[EDITED: I wrote the original letter in one sitting. I have edited some of the poor grammar and typos.]
I was sent the autopsy report by Irv Muchnick and this is an edited excerpt of my email back to him - Warning the description of the cause of death is very macabre - this was a very painful passing as are all drownings or near drownings and this description is graphic:
"... Good God!
Here is my interpretation: The most important aspect of this autopsy report is that there was no heart defect nor circulation problems. This boy was fit and the specialist doing the autopsy was impressed with his state of health. Louis stood at nearly 6-feet-tall, was 14-year-old, and weighed 157-pounds. As you predicted he was healthy.
When Louis went into oxygen debt his brain began to bleed in the most most critical part of the organ, the ventricle area where the brain creates and circulates Cerebral Spinal Fluid. (CSF). The purpose of CSF is to cradle our brain, help circulate blood, and provide immunological protection. This fluid circulates up and down the spine and flushes itself out about four-times-a-day. The portion of the brain that creates this fluid is called the Choroid Plexus region. (Choroid is Greek for the "membrane that encloses the fetus" - Plexus means network) This area of the brain creates massive amounts CSF so it is always fresh, clean, and pure .
As I suspected from the summary you mentioned on the phone on Tuesday, brain bleeding within the core of the brain led to immediate Hydrocephalus (brain swelling - water on the brain). The pathway the CSF circulates through from brain to spine is called the "Sylvius Aquaduct" and the report says it was "obliterated." That is a strong sentence! His third ventricle was elongated meaning that severe blood clots were jamming the pathway for Cerebral Spinal Fluid (CSF) to circulate. This caused the Hydrocephalus to expand the ventricle and cause the subsequent obliteration of the Sylvius Aquaduct . When a blockage occurs it like a fire hydrant going off in a weather balloon but the fluid can only stretch the balloon so far before destruction or "obliteration." Thus when the blockage occurs the ventricles dilated and his brain got squished.
His tonsils were bleeding perhaps due to being on the ventilator or having the ventilator tube shoved down his throat to keep him alive. Autolysis was occurring meaning the brain cells were pretty much digesting themselves or committing suicide en masse. As a result his frontal cortex, that portion where our "selves or souls" may reside pretty much died screaming!
Drowning is not a "peaceful" way to pass. I hope he was so utterly unconscious that he had no physical feeling whatsoever as to what was going on for this was a cruel death. Herniated tonsils, ventricle bleeding, sinus thrombosis meaning swelling and blood. OH MY GOD!
I am told that Meadowbrook only had one lifeguard on duty that day despite a slew of kids swimming. Louis was one of those healthy kids who needed supervision and the Meadowbrook pool and the coaches at North Baltimore Aquatic Club failed him.
If NBAC shows up to the pool and there are not enough lifeguards there for the amount of swimmers they bring then it is incumbent on NBAC to demand lifeguards be present, provide them, or cancel the workout.
Tony ..."
For more details follow Irv Muchnick's coverage of the autopsy report: [Link]
14 comments:
This is horrifying. Some points of confusion for me:
In Muchnick's coverage, it says he was swimming by himself, unsupervised. Why are you saying there was a slew of kids, and one lifeguard?
If he was swimming by himself, why do you think he would do a breath control set?
In the end he was by himself and unsupervised but during workout he was with a slew of swimmers and supervised by just one lifeguard.
If you satellite view the Meadowbrook Aquatic & Fitness center at Google, look to the left of the LCM pool and you will see a building that houses the indoor pool. An opaque curtain separates the indoor on the left from the outdoor pool to the right.
When workout was over; (and this is how I understood it), Louis went under the curtain to the long course pool and began swimming unsupervised. The lifeguard at the indoor pool could not see that Louis had done this for an opaque curtain obfuscated his view of the LCM pool. Believing that everyone left the indoor pool area the lifeguard left the indoor pool and went inside since his "shift" was seemingly over.
Some time later in the LCM pool Louis was found near dead. I was told he was underwater for about 8-12 minutes, but the autopsy report is so vicious I presume he was underwater much longer than that.
I was told by one source he was doing breath control sets, I was told by another he was screwing around underwater. Both equate to breath control in some fashion. Both equate to an unsupervised teenager.
Here is what I wrote:
"... If NBAC shows up to the pool and there are not enough lifeguards there for the amount of swimmers they bring then it is incumbent on NBAC to demand lifeguards be present, provide them, or cancel the workout. ..."
Keyword: unsupervised. No part of an aquatics facility should be unsupervised. NONE When the NBAC team showed up to the pool that morning they had three options.
1.) Demand the whole pool area be supervised
2.) Provide the supervision themselves
3.) Cancel workout till one of the above could be figured out.
Even a obvious sign such as - "Long Course Meter Pool Closed" probably would have gone a long way and probably saved a life.
Both you and Muchnick need to focus more on the coach. There is hardly any mention of the coach. Where the heck was the coach in all this? As a former USS certified coach I would never leave the pool deck until all my swimmers were out of the pool. In fact, my co-coach and I never even left the pool site until all our swimmers were picked up. The coach is responsible for his/her swimmers.
You raise a good point - a very strong one in fact.
The NBAC coaches are well aware of the poor layout of the Meadowbrook Aquatic Center and perhaps they should do a head count during a warm down or at the end of workout.
Not sure but the autopsy report to me seems like a lifeguard would not have been able to save him. Even if witnessed. Not excusing the lack of supervision as that is unexcusable. But if they were doing a typical breath control set in the presence of enough coaches and lifeguards i'm thinking that with what occured physiologically there is nothing anyone could have done. Leads me to believe he was doing things far beyond breath control swim training.
If a lifeguard was standing on deck and saw him when he began to sink, I suspect he could have been saved and his heart restarted if that was necessary with a defibrillator.
It's oxygen debt that killed his brain, not unconsciousness or fluid aspiration into his lungs.
The workout was in the outdoor pool. Louis never left the pool until he was pulled from the bottom.
You wrote: "When workout was over; (and this is how I understood it), Louis went under the curtain to the long course pool and began swimming unsupervised."
This is not accurate.
Please elaborate - it's so important. Can you tell us what you witnessed?
Anonymous 7:38pm has it right. In addition, he was found when a life guard came on duty. He was out there alone. Lesson here is coaches and pool managers need to make sure swimmers are supervised at all times. Drowning can happen silently and quickly. There is a video demonstrating what most drownings look like. They are quiet and the swimmer bobs up and down with their arms up. It almost looks like they are playing except the head goes under water and there is no lateral progress or call for help.
The above poster is correct. You continually focus on "breath control," but this isn't about that. He never should have been unsupervised to begin with.
Yes it was all about supervision. I stated in this paragraph:
"... I am told that Meadowbrook only had one lifeguard on duty that day despite a slew of kids swimming. Louis was one of those healthy kids who needed supervision and the Meadowbrook pool and the coaches at North Baltimore Aquatic Club failed him. ..."
Can you shed some light on why a text was sent to 911, instead of someone making a phone call to report an emergency? I have never heard of someone texting 911. Who sent the text? Was it a Meadowbrook Swim Club employee or a member?
I will see what I can fond out!
I will see what I can fond out!
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