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Ana Catarina Queiroga and Jonathon Webber
This chapter will focus on medical facilities at beaches in two environments with diametrically opposed circumstances. Considering the wide variety of situations both locally and globally that affect the level of medical training and equipment provided by lifeguards, the Medical Commission of the International Life Saving Federation (ILS) has developed a set of guidelines based on three priority levels to assist lifesaving agencies in determining what first aid/CPR training and equipment to provide (Table 102.1). These guidelines will be used to assess what levels of priority have been met in two case studies.
102.1
Development of Medical Aspects in Lifesaving Worldwide
Parallel to the distinct sociocultural and politico-economic features of countries worldwide, medical resources available on beaches are also varied. There are large discrepancies internationally and even within countries in terms of levels of training, skills and equipment available. While in some areas, such as in some parts of the USA, lifeguards are trained to the level of emergency medical technician (EMT) [1], in other areas only a few are trained at basic first aid. Furthermore, a large percentage of aquatic environments, mainly concentrated in low and middle-income countries (LMICs), lack qualified
A.C. Queiroga AsNaSA Portugal, Rua Ezequiel Seabra 104, Matosinhos 4455-128, Portugal e-mail:
[email protected] J. Webber (*) Surf Life Saving New Zealand, PO Box 39129, Wellington Mail Centre, Lower Hutt 5045, New Zealand e-mail:
[email protected] J. Bierens (ed.), Drowning, DOI 10.1007/978-3-642-04253-9_102, © Springer-Verlag Berlin Heidelberg 2014
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human resources and equipment for drowning prevention and rescue. Nonetheless, counties or regions are different and what works in one area may not necessarily work in another. Table 102.1 Priority levels met in Tarrafal Beach and Piha Beach
Communication Sign or flag outside that shows that first aid facilities are available inside Signs at each beach access where first aid facilities are available Signs at each beach access where medical facilities are available Static or mobile phone at central post Mobile phone or other means of communication during patrol Integration in local/regional communication emergency network Direct communication with hospital or medical adviser Local/regional communication between lifesavers for educational purposes Internet access Critical incident debriefing Medical training First aid and basic life support training for each lifeguard Drowning-related first aid and basic life support training for each lifeguard Rescue boat BLS In water BLS Use of AED Mouth-to-mask ventilation Mechanical suctioning Use of oxygen Spinal immobilisation on land (without equipment) Spinal immobilisation in water Advanced life support Refresher training on location each 6 months Recertification each 2 years Knowledge of health risks in lifesaving Marine stings Hypothermia Hyperthermia Medical disorders Psychological disorders Scuba injuries
Tarrafal Beach
Piha Beach
Priority level
Met
Met
1
No
Yes
2
No
Nob
3
No
Nob
1 2
Yes No
Yes Yes
1
Yes
Yes
3 3
No Yesa,b
Noc Yes
3 1
No Noa,b
Yes Yes
1 1
Noa,b Noa,b
Yes Yes
2 2 2 2 2 2 2 3 3 1 1 1 2 2 2 3 3 3
No No No No No No No No No Noa,b Noa,b Noa,b No No No No No No
Yes Nod Yes Yes Yes Yes Yes Nod Nod Noe Yes Yes Yes Yes Yes Yes No Yes
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Table 102.1 (continued)
Quality control Standard of care review Injury reporting and statistics Equipment Professional medical expertise available to the location Basic first aid set Extended first aid set Mechanical suctioning Free flow oxygen bottle static Free flow oxygen bottle mobile Non-rebreathing (NR) oxygen mask Oxygen mask for mouth-to-mask ventilation with oxygen inlet Bags and masks for ventilation Pulse oximetry Automated external defibrillator static Automated external defibrillator mobile Equipment for spontaneous external rewarming Cervical collar Spinal board Eye cleaning set Simple treatments for stings Stretcher Ambulance stretcher Clean water Logistics Arrival at site of incidence of ambulance, helicopter or four-wheel drive ambulance within 15 min Ambulance or helicopter access plans for transfer to an emergency medical system Ambulance and lifesaving stations use identical standard equipment a
Tarrafal Beach
Piha Beach
Priority level
Met
Met
1 1
No No
No Yesf
3 1 2 2 2 3 2 2
No No No No No No No No
Yes Yes Yes Yes Yes Yes Yes Yes
3 3 2 3 3 2 2 2 1 1 3 1
No No No No No No No No No No No Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes
2
Yes
Yes
1
Yes
Yes
3
No
No
During high season only Still not extended to all lifeguards c SurfCom(HQ) can contact the hospital on behalf of lifeguards for medical advice and connect them by telephone or relay instructions by radio d Not appropriate for a heavy surf environment or not deemed necessary by SLSNZ or the club or not considered the role of lifeguards in New Zealand e Surf lifesaving clubs only operate for 6 months of the year. Annual refresher training is provided f An incident/accident report form is completed for every intervention, but the only data reported back is the total number of interventions performed and no breakdown by injury type/age/sex, etc. b
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Drowning Resuscitation Centres, Brazil
Perhaps the best example of a fully integrated beach medical service is that provided by the Fire Department of Rio de Janeiro in Brazil. Rio de Janeiro has one of the most populated beaches in the world, with three million beach visitors annually. The lifeguard service is responsible for 100 km of coastline employing 1,600 lifeguards along with specialised medical teams in three patient treatment centres known as Drowning Resuscitation Centres (DRCs). The DRCs are medical facilities at the beach developed in the 1960s specifically to deal with aquatic emergencies (Fig. 102.1). The medical retrieval team is comprised of a medical doctor, an EMT and an ambulance driver. DRCs are staffed between the hours of sunrise and sunset. An emergency room with full advanced life support equipment is available at each DRC to provide initial treatment before a decision is made to transport the patient to hospital. A helicopter medical service is also available. In the past 42 years there have been 256,000 rescues, of which 12,850 (5 %) required medical attention [2]. In a 9-year retrospective study in one DRC responsible for 50 km of coastline, there were 46,060 rescues made by lifeguards, 97 deaths by drowning, 5 bodies not found and 34 bodies found at least 1 h after submersion. From these rescues, 930 (2 %) were referred to the DRC. The remaining 45,130 cases were released directly from the beach. The medical team also provided assistance in 3,480 other incidents. These included 1,590 medical cases,
Fig. 102.1 Drowning Resuscitation Centre, Rio De Janeiro, Brazil (Picture: David Szpilman)
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1,404 trauma cases and 375 marine envenomations. Among these cases there were 12 deaths [3]. The creation of DRCs has proven extremely worthwhile in reducing dispatch times and the need to refer some patients to hospital. It has also strengthened the link between pre-hospital services and hospitals. By providing advanced life support at the beach, this system delivers a high standard of patient care and excellent backup service to lifeguards.
102.3
Background: Lifesaving in Two Extremes
102.3.1 Piha Piha is a small coastal village located 40 km west of Auckland, the largest and most populated city in New Zealand (Fig. 102.2). Regarded as one of the most popular surfing beach in New Zealand, it is also one of the most dangerous. Piha has a grade eight hazard rating and the highest total number of surf rescues and drownings of any beach in New Zealand [4]. With its close proximity to the city of Auckland, Piha is a popular recreational destination and in the summer months attracts thousands of visitors. The Piha Surf Life Saving Club started in 1934 and has been at the forefront of lifesaving innovation for over 75 years. The club introduced Malibu surfboard riding from the USA to New Zealand in 1958, and with the Auckland Surf Life Saving Association, jet rescue boats and the first civilian rescue helicopter in the world. The Arancia inflatable rescue boat was also trialled and developed at Piha [5]. Despite its dangerous reputation, the drowning toll in Piha now averages 0–2 per year. This low toll may be due in part to a number of collaborative drowning
Fig. 102.2 Piha Beach, New Zealand (Picture: Kim Kerrgan)
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prevention strategies operating on multiple levels. Examples of these include beach safety signage, lifebuoys at fishing black spots, media campaigns and integrated rescue services. Two surf lifesaving clubs patrol during weekends and public holidays from late October until Easter, and paid lifeguards operate during the week from December to March. Resident lifeguards also respond to after-hours emergencies. On a regional and national level, activities are coordinated by the parent body of the club, Surf Life Saving New Zealand (SLSNZ).
102.3.2 Tarrafal Tarrafal is a seaside city and fishing port on the north-western coast of Santiago, which is the largest island of Cape Verde archipelago [6], and a popular holiday spot not only for foreigners but also for Cape Verdeans (Fig. 102.3). As in other LMICs with water-related tourism, visitors and locals residing inland are often unaware of beach hazards making them a high-risk group [7]. Mainly due to increasing tourism and concomitant concerns around preventing injury to foreigners, partnerships have been established at the institutional level to address public safety issues in and around aquatic environments [8]. As a result of the cooperative efforts between Associação de Nadadores Salvadores (AsNaSA: National Association for Water Safety) in Portugal and other Portuguese-speaking nations, AsNaSA Portugal provided also the international assistance that led to the creation of AsNaSA Cape Verde in April 2010 [9]. Since its foundation, AsNaSA Cape Verde has adopted the system of three priority levels for drowning-related medical assistance as recommended by ILS and will be responsible for its implementation in Tarrafal. As a short-term measure,
Fig. 102.3 Tarrafal de Santiago Beach, Cape Verde (Picture: Ana Catarina Queiroga)
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the Tarrafal municipality and AsNaSA Cape Verde agreed to provide a lifeguard service during the summer of 2010 to ensure the safety of swimmers on the 700 km of Tarrafal coastline. Tarrafal Beach is now patrolled by lifeguards from June to September. Accidents and incidents around water, as well as drownings, are not systematically recorded. The few records that do exist are based on verbal reports, so there is limited appreciation of the real burden of drowning.
102.4
Case Study 1: New Zealand, Piha Beach
Under the SLSNZ qualification pathway, all new lifeguards are trained in basic first aid and CPR as part of the Surf Lifeguard Award [10]. Three modular levels of advanced resuscitation and first aid training are then offered [11]. By the time all modules are achieved, lifeguards hold the equivalent of First Responder under the ambulance qualification framework [12]. Certificates are valid for 2 years, and all lifeguards must undertake an annual refresher course. The new medical room in Piha was opened in 1996 and features a 3-bedded room complete with piped oxygen supply (Fig. 102.4). Two bed spaces are for first aid, the third for resuscitation. A flexible shower head and foot-wash station was recently installed for cleaning wounds and treating bluebottle jellyfish stings with hot water. The resuscitation bay has a wall-mounted power suction unit; non-invasive patient monitoring such as blood pressure, heart rate, temperature and pulse oximetry; a height-adjustable trauma bed; and advanced airway and intravenous equipment for
Fig. 102.4 Piha SLSC First Aid Room (Picture: Jonathon Webber)
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use by health professionals. An automated external defibrillator (AED) has been available since 1997. Several portable kits and a variety of stretchers are also available for major incidents or in the event of equipment failure in the medical room. The standard ambulance response time to Piha is 30 min by road or 13 min by air. Due to the rugged geography of New Zealand and high number of isolated beaches and coastal townships, response times of 30–45 min or longer are not uncommon. Volunteer first responders are normally on scene within 5 min; however they do not attend all beach-related emergencies. It is not uncommon therefore for nonurgent cases to be in the care of lifeguards for an hour or more. Despite this, having a purpose-designed facility, coupled with the qualification pathway provided by SLSNZ, has allowed the Piha Surf Life Saving Club to meet the majority of ILS Medical Commission priority levels (Table 102.1).
102.5
Case Study 2: Cape Verde, Tarrafal de Santiago Beach
The approach to drowning-related first aid in Cape Verde is fragmented in comparison to a reasonable level of medical service inland. At beaches with large numbers of tourists such as Tarrafal, there is direct intervention by lifeguards during the high season from June to September. Some lifeguards have basic training in first aid, a level 1 according to the European Qualification Framework (EQF) (Chap. 57). There are other lifeguards with no training in CPR at all. Institutionally, the Tarrafal city mayor is supporting these services; however there is no first aid equipment available and only one rescue board plus a few rescue tubes. This is less than one for each lifeguard on patrol. This level of service reflects in part the difficulties the country has experienced since independence but also suggests that increased development needs to take place using local resources supplemented with international support. Nevertheless, the lack of specialised resources for a structured system of medical care in aquatic areas has been offset somewhat by the existing emergency response provided by paramedics and fire fighters and the relatively low-risk conditions at Tarrafal Beach. Tarrafal opened a new community health centre in March 2011 located only 5 min from the beach. The centre has ramp access for vehicles and is approximately 15 min from the Central Hospital. Despite this improvement the link between the first-level responders and other systems of secondary and tertiary prevention is practically non-existent. Table 102.1 details the priority levels of medical facilities met in Tarrafal Beach.
102.6
Future Developments
The challenge for Piha and surf lifesaving clubs throughout New Zealand will be to ensure that sufficient members are trained in first aid and that lifeguard services are located where a demonstrated need exists. Being a not-for-profit organisation,
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building construction, facility maintenance and equipment-related costs are important considerations as not all New Zealand beaches will require ILS priority level 3 medical facilities. A site-specific assessment should therefore be conducted to determine the level of cover required, which also takes into account ambulance response times, distance to hospital and local medical resources available. Despite recent developments in the study of drowning and prevention strategies in LMIC, which have helped modify the implementation plan for 2010–2013 in Cape Verde, it is still necessary to conduct similar studies under the unique circumstances that affect drowning in this setting so that appropriate interventions can be identified and implemented in the future [13–16]. An action plan has been developed with the cooperation of local, regional, national and international agencies to reach the first priority level by the end of 2013. The Drowning Prevention Strategic Framework 2010–2013 is ambitious in scope and positioned to reduce water-related injuries. Five core areas have been identified as urgently needing research investment so that appropriate interventions can be identified and implemented: • Improving injury data collection • Defining the epidemiology of unintentional injuries • Estimating the cost of injuries • Understanding public perceptions about injury causation • Engaging with policymakers to improve injury prevention and control Before AsNaSA Cape Verde started, there was no formal structure dedicated entirely to drowning prevention. With the continued support of AsNaSA Portugal, qualified lifeguards can be trained abroad to higher levels of emergency care (level 4, EQF) in accordance with the ILS framework [9, 17]. This will provide additional resources for the creation of local and regional organisations with first aid and resuscitation units, leading to an improved standard of medical care. In these settings the prevention of drowning takes place through progressive social adaptations that occur in the short to medium term.
References 1. Brewster BC (2003) Open water lifesaving: the United States lifesaving association manual, 2nd edn. Pearson, Boston, p 19 2. Szpilman D (1997) Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest 112:660–665 3. Szpilman D, Elmann J, Cruz-Filho FES. Drowning resuscitation centers; ten years of medical beach attendance in Rio De Janeiro, Brazil. Book of abstracts. World Congress on Drowning, Amsterdam 2002, p 167 4. Water Safety New Zealand (2008) Beach drownings at New Zealand beaches (Data file 1980–2008). Retrieved from Water Safety New Zealand Drownbase™ 5. Coney S (2009) Piha guardians of the iron sands; the first 75 years of the piha surf life saving club. Piha SLSC, Auckland 6. Peace Corps (2013) The Peace Corps welcomes you to Cape Verde. www.peacecorps.gov/ welcomebooks/cvwb655.pdf Accessed 10 Aug 2011
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7. Lakadamyali H, Dogan T (2008) Investigation of drowning cases in tourism region of turkey. Turkiye Klinikleri Tip Bilimleri Derg 28:143–148 8. Cortes LM, Hargaten SW, Hennes HM (2006) Recommendations for water safety and drowning prevention for travellers. J Travel Med 13:21–34 9. Martinho F, Seabra R, Domingos J, et al (2011) Strategies to promote new water safety organizations in Angola, Cape Verde, Mozambique and São Tomé and Príncipe a case study of AsNaSA Portugal’s cooperation for Africa. In: Scarr J. et al (eds) World Conference on Drowning Prevention, Danang, 2011. International Life Saving Federation, Leuven, p 280 10. Surf Life Saving New Zealand (2013) Become a surf lifeguard. http://www.surflifesaving.org. nz/lifeguarding/become-a-lifeguard/become-a-surf-lifeguard/ Accessed 28 Aug 2011 11. Surf Life Saving New Zealand (2013) First Aid Levels 2012. http://www.surflifesaving.org.nz/ media/148167/2012_slsnz_firstaid_levels.pdf Accessed 28 Aug 2011 12. St John (2013) What we do; St John ambulance services. http://www.stjohn.org.nz/Whatwe-do/St-John-Ambulance-Services/Our-People/ Accessed 28 Aug 2011 13. Mashreky SR, Baset K, Rahman F et al (2011) The social autopsy – a tool for community awareness after a drowning event. In: Scarr J. et al (eds) World Conference on Drowning Prevention, Danang, 2011. International Life Saving Federation, Leuven, p 65 14. Mecrow T, Rahman A, Nusrat N et al (2011) Barriers to CPR in a rural LMIC setting. In: Scarr J. et al (eds) World Conference on Drowning Prevention, Danang, 2011. International Life Saving Federation, Leuven, p 67 15. Nusrat N, Mecrow T, Rahman A et al (2011) Large-community training in CPR as a basis for a community response system in a LMIC. In: Scarr J. et al (eds) World Conference on Drowning Prevention, Danang, 2011. International Life Saving Federation, Leuven, p 72 16. Walker D, Rahman A, Hosaain J et al (2011) Behavioral change communications for drowning prevention in low literacy environments. In: Scarr J. et al (eds) World Conference on Drowning Prevention, Danang, 2011. International Life Saving Federation, Leuven, p 84 17. International Life Saving Federation (2013) ILS Drowning Prevention Framework 2008 edn. www.ilsf.org/sites/ilsf.org/files/filefield/drowning-prevention-strategies-ils-boardapproved-200807101.doc Accessed 10 Aug 2011
