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Spinal Injuries in the Aquatic Environment
Part 1: Prevention
by Gerald M. Dworkin
One hot Sunday afternoon, a family
was enjoying a leisurely barbeque around their new backyard
swimming pool. The children played a game of tag in the pool,
while the father cooked on the grill. The mother was carefully
watching the children as she sat along the pool edge.
Suddenly, the 12-year-old boy quickly climbed out of the pool,
in order to avoid being tagged, and immediately dove back in. In
the boy's effort to keep away from his sister, who was trying to
tag him, he dove too deeply into the water and struck his head
on the pool's bottom. The child floated motionless to the
water's surface. The mother quickly jumped into the pool and
supported the boy by placing one arm under the child's neck, and
the other arm under the child's knees. She then lifted the boy
onto the pool deck.
In the mother's attempt to rescue her child, she actually
further aggravated a spinal cord injury that occurred when the
boy dove into the water and struck his head on the pool's
bottom.
Each year, doctors identify and treat approximately 10,000 new
spinal cord injuries in this country. The average age of onset
is 28.7, and the most common age is 19. Fifty percent of the
injuries occur in the 15- to 24-year age group. Eighty-two
percent of all spinal cord injuries occur in males.
The following statistics represent the etiologic causes of
spinal cord injury in this country: Motor Vehicle 36.5%; Falls
15.8%; Gunshot 11.6%; Diving 10.6%; Other Causes 24.5%.
The major cause of these devastating traumatic injuries is, as
you probably expected, motor vehicle accidents. However, the
second leading cause are those injuries resulting from sports
and recreation activities. Water-related activities are the
number one cause of spinal cord injuries resulting from sports
and recreation activities.
Each year, approximately 13,000 diving-board-related injuries
are sufficiently serious to be brought to hospital emergency
rooms; diving accidents cause approximately 800 spinal cord
injuries. The Consumer Product Safety Commission (CPSC)
estimates that this is a yearly occurrence.
According to the CPSC, "... one of the major accident patterns
associated with swimming pools was striking the bottom or sides
of the pool because of insufficient depth for diving or
sliding...." Further, "... in addition to striking the bottom of
the pool, people are injured when they hit protruding
waterpipes, ladders, or other objects in the pool."
Diving should be strictly prohibited in shallow water. Over half
of the swimming pools in the United States are above-ground
vinyl swimming pools, most of which have a constant depth of
three to three and-one-half feet. In order to gain entrance into
a pool of this type, most pools provide a ladder or platform.
Many injuries occur each year when children or adults attempt to
dive into the pool from these ladders and platforms.
There are four major factors which can cause spinal injuries in
aquatic facilities. By realizing this, you can develop or adopt
prevention and training strategies and activities to reduce or
prevent these injuries from occurring. These factors include:
 (A)
Diving too deeply off a diving board and striking the bottom
before leveling off.
(B) Diving too far out off the diving board or sliding too far
out off the slide and hitting the bottom incline of swimming
pools.
(C) Diving or sliding into shallow water and striking the
bottom.
(D) Striking an object underwater( i.e. side of the pool,
obstacles, or another swimmer.
Diving or sliding injuries result from the victim propelling
into head contact with some part of the pool or facility bottom.
The position of the head and neck, the impact site, and the
victim's direction all determine the resulting spinal injury.
You should suspect any victim of a diving or sliding accident of
having a spinal injury and handle the victim accordingly.
There are several nationally recognized spinal injury prevention
programs you can integrate into you school curriculum or
community swim program. The two largest programs are the
National Swimming Pool Foundation's Learning How to Dive
program, and the Feet First, First Time, Inc. program.
The National Swimming Pool Foundation (NSPF), in cooperation
with the National Spa and Pool Institute (NSPI), produced an
eight minute film, "Learning How to Dive," on safe diving
techniques, and accident prevention principles. Using this film
is an ideal way to instill the importance of proper diving
techniques; you can use it in a school classroom setting, or at
any social, recreational, or educational gathering of youth
groups. You can also integrate the film into organized
progressive swimming courses conducted through such
organizations as the American Red Cross, the YMCA, and the Boy
Scouts of America.
"Learning How to Dive' presents the story of a young boy who
broke his neck when diving into shallow water. The film
instructs proper diving techniques with the help of Olympic Gold
Medal Diving Champion Greg Louganis, U.S. Olympic Coach Ron
O'Brien, and actor Patrick Wayne. (You can obtain '"Learning How
to Dive" from the National Swimming Pool Foundation, 10803
Gulfdale, Suite 300, San Antonio, Texas 78216; 512-341 -5153, or
through your local NSPI chapter or regional office.)
Another program that you can easily implement within your school
or community recreation setting is a diving accident prevention
program called, "Feet First, First Time." This is a proven
prevention program for teenagers and adults. The program aims to
convince swimmers to check the depth of the underwater area by
jumping, not diving head-first, even if they are certain it's
safe to dive.
Feet First, First Time, Inc. provides a marketing guide to help
you start safe diving and prevention programs. The booklet
contains an explanation of how the program began and useful
ideas to promote prevention activities. The complete marketing
guide follows proven techniques used by advertising agencies and
public relations firms.
(You can get the Feet First, First Time marketing guide from
Feet First, First Time, Inc., North Davis Highway, Pensacola,
Florida 32523-8900; 904-478-4460.)
The following sections contain various prevention principles and
activities you can implement to help reduce or eliminate spinal
cord injuries in the aquatics environment. All aquatic
facilities should enforce these principles.
Principles of Safe Diving
Know the water depth before you dive. Be sure there are no
submerged obstacles or surface objects. Don't dive into an
aboveground pool or into the shallow end of a swimming pool.
Don't dive into unfamiliar bodies of water.
Plan your dive path. Don't dive from the edge across the narrow
part of a swimming pool without having at least 25 feet of clear
dive path in front of you. Don't run and dive.
When you dive, you must steer up. Hold your head and arms up,
and steer up with your hands. Keep your arms extended and head
and hands up during the dive.
Practice carefully before you dive. Test the diving board for
its spring before using it to dive. Don't do back dives or fancy
dives, or dives with straight vertical entries without proper
guidance and instruction, and then only in pools designed for
diving.
Don't dive from retaining walls, ladders, slides or other pool
equipment. Don't dive from rooftops, balconies, ledges, or
fences.
Don't dive from racing starting blocks without proper training
and direct supervision from a qualified coach. Don't dive at or
through objects such as inner tubes.
Don't swim or dive alone. Do so only with a "buddy" and
preferably under qualified supervision.
Don't drink or take drugs during or prior to participating in
aquatic activities. The slowing effects of alcohol or drugs on
reaction time can be extremely dangerous in diving.
Principles of Safe Sliding
Do not allow any slider to slide headfirst at any time. Allow
only sitting slides.
Allow only one slider on the slide at a time. Clear the landing
area before you allow the next slider.
Prohibit other people from using the water landing area in front
of the slide.
Maintain a minimum water depth of five feet in the slide landing
area.
Reducing Springboard Diving Accidents
The following recommendations minimize or eliminate springboard
diving accidents. Unfortunately, there is no legislation in most
states that mandates that the swimming pool industry follow
these standards.
The safest pool design provides a pool for springboard and
platform diving, and a separate pool for swimming. Where this is
not feasible, divide the diving area from the rest of the pool
by a bouyed line.
A minimum water depth of 12 feet in the landing area is
necessary for safe diving from competitive diving boards, which
are usually 16 feet long, and placed either one or three meters
above the water's surface.
Recreational diving boards (12to 14-feet long) should have a
landing area with a minimum water depth of ten feet. However, we
still recommend the 12-foot minimum.
Extend the maximum of water immediately below the tip of the
diving board forward for a distance of 16 feet before the bottom
slopes upward.
Carry the maximum depth of water laterally ten feet on either
side from the center line of the board.
Do not permit recreational divers to manipulate the adjustable
fulcrum on springboards, unless they have been trained to do so.
During recreational swimming periods, the adjustable fulcrum
should be locked in a fixed position, preferably in its most
forward position, in order to reduce the spring of the board.
Provide water surface agitators to provide greater visibility of
the water's surface and help reduce the potential for injury.
Factors Contributing to Springboard Diving Accidents
The following are contributing factors of springboard diving
accidents. By identifying the causes, facility managers can
reduce or completely eliminate these factors.
Inadequate underwater and overhead lighting. This condition can
prevent the diver from seeing the pool bottom.
Cloudiness (turbidity) of the water. This condition is usually
caused by a chemical imbalance, or a faulty filter system.
Lack of any markings, lines, or targets on the pool's bottom
fails to provide divers with a visual reference for judging the
bottom's profile and water depth.
Glare on the water's surface, caused either by the sun or from
lights which are improperly located.
Impaired vision of the diver, caused by the need to remove eye
glasses before diving.
Recommendations for Open
Water Areas
In addition to the recommendations and principles previously
mentioned in this article, you should place warning signs,
lifeguards, and fencing at sites where the water depth is
insufficient for diving, or where the bottom contains dangerous
obstacles. Diving should be strictly prohibited in these areas.
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Spinal Injuries in the
Aquatic Environment
Part 2: Emergency Procedures
by Gerald M. Dworkin
All public and semi-public aquatic
facilities should be equipped with appropriate spinal
immobilization devices (SIDs), in addition to cervical collars,
lateral stabilization items (i.e. blankets, towels, sand bags,
and so forth), and appropriate immobilization material (i.e.
straps and bandages). Aquatic personnel should be well trained
in using this equipment, as well as in appropriate response
procedures should a spinal emergency occur. Backyard swimming
pool owners should also know what to do to stabilize a victim
with a suspected spinal injury until they can obtain emergency
medical services personnel.
A. Handling Victims in Shallow Water
If you find the victim face down in
the water, you must carefully rotate the victim to a supine
position. To do this, you must be careful to avoid any bending
or twisting of the victim's neck and torso to avoid aggravating
existing injuries.
Place one forearm along the length of
the victim's sternum with the hand of that arm supporting the
bony structure of the victim's lower jaw. Simultaneously place
your other forearm along the length of the victim's spine,
supporting the victim's head at the base of the skull with your
hand. Then support the victim's head and torso with your
forearms and hands with an inward and upward pressure. As you do
this, submerge, while maintaining this support position on the
victim, and rotate the victim to a supine position.
Once the victim is in a supine
position, you must then continue to support the victim from the
side by placing one hand behind the neck and the other hand
along the victim's back. This technique will maintain proper
alignment of the victim and will keep him/her in a supine
position. Additional rescuers should bring the necessary
equipment (i.e. SID, straps, lateral head/neck restraint, and so
forth, and position a cervical collar around the victim's neck.
To place a spinal immobilization
device under the victim, rescuers should position themselves at
each end of the device, which is floated alongside the victim in
the water. On command, the rescuers lower the SID beneath the
victim and allow it to come up slowly until the victim is
completely supported. Care must be taken during the ascent of
the SID to properly align it with the victim. The first rescuer
is responsible for maintaining the victim in alignment, in a
supine position, until this is accomplished. Once the SID is in
place and the victim is adequately resting on it, the first
rescuer may then begin immobilizing the victim to the SID.
Place head and neck lateral
immobilization restraints along both sides of the victim's head
in order to reduce the risk of any lateral move meet. Once you
accomplish this you may begin immobilization of the victim to
the SID.
I recommend the following sequence for
securing the victim to the SID using traditional straps and
cravat bandages:
1. Across the chest.
2. Above the waist to include the arms
at the sides.
3. At the hips to include the hands at
the sides.
4. Above the knees.
5. Below the knees.
6. Across the forehead.
7. Other - to include feet or other
areas for additional support.
This technique of immobilization
allows for the greatest mass of the body to be secured prior to
securing the head. This procedure reduces the risk of
aggravating injury to the cervical spine should the body move
because of wave action.
B. Handling Victims in Deep Water
If you suspect a spinal injury in deep
water, you should turn the victim from a prone to a supine
position and then float the victim to shallow water, where you
can then immobilize him/her onto an appropriate SID. However, in
aquatic facilities which have a uniform deep water area (i.e.
diving wells) or those facilities where the deep water is
divided from the shallow water by a buoyed line, bulkhead, or
other obstruction, you must bring the SID to the victim. First
attach flotation collars or other suitable flotation devices to
the SID. Place the flotation device/collar on the upper half of
the SID only, to allow the rescuers to submerge the lower half
under the victim.
The flotation device-collar should be
attached to the SID at all times, but still be easily removed
while you immobilize the victim to the SID for transportation by
ambulance to the medical facility.
Rotate a victim in deep water from the
prone to the supine position in the same way you would in
shallow water. You can also use this same technique for a victim
who is submerged and who may be lying on the bottom of the pool
or open water facility. You must use extreme caution when
recovering the victim in order to assure that the victim is
maintained in alignment while being brought to the surface. To
do this, support the victim as previously described and swim
diagonally to the surface while rotating the victim to a supine
position.
Placing the flotation SID under a
victim in deep water requires two to three rescuers. It is
preferable that the rescuers wear some type of personal
flotation device (PFD) during the rescue to lessen their
fatigue.
Rescuer #1 rotates the victim to, or
maintains the victim in, a supine position. Rescuer #2 places a
cervical collar around the victim's neck while Rescuer #3
positions the flotation SID in preparation for placement under
the victim. One rescuer places the foot end of the flotation SID
at the victim's head. Rescuer #1 supports the victim's head and
neck with one hand and guides the flotation SID with the other
hand in order to prevent the SID from hitting or making contact
with the victim. Rescuers #2 and #3 grab the victim's upper arm
near the armpit, and slide the victim onto the flotation SID.
Because the lower half of the flotation SID has no flotation
attached, it is easily submerged for this purpose. The support
provided by the water and the flotation SID provides sufficient
support for the entire body.
Once the rescuers have placed the
victim appropriately onto the flotation SID, they temporarily
immobilize the head with a lateral restraint device (i.e. rolled
blanket or sandbags) and secure the torso and extremities.
Cravat bandages are then used to immobilize the head.
After the rescuers immobilize the
victim onto the flotation SID, they should float the victim
along the long axis of the body to the platform or deck for
removal from the water, then pull the head of the flotation SID
onto the platform while allowing the foot of the device to drop
deeper into the water.
To expedite the handling of suspected
spinal injuries in open water areas where additional protection
of the victim may be required, you can use a flotation basket
stretcher. This device consists of a standard basket stretcher
with a suitable SID secured within it, and a flotation collar
attached around the upper half of the stretcher. The SID should
be secured to the basket stretcher at the head and foot so that
you can easily remove it from the basket stretcher once the
victim is placed on shore. The victim immobilization straps are
attached to the SID and not to the basket stretcher.
The flotation basket stretcher is
especially beneficial in white water rescue operations and when
the victim is being handled in surf, moving water, or cases when
the victim will be transferred from the water to a boat or
helicopter.
Placing the flotation basket stretcher
under the victim and immobilizing the victim into the device are
very similar to the techniques used to immobilize the victim
onto the flotation spinal immobilization device. However, after
removing the flotation basket stretcher from the water, you also
remove the two straps securing the head and foot of the SID to
the basket stretcher. This allows you to remove the SID, with
the victim attached to it, from the basket stretcher for
emergency transport to the medical facility.
C. Handling Victims in Backyard Swimming
Pools
Once you have turned the victim from a
prone to a supine position in the water, you should maintain the
victim in a horizontal position until emergency medical
personnel arrive. If a rigid support is available, such as an
ironing board or picnic bench, place it under the victim and
then raise it until the victim is resting adequately on the
support. This will help immobilize the victim's spine until the
EMS personnel arrive. If a rigid support is not available, you
should support the victim on the surface of the water until
additional medical help arrives.
D. Rescue Breathing and CPR
In all cases, once you have turned the
victim from a prone to a supine position in the water, you
should determine whether or not the victim is breathing. To do
this, keep the head and neck in a neutral position, place your
cheek directly above the victim's mouth and nose and look at the
chest. If the victim is breathing, you should be able to observe
chest movement and hear and feel the victim's breath against
your cheek.
If the victim is not breathing, you
should provide two slow, full breaths to the victim and then
check the victim's pulse. If the victim is not breathing, but
has a pulse, then perform rescue breathing with the victim
maintained in the water until he/she can be immobilized onto an
SID and removed from the water. If the victim is not breathing
and does not have a pulse, you must immediately remove the
victim from the water to a firm flat surface and administer CPR.
When removing the victim, attempt to keep the victim from
twisting or bending.
SUMMARY
To reduce or eliminate spinal cord
injuries in the aquatics environment, general principles for
safe behavior must be practiced by the public, and must be
enforced by the facility management. Recreation personnel-
responsible for providing aquatic recreational opportunities
must implement and enforce every safeguard possible to eliminate
or minimize the risk of injury which may lead to spinal injury.
Families with backyard swimming pools
should know proper first aid, CPR, and basic water rescue
skills. This training is offered by such organizations as the
American Red Cross, YMCA, American Heart Association, as well as
many others. First aid kits should be available with sufficient
dressings and bandages to stop bleeding and prevent infection
from cuts, scrapes, and so forth. A telephone should be
available with the local emergency medical services (EMS)
telephone number posted near it so that these services can be
contacted if needed.
The same principles apply to
recreation personnel. Lifeguards need to know first aid, CPR,
and lifesaving techniques. Spinal immobilization, first aid, and
water rescue equipment must be readily available for use during
an emergency. And, the lifeguard personnel must be proficient in
its use.
Recreation
agencies and personnel can play a crucial role in educating the
public in preventing spinal cord injuries. Whenever possible,
spinal injury prevention programs, such as the Feet First, First
Time program and the Learning How to Dive program mentioned in
Part I of this article July, 1987, PARKS & RECREATION) should be
implemented and integrated into school and community settings in
order to educate the public, especially pre-teenagers, about the
dangers of diving into unknown bodies of water or shallow water.
These educational programs should also include basic principles
of how to dive properly.
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