In Critical Decisions (August 2013), “Submersion Injuries,” there are two areas I would like to question.

“The patient is not dead until he is warm and dead,” was chiseled on the tablets we used during my residency (1976). But I have yet to find a definitive statement on how warm. The authors state that “resuscitation efforts must persist until normal core temperature is reached.”

Not everyone will be able to be brought back to a normal core temperature – unless you are using cardiopulmonary bypass. I watched a colleague struggle for over 4 hours to warm a patient who would get up to 94-95°F, only to start sliding back. Successful defibrillation and metabolism of drugs still occur somewhere below 98.6°F. I would suggest that from a pathophysiology standpoint

(I know of no studies) that if the patient is up to 93°F degrees and still in asystole, you are done.

The other area of concern was the recommendation for blood gases. I recently had a respiratory therapist tell me he hated July because all the new residents order ABGs frequently. This is one of those tests, like an NG, that you shouldn’t be able to order until you have had them done to you – preferably by an inexperienced nurse or medical student. The pulse oximeter, which is adequate above SpO₂ of 92, tends to diverge below that. Side stream CO₂ levels are available with a modified nasal cannula or ET adapter. Venous blood gases will give you a reasonable pH.

–M. Jo McMullen, M.D.