Overview: Water & Lightning Emergencies
Rivers, open water, and exposed ridges are where drowning and lightning happen, and both kill fast. On a whitewater trip or a ridgeline road, the first few minutes usually decide whether it's a close call or a fatality. What decides it is prevention, your rescue decisions, and knowing which patient needs you first.
Both of these run against instinct. Drowning is fast and silent, nothing like the movies. When lightning drops several people at once, triage runs backward, and you treat the apparently dead first.
On river & road trips
- Moving water: rapids, strainers, and foot entrapment turn a swim into an emergency in seconds. Rescue technique counts for more than swimming strength.
- Cold water: even strong swimmers drown in the first minutes of cold-water immersion. Cold shock and swim failure kill them long before hypothermia can.
- Exposure: open water, ridges, and exposed roads give you no shelter from lightning. You manage the risk with timing and terrain, because there's no safe spot out there.
- Delayed help: patients can get worse over hours after a submersion or a strike, and it's on you to decide when they go out.
Key points
Real drowning is silent and vertical. No waving, no yelling. Watch your group.
Rescue hierarchy: talk, reach, throw, row, and go last. Never become the second patient.
Never stand up in moving water deeper than your knees. Foot entrapment kills.
Cold-water immersion runs on 1-10-1. Float first and get your breathing under control.
Drowning CPR is breaths first: 2 initial rescue breaths, then 30:2 (see Lesson 03).
Lightning: spread the group out, and use reverse triage. Treat the apparently dead first.
Drowning
What drowning is
Definition: Drowning is respiratory impairment from submersion or immersion in liquid. The word covers survivors too. Someone can drown and live, with or without lasting injury.
- The process: water hits the airway → reflex breath-holding → an involuntary gasp → laryngospasm (the vocal cords clamp shut), water breathed into the lungs (aspiration), or both → oxygen levels fall → loss of consciousness → cardiac arrest from lack of oxygen
- It's fast: a struggling swimmer can go under in as little as 20 to 60 seconds
- The core problem is oxygen: rescue, positioning, and CPR all aim at the same thing, getting oxygen back into the patient
Recognition: real drowning is silent
Movie drowning, with the waving arms, the splashing, and the yelling for help, is fiction. Real drowning (the instinctive drowning response) looks like this:
- No yelling: breathing comes before speech, and a drowning person has no air to spare for calling out.
- No waving: the arms press down on the surface by instinct. They can't reach for a rope or wave for help.
- Vertical posture, head low: body upright in the water, head tilted back, mouth at the waterline, bobbing under and back up
- No progress: they aren't swimming anywhere. They're just fighting to keep the airway above water.
Quiet is the warning sign. If someone in your group goes quiet in the water, assume trouble. After any raft flip or swim, count heads, and keep counting.
Myths to retire: "dry drowning" & "secondary drowning"
- "Dry drowning" and "secondary drowning" aren't medical terms. Modern drowning medicine doesn't use them, and they cause more fear than understanding.
- The question to ask instead: after submersion, is the person symptomatic or asymptomatic?
- Symptomatic (coughing, trouble breathing, abnormal behavior): the lungs were injured, and the symptoms can get worse over the next several hours. They need evaluation.
- Asymptomatic (brief submersion, breathing and acting completely normally): people don't suddenly die days after a normal swim. Watch them closely, and evacuate only if symptoms develop.
Forget the scary labels and watch the patient. Symptoms after submersion mean evaluation. No symptoms means you keep a close eye on them.
Rescue safety first: the rescue hierarchy
More would-be rescuers drown than you'd think. A drowning person will instinctively climb whatever is nearest to get their head above water, and that includes you. Work from lowest risk to highest:
TTalk: coach them in. "Swim to me! Grab the rope! Feet up!"
RReach: hold out a paddle, pole, or branch from a secure position
TThrow: a rope bag, a spare PFD, anything that floats
RRow: come in by raft or boat and pull them over the tube
GGo: a swimming contact rescue. The last resort, and for trained rescuers only.
Never become the second patient. An untrained swimming rescue often turns one victim into two. If you have to go in, take flotation with you and come in from behind, because a panicked swimmer will climb their rescuer.
River hazards
Foot entrapment
- The rule: never stand up in moving water deeper than your knees.
- Why: a foot wedges between rocks on the bottom, and the current pushes your body over and under. Even strong adults can't fight a river pushing on their torso, and rescuers often can't reach them in time.
- Instead: if you're swimming a rapid, stay in the defensive swim position until you can swim aggressively for shore. That's on your back, feet up at the surface and pointed downstream, so your feet fend off the rocks.
- Aggressive swim: when you see your exit, an eddy or the shore, roll over and swim hard for it. Don't drift past your chance to get out.
Strainers
- What: downed trees, log jams, fences, anything water flows through but a body can't. The current pins you against it and pushes you under.
- The rule: if you can't avoid being swept into a strainer, swim aggressively straight at it and go up and over the top. Never let the current take you under it.
PFDs on, every time. Everyone wears a properly fitted PFD on and around moving water, no exceptions. Most river drowning victims weren't wearing one.
Post-rescue care
Unresponsive and not breathing
- Unresponsive and not breathing, or only gasping, means CPR now, with no pulse check first. Drowning is an asphyxial (oxygen-deprivation) arrest, so open the airway and give 2 initial rescue breaths first, then continue CPR at 30:2.
- Hands-only CPR is not appropriate for drowning. This patient ran out of oxygen, and the rescue breaths are how you give it back. If you can't or won't give breaths, compressions alone still beat nothing. (Full CPR technique is in Lesson 03, Airway & Breathing.)
- Don't waste time trying to "drain water from the lungs." Abdominal thrusts and drainage maneuvers delay the breaths and make the patient vomit.
Breathing patient
- Recovery position: vomiting after submersion is common, so protect the airway.
- Watch the breathing closely: in drowning, the problem is getting oxygen in. Recheck rate, effort, and sounds often. If the breathing gets worse, evacuate.
- Strip wet clothes and insulate: anyone pulled from the water is losing heat fast. Dry them, insulate them, and treat by hypothermia stage (see Lesson 09, Cold-Related Emergencies).
- Everyone pulled from the water gets assessed, including the swimmer who insists they're fine.
Spine note. Spinal injury in drowning is rare unless there's a diving or impact mechanism, like a headfirst entry or being thrown against rocks. Don't let worry about the spine delay the airway and breathing. A and B come first.
Who evacuates after submersion
- Any symptoms mean evacuation for evaluation. Symptoms can progress over hours as the lung injury develops:
- A cough that won't settle
- Foamy or frothy sputum
- Shortness of breath, or working harder to breathe
- Abnormal breath sounds (wheezes, crackles, gurgling)
- Vomiting
- Altered mental status: unusual sleepiness (lethargy) or confusion
- Brief submersion, no symptoms right after (breathing normally, acting normally): watch them closely for 4 to 8 hours, and evacuate if anything develops.
Cold-Water Immersion
Immersion is not (yet) hypothermia
Cold-water immersion and hypothermia are different problems on different clocks. Hypothermia (core temperature below 35°C) takes tens of minutes to develop, and Lesson 09 covers staging and treatment. What kills people in cold water happens much faster:
- Most cold-water deaths are drownings in the first minutes. Cold shock and swim failure cause them, long before the core cools.
- The first fight is keeping the airway above water. Staying warm isn't the immediate problem.
The 1-10-1 principle
Sudden immersion in cold water gives you three windows. Know them before you ever fall in:
11 minute of cold shock: gasping and hyperventilation. Get your breathing under control. Do not try to swim through it. Float first.
1010 minutes of meaningful movement before the cooling muscles fail (swim failure). Self-rescue in this window, or get stable on flotation.
11 hour before hypothermia incapacitates you. In a PFD, you have time. Conserve heat and wait for rescue.
Cold shock kills swimmers. The involuntary gasp on entry can pull in water. Hyperventilation plus frantic swimming ends in swim failure. So float first, and breathe until the shock passes. It takes about a minute.
Float first, then decide
- Float first: lean back, keep the airway high, and ride out the first minute of gasping before you do anything else.
- In a PFD, cut your heat loss:
- HELP position (Heat Escape Lessening Posture): knees pulled to the chest and arms hugged tight to the sides, covering the areas that lose the most heat (groin, armpits, chest)
- Huddle: several people in PFDs press chest-to-chest in a tight circle. It holds heat, and it's easier for rescuers to spot.
- Swim only for a target you know you can reach: a shore or boat inside your ~10 minutes of useful movement. Otherwise, stay with the flotation and save your heat.
After extraction
- Handle them gently, and keep them horizontal if you can. A cold patient hauled out upright or handled roughly can go into cardiovascular collapse (rescue collapse).
- Treat by hypothermia stage: dry, insulate, wrap, heat to the trunk. Full staging and rewarming are in Lesson 09.
- Think drowning too: if they were struggling or went under, the post-submersion assessment and evacuation rules from the Drowning section apply to them too.
Lightning
Exposure management: there's no safe place outside
"When thunder roars, go indoors" has no wilderness version. There's no lightning-safe position outdoors. Your job is to cut the risk, and to start early:
- Move at the first thunder: get off ridges, peaks, and open water right away. Don't wait for the storm to arrive.
- Stay away from the tallest objects: lone trees, poles, and summit blocks attract strikes. A uniform stand of smaller trees is lower risk.
- Spread the group 20+ feet apart, so one strike can't take everyone down and someone uninjured is left to give care.
- Avoid cave mouths and overhangs: ground current arcs across those gaps. A shallow rock overhang is worse than open low ground.
- The lightning crouch is a last resort. It offers little real protection, so put your effort into getting off exposed terrain early. Crouch only if you're caught in the open with no time left to move: feet together, on a foam pad if you have one, hands over your ears.
- The 30-minute rule: wait 30 minutes after the last thunder before you go back to exposed travel.
Rivers & bikes: plan around the afternoon
- Open water is high exposure: a raft mid-river is the tallest object around. At the first thunder, get the boats to shore, the group off the water, and everyone away from the lone trees on the bank.
- Exposed roads and ridgelines are high exposure: riders strung out along a ridge road are a line of isolated high points. Get down to lower terrain, and shelter in a vehicle or building if there is one.
- Plan around afternoon storm patterns: in mountain terrain, thunderstorms build predictably in the afternoon. Put big water and exposed crossings in the morning, and be off high ground by early afternoon.
Lightning injuries
- How lightning kills: cardiac arrest, respiratory arrest, or both. The strike stuns the heart and the brain's breathing center. The heart may restart on its own while the breathing doesn't. Without rescue breathing, the victim arrests again from lack of oxygen (hypoxia).
- Keraunoparalysis: temporary paralysis, often of the legs, with pale, mottled limbs that can look pulseless. It's frightening, and it usually resolves within hours.
- Burns: superficial "ferning," a feathery pattern on the skin (Lichtenberg figures), usually minor. Lightning burns are typically not deep, because the current flashes over the body's surface.
- Ruptured eardrums: very common. Expect hearing loss and disorientation.
- Confusion and amnesia: victims may not remember the strike, and they may act strangely.
- Blunt trauma: victims can be thrown. Assess for fractures and head or spine injury, the same as after any fall.
Reverse triage: treat the apparently dead first
Lightning turns normal triage around:
- Normal triage: with multiple victims, you treat the living who can be saved. Victims in cardiac arrest are usually beyond field help.
- Lightning triage runs in reverse: go first to the victims who appear dead (unresponsive and not breathing).
- Why: lightning arrest is typically a stunned heart or a stopped breathing center in an otherwise healthy person, so the odds of resuscitation are unusually good. Victims who are moaning, moving, or walking are already breathing, and they'll very likely survive without immediate help.
- What to do: unresponsive and not breathing, or only gasping, means start CPR with rescue breaths right away (see Lesson 03). Don't stop to feel for a pulse. The breaths matter most here, because the breathing center can stay stalled after the heart restarts.
No residual charge. A lightning-strike victim carries no electrical charge. They're safe to touch immediately, so start care without delay. The storm is still a hazard to you. The victim's body isn't.
Evacuation after a strike
- Every lightning-strike patient gets evacuated for medical evaluation, including the ones who seem completely fine.
- Why: the heart's electrical system may be injured. Delayed rhythm problems need cardiac monitoring, and only a hospital can provide it.
- Write down what you saw: the strike, loss of consciousness, paralysis, memory gaps. The hospital team will use it.
Case Scenarios
Scenario 1: Raft flip in a rapid
Setting: Your raft flips in a Class III rapid. One swimmer rolls onto her back, feet downstream, then swims hard into an eddy and self-rescues. A second swimmer gets pinned against a rock mid-current for a moment before he washes free, and a throw rope brings him to shore. Twenty minutes later he's still coughing and says his chest feels "tight." Everyone's cold and wet. You're a half-day float from the take-out.
What went right:
- Swimmer 1 held the defensive swim position (on her back, feet up and downstream) through the rapid, then switched to an aggressive swim to reach the eddy. Textbook self-rescue.
- Nobody stood up in the moving water. The pinned swimmer stayed off his feet, and he came out on a rope (throw) instead of with a swimming rescuer (go).
Post-submersion assessment:
- Everyone who swam gets assessed. Count heads first, then check each swimmer's breathing, mental status, and injuries.
- Strip wet clothes, insulate, and watch every swimmer for hypothermia (see Lesson 09).
- Swimmer 1 has no symptoms after a brief swim. Watch her closely for 4 to 8 hours, and evacuate if anything develops.
The evacuation decision: Swimmer 2 is symptomatic after submersion, with a persistent cough and chest tightness. Lung injury from aspirated water can progress over hours. He's an urgent evacuation. Keep him at rest, watch his breathing rate, effort, and sounds continuously, and start moving him toward a hospital now. Do not "wait and see" overnight at camp. If his breathing gets worse or isn't resolving, it becomes an emergent evacuation. Call for rescue (Lesson 13).
Scenario 2: Lightning strike on an exposed ridge
Setting: An afternoon storm builds fast while your dual-sport group is strung out along an exposed ridge road. Thunder cracks. Before the group can get down, lightning strikes nearby. One rider is down and not breathing. Another is conscious but confused. He says he can't feel or move his legs, and there's a feathery red pattern across his shoulder. A third rider is shaken but uninjured.
Scene first:
- The storm is still overhead. First make a short move off the exposed spot, carrying the patients if you can do it quickly. Then start CPR right away. The full descent can wait. Spread the uninjured riders 20+ feet apart so a second strike can't take down the rescuers.
- Victims carry no residual charge. Touch them and treat them immediately.
Reverse triage:
- Go first to the rider who appears dead. The confused rider is talking, so he's breathing, and he can wait.
- The rider who isn't breathing (apneic): open the airway and check breathing. If they're unresponsive and not breathing, or only gasping, start CPR now, with no pulse check first. Begin with 2 rescue breaths, then 30:2, and use an AED if by some chance there's one around (see Lesson 03).
- Lightning arrest in a healthy rider has unusually good resuscitation odds, so give it everything you've got.
The confused, paralyzed rider:
- Leg paralysis after a strike is most likely keraunoparalysis. It's temporary, and it usually resolves within hours. Reassure him, keep him still and warm, and reassess.
- He was also thrown, or he fell. Assess for blunt trauma, and treat the feathery burn pattern (ferning) as the minor, superficial finding it usually is. Thrown plus legs that won't move means you can't sort keraunoparalysis from a spine injury out here, so take spine precautions and move him as one unit (Lesson 7).
- Expect ruptured eardrums, confusion, and memory gaps. Speak clearly, face to face.
Evacuation: every rider who was struck, or might have been, evacuates for cardiac monitoring. That includes the shaken third rider who "feels fine." Wait 30 minutes after the last thunder before the group goes back to exposed travel.
Knowledge Check
12 questions. Pick an answer to get immediate feedback. Answer order is shuffled each attempt, and your best score is saved on this device.
Lesson Summary
Key concepts
Drowning is fast and silent: vertical posture, head low, no waving, no yelling. Count heads after every swim.
"Dry drowning" and "secondary drowning" aren't medical terms. The question is whether they have symptoms (symptomatic vs. asymptomatic) after submersion.
Rescue hierarchy: talk, reach, throw, row, go. A swimming rescue is the last resort. Never become the second patient.
Never stand up in moving water deeper than your knees (foot entrapment). Swim over strainers, never under. PFDs on, always.
Drowning CPR is breaths first: 2 initial rescue breaths, then 30:2. Hands-only CPR is not appropriate here, but if you can't or won't give breaths, compressions alone still beat nothing (Lesson 03).
Any symptoms after submersion mean evacuation. No symptoms means close observation for 4 to 8 hours.
Cold-water immersion runs on 1-10-1. Float first through cold shock, and use HELP or a huddle in a PFD. Most deaths are early drownings, not hypothermia.
Lightning: get off ridges and water at the first thunder, spread the group 20+ feet apart, and wait 30 minutes after the last thunder.
With multiple lightning victims, triage runs in reverse, and you treat the apparently dead first. Victims carry no charge, and they resuscitate well.
Every lightning-strike patient evacuates for cardiac evaluation, even if they seem fine.