Lifeguarding Procedures
A few tweaks that make sense
By Greg Schmidt
Photos: Courtesy Of Greg Schmidt / Eastern Washington University Aquatics
Most of us as aquatic center managers have adopted one program or another to certify lifeguards. Whether it’s the Red Cross, YMCA, Ellis & Associates, Canadian, or other, we tend to stick with the procedures taught by the program we chose. However, what if we chose to use the best practices from all those programs, and still chose one for certification? We would have the best of both worlds, in a sense. Here are two concepts representing the pragmatic approach to lifeguard protocols. Plus, there are a few gear suggestions you might not find in any of the most commonly used programs. Why? Because they’re derived from plain old common sense.
Photo 1
Procedure #1—Airway Protection
In virtually all of the programs we use, a procedure exists for turning over an unconscious victim at or near the surface. Often, this involves swimming up the victim’s back and grabbing him under the armpits and flipping him over. I affectionately refer to this as the “fly-by.” But what if we reached under his armpits with both hands and cupped our hands over his mouth and nose instead? This small change would protect the victim’s airway during the flip over. If he is truly unconscious, he cannot exhale upon being turned face up. Water can passively flow into his nose and/or mouth. If he’s in laryngospasm, water will go into his stomach primarily and later encourage him to vomit. If his larynx has relaxed, water may go directly into his lungs. Either way, it is an undesirable result. Instead, seal the airway for ALL unconscious victims using a slight modification of the procedure you already know.
What about a submerged victim? It’s the same procedure, only deeper. Perform a feet-first surface dive and swim up the back of the victim, reaching under the armpits to seal the airway. During the ascent to the surface, pin his head against your shoulder to maintain a tight seal over the mouth and nose. Once you break the surface, release the protection and slide directly into the “do-si-do” position used for taking an unconscious victim to the side. Your other arm will quickly tilt the victim’s head back. Resting the heel of your hand on his forehead, extend your pointer over his nose to check for breathing. This breathing check should be done for all unconscious victims.
Photo 2
What about a seizure? The most dangerous phase of a seizure in the water is the clonic (twitching) phase. During this phase, the victim’s epiglottis and larynx may be convulsing along with the rest of his body. If that’s the case, water may flow freely into his lungs. Because of this potentially fatal threat, we must get his head up as quickly as possible. But why not protect his airway on the way to getting his head up? Use the same technique described above until you reach the surface. Once his mouth and nose are clear of the surface, shift to a “full Nelson” hold, with the hands behind his head. That will protect you from getting hit in the face, if his head is twitching back and forth.
What about a spinal? To protect the airway on a spinal rescue, you use a modified head/chin support. To be more accurate, it should probably be called a head/zygomatic bone support. Why? Because your clamp on the victim’s head should be like this: forearm of the anterior clamp directly over the sternum; thumb and opposing fingers on the cheekbone (zygomatic bone). When the victim is face down and must be turned over, there is the same problem with passive infusion of water into the airway, so adjust the anterior clamp to cover the mouth and pinch the nose between your thumb and index finger. The posterior clamp is the forearm directly over the spinous processes of the vertebrae and your hand turned slightly in a “V” on the occipital bone, just below the occipital protuberance. The V position allows space for the backboard to be placed under the victim’s head, without getting your hand stuck between the two. You must hold the occipital bone, however, or you will not have an effective clamp. As most lifeguards have learned, turn the victim face up by moving forward first to align the spinal column, then turn him over, maintaining the airway seal until his mouth and nose are clear of the surface. Your wrists must NOT turn as you turn the victim. Now adjust the anterior clamp to carefully shift your fingers into the breathing-check position. Move your fingers so the pointer is again extended over the nose, and your thumb will oppose the other three fingers on the zygomatic bone.
Procedure #2—Extrication
Photo 3
Most guards use a backboard for the extrication of any victim, unless the victim is a small child. Instead, ditch the backboard and use an extremity lift. It’s MUCH faster when done right, and there’s no risk of dumping the victim off the board sideways, due to the difficulty with lateral stabilization. Plus, both rescuers are in a position to contribute nearly 50 percent of the lift, whereas, with a backboard extrication, the primary rescuer in the water has very little leverage to contribute to the lift, and the person on deck is doing most of the lift alone. The extremity lift is effective for all average-sized victims. It is not effective for exceptionally large victims. Neither is the backboard lift.
Photo 4
To perform an extremity lift on an unconscious/passive victim, bring the person to the side of the pool in a “do-si-do” carry. As you approach the edge, extend the do-si-do arm to create space for your back-up guard to catch the victim’s wrists in front of his chest. The back-up on deck will lie flat on his stomach and reach under the armpits to grasp the victim’s wrists and pull them close together in front of his chest. Pulling the victim against the wall, the back-up will sweep his elbows onto the deck and quickly jump to his feet. The primary will release the do-si-do and wrap his arm around the victim’s waist. As he does this, he will help pull the victim against the wall and sit him up straight, so his back is pinned against the wall. In the same motion, the primary will turn his outside leg horizontally and plant his foot against the pool wall, making a “chair.” The victim will sit erect in the chair and be “walked” up the wall by the primary. This action will provide the back-up with room to get to his feet quickly. On the back-up’s count, he will duck under the victim and sit him on his shoulder, pressing both feet against the wall and both hands up to the deck. The primary will essentially stand up and lean forward to lift the victim out of the water, while the back-up stands up, keeping his bottom low to avoid strain on his back. The victim will slide off the primary’s shoulder onto the deck, while the back-up takes a step back. Note that the back-up MUST stand on both feet at the very edge of the pool to avoid falling or scraping the victim’s back on the edge. Keep the victim’s hands close together in front of his chest, even overlapping them, if possible. This will avoid stress on the victim’s shoulder joints. Never allow the elbows to fly out to the sides.
In photo 1, the primary approaches in do-si-do; the back-up is on his stomach with arms extended. In photo 2, the primary assumes the chair position, while the back-up secures the wrists in front of the chest. In photo 3, the primary boosts the victim up so the back-up can get to his feet. In photo 4, the primary lifts as the back-up stands; the victim stays upright and is lifted onto the deck.
For an extremity lift for a seizure, the lift is the same as above, with the exception of the approach. As described, bring the victim to the nearest edge in a “full Nelson” hold. You can use a rescue tube behind the victim’s back, if necessary. Once you’re close to the wall, rotate your body 90 degrees, keeping the tube under your arms and sliding your hands from the back of his head to his armpits. Now transfer him to the feet of the back-up, who is waiting in the “feet-hook” position. This position is performed by sitting at the edge of the pool and extending your legs over the water about ¾-full extension. Dorsiflex both feet to hook the victim under his armpits. He is now safely away from the edge, head up, and no one has to swim to keep him up. This position is used for the clonic phase of the seizure. Once the victim transitions into the postictal phase (sleepy phase), the back-up will gently pull the victim’s head back and check for breathing by extending the hand over his mouth and nose. The victim’s head can rest on the deck, with the airway open, while the back-up gets into position for the extremity lift. The primary rescuer assumes the chair-position again, and walks the victim up until the back-up has the wrists secured. The lift is the same now.
The back-up is in the feet-hook position, and the primary has transferred the victim onto his feet. This position is maintained until the clonic phase is complete and the victim becomes postictal.
Once the victim has been extricated, he will be placed in the recovery position. This also can be completed in one smooth transition—called the TAFT maneuver.
Equipment That Makes Sense
Here are a couple of minor changes to equipment you might find helpful:
Backboard—Use SCUBA weight belts for straps instead of Velcro. They never fail, nor wear out. Use a notched book-end style immobilizer, so you can do a jaw thrust without the immobilizer being in the way of your hand placement on the mandible. Put runners on your board, so a guard’s fingers don’t get smashed when removing the victim. You can slip the weight-belt straps through slits cut in the runners. This provides flexibility for moving straps around to accommodate different-sized victims. Weight belts can be attached to one another quickly to make an instant extension if the victim is obese or has a huge chest that typical strap lengths cannot accommodate.
Pocket mask—Use an intraoral mask instead of a traditional pocket mask. This small mask fits under the lips like a snorkel, and has no inflated skirt (which inevitably fails at the worst moment), so the mask is always ready to go. Plus, it fits in any fanny pack. It also stays in the victim’s mouth between ventilations, eliminating the need for repositioning. It has a one-way valve like any pocket mask, yet it is much more practical for a lifeguard.
Rescue tubes—Use the new, dense, closed-cell foam designs that have a channel for a tow line to restrain it. These tubes are far more resilient than traditional tubes and are very buoyant. They are slender, yet have more breadth to displace more water when horizontal.
Greg Schmidt, AFOI, LGIT/WSIT, is the Aquatic Center Manager for Eastern Washington University in Cheney, Wash. Reach him at (509) 359-4252, or leos@ewu.edu.