Improving understanding and changing protocols for the rescue & resuscitation of immersion victims
Submitting InstitutionUniversity of Portsmouth
Unit of AssessmentSport and Exercise Sciences, Leisure and Tourism
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Clinical Sciences, Public Health and Health Services
Summary of the impact
Internationally, immersion is a leading cause of accidental death and the
leading cause of death of sportspeople (221 of the 635 UK immersion deaths
in 2012 were sports-related). The Extreme Environmental Medicine &
Science Research Group (EEMSRG) publishes widely, from scientific papers
to specific reports for a wide range of international end-users, including
various emergency services. Our research has had global impact on (i) The
protection, rescue and treatment of immersion casualties, (ii)
International standards, guidelines, policies, campaigns and training
manuals of those responsible for the protection, rescue and resuscitation
of casualties, (iii) Raised public awareness of immersion issues.
The research underpinning this ICS was led by Professor Tipton, with
contributions from Dr Eglin (Principal lecturer); both appointed in 1998.
More recently Dr Lunt has contributed (appointed as lecturer in 2013 after
completing PhD and post-doctoral studies within EEMSRG). Dr (Admiral)
Frank Golden OBE has acted as medical consultant to the group, which
investigates the fundamental and applied aspects of the pathophysiological
and physiological responses to immersion.
The WHO estimates 1.2 million people drown each year; drowning kills more
children than Malaria, TB, HiV or Polio. In the UK, one child drowns each
week on average. Tipton highlighted the role of the initial
cardio-respiratory responses to cold water immersion ("Cold Shock") as a
precursor to drowning and thereby changed the priority for risk assessment
and therapy from hypothermia to drowning, and the emphasis on protection
to include the provision of emergency underwater breathing aids (EBA).
Subsequent applied R&D work produced the first EBA for helicopter
passengers ("Air Pocket") and a methodology for the standardised
assessment of EBA (Barwood et al, 2010). The group described
"Circum-rescue collapse" for the first time, with consequences for the way
immersion casualties are rescued. The group also characterised the
progression towards swim failure in cold water, assisting its
identification and prevention (1).
Since establishing the EEMSRG in 1999 Tipton and colleagues have proposed
fundamental mechanisms to explain sudden death and prolonged survival
underwater (2 & Tipton 2003, Lancet). Again, and importantly, the
applied implications of these findings for the search, rescue and
resuscitation of submerged casualties were developed by meta-analysis and
consensus meetings into a decision making guide to assist the search and
rescue community (4). With the aim of making search and rescue policies as
realistic as possible, the ability to undertake basic life support on
small boats has also been studied (3). In addition to looking at
technology-based protection against cold (EBA, specialist clothing), the
EEMSRG have undertaken a detailed examination of habituation to cold, as
well as studied the novel concept of "cross-adaptation" between cold
immersion and altitude (Lunt et al, 2012).
Recent work has included a new theory for sudden cardiac death on
immersion and in other circumstances. "Autonomic Conflict" occurs when the
two branches of the autonomic nervous system are co-activated (Tipton et
al, 2010). The proposed mechanism underlying Autonomic Conflict has been
investigated by a combination of human and isolated heart studies (5).
Consistent with the EEMSRG's approach of ensuring that the relevance and
application of fundamental work is communicated to those who may be most
impacted, additional applied research work and papers have been produced
in the areas of helicopter underwater escape training (Tipton et al, 2010)
and open water sporting events (6). This work is already having an impact
on the interpretation of immersion-related deaths and the planning of
sporting events. Much of the applied output of the EEMSRG is through
scientific reports directly to specific agencies; it is by this route that
the most direct impact occurs; we have published 58 such reports since
References to the research
1. Tipton MJ, Franks CM, Gennser M & Golden FStC (1999) Immersion
death and deterioration in swimming performance in cold water. The Lancet
Vol 354 (Fast track) 21 Aug, No. 9179: 626-9. ISSN 0140-6736 10.1016/S0140-6736(99)07273-6.
This paper was the first to provide a detailed characterisation of swim
failure in humans. Its findings and figures have been reproduced in many
publications on water safety. Impact Factor: 39.06.
2. Datta, A. & Tipton, M. J. (2006) Respiratory responses to
cold water immersion: neural pathways, interactions and clinical
consequences. Journal of Applied Physiology. 100(6): 2057-2064. ISSN
This paper was the first to describe the central neural pathways and
cerebral blood flow changes associated with "Cold Shock" and the
possible neuro-anatomical correlate of what was subsequently called
"Autonomic Conflict" (AC), as well as the association of AC with
survival on immersion, during birth and sleep, and the implications of
AC for sudden death in other circumstances. Impact Factor: 3.75.
3. Tipton MJ, David G, Eglin CM & Golden FStC (2007) Basic life
support on small boats at sea. Resuscitation 75(2): 332-337. ISSN 0300
This was the first paper to measure the ability to perform basic life
support at sea on small boats. It helped inform the safety cover policy
for oil companies operating in the North Sea and elsewhere. Impact
5. Shattock MJ, Tipton MJ
(2012) "Autonomic conflict": a different way to die during coldwater
immersion? J Physiol. 15; 590(Pt 14): 3219-30. ISSN 0022-751 DOI: 10.1113/jphysiol.2012.229864.
On the basis of original human & animal work, this was first paper
to fully elucidate our theory of Autonomic conflict with human and
animal supporting data. The evidence from different meetings and
websites is that it is changing the way sudden death, particularly on
immersion, is being regarded. This work won "Best paper" at the 2011
World Congress on Drowning Prevention and the theory has already been
incorporated into: the ILS position statement on cold water immersion;
the Oxford handbook of Expedition and Wilderness Medicine; and
Caroline's Textbook of Emergency Care. Impact Factor: 4.834. Ref2
6. Tipton, M. J. (2013) Sudden cardiac death during open water swimming.
British Journal of Sports Medicine. Online First, published on February 1.
ISSN 0306-3674 10.1136/bjsports-2012-092021
This paper contextualises our theory of Autonomic Conflict for the
sporting population; in particular it proposes a theory for death during
open water swimming (79% of deaths during triathlon occur during the
swim). It is already changing the way open water sporting events are
organised. Impact Factor: 3.668.
Details of the impact
Research in the department's Extreme Environments Laboratory (EEL) by the
EEMSRG has had profound, global and paradigm-altering significance within
the REF period.
a. Impact on the protection, rescue and treatment of immersion
casualties. The EEMSRG introduced the concepts of "Cold Shock";
"Circum-rescue collapse" and "Autonomic conflict"; these major advances in
the understanding of the physiological response to immersion have directly
informed the protection (equipment provided), rescue (methods) and
treatment (priorities) of immersion casualties: "Dr Tipton's
elucidation of cold water shock has transformed the physiologic
understanding of drowning." (1). "The work of the laboratory has
significantly influenced our thinking and understanding of the hazardous
responses to immersion and ... our policies for the search, rescue and
treatment of immersion casualties" (2). EEMSRGs work is regularly
used in fatal accident enquiries and legal cases, ranging from child abuse
to murder, informing decisions and recommendations (3, 4).
b. Impact on International standards, guidelines, training manuals.
The premier organisation for establishing international standards in sea
survival is the UN's International Maritime Organisation (173 member
nations). Its "A Pocket Guide to Cold Water Survival", was "largely
based on the work of the EEL (EEMSRG)" (5). Published in 2012, it
sold in excess of 10,000 copies in the first three months. This
publication forms the basis of the immersion survival, protection and
search and rescue policies of member states.
EEMSRG research has informed the training programmes of numerous
international organisations including the International Lifesaving
Federation, the world authority for drowning prevention, lifesaving and
lifesaving sport. Our work has "influenced the development of
international lifesaving programmes and standards" and "a number
of the ILS International Lifesaving Certificates have standards based on
evidence arising from the University of Portsmouth" (6). The work of
the EEMSRG appears in many first aid and search and rescue training
manuals, including those of: the Royal National Lifeboat Institution
(RNLI), Royal Yachting Association (RYA), Mountain Rescue; Surf Lifesaving
GB and New Zealand; Moroccan SAR; Royal Netherlands SAR; US Lifesaving
Association; UK and Canadian military SAR; Yachting Australia. "The
research work (of the EEMSRG) has produced the science to base our
current casualty care syllabus, teaching and practice upon in the fields
of immersion, submersion and hypothermia" (7, 8).
Recent research on "Autonomic Conflict" (2012, Section 3, Reference 5) is
already described in the first aid manuals and training material of Surf
Lifesaving GB and the RNLI. Our recent publication "A proposed
decision-making guide for the search, rescue and resuscitation of
submersion (head under) victims based on expert opinion" is being used
internationally. In the UK it has been the catalyst to move the different
SAR agencies towards using a common operational protocol: "Portsmouth
University influenced our thinking, assisted and supported the
development of National Guidance" (8, 9). Our work appears verbatim
in the Fire & Rescue Services National Operational Guidance on Water
Rescue and Flooding. Recent research on survival time during head-out
immersion has been used by the US Coastguard to produce new search and
rescue models and strategy.
c. Impact on public awareness. An important method for reducing
the number of annual immersion deaths involves educating the public about
the risks of cold immersion. This form of "preventative medicine" has been
achieved through involvement with various agencies noted above; helping
them produce campaigns for lifejacket usage e.g. "Useless unless worn"
(UK: RNLI, HMCoastguard); ""Stay on top with a lifejacket" (Maritime New
Zealand); "Wear one for openers" (Maritime Australia). We have also been
involved in water safety campaigns (e.g. RNLI "Respect Water" campaign
August 2013) and appeared in, and helped write the script for the RNLI
water safety video "Cold Shock" (2010), as well as taught on RNLI, RoSPA
and RYA sea survival courses. Between 2008 and 2012 EEMSRG staff were
involved in over 100 media appearances demonstrating and discussing the
risks of immersion. Tipton also lectures on immersion and drowning to
medical students in London, Leeds and Birmingham.
It would be nice to think that the impact outlined above has saved lives.
This is difficult to determine definitively, however it is encouraging to
hear from those that should know that this is the case: "There is little
doubt that the work the (EEMSRG) does in the field of cold water survival
continues to save lives every year (10); "Without doubt the excellent work
carried out by (EEMSRG) has contributed significantly to our goal of
saving lives at sea" (7); "The work of the EEMSRG has undoubtedly saved
the lives of immersion casualties" (8). "This has been literally
lifesaving work. Thank you" (2).
Sources to corroborate the impact
- Letter: Professor of Paediatrics, Paediatric Emergency Medicine,
Seattle Children's hospital and University of Washington School of
Medicine, Seattle, USA.
- Letter: Head of Intensive Care del Centro del Hospital Municipal
Miguel Couto, Rio de Janeiro; Medical Center recuperación del Ahogados
of Barra de Tijuca, Cuerpo de Bomberos, Rio de Janeiro; Medical Director
SOBRASA Sociedade Brasileira de Salvamento Aquatico, Brasil.
- Letter: Chief Medical Adviser, Royal Life Saving Society UK; Honorary
Medical Adviser ILSE; Honorary Secretary, Medical Committee ILS;
Honorary Consultant Physician & Cardiologist, Colchester General
Hospital, England; Immediate Past Co-Chairman of the Basic Life Support
Task Force of the International Liaison Committee on Resuscitation
(ILCOR). Member of the European Resuscitation Council (ERC) BLS Task
Force in ILCOR, and is Chairman of the ERC International BLS Course
Committee. Past Chairman of the Resuscitation Council (UK) and currently
Chairman of their BLS/AED Subcommittee.
- Letter: Deputy Chief Inspector of Marine Accidents, Marine Accident
Investigation Branch, Southampton.
- Letter: Secretary, International Maritime Rescue Federation,
- Letter: Chairman, International Lifesaving Federation Business
- Letter: Chairman, RNLI Medical & Survival Committee; Consultant in
cardiothoracic anaesthesiology at Southampton University; Medical
Director for South Central Ambulance Service (Hampshire); Author of UK
Resuscitation Council courses for Advanced Life Support; Co-chair of the
Advanced Life Support Group of the International Liaison Committee on
- Letter: Medical & Technical Consultants to Surf Lifesaving GB.
- Letter: Medical Director, National Ambulance Resilience Unit, West
Midlands; Associate Medical Director at East
Midlands Ambulance Service NHS Trust.
- Letter: Royal Yachting Association Training Manager and Chief