Discussion

Rescuer protection is essential in any emergency. In addition to the usual risks (usually traumatic), now there is the risk of COVID-19 infection. For this reason, it is suggested that professionals should use isolation devices which prevent contact and virus inhalation if the victim is infected. So far, recommendations for resuscitation have been based on the most common “medical” settings (ie, hospital or ambulance), without yet having evaluated the options for PPE in other less common and less controlled environments (such as lifesaving situations) in which CPR is also performed. Therefore, this study had the novel objective of evaluating three levels of protection during the resuscitation by rescuers on an IRB. In the controlled simulation conditions in a real environment in which the tests were carried out, it was observed that: (1) there was less loss of time at the start of on-boat resuscitation using the BVM and HEPA filter, with a basic level of protection; (2) the use of an extra waterproof barrier such as a plastic blanket seemed faster and easier than a conventional waterproof apron; (3) CPR quality was not affected by the level of protection used; and (4) finally, on-boat CPR with two rescuers did not generate much fatigue amongst trained lifeguards.

Drowning is considered a public health issue by the World Health Organization (WHO; Geneva, Switzerland), ¹⁹ and lifeguards are recognized as the first barrier to prevention and intervention. The IRB is commonly used in lifeguarding as it is small, safe, fast, and easy to use, and is common in surveillance and rescue near the coast. ^{Reference Barcala-Furelos, Abelairas-Gomez and Palacios-Aguilar5} The use of IRBs in the event of drowning can gain valuable time in an incident in which every second counts. The systematic review and meta-analysis by Quan, et al ^{Reference Quan, Bierens, Lis, Rowhani-Rahbar, Morley and Perkins20} found that immersion time is the most influential factor in the prognosis of the victim. Stopping the drowning process quickly ^{Reference Szpilman, Bierens, Handley and Orlowski2} and initiating on-boat resuscitation would avoid the time delay involved in the rescue and transfer to land without life support. Another finding by Quan, et al ^{Reference Quan, Bierens, Lis, Rowhani-Rahbar, Morley and Perkins20} is the favorable outcomes witnessed thanks to the shorter Emergency Medical Service response times. This evidence reinforces the importance of on-boat resuscitation, which is not a common practice but is definitely possible, ^{Reference Seesink, Nieuwenburg, van der Linden and Bierens7,Reference Kingdon, Stapleton and Stahl21} and therefore needs planning and training.

At present, any unknown victim of cardio-respiratory arrest will be considered a potential carrier of SARS-COV-2, and in the case of rescuers, exposure to the risk of contagion may be high since beaches are a place with a large concentration of bathers and rescue techniques inevitably require direct contact. ^{Reference Barcala-Furelos, Aranda-García and Abelairas-Gómez11} The risk may be reduced depending on the PPE that can be used. ^{Reference Barcala-Furelos, Aranda-García and Abelairas-Gómez11} From a theoretical perspective, the most complete option of F-PPE could be used on the IRBs; however, it would not be realistic for two reasons: (1) it is neither viable nor safe to patrol with a waterproof gown while awaiting an incident requiring CPR, since it is a low-probability event (it represents just 0.02% of actions carried out by lifeguards); ^{Reference Szpilman, de Barros Oliveira, Mocellin and Webber22} and (2) the time spent wearing the waterproof gown on a boat, as well as the probability of doing it incorrectly, is a sufficiently important limitation affecting this choice of PPE.

Maintaining on-boat resuscitation as a protocol on IRBs involves starting CPR with a basic protection (B-PPE) and ventilating using HEPA-filtered BVMs. However, this procedure does not offer the greatest protection against possible infection and should be assessed by rescue agencies, and the rescuers themselves, to weigh up the risk they are taking considering epidemiological data on local incidence of the virus, the age of the rescuer (usually young) or his/her previous health status (eg, previous pathology, possible immunity due to having previously overcome COVID-19, or other factors), or the type of victim (eg, a child) and the rescue conditions (eg, a short time underwater). An intermediate position could be the use of B-PPE in combination with a plastic blanket (B+PPE) so as to create an insulating barrier between the rescuers and the victim. According to these results, this extra protection allows quick positioning on the patient and does not affect the QCPR.

A fundamental criterion for the decision to continue with on-boat resuscitation is to know whether it is possible to perform quality CPR with the PPE. Studies prior to the pandemic have shown good performance by lifeguards or fishermen during on-boat resuscitation, although the QCPR was conditioned by the size of the boat, ^{Reference Tipton, David, Eglin and Golden6} the waves, ^{Reference Tipton, David, Eglin and Golden6} the wind, or the speed, ^{Reference Barcala-Furelos, Abelairas-Gomez and Palacios-Aguilar5,Reference Fernández Méndez, Barcala-Furelos, Fungueiriño-Suárez, Mecías-Calvo, Abelairas-Gómez and Rodríguez-Núñez23} but until now, neither the PPE variable nor on-boat resuscitation in teams (by two lifeguards) had been introduced. These findings show results in V and CC above 70%, a value arbitrarily assumed in numerous studies as the cut-off point in CPR quality. ^{Reference Perkins, Colquhoun and Simons24} Similar results were found in a Spanish study on an IRB, ^{Reference Barcala-Furelos, Abelairas-Gomez and Palacios-Aguilar5} with the same maritime conditions and at a very similar speed (10knots/18.52Km/hour) in comparison with the current study (11knots/20Km/hour). The main difference between both studies was the RPE. In the case of a lone rescuer, the perceived effort was five (Heavy/Strong big-major effort) on the RPE scale, ^{Reference Foster, Florhaug and Franklin18} and when there were two rescuers (ie, in this research), the RPE did not exceed two (a light effort) for the rescuer performing V and three (moderate effort) for the CC rescuer. It seems, therefore, that CPR by two lifeguards has a number of advantages, at least in terms of fatigue, although the crew of an IRB is usually made up of two people (skipper and lifeguard) since a conditioning factor is the limited space. ^{Reference Seesink, Nieuwenburg, van der Linden and Bierens7} This circumstance could be a limitation for team resuscitation on small IRB models.

Correct PPE donning and doffing is not easy and requires specific training, ^{Reference Barcala-Furelos, Aranda-García and Abelairas-Gómez11} and misuse may lead to a false sense of security. ^{Reference Amoroso, Poncetti, Regueira, Pocebon and Guimarães25} Wind and waves are common circumstances at sea, and tests performed with mild gusts of wind prevented several rescuers from wearing the waterproof gown properly.

This study has a practical and direct impact on lifeguards, regarding how to deal with the most critical situation of drowning (ie, cardio-respiratory arrest). Europe is immersed in the first summer of the COVID-19 Era and this has not prevented the beaches of Mediterranean countries from continuing to be a meeting point for bathers and the scene of potential drownings. Summer will be at the end of 2020 in the Southern Hemisphere, so lifeguards need evidence-based guidance to intervene as safely as possible, in a context in which there are no previous experience and therefore recommendations must be adapted to each specific environment. Preliminary results are offered here in three aspects relevant to on-boat resuscitation: (1) whether it is feasible with current recommendations; (2) how precious time can be saved so as not to delay assistance; and (3) how to protect rescuers to prevent contagion.