Touched by a Drowning

You have seen the video Touched by a Drowning, copyright 2001 by Ellis & Associates.

Below I have tried to write out a transcript of the audio for your review before you consider what you saw from the point of view of a lifeguard or a manager. The homework questions follow the transcript.

The video opens with a person held in a head-chin support (rescue method for a suspected spinal injury) by a lifeguard.

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Voice off screen "It's a memory that can never be erased. An innocent child discovered at the bottom of a pool."

The time of day of the drowning, captured on a home video, is shown on the screen as parts of the home video are shown. 3:30:19 p.m. Voices in background, much like people counting compressions while doing CPR "1 and 2 and 3 and 4 and 5."

3:29:21 p.m. (Narrator) "It's a memory which can never be erased." (Nick Landry, Lifeguard) "I kept saying, I kept saying. Oh God please don't (pause) let him die."

(White letters flash on black screen) "Don't Let Him Die"

"(pause) I mean and I was just praying, praying hard that a miracle would happen because I didn't know what else to do."

3:32:54 (Narrator) "An innocent child discovered at the bottom of a swimming pool."

(Nick Landry) "I didn't know what else to do."

3:33:42 "Young lifeguards unable to make a difference."

(Lifeguard whose name is not put on the screen) "I was just waiting to hear the sirens. And when I heard 'em I was like, Hurry Up. Hurry Up."

(White letters flash on black screen "Hurry Up.")

(Jarvis Claibourne, Lawyer) "This boy suffered a long time before he died. He literally died in their arms."

(White letters on black screen "He Died in their Arms."

3:34:17 (Narrator) "Forever touched by a drowning."

(On screen we see a child being handed from lifeguard in shallow pool to officer on deck, without a backboard).

(Jeffrey Ellis) "In a drowning there are two fatalities. One is of course the person who is died and buried. The other fatality, in many instances, is" (on screen changes to a victim on a gurney with a uniformed officer and a small crowd) "the lifeguard, who happened to be at the wrong place at the wrong time, but knows that they have killed somebody because they weren't able to do what people were expecting them to do in the first place."

(From off screen) "No one had taught you to open the airway, to get the water out of his lungs?"

(Lifeguard), initially smiling and nodding his head briefly, then quickly looking more serious "I don't know...pay a million dollars to have known that back then. I'd give anything to have known that back then. I'd have been a hero."

(Tom Merriman, on screen) "Welcome to this edition of Skill Quest. This year, like every year, the lives of hundreds of children will be cut short by a drowning. Most will die in a pool like this, full of clear water, just a few yards or even just a few feet from a lifeguard. But for every child who dies, countless others will be saved, and the only difference between life and death will be you."

(Title on screen) Ellis & Associates presents Touched by a Drowning

Video scenes of Cajun country, the culture and history of Louisiana.

Mayor Eric Martin talks of why he wanted a pool for the city of St. Martinsville

(Narrator) There hadn't been a city pool open in St. Martinsville in more than six years, but with six freshly trained Red Cross lifeguards Mayor Martin believed his city was ready. We had prepared, we said you know we know we are getting a crowd. We want to make sure we can handle a crowd. We cannot have a drowning.

(Narrator) I talked to the mayor and he says we did everything we could that we knew to do.

(Edna Landry) That's probably right, we knew to do. That they knew to do, that they did everything they could.

(Narrator) And on opening day, that was just enough.

(Edna Landry) There was water in the pool, there was kids who wanted to swim, and they had lifeguards.

(Narrator) But on day two, their luck would run out.

It was May 23rd, 1999. The St. Martinsville city pool was filled with excitement.

(Mayor) Full to the gills, y'know, everybody's runnin' around having a good time, it was, it was awesome.

(Narrator) In the middle of the chaos, was 12-year-old Norman Lee.

(Tiffany Blanchard) He knew how to swim, if you goin' to swim in the bayou, you know how to swim. (Nick Landry, lifeguard) It was just (pause) a kind of terror, almost, it's like (pause) I had a feeling, that you know with all the people, that something bad was going to happen.

(Narrator) "It was a day Nick Landry will never forget. It was just after 3 o'clock, sitting in the chair at the deep end of the pool, people in the crowd began to scream.

(Nick Landry, lifeguard) "When I looked down, it was almost like I didn't want to believe what I saw."

(Narrator) A young boy, motionless at the bottom of the pool.

(Nick Landry, lifeguard) "It was almost like saying please let it be something else but deep down I knew it was somebody, someone.

(Narrator) Nick and fellow guard Jason Desimeaux (sp?) plunged into the water. Jason pulled an unconscious Norman Lee to the surface. Nick struggled to find a pulse.

(No time display on video)

(Nick Landry) "I thought he had a pulse, but you can't check pulses in water. We didn't know that at the time."

(Narrator) Norman had foam coming from his mouth. Clearly, not breathing.

(Narrator) "No one had taught you to open the airway, to get the water out of his lungs?"

(Lifeguard) "I don't know....pay a million dollars to have known that back then."

(Narrator) "Lyle Willis was the third guard to respond."

(off screen) "I'd do anything to have known that back then. I'd have been a hero."

(Narrator) "But there would be no heroes that day, only victims."

Woman's voice in background, as type flashes on screen over pictures of three guards and one victim in a head-chin "Why don't you just take him out of the pool?"

(Nick) "I wanted to bring him out, but they were like 'We can't.'

(Lifeguard) That was the way we were trained, um, with the Red Cross."

(Narrator) "Fearing a spinal cord injury, the guards simply held the child at the surface of the water, waiting for a rescue squad."

(Lifeguard) "Because they say, don't ever, ever, ever bring anybody out of the water if you find them at the bottom of the pool without a backboard."

(Narrator) "But you don't have a backboard, right"

(Nick Landry) "I kept saying 'Oh God please don't (pause) let him die (pause) I mean that's all I could think of, and (pause) I was just praying, praying hard that a miracle would happen because I didn't know what else to do."

(Narrator) "The child lay motionless in their arms for nearly twenty minutes, without a breath, barely a pulse, hardly a chance."

(Lifeguard) It was, I was just waiting for the, I heard, I heard, I was just waiting to hear the sirens. And when I heard 'em I was like, Hurry Up. Hurry Up.

(Narrator) When EMS workers finally arrived, they quickly yanked Norman Lee from the water, opened an airway and headed for a nearby hospital, but the damage was already done.

(Mayor being interviewed on television, comments from guards).

(Narrator) "Within hours, Norman Lee was dead."

(Discussed reaction of lifeguards and family, on TV, in newspapers, of citizens, lawsuits filed.)

(Mayor) "If you're serious, and if you're responsible, and you don't want to see a drowning, you should not let the Red Cross train your lifeguards."

Video of Jeff Ellis being a victim at one of his trainings.

(Jeff Ellis) "For someone who is alive and well to go into a swimming pool where water is so clear, you could see a dime on the bottom of the pool, and say that a child or an adult could be under water four minutes, and we didn't see it? That's unacceptable and inexcusable to me."

(Narrator) "The guards had never been properly trained to scan a swimming pool and once they did discover the child, they failed to recognize a most basic symptom."

(Jeff Ellis) "It was clear he was unconscious, with all of the visible foam coming from his mouth, it was clear at that point that the first care had to be respiratory care, opening an airway and getting air into this patient."

(Narrator) "And yet the lifeguards had been taught to make stabilization of a possible spinal cord injury their highest priority."

(Lawyer) "To me that made no sense at all. I mean I'd rather be alive with a broken back instead of be drowned and have a good back."

(Jeff Ellis) "You can treat for a spinal all day long and the patient will be dead."

More videos of Ellis training. Jeff Ellis talking about how his training system works with follow through after training.

Todd " Value life so much, that you're scared every time you get into the guard stand. You're scared to the point of you never take your eyes off the water, scared to the point of that no one would drown in your pool."

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Things we know from the video:

There was no backboard at the pool.

The six lifeguards had recently completed their training, but we don't know how long before.

Jeff Ellis says that the child was on the bottom for four minutes and there was foam coming from his mouth. When people drown, they sometimes do have frothy fluid accumulate in their lungs. This could be the reason that time is estimated, but the video does not tell us why that estimate is given.

Things we don't know, which are the first questions in this homework for you to answer:

1) Who hired the guards? Was it anyone who knew how to manage a pool?

2) Were the guards tested for skills in any way when they were hired, or did the person hiring them assume that they could properly apply all their training?

3) Did they have a written emergency action plan for their pool?

4) Did they have any in-service training to practice it and learn to apply it?

5) Was there a manager on site that day, or were newly trained guards expected to fend for themselves?

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Ellis & Associates has been the only major lifeguard training organization teaching the use of abdominal thrusts on drowning victims.

The International Lifesaving Federation (ILSF) says, in one of their medical position statements, that not only is it not proven to be effective, has "poor efficacy and purely anecdotal support," it can "pose a great risk of precipitating gastro-oesophageal regurgitation and subsequent inhalation of stomach contents into the lungs." The Red Cross agrees with this and does not teach students to use this skill in this manner. (The entire ILSF statement is printed at the bottom of this page.)

When asked "No one had taught you to open the airway, to get the water out of his lungs?" One guard replies:

"I don't know...pay a million dollars to have known that back then. I'd give anything to have known that back then. I'd have been a hero."

When classes have watched this, they universally comment afterwards that every guard is taught that they must open the airway of an unconscious victim lying on their back. They are all taught how to do this using a modified jaw thrust if a spinal injury is suspected. So if the guard passed Red Cross lifeguard training, he was taught to open an airway. (As are all YMCA, Ellis & Associates and ILSF guards.)

Some people surmise that when he says " I don't know," it could be taken to mean that he was too emotionally charged to properly answer the question, or he was trying to rationalize that it was not his fault, but was the fault of his instructor, or that he was wishing he had paid better attention in class. Others surmise that he was giving the answer to the second question asked him, about getting "water out of his lungs." Yet an untrained person watching this video could easily believe that water does need to be removed from lungs and that the guard was not taught in his Red Cross training to open an airway.

6) What do you think?

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Jeff Ellis says: "For someone who is alive and well to go into a swimming pool where water is so clear, you could see a dime on the bottom of the pool, and say that a child or an adult could be under water four minutes, and we didn't see it? That's unacceptable and inexcusable to me."

The narrator says of the size of the crowd at the pool "in the middle of the chaos," the Mayor said "we know we are getting a crowd. We want to make sure we can handle a crowd," and the video seems to show a large number of pool patrons.

7) Is the pool water clarity an issue? Would a guard be able to see a dime at the bottom of a pool crowded with swimmers?

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It is unacceptable to any person, and certainly to any lifeguard training organization for a pool patron to drown. Yet no training organization has yet found a way to prevent all drownings at guarded facilities. The Red Cross teaches that the three main reasons for drownings at a guarded facility are failure to recognize a victim, intrusion of other duties and distraction.

8) Which of these do you think was a factor that day?

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In an article in Aquatics International magazine, March 2002 article "Yes, It's true." (Tom Griffiths)

We read that an Ellis and Associates study during the summer of 2001 did 500 tests in 90 pools. The average response time to a lifelike manikin placed on the bottom of the pool was 1 minute 14 seconds.

May 2002 "Research Findings"

(Griffiths) "Individuals become less vigilant after only 15 minutes on surveillance duty; a significant reduction in alertness occurs after 30 minutes on the job. Mild exercise and sensory stimulation may improve attention, especially with low levels of arousal and stimuli. Breaks every 15 to 20 minutes and changes in activity should help maintain alertness. Staying cool when on duty, either by dipping into the water or using shade, may improve vigilance, particularly when the ambient temperature climbs above 84 degrees Fahrenheit. Drinking water might also help."

9) Which of the above to you intend to use for yourself or your guards to prevent drownings at your pool? What other techniques have you learned that you will use?

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One guard says: "Because they say, don't ever, ever, ever bring anybody out of the water if you find them at the bottom of the pool without a backboard." Yet the Red Cross training does not say that, it stresses the need for proper equipment before a pool can be opened or after an incident before it can be reopened. Many states or counties have building codes and/or health and safety codes that require specialized rescue equipment, signage at pools, number of showers per patron, maximum number of patrons, etc.

10) Whose responsibility was it to have the proper equipment on site?

A. freshly trained lifeguards

B. (if they had them), experienced lifeguards

C. (if they had one), a head lifeguard

D. a pool manager

E. (in the absence of a pool manager), a city recreation department official

F) or who...?

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In the section of the Red Cross lifeguard training book being used at the time of the incident, the scanning material, "Proper scanning: the second element of proper surveillance," is much the same as it is in the current manual.

Guards are taught to scan the bottom of the pool as well as the surface, and to scan crowded areas carefully. The section emphasizes that "you are not just passively observing patrons in the water. You are actively monitoring their behavior and looking for signals in the water that someone needs help." They are taught about blind spots, conditions that affect visibility, and how to spot weak swimmers. One section addresses how to adapt scanning depending on patron activity, the number of people in the pool, the number and location of lifeguards.

In class discussions we have tried to surmise why the narrator accuses that the six guards were not taught properly.

The Narrator says "The guards had never been properly trained to scan a swimming pool."

11) Why do you think the narrator says this? Was he referring to their Red Cross training or could he be referring to the lack of in-service training at their pool?

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12) Whose responsibility was it to have in-service training on site

A. freshly trained lifeguards

B. (if they had them), experienced lifeguards

C. (if they had one), a head lifeguard

D. a pool manager

E. (in the absence of a pool manager), a city recreation department official

F) or who...?

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The Mayor says: "If you're serious, and if you're responsible, and you don't want to see a drowning, you should not let the Red Cross train your lifeguards."

The Red Cross makes the necessity of having a written emergency action plan and in-service training to practice it and learn to apply it, a prime part of training.

13) Would blaming the training organization hold up in a lawsuit?

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The narrator says: "The child lay motionless in their arms for nearly twenty minutes" and "When EMS workers finally arrived."

In some parts of the US the EMS response time is lengthy. The video doesn't say that the guards failed to call 911 promptly. Since this video sharply criticizes the guards, but never mentions a manager, or criticizes the city recreation department or city government official who set up the pool, we can probably assume that if the guards had failed to promptly call 911, the video would have mentioned it.

14) If the normal EMS response time in St. Martinsville was lengthy, whose responsibility was it to be certain to reflect this in the emergency action plan?

A. freshly trained lifeguards

B. (if they had them), experienced lifeguards

C. (if they had one), a head lifeguard

D. a pool manager

E. (in the absence of a pool manager), a city recreation department official

F) or who...?

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Jeff Ellis says "It was clear he was unconscious, with all of the visible foam coming from his mouth, it was clear at that point that the first care had to be respiratory care, opening an airway and getting air into this patient."

Followed by the narrator saying "And yet the lifeguards had been taught to make stabilization of a possible spinal cord injury their highest priority."

The Red Cross does not, and did not at that time, tell students to make spinal immobilization a priority over immediate life threatening conditions.

The emergency action principles stated in the American Red Cross CPR for the Professional Rescuer text in use at the time are:

1. Survey the scene.

2. Do a primary survey to identify and care for immediate life threatening conditions.

3. Summon additional medical personnel if necessary.

In the text Lifeguarding Today, in use at the time of these guards' training, at the beginning of the chapter on

Being Prepared for Emergencies,

we read:

"A lifeguard has four basic responsibilities in an emergency:

1 To keep all patrons safe by ensuring all zones stay covered at all times

2 To rescue and give first aid, including CPR," (which includes opening an airway and giving rescue breathing) "or to help another guard doing so.

3 To make sure EMS personnel are called when needed for the victim's condition.

4 To ensure the victim gets the best possible care until EMS personnel arrive and to help these personnel as needed."

15) Why do you think the video says that the lifeguards had been taught to make stabilization of a possible spinal cord injury their highest priority?

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One guard says: "I thought he had a pulse, but you can't check pulses in water. We didn't know that at the time."

We would all agree that it would be difficult, if not impossible to check the pulse of a victim in deep water, or in very cold water. And studies have shown that "pulse checks in the water are highly unreliable and a waste of time." (ILSF)

But checking a pulse is far along the timeline of dealing with immediate life threatening conditions, for CPR at the time of the incident. Opening the airway, checking for breathing and giving the first ventilations (rescue breaths) would have come before a pulse check.

16) What does this quote tell you about the retention of skills of this guard? As a manager, what percentage of their training can you expect your guards will retain? What cna you do about it? Why do you think it was put into the video?

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The lawyer says: "To me that made no sense at all. I mean I'd rather be alive with a broken back instead of be drowned and have a good back."

As guards we know that these two things, being alive and/or having a spinal injury, are not mutually exclusive. Neither Ellis & Associates, the Red Cross, the YMCA nor ILSF trains guards to deal with one to the exclusion of the other.

17) Do you feel that your training made this clear? As a manager, what steps can you take to make it clear to your guards?

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Ellis says: "they have killed somebody because they weren't able to do what people were expecting them to do."

18) From the point of view of a guard and a manager, will it be your attitude that if a guard doesn't fulfill his/her duties and a pool patron dies, that they were killed by that guard? Why or why not?

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Todd said "Value life so much, that you're scared every time you get into the guard stand. You're scared to the point of you never take your eyes off the water, scared to the point of that no one would drown in your pool."

19) From the point of view of a guard and a manager, will it be your attitude that a guard should be scared? If not, what vision do you have for your guards?

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"ILSF STATEMENTS ON THE USE OF ABDOMINAL THRUSTS IN NEAR DROWNING

During near drowning victims usually swallow large quantities of water and air. Their stomachs often also contain food and drink consumed just prior to entering the water. Since drowning is a process of asphyxiation, the victim is frequently profoundly hypoxic. This combination of hypoxia and a full stomach is the cause of the vomiting that is very familiar to lifeguards and is an almost inevitable accompaniment of near drowning. This has been well documented in the literature.

The Medical Commission of the International Life Saving Federation has carefully considered the management of near drowning, and in particular the use of upper abdominal thrusts (Heimlich Manoeuvre) to relieve airway obstruction. Because of the risk of precipitating gastro-oesophageal regurgitation and subsequent inhalation of stomach contents into the lungs, the Commission regards near drowning as an absolute contraindication to the use of upper abdominal thrusts unless a solid foreign body (not water) is present in the upper airway and cannot be dislodged by other means.

Background

In January 1996 the Medical Commission of the International Life Saving Federation issued a statement on the use of abdominal thrusts in near drowning.

At a meeting of the Commission in San Diego in September 1997 the Statement was again discussed in the light of several papers presented at the preceding International Medical/Rescue Conference.

The Commission decided to endorse the previous statement but with expanded explanation and list of references.

Statement

Near drowning victims present unique and challenging problems in airway management because of the nature of the episode. Since drowning is a process of asphyxiation, the victims are usually profoundly hypoxic. They have often swallowed large quantities of water and air; their stomachs frequently contain food and drink consumed just prior to entering the water. This combination of hypoxia and a full stomach is the cause of the regurgitation that is very familiar to lifeguards and is an almost inevitable accompaniment of near drowning. This has been well documented in the literature (1, 2). Submersion victims may aspirate some fluid into their lungs but there is no evidence that this can or need be removed by any technique.

The priority for rescuers is to implement resuscitation at the earliest possible opportunity. In doing this, the maintenance of a clear airway and prevention of aspiration are of paramount importance.

The Medical Commission of the International Life Saving Federation has carefully considered the particular problems of upper airway management in near drowning. Techniques which have poor efficacy and purely anecdotal support are strongly discouraged. Abdominal thrusts (Heimlich Maneuver) to relieve airway obstruction have been carefully considered and the following conclusions drawn:

· In near drowning upper abdominal thrusts pose a great risk of precipitating gastro-oesophageal regurgitation and subsequent inhalation of stomach contents into the lungs.

· There is no clear medical rationale for its use and in particular it seems clear that the manoeuvre cannot expel sufficient water from the lower portions of the respiratory tree to aid in resuscitation.

· There are no well controlled blind studies to validate its value in near drowning.

· The use of abdominal thrusts as a first maneuver will merely serve to delay the institution of appropriate cardiopulmonary resuscitation which has been well proven to save life in this condition.

Therefore the Medical Commission of the International Life Saving Federation strongly recommends that in cases of near drowning the use of upper abdominal thrusts is contraindicated unless a solid foreign body (not water) is present in the upper airway and cannot be dislodged by other means. This would be demonstrated by inability to obtain adequate ventilation of the lungs in the course of basic resuscitation measures."