Water Rescue Tradecraft: In-Water Mouth-to-Mouth Ventilations, Risk vs. Efficacy

Lifeguards practice resuscitating a drowning victim on a dummy

For more than 70 years, veteran ocean lifeguards and water rescue techs have told stories of dramatic rescues involving intoxicated combative victims, austere conditions, dangerous hydraulics, mouth-to-mouth ventilations, and a lot of vomit. Some of the more obscure lifeguard instructors I have known speak about the rapid administration of mouth-driven ventilation as a necessity for a drowning victim to survive the event. Some of the more ill-informed instructors that dot our profession boast of their vast experience in the trenches using the pocket mask during resuscitation, which they swear provides adequate protection from disease, even when full of emesis and respiratory fluids. Today, most every lifeguard and water rescue manual agree that rescuers should consider ventilating a drowning patient even while still in the clutches of a rescue. In the same breath, our industry’s manuals tend to downplay the probability and the danger of rescuer exposure to lethal chemicals and diseases while administering mouth-to-mouth or mouth-to-mask ventilations. Sometimes the warnings associated with these procedures are buried in another chapter or never mentioned at all.

The Study That Set the Standard

America’s leading lifesaving organizations and the authors of our industry’s technical manuals—United States Lifesaving Association (USLA), National Fire Protection Association (NFPA), American Red Cross (ARC), Young Men’s Christian Association (YMCA)—set the standards and practices for water rescue operations in the United States. When it comes to clinical resuscitation of drownings, lifeguard experts look to one resource to set their medical standards: the American Heart Association’s (AHA) Emergency Cardiovascular Care (ECC) Guidelines.⁽¹⁾ Since the mid-1980s, the AHA has set the standard for drowning resuscitation^.(1) Strangely, the importance of ventilating a drowning patient without delay (including in-water ventilations) is based on one study⁽²⁾ in particular which was completed over 25 years ago in Pasadena (inland), California, that looked at a mere 166 cases of freshwater submersion injuries (86% occurring in pools/spas and 14% occurring in a bath, lake, or pond). The study shows a significant increase in survival in the one- to four-year-old age group. Most of the total survivors in this study had only momentary shallow water submersions, with the event occurring within arm’s reach of their parents/guardian who made the rescue with little delay. Most of the pediatric survivors were underwater only briefly and were given mouth-to-mouth ventilations by their parents/guardians without delay following the rescue. It is important to mention that not one surviving child from this study was rescued by a lifeguard or received in-water ventilations. Not one of the cases mentioned the administration of in-water ventilations, thus failing to show the efficacy of the procedure. Another well-cited study shows that avoiding delays to ventilate drowning victims is an important factor leading to successful resuscitation and suggests that in-water ventilations prevent those delays, but it proves little about efficacy or safety of the procedure.⁽³⁾ Conversely, one professional aquatic organization took a bold stance and published their position on the matter of in-water ventilations. The International Journal of Aquatic Research and Education published their position on the matter in 2008.

From the International Journal of Aquatic Research and Education: “We could not find any experimental or scientific studies conducted specifically by any of the lifeguard agencies that support the methods and practices they have implemented for in-water rescue breathing.” ⁽⁴⁾ This was a quantitative peer review of American lifeguard training practices and relative curricula as well as the studies and associated science that reflect the use or suggest the theory that in-water ventilation improves outcomes for those victims rescued in a peri-arrest state or those in complete respiratory cardiopulmonary arrest. Today there is still zero evidence from any lifeguard service, clinical care program, or prehospital training source that this procedure works.

Procedural Risk Assessment

Postmortem studies looking at fatal drownings report that 72-80% of victims aspirate water as well as emesis at some point during the fatal event. The cause of aspiration can be attributed to overzealous first responder ventilations and can also be explained through the pathophysiology of the active drowning process, which includes air gulping and involuntary ingestion of water by the victim. Even before resuscitation measures begin, gastric distension combined with a major influx of adrenaline can lead to vomiting and then aspiration. Usually, during the final panic to live, the victim struggles to get as much air as possible before submerging with their mouth wide open, gulping a mixture of air and water. If a rookie lifeguard making a critical rescue is mandated to provide in-water resuscitation, there is a risk of a sudden eruption of emesis during mouth-to-mouth ventilation. If that lifeguard contracts an infection or is poisoned, this could be considered a possibly negligent procedure (for management) because this is a preventable exposure.

The Occupational Safety and Health Association’s (OSHA) position: OSHA does not recognize, nor classify as safe and prudent, any mouth-based medical procedure administered by professional health care workers. OSHA has taken a stance against mouth-to-mouth ventilation due to the inherent risk of cross contamination and exposure to bloodborne pathogens. It is logical to assume that this stance should also include mouth-to-mask procedures too. Please see OSHA’s official position statement.

Infectious Disease Cross Contamination

The industry’s standard pool and open water lifeguard training curricula follow the AHA’s recommendations of considering mouth-to-mask ventilation as safe and in-water mouth-to-mouth ventilation as a key to victim survival. What is troubling is that most water rescue training organizations and resuscitation curricula fail to sternly warn professionals in strong enough terms about the extreme health dangers from exposure to body fluids and respiratory secretions. ^5,6,7,8 The risk of bloodborne pathogens is often just a side note, sometimes hidden in a separate chapter, even though the dangers from infectious disease have been apparent for the last four decades. The last 40 years are chock full of thousands upon thousands of cases of infected health care workers and rescue personnel exposed during patient care to Hepatitis B, TB, HIV, Strep, Influenza, Salmonella, E Coli, ARDS, SARS, RSV, and now SARS CoV2 (COVID-19). Per OSHA, more than 8,700 health care workers every year have contracted Hepatitis B during the course of their duties. ⁽⁵⁾ Now consider the thousands of first responders that have been infected with COVID-19 who suffered catastrophic consequences over the last two years and you will see the training conundrum for these dangerous procedures. The probability of a line-of-duty exposure to a lethal virus increases exponentially when mouth-to-mouth, mouth-to-nose, mouth to stoma, or mouth-to-mask ventilations are performed. ⁽⁸⁾

Chemical Cross Contamination (Poisoning)

Drowning resuscitations are known for “messy airways” caused by emesis, sputum, or respiratory secretions secondary to pathological pulmonary edema which may or may not contain lethal amounts of a dangerous narcotic or chemical. Water rescue instructors, no matter the discipline, need to stress the dangers of cross contamination and poisoning from mouth-to-mouth and mouth-to-mask ventilation. A good majority of adult and teenage water rescue victims that happen each summer involve alcohol or drugs, with one of the most prominent and deadly drugs today being fentanyl. Fentanyl can easily cross-contaminate during resuscitation with lethal consequences. It is not uncommon to hear about innocent bystanders, police officers, and nurses being poisoned via cross contamination from drugs like fentanyl. For example, look at the recent mass overdose in Miami where six college students at one pool party overdosed on fentanyl-laced cocaine. Three of the six revelers fell ill trying to resuscitate their friends, according to a Miami-Dade Fire Rescue PIO; two of the cases remained in the ICU for an extended period of time, suffering from multiple issues secondary to the overdose.

Pocket Masks

Don’t be fooled by those lifeguards who carry pocket masks everywhere they go. Those masks give young rescuers a false sense of security. In the water, a pocket mask is a moot point, primarily because the use of a pocket mask relies on a good seal with a rescuer using both hands to maintain mask position in conjunction with an airway maneuver. Experienced lifeguards know it is virtually impossible to float with an unresponsive victim while maintaining an open airway and a good seal. Even worse than a bad seal, the typical pocket mask still relies on the rescuer using their mouth to ventilate through a one-way valve just a few inches from a patient’s airway. A pocket mask does little to prevent the spread of deadly contaminants and pathogens, especially if a rescuer is dealing with a messy airway. Lastly, forget about the one-way-valve and the myths of HEPA filter-equipped pocket masks providing any significant protection against bloodborne or respiratory droplet pathogens in the prehospital environment. One can conclude that pocket masks are useless based on the pathophysiology of the spread of COVID-19 as the science shows that a barrier device cannot protect a rescuer from a coronavirus infection.

Curriculum Modification

First, rapid airway management and immediate oxygen delivery remains a primary factor for a successful drowning resuscitation.⁽¹⁾ However, the water rescue and lifeguard community should look towards ways to rapidly and safely deliver oxygen using prioritized procedures that align with current resuscitation science. Second, the time has come to consider removing the procedure of in-water ventilation and all mouth-based medical procedures from rescue and resuscitation curriculum, and instead emphasize specialized resus training that includes early implementation of a bag valve mask (BVM) for initial ventilations. The following is a task list outlining the preparation and execution of a water rescue of an incapacitated victim who is not breathing, minus both in-water ventilations and on-shore mouth-to-mask ventilations.

Only attempt a water rescue if properly trained and equipped to do so.
All water rescue personnel should train extensively and be functionally fit for low probability/high-risk events such as the rescue of incapacitated victims who need resuscitation.
The top priorities for drowning events encompass getting to the victim quickly, securing the victim in the rescue flotation device, and effecting the rescue. No delay is ever indicated for resuscitation efforts during the actual physical rescue.
Bleeding cannot be controlled effectively in the water. Get the victim out of the water before BCON.
Once on shore, the quick initiation of compression-only CPR is key to survival, followed by airway management and ventilation .
BVMs equipped with a PEEP valve and HEPA filter should be readily available in all rescue apparatus and jump kits that deploy with water rescue personnel.
Every rescuer should know how to communicate to shore using arm signals that they have a resuscitation case. This allows dry-sand rescuers to retrieve an AED, BVM, and set-up for immediate airway management, oxygen delivery, and early defibrillation once the victim is extracted from the water.
During extrication from the water, the victim is rapidly moved to a dry area where the rescuer will then initiate high-quality ‘compression only’ CPR/CCR which will in turn ventilate the victim via passive ventilation accomplished by the Bellows Effect. ^9,10,11 This can provide a stopgap until PPE is available and proper oxygen delivery devices can be used^{. 1}
Rescuers will manage the airway and ventilate using a BVM once it is available. Breaths should be delivered at an appropriate rate and volume, paying special attention not to over-ventilate, hyperventilate, or under-ventilate.
Supplemental oxygen should be used as soon as available. ¹
Rescuers should deploy the AED as soon as available without interrupting compressions to place pads. ⁽¹⁾
Rescuers should not interrupt resuscitation once it begins; chest compressions should not be interrupted for more than five seconds. Ten seconds is the maximum time gap allowed for an interruption in compressions. ⁽¹⁾
Don’t forget mechanical electric suction. Manual suction is not as effective in cases of pulmonary edema.
Consider advanced airway management; intubation with weight specific ventilation tidal volumes, in-line suctioning, placement of an NG tube, and adjustable mechanical ventilation with PEEP and BiPAP.

Below is one of the best videos of a resuscitation I have ever seen, showing proper resuscitation provided only by lifeguard personnel. This video shows the proper order of events as an elite team of Aussie lifeguards take care of business safely and aggressively. Though some of the guards failed to don gloves initially, the video shows how things really go down during a drowning resuscitation, and the risk presented is minimal.

There can be little doubt as to the risk and lack of benefit associated with in-water ventilations or the threat posed by infectious diseases and narcotics during mouth-to-mask ventilation. The rapid removal of a victim from the water with immediate resuscitative procedures on land is a much better choice than starting resuscitation mid-rescue only to pause efforts to complete the rescue. It is my hope that the physicians and faculty as well as my higher-ranking colleagues who set our curricula, especially within the AHA, will sit down and reevaluate their position on the safety and efficacy of mouth based ventilatory procedures, the time has come. The bottom line is that in-water mouth-to-mouth or in-water mouth-to-mask breathing has never been proven effective or beneficial enough to ignore the golden rule of rescuer safety. Mouth-based procedures have no place in modern professional water rescue curriculum nor do they belong in any HCP training curriculum, even though they are still endorsed by some of America’s top resuscitation curricula and lifeguard training programs around the globe.

REFERENCES

(1) AHA 2020 ECC Guidelines, Adult Basic Life Support, Part-3, Drowning Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care | Circulation (ahajournals.org)

(2) Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. 1994; 942 Pt 1137–142. Effect of immediate resuscitation on children with submersion injury

(3) Szpilman D, Soares M. In-water resuscitation–is it worthwhile? Resuscitation. 2004; 63:25–31. doi: 10.1016/j.resuscitation.2004.03.017

(4) International Journal of Aquatic Research and Education, Published 2/1/2008 Volume 2, Number 1, Article 5, The Issue of In-Water Rescue Breathing: A Review of the Literature Tomas Leclerc Alabama A&M University, Juan Canabal Mayo Clinic Transplant Center, Heather Leclerc University of Alabama-Tuscaloosa. https://scholarworks.bgsu.edu/cgi/viewcontent.cgi?article=1261&context=ijare

(5) Health Care Occupational Deaths a CDC report https://wwwnc.cdc.gov/eid/article/11/7/04-1038_article

(6) Accidental exposures to blood and body fluids among health care workers in a Referral Hospital of Cameroon Julienne Stéphanie Nouetchognou, Jérôme Ateudjieu, Bonaventure Jemea & Dora Mbanya BMC Research Notes volume 9, Article number: 94 (2016) https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-016-1923-8

(7) International Safety Center – EPINet Reports on Body Fluid Exposures BFE 10 published annual reports from 2010 to 2019 American https://internationalsafetycenter.org/exposure-reports/

(8) In memoriam: COVID-19 deaths among public safety, local government personnel. Author Sarah Sinning with imbedded links to US government COVID fatality statistics for 5 separate public safety job categories In memoriam: COVID-19 deaths among public safety, local government personnel (gov1.com)

(9) Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. A Hallstrom¹, L Cobb, E Johnson, M Copass N Engl J Med 2000 May 25;342(21):1546-53. https://pubmed.ncbi.nlm.nih.gov/10824072/

(10) Bystander-initiated chest compression-only CPR is better than standard CPR in out-of-hospital cardiac arrest HSR Proc Intensive Care Cardiovasc Anesthesia. 2010; 2(4): 279–285. L Cabrini,¹ G Biondi-Zoccai,² G Landoni,¹ M Greco, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484593/

(11) Passive Ventilation in Chest Compression-Only CPR by Untrain… : Anesthesia & Analgesia (lww.com) Anesthesia and Analgesia, published February 2018 – Volume 126 issue # 2

Mike Hudson has been an ocean lifeguard-paramedic since 1990 and has worked as a street level paramedic and EMS instructor for almost as long. He is a former Navy Corpsman and taught the in-house SOT EMT and paramedic courses at NSWG-1 (West Coast SEAL and Marine Force Recon teams) for almost 10 years. He served as an ocean lifeguard and paramedic in San Diego, California, and Panama City Beach, Florida, for more than 18 years before spending another four years in the Rocky Mountains as a HEMS SAR paramedic in Gunnison and Montrose counties. Since 2014, during the summer, Mike commands a nationally certified surf/river RWC response team and directs municipal open water and surf lifeguard operations for two separate beach towns in Monmouth County, New Jersey. In the winter, Mike works as a paramedic rescue diver coordinating marine safety and medical operations for several major networks that create high-risk productions involving apex predators, including extensive work since 2003 for Shark Week and Shark Fest. He is a technical rescue contributor for Fire Engineering magazine and has a recurring column in JEMS called pre-hospital tradecraft. As a hobby, Mike produces a nationally recognized public safety/technical rescue podcast aptly titled “Lifeguards 10-8.”