Rambam Hospital Physicians Discover Causes of Kidney Injury in Near-Drowning Victims

Rescue me from the mire; let me not sink; let me be rescued from my enemies, and from the watery depths. Psalms 69:15

Magen David Adom and United Hatzalah rescue teams treated almost 250 cases of near drowning or death by drowning– most of them off the Mediterranean coast – since the beginning of the swimming season in the middle of March; of these, 53 people, including 30 young children, have died. Most of the victims went under in the Mediterranean, with about 40 in public swimming pools, 22 on the shores of the Dead Sea, 22 in private pools, eight in the Sea of Galilee and eight off the coast of Eilat. Three more were at the Gan Hashlosha natural pool in the north and two in a water reservoir.

Living in a hot country, Israelis are lucky that the Mediterranean Sea is at its western border and the Sea of Galilee’s blue waters lie temptingly to the northeast. A growing number of Israelis have installed swimming pools in their backyards or go spend vacations at bed-and-breakfast guest houses with pools in various parts of the country.

But there is a dark side to these waters – drownings by children, teens and adults who don’t know how to swim well or who are pulled down and out by unexpected strong currents. Ultra-Orthodox Jews and Israeli Arabs, many of whom do not take swimming lessons for financial or other reasons, are among the most common drowning victims, but the tragedies affect every sector.

There are also periodic incidents of infants and toddlers drowning in bathtubs or even pails of water left momentarily for washing the floor. During the whole 2017 swimming season through October of last year, 39 people drowned and 234 were treated, making the current trend very worrisome.

Raphael Poch of the volunteer emergency rescue organization United Hatzalah said that many countries are attributing the rise in drownings and near-drownings to the addictive use of cellphones and adults not paying attention to what is going on around the pool or water area. The same cause has been blamed on road accidents.

He urged all parents, camp counselors, lifeguards and even bystanders near bodies of water to put down their cellphones and maintain vigilance over children near or around sources of water at all times.

“Unlike popular theory, drowning is silent and people will most often not hear a sound when a child or adult drowns. Visual cues are the only way to tell that a drowning is occurring in most instances. One simply must watch children around water sources at all times,” Poch said.

Moshe Mizrachi, a volunteer emergency medical technician at United Hatzalah, recently described the traumatic event in which he tried but failed to save a young drowning victim. “It was a sight I can never forget, and a fight that I lost. I was planning a vacation with my family for quite some time, and I said to myself that this will be a real vacation and that I won’t get bogged down with work, or volunteering. I left my radio at home and made up my mind that I would only go out to life-and-death emergencies. I took my medical equipment with me, it is always with me. In my heart, I knew that I might need it.”

Little time passed before he got a phone alert about a child suffering from shortness of breath right near the guest house where he and his family were staying. “I thought about it for a second, telling myself I was on vacation and that others would respond, but I knew in my heart what would really happen,” he recalled. “The phone rang, United Hatzalah’s dispatch and command center told me that I was the closest responder, and I ran. It was mere seconds between the time the phone rang and the time I arrived at the scene of the emergency. The events that then unfolded, will remain seared into my mind forever.”

A young girl had been pulled from the water of the on-site pool and was unresponsive. He rushed to her side and found she wasn’t breathing and didn’t have a pulse. He immediately attached a defibrillator and began coronary-pulmonary resuscitation. “I performed chest compressions and assisted breathing by myself for more than eight minutes. My focus honed in and my world contracted to only the three of us, the little girl, myself and the angel of death hovering above us. It took eight minutes for the next responder, a doctor from a private ambulance company, to arrive – eight minutes that turned into an eternity.”

Nearby, the girl’s family were screaming uncontrollably. “I couldn’t scream. I was focused on my work at hand. But had I spoken at that moment, had I put words to my thoughts, I would have screamed. I would have screamed at the angel of death to leave this girl alone, to let her enjoy her vacation with her family, to let me enjoy mine… We lost the fight. I looked up and other first responders had joined in the CPR efforts. The girl was taken to the hospital in an ambulance that had arrived. She still wasn’t breathing, and they were continuing CPR efforts on the way to the hospital.”

United Hatzalah’s psychotrauma and crisis response unit, which comes to emergencies wherein a traumatic event was experienced by numerous people arrived and began talking to the family and treating them, providing every bit of comfort that they could.

“I beg everyone reading this to please guard your children and set for yourselves clear boundaries so that no one has to endure this scenario ever again for it is too heavy a burden to bear.”

Meanwhile, doctors at Haifa’s Rambam Medical Center have discovered that acute kidney injury is a common complication of near-drownings – due to lack of oxygen and the fight-or-flight response. Their research suggests that men are at the highest risk for this complication. According to the World Health Organization, drowning is the third-leading-cause of accidental death globally, with males especially susceptible.

The doctors, who published their findings in Kidney International Reports of the International Society of Nephrology, observed that a relatively high number of nearly drowned patients developed a sudden reduction in kidney function – with potentially fatal consequences – within days of being admitted to the hospital. This is especially worrisome, since the kidneys are critical for health: They remove wastes from the body while maintaining a healthy balance of water, salts, and minerals in the blood. 

Two years ago, a 31-year-old man who had been submerged in seawater for four minutes arrived at Rambam with water in his lungs, respiratory distress, elevated heart rate, low blood oxygen concentration and low phosphate levels; he subsequently developed acute kidney injury (AKI). This case study induced the physicians – led by internal medicine Prof. Mogher Khamaisi, together with Rambam Drs. Yuri Gorelik and Said Darawshi – to investigate the frequency of AKI in near-drowning victims, its clinical characteristics, warning signs and causes. 

Theirs was the largest and most comprehensive study researching the mechanism of kidney damage in near-drowning patients immersed in seawater to date; previous studies only looked at a few patients. The team reviewed the medical records of 95 patients treated in the Haifa hospital between 2000 and 2017 who nearly drowned in the Mediterranean Sea. A total of 43 patients (45 percent) developed AKI, and 17 reached an advanced stage of disease (stage 2/3) as indicated by a high increase in creatinine levels in the blood and reduced urine output. 

The main causes of kidney damage appear to be temporary lack of oxygen combined with the victims’ physiological fight-or-flight response – increased heart rate, very-high blood sugar levels, constriction of the kidney blood vessels, reduced potassium levels, and increased demand for oxygen.

The researchers concluded that AKI is a common complication of near-drowning and associated with increased in-hospital deaths. They recommended further studies on near -drowning patients at risk for developing AKI, based on this research; and treating and monitoring patients by restoring oxygen levels throughout their body, maintaining proper dilation of kidney blood vessels, and other medical practices to prevent kidney complications.

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