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Letter To The Editor

From Henry Oakeley, M.R.C.P.

Dear David,

Thank you for passing on Dr. Lloyd’s 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!).  Oliver’s 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, London.