CPR training for lifeguards: new research, new thinking.

Our lifeguards call it "Baywatch CPR." It's the miracle of television and films. To a tense musical soundtrack, a lifeguard checks the victim's neck and dramatically shouts out, "No pulse!" The heroic lifeguards complete an average of three cycles of chest compressions and breathes when the victim suddenly sits up and coughs. "You'll be all right," the lifeguards say. In the next scene the victim is sharing a romantic dinner with one of the lifeguards.

Of course we recognize these scenes for what they are, fiction. In real life, people who require CPR don't get up and walk around a few minutes later. In fact, most don't get up at all. Extensive research into survival rates for cardiac arrest victims indicates that the survivor rate is surprisingly small, maybe less than five percent.

Most of these studies focused on adult victims whose cardiac arrest was brought on by non-traumatic factors. There is no extensive research into survivor rates for children who experience cardiac arrest or for drowning victims who experience cardiac arrest as a result of respiratory failure. Still, there is no reason to believe that the survivor rates for such circumstances would be significantly different.

Yet, research into CPR has recently produced a development with implications for lifeguarding. A three-year study in New York City examined 662 cases of individuals who received CPR from a bystander. The survivor rate for these victims was found to be 4.6%. Yet, in cases when CPR was performed ineffectively, the survivor rate dropped to only 1.4%. From this study we can infer that doing CPR poorly is only marginally better than not doing it all.

The implication of this study is that we cannot tolerate lifeguards having poor CPR skills. The contemporary expectation of our profession is that lifeguards are professional rescuers, as capable of performing effective CPR skills as any police officer or emergency medical technician (EMT). Unfortunately, this is not always the case. The most common reason lifeguards fail audits or examinations by outside firms like the American Red Cross or Ellis and Associates is not lack of skill in the water, but mistakes in CPR skills.

The Catch-22 in lifeguard CPR skills is that, while these skills are critical, they are also very unlikely to be needed. EMTs in highly populated areas may perform CPR several times a month. Yet, most lifeguards will never need to administer CPR in a real situation.

Without the experience of real emergencies, lifeguards must rely on simulations to maintain effective CPR skills. Since CPR skills are more complex than other lifeguard skills, they require more training and more reinforcement to maintain. Evidence of this can be seen in the amount of time devoted to CPR in current lifeguard certification courses. In Red Cross Lifeguard Training, for example, nine hours is spent on CPR training: this accounts for one third of the course.

However, even with the amount of time spent on CPR skills in lifeguard courses, we would be fooling ourselves to believe that all lifeguards will come to work for us with excellent skills right from the start. CPR skills are a lot like driving skills. We may hand our car keys to a 16-year-old with a brand new license, but only with a great deal of trepidation. The license only says the teenager knows how to drive, not that they are a skilled driver. With a couple months of practice, the average teenager will be able to eat a hamburger, tune the radio and change lanes all at one time. We have to give the same attention to practicing CPR skills for lifeguards.

Skills Need Reinforcement

New lifeguards and lifeguards returning from a long winter season off should have CPR skills reinforced several times a week in the early part of the season. Lifeguard trainers should also watch for guards who experience trouble remembering skills or performing them consistently. These guards should be assigned additional practice, possibly even on a daily basis.

Yet, the amount of practice is not as important as the approach. Naive lifeguard trainers may believe that watching video-tapes and demonstrations, or holding verbal discussions are sufficient methods for reviewing skills. This is not true. CPR is a psychomotor skill that requires active practice.

Like other psychomotor skills, CPR is best learned in basic forms first. Other skills are then more easily assimilated. For example, new lifeguards should probably practice only adult CPR skills at first. When these skills are performed effortlessly and flawlessly, the additional skills for infants, children and two-person rescues are more easily assimilated.

CPR skills practice should also give lifeguards as close a taste of reality as possible. Some trainers try to accomplish this with "live victim" practice. Lifeguards who are trained exclusively on manikins often express surprise at how different the skills "feel" on a real person. However, there are disadvantages to live victim practice. A lifeguard cannot do actual chest compressions or abdominal thrusts on a live victim. It is also difficult to practice rescue breathing since most "victims" are unlikely to tolerate the experience. The best experience is a combination of manikin and live victim training.

Lifeguards should also practice CPR skills under conditions that simulate a real emergency. For example, it is a good idea to practice scenarios that integrate an unconscious victim rescue with performing CPR on the pool deck. Pulling the victim from the water and performing CPR while dripping wet is an experience all lifeguards should practice before they really need to perform. It is also a good idea to take steps to simulate the stress a lifeguard will experience in a real cardiac arrest situation. Lifeguards should be able to perform effective CPR skills in spite of distractions around them.

The same principle applies to the equipment used in CPR. All lifeguards in the United States are now trained to use resuscitation masks for rescue breathing, regardless of which agency does the training. Yet, when they arrive at work they often find a different type of mask, a microshield-packaged in sterile pouches, intended for a single use-or nothing at all. Facility operators that provide no protective barriers for lifeguards to use in rescue breathing are either ignorant or reckless. Facilities that rely on micro-shields are not much better.

Research into CPR may also lead us to question the methods we use to train life-guards. For example, CPR instructors have always emphasized the importance of avoiding low hand position in chest compressions. Low hand position, we have always said, risks breaking off the tip of the breastbone and doing damage to internal organs. So much emphasis has been placed on this single element of CPR skills, that lifeguard auditors and examiners fail lifeguards who make this mistake, even if all their other skills are acceptable. An interview with Dr. E. John Gallagher, one of the authors of the New York City study, reveals that this approach to training may be counterproductive.

Understanding the Two Theories

"There is little evidence of damage from a broken xiphoid or ribs," says Dr. Gallagher. "You have to remember that a cardiac arrest victim is dead. Compared with that fact, a broken rib is nothing."

Although there is no medical research on hand position in CPR, there is a possible danger that improper hand position will not produce effective circulation. This is why our current training approach is questionable. By penalizing lifeguards for low hand position we risk them over-compensating with high hand position, a technique that is unlikely to be effective.

To illustrate this, it is important to understand the two theories about how CPR circulates blood. Dr. Gallagher describes one theory as the compression of the heart between the sternum and the spine, an action that forces blood out of the heart into the arteries. The other school of thought, according to Dr. Gallagher, is the thoracic pump model. This theory holds that the release of the chest compression creates a vacuum in the heart, drawing blood into it. In either event, hand position over the lower third of the sternum is critical since this is where the heart resides in the chest.

If we train lifeguards with this information in mind, we may adopt different standards for an acceptable chest compression. To use the criteria of Dr. Gallagher's study, any chest compression that produces an artificial pulse is an effective compression, regardless of hand position on the chest.

Medical research on CPR has also produced the "Chain of Survival" concept that is incorporated into contemporary training courses. Dr. Richard Cummins and other members of the Emergency Cardiac Care Committee of the American Heart Association developed this concept in the latest CPR standards published in 1991. According to the committee, the best hope for cardiac arrest victims lies in early CPR and early defibrillation.

Applying these principles to lifeguarding, early CPR should not be a problem. Lifeguards should have no trouble beginning CPR within the four-minute standard set by the committee. However, defibrillation in less than eight minutes may be a challenge in communities without adequate EMS coverage. It is difficult to imagine an EMS response time of more than eight minutes at a suburban swimming pool. Yet, in a densely populated metropolitan area, at a remote beach or in a large waterpark, the possibility of an extended response time does exist.

Technology may have produced an answer to this problem. Computerized defibrillator units that require little training are now available. Some medical experts advocate making these units more accessible, as well as training more people to use them. There may come a time when these units are included in lifeguard training.

For now, however, we should share the cold reality of CPR research with the lifeguards we train for two reasons. First, we can help debunk the hero image held by many young people in the profession. This image can be haunting if they are ever involved in a catastrophic emergency; they may not understand why their best efforts to revive a victim still failed. More importantly, understanding the realities of CPR survivor rates may help make lifeguards more vigilant. All lifeguards must know that a victim has a far greater chance of surviving if the circumstances never reach the point where CPR is necessary. The little voice inside that says, "I can save someone so I don't need to be as careful" is a voice we should train lifeguards to ignore.