Preventing Drowning and Advancements in Reducing Brain Damage: A Conversation with Dr. Ted Wu

I'm Holly Wehmint, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.

Click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on our topic or podcast. This is my first time back in the podcast studio after an unintentional injury. Unintentional injuries are the leading cause of death in children. And in my case, it was a snow skiing accident over spring break. And I credit the doctors at UT Health for saving me.

Makes me emotional to think about it. So I'm not going to talk about it too much, but it's great to be back. And I'm here with one of our amazing doctors on the pediatric side. It's Dr. Ted Wu. Dr. Wu, thank you so much for being here in this podcast studio on Pediatrics Now with me. Thanks for inviting me. It's such a tough topic, the unintentional injuries that you see often as the director of the PICU and a professor of pediatric critical care. You've been doing this for 19 years.

You see the drownings, near drownings.

What do you want to say about that right off the top? Yeah. I mean, it's one of the most preventable things that we can do. I mean, in pediatrics, we always echo that prevention is like our number one education to our families and parents and caregivers, right? So being, you know, it's the summertime now and everyone's out and about enjoying the pool or being close to water.

So having a strategy and talking about who's going to watch over the kids while they're playing in the water is a much needed role, right? And, And, you know, we all enjoy being around the water and enjoying drinks as well. So I get it. But having a designated role, like we would have a designated driver, we would have a designated role that would watch the kids as they play in a pool or within, you know, a body of water as well.

So I can't echo enough about the necessary kind of role for prevention, right, for against drownings as well. Because it can happen in seconds. Yeah, the cases that we see, unfortunately, you know, that come to our pediatric ICU are, yeah, it's always, the stories are all very similar. Toddlers missing for five minutes, you know, just walked off. And the next thing you know, they're on the bottom of a swimming pool and everyone's rushing to get them out.

They start some sort of CPR if they know any of it. And yeah, EMS comes about and, you know, they usually get a heart rate back in that resuscitation, those critical like 10, 15 minutes. But that drowning time, water time, that's very variable. And that's, you know, because it's subjective, right? No one's timing.

No one's actually witnessed when it happens. So we kind of don't know when that amount of time that we call anoxia or that time of lack of oxygen to the brain, we don't know what that time is, you know, and we know once 10 minutes of anoxia happens, then the brain starts having all these cascades of injury to it. And part of ICU care is kind of limiting the injuries. We're going to talk about advances in post-cardiac arrest care.

But before that, since it's summertime, for our pediatric practitioner listeners here in the United States and wherever in the world where you're listening, where it's warm weather and people are swimming, is it something that should be mentioned to every patient in the precious moments in the exam room or what's your advice? Yeah, exactly. I mean, that's where I remember being a general pediatrician is in the early months or even during the summer months.

So starting in April, May, when it starts getting warm and people are going towards the pools or even during the summer months is they put in the reminder. Right, of, hey, if anyone's going toward the water, making sure everyone's being properly observed. Right. So I'm being safe. And then I know we're pediatricians out there that are doing it because I don't see it as often. but it does happen in a warm state like Texas here.

So always an opportunity as part of our, what we call anticipatory guidance for our pediatricians, right? And it should be part of their talk during the summer months. And I was reading that 87% of the drowning deaths happen in pools. Involving kids age one to four. And then for older kids, it's in open water where they're drowning. Yeah. Well, with older kids, it becomes a little bit more cloudy because there's always a mixture, goofy mixture of drugs and alcohol mixed with that.

But yeah, you're correct. I mean, a lot of open water, water sports. So we'll have teenagers, you know, doing flips and dips and slides on water, you know, boats and all that. So, yes, then we'll see those types of injuries. Wear the life jacket. Yeah, wear the life jacket. State law. Yeah, state law, you know, for all kids. And I get it. 18 and under, right? Yeah, exactly. So, I get it. There's sometimes with teenagers, it's like wearing a helmet.

It's like you're the kid with the helmet and the life jacket, you know, but it's those little kind of reminders for our kids to do those preventative, you know, safety measures. And it saves lives. Yeah, when we do that. And when it's for the younger kids in pools or hot tub, instead of everyone watching the kids, it's one person. You're the person in charge. Or even there's bracelets you can get online or where you could hand off to

that person. You're the person watching the child or children in the water. Yeah, yeah. There's a lot of different techniques. You're right. There's either a bracelet or a baton, like flat out, like it looks like a baton. And you are the person that's concentrating on watching everyone in the pool. Yeah. So especially at pool parties. Yeah. So those are some strategies as well.

There are some things out there, I don't know, part of your research that looked at safety alarms of when kids, that the kids would wear if they would, you know, fall into the pool. That alerts families on their phones when that happens. Those haven't been validated. They have pretty good marketing in them, but not really validated. So that could be something that could be an option where they wear it in the

water. And when they the kids wear like it comes in a like a onesie of some sort or a bracelet. Yeah, as well. And it alerts them when they go into the pool, alerts the parent that they're in the pool. Wow. Yeah. So, again, it's it's not quite validated quite yet, you know, because it hasn't gone to scale. Yeah. So but it is in the efforts to kind of eliminate drowning. Yeah. And then it's like or does it create a false sense of security?

Right. Exactly. You just can't be. It'd be another layer, not in place of watching. Correct. Correct. It's another layer of complexity.

Are you watching your phone versus just flat out just watching your kid or the kids, you know, playing out in the pool? Right. Yeah. So. I was saying, as a news reporter, we knew so many accidents were going to happen. And it's just, and I know as a critical care doctor, you knew the same. And you guys were, you said, holding your breath. And then, in fact, was it that weekend that a child drowned? Yeah, yeah.

It's always like holiday weekend that occurs and where, you know, family and friend gatherings are occurring. Yeah, usually that's when it happens. Yeah, so. And we, did San Antonio see a drowning that weekend or was it just recently? I know there was a child drowned in the spring time, right? Yeah, there's springtime and there was another one, yeah, recently as well. So, and we're only just one hospital.

So in the area, there's quite a bit, you know, in the San Antonio area, you know, because we have so many other hospitals here. In talking to the families, is there a common thread or anything that you want to mention to pediatricians to like, do they, are they saying like, I thought someone else was watching. or I just turned away for a second. Yeah, it's always kind of that moment of opportunity that they're distracted. And we live in such a distracted world with our phones.

But yeah, it's in all kinds of scenarios. Sometimes they're freakish, you know, in the sense that, oh yeah, I understand if there's another child that they're watching over that's younger, they're watching over them and they're running off. You know, it is an element of distraction. and the timing is right on, you know. So, but it's never, it's seldom just one person, right? If it's just one person watching over the kids, actually that works out okay.

It's when a group of people who make the assumption that the other person is watching or if it's, yeah, it's just being distracted really easily. Yeah, so. That's a great point, Ted. I remember when I was a news reporter and we were rushing to the scene where it was in that body of water near the zoo and it was a party happening over... It was Easter Sunday. Oh, man. And it was a nine-year-old who ended up... Who drowned. And I remember getting there and the emergency...

People in the water who they had their wetsuits on. And I just remember getting there and it was so quiet and they were getting out of the water and everything. Like, why is it so quiet? And then it was just like, just so heartbreaking. I'll never forget that moment. But it was that where the family was saying, we all thought someone else was watching her and she didn't know how to swim very well.

Well, you all are doing such a wonderful job helping children, and we're talking about advances in post-cardiac arrest care. So what are some of the advances you can tell us about? Yeah. So, you know, this kind of comes up from a couple decades worth of literature. What we found was in adult patients that had cardiac arrest, when they used hypothermia after their care or in their care afterwards, they had better neurologic results. They had less disability and mortality from that.

With that knowledge, they applied it to babies with suffered birth asphyxia, and they had extreme acidosis when they were born. And when they used hypothermia in the first 72 hours after that birth, they also encountered less morbidity and mortality as well. So a group of us in pediatric critical care now about 10, 15 years ago decided to use the same type of therapy, which is using hypothermia for pediatric cardiac arrest. I actually was doing training in fellowship in California.

And again, my attendings and faculty were like, we have a lot of drownings here, you know. And can, is there any utility using hypothermia to lessen the injury from this anoxia to the patient's brains. So it took a while to formulate, but basically we formulated the largest pediatric cardiac arrest group all around the country, and in fact, extending to Canada and Australia as well. Wow. So our first study is called the FAPCA studies, and that's an acronym standing

for Therapeutic Hypothermia After Pediatric Cardiac Arrest. arrest. And that was looking at cardiac arrests, whether they happened in hospitals or outside of the hospital, and just compared using hypothermia and normalthermia. And what the past studies had shown was comparing hypothermia versus nothing. And they had showed better outcomes when those studies. But when we compared it just to normalthermia, there was actually no difference.

So what that meant to us was that, It was really critical to protect patients' brains after their cardiac arrest and not get them hyperthermic, not having fevers afterwards, and to control their temperature. So this is where we call it targeted temperature management, TTM. So that's one of the major developments that we've seen now that has good outcomes in protecting patients' brains. So, Ted, that's so fascinating. And what does that look like? So say if a child's pulled from the water. Yeah.

So once they're pulled from the water, they're actually usually pretty cool. Then their temperatures are usually in the 92, 93 degrees. And a lot of our practice now is we don't actively warm them. In the past, we would actively warm them back to normal, which is 97, 98. Now we just let that be because we kind of think it's protective in that form, right?

And then when they come to the ER, and we work with our ER colleagues now to activate cooling then, as soon as we can put them in some kind of, we call it thermal blanket, we wrap them in this blanket that's laced with water that is actively cooled or warmed, depending on what the target temperature is. So we do that starting in the emergency room and then we continue it to the ICU care.

So hypothermia and its use has been used for a lot of other diseases, but cardiac arrest seems to be the most benefit of protecting the brain. It's so interesting where it's hypothermia can be its own emergency. It's like inducing this pain. Emergency to help save someone and to help save their brain. Yeah. I mean, it came from, you know, the old tales where, you know, the kid in Lake, you know, drowned in Lake Michigan in the middle of winter and was down for like 30 minutes.

The divers were going in, they pulled them out and came back and it was absolutely normal. Right. And there were some studies that did older studies that looked at that and found that when they cooled patients too long for like a week, they had worse outcomes. They had worse outcomes with that. So we found out there's probably some utility in using hypothermia, but probably not too long. It has to be the exact right amount. Yeah. And what the right exact amount, we don't know.

So that's actually where we're involved now. Now, the same hospitals that did the THAPCA studies are doing now what we call a pediatric ice cap study. And it's just looking at, we initiate hypothermia for also pediatric cardiac arrest patients. And they're usually drowners or near drownings. And then cooling them and they get randomized to the duration. So they all get hypothermia, but the duration is where they randomize.

To see where the optimal time duration to optimize or lessen their injuries when we look at them. So we will enroll these patients and we follow them a year later. Have them evaluated by our neurologist. And we have a developmental pediatrician who also evaluates them as well, just to kind of see what outcomes come out of that. So that's ongoing right now. And because a lot of families may not realize that the child survives, that child may have long-term brain damage.

Yeah, brain damage, a lot of developmental disabilities, you know, some disability, and it ranges. That's the hard thing to predict, right? Some could be, you know, not able to walk properly. Some might lose, you know, the ability to speak well, you know, but we don't know what happens with what. There's no enough brain imaging to kind of help predict that as well.

We just kind of teach our families that these injuries happened, and then kind of get them to therapy and rehab to help, you know, train or, you know, get those abilities back. But it's hard with toddlers because with toddlers, we kind of didn't know because they're developing as well. So we didn't know what they could developmentally do anyways.

Right. So, but we try to optimize that while they're recovering. Music. Or cardiologists follow, those are the ones that also have cardiac arrests outside of the hospital. Okay. And I saw that San Antonio now has its first confirmed case of measles and pneumonia is, I think, the most common side effect of measles. And hopefully pneumonia will not become more common as we see more cases of measles. It's so awful, heartbreaking. Yeah. Yeah.

Yeah. I mean, as our unvaccinated rates go higher, yeah, we're going to see more measles cases. Yeah. So. And we do have an episode here in the Pediatrics Now News Feed. The episode right before this is a COVID update. And we talk about COVID and flu shots with our pediatric infectious disease doctor and advice on what does science show, what to say to patients in that regard.

Ted, is it good for all of us to have cold water, a cold water plunge or get in the cold water? Do you want to say anything there? Do you try to do that? No. I mean, I've done half marathons or trained for them. You know, I've heard the whole ice cold plunge. I've also read the literature. There's a lot of sports physiology about swimmers that swim in cold water, like truly like frigid water.

And there is some benefit in definitely making decisions energy efficient for oxygen consumption for your muscles, right? They don't know if there's some anti-aging effects in that, but I know swimmers, as we talked about, you know. Yes, we're both swimmers. Yeah. And they live long lives because of that. But that science is really out there.

So there's still more to come about that. Yeah. So. My son did an outward bound expedition in January, which I highly recommend, But he went to an area called the Boundary Waters in Minnesota, and it was seven days of dog sledding and cross-country skiing. And then at the end, they go into the sauna, and then they do a cold plunge. And the maximum I think you could do the cold plunge was stay in for two minutes, which he got very close to that. But he loved it.

He loved it. That was his favorite part. Oh, wow. There you go. And he wants to go back. So ted it's such an honor to be talking to you here today and i so appreciate you being here in the podcast studio how are things going in the pic you are there any other, unintentional injuries you want to mention i mean you know in the pic you especially during the summer seasons all of the preventable diseases are preventable injuries which are burns and sunburns?

No, burns from fireworks and outside gatherings, right? As we lead into the 4th of July weekend. Right, exactly. So fireworks is the big thing. In San Antonio, they are illegal, but outside it is, you know, open flames, I guess. But yeah, that's a lot of where our injuries see from our, you know, from toddlers, you know, handling, you know, fireworks or sparklers, Or teenagers too Or teenagers too, right, exactly And with the teenagers then it gets with

open fires and adding gasoline to them. We'll see those. They add gasoline to the fire? Yeah, they add gasoline to the fire. They'll see someone do it, but not knowing how much to do. And that's actually still really dangerous to do.

And the grill and being safe around that. So we'll see various injuries related to fire in that. The other one is just flat out family travel, right? Making sure all the kids actually are in car seats and not sitting in a family member's lap because we see a lot of those types of accidents during the holiday weekend as well.

So mentioning that, having everyone kind of in a buckle seat and it's not worth the, you know, the cram seating in those situations, you know, and having, you know, your loved one get really injured because of that, you know. So those are the types of things that we'll see during the summertime right now. And you're on call tonight, right? Yeah, I am on call tonight, yes. I so appreciate you being here as we head into this holiday season, which is that travel's already started.

Yeah, right. That's true. So we'll see. What else would you like to say to the pediatric practitioner listener? I think it's so incredible and inspiring that we are seeing fewer drownings, thanks in a huge part to pediatric practitioners mentioning something to families in the exam room. Yeah, you know, I think, you know, as our good general pediatricians are out there, you know, counseling our families, never underestimate your advice. It still carries a lot of weight.

Sometimes I feel that our pediatricians might feel that they, you know, there's so much information out there and it's so accessible. But the pediatrician still has a lot more weight in ways that you probably don't know and just being receptive to your families and what they're trying to tell you. If they, sometimes if a parent or the patient have suspicions of things, it'd be a good opportunity to kind of really delve into that.

I know sometimes it's really busy to kind of go into the details of things but I think sometimes it's worth the time to kind of delve into more of that and that's where we run in. For us in the ICU, we see the patients have gone to the pediatrician X amount of times and didn't really identify. And they have very vague symptoms. I get it. And how do you.

Weed out all of that, you know, but some, some of our pediatricians out there are able to kind of able to ask the right questions and really figures, help figure things out. So I think being attuned to that is a good opportunity to talk to your families and your patients to do so. So, and I know with, with my three kids, I'm every time there might be something that I've been talking to them about.

And then when the pediatrician says it, then they really, that's when they really start doing it you know there is that power and then we do have a couple of episodes in this news feed on motivational interviewing which can really help you drill down in that short amount of time in the exam room you have to really get to the heart of the matter which it can be so tough like you're saying well the funny thing about that is that so my wife and I are both pediatricians and even with our kids

we we tell them hey we're gonna let doctor are you know your pediatrician know that you're doing this and then they're like no no no no no don't let her know oh that's good yeah so i was like see you know i so the pediatrician does have a lot more you know weight you know outside the parent right you know so that's great yeah my son was so he he had listened to the both of our motivational interviewing episodes or the all three of the motivational interviewing episodes and then

i was asking my older daughter about something and then he's like mom why did you ask a closed-ended question which is part of it i'm like oh yeah why did i and it's a lot of in motivational like interviewing reflecting back like so what you're saying is all right and then repeating back so you're understanding it yes so. Ted, before we wrap up, do you want to talk about, I like to promote doing stuff outside of medicine in this high burnout, high stress career. I know you swim.

Is there anything else you want to talk about that you do for fun?

I actually golf, you know, for my fun. I like the nature of it's it's so hard and difficult but I like it because there's not time where you can spend so much time outside outside of hiking and but but you're kind of always I like how it engages your mind and you're trying to figure things out it's all every every hole is a puzzle once you get part past part the part of how to you know hit your golf ball and control it but then there's so many other things to it that's it's so engaging and

and mind-boggling so that part i really enjoy the swimming part for me is just not only to maintain some fitness and stamina but it's also a quiet time as well right so i really enjoy that that moving meditation yeah exactly outside that yeah it's really you know daddy time with with the kids that's kind of how I maintain some balance there. So, yeah. And you're a father of two? Yes. Yes. And did you and your wife meet in medical school?

We met during training. I did my training in Las Vegas, Nevada. Yes. So, yeah. And then were you friends first or do you want to talk about that at all? Yeah, we were friends first and then we didn't actually start dating until after training. Yeah. And then I moved. So I had to do additional training after that training and that moved me to Southern California. at Loma Linda. So it was not until then we were, we were dating. So, yeah.

So, and you were talking about golf. My, my son, I've been playing with him some, and he told me like, it takes a lot of work to just get to where you're bad at golf, but you're playing actually.

I'm like, oh, great. It's like a little bit intimidating. So that's my first goal is to at least be playing, but be bad at golf. Yeah. Right. I guess. Yeah, exactly. So there is like This threshold where you put in a lot of work just to hit the ball, hit it in some fashion that's consistent. But it is so beautiful to be out there. Yeah, I know. And Texas is awesome for golf. It is hot, though, but it is pretty awesome for a lot of the golf here.

Music. Department of Pediatrics at UT Health San Antonio and University Health's new Women's and Children's Hospital. Thank you so much for listening. We are so grateful to our listeners and also to the educational grants that help support Pediatrics Now. Our website is pediatricsnowpodcast.com. For episode ideas or questions, please reach out to me. My email address is on there. I'll see you soon.