Drownings in Lifeguard Pools: Why Submerged Victims Go Unnoticed Maria Bella

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1 Denver, CO October 18-20, 2017 Drownings in Lifeguard Pools: Why Submerged Victims Go Unnoticed Maria Bella Maria Bella has been actively involved in the aquatics industry for more than 40 years. She has operated numerous swimming pool complexes, owned highly successful swim schools, and served as a subject matter expert for APSP s Technical Committee on ANSI standards; the CDC s Model Aquatic Health Code; IAPMO's Uniform Swimming Pool, Spa and Hot Tub Code; and the ICC's International Swimming Pool and Spa Code. Bella provides consulting services to directors of college/university, municipal, school district, and the hospitality industry in standard of care for aquatic facility operations as well as positioning and supervision of lifeguards. Abstract Lifeguards are perceived as the premier drowning prevention strategy and expected to recognize and respond to patrons in distress before injury occurs. However, per a 2011 report from the Centers for Disease Control and Prevention, from 2000 to 2008, 140 fatalities occurred at swimming pools with lifeguards on duty. Though tragic, these results represent only about 50% of fatalities at lifeguarded pools during that time. (2001 Baullinger, et al.; 1992 Rainey, et al.; 2009 Barss, et al. cited Pelletier, et al. 2011, p. 252) It is estimated that for every drowning death of a child less than 15 years old, there are four non-fatal submersion incidents; two of which result in release from emergency departments and two more that require hospitalization. (2004 CDC MMWR cited Pelletier, et al p. 252) When drownings occur with lifeguards on duty, lifeguards are often accused of being negligent and blamed for the tragedy. But, based on scientific studies conducted during the past two years, lifeguards are frequently positioned where drowning victims cannot be identified while at the surface or on the pool bottom. STUDY Visibility testing was performed to determine what a lifeguard would be able to see based on chair height and position relative to glare from natural and artificial lighting. Initially manikins and silhouettes were used for the testing but results were invalid due to patron response to these tools. Valid testing required the development of a different device. Investigations have shown that when children drown, after they cease struggling, they may tuck into a fetal position. Toddlers are the smallest children likely to slip away from their caregivers and end up drowning in pools. For these reasons, an anthropometrically accurate device was developed to represent a toddler in the fetal position (length, width, and height) without looking National Swimming Pool Foundation conference@nspf.org

2 Denver, CO October 18-20, 2017 like a submerged child. These devices, referred to as ANGELS (Area Notification Gear for Effective Lifeguard Surveillance) were placed in swimming pools. Testing showed that patrons disregarded the ANGELS and continued to play and swim as though there was nothing unusual on the pool bottom. ANGELS were placed in a grid pattern at indoor and outdoor pools. Lifeguards were asked to count the number of ANGELS that they could see during various levels of patron activity. In scenarios where 25 ANGELS were positioned in the lifeguard s assigned zone, lifeguards identified 19 to 21 ANGELS. In scenarios where 33 ANGELS were positioned in the lifeguard s assigned zone, lifeguards identified 21 to 27 ANGELS. Testing demonstrated that these lifeguards were not properly positioned to identify a submerged victim throughout their entire assigned zone. During testing, photographs were taken simultaneously from elevations equivalent to lifeguards seated on 3, 6, and 8 tall stands. These photographs provide a frame of reference for understanding the challenges that lifeguards cannot overcome due to positioning. Prior to testing, neither lifeguards nor pool management were aware of the lifeguard s limitations. Following testing, lifeguards were repositioned and zones were redefined to improve each lifeguard s ability to identify drowning victims. Failing to properly position lifeguards provides a false sense of security to the public and sets lifeguards up to fail. This has resulted in serious injury and death of patrons, extensive emotional trauma to families and staff, and financial hardships for families and organizations. By incorporating scientific testing for the positioning of lifeguards, the aquatics industry can further reduce the risk of drowning. National Swimming Pool Foundation conference@nspf.org

3 Drownings in Lifeguarded Pools Why submerged victims go unnoticed Fatalities in swimming pools with lifeguards USA, A case was defined as a death in a swimming pool with at least one lifeguard on duty. Media accounts, using Lexis Nexis and ProQuest databases, were searched, analyzed, and data further investigated to ensure that non fatal drowning incidents and drownings in bodies of water other than pools (i.e. natural occurring bodies of water) were excluded from the results. Because not all drownings are reported by the media, results represent an underestimate of the true number of fatalities in pools with lifeguards on duty. For example, in Washington state, 514 of 983 (52%) drownings were reported in newspapers between 1993 and Reporting was more likely when victims were less than 20 years old. In North Carolina, 42 of 58 drownings (72%) involving individuals less than 19 years old were reported in Pelletier, A., Gilchrist, J. (2011) Fatalities in swimming pools with lifeguards USA, Based on available reports, from , there were 140 drowning deaths in pools with lifeguards on duty. States with the most fatalities were PA (14); CA, MD, OH (9); MI, NY (8); FL, TX (7) Sites of fatal incidents included municipal pools (38%), community organizations (15%), and schools (14%). Fatal drowning victims were initially identified in the pool twice as often by non lifeguards (e.g. other swimmers or bystanders) as by lifeguards. The median swimmer to lifeguard ratio was 13:1. Among children less than 15 years old, it is estimated that for every death there are four additional drowning incidents; two that are treated and released from emergency departments and two more that require hospitalization. Pelletier, A., Gilchrist, J. (2011)

4 Pelletier, A., Gilchrist, J. (2011) International Journal of Aquatic Research and Education How Lifeguards Overlook Victims: Vision and Signal Detection 3 There are at least two subject areas where research can improve lifeguarding effectiveness. The first area is to continue the application of physics and visual physiology to the field of lifeguarding by investigating such issues as the height of the lifeguard s chair, the use of polarized lenses, the required visual acuity of a lifeguard, and the impact of zone size on lifeguard effectiveness. Hunsucker, J., Davison, S. (2008) Patrons, especially children, find life like tools disturbing. Typically manikins and/or silhouettes are used as testing and training devices.

5 Scientific testing equipment Silhouettes are 2D. Accurate testing requires 3D objects with contrast. Because patrons find manikins disturbing, even when notified that these are testing devices, patrons change their swimming activities, invalidating testing. Since refraction causes submerged bodies to break apart, lifeguards are taught to look for blotches at the bottom of the pool while scanning. Testing devices do not need to be life like in shape but do need to be lifelike in size. The smallest person likely to drown in a public pool is a toddler. As children drown, when they stop struggling, they ve been known to tuck into the fetal position, decreasing their size at the bottom of a pool. Targets were constructed to anthropometrically represent a toddler in the fetal position (length, width, and height) without looking like a submerged child. Patrons disregard these devices and continue to play and swim as though nothing unusual is on the pool bottom. Child at play and patron standing on ANGELS devices on pool bottom. AREA NOTIFICATION GEAR FOR EFFECTIVE LIFEGUARD SURVEILLANCE

6 ANGELS devices are placed in a grid on the bottom of the swimming pool. Visibility testing is performed to determine what a lifeguard is able to see based on chair height and position relative to glare from natural and artificial lighting. Lifeguards are asked to count the number of ANGELS devices during various levels and types of swimming pool activity. Images on the following screens were captured during testing performed at an outdoor municipal swimming pool. Cameras were positioned at heights equivalent to a lifeguard seated on a 3 foot, 6 foot, and 8 foot high chair. Focal length was set to represent 20/20 vision and the camera shutters were released simultaneously. View from a 3 ft. high lifeguard chair View from a 6 ft. high lifeguard chair View from an 8 ft. high lifeguard chair

7 In testing scenarios where 25 ANGELS devices were positioned in the lifeguard s assigned zone of coverage, lifeguards identified 19 to 21 ANGELS. In testing scenarios where 33 ANGELS devices were positioned in the lifeguard s assigned zone of coverage, lifeguards identified 21 to 27 ANGELS. Testing demonstrated that these lifeguards were not properly positioned to identify a submerged victim throughout their entire assigned zone. Prior to the testing, neither the lifeguards nor pool management were aware of the lifeguards limitations. Following testing, lifeguards were repositioned to ensure that they could identify a drowning victim anywhere in their zone. If lifeguards are supposed to evaluate arm and leg movements to determine if a patron is in distress, the lifeguard must be positioned high enough for those movements to be observed.

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10 Chair height ALONE is NOT the answer

11 ANSI/NSPI , the American National Standard for Public Swimming Pools states: 18.4 Lifeguard station. When lifeguards are required, chairs and stations shall be positioned to allow guards to meet the 10/20 rule. The 10/20 rule is defined: A pool or aquatic facility shall be provided with a qualified lifeguard or a number of lifeguards trained and stationed in a manner that will permit them to identify an incident or trauma within ten (10) seconds of its initiation. Upon identification of the incident or trauma, the guard shall be able to respond to and initiate indicated protocol appropriate to the circumstance within twenty (20) additional seconds. According to Ellis & Associates: Recognition, reaction, and management of a guest in distress within the first 30 seconds has proven to effectively save lives and has resulted in more successful outcomes. By using the 10/20 protection standard, facilities can better determine the appropriate position for lifeguard stations and the size of each zone of protection. (Ellis & Associates 2001, 8)

12 According to the American Red Cross: Lifeguards should be able to recognize and respond to a drowning victim within 30 seconds. (American Red Cross 2017, 59) Effective Surveillance Zones of Surveillance Responsibility New lecture points to reinforce recognition and response benchmarks: Lifeguards should be able to recognize and reach a victim in their zone within 30 seconds. (American Red Cross Lifeguarding Instructor/Instructor Trainer Update) Lifeguards are often blamed when a drowning victim is not recognized in a timely manner, but management is responsible for the training, staffing, and positioning of lifeguards. In their Lifeguard Management manual, the American Red Cross states: Area of Responsibility The facility manager and lifeguard supervisor establish each lifeguard s area of responsibility for patron surveillance. (American Red Cross 2007, 26) Lifeguard Stations A lifeguard must be in a position to recognize and respond to an emergency at all times. Lifeguard stands should be located where lifeguards can observe patrons easily and react quickly to any situation in their area of responsibility. Lifeguards cannot save what they cannot see; knowing what your lifeguards can and cannot see is extremely important. You need to establish a system of coverage that places the lifeguards where they can provide the best possible safety for the patrons. (American Red Cross 2007, 24)

13 Both lifeguards were attentive and constantly scanning. The caretaker was attentive and engaged with the two children that she brought to the pool, but lost track of one child while briefly focused on the other child. Assuming that lifeguards can see a submerged patron in any area of the pool under all conditions sets lifeguards up to fail. To ensure that lifeguards are positioned to identify patrons in distress in any part of the pool, proper scientific testing must be conducted. Results of testing should be documented, analyzed, and shared with stakeholders. Testing should be completed regularly throughout the season, under different loading and lighting conditions. Studies have shown that the most effective way to search an area is by following a grid pattern. Testing should reinforce this scanning technique.

14 Drowning in Lifeguarded Pools is Preventable 2017 Aqua Conscience