Local Lifeguards Trained In Dangerous Techniques - CBS11 last night

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Local Lifeguards Trained In Dangerous Techniques Reporting
Bennett Cunningham DALLAS (CBS 11 / TXA 21)

It has been described as reckless, negligent, unethical and useless. CBS
11 News has learned that some local lifeguards may be trained to use the
Heimlich Maneuver before using CPR on an unconscious drowning victim.
The result could be fatal, and has the local medical community very
concerned.

Cities like Rowlett and Dallas hired a Houston-based company called
NASCO (National Aquatic Safety Company), which instructs lifeguards to
use the maneuver as a first-response to a drowning victim. NASCO runs
one of the country's largest water safety certification programs.

Dr. Paul Pepe is the Director of Medical Emergency Services for the City
of Dallas, and a highly respected national expert on emergency medicine.
Pepe helped write "The Handbook on Drowning." His conclusion, there is
"no need to perform the so-called Heimlich Maneuver" - CPR is the first
aid you render. "When it's a general rescue, when they're unconscious,
when they're basically needing immediate resuscitation, we don't waste a
lot of time doing that. We get right to the resuscitation techniques,
compressions."

The American Heart Association states, "After thorough review, the AHA
believes the most important thing is give two rescue breaths and then
CPR." The American Red Cross teaches CPR all over the country and states
using the Heimlich - or, as it is sometimes called, abdominal thrusts --
wastes precious moments.

The fear among medical professionals is real. In 1987, the Journal of
the American Medical Association documented the case of a 10-year-old
boy found at the bottom of a swimming pool. He was given the Heimlich
Maneuver, causing him to breathe in his own vomit. He ended up in a
vegetative state for seven years until he died.

Dr. John Hunsucker runs NASCO. Hunsucker is a university Assistant
Professor of Industrial Engineering, and is not a medical doctor.
Hunsucker claims using the Heimlich Maneuver on a drowning victim saves
lives, and he teaches the technique all over the world.

When CBS 11 News asked Hunsucker for scientific evidence to support his
position, he sent us a three-page paper stating the maneuver "does not
delay CPR " and that "..medical professionals are hesitant to do
mouth-to-mouth resuscitation." In one news report, Hunsucker was quoted
as saying CPR puts the rescuer at risk of AIDS, hepatitis and
tuberculosis. Click here to read Hunsucker's thoughts on "CPR Issues For
Lifeguards."

The American Red Cross says it has scientific proof that CPR works. "We
spend countless hours verifying that what we are teaching someone to do
- that it is proven to be effective," said local American Red Cross
spokesperson Anita Foster.

Despite backlash in the medical community, a spokesperson with the City
of Rowlett told CBS 11 News, "We've read and researched. We feel
comfortable with our lifeguards being trained under NASCO protocols."

The City of Dallas uses the NASCO protocols in its training, but told
CBS 11 News its lifeguards are instructed not to use the Heimlich
Maneuver as the first response on an unconscious drowning victim.

City-operated pools may not be the only ones at risk. CBS 11 News
obtained a 2008 NASCO client list and found the Hawaiian Falls
waterparks in Garland & The Colony were listed as clients. When CBS 11
News contacted Hawaiian Falls to find out if it still uses NASCO
protocols and trains lifeguards to use the Heimlich Maneuver as a first
response - the company's public relations firm sent an e-mail stating:
"Our client does not care to participate in this story."

The Texas Municipal League, which represents cities across the state has
a contract with NASCO, says the training it provides locally does not
include the Heimlich Maneuver.

The City of Rowlett sent us this statement:

"After conducting extensive research, staff recommends that lifeguards
at the Wet Zone continue to use the NASCO protocol as described below.
Abdominal thrusts are to only be used, if necessary, as a lifesaving
tool on a victim who is found unconscious in the water while
transporting them to the side of the pool for extraction. From the point
of extraction from the water, abdominal thrusts are not to be used.
These guidelines are in line with the NASCO guidelines and those set
forth by the American Heart Association. The Wet Zone lifeguards will
review and practice this training in the weekly in-service conducted
this week. Our number one concern and goal is for our lifeguards to
continue to provide the best, safest and most effective procedures for
our patrons."
((c) MMIX, CBS Broadcasting Inc. All Rights Reserved.)

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While I do appreciate the value of several of the items that are in the most current version of the NASCO Lifeguarding Manual, I have to say this is an area where I disagree. Setting a protocol around the assumption that many lifeguards and health care providers will hesitate to perform mouth to mouth, the data for which comes from an article that is 12 years old, is not a responsible approach. Straight mount to mouth AR has not been the standard for professional rescuers certified by either the AHA or the ARC for at least 5 years; we are all trained to use rescue masks or BVM's to prevent the possibility of disease transmission from victim to rescuer. I also don't seen much merit in the claim that mouth to mouth contact can transmit pathogen's such as AIDS or Hepatitis, everything I have ever read from the CDC, OSHA, the AMA, and various Health Departments lists these pathogen's as blood-borne with little likelihood of transmission through saliva. In short while I recognize that NASCO has documented several cases of successful application of abdominal thrusts to a drowning victim resulting in ressecuitation, I would argue that these cases are the exception to, not the example of, the rule.
For Terri Smith:
I have had personal experience with this....
I worked on a child that was removed from the water after being submerged for an undetermined amount of time. Attempts to ventilate were unsuccessful because of the amount of water in the child's lungs/system. (Each time a breath was administered, water would come out of his mouth and nose....his airway was not obstructed by anything other than water)
We did abdominal thrusts and large amounts of water and vomit escaped from his mouth and nose.
I STRONGLY believe the had abdominal thrusts been performed before ventilations were attempted it would have assisted with the ability to ventilate, therefore not delaying CPR. (i.e.....attempting to ventilate, retilting and attempting again, THEN performing abdominal thrusts after that time had past....) Even providing chest compressions or something like that would have helped. I'm not a medical doctor, and no 2 cases are the same (victims don't go to victim school), but I saw it with my own eyes. Just the thoughts of a rambling mind....




Terri Smith
Water Design, Inc.
5047 South Galleria Drive
Salt Lake City, Utah 84123
I too experienced resuscitation first hand when I, as a lifeguard and pool manager, provided care to a 10-year old boy another lifeguard had rescued and brought to the deck. My perspective and conclusions are completely different, however.

The main goal of resuscitation efforts is to provide oxygen to the victim's body. Depending on the victim's condition, this might involve opening the airway and performing rescue breathing, CPR, and/or airway management protocols (including chest thrusts/abdominal thrusts). The choice of which protocol to employ depends upon the initial assessment of the victim.

Even though, in my rescue, the abdominal thrusts saved the day, I used them in the context of accepted protocol (i.e., I attempted ventilation and when water and vomit came rushing out of the victim's mouth and nose, I began the unconscious choking protocol which included attempting to ventilate in each cycle.) After 3 cycles, the victim began breathing on his own. I never got to the pulse check. I also never retilted the head because the presence of fluids and vomit in the mouth and nose was so obvious I knew the airway was blocked.

The answer to the question which protocol comes first must always be the initial assessment. Assessment tells us how to proceed; it is set up so we do the correct thing for each victim at the appropriate time. It is foolhardy to say that we will ALWAYS do abdominal thrusts first (even before we check the victim); clearly those who do that will be applying this some of the time when not needed.

Performing abdominal/chest thrusts can cause the victim to vomit or be injured. These complications may be acceptable when clearing an airway to save a life, but they are not acceptable when the airway is already clear. You cannot know whether an airway is clear until an assessment is performed.

More later....

Ron Arendas
The Water Safety Guy(TM)
Unconscious, floating in the water face down.. You think there is water in the airway? I am willing to bet that 99.9% of the time there is. Nothing says that even if you follow the current "accepted" protocols that vomit won't get in the lungs, this is part of the normal risks associated with administering care when aspiration of water, or wet drwoning, occurs. As for what really works or not, airway clearing compressions first of the current protocol, I would say that there is not enough research to prove that the compressions first hurt, I'm willing to bet that if you look at the current standardly practiced methods that there have been incidents wher vomit or something else caused death too. History Lesson: When E&A fiirst introduced this working with Dr. Heimlich it was turned back due to a lack of research and fear of litigation for using a non accepted method, not that the idea was wrong or that it has not worked to save many lives. If NASCO and their clients want to use this because they believe it works that is their perogative. If someone dies due to vomit in the airway and lungs during an immersion incident, well that happens when people work on someone in that situation. If we could just get our guards to respond faster and beeter and smarter the problem would away.
Actually, there has been lots of scientific research into the effectiveness (I mean lack thereof) of abdominal thrusts for submersion victims. I would direct you to a scientific review by the American Red Cross Advisory Committee on First Aid, Aquatics, Safety, and Preparedness on this subject. If you really have an open mind, you can read about all the research that has been done and the conclusions of so many doctors and scientific experts that show how Dr. Heimlich stands completely alone in his opinion or belief that his practice is an effective first measure for submersion victims. You can find the article on Instructor's Corner in the Ask the Expert section under ACFASP Scientific Reviews.

By the way, when you say: "If NASCO and their clients want to use this because they believe it works that is their perogative (sic)," you sound as though you do not understand the concept of Standard of Care. The entire international scientific and medical community is in agreement based on solid research and medical consensus and you are saying it is OK to go against that and with the opinion of one dissenting doctor with an obvious agenda and one small certifying agency.

What would you be willing to accept in a backboarding protocol: chicken wire?
Questions Continue To Rise About Houston-Based Lifeguard Program by Mike Giglio, Houston Press, August 24, 2009

Since mid-May, there have been three drownings at NASCO-client parks. In at least one, the Heimlich was used as the first step in resuscitation.

"For somebody to continue to do this and to teach it is foolish and borders on the insane," (says) Dr. James Orlowski, the chief of pediatrics at University Community Hospital in Tampa, Fla. and an expert on drowning.

"You've got the International Liaison Committee on Resuscitation, the American Heart Association, the American Red Cross and the Institute of Medicine all coming out to say the Heimlich has no role in resuscitating drowning victims."

Orlowski and others point out that the Heimlich can lacerate or rupture organs and cause vomiting, and the aspiration of vomit into the lungs, which is extremely harmful. They say it also wastes precious time, as brain damage can occur within minutes.

...Andy Maurek, operations manager at the Water World in Denver, Colo., where a 48-year-old man drowned on July 21, says his park follows NASCO protocols directly -- and that it did so in this case.

"We did the Heimlich while we were in the water. When we pulled him out, we began our CPR procedure."

Hunsucker's critics believe this could be the next and crucial step in removing the Heimlich from NASCO training entirely.

"It would appear at this point that the emperor has no clothes," Brewster says. "You put yourself at tremendous legal risk, because you're essentially practicing medicine outside the confines of approved process. I mean it's essentially human experimentation."
Another great attack on NASCO. If you are going to tell me there is no research supporting the use of the Heimlich on drowning victims prior to doing CPR, then you need to show me actual research data that is specific to this topic that supports why you don't do it before CPR. 3 people drown in NASCO client parks this year huh? How many have drown in Red Cross, YMCA, Ellis and other trained pools and parks this year? Just because these agaencies don't do it, doesn't mean they have done anymore research on this then NASCO. It's not their protocol "and has no role in ..." Show me their research.
Scientific Review: Sub diaphragmatic Thrusts and Drowning Victims, American Red Cross Advisory Council on First Aid and Safety (revised November 9, 2006)

Fighting for Air: Drowning and the Heimlich Maneuver by Todd Spivak, Houston Press, October 11, 2007
(John Hunsucker): "All the agencies that say, 'Don't do (the Heimlich for drowning),' have never asked me for our data." When the Press requested to see any and all unpublished data, Hunsucker said there was none..."These so-called medical experts," he says in a gruff, laconic voice through tobacco-stained teeth. "Screw 'em. What do you want me to do, walk in lockstep?"
Hi Jim,

Attached should be an article of interest about this topic. If you would like more I will be glad to provide it. Have a good weekend.
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