Portal de Periódicos da CAPES

Aquatic Emergencies

2017; Lippincott Williams & Wilkins; Volume: 21; Issue: 4 Linguagem: Inglês

10.1249/fit.0000000000000304

1536-593X

Anthony A. Abbott,

Disaster Response and Management

Water — you can’t live without it, but you can’t live within it. It is somewhat ironic that the compound of which we are most composed (water) is one that can kill us. Drowning is not only a major concern in the United States but also remains as a significant worldwide public health issue, ranking as the third leading cause of unintentional death and accounting for 7% of all injury-related deaths. Among children, it is a major cause of disability and death. At least one third of survivors sustain moderate-to-severe neurologic sequelae or pathological conditions resulting from this injury (3). Drowning is not only a major concern in the United States but also remains as a significant worldwide public health issue, ranking as the third leading cause of unintentional death and accounting for 7% of all injury-related deaths. Among children, it is a major cause of disability and death. Within the United States, as you would expect, most drowning injuries/deaths occur in those states with warmer climates and bordered by water. Hawaii, Louisiana, and Florida average two or more drowning deaths per 100,000 persons. What is surprising is that Alaska has the highest incidence with 3.4 deaths per 100,000 (18). During one period from 2000 to 2006, the statewide average annual drowning rate was 8.9 per 100,000 or seven times the national average of 1.2 per 100,000 (15). A natural response to this alarming statistic would be “why Alaska”? Recognizing that commercial fishing is a major industry in Alaska, it is no wonder that almost 70% of the drowning deaths were due to boating activities. The primary circumstance preceding these deaths was falling overboard from a boat or vessel coupled with the fact that approximately 50% of the victims were not wearing a personal flotation device. Another major contributing factor was weather conditions (10). When looking at pool deaths per state, again those warmer states bordered by water have higher incidents, with Florida leading the nation. As would be anticipated, a great number of deaths are among children with drowning as the leading cause of unintentional death for children ages 1 to 4. Approximately 75% of the deaths of children involve those younger than 5; and regarding children younger than 14, 75% occur at a residence with in-ground, above-ground, and portable pools (17). However, pool deaths are not limited to children; adults also die from unintentional drowning, and some of these deaths occur within pools. Every day, approximately 10 people die from drowning, and of these, only two are children aged 14 or younger. Drowning ranks fifth among the leading causes of unintentional injury/death in the United States (4). Equally disturbing is the fact that nonfatal drowning injuries frequently cause severe brain damage that often results in long-term disabilities such as memory problems, learning disabilities, and permanent loss of basic functioning (e.g., permanent vegetative state) (14). Sadly, too many needless drowning deaths have occurred in fitness facilities. Try googling drowning deaths at fitness facilities and note the number of hits that is elicited. However, this number is far from inclusive, to which this author can attest in that he has been retained as an expert witness in a number of drowning deaths at facilities, none of which were reflected in this type of search. In one such drowning, a 53-year-old man was found in an unsupervised facility pool by two other members who noticed that the victim was sitting at the end of the pool with his head underwater (19). It was estimated that the victim had been in the pool area with his head submerged for at least 15 to 20 minutes before being discovered. Three members were responsible for extracting him from the pool and then providing cardiopulmonary resuscitation (CPR) while a facility employee contacted emergency medical services (EMS). Upon being brought to the pool deck, it was noted that he was cyanotic and large amounts of water were expelled during the CPR effort. No pulse was established by the EMS personnel nor by physicians upon arrival at the hospital.It was noted that no employees took part in the rescue effort except for the one who called EMS. The manager, who eventually arrived on the scene, remained for only a short period of time and failed to take charge of the emergency response. On discovery, it was documented that there was no comprehensive, written emergency response plan (ERP) that delineated staff roles nor was there a record of any emergency drills having been conducted. Depositions revealed that employees were not prepared to provide CPR that included the deployment of a defibrillator. A casual walk-through of the pool area by staff was conducted once every 2 to 3 hours, an area inspection that was for maintenance reasons rather than safety concerns. In a similar case, an elderly gentleman was found at the bottom of a pool by members/bystanders who were unaware of how long he had been submerged before being discovered (11). As with the previous case, the pool extraction of the victim and the provision of CPR were conducted by members rather than facility employees. And as before, discovery disclosed a lack of a comprehensive ERP and any emergency response drills. There were no scheduled safety walk-throughs or tours of the pool area. This elderly gentleman, who had a history of heart disease, was enrolled as a member without any screening, not even a Physical Activity Readiness Questionnaire. The defendant facility negligently trained its sales staff to aggressively market potential members while ignoring their health status. Because they failed to screen members, they were not able to notify potential members with serious health concerns that they were not good candidates for vigorous exercise, especially in a swimming pool without supervision. Once again, a lack of appropriate preactivity screening and aquatics supervision was responsible for another drowning death (13). In this particular incident, next to the indoor pool, there was a whirlpool in which a gentleman in his 60s passed out and drowned. Similar to the previous case, this member, who was not screened properly, had a history of passing out and a number of serious cardiovascular concerns. In addition, he had a diabetic ulcer that had not healed completely and should have prevented him from using a hot tub. Without supervision of the area and with this member using the whirlpool alone, it is unknown how long he had been underwater before being discovered by another member. Again, members provided the extraction from the whirlpool along with the initial CPR. Because of his medical history, he should have been prevented from vigorous exercise in which he had participated previously as well as the use of a hot tub. Whether a whirlpool, sauna, or steam room, these venues need to be supervised. In another recent case in which this author was retained, a facility member died as a result of passing out in a steam room where he remained for an extended period of time before being found (12). In addition to the whirlpool and steam room cases just cited, there are numerous anecdotal reports of people being discovered dead in whirlpools, sauna, and steam rooms (6,7). Not only should these areas be under constant surveillance, but they also should have signs warning of potential dangers (2).As far back as 1998, the International Health, Racquet and Sportsclub Association (IHRSA), the professional trade association of the fitness industry, published a Standards and Facilitation Guide that addressed the concern for supervision within fitness facilities. Standard number 8, within its Health and Safety Standards, reads “The principal objective of this standard is to ensure that IHRSA facilities provide credible and professional supervision of all physical-activity areas and programs” (9). Swimming pools in facilities provide a venue for not only group exercise classes that obviously are supervised but also a venue for serious lap swimming that should be supervised as well. Just as we would anticipate that there would be instructor supervision on an exercise floor within a facility, there should be such supervision of a swimming pool wherein individuals are exercising by swimming laps. In fact, how much more dangerous is it for the individual who passes out while swimming laps versus passing out on an exercise floor? Regarding professional supervision for pools, IHRSA’s Standards and Facilitation Guide recommends that there be an aquatics director who is certified in advanced lifesaving and water safety instruction along with appropriate CPR training (9). Swimming pools in facilities provide a venue for not only group exercise classes that obviously are supervised but also a venue for serious lap swimming that should be supervised as well. Just as we would anticipate that there would be instructor supervision on an exercise floor within a facility, there should be such supervision of a swimming pool wherein individuals are exercising by swimming laps. In the fitness industry, this lack of supervision reflects a failure on the part of facility management to have in mind the best interests of the membership. The number 1 priority of any facility should be the health and safety of its members; however, frequently, such a priority takes a subordinate precedence to generating revenue and achieving the highest profitability. Providing supervision of a swimming pool would require additional personnel and consequent funding. However, this could be avoided legally because county ordinances may only require the visibility of cautionary signage such as “swim at your own risk, no lifeguard on duty.” Similarly, management may take the attitude that supervision of steam rooms, sauna, and whirlpools would be too costly when cautionary signage would meet legal requirements. Too often, management fails to feel responsible and to recognize that morality should supercede legality. Supervision is a primary responsibility of instructor personnel, whether on a facility floor or on a pool deck, should such aquatic vigilance be required. Negligent supervision on the part of instructors, even lifeguards, also can make managers liable through the application of a legal doctrine known as respondeat superior (5). Supervision is a primary responsibility of instructor personnel, whether on a facility floor or on a pool deck, should such aquatic vigilance be required. Negligent supervision on the part of instructors, even lifeguards, also can make managers liable through the application of a legal doctrine known as respondeat superior (5).Figure: Shallow water blackout.Unfortunately, drownings do occur even in those venues where certified lifeguards are present. In recreational pools, there may be multiple lifeguards on duty because of large numbers of pool patrons. However, individuals in distress may be overlooked as a result of numerous causes for a lack of vigilance. Such was the case in a recent litigation in which this author was retained relating to the death of a 17-year-old youth in a large, metropolitan recreational pool where three lifeguards were in attendance (16). Lifeguards have a legal duty to act while on the job, and failure to adhere to this duty can result in litigation. Lifeguards are expected to meet a minimum standard of care, which may be established by the lifeguard’s training program and by state or local authorities. Typically, the standards are 1) communicating proper information and warnings to pool patrons to prevent injuries and drownings, 2) recognizing someone in need of care or distress, 3) attempting to rescue those needing assistance, and 4) providing emergency care according to one’s level of training (1, p. 6). Negligence can be established when a pool participant is injured or experiences additional harm because lifeguards failed to act or failed to adhere to a standard of care. Negligence includes 1) failing to control or stop any behaviors that could result in harm or injury, 2) failing to provide any care, 3) providing inappropriate care, and 4) providing care beyond the scope of practice or level of one’s training (1, p. 6). When lifeguards are on duty, the question that naturally arises is “how can a drowning victim go unobserved”? Three primary causes have been identified as the principle reasons for a failure to detect an active drowning. They are 1) lifeguards fail to recognize the victim’s instinctive drowning response, 2) secondary duties intrude on a lifeguard’s primary responsibility of patron surveillance, and 3) lifeguards are distracted from surveillance. These causes often are referred to as the “RID factor,” where the acronym, RID, stands for Recognition, Intrusion, and Distraction (1, p. 44). RECOGNITION Knowing how to recognize a patron in distress or one who is drowning is the most crucial lifeguarding skill. The lifeguard must be able to distinguish between one who is truly in danger and one who may be playing in the water. The lifeguard must recognize when there is a victim in need of rescue and cannot expect that everyone in an aquatic emergency will yell for help. With well-honed scanning and surveillance skills, the properly trained lifeguard can detect a passive victim who has slipped underwater without a struggle. Knowing how to recognize a patron in distress or one who is drowning is the most crucial lifeguarding skill. The lifeguard must be able to distinguish between one who is truly in danger and one who may be playing in the water. The lifeguard must recognize when there is a victim in need of rescue and cannot expect that everyone in an aquatic emergency will yell for help. INTRUSION Too often, lifeguards get diverted with secondary duties such as maintenance tasks. It is incumbent upon lifeguards to recognize the priority of patron surveillance, and therefore, to ensure that other lifeguards conduct patron surveillance when maintenance tasks are performed. Other responsibilities such as teaching swimming or conducting swimming tests also can intrude upon adequate surveillance duties. Although maintenance and teaching/testing duties are a frequently part of a lifeguard’s responsibilities, they must never take precedence over patron surveillance. DISTRACTION There are potentially numerous distractions that can redirect a lifeguard’s attention from patron surveillance. Obviously, mobile devices along with conversations with patrons, friends, and other lifeguards can distract one from his/her principle duty. Lifeguards are instructed not to engage in social or even brief conversations while on duty, for a momentary distraction could result in not witnessing or observing a life-threatening struggle of a patron. In the previously mentioned case concerning the drowning of the 17-year-old youth, the principle causes were a combination of recognition, intrusion, and distraction. The victim was not recognized at the time he passed out underwater, which lead to a delay in his recovery. There was an intrusion on the lifeguard’s responsibility because he had to conduct a swimming test on two individuals at the same time that he was surveilling the pool. And, the lifeguard was distracted because he was carrying on a conversation with another lifeguard that went beyond the necessary discourse involved with their scheduled lifeguard rotation. The victim was not an experienced swimmer and, therefore, was required to undergo a swim test before being allowed to use the diving boards at the deep end of the pool. The lifeguard at the midpool area was to administer the test to the victim along with another youth while also maintaining surveillance on his half of the pool. The youths were instructed to swim across the 25-m width of the pool and then return to the other side. The victim found the surface swim difficult on the first leg across the pool and so decided to attempt the return leg by swimming underwater. Already winded from the first leg, he hyperventilated some more and began his submerged return. With 80 patrons in the pool, the lifeguard failed to note whether the victim actually completed the return leg but assumed that he had completed the test. To compound the problem, this occurred while there was a scheduled rotation of lifeguard stations that lead to an intrusive conversation between the guards on duty. During the submerged pool crossing, the victim drifted toward the deep end of the pool and succumbed to “shallow water blackout.” Shallow water blackout results from low levels of oxygen to the brain (hypoxia) that causes one to faint or pass out. The actual trigger that signals one to breathe is not a low level of oxygen but rather an elevation of carbon dioxide (CO2). As a result of hyperventilation, CO2 levels significantly diminish and fall below the threshold that triggers the need to breathe, thereby allowing for the hypoxic state that causes one to pass out. The swimmer passes out before being alerted or sensing that he/she needs to breathe; and then as instinctual breathing is initiated, water infiltrates the lungs and the drowning process begins (1, p. 39). It is for this reason that the ARC Lifeguarding Manual lists hyperventilation and extended breath holding as a dangerous behavior about which patrons should be warned. Lifeguards are trained not only to warn patrons of this danger but also to prohibit any such behavior during recreational swimming (1, p. 39). In this case, the lifeguard failed to warn, recognize, and prevent this life-threatening behavior as well as to recognize that the victim did not complete the swim test but rather passed out underwater. Shallow water blackout is not limited to novice swimmers; in fact, it is most common among physically fit swimmers, competitive swimmers, snorkelers, spear fishermen, free divers, and even military combat divers. In April 2015, two decorated Navy SEALS drowned during off-hour physical conditioning in a Virginia Beach training facility because they knowingly disregarded breath-holding safety guidance. Investigators determined that the two qualified swim buddies were pushing their underwater swimming limits without the supervision of qualified trainers with appropriate lifesaving equipment at the pool (8). Aquatic emergencies are far too frequent and most often unnecessary. In fitness facilities with pools, it is incumbent upon management to ensure that members are screened properly before using pools as well as amenities such as steam rooms, saunas, and whirlpools. In addition, these areas must be supervised continuously, and ERPs need to include special contingencies for these high-risk venues. Regarding recreational pools with lifeguards, drownings will continue to occur unless strict standards with reference to the “RID factor” are maintained. Among well-trained swimmers, it must be remembered that hyperventilation before extended breath holding greatly can increase the possibility of shallow water blackout and consequent drowning. The hallmark of a professional facility or recreational program is the ability of its management to prioritize the health and safety of its members/patrons to conscientiously justify all physical activities conducted on the premises and to ensure the availability of a timely ERP that is rehearsed with regularity. In addition, the standard to which the fitness instructor, personal trainer, or even a lifeguard should aspire is to develop the knowledge, skills, and ability of a true professional and couple this with a sincere concern for their members, clients, and patrons. The certified, qualified, and morally committed instructor, trainer, and lifeguard can enjoy not only a personally rewarding and financially profitable career but also a bright and sunny future free from the ominous clouds of litigation. The hallmark of a professional facility or recreational program is the ability of its management to prioritize the health and safety of its members/patrons to conscientiously justify all physical activities conducted on the premises and to ensure the availability of a timely ERP that is rehearsed with regularity.