Rescue Course -- Should it be changed?

[t-mac]

There was a recent thread on in-water chest compresssion techniques. This was prompted by the current philosophy of CPR that the focus should be on chest compressions to the exclusion of rescue breaths. The current understanding is that the the blood O2 levels are not so much the problem as is gettting the blood to circulate. Setting aside the issue of chest compressions, I wanted to start a separate thread to ask whether, in light of this shift in thinking, we should still be doing in-water rescue breaths at all. Should we change our rescue curriculum?

Current rescue courses (I'm generalizing from PADI, my experience) recognize the change in CPR thinking towards compressions alone, but continue to teach in-water rescue breathing (since there is no practical way to do in-water chest compressions). The philosophy here is that near drowning victims may benefit from the rescue breaths. There is also the 5 minute rule -- if you are less than 5 minutes from getting out of the water, don't bother with breaths, but if you are more than 5 minutes away, do rescue breaths. At the same time, we are taught to remove gear while towing and administering breaths. A fantastic task-loading exercise that I enjoyed very much for the challenge, but even then I was wondering if this was really the right approach.

I kind of wonder if the in-water rescue breathing is kept more to preserve content of the course and if it would be better in real-life to simply get the victim out of the water as fast as possible in all situations. One thing that is certain is that rescue breathing will increase the amount of time to get the victim from the water, meaning it is prolonging the ischemic insult resulting from no circulation. In these situations it is said that "time is brain" and in delaying the restoration of circulation, are we possibly doing more harm? Some near drowning victims may benefit from rescue breaths, but as we delay compressions brain (and other) cells are dying in all victims. If not a black-and-white, yes or no rescue breaths, would it make more sense to do them less frequently, or try a few rounds for those it may help and then stop, thereby emphasizing getting out of the water faster?

Thanks for the thoughts.

 

[Peter Guy]

You've outlined the issues quite well.

I remember my Instructor Examiner telling us "Remember, take all the time you want to strip the gear and tow to shore. The important thing is to keep a steady and regular rescue breathing pattern."

I thought then, and still think, this absolutely teaches the wrong thing and should be changed.

 

[g1138]

If the victim has water in their lungs, chest compressions won't circulate O2 rich blood, it will however pump out some water from the lungs. Giving a rescue breath should as well; and in my mind would be more effective than a chest compression in water. You can displace more water with a rescue breath than a chest compression, I think.

I haven't been up to date on my Lifeguard/CPR Pro, but I think they still teach the ABC's and do compressions after checking breathing/circulation then giving 2 rescue breaths.
The current trend of going straight to compressions is for simplicity/ease of mind for the general public. Not everyone wants to touch mouth to mouth and you won't believe how "complicated" things get when there's more than one step to do.

I do however still think that the "Take as much time as you need to get the vic out of their gear and to shore" is the wrong mindset.

 

[t-mac]

If the victim has water in their lungs, chest compressions won't circulate O2 rich blood, it will however pump out some water from the lungs. Giving a rescue breath should as well; and in my mind would be more effective than a chest compression in water. You can displace more water with a rescue breath than a chest compression, I think.

Likely. This is the near-drowning point. My question here is really about playing the odds a little. How many people will this really help compared to the number of people rapid access to chest compressions will help. If we still think breaths are important, what about trying a couple do accomplish this in victims that can be helped and then bolt for shore?

The current trend of going straight to compressions is for simplicity/ease of mind for the general public. Not everyone wants to touch mouth to mouth and you won't believe how "complicated" things get when there's more than one step to do.

This is not my understanding. I was taucht there is a physiological basis for the new recommendation and that it is not simply a hygeine or convenience factor. We are talking about saving a life. It may be gross, but the recommendations are not and should not be concerned with that.

I do however still think that the "Take as much time as you need to get the vic out of their gear and to shore" is the wrong mindset.

My main point.

Thanks for the input.

 

[TSandM]

I have said this before. Since breathing is installed deep in the brainstem (and patients in cardiac arrest will continue to show what's called agonal breaths for a period of time), a patient who is not making any attempt to breathe has experienced major central nervous system shutdown. Yes, this can occur from hypoxia or hypercarbia . . . but by the time the patient stops trying to breathe, generally he is either in cardiac arrest, or very close to it. The "close to it" part is why I think a couple of rescue breaths is completely appropriate -- not to mention the fact that stimulating the airway may cause some reflex to cough or gasp. But if two or three rescue breaths doesn't gain any response from the victim, I think you make the assumption that there's no circulation to the brain, and your next imperative is to restore that. You cannot do that in the water, so get the person OUT of the water as fast as you can.

I think the practice of giving rescue breaths while trying to tow is so unlikely to provide benefit to the victim that it should be dropped. JMHO.

 

[Dive-aholic]

You've outlined the issues quite well.

I remember my Instructor Examiner telling us "Remember, take all the time you want to strip the gear and tow to shore. The important thing is to keep a steady and regular rescue breathing pattern."

I thought then, and still think, this absolutely teaches the wrong thing and should be changed.

That's just for the benefit of passing the IE because that's what matters there.

The way I teach it in my course is if you can get to the boat or shore within a couple of minutes or so, give a couple of rescue breaths and then haul a$$. And don't worry about removing gear until you have help. If it's going to be much longer then give rescue breaths and get that gear off. I even have my students tow "unconscious" divers with full gear on and with no gear on because they question the advantage of removing gear. On average, with full gear on it takes 3-4 times longer to tow the "unconscious" diver than with no gear over a 100 foot distance. It would likely take even longer over a longer distance because the rescuer would get tired.

I agree with Lynne about the agonal breaths and stimulating breathing but I will also add that it is very difficult to tell if someone floating on the water is breathing. For the very same reason that we don't check pulses in the water, checking for breathing might not be feasible. A thick wetsuit or dry suit plus hood, BC, etc can make it very difficult. Standards require me to teach rescue breaths every 5 seconds but standards don't prevent me from talking about all of these considerations and in a real situation the need to use your judgment in how to effect the rescue. Fortunately, my rescue students are more than the average vacation diver and can think beyond the standards.

 

[tracydr]

I have said this before. Since breathing is installed deep in the brainstem (and patients in cardiac arrest will continue to show what's called agonal breaths for a period of time), a patient who is not making any attempt to breathe has experienced major central nervous system shutdown. Yes, this can occur from hypoxia or hypercarbia . . . but by the time the patient stops trying to breathe, generally he is either in cardiac arrest, or very close to it. The "close to it" part is why I think a couple of rescue breaths is completely appropriate -- not to mention the fact that stimulating the airway may cause some reflex to cough or gasp. But if two or three rescue breaths doesn't gain any response from the victim, I think you make the assumption that there's no circulation to the brain, and your next imperative is to restore that. You cannot do that in the water, so get the person OUT of the water as fast as you can.

I think the practice of giving rescue breaths while trying to tow is so unlikely to provide benefit to the victim that it should be dropped. JMHO.

I do think it may be difficult for the average person to determine if a victim is truly breathless and pulse-less while towing to shore. Hard enough to take the pulse of a downed victim in better circumstances. But, all the more reason to out of the water quickly.
I've only been involved in one poolside rescue, a one year old child, my neighbor. He did require CPR and was severely hypothermic. I was fortunate enough to see him walking, completely intact and normal a few days later. What a wonderful Christmas present when he and his grandparents came by the house a few days later with a baked goody for me!

 

[t-mac]

The way I teach it in my course is if you can get to the boat or shore within a couple of minutes or so, give a couple of rescue breaths and then haul a$$. And don't worry about removing gear until you have help. If it's going to be much longer then give rescue breaths and get that gear off. I even have my students tow "unconscious" divers with full gear on and with no gear on because they question the advantage of removing gear. On average, with full gear on it takes 3-4 times longer to tow the "unconscious" diver than with no gear over a 100 foot distance. It would likely take even longer over a longer distance because the rescuer would get tired.

This makes a lot of sense to me, including the gear removal point. I think what you are saying with respect to gear is that if you decide it should go, give a couple of breaths, stop, take the gear off quickly and then haul a$$. This makes much more sense than swimming, removing gear and giving breaths all at once, which seems to be the worst of all worlds.

 

[OldNSalty]

I never fully got the 'remove the equipment in the water concept.' I mean, I get that when you get them to the boat or what not you want to be able to easily lift them and get to what ever you need to get to but I always found the BCD to be helpful. In class, I was quick to drop their weight belt...but the BCD? Amazingly I never managed to get it fully off until that last big kick to the dock.

 

[victorzamora]

My question about rescue breaths is this: can we use a regulators for rescue breaths? If you keep the mask on, airway open, reg in (after clearing ?) and purge the reg every few seconds. My favorite tow method is by the tank (like a tired diver) as I believe it to be one of the quickest. That would give easy access to the purge button, jaw to open the airway, and ability to keep their mask on. Especially when diving Nitrox. I mean, I know the exhaust valve mitigates a lot of the benefit...but it's still quite a bit of air pressure in their airways.