The Final Breath: Preventing Hypoxic Blackout

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Recently, as I deliver Lifeguard information and training sessions, the more I find I am talking about Hypoxic Blackout (commonly referred to as Shallow Water Blackout) in much greater detail. I spend a lot of time explaining to Lifeguards what drowning actually looks like, some of the distinctive signs and of course the completley indistinct!

I spend some time explaining to Lifeguards the physiology behind blackouts as it seems to me that many know the term ok, know it's bad and know it can kill, but maybe not why!

Educating the public about the dangers of Hypoxic Blackout can be aided greatly by well informed and knowledgable lifeguards. I came across this article by Kirsty Kinzer and thought it was brilliant, needed to be shared and used to reinforce the dangers of hypoxic blackout.

To be honest, the scariest people I talk to about the subject are those whose children are competition swimmers or certain swimming coaches - I cannot get over how blase some are - I hope they read this!

By Kristy Kinzer, Swimming World College Intern.

Swim parents are used to the daily grind of carpooling their kids to practice, entrusting them to the care of well-meaning coaches for a few hours, then waiting for their dawdling, hot-shower-loving athlete to emerge from the natatorium in one piece. Sometimes they’re laughing with teammates and sometimes they’re beat from a challenging practice.

But the morbid thought that their child may never come back out of the pool back into their loving care is out of the question. The coaches overseeing practice are CPR/AED and lifeguard certified, have years of swimming experience under their belts, and couldn’t possibly allow one of their beloved athletes, who is usually no more than a few inches from the surface of the water, to drown.

These athletes are swimmers after all, so they have the least chance of drowning than most of the population, right? Unfortunately, this is not the case for all families. An under-reported accident called hypoxic blackout, aka shallow water blackout, can have debilitating and fatal consequences for those who are training for competition or free swimmers alike

Many swimmers jokingly use the phrase “water is my oxygen” due to the countless hours they spend at practice. One cannot breathe water, of course, but most swimmers wish that could be the case during “no-breather” sets where limited breaths or no breaths are allowed while training. Little scientific backing exists to prove any significant athletic improvement with hypoxic swim sets, and others credit the head-down position practiced during hypoxic sets for decreased water resistance thus leading to faster times. Never mind Nathan Adrian’s gold medal at the 2012 Olympics in the 100 meter freestyle where he breathed every other stroke until the last few meters, proving that you can be the best in the world and use oxygen to your advantage.

The Physiology Behind Blackouts

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The key to preventing hypoxic blackouts is getting to the root cause of how athletes faint when exposed to breath-limiting, high stress practices. The body’s autonomic nervous system controls our breathing at an unconscious level and bases your need to breathe on the balance of oxygen and carbon dioxide (CO2).

A build-up of CO2 in the body signals the response to exhale the toxic build-up of CO2 and bring in fresh oxygen to nourish our vital organs and muscles; however, when CO2 levels are relatively low due to hyperventilation, whether intentional or from a difficult practice, our brain loses the ability to signal to take a breath. It thinks we don’t have enough waste product built up to require a breath, when in reality, our body needs that breath of air to survive.

Without adequate oxygenation, the brain will start to shut down and the swimmer will lose consciousness. It can take only about two and a half minutes to experience brain damage and death as opposed to the recognized six to eight minutes with a “normal” drowning submersion due to the body’s already oxygen-deprived state and the warmth of the pool water. The Shallow Water Blackout Prevention website, created by medical doctor and mother of a blackout victim Rhonda Dawes Milner, gives in-depth detail of the physiological process and tips to prevent hypoxic blackout.

The Scope of the Issue

According to the Center of Disease Control (CDC), nearly 10 people die each day from unintentional drowning and it ranks fifth among the leading causes of unintentional injury death in the United States. Those statistics may be easy to gloss over, but these are all very preventable deaths and include those who spend many of their waking hours trying to improve their swimming abilities. Ironically, most shallow-water blackout victims were experienced and highly competitive swimmers, free divers, Navy Seals, and spear fishermen. No one is immune to passing out in the water.

The CDC also sites that for every one person who dies from drowning, an additional five receive emergency department care for nonfatal submersion injuries. Of those five, over half require hospitalization for further care and can experience long-term disabilities from severe brain damage. The loss of functioning ranges from memory problems to permanent vegetative state.

With my nursing experience in the hospital with stroke victims who typically lose functioning to some capacity, most patients state that their worst nightmare is not death but living with a severe impairment. The adjustments for a drowning victim and family to make regarding physical and cognitive impairments from hypoxic blackout are too extensive to cover in detail in just one article.

Drawing the Line

It is the duty of every swim and dive coach to educate his or her assistants, athletes, and parents of the dangers of extended breath-holding in detail. Ground rules should be set early in the season regarding breath-holding practices, if they are even included in the training regimen at all. When teaching individuals to swim, relaxed breath-holding is the key to safety and should have built-in rest periods.

When training competitive swimmers, it is recommended that restricted breathing exercises should only be practiced one drill at a time and with plenty of rest. However, if a swimmer is unable to accomplish a drill, he should not be pushed passed his limits and should never be encouraged to resist the urge to breathe. Coaches should not give rewards, have contests, or encourage swimmers to resist the urge to breathe through prolonged breath-holding.

I remember being rewarded with candy for swimming the length of the pool underwater at just 6 years old. My mom once nearly had a heart attack when she found me practicing holding my breath face-down in the bath tub at that age. I had already been socialized into the swimming community that resisting the natural urge to breathe for extended periods of time was to be celebrated. A high school teammate passed out during a breath-holding set while a teammate lifted him above the surface. He told the coach he was alright and promptly resumed the set.

Coaches acknowledged my athletic success in college due to the length of time I could kick off the wall underwater. Thankfully, nothing bad happened to me. But that unfortunately was not the case for the following reported swimmers: 14-year-old Louis Lowenthall, Dartmouth University’s Tate Ramsden, free diver Whitner Milner, Navy Seal student James Derek Lovelace, and countless others around the world. I highlight these stories and deaths not to put down coaches but to raise awareness of dangers of hypoxic practices and eventually to see a culture change in the sport of swimming.

Though the practice of breath-holding sets can have its merits under appropriate parameters and safe guidance for kick-outs off the wall or extending breathing patterns, many coaches and athletes are unaware of the deadly consequences of hypoxic workouts and tend to push the limits so far as to cause shallow water blackout. Having athletes take their final breath under the supervision of lifeguards, the direction and guidance of CPR/AED and lifeguard-certified coaches cannot continue to be justified- we need to draw the line and raise awareness to stop further preventable tragedies.
Coaches and swimmers should take precautions to avoid shallow water blackouts when performing underwater drills. All training should be conducted by a certified and experienced coach. Coaches and swimmers who use these drills should do so at their own discretion. Learn more about shallow water blackouts