any effect on
reversing cold exposure once it has developed, and the undesirable side effects
of amphetamine such as irrational behaviour, over activity and bizarre mental
states would be detrimental to the safety of the affected individual and hasten
his death. Glucose is a first rate treatment
and has no side effects; it would be wise to stick to this alone.
The conclusion which I hope that your readers will draw from
this correspondence is that a few hours of practical experience in lifesaving
techniques is worth far more than a millennium of collecting references in
learned journals, and will proceed to emulate Dr. Lloyd and Barry Lane and
enrol in a life saving course.
Henry Oakley, M.R.C.P.
St. Thomas Hospital,