LAUSR

The goal of a definition for a disease, injury, or process is to efficiently and effectively contain the unique physiologic change and/or inciting event so that itmaybe clearly separated fromother pathologic states. The goal of the Ciba Guest Symposium in 1959 was to standardize the definition of chronic obstructive pulmonary disease (COPD) to combat themultitude of overlapping definitions for the disease which, in the words of the participants, ‘...results in confusion and misunderstanding between investigators working in different centres and in different branches of medicine and thus retards advance in knowledge of a group of common and often disabling diseases’ [1]. In 2002, international leaders in the science of drowning resuscitation and prevention met to begin the process of standardizing the discussion of drowning around the world. It was well known that the term drowning carried numerous different definitions in the scientific literature; this was later validated by a review of 60 years of literature which found 33 different definitions for drowning [2]. To address this, they defined drowning as: ‘The process of experiencing respiratory impairment due to submersion or immersion in a liquid’ [3]. For this definition, ‘submersion’ refers to the entire body under water and ‘immersion’ refers to a part of the bodybeing covered inwater, involving at least the face andairway. This definition has since been accepted by the World Health Organization, Centers for Disease Control and Prevention, American Heart Association, European Resuscitation Council, American Red Cross, and every other governing body associated with the treatment of drowning patients. Inherent in this definition are that a drowning event (1) must involve a liquid medium, (2) is a process that begins at time of submersion or immersion, and (3) requires respiratory distress immediately following the submersion/immersion. Respiratory impairment may include any involuntary derangement from sustained cough to respiratory arrest, not to include voluntary breath holding [4]. Moreover, the definition is not dependent on the outcome. Furthermore, recommendations were made to discontinue the use of modifiers such as near, dry, wet, secondary, and delayed. The term ‘near drowning’ had been used to describe a drowning event in which the patient survived but for varying periods of time. Instead, the event can result in a non-fatal drowning wherein ‘there must be evidence of respiratory impairment to be classified as a non-fatal drowning’ [4]. The modifiers ‘dry’ and ‘wet’were originally used in forensic science to describe the presence or absence of water in the airways following a fatal drowning. Pathologists described the 10% of drowning cases without evidence of water in the alveoli or airways on autopsy as ‘dry drowning’, which they attributed to laryngospasm leading to suffocation [5]. ‘Secondary’ and ‘delayed’ have been used to describe the development of symptoms or sudden death hours to days following a submersion in patients who were otherwise clinically normal [6]. Recently, the modifier ‘dry’ has also been used to describe these cases, referring to a patient who suddenly ‘drowns’ while on land. With a uniform definition in place, it should be clear that none of these modifiers or their associated conditions can exist. Drowning is a process that rapidly leads to hypoxia and cardiac arrest. From a pulmonary standpoint, processes which contribute to hypoxia include airway obstruction, surfactant washout, atelectasis, ventilation perfusion mismatch, and pulmonary edema. As this is a process, a person either drowns or does not; one cannot be nearly drowned. Additionally, as the process has already begun, it does not suddenly start hours to days after submersion; drowning cannot be secondary, delayed, or dry. Despite over 15 years since the development of this uniform definition, and its universal acceptance by all major governing health-care organizations, outdated andmisleading terminology is still prevalent, not only in laypublications, but also peer-reviewed literature [3]. A 2017 study by Schmidt et al. [7] found that 32% of peer-reviewed drowningrelated literature published between 2010 and 2016 contained non-uniform terminology and definitions.While this study showed a slight improvement over a similar one conducted 5 years earlier [8], it still represents an alarmingly high rate of misinformation in the medical community. Recently, an increasing number of professional media and social media stories, as well as articles in peer-reviewed literature, have described terrifying stories of children who have been healthy following swimming with or without a known short submersion period, only to die suddenly days later [9]. The authors of these articles and medical professionals have almost universally attached the terms dry, delayed or secondary drowning to these cases in an attempt to explain how such an abrupt change in condition could have occurred. In most of these cases, no event leading to respiratory distress was reported; instead, a coincidental exposure to water occurred in the hours to days preceding the