 This is ThinkDex Hawaii, Community Matters here. This is Craig Thomas, your host on Much More on Medicine, part of ThinkDex Hawaii's live streaming series, and our engineers today, as always, and it's wonderful, Rich and Ray. And joining me today is Ralph Godo, my friend of many years. Thanks for coming, and tell me a little bit about yourself. Well, the most important thing is that I'm retired after 30 years of working with the city, with the lifeguard system, and right now, do whatever I want, come and talk with you, do a little bit of ocean safety stuff, but happily retired. Happily retired, honestly, I always thought you were happily working, too, so that's a credit. You were the, honestly, you're an inspiration to me in a number of ways, so I might as well tell you about a couple of them. One was, I know that you generally went for a swim in the middle of your work day, and that's pretty cool. I don't know how often you pulled that off, but I know it happened. And I think that's important, because part of our health is making sure our bodies are engaged. Absolutely. The other way that you are an inspiration to me is that you've focused on how to keep people healthy, not on the drama of the intervention in ocean safety, that I think it was called lifeguarding when you started, likely. It was always the rescue. And we do too much of the rescue in medicine, whether it's pre-hospital, an emergency department, the dramatic therapy. Almost always those things mean something, well, they always mean something's gone wrong, and they usually mean we failed in some way to anticipate a bad event and didn't intervene. I think that whole concept of reaction versus prevention is so true, and you and I have spoken about that many times. The prevention stuff isn't real dramatic. It's not real glitzy. It's not like, oh, they made a rescue in a 20-foot surf at Waimea. It's something that's ongoing that has to be a part of what we do as lifeguards and as safety people. I agree. And the challenge is, there are many challenges. What works in prevention, what doesn't, hypotheses are fine, anecdotes are fine, but they aren't science. And they shouldn't shape policy. But in addition, you touched on something else. Everybody loves drama. People pay for drama. The actual saving a life or preserving health or making a more healthy place to live, that's often unexciting and it's work. That's what you folks, walk us through sort of the evolution of what is now ocean safety? I think that when I first started, which was a number of years ago, 1981, people said you should go to Australia and LA County to find out what's really going on in life-saving. So I went and saw some really good things. I came back to Hawaii and said look, there are things that are going to work in LA that aren't going to work here in Hawaii. So we took some of the concepts and some of the things that we learned and applied them here with that perspective. You weren't going to stop people from surfing. You weren't going to stop guys from going and laying net and diving for fish. I mean, that's part of their lifestyle. So I think that's something we accepted. We were very impressed with Australia's surf life-saving. They're very dramatic. They have these studs that do all this wonderful stuff. And from LA County, we learned about organization because LA County, they're probably the highest paid public servants anywhere in the country. They make a lot of money. But it's not because they're cool or they're ocean guys. They worked at it intelligently, systematically. They have a pretty enlightened coastal community that they worked politically and got to where they are. So they are, in my view, the example of what a public safety agency should strive towards. So we worked at that. And when we first started, Craig, well, you were around. It's true. I think our career spans pretty much the same decades. There were the surfer guys. There were the ocean guys. There were the studs. No one, not really any formal training, you're going to be the lifeguard at Hanama Bay. And at one point, there were two lifeguards at Hanama Bay. Now there are like 12. So it's evolved from a reactionary sit-in-the-tower wait for something to happen, go make your dramatic rescue, do CPR, do mouth-to-mouth, to more of a prevention-oriented organization. It's been a pleasure to watch it. Because pretty clearly, if you're doing CPR, it's not likely to end well. As an aside, I like the TV shows on medicine that portray actual adverse outcomes, failures in diagnostic acumen, because we're all human. And one beef I have with most of those shows is that the CPR success rate is on the order of 80%. So the public expectation is, oh, they're doing CPR. It's going to be fine. No, almost never is it fine. So that's been a pleasure to watch. I know you also innovated some sort of Hawaii-specific, or should I say, innovated in Hawaii, some things that worked well here, and I think have been adopted largely across much of the ocean community. I think the two areas where Hawaii has really taken leadership in life-saving, one is rescues in the big surf, because this is, you know, this is Mecca. This is Waimea at 30 feet. People come from around the world to challenge that environment, to surf it. So the work that the North Shore Life Guards have done, and the West Side Life Guards have done, really been pioneer work. How do you do a rescue at Waimea when it's closed out at 30 feet? And back in the day, you know, you stuck your fins in the back of your shorts, you got on the board, you took a tube, and you may make it through the shore break. You know, when you get out there, it's too gnarly to come in, so you wait for the chopper, and it's drama and trauma. And it's slow. Yeah. Because you're saying, if you get out there, I mean, it is, really is, if you get out there. So one of the, you know, the other area where we definitely did the original work was the use of personal watercraft, the jet skis. And originally they were looked at as dirt bikes on the water. They're offensive. Nobody wanted to play with them. And there were a couple of lifeguards that saw the potential. Brian Kailan, it was one of them who, during a surf contest, got wiped out, and a guy came up with the jet ski and put him on it, and the light went on. He goes, wow, this is something we could use. They developed the use of the ski. They put a sled on the back, started as a boogie board, and now it's evolved into an actual rescue platform. And it's just, it really has revolutionized life-saving, surf life-saving. And that was done here, not in Australia. It was done here. I bike down the east coast of Australia, and I love the aspect of the surf life clubs to popularize the, how to do water activities and the fitness and culture associated with them. I prefer your approach to keeping people from getting hurt. And on a personal, I have a friend, a windsurfing friend, who, if there was a jet ski in the presence out at Phantom, so years ago, he'd be alive today. So, you know, it's, it's personal for me as well as just as an ER doc. Familiar with the case, and you know, a lot of those situations without the ski, people, the outcomes would have been a lot worse. Yeah. I mean, he was a guy, definitely could have been gotten by a ski. There wasn't one, and he died, as we know. The other thing about the ski, or I think one of the important things about the ski, is it's another tool. But you know, it's another weapon in the quiver, if you will, which has really helped the lifeguards in their rescue response. And it takes its own training. You know, guys don't just hop on the ski and go. Oh no. It's pretty rigorous training, actually. The last Eddie, there were, I don't know, how many skis, but a huge set came through, and there were five, I believe, all going like crazy for sure on the same wave, because they were caught inside. So these guys were really good. That was classic. That was awesome. And you know, that has really, it caught the attention of a lot of people. I showed that video piece at a World Conference on Drowning Prevention a couple months ago. And you know, those are the, once again, the drama, the glitzy stuff that people see that you can use to draw attention to your basic safety and health messages. Absolutely. And to me, it was just also a demonstration of tremendous skill. Absolutely. Let's talk. There's always a hazard of getting in the ocean. Maybe we could get the leading causes of fatal injury slide up. I'm a water guy. If and when I go, it could easily be in the ocean, although I'll try to avoid going prematurely. Why don't you talk about sort of the relative risks of the various events in the ocean and patterns you're seeing. There's been a possible blip this spring. Small numbers and a long set, so it's hard to know. You know, one of the things that we've tried to do is look at the data, you know, a little science if you will, because if you have the data and the information, then you can make some intelligent decisions about what you're going to do, how you're going to deploy your resources because you only have so many jet skis and so many lifeguards. If you look at the data, the data really shows that in Hawaii, drowning is the fifth leading cause of unintentional injury, death. But by far the leading cause of fatal injury for visitors. What that tells us is, okay, are the visitors, how are they more susceptible to this? Are they less educated? Are they inexperienced? Do they come to Hawaii with heart or lung conditions? All of those things have to be factored into what you see and what you can do to prevent it. Because, you know, we used to think, the tourists, they don't know what's going on, watch this guy, he's going to get caught in the river. I think we've shifted that perspective from, okay, we need to know what's going on, and we need to educate people about risk, about putting your foot in the ocean involves some risk, you know, and that's been a real challenge for us. Yeah, and honestly, you've done a big job. When I started years ago, one of the places we staffed is Castle, another one is Wahiwa, they both get ocean-related injuries, and I'm sure it's still happening, but the rate of shoulder dislocation, cervical spine injuries from makapu and sandies has plummeted, and I'm sure it's because I know I've watched your folks do it. Sir, I wonder if you should read again. Do you realize those kids are really good at this, but you might not be? Yeah. I've seen it happen, and it makes a big impact. The next slide shows drownings in Hawaii by tourists versus residents, and also what they were doing. I think it's pretty interesting. It's very interesting because I think one of the things that we kind of take for granted is that people, visitors, especially come to Hawaii, why do they come? They come for the beach. I mean, 90% of them, I dare say, would be going into the ocean, not just once, but a couple of times during their stay. The data shows that the leading cause or the leading activity involved in non-resident drowning is snorkeling. So what's going on? And that's what we're trying to find out. Exactly. So in the second half, as soon as we're back, we'll talk about snorkeling. This is Craig Thomas, much more on medicine with my guest Ralph Goto. See you in a minute. I'm Ethan Allen, host of Likeable Science on Think Tech Hawaii. Every Friday afternoon at 2 PM, I hope you'll join me for Likeable Science, where we'll dig into science, dig into the meat of science, dig into the joy and delight of science. We'll discover why science is indeed fun, why science is interesting, why people should care about science, and care about the research that's being done out there. It's all great. It's all entertaining. It's all educational. So I hope you'll join me for Likeable Science. Welcome back. This is your host, Craig Thomas. I'm much more on medicine with my guest, Ralph Goto, who I've known for at least 30 years in our sort of parallel careers and trying to hopefully improve health. And when things go sideways, do what we can to fix it. Was it 30 years ago, we did the jellyfish manual? It was more like 20, more than 20. And it's actually interesting you say that, because in fact, hold that thought for a moment. I want to talk slightly more about snorkeling, but the jellyfish thing was fascinating. And I think we should talk about it, because it demonstrates the difference between hypothesis and science. Absolutely. So before the break, we were talking about how people get in trouble in the ocean. And we were talking about the fact that visitors seem to have a real challenge and have for many years with snorkeling. A little later, we're going to talk about a workshop to investigate sort of current states of knowledge and possible areas of research. And also see if the trend is changing. So this is applying science. The years ago, Ralph and I collaborated with Susan Scott, my wife, and the Ocean Watch columnist who put in a plug, on what works or not when you get stung by either a box jellyfish or a Portuguese man of war. And with the assistance of a couple of your guys, particularly Landy, worked his butt off on this, we did some studies. And we, among other things, used the product that was, I think, was that important from Australia? I don't think so. I don't think so. There was some miracle product that was being used by the gallon at the time. But there was also meat tenderizer. There was saltwater. There was freshwater. And this was all done in a blinded, controlled fashion. We also looked at heat and cold. But the more important data was the solutions. And to me, the really interesting, there were two fascinating things about the study. The first was, there were a number of people, both lifeguards, but also people on the beach, entirely convinced that this was unethical, because you were potentially putting a placebo on somebody. And we were. But it turned out that the placebo worked every bit as well as everything else, including the expensive commercial product. And it changed practice. That stuff disappeared. It's a great story and a great example. It really was the first time we, as a lifeguard operation, got involved in some science, some data, some research. And I think it was, for us, it was very enlightening how we had to do that double blind study, getting people's permission to do this and getting acceptance to do it. But I think the parallel is stuff was going on. Everyone had a theory. Everyone had their answer or their solution. And we actually were able to test those hypotheses and come up with some answers, which is really what we're trying to do in a lot of areas. Exactly. And it ended up in changing practice. And by the way, Ralph, our papers were recently cited in the Annals of Emergency Medicine as part of their addition on treatment of environmental injuries. And it's still current. So that's great. We actually, I'm pleased. Studies don't always stand a test of time. So let's talk a little bit about what do we think's happening with these tourists, if anything. And it's local people too. Incidentally, before we actually focus on tourists, I'd like to talk very briefly about freedivers. I like freedivers. I am fortunately a chicken freediver. And as I've learned more, I've become more and more chicken because, first of all, almost all the good stuff's not all that deep anyway. But second of all, well, talk about it, shallow water blackout and those things. The focus and the attention that we've put on, these snorkeling incidents, if you will, results in a lot of, once again, theories. Everyone has their point of view. Some say it's shallow water blackouts. Some say it's O2 deprivation. Some say it's pre-existing medical conditions. There are a lot of theories that people are holding and subscribing to. The freediving issue is a little different, I think, because most of the fatalities that we're seeing happen on the surface. They're not going down and getting stuck in a hole. No, no. Or they're not chasing a big oolua, which is what happens with the local guys. And believe me, local people get in trouble, too, by overextending their abilities or trying to stay down too long. But the majority of the ones that we've been seeing, especially in the past couple of months, are primarily not beginners, but not super experienced people. They're in the ocean. They're on the surface. And that's what we're trying to figure out. What's going on with these people? What's happening? We used to think, well, look at this guy. He's at Hanama, and he wasn't paying attention at the video. And he gets a mouthful of water, and he panics, and he drowns. Well, there's something a little more than that, I think. And that's what we're trying to figure out, is what happens right before that sequence of events. Do you think there's been a change? And I'm not talking about this spring blip. And maybe we should get Dan Golanus, who I know is going to be presenting it to your workshop that's coming up, to look at this. But do you think there's been a change in incidents of snorkeling death? It's a little tricky, because the number of snorkelers, tourist snorkelers, has dramatically increased over the years. Yeah, there's a couple ideas that we could put out there. If you read the paper, which I know you do, Greg. Actually, I do. It's my job as assigned at home. It's 9.5 million visitor arrivals, looking at 10, which HCA says, that's great. They're filling the rooms. Well, what are they doing when they get here? They're going to the beach, most of them are going to the beach. And it's an access issue as well, I think. For instance, did you go to the Great Barrier Reef? Did you die there? I've done both. When you go to the Great Barrier Reef, I think you have to go on a boat, or you can't just kick your way out there, right? If you come to Hawaii. Well, I don't know. It's 25, 30 miles, so are you good at kicking the road? So you have to be short. The bottom line is you're supervised of some sort. Maybe it's a boat captain drops you off, blah, blah, blah. But you fly into Honolulu, you go check in your hotel room, you go to the ABC store, or if you've done your homework, you go to Costco, and you can get snorkeling stuff. You get it, you walk right out of your hotel room, and you can go snorkeling. Absolutely. So there's many more people doing it, and many more unsupervised people doing it. And there's some challenging environments. Most of the places people snorkel in the Great Barrier Reef, which is an astonishing thing, but most of the places you actually snorkel or died are places that are sort of pre-vetted. And that makes a big difference. And you know what, and we did, we polled my colleagues Miami Beach, what's happening, Florida Keys, what's happening in the Bahamas. I talked to my friend on the Gold Coast about the Great Barrier Reef, and there are clusters of these things going on around the world. But this is ground zero. We're here, I mean, this is what's happening. It's snorkeling by far is happening here, and I think that gives us an opportunity to really look at it and try to figure out what's going on. Well, I'm really pleased you're doing this because my suspicion, my hypothesis, so my hypothesis is when you have a theory and you, and this happens to all of us in life, you have a theory. You then need to decide how to test it, and you need to test it in a way that's controlled for as many variables as possible, ideally blinded, although that's not always easy to do, because if you don't do that, that's all it is, is a hypothesis. And medicine is full of many more wrong hypotheses, proven wrong by just like the jellyfish trial, than right ones. And I know that's your focus. And the other thing to be careful about is the sort of what we call surrogate marker problem. So there's the blind adoption of a hypothesis, you don't want to do that. And then there's surrogate markers, which might be some characteristic of a piece of equipment or some measurement of carbon dioxide, let's say. I'm not saying those things aren't important, but they aren't actually proof of the answer. One of the things that we've discussed is we need to find out more information about what's going on with the patients or the victims of fatal drownings or fatal drownings. You can't interview them with all due respect, because you can't interview them. But you can interview. We might have a blind enjoyed you over the years. But you can interview the survivors. You can interview the guys that we say that we rescue and say, hey, what happened? What would happen? Look at their equipment. That's one part of it. Interview them to find out what activities they were doing before they got in the water, their general health status, and things that may have contributed to it. Because like you say, it's theory. And until we can really get more reliable data, if you will, we're shooting into the wind. Ultimately, we'd like to be able to actually put some prevention messages out there that mean stuff, not like just be careful, and try to get it right. I mean, we need to tell people, hey, this is what we think is going on. And this is what you should be aware of. Yes. And if we hadn't developed hypotheses and then tested them, we'd still be doing blood lighting or leeches I could go on. We're about to wrap up. But I think it would be great if you could give a little description of this upcoming workshop and invite people to come. Great. Next Wednesday, the 28th of March, we're having a workshop. We're calling it the Snorkel Safety Workshop at the Hilton Hawaiian Village. And it's open to the public. There is a slight fee to pay for lunch. In the afternoon, well, in the morning, we have a series of presenters, excellent presenters, physicians that are in the field, emergency room physician, the city and county medical examiner to talk about what he's found. Dan Galanis, the epidemiologist from the state, will present the scope and where it's going and what's happening. And in the afternoon sessions, we're going to get people in the water to look good. Perfect. Put the equipment on, test it out, and then have discussions about, OK, what's going on? What do we think? And hopefully begin to come up with some strategies and some messages. You know, that's just the way it should go. I'll look forward to seeing you there. Great. Thanks. Thank you. So this is Craig Thomas, your host on Much More Medicine with Ralph Godo. We'll look forward to seeing you next Wednesday down at the workshop.