Imagine the following situation: The rescuers rescue an unconscious victim with clear symptoms of drowning in the water and after its evaluation, they found that is not breathing and has no pulse either. They call EMS and start applying the resuscitation protocol (CPR) which involves mouth-to-mouth and compressions. But what if the victim were a possible COVID-19 carrier and the Lifeguards were infected?
Facing an unprecedented situation
We are talking about something that is affecting millions of people around the planet, with hundreds of thousands of deaths if we take into account official statistics, which most likely do not reflect the entire figures, nor has the most serious phase of this pandemic yet been overcome. And each of those figures is a person like you or me, with their own history, family and circumstances.
We are going through an unprecedented situation and the hubbub of information, confusing, full of hoaxes and lacking real evidence in which we move is both exasperating and frustrating. We all look for messages that alleviate our concerns and give us hope, and although the messages we hope to receive may be different for each of us, what we all hope for are concrete and reassuring guidelines that definitively address the problems and help us cope with their consequences.
The fact that information moves and changes so quickly is creating a paradigm that just a few months ago would have seemed unusual to us. Decisions such as treatment of the infection, which were made over months or years and after studies and clinical trials, are now made in weeks, days or hours. And almost nothing else to publish have to be modified or updated because new tests or pieces of evidence appear and there are changes as our understanding of the problem progresses.
It must also be borne in mind that the health authorities that direct the fight against the pandemic and struggle with these same problems at the front line, do not have beaches and water facilities among their most urgent priorities. These are problems that will be addressed when others, much more pressing and with an immediate impact on public health or the economic structure, so severely damaged, are more established
Uncertainties opening the beaches and swimming pools
There is a wide range of facilities and aquatic environments that should be intervened, from services that cover public beaches, through water parks, public pools or leisure and hotel establishments, inland waters, to domestic pools. And each of them will require guidelines as clear and defined as possible. The Spanish situation, with a large part of the regulatory powers transferred to the autonomous communities and with the municipalities as the ultimate responsibility for the management of beaches and water facilities, makes it very difficult, but not impossible, for there to be harmonization in these guidelines.
The situation may be even worse in the facilities of small municipalities and especially in those of private management, where decisions will be made mainly based on business and profitability criteria and we may find that facilities are opened or, on the contrary, remain closed, even in opposition to the official recommendations and it is foreseeable that there will be atomization within those initiatives. The risk evaluations, plans and implementation guides –if they are carried out- will depend to a great extent on the availability of local or internal “experts” or auxiliary companies capable of their study, preparation and start-up, something unthinkable in localities or companies of small size or technical capacity.
Many regulatory gaps
Even though in recent years there has been substantial progress in research and guidelines on aquatic risks, there are huge gaps that remain unfilled, both globally and in our country. The first of them is that practically all of the different existing regulations in Spain are designed with hygienic or sanitary criteria and hardly contemplate the aspects of safety and prevention of drowning, nor do they clearly describe the responsibility and functions of the professional aquatic lifeguard within the general organization of an installation in light of the knowledge that has already been developed in this matter.
Nor does it contemplate what implies the implementation of the guidelines established by the internationally accepted protocols (ERC, AHA) and the urgent need to adapt these protocols to the practices that best adapt to the reality of each installation or aquatic environment.
Nor does it contemplate what the implementation of the guidelines established by the internationally accepted protocols (ERC, AHA) entails and the urgent need to adapt these protocols (and their implementation in reality) to the practices that best adapt to the reality of each installation or aquatic environment. Take an example: the performance guidelines and equipment requirements cannot be the same for a beach with fully equipped lifeguards and a first-aid post with nurse staff, as for a small town pool with a single lifeguard and in which the EMS response time can be measured in half-hour stretches, where the grade of the response and the equipment needed have to take that into account. In other sectors, this adaptation does occur and, based on the general rules, a re-dimensioning of the requirements to be met is required.
The regulation urgently needs to include the existence of an expert figure (ideally a medical director with training in aquatic safety or with the advice of other sectoral experts) who interprets these adaptations taking into account all the key aspects (including the possible repercussions on the legal scope) according to the risk group to which each installation belongs, and has sufficient capacity and authority to implement individual adaptations that ensure its optimal risk management and its reduction to the minimum possible level. The safety of the installation’s personnel and that of its users – in that order – must always be priorities and must not fall prey to the tension between public safety and health and political, business or profitability criteria.
Implications for aquatic facilities
There are still many doubts about how the facilities – swimming pools, water parks, beaches – will have to face the reopening or start-up of their activities. Some companies are already preparing plans and establishing how they will implement them, which is very commendable but as I pointed out and however successful those plans maybe, this is a response that does nothing but disperses efforts and most likely will be repeated and amplified the mistakes. The Spanish Central Administration should be responsible for preparing a report and defining the minimum essential criteria for starting aquatic activities and defining with specifications and objective and measurable criteria the requirements to be met so that each facility can act accordingly. And in this case, coordination and consensus with the autonomous regional governments must be above any political or economic interest and have as a priority to place our country in the leadership of aquatic security, in the same way that we become the head of world tourism.
As is already being highlighted in other sectors, the consequences and implications will be significant and a good number of companies, especially small ones and temporary dealers, will probably not be able to face them economically or organizationally. In addition to being an occasion for the greats to take a slice of the troubled water, it remains to be seen whether this will suppose an impulse in the right direction or, on the contrary, an impoverishment of the overall conditions of the sector, including also those referring to the aquatic safety. Doubts arise everywhere and many managers of lifesaving companies are understandably concerned about the implications, including in the legal and criminal field, that they may have and their possible consequences.
The deficiencies in the figure of the Professional Lifeguard
It is in this situation where the deficiencies that surround the figure of the Professional Lifeguard are becoming even more evident. As mentioned, the regulation of the Lifeguard training is scattered, is very uneven, is out of date and has been born subject to the veil of the fickleness of the political winds that were blowing at the time they were published, or conversely, simply it does not exist as it happens in many Spanish regional regulations. I do not want to go deeper into this part (which has already been discussed on other occasions and which in any case deserves a much broader comment), but the practically unanimous reality in the sector is that none of the training lines currently in force in Spain provides the adequate preparation that they should have according to the literature and the real needs of job performance. And this gap is even greater in terms of defining their tasks within the safety of an aquatic facility.
A response that is assimilable to that of a health professional is expected of us, but we are not, nor are we considered as such in any regulation that I know of. It is time for the situation to normalize, once and for all, and with the involvement and contribution of those who are truly an integral part of the Aquatic Lifeguard profession, their job performance and the business sector and we definitely put those aside. like sports entities, which are not.
At aquatic lifesaving, there has never been a recipe that was «the solution to everything.» As we commented, the protocols that the reference entities periodically issue cover a wide spectrum, but after their broad consensus, they always leave some gaps and reasonable doubts that are still being studied and revised. Unfortunately, with the perspective of COVID-19, it is not possible to claim today to have a solution that satisfactorily addresses all the problems that we are being forced to face, nor at lifeguarding. There are still many things to define regarding how to adapt the response of the aquatic teams to the COVID-19 and as the details were chosen are one or other will greatly influence how we will have to manage the work systems and internal protocols at the facilities and the lifeguard services, because they may imply the need for more equipment, personnel, resources and specific training. Many questions are still in the air and need to be answered.
What is the most suitable PPE? Is it better to have a rescue team and another team ready for CPR? What will happen when the protocol indicates that mouth-to-mouth breathing is not practised on a drowning victim, because there is a possibility that they can get COVID-19? What margin of flexibility or interpretation does the Lifeguard or those responsible for the facilities have in a situation of this type? Could such a case have legal repercussions on the Lifeguard himself and on the facility or company where he works? What will be the psychological consequences for Lifeguards?
Several working groups have already issued reviews of the CPR protocols adapted to COVID-19 -and their adaptation to victims of drowning is expected shortly- which include substantial modifications in the guidelines that are likely to have repercussions on the outcome of the victims to whom they are applied and also in the exposure of the participants to the risk of infection and, therefore, a threat to their physical integrity and health. There is still no conclusive evidence in this and while the reference organizations publish revised protocols and update them with the new evidence, we must be very attentive to the latest developments and immediately incorporate them into our work systems and training actions.
Shortening distances in the training
Another of the revolutions that COVID-19 has brought about has been the questioning, at least temporarily, of any activity that involves personal contact, such as training in Aquatic Lifeguard, which implies activities and practices at the classroom and into the water with very close personal contact and the empowerment of remote and online training, in addition to the increasing precautions of prevention of contagion that must be taken during such practices.
How do we adjust that «distance» to the first aid and rescue training?. Implementing online teaching platforms is common today, but it comes at an additional cost and not just on the technological side. The contents must also be specifically reviewed and prepared for those that are susceptible to this new modality, and the teachers must be trained and adapted to teach their classes or tutoring remotely, and also define and establish which should be the best routes for the evaluation of the students. And since not all content can be taught remotely, it will be necessary to reduce the number of students per session, provide the appropriate PPE for face-to-face activities, etc.
And this also influences the training materials. A CPR dummy, for example, when used for mouth-of-mouth practice will produce potentially contaminating sprays if the student is a carrier and will need to be thoroughly disinfected or dispose of and replace sensitive parts after each student uses it. Personal protective equipment, practices or rescue materials must also be reviewed and renewed. The time and cost necessary for this or the alternative of substantially increasing the number of devices to minimize breaks or have one per student will entail such a high cost that they can become unaffordable or raise the price of training for students at unaffordable levels.
But beware, not everything goes for remote training. We must not allow advertising and, which is certainly inadmissible, to accept an official acceptance for courses taught 100% online. Here again, appears the responsibility of the different Administrations in the regulation and monitoring of training in professional lifeguarding. There should be no doubt as to how it should be reliably taught and verified and enforced that the guidelines are thoroughly followed.
And what is going to happen with the regulations that establish periodic deadlines for compulsory refreshing courses, when the Lifeguards cannot prove that they have carried out their periodic training because there has been no call to do so? Will the validity of the accreditations be extended, with the risk of not having professionals with their training duly updated? Will companies risk hiring them? At this point, only out of 18 Spanish regional governments have extended that deadline.
An ethical dilemma
If we look at the training figures for the past 10 years, we easily see that professional first aid is a declining occupation. Some of the possible reasons can be deduced from all of the above, in addition to job insecurity, lower wages, increasing undervaluation in public opinion and public officials of the lifeguard figure. Many of us agree for years on the analysis and diagnosis of the disease, but until now we have not been able to agree on the remedy.
I have the feeling that COVID-19 has put us in front of the mirror of our miseries and that what we see -although we were already aware of it- not only do we not like it, but perhaps for the first time we have been stirred by that consciousness that long ago seemed to have been drowsy. Now we cannot sin by omission nor by lukewarmness. I perceive it as both an ethical dilemma to be solved, and a personal need to promote what I have considered a moral obligation throughout my career as a lifesaver trainer. If I keep being it is because I firmly believe that my -our- obligation is to produce the best professionals and keep struggling for all of this.
It is time for the extensive Spanish and international network of personal contacts that have been gradually expanding in recent years through personal friendships, selfless collaborations, conferences and technical meetings and that gather many people (researchers, teachers, first responders, managers, businessmen, public officials, trade unionists, legislators, etc.) who share that deep conviction of the need for a profound and perhaps revolutionary change, speak with as a single voice and black over white the priorities that this crisis has brought out so starkly. We have to be able to put aside any circumstantial interest, focus on the essentials, and make our proposals heard and finally carried out.