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Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 29
Recognition of a Drowning Victim by Bystanders: A
Scoping Review
Luis-Miguel Pascual-Gomez1, Lauren Petrass2,
1 Escuela Segoviana de Socorrismo (Segovia, Spain)
2 Federation University Australia, Institute of Education, Arts and Community
With an estimated 236,000 annual drowning
deaths worldwide, drowning prevention is a
complex global public health challenge (World
Health Organization [WHO], 2021). The WHO
has identified bystanders as potentially valuable
contributors to drowning prevention worldwide.
Of the 10 key actions to prevent drowning
identified in the Global Report on Drowning, the
fourth is to train bystanders in safe rescue and
resuscitation (WHO, 2017). In this context, a
bystander is defined as any member of the public,
be that family, friend, or stranger, who offers
assistance (by attempting a rescue) to someone in
distress (Franklin & Pearn, 2011; Pearn &
Background: Globally, drowning is one of the leading causes of unintentional death. Whilst the World Health
Organization (WHO) has identified that bystanders could play an important role in decreasing drowning deaths,
few studies have evaluated whether bystanders can recognize a drowning victim. This scoping review aimed to
identify common drowning characteristics to support bystanders in recognizing drowning.
Method: Studies were identified through a systematic search of databases from the year 2000 until 2020, with
the review guided by the PRISMA Scoping review process. Two hundred and nineteen potentially relevant
articles were identified, of which 23 met all inclusion criteria.
Results: There is limited to very limited empirical data describing how bystanders detect a distressed victim in
the early stages of the drowning process.
Implications: When preventative measures fail (drowning chain of survival step one), responders need to be
able to perform the necessary steps to interrupt the drowning process. This study categorizes behaviors that
may indicate that a person is in danger or in need of help in the water, which should support bystanders in
recognizing someone in distress and the need to activate rescue and emergency medical services (drowning
chain of survival step two and “early recognition" in the domain of first aid education).
Conclusion: Whilst evidence is sparse, this review provides educators and training organizations with evidence-
based behaviors which they can use to assist bystanders in understanding and identifying persons in danger or
in need of help in the water.
Keywords: bystander, drowning recognition, drowning, rescue
Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 30
Franklin, 2012). The issue of aquatic rescue
undertaken by bystanders is significant, as the
initial response and action of a bystander can make
a critical difference in preventing loss of life, both
through rescuing someone from the water and
early intervention after the rescue, such as
application of CPR (Attard et al., 2015; Moran &
Stanley, 2013; Venema et al., 2010). However, little
is known about how informed members of the
public (bystanders) are to recognize a victim who
is drowning and whether they are equipped to
engage in an aquatic rescue.
In the event of a drowning incident, the
recognition of distress is a critical step, with early
recognition the second link in the Universal
Drowning Chain of Survival (Szpilman et al.,
2014). However, a challenge for bystanders is that
the signs of drowning are not always apparent.
Many victims in significant difficulty are unable to
ask or signal for help, and this makes early
recognition difficult. Whilst bystanders are
frequently involved in rescues in water
environments, their level of experience varies
considerably (Moran & Stanley, 2013). Many
bystanders not trained or experienced in water
safety, water-based rescue or medical assistance
may not be aware when a rescuee requires
assistance, as they lack the skills to assess the
situation and associated hazards (Moran &
Stanley, 2013; Pearn & Franklin, 2012).
Unfortunately, in these situations it is not
uncommon for the bystander to place both
themselves and the rescuee(s) at risk while
performing a rescue (Attard et al., 2015).
A recent Australian study (Petrass & Blitvich,
2018) indicated that many young adults lacked
both the physical capacity and knowledge required
to safely perform a rescue, a factor that may place
them at increased risk if they are to attempt a
rescue. Similarly, a New Zealand study found that
almost half of the survey respondents (47%)
reported that they would jump in and attempt to
save someone, despite almost two-thirds (62%)
identifying themselves as weak swimmers (Moran
& Stanley, 2013). This may explain why it is not
uncommon for the bystander rescuer to drown
attempting a rescue with retrospective studies of
such incidents reported in Australia (Franklin et
al., 2010); the Netherlands (Venema et al., 2010);
Turkey (Turgut, 2012) and the United States
(Smith & Brenner, 1995).
The initial stressor for drowning is thought to be
any event that results in a loss of control of
breathing, flotation and/or ability to move within
the water. The need to breathe and the desire to
return to a point of safety is typically a victim’s
primary behavioral response when in distress, with
breathing taking precedence over everything else
which is primal.
The drowning process has been defined as a 4-
stage sequential process (Pascual, 2014):
1. Incident: defined as the event that takes the
victim out of his expected or normal
situation and triggers a potentially
threatening situation.
2. Loss of aquatic competence: defined as a
situation in which a swimmer suffers a
momentary physical disorder either in
breathing, floating, or swimming, or in their
ability to move within the water.
3. Distress: a period where swimmers
voluntarily hold their breath, become
psychologically and physiologically stressed
and struggle to keep afloat and breathing.
4. Drowning: a period where swimmers start
to breathe in liquid.
Drowning is a hypoxic injury that often starts
before the victim submerges (Salomez & Vincent,
2004). Hypoxia causes weakness, inability to swim
effectively, air hunger, confusion, and
psychological activation with a stress response. In
periods of loss of control and distress (Pascual
(2014) drowning process Stage 2 and 3) victims are
blindly focused on trying to get their airway above
water to breathe; this may cause some to flail their
arms and position their head facing upward.
Often, a lack of oxygen makes them unable to
Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 31
cooperate and respond appropriately. Pascual’s
(2014) Stage 3 (distress) in the drowning process,
has also been referred to as the Instinctive
Drowning Response (IDR) (Pia, 1974). However,
empirical evidence indicates that it is not an
autonomic response, with some victims showing
no signs of distress, but simply becoming
submerged. Uninterrupted, the distress stage
results in: water aspiration, complete anoxia, and
submersion, resulting in the victim typically
becoming lost from sight.
When preventative measures fail (drowning chain
of survival step one), responders need to be able
to perform the necessary steps to interrupt the
drowning process. The challenge is then to
recognize someone in distress and identify the
need to activate rescue and emergency medical
services (drowning chain of survival step two).
The sooner the chain of survival is initiated
through early identification and interruption of
the drowning process, the shorter the period
without breathing, anoxia, and typically the better
the outcome. Thus, early recognition of drowning
and appropriate rescue action is paramount
(Moran et al., 2016; Pascual, 2011; Quan et al.,
2016). Accordingly, the aim of this review was to
determine common behavioral drowning
characteristics and ascertain how bystanders can
recognize drowning. It is anticipated that such
findings will have useful implications for
drowning prevention, particularly for educators
and training organizations that are responsible for
curriculum development, and/or upskilling
individuals within the community. Further, study
findings should directly help bystanders to
intervene early in the drowning process, a key
element in the drowning response chain, thus
enhancing the victim’s recovery outcomes.
Methodology
The review was guided by the Preferred Reporting
Items for Systematic reviews and Meta-Analyses
extension for Scoping Reviews (PRISMA-Scr)
Statement, including the checklist and
recommendations (Tricco et al., 2018). Four
academic databases (PUBMED, SPORTDISCUS,
EMBASE, SCOPUS) were searched for articles
published between the year 2000 and 2020,
inclusive. We chose 2000 as the cut off year as the
new definition of drowning was adopted by
consensus in 2002 (van Beeck et al., 2005), and
this definition enabled more reliable and
comprehensive information to be reported. The
search was restricted to English search terms, with
keywords such as “drowning detection”,
“drowning recognition”, “rescues”, “drowning”,
“layperson” and “bystander” employed in
different combinations using Boolean operations
AND/OR to search. The truncation/stemming
technique was also used to broaden the search to
include various word endings and spellings.
Finally, the reference lists of all included articles,
previous literature reviews on the topic and top
hits from Google Scholar were hand-searched for
further identification of potentially relevant
studies and were assessed using the inclusion and
exclusion criteria.
Eligibility Criteria
All studies assessing the phenomenon of aquatic
rescues by bystanders and lifeguards/lifesavers
were eligible for review. The inclusion criteria
were (i) publication date between 2000 and 2020,
(ii) written in English language, (iii) published in a
scholarly peer-reviewed journal, and (iv) described
behavioral characteristics that had been observed
in drowning victims. Studies were excluded from
the review if they were (i) unpublished thesis and
dissertation studies, (iii) not published in a peer-
reviewed journal, and (iii) examined fatal
drowning associated with aquatic rescues but did
not consider characteristics of victims.
Study Selection and Data Collection
Processes
After performing the initial literature searches, the
first author screened each study title and abstract
for eligibility. Full text of all potentially relevant
studies was subsequently retrieved and further
examined for eligibility by both authors. The
Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 32
PRISMA flow diagram (Figure 1) provides more
detailed information regarding the selection
process of studies. Studies that met inclusion
criteria were then analyzed and synthesized in an
electronic spreadsheet designed by the first
author. Information extracted from each study
included: (i) country in which study conducted, (ii)
study design, (iii) participant characteristics; (iv)
quality assessment score (ranging from 0–5 with
higher scores indicating higher quality), (v) key
findings, among others. This scoping review did
not include a statistical synthesis called meta-
analysis, as the studies were too dissimilar
regarding methodology and data to enable the
results to be combined in a meaningful way.
Results
The comprehensive search strategy resulted in a
total of 219 articles, of which there were two
duplicates. After reviewing the titles and abstracts,
158 articles were excluded because they did not
fulfil the inclusion criteria. A total of 59 full text
Figure 1. PRISMA chart of the selection process.
Records identified through
database searching
(n=197)
Additional records identified
through hand searching
(n= 22)
Records after duplicates removed
(n = 217)
Records screened
(n= 217)
Records excluded by reading title and abstract
(n=158)
72)
Full-text articles assessed
for eligibility
(n=59)
Full-text articles
Excluded with reasons
(n=36)
Studies included in scoping
review
(n=23)
Screening
Included
Eligibility
Identification
Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 33
articles were screened for suitability, with 36
excluded based on a priori criteria (Figure 1). A
total of 23 papers met the inclusion criteria and
were included in the qualitative analysis
(Supplementary Table 1).
In contrast to the stereotypical drowning
portrayed in the media and movies, where
drowning is depicted as a dramatic event where
people wave and scream, the results from the 23
included studies indicate that the signs of
drowning are much more subtle. The results
illustrated that drowning is often quiet, with one
or more of the following behaviors a common
sign of distress/drowning for children (defined as
those aged ≥ 6 years) through to senior adults
(defined as those ≥ 60 years). As there is limited
information available for toddlers (defined as
those aged 1 to 3 years), behaviors specific to this
age group are noted explicitly. No empirical
observation studies specific to infants (defined as
≤1 year) were identified, however videos of infant
survival swim teaching show that this group do
not spontaneously show self-save responses and
tend to sink.
What must alert us to a potential
incident/issue:
● Behavior or actions that do not correspond to the
person's abilities/skills: for example, a child
alone/unsupervised in the water; swimming in the
deep area; and/or
● Submerged head, head underwater or face down;
and/or
● Motionless for more than 10 seconds.
Facial Expression and Communication:
● Eyes closed or glossed over and unfocused;
● Hair over forehead or eyes;
● Mouth below the surface of the water; or appearance
of gasping/fighting for air;
● Lack of respiration, cough.
Body Position and Motor Actions:
● Head is low in the water, with mouth typically at or
below water level;
● Head tilted back, nose-up posture;
● Change of the body position from horizontal to a
more vertical position, sometimes appearing like they
are climbing an invisible ladder;
● No or very limited leg movement;
● Arms pressing down on the surface of the water
(either out to sides or in front) trying to push down
to lift themselves above the waterline, not performing
effective propulsion movements;
● For children (with limited aquatic
exposure/experience), a vertical or face-up position
with uncoordinated kicking and arm movements;
● Toddlers can adopt a vertical position, either face up
or face down depending on the buoyancy of their
body, but do not spontaneously show self-save
responses;
● Toddlers tend to remain submerged or with the top
of the head at surface level.
Displacement:
● Lack of movement in any direction other than
bobbing up and down at the waterline; or
● Trying to swim in a particular direction but not
making progress.
● Toddlers and children (with limited aquatic
exposure/experience) do not attempt to more in a
particular direction and displacement is only a result
of motor actions in water.
Discussion and Implications:
Lifeguarding and lifesaving literature have long
focused on surveillance and the capacity to
recognize the signs of a person in trouble, as this
is a critical lifeguarding skill (Fenner et al., 1999;
Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 34
Pia, 1997). Lifeguards are commonly taught to
look for a specific set of behaviors that are
considered to show drowning or distress
situations, including splashing, frequent
submersion, changes in body position,
impairment of swimming effectiveness, and a lack
of progress through the water, such as what might
occur during the IDR (Pia, 1974). However, it is
not possible for all individuals in the community
to be trained as lifeguards, and therefore it is
critical that bystanders are vigilant for behaviors
that are earlier signs of distress, for example, a
patron moving slowly due to weakness, physical
condition, or fatigue, or apparently acting, or
moving into the water beyond their skill level
(Pascual, 2011).
Despite the limited opportunities to observe and
record real drowning situations, findings from this
review illustrated consistent behaviors that
educators and training organizations can use to
assist bystanders in understanding and identifying
persons in danger or in need of help in the water.
This will ensure the chain of survival is initiated
through early identification of people
experiencing difficulty in the water. Results from
this scoping review indicate that victims show
some or all these behaviors in almost all
circumstances in which drowning occurs.
However, as these behaviors (described in the
Results section of this paper) are common, it may
make it challenging for bystanders, particularly in
crowded, unfamiliar, or challenging conditions, to
recognize a person that is drowning. For example,
bystanders in aquatic settings are faced with the
challenge of dynamic scenes that are constantly
changing, as splashing and submersions happen
very frequently, and even strong swimmers will
slow down or stop eventually.
Whilst the findings from Lanagan-Leitzel (2012)
indicated that bystanders were especially good at
identifying events where young children were
performing dangerous activities, such as
repeatedly submerging, horseplay, or going too far
from shore, there is a need for untrained
bystanders to be further educated on behaviors
that characterize distress/drowning across all age
groups. Further consideration and investigations
are required to determine the most effective and
efficient way to educate untrained bystanders
across various age ranges. In circumstances where
one is concerned about an individual in an aquatic
setting, it is recommended that one ask the person
"Are you okay?”. If there is no response, call for
help (alert a trained lifeguard/lifesaver; seek
assistance from others etc.) and if in an
unsupervised area, follow the recommendations
for a safe rescue, remembering that one’s personal
safety should always be the priority. A quick
response, through early identification of a
potential distress or drowning incident will
minimize the likelihood of an individual
experiencing serious injury from the incident
(Lanagan-Leitzel, 2012).
Further, whilst many studies have evaluated the
quality of adult supervision that children receive
when they are in aquatic environments (Petrass et
al., 2017) investigations are warranted to
determine whether parents responsible for the
supervision of young children in aquatic settings
have the knowledge and capacity to recognize
individuals having trouble in the water. Finally,
none of the included studies within this review
considered that some victims display no signs,
they just submerge. This notion, that drowning
persons display no precursory signs adds to the
complexity of observation and visual searching
particularly for bystanders. Unless the person is
observed submerging, it is unlikely that they will
be detected and rescued in a timely manner. This
is highly important because the longer an
individual is submerged, the greater the risk of
severe and permanent brain damage or death
(Quan et al., 2016).
Limitations
Despite the comprehensive search across
databases, some related papers might be missed
due to application of English search terms and
Review Article
International Journal of First Aid Education, Vol. 5 Issue 1 35
including only studies published in English.
Additionally, important data might be contained
in non-peer-reviewed studies, conference
abstracts, dissertations, or unpublished theses
which were not considered in this scoping review.
We do however believe that this work synthesizes
the relevant evidence in the literature and will help
guide educators and training organizations with
evidence-based behaviors which they can use to
assist bystanders in understanding and identifying
persons in danger or in need of help in the water.
Conclusions and Recommendations.
Unquestionably, prevention is the first link in the
drowning chain of survival. However, if
preventative measures fail, early identification and
interruption of the drowning process will reduce
rescue time and improve the victim's prognosis.
Knowledge about the behaviors of a drowning
victim have been improving over time, and we
now have a reasonably adequate level knowledge
to identify the types of behaviors that are
characteristic of a person in distress within an
aquatic context. However, it remains unknown
whether bystanders: (i) are aware of these
characteristics, and (ii) can identify and act
appropriately if they observe these behaviors.
Based on the evidence available, we can
reasonably suggest that bystanders should observe
certain behaviors that may indicate that a person
is in danger or need of help in the water and
activate the recommended sequence of action
(drowning chain of survival). Whilst further work
is required to understand the most effective way
to educate untrained bystanders, we recommend
that educators consult the “Drowning" topic
covered in the 2020 Guidelines for further reading
on recognizing signs of distress (The Global First
Aid Reference Centre, 2021).
Acknowledgements & Funding
The authors would like to thank the Belgian Red
Cross librarians for the initial bibliographic search and
Linda Quan for filtering the first bibliographic list and
everlasting support in this review process.
This research was supported by AETSAS and ESS
within their drowning prevention joint program
http://www.ahogamiento.com
Conflict of Interests
No conflicts of interest to be declared.
Corresponding Author
Lauren Petrass, l.petrass@federation.edu.au
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van Beeck, E. F., Branche, C. M., Szpilman, D., Modell, J. H., & Bierens, J. J. (2005). A new definition of
drowning: towards documentation and prevention of a global public health problem. Bulletin of
the World Health Organization, 83, 853-856.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2626470/
Venema, A. M., Groothoff, J. W., & Bierens, J. J. (2010). The role of bystanders during rescue and
resuscitation of drowning victims. Resuscitation, 81(4), 434-439.
https://doi.org/10.1016/j.resuscitation.2010.01.005
Webber, J. (2012). Surf lifeguard response to drowning: The SENTINEL system revisited.
https://doi.org/10.13140/RG.2.1.3844.3041
World Health Organization (Ed.). (2017). Preventing drowning: An implementation guide. World Health
Organization. https://www.who.int/publications/i/item/9789241511933
World Health Organization (2021). Drowning Fact Sheet. World Health Organization.
https://www.who.int/news-room/fact-sheets/detail/drowning
Pascual-Gomez & Petrass, 2022.
CC Attribution-ShareAlike 4.0 International License
Supplemental 1
Qualitative Analysis
Citation
Evidence
Level*
Key Findings
Avramidis et al.
(2009)
3B
Professional lifeguards and other rescuers reacted while bystanders
failed to do so. Thus, demonstrating professional lifeguards’ ability
to do risk assessment and their willingness to take responsibility for
the situation. A lack of response in untrained people is
understandable and expected. Aquatic safety professionals and
bystanders were unaware in most of the cases of the outward
behavior of a drowning casualty. Even though most of the
lifeguards remained alert while on duty, it was discouraging to note
that only one-third were able to recognize someone who was
drowning
Brander et al. (2011)
5
Hypothetically, we can assign the following commonly observed
reactions to distress in the water to the fight, flight, and freeze
terminology:
• Lashing out in bursts of energy attempting to remain
above water in primal movements such as “climbing the
ladder” (fight);
• Struggling toward an object that will help them stay
afloat, including family or friends who may be in the rip
current with them (flight);
• Becoming overwhelmed with the situation and struggling
on the spot, usually probing with their feet while sinking
under water in their indecisiveness (freeze).
The instinctive reaction is to swim directly toward the shoreline.
When this initial response to the stressor is ineffectual and the
logical centers of the brain are shutting down, panic can set in
which further limits effectual response.
Carballo-Fazanes et
al. (2020)
4
The visual drowning behaviour showed a broad range of
behaviours. The pattern of drowning behaviour in children, who all
drowned in pools, was much more homogenous than the pattern in
adults, who drowned in various settings. A behaviour that matched
the IDR was recognised by the observers as well as a modified
version with “climbing ladder motion”. A typical behaviour
recognized by observers was like one of the components of the
IDR—the non-voluntary control movement consisting of extending
the arms laterally and beginning to press down on the surface of
the water to try to breathe—but was more forceful and with clear
splashes of water while the arms were rotated fiercely backwards
to keep the front of the head out of the water. There was no
evidence in any of the videos of persons waving for help and there
were no indications that any of the drowned persons tried to shout
or scream.
Doyle & Webber
(2007)
3B
The authors divided behaviours into five different classifications to
create the SENTINEL model. We tested the application of the model
on a category 8 (ABSAMP) rated beach. Each series of data (in
water behaviour) was grouped and provided a status code from 1
to 5.
Fenner et al. (1999)
5
A distress situation involves a swimmer who is unable to return to
safety without assistance, but because of their floating or
swimming skills, is generally able to summon aid by waving, or
calling out for help – i.e. they
Citation
Evidence
Level*
Key Findings
have voluntary control of their actions and could actually assist the
rescuer.
• The passive victim slips under water without waving or
calling out for help or struggling on the surface of the water
- usually because of a sudden loss of consciousness.
• The active conscious, drowning non-swimmer exhibits a
struggling behavior that an attentive, properly trained
lifeguard can detect. Importantly they characteristically flail
their arms sideways in the water,
extend their head backwards but, importantly, do not call
for help.
Franklin et al. (2019)
3B
Rescues are often performed when the rescuer is young and, in
general, people only undertake one rescue in their lifetime, usually
of a family member or loved one. Males were most likely to
perform rescues at the beach, while females were more likely to
perform rescues of young children at swimming pools. There is a
need to train people early in their life on how to undertake a safe
rescue and it would be useful to refresh these skills regularly, if
supervising young children around water. Preventing rescuer
drowning deaths will be an ongoing challenge due to the altruistic
nature of the rescue attempt.
Hunsucker &
Davidson (2008)
5
Recognizing drowning victims:
• On or near surface
o Facial Express
o Irregular motion including the absence of motion
o Loss of body position
o A head-back, nose-up posture
o No leg kick
• Victims on or near the bottom
o Unexplained colour variation in pool
o Elevated chest and drooping head
o Lack of motion
o Bubbles
Victims might exhibit some or none of the above characteristics.
Guard training is essential for better recognition of drowning
victims.
Lanagan-Leitzel &
Moore (2010)
3B
The coverage of surveillance focuses on two basic processes—how
to scan the zone of coverage and how to identify a drowning when
it occurs. Proper scanning ensures that each swimmer is monitored
and no swimmer is ignored. Yet, even with proper scanning,
lifeguards must also be able to identify a drowning when it occurs
and identify precursors that allow them to take preventative action
to ensure that a drowning does not occur.
A swimmer who is in distress is one who is struggling to stay afloat
and may be cognizant enough to be able to call out for help and
grab onto lane dividers, the pool edge, or rescue equipment. If
unaided, a distressed swimmer could begin to panic and
demonstrate a set of behaviors known collectively as the instinctive
drowning response (Pia, 1974). This set of behaviors includes
sinking very low in the water and frequent submerging, coupled
with frantic efforts to keep the mouth and nose above the surface
of the water (through flailing arms and a head that is tilted back). At
this stage, the drowning person is devoting full attention to staying
Citation
Evidence
Level*
Key Findings
above the surface of the water, so s/he may be unable to call out
for help. This struggle only lasts as long as the patron’s energy
permits—a weak patron or a child may struggle for less than a
minute before submerging. Once the patron slips underwater and
can no longer breathe, critical body functions that require oxygen
begin to shut down. The heart stops beating, preventing oxygen
from reaching the brain. The longer a person is submerged without
oxygen, the greater the risk of permanent brain damage, so
lifeguards are taught the behaviors associated with each of these
stages and are instructed to search for patrons exhibiting any of
these behaviors.
This analysis showed no large differences between lifeguards and
non-lifeguards in monitoring behaviors consistent with drowning or
distress. This suggests either that the behavior present in the video
was salient enough to attract the attention of the non-lifeguards or
that the lifeguards had modified their search strategy away from
searching for specific behaviors they were taught in training.
Lanagan-Leitzel
(2012)
4
Lifeguards are instructed to look for a specific set of behaviors that
are thought to accompany drowning or distress. The most
dangerous set of behaviors are splashing, frequent submersion, and
a lack of progress through the water, such as what might occur
during the instinctive drowning response (Pia, 1974). Lifeguards
must also be vigilant for behaviors that indicate that a patron is
distressed or soon may become so a patron who is moving slowly
due to weakness, physical condition, or fatigue, or who is moving
into water that is beyond their skill level.
One problem with these definitions is that the behaviors described
are not always indicative of drowning or distress—splashing and
submersion happen very frequently in an aquatic environment, and
even strong swimmers will slow down or stop eventually. An
overreliance on these behaviors can result in surveillance that is
haphazard and incomplete.
One way that lifeguards could manage the task of surveillance is to
search not for specific behaviors but for critical events. A critical
event would be a specific event used by each individual lifeguard to
determine attentional priority in a scene. Experienced lifeguard
instructors, lifeguards, and non-lifeguards do not identify the same
events as critical for a lifeguard to monitor. The non-lifeguards did
surprisingly well at identifying many of the events that the lifeguard
instructors had identified. They were especially good at identifying
events where young children were performing dangerous activities,
such as repeated submerging, horseplay, or going too far from
shore
Langendorfer (2011)
5
Competence to swim surprisingly depends upon what kind of
swimming I am intending to do and where. Individual
characteristics illustrate the personal qualities that any human
brings to aquatic endeavours. These include a person’s size, body
segment relative proportions, their force production capabilities,
their body composition, the state of their nervous system including
consciousness, and a host of other relevant abilities/disabilities.
Citation
Evidence
Level*
Key Findings
McCool et al. (2008)
3B
The findings identified considerable variability in self-estimated
swimming competency among beachgoers. Perhaps it is not
surprising that higher perceived swimming competency was
associated with lower perception of risk, which raises the possibility
that some individuals (especially young males) might be overly
confident about their ability to manage risky situations through
overestimation of their swimming skill. When associated with lower
estimations of risk as indicated in this study, this combination of
factors might prove to be potentially fatal.
Indeed, past risky behavior was associated with lower risk
perceptions, raising the possibility that a perceived invulnerability
factor might override protective swimming skills and behaviors.
Moran et al. (2017)
4
Most respondents incorrectly thought that the waving of arms was
a characteristic of a drowning person both pre- (incorrect response
72%) and post-intervention (incorrect response 60%). When asked
about their rescue knowledge, levels of understanding varied
considerably. While two-thirds of the respondents correctly agreed
for the need to shout ‘Are you okay?’ to the person in the water,
less than a quarter (23%) correctly disagreed that waving arms and
shouting for help were normal signs of someone drowning. The
persistence of the misconception that drowning people wave their
arms and shout for help suggests that this is a strongly held belief
that was not corrected by the intervention. Further emphasis on
this
critical factor of victim identification is strongly recommended in
future bystander water safety programmes.
Citation
Evidence
Level*
Key Findings
National Aquatics
Safety Company
(2017)
5
Facial Expressions: Terror is many times exhibited through the
expression on the face. Look for wide eyes with a lot of white
showing. The face may be pinched and drawn. They may look as if
they are over the edge of emotional control. They just look scared.
All of these are signs that the victim is in an environment that they
cannot control.
Irregular Motion Including the Absence of Motion: What the victim
is doing does not look like swimming. A flapping of the arms like a
side-straddle-hop may occur. A pawing action is not uncommon.
They may look as if they are trying to crawl or climb out of the
water. Included in this symptom is the absence of motion. It is very
difficult for even a trained swimmer to remain motionless in a
floating position on the surface.
Loss of Body Position: Most, but not all, victims drown in the
vertical position. Once a swimmer goes vertical and starts fighting
the water, they may become a victim. Remember though, some
people who float can drown in the horizontal position.
Head Back, Nose Up: Look at the nose of the victim. The position of
the head controls the position of the body in the water. As the head
goes back and the nose goes up, the victim goes to the vertical
position. This may be the start of the drowning process. Watch
children playing in chest deep water. Those that play with their
nose pointed up are usually uncomfortable in the water. They don’t
like the water in their face. This is a dead giveaway of a potential
victim.
No Leg Kick: Swimmers kick. Victims usually don’t. The absence of
leg action implies that the person is using only their arms to keep
themselves on or near the surface. If they can kick, they can swim.
Page et al. (2011)
3B
Cue extraction and integration are indicators of expertise rather
than visual search per se. In addition to effective cue extraction,
contextual knowledge is suggested to underpin decision making by
influencing the categorisation and integration stages. There is also
extensive literature documenting the differences between the
knowledge of experts and novices. Lifeguards often must observe
complex environments and extract relevant cues for long periods of
time.
Pascual-Gomez
(2011)
4
The aquatic incidents could be categorised as:
• Contacts and collisions between swimmers. This is a
potential cause of disorientation and loss of breathing or
movement.
• Splashing from other swimmers or waves. This causes
discomfort and activates the apnoea reflex.
• Accidental water swallowing. This causes choking, cough,
and apnoea reflex.
• Being out on the deep or not reaching the edge or shore.
This is a potential cause of fear and psychological distress.
• Accidental falls, tiredness, discomfort, illness, stroke, or
seizure. This may disturb or hamper the normal
performance.
Citation
Evidence
Level*
Key Findings
Pascual-Gomez
(2014)
3B
The observations showed that the swimmers who have a
considerable risk to lose control in the water can be recognised by
their behaviour:
1. Swimmers who do not know how to place their face, eyes
or head under the water and do not use goggles to prevent
eyes contacting water
2. Swimmers who do not know how to achieve apnoea or
hold their breath underwater
3. Swimmers whose basic skills as floating, propulsion and
breathing are weak or lack self-confidence, thus feeling
insecure in water
4. Swimmers who increase supporting swimming movements
with their hands and arms to keep afloat
5. Swimmers who are not able to tread water and not able to
roll over their back or change strokes
Swimmers who demonstrate the first and second types of
behaviour when involved into an incident will be unable to react
properly and, when their head gets into the water, will easily get
distressed or panic. Those who demonstrate the third and fourth
types of behaviour will be frightened because they have the feeling
that their abilities are too weak to keep them safe. These swimmers
become psychologically distressed, lose control of their swimming
movements, and submerge due to their inefficacy. Swimmers who
demonstrate the fifth type of behaviour are highly handicapped.
They lack the ability to keep their airway above the water surface.
Pearn & Franklin
(2012)
4
The syndrome of the rescuer-who-drowns comprises a hitherto
neglected and under-identified set of victims where preventive
approaches are difficult. Rescuers who drown give their lives,
involuntarily but altruistically
Petrass & Blitvich
(2017)
4
Supervision is multifaceted and other factors that were consistently
associated with the notion of lower levels of supervision and
potential drowning risk in public pools included: the caregiver being
responsible for multiple children (83%); the caregiver leaving the
younger children under the supervision of older children (17%); and
a busy pool environment (25%).
Petrass & Blitvich
(2018)
3B
This study examined perceived ability of young adults to
perform a rescue; determined the level of aquatic rescue
knowledge; and measured the effect of an aquatic rescue
intervention. Findings indicated that many young adults lacked
both the physical capacity and knowledge required to safely
perform a rescue, a factor that may place them at increased
drowning risk if they attempt an aquatic rescue. Participants had a
low level of rescue knowledge and the relationship between
perceived rescue ability and practical rescue testing was weak.
Post-intervention, ability to perform a contact tow demonstrated
significant improvement and rescue knowledge also improved
significantly, demonstrating a rescue-based intervention can
significantly improve competency of young adults regardless of
previous experience and/or qualifications.
Citation
Evidence
Level*
Key Findings
Pia (1974)
5
There are two types of water crises, distress situations and
drowning situations. Distress situations are those in which
swimmers with varying degrees of skill are unable, because of tidal
conditions (surf or tip tides) or fatigue, to return to shore without
some assistance.
Drowning situations involve non-swimmers who, for a variety of
reasons, suddenly find themselves in water above their heads. A
non-swimmer is defined here as an individual who cannot support
himself by swimming or floating. When drowning, the person:
• Rarely can call out for help.
• Has instinctual arm movements which, unlike the hailing or
waving of persons in distress, appear to push the victim
upward in the water by thrashing the water with both arms
partially extended from his sides. The arm movements of
the non-swimmers are instinctive efforts to keep their
heads above water and remain breathing.
• Usually manages to turn toward shore, with his body in an
upright position, with no apparent support kick. As the
drowning progresses, the drowning person’s head sinks
lower in the water. His arm movements become less visible
- and more feeble - until only the top of his head and
grasping hands may be seen. The whole process may be as
long as 60 seconds or as short as 20 seconds.
Pia (1984)
5
The Instinctive Drowning Response.
The person is rarely able to call out for help. This apparently odd
fact becomes believable when one remembers that breathing, not
speech, is one of the primary functions of the respiratory system.
Therefore, in time of extreme peril in water, breathing must take
precedence over speech. Accordingly, onlookers may be watching a
person drown-unaware that he or she is drowning, because there
has been no call for assistance.
The person has instinctive arm movements, which appear to be an
attempt to push the victim upward in the water by thrashing the
water with both arms extended laterally. This type of arm
movement cannot propel the person in any direction; it merely
raises and lowers the person out of and into the water as he or she
tries to breathe.
The person usually manages to turn toward shore. The body is
upright with no apparent supporting kick. The person’s head sinks
lower and lower in the water as the drowning progresses. The arm
movements become less visible and feebler, until only the top of
the head and grasping hands can be seen. The process can last for
as long as 60 seconds or for as few as 20 seconds.
Citation
Evidence
Level*
Key Findings
Pia (1997)
5
Characteristics which differentiate distressed swimmers from a
drowning person is that the distressed swimmer have voluntary
control over their movements. Movements such as attempting to
but not making any progress toward safety, trying to use another
patron for support, or waving or calling out for help, all signal the
lifeguard, and often other patrons, that help is needed.
An active drowning person struggles on the surface of the water in
a highly predictable, patterned, and to the trained eye,
recognizable way. The Instinctive Drowning Response represents a
person's attempts to avoid the actual or perceived suffocation in
the water. The key concept in understanding a drowning person's
behavior is to keep in mind that suffocation in water triggers a
constellation of autonomic nervous system responses that result in
external, unlearned, instinctive drowning movements.
Characteristics of the Instinctive Drowning Response (IDR)
1. Persons, except in very rare circumstances, are
physiologically unable to call out for help. The respiratory
system was designed for breathing; speech is the secondary
or overlaid function.
The second reason drowning persons cannot call out for
help is their mouths alternately sink below and reappear
above the surface of the water. When the drowning
persons' mouths are above the surface, they exhale and
inhale quickly as their mouths start to sink below the
surface of the water. While their mouths are below the
surface of the water drowning persons keeps them tightly
closed to avoid swallowing water.
2. Drowning persons cannot wave for help. Immediately after
drowning persons begins gasping for air, they are
instinctively forced to extend their arms laterally and begin
to press down on the surface of the water with their arms
and hands.
3. Drowning persons cannot voluntarily control their arm
movements. Physiologically, drowning persons who are
struggling on the surface of the water cannot stop
drowning and perform voluntary movements such as
waving for help, moving toward a rescuer, or reaching out
for a piece of rescue equipment.
4. Drowning persons' bodies are perpendicular in the water,
and they are not able to move in a horizontal or diagonal
direction. Also, there is no evidence of a supporting kick.
5. Drowning persons struggle on the surface of the water
from 20 to 60 seconds
Citation
Evidence
Level*
Key Findings
Stallman et al. (2008)
5
Whiting, noted expert in motor learning, characterized a person
who can swim as “able to cope with an unexpected and involuntary
submersion
When considering the analyses of the drowning accident reports,
the interviews of survivors and observation of simulated episodes
together, several key elements constantly appeared. The list of
these key elements include the following:
1. The victim didn’t realize the danger. It looked safe to them (e.g.,
the victim did not know about the undertow).
2. The victim suffered an unexpected occurrence before or in
conjunction with entering the water (e.g., fall from height, awkward
landing, loss of breath, wind knocked out at landing).
3. The victim suffered an unexpected result or experience during
submersion (e.g., deep submersion after fall, difficulty in regaining
the surface, couldn’t see where I was going, water was cold, clothes
heavy).
4. Following submersion, the victims skills were inadequate to
survival (e.g., unable to turn back toward safety, unable to roll over
and change strokes, couldn’t swim in waves, became quickly tired—
couldn’t swim far, couldn’t stop and rest/float).
In too many cases, children are not taught what is necessary for
them to cope with an unexpected submersion that could lead to
drowning.
Turgut & Turgut
(2012)
3B
Rescuers who died from drowning -in this study- weren't trained to
perform in water rescues. People can be prepared to attempt such
a high-risk activity with prior knowledge in water rescue training.
MDIs are an important part of the drowning incident problem, and
for that reason it is important for individuals to know how to
identify drowning and how to properly help someone who is
drowning.
Webber (2012)
5
The ability to recognise a victim in distress is a core lifeguarding
skill. With junior and less experienced lifeguards, these skills may
be lacking. Cognitive and developmental issues can also impact on a
lifeguard’s ability to recognise a person in distress. Preliminary
research suggests that detection rates in both groups can, however,
be improved with training and experiential learning
• Levels of evidence are based on the work of Burns, P. B., Rohrich, R. J., & Chung, K. C.
(2011). The levels of evidence and their role in evidence-based medicine. Plastic and
reconstructive surgery, 128(1), 305 and Centre for Evidence-Based Medicine,
http://www.cebm.net.
