Report on the Lake Accident 2015

Summary

The Transformus Board of Directors would like to thank our community for its patience while we reviewed and processed this summer’s tragic loss of our community member, Jay Marx. We know that it has been trying for you all to wait for a thorough report; however, in order to base our response on comprehensive information, it was necessary to have access to the full official autopsy report.

Now that the document is publicly available, the Board of Directors has completed a full review of the Medicolegal Autopsy Report of Mr. Marx’s death. The Office of the Chief Medical Examiner ruled his death to be a result of a diving accident. (The details of the autopsy are summarized in the last paragraph of this report.) The BOD concurs with this conclusion; it is consistent both with witness reports from the scene and the timeline which we have reconstructed from that day.

Timeline

Please note that any time reference here is approximate. So far as we know, no one was referencing timekeeping devices during the events unfolding at the lower lake.

According to our information, Jay Marx was last seen in the lower lake near mid day on Sunday, July 19th, swimming and diving in good health and spirits. At about 2 pm Jay was discovered unconscious under the water by a participant. He was taken promptly to the shore where a trained participant immediately began efforts to save him. Our emergency response was carried out in accordance with our established procedures. As Mr. Marx was being pulled ashore, a bystander alerted First Aid. First Aid called EMS and 911. Bystanders performed CPR for the few moments that it took for our First Aid volunteers to arrive, followed very quickly by our professional medical team. Our EMS and First Aid teams provided vigorous, quality CPR until Henderson County emergency response arrived. Performing CPR takes both a physical and emotional toll, and much of our community watched as our teams proved themselves worthy of our trust. Rangers held a perimeter around the scene while EMS worked, and our security team quickly cleared the roads so that the ambulance and sheriff’s deputies could enter unimpeded.

The CPR provided by our professional and volunteer medical teams, as well as by bystanders, kept blood and oxygen moving to Jay’s tissues until Henderson County emergency response arrived at the lake. After Jay was transported by ambulance to the Deerfields gate, he was transferred to a second ambulance that contained more advanced lifesaving equipment. This ambulance was observed to pause to provide stationary care for approximately 30 minutes. Then it suddenly rushed to the hospital with full lights and sirens. The Autopsy Report does not include details about the events that occurred in the ambulance or at the hospital.

Immediately after the ambulance left the lake, BOD members contacted the Sanctuary [1] leads, and our Sanctuary team mobilized to go directly to the lakefront and offer support to the community. They also called in more volunteers in preparation for a challenging night. Rangers coordinated radio communications and walked our city, alert for anyone who might need assistance in the aftermath. The BOD was in contact with the Henderson County Sheriff’s office twice more that day. We posted updates to our website and official facebook page for those of our community who were not at Transformus or who were leaving on Sunday.

Later that Sunday night the BOD received word that Jay had been pronounced dead at the hospital. On Monday, BOD members accompanied Sheriff’s deputies as they investigated the scene, and a BOD member was present when the deputies spoke with a friend of Jay who had seen him around mid day on Sunday. We have continued to cooperate fully with local law enforcement. In the days following the close of the event, Sanctuary also reached out to the community via social media to offer grief counseling and assist with decompression.

Conclusions

The Board of Directors concurs with the medical examiner’s analysis that Jay’s tragic death was the result of a diving accident. We share with the community the sense of acute and painful loss from this tragedy. We sympathize with the members of our community and Jay’s extended friends and family who are grieving, and we will do anything in our power to support those affected.

In response to this accident we’ve performed a full and thorough review of our emergency practices and escalation procedures and we believe that they are robust and appropriate [2]. We have arrived at these conclusions despite the fact that Mr. Marx died; it is a sad truth that even in a hospital environment the best CPR can only revive one in five patients; in the field, the numbers are closer to one in ten [3].

Deerfields’ lakes are a large part of the base on which we create such a special and unique place for us to burn. On clear days like this year’s Sunday afternoon, swimming, floating, and sunning on those lakes are some of the purest joys to be found at Transformus. Art on the lakes has always been a welcome part of that experience. We want our community to continue to be able to use these resources, but we want them to be assets, not hazards. To this end, the BOD is examining ways to improve safety at the lakes while still allowing everyone to enjoy them, and we intend for the Deerfields lakes to continue to be places of comfort, delight, and solace. We wish to work with our community in continuing to heal from the trauma of this loss, and we welcome your thoughts. As always, please feel free to send any comments, concerns, criticisms, or statements of support to [email protected].

Additional Information

The next paragraph will summarize the details of the Medicolegal Autopsy Report. The medical terms can be graphic and can seem detached at times. Please use your personal judgement to determine if you’d like to skip this section, because it could be distressing.

The Summary of Findings states that the cause of Mr. Marx’s death was “blunt force injuries to the head and neck due to a diving mishap.” His C4 C5 vertebra had multiple fractures, this portion of his spinal cord was bloody and swollen, and the neck muscles around his spine were hemorrhaged. He had multiple hemorrhages in the skin and muscle on the front and side of his head, as well as bleeding in a deep internal sinus. He had no significant injuries of his hands or forearms. These observations suggest a headfirst fall, with no attempt to catch himself; in other words, a dive into the water. The pathologist observed changes in Jay’s lungs which indicated that he had inhaled water. Toxicology tests were “negative for ethanol”, meaning Jay had not been drinking before swimming in the lake. The other significant results from the autopsy (injuries to ribs, sternum, and liver) were all signs of vigorous, quality CPR.

Notes

[1] The Sanctuary team is an all volunteer team that provides mental or emotional support to participants who need it for whatever reason.

[2] Here is a link to the 2015 version of the Transformus Emergency Services Department’s Medical Escalation Procedures, which have been in place since 2014: https://drive.google.com/file/d/0B4zoqKwtmmdqZW1OWXlzbFQwVmc/view

[3] Our statistics concerning survival rates from CPR are supported here: http://www.cnn.com/2013/07/10/health/cpr lifesaving stats/