In the water resuscitationOnline users please note this is not complete instruction in these skills. It is for lifeguard students to try, and to consider
recommending to their pools. NOTE: it is not the method for a victim you suspect of having a spinal injury.
If you decide to use any of this at your pool you will need to practice it and carefully evaluate it.
The current Red Cross method in the Lifeguarding book instructs you to do any and all rescue breathing
after you've removed the victim from the pool. This may be the policy where you go to work, in which case do
what the policy says. Also follow any local EMS protocols.
At De Anza we teach people how to do rescue breathing in the water because they may find situations where they
don't want to wait until they get the victim out of the pool.
Situations include:
You're in standing-depth water.
In deep water, when you get to the side, if you have assistance or are strong enough
in comparison to the victim's size or have sufficient equipment; or as you hold the victim a second guard can lie on
the deck and lean over the victim with a pocket mask and get a couple of breaths in before removal from water.
At any time, you may change your mind and decide to remove the victim from the water.
It will be your judgement call (or maybe your boss's).
The International Life Saving Federation (see links at the bottom of this page) looks at in-the-water-resuscitation from this point of view:
"Whenever an apparently non-breathing victim is found in the water, the rescuer is confronted with a difficult
choice. Should the rescuer attempt resuscitation procedures in the water or should the rescuer bring the victim to
shore first, then attempt resuscitation?"
They also say "When respiratory arrest is corrected prior to onset of cardiac arrest, the death rate is less (0% to
44%) than in those cases where full CPR (including chest compressions) is needed (33% to 93%). For these
reasons, in cases of respiratory arrest without cardiac arrest while the victim is still in the water, the time involved
in rescue will be enough, in the majority of cases, to result in cardiac arrest. This will lead to an increase in the
likelihood of death. If hypoxia can be corrected in the water, before cardiac arrest takes place, the victim's chance
of survival increases significantly. "
In other words, if the victim is not breathing and it takes too long to get them
out of the water and start rescue breathing, their heart may also stop beating and then they have a much smaller
chance of survival.
ILSF continues: "What if the victim is actually breathing and the rescuer mistakenly gives ventilations?
It can be difficult to determine whether an unconscious victim is breathing spontaneously while the rescuer and
victim are still in the water. Even so, if the rescuer ventilates a breathing victim, it is very unlikely to have a
negative impact. On the other hand, ventilating a victim who is not breathing may revive the victim, or at least
maintain circulation."
"If the victim is in cardiac arrest, won't the time involved in giving ventilations in the water delay CPR, early
defibrillation, and other critical interventions?
There will indeed be a delay, but the brief time involved in trying to immediately restart breathing is the best
approach. The higher death rate resulting from cardiac arrest (33% to 93%) versus respiratory arrest alone (0% to
44%) justifies the risk of attempting in-water resuscitation immediately. In the majority of these cases, breathing is
usually restored by mouth-to-mouth ventilation in the first minute."
The following presumes you, and any other guards, will have a pocket mask near you or on you as you guard.
RESCUE BREATHING IN WATER ADULT WITH NO SPINAL INJURY
You saw someone in the water seem to go unconscious. You had no reason to suspect a spinal injury.
You activated your facility's emergency action plan (examples: three blasts on a whistle; raise a flag; yell for help).
You went in to rescue.
A well managed pool would have a rule that any patron who wants to float motionlessly and stare at the bottom of
the pool, feel the sunshine on their back or let their kids climb on them, will do so with thumbs-up so the guards
know they are okay. If your pool does not have that rule, then you might want to partially determine consciousness
before grabbing a 'victim' who turns out to not be a victim after all.
If the victim is at the surface, without taking any extra time, splash and yell at them as you swim up as part of
determining consciousness (or determining they're just playing games with you or staring idly at the bottom of the
pool).
Move the victim from face down to face up or from below the surface to at the surface face up using an
appropriate rescue technique.
IF THE VICTIM REALLY IS UNCONSCIOUS
Tell a bystander or other guard to call 911 and tell the dispatcher there is an unconscious victim. For the purposes
of this class, we assume the bystander you ask to call 911 is a lifeguard and doesn't need a detailed description of
how to call 911 (such as "Don't hang up first" or "come back and tell me what they say").
If you are in shallow water where you can stand:
Get a pocket mask and possibly with another guard's help, do a primary survey. The ILSF says: "Do not check
victim's pulse or attempt compressions while in the water. These are difficult and inefficient, and will slow the
rescue process." But in standing depth in a warm swimming pool (as opposed to cold open water where your
fingers might have trouble feeling for a pulse), or in deep water at the side with assistance from another guard (as
opposed to treading water and trying to do it by yourself), you may be able to easily check for pulse.
If there is no pulse (are no signs of circulation):
A. Perform a lift from water.
B. Get another guard to get the defibrillator, if your facility has one, and oxygen, if your facility has the equipment, as you start CPR (this should have been
practiced as a part of your emergency action plan so you shouldn't have to tell someone, but be sure it was done;
people have forgotten they had an AED around).
C. If you had to perform a lift from water without a backboard, when possible as you are doing CPR, move victim from puddle to dry
part of deck for possible defibrillation, either by your staff or by the arriving EMTs. If there are enough extra
people to help they can dry and warm the victim, look for a medic alert tag and see if anyone knows who the
victim is.
If there are signs of circulation/is a pulse: give rescue breathing before doing a lift from water (unless the victim
has heavy bleeding another guard can't control, etc.). The ILSF says: "If breathing is not restored after one minute of
ventilation, the rescuer should rescue the victim.... Attempt to prevent unnecessary neck movement if there is a
suspicion of head or neck trauma."
DEEP WATER:
After determining consciousness and getting another guard to call 911, as you start swimming
toward the side, open the airway with your free hand on the victim's forehead.
If you aren't strong enough to do a breathing check on the way to the side, at least get someone to call 911 and at
least put your hand on their forehead to tilt their head back and get their airway open. When at the side, if the
other guard and a backboard isn't there yet to do the lift from water, then you might have five or more seconds to check for
breathing and pulse (signs of circulation), and go with the steps below. If you are strong enough to move the
victim quickly and do a check, as you swim, check breathing (look, listen, and feel) for about 5 to 10 seconds.
If the victim is breathing:
A. Keeping the victim's airway open, bring the victim to the side.
B. Perform a backboard or other lift from water.
C. Recheck airway, breathing, and circulation including looking for bleeding.
D. Monitor breathing, maintain airway open. You might want to give oxygen as well.
E. Do a secondary survey at least to the extent of checking pulse and breathing rate, looking for a medic alert tag
and see if anyone knows who the victim is. Dry and warm the victim.
F. Get another guard to get the defibrillator, if your facility has one, just in case (this should have been practiced
as a part of your emergency action plan so you shouldn't have to tell someone, but be sure it was done; people
have forgotten they had an AED around).
If the victim is not breathing: keep the airway open (sometimes if you yell at the victim to breathe they will start
breathing), hustle to the side faster. At the side, have a second guard lean over the side to assist and check for a
pulse (signs or circulation).
If they are not breathing but they have a pulse give rescue breathing before doing a lift from water (unless the
victim has heavy bleeding another guard can't control, etc.). When you get the victim to the side, have another guard get
out their pocket mask, lie on the deck and get a breath or two into the victim, or maybe even give rescue breathing
for a minute before you do a lift from water.
If there is no pulse (are no signs of circulation):
A. Perform a lift from water.
B. Get another guard to get the defibrillator, if your facility has one, as you start CPR (this should have been
practiced as a part of your emergency action plan so you shouldn't have to tell someone, but be sure it was done;
people have forgotten they had an AED around).
C. When possible, move victim from puddle to dry part of deck for possible defibrillation, either by your staff or
by the arriving EMTs.
If there are enough people to help, dry and warm the victim, look for a medic alert tag and see if anyone knows
who the victim is.
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When do you stop rescue breathing or CPR?
--When the victim's breathing or pulse starts again.
--When someone else with equal or greater training (lifeguard, EMT, etc.) takes over.
--When it would endanger you to go on.
--When an AED becomes available.
--(Technically) when you are too exhausted to go on (but this probably won't happen at work).
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When practicing on people in the water in class don't try to open the victim's mouth (they don't want to have to
choke on water that might get in). Don't breathe into anybody's mouth even as a joke. Instead, fake it with a
pocket mask.
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When you are being the victim, critique your rescuer, including silently counting seconds on checks and breaths.
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Do not continuously correct your rescuer; they won't learn if you keep doing it for them.
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The ILSF material on this page was taken from a page linked to from the American Red Cross Lifeguard Management website.
To read all of the International Life Saving Federation Medical Commission
STATEMENT ON IN-WATER RESUSCITATION
go to the new American Red Cross Lifeguard Management page at:
http://www.redcross.org/services/hss/aquatics/lgm.html#3
Click on archived articles.
Scroll down to International Life Saving Federation. Originally you could click on the link to get to the ILSF page, then click on In-Water Resuscitation (Download pdf format 137KB), but the last time I tried I got lots of error messages. Try this link instead:
ILSF Statements on In Water Resuscitation
http://php.dsnsports.com/lifesaving/content.php?name=medical&file=medical_policy_07
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How can you tell if someone is just floating idly, staring at the bottom of the pool, or enjoying the sun on their back?
Have a rule that any person who wants to float without moving must signal to the lifeguards that they are okay
by giving a "thumbs-up" signal as they float.
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