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Analysis of drownings in Poland from the past quarter century.


Christopher Truszkowski1, Julia Schulz1, Hawsoz Mohammed1, Ine Marie Wikestad1, Mirjana Ristic1



Introduction

Drowning and near drowning are tragic events that occur unexpectedly often in the lives of young and otherwise healthy individuals. There are phases that have been established that describe the course of a drowning. As depicted in Figure 1, the phases begin with a state of surprise and conscious attempts to inhale frequently, followed by submersion, then involuntary inspiration of water and air, then loss of consciousness, and finally cerebral hypoxia followed by death [1, 2]. Common mechanisms of injury are hypoxemia, acidosis and hypoperfusion. While neurological and pulmonary damage is a major cause of mortality and morbidity, a submersion event can be devastating to all the major organ systems. Other possibly fatal abnormalities include cardio-vascular instability and renal failure due to ischemia and metabolic abnormalities and disseminated intravascular coagulation [3, 4]. Infection is also a potential life-threatening complication of near drowning. While attributable morbidity and mortality associated with infection in victims of near drowning are not known, fungal and bacterial infections certainly should be considered. Of the infections associated with near-drowning, pneumonia is one of the most devastating [5].

Furthermore, there are differences that occur in the progress of drowning depending on the physical and chemical properties of the water source. Cold water drowning often results in rapid hypothermia and subsequent effects, such as a cardiac reflex arrest [1, 6]. One possible positive effect of the hypothermia would be the protection of neurological function from the hypoxia experienced during the drowning. Cold water drownings will require the body to be rewarmed during any hospitalization [6]. Drownings that occur in warm or hot waters would have to take burns into consideration during treatment. Also, there are differences seen in drownings that occur in fresh water versus sea water. In freshwater drownings, aspirated hypotonic water quickly passes through the lungs and into the intravascular compartment, resulting in volume overload and dilution of electrolytes [7]. In sea water drownings, the hypertonic saltwater causes water to be pulled into the pulmonary interstitium and alveoli, resulting in pulmonary oedema and hypertonic serum [7].

Drowning is defined as death from asphyxia within 24 hours after submersion. Secondary drowning is death from complications >24 hours after the submersion event. Immersion syndrome is sudden death, probably vagus mediated, due to cardiac arrest after contact with cold water. Submersion injury is any submersion resulting in hospital admission or death (e.g. near-drowning, drowning, or spinal cord injury). A save is a water rescue or removal of a victim from water by someone who perceived the individual to be a potential victim of a submersion injury [5].


figure1
Figure 1. The phases of drowning represented in a graphic form. The phases begin with a state of surprise and conscious attempts to inhale frequently (1), followed by submersion (2), then involuntary inspiration of water and air (3), then loss of consciousness (4), and finally cerebral hypoxia followed by death (5). Adapted from Medycyna Sądowa: podręcznik dla studentów medycyny by Jakliński A, Kobiela JS (eds.), PZWL, Warszawa 1975.
[please click on the image to enlarge]


First aid interventions for drowning incidents

Resuscitation before EMS arrival is an established important predictor of survival outcomes [8-10]. In the newest CPR guidelines for drowning, it is written that submersion time is the strongest predictor of outcome [11]. Resuscitation should be started in unconscious and non-breathing patients. The availability and quality of resuscitation may vary when performed by a common person without medical training. However, Youn CS et al. did not find statistically significant associations between resuscitation and survival [12]. These contradictions may indicate that the association may be dependent on the predominant body of water involved in the drowning, as the availability and quality of resuscitation may be different when a patient drowns in the river versus in a pool. Different forms of management may be required depending on the source of the drowning.


Drowning and pneumonia

Infection is one of the complications associated with near-drowning, and pneumonia is the most severe of these infectious complications. The percentage of near drowning victims who develop pneumonia is however unknown. While incidence of pneumonia associated with near drowning is unknown, the findings in some series suggest that it is not a rare event [5]. There are several factors associated with near-drowning pneumonia. Aspiration is one of them. Most near drowning victims aspirate fluid, the volume of aspirate may influence the risk of pneumonia after a submersion event. A submersion event in contaminated water also increases the risk of pneumonia. The temperature of water involved in a submersion event may affect both the likelihood of pneumonia and the type of organism causing its illness. The metabolic and division rate of organisms generally increase with increasing temperature [13].

The aspiration of gastric contents as a result of near-drowning may also increase the risk for near-drowning-associated pneumonia. Individuals in the panic of an unexpected submersion event swallow a significant amount of water. This places the near-drowning-victim at significant risk for vomiting. With the victim often neurologically compromised, aspiration of vomits easily occurs. Autopsy studies have shown that approximately 25% of drowning victims aspirated vomitus [14].

Individuals who experience near-drowning events are also at significant risk for nosocomial pneumonia. The significant damage done to the epithelial lining of the lungs places these individuals at higher risk for developing pulmonary infections. Many of these victims require monitoring in the intensive care unit, mechanical ventilation and H2 blockers. These factors also increase the risk of nosocomial pneumonia. The organisms that cause pneumonia after submersion either originate from the aquatic environment or from the oropharyngeal airway after an aspiration event. Aerobic Gram-negative bacteria are the most frequent implicated bacteria in these infections [15]. Case fatality rate associated with near-drowning-associated pneumonia is 60%. Pneumonia caused by Aeromonas species, Burkholderia pseudomallei, and Pseudallescheria boydii after near drowning appears particularly morbid [15-23].


Polish drowning analysis

All data on drownings reported in Poland has been provided publically by the Polish Police [24]. Some of the drowning data from the Polish Police was adapted into figures and basic statistical analysis was performed using Microsoft Excel. Data collection began in 1998 and continues to 2020. Most data from 2021 have not yet been released. Some changes in data collection and reporting have been made over the years; however, there is still a lot of overlapping data from over the past two decades.

In total from 1998 to 2020, there have been 14,726 drowning incidents reported to the Polish Police. Of these drowning incidents, a total of 13,016 drownings resulted in death. A total of 3,729 drowning incidents were alcohol related. On average from 1998 to 2020, there was 640 drowning incidents per year with 566 of these incidents resulting in death. As seen in Figure 2, the highest amount of drowning incidents and deaths occurred in 1999 with a total of 904 incidents and 828 deaths. The lowest amount of drowning incidents and deaths occurred in 2011 with 464 incidents and 396 drownings.

figure2
Figure 2. Total reported drowning incidents and deaths in Poland from 1998 to 2020. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


As shown in Figure 3, five-year averages of drowning incidences and deaths from 2001 to 2020 showed a general decline. Between 2001 and 2006 the average incidence of reported drownings was 760 incidents per year and the respective death average was 645 deaths per year. By the 2016 to 2020 range, the average incidence of reported drownings was 499 incidents per year and the respective death average was 484 deaths per year [24].

figure3
Figure 3. Five-year averages of reported drowning incidences and deaths in Poland from 2001 to 2020. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


Data reporting the gender of those who drowned was collected from 1999 to 2009 and 2014 to 2020, as shown in Figure 4. In this time period, about 87% (n=8866) of the drownings were male compared to around 13% of the drownings being female (n=1327) [24].

figure4
Figure 4. Reported drownings in Poland by gender from 1999 to 2009 and 2014 to 2020. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


Ages of the drowning incidents were reported from 1998-2020. Ages were grouped together in the following: under 7 years old, 8 to 14 years old, 15 to 18 years old, 19 to 30 years old, 31 to 50 years old, and over 50 years old. As shown in Figure 5, most drownings occurred in the over 50 age group. The over 50 age group made up around 36% (n=4608) of drownings in this time period. Overall, around 86% of drownings were made up by the 19 to 30, 31 to 50 and over 50 years old age groups. The least number of drownings occurred in the under 7 years old. The under 7 age group made up around 3% (n=367) of the drownings for that time period [24].

figure5
Figure 5. Reported drownings in Poland by age group from 1998 to 2020. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


Data was collected on water source in the reported drownings. There were 5 main sources of water reported on from 1998 to 2020, as shown in Figure 6. These include rivers, lakes, ponds, lagoons, and the sea. Between 1998 and 2012 there was also further data collected on other sources of water; however, these were dropped from reports beginning in 2013 and will not be included in this article. Most drownings from 1998 to 2020 occurred in rivers, accounting for about 37% (n=3968) of reported drownings. The least number of drownings occurred in the sea, making up for about 5% (n=505) of reported drownings. Around 28% of reported drownings occurred in lakes, about 20% occurred in ponds, and around 10% occurred in lagoons [24].

figure6
Figure 6. Reported drownings in Poland by water source from 1998 to 2020. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


Data regarding the most common circumstances of the drownings were also collected and reported by the Polish Police. This data was generally inconsistent over the years but data from four main categories of circumstances were collected and reported on. These four circumstances were swimming in unguarded, but not restricted areas; swimming in restricted areas; carelessness while in the water; carelessness while fishing. As shown in Figure 7, most reported circumstances of drownings, around 45% (n=2404), were reported to have occurred when swimming in an unguarded, but not restricted areas. The lowest reported circumstance of drowning was carelessness while fishing, which made up of about 16% (n=845) of total reported circumstances of drowning [24].





























































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figure7
Figure 7. Most common reported circumstances of drownings in Poland from 1999 to 2020. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


Between 1998 and 2002, data was collected on the day of the week that the drowning occurred. As shown in Figure 8, the days with the most drownings occurred on the weekend days Saturday and Sunday. Sunday was the day with the most drownings. About 22% (n=935) of reported drownings occurred on Sunday. Saturday was the day of the week with the second highest drownings, which made up about 17% (n=737) of reported drownings. The lowest number of drownings occurred on Monday, which made up around 11% (n=469) of the reported drownings [24].

figure8
Figure 8. Drownings by day of the week in Poland from 1998 to 2002. Adapted from Utonięcia-Statystyka by Polish Police [24].
[please click on the image to enlarge]


Drownings in global statistics

According to WHO, it is estimated that around 236 000 people died from drowning in 2019, which makes it the 3rd leading cause of unintentional injury death worldwide. Of those 236 000 drowning deaths, over 90% occur in low- and middle-income countries. There is a high incidence among children and young adults, where over 50% occur in people younger than 25 years. The highest drowning rates globally include children from 1-4 years of age, followed by those aged 5-9 [25]. Males are twice as likely to drown as females worldwide, as we also can see in the data collected from Poland where around 87% of those who drown are males [24, 25]. Men in Poland, and globally, may have more incidents of drownings than women due to increased associations with risk factors, such as alcohol consumption, risky behaviour, carelessness by the water, swimming in unprotected areas or rough waters, and other reasons. According to WHO there is limited data available on drownings worldwide, especially in low- and middle-income countries, which means that there is an underrepresentation of the extent of drownings in the world [25].


Common locations and causes

Most drownings happen inland. Possible common locations include buckets, water containers, bathtubs, ponds, ditches and pools. In Poland most drownings happen inland, where 37% happen in the river, followed by lake (28%) and then pond (20,4%) [24]. In Bangladesh, 80% of drownings among children <5 years of age happened in ponds, ditches and water containers close to home. In older children and adults, drownings typically happen in natural water bodies (e.g. lakes, rivers, streams and oceans) further away from home. In the US the most common drowning locations for children <1 years are bathtubs, for children between age 1-4 and 5-13 years it is swimming pools, while for older children aged 14-17 years it is natural bodies of water. As with older children and adults in Bangladesh. In Australia the top 3 locations of drowning deaths are river/creek (26%), beach (22%) and ocean/harbour (15%) [26-28]. It is important to stress that developing versus developed nations will show many differences in factors revolving drownings.

Other possible causes of drowning to consider include accidental drownings, workplace drownings, drownings caused by catastrophes including floods and severe weather, drowning caused after falling under ice, and criminal or homicidal related drownings.

In recent years there have been many drownings occurring in the Mediterranean Sea by migrants who are attempting to cross the treacherous water in small boats to reach Europe. Since 2014, according to the International Organization for Migration, there have been 22,930 recorded dead or missing persons who attempted to cross the Mediterranean Sea [29]. The United Nations High Commissioner for Refugees estimates that 1,600 migrants have died or gone missing attempting to cross the Mediterranean Sea in 2021 [29].

As seen, there are many locations where drownings can happen and especially in children. Those less than 12 months old can drown very quickly and in the presence of a small amount of water, e.g. in a bucket or in a ditch. Some reasons why children drown are the absence of supervision and barriers, and that they are too young to recognize danger or get out of the water. One example would be diving into shallow water headfirst, which could result in severe injury, drowning, or death. Reasons for drownings in adolescents include that they are more likely to act reckless around water, they are less supervised, and they might have consumed alcohol or drugs. Other reasons for drownings in general, and especially in low- and middle-income countries, include lack of physical barriers or signs, unprotected water supplies, poor flood disaster protection, lack of safe water crossings, travelling on water (especially when overcrowded or poorly maintained mode of transportation) and lack of water safety awareness. Other factors such as socioeconomic status and climate may also play a role in the prevalence of drowning. In low-income and in some middle-income nations having a pool in proximity of the house may not be common. Socioeconomic status could also have an impact on the sources of water used and the reasons for being in or near the water. For example, in the United States, it is common to have a pool in the yard that generally is unsupervised by a lifeguard, thus increasing accessibility to a source of water. In Poland, it is not that common to have a pool in the yard but rather having access to public swimming pools that generally do have a lifeguard. However, with time these trends could change. Climate also plays an impact on the prevalence of drownings. Warmer, more temperate climates may have more people trying to access sources of water as a form of recreation or for other reasons when compared to areas with colder climates. This further shows that there are many factors that should be considered with drownings, especially among differences between developing and developed nations.


Conclusions

Drownings will continue occur with time, thus requiring more public education and safety practices being put into place to reduce the number of incidents occurring. More should be done to educate children and young adults about general safety while swimming and being near or around water. This should be taught to children while they are still in school, and first lessons should begin from a young age considering that globally children and young adults make up most of the drowning and near drowning incidents [25]. Special attention should be focused on education topics such as teaching them how to swim, teaching how to behave properly when around water, teaching how to call for help in drowning situations, teaching to avoid jumping into water of unknown depth headfirst, and teaching them to not swim without supervision or in restricted swimming areas. Also, basic education of first aid related to drowning and near drowning should be provided to those at an acceptable age to learn it. By teaching children and young adults how to swim and basic safety practices near or around water, incidents of deaths in drownings and near drownings would be expected to decrease.

Education must also be provided to parents of children swimming and to any adults who themselves are swimming. As seen in the data provided by the Polish Police, men and those aged over 50 years old made up most drowning incidents in Poland [24]. Thus, adults must also be educated on safe swimming practices and how to supervise their children who may be swimming. Supervising adults should pay close attention to young children as they are playing near or in the water. Adults and young adults should refrain from drinking alcohol or any form of recreational drugs when swimming or around water. Public swimming areas should display signs and posters reminding that the use of alcohol or other substances be absolutely prohibited when near or in the water. Adults should also have some basic understanding of first aid principles related to drowning incidents and should be aware that it is necessary to call for emergency services in such cases as near drownings can often result with life threatening consequences. Organizations, either governmental or non-governmental, should work to establish swimming areas for the public to use that is under trained supervision.

There should also be public campaigns done via posters that show the rules and expected behaviour near or around water. These campaigns should also provide information about basic first aid related to drowning and other actions that should be taken as well, such as calling emergency services, learning how to swim and teaching basic water safety. Furthermore, these organizations should work to improve safety measure by popular recreational sources of water, such as ensuring that lifesaving first aid items are located nearby to the water for quick access in case of emergency.

Also, improving training of doctors and medical professionals regarding management of incidents of near-drowning is crucial.

Overall, drownings are often accidental and often occur when carelessness of some kind was involved. Quick removal from the water and first aid resuscitation is a crucial aspect of saving a drowning individuals life. Education, i.e. teaching adults, parents, and children about water safety and how to swim should be offered. Basic first aid related to drowning should also be taught as well as the proper procedure to follow in drowning incidents. In taking such preventative measures, it would be expected for incidents of near drownings and drowning related deaths to decrease.


References

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Conflict of interest: none declared.

Authors’ affiliations:
1 Jagiellonian University Medical College, School of Medicine in English, Cracow, Poland


Corresponding author:
Christopher Truszkowski
4241 Jefferson Dr.
Sterling Heights, Michigan 48310
USA
e-mail: christruszko@gmail.com

To cite this article: Truszkowski C, Schulz J, Mohammed H, Wikestad IM, Ristic M. Analysis of drownings in Poland from the past quarter century. World J Med Images Videos Cases 2022; 8:e1-11.

Submitted for publication: 19 January 2022
Accepted for publication: 31 January 2022
Published on: 19 February 2022





























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