BESTGuard Lifeguarding Program
Unit 4: General Patient Assessment
Lesson 7 – Human Body Systems as Related to First Aid
BESTGuard lifeguards are expected to have a basic understanding of human body systems and
how they relate to the first aid situations that they may encounter, including drowning. The
following pages provide lifeguards with a solid foundation for understanding the basics of how
the body works, and some of the terms commonly used by the EMS/ICS personnel that come
after them.
Terms used in anatomy/first aid –
Body cavities: a hollow place in the body that contains organs. There are 5 cavities to
remember – SPACT for spinal, pelvic, abdominal, cranial, thoracic
 Cranial – contains the brain (the skull is also called the cranium)
 Spinal – contains the spinal cord
 Thoracic – contains the heart and lungs
 Abdominal – contains the digestive organs: stomach, liver, pancreas, kidneys,
intestines, spleen (the diaphragm and pelvis border this cavity)
 Pelvic – contains the rectum, bladder, and reproductive organs
The body cavities are referred to when performing a physical exam or when locating an injury
or medical problem.
Quadrants: 4 sections of the abdomen that assist in location of injuries. They are divided by the
navel both horizontally and vertically. The vertical line cuts through the navel and extends to
the xiphoid process on the sternum. The horizontal line cuts through the navel and essentially
rests on the iliac crest. –
 Upper right
 Upper left
 Lower right
 Lower left
The quadrants are each palpated during the physical exam for abnormalities.
Directional/motion terms used in anatomy: terms of locations/directions/motion (always from
the reference point of the patient) –
 Medial – toward the mid-line or center
 Lateral – toward the outside or away from the mid-line
 Anterior – toward the front, or in the front
 Posterior – toward the back or in the back
 Superior – above or on top
 Inferior – below or on the bottom
 Distal – farthest from the body or midline (i.e. distal phalanges)
 Proximal – closest to the body or midline (i.e. proximal phalanges)
 Supinate – upward rotation, hands or entire body (supine)
 Pronate – downward rotation, hands or entire body (prone)
 Flexion – contraction of muscles that make limbs shorten, as in the biceps or
hamstrings
 Extension – contraction of muscles that make limbs lengthen, as in the triceps or
quadriceps
 Dorsiflexion – curling up the foot (anterior tibialis muscle does this)
 Plantarflexion – pointing the toes (gastrocnemius, soleus)
 Adduction – adding to the body, such as bringing an extended arm back to your side
 Abduction – moving away from the body, such as moving an arm from your side up
into a horizontal position
 Process – a protrusion on a bone, such as the spinous processes on the vertebrae, or
the acromion process on the scapula
 Tuberosity – another bump on a bone; one of the most notable is the ischial
tuberosity – because you literally sit on the pair of them whenever seated.
 Tendon – connective tissue that connects muscle to bone
 Ligament – connective tissue that connects bone to bone
Circulatory System –
The circulatory system is involved in at least three functions vital to the human body:
transportation, temperature regulation, and defense against diseases. It is failure of this
system that results in heat stroke, heart attacks, strokes, and aneurysms.
The components of the circulatory system are:
 Blood – composed of platelets and plasma, as well as red & white blood cells, the blood
is like a mighty river that transports products on barges to different ports along the
river. Plasma is the fluid portion of the blood, and platelets are mostly solid cell
fragments (fragmented white blood cells). White blood cells are the body’s tiny army.
They attack anything that is considered hostile to the body, like bacteria. They are far
fewer in number than the red blood cells. Red blood cells are in charge of
transportation. Their main function is the transportation of iron and oxygen/CO2. Red
blood cells out-number white about 1000 to 1.

Arteries – are the high pressure blood vessels that carry blood away from the heart via
the ventricles. Ventricles produce the high pressure that is measured in the systolic
blood pressure. Arteries are the biggest “pipes” in the system. They divide into smaller
arterioles, and end as microscopic capillaries. It is in the capillaries that all the business
of the blood takes place: oxygen and carbon dioxide is exchanged in the tissues and the
lungs. The tissues’ cells give off CO2 into the capillaries, while the capillaries supply
fresh O2. In the lungs, blood releases CO2 into alveoli, and picks up fresh O2 that is
delivered back to the cells.
The major arteries that lifeguards should be familiar with include: the carotid – the main
arteries in the neck (used for pulse check during CPR); the brachial – in the upper arm
and across the elbow joint (used for pulse check in an infant during CPR, and for
auscultation blood pressure); the radial – in the lower arm, next to the radius bone on
the thumb side of the wrist (used for pulse rate and for palpation blood pressure); the
aorta is the biggest artery in the body, ascending out of the left ventricle. The aorta’s
branches form all the other major arteries of the body, except for the pulmonary
arteries; the pulmonary artery branches into the right and left pulmonary artery which
supply oxygen poor blood to the lungs. The pulmonary artery comes directly out of the
right ventricle. It is the only artery to carry O2 poor blood. This is usually the job of the
veins. The coronary arteries are the very first branches of the aorta. They supply blood
directly to the heart muscle (myocardium). These are the arteries that become
obstructed in an acute myocardial infarction (heart attack). An abdominal aortic
aneurysm is dilation in a branch of the aorta. Arterial bleeding is often life threatening,
due to the high pressure, especially if it’s to one of the main arteries.

Veins – Veins carry oxygen-poor blood back to the heart, where they deliver it to the
atria; the two chambers in the top of the heart. Veins are thinner walled than arteries,
and have a series of one-way valves to prevent back-flow of blood.
They are of much lower pressure than arteries, thus don’t bleed nearly as freely. Veins
start as capillaries, grow to venules, then larger veins. There are only a few veins that
lifeguards need to know: the vena cava, the jugular veins, and the pulmonary veins. The
vena cava is the largest vein in the body, and has both an inferior and superior
component. The inferior vena cava is below the heart and brings blood back from the
torso and lower body; the superior vena cava is above the heart and brings blood back
from the upper body. Both deliver it to the right atrium. The jugular veins are also quite
large and are adjacent to the common carotid arteries in the neck. The pulmonary veins
bring oxygen-rich blood back from the lungs to the left atrium.

Heart – The heart has four chambers: two atria and two ventricles. The atria receive
blood into the heart from veins, and the ventricles push blood out of the heart through
arteries. The right side of the heart is the pulmonary circuit, bringing oxygen-poor blood
to the lungs to receive oxygenation. The left side is the systemic circuit, bringing oxygen
rich blood to all the tissues via the left ventricle and the aorta. Atria pump the received
blood down into the ventricles as commanded by the sino-atrial node located at the top
of the right atrium. The atrio-ventricular node then commands the ventricles to pump
the blood out. These two nodes control the pulse, and are what malfunction during Vfib or V-tach. Atrial fibrillation can also occur, which is very much like the irregular
twitching characteristic of V-fib. A-fib is generally not a life-threatening, no pulse
situation, as in V-fib. It creates an inefficient arrhythmia that affects the blood flow, but
does not usually stop the heart from beating altogether. Blood flow through the body
and through the heart works in a continuous loop: blood coming from all the body’s
cells enters the heart via the right atrium, is pumped down into the right ventricle, then
pushed into the pulmonary artery and into the lungs. It unloads CO2 , picks up oxygen
and brings it back to the heart via the pulmonary veins. The pulmonary vein delivers
this blood to the left atrium, which pumps it down into the left ventricle, then out via
the aorta to all the body’s cells; where it delivers the oxygen, picks up CO2 and starts the
loop over again.
O2 poor blood arrives in vena cava
It enters right atrium
Is pumped to right ventricle
O2 poor blood to lungs via
pulmonary artery
O2 rich blood returns to left atrium
Is pumped to left ventricle
O2 rich blood exits heart via aorta
In addition to circulating blood, which is the transportation function, the circulatory system
cools the body, and helps to maintain warmth by precise distribution of blood and constriction
or dilation of vessels close to the skin. When cold, these vessels constrict , slowing the release
of heat to the surrounding environment. When hot, they dilate to release heat and provide
cooling. The system can also regulate where blood goes to protect the vital organs first, as
during hypothermia or hemorrhagic shock. The temperature regulation function works in
harmony with other systems, such as the pilomotor (arrector pili) muscles in the dermis, that
make hairs stand up to create a layer of dead-air.
Arrector pili muscles
creating layer of dead air over
the skin
As mentioned earlier, the third function is to transport the army of white blood cells and antibodies that fight diseases. The blood transports everything else to the cells as well, drugs,
nutrients, etc.
Respiratory System –
This system works in tandem with the circulatory system to provide oxygen to the body’s cells
and to release carbon dioxide from the cells. Breathing is accomplished through a change in
chest cavity pressure: when inspiring (breathing in) the pressure is lowered in the lungs relative
to the outside air so the air rushes in. When expiring (breathing out) the pressure in the lungs
is greater than the outside air, and the air in the lungs is pushed out. Because it takes effort to
expand the chest volume by the diaphragm and intercostal muscles, inspiration is the “active”
part of breathing. Expiration is accomplished by merely relaxing the muscles of inspiration.
The components of the respiratory system are:
 Lungs – Located inside the rib cage, and separated by the descending aorta and the vena
cava, the lungs are the main component of the system, where O2 is exchanged with CO2.
 Mouth – Air is inhaled and exhaled through the mouth and/or nose. OPAs are inserted
into the mouth, and NPAs into the nose to the pharynx, to provide a clear passage of air
and prevent the tongue from obstructing the airway.
 Nose - Breathing is mostly through the nose, except during exertion when more oxygen
is needed, and the mouth is used as well.
 Pharynx – Is the back of the throat. The area that becomes obstructed by the tongue
when the tongue falls back on an unconscious patient; or during anaphylaxis when the
tongue is swelling into the pharynx.
 Larynx – The voice box, located near the top of the trachea. Sounds and pitch are
formed in the larynx, while words are formed by the tongue and lips.
 Trachea – The wind-pipe. Air comes through the pharynx into the trachea where it
branches off into the right and left bronchi. These two pipes supply the right and left
lungs.
 Epiglottis – The small flap over the opening to the trachea. It is a valve that prevents
food or liquids from entering the trachea. Only air should be allowed in there! During a
seizure, the epiglottis may be twitching along with other muscles in the body, allowing
water to flood the lungs and disable alveoli.
 Bronchioles – Smaller divisions of the bronchi that eventually end in the microscopic
alveoli. COPD patients suffer from chronic inflammation, mucous production, and
obstruction of these passages.
 Alveoli – The microscopic sack-like structures that exchange oxygen and carbon dioxide.
Respiratory distress refers to difficulty breathing. Breathing rates that are outside the normal
ranges for resting rate constitute respiratory distress: Respirations of less than 12 or more than
20 (adult), less than 15 or more than 30 (child), less than 25 or more than 50 (infant).
Respiratory arrest means breathing has stopped.
Note: The esophagus is NOT a component of the
respiratory system. It is the tube directly behind the trachea
through which food is transported to the stomach.
Musculo-skeletal System –
Bones, muscles, tendons, and ligaments, along with cartilage, and other specialized tissues
comprise this system. Its functions are support and movement. Some of the major
components are:
 Bones – There about 206 bones in the body. Many have duplicates or numbers, so most
of the bones can be identified by a lifeguard. A list of the major bones follows:
o Bones of the skull/cranium – frontal: the forehead; parietal: the sides of the
head above the temporal; temporal: the temples or sides of the head; occipital:
the bone in the back of the head; zygomatic: the cheek bone; maxilla: upper lip
(houses upper teeth); mandible: the jaw bone (houses lower teeth). The
zygomatic and mandible are the two bones that are grasped by guards during
the head/chin support position. The nasal bones are at the top of the nose and
are quite thin & delicate. The vomer and lacrimal bones are also at the top of
the nose: the vomer is in the center, and the lacrimal bones are just superior to
the nasal bones. These bones are again quite thin and delicate. One other bone
that is prominent on the skull is the mastoid process, just behind the ear (part of
the temporal bone). There are other bones in the skull not in clear view:
ethmoid, sphenoid, hammer (malleus), anvil (incus), stirrup (stapes).
Bones of the cranium
o Bones of the torso – The torso is formed by the ribs, clavicles, sternum, scapula,
and vertebrae in the back. The ribs: are numbered, and have 12 pairs. The
bottom two sets are called “floating” because they don’t articulate directly with
the sternum. The sternum: the breastbone. It has 3 parts that guards should
know – the manubrium, or upper part that articulates with the clavicles, the
body – the main portion that is compressed during CPR, and the xiphoid process
– the sharp tip at the bottom. There is one other bone in the front of the neck,
just below the mandible, that is kind of isolated – the hyoid bone. It’s a slight
structure, roughly horse-shoe shaped.
o Bones of the pelvis – The pelvis has several bones, sometimes referred to
collectively as the os coxae. The ilium, ischium, pubic bone, and sacrum are the
four main bones. The coccyx: is the tiny tip of the sacrum, often referred to as
the “tail bone.” The ilium: large wing like bones that hold up your pants and fold
out and back. The ischium: smaller bones that have a hole in the middle. They
are connected to the ilium and are the bones that we literally sit on. The pubic
bone or pubis: a small bone directly in the center that separates the two ischium
bones. The sacrum: a triangular shaped bone that is comprised of 5 fused
vertebrae. The bottom of the sacrum is the coccyx, which consists of about 4
more tiny fused vertebrae.
o Bones of the arms – The arms consist of many bones, most of which are in the
wrists and hands. The humerus: the upper arm bone; the radius: the smaller
forearm bone on the thumb side; the ulna: the other forearm bone on the little
finger side (the elbow is part of the ulna). The wrist bones are called the carpals:
there are 7 of them. The metacarpals: the bones of the hand (before the
fingers).
Phalanges: the finger bones – have three sections: distal, middle, and proximal.
Metacarpals and phalanges are numbered, whereas carpals have individual
names.
o Bones of the legs – The legs are similar to the arms in number of bones, and
names. The femur – the upper leg bone, and one of the strongest bones in the
body. The tibia – the shin bone. The fibula – a smaller support bone to the
lateral side of the tibia. Instead of carpals, the ankles have the tarsals: again 7
bones all with individual names. Metatarsals: are the bones of the feet, and are
numbered. Phalanges: are the same as in the hands. An additional bone is the
calcaneous or heel bone. The big toe is called the talus, whereas the thumb is
called the polis.
o The vertebral column – The vertebral column consists of five sections totaling
approximately 33 vertebrae. Vertebrae have three main processes: the lateral
processes called the transverse, and the central process called the spinous
process. It is the spinous process that protrudes directly backward, and thus can
be felt just under the skin. The top section of the column is the cervical, of which
there are 7 vertebrae. The top two are the atlas and axis. The remaining
vertebrae have numbers, rather than names: the atlas is C-1, axis is C-2, etc. The
cervical vertebrae are by far the most commonly injured, due their lack of
protection from trauma, and smaller size.
The next section corresponds to the 12 pairs of ribs, thus there are 12 in the
thoracic section. They are numbered T-1 to T-12.
The lower back is the lumbar section, of which there are 5. They are numbered
L-1 to L-5 and are the strongest of the 33.
The sacrum has another 5, but fused together; the sacral vertebrae are
numbered S-1 to S-5.
The coccyx makes up the last four, again fused; the coccygeal are not often
referred to individually, since they are so small. They make up the point of the
sacrum (the “tailbone”).
Coccyx
The Integumentary System –
Integument is the anatomic name for the skin. The skin is the largest organ in the body.
It has several functions: protection from disease and injury, temperature control,
mineral storage and vitamin D production. The integumentary system includes the hair,
nails, and skin. Oil glands provide waterproofing, softness, and elasticity to the skin.
Sweat glands work in tandem with the arrector pili muscles in the dermis to assist in
temperature control. To relieve excess heat, sweat glands release moisture through
pores to produce cooling from evaporation.
Some of the major components of the integumentary system are:
 Epidermis – The outer layer of the skin; mostly for protection from injury and disease.
 Dermis – The second layer of the skin. The dermis contains the hair follicles, sweat
glands, oil glands, blood vessels, and nerves.
 Hypodermis – Inner layer (also called the subcutis or superficial fascia), containing the
adipose (fat) layer. This layer allows the underlying muscles to move freely. At points
where there are no underlying muscles, the skin attaches directly to the structure
underneath.
The skin works in tandem with the circulatory system to provide body temperature
regulation, through the constriction or dilation of blood vessels near the surface. Vessels
are dilated when cooling is needed, making the skin appear flushed. Sweat glands release
moisture onto the surface of the epidermis to assist in the cooling. Vessels are constricted
when warmth is needed, making the skin appear pale. In addition to arrector pili muscles
creating the “dead air” space to assist in warming, shivering reflexes are initiated to further
generate heat. This system is also responsible for redistribution of blood in trauma
situations where the body is trying to protect the vital organs (heart, lungs, and brain).
When hypothermic, the temperature regulatory system becomes even more dramatic, by
cessation of respirations, preservation of extremities via removal of blood flow, and
establishment of a tiny circulatory loop that essentially includes only the heart muscle
(myocardium) and brain. The temperature control system is overwhelmed when shivering
ceases and the body begins to stiffen. Although the blood flow continues to be controlled
by initiating the tiny loop just described, eventually all systems will fail due to hypoxia. This
tiny loop can be effective for up to 1 hour before the heart and brain die.
Diagram of the integumentary system
Nervous System –
The nervous system has several functions, all of which can be categorized into three
divisions: coordination, orientation, and thought/intelligence. It is by far the most
complex system in the body, and quite possibly the most complex system on earth. The
nervous system has over 3 trillion cells that can run millions of different tasks at once.
Although the nervous system for all mammals is amazing, the human version is far more
complex, due to our extensive cerebral cortex – thus the ability to reason, dream, and
seek answers to questions about how it all works.
Orientation – This spatial awareness/balance information is processed through organs of
special sense and the information is transmitted via sensory neurons where it is
processed in central coordinating areas of the brain; then sent out to organs which
respond to the impulses sent from the brain (central coordinating). The ability to orient
successfully to an ever changing environment is what keeps us safe.
Coordination – Refers to the ability of the nervous system to direct our bodies to move
or react to a given stimulus in a coordinated fashion. Coordination works in tandem
with orientation, since the sensory organs receive the initial stimulus, transmit it to the
brain where it is processed, and a response is sent to the muscles (via efferent pathway)
to cause a reaction.
Thought/intelligence – Refers to the ability to reason, calculate, imagine, create, predict,
and exercise restraint. These qualities are unique to human brains, and are a function
of our advanced cerebral cortex.
Diagram of neuron
Parts of the nervous system –
 Central nervous system (CNS) – brain, spinal cord
 Peripheral nervous system (PNS) – cranial nerves, spinal nerves: send impulses
to the head and neck; or from spinal nerves to the rest of the body.
 Autonomic nervous system – sympathetic, parasympathetic nerves connect to
the midbrain and medulla via cranial nerves, and to spinal nerves.



Visceral afferent fibers – bring impulses from the PNS to the CNS, such as pain,
nausea, hunger, and sexual impulses.
Neurons – consist of axons, dendrites, cell bodies, satellite cells, myelin sheaths,
motor end plates, Schwann cells, Nissl bodies, neurofibrils, and a host of other
structures. Neurons send impulses that travel along the axons and dendrites to
a junction, called a synapse. The impulse jumps the synapse and continues on
the journey following additional axons and dendrites.
Brain – consists of several bodies, all with specific functions. The terms
forebrain, midbrain, and hindbrain originate from prenatal development; where
the brain parts are lined up this way. As our brains develop, the sections fold on
top of one another, until the terms really don’t describe the positions of the
structures anymore. However, the structures are distinct, and have separate
functions. A quick summary follows:
o Forebrain (prosencephalon) – cerebral hemispheres
o Midbrain (mesencephalon) – tiny section just above the pons
o Hindbrain (rhombencephalon) – cerebellum, pons, medulla oblongata.
The term brain stem refers to the pons and medulla.
Lateral view of brain, showing lobes

Cranial nerves – there are 12 cranial nerves; each with a particular job. The
cranial nerves originate from the midbrain and brain stem. They are listed here
merely to demonstrate the enormous complexity of the nervous system. Most
of these functions are autonomic.
o Olfactory I – smell
o Optic II – vision (rods & cones connect)
o Oculomotor III– pupil constriction/dilation, sensory of eyes
o Trochlear IV – same as oculomotor, different eye muscles
o Trigeminal V – chewing muscles, both sensory and motor
o Abducens VI – another eye nerve, both sensory and motor
o Facial VII – motor to facial muscles, sensory for taste and skin
o Vestibulocochlear VIII- hearing and equilibrium
o Glossopharyngeal IX – taste, sensory, swallowing, salivary secretion
o Vagus X – sensory, taste, speech, respiration, digestion
o Accessory XI– swallowing, speech, muscles of head/shoulder
o Hypoglossal XII – muscles of the tongue



Spinal cord – the spinal cord is a bundle of nerves about 1 centimeter in
diameter which ends at the base of the coccyx. At the level of about L3, the
bundle breaks up, and points directly downward in a collection of fibers called
the cauda equina (horse’s tail). Only one small fiber, the filum terminale,
extends all the way to the tip of the coccyx. Individual nerves extend from the
cord laterally through holes in the vertebrae called intervertebral foramen.
Meninges – the 3 linings of the brain and spinal cord (pia mater, dura mater,
and arachnoid). Myelin sheaths are different; they are protective coverings over
individual axons.
Cerebrospinal fluid – produced in the ventricles (spaces) in the brain, it bathes
the brain and spinal cord, and is outside the meninges in an area called the
subarachnoid space.
Spinal nerves diagram, explaining innervations at each level.
In a spinal injury, the nerves below the site are often affected.
Sensory nerves are afferent, and motor nerves are efferent. Another way to look at this is that
afferent nerves travel from the PNS to the CNS (from peripheral to central) and that efferent
travel from CNS to PNS (from central to peripheral). Sympathetic nerves are those that are
involved in the “fight or flight responses” that are more animalistic in nature. They
communicate with the spinal nerves from T1 to L3 in location. Parasympathetic nerves are
involved in more of the “relax or rest responses,” and communicate with the midbrain,
medulla, and sacral spinal nerves. Remember that the sympathetic and parasympathetic
nerves are part of the autonomic (subconscious) nervous system.
The voluntary nervous system has conscious control of its nerves; thus it encompasses the
central nervous system. It is more complex than that, of course; since these two systems
overlap some.
Summary – The nervous system is so complex that even an overview is somewhat
overwhelming. Although the information provided here is beyond the scope of what most first
aiders will need, it is intended to provide lifeguards with a basic understanding of the way the
nervous system is designed, and what the main structures are.
Injuries to the nervous system are manifested by burning pain, numbness, tingling, loss of
function, paralysis, swelling, redness, head injury, deformity. Meningitis, particularly the
bacterial version, is very serious and can be life-threatening. Another very serious nervous
system condition is encephalitis; an inflammation of the brain.
Digestive System –
The digestive system has four functions: ingestion – eating; digestion – processing or
decomposing food; absorption – taking processed nutrients into the blood; egestion –
elimination of wastes.
Ingestion: mouth & esophagus
Decomposition, digestion: stomach
Absorption: small intestine
Egestion: large intestine, rectum
Structures of the digestive system –
 Mouth – includes uvula, soft and hard palate. Digestion begins here.
 Pharynx – includes nasopharynx, oropharynx, and laryngopharynx
 Esophagus – tube going to the stomach
 Stomach – first organ of digestion, does little absorption; mostly food decomposition.
 Small intestine – second organ of digestion, includes the duodenum, jejunum, and ilium
totaling about 21 feet. The duodenum is about 10 inches, the jejunum 8 ft and the ilium
about 12 feet. This organ is in the absorption phase, and produces significant secretions
through glands that facilitate absorption. The majority of digestion occurs here.
 Large intestine – third organ of digestion, includes the cecum, colon (ascending,
transverse, and descending), rectum, and anal canal. The large intestine is about 5 feet
long. It has a folded, sack-like structure (the haustra) that distinguishes its appearance
from the small intestine. The large intestine also produces secretions, but these are
primarily mucus which aids in the formation of feces.
 Vermiform appendix – a tiny worm-like tube that extends from the cecum of the large
intestine.
 Liver – produces enzymes that facilitate absorption. It also produces bile, which is
involved in fat absorption and is stored in the gallbladder. It converts glucose to
glycogen, makes vitamin A, and assists in blood clotting.
 Gallbladder – stores bile and releases it into the duodenum when food is present.
 Pancreas – a gland that produces the hormone insulin for the absorption of sugar.
Although insulin production is an endocrine function, the pancreas also produces
digestive enzymes that are emptied into the duodenum.
Structures of the digestive system are somewhat unprotected and are subject to blows and
stab wounds, which can cause internal bleeding or serious infections.
The Genitourinary System –
This is really 2 systems combined into one: the reproductive system and the urinary system.
The urinary system is composed of the organs that eliminate wastes from the blood. The
reproductive organs are very close in proximity to the urinary organs, and thus are susceptible
to injury from the same incident.
Structures of the genitourinary system –
 Kidneys – organs located behind the abdominal cavity that filter wastes from blood and
form urine.
 Ureter – the tubes that connect the kidneys to the urinary bladder.
 Urinary bladder – the storage space for urine.
 Urethra – the tube that connects the bladder to the exit point from the body (the
external urethral orifice). The urethra exits above the vagina in females forming an
external sphincter muscle. In males, the urethra exits from the glans of the penis.
Urination (micturition) is the process of emptying the urinary bladder.
Kidney injuries can be very painful, and the kidneys are somewhat vulnerable to blows from
behind. Blood in the urine may indicate a kidney stone, which is also accompanied by severe
pain in the abdomen.
Reproductive system:
Male anatomy  Scrotum – the sacklike structure
that encloses the testis.
 Testis – organs that produce sperm and
hormones, such as testosterone.
 Epididymis – a small duct system at the top of the testis, contiguous to the vas deferens.
It serves as a storage system for spermatozoa.
 Vas deferens (ductus deferens) – the tube that connects the testis to the urethra in the
penis. This is the tube that is cut in male sterilization surgery.
 Seminal vesicles, prostate and bulbourethral glands – secrete fluids into the semen
 Penis – external male reproductive organ, consisting of: the glans, prepuce (foreskin),
the corpus cavernosum and corpus spongiosum (which make up the main body of the
structure).
Injuries to the male genitalia are common, since the organs are unprotected and are outside of
the body cavity. Priapism is a symptom of spinal cord injury that can occur in males. Hernias
are another type of injury, where strain to the structure of the peritoneum causes extension
beyond its normal location creating a “hernial sac” - that can protrude as far as the inferior
portion of the scrotum (complete congenital inguinal hernia).
Female anatomy –
 Ovary – organs that produce ovum (eggs) and the hormone estrogen.
 Fimbria – little finger-like projections at the ends of the uterine tubes.
 Uterus – the organ where a fetus develops: consists of the fundus, body, and cervix (or
neck). This organ develops a thick lining each month, which is sloughed off
(menstruation) when impregnation does not occur.
 Fornix – a small cavity at the top of the vagina just posterior to the cervix.
 Vagina – “birth canal” through which the fetus must pass to exit the uterus.
 Clitoris – the female counterpart to the glans penis, located at the top of the labia
minor: consisting of a prepuce, body, glans, and crus.
 Labia – two sets of folds that cover the vaginal vestibule. The labium minora are the
inner folds, and the labium majora are the outer folds. The vaginal vestibule is the area
surrounding the vaginal orifice separated by the labia minora.
 Vulva (pudendum) – term for the female external genitalia.
 Mons pubis – a fatty protrusion covering the pubic bone.
Female reproductive system, lateral view (internal organs)
Lesson 8: Patient Assessment Protocol –
Introduction – As with other patient assessment models you may have learned in first aid
courses, this model follows general steps, of which there are five:
1. Do a scene size-up: what happened, how many victims, what kind of situation is this
(medical vs. trauma), how dangerous is the scene, does the victim need to be moved,
who is available to help, etc.?
2. Do an initial assessment: check the patient for life-threatening conditions, including
airway obstruction, respiratory arrest, cardiac arrest, severe bleeding, and obvious
deformity.
3. Do a physical exam: If the patient is injured badly, or has potential multiple injuries,
check him from head to toe for injuries.
4. Do a SAMPLE History: Look for signs of injuries or illness, ask if the patient is
experiencing any Symptoms that you cannot see; ask if he has any Allergies that might
be contributing to the condition; ask if he takes any Medications; ask if he has any
pertinent Past medical history that might be contributing to his condition; ask when he
Last ate or drank anything (including his medications); ask what happened right before
he ended up in his current condition (Events leading up to the incident.)
5. Do an ongoing assessment: Check Blood pressure, Level of consciousness, Skin
color/temperature/wet or dry, Capillary refill, Pulse rate, Respiration rate. The
highlighted letters spell BLSCPR.
What distinguishes the Emergency Medical Response model from more basic first aid is the
level of detail in doing the assessments. Below is a set of acronyms that will help you to
remember the details of each step.
Initial assessment –
BSI – Body Substance Isolation: putting on your gloves and other protection prior to contacting
the patient.
MOI – Mechanism of Injury – how did the patient get injured? This is critical for determination
of other injuries besides the chief complaint.
ABCD – Opening the patient’s airway, Checking for breathing, pulse/signs of circulation and
bleeding for 10 seconds. Look for deformity.
LOC – Level Of Consciousness, relates directly to the next acronym AVPU.
AVPU – Alert: the patient is conscious, and can talk to you normally; Verbal: the patient is
conscious, cannot talk normally to you, however will respond to a verbal stimulus. For
example, if you call the patient’s name, he will turn and look at you, but may not be able to
articulate a verbal response. Painful: the patient will twitch if a painful stimulus is applied, such
as a pinch just above the clavicle. Unresponsive: the patient is unconscious and will not
respond to any stimulus.
Physical Exam DOTS – Deformity: areas oddly shaped, hard and lumpy, or soft and depressed. Open wounds:
areas that may be open to infection, where the skin is broken (either of these may be under
clothing, and thus require exposure.) Tenderness: areas especially sensitive to palpation or
movement. Swelling: areas greater than their normal size, due to collection of fluids/blood.
OPQRST – These refer to pain description. Onset: when did it start? Provocation: what
provokes it? Quality: describe it – sharp, dull, ache, etc. Radiation/region: does it radiate down
your arm/leg/neck, etc.? Severity: how would you rate it from 1-10? Time: how long does it
last? Is it constant, does it come and go or change over time? If so, on what interval?
DCAP and BTLS are other acronyms commonly used by EMS, but we’re sticking with DOTS only,
since they have some overlap with these.
SAMPLE History –
SAMPLE - Look for Signs of injuries or illness, ask if the patient is experiencing any Symptoms
that you cannot see; ask if he has any Allergies that might be contributing to the condition; ask
if he takes any Medications; ask if he has any Pertinent Past medical history that might be
contributing to his condition; ask when he Last ate or drank anything (including his
medications); ask what happened right before he ended up in his current condition (Events
leading up to the incident.)
Chief Complaint – What seems to be the patient’s main problem? Is it their leg, arm, stomach,
etc.? We should focus first on the area that corresponds to the chief complaint, then look for
other injuries or problems. Remember that just because the patient doesn’t complain about an
injury, doesn’t mean that it isn’t there. The chief complaint may overshadow other injuries that
could become very major later! When in doubt, do a complete physical exam along with your
SAMPLE history.
Ongoing Assessment –
BLSCPR - Check Blood pressure, Level of consciousness, Skin color/temperature/wet or dry,
Capillary refill, Pulse rate, Respiration rate. These factors are checked every 5 minutes for
unstable patients, and every 15 for stable patients. A stable patient is one who’s condition is
alert and not worsening, but virtually staying the same. An unstable patient is one who’s
condition is worsening or is already unconscious/unresponsive. Since it takes about five
minutes to complete the six components of BLSCPR, you’re continually checking an unstable
patient.
BBP: Bloodborne Pathogens - Remember that pathogens make people sick by the existence of
four conditions: 1. A pathogen is present that can make you sick. 2. It is of sufficient quantity
to get you infected. 3. You are susceptible to that particular pathogen. 4. It has an effective
way of entering into your system. With BSI (body substance isolation), we’re looking at
blocking #4 on this list. Don’t let it get in! We do this by wearing personal protective
equipment (PPE) that creates an effective barrier to the pathogen. Although the Bloodborne
pathogens are of great concern when dealing with bleeding patients, so are those transmitted
by other means. We must use common sense to avoid contact with ANY potentially infectious
substance. A quick BESTGuard rule of thumb: always put on your BSI gear before touching a
patient on land, but do NOT stop to glove up before entering the water to rescue someone in
the pool. Go get him first! Once he’s on deck, follow the protocols listed in this book for
donning your gloves and other PPE. We strongly recommend that all lifeguards get vaccinated
against Hepatitis B. As of this writing, there is still no vaccination for Hepatitis C, which is the
most prominent chronic liver disease in the world. A well organized and properly functioning
aquatic facility will combat all four of these conditions by requiring swim diapers and
prohibition of anyone with open sores, active infections, etc. from swimming; by using UV,
ozone, or another secondary oxidizer capable of killing the organisms that chlorine struggles to
kill (crypto and giardia, for example); providing appropriate vaccinations for free to all guards
on staff; requiring BSI and proper work practices be employed; and providing the PPE to do so.
Incident Command System – As we discussed earlier in unit 1, a key part of patient assessment
is the seamless transition from first responder patient care to more advanced pre-hospital care
that is provided by EMTs and Paramedics. Use your established patient assessment forms to
guide you through the steps and record what you’ve found. Hand this off to the Paramedics or
EMTs that come and take over for you. Be prepared to “package the patient” for transport
when time and equipment allow you to do so. If you can save precious time by fully packaging
a patient prior to when Paramedics arrive, he may have a greater chance of survival. For
example, a possible spinal injury removed from the pool on a backboard, fully strapped in, with
head immobilizer secured, and covered in a blanket - may be ready to go into the ambulance
with attaching the backboard to the stretcher the only packaging required by the Paramedics.
ASSESSING A CONSCIOUS VS. UNCONSCIOUS PATIENT
There are a few fundamental differences when assessing a conscious patient vs. an unconscious
one.
Assessing a Conscious Patient –
Step 1 – Scene size-up and initial assessment: After checking the scene for safety, immediately
identify yourself as a lifeguard trained in first aid, ask for permission to help; such as “Hi, I’m
Greg - a lifeguard trained in first aid. May I help you?” While introducing yourself, put on your
gloves. If the patient is a child, ask the guardian for permission. If the child’s injuries are lifethreatening, you may help the child without permission from the guardian, but you cannot
override the guardian’s wishes. However, if the injuries are to an adult, they may refuse your
help until they’re unconscious. Be sure to have a witness when care is refused by an adult or by
a guardian when trying to help a child.
Step 2 – Chief complaint and MOI: Ask about their chief complaint, “What seems to be the
problem?” and/or “What happened?” Ask the patient to describe the pain and location of the
pain, “Can you describe the pain for me?” Quickly assess their LOC (level of consciousness)
using the AVPU scale. Any patient who can talk to you normally does NOT have an ABC
problem, unless it’s severe bleeding. The bleeding, if present, should be their chief complaint,
but may not. So…always look for it quickly! Remember MOI, mechanism of injury. Decide – Is
this trauma or medical? Is this patient suffering from a medical condition, or has he been
injured? If suffering from a medical condition, a physical exam is rarely needed. If the medical
condition results in an injury due to a fall, then a physical exam is likely needed. You have to
use common sense.
Steps 3-4 – Physical exam and SAMPLE history: If the patient is injured, and the chief complaint
is unclear, or there is definitely the potential for other injuries, both a physical exam and
SAMPLE history should be done. With practice, you can do both at the same time – while
palpating and checking the patient, ask him the SAMPLE questions. If the patient is not injured
and has a medical problem, a SAMPLE history may be the only thing needed between step 2
and step 5 (ongoing assessment). SAMPLE is done on virtually every conscious patient,
whether it’s medical or trauma; since it’s always applicable to the patient’s condition. The
physical exam is done when there is potential for injuries beyond the chief complaint.
Step 5 – On-going assessment: Since most conscious patients are stable, you will likely do
ongoing assessment in 15 minute intervals. However, if the patient’s condition seems to
worsen with time, repeat assessments every 5 minutes (looping continually through). Some of
the step 5 stuff can be done during the physical exam, or just tacked onto the end of it. For
example, check capillary refill when checking the hands. Check eyelid and lip color when
checking the head. Note skin color and temperature when palpating. When checking the
wrists, note the strength of the radial pulse. Watch for normal respirations when checking the
chest and abdomen. By practicing these “multitasking” functions, you will be more efficient in
your time of assessment. When done with the physical exam, check the blood pressure. Use
the BP monitor whenever possible, since it may be more accurate than either auscultation or
palpation BP; and it can be done in a loud room. Checking BP when the patient is in different
positions is a good idea too: lying, sitting, & standing. Note any dramatic drop in BP when the
patient sits or stands. If not doing a physical exam, then use the incident report form and check
off the BLSCPR components one at a time. The ongoing assessment, along with physical exam
and SAMPLE results are laid out for you on the incident report form so you won’t have to
remember every acronym in a crisis!
Photo from video demonstration
Assessing an Unconscious Patient –
Step 1 – Scene size-up and initial assessment: After checking the scene for safety, put on your
gloves as you approach the patient (on land). Leaving the patient in the position you found
him, tap him on the shoulder next to you and say “sir, are you OK? Can you hear me?”
Assuming there is no response, position the patient onto his back and open the airway. From
the Lateral position (side of the head) perform your initial assessment (ABCs). If it’s a trauma
situation, look for mechanism of injury. Provide in-line stabilization if appropriate. When
suspecting a spinal injury due to MOI, establish in-line stabilization first, then speak softly into
his ear, “sir, can you hear me?” You don’t want to yell, it may startle him; he may jerk and be
injured further.
Step 2 – ABC care: Tell your back-up what the initial assessment results are; for example, “no
breathing, has a pulse; go get the oxygen. I’ll start rescue breathing.” When dealing with an
ABC problem, no other care is given. Care for the life-threatening condition. Don’t forget to
check for bleeding carefully. There have been situations where the rescuers didn’t notice a
severe wound under the patient, and he bled out.
Step 3 – SAMPLE History & Physical Exam: Once the ABC problem is corrected, a SAMPLE
history can often be obtained from a bystander/relative who knows the patient well. If the
patient has serious injuries, do a complete physical exam. For example, a patient hit by a car
and unconscious would need a complete physical exam. However, an unconscious 50 year old
man who collapsed while sitting in a chair at his desk does not need a physical exam.
Step 4 – Perform an ongoing assessment: Follow the BLSCPR acronym. This will be a
continuous loop of assessments, since an unconscious patient is virtually always more sick than
a conscious patient. When checking pulse and respiration rate, note the number of
beats/breaths per minute, and the strength of the pulse or breaths. Check these assessments
for 30 seconds each and multiply by 2. Not wearing a watch? If you have a pace clock, look up
at the pace clock on the wall. Write the respiration and pulse rates down on the incident report
form. Again check skin color, temperature, wet/dry, and capillary refill. Normal response is
under 2 seconds. Note LOC (level of consciousness) on the AVPU scale and record it every five
minutes. Use the electronic BP monitor if possible.
Note: detail on specific injuries, medical conditions or scenarios are found in the main text of
this book. Look up the type of incident in the table of contents and reference the section
contents at the beginning of each section for the exact location of the procedure that you need
to learn.
Photo from video demonstration
Lesson 9: Lifting and Moving Patients
There are a few critical principles for lifting and moving a patient. We’re going to cover those,
and the techniques that BESTGuard lifeguards should know for handling the most likely
emergencies.
First principle - NEVER enter an unsafe scene to move a patient. It’s not logical for you to
become another victim when the scene is truly unsafe. When would a scene be unsafe for a
pool or waterpark lifeguard? During a fire, earthquake, flood, or other MCI (Multiple Casualty
Incident), or any scenario where building structures can be compromised. Also, when an
intruder has a lethal weapon, or when gas chlorine has leaked, acids have spilled, etc.
When the scene is safe to enter briefly, but is becoming unsafe due to eminent danger
approaching, move the patient quickly away from the danger if you can, with the resources
available.
Second principle - only move a patient when you must to provide care.
 The scene is becoming unsafe – some examples below:
o On train track
o On highway or busy street
o Tornado approaching
o Fire encroaching the area
 The victim’s position is causing additional injury – examples:
o Hanging
o Electrocution
o Drowning
o Caught in machinery in the pump room or other mechanical room
Third principle – use the easiest move that fits the situation. For example, using a beach drag
to remove a patient from 3 feet of water in a wave pool makes more sense that a firefighter’s
carry. Also, don’t attempt moves that are beyond your scope or strength. It’s just like entering
an unsafe scene. If you become injured by attempting a move that you really cannot do with
the available resources, you’ve only exacerbated the scenario.
Specific Patient Lifts and Moves –
 Lifts and moves on land:
o Extremity lift – 2 guards lift the patient by holding under the knees and the wrists
in front of the chest. When you’re the guard holding the wrists, reach under the
armpits and keep the wrists very close together (overlapped, if possible). Don’t
allow the elbows to fly out and wrists to separate, this will put too much weight
on the shoulder joint and could cause a dislocation. It may also cause the arms
to suddenly extend overhead, resulting in dropping the patient. When you’re
the guard holding behind the knees, watch or wait for the guard with the wrists
to give the stand up command before standing. If transferring a patient from the
pool deck to a backboard, the guards should face each other so they can both
see the board and set the patient down with a coordinated motion. If moving a
patient from a building, or for a significant distance where the guards must walk
while holding the patient, both guards should face forward. The guard holding
the wrists always faces the patient’s back. Note: this lift can be very difficult for
a small lifeguard trying to lift a very large person. A small guard’s arms may not
reach around the chest of a large patient, nor will the guard’s hands reach
around the wrists for a secure hold.
o 2-person seat carry – Much life the extremity lift, the guards are lifting the
patient under the back of the knees, and the other point of contact is around the
patient’s back. The guards are on either side of the patient, wrists interlocked
behind the patient’s back, with his arms over the guards’ shoulders. Each guard
has the other hand under the corresponding knee. This lift is great for conscious
patients, but not as good for unconscious patients. If the patient is unconscious,
use the extremity lift.
o Direct lift/direct carry – Although these are actually two separate lifts, they are
essentially the same. A patient who is lying on his back is lifted using this
technique either to place the patient on a stretcher (direct lift), or to transfer
him from the stretcher to another surface, like an examination table (direct
carry). The difference between the two lifts is that a direct lift is from the
ground to the stretcher or backboard, whereas the direct carry is from one
elevated surface to the other. In either lift, 2 or 3 guards stand on one side of
the patient, crossing arms to overlap support of the patient. Next, roll the
patient onto his side a little to get your arms underneath. With your backs
straight, lift the patient up in a coordinated motion. The guard at the head is in
charge and calls the lift. If you’re the guard at the head, support the head and
neck by cradling the head in the crook of your elbow, with your hand on the
patient’s shoulder. It’s certainly possible that the patient is lying on his stomach.
In that scenario, straighten out both legs carefully, and move his arm closest to
you alongside his head. Now using your team as before, roll him onto his side,
then onto his back and onto your arms. Once he’s on his back, put the arm back
down.
o Draw sheet – Draw sheet is most commonly used in hospitals and nursing homes
for moving a patient in bed. However, draw sheet is a handy lift for transfer to
our backboards with runners underneath. Although EMS personnel routinely slip
backboards under a patient from the side without any trouble; our boards’
runners make this maneuver very difficult. To remedy this problem, use the
draw sheet method when putting your patient onto the backboard from the pool
deck. Because draw sheet can be used very effectively while maintaining in-line
stabilization for spinal injuries, it is recommended for this move over a direct lift.
Start by establishing in-line stabilization, next roll the patient onto his side with
him facing away from you (as described in the direct lift). Next, lay a blanket out
lengthways next to the patient. Roll some of it up in your hands and set the roll
on top of the patient’s side, drape the rest behind his back, and tuck the excess
under him. The guard at the head is in charge of the turn and maintaining in-line
stabilization during the turn. The other two guards carefully roll the patient back
onto his back and onto the blanket. One guard goes to the opposite side and
gently pulls the blanket out enough to make a roll and hold on (this should be
quite easy, if the blanket was tucked in well). Hold the blanket just above the
shoulders and just below the hips. It’s best to have another helper to hold the
feet level with the blanket. If not, the two guards on either side of the patient
will need to try to hold just below the knees. This may not be possible with a
taller patient. The blanket may “hike up” to the point where you’re holding it,
causing the feet to fall, because they’re no longer supported. This is why an
additional person is so helpful. Be sure that you have a very sturdy blanket. A
flimsy sheet or worn blanket will likely tear when lifting the patient, especially a
heavy one! After transferring the patient to the backboard, the guard at the
head continues to hold the head in line until the head immobilizers are placed
and the head is secured. The blanket is just left under the patient.
o Walking assist – This move is basically a “buddy hug” where the rescuer puts
his/her arm around the waist of the patient, and holds the patient’s wrist with
the other hand, which is over your shoulder. This assist is used for assisting the
green tagged triage victims to the first aid station, or for helping a person with a
leg injury to the car or first aid area. When helping a person with a leg injury,
stand on the side of the injured leg, to replace that leg with your support. Often,
you’ll have a patient sitting or lying down that needs to be stood up to be
moved. With one leg injured, have the patient move his uninjured leg into a
knee up position. Leave the injured leg in the position it was. Crouch down next
to the patient on the side of the injured leg and help him stand on his good leg,
with you replacing the injured leg with your support. The walking assist is also
very good for persons who are not fully alert, and/or unsteady on their feet. The
walking assist can be done with two guards as well; one on each side of the
patient.
o Firefighters’ carry – This carry is used only when the rescuer is large enough to
safely execute the lift without becoming injured him/herself. However, it is a
very effective technique for removing a patient from a dangerous scene where
further injury is eminent. It is a one rescuer technique that allows you to carry a
person to safety (whether conscious or not) and still have one arm free to open
doors or move obstructions from your path to safety. Start this lift by kneeling in
front of the patient. Draw the patient’s knees up and put yours against his to
keep them stable. Grab both of the patient’s wrists and pull him up, putting your
shoulder into his abdomen. Be careful not to lean too far forward. You could
injure your back. Drape the patient over your shoulders, wrapping your arm
around his legs and grasp the wrist of the arm that hangs in front of you. Put the
wrist in your hand that is wrapped around the legs, so you have one hand free.
Stand up straight, using your legs not your back. Note: practice this on a tiny
person first, and on a tumbling mat in case you fall. After you’ve perfected the
skill, try someone closer to your size (but still use the mat for safety).
o Pack-strap carry – Although primarily for a conscious, but non-ambulatory
patient, this carry can also be used for an unconscious patient. For a conscious
patient, stand in front of the patient and drape his arms over your shoulders.
Crossing them in front of your chest, grasp his wrists and lean slightly forward to
pick him up. Make sure that you have pulled his arms far enough that the
armpits are over your shoulders; to avoid putting his weight on the humerus
bones in the upper arms. Note: this technique will not work on victims much
taller than you – you’ll have to bend over too far and may injure your back. For
an unconscious patient, start by turning the patient face up on the ground.
Move his legs slightly apart and crouch down between his legs facing away from
him. Grasp both wrists and sit him up behind you. Drape his arms over your
shoulders as described above. Stand up using your legs, not your back and lean
slightly forward to carry him.
o Drags – There are four that can be used in an aquatic facility. All of these
techniques are for non-ambulatory or unconscious victims.
 Clothes drag – from the cephalic (top of the head) position, grasp a bunch
of the victim’s shirt behind the neck/shoulders. Carefully cradle his head
on your forearms, pulling gently on his shirt to slide him along. With
careful positioning of the head, the clothes drag can be used for a person
with a spinal injury who must be moved out of a dangerous area.
 Beach drag – for land or zero depth pools, this drag technique is similar
to the clothes drag, except the guard holds the victim under the armpits
and again rests the victim’s head on his/her forearms as the victim is
dragged backward. The shoulder drag is similar to the beach drag.
Instead of grasping the victim under the armpits, grasp the wrists as you
would in the extremity lift and drag the victim backward.
 Foot drag – When the victim is especially heavy and you’re alone, this
method may be effective. Grasp the victim’s ankles and drag him
backwards. Note: this technique cannot be used on stairs, since it does
not protect the victim’s head.
o HAINES recovery position – HAINES is an acronym for High Arm In Endangered
Spine position. The HAINES recovery position is nearly identical to the traditional
lateral or ¾ prone recovery position that has been used for decades. HAINES
uses a slight modification to maintain in-line stabilization. To put a patient into a
normal recovery position, start by moving the arm away from you alongside the
patient’s head. Lift the knee closest to you so the patient’s foot is flat on the
floor. Leave the leg on the other side straight and flat against the floor. Cradle
the victim’s head with one arm by splinting across to the shoulder. With your
other arm, hold the victim’s wrist (on the side closest to you). Hook his wrist
under the ilium (hip bone). Roll the patient onto his side, holding the head in
line as you do. Leave the arm extended above the head, and place the top arm
next to the patient’s face to provide stability. The bent leg on top will act as a
“kick stand” and will keep the patient on his side. For the HAINES position, lift
the patients outside leg instead of the one next to you. Be extra careful to hold
the head straight as you gently roll him onto his side. Once on his side, place the
leg closest to you on top of the bottom leg (which is bent). The hand is again
placed next to the patient’s face. This position is used if you must leave the
patient to get help, or if he is tagged as yellow during an MCI; and someone will
be coming back for him later.

Lifts and moves in the water –
We’ll cover lifts and victim positioning in detail during each rescue section, so
here we’ll just be defining the primary lifts from the water. There are three used
in BESTGuard: Backboard lift from deep water, Canadian 2-person lift, and
backboard lift from shallow water.
Backboard lift from deep water – popularized by the Red Cross, this lift uses a
backboard to assist two guards in lifting patients of small to average size. Very
large patients are likely to be problematic with this lift, because of their weight,
and the size of their wrists relative to the hands of the guards. The back-up
guard gets the backboard closest to the exit point and sets it next to the pool’s
edge. Later in the procedure, the primary guard will put the board into the
water. This lift requires that the victim is brought to the side of the pool facing
the wall, which is rarely the case when making a rescue – virtually all carries
approach the poolside with the victim’s back to the wall. An awkward turnaround is then required, so the back-up guard can catch the victim’s wrists.
Catch the wrists right hand to right wrist and left hand to left wrist (arms crossed
over one another). Again a very large victim’s arms are going to be heavy and
bulky, making this step difficult for the primary guard in the water to try to hand
them over to the back-up on deck. Once the hand-off is completed, the back-up
guard must make sure that the victim’s head is back to maintain an open airway.
The head is often forward, closing the airway. The primary guard should pull the
head back before exiting the pool, so the back-up guard does not have to
struggle with this. If holding the wrists of the victim, stay low, with your bottom
down and resting your elbows on your knees while holding up the victim, to
protect your back. As the primary gets out, tell him/her which side to put the
board in on. It’s the side of your top arm. The primary puts the board in
straight down against the wall, and you both hold it in place with your outside
foot, so it doesn’t float sideways. The back-up hands one wrist to the primary
and you both lift the patient as you turn him onto the board. This lifting action
will prevent the victim’s head from being stuck sideways against the board. With
both guards holding a wrist and one hand hold on the board, the lift out is on the
primary’s count. Realize that some pool or waterpark decks are very narrow – in
our state a 4’ walkway is the minimum. If your deck is narrow and you must turn
the victim 90˚ to get him onto the deck, pull him as close to the wall as possible
before swinging him over into a position parallel to the pool wall. Trying to
swing the foot-end of the board around before his center of gravity is completely
on the deck doesn’t work. He’ll just slide sideways on the edge of the pool, and
may be dumped from the board – or crash into something, such as a pool ladder.
Canadian 2-person lift – This lift was made popular by the Royal Life Saving
Society of Canada and does not require a backboard. It is the recommended lift
for BESTGuard lifeguards. As with the backboard lift, it is also intended for small
to average sized victims. Huge victims, especially those that have very large
wrists and chests will be difficult to remove without injury to the guards and/or
the victim. We recommend anyone that is of questionable size be removed in
the shallow end, on a backboard. Yes, it will be slower than using this lift (if this
lift works), but if the patient is too big, it simply won’t work to use either of these
first two lifts. For the average sized victim, however, the Canadian lift is very fast
and much more efficient than the backboard lift in deep water.
To perform this lift: bring the victim up to the pool wall facing away from the
wall. You don’t have to turn around. Once close to the wall, adjust your carry so
that you are to the side of the victim and no longer behind him. This will enable
the back-up guard to catch the victim’s wrists in front of his chest immediately.
If using a rear huggy, move briefly to a single armpit tow to get out of the way. If
using a do-si-do, just extend your do-si-do arm to move out of the way. The
guard on deck should lie down on his/her stomach and reach out with both arms
to catch the victim’s wrists as he’s approaching the wall. With practice, you can
catch the wrists before his back is against the wall and sweep your arms toward
you, lifting your elbows onto the pool deck. For most modern pools, this is
pretty easy since these decks are typically only a few inches above the water
level, if not equal to it. The back-up guard may not be able to do this quick
sweep to the elbow position, particularly if he/she cannot reach forward far
enough to catch the wrists before the victim is sitting up. If not, the primary
must pull the victim into the “chair” position to sit him straight up. Use the
momentum of your approach to pull him into a sitting position by grabbing the
gutter with one hand and wrapping the other around the victim’s waist. Make
your chair by bending your outside leg about 90˚ and planting your foot against
the wall. Your leg should be horizontal and the victim should sit on your lower
leg. Make sure that he is pulled tight against the wall, and is sitting straight up.
If he’s diagonal at all, he’ll be injured on the lift out, and the guard on deck may
fall backwards, landing the victim on top of him/her. Once the victim is sitting
upright, the guard on deck can reach around under his arms to grab the wrists in
front of his chest (just like the extremity lift). The primary guard must then push
the victim up the wall by walking his/her foot toward the surface. This will
enable the guard on deck to crouch on both feet. When you are crouched, you
must have your toes right at the edge of the pool. That will prevent you from
scraping the victim’s back on the pool’s edge, and potentially losing your
balance, and falling backward. The primary guard will now shift to a new
position to prepare to lift the victim on his/her shoulders. The primary guard will
remove his/her hand from around the waist of the victim and reach under his
hips, NOT his knees. Leave your other hand in the gutter. Call the lift when both
guards are ready by saying 1-2-3. Duck under the victim’s bottom and sit him on
your shoulder, reaching up to the deck with the hand on that side. Plant both
feet against the pool wall and using your legs, straighten up to lift the victim
straight up to just above the deck level. The back-up guard will stand up straight
as you push the victim up and sit him on the edge of the pool. Back-up guard will
take one small step backward once the victim has cleared the deck level and sit
him down. If he’s unconscious, you’ll drag him backward so his legs are on deck
past the knee joint and his legs won’t hang down over the side of the pool.
Failure to do this may result in blood pooling in his legs during CPR.
We’ll cover the variations of this lift in detail for conscious, unconscious, and
seizure patients in the specific protocol for each type of rescue.
Photos of this procedure from the
video
Backboard lift in shallow water – Use this lift whenever the patient is too large
for the guards to lift out safely using one of the first two lifts just described.
Also, this lift is used for a spinal injury with complications (with the addition of
head immobilizers to maintain in-line stabilization). This lift uses the “slant
board” removal, which has been adopted by a several lifeguarding programs.
To perform the backboard lift in shallow water, start by bringing the victim to the
focal point in the shallow end (the location where major extractions are done).
Use the carry that’s appropriate for your scenario: spinal clamp, do-si-do, rear
huggy, etc. As you get close to the backboard, adjust your carry and move to the
side as you did in the Canadian lift. Gently guide the victim onto the backboard
propped against the gutter at about a 45˚ angle. Your back-up will grab the
victim by the armpits and secure him in place with his/her elbows against the
sides of his head. As soon as the back-up guard has the victim secured, release
your hold and put on the chest strap tight up under the armpits. This will keep
him from sliding down. If the victim does not have a suspected spinal injury, the
back-up guard can let go of the armpits after the chest strap is secured. (We’ll
describe this lift for spinals in detail in the spinal injury section of the protocol.)
The back-up guard will grab the top of the board and hold it while the primary
guard goes to the foot end of the board. The primary guard will push the foot
end down to lift the head end up and make the transition to the deck easy. If on
deck, watch your fingers so they don’t get squished under the board during this
transition. Put the board onto its runners. The primary guard will now duck
down and lift the foot end of the board into a press position at the level of
his/her shoulders. This will level the board out. Now walk forward to slide the
board on its runners. Do NOT leave the board diagonal as it’s being slid onto the
deck. This may create too much weight for the back-up to hold and he/she may
drop the victim onto the deck. Always tip the board just enough to get the
runners on deck, then slide it from the horizontal press position. Virtually no lift
is required by the back-up guard using this technique, and the primary is using
only his/her legs to lift the board into the press position.
Photos of this procedure from the
video
Please see following pages for Unit 5 – First Aid….
BESTGuard Lifeguarding Program
Unit 5: First Aid
Definition First Aid is emergency care given to persons who are injured or suffer a sudden illness while
present in or around our facility. First aid can be either: code blue/no EMS, or code red/EMS
required. Conditions covered in this section include:
 Heart attacks, respiratory emergencies on land for both adults and children
 Soft tissue injuries – abrasions, lacerations, contusions, punctures, and avulsions
 Musculoskeletal injuries – fractures, dislocations, sprains, and strains
 Severe bleeding
 Stroke (CVA/apoplexy)
 Heat exhaustion, heat cramps, and heat stroke
 Anaphylaxis (allergic reaction)
 Hypoxia/fainting & hyperventilating
 Diabetic emergencies
 Shock
 COPD (chronic obstructive pulmonary diseases) conditions
 Burns
Mechanism of Injury (MOI) – In trauma/injury situations, the MOI is what helps you to
determine what kind of injury is present, and to form a general impression of the extent of the
injury. Look carefully at the scene to ascertain what happened and what type of injury is likely
to be the result. Also – ask the conscious patient what happened, and do you hurt anywhere?
The patient’s chief complaint will also help you determine what type of injury he has.
General first aid care steps – Although this is covered in detail at the front of this book, it’s
worth a review in the first aid section. We are using the following patient assessment model:
 Size up the scene – form your general impression and take in everything around you
o Does the victim(s) need to be moved?
o Can I approach and help safely?
o How many people are around?
o What equipment is available for first aid/rescue/transport?
o Is this an EMS call or not?
 Perform an initial assessment – check for life-threatening conditions
o Consciousness – AVPU
o ABCD – Airway, Breathing, Circulation/bleeding, Deformity
o CALL EMS FOR ANY LIFE-THREATENING CONDITION
o Provide care for these conditions first


Perform a SAMPLE history and physical exam
o SAMPLE – Signs/symptoms, Allergies, Medications, Past pertinent medical
history, Last oral intake, Events leading up to the injury/medical condition
o Physical exam – Perform head to toe exam, using appropriate palpation
techniques whenever other injuries are likely, due to MOI. If no injuries are
present other than the chief complaint, or the condition is medical, do not
perform a physical exam.
Perform ongoing/secondary assessment – This is check of vital signs and continued
patient monitoring once the first aid is finished. It includes the acronym BLS CPR for
Blood pressure, Level of consciousness, Skin characteristics, Capillary refill, Pulse rate,
and Respiration rate.
Lesson 10: Medical conditions on land The following sections cover medical conditions, what they look like, and how to perform first
aid out of the water for each. These sections are written like a play script, so it’s easy to follow
each team member’s responsibilities. Each section also goes from the beginning (recognition)
to end (follow-up), so you can refresh your skills by reading and practicing one complete
procedure at a time without skimming through the book to find the missing pieces. We start
each section with a definition of the term(s) referenced in that section. The sections are
sequentially numbered for quick reference.
Because CPR, AED, Oxygen Administration, Suctioning, and airway management are 1 st aid
components, the heart attack detail is included in 1st aid. Seizures and behavioral emergencies
are covered separately.
Heart Attack/Acute Myocardial Infarction – procedure #1.0
Definition –
A heart attack is an acute myocardial infarction (AMI), often referred to as an MI - for
myocardial infarction. It means the rapid onset (acute) of tissue death (infarction) of the
myocardium. The myocardium is the heart muscle. A heart attack is caused by a sudden
blockage of a coronary artery, cutting off the blood flow to an area of the heart muscle. The
affected area soon dies, and the affected muscles can no longer contract. The larger the
affected area, the more serious the attack; thus a large area may result in no pulse, sudden
collapse and death without immediate care. A small area can cause pain and SOB (shortness of
breath), but the patient will probably not lose consciousness or pulse. In fact, he may not even
know that anything happened.
Symptoms –
Heart attacks are traditionally characterized by squeezing & oppressive chest pain, shortness of
breath, profuse sweating, nausea, and general ill feeling. Pain in the arm, neck, back, or jaw is
also common. The chest pain does not come and go, but is generally a steady pressure.
Remember that a “massive heart attack” will result in sudden collapse, unconsciousness, loss of
pulse and breathing. The victim may be swimming or walking, then suddenly become very
short of breath and collapse. A minor heart attack may happen several times to the same
person.
Note: studies on female heart attack victims show a different pattern of pain; with a more
inconsistent pain than that occurring in men; and more pain in the back, neck, or jaw than with
men. Watch for the other signs in women, such as nausea, sweating, and general ill feeling.
Don’t rule out a heart attack if the pain is not constant.
Anyone experiencing chest pain, shortness of breath, and sweating should be considered a
heart attack victim.
An occlusion or clot forms in a
Coronary artery causing the muscle
Beyond it to die (infarction). Angina
Is similar, except the arteries are not
Completely blocked, just narrowed.
Angina pectoris –
Is a condition that is often associated with heart attacks. It’s not the same thing however.
Cardiovascular disease causes restriction to the blood flow of the coronary arteries. When the
arteries are too constricted, chest pain results from the lack of oxygenated blood delivered to
the myocardium. The victims of angina usually take nitroglycerin or other medication for their
chest pain episodes. The medications help expand the arteries and relieve the constriction.
People with angina are much more likely to have a heart attack than those with clear coronary
arteries.
Note: All of the BESTGuard procedures start with - blow your whistle into the mike and radio – because
we strongly recommend that your facility has both to ensure proper activation of your emergency action
plan. Code red emergencies are those that require an ambulance. Code blue are those that the guards
can handle without additional EMS support.
Heart Attack - Conscious Victim: 1.1
Conscious victim on deck: 1.1.1
(Code red emergency)
Primary - Stand up, blow your whistle into the mike and radio. Say, “code red, I’ve got it”
and give the heart attack hand signal. Climb down and hurry over to assist the victim.
Avoid yelling “heart attack!” while the victim is still conscious.
Back-up - Upon hearing the whistle and code red signal, look to see if the primary is giving
a heart attack hand signal. If so, yell “we have an emergency! Please clear the pool!” Hurry
over to the primary and victim. The primary will be doing the initial assessment. He/she
will direct you to go get the victim’s medication and/or the first aid equipment.
Cashier - Upon hearing one long whistle blast, immediately hurry onto the deck to see
what’s happening. Stop and grab the cordless phone and emergency clipboards on your
way. If the guard yells code red, call 911 on the cordless phone (if you don’t know whether
it’s code red or blue, ASK!)
Primary -
If the victim is complaining of chest pain and shortness of breath, blow your
whistle (one loud tweet) and give the heart attack hand signal. Ask the victim if
he has had this problem before and if he is an angina patient. If he says yes,
have the back-up get his nitroglycerin pills (or other medication). While talking to
the victim, put on your gloves.
Perform a SAMPLE history 1.1.1.1
Ask him “How are you feeling? Do you have pain anywhere?” Look for signs of
heart attack – sweating, shortness of breath, clutching his chest and/or left arm.
Ask, “Do you have any allergies?” Write them down. Ask, “Are you taking any
other medications?” Write them down. Ask, “Do you have any other related
medical conditions?” Write them down. Ask, “When was the last time that you
ate or drank anything; including your medication?” Ask, “What were doing right
before you started feeling this way?” Write it down.
Primary -
Have the cashier Call EMS! This is a code red emergency.
Cashier -
Call EMS, and give the dispatcher whatever information the primary is giving you
about the patient. Describe what the guards are doing in response to the
patient’s condition. Stay on the phone until the dispatcher says good-bye. If the
dispatcher asks you for address verification, be prepared with the address and
which door to enter. Be ready to meet them and direct them to the patient.
Back-up -
Go and get the nitro pills (or other medication) from the victim’s stuff. If they
are in a bag or other personal storage container, ask the victim where and if it’s
OK to get the bottle out. Give the bottle to the primary. Go and get the O 2 and
the jump bag.
Primary -
Open the bottle and hand one pill to the victim. Do NOT put the pill in the
victim’s mouth!
Primary &
Back-up
Keep the victim sitting or lying down.
Do not leave the victim’s side until EMS takes over.
Back-up -
As soon as you return with the equipment, stop and put your gloves on.
Cashier - Give the patient assessment clipboard to the guards. After making the 911 call,
go out and meet the ambulance. Direct them to the patient.
Administer Emergency O2-Conscious: 1.1.1.2
Back-up If the victim is having a lot of trouble breathing, but is still conscious, open the
jump bag and set up the oxygen using the non-rebreather mask in the bag.
Inflate the oxygen reservoir bag quickly by holding your finger over the valve.
Once the reservoir bag is full, place the mask on the patient.
If the victim is uncomfortable with a mask, use the nasal cannula. Remember –
set the flow meter to 15 lpm when using the non-rebreather, and to 2-4 lpm
when using the cannula.
Perform Ongoing Assessemnt – BLSCPR: 1.1.1.3
Primary While the back-up sets up the non-rebreather mask or cannula, keep your hand
on the victim’s shoulder in case he passes out. Begin taking your first set of
vitals: BLSCPR. B = blood pressure. We recommend using a digital BP Monitor,
so auscultation is usually not necessary. If you need to perform auscultation,
begin by placing the BP cuff on the arm closest to you about 1 inch above the
elbow joint. Place the tubes over the brachial artery (on the inside of the arm).
Hook the sphygmomanometer (gauge assembly) onto something so the gauge is
directly in front of you and you’ll be able to read it easily. A pant leg of the swim
trunks works well for this. Put the stethoscope into your ears and place the head
of the stethoscope over the brachial artery. Hold it between your index and
middle fingers. Apply light pressure to listen for the pulse. Close the valve and
inflate the cuff to about 180 mm Hg. Tell the patient that the cuff will feel tight
for a few seconds. Loosen the valve slightly to descend at the rate of about 2
mm Hg per second. Listen for the pulse to appear. When it does, note the
number on the gauge. This is the systolic pressure. Continue listening until the
pulse disappears again. Note that number. This is the diastolic pressure. Write
down the BP as systolic over diastolic pressure. Normal BP is around 120/80,
with 118/78 preferred. Use only even numbers. By convention, BP is not
interpolated between the calibrations on the gauge.
Note:
Palpation BP may be necessary when you cannot get the area surrounding the
patient quiet enough to hear the pulse during auscultation. To do palpation, use
the BP cuff without the stethoscope. Place the cuff, then obtain a radial pulse.
Inflate the cuff until the pulse disappears. Go 20 mm Hg past the number in
which the pulse disappeared.
Now, release the valve slowly to descend at the rate of 2 mm Hg per second.
When the pulse reappears, that’s the systolic pressure. For example, if it
reappears at 120, write it down as 120/P. You will not have a diastolic pressure
using this method, thus it’s written as 120/P.
Check level of consciousness (L step of BLSCPR) – Use the AVPU scale
defined in Unit 2. The patient is either:
Alert – can respond with appropriate verbal answers; Verbal – can respond to a
verbal stimulus, but not articulate an appropriate response; Painful – can
respond to a pinch; Unresponsive – cannot respond at all/unconscious. Write
down what you find on the incident report form.
Next, check skin condition (S step of BLSCPR) – Is the skin pink, white, gray,
yellow, blue/purple, red, blotchy, covered with hives, streaked from a bite or
other infected wound, wet, dry, hot, cold?
Now, check capillary refill (C step of BLSCPR) – Take the hand closest to
you and gently squeeze the fingernail of the pointer finger. The nail
should turn white, then pink again within 2 seconds. If it takes longer,
note how long it took. Write it down.
Pulse is next (P step of BLSCPR) – Check the carotid or radial pulse for
30 seconds. Watch the pace clock. Multiply the result by 2; then write it
down on the incident report form. If your facility has no pace clocks,
you’ll need to wear a watch, or keep a stopwatch in your jump bag.
Note:
Carotid pulse is on the neck. The carotid artery is in the groove between
the Adam’s Apple and sternocleidomastoid muscle on the side of the neck.
Push in gently on the side closest to you, with your thumb pointing toward
the top of the patient’s head. To check radial pulse, find the radial artery
on the thumb side of the wrist. Turn the patient’s hand palm up. Find the
tendon just to thumb side of center. The radial artery is just to the
outside of this tendon.
The last step is respiration (R step of BLSCPR) – Check respiration rate by
watching the chest rise and fall for 30 seconds and counting the number.
Multiply by 2 and write it down on the form. Normal respiration rate for
an adult is about 12-20.
If respirations are under 12 or well over 20, the victim may be in
respiratory distress.
Remember that ongoing assessment for a heart attack patient is on the
unstable time-line. You’ll be continuously cycling through the acronym
BLSCPR until EMS arrives and takes over.
Cashier-
Keep the witness report forms and gather witnesses’ statements. You
may need to make copies of the witnesses’ statements for them after
they are done filling out the reports.
Primary and Back-up
The victim may pass out. If he does, primary will take the non-rebreather
mask off quickly.
Back-up - If the victim is in a puddle of water, hurry over and get the closest backboard.
Primary - Lay the victim down on his back and perform a 10 second assessment of
breathing and pulse.
At this point, you have begun procedure 1.2.2 – unconscious victim on deck.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team.
You must be isolated while writing down your description of the rescue. You
must do it before talking to anyone about it. If the paramedics ask you questions
about the victim, answer them. Do not answer any questions that the patrons
ask. Explain that you are not at liberty to discuss the rescue. If patrons have
questions, they should address them to the Aquatics Manager. Remember to
think carefully about time sequences when writing your report (was it 10 seconds
or 30? Was it 1 minute or 5 minutes?). Time sequences are crucial if litigation is
involved. You should re-enact the time sequence if unsure. Ask the Aquatics
Manager for help with this when you need to re-enact the scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - A heart attack is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other appropriate officials. These officers will coordinate the
distribution of information to the press. Lifeguards should politely defer ALL
questions about the incident to the Aquatics Manager. Guards should remain at
work until after a debriefing meeting.
Your employer should give you all as much emotional support as possible to
cope with the rescue. You should not be expected to return to duty after an
incident of this magnitude.
Unconscious victim on deck – and transfer to backboard: 1.2.2
There are a few tips to keep in mind when performing the skills that follow:
 Always use the cephalic position for the purpose of the jaw thrust plus head tilt, and
better seal on the face.
 We’re always starting with ONE person CPR, because the back-up guard is going to get
the AED and setting it up. 2-person CPR is done only when the AED is hooked up and
there is no detectable pulse.
 The back-up guard is almost always who prepares a pocket mask for use while the
primary finishes the initial assessment.
 With patients on deck, BSI is done before touching the patient, whereas patients
removed from water are touched in the water without gloves on, then the gloves are
put on after the extrication.
If a customer has a massive heart attack at your facility, it could be in the sauna, locker room,
exercise area, or even the parking lot. AEDs work best with the victim on a dry surface;
however, they do work in the rain. What we want to avoid is a puddle of water. The patient is
always wet from being sweaty, so drying off the pad placement positions is usually all that’s
needed for the AED to work. A wet deck that drains properly is probably not going to cause any
problem with cardio-conversion. Just hook up the machine and leave him where he is. If he is
lying in a puddle, you’ll have to transfer him to a backboard, or drag him to a drier spot. Here’s
the procedure to use when you have to move him.
Primary -
Recognize that a patron has collapsed. Stand up and blow your whistle loud for
a full second (one long blast) into the mike and radio. Yell, “Code red, I’ve got
it!” I may be pretty clear that it’s a heart attack. If so, give the heart attack
closed fist hand signal when you stand up and yell “heart attack.” An
unconscious victim doesn’t care if you yell heart attack or not!
Climb down and/or hurry over to the victim.
Primary and
Back-up
PUT YOUR GLOVES ON NOW!
Your gloves are in your fanny pack.
Back-up -
Upon hearing the signal, yell “We have an emergency, please clear the pool!”
Then go get the backboard and blanket. Bring it over next to the victim and
primary.
Primary -
Do the initial assessment. Upon checking breathing and pulse for 10 seconds, if
he has a pulse but is not breathing - say “No breathing, I need the pocket mask.”
If no pulse when the pulse is checked say, “no pulse. We have to transfer.” OR
“We need to move him out of the puddle.” Give 2 breaths to inflate the lungs
before you transfer/move the patient.
Note:
If the back-up is setting up the backboard, you may need to get your own pocket
mask out to deliver the first two breaths. Normally, your back-up will set up his
pocket mask for you. But in this scenario, he may not be able to do so in a timely
manner.
Back-up -
While the primary does the ABC’s, set the board down with the head end next to
the victim’s head. Take off the head immobilizers. Remove the blanket from the
head immobilizers and lay it on the board lengthways. It will absorb some of the
water dripping from the patient.
Back-up -
Extremity lift (see lifting and moving in Unit 4) - Move into the lift position by
standing between the legs of the victim, facing him. Grasp his wrists and pull up
the arms to sit the victim up. The primary will get the wrists in front of the chest.
Primary -
Go to the top of the head. Reach under the victims arms from behind and grasp
the wrists: right to right and left to left. Keep the hands touching, elbows in.
Wait for the back-up’s count. Lift and transfer by sitting the victim down.
Finally, gently lay his head down onto the board.
Back-up -
Grasp the legs under the knees. Lift on your count. Step over the board and set
the victim back down on the blanket. Set him down bottom first.
Note:
This lift may be referred to as the extremity lift or the front and back carry. The
guard at the knees may face either direction, depending upon if the lift is just a
step to the side or transporting the victim to a safe/dry location. You may use a
drier spot on deck that is close by, to save time and eliminate the need for the
backboard.
Cashier -
After hanging up, make sure the pool is clear and there is no crowd around the
rescue. Give the patient assessment clipboard to the guards.
Use the witness report forms to gather witnesses’ statements. Go out to the
appropriate door and wait for EMS there. Show them where the emergency is
when they arrive. You may need to make copies of the witnesses’ statements
for them after they are done filling out the reports.
Initial Assessment after transfer: 1.2.2.1
Primary Since you know the victim is not breathing and has no pulse from your first
assessment, say, “I need the pocket mask.”
Note 1:
All rescue breathing done in the BESTGuard program is performed from the
cephalic position, unless an obstruction makes it impossible.
Note 2:
Agonal breathing (or agonal gasps) are reflexive and have no pattern. They are
NOT normal breathing and do not represent a sign of life. They should be
ignored. As with vomiting, agonal breathing can occur when the patient has no
pulse.
Back-up -
While the primary positions the head for rescue breathing, pick up his/her mask
and hand it to him/her when he/she is ready. The primary should have already
delivered the first two breaths prior to the transfer. Since there is no pulse or
breathing, go get the AED and first aid equipment.
Primary -
Move to the top of the head. Put the pocket mask on using the triple airway and
give 2 breaths. Make sure the chest rises. The breaths must go in. If not, retilt
and try one more. Using the triple airway, you should be thrusting the mandible
forward as well as tilting the head back. After the chest rises, go straight to
compressions, since you already checked pulse before the transfer (and no signs
of life are present).
Primary -
Begin CPR by moving over the chest, measure between the nipples and give 30
compressions 2 inches deep at a rate of about 100 per minute. Count one-andtwo-and-three-etc. Give two breaths with the pocket mask. Remember no
reassessments unless “an obvious sign of life is present.” The back-up should
have the AED connected and analyzing within 2 minutes. If the victim should
vomit while the back-up is gone for the equipment: turn his head away from you,
scrape out the mouth with your gloved hand.
Note:
When a non-spinal patient vomits, there is no need to strap him down, or
even to roll him over to clear the vomit, just gently turn his head
away from you with both hands. Then wipe out the mouth by reaching
over the patient. Use the suction device to finish clearing the mouth of
smaller debris.
AED use: 1.2.1.1.6
Back-up You should return with the equipment in less than 30 seconds. If it takes longer,
it’s too far away! The primary will continue to do CPR while you prepare the
AED, until the AED says, “analyzing, stand clear of the patient.” Then stop and
move back so it can analyze the heart rhythm. You are in charge of the AED, and
will give all the stand clear warnings, and commands to resume CPR. Once the
AED is hooked up, it’s just a matter of doing what it says. However, you must do
CPR anytime that you cannot detect a pulse, and the AED is not analyzing or
shocking.
To set up the AED, put it next to the victim’s head and turn it on. It will
immediately say, “apply pads to patient’s bare chest.”
Take the towel out of the jump bag (or use the towel attached to the backboard)
and wipe off the upper right chest, and left armpit of the victim. Attach the right
pad just under the clavicle, pressing firmly on all edges of the pad. Attach the
left pad a few inches below the armpit. Try to keep the wires clear of the
sternum, so they’re not over the compression point for CPR. Attach a wrist
restraint prior to plugging in the electrodes. This is usually just a long hair tie or
a loop of Velcro that can hold the hands together on top of the chest – to keep
them out of the water, and from falling under the edge of the backboard when
the patient is rolled over. If the patient vomits, the hands can be seriously
injured if not tied together before rolling him onto his side.
Primary -
Keep doing CPR until the AED says, “analyzing heart rhythm, stand clear of the
patient.” Then stand clear.
Electrode precautions - If the victim is female, or a male wearing a T-shirt, it may
be necessary to cut off the top of her suit (or cut the T-shirt) to expose the pad
placement positions. Many strap configurations are easy to pull down off the
shoulder and expose the chest area. This may be faster than cutting, plus it
won’t ruin her suit. If the area just below the right clavicle and left armpit is
already exposed (wearing a bikini for example), do not waste time cutting off the
suit. Dry the area and apply the pads immediately. There is no longer a
contraindication for jewelry or metal touching the chest; so the only concern is
proper pad placement and drying the chest.
A male victim with a hairy chest may prevent the AED from making a proper
connection. If the improper connection voice prompt is heard, rip the first set of
pads off and apply the second set. There must be two sets in the AED case. If
the victim has a medication patch on the chest, pull it off using a gloved hand. If
he has an implanted pacemaker, keep the electrode at least 1 inch from it.
Safety tips – Keep the cordless phone and radios away from the AED. Cut or remove clothing
covering the pad positions while the primary is doing breaths, so you are not in one another’s
way.
CPR (two person): 1.2.1.1.6
The AED will go into pause mode after it has delivered a shock, whether it has
obtained cardio-conversion or not. It will say, “paused. It is safe to touch the
patient. Do CPR for 2 minutes.” (about 5 cycles)
Primary -
Upon hearing this command, begin with two breaths using the pocket mask.
Have your back-up do 30 compressions.
Always do breaths from the cephalic position and use the triple airway.
Back-up -
Do 30 compressions. Continue the 30-2 pattern for 2 minutes. The AED will
break in and say, “analyzing heart rhythm, stand clear of the patient.” Then
move back. Again, follow the AED’s instructions.
Note -
If the AED says, “no shock advised. It is safe to touch the patient,” then the
rhythm is not a shockable rhythm. The patient may be in asystole. If no pulse,
you’ll be doing CPR until the paramedics arrive. In this scenario, you may need to
change positions.
Changing positions: 1.2.1.1.7
Back-up To change positions while doing two person CPR, you (the compressor) will call
the change by saying “change” instead of “30” on the compression count. After
the two breaths, switch places. Resume compressions within 5 seconds. Change
positions about every 2 minutes. Reassess breathing and pulse only when there
is an obvious sign of life.
Primary -
After the back-up says, “change” on compression number 30, give two breaths
and move over to the compression position. Compress directly over the body of
the sternum, between the nipples. Immediately resume compressions.
Safety tip – use your own pocket mask when doing the change on two person CPR; to avoid
swapping saliva with the other rescuer.
Administering Emergency Oxygen-Unconscious: 1.2.1.1.8
Primary If after you successfully get the chest to rise with two breaths and the pulse
check indicates a pulse present – say, “has pulse, no breathing. Go get the first
aid equipment.” Begin rescue breathing immediately using your pocket mask.
Go back to the top of the head and use the triple airway. Give one breath every
five seconds by counting one-one thousand, two-one thousand, three-one
thousand, inhale, breathe. The back-up should be back with the first aid gear
and oxygen in less than 30 seconds. Continue rescue breathing for 2 minutes or
until the BVM is ready to substitute for your pocket mask. If you are at the 2
minute mark – stop for the reassessment before continuing with the BVM.
Back-up -
You’re in charge of setting up the oxygen. Set up the BVM with the tank on 15
lpm. Start by checking the wing nut for snugness. Next, open the cylinder valve
one full turn. Check the pressure. You need over 200 lbs. to do anything. Attach
the poly-tubing to the BVM. Attach the other end to the cylinder. Set the
flowmeter and check flow. Replace the pocket mask with the BVM over the face
of the victim without interrupting the count. Remember to reassess pulse and
breathing EVERY 2 minutes when doing rescue breathing alone.
Safety tips – Keep the AED 6 feet away from the oxygen bottle. Do not to use the oxygen and
the AED at the same time.
Note – if your variable flow oxygen system has 25 lpm capacity, you may use this setting during
BVM rescue breathing. All BESTGuard protocols are written for 1-15 lpm.
Vomiting/suctioning: 1.2.1.1.9
Back-up or compressor When the victim vomits – gently roll or turn the head of the victim to the side,
away from you. Do this by placing one hand on each side of the head and
carefully turning it away from you. Rolling the entire patient is unnecessary and
slower. However, if you need to roll the patient Primary or ventilator Move the arm on the side opposite you above the head before the roll. Hold the
head and shoulder on the turn.
Back-up -
Scrape any large chunks of vomit from the mouth with a gloved hand. Then use
the manual suction device to get the smaller particles. If your suction tube has a
cap, take the cap off the end. Attach the fine tip/tube (there’s usually a bigger
and smaller tube to choose from). Measure the insertion distance from the
corner of the mouth to the earlobe. Hold the suction tip at that point and insert
the tip into the back of the throat. Put the tip against the inside of the cheek
closest to the ground, where debris will collect. Using a circular motion,
withdraw the tip as you circle it. The withdrawal should take 15 seconds or less.
Keep pumping the device’s handle as you suction.
Note:
Although mechanical suction devices are also available, they are considerably
more expensive and are bulkier to have in your jump bag. We recommend using
a manual device because of its portability and inexpensive replaceable
cartridges.
Primary -
Keep holding the victim on his side while the back-up does the suctioning.
Back-up -
When done suctioning, roll the victim back onto his/her back and resume rescue
breathing with O2 or CPR.
Primary -
If doing rescue breathing alone, without CPR, a reassessment of breathing and
pulse should be done after vomiting. Reassessment is not done if vomiting
interrupts full-blown CPR, unless the patient shows an obvious sign of life after
vomiting.
Note -
Remember: roll the victim carefully, without twisting the back or neck; and
supporting the head at all times. Do the same thing if the victim starts to cough,
or acts like he is trying to vomit. When there is no risk of spinal injury, you may
just turn the patient’s head gently away from you and scrape out the mouth.
Have your back-up prepare the suction device for use and suction out the
remaining debris.
Safety tip –
When vomiting occurs during AED use, and the victim must be turned as a unit,
(rather than just turning his head) the wires may yank the AED off the ground while turning the
victim. You will still roll away from the compressor, but the ventilator will need to hold the AED
next to the victim’s head. Hold the AED with one hand while holding the head in the other
hand. This will prevent vomiting on the AED (usually, the AED is on the compressor’s side of the
victim, since he/she was the person who went to get it). Again, a simple head turn will
eliminate the need for this procedure.
Obstructed airway: 1.2.1.1.10
Primary If during the initial assessment your first 2 breaths do not go in, re-tilt the head.
It’s probably the tongue in the way. Try another breath. If it won’t go in, the
victim is choking (has an obstructed airway). Say “airway obstructed, begin chest
compressions.”
Back-up -
Upon hearing the command, do 30 compressions, remaining in position
afterward.
Primary -
After the back-up does the compressions, check the mouth for foreign objects,
and try again to put 2 breaths in using the mask.
If no success, say “still didn’t go in, repeat chest thrusts.”
Primary &
Back-up
Continue this sequence until 2 breaths go in.
Primary -
When they do go in, you’ll begin either rescue breathing or CPR. If no pulse, say,
“no pulse; go get the AED & jump bag.” Begin one person CPR. If the patient has
a pulse but is not breathing, call for the oxygen and jump bag.
CPR (one person): 1.2.1.1.4
Primary Begin CPR by moving over the chest, measure between the nipples and give 30
compressions 2 inches deep at a rate of about 100 per minute. Count one-andtwo-and-three-etc. Give two breaths with the pocket mask. Remember there
are no reassessments unless “an obvious sign of life is present.” The back-up
should have the AED connected and analyzing within 2 minutes. If the victim
should vomit while the back-up is running for the equipment: turn his head away
from you, scrape out the mouth with your gloved hand. Turn his head back to a
face-up position, then resume ventilations and compressions.
Back-up -
If the primary says that the breaths went in, go and get the equipment.
Once the AED is connected, you are now back at procedure 1.2.1.1.6, two person
CPR.
SAMPLE History –
Note:
In this procedure, a SAMPLE history would not be done, since the patient is unresponsive. However, if the patient is
accompanied by a person knowledgeable about the patient, you may ask that person the SAMPLE questions.
Conduct a SAMPLE history – 1.1.1.1.1
Since you cannot ask for current symptoms, begin with looking for signs that indicate
the patient’s current condition. Ask, “Does he have any allergies?” Write them down. Ask,
“Is he taking any medications?” Write them down. Ask, “Does he have any other related
medical conditions?” Write them down. Next ask, “When was the last time he ate or drank
anything; including his medication?” Finally, ask, “What was he doing right before he
collapsed? What symptoms or signs did you see?” Write it down.
Ongoing assessment - (use the acronym BLSCPR)
Note:
If at any time the patient stabilizes and regains respiration; the back-up should
record vitals that are taken by the primary. The vitals include - blood pressure,
level of consciousness, skin color/temperature/moisture, capillary refill, pulse
rate, respiration rate.
Back-up -
Upon regaining regular respirations and pulse, set up the O2 for delivery with the
nonrebreather at 15 lpm, or the cannula at 2-4 lpm.
Perform ongoing assessment – 1.1.1.3
Primary -
While the back-up sets up the non-rebreather mask or cannula, keep your hand
on the victim’s shoulder in case he passes out. Begin taking your first set of
vitals: BLSCPR – Check BP with the BP Monitor. If it doesn’t work, do an
auscultation blood pressure. To perform auscultation, begin by placing the BP
cuff on the arm closest to you about 1 inch above the elbow joint. Place the
tubes over the brachial artery (on the inside of the arm). Hook the
sphygmomanometer (gauge assembly) onto something so the gauge is directly in
front of you and you’ll be able to read it easily. A pant leg of the swim trunks
works well for this.
Put the stethoscope into your ears and place the head of the stethoscope over
the brachial artery. Hold it between your index and middle fingers. Apply light
pressure to listen for the pulse. Close the valve and inflate the cuff to about 180
mm Hg.
Tell the patient that the cuff will feel tight for a few seconds. Loosen the valve
slowly until the needle descends at the rate of about 2 mm Hg per second.
Listen for the pulse to appear. When it does, note the number on the gauge.
This is the systolic pressure. Continue listening until the pulse disappears again.
Note that number. This is the diastolic pressure. Write down the BP as systolic
over diastolic pressure. Normal BP is around 120/80, with 118/78 preferred.
Use only even numbers. Do not interpolate between the calibrations on the
gauge.
Note:
Palpation BP may be necessary when you cannot get the area surrounding the
patient quiet enough to hear the pulse during auscultation. To do palpation, use
the BP cuff without the stethoscope. Place the cuff, then obtain a radial pulse.
Inflate the cuff until the pulse disappears.
Go 20 mm Hg past the number in which the pulse disappeared. Now, release the
valve slowly to descend at the rate of 2 mm Hg per second. When the pulse
reappears, that’s the systolic pressure. For example, if it reappears at 120, write
it down as 120/P. You will not have a diastolic pressure using this method, so you
record the palpation as P; thus it’s written as 120/P.
Check level of consciousness (L step of BLSCPR) – Use the AVPU scale defined at
the beginning of the book on page 2. The patient is either Alert – can respond
with appropriate verbal answers; Verbal – can respond to a verbal stimulus, but
not articulate an appropriate response;
Painful – can respond to a pinch; Unresponsive – cannot respond at
all/unconscious. Write down what you find on the incident report form.
Next, check skin condition (S step of BLSCPR) – Is the skin pink, white,
gray, yellow, blue/purple, red, blotchy, covered with hives, streaked from
a bite or other infected wound, wet, dry, hot, cold?
Now, check capillary refill (C step of BLSCPR) – Take the hand closest to
you and gently squeeze the fingernail of the pointer finger. The nail
should turn white, then pink again within 2 seconds. If it takes longer,
note how long it took. Write it down.
Pulse is next (P step of BLSCPR) – Check the carotid or radial pulse for
30 seconds. Watch the pace clock. Multiply the result by 2; then write it
down on the incident report form.
Note:
Carotid pulse is on the neck. The carotid artery is in the groove between
the Adam’s Apple and sternocleidomastoid muscle on the side of the neck.
Push in gently on the side closest to you, with your thumb pointing toward
the top of the patient’s head. To check radial pulse, find the radial artery
on the thumb side of the wrist. Turn the patient’s hand palm up.
Find the tendon just to thumb side of center. The radial artery is just to
the outside of this tendon.
The last step is respiration (R step of BLSCPR) – Check respiration rate by
watching the chest rise and fall for 30 seconds and counting the number.
Multiply by 2 and write it down on the form. Normal respiration rate for
an adult is about 12-20. If respirations are well over 20, the victim may
be in respiratory distress.
Remember that ongoing assessment for a heart attack patient is on the
unstable time-line. You’ll be continuously cycling through the acronym
BLSCPR until EMS arrives and takes over.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT collaborate your story with the
members of your team.
You must be isolated while writing down your description of the rescue. You
must do it before talking to anyone about it. If the paramedics ask you questions
about the victim, answer them. Do not answer any questions that the patrons
ask. Explain that you are not at liberty to discuss the rescue. If patrons have
questions, they should address them to the Aquatics Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - A heart attack is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other officers. These officers will coordinate the distribution of
information to the press. Lifeguards should politely defer ALL questions about
the incident to the Aquatics Manager.
Guards should remain at work until after a debriefing/counseling meeting with
your employer. Your employer should give you as much emotional support as
possible to cope with the rescue. You should not be expected to return to duty
after an incident of this magnitude.
Unconscious victim on deck – move to drier area/transfer to backboard: 1.2.2
When a major heart attack occurs out of the water, the procedure is different. Because for AED
use the victim needs to be either on the backboard or moved out of standing water on the
deck, a move may be needed. When the patient is lying in a puddle on the deck, the AED’s
shock may be dissipated into the puddle, reducing the chance of effective cardio-conversion;
plus the AED could shock the rescuers if they’re kneeling in the same puddle as the patient.
Primary -
Recognize that a patron has collapsed. Stand up and blow your whistle loud for
a full second (one long blast) into the mike and radio. Yell, “Code red, I’ve got
it!” I may be pretty clear that it’s a heart attack. If so, give the heart attack
closed fist hand signal when you stand up and yell “heart attack.” An
unconscious victim doesn’t care if you yell heart attack or not!
Climb down and/or hurry over to the victim.
Primary and
Back-up
PUT YOUR GLOVES ON NOW!
Your gloves are in your fanny pack.
Back-up -
Upon hearing the signal, yell “We have an emergency, please clear the pool!”
Then go get the backboard and blanket. Bring it over next to the victim and
primary.
Primary -
Check the location of the patient to see if he’s lying in a puddle. Do the initial
assessment. Upon checking breathing and pulse, say “No breathing, I need the
pocket mask.” Give 2 breaths to inflate the lungs before you transfer or move
the patient. If no pulse when the pulse is checked say, “no pulse. We have to
transfer (or move) him.”
Note:
If the back-up is setting up the backboard, you may need to get your own pocket
mask out to deliver the first two breaths. Normally, your back-up will set up his
pocket mask for you. But in this scenario, he may not be able to do so in a timely
manner.
To transfer the patient to the backboard, use the extremity lift as described below:
Back-up -
While the primary does the ABC’s, set the board down with the head end next to
the victim’s head. Take off the head immobilizers. Remove the blanket from the
head immobilizers and lay it on the board lengthways. It will absorb some of the
water dripping from the patient.
Back-up -
Extremity lift - Move into the lift position by standing between the legs of the
victim, facing him. Grasp his wrists and pull up the arms to sit the victim up. The
primary will get the wrists in front of the chest (the extremity lift is like the
Canadian lift from the water).
Primary -
Go to the top of the head. Reach under the victims arms from behind and grasp
the wrists: right to right and left to left. Wait for the back-up’s count. Lift and
transfer by sitting the victim down. Finally, gently lay his head down onto the
board.
Note:
If you can drag the victim a few feet to a drier spot, this is preferred because it’s
much faster than the transfer to the backboard. If there is no drier spot nearby,
the backboard is your best choice.
Back-up -
Grasp the legs under the knees. Lift on your count. Step over the board and set
the victim back down on the blanket. Set him down bottom-first.
Note:
This lift may be referred to as the extremity lift (guards facing each other) or the
front and back carry (guards both facing forward). The guard at the knees may
face either direction, depending upon if the lift is just a step to the side or
transporting the victim to a safe location. When walking a significant distance
to a safe location (such as evacuation of an unstable building), both guards
should face forward.
Cashier -
After hanging up, make sure the pool is clear and there is no crowd around the
rescue. Give the patient assessment clipboard to the guards.
Use the witness report forms to gather witnesses’ statements. Go out to the
appropriate door and wait for EMS. Show them where the emergency is when
they arrive. You may need to make copies of the witnesses’ statements for them
after they are done filling out the reports.
Initial Assessment after transfer: 1.2.2.1
Primary Since you know the victim is not breathing and has no pulse from your first
assessment, say, “I need the pocket mask.”
Back-up -
While the primary positions the head for rescue breathing, open your fanny pack
and prepare your pocket mask (if not already out). If you’re still close to the
original location of the incident, you can grab the primary’s pocket mask and
hand it to him/her. The primary should have already delivered the first two
breaths prior to the transfer or move. Since there is no pulse or breathing, go
get the first aid equipment.
Primary -
Move to the top of the head. Put the pocket mask on using the triple airway and
give 2 breaths. Make sure the chest rises. The breaths must go in. If not, retilt
and try one more. Using the triple airway, you should be thrusting the mandible
forward as well as tilting the head back. After the chest rises, go straight to
compressions, since you’ve already checked pulse before the transfer or move.
Primary -
Begin CPR by moving over the chest, measure between the nipples and give 30
compressions 2 inches deep at a rate of about 100 per minute. Count one-andtwo-and-three-etc. Give two breaths with the pocket mask. Remember no
reassessments are done unless “an obvious sign of life is present.” The back-up
should have the AED connected and analyzing within 2 minutes. If the victim
should vomit while the back-up is running for the equipment: turn his head away
from you, scrape out the mouth with your gloved hand.
Note:
When a non-spinal patient vomits, there is no need to strap him down, or
even to roll him over to clear the vomit, just gently turn his head
away from you with both hands. Then wipe out the mouth by reaching
over the patient. Use the suction device to finish clearing the mouth of
debris.
AED use: 1.2.1.1.6
Back-up You should return with the equipment in less than 30 seconds. The primary will
continue to do CPR while you prepare the AED, until the AED says, “analyzing,
stand clear of the patient.” Then stop and move back so it can analyze the heart
rhythm. You are in charge of the AED, and will give all the stand clear warnings,
and commands to resume CPR. Once the AED is hooked up, it’s just a matter of
doing what it says. However, you must do CPR anytime that you cannot detect a
pulse.
To set up the AED, put it next to the victim’s head and turn it on. It will
immediately say, “apply pads to patient’s bare chest.”
Take the towel out of the jump bag (or use the towel attached to the backboard)
and wipe off the upper right chest and left armpit of the victim. Attach the right
pad just under the clavicle, pressing firmly on all edges of the pad. Attach the
left pad a few inches below the armpit. Try to keep the wires clear of the
sternum, so they’re not over the compression point for CPR. If the patient is on
a backboard, remember to attach the wrist restraint to keep the patient’s hands
from falling into the water. The hands are also protected from a vomiting turn,
where they can be crushed under the edge of the board.
Primary -
Keep doing 1-person CPR until the AED says, “analyzing heart rhythm, stand clear
of the patient.” Then stand clear.
Electrode precautions - If the victim is female, or a male wearing a T-shirt, it may
be necessary to cut off the top of her suit (or cut the T-shirt) to expose the pad
placement positions. If the area just below the right clavicle and left armpit is
already exposed, do not waste time cutting off the suit. Dry the area and apply
the pads immediately. There is no longer a contraindication for jewelry or metal
touching the chest; so the only concern is proper pad placement and drying the
chest. Note that some suit straps can be easily pulled down out of the way, and
do not require cutting. Plus, this method is faster and saves an expensive suit!
A male victim with a hairy chest may prevent the AED from making a proper
connection. If the improper connection voice prompt is heard, rip the first set of
pads off and apply the second set. There are two sets in the AED case. If the
victim has a medication patch on the chest, pull it off using a gloved hand. If he
has a pacemaker, keep the electrode at least 1 inch from it.
Safety tips – Keep the cordless phone and radios away from the AED. Cut or remove clothing
covering the pad positions while the primary is doing breaths, so you are not in one another’s
way.
CPR (two person): 1.2.1.1.6
The AED will go into pause mode after it has delivered a shock, whether it has
obtained cardio-conversion or not. It will say, “Paused. It is safe to touch the
patient. Do CPR for 2 minutes.” (about 5 cycles)
Primary -
Upon hearing this command, begin with two breaths using the pocket mask.
Have your back-up do 30 compressions.
Always do breaths from the top of the head and use the triple airway.
Back-up -
Do 30 compressions. Continue the 30-2 pattern for 2 minutes. The AED will
break in and say, “analyzing heart rhythm, stand clear of the patient.” Then
move back. Again, follow the AED’s instructions.
Note -
If the AED says, “no shock advised. It is safe to touch the patient,” the rhythm is
not a shockable rhythm. The patient may be in asystole. If in asystole, there will
be no pulse, and you’ll be doing CPR until the paramedics arrive. In this scenario,
you may need to change positions.
Changing positions: 1.2.1.1.7
Back-up To change positions while doing 2-person CPR, you (the compressor) will call the
change by saying “change” instead of “30” on the compression count. After the
two breaths, switch places. Resume compressions within 5 seconds. Change
positions every 2 minutes. Reassess breathing and pulse only when there is an
obvious sign of life.
Note:
Every 2 minutes is an approximate interval and is decided by convention, so don’t
be overly concerned about changing at precisely 2 minutes. About 2 minutes is
fine!
Primary -
After the back-up says, “change” on compression number 30, give two breaths
and move over to the compression position. Compress directly over the body of
the sternum, between the nipples. Immediately resume compressions.
Safety tip – use your own pocket mask when doing the change on two person CPR; to avoid
swapping saliva with the other rescuer.
Administering Emergency Oxygen-Unconscious: 1.2.1.1.8
Primary If after you successfully get the chest to rise with two breaths and the pulse
check indicates a pulse present – say, “has pulse, no breathing. Go get the first
aid equipment.” Begin rescue breathing immediately using your pocket mask.
Go back to the top of the head and use the triple airway. Give one breath every
five seconds by counting one-one thousand, two-one thousand, three-one
thousand, inhale, breathe. The back-up should be back with the first aid
equipment in less than 30 seconds. Continue rescue breathing for 2 minutes or
until the BVM is ready to substitute for your pocket mask. If you are at the 2
minute mark – stop for the reassessment before continuing with the BVM.
Note:
Remember that when doing rescue breathing, a 2-minute reassessment IS DONE
because of the continuing risk of cessation of pulse. The “obvious signs of life”
standard applies ONLY to full-blown CPR.
Back-up -
You’re in charge of setting up the oxygen. Set up the BVM with the oxygen on 15
lpm. Start by checking the wing-nut for snugness.
Next, open the cylinder valve one full turn. Check the pressure. You need over
200 lbs. to do anything. Attach the tubing to the BVM. Attach the other end to
the cylinder’s flowmeter. Set the flowmeter and check flow. Replace the pocket
mask with the BVM over the face of the victim without interrupting the count.
Safety tips – Keep the AED 6 feet away from the oxygen bottle. Do not to use the oxygen and
the AED at the same time.
Vomiting/suctioning: 1.2.1.1.9
Back-up or compressor When the victim vomits – the primary will roll or turn the head of the victim to
the side, away from you.
Primary or ventilator If you need to roll the victim: Move the arm on the side opposite you above the
head before the roll. Hold the head and shoulder on the turn. If turning the head
only, gently grasp the head between both hands and turn it away from the backup. Although it’s more awkward to suction with the victim’s head turned away, it
makes sense because he could begin vomiting again at any time. Lean over him
to suction his mouth, so if he does vomit again, the back-up will be out of the
“line of fire!”
Back-up -
Scrape any large chunks of vomit from the mouth with a gloved hand. Use the
manual suction device to get the smaller particles. If your suction tips have caps,
take the cap off the end. Attach the fine tip (it’s in the first aid bag). Measure
the insertion distance from the corner of the mouth to the earlobe. Hold the
suction tip at that point and insert the tip into the back of the throat. Use a
circular motion, withdrawing the tip as you circle it. The withdrawal should take
15 seconds or less. Keep pumping the device as you suction. Suction against the
lower cheek where the debris will collect.
Primary -
Keep holding the victim on his side (or his head) while the back-up does the
suctioning.
Back-up -
When done suctioning, help the primary roll the victim back onto his/her back
and resume rescue breathing with O2 or CPR.
Note:
The back-up’s hand will be slimed from scraping the mouth, so he/she should
put on a new glove before touching any other equipment.
Primary -
When engaged in rescue breathing alone - A reassessment of breathing and
pulse can be done after vomiting. Reassessment is not necessary if you’re doing
full-blown CPR.
Note -
Remember: if rolling the victim - roll the victim carefully, without twisting the
back or neck; and supporting the head at all times. Do the same thing if the
victim starts to cough, or acts like he is trying to vomit.
Safety tip –
When rolling a patient during AED use, the wires may yank the AED off the
ground while turning the victim. You will still roll away from the compressor, but the ventilator
will need to set the AED on the backboard next to the victim’s head. Hold the AED with one
hand while holding the head in the other hand. This will prevent vomiting on the AED (usually,
the AED is on the compressor’s side of the victim, since he/she was the person who went to get
it). Again, a simple head turn will eliminate the need for this procedure.
Obstructed airway: 1.2.1.1.10
Primary If during the initial assessment your first 2 breaths do not go in, re-tilt the head.
It’s probably the tongue in the way. Try another breath. If it won’t go in, the
victim is choking (has an obstructed airway). Say “airway obstructed, begin chest
compressions.”
Back-up -
Upon hearing the command, do 30 compressions, remaining in position
afterward.
Primary -
After the back-up does the compressions, check the mouth for foreign objects,
and try again to put 2 breaths in using the mask.
If no success, say “still didn’t go in, repeat compressions.”
Primary &
Continue this sequence until 2 breaths go in.
Back-up
Primary -
If the victim is not breathing but has a pulse, send the back-up for the oxygen.
Begin rescue breathing 1 breath every 5 seconds. If no pulse, say, “no pulse; go
get the AED.” Begin one person CPR.
CPR (one person): 1.2.1.1.4
Primary Begin CPR by moving over the chest, measure between the nipples and give 30
compressions 2 inches deep at a rate of about 100 per minute. Count one-andtwo-and-three-etc. Give two breaths with the pocket mask. Remember there
are no reassessments unless “an obvious sign of life is present.” The back-up
should have the AED connected and analyzing within 2 minutes. If the victim
should vomit while the back-up is running for the equipment: turn his head away
from you, scrape out the mouth with your gloved hand. Turn his head back to
the face-up position, resume ventilations and compressions.
Back-up -
If the primary says that the breaths went in, go and get the first aid equipment.
Once the AED is in operation, you are back at procedure 1.2.1.1.6, 2-person CPR.
SAMPLE History –
Note:
In this procedure, a SAMPLE history would not be done, since the patient is unresponsive. However, if the patient is
accompanied by a person knowledgeable about the patient, you may ask that person the SAMPLE questions.
Conduct a SAMPLE history – 1.1.1.1.1
Since you cannot ask for current symptoms, begin with looking for signs that indicate
the patient’s current condition. Ask, “Does he have any allergies?” Write them down. Ask,
“Is he taking any medications?” Write them down. Ask, “Does he have any other related
medical conditions?” Write them down. Next ask, “When was the last time he ate or drank
anything; including his medication?” Finally, ask, “What was he doing right before he
collapsed? What symptoms or signs did you see?” Write it down.
Ongoing assessment - (use the acronym BLSCPR)
Note:
If at any time the patient stabilizes and regains respiration; the back-up should
record vitals that are taken by the primary. The vitals include - blood pressure,
level of consciousness, skin color/temperature/moisture, capillary refill, pulse
rate, and respiration rate.
Back-up -
Upon regaining regular respirations and pulse, set up the O2 for delivery with the
nonrebreather at 15 lpm, or the cannula at 4 lpm.
Perform ongoing assessment – 1.1.1.3
Primary -
Begin taking your first set of vitals: BLSCPR – Check BP with the BP Monitor. If it
doesn’t work, do an auscultation blood pressure. To perform auscultation, begin
by placing the BP cuff on the arm closest to you about 1 inch above the elbow
joint. Place the tubes over the brachial artery (on the inside of the arm). Hook
the sphygmomanometer (gauge assembly) onto something so the gauge is
directly in front of you and you’ll be able to read it easily. A pant leg of the swim
trunks works well for this.
Put the stethoscope into your ears and place the head of the stethoscope over
the brachial artery. Hold it between your index and middle fingers. Apply light
pressure to listen for the pulse. Close the valve and inflate the cuff to about 180
mm Hg.
Tell the patient that the cuff will feel tight for a few seconds. Loosen the valve
slowly until the needle descends at the rate of about 2 mm Hg per second.
Listen for the pulse to appear. When it does, note the number on the gauge.
This is the systolic pressure. Continue listening until the pulse disappears again.
Note that number. This is the diastolic pressure. Write down the BP as systolic
over diastolic pressure. Normal BP is around 120/80, with 118/78 preferred. By
convention, only even numbers are used. There is no need to interpolate
between the calibrations on the gauge.
Note:
Palpation BP may be necessary when you cannot get the area surrounding the
patient quiet enough to hear the pulse during auscultation. To do palpation, use
the BP cuff without the stethoscope. Place the cuff, obtain a radial pulse. Inflate
the cuff until the pulse disappears.
Go 20 mm Hg past the number in which the pulse disappeared. Now, release the
valve slowly to descend at the rate of 2 mm Hg per second. When the pulse
reappears, that’s the systolic pressure. For example, if it reappears at 120, write
it down as 120/P. You will not have a diastolic pressure using this method, so you
record the palpation as P; thus it’s written as 120/P.
Check level of consciousness (L step of BLSCPR) – Use the AVPU scale defined at
the beginning of the book on page 2. The patient is either Alert – can respond
with appropriate verbal answers; Verbal – can respond to a verbal stimulus, but
not articulate an appropriate response;
Painful – can respond to a pinch; Unresponsive – cannot respond at
all/unconscious. Write down what you find on the incident report form.
Next, check skin condition (S step of BLSCPR) – Is the skin pink, white,
gray, yellow, blue/purple, red, blotchy, covered with hives, streaked from
a bite or other infected wound, wet, dry, hot, cold?
Now, check capillary refill (C step of BLSCPR) – Take the hand closest to
you and gently squeeze the fingernail of the pointer finger. The nail
should turn white, then pink again within 2 seconds. If it takes longer,
note how long it took. Write it down.
Pulse is next (P step of BLSCPR) – Check the carotid or radial pulse for
30 seconds. Watch the pace clock. Multiply the result by 2; then write it
down on the incident report form.
Note:
Carotid pulse is on the neck. The carotid artery is in the groove between
the Adam’s Apple and sternocleidomastoid muscle on the side of the neck.
Push in gently on the side closest to you, with your thumb pointing toward
the top of the patient’s head. To check radial pulse, find the radial artery
on the thumb side of the wrist. Turn the patient’s hand palm up.
Find the tendon just to thumb side of center. The radial artery is just to
the outside of this tendon.
The last step is respiration (R step of BLSCPR) – Check respiration rate by
watching the chest rise and fall for 30 seconds and counting the number.
Multiply by 2 and write it down on the form. Normal respiration rate for
an adult is about 12-20. If respirations are well over 20, the victim may
be in respiratory distress.
Remember that ongoing assessment for a heart attack patient is on the
unstable time-line. You’ll be continuously cycling through the acronym
BLSCPR until EMS arrives and takes over.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team.
You must be isolated while writing down your description of the rescue. You
must do it before talking to anyone about it. If the paramedics ask you questions
about the victim, answer them. Do not answer any questions that the patrons
ask. Explain that you are not at liberty to discuss the rescue. If patrons have
questions, they should address them to the Aquatics Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - A heart attack is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other agency’s officers. These officers will coordinate the
distribution of information to the press. Lifeguards should politely defer ALL
questions about the incident to the Aquatics Manager.
Guards should remain at work until after a debriefing/counseling meeting with
your employer’s officials. Your employer should give you all as much emotional
support as possible to cope with the rescue. You will not be expected to return
to duty after an incident of this magnitude.
CPR/Respiratory Care for Children and Infants
It’s less likely that you’ll be doing CPR or rescue breathing on a child, but it is possible. Kids
suffer from drowning, head injuries, electrocution, obstructed airways, anaphylactic reactions,
Long QT Syndrome, or poisoning. Also – kids with seizure disorders may stop breathing after a
major seizure.
Unconscious child or infant on deck: 1.3.2
Recognize that a child or infant on deck has become unconscious. Hopefully, the child’s mom
will yell for help if this happens. This procedure is different from the adult on deck, because the
AED will be used with the pediatric pads, unless the child is over 55 pounds. An unconscious
infant or child who is out of the water and weighs less than 55 lbs. will require pediatric set-up
for rescue breathing with oxygen or CPR.
Note:
BESTGuard lifeguards are expected to have pediatric pads which automatically
adjust the energy level for a child or infant under 55 pounds. Children weighing
over 55 pounds are shocked with the adult pads.
Primary -
Upon recognition of or being alerted to an unconscious infant or child, stand
stand up and blow your whistle into the mike and radio. Yell “code red, I’ve got
it” and hurry over to the child.
Back-up Upon hearing the signal, yell “we have an emergency, please clear the
pool!” Hurry over next to the primary and get your pocket mask out.
Cashier -
Upon hearing the whistle and announcement, run out onto the deck to
see what’s happening. Take the clipboards and cordless phone with you.
Initial Assessment for child and infant: 1.3.1.2
Primary Tap and shout, “Are you OK?” Say to the back-up, “No response.” Tap the child
ages 1-12 on the shoulder. Tap or flick an infant under 1 year old on the foot.
Back-up -
Get your pocket mask ready for the primary.
Primary -
Open the airway to the neutral-plus (slightly past neutral) position for a child; to
the neutral position for an infant. Look, listen, and feel for breathing and check
carotid pulse for about 10 seconds (brachial pulse for an infant). If there’s a
pulse, but no breathing, say, “No breathing, I need the pocket mask.”
Back-up -
Give your pocket mask to the primary. Put on your gloves now if you haven’t
already.
Primary -
Give two breaths with the mask. For infants, the mask will cover most of the
baby’s face. That’s OK, just make sure it covers the mouth and nose. Don’t
overblow!
Back-up -
After you’ve given the primary your mask, go get the first aid equipment.
Primary -
If breaths go in and a pulse is present, begin rescue breathing with your pocket
mask. Tell the back-up to hook up the oxygen equipment.
Note:
Brachial pulse is used on infants and is located on the inside of the upper arm. To
find the pulse, place your thumb on the outside of the arm, and reach around
underneath with your fingers. Manipulate your fingers between the biceps and
triceps muscles; gently digging in to push the brachial artery against the humerus
bone.
Cashier -
Relay the information being obtained by the primary to the dispatcher. Make
sure the pool is cleared. Leave the secondary assessment/incident report
clipboard with the primary and go out to meet the ambulance. Direct the
paramedics to the scene. Usually, a door directly onto the pool deck is their best
access point. In many facilities, the ambulance can be backed right up to that
door.
Rescue breathing for child and infant 1.3.1.3
Primary Give one breath every three seconds: counting one-one thousand, inhale,
breathe. Always use the triple airway from the top of the head (cephalic
position), even with infants.
Note:
With a Seal Easy pocket mask, there is no need to turn the mask differently for an
infant; the mask is symmetrical and round. If using the NuMask IntraOral system
on an infant, the flange goes on the outside of the lips, just like a traditional
pocket mask. The NuMask IOM normally inserts under the lips and the notch fits
against the frenulum of the upper lips (superioris labii).
Back-up -
When you return with the first aid equipment, set up the oxygen. Since the child
is unconscious, use the pediatric BVM.
Primary -
When the back-up has the BVM set up, substitute the pediatric BVM for the
pocket mask without interrupting the sequence.
Back-up -
Squeeze the bag once every three seconds. Count is one-one thousand, two-one
thousand, breathe.
Primary -
Call for a pulse check after about 2 minutes of rescue breathing.
Administering Emergency Oxygen-Unconscious: 1.2.1.1.9
Primary If after you successfully get the chest to rise with two breaths and the pulse
check indicates a pulse present – say, “has pulse, no breathing. Go get the first
aid equipment.” Begin rescue breathing immediately using your pocket mask.
Go back to the top of the head and use the triple airway. Give one breath every
3 seconds by counting one-one thousand, inhale - breathe. The back-up should
be back with the first aid equipment in less than 30 seconds. Continue rescue
breathing for 2 minutes or until the BVM is ready to be substituted for your
pocket mask. If you are at the 2 minute mark – stop for the reassessment before
continuing with the Pediatric BVM.
Back-up -
You’re in charge of setting up the oxygen. First, check the wing nut on the
regulator for snugness. Open the tank valve one full turn. Check the pressure. If
pressure is less than 200 lbs., you don’t have enough O2 to do oxygen delivery. If
pressure is over 200 lbs., attach the tubing to the Pediatric BVM and cylinder.
Set the flow meter on the tank to 15 lpm. Verify flow by listening to the oxygen
hissing. Check the oxygen reservoir bag next to the inlet on the BVM. It should
fill quickly. Replace the pocket mask with the BVM over the face of the victim
without interrupting the count. Remember to reassess pulse and breathing
every 2 minutes when doing rescue breathing alone.
Safety tip – Keep the AED 6 feet away from the oxygen bottle. Do not to use the oxygen and the
AED at the same time.
Vomiting/suctioning: 1.2.1.1.10
Back-up or compressor When the victim vomits - roll the victim onto his side, away from you. With small
children or infants, it may be just as fast to turn the entire patient than just the
head, plus the head and neck of a small child or infant is more fragile than that of
an adult. So the patient turn makes sense.
Primary or ventilator Move the arm on the side opposite you above the head before the roll. Hold the
head and shoulder on the turn. Turn the child/infant away from you.
Back-up -
Scrape any large chunks of vomit from the mouth with a gloved hand. Use the
manual suction device to get the smaller particles. Attach the fine tip. Measure
the insertion distance from the corner of the mouth to the earlobe. Hold the
suction tip at that point and insert the tip into the back of the throat. Use a
circular motion, withdrawing the tip as you circle it. The withdrawal should take
15 seconds or less. Keep pumping the device as you suction.
Primary -
Keep holding the victim on his side while the back-up does the suctioning.
Back-up -
When done suctioning, together, roll the victim back onto his/her back and
resume rescue breathing with O2 or CPR.
Primary -
A reassessment of breathing and pulse can be done after vomiting.
Reassessment is not necessary if you’re doing full-blown CPR, unless there is an
obvious sign of life.
Safety tip - When vomiting occurs during AED use and the patient is on a backboard, the wires
may yank the AED off the ground while turning the victim. Remember –use pediatric pads on a
child who weighs under 55 pounds.
Note:
Remember that some children are too small for the traditional pad placement
under the right clavicle and left armpit. If the pads are touching, or nearly so,
place one pad on the center of the chest and the other on the center of the back.
Roll the patient carefully onto his side when placing the pad on the patient’s
back. You’ll still need to put the child/infant on a backboard if he’s in a puddle of
water. Use the pediatric pads for infants, or children under 55 pounds.
Child and infant one-person CPR: 1.3.1.4
Primary If at any time during rescue breathing or after the initial assessment, you cannot
detect a pulse, begin CPR.
Child – Compress a child’s chest about 2 inches with one or both hands, directly
over the center of the sternum. Compress at the rate of about 100 per minute.
Give 30 compressions when performing CPR by yourself. Count one-and-twoand-three, etc. Give 2 breaths with the pocket mask after every 30
compressions.
Infant – Compress an infant’s chest about 1.5 inches, using your middle and ring
fingers. Put your pointer at the nipple line, then lift your pointer. Compress
straight down at a rate of 100 per minute. Perform 30 compressions and 2
breaths.
Note:
You may elect to do either one person or 2-person CPR on a child or infant. We
recommend doing 2-person always, so primary and back-up can support each
other. However – you will ALWAYS start with 1-person CPR when the initial
assessment indicates no pulse; because the back-up will have to leave to get the
AED and jump bag.
Child and infant 2-person CPR: 1.3.1.5
Back-up If at any time during rescue breathing or after the initial assessment you
cannot detect a pulse, begin CPR. Remove the oxygen for a child who
may need to be defibrillated.
Child – Put one or both hands on the center of the sternum, between the
nipples. Compress with the heel of your hand(s) about 2 inches
at about 100 per minute. Give 15 compressions for every 2 breaths.
Infant – Go to the feet of infant. Put your thumbs together on the center of the
sternum.
Measure by placing both thumbs slightly below the nipple line. Compress
with both thumbs about 1.5 inches at 100 per minute. It’s your count.
This technique is called the two-thumbs encircling hands technique; and is best
done across a table. Give 15 compressions for every 2 breaths.
Note:
2-person Infant and Child CPR are the only sequences in which the 15-2
cadence is used. ALL other CPR uses the 30-2 cadence.
Primary Perform ventilations after the back-up does compressions. Use triple
airway and a pocket mask at all times. Periodically check the
effectiveness of compressions by checking the carotid/brachial pulse.
Good compressions should create a faint pulse. Stop and recheck pulse
only when there is an obvious sign of life.
Child and infant obstructed airway: 1.3.1.6
Primary -
If during the initial assessment your first two breaths do not go in, re-tilt
the head and try one more breath. It’s probably the tongue causing the
problem. If they still don’t go in, say “airway obstructed.”
Child/Infant – Say “airway obstructed, begin compressions.” While the
back-up performs 30 compressions, stay at the top of the head. After the
compressions, open the mouth, lift the jaw by pressing your thumb on
the tongue. Look into the mouth. If you see the object, sweep it out with
the pinky of your other hand. Kids have little mouths. Finger sweeps
require both hands. Try to ventilate. If no luck, say “repeat
compressions.” Repeat this procedure until it works, or EMS takes over.
Back-upMaintain the two-thumbs encircling hands position on the chest,
with thumbs between the nipples. Give 30 compressions. Wait for the
primary to give you directions to repeat.
Cashier Give out witness report forms to any witnesses that you can find. You
may need to make copies of the witnesses’ statements for them after
they are done filling out the forms.
If the child is stabilized and has regained breathing and pulse- continue with ongoing
assessment as described below in procedure 1.1.1.3.
Perform Ongoing Assessemnt – BLSCPR: 1.1.1.3
Primary Begin taking your first set of vitals: BLSCPR – Check blood pressure with the BP
Monitor in the jump bag. Apply the BP cuff 1” above the elbow crease with the
tube over the brachial artery. Push the start button. The machine will take the
BP automatically and display the pulse rate. If the machine fails, do an
auscultation blood pressure. To perform auscultation, begin by placing the BP
cuff on the arm closest to you about 1 inch above the elbow joint. Place the
tubes over the brachial artery (on the inside of the arm). Hook the
sphygmomanometer (gauge assembly) onto something so the gauge is directly in
front of you and you’ll be able to read it easily. Put the stethoscope into your
ears and place the head of the stethoscope over the brachial artery.
Hold it between your index and middle fingers. Apply light pressure to listen for
the pulse. Close the valve and inflate the cuff to about 180 mm Hg. Tell the child
that the cuff will feel tight for a few seconds. Loosen the valve to descend at the
rate of about 2 mm Hg per second. Listen for the pulse to appear. When it does,
note the number on the gauge. This is the systolic pressure. Continue listening
until the pulse disappears again. Note that number. This is the diastolic pressure.
Write down the BP as systolic over diastolic pressure. Normal BP for adults is
around 120/80, with 118/78 preferred. For children BP is lower, with a range of
about 104-117 for systolic. Systolic pressure increases with age. 104 is common
for 3 year olds, whereas 117 is common for 10-12 year olds. Diastolic pressure is
around 63 for 3 year olds and as much as an adult for 10-12 year olds (80+). It
also increases with age. By convention we use only even numbers. There is no
need to interpolate between the calibrations on the gauge.
Note:
Palpation BP may be necessary when you cannot get the area surrounding the
patient quiet enough to hear the pulse during auscultation. To do palpation, use
the BP cuff without the stethoscope. Place the cuff, then obtain a radial or
brachial pulse. Inflate the cuff until the pulse disappears. Go 20 mm Hg past the
number in which the pulse disappeared.
Now, release the valve slowly to descend at the rate of 2 mm Hg per second.
When the pulse reappears, that’s the systolic pressure. For example, if it
reappears at 120, write it down as 120/P. You will not have a diastolic pressure
using this method, thus it’s written as 120/P.
Check level of consciousness (L step of BLSCPR) – Use the AVPU scale
defined at the beginning of the book on page 2. The patient is either
Alert – can respond with appropriate verbal answers; Verbal – can
respond to a verbal stimulus, but not articulate an appropriate response;
Painful – can respond to a pinch; Unresponsive – cannot respond at
all/unconscious. Write down what you find on the incident report form.
Next, check skin condition (S step of BLSCPR) – Is the skin pink, white,
gray, yellow, blue/purple, red, blotchy, covered with hives, streaked from
a bite or other infected wound, wet, dry, hot, cold?
Now, check capillary refill (C step of BLSCPR) – Take the hand closest to
you and gently squeeze the fingernail of the pointer finger. The nail
should turn white, then pink again within 2 seconds. If it takes longer,
note how long it took. Write it down.
Pulse is next (P step of BLSCPR) – Check the carotid or brachial pulse for
30 seconds. Watch the pace clock. Multiply the result by 2; then write it
down on the incident report form.
Note:
Carotid pulse is on the neck. The carotid artery is in the groove between
the Adam’s Apple and sternocleidomastoid muscle on the side of the neck.
Push in gently on the side closest to you, with your thumb pointing toward
the top of the patient’s head. To check brachial pulse, wedge your fingers
between the head of the bicep and tricep muscles in the upper arm. The brachial
artery is very close to the humerus bone. Push gently against the bone to feel the
pulse. Put your thumb on the opposite (outside) side of the arm.
The last step is respiration (R step of BLSCPR) – Check respiration rate
by watching the chest rise and fall for 30 seconds and counting the
number. Multiply by 2 and write it down on the form. Normal
respiration rate for a child is about 15-20. If respirations are well over 30, or
under 15, the child may be in respiratory distress. Normal respiration for an
infant is about 20, and over 50 is considered respiratory distress.
Remember that ongoing assessment for a cardiac patient is on the
unstable time-line. You’ll be continuously cycling through the acronym
BLSCPR until EMS arrives and takes over.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask. Explain that you are not at liberty to discuss
the rescue. If patrons have questions, they should address them to the Aquatics
Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?).
Time sequences are crucial if litigation is involved. You should re-enact the time
sequence if unsure. Ask the Aquatics Manager for help with this when you need
to re-enact the scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - A cardiac arrest or respiratory arrest is a MAJOR emergency. The Aquatics
Manager must be called immediately after the rescue (even during it, if
possible). The Aquatics Manager will call the other appropriate officers in the
organization. These officers will coordinate the distribution of information to
the press.
Lifeguards should politely defer ALL questions about the incident to the Aquatics
Manager. Guards should remain at work until after a debriefing/counseling
meeting with your employer’s officials.
Your employer should give you as much emotional support as possible to cope
with the rescue. You should not be expected to return to duty after an incident
of this magnitude.
Respiratory distress for infant or child: 1.3.3
Children and infants don’t normally have heart attacks, so chest pain, nausea, and shortness of
breath are not common symptoms; however, an infant or child can be in respiratory distress for
other reasons. For example, asthma, chronic bronchitis, pneumonia, or other diseases like
tuberculosis may cause respiratory problems. Children and infants may also suffer from
anaphylaxis, obstructed airways, or injuries such as electrocution which may result in
respiratory distress or arrest.
Primary Recognize that an infant or child is having trouble breathing. Stand up,
blow your whistle into the mike and radio and yell, “code red, I’ve got it”
then hurry over to the victim.
Back-up Upon hearing the signal, yell “we have an emergency, please clear the
pool!” Hurry over next to the primary and get your pocket mask out.
Cashier -
Upon hearing the whistle and announcement, hurry out onto the deck to
see what’s happening. Take the clipboards and cordless phone with you.
Primary Ask the child (or mother/guardian) “what’s the matter? Are you having
trouble breathing?”
Back-up -
If the child (or mother) says yes, hurry and get the first aid equipment.
Cashier Call EMS and tell them that we have a child or infant in respiratory
distress. The guards are going to administer oxygen. Finish clearing the
pool.
Primary Stay with the child, have him sit down and lean against the wall. Keep
your hand on his shoulder in case he passes out. If mom is right there,
have her do this. If the mom is hysterical and causing problems, send the
cashier to comfort her away from the scene a bit, so you can take care of
the child. Be very gentle and comforting to the child. He will likely be
very scared.
Oxygen use – conscious child or infant 1.3.3.1
Back-up When you return with the first aid equipment, set up the non-rebreather
for supplemental oxygen. Explain to the child that he should just
breathe normally into the mask and that it will help him breathe easier.
Hold the mask gently over the child’s face (or have the mom do it – if she’s
calm). This may be a good time to use the cannula. It’s less scary than a mask. If
the child is afraid of the mask, get out the cannula and use it. Remember – set
the flow meter to 15 lpm when using the mask, and to 2 lpm when using the
cannula. Do NOT use the BVM on a conscious patient.
Cashier If the mom is freaking out, try to get her away and comfort her. Explain
that she needs to be calm to help relax her child. The more
hysterical she is, the more hysterical he will likely be.
Use the witness report forms to gather witnesses’ statements. If they ask,
provide copies for them after they are done filling out the forms.
Primary and - The victim may pass out. If he does, the primary will take the mask off.
Back-up
Primary Lie the victim down on his back and check ABC’s. Follow protocol for
unconscious child (procedure #1.3.2).
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask. Explain that you are not at liberty to discuss
the rescue. If patrons have questions, they should address them to the Aquatics
Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - Respiratory distress is a significant emergency. The Aquatics Manager must be
called immediately after the rescue (even during it, if possible). The Aquatics
Manager will call the other officers in the organization. These officers will
coordinate the distribution of information to the press. Lifeguards should
politely defer ALL questions about the incident to the Aquatics Manager. Guards
should remain at work until after a debriefing/counseling meeting with your
employer.
Your employer should give you as much emotional support as possible to cope
with the rescue. You should not be expected to return to duty after an incident
of this magnitude.
Soft tissue injuries Abrasions – scrapes. Usually caused from falls onto hard surfaces, abrasions are painful; and
can result in infection due to the contaminated surface being ground into the skin. They may
also involve a large surface area, increasing the risk of infection. Abrasions are rarely life
threatening and are usually code blue emergencies.
Abrasions to the lateral right knee and right elbow
Lacerations – cuts. Customers can get a laceration from any sharp surface, including screws,
knives, paper, glass containers, broken equipment, etc. Usually, infection is not as much of a
problem, but still is a risk when a contaminated sharp object penetrates the skin. Lacerations
can be either code blue or red, depending on the severity and location of the cut.
Contusions – bruises. Bruises are sometimes referred to as hematomas (a tumor or swelling
containing blood) because they swell and contain blood. Contusions are formed from bleeding
under the skin. The area will become red, blue, purple, yellow and/or all of the above.
Contusions are rarely a code red situation, and usually just an annoyance. However, contusions
of the abdomen can indicate internal bleeding that may be very serious. Hard, lumpy
contusions of the abdomen are code red.
The contusion on left would be code red, because of its enormous size and abdominal location.
The woman on right appears to have been beaten, but these contusions could be a result of an
accident, such as a car wreck. Because of the severity and location, this would also be code red.
Avulsions – tears, rips. Avulsions are gross injuries in which the skin is ripped or torn off.
Sometimes the entire body part is torn off, or the avulsion affects several tissue layers. They
usually bleed significantly. An avulsion is probably a code red, unless it’s to a single finger and
the bleeding can be controlled easily. Since avulsions typically require stitches, a trip to the
doctor is usually needed.
Avulsion to the medial side of the right foot.
Avulsion to the inferior side of a finger
Punctures – hole in the skin. Punctures are typically caused by stepping on a nail, falling onto a
sharp stick, pencils/pens impaled into the skin, etc. They usually do not bleed much, unless an
artery is punctured by the embedded object. Punctures can be either code blue or red. If the
object is embedded (impaled), it may be code red. This patient will have to be transported by
either a family member or EMS. Any patient displaying significant symptoms of shock should
be code red.
Puncture wound from BB gun
Puncture wound from metal shard/imbedded
Musculoskeletal Injuries Injuries to muscles, bones, and joints are musculoskeletal. These injuries are caused by impacts
to the affected area such as falls and/or blows. Snapping, cracking, or popping sounds are
common indicators. When treating these injuries, it’s best to assume the worst. Treatment is
basically the same for all.
Fractures – are chips, cracks, or breaks in bones. Fractures can be simple or compound. Simple
fractures are under the skin. Compound fractures, also called open fractures, break through the
skin. Simple fractures, also called closed fractures, are usually code blue. Compound fractures
are always code red. Since simple fractures are rarely life threatening, EMS is not needed.
However, if you cannot reach a family member, the victim cannot drive, and he needs to be
transported for X-rays and casting, EMS may have to be called. Another example is when the
victim is in an awkward position that requires specialized equipment to free the patient – such
as caught in mechanical equipment, or hanging from a significant height.
Closed fracture of wrist (radius & ulna)
Open fracture of ulna (olecranon process)
Dislocations – occur when bones are pushed out of normal position, but don’t break. Examples
are shoulder (humerus), fingers (phalanges), and knee (patella). Dislocations create obvious
deformity and inability to use the injured limb. They are very painful. Dislocations can be
either code blue or red, depending on the severity of the pain and deformity. Any dislocation
that comes through the skin is code red. They are generally not life threatening and thus
transporting to the doctor can be done by the victim’s family. However, immediate medical
attention is needed to put the joint back in place and/or correct any damage.
Sprains – Stretching and tearing of ligaments. Ligaments are the connective tissue that join
bones together, such as in the knee or ankle. These injuries are rarely life threatening and are
code blue. Usually, the victim doesn’t even need to go directly to the doctor, but an X-ray is a
good idea to make sure the joint hasn’t been fractured. These injuries are extremely painful,
and may feel numb to the victim. Rapid and severe swelling is common, along with
discoloration. Apart from the swelling, there is usually no deformity, unless the ligament is
completely ruptured. The joint may be unstable and may not support any weight.
Strains – Stretching and tearing of tendons or muscles. Tendons are the connective tissue that
join muscles to bones and allow the bones to move with contraction of the attached muscle.
The patellar tendon and Achilles tendon are common strains. Anytime a patron moves a limb
beyond normal range of motion, the muscles and/or tendons are susceptible to injury. These
injuries are not life threatening, but can require immediate medical attention (usually surgery).
These injuries are also extremely painful.
Severe bleeding Cuts to major blood vessels are life threatening. Arterial bleeding is the most serious because of
the high pressure; resulting in rapid loss of blood. The radial, femoral, and carotid arteries are
close to the surface, thus more susceptible to injury than arteries deep inside the body. A
laceration to one of these arteries can result in blood squirting from the wound. Severe
hemorrhagic shock is virtually certain in cases of severe bleeding. All severe bleeding is a code
red emergency.
Arterial bleeding is life-threatening, producing hemorrhagic shock
Stroke –
Also known as aploplexy or cerebrovascular accident (CVA), stokes are blockages (ischemic) or
ruptures (hemorrhagic) of arteries in the brain. They happen to elderly people mostly, whose
arteries aren’t as elastic as they once were and are more prone to failure. Strokes are
characterized by paralysis on one side, loss of balance, sagging of one side of the face, slurred
speech, loss of bowel and/or bladder control, unconsciousness, or even death. A diagnostic
tool for strokes is the FAST test: F = face. Can the patient smile evenly? Does one side of the
face droop? A = arms. Can the patient raise both arms evenly, or does one hang down? S =
speech. Can the patient repeat a sentence that you say to him, or are the words slurred &
garbled? T = time. Note the time that these symptoms first appeared.
A “mini-stroke” is called a transient ischemic attack (TIA). It is a brief interruption in the blood
flow to the brain; and the victim recovers quickly. TIA victims usually recover within an hour,
but sometimes can show stroke symptoms for up to 24 hours. However, someone who has had
a TIA is 10 times more likely to have a stroke in the future; with 1/3 of TIA victims suffering an
acute stroke later. They should be checked out by the doctor.
An aneurysm is similar to a stroke, but does not involve a blockage or rupture. It is an abnormal
dilation or ballooning of a blood vessel. It is filled with blood. The pool lowers the pressure on
the other side, which may cause damage to the tissue (even death in severe brain aneurysms).
There are two main types of aneurysms: the abdominal aortic aneurysm, which is in the
abdomen, and the cerebral aneurysm in the brain. An aneurysm that ruptures is a hemorrhagic
stroke. Symptoms for aneurysms are virtually identical to those of a stroke.
Heat Emergencies –
Heat emergencies are caused by exercise in warm or hot conditions without sufficient rest,
cooling and water. Heat cramps usually develop first, signaling that the person needs to slow
down, cool down, and get some water. Continuing to exercise after having cramps without
cooling down and re-hydrating is an invitation for heat exhaustion or heat stroke to develop. In
2001, an NFL player died on the practice field from heat stroke because he did not stop
exercising in the hot weather after exhibiting the signs of having a heat illness. The young man
was a lineman over 300 pounds with a temperature of 108 degrees. Watch those swim team
kids who are overdoing it!
Heat cramps – Painful muscle spasms usually in the legs or abdomen. Heat cramps are the first
signal that worse might be on the way if the activity isn’t stopped. Cooling and re-hydrating
must be started. Not a life threatening condition; a code blue emergency. The swimmer can
probably go back to his workout after rest, cooling, and water.
Heat exhaustion – More serious than heat cramps, but still not generally life threatening.
Symptoms are cool, pale, sometimes flushed, moist skin (heavy sweating), headache, nausea,
dizziness, weakness, and exhaustion. Heat exhaustion is easily corrected with water, rest, and
cooling. A person with this condition should probably discontinue working out and take the
rest of the day off from practice.
Heat stroke – A life threatening condition in which the body loses its ability to sweat; in spite of
already being too hot. Although the skin may be sweaty at first, soon the skin is red, hot, and
dry. Pulse is rapid and weak, breathing is rapid and shallow. The victim is losing consciousness
or may be unconscious. Body temperature can be as high as 108 degrees.
At temperatures above 105, the brain cells may be damaged. The victim will die if not
immediately cooled. Re-hydrating can be done orally only if the victim is fully conscious.
Otherwise he must be re-hydrated at the hospital.
Anaphylaxis – An allergic reaction to insect bites or stings, food, or medications. Symptoms
develop very quickly including rash, feeling of tightness in the chest and throat, swelling of the
neck, tongue, and face. Dizziness and confusion may also occur. Anaphylaxis is usually already
known, since it’s from prior contact to the causative agent. The patron might wear a medical
alert tag identifying the agent. They may also carry an anaphylactic kit (EpiPen) with them
containing epinephrine. The pen contains the proper shot already loaded and ready so it can
be administered quickly. In severe anaphylaxis, it may be necessary to administer two or more
EpiPens to counteract the reaction. Newer designs, like the one below, do not require pushing
a button to inject the epinephrine. The needle comes out of the orange end and injects the
drug (an auto-injector). Adult EpiPens are designed for persons weighing 66 lbs or more and
are usually 0.3 mg of epinephrine. For kids weighing 33-66 lbs an EpiPen Jr is used with a ½
dose of 0.15 mg epinephrine.
Hypoxia/fainting and hyperventilating Hypoxia – Hypoxia is a lack of oxygen to the brain. If the oxygen is not sufficient, usually due to
insufficient blood supply, the victim becomes faint and passes out. Hypoxia will also occur from
suffocating. Note: you can easily become a victim of fainting yourself by standing still at your
walking station with your knees locked. The low pressure of the venous blood returning from
the feet is aggravated by standing still and locking out the knees. Blood pools in the legs and
blood pressure to the brain drops, causing hypoxia. Always move at your station, walking back
and forth slowly to keep alert and blood flowing properly. Fainting victims usually recover
quickly, once they are lying down.
Hyperventilating – Literally means excessive ventilating (or breathing too dang fast!) It’s
characterized by shallow, rapid breathing. The victim feels like he can’t catch his breath and is
suffocating. He may feel dizzy and have tingly and numb fingers or toes. The O 2/CO2 balance is
off during hyperventilating; with too much CO2 being expelled. That’s why you see victims
breathing into a bag: to re-breathe some CO2. Hyperventilating is also common prior to
swimming underwater, because this upsets the O2/CO2 balance and allows the swimmer to stay
down longer without having the overwhelming urge to take a breath. This behavior is of course
EXTREMELY DANGEROUS and should never be allowed. Further, it is the recommendation of all
BESTGuard facilities to require no more than 25 meters without a breath. This can be a
problem with coaches of swim teams and synchronized swimming, where breath holding is
required for certain events or activities. Extended underwater swimming simply cannot be
allowed.
Diabetic Emergencies Diabetic emergencies are caused by improper insulin balance. Insulin is a hormone produced by
the pancreas. It facilitates the absorption of sugar (glucose) from the blood. If the production
of insulin is insufficient, or nonexistent – the victim is diabetic. Type I diabetes is insulin
dependent; Type II is non-insulin dependent. Type I is also often called Juvenile Diabetes
because it usually starts in childhood. Patrons with Type I diabetes will have an insulin kit with
them all the time. They have to continually monitor their blood sugar level with a test kit.
Insulin pumps, like the one below, are now being used by many people with type 1 diabetes,
because they can provide better control over the insulin levels with constant monitoring. The
disadvantage is that they must be attached to the patient 24/7.
For type 1 diabetes - an insulin pump is a good alternative to the traditional insulin injection kit
Insulin Reaction – Hypoglycemia. Insulin reaction is a response to too much insulin injected and
too little sugar in the blood. Symptoms are feeling sick, changes in consciousness, rapid
breathing and pulse. This condition is usually code blue, because giving the patient sugar
(honey or glucose packets) will quickly improve the condition. If the patient has become
unresponsive, EMS must be called since sugar cannot be administered to an unresponsive
patient.
Diabetic Coma – Hyperglycemia. Not enough insulin is present and too much sugar is in the
blood. Symptoms are essentially the same as for insulin reaction. LOC is critical in this
condition, since sugar will not improve the condition. The patient needs insulin, which a first
responder cannot administer.
Shock Is the inability of the circulatory system to deliver oxygenated blood to all parts of the body.
Blood loss is probably the most common cause of shock (hemorrhagic shock); however, any
major fluid loss can bring on shock, including severe diarrhea or vomiting (metabolic shock).
Extreme psychological stress can induce psychogenic shock. Symptoms include: restlessness or
irritability, confusion, changes in level of consciousness, pale face and skin, cool clammy, moist
skin surface, rapid breathing and pulse. Since shock takes blood away from the extremities to
supply the brain, heart, and lungs; the tissues in the extremities begin to die. Blood is then
forced back to the extremities. The heart, brain, and lungs are then deprived of what they need
and they begin to die. If critical fluid continues to be lost, the victim will not survive. Shock
brought on by severe trauma is indeed life threatening and must be corrected immediately.
COPD –
Chronic Obstructive Pulmonary Diseases include Emphysema and Chronic Bronchitis. These are
conditions which make breathing difficult (cause respiratory distress.) Asthma is no longer
typically considered COPD, since it affects mostly young people. There are approximately
122,000 deaths from COPD annually in the USA. 11.4 million Americans are afflicted with COPD.
About 80-90% of COPD deaths are attributed to smoking. Moral of the story - Smoking is a
dumb idea.
Asthma – A chronic condition most common in children and young adults in which the
bronchioles are constricted, making breathing difficult. Asthma attacks are brought on by
reactions to food, pollen, medications, insect stings, emotional distress, or exercise. Excessive
mucus is produced, decreasing airway size. Most asthma is controlled with medication (an
inhaler). Attacks are characterized by wheezing.
Emphysema – A more serious condition in which the alveoli collapse, the lungs lose their
elasticity, and become distended due to secretions. Secretions cause restriction to normal air
flow. Emphysema creates CO2 to build-up. Emphysema is so stressful to the pulmonary circuit
in the heart that heart failure is common. Symptoms are little coughs, puffing and wheezing
when trying to exhale.
Chronic Bronchitis – A long term inflammation of the bronchioles. Patients with this condition
have a perpetual cough, increased mucus and decreased ability to remove it. The airway is
restricted in size. They’re sometimes called blue bloaters due the bluish color of their skin from
lack of oxygen. They have tightness in their chest. They are also subject to pulmonary circuit
heart failure.
In any of the above three conditions, oxygen is the recommended treatment, using either a nonrebreather or a nasal cannula.
Burns There are four types of burns: electrical, chemical, radiation, and heat. Burns are generally
grouped into three categories: first degree or superficial; second degree or partial thickness;
and third degree or full thickness. The severity of a burn depends on the intensity of the burn
source, the contact time, location and size of the area burned, and the age & condition of the
patient. Always stop the burning first.
Electrical burns – Burns from being electrocuted. They may still be hot once the power is off,
and can leave nasty injuries; plus, nerve damage is typically involved and the patient may not
feel any pain. After removing the victim from the electrical source, cool it, cover it with a sterile
dressing and treat for shock. Respiratory or cardiac arrest is common with severe electrical
burns.
Chemical burns – Burns caused from having a chemical spilled on you. Muriatic acid (HCl) is
probably the most likely chemical to burn you at an aquatic facility. Although likelihood of
exposure is very low, HCl is present in many facilities, and is very dangerous. Caustic soda is also
used in a few facilities where a very acidic oxidizer is used, such as chlorine gas or
trichloroisocyanuric acid. Other likely candidates are toilet bowl cleaners, or other powerful
oxidizers such as calcium hypochlorite. Cal-hypo is used for cleaning up contamination incidents
in the water. Chemical burns are treated by flushing the burn with water for at least 20 minutes
or until EMS takes over. Patrons are not likely to suffer from this type of burn, but staff
members are.
Note: In recent years a buffered version of HCl has been developed called “acid magic.” It will
not burn intact skin, and has very little odor; yet virtually the same pH effect.
First degree/superficial burns – Minor burns in which only the epidermis is involved. The skin is
red and hot, but not blistered or charred.
Second degree/partial thickness burns – More serious burns in which both the epidermis and
dermis are affected. Blisters form, the skin is red, swollen, and painful.
Third degree/full thickness burns – The most serious burns, in which all tissue layers are
involved including muscle and bone. The burn may look white, gray, black, and charred. They
may be excruciatingly painful, or not very painful at all; depending on the effects on the nerves
involved.
Treatment for burns is universal: First – stop the burning. 2nd – cool the burn with water; 3rd –
cover with the dry, sterile dressing and loosely bandage; 4th – treat for shock. Note that
chemical burns are flushed with water for 20 minutes (step 2).
Section 5.1: Soft Tissue Injuries
Minor wounds: 5.1.1
(Code blue emergency)
Note:
Minor wounds are lacerations, abrasions, contusions, or avulsions that are not
serious (more like “an owie”).
Primary -
Upon recognizing a first aid situation, stand up, blow your whistle into the mike
and radio, yell “code blue, I’ve got it!” and give first aid signal. Point to the
location of the victim and hurry over to him/her. Put gloves on.
Back-up - Upon hearing the whistle and seeing the first aid signal, go over to the tower and
assume total coverage. If the pool is too crowded to use total coverage, yell, “we have an
emergency, please clear the pool.” Judge the conditions of the incident, and if the cashier
can just take care of it. If it’s just an “owie” there is no need to clear the pool. The primary
will ask the cashier to handle it and you both can remain scanning.
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. The guard may ask you to handle the first aid, since this is just a minor
wound. Then the pool will not need to be cleared at all.
Primary - For a minor injury, perform the first aid yourself if the back-up can cover the
pool alone. If it’s too crowded for that, ask the cashier to perform the first aid, so you can
go back to scanning.
Primary or Put on your gloves. Apply direct pressure with a sterile dressing until the
Cashier - bleeding stops. Remove the dressing and wash the wound with soap and water.
Apply a new sterile dressing; probably a band-aid. Don’t put on an antibiotic ointment. He
could be allergic to it.
Follow up for minor injuries: 5.1.1.1
All staff - Usually, no follow up is needed other than an incident report. If the wound
requires stitches, then a follow-up call is warranted. Leave a note for the manager to call
the next day. When deciding whether or not a wound should be stitched, if in doubt, it
probably should be stitched. If you’re overly cautious, that’s OK. You can ask the supervisor
to look at it.
Note: If you wash the wound and put on a band-aid, you’ve administered first aid and will need
to complete an incident report. If you just hand a band-aid to a customer with an “owie” you
probably don’t need to document that. Check with your facility’s protocol for this.
Major wounds: Severe bleeding 5.1.2
(Code red emergency)
Primary -
Primary - Upon recognizing a EMS first aid situation, stand up, blow your
whistle into the mike and radio, yell “code red, I’ve got it!” and give first aid
signal. Point to the location of the victim and hurry over to him.
Note:
First aid emergencies are more difficult to ascertain from a distance than water
rescues, so an initial code blue call could be changed to code red at any time.
Back-up - Upon hearing the whistle and seeing the first aid signal, yell, “we have an
emergency, please clear the pool.” Go over to the victim and primary to see what gear is
needed. If the primary calls code blue, move over to assume total coverage instead of
clearing the pool.
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. Both guards will be involved in the care of the patient, so clear the pool
immediately.
Primary -
While you put on your gloves, ask the victim to put direct pressure over the
wound. Then grab the sterile dressings from your fanny pack and open them.
You may need to use several of them for really heavy bleeding. Put the dressings
over the wound and use direct pressure to control the bleeding. Ask the patient
to lie down. Apply a pressure bandage using roller gauze. If the bleeding does
not stop, and the dressings become soaked with blood, use more dressings and
another pressure bandage. Remember to roll from distal to proximal, and
overlap your bandage about 50% on each pass. Also, you’ll have better luck with
the roll by rolling off of the back side of the roll. It’s harder to hold onto the roll
while rolling the gauze out the other way. You can use the dressings and
bandages from the back-ups fanny pack too. Send him/her for the jump bag and
oxygen.
Back-up -
Upon hearing the whistle, look to see who needs to provide care. If it is the
other guard, move over to cover their zone and watch both the pool and the first
aid – unless they yell “code red.” Code red is an automatic back-up call. If they
call a code blue first, but then call for back-up, yell “clear the pool, we have an
emergency” and run over to assist. When the cashier comes out, tell him/her
what’s going on and direct him/her to call EMS.
Note: Back-up doesn’t wait for the pool to be cleared. Let the cashier finish clearing it. Help
with the rescue. Especially in a life threatening scenario, it makes more sense for the back-up to
be rendering first aid than to be clearing the pool. If someone starts to drown while everyone is
getting out, the cashier will yell for you to rescue him.
Cashier -
Upon hearing the whistle, grab the cordless phone, emergency clipboards, and
hurry out on deck to see what is happening. The guard(s) will tell you if it’s code
red or blue. If they don’t, ASK! Call EMS and report the situation. After the call,
give the incident report clipboard to the guards at the scene, and witness report
forms to the witnesses. Make sure everyone is out of the pool (if two guards are
involved in the first aid). Go out to the appropriate door and wait for EMS.
Direct them to the victim.
Back-up -
Keep the patient lying down until EMS arrives and takes over. Treat the victim
for shock by maintaining normal body temperature and reassuring the victim.
The victim should lie flat on his back. If you need to assist with applying
dressings or bandages, put on your gloves first! While the primary applies the
dressings and bandages, conduct a SAMPLE History. Ask the patient about other
injuries. If there is any potential for other injuries, conduct a physical exam.
Take a set of vitals (BLSCPR): Blood pressure, Level of Consciousness, Skin
conditions, Capillary refill, Pulse rate, Respiration rate. Monitor vitals and
consciousness carefully. If the bleeding is controlled by the primary rescuer,
AND the vitals are clearly stable, you may return to the total coverage station
and resume guarding. The primary will wait with the victim until EMS takes him
away. Again, if the number of swimmers is more that the single guard to
swimmer ratio, do not reopen the pool until you have another guard on deck.
Note:
New research does not support elevating the legs to treat for shock. Remember
shock is a blood distribution problem, so do whatever you can to correct the fluid
loss.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask. Explain that you are not at liberty to discuss
the rescue. If patrons have questions, they should address them to the Aquatics
Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Supervisor -
Severe bleeding is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other officers in the organization. These officers will coordinate the
distribution of information to the press. Lifeguards should politely defer ALL
questions about the incident to the Aquatics Manager.
Guards should remain at work until after a debriefing/counseling meeting with
your employer. Your employer should give you as much emotional support as
possible to cope with the rescue. You should not be expected to return to duty
after an incident of this magnitude.
Musculoskeletal Injuries: 5.2
Fractures: 5.2.1
(Code red or blue emergency)
Note Since it is sometimes impossible to distinguish injuries to bones, joints, and
muscles, they are all treated the same way, based on the inability to use the injured part.
The acronym RICE is used for treatment of all sprains, strains, fractures, and dislocations:
Rest, Immobilize, Cold, Elevate.
Primary -
Primary - Upon recognizing a first aid situation, stand up, blow your whistle
into the mike and radio, yell “code blue, I’ve got it!” and give first aid signal.
Point to the location of the victim and hurry over to him. If the injury is
obviously a compound fracture, call it code red.
Back-up - Upon hearing the whistle and seeing the first aid signal, go over to the tower and
assume total coverage. If the pool is too crowded to use total coverage, yell, “we have an
emergency, please clear the pool.” Clear the pool immediately if the call is code red.
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. If the call is code red, clear the pool and call EMS. If it’s code blue, get
the incident report clipboard to the guards and get witnesses. If code red, direct the EMS
personnel to the appropriate door and to the patient. Remember to make copies of
witnesses’ statements if they ask for them.
Primary -
Once you have gotten to the victim, put your gloves on, then survey the scene
and determine if the victim MUST be moved. If not, don’t! Leave the fractured
limb in the position that it was found, unless it must be moved. With fractures
MOI is critical! Determine the chief complaint. Perform a SAMPLE History and
physical exam, if further potential injuries exist. Treat for shock by covering the
patient with the emergency blanket and reassuring him. Have him lie flat on
his back (if possible). Maintain normal body temperature. If a simple fracture
occurs to a child and the mom is here, ask the mom if she wants to take her
child to the doctor herself. If she does, you’ll need to apply a splint to the
fracture. The same thing is true for adults here with a companion. A simple
fracture is not a code red emergency, and should be treated with just one
guard. The SAM splints in the first aid jump bag are a good choice for most
fractures, since they conform to just about any shape or size.
Back-up - Scan the pool and include the rescue in case the primary needs help. If the
primary calls for you to back-up, clear the pool and hurry over to help out. Ask what gear is
needed, and go to get it.
Applying a splint: 5.2.1.1
Primary -
Splinting is done as follows: support the injured area, check for feeling, warmth
& color, pad the splint, place the splint (SAM splints are recommended), tie it in
place, recheck feeling, warmth & color. Remember splints must immobilize the
joints above and below the point of injury when the injury is to the bone(s)
between joints. When the injury is at a joint, immobilize the bones above and
below the point of injury.
For example, a splint applied to the radius or ulna requires either a very long
rigid splint extending beyond the wrist and elbow, or both a rigid splint and a
sling with a binder. Whenever in doubt about how serious the injury is, or
whether you can splint it without causing further injury, have EMS do it. Apply
splints to simple fractures only, and only when the victim is calm, conscious, and
alert. Remember that leg splints require placing the ties before the splint (in
order to slip the ties under the injured leg).
Note:
Use common sense with fractures when deciding what to do. Talk to the parent
of a child victim. A simple fracture is not a life-threatening emergency, and
should be dealt with accordingly. Open (compound) fractures are always code
red and are splinted by EMS. If dealing with an open fracture, control bleeding as
you would for an impaled object, and treat for shock. Do a SAMPLE History,
physical exam, and ongoing assessment (BLSCPR) [see procedure #5.2.1.2 for
open fractures]
Back-up -
If you are assisting with splinting a leg, get the cravats out for the primary and
lay them into strips. Watch for signs of shock. If the victim goes into shock,
reassure him and maintain his temperature. Lie him flat on his back, if possible
to do without causing further injury.
Splinting variations: 5.2.1.1.1
Primary -
For an injured ankle, use a soft splint. The blanket in the jump bag is suitable.
You should also have a blanket or large towel on every backboard. Either will
work. Fold it into a narrow strip. Use the short direction. After placing three or
four cravats under the ankle, calf, and heel; place the blanket by wrapping it
around the foot and up the sides of the leg. Pull the cravats up around the
blanket and tie it in place.
For an injured finger, use a combination splint. This will be both an anatomic and
rigid splint. Take some roller gauze and wrap the injured finger 2-3 rotations.
Take a pencil or pen and wrap it in a sterile dressing. Place it alongside the
injured finger. Pull the adjacent finger alongside and wrap the fingers together
using the remainder of the roll. Tie it off or tape the end.
For an injured shoulder, use a soft/anatomic splint. Take the blanket and fold it
into a large square. Carefully put it under the arm on the injured side. Put a
wide binder around the arm to hold the arm against the chest. Another good
method is to use a sling around the affected arm first, then place the blanket and
binder as before.
For an injured leg, use a rigid splint. Use a rescue tube, or SAM splints. Place the
cravats first, as in the ankle splint. Use the space behind the knee to slip the
cravats in place. Place the splint on the outside of the injured leg. A rescue tube
or SAM splint needs no padding. Tie it in place.
Note:
Using both a rescue tube and a SAM splint may be even better. Put the tube on
the lateral side and the SAM splint on the medial side. Remember to extend the
tube above the hip, and barely beyond the ankle, since this will provide for easier
mobility when transporting the patient to the car.
For a fractured vertebrae, use the backboard for a splint. See section 2 – spinal
injuries for details.
For a fractured rib, use the same splint as described for an injured shoulder,
without the sling. The blanket will provide some comfort and support, but a
sling will only restrict movement of an arm that is not affected by the fractured
rib.
For a fractured skull, there is NO SPLINT that can help. Protect the head from
further injury by immobilization on the backboard. Pad the back of the head
with a towel or folded blanket and strap the patient down carefully. Do NOT use
excessive tightening of the head strap when the patient has a skull fracture.
Compound fractures: 5.2.1.2
Primary -
Primary - Upon recognizing a first aid situation, stand up, blow your whistle
into the mike and radio, yell “code red, I’ve got it!” and give first aid signal.
Point to the location of the victim and run over to him/her.
Back-up - Upon hearing the whistle yell, “we have an emergency, please clear the pool.”
This is most likely a scenario where you must clear the pool. Rarely are compound fractures
a simple first aid job for the primary.
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone with you. Compound fractures are all code
red, so call EMS and direct them to the appropriate door. Show them to the patient. Get
witnesses’ statements and make copies if they ask for them. Make sure that the guards
have incident report forms.
Primary - Once you have gotten to the victim, put on your gloves. Survey the scene and
determine if the victim MUST be moved. If not, don’t! Leave the fractured limb in the
position that it was found, unless it must be moved, due the position of the victim and risk
of further injury.
Determine the chief complaint. Although you may immediately focus on the compound
fracture, you must be sure that there is not a more life-threatening injury present. If there
is, treat that first. Treat for shock by reassuring the patient and maintain normal body
temperature by covering him with the first aid blanket.
Note:
Shock is virtually certain in this scenario. The patient will likely be hypoperfused
from bleeding and also experience psychogenic shock as well, since this injury is very painful
and traumatic to look at.
Primary - If a compound fracture exists with bleeding, treat the bleeding, but don’t splint
the fracture. Control bleeding with sterile dressings and direct pressure. Do not push on the
exposed bone, but put pressure around it. A bone sticking out should be treated as an
impaled (embedded) object. Once bleeding is controlled with dressings, place rolls of roller
gauze on the sides of the exposed bone. Secure them with roller gauze in a figure 8 pattern.
Again, try not to move the fractured limb. Support the fracture with your hands or the
ground, whichever is practical. Wait for EMS to take over. Conduct a SAMPLE History and
physical exam as soon as you have taken care of the bandaging. Here again, think about
MOI, so you don’t overlook something serious. How did this happen, and are there other
injuries that may be obscured from your view?
Back-up -
Perform ongoing assessment. Use the acronym BLSCPR. Fill it in on the incident
report form.
Note:
Because of the skill and equipment required to do it well, we will not splint
compound fractures unless it is after an earthquake and EMS is not likely to
come. As indicated above, perform a SAMPLE History, physical exam and ongoing assessment; and wait for EMS to apply a commercial splint.
Cashier - You may be the person to talk to the mom about transporting the child. If so,
communicate the mom’s wishes to the guards. Make sure that the mom signs the incident
report form indicating that she took the child to the doctor herself. As always, your primary
job is to clear the pool if needed, and call EMS.
Follow-up: 5.2.1.3
The chain of command does not need to be notified for a compound fracture unless there are
other injuries; however call the Aquatics Manager and let him/her know of the incident.
Because this will necessitate an EMS call, the guards should leave a note along with the incident
report for the Aquatics Manager so he/she is aware of the situation. If you disagree with the
victim or mom on whether EMS should be called, do it anyway. Explain the dispute to the
dispatcher. It’s always better to be safe than sorry. The manager will deal with the dispute for
you.
If needed, the Aquatics Manager will conduct a short debriefing after the incident to make sure
everyone is OK and to perform some basic fact finding. Anytime a rescue like this doesn’t feel
good to you, call the Manager to come in and help with the debriefing.
Sudden Illnesses: 5.3
Strokes and Aneurysms: 5.3.1
(Code red emergency)
Primary -
Recognize a stroke or aneurysm by a sudden collapse or fall. Small strokes may
not be recognizable at all. Stand up, blow your whistle into the mike and radio,
and yell, “Code red, I’ve got it!” Give the first aid signal and hurry over to the
person.
Note:
Of course strokes, aneurysms, and other first aid scenarios can happen in the
water as well as on land. Always follow the water rescue protocol for a
conscious or unconscious victim first. Complete the first aid care once on deck.
If the victim has an apparent fracture, it may be necessary to go to the shallow
end to backboard the victim for removal.
Back-up - Upon hearing the whistle and seeing the first aid signal, yell, “we have an
emergency, please clear the pool.” A stroke or aneurysm is a two guard rescue every time.
Cashier -
When you hear the whistle and the announcement, come out on deck to see
what’s happening.
Primary -
Ask the victim what happened. Look at his face when you talk to him. Put your
gloves on as you question him. If conscious, administer the FAST test: F = face;
ask him to smile. With a stroke, his face is likely to droop, and/or he may be
drooling. One eye might be dilated while the other pupil is constricted. A =
arms; ask him to raise both arms. Watch for one arm being limp or partially
paralyzed. S – speech; ask him to repeat a sentence, like “the water is really
warm today.” He may have difficulty articulating words and have very slurred
speech. T = time. Note the time the symptoms first appeared. A stroke is not
something you can “treat” with first aid. You can only react to the condition of
the victim.
 If he’s breathing, put him on his side in the recovery position – one arm
extended above the head, his head lying on that arm, airway open, the
top leg bent at about 90 degrees and flexed at the hip with the knee on
the ground (a kickstand) and the ankle draped over the extended leg.
You may elect to use the HAINES recovery position instead. It’s the same,
except both legs are bent at about 90˚ and laying on top of each other.
 If he’s not breathing, put him on his back and follow the protocol for an
unconscious person – check pulse/breathing for 10 seconds, give two
breaths with the pocket mask, do 1-person CPR and then AED if needed.
 Suctioning may be very helpful for a person who’s suffered a stroke.
 Once you’ve ascertained the victim’s condition, tell the cashier to call
EMS.
 Perform a SAMPLE History and physical exam. Stroke patients nearly
always fall, and they’re usually elderly; so injury is likely from the fall.
 Perform on-going assessment (assisting the back-up) once the physical
exam is finished.
Back-up -
Perform ongoing assessment, using the acronym (BLSCPR). Fill in the
appropriate vital sign information on the incident report form.
Cashier -
Call EMS on the cordless phone and direct them to the victim when they arrive.
All strokes are code red. Get witnesses using the witness report forms.
Note - The supervisor will call the victim’s spouse or next of kin to notify him/her of the incident
and where to meet the victim (at the hospital, doctor’s clinic, etc.)
Follow-up: 1.1.1.1
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask. Explain that you are not at liberty to discuss
the rescue. If patrons have questions, they should address them to the Aquatics
Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.2
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command:1.1.1.3
Supervisor - A stroke is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other officers in the organization. These officers will coordinate the
distribution of information to the press. Lifeguards should politely defer ALL
questions about the incident to the Aquatics Manager. Guards should remain at
work until after a debriefing/counseling meeting with your employer.
Your employer should give you all as much emotional support as possible to
cope with the rescue. You should not be expected to return to duty after an
incident of this magnitude.
Diabetic Emergency 5.3.2
(Code red emergency)
Primary -
Upon recognizing a person is having a medical emergency, stand up, blow your
whistle into the mike and radio, and yell, “code blue, I’ve got it!” You won’t
recognize a diabetic emergency unless you know the person is a diabetic. Give
the first aid signal and hurry over to the person. Determine the chief
complaint. If the patient identifies himself as a diabetic, (assuming he is
conscious) give him some honey or glucose from your fanny pack. Ask him to
sit down against the wall. The sugar should make him feel better within a
couple of minutes. This is a code blue emergency. If he passes out, it’s code
red.
Note-
It’s unwise to put the honey into his mouth. Always let the patient give himself
the “medication.” Get the packet out, open it and hand it to the patient. If he’s
unconscious, or unable to take the honey himself, DON’T give him any. The same
applies to giving nitroglycerin tablets to angina patients, inhalers to asthma
patients, or aspirin to heart attack patients.
Back-up - Upon hearing the whistle and seeing the first aid signal, go over to the tower and
assume total coverage. If the pool is too crowded to use total coverage, yell, “We have an
emergency, please clear the pool.”
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you.
Primary -
If the sugar does not help, have the cashier call EMS. Talk to the victim about his
diabetic supplies. The victim will likely have a supply of food or insulin with him
if subject to reactions. You may need to have the cashier run and get the
victim’s insulin kit and/or blood tester. If he becomes unconscious, perform the
protocol for an unconscious person (#1.2.2). Yell, “Code red!” Perform an initial
assessment – check breathing and pulse for 10 seconds. Maintain an open
airway. Stay with the victim until EMS takes over.
Cashier -
If the victim doesn’t respond to the sugar or is already unconscious, the guard
will direct you to call EMS. Direct EMS to the victim when they arrive. Get
witnesses using the witness report forms.
Back-up -
This is a single guard rescue unless the victim is unconscious. If the victim
becomes unconscious, yell “we have an emergency. Please clear the pool.” and
go over to get the equipment. Administration of O2 is suggested, along with
ongoing assessment using the acronym BLSCPR.
Note -
Remember that insulin reaction and diabetic coma are difficult to distinguish.
The first aid is always to give sugar to the conscious diabetic, even if they already
have too much sugar in their blood.
Follow-up for Diabetic Emergencies 5.3.2.1
All staff A diabetic emergency is not usually a major emergency. If no EMS call, you don’t
need to call the chain of command. If EMS is called, call the Aquatics Manager
immediately. He/she will call the other appropriate personnel and come in to
assist the staff. If no EMS, then fill out an incident report form and leave it on
the Manager’s desk. If the diabetic only needs some sugar, you can just hand it
to them. Since the sugar is still technically “administering first aid” you need to
fill out the incident report. If the patient shows any signs/symptoms of
continued glucose imbalance, complete a set of vitals and monitor the patient.
This procedure is not likely to generate any media interest, thus the media
section is deleted.
Heat Emergencies 5.3.3
(Code red or blue emergency)
Heat Cramps and Heat Exhaustion 5.3.3.1
(code blue emergency)
Primary - Recognize a heat emergency by a person who seems tired, has cramps, is very
sweaty, and feels overheated. Skin color with heat cramps or heat exhaustion is generally
pale, but could be flushed. Temperature is at or near normal. Stand up, blow your whistle
into the mike and radio, give the first aid signal, and yell, “Code blue, I’ve got it!”
Back-up - Upon hearing the whistle and seeing the first aid signal, go over to the tower and
assume total coverage. If the pool is too crowded to use total coverage, yell, “We have an
emergency, please clear the pool.”
Casher - When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you.
Primary - Hurry over to the victim. These situations are rarely swimming rescues, but they
can be when a swimmer suddenly is incapacitated by a cramp. If so, follow procedure #4.1
or #4.2 for simple pull outs. After the victim is on deck –


For cramps – gently stretch the contracted muscle for about 15-20
seconds. Let go and vigorously massage the muscle. Repeat until the
contraction releases. Give the victim some cool water. Remove the
victim from the warm environment and cool him. If he’s working out,
stop the workout for at least 10 minutes to allow the victim to rehydrate, cool down, and rest.
For heat exhaustion – Stop the activity, remove the victim from the warm
environment and apply cool moist towels and moving air. Give the victim
cool water to drink. Remove any unnecessary clothing to promote
cooling. If this person was working out, he’s done for the day.
Cashier -
If the victim doesn’t respond to the water and cooling, or becomes unconscious,
the guard will direct you to call EMS. Direct EMS to the victim when they arrive.
Get witnesses using the witness report forms.
Back-up -
This is a single guard rescue unless the victim is unconscious. If the victim
becomes unconscious, yell “we have an emergency. Please clear the pool.” and
go over to get the equipment.
Follow-up for Minor Heat Emergencies 5.3.3.1.1
All staff Heat cramps or heat exhaustion are not usually major emergencies. If no EMS
call, you don’t need to call the chain of command. If EMS is called, call the
Aquatics Manager immediately. He/she will call the other appropriate personnel
and come in to assist the staff. If no EMS, then fill out an incident report form
and leave it on the Manager’s desk.
This procedure is not likely to generate any media interest, thus the media
section is deleted.
Heat Stroke Procedures 5.3.3.2
(Code red emergency)
Primary -
Recognize heat stroke by changes in level of consciousness, loss of sweating, red
hot, dry skin, very high temperature (as high as 108 degrees).
Stand up, blow your whistle into the mike and radio. Yell, “Code red, I’ve got it!”
and give the first aid signal. Hurry over to the victim.
Note 1 -
The victim could be a swimmer in the water working out hard, but if so, he will
most likely be at the edge or at the ladder. If you have to make a swimming
rescue for heat stroke, follow procedure #1.2.1.
Note 2 –
A heat stroke victim will soon become unconscious and quickly lose both
breathing and pulse if not immediately cooled!
Back-up -
Upon hearing the signal, yell “We have an emergency, please clear the pool!”
Because heat stroke is life threatening and the high temperature causes brain
damage, cooling is imperative. Run over to your towel supply and grab at least 4
towels. Run cold water over them from the nearest deck faucet or drinking
fountain until they’re soaked. Drape the towels over the victim.
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you.
When the primary tells you that it’s heat stroke, immediately call EMS. Do what
you can to help cool the victim – get fans, open doors, etc.
Primary -
If your response is fast and you are able to cool the victim before he becomes
unconscious, the only equipment you’ll need is cooling supplies. Remember to
loosen his clothing (if he’s not in a swim suit). Cover him with the cool moist
towels. Switch the towels every 30 seconds or so to keep them cool. Perform a
SAMPLE History. Physical exam is not needed, unless the patient collapsed and
sustained an injury.
Back-up -
Go get the oxygen, AED, etc. in case the patient becomes unconscious. Provide
oxygen using the non-rebreather mask at 15 lpm if the patient is having any
trouble breathing. Perform ongoing assessment using the acronym BLSCPR.
Note -
If the victim becomes unconscious, follow the CPR procedure #1.2.2. Even in the
presence of advanced medical care, heat stroke may be fatal. Cooling is the key
to survival, because brain tissue is being killed by the high temperature, making
recovery very unlikely if allowed to continue.
Cashier -
Direct EMS to the victim, get witnesses, and give the incident report form to the
back-up.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask. Explain that you are not at liberty to discuss
the rescue. If patrons have questions, they should address them to the Aquatics
Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command:1.1.1.6
Supervisor - Heat stroke is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other officers in the organization. These officers will coordinate the
distribution of information to the press. Lifeguards should politely defer ALL
questions about the incident to the Aquatics Manager. Guards should remain at
work until after a debriefing/counseling meeting with your employer.
Your employer should give you as much emotional support as possible to cope
with the rescue. You should not be expected to return to duty after an incident
of this magnitude.
Anaphylaxis/Allergic Reaction: 5.3.4
Primary -
Recognize an allergic reaction (anaphylaxis) by sudden difficulty with breathing,
hives/rash, swelling of the face, neck, and tongue, tightness of the throat and
chest, feeling dizzy or confused. The symptoms develop quickly after being
exposed to the allergen. Ask the victim what happened. He should know what is
causing the problem. Look for medic alert tags and ask about an anaphylactic kit
(EpiPen). If he has a kit, have the back-up get it for him – and FAST!
Back-up - Upon hearing the signal, yell “We have an emergency, please clear the pool!” Go
over to the primary and victim. Ask the victim where his anaphylactic kit is (if he has one).
Run and get it for him. Give him the EpiPen quickly before he passes out. He must give
himself the shot. Don’t give him the shot yourself. If you do, you’ve administered a
medication that you don’t have a license to do. However, you can assist the patient by
helping him to hold it steady for 10 seconds.
Note:
Newer EpiPens (auto-injectors) don’t even require holding down the button, but
only a jab into the outer quadriceps to administer the epinephrine. The needle
comes out of the orange end and injects the drug automatically.
Cashier - When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you. Anaphylaxis is a
code red emergency. Call EMS even if the shot is administered in time. Let the paramedics
make a determination about transporting the victim. Finish clearing the pool.
Primary - Stay with the victim and monitor vital signs. ESTABLISH AN AIRWAY! It might be
too late already to get the airway in, but try. Ask for permission to insert an airway. If he
agrees, select the correct size and insert the airway while you still can. If he passes out, do
an initial assessment. Give the two breaths. If they won’t go in, do the hardest triple airway
you can and keep trying.
Note:
Nasopharyngeal Airways (NPAs) do not cause gagging, and can be inserted while
a patient is conscious, thus they could be used for anaphylaxis. An NPA may not be long
enough to prevent the closure of the pharynx, however. But, anything that might help can
be tried. Ask the patient if he has a gag reflex. If not, insert an OPA instead – it’s much
quicker to insert than the NPA which requires lubrication and careful insertion.
To insert an oral airway (OPA) - measure the distance from the front of the teeth to the
angle of the mandible or from the corner of the mouth to the earlobe. Select the right size
for this distance or cut the airway to that size with your trauma scissors. Glide the cut end
into the mouth with the end toward the palate. When you touch the uvula at the back of
the palate, turn the OPA 180˚ and rest the flange on the patient’s lips (or teeth for a NuMask
OPA).
To insert a nasal airway (NPA) – measure the distance from the tip of the nose to the
earlobe and select the proper sized NPA that spans that distance. Lubricate the airway with
a water soluble jelly lubricant. Glide the airway into one nostril, turning the beveled edge
toward the nasal septum. Insert the airway until the flange rests on the end of the nose.
Back-up - After getting the kit, run and get the equipment. Hook up the O2 and BVM. Give
him 15-25 LPM. Keep trying even if it doesn’t seem to be going in.
Note If you are successful in getting air and/or oxygen into the patient, perform a
SAMPLE History and ongoing assessment: BLSCPR – blood pressure, level of consciousness,
skin condition, capillary refill, pulse and respiration rates.
Note There’s nothing else you can do but try to get breaths and O2 in. After a couple of
minutes with no success, the pulse will likely be lost. If so, attach the AED, be prepared to do
CPR, and continue to attempt breaths until paramedics arrive. Even if you cannot get any
air past the swollen pharynx, the air still left in the lungs can be circulated and may delay the
onset of brain damage.
Cashier -
Direct EMS to the victim, get witnesses, and give the secondary survey form to
the back-up.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask.
Explain that you are not at liberty to discuss the rescue. If patrons have
questions, they should address them to the Aquatics Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - Anaphylaxis is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue. The Aquatics Manager will call the other officers
in the organization. These officers will coordinate the distribution of information
to the press. Lifeguards should politely defer ALL questions about the incident to
the Aquatics Manager. Guards should remain at work until after a
debriefing/counseling meeting with your employer.
Your employer should give you as much emotional support as possible to cope
with the rescue. You should not be expected to return to duty after an incident
of this magnitude.
Hypoxia/fainting: 5.3.5
(Code blue or red emergency)
Primary -
Recognize that someone has suddenly collapsed. Fainting comes on very
suddenly – in just a few seconds or less. Since there is usually no pain associated
with it, fainting is distinguishable from heart attacks (as long as there was a
witness). Stand up, blow your whistle into the mike and radio. Yell “code red,
I’ve got it!” Give the first aid signal and hurry over to the person.
Note -
Since hypoxia causes fainting, falling down usually corrects the situation by itself,
provided the victim doesn’t get injured from falling. Once the victim is horizontal,
blood flows easily to the brain and the victim usually wakes up again in a few
seconds.
Because this emergency appears to be a code red, you will call code red until you
do your initial assessment; and discover that the patient is fine. Change the code
to blue. If the cashier has already called EMS, he/she is a bit premature in
hanging up, since you are to give the cashier the patient’s condition and
treatment while he/she is talking to the dispatcher. Hopefully, the cashier will
still be on the phone and you can cancel the EMS call when the patient wakes up
and is fine. If you are not comfortable with the patient’s LOC, leave the code red
in place.
Back-up -
Upon hearing the signal, yell “We have an emergency, please clear the pool!” Go
over to the primary and victim. By the time you get there, the victim should be
awake again. Go over to the tower and assume total coverage. The fainting
victim will not need more than a couple minutes of first aid, so even if the swim
is too big for total coverage, it may take longer to clear the water than it would
for the other guard to resume scanning! Use common sense, when deciding
whether or not to clear the pool. Remember that whenever the care requires
more than one guard, the pool must be cleared.
Cashier -
When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you. The
primary will change the signal to code blue. Do not call EMS for a person who
faints once and immediately wakes up again (and has no injuries). As indicate
above in the notes, if you’re on the phone with the dispatcher, stay on the
phone until you have a report from the guards on the initial assessment. You
can tell the dispatcher to cancel the call, since the patient just fainted and was
not injured. Be prepared to watch the patient for a few minutes after he faints,
so the primary can return to his/her station.
Primary -
Once you get to the victim, keep him lying down on his back and maintain
normal body temperature by placing the emergency blanket over him. Reassure
the patient. He should feel better in a couple of minutes. If he has no other
injuries, ask the cashier to watch him for the next five minutes and return to
your station.
Follow-up for fainting: 5.3.5.1
All staff All that’s needed for this one is an incident report. Leave it on the manager’s
desk for his/her review the next day.
Shock: 5.3.6
(code red emergency)
Primary - Shock is a complication from other injuries or problems. That’s why this
procedure doesn’t start with blow the whistle, etc. You’ve already done that. Since shock is
defined as the inability of the circulatory system to provide O2 to all parts of the body, your
main objective is to stop any fluid/blood loss that is occurring. Severe emotional trauma
can also bring on some of the physical symptoms of shock. Look for:





Pale, sweaty, cool skin
Changes in consciousness
Rapid, weak pulse and breathing
Confusion, irritability, restlessness or irrational behavior
Signs of fluid loss: bleeding, diarrhea, vomiting, emotional trauma
As soon as you detect the presence of shock, yell code red and have the cashier
call EMS. Shock is a life threatening condition when the injuries are serious,
and/or the victim has lost a lot of fluid.
Note:
This is truly a better-safe-than-sorry scenario, where the guards may be unsure if
this is an EMS call or not. If unsure, CALL!! They’re not going to get mad at you,
and your Aquatics Manager certainly should not. With shock, LOC is really the
key and whether or not the patient’s condition is declining or improving.
Back-up -
Get the blanket out of the first aid kit and cover the victim if he’s cold. Fold
another blanket or towel to put behind his head to make him comfortable.
Primary -
Do a careful SAMPLE History and physical exam. If blood loss is not evident, but
the victim is losing consciousness, be prepared to do CPR/AED, etc. The fluid loss
could be from severe diarrhea or vomiting.
Note:
Blood or fluid loss may be coming out underneath the patient, so LOOK by rolling
the patient onto his side and inspecting the other side.
Back-up -
Provide ongoing assessment: BLSCPR – blood pressure, level of consciousness,
skin condition, capillary refill, pulse and respiration rates.
Note:
Use the BP Monitor for blood pressure. If it doesn’t work for some reason (dead
battery, etc.), perform auscultation BP.
Cashier -
Call EMS if directed to do so by one of the guards. Direct the paramedics to the
victim. Give out witness report forms and make sure the back-up has the
incident report form. Call the victim’s next of kin and report where EMS is taking
him.
Primary & Back-up
Usually, dangerous shock is a result of severe blood loss. To stop the
affects of shock, you must control the bleeding as fast as possible. If bleeding is
the problem, follow procedure 5.1.2 of this section. Shock brought on by other
means will require you to react to the symptoms, including performing CPR/AED,
etc.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask. Explain that you are not at liberty to discuss
the rescue. If patrons have questions, they should address them to the Aquatics
Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - Severe shock is a MAJOR emergency. The Aquatics Manager must be called
immediately after the rescue (even during it, if possible). The Aquatics Manager
will call the other officers in the organization. These officers will coordinate the
distribution of information to the press. Lifeguards should politely defer ALL
questions about the incident to the Aquatics Manager. Guards should remain at
work until after a debriefing/counseling meeting with your employer.
Your employer should give you as much emotional support as possible to cope
with the rescue. You should not be expected to return to duty after an incident
of this magnitude.
Chronic Obstructive Pulmonary Diseases: 5.3.7
(Code blue or red emergency)
Primary -
Recognize that a patron is having difficulty breathing. The patient may be
wheezing, coughing, making a puffing noise, and may have tightness in the chest.
They may be pink (puffers) or blue from hypoxia. If the symptoms are not
distinguishable from a heart attack – it’s code red!
Stand up, blow your whistle into the mike and radio and yell, “code red/blue, I’ve
got it!” Hurry over to the victim.
Note -
Chronic bronchitis and emphysema both run a risk of pulmonary circuit heart
failure due to the strain that they put on the right side of the heart. The victim
may lose both breathing and pulse.
Back-up -
Upon hearing the signal, yell “We have an emergency, please clear the pool!” Go
over to the primary and victim. COPD attacks can be no big deal, or they can be
life threatening, so always clear the pool and go to the primary to help out.
Cashier -
When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you. Finish
clearing the pool. Call EMS if the guards direct you to. Go out and direct the
paramedics to the victim. Give out the witness report forms and the incident
report form to the back-up.
Primary -
The victim will likely be conscious, but may be turning blue. Direct the back-up to
get the O2. Both of you hook up the O2 and give O2 with the non-rebreather mask
at 15 LPM. Keep the patient sitting down. Perform a SAMPLE History. A physical
exam is not needed, since this is a medical condition.
Back-up -
You’ll need the O2, so go get it. You’ll hook it up together with the primary. Both
of you should stay with the patient until EMS arrives. He might collapse at any
time. Perform ongoing assessment: BLSCPR – blood pressure, level of
consciousness, skin condition, capillary refill, pulse and respiration rates.
Note -
For an asthma attack, the patient probably needs only a shot from his inhaler.
Get it for him. He will self administer. O2 may not be needed. If it is needed,
follow the procedure above – nonrebreather at 15 lpm.
Follow-up: 1.1.1.4
All staff When you have completed the rescue - Immediately write down exactly what you
did, and what your team members did. DO NOT corroborate your story with the
members of your team. You must be isolated while writing down your
description of the rescue. You must do it before talking to anyone about it. If the
paramedics ask you questions about the victim, answer them. Do not answer
any questions that the patrons ask.
Explain that you are not at liberty to discuss the rescue. If patrons have
questions, they should address them to the Aquatics Manager.
Remember to think carefully about time sequences when writing your report
(was it 10 seconds or 30? Was it 1 minute or 5 minutes?). Time sequences are
crucial if litigation is involved. You should re-enact the time sequence if unsure.
Ask the Aquatics Manager for help with this when you need to re-enact the
scenario.
Media: 1.1.1.5
All staff If the media arrives immediately, and you are still performing the procedure, just
ignore them. Finish the procedure, fill out your reports, and wait for the
manager to come and help you. Do not interrupt the protocol to talk to
reporters. If they press you for information, politely refer them to the manager,
who is going to be here shortly. Please don’t say, “no comment.” Say, “we’re
still in the middle of the protocol for this incident, and don’t really have any
information yet. However, I’m sure that the manager or the PR Director will be
happy to talk to you as soon as they can.” Please don’t be rude.
Chain of Command: 1.1.1.6
Supervisor - Chronic bronchitis and emphysema can present a MAJOR emergency. The
Aquatics Manager must be called immediately after the rescue. The Aquatics
Manager will call the other officers in the organization. These officers will
coordinate the distribution of information to the press. Lifeguards should
politely defer ALL questions about the incident to the Aquatics Manager. Guards
should remain at work until after a debriefing/counseling meeting with the
school district officials.
EWU will give you all as much emotional support as possible to cope with the
rescue. You will not be expected to return to duty after an incident of this
magnitude.
Burns: 5.3.8
(Code red or blue emergency)
Primary - Recognize a burn from the mechanism of injury. Stand up, blow the whistle into
the mike and radio. Yell, “code blue/red, I’ve got it” and run over to the victim.
Back-up -
Upon hearing the signal, yell “We have an emergency, please clear the pool!” Go
over to the primary and victim. Burns are all treated the same way, so go get the
hose to cool the burn, unless the victim can be moved to the sink or emergency
eye-wash station.
Cashier -
When you hear the whistle and the announcement, come out on deck to see
what’s happening. Bring the cordless phone and the clipboards with you. Finish
clearing the pool. Call EMS if the guards direct you to. Go out and direct the
paramedics to the victim. Give out the witness report forms and the incident
report form to the back-up.
Primary -
First - stop the burning. Remove the source of the burning from contact with the
victim. Next - cool the burn with plenty of cool water. The nearest sink, water
fountain, or eye-wash. Don’t put the victim in the pool. Let the area air dry.
Now - cover the burn with a dry sterile dressing. Do a SAMPLE History and
physical exam to check carefully for other burns or injuries.
Back-up -
While the primary is doing the first aid, perform ongoing assessment: BLSCPR –
blood pressure, level of consciousness, skin condition, capillary refill, pulse and
respiration rates.
Note1 -
Burn dressings are not pressure bandages. They should not be tight, only a
covering to prevent infection.
Note 2 -
When to call EMS: whenever in doubt, call. Any burn to an elderly person
or small child that is at all significant is code red. A small single blister from a
burn is generally not code red. However, a second degree burn over a large area,
or to the head, face, neck, or genitals is code red.
Follow up for burns 5.3.8.1
All staff Most burns are minor and don’t require anything other than an incident
report. A burn that appears to be life threatening and requires EMS
(from an explosion, fire, or electrocution) would use the entire
follow-up procedure #1.1.1.4-1.1.1.6.
See photo gallery below for types of burns, and rule of 9’s for determining how much of the
body was burned.
Rule of 9’s for determining severity
affected
3rd degree burn – all tissue layers affected
affected
2nd degree burn – epidermis and dermis
1st degree burn – only epidermis
(hard not to admire his”handiwork”)