Potential Misdiagnosis of Drowning during diving in shallow water

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Hey Jude

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Just reading with interest news article of experienced diver death due to immersion pulmonary oedema La Perouse last year. My brother died while diving in Parramatta River in 2005 in 3.5 metres of water. He was 52, no health (heart) problems, had not dived for 8 years prior to this dive due to finances. He was diving with gear which Police Diver's determined was not in good repair. He would have been close to upright as his plan was to clean the bottom of his moored boat. Coroner determined death due to drowning. There was no brain embolism, however from memory I think the report mentioned bubbles / froth in lungs. There was some suggestion by Police Divers, that coughing underwater was a possible cause of him spitting out his regulator. My brother surfaced after kicking hard when he apparently realised he was in trouble, yelling for help (as he was unfortunately diving alone, a non diving buddy aboard his moored boat). My brother quickly dropped - unconscious, and the search was commenced by buddy, nearby boat builder then Water & Air Police. After 90 mins his body was found. Was his death due to immersion pulmonary oedema rather than drowning as recorded by coroner? My daughter and I both have exercised induced asthma and I fear than in our mothers later years she was also asthmatic but never diagnosed.
 
Was his death due to immersion pulmonary oedema rather than drowning as recorded by coroner?

First off Hey Jude, sorry for your loss. I realize time does little to diminish the pain.

In case you don't know, I work as a forensic consultant for the LA County Coroner for scuba fatalties. Understand that protocols may vary from jurisdiction to jurisdiction but based on the way things are don here, it's not uncommon for the cirumstances you describe to result in a cause of death (COD) that's drowning.

Remember that the coroner's job is to determine COD with reasonable medical certainty. And when we're talking COD, it means the mechanics of death, not necessarily what caused the mechanics to occur in the first place (which DAN refers to as the "trigger"). Also, drowning is a diagnosis of exclusion. In other words, you can "prove" that someone drowned. You can have "dry" drowning and you can have "wet" drowning, so water in the lungs in and of itself or the absence of that is not necessarily indicative. But what you can do is take the fact that someone was found underwater, rule out things like heart attack, head trauma, etc., and eventually all you're left with is drowning.

Here's what DAN says about it: "Pulmonary edema is an abnormal leakage of fluid from the bloodstream into the alveoli, the microscopic air sacs in the lungs. It is most often the result of heart failure or other cardiac problems. Sometimes, however, pulmonary edema is observed in swimmers and divers when no underlying medical cause is apparent. This condition, immersion pulmonary edema (IPE), presents as a rapid onset of shortness of breath, cough and sometimes blood-tinged, frothy sputum. Because the fluid builds up in the air-containing spaces of the lungs and interrupts gas exchange, IPE resembles drowning. The important difference is that the obstructing fluid comes from within the body rather than from inhalation of surrounding water."

In the case of your brother, just from what you've described, it could be that immersion pulmonary edma (IPE) started everything going wrong. He then possibly could have embolised, which given the depth, his lack of recent dives, likely problem of breathing with IPE, all could have contributed to a rapid, breath-holding ascent which at that shallow depth easily could produce an embolsim. But no matter how it started, then end result in terms of COD still could be drowning. It could also be that, as the DAN statement points out, that he "drowned" in his own fluids.

Because he was alone, you don't really know if he was upright or not, you don't know if he coughed underwater (the police comment is simply speculation), you don't know if he kicked hard, and you don't know when he realized he was in trouble because none of these things were observed by anyone. It may all be correct but there's no way to know for sure.

If foul play was not suspected by the coroner (which I assume it wasn't) and given everything else you've stated, at some point the politics of the situatoon are such that the coroner would like to close the case and probably felt there was little real difference between drowning and IPE. And if they don't deal with diving deaths very often, it's certainly possible they could have missed the IPE and just gone with drowning. Absent a re-test of the fluids collected from the lungs, I'm not sure there's any way at this point to know for sure.

Hope this helps and for any of the medicos here, feel free to correct or expand on anything I haven't gotten 100% correct.

- Ken
 
Hey Jude,

I'm terribly sorry for your loss. I don't have much to add to what Ken said above. It's possible that your brother suffered from IPE but it would be imprudent for anyone to second-guess a coroner's finding over the internet.

Best regards,
DDM
 
I'm sorry for your loss.

I have also wondered if some inexplicable scuba deaths may have been due to this entity. It may be quite difficult to determine whether lungs which are full of fluid are that way because of intrinsic fluid, or aspirated fluid, especially when fluid in the lungs is an expected finding. Unfortunately, as already stated, there is simply no way to know at this point.
 

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